The Pediatric Cardiac Surgery Inquest Report



Autopsy findings

A staff pathologist at the HSC, Dr. Joseph de Nanassy, performed the autopsy. He concluded that the immediate cause of death was "Cardiac arrest post cardiac surgery due to or as a consequence of coagulopathy and hemorrhage during weaning from ECMO." (Exhibit 13, page ULI 22) He noted that her superior vena cava had been narrowed by a suture. This likely was caused during the original surgery. There was also the presence of a needle near the cannula site.

Odim commented on the needle found in Jessica during the autopsy. He felt that this needle was in all likelihood one that was used during attempts at removing Jessica from the ECMO machine in the PICU. In his testimony, Odim said the needle was the needle "from my reinforcement, attempt to reinforce that suture line before I started to massage the heart and aborted that when the blood pressure and the cardiac action was going down." (Evidence, page 24,211) The evidence suggests that the needle likely became lodged in Jessica during the attempt to wean her from ECMO in the PICU and played no role in her death.

The only item in de Nanassy's report that has come under question is his conclusion that Odim's second repair was intact. Two of the consulting witnesses who prepared reports for this Inquest disagreed with this finding. Drs. Walter Duncan and Glenn Taylor4 both reviewed the autopsy report, as well as the heart specimen. Duncan also reviewed a videotape of the heart echocardiogram done immediately after the second attempt at repairing the VSD. They both concluded that the VSD had not been successfully repaired at all. In other words, both the first and second attempts were not done properly.

Duncan and Taylor concluded that, rather than placing the patch across the hole in the septal wall, Odim had in fact sutured the patch to a muscle bundle that was attached to another part of the wall of the ventricle. As a result, blood continued to shunt through the opening in the septal wall in the VSD and heart performance remained poor.

Jessica Ulimaumi - pre-operative heart
Jessica Ulimaumi - pre-operative heart

Diagram 6.6 Jessica Ulimaumi - post-operative heart
Diagram 6.6 Jessica Ulimaumi - post-operative heart
1 - Suture constriction of superior vena cava
2 - Suture closure of atrial septal defect
3 - Surgical needle, inferior vena cava
4 - Ligation of ligamentum arteriosus (former ductus arteriosus)
5 - Portion of VSD not closed by surgery
6 - Patch closure of portion of ventricular septal defect
7 - Patch sutured to right ventricle muscle bundle as
opposed to septal wall

Compare pre- and post-operative diagrams side by side


Neither doctor could point to this factor as a cause of death, since the events that led directly to Jessica's death related to the failed attempt at removal from the ECMO machine. Both were of the opinion, however, that the failed repair would explain why Jessica did not recover well enough after the operation to be weaned from the CPB machine in the operating room or be weaned from ECMO. Indeed, if the repair had not been properly done, it would have been impossible to wean Jessica from ECMO.

Duncan conceded that the heart specimen he reviewed was not in very good condition. As a result, it might not have reflected the true condition of the repair. However, he also reviewed the echocardiogram videotapes (something that he specializes in doing as a pediatric cardiologist) and concluded that the tapes confirmed his view that the repair was unsuccessful.

Duncan concluded that, because of the failed operation, the cannula site would have been exposed to very high blood pressures while Jessica was on ECMO. This would explain why there was so much damage to Jessica's cannulation site when the venous cannula was first removed. The increased pressure at this location would have resulted from the fact that the blood was not flowing properly, as a result of the failed repair. Duncan therefore concluded that the failed repair had a direct bearing on what occurred in the PICU during the ECMO weaning process.

De Nanassy thought that Taylor and Duncan had reached their conclusions from assessments made on the study of a dissected heart specimen. He stood by his initial report, which was based on examination of the heart shortly after death. However, Duncan's evidence, based on his viewing of the echocardiogram tapes, is persuasive. This evidence clearly suggests that the VSD was not properly repaired at the time of Jessica's initial operation.



Dr. Glenn Paul Taylor received his medical degree from the University of British Columbia in June 1976. He completed post-graduate training at Toronto General Hospital in 1976, as well as the University of British Columbia in 1977 and the University of Toronto in 1979. He was appointed a fellow of the Royal College of Physicians in Canada in anatomical pathology in December 1981. He was certified in anatomic pathology by the American Board of Pathology in June 1991 and awarded special qualifications in pediatric pathology in June 1992 by the same body.

A member of the hospital staff at the Toronto Hospital for Sick Children, he was also affiliated with the University of Toronto Department of Laboratory Medicine and Pathobiology, the University of Toronto Department of Pathology and the University of British Columbia Department of Pathology.

At the time of his evidence, Taylor was a staff pathologist with the Department of Pediatric Laboratory Medicine at the Hospital for Sick Children in Toronto as well as an associate professor in pathobiology, Department of Laboratory Medicine, at the same institution. He was also a consultant pathologist at the British Columbia Children's Hospital.

Taylor has delivered several lectures, workshops and courses on pathology and has published extensively in the area. He was acknowledged as having special expertise in anatomic pathology and was permitted to give expert evidence to the Pediatric Cardiac Surgery Inquest in that area.



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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