Jesse Maguire was born at the HSC Women's Centre on Friday, November 25, 1994, at 0829 hours. The child of Laurie Maguire and Richard Shumila, Jesse was delivered at 38 weeks gestation by caesarean section.

On his admission to the nursery at 1100 hours, Jesse was slightly cyanosed and pale. The neonatal resident, Dr. Carr, examined him and found that his pulses and perfusion were good. His chest was clear, with good air entry. Jesse had a heart murmur and an irregular heart rhythm. The heartbeat would occasionally accelerate to a rate faster than two hundred beats per minute. Carr ordered diagnostic tests and consulted with Ward.

An echocardiogram showed Jesse had a number of heart defects:

• an interrupted aortic arch (In this condition, the aorta does not develop completely in the area of the arch. As a result, the aorta is divided into two parts that are not connected to each other, and there is no blood flow through the aorta.)

• a large ventricular septal defect with misalignment (The septum bulged into the outflow tract of the left ventricle.)

• a patent foramen ovale (During surgery, Odim identified this PFO as an atrial septal defect.)

• a bicuspid aortic valve

• an enlarged left atrium

• a restrictive patent ductus arteriosus (PDA).

It was the natural closing of this PDA that caused Jesse's initial problems. As a result, he was treated with prostaglandin to keep his PDA open. Ward concluded that Jesse needed surgery in the immediate future.

Healthy heart

Diagram 8.7 Jesse Maguire - pre-operative heart 1 - Hypoplasia of ascending aorta 2 - Atrial septal defect 3 - Interrupted aortic arch 4 - Descending aorta 5 - Patent ductus arteriosus 6 - Bicuspid valve (identified at post-mortem) 7 - Ventricular septal defect

In his testimony, Ward said there were three different ways that a heart condition such as this could be approached. He noted that all three approaches were difficult and carried a significant degree of risk. The two approaches with which Ward was most familiar both involved entering the heart from the side and repairing the interruption in the aortic arch. One of these methods involved placing a band on the pulmonary artery to restrict the flow from the VSD, while the other involved simply repairing the arch and then, at a future date, repairing the VSD. Both of these methods required a second repair.

A third approach involved entering the heart from the front and repairing both the VSD and the aortic arch. The difference in this third approach was that to perform the repair from the front, it is necessary to put the patient on bypass.

In his testimony, Ward explained that it was difficult to make clear-cut statements about the comparative risk of these approaches.

If you do it from the side and you do it with an interposition graph, then it's relatively low risk surgery but you encounter other risks down the track that then increase your risk down the track, in your morbidity and mortality down the track. So you may not play all your cards up front but you're placing yourself at risk down the track.

Whereas to do it all in one procedure puts basically all your eggs in one basket and it puts all your risks up front. You can argue it in numerous ways and it is argued in numerous ways in the medical literature. (Evidence of Dr. Ward, pages 148-149)

Ward recommended that Jesse undergo a two-stage repair.

Jesse was transferred to the NICU at 2100 hours on November 25. While his chest was clear, his tongue and lips were becoming more pale and his fingers and toes were becoming cyanotic. During the night, his breathing became increasingly shallow, rapid and irregular. His breathing eventually stabilized; however, he had bouts of irritability.

Casiro and Ward spoke with Jesse's parents that evening. Ward testified that in that conversation he did not suggest referring Jesse out of province. According to Laurie Maguire, Ward told her and Jesse's father that the success rate for these operations was approximately 85 per cent. She also testified that Ward explained the options and indicated that he believed Odim would probably opt for the one-stage approach.