The Pediatric Cardiac Inquest Report - Chapter 1




In October 1995, hearings were conducted into the question of the disclosure of documents relating to the matters under investigation by this inquest that were in the possession of the Province of Manitoba and the HSC. Disclosure was directed to be made, but for the most part, both the HSC and the Province had voluntarily disclosed a great deal of material. That disclosure resulted in several volumes of documents being marked as exhibits in these proceedings.

Despite the disclosure that was made, it became apparent that there continued to be materials that were in the possession of some of the parties, particularly the HSC, that had not been disclosed as ordered. A considerable amount of material was discovered as the proceedings went on and the witnesses testified. Personal notes, hospital data, memos and correspondence, minutes of meetings and briefing documents were discovered even after disclosure had been ordered. It is conceivable that not every document bearing on the issues under examination was discovered and disclosed during the proceedings. With an institution the size of the HSC and the Department of Health, such an event is entirely possible. However I am satisfied that every effort was made to provide what materials were known to exist, and that any non-disclosure was inadvertent. For that reason I concluded that while any failure to disclose was a cause for concern, it was not enough for any sanctions to be considered.

Despite the lateness of some disclosure, and the fact that not all of the relevant materials may have been provided to the Inquest in a timely manner or at all, the evidence disclosed enough about the events that happened surrounding the program, and in particular the events of 1994, that the facts as they occurred were readily determinable.



Current Home - Table of Contents - Chapter 1 - Disclosure
Next The Taking of Evidence
Previous In camera proceedings
Section 1 Chapter 1 - Introduction to the Issues
  Chapter 2 - Pediatric Cardiac Issues
  Chapter 3 - The Diagnosis of Pediatric Heart Defects and their Surgical Treatment
  Chapter 4 - The Health Sciences Centre
Section 2 Chapter 5 - Pediatric Cardiac Surgery in Winnipeg 1950-1993
  Chapter 6 - The Restart of Pediatric Cardiac Surgery in 1994
January 1, 1994 to May 17, 1994
  Chapter 7 - The Slowdown
May 17 to September 1994
  Chapter 8 - Events Leading to the Suspension of the Program
September 7, 1994 to December 23, 1994
  Chapter 9 - 1995 - The Aftermath of the Shutdown
January to March, 1995
Section 3 Chapter 10 - Findings and Recommendations
Appendix 1 - Glossary of terms used in this report
Appendix 2 - Parties to the Proceedings and counsel
Appendix 3 - List of witnesses and dates of testimony
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