The Pediatric Cardiac Surgery Inquest Report



Pre-operative status

During the night of December 20, Erin's extremities were very cool, and she was placed under a radiant heater. She was very irritable and tremulous but settled with sedation.

In his report, Hudson raised a potentially serious point. He wrote that:

A coagulopathy was present before surgery. I was not able to locate any notations in the chart that indicated that anyone involved in the care of this patient was aware of these results. Intraoperative and postoperative bleeding were major problems that likely contributed to the death of this patient. The failure to diagnose and treat this coagulopathy before surgery are major deficiencies in the management of this patient. (Italics and bolding in original) (Exhibit 307, page 12.14)

Hudson subsequently revised this conclusion. Documentation was presented to him indicating that there had been a pre-operative administration of Vitamin K, the treatment that he believed had not been provided. Secondly, he agreed that the lack of bleeding in the early stages of the operation indicated that Erin did not have a coagulopathy pre-operatively:

I would agree with Dr. McNeill's conclusion that those results then, in a neonate and in the context of having been given vitamin K, are at best mildly abnormal. (Evidence, page 40,049)

With the resolution of this issue, it can be concluded that the diagnosis, pre-operative care and surgical plan were appropriate in this case.



Current Home - Table of Contents - Chapter 8 - Pre-operative status
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Previous The decision to operate and consent
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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