Referral to the College of Physicians and Surgeons of Manitoba

Finding

The evidence suggests that there may be a need for the College of Physicians and Surgeons of Manitoba to investigate the evidence set forth in these proceedings to determine if other proceedings may be necessary.

A number of facts that were disclosed in the evidence suggest that appropriate medical standards may not have been met. It is not the role of this Inquest to determine whether there are grounds for disciplinary or any other action as a result of any such finding. Where medical professionals have not performed their responsibilities in an appropriate manner, or in a manner that meets an appropriate professional standard, the College of Physicians and Surgeons has a responsibility to conduct an investigation and determine if disciplinary proceedings should be undertaken.

According to the evidence of Dr. Ken Brown, the registrar of the College, no official complaint has ever been filed with the College with respect to any of the medical professionals associated with the care of the patients whose deaths were the subject of these proceedings. Therefore the College has never undertaken any official investigation of any of these cases from a disciplinary perspective. This apparently stems from a policy that the College maintains of waiting for a formal complaint before undertaking any such proceedings.

It is recommended that: The College of Physicians and Surgeons of Manitoba revamp its policies and procedures so that in the future investigations and disciplinary proceedings no longer depend on whether or not a formal complaint has been filed with the College.

It is recommended that: The College of Physicians and Surgeons review this report to determine if there are grounds for undertaking disciplinary proceedings against any of the medical professionals involved in the care of any of the 12 children whose deaths were the subject of these proceedings.