The Pediatric Cardiac Surgery Inquest Report



Reactions to Erin's death

The death of Erin Petkau brought the long-simmering crisis in the Pediatric Cardiac Surgery Program to a head. Her death, coming so quickly after the death of Jesse Maguire and the complications suffered by JR and ID, demoralized almost everyone involved with the program.

Giddins testified that the Petkau case left him saddened, exhausted and perplexed. He said the outcome had shaken his confidence in the program.

I remember being shaken, just in the course of events, that all things considered, particularly in the neonatal intensive care unit, that the outcomes and the efforts involved in the preceding months didn't seem to correlate.

Everybody had been working, extraordinarily busy on numbers of both simple cases, more complicated cases, cases that seemed to go without a hitch and cases that seemed to go with lots of hitches. (Evidence, page 4,581)

Youngson had left the OR before the end of the case, having participated in the Petkau case until 1530 hours, when her shift ended. At the time she left, the operation had been progressing well. She learned of Erin's death from McGilton when she came to work the following morning. Youngson testified that she spent the Christmas holidays in a state of desperation. She resolved that when she returned to work in January, she would contact a co-worker whom she believed knew the then-Minister of Health, James McCrae. Through this person, she intended to contact McCrae and communicate her concerns about the program. However, on her first day back at work in January, Youngson was informed by Swartz that the program had been suspended pending an external review, rendering her plan to approach the Minister of Health unnecessary.

McGilton had been involved in the Petkau case until Erin was transferred from the OR to the NICU. When McGilton arrived for work the following morning, she asked how the baby was doing. When Odim told her that the Erin had died, McGilton testified that she broke into tears.

I just, I left and I went into another room where there wasn't anything going on and kind of got myself together.

I went to the desk, and Karin Dixon asked me if I was okay, and I lost it again.

She phoned Isobel and said that I should go see her, and I did talk to her later that day, and told her that I absolutely couldn't do it anymore. That was it. And what had happened, and it was-she said that she would talk to somebody and do something, but I don't know who she talked to. (Evidence, page 10,648)

Following this conversation, Boyle spoke with Postl:

There was a case booked for the next day, and ICU was very busy, there was some insistence that that case be done. And I said, Brian, I can't ask those nurses to go back in there, I just can't do that. I said, we are three days, four days before Christmas, ICU is full, we don't have a bed there, we have two kids already, cardiac kids in the unit, or what it was. I said it is hard, I can't find extra staff to staff at this time, and most of all I couldn't get the nurses to go in. (Evidence, pages 32,712-32,713)

McNeill said that when she heard that Erin had died, she experienced a sense of total frustration.

I think, I mean, it was an accumulation of things up until then. We had had some events in cases that we had been doing over the fall that were difficult to understand or were concerning, and we were involved in this process of review that at times felt inadequate, and almost impotent really, and to be involved again on a personal level with a patient who died, just mounted to that sort of feeling. I felt really we weren't progressing, or we hadn't made any strides forward from where we had been in the couple of months before. (Evidence, page 13,653)

She decided that she would withdraw from pediatric cardiac anaesthesia. Before taking any action on this determination, she spoke with Seshia, who questioned her about the course of the operation. Seshia then met with Postl.

I told Dr. Postl that we had now had problems with two babies with B-T shunts. I told him that we had a baby who was paralyzed, okay, following an arterial switch, which he already knew, and he knew about Jesse Maguire. I indicated that ethically, I was also speaking generically for my colleagues, that we would have difficulty ethically referring a neonate for cardiac surgery here. (Evidence, page 33,583)

Seshia was very disturbed by the fact that two procedures, which in her opinion, were low-risk, had gone so wrong. Postl asked her what she thought should be done. She said that she told him "I don't think we can go on with things the way they are." (Evidence, pages 33,584-33,585) Postl agreed to set up a meeting for later that day.

Seshia then met with McNeill and Swartz, who told her of their concerns over mortality with the program. The two anaesthetists also told Seshia of their concerns about Odim's problems with cannulation and the duration of the procedures.

In his testimony, Postl said he believed that it was on this morning, not earlier in December, that Casiro came to him with his concerns with the program.



Current Home - Table of Contents - Chapter 8 - Reactions to Erin's death
Next Postl calls a meeting
Previous The case of Erin Petkau - 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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