The Pediatric Cardiac Surgery Inquest Report



Meetings in late April and early May

Boyle testified that within 24 hours of her April 28 meeting with Hinam, she spoke to Bishop about the concerns that had been raised. According to Bishop, she did not meet with Boyle to discuss the program until early May. Whether the meeting took place in late April or early May, Bishop confirmed that Boyle told her there were concerns with cannulation, bleeding, morbidity and mortality. In addition, she was told that the anaesthetists involved in the program had similar concerns.

Boyle testified that in May she also informed the vice-president in charge of nursing, Susan VanDeVelde-Coke, about the issues that the nurses had brought to her attention about the Pediatric Cardiac Surgery Program. VanDeVelde-Coke on the other hand, could not recall Boyle speaking to her about the PCS program until the fall of 1994.

Bishop testified that after Boyle had contacted her with concerns from the nursing staff about the program, she asked Wiseman for his assistance in determining how well-founded the concerns were. According to Bishop's testimony, Wiseman did not inform Bishop that any of the nurses and anaesthetists had already approached him. Wiseman again testified that he had no specific memory of that conversation with Bishop. However he did take steps to gather information for Bishop.

With regard to the conversations that Wiseman said he could not recall, he never denied that any of the conversations took place. In most instances, he accepted that in all likelihood they had taken place. He could not, however, recall them specifically. He apparently made no notes of them, nor of any action plan arising from them. This seems surprising, given the mounting tensions within the program, and the number of people raising concerns about what was occurring.

By mid-May, Wiseman had reported back to Bishop that he had spoken to the anaesthetists, Giddins, Hancock and a perfusionist. In addition, he had reviewed most of the cases with Giddins. He testified that following the death of Alyssa Still on May 6, Wiseman, as chief of pediatric surgery, requested a meeting with him. He said that he and Wiseman reviewed all the operations up to that point at that meeting. Giddins testified that he believed that Wiseman was satisfied with his accounting for the surgical outcomes. Wiseman, surprisingly, could not recall this meeting. Bishop testified that Wiseman anticipated speaking with a number of nurses before reporting back to her in full.

Bishop also spoke with Kesselman and Giddins. Kesselman was not prepared to assess Odim's surgical skills at that point. However, he did point to communication issues between Odim and two of the anaesthetists, McNeill and Swartz. Giddins, Bishop recalled, was very supportive of Odim.

Bishop said that she was attempting to develop a broad idea of the nature of the problems emerging in the program. She thought that it was possible that a review committee might have been set up once she knew what the problems were, but she admitted that there had been no plan to set one up when events overtook her.



Current Home - Table of Contents - Chapter 6 - Meetings in late April and early May
Next Nurses seek reassignment
Previous Ullyot meets with Wiseman
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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