The Pediatric Cardiac Inquest Report - Chapter 1




A number of individuals and organizations interested in the outcome of these proceedings applied for standing early on in the process.

At common law, the public has no inherent right to attend inquest hearings (Granger: Canadian Coroner Law, 1984, The Carswell Company Limited, at page 243). Additionally, no one else had such a right, even the deceased's family. The Fatality Inquiries Act of Manitoba now provides that a person who, in the opinion of the presiding Judge, is "substantially and directly interested" in the inquest, may attend the inquest in person or by counsel and may examine or cross-examine witnesses called at the inquest. (Fatality Inquiries Act s.28 (1)).

A Provincial Judge may limit examination or cross-examination of witnesses by a party granted standing where "the examination or cross-examination. . .is beyond what is necessary for the purpose of the Inquest."

The question of determining when a party is "substantially and directly interested in the Inquest" has been the subject of some consideration in the case law (Granger: Canadian Coroner Law, supra, at page 217 and page 307 et seq).

Based on the principles set out in those cases, and upon the facts of this case, certain individuals and groups of individuals were granted standing to participate in these proceedings. In October 1995, standing was granted to the following:

1. The families of the 12 children were granted full standing.

Although not all families sought standing, their right to standing was declared and recognized from the outset. Counsel appeared for the Terziski, Still, Baumann, Tena, Capili, Feakes, Maguire and Petkau families. The Caribou, Ulimaumi, Goyal, Piller and Bichel families neither appeared personally nor via counsel to ask questions or make submissions, despite being notified of their right to do so.

Additionally, while the Caribou, Goyal, Piller and Bichel families declined to appear via counsel or to examine witnesses, members of those families did testify. However, John and Emalee Ulimaumi, parents of Jessica, declined to attend in order to testify. Despite the obvious importance of their version of the events concerning their daughter, it was decided not to pursue the matter, especially given the magnitude of their loss, and the fact that much of what occurred concerning Jessica's death could be otherwise determined.

2. The Health Sciences Centre was granted full standing.

3. The Department of Health of the Province of Manitoba was granted full standing.

4. The Manitoba Association of Registered Nurses, representing the nurses involved in the care of the 12 children, was granted full standing.

5. The pediatric cardiac anaesthetists and pediatric intensivists involved in the care of the 12 children were granted full standing, to be represented by one counsel.

6. A group consisting of Dr. Jonah Odim and other surgeons involved in pediatric cardiac surgery at the Health Sciences Centre in 1994 was granted full standing.

7. A group consisting of neonatologists and other physicians involved in the delivery of medical care to patients in the neonatal intensive care unit in 1994 was granted full standing.

8. HSC pathologists were granted limited standing.

Standing was granted to each of the parties on the basis that they had a real and direct interest in the proceedings. Obviously the status of the families in that regard could hardly be questioned. The interest of the HSC in the proceedings was also deemed to be direct and substantial, given the issues of supervision and accountability that were raised by the evidence. Similarly, the Department of Health's role in funding and monitoring the hospital and the program was raised in the course of these proceedings, causing a substantial and direct interest to arise on their part.

The participation of the various medical professionals in the care and treatment of the 12 children who died resulted in sufficient interest on their part to justify standing. Additionally, however, because much of the evidence concerned personality conflicts between members of the health-care team, as well as miscommunication and professional disagreements over treatment, that further justified granting full standing to each of the parties.

At a later point in the hearings, limited standing was granted to a group consisting of the pathologists involved in performing autopsies on the deceased. There was a suggestion that delays in the performance and completion of autopsy reports may have contributed to institutional delay in responding to growing problems within the pediatric cardiac surgery program, and on that basis, counsel for pathologists at the HSC was allowed limited standing to question witnesses who testified about that issue.



Current Home - Table of Contents - Chapter 1 - Standing
Next Culpability
Previous The mandate of the Inquest
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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