The Pediatric Cardiac Surgery Inquest Report




Ward and Dr. R. Savani outlined Shalynn's condition to her parents. When Sharon Piller was told that her daughter needed heart surgery, she thought this meant she would have to go to Toronto. However, Savani told her that Odim could do the operation in Winnipeg. Sharon Piller testified that Savani told her that Odim was from the United States and implied that this was a sign of his qualifications. She testified that Ward also spoke highly of Odim's qualifications.

Odim spoke with the parents about Shalynn's difficulties on Friday evening. Sharon Piller testified that Odim told her Shalynn's chances of recovery were 92 per cent. Odim testified that he could not recall providing the parents with a specific estimate of the degree of risk involved in the case. He did tell them that further surgery would likely be needed to correct other defects. He did not tell them of the reduction in the capacity of the Winnipeg program or of any of the problems the program had experienced.

Odim and the Pillers also spoke the following day, July 31. In Shalynn's chart Odim wrote, "In view of multiple VSDs a staged biventricular approach is preferable: aortic coarctectomy and PA band via left thoracotomy. I have discussed the attendant risks and the family appears to understand and give their verbal and written consent for operation tomorrow." (Exhibit 10, page PIL 38)

In a letter to Omichinski, Odim explained that because Shalynn had multiple ventricular septal defects, he felt that a complete repair in one operation would be an unreasonable goal. He hoped with time that some of the smaller VSDs would close on their own. At that point, further surgery to close the remaining VSDs and remove the pulmonary artery band would then take place.

In his testimony, Giddins indicated that he believed Shalynn's was a low-risk case. Because it was closed rather than open-heart surgery, he also said it fell within the Wiseman Committee parameters for permissible surgery in that period. Giddins testified:

The Wiseman committee referred to low risk open, and did not specifically get into issues of grading closed procedures, because closed procedures are a category different from open. And there had been no difficulties with any closed procedures up until that time, so this case fit in. (Evidence, page 3,925)

Because the committee's records were not well kept, it is risky to make categorical statements about what the committee did and did not approve. However, at the May 18 meeting, it was agreed that major neonatal anomalies would be transferred to Saskatoon. Shalynn Piller's case fit the classification of a major neonatal anomaly. According to the consulting witnesses who appeared before this Inquest, hers was not a low-risk condition. In their report, Duncan and Cornel wrote, "VSD and coarctation remains a condition with a relatively high risk. The addition of sub-aortic stenosis produces the potential for obstruction to both outlets - {the right side from the band and the left side from the sub-aortic stenosis}, which is not a well tolerated phenomenon." (Exhibit 354, page 9) In his testimony, Duncan stated that there were major risk factors in the operation (Evidence, pages 41,619-41,620). This leads to the conclusion that the operation should not have been performed in Winnipeg.



Current Home - Table of Contents - Chapter 7 - Consent
Next Pre-operative status
Previous The decision to operate
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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