As identified in the introduction, this case gives rise to the following issues:

• Should the Winnipeg team have attempted a Norwood procedure, given its recent history and its level of experience?
• Should Erica have been transferred out of Winnipeg?
• Should the operation have taken place before October 4?
• Were the parents provided with sufficient information to allow them to give informed consent to the procedure?
• Was Erica given adequate myocardial protection?
• What was the cause of death and was it preventable?

Should the Winnipeg team have attempted a Norwood procedure, given its recent history and its level of experience?
Should Erica have been transferred out of Winnipeg?
Should the operation have taken place before October 4?

These three questions are inter-related and cannot be answered separately. They go to matters at the centre of this Inquest.

Findings

The evidence presented to this Inquest suggests that the HSC Pediatric Cardiac Surgery Program should not have been looking after all the patients who came through the door in 1994. As has been noted several times in this report, the evidence suggests that the surgeon lacked the skill, experience and dexterity to undertake a number of high-risk procedures.

This was one such procedure. Indeed, the length of time the procedure took is one more piece of evidence suggesting that the surgeon did not have the necessary skills and experience to handle high-risk operations. That being so, there should have been a protocol under which all high-risk patients would have been considered as candidates for referral out of Winnipeg.

Several witnesses raised the question as to whether or not it would have been appropriate to transfer Erica out of Winnipeg. Duncan and Cornel, for example, asked, "Were the options for transfer to another centre provided? Such a transfer might not have been conceivable given the precarious status pre-operatively." (Exhibit 354, page 12)

Dr. Oscar Casiro, an intensivist who treated Erica, did think it would have been possible to transport Erica out of province. It is clear that transfer would have been risky. Furthermore, the evidence suggests that many centres might not have accepted Erica because she was too ill for them to consider operating on her. In the end, transfer might not have been feasible.

However, because the Winnipeg approach was essentially to take all comers, it appears that Ward, Giddins and Odim did not give consideration to transfer. In fairness to Ward, he was new to the program and had been informed that the team was capable of undertaking high-risk procedures.

However, Odim and Giddins were well aware of the problems that the team had been having and of the failure of the previous Norwood. A failure in a single case should not necessarily mean that the program should not undertake similar procedures in the future. However, the difficulties inherent in the Norwood procedure, and its extreme risk, placed it in a category of cases that the program should simply not have been attempting during 1994.

If there was to be no transfer, the only real options were to allow the team in Winnipeg to operate or to arrange for comfort care for Erica until she died. After Erica's death, Judith Bichel said that her family doctor had suggested that Erica would have been a good candidate for a heart transplant. However, this suggestion does not appear to be widely supported by the consulting witnesses to this Inquest. In addition, while it was conceivable that another surgeon coming to Winnipeg from another location could have performed the operation, the logistics of arranging this probably exceeded the time available to the child. Furthermore, there are real problems with bringing an outside surgeon in to undertake high-risk surgery. Advance planning and co-ordination are required.

Finding

There is evidence that the planning that went into this procedure was wanting in several respects. Although Erica did not survive to be transferred to the NICU, the evidence suggests that, as with Daniel Terziski, there had not been adequate planning with the NICU as to her post-operative care.

While there are real questions as to whether or not the Winnipeg team ought to have undertaken this operation, the decision to delay surgery for a number of days was legitimate. Erica was very ill when her condition was first diagnosed. It was reasonable to attempt to strengthen her before taking her to surgery. In the end, this strategy failed to bring about the desired results.

Were her parents provided with sufficient information
to allow them to give informed consent to the procedure?

Finding

Erica Bichel's parents were not told of the program's recent history. The evidence suggests that they were not provided with sufficient information to determine if they had the option of taking their child to another centre for surgery. They were entitled to this information, before giving their consent to having the operation done in Winnipeg. The evidence tends to suggest that Erica's parents were not provided with sufficient information to allow them to give informed consent to the procedure.

Was Erica given adequate myocardial protection?

Finding

This seems to be a matter of some dispute among the medical professionals who have examined this case. While Odim said that he generally administered one dose of cardioplegia, the evidence suggests that he did not do so in this case. He also said that the administration of the cardioplegia was not always done in this operation in any event, suggesting that even if he did not give any cardioplegia, it was not unreasonable not to do so.

Taylor and others do suggest that there was myocardial damage, perhaps due to the lack of myocardial protection (which cardioplegia is intended to provide). However, they were unable to say with certainty whether the myocardial damage they found had occurred before or during the operation. Therefore, it is not possible to say with any degree of certainty that lack of cardioplegia led to or caused any of the myocardial damage that the child suffered.

What was the cause of death and was it preventable?

Finding

Erica had a very serious congenital heart condition. The condition weakened her heart in the period before a very lengthy and risky operation and left her heart in a condition where it could not function following the procedure.

In their joint report, Cornel and Duncan wrote:

This was a very high risk procedure in a child already requiring potent drugs to maintain blood pressure prior to surgery. We believe that this death occurred due to depleted myocardial substrate reserves [The heart was too weakened to be able to continue to function.] as well as potential myocardial preservation problems. (Exhibit 354, page 12)

In other words, they were of the opinion that Erica's heart was too weak and/or damaged to survive this operation. This condition likely precluded any chance of her surviving the operation.

Finding

The evidence suggests that Erica would have stood a better chance of success in the hands of another, more experienced surgeon and surgical team, but whether or not she would have survived (given her pre-operative condition) is impossible to say. She also might have survived if she had been operated on earlier, but that would have to be weighed against the trauma that would likely have been caused to her through transportation to another facility. Given all of the available information, it is not likely that her death was preventable.