Administrative issues

Finding

The evidence suggests that Drs. Blanchard and Bishop, the department heads responsible for the program at the relevant time, did not address the underlying issues that led to the departure of Collins and Duncan. Instead, the program was placed in the hands of a relatively inexperienced cardiologist and an even more junior surgeon who had just completed his training.

Two key members of the program's medical staff, Dr. George Collins and Dr. Kim Duncan, resigned from the Variety Children's Heart Centre in 1993, in part, because they believed the centre was not receiving sufficient support from the HSC. While the lack of support they mentioned was partially related to finances, the issue seems to have been related primarily to whether or not the hospital was prepared to support the program in a manner that allowed it to meet the objectives and standards that both Duncan and Collins had set for it.

Finding

The evidence suggests that Drs. Blanchard and Bishop failed to recognize that, in light of the significant changes in personnel at the Variety Children's Heart Centre, the lack of experience of the new leadership of the Pediatric Cardiac Surgery Program, and the fact that the cardiologists who had left the program in the previous year and a half had not yet been replaced, the program would require close supervision and monitoring in early 1994.

It would appear that the budgetary and administrative changes undertaken at the hospital during 1993-94 were a significant distraction for the department heads and other supervisory staff. Given those demands during this period, it is conceivable that the department heads did not have the time to provide the necessary leadership for a program that was being restarted. If that was so, Blanchard and Bishop should have recognized that and should have considered delaying the program's restart.

Finding

The evidence suggests that Drs. Blanchard and Bishop furthermore did not prepare for or have in place a proper orientation for either a new surgeon or a new director of the VCHC. Giddins was assigned interim responsibility for the position vacated by Collins, but there is no evidence that he was prepared for the duties he was assigned.

Finding

The evidence suggests that Drs. Blanchard and Bishop, along with Giddins, also did not ensure that there was either formal or informal mentoring of Odim upon his arrival at the HSC. In the case of a young surgeon in his first appointment following his residency, more careful consideration ought to have been given to the fact that he was facing an entirely different experience from what he had faced as a surgical resident.

Finding

The evidence suggests that Drs. Bishop, Blanchard and Giddins also did not ensure that anyone was assigned responsibility or took responsibility for building and mentoring the Pediatric Cardiac Surgery team as a whole in the early part of 1994. Without this leadership, the problems that arose in the early operations rapidly led to unresolved-and, in the end, unresolvable-conflicts.

As a result of the lack of appropriate orientation and mentoring, the program was plagued throughout 1994 with a variety of very serious problems. HSC operating-room and ICU staff were not properly prepared for Odim's particular approach to surgery and post-operative care, while Odim often made assumptions based on his limited experience at other institutions. Examples are numerous and are found in the preceding chapters. These problems may, in fact, have compromised patient care.

Finding

The evidence suggests that Drs. Bishop, Blanchard, Giddins and Odim did not give sufficient consideration both to Odim's lack of experience and to the level of team development.

Finding

The evidence suggests that the lack of supervision and the lack of a phased start-up plan meant that the Pediatric Cardiac Surgery Program was marked by poor case selection in 1994 and that the program undertook cases that were beyond the skill and experience of the surgeon and the team.

Finding

The evidence suggests that the cardiologist and the surgeon did not take appropriate steps to establish and maintain open and ongoing lines of communication with other related medical services in the hospital, such as nursing and anaesthesia.

Additionally, one of the factors that increased team dysfunction was the surgeon's use of techniques and approaches with which other team members were not familiar and for which the surgeon did not prepare them. The surgeon seems to have erroneously assumed that everyone knew what he was talking about. In some cases there was a lack of sufficient consultation and briefing before the team undertook specific, complicated procedures. For example, it would appear that the neonatal intensive care unit staff were not sufficiently briefed and prepared by the surgeon, or the cardiologist, for the patients undergoing Norwood procedures.

Recommendations

It is recommended that: The Health Sciences Centre develop protocols for providing orientation and support to all new staff and staff moving into new positions. This should be done even when the appointment is to an Acting position.

It is recommended that: Any re-established Pediatric Cardiac Surgery Program involve all units that would be affected by the program in the development of appropriate protocols. Such protocols should include a requirement that the entire team, including those individuals responsible for post-operative care, be fully prepared before the program moves to higher-risk cases or new procedures.