The Pediatric Cardiac Surgery Inquest Report




At the end of February 1994, the pediatric cardiac surgery program resumed service. While the resulting problems were not yet fully apparent, the program's structure was clearly flawed. Lines of authority were fractured, team members had not had a chance to develop trust or confidence in one another-indeed, difficulty with communication was already emerging as an issue. Other issues that could have been identified at this point, such as Odim's concern with the number of anaesthetists or the limitations of the ICU wards, had not been properly flagged. These problems stemmed from the fact that the Department of Surgery and the Department of Pediatrics had not provided Odim with a strong orientation, while, at the same time, Odim appears to have declined to benefit from the more informal opportunities that had been presented to him.



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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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