The Pediatric Cardiac Surgery Inquest Report




Daniel's death occurred within a short time of an operation and therefore, under the rules of the Office of the Chief Medical Examiner, should have been the subject of an autopsy. Despite this, no autopsy was performed. There is conflicting testimony as to how that happened.

Danica Terziski testified that, on the evening of Daniel's death, she was informed that autopsies were compulsory in cases such as Daniel's and that she could expect a report in a matter of weeks. This information was accurate. However, it was still necessary for someone to obtain her formal consent. This did not happen.

She testified that the following morning, Odim telephoned her. In the course of their conversation, Danica testified that Odim:

. . . asked if we could have another look around. He explained that this is a very rare, complex procedure and maybe we can learn something from it. (Evidence, page 1,774)

This left her with the impression that Odim wished to perform research on Daniel, in addition to the mandatory autopsy. She withheld her consent to what she thought would be research. In his testimony Odim said that he could not recall any of the specifics of this conversation. He did state that on the evening of Daniel's death, he believed that Belik had taken responsibility for arranging the autopsy. If he had thought so, it is unclear why he phoned Danica Terziski the next morning.

In his testimony, Dr. Peter Markesteyn, the Chief Medical Examiner, gave a slightly different account of the events, although his evidence is second-hand. Markesteyn testified:

I was consulted by the medical examiner investigator, or the M.E.I., about the fact that an autopsy had been ordered, or Dr. Odim would get permission.

Q: I see.

A: He would get an autopsy, or Dr. Giddins or both and, unfortunately, that it not, due to misunderstandings, that did not happen.

Q: So your information was that Daniel Terziski would have an autopsy?

A: Yes.

Q: Performed by the hospital?

A: Yes. (Evidence, pages 38,676-38,677)

The written notes of the MEI indicate that in this case Odim informed the Chief Medical Examiner's office that he would contact the family and arrange for an autopsy.

The evidence tends to suggest that Odim did in fact telephone Danica Terziski the morning after her son's death to ask for consent to carry out an autopsy. It also suggests that he did not make his request very clear, and as a result of a misunderstanding, Danica told him she would not consent to what he was asking. She had already accepted the fact that an autopsy would be conducted. Odim, however, believed that she would not consent to the holding of an autopsy. Odim never forwarded this information to the CME's office. As a result, the CME was left with the impression that the HSC was arranging and carrying out an autopsy.

Since Markesteyn believed that the hospital pathologist was going to carry out an autopsy, and was never informed to the contrary, he did not order one on his own.

The matter was exacerbated when staff in the CME's office placed an official release on the chart, indicating that the CME was not going to direct that an autopsy be held. Markestyn said this was done because his office had been informed that the hospital would seek the family's consent to an autopsy. Obviously that release was premature until it was known that the consent had been obtained. This release, combined with a lack of a written consent on the chart, was apparently understood by hospital staff as an indication that an autopsy was not to be held at all. Therefore, the baby's body was soon released to the family for burial. The family assumed that the autopsy had been performed before the body had been released and proceeded with funeral plans for Daniel. It was not until several months later, when Daniel's mother inquired about the status of the autopsy report, that it was determined that an autopsy had in fact not been performed.

Unfortunately in this case, it appears from the evidence that cost factors may have played a role in the decision of the staff in the Chief Medical Examiner's office not to follow the usual procedure and order an autopsy. Markestyn testified that when the hospital asks for an autopsy report, the hospital must pay for the cost of performing the autopsy. When his office orders an autopsy, the cost of the autopsy is paid for from the Chief Medical Examiner's budget. In this case, the decision not to place a Chief Medical Examiner's direction on the chart seems to have stemmed from the desire on the part of the CME's office to avoid paying for the autopsy. These events give rise to recommendations in the final chapter of this report.



Current Home - Table of Contents - Chapter 6 - Autopsy
Next Findings
Previous Post-operative Course
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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