The Pediatric Cardiac Surgery Inquest Report




Jessica Ulimaumi died on March 27, 1994, after undergoing pediatric cardiac surgery on March 24. Her case gives rise to the following issues:

  • 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 - Issues
Next Background and diagnosis
Previous The case of Jessica Ulimaumi
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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