This document is the final report of the Pediatric Cardiac Surgery Inquest. Readers are advised that there are three sections to this report.

Section One of this report outlines the legal, medical, and organizational issues that the Inquest addressed and contains four chapters. Chapter One deals with legal issues. Chapter Two outlines the pediatric cardiac anomalies that are discussed in this report. Chapter Three provides an introduction to the various medical professions involved in treating these anomalies and the steps through which a pediatric cardiac patient would have progressed in Manitoba in 1994. Chapter Four outlines the structure and staff of the Winnipeg Health Sciences Centre in 1994.

Section Two is a narrative account of events in the Pediatric Cardiac Surgery Program. Chapter Five outlines the program's history up until January 1994. Chapters Six, Seven and Eight recount the program's history in 1994, providing detailed accounts of the events surrounding the deaths of the twelve children whose cases are under examination in this report. Specific findings are made at the end of the discussion of each case. Chapter Nine recounts the events of 1995 up until the calling of this Inquest.

Section Three contains only one chapter, Chapter Ten. This chapter contains further findings, which provide an understanding of why these deaths occurred, as well as recommendations for the prevention of future deaths.

Throughout the report there are numerous diagrams illustrating specific heart anomalies, procedures, and areas in the Winnipeg Children's Hospital. In addition, there are pre-operative and post-operative representations of the hearts of the twelve children who died in 1994. Readers should be aware that these illustrations are generic diagrams, meant to assist in understanding the text. These diagrams are not intended to be anatomically accurate nor are they intended to represent detailed drawings of each specific child's heart. Doctors Glenn Taylor and Jan Davies provided extensive advice in the preparation of these drawings. They are, however, the product of the Inquest.

A note on sources

This report is based on the evidence that was presented to the Inquest. The evidence and transcripts will be available through the Provincial Archives of Manitoba. However, in camera testimony will not be made available to the public. The report does not identify certain children who successfully underwent cardiac operations in the Children's Hospital in 1994. Although the transcripts and evidence do identify the names of those children, readers are reminded that information about their cases was deemed to have been given in camera and therefore restrictions on public dissemination of their identities and cases apply.

Quotations from the oral testimony presented to this Inquest are cited by referring to the page or pages of transcript of the evidence. The evidence of the first witness to appear before this Inquest, Dr. Cameron Ward, makes use of a different numbering system than the rest of the transcripts. As a result quotations from his transcript are cited as being from the Evidence of Dr. Cameron Ward. Documentary evidence is identified by the exhibit and document numbers that were assigned to them by the court.