The decision to operate

On April 13, when Daniel was 26 days old, his mother took him to see Taylor's partner, a Dr. Friesen. The doctor quickly determined that Daniel needed more significant attention and told Danica Terziski to take her son straight to the Children's Hospital emergency department. At the HSC, he was seen by Giddins, who told Danica that her son had a serious heart defect and needed surgery.

Daniel was admitted to neonatal intensive care (NICU) at 1620 hours on April 13. The admitting NICU resident examined Daniel and found he was breathing rapidly, at 80 breaths a minute at rest, with moderate in-drawing below the ribs and the breastbone, and nasal flaring. Daniel was pale, his liver was enlarged and he had poor circulation to his lower body. His oxygen saturation was low, and a heart murmur was detected. A chest X-ray showed a small right ventricle, a large left heart and evidence of pulmonary edema. An echocardiogram showed:

• tricuspid atresia (he had no tricuspid valve)
• transposition of the great arteries (his arteries did not connect to the appropriate ventricles)
• a small ventricular septal defect (there was a hole in the septum between the ventricles)
• a patent foramen ovale with an unobstructed right-to-left shunt (the foramen ovale was open)
• a rudimentary right ventricle (his right ventricle was underdeveloped)
• aortic coarctation with a hypoplastic aortic arch (his aortic arch was pinched and underdeveloped).

The transposition of the great arteries and the underdevelopment of his right ventricle meant Daniel had functional hypoplastic left heart syndrome. Cornel said this could in some measure account for the delay in making a proper diagnosis. Giddins and Odim concluded that Daniel needed a stage one Norwood repair, as described in Chapter Two of this report.

Healthy heart

Diagram 6.8 Daniel Terziski - pre-operative heart 1 - Patent foramen ovale 2 - Tricuspid atresia 3 - Aortic coarctation with hypoplastic aortic arch 4 - Patent ductus arteriosius 5 - Transposition of the great arteries 6 - Ventricular septal defect 7 - Rudimentary right ventricle

The cardiology resident, Doyle, also examined Daniel before he was transferred to the NICU. She wrote that he needed open-heart surgery in the next 24-48 hours and might require transfer to another centre (Exhibit 12, page TER 45).

In his initial report, Cornel wrote:

The diagnosis appears straightforward so far as it goes, however the aortic valve and ascending aorta are described as mildly hypoplastic the ductus appears to have shunted very little on echo leading me to the conclusion the aortic outflow was supporting the systemic circulation. The VSD is described as small but no measurements are given and arm pulses were normal and blood pressure was normal or elevated.

I suspect the decision to perform a Norwood type operation was probably correct but the data that I have on hand could also support repair of coarctation with distal arch augmentation and pulmonary artery banding as the primary procedure. (Exhibit 353, page 30)

However, in his later testimony, Cornel stated that having reviewed additional evidence, including the transcripts of some of the witnesses, he believed a Norwood was required. In his assessment, Dr. Walter Duncan wrote:

Would question wisdom of Norwood attempt this early in surgical experience, but again, the child was unstable and might not have tolerated transfer. Canadian results with Norwoods are generally poor in any event. (Exhibit 20, document 363, page 5)

In his testimony, Cornel said that the decision to undertake a Norwood in Winnipeg at this point was very questionable, particularly considering the outcomes in the Caribou, Ulimaumi and Goyal cases.

I would expect that after these three deaths that the morale of the group is not good. If there was this failure of communication that took place in the case of Vinay Goyal, I have to wonder how functional the team was. To undertake really one of the most difficult procedures in [the] book under those conditions is unwise. The outcome is likely to be bad, and all that can do is add to the troubles for the team. (Evidence, pages 44,772-44,773)