The Pediatric Cardiac Surgery Inquest Report

 

 

Table of Contents

Chapter 8

Events Leading to the Suspension of the Program
September 7, 1994 to December 23, 1994


Preamble
September 7-the return to full program
Craig's meeting with the anaesthetists
The case of Marietess Tena Capili

Issues
Background and diagnosis
The decision to operate
Consent
Pre-operative status
The operation-September 13
Cannulation issues
Problems with distension of the heart
Surgical bleeding and coagulopathy
The superior vena cava syndrome
Post-operative course
The family on the day of surgery
Operative reports
Post-mortem findings
Findings
Should the operation have been performed in Winnipeg or should Marietess have been referred out of province?
Were Marietess's parents provided with sufficient information to allow them to give informed consent to the procedure?
What caused the superior vena cava syndrome?
Should the surgical team have kept Marietess in the OR until the cause of the superior vena cava syndrome from which she was suffering was identified?
What was the cause of death and was it preventable?

The appointment of Dr. Andrew Hamilton
Dr. Brian Postl is appointed head of pediatrics
September 20-the case of ML
Wiseman's memorandum to the department heads
Odim's letter of September 26
September 27-the case of JB
The September 28 meeting of the Wiseman Committee
September 30-the meeting of department heads
The end of September: the nurses are distressed

Whistle-blowing

The case of Erica Bichel

Issues
Background and diagnosis
The decision to operate
Pre-operative status
A desperate situation
Preparation of the NICU
The operation-October 4
The issue of cardioplegia
The failure to wean from bypass
Post-mortem findings
Findings
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 her 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?

October 20-the case of ER
The Wiseman Committee meeting of October 17
The meeting of the anaesthetists on October 19
The department heads meeting of October 28

The case of Ashton Feakes

Issues
Background and diagnosis
The decision to operate
Consent
Pre-operative status
The operation-November 1
Post-operative course
Increase in mitral regurgitation
November 7-the mitral regurgitation worsens
November 8-a small improvement
November 9 - a turn for the worse
November 10-the opportunity for mitral valve replacement passes
November 11
Post-mortem findings
Findings
Were Ashton's parents provided with sufficient information to allow them to give informed consent to the procedure?
Should Ashton have been referred out of the province during the summer of 1994?
Should consideration have been given to performing a mitral valve replacement before November 10?
What was the cause of death and was it preventable?

Early Winter
November 8-the case of KF
November 10-the case of ID
The November meeting with Marietess Tena Capili's family
The case of Jesse Maguire

Issues
Background and diagnosis
The decision to operate
Consent
Notifying the OR nurses
Hamilton not called in
Pre-operative status
The operation-November 27
Repairing the VSD while on TCA
The dislodging of the cannula
Post-mortem findings
Findings
Should the operation have been performed in Winnipeg or should Jesse have been referred out of province?
Were Jesse's parents provided with sufficient information to allow them to give informed consent to the procedure?
Should Dr. Andrew Hamilton have assisted in this operation?
Was a cannula inadvertently dislodged at 1630 hours?
Were all the repairs intact?
What was the cause of the poor perfusion following the initial repair?
Were Jesse's parents fully informed about the circumstances surrounding his death?
What was the cause of death and was it preventable?

Meeting of the department heads - November 28
The impact of the Maguire case
The case of JR - December 2
Blanchard's meeting with Unruh and Odim-December 5
The case of KQ-December 7
The Wiseman Committee meeting of December 7
Ullyot meets with Postl-December 9
The case of Erin Petkau

Issues
Background and diagnosis
The decision to operate and consent
Pre-operative status
The operation-December 20
Autopsy findings
Findings
Were Erin's parents provided with sufficient information to allow them to give informed consent to the procedure?
Should the ventilation intra-operatively have been different?
Was the Blalock-Taussig shunt too small?
What led to the shunt failures?
Should Dr. Andrew Hamilton have assisted in this operation?
What was the cause of death and was it preventable?

Reactions to Erin's death

Postl calls a meeting

 

Current Home - Table of Contents - Chapter 8
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
Diagrams
Tables
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