The Pediatric Cardiac Surgery Inquest Report



Autopsy findings

Despite the policy of the Chief Medical Examiner to hold autopsies in all pediatric intra-operative deaths, an autopsy was not held because Gary's family objected. Charlotte Caribou testified that she withheld her consent because she felt that "they cut him up enough." (Evidence, page 1,955) Her wishes were respected.

It is hard to disagree with the Chief Medical Examiner's decision to respect the wishes of the mother of the dead child. The Chief Medical Examiner, Dr. Peter Markestyn, testified that wishes of the family would be respected if sufficient information as to the cause of death was otherwise available and the attending doctor was prepared to certify the cause of death. In Gary's case, Odim had indicated to the CME's office that he was prepared to certify Gary's cause of death. He wrote that Gary died of cardiac failure (Exhibit 5, page CAR 14).



Current Home - Table of Contents - Chapter 6 - Autopsy findings
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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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