The Pediatric Cardiac Surgery Inquest Report



The case of Daniel Terziski

Background and diagnosis
The decision to operate
Pre-operative status
Preparing the NICU staff
The operation-April 20
Untoward events during surgery

Preparation of the homograft
Removing the cap from the line
Problems with the shunt

The assessment of the consultants
Post-operative Course

Findings - Should Daniel's condition have been diagnosed earlier?
Findings - Was Daniel's family provided with sufficient information to allow them to give informed consent to the procedure?
Findings - Was Daniel healthy enough to undergo an operation?
Findings - Should the HSC team have attempted the operation or should Daniel have been referred out of province?
Findings - Should there have been better planning for this procedure?
Findings - Did the length of surgery contribute to Daniel's death?
Findings - Was there appropriate post-operative care?
Findings - What was the cause of death and was it preventable?



Current Home - Table of Contents - Chapter 6 - The case of Daniel Terziski
Next Issues
Previous Reaction of the PCS team following the deaths - April 18
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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