The Pediatric Cardiac Surgery Inquest Report



The response of the nurses

Many of the nurses were developing reservations about Odim's surgical techniques and their impact on patients. Youngson testified about these concerns at length before this Inquest.

There were other things going on, other cannulation problems, other bleeding problems, or just technical things that were happening in the operating room on sort of the routine case that we were doing, you know, on the kids that are still alive. (Evidence, page 8,385)

Youngson also felt that Odim exhibited unnecessary roughness while undertaking cannulation during these early operations.

Well, he would be trying to put in a cannula, and I felt that he was very rough, his technique was very rough. He seemed to want to get that cannula in no matter what. And on occasion I would sometimes feel that the cannula was maybe too big for this particular vessel, or some concern like that.

Occasionally, he would tear the purse string, so that when the cannula was in and you went to snug up the wall of the vessel around it, you couldn't do that, and then you would be faced with a bleeding situation again. And these sorts of things were happening on an ongoing basis. We would have to repair these vessels, we would have to redo the purse strings. (Evidence, pages 8,385-8,386)

Youngson said that the roughness also extended to the manner in which Odim would handle the children's hearts. She said that she was not used to a surgeon who touched and prodded the patient's heart as much as he did.

During the Inquest, Youngson was asked why she did not take these concerns up with Odim directly. She gave the following answer:

Historically and traditionally, when nurses have a serious concern, and I'm not just talking about a little fight that you might have had with a surgeon in the OR, but a serious concern about competency, for instance, you go through what are considered the proper channels.

My understanding of that was to go to my head nurse, and then go to the director of nursing. (Evidence, pages 8,775-8,776)

Youngson followed just such a course. At first she raised her concerns informally, speaking with Dixon during their regular workday encounters about her early concerns with Odim's problems with cannulation.

Dixon recalled meeting with Youngson and other nurses after the Ulimaumi case. She testified that the primary concern they voiced was that there did not seem to be anyone in a position of authority who was aware of what was going on. She and the nurses decided to see what they could do to get someone in such a position to take an interest in what was happening.

Borton began to have a number of doubts about the program following Jessica Ulimaumi's death. Her concerns increased during the spring.

After the death of Vinay Goyal, Youngson again went to speak with Dixon about her concerns. Dixon suggested that she speak with nursing director Isabel Boyle, and a subsequent meeting took place between Boyle and Youngson.

Hinam testified that in April a number of nurses approached her with their concerns about the program. These nurses included Feser, Plouffe, Armitage and Kiesman. She said they were concerned about the amount of post-operative bleeding in patients in the pediatric cardiac program. They also expressed concern about the fact that patients were having their chests closed in the intensive care units, rather than being taken back to the OR. While Hinam had concerns about what she had witnessed in the OR, she told the nurses that she thought they ought to give Odim a chance. However, Hinam testified that Odim seemed to have continuing problems with cannulation and operative procedures:

How to hook everything up and how to put everything together, clamps not being taken off when they should, cannulas coming out, bleeding, long pump times, long circulatory arrests. There was a lot of things in the OR that were raising red flags. And you thought, is it just me or is everybody seeing this? (Evidence, pages 11,484-11,485)

Hinam and Youngson both recalled that they met with Boyle more than once during April 1994. On April 28, after the death of a fourth child, Daniel Terziski, Hinam and Youngson met with Boyle to outline their concerns. According to Hinam, Boyle indicated that she would speak to Bishop about this issue. Furthermore, Boyle told Hinam that she should continue to encourage other nurses to give Odim the benefit of the doubt. Youngson once again relayed the concerns that the nurses had over the results in the pediatric cardiac program and the effect that the deaths of the children were having on her and her colleagues. According to Youngson's testimony, Boyle agreed to ask those in charge of a special program in the hospital called the Critical Incident Response Team to meet with the nurses in order to assist them in dealing with the emotional impact of the series of deaths. In her testimony, Hinam said that at one point in the meeting with Boyle, both she and Youngson were in tears.

