The Pediatric Cardiac Surgery Inquest Report



Early Winter

On November 2, Postl, partly at Blanchard's prompting, met with Odim over lunch. At that meeting, Odim told Postl that he felt that a number of team members had not given him a fair chance. He also indicated that there was a poor turnout for M & M Rounds. Finally, Odim restated his belief that fewer anaesthetists should provide anaesthetic care to pediatric cardiac surgery patients. After this meeting, Postl attempted to attend a pediatric cardiac M & M Round, only to discover that it had been cancelled.

At some point in late autumn or early winter, Postl received a phone call from Ward, who said that he had met McNeill by chance at a public skating rink. Postl testified that Ward told him about his conversation with McNeill. She had said to Ward that the only problem with the Pediatric Cardiac Surgery Program was Odim. If he was removed from the program, then it would be fine. Ward told Postl that this was evidence that the anaesthetists were not giving Odim a chance. Postl spoke to Craig about the encounter, who in turn, passed the information on to McNeill. In her testimony, McNeill gave this account of her meeting with Ward.

So he and I skated together for a little while; and during that time I expressed my concerns with some of the recent events in the operating room, that perhaps some of our concerns that we had had earlier in the spring were recurring. I guess I was partially informing, partially ventilating, and partially asking what he thought of what had occurred, because he knew some of the patients involved.

At the time, I didn't really think much of the conversation, it was shop-talk type of a thing. He was one of the cardiologists in the program, and I thought it was a reasonable thing to talk to him about events that were occurring in the program. (Evidence, page 13,530)

McNeill testified that Craig told her he thought her comments would serve to undermine the program. McNeill arranged to meet with Postl. She testified that she:

. . . explained to him, you know, that I really hadn't meant to be malicious or had no intent to undermine the program, and it was really, I thought, a relatively innocent conversation between people that were involved in the same work. (Evidence, page 13,532)

Postl said that he did not view the encounter as a major issue, but recommended that she not be indiscreet in public places.

Postl testified that as November progressed, he became troubled that the numbers of concerns about the program were increasing. Also, he said, people seemed to be, in his words, simply handing off their concerns when they reported them to someone else. The problem appeared to be, however, that those to whom the concerns were being reported were not resolving the issue.

On November 7, Craig wrote to Blanchard, stating that he had read Odim's letter and saw it as a warning. He recommended that there be an external review of the program (Exhibit 19, Document 265).

Odim testified that some time after he sent his letter to Blanchard, Craig spoke to him about Odim's concerns with anaesthesia. Odim recalled that Craig told him that he would ask Reimer if he was prepared to do the majority of Odim's cases. Odim said that Craig also told him about the possibility of having Dr. Heather Tulloch work with Odim. Tulloch was an anaesthetist who had trained at the Children's Hospital of Pennsylvania and was working in adult anaesthesia at the HSC. Odim said that he was agreeable to those proposals, but that he never heard back from Craig.

In contrast to Odim's testimony, Craig testified that he never met with Odim at that time, stating that their one meeting had been in June 1994.

Craig did testify that Tulloch had contacted him to inform him that Giddins had sounded her out about the possibility of her working in pediatric cardiac surgery. Craig testified that he pointed out that Giddins was neither the section head of pediatric anaesthesia nor the department head of anaesthesia. Craig also said Tulloch was aware that the situation was highly charged and therefore she was hesitant about entering into it. Craig also said that he recalled that her name had been put forward at another meeting, possibly by Wiseman or Blanchard. At the time, Craig said that, before he agreed to her working in the PCS program, he would have to check on her knowledge and skills in anaesthesia for pediatric cardiac surgery. Because there was no further discussion of the prospect of Tulloch providing anaesthetic care for pediatric cardiac surgery, Craig did not pursue the option.

Craig also testified that at some point after the program had resumed full service in September, Blanchard had suggested that Swartz take a three or four-month break from the PCS program. Craig discussed this proposal with McNeill, who said that it would be a loss to the service since she regarded Swartz as one of its most capable members. During this same period, the anaesthetists decided that, whenever possible, two anaesthetists would participate in each case.



Current Home - Table of Contents - Chapter 8 - Early Winter
Next November 8-the case of KF
Previous The case of Ashton Feakes - Findings
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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