Preamble

On September 7, 1994, the Wiseman Committee determined that it was appropriate for the Pediatric Cardiac Surgery Program to resume full service, which it did for the next three and a half months. Following the deaths of five more children, however, the program was stopped, pending the institution of an external review. The program has not reopened since the suspension.

The events of that three-and-a-half-month period are described and discussed in this chapter. It should be noted that, during this period, Dr. Brian Postl assumed the position of head of pediatric services. While Postl was originally under the impression that the problems of the PCS program had been resolved, he became increasingly concerned about the program. As problems mounted, he sought more information and took steps that he had reason to believe would address problems in the program.

As opposed to the first half of 1994, many of the difficult operations that were carried out and deaths that occurred during this period involved newborns. As a result, the neonatal intensive care unit became increasingly involved in the care of children from the Pediatric Cardiac Surgery Program. Representatives of that unit played a key role in the decision to suspend the program in December 1994. At the same time, as the following text indicates, the program continued to be plagued with problems in communication and with concerns about the surgeon's technical abilities.