The Pediatric Cardiac Surgery Inquest Report



Background and diagnosis

Daniel Terziski, the third son of Kiril and Danica Terziski, was born on March 18, 1994, at the Misericordia General Hospital. An ultrasound done at six months gestation was reported as showing a normal fetus. At birth, Daniel was considered an active and healthy baby and was discharged with his mother on March 23. It is clear now that he was in fact suffering from a very serious heart condition at the time of his discharge.

One of the first questions raised in this case is the accuracy of the ultrasound done at six months gestation. In their joint report to this Inquest, Duncan and Cornel state:

The information contained in the medical record suggests that a fetal echo was done and reported as normal. This seems unlikely given the fact that there was only one atrio-ventricular valve. (Exhibit 354, page 6)

As Dr. Walter Duncan testified, Daniel did not have a tricuspid valve-therefore the scan could not have shown a healthy heart.

Cornel also noted that if the perinatal and neonatal diagnoses had identified the defects earlier, the treatment might have been more successful. Cornel testified:

When dealing with univentricular circulation, one of the things that we like to avoid as early in life as possible is massive volume overload of the ventricle. That means we like to try and control the amount of blood flow through the lungs so that the return to the ventricle is less than it might be, so that there is much less work for the heart to do. And earlier diagnosis and more precise management can reduce those problems, and sometimes earlier surgery is an advantage. (Evidence, page 44,790)

Very soon after going home, Daniel's mother noted that Daniel was weak, tired easily and had difficulty feeding. On at least two occasions his mother took him to a nursing clinic at the HSC Women's Pavilion. She testified that she also took Daniel to see the family doctor, Dr. Hugh Taylor, who encouraged her to supplement his feedings.



Current Home - Table of Contents - Chapter 6 - Background and diagnosis
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Previous Issues
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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