Introduction

Pediatric cardiac surgery is one of the most professionally difficult and personally satisfying medical disciplines in which to work. It demands precision and accuracy from the surgeon, as well as a high degree of efficiency and teamwork from the other doctors, nurses and technicians who form its operating-room teams. It is a field of medicine that has as its focus the very symbol of love and life in our society: the human heart. Pediatric cardiac surgery offers the promise of life to those who will otherwise die, and it offers to parents the opportunity to continue to raise and love a child they have been told might otherwise be lost to them.

Children with potentially fatal heart problems represent a particularly powerful symbol of vulnerability. Born with a condition that they had no hand in creating, they rely totally on adults to do what can and needs to be done to give them an opportunity to survive and to live as normal a life as possible. Invariably, the survival of children with heart problems depends on some sort of medical intervention. Recent medical developments, particularly in the field of surgery and pharmacology, have come to offer such children greater and greater hope for a long life well into adulthood.

Surgeons these days are performing medical feats on children's hearts that their professional predecessors would have considered impossible. Today, children's hearts are routinely opened, closed and rearranged in a manner that medical professionals of the past never dreamed of. These children can and often do go on to live in a manner that makes them no different from any other child.

But not all surgical outcomes are so rewarding. There are very few pediatric cardiac surgical cases that come with a one hundred per cent guarantee of success. As with any surgical procedure, almost all cardiac surgery has a small degree of risk associated with it.

Recognizing that risk, ensuring that the patient understands that risk before agreeing to surgery and performing its tasks in a manner that does not exacerbate that risk are primary obligations of the surgical team.

It is in keeping with the latter point that medicine has developed the aphorism "First, do no harm."

During 1994, 12 children died while undergoing, or shortly after having undergone, cardiac surgery at the Children's Hospital of Winnipeg.

Gary Caribou, born August 22, 1993, was the son of Charlotte Caribou and Morris Dell of Lynn Lake, Manitoba. He underwent a heart operation on March 14, 1994, and died on March 15, 1994, in the pediatric intensive care unit (PICU), within twenty-four hours of surgery. He was six months twenty days old.

Jessica Ulimaumi, born August 18, 1993, was the daughter of Emalee and John Ulimaumi of Arviat in the Northwest Territories. She underwent cardiac surgery on March 24, 1994. She died three days later on March 27, 1994, in the PICU. She was seven months nine days old.

Vinay Goyal, born March 2, 1990, was the son of Virpan and Sheena Goyal of Winnipeg. Vinay had two operations in 1994, the first on March 17, and the second on April 18. The second operation was necessitated because the first operation was not successful. He died during the second operation. He was four years one month sixteen days old.

Daniel Terziski, born March 18, 1994, the son of Danica and Kiril Terziski of Winnipeg, underwent cardiac surgery on April 20, 1994. He died the same day in the neonatal intensive care unit (NICU) within hours of leaving the operating room. He was 33 days old.

Alyssa Still, born November 14, 1993, was the daughter of Donna Still of Thunder Bay, Ontario. Alyssa had heart surgery on May 5, 1994. She died May 6, 1994, in the PICU, within hours of her operation. She was five months twenty-two days old.

Shalynn Piller, born July 20, 1994, was the daughter of Sharon and Ken Piller of Carman, Manitoba. Shalynn had a heart operation on August 1, 1994, and died August 3, 1994 within forty-eight hours of surgery. She was 14 days old.

Aric Baumann, born December 7, 1993, was the son of Deanna and Curtis Baumann of Winnipeg. Aric underwent cardiac surgery on June 30, 1994. He died fifty-two days later on August 21, 1994, never having left the PICU. Aric was eight months fourteen days old when he died.

Marietess Tena Capili was born December 15, 1991, to Sarah Tena and Benedict Capili of Winnipeg. She had undergone two operations early in life to provide her with temporary relief. Both of them had been performed in 1992 by the pediatric cardiac surgeon then on staff at the Children's Hospital, Dr. Kim Duncan. Marietess was scheduled to undergo a more definitive repair in 1994. She had that operation on September 13, 1994. She died September 14, 1994, within a few hours of being moved from the operating room to the PICU. Marietess was two years nine months old.

Erica Bichel was born September 29, 1994, to Judy and James Bichel of Winnipeg. Erica underwent a heart operation on October 4, 1994. She died while still in the operating room. She was five days old.

Ashton Feakes was born April 15, 1993, to Linde and John Feakes of Winnipeg. His operation took place November 1, 1994. He died November 11, 1994, while still in the PICU. He was one year three months twenty-seven days of age.

Jesse Maguire was born November 25, 1994, to Lauren Maguire and Richard Shumila of Winnipeg. He had to undergo a heart operation on November 27, 1994. He died while still in the operating room. He was two days old.

Erin Petkau, born December 17, 1994, was the daughter of Walter and Barbara Petkau of Morden, Manitoba. Her heart operation took place on December 20, 1994. She died in the early morning hours of December 21, 1994 in the NICU shortly after leaving surgery. She was three days old.

The surgeon involved in these cases, Dr. Jonah Odim, had assumed the position of Chief of Service, Pediatric Cardiac Surgery at the Children's Hospital in February 1994. This was his first staff appointment and the operations he performed at the Children's Hospital were the first that he had undertaken without supervision.

Throughout 1994, concerns about the deaths of each of these 12 children and about the condition of children from other operations had been expressed to people in authority at the hospital by members of the nursing and medical staff, particularly the surgical and intensive care nurses and the doctors in the Section of Pediatric Cardiac Anaesthesia.

In May 1994, following the death of the fifth of the 12 children, the members of the Section of Pediatric Cardiac Anaesthesia unanimously agreed to refuse to participate in any further pediatric open-heart cases until a review had been undertaken. A review committee was appointed and the program continued to provide services for low-risk cases during the review period. Cases that could not await the outcome of the review were transferred to pediatric cardiac surgical facilities in other provinces. During this period of reduced services, two more children died following surgery in Winnipeg.

The review committee recommended that the program return to full service in September 1994. From that point until December 21, 1994, five more children died.

After the death of the twelfth child, the Head of the Children's Hospital directed that no further pediatric cardiac patients be referred for surgery to the Pediatric Cardiac Surgical Program until a review could be completed by an outside review team.

The outside review team presented its findings to the hospital in early February 1995. On receipt of the review, the HSC suspended the program for a further six months and issued a press release to that effect. Following this announcement the parents of the children who had died became aware for the first time of problems with the program in 1994 and some of them demanded a public inquiry into the events surrounding the deaths of their children.