The Pediatric Cardiac Surgery Inquest Report



Postl calls a meeting

Later that day, Postl convened a meeting in the HSC's Community Services Building on William Avenue. Present at this meeting were the pediatric section heads involved in the program: Seshia, Giddins, Ullyot and Kesselman.

It should be noted that no one from the Department of Surgery was present. Giddins said that he indicated that it was inappropriate for Odim not to be at the meeting. He said that if Odim was not going to be present, he felt he should not participate. Postl testified that, in response, he told Giddins 'to sit down', that those present were there to discuss the outcomes and that he was expected to participate (Evidence, page 35,566).

Postl told those in attendance that he thought the Pediatric Cardiac Surgery Program should be shut down and asked if they had any thoughts on that. He recalled that all of them agreed, although Giddins did so reluctantly because, as Postl recalled, he was not sure that there was support from the data to make such a decision.

Seshia indicated that the neonatal staff was losing confidence in the Pediatric Cardiac Surgery Program. She spoke both of the deaths of patients and the extended stays in ICU of those infants who survived surgery. Others brought up concerns with the length of bypass times and problems with pacemakers. It became apparent that the neonatologists had lost confidence in the program and were reluctant to refer even emergency cases to it.

A decision was made that such cases would, for the immediate future, be referred out of province. Since no elective operations were scheduled for the Christmas period, this meant that the program was temporarily inactive. Those at the meeting expressed the hope that the PCS program would be reviewed by Lindsay when he arrived in Winnipeg in January 1995.

According to Postl's testimony, the question was raised as to what would happen if the Department of Surgery chose to keep the program active. Postl indicated that his response at the meeting was that he would instruct all Section Heads of the Department of Pediatrics not to participate in the program.

Postl telephoned Craig and Blanchard and informed them of the conclusion reached at the meeting of his section heads. Craig was supportive. Blanchard accepted the decision, although the nature of the program's suspension was not determined at that point. Blanchard took it upon himself to speak with Odim. He told Postl that he would encourage Odim to take his holidays. The following day, Postl informed Wright of the decision. On December 22, Blanchard issued a memorandum stating that Odim would be on vacation for two weeks (Exhibit 19, Document 271).

Blanchard testified that he spoke with Odim, on either December 21 or December 22.

Well, I can't remember the details of it either, but we reviewed the particular case briefly, and then I told him that there has been a crisis of confidence, and it is not going to be possible to carry on in the near future. And I suggested to him, that being the case, he should take advantage of the gap and take a proper holiday. (Evidence, page 36,667)

In his testimony, Odim recalled that the meeting was with Postl, not Blanchard.

And I was called into Dr. Postl's office and he told me at that point that the program was going to suspend its activities, that there was too much tension within the hospital coming from the ICU staff and the nursing staff, and that they were simply going to wait until the end of the year when the new chief came to review the program.

And he felt that since they were suspending activities, I probably would need to take a break and I could use a rest, and he suggested that I take a vacation, you know, take my Christmas holidays. (Evidence, page 26,351)

Odim testified that this decision came as a surprise to him. He said that he did not ask Postl any detailed questions about who had raised the concerns.

It was clear that I was having difficulty rounding the troops towards my ends and my goals and my concept of a team. And it seemed that decisions were just being postponed and postponed, and I was sort of beginning to wonder whether it was really going to happen. And that was sort of my state of mind, and I did not get into a question and answer dialogue with them as to who and, you know, what group, what facet? (Evidence, page 26,354)

Erin Petkau was not the last child to undergo a procedure in the PCS program in Winnipeg, however. On December 21, Odim performed a scheduled ligation of a PDA on a two-and-a-half-year-old child. He performed this surgery after being up all night with Erin Petkau and taking a brief nap at the hospital. On December 22, he implanted a pacemaker in a five-year-old child.

The autumn and early winter had been a tragic and difficult period for everyone involved in this program. In September, the Wiseman Committee had released a report indicating that, after a period of review, serious communication issues had been resolved and the program was ready to undertake high-risk operations. However, by the end of September, Odim had written a letter that indicated a deep sense of frustration and a lack of confidence in his colleagues. This lack of confidence was reciprocated and only increased, as difficulties arose in the operating room and in the intensive care units.

Professionals are expected to rise above personal animosities. However, a team that is meant to perform pediatric cardiac surgery cannot function successfully in the absence of trust and confidence. Nothing was done in the Wiseman Committee to examine the roots of the distrust that program members felt towards each other. Little took place after the Pediatric Cardiac Surgery Program returned to full service to ensure that the team functioned as a team. This became increasingly apparent to the department heads throughout the autumn of 1994 and led to their decision to commission an external review. The decision to have Hamilton assist at Odim's operations represented a positive move in response to concerns and recommendations from a variety of people involved in the program. When Erin Petkau died following an operation in which Hamilton should have been asked to assist, the issues of surgical outcomes and lack of faith in the surgeon came together once more. The department heads had little choice but to stop the program, pending the outcome of a review.



Current Home - Table of Contents - Chapter 8 - Postl calls a meeting
Next Chapter 9 - The aftermath of the shutdown
Previous Reactions to Erin's death
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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