The Pediatric Cardiac Surgery Inquest Report



The College of Physicians and Surgeons of Manitoba

The College of Physicians and Surgeon of Manitoba (CPSM) is the licensing body for physicians and surgeons in Manitoba. Pursuant to the provisions of The Medical Act (RSM 1987, c. M90), and various regulations and bylaws thereunder, the College of Physicians and Surgeons created a Medical Standards Committee for the Province of Manitoba. The College also established a standards committee, the Pediatric Death Review Committee, to review all cases of pediatric deaths in the province. This committee met approximately six times a year.

The College also designated medical standard committees for each of the hospitals and/or regions of Manitoba. The Health Sciences Centre had a Medical Standards Committee (referred to as the Centre-Wide Committee) created under its bylaws. This committee oversaw medical standards for the entire hospital, including the Children's Hospital, General Centre and Women's Centre. The College had recognized the Centre-Wide Committee as the Medical Standards Committee for the Health Sciences Centre.

There also existed a Children's Hospital Standards Committee that reported to both the Centre-Wide Committee and the College's Paediatric Death Review Committee. In 1994, Dr. Milton Tenenbein chaired this committee. The Children's Hospital Standards Committee had approximately 12 members, some of whom were on the committee by virtue of their office, while others were appointed. Each committee member was a doctor who worked at Children's Hospital.

A panel of three surgeons, each of whom was appointed by the Department of Surgery, reviewed all surgical deaths at Children's Hospital. A surgical death was defined as a death of a child who had had surgery immediately before death or was admitted to hospital and died under the care of a surgeon. In 1994, Dr. Nathan Wiseman chaired this panel. The other two members of the committee were Dr. Odim and Dr. Postuma. The panel's finding would be reported to the Children's Hospital Standards Committee by Wiseman, who was also a member of the Standards Committee.

The Standards Committee would receive the panel's report and then discuss the case. In doing so the panel members might make use of personal information, information in the patient's chart, or information that had been brought forward from the panel. It was not the committee's practice to hear testimony or evidence from non-members.

Following the discussion, Tenenbein would summarize the case and forward it to the Paediatric Death Review Committee. He would also prepare a generic report that did not identify specific cases. This summary would be forwarded to the Centre-Wide Committee. From there the summary would be circulated to department heads as a part of the Centre-Wide Committee's report.

In 1994, Dr. Michael Moffat was the co-ordinator of the Paediatric Death Review Committee. He reviewed the reports from the Children's Hospital Standards Committee and other reports (such as police and child welfare reports) that may have been filed on the child's death. He then would summarize the case for the Paediatric Death Review Committee. That committee (which included in its membership not only Tenenbein, but also Wiseman and the HSC's chief pediatric pathologist, Dr. Susan Phillips) would then review the case.

The role of the hospital Standards Committee included the assessment of medical practice through peer review, analysis and education to improve, rather than to discipline. In his testimony, Tenenbein said that the Standards Committee was the only specific mechanism or program for quality assurance within Children's Hospital in 1994.

The Standards Committee filled an educational purpose in the sense that the committee investigated incidents to determine if there was anything to be learned from them. If the committee concluded that there was something to learn from a death, the chairperson then communicated the committee's conclusions to the individual, along with a recommendation either for a change in procedure or in how similar cases should be handled in the future, or for upgrading of skills.

The committee could issue a more public statement to the profession to alert it to a particular issue. The committee could also communicate with a department or the hospital about its findings, and might also communicate with the government. In all such cases, the communications were of a general nature, without specific reference to a particular patient and without identifying any of the persons involved.

Members of the general community and members of the hospital staff could also bring a particular matter to the attention of the Standards Committee. While the committee would investigate matters brought to its attention in such a manner, it did not normally communicate its results and findings back to the source of the question.



Current Home - Table of Contents - Chapter 4 - The College of Physicians and Surgeons of Manitoba
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Previous Quality assurance
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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