The Pediatric Cardiac Surgery Inquest Report



The case of Marietess Tena Capili

Background and diagnosis
The decision to operate
Pre-operative status
The operation-September 13

Cannulation issues
Problems with distension of the heart
Surgical bleeding and coagulopathy
The superior vena cava syndrome

Post-operative course
The family on the day of surgery
Operative reports
Post-mortem findings

Should the operation have been performed in Winnipeg or should Marietess have been referred out of province?
Were Marietess's parents provided with sufficient information to allow them to give informed consent to the procedure?
What caused the superior vena cava syndrome?
Should the surgical team have kept Marietess in the OR until the cause of the superior vena cava syndrome from which she was suffering was identified?
What was the cause of death and was it preventable?



Current Home - Table of Contents - Chapter 8 - The case of Marietess Tena Capili
Next Issues
Previous Craig's meeting with the anaesthetists
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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