The Pediatric Cardiac Surgery Inquest Report



What happened after the Terziski case

After the Terziski case, the NICU management set about creating a cardiac bin similar to the one the PICU staff were in the process of establishing. An NICU nurse spoke with Odim and Hancock following the operation and created a list of equipment they might need in the unit. The NICU clinical instructor, Judy Wiebe, took the list and began to finalize the bin. Wiebe consulted with Youngson, Hinam and Plouffe from the PICU about their cardiac bin. The revised list was sent to Odim for a final approval. According to Armitage, Odim never provided any feedback. It was not until January 1995 that Wiebe spoke with Odim informally and got approval for the list of bin contents.

Following Daniel's death, Borton went to speak with her immediate superior, Lois Hawkins, about her concerns with the program. She also spoke with Giddins about her concerns over the surgical outcomes. She indicated that one of her concerns was the amount of bleeding that children were experiencing after surgery. According to Borton's testimony, Giddins indicated that Odim was part of a new, faster generation of surgeons and that one of the results of changes in technique was increased bleeding. Borton also testified that she asked Giddins to speak with Youngson about the events that were taking place during surgery. Borton said that she later asked Youngson if Giddins had ever approached her to discuss the events in surgery, and she said that this had never occurred.

Borton also came to a more direct realization of her concerns when the parent of a child who was to be treated at the centre asked her if she, Borton, would allow a child of hers to be operated on by the Winnipeg Pediatric Cardiac Surgery Program.

I said, well, I really can't answer that because she's not my child, you know, I can't-well, I can't say that, I can't answer that because she's not my child.

And, in fact, that was a lie, because I had always been able to say to people, in terms of support, to say to them before, Dr. Duncan could operate on my child. I don't have children, but if I did have children, he could operate on them. I had all that confidence, I was able to say that. (Evidence, page 18,177)

Borton was not alone in having grave concerns. In the following month two other nurses asked not to be assigned to pediatric cardiac surgery cases.

Giddins himself had a very different response to Daniel's operation. He told this Inquest that the Terziski case improved his assessment of the surgical team.

That it was an extraordinarily heroic and difficult surgery, that I had seen on many occasions end with an unsatisfactory result in the operating room. This patient survived the operation.

Q: But died an hour after?

A: That's correct. Of circumstances that are difficult to be certain of, but most of the cases of that sort that I had had experience with before hadn't even made it to the NICU. (Evidence, page 3,760)

This is a disturbing comment. It is true that the Winnipeg program's success rate with Norwoods was very poor. It suggests that Giddins was gauging the team's progress along a learning curve, and the fact that child did not die in the operating room should be seen as a sign of the team's improvement. It is the case that surgeons do travel along a learning curve. However, there should be no allowance for a learning curve when analysing results of surgery where patient safety is concerned. Undoubtedly the two most effective tools in protecting patients as surgeons develop their skills are judicious case selection and careful preparation. Both were absent from the Winnipeg program in 1994.



Current Home - Table of Contents - Chapter 6 - What happened after the Terziski case
Next The results up to that time
Previous The case of Daniel Terziski - Findings
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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