The Pediatric Cardiac Surgery Inquest Report



Anaesthetic meetings

McNeill testified that, from the middle of April onwards, she spoke informally to Ullyot about her concerns with pediatric cardiac surgery. She also said she had a formal meeting with Ullyot, in which she asked Ullyot how she should go about raising these concerns. Swartz also raised her concerns with Ullyot, who recommended that Swartz meet with the head of the Department of Anaesthesia, Dr. Doug Craig.

Ullyot had a number of conversations with Swartz about her concerns with poor outcomes in the Pediatric Cardiac Surgery Program. The issue was also discussed at a pediatric anaesthesia meeting on

April 18. Ullyot said that throughout late April and early May, she had a number of discussions with McNeill and Swartz about the cardiac surgical program.

In late April, shortly after McNeill's meeting with Ullyot, both McNeill and Swartz met with Craig. At that meeting they expressed their concerns over the program's mortality rate, particularly among the younger patients. McNeill testified that she and Swartz also had concerns that "we didn't know there was anybody actually monitoring the outcomes of the program." (Evidence, page 13,228)

On a more personal level, we asked him at that time what our responsibility was, as department members, to give anaesthetics for surgery if we felt that we couldn't do it or were not willing to do it, or had, you know, had any significant reason for not wanting to participate.

We asked him that and he reassured us that, you know, if we had valid and significant reasons for not wishing to participate in a surgical procedure of any kind, at any time, we could refuse to do so.

I guess the exception being obvious, if you are the only person available and the patient needed-you know, I am talking in general circumstances. (Evidence, page 13,229)

Swartz testified that it appeared as if there was no one in charge of the program.

There had been really no accountability that we could tell. There had really been no reviews or assessments of morbidity and mortality. We didn't know what was-you know, what was the controls of the program. (Evidence, page 15,748)

McNeill testified that at the meeting with Craig, she and Swartz also asked if there was any mechanism by which he could help them instigate a review of the program. She said that at the time Craig was supportive of the pediatric cardiac anaesthetists and was aware of the steps they were taking.

In his testimony, Craig indicated that Swartz and McNeill had told him they were worried about the results from pediatric cardiac surgery, that they had not been able to get anyone to listen to their concerns and that they wanted to know what action they might take. Craig said he told them that no anaesthetist was obliged to provide a service if the anaesthetist felt the situation was unethical or medically inappropriate. In testimony he pointed out that at the HSC, anaesthetists were allowed to refuse to provide anaesthetic care to patients undergoing abortions or for certain operations on patients who refused to receive blood products. He also said the HSC had respected the wishes of anaesthetists who "don't want to or can't work with an individual surgeon." (Evidence, page 34,480)

Craig testified that he believed from his conversations with McNeill and Swartz, and from previous conversations with Ullyot, that these concerns had been effectively communicated to Wiseman. He also testified that he had assumed that these concerns had been communicated to Odim. He was correct on the first point, but incorrect on the second point. It would appear that Swartz and McNeill had both been left very frustrated by their conversations with Odim following Vinay Goyal's death and saw little point in raising concerns with him.

Craig then spoke with Ullyot, and it was agreed that Craig would contact Blanchard, while Ullyot would contact Wiseman. Following that meeting, Craig spoke with Blanchard and told him of the concerns that his department members had with the Pediatric Cardiac Surgery Program. Blanchard testified that this was the first time he had heard of concerns with the program (Evidence, page 36,498). He asked Craig to keep him informed of further developments, but testified that he could not recall taking any other steps.



Current Home - Table of Contents - Chapter 6 - Anaesthetic meetings
Next April 18 - Meeting of the Section of Pediatric Anaesthesia
Previous Approaches to Wiseman
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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