The Pediatric Cardiac Surgery Inquest Report



The case of RM

Other people who worked at Children's Hospital were becoming aware that there were growing concerns about the Pediatric Cardiac Surgery Program. Mary Jane Wasney, a surgical nurse at Children's Hospital, had heard about the deaths of a number of children and knew that operations were taking longer than expected. This was of particular importance to her, since her nephew, RM, was scheduled for a staged Fontan procedure in June 1994 at the HSC. This was similar to the type of surgery that FE had undergone. When FE had to be taken back to the OR the day after his first operation, she became alarmed. She shared her concerns with Youngson, who advised her to speak with Borton. She went to Borton in tears, worried that her nephew was going to die. Borton testified:

I told her that if you have reservations, you need to talk to Niels, you need to talk to Niels about your reservations about the surgery, and you can get him referred out, Niels could refer [the nephew] out of Province if it came to that. (Evidence, page 18,210)

Wasney made an appointment to see Giddins and Hawkins. She gave this account of that meeting to the Inquest:

I said that I wouldn't be worried if things were going well. And then he said, which shocked me, was that he would be surprised if things were going too well, that there is always a learning curve in any new program.

I understood that, and I said, yes, but children are dying. He said, yes, but that was unfortunate, but he was confident that Dr. Odim could do [the nephew's] surgery because he had done numerous of these types of surgeries. (Evidence, page 20,357)

Here again, one sees the concept of a learning curve being invoked to justify poor surgical outcomes. It should be remembered that at the same time that Giddins appeared to acknowledge that the team was making difficult progress along a learning curve, he was discouraging parents from having their children treated at other, larger centres.

Wasney also asked Wong, Swartz and McNeill for advice. Wong testified that he told her that:

. . . in view of all of the innuendo and all of the circumstances that were happening at that time, especially-I didn't tell her about the walkout [described in the next section of this report], but in view of the circumstances at that time, I suggested that Saskatoon might be a better place to go. (Evidence, pages 19,859-19,860)

In her testimony, Wasney recalled that all three anaesthetists she spoke with recommended against having the operation done in Winnipeg. In the end, the child was operated on in Saskatoon in June, after the Winnipeg program had reduced its scope of activity.



Current Home - Table of Contents - Chapter 6 - The case of RM
Next The anaesthetists withdraw services
Previous May 11-12-the case of FE
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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