The Pediatric Cardiac Surgery Inquest Report



Reaction of the PCS team
following the deaths of Gary Caribou,
Jessica Ulimaumi and Vinay Goyal

Vinay Goyal's death had a significant impact on many of the people who had been involved in his case. Feser testified that she recalled walking into work on the morning after Goyal's death and seeing his empty bed. She assumed at first that he had been moved to another ward. When she was told what had happened to him, she said she cried.

In fact, I had to turn around, go back to my office, and do what I am doing now, had a good cry. And I came back to the unit because I had to come back and listen to, I wanted to know the details on what happened and I would go in to report. And I still to this day keep thinking, you know, that boy should not have died. (Evidence, pages 29,952-29,953)

Swartz testified that she felt that she and other members of the team, specifically McNeill, Hinam and Youngson, were shocked by the death of Vinay Goyal.

The deaths of three children in such a short period of time would have been unsettling for any pediatric cardiac surgery program. As suggested above, these deaths and the circumstances surrounding them ought to have led to a review of the program. The fact that no such review was ordered was a source of real concern for many of the people involved in the program, particularly the nurses and the anaesthetists. By this point, they had concerns about Odim's skills, both as a surgeon and as a team leader. Such reservations, unless expressed openly and directly, can be poisonous for a team.

Because of their concerns, by April many members of the team were trying to attract the attention of those in some position of authority in the hope of instigating a review of the program. The anaesthetists were eventually able to trigger a reduction in the program's activities in May 1994.



Current Home - Table of Contents - Chapter 6 - Reaction of the PCS team following the deaths
Next The response of the nurses
Previous Vinay Goyal - The second procedure - Findings
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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