The Pediatric Cardiac Surgery Inquest Report



The Office of the Chief Medical Examiner

Deaths in the HSC and other hospitals in Manitoba fell under the jurisdiction of the Office of the Chief Medical Examiner of Manitoba (CME). When a child died, the death had to be reported to the Medical Examiner's office. In the case of a hospital death, a Medical Examiner's Investigator (MEI) would go to the hospital and conduct an initial investigation. Deaths were categorized under five classifications that the CME used: natural, accidental, suicidal, homicidal or undetermined. Under the policy of the Chief Medical Examiner's office, autopsies were to be ordered when children died either during or immediately following operations. The CME's office did not order an autopsy if it had been informed that the hospital's Department of Pathology intended to perform one.

In those cases of surgical death where the cause of death was known and the parents were opposed to an autopsy being performed, the CME could agree to waive the requirement for an autopsy. For this reason, autopsies were not performed in the case of two children whose deaths were under investigation. The MEI's chief source of information in such cases was the attending surgeon.

A further investigation, conducted by a medical examiner (who must be a doctor), could be ordered. This was invariably the case when the CME's office ordered an autopsy. These were then referred to as medical examiner's cases.

An autopsy involves the examination of a dead body and its structures and organs to determine the cause of death. An autopsy is meant to observe the effects of aging and disease, and determine the evolution and mechanisms of disease processes. Doctors who have been trained in pathology carry out autopsies. The pathologist usually dissects the body and examines its internal organs.

The findings are then recorded and balanced against one another, in an attempt to tell the specific story in the form of a sequence of events that led to a patient's death. The pathologist can, but does not always, list an immediate cause of death, which is considered to be the one lesion without which death would not have occurred, as well as an underlying cause of death. The underlying cause of death is the specific disease or injury that started the course of events that led to the immediate cause of death. In addition, the pathologist may report other conditions that pre-existed or co-existed and contributed to the patient's death, but did not result in the death. (In a death certificate, there is usually a list, which starts with the most recent condition and then goes back sequentially in time, with each earlier condition causing the later condition.)

The pathologist may not always be able to give an immediate cause of death and may express some degree of uncertainty by the use of words such as 'presumed' or 'probable'. Like many other aspects of medicine, cause of death is, in essence, a concept or opinion based on all available information. As such, this opinion may be subject to differences in interpretation.

During 1994, the Chief Medical Examiner maintained a process to assist his office in determining if and when to order an inquest. Following a medical examiner's investigation the case could be referred to the Children's Inquest Review Committee. This committee included representation from the police, the Justice Department, the College of Physicians and Surgeons and family service agencies, and met approximately eight times a year. The committee advised the CME as to whether or not an inquest should be called, although the CME could order an inquest without the committee's input. Inquests were called when, in the public interest, it appeared that there were preventable aspects to a death and if the CME perceived a trend in deaths in a particular hospital or industry. Inquests were also called to allay public concerns and make known the circumstances surrounding a death.



Current Home - Table of Contents - Chapter 4 - The Office of the Chief Medical Examiner
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Previous The Manitoba Association of Registered Nurses
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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