The Pediatric Cardiac Surgery Inquest Report



Background and diagnosis

Erin Petkau was born at Morden District General Hospital on December 17, 1994, at 0706 hours. The child of Walter and Barbara Petkau, she was born at 41 weeks gestation and weighed only 2,610 grams.

On December 18, after Erin had cyanotic spells and a heart murmur was detected, she was transferred to the HSC. On admission to the HSC at 2007 hours, her colour was pink and her oxygen saturation was good. She was also noted to have good femoral pulses and peripheral perfusion.

Tests conducted on December 18 and 19 identified:

  • Tetralogy of Fallot with a marked aortic override above a large ventricular septal defect and right ventricular hypertrophy
  • either an atrial septal defect or a patent foramen ovale
  • severe pulmonary valve stenosis
  • small pulmonary arteries
  • a patent ductus arteriosus.

Erin's aorta was positioned over the top of the ventricular septum (and thus termed an 'overriding aorta'), rather than being attached to the left ventricle. She had a large hole in the septal wall separating the ventricles. In addition, her ductus arteriosus was open and she had either an atrial septal defect or a patent foramen ovale, linking her atrial chambers.

Healthy heart
Healthy heart

Diagram 8.9 Erin Petkau - pre-operative heart
Diagram 8.9 Erin Petkau - pre-operative heart
1 - Atrial septal defect
2 - Severe pulmonary valve stenosis
3 - Right ventricular hypertrophy
4 - Patent ductus arteriosus
5 - Ventricular septal defect with overriding aorta
6 - Right ventricular outflow tract obstruction

Compare the pre-operative heart to a healthy heart side by side


Erin was treated with antibiotics for a possible infection. Dr. Soni saw her at 0400 hours and performed an echocardiogram. Soni assessed Erin as a pink Tetralogy of Fallot and recommended treatment with prostaglandin if there was a decrease in oxygen saturation. Giddins concurred with this assessment and indicated that surgery to insert a shunt was required. According to Barbara Petkau, Soni told the family that Erin would likely need surgery within one or two weeks.



Current Home - Table of Contents - Chapter 8 - Background and diagnosis
Next The decision to operate and consent
Previous Issues
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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