The Pediatric Cardiac Surgery Inquest Report




Vinay Goyal died on April 18, 1994, after undergoing two operations in the spring of 1994 (one on March 17 and one on April 18) and after experiencing a lengthy stay in the PICU. His case gives rise to the following issues:

  • Were Vinay's parents provided with sufficient information to allow them to give informed consent to the procedure?
  • Would Vinay have been taken to surgery with a potential infection if his parents had not intervened?
  • Did the surgeon demonstrate the skills and experience necessary to undertake this high-risk surgery?
  • What was the cause of death and was it preventable?

This case will be discussed in two sections. The first section deals with events leading up to the first operation. The second section (which is separated from the first by a discussion of the case of Jessica Ulimaumi) deals with the second operation. The findings are placed at the end of the second section.



Current Home - Table of Contents - Chapter 6 - Issues
Next Background and diagnosis
Previous The case of Vinay Goyal - his first operation
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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