The Pediatric Cardiac Surgery Inquest Report




Jesse Maguire was born November 25, 1994, and was immediately diagnosed as suffering from an interrupted aortic arch, ventricular septal defect and an atrial septal defect. He underwent surgery on November 27, 1994, and died while on the operating table.

The issues to which this case gives rise are:

  • Should the operation have been performed in Winnipeg or should Jesse have been referred out of province?
  • Were Jesse's parents provided with sufficient information to allow them to give informed consent to the procedure?
  • Should Dr. Andrew Hamilton have assisted in this operation?
  • Was a cannula inadvertently dislodged during the operation?
  • Were all the repairs intact?
  • What was the cause of the poor perfusion following the initial repair?
  • Were Jesse's parents fully informed about the circumstances surrounding his death?
  • What was the cause of death and was it preventable?



Current Home - Table of Contents - Chapter 8 - Issues
Next Background and diagnosis
Previous The case of Jesse Maguire
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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