The Pediatric Cardiac Surgery Inquest Report



The interim report is distributed

On August 22, 1994, Wiseman sent copies of the report to Blanchard, Craig and Dr. John Bowman, the acting head of pediatrics. On August 23, Blanchard responded in a note to Wiseman:

I have some difficulty with statements in the latter part of the report. The assignment of arbitrary risk levels as a basis for the decision regarding whether the patient should have an operation in Winnipeg makes no sense in and of itself. The mere existence of increased risk for certain categories of congenital cardiac defects should not be a criterion for acceptance or rejection of the patient for treatment in Winnipeg or elsewhere. After all of the meetings and the improved communication why is there need for a further moratorium of three to six weeks during which so-called low and medium risk patients will be acceptable for surgery in Winnipeg and higher risk patients deferred? (Exhibit 19, Document 249)

There is some merit to Blanchard's question. Why were people still reluctant to take the program to full service after a summer of team building? The fact that there was such reluctance should have caused Blanchard to question whether the program should undertake such a step without full support and confidence. However, instead of raising that concern, Blanchard went on to question why the program could not have moved to full service sooner.

Blanchard saw the use of risk categories as being artificial. He said his concerns about the levels of risk reflected a worry that the program might be attempting to improve its surgical outcome by avoiding cases it was capable of doing but that carried a higher risk. He testified:

It wasn't clear to me, in reading the report, you know, what were the decisions they had to make now, what were the obstacles? Were we missing some equipment? Were there some problems with deciding on cases? It wasn't sort of totally clear to me just how they were going to make this decision, and what would another few weeks difference make? (Evidence, pages 36,537-36,538)

Wiseman responded to Blanchard's memorandum on September 6, with the following comments:

With respect to the "arbitrary risk levels" and decisions regarding surgery we discussed this at length and it seems that this is the only way that the program could continue with the participation with the Department of Anesthesia. In truth, the risk levels are not quite so arbitrary. They do represent patients with low, medium and high mortality rates and it was initially stated that the program should recommence with a graduated case load, specifically with respect to case complexity. I would only add that it seems in retrospect that this was perhaps not a bad decision in view of the fact that there have been an additional 16 cases carried out since our deliberations commenced and all [underlining in original] of these patients have had a successful outcome.

I believe we are on the verge of allowing this program to go forward at full capacity and at the present time the team members do appear to be gaining confidence with each other. (Exhibit 19, Document 250)

It should be again noted that this overstated, by a considerable degree, the degree of team cohesiveness that had been developed by this point. There is an even more disturbing overstatement. Wiseman stated that all the patients who had undergone surgery since the shutdown had experienced successful outcomes. By the time he wrote his response, two children who had undergone surgery in Winnipeg, Aric Baumann and Shalynn Piller, had died. Furthermore, Wiseman had been informed about these deaths by August 24. When questioned about this omission, Wiseman was not able to offer any explanation, other than to suggest that he had forgotten.



Current Home - Table of Contents - Chapter 7 - The interim report is distributed
Next The Wiseman Committee plans to return to full service
Previous The draft interim report
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
Table of Contents