The Pediatric Cardiac Surgery Inquest Report



The existing rounds and conferences

In his testimony Odim said that he believed the M & M Rounds were an appropriate forum for reviewing case outcomes.

It's usually been in the surgical arena when the cases are presented and things are discussed, that is the forum that those types of things come out. It sort of serves also as an audit function in addition to reviewing what one could do better, that type of thing. (Evidence, page 23,999)

The M & M Rounds were held once a month on Friday afternoon, although the timing of the meeting could vary. At the meetings there would usually be a presentation from Odim, Giddins or both. A wide range of people-medical students, nursing students, residents, pathologists and members of the pediatric cardiac surgery team-could attend M & M Rounds on a voluntary basis. There was generally a considerable delay between the time that an operation took place and the time it was dealt with at the rounds, particularly in the case of a death. This was to allow the pathologists time to have completed a post-mortem and to have prepared material for the presentation. McNeill gave this description of how the M & M Rounds functioned.

They would go through a sort of a listing of the cases that had been done since the last M & M conference, and perhaps sort of outcomes, and also if there had been a problem involved with the case, how that had been handled or what had been the outcome of that. That was often a fairly, like a listing, you know, we wouldn't go case by case in depth, it would be done that way.

And then there would probably be one or two cases that were presented in more detail. They could have been cases that were done relatively, like in the immediate past, or potentially a child that had had surgery three or four months before. (Evidence, page 12,916)

Anaesthetists often were not able to attend these Rounds. The Rounds were scheduled to start at 1500 hours and the anaesthetists were often in the operating room until 1530 or later. As a result, McNeill said, she attended only one or two Rounds in the spring of 1994.

Odim commented that the Winnipeg M & M Rounds were poorly attended and, as a result, the quality and substance of the discussion suffered.

Youngson could not recall if the cases of the children who had died were discussed at any of the M & M Rounds. Swartz testified that even if they had been presented, the types of issues that the anaesthetists wanted to discuss were not normally dealt with in M & M Rounds.

Generally speaking, M & M rounds were run by Dr. Odim, and so these issues would not usually come up at M & M rounds.

M & M rounds would be more to review the pathology, to review the nature of the surgery, the proposed procedure, what was actually carried out, the results, if there was morbidity or mortality, that sort of thing; but not to review technical difficulties. (Evidence, pages 15,778-15,779)

McNeill concurred with that view. She did not see the M & M Rounds as an appropriate forum in which to challenge the surgeon's approach to specific issues. She said this had also been true of the M & M Rounds when Duncan had been the pediatric cardiac surgeon. After the Goyal case, McNeill said, she had not considered taking her concerns to the M & M Rounds because she viewed it as essentially an educational venue.

Swartz testified that she also did not believe that pre-operative conferences provided the appropriate forum for discussing these issues, since they were focused on introducing the issues surrounding new patients. When asked if it would have been appropriate at such conferences to question if the program was ready to take on a specific operation, she answered that it would not have been.

It is clear that by the end of April, the Pediatric Cardiac Surgery Program was in serious trouble. The results from the procedures conducted to date were not good. An objective consideration might well have concluded that the team was not providing a level of care appropriate to the needs of the population of the province.

Additionally, two of the department heads and possibly one of the hospital's vice-presidents had been informed that the OR nurses and the pediatric cardiac anaesthetists had serious concerns about the program.

Some of the staff in the program were worried that the HSC was incurring potential civil liability in the way it was handling cases, and that when blame was being apportioned, it would fall heavily on them.

The surgical team existed in name only. The need for a cohesive collective approach to the treatment of children was badly missing, and little was being done to address that fact. Warnings had, in fact, been given-and by and large, they had either not been fully understood or had been ignored.



Current Home - Table of Contents - Chapter 6 - The existing rounds and conferences
Next The case of Alyssa Still
Previous Odim's view
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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