Unclear lines of authority

The responsibility of department heads

Finding

The evidence establishes that the ultimate responsibility for the Pediatric Cardiac Surgery Program at the HSC was jointly held by the head of the Department of Surgery and the head of the Department of Pediatrics.

Finding

The evidence establishes that the lines of authority and responsibility for the Pediatric Cardiac Surgery Program were unclear and confusing to hospital staff during 1994.

The heads of the Department of Surgery and the Department of Pediatrics had overall responsibility for ensuring that the program was providing an appropriate level of service. Their joint agreement was needed for a reduction in service in May and a suspension of the service in December. For the purposes of this report, the persons who held those positions throughout 1994 were:

1. Dr. Robert Blanchard-head of Surgery throughout 1994;
2. Dr. Agnes Bishop-head of Pediatrics until June 1;
3. A variety of persons who held the position of acting head of Pediatrics until September 15;
4. Dr. Brian Postl-head of Pediatrics from September 15.

There was considerable confusion among the staff in the program as to who had immediate responsibility for taking action with respect to their concerns. That confusion was in part due to the fact that the Pediatric Cardiac Surgery Program was a multidisciplinary program within which medical professionals from a variety of departments (Nursing, Perfusion, Surgery, Cardiology, Anaesthesia, Pediatrics, Intensive Care, Neonatology and Pathology) worked on cases in a joint endeavour. This created confusion when it came to determining who had overall responsibility for the entire program, or if those who did have such responsibility were also responsible for specific professionals. This was the case with regard to determining who was responsible for monitoring the performance of the surgeon.

The matter was exacerbated by the fact that, historically, the medical director of the Variety Children's Heart Centre had provided day-to-day management and monitoring of the surgical aspect of the program. This was despite the fact that the surgeon was formally responsible to the section head of Cardiovascular Thoracic Surgery, a position held by Dr. Helmet Unruh on an acting basis. In addition, many hospital staff believed that Dr. Nathan Wiseman, the head of Pediatric Surgery had some responsibility for monitoring the Pediatric Cardiac Surgery Program by virtue of his title. He did, in fact, have very little such authority.

It appears that Dr. Helmut Unruh, the acting section head of CVT Surgery, assumed that Giddins, as Collins's interim replacement, would take over Collins's role in monitoring the Pediatric Cardiac Surgery Program's outcomes. This assumption was neither correct nor appropriate. When Giddins replaced Collins as the head of the VCHC, he did not approach the position in the same manner as Collins had.

Additionally, Unruh and Blanchard should have been involved enough with the Pediatric Cardiac Surgery Program to have recognized the staffing problems the program faced in 1994. They ought to have spoken directly to Giddins about whether or not their expectation was reasonable that Giddins would monitor surgical outcomes.

Recommendations

It is recommended that: If a Pediatric Cardiac Surgery Program is re-established at the HSC, it have clear written lines of authority and responsibility. Efforts must be made to ensure that program members understand these lines of authority. This is of particular importance in a multidisciplinary program.

It is recommended that: If a Pediatric Cardiac Surgery Program is restarted at the HSC, overall supervision for the program should be the responsibility of a single Department Head-logically the head of Pediatrics. The head of Pediatrics can more easily supervise a program that has as its focus pediatric cases. Staff providing service to any revamped Pediatric Cardiac Surgery Program should be primarily assigned to the program and be accountable to the head of Pediatrics through their appropriate department head or line manager for their performance. In particular, the head of Pediatrics should also have responsibility for monitoring the surgical performance of the pediatric cardiac surgeon through the assistance of the head of Pediatric Surgery and the head of Pediatric Cardiology. The head of Pediatrics should ensure that the surgeon, the head of Pediatric Cardiology and the head of Pediatric Anaesthesia have a plan to phase in the surgical program. In addition, the program should be monitored closely, with regular reports going to the head of Pediatrics.

The responsibility of Dr. Jonah Odim and Dr. Niels Giddins for the events of 1994

Finding

The evidence suggests that neither Dr. Odim nor Dr. Giddins carried out their responsibilities to monitor and respond suitably to the poor surgical results in the program.

While the department heads had ultimate responsibility for the program, it was the responsibility of the pediatric cardiac surgeon, Dr. Jonah Odim, and the acting medical director of the Variety Children's Heart Centre, Dr. Niels Giddins, to ensure on a day-to-day basis that the program was providing an appropriate level of care.

Additionally, as the referring cardiologist, Giddins, regardless of his role at the Variety Children's Heart Centre, had an additional responsibility for monitoring the surgical outcomes of the cases he referred to Odim.

It is noted as well, that Giddins not only referred patients to Odim, he reassured parents of those patients that Odim was capable of performing any and all of the procedures required for his patients. Therefore he had a responsibility to ensure that the assurances he was giving were justified.

As the chief of service, Odim also had a responsibility to ensure that the program did not undertake cases that were beyond his and the program's ability and experience, to monitor results and ensure the orderly development of the surgical team.