The Pediatric Cardiac Surgery Inquest Report



The case of Alyssa Still

Background and diagnosis
The decision to operate
Pre-operative condition-first admission
Pre-operative condition-second admission
Alyssa's admission to the Children's Hospital
The operation-May 5
Post-operative course

Did suctioning contribute to Alyssa's problems?

Autopsy findings

The presence of a suture in the coronary sinus
Contraction band necrosis

Cause of death

Was Alyssa's family provided with sufficient information to allow them to give informed consent to the procedure?
Was Alyssa healthy enough to undergo an operation?
Was the PICU adequately equipped for her case?
Were there technical problems with the operation?
What was the cause of death and was it preventable?



Current Home - Table of Contents - Chapter 6 - The case of Alyssa Still
Next Issues
Previous What happened after the Terziski case - existing rounds and conferences
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
Search the Report
Table of Contents