Erica Bichel was born at the Victoria General Hospital in Winnipeg, on Thursday, September 29, 1994, at 2301 hours. The third daughter of James and Judith Bichel, Erica had a normal delivery at only 36 weeks gestation.

On her admission to the nursery at the Victoria General at 0010 hours on September 30, the initial nursing assessment found Erica to be alert, active, with pink colouring and in no respiratory distress. There was no detectable heart murmur. Over the next 24 hours, however, as her ductus arteriosus began to close, Erica's condition started to deteriorate. Her colour became dusky, her respiratory rate increased and she had trouble feeding. On October 1, the Neonatal Transport Team transferred Erica to the HSC, arriving at 1651 hours. This was just over 40 hours after she had been born.

Erica was admitted to the NICU at 1700 hours. By 1930 hours, she was pale and mottled, with increased duskiness. Her heart rate was rapid at 178 beats per minute, her blood pressure had dropped and her oxygen saturation had fallen. A chest X-ray revealed her heart size to be at the upper limits of normal and the findings suggested pulmonary edema.

She was diagnosed with:

• tricuspid atresia
• an atrial septal defect
• anomalous pulmonary venous connection
• transposition of the great arteries
• a hypoplastic aortic arch with coarctation
• a small VSD
• severe hypoplasia of the right heart.

The ductus arteriosus had closed, but reopened after Erica had been given prostaglandin.

Tricuspid atresia meant that Erica lacked the normal opening (or tricuspid valve) between the right atrium and right ventricle. The large atrial connection denoted a hole in the wall between her left and right atria. The pulmonary veins usually connect to the left atrium individually; however, in this case they came together as a single vessel before connecting to the atrium. As a result of the transposition of the great arteries, Erica's aorta and pulmonary artery were each connected to the wrong ventricles. Because of the coarctation of the aorta, this blood vessel was pinched and underdeveloped. The pinching restricted blood from flowing from the heart to the rest of the body. In Erica's case, the right ventricle was severely hypoplastic (underdeveloped). This left her reliant on her left ventricle for all of the heart's pumping action to the body and to the lungs. It should be noted that she also had a hole in the septal wall between her ventricles.

The presence of an underdeveloped right ventricle and transposition of the great arteries meant that Erica had functional, as opposed to a true, hypoplastic left heart syndrome.

In their report for this Inquest, Duncan and Cornel concluded that Erica's difficulties had been properly diagnosed. If she was to survive, it was necessary that surgery take place within days of the diagnosis.

Healthy heart

Diagram 8.3 Erica Bichel - pre-operative heart 1 - Transposition of the great arteries 2 - Atrial septal defect 3 - Tricuspid atresia 4 - Hypoplastic aortic arch (with coarctation) 5 - Patent ductus arteriosus 6 - Confluent pulmonary veins (diagnosed as anomalous pulmonary venous connection) 7 - Dysplasia of mitral valve 8 - Ventricular septal defect 9 - Hypoplastic right ventricle