As noted at the outset, the following issues arise in this case:
As in the other cases dealt with by this Inquest, the evidence suggests that the parents did not receive sufficient information to give informed consent. They were never informed about the state of the team during the summer months while they were waiting for the operation to be performed. While Odim and Giddins were probably accurate in their assessment of the degree of risk that the operation presented, the evidence would suggest that they did not seem to have factored into their thinking the relative inexperience of the surgeon and of the team in dealing with this type of surgery. This information is something that would probably have been a factor in the thinking and granting of consent by any reasonable person, and should have been provided to the Feakes. This evidence tends to suggest that Ashton's parents were not provided with sufficient information to allow them to give informed consent to the procedure.
Given the seriousness of Ashton's condition, it would have been appropriate for the VCHC to have referred Ashton out of province for surgery in the summer of 1994. It was clear that Ashton was not an appropriate patient for the surgical team to undertake care of, during the summer of 1994, when the program was in hiatus and performing only low-risk procedures.
During the summer months, the review team was considering the question of whether or not to allow the program to proceed to high-risk cases. At that time, Giddins, in consultation with the Wiseman Committee, made the decision to defer high-risk cases until the program could do them. No consideration was given to transferring such patients unless the parents demanded that the child be transferred or unless the patient could not wait for surgery.
The Feakes were not given the option of considering a referral to another centre. They should have been. More importantly, however, was the fact that Ashton could not have benefited from waiting additional time for his surgery. There is evidence that Odim thought the operation should have been done sooner, rather than later. While the program waited for the hiatus to end, Ashton's condition was becoming worse. His muscle bundles, for example, became more and more problematic as time passed.
The evidence suggests that the team and its surgeon were not in a position, even in November, to be able to provide the best possible care for this child. While the operation was judged a success, it was a very high-risk process. It may be that the valve dehisced as a result of a problem with surgical technique, although this is only a possibility. However, it would have been appropriate for the team to have referred this child out of province, even after the PCS program had gone back to full service.
The treatment team came to the conclusion on November 10 that the surgical repair had failed and that the mitral valve needed to be replaced. However, by that time, Ashton had deteriorated to such a condition that it was not possible to consider another surgical procedure.
There is evidence to suggest that the team had sufficient information before November 10 to enable it to consider performing a mitral valve replacement. Cornel was of that view. He thought the echocardiogram on November 4 showed that the regurgitation was at the point of indicating a valve repair failure. Soder's view was the same. He said that so long as the patient was improving, regurgitation was tolerated, but the evidence suggests that Ashton did not improve to any degree after November 4. Giddins felt that Ashton's failure to improve on November 5 was actually a sign that he was getting worse.
By November 7, Ashton was showing evidence of an inability to tolerate another surgical procedure. That should have caused the team to consider a valve replacement if Ashton rallied, which he did on November 8. However, despite interpreting that as a sign of overall improvement-which seems more like wishful thinking, in hindsight-no steps were taken to replace Ashton's mitral valve. He quickly deteriorated thereafter.
It seems clear that Ashton died from pulmonary hemorrhage. The question is: what caused the hemorrhage? The consulting witnesses believe that the dehiscence of the mitral valve repair led to the mitral valve regurgitation that ultimately led to Ashton's lungs becoming congested and hemorrhaging. No firm conclusion can be reached as to what caused this dehiscence.
The evidence also suggests that with a different approach to post-operative care, a decision would have been made earlier on to repair the dehisced mitral valve, although this would have been a high-risk venture.
Both the dehiscence and the failure to attempt to repair the mitral valve do lead to one very significant conclusion: this death could have been prevented if the case had been referred to a larger medical centre in the summer of 1994, rather than being deferred until November 1994.
|Current||Home - Table of Contents - Chapter 8 - Findings|
|Section 1||Chapter 1 - Introduction to the Issues|
|Chapter 2 - Pediatric Cardiac Issues|
|Chapter 3 - The Diagnosis of Pediatric Heart Defects and their Surgical Treatment|
|Chapter 4 - The Health Sciences Centre|
|Section 2||Chapter 5 - Pediatric Cardiac Surgery in Winnipeg 1950-1993|
|Chapter 6 - The Restart of Pediatric Cardiac Surgery in 1994
January 1, 1994 to May 17, 1994
|Chapter 7 - The Slowdown; May 17 to September 1994|
|Chapter 8 - Events Leading to the Suspension of the Program
September 7, 1994 to December 23, 1994
|Chapter 9 - 1995 - The Aftermath of the Shutdown
January to March, 1995
|Section 3||Chapter 10 - Findings and Recommendations|
|Appendix 1 - Glossary of terms used in this report|
|Appendix 2 - Parties to the Proceedings and counsel|
|Appendix 3 - List of witnesses and dates of testimony|