The Pediatric Cardiac Surgery Inquest Report



The case of Jessica Ulimaumi

Background and diagnosis
The decision to operate
Pre-operative condition
The operation-March 24
Post-operative course
Autopsy findings
Post-mortem events

Was there an inappropriate delay between the time of her diagnosis and the date of the operation on her heart?
Was Jessica's family provided with sufficient information to allow them to give informed consent to the procedure?
Was Jessica healthy enough to undergo an operation?
Did the length of surgery contribute to her death?
Were the repairs properly carried out?
Did irregularities in the process of weaning her from ECMO contribute to her death?
What was the cause of death and was it preventable?
Should this death have triggered a review of the program?



Current Home - Table of Contents - Chapter 6 - The case of Jessica Ulimaumi
Next Issues
Previous The case of Vinay Goyal - Decision to reoperate
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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