The Pediatric Cardiac Surgery Inquest Report



The meeting in Bishop's office

On the morning of May 17, on arriving at her office, Dr. Agnes Bishop, the head of the pediatrics department, was told that the pediatric anaesthetists had withdrawn their services from the Pediatric Cardiac Surgery Program. Given the assurances she had only recently received from Dr. Nathan Wiseman, that the issues being raised about the program were not shared by all the anaesthetists, she was understandably surprised and even angry.

In early May, it will be recalled, Bishop had asked Wiseman to gather information about complaints that had been made to her about the program. She had spoken to Isobel Boyle, the director of pediatrics and child health nursing, about the concerns of the nurses and to Dr. Suzanne Ullyot about the anaesthetists' concerns. Ullyot had told her that the anaesthetists had agreed to establish a liaison with Dr. Jonah Odim and Dr. Niels Giddins. Yet, when Bishop called Odim and Giddins that morning, she was informed that neither had been approached by the anaesthetists about their concerns with the program. It was obvious to Bishop that the team was communicating at an extremely poor level.

Her immediate concern on learning about the anaesthetists' withdrawal was for the patients who were scheduled for cardiac surgery that day and later in the week. If those patients could not be operated on in Winnipeg, arrangements would have to be made to offer their families options, including the possibility of deferring the procedure or transporting the child to another facility. In addition, to prevent the spread of rumours, she wanted to ensure that the HSC gave all parents a coherent explanation of why cases were being delayed.

Bishop called Dr. Doug Craig, head of the Department of Anaesthesia, Dr. Robert Blanchard, head of the Department of Surgery, Ullyot, Odim, Giddins and Wiseman to attend a meeting in her office that morning. She did not invite Boyle, nor any of the nurses involved in the program, because in her view, the meeting was meant to deal with the medical implications of the anaesthetists' action. Dr. Ann McNeill also attended the meeting, at Ullyot's invitation.

At the outset of the meeting, Bishop expressed her dismay at the withdrawal of services and the fact that it had been undertaken on such short notice. In response, McNeill and Ullyot explained that the anaesthetists had become concerned over the fact that deaths in the program were apparently not being systematically reviewed, and that the anaesthetists were not confident that events within the program were going to be reviewed.

However, they did not voice their concern over the ability of the pediatric cardiac surgery team and, in particular, the surgeon, to perform the operations that the program was undertaking. When asked to explain during her testimony why the anaesthetists were hesitant to state that concern explicitly, McNeill said they were not certain that they were qualified to pass judgment on Odim's skills and abilities, but they wanted someone to do so. She explained that she was particularly hesitant to criticize Odim since she was not a surgeon. She felt, however, that if a review was undertaken, any surgical problems would be identified and would lead to an appropriate resolution.

During the meeting, it was revealed that the anaesthetists had not spoken with either Odim or Giddins about their concerns. Giddins testified that, aside from the comments made to him earlier by Joan Borton and Wiseman, this was the first time he had been made aware of the anaesthetists' concerns with morbidity and mortality.

Craig wondered if his assumption that there were appropriate lines of communication between the pediatric cardiac anaesthetists and Odim had been correct. It was becoming apparent to him that there had been little, if any, communication between the anaesthetists and Odim and Giddins about the anaesthetists' concerns. However, at the meeting Craig kept those concerns to himself. Both McNeill and Ullyot felt that Craig was supportive of the anaesthetists' actions at the meeting.

Both Blanchard and Bishop expressed their concern that they had not been made aware of the extent of the concerns held by some members of the program. When McNeill expressed the view that the anaesthetists were concerned about deaths in the program, Blanchard asked, perhaps facetiously, if the anaesthetists had thought that there would be none.

Odim testified he was shocked by the decision to withdraw services. While there had been some operating-room friction to that point, he put it down to personality differences. He indicated in his evidence that he too had been concerned about the deaths:

It was of some concern that we certainly had some bad luck, had some tough cases, and had some children that we didn't anticipate would die who died in the post-op period. And obviously those were concerns. And all along I was formulating ways in which we could help and improve the situation both from the surgical point of view, from the pre-surgical point of view and post surgical point of view in terms of developing a more efficient team. (Evidence, pages 25,027-25,028)

He testified that he had tried to encourage members of the team to attend post-operative Morbidity and Mortality Rounds, where individual cases would be reviewed, but there had been a significant lack of attendance at those sessions. He felt that the members of the team had been given several opportunities to bring their concerns about individual cases to his attention, as well as to that of other members of the team, at the pre-operative conferences. He said he was frustrated by the other team members' lack of co-operation.

However, at the meeting Odim also kept those opinions to himself. He did so because he felt himself to be "on the hot seat" at the meeting and did not take part in the discussion. It is interesting that he would see himself as the centre of attention, given the lack of specific comments directed at or about him by the anaesthetists, who themselves felt that they were under the gun to justify what they had done.

It is also noteworthy that, despite the fact that Odim seemed to think that the anaesthetists were targeting him, he refused to read the memo they had circulated to Wiseman and others following their May 16 meeting. Odim testified that he did not read the memorandum until just before appearing for this Inquest. It is difficult to understand why he would not have read the memorandum earlier. This fact does not speak well of him.



Current Home - Table of Contents - Chapter 7 - The meeting in Bishop's office
Next The decision to conduct a review
Previous Preamble
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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