The Pediatric Cardiac Surgery Inquest Report



Membership on the Wiseman Committee

The pediatric cardiac review team was to be chaired by Wiseman. It was to comprise McNeill, Odim, Giddins, Dr. Murray Kesselman from the PICU, and Michael Maas, the senior perfusionist. A recommendation from Ullyot that the review team include nurses was accepted. Carol Youngson, in her position as the senior cardiac operating-room nurse, was asked to be on the committee. It appears that there was no consultation with Boyle as to how nursing should be represented. Nor were nurses themselves asked about how they wished to be involved, and they had no input into the selection of their representative.

Wiseman was chosen to head the team both because of his position as head of pediatric surgical services and his experience and knowledge of the people involved. Bishop said she supported Wiseman as the head of the committee because he was the head of pediatric surgery, was not personally involved with the program and was seen as someone with whom all the main actors could work.

It was never made clear if the members sat on the review committee as individuals or if they were responsible to a larger constituency. Certainly, none were ever selected by any constituency since, except for Youngson, they were selected at the initial meeting without reference back to any constituency. When members could not attend meetings, they often arranged to be replaced by someone from their employment area: a nurse substituted for Youngson, an anaesthetist for McNeill and a perfusionist for Maas. This suggests there was a sense that the members were in some way representative of a broader community. However, some communities were not represented at all, while others, such as nursing, were under-represented.

There was no one, either a doctor or a nurse, on the team from the neonatal intensive care unit. It was only after the committee began to consider relieving the NICU of its responsibility for treating neonatal cardiac surgery patients post-operatively that the head of the NICU, Dr. Molly Seshia, was invited to sit on the committee.

Youngson was the only nurse on the committee. As a member of the operating-room nursing unit, her selection meant that nurses from the PICU, the NICU and the VCHC had no direct representation. Youngson, in her evidence, acknowledged that she had little direct contact with her colleagues in those other units, and that she was unclear about exactly whom she represented.

In her testimony, nurse Joan Borton said that she and Lois Hawkins spoke with Giddins about the possibility of one of them being on the committee. Borton said they were told that there was no reason for them to be members. In her testimony, Feser noted that the PICU nurses were not consulted about the creation of the committee; nor did it consult them during its existence.

There was never any requests to our unit from a nursing perspective to have any insight on what was going on, or what our thoughts were on the whole program. (Evidence, page 29,986)

Everyone involved in the Pediatric Cardiac Surgery Program endorsed the importance of teamwork. However, the actions of the program's leadership make it clear that they believed that some team players were more important than others. Nurses were no longer being told to 'see and be silent,' but their input was not actively sought. By failing to have representation from the PICU, the NICU and the VCHC nurses, the committee was cut off from important sources of information.

Finally, the team membership was deficient in that it included no outside source of pediatric cardiac surgical expertise. There was no one who could, as McNeill had anticipated, be in a position to state whether or not any of the deaths arose from surgical shortcomings. This would have required that outside expertise be on the committee.



Current Home - Table of Contents - Chapter 7 - Membership on the Wiseman Committee
Next Assessing the problems
Previous Informing HSC senior management
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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