Following the meeting with Boyle, Hinam and Youngson discussed the question of making notes about what they had witnessed and heard. Hinam recalled:

I said to her that she should start making notes. I said, you know, you are the one that's right there, I'm in and out, I don't see it, but you are right there. And I said, one of these days, one of these days this is not going to be an aboriginal child, this is not going to be a child from up north, it is going to be an upper middle class white family that has the ins into the medical system and is going to know that this shouldn't have happened, and there is going to be a lawsuit, and I think you should chart about it, because you are going to be called for sure. (Evidence, pages 11,485-11,486)

The point that Hinam was making deserves comment. The first three children who died in 1994 were children of visible-minority families. Caribou had been a member of Mathias Colomb First Nation, Jessica Ulimaumi had been an Inuk child from the Northwest Territories (now Nunavut), and Vinay Goyal had been the son of an East Indian family. The order in which their cases had been selected appears to be nothing more than coincidence. However, their deaths did not result in any significant public or other reaction against the hospital or the Pediatric Cardiac Surgery Program, even though two of the deaths had been clearly preventable.

In the overall scheme of things, the victims of these tragic events were from families of the least powerful in society. None of the families of the children who had died to this point were in a position to be able to influence large institutions, such as the HSC. Charlotte Caribou and Emalee Ulimaumi were from the far north, and the Goyals left the city shortly after the death of their son for an extended stay in India.

There is nothing to suggest that there was any discrimination at work with respect to these cases. However, it seems clear that if any of the deaths had involved a family that had more socio-economic standing, as Hinam suggested, events might have proceeded differently. As later evidence indicates, there were two cases in which people who were personally acquainted with individuals involved in the Winnipeg program were warned to take their children elsewhere for pediatric cardiac surgery.

Hinam's recommendation was also shaped by the earlier experiences of cardiac nurses in Toronto. Their subordinate status was underlined in 1981 when Susan Nelles, a nurse at Toronto's Hospital for Sick Children, was arrested for the murder of four children. Before Nelles's arrest, the nurses in the cardiology ward had raised concerns with their supervisors that low numbers of staff were endangering children's lives. They pointed to the deaths of 32 children in the ward. The charges against Nelles were eventually dropped for lack of evidence and motive. A Royal Commission, headed by Mr. Justice Samuel Grange, investigated both the deaths and the case against Nelles.

It is beyond the scope of this Inquest to review or comment on the Grange Commission. However, it is apparent that its impact on the nursing profession was significant. The Inquiry concluded that the deaths were the result of foul play and that the perpetrator was likely to be a nurse. Medical historian Katheryn MacPherson gives this description of how many in the nursing profession viewed the Inquest.

Still convinced that foul play had occurred, inquiry attorneys aggressively interrogated the testifying nurses. Any expertise nurses might have offered to unravel the mysterious deaths was not sought out, while medical testimony was actively recruited and respectfully received. (MacPherson, page 256)

For many nurses the Inquiry confirmed that, while they had the responsibilities of professionals, they were still subordinate-lacking in control and authority. In telling the nurses to keep notes, Hinam was recommending that the Winnipeg nurses protect themselves from being made scapegoats.

Boyle testified that throughout April she had a number of conversations and meetings with nurses about the program. She recalled that Borton and Hinam came to speak to her following Vinay Goyal's death. She said they outlined their concerns with bleeding, cannulation, and team communication.

In early May, the Critical Incident Response Team held a meeting with the nurses. McGilton testified that at this meeting the nurses were encouraged to discuss their feelings about the deaths. She said there was also discussion of the fact that Odim did not appear to be distressed by the mortality rate. However, there was no discussion of surgical issues. McGilton told the Inquest:

It was difficult for me because I'm not a sharing person with people I don't know that well anyway. I guess it was helpful to talk about it, but I came away from that thinking it hasn't fixed anything, you know, nothing is -nothing has changed, but I think that [Karin] thought it was important that we do go through that and talk about it, because it was such a very difficult time for us then. (Evidence, page 10,534)

Hinam testified that the meeting helped, in that each nurse no longer felt that she was the only one who was experiencing concerns about the program. She also indicated that at that point, the nurses thought it would have been appropriate if the program had slowed down, and complex cases had been sent out of province.

Youngson said that she made notes at home on her personal computer. When the HSC commissioned an outside review of the program in early 1995, she revised those notes to form a document to use in addressing that review. The file itself was deleted from her computer, but not until after the documents were printed. McGilton also began to keep notes on cases.

Boyle also spoke with Feser to determine if problems were arising in the PICU. She said that Feser informed her of the concerns that the PICU nurses had with the program.



Current Home - Table of Contents - Chapter 6 - The response of the nurses
Next Perfusionists
Previous Reaction of the PCS team following the deaths
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
Search the Report
Table of Contents