The Pediatric Cardiac Surgery Inquest Report



The work of the committee during the month of June

Throughout June and July, the committee reviewed cases. Issues such as morbidity and mortality, length of bypass and cannulation were discussed as they arose in individual cases, but not as separate, overarching topics. The meetings were held once a week in the late afternoon and generally lasted for two hours.

Odim said that during the early period of the committee meetings, there was discussion about ways in which the team could reduce the time spent in the operating room. At the same time he testified that attendance at team functions continued to be, in his opinion, poor.

McNeill felt that as time passed, the relations between team members deteriorated. She was pleased with the success that was being achieved with the low-risk operations, but felt there was growing pressure to move the program back to full service, a move with which she was not completely comfortable. As a result, relations between herself and Giddins and Odim, particularly at committee meetings, were marked by animosity. Giddins and Odim were eager to return to a full-service program, while McNeill resisted. Ullyot said that by a certain point in the committee's proceedings, there was conflict on this issue at nearly every meeting. Ullyot said that for the most part, Wiseman, Kesselman, Maas and Youngson did not participate in these discussions.

Kesselman said that he believed the committee was addressing problems that were situated in the OR.

This is an issue with the surgeons and with the anaesthetists and the nurses there primarily, and that if they can agree that the program should be escalated at this point, for our part, we are able to comply with that and we can manage the patients. And my view really was more from that point of view, that I was willing to go along with that so long as they were able to agree on it. (Evidence, page 34,043)

Wiseman testified that at the outset the committee members clustered themselves into three camps: the surgeon and the cardiologist in one camp; the anaesthetists and the nurse in another; the perfusionist and the intensivist in a third. The last camp was seen to lie between the other two.

Wiseman said that at times he felt there was a need for freer communication on the committee than existed. He also noted that team building could not take place until honest communication took place; without that communication, the team would be built on false pretences. He did not, however, seem to have taken any steps to address this issue.



Current Home - Table of Contents - Chapter 7 - The work of the committee during the month of June
Next The trip to Saskatoon (June 13-14)
Previous Corporate reorganization takes effect
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