The Pediatric Cardiac Surgery Inquest Report



September 7 - the return to full program

Following the September 7, 1994, Wiseman Committee meeting, the members of the pediatric cardiac surgery team prepared to return to a fully operational program. Some team members still harboured significant concerns about the program's ability to provide appropriate care for patients with heart defects of high complexity. As was the case before the original slowdown of May 17, that concern rested almost exclusively with the nurses and the anaesthetists.

Although the program had been through a hiatus in providing care for patients with complex anomalies, it was obvious that little had been learned from the experience of earlier in the year; once again, little time was spent in preparation for the return to high-risk operations.

While a number of significant issues had been identified during the committee process, none of the procedures that had been in place before May 17 were altered when the program returned to full operation in September. Case selection and preparation had been raised as a significant issue at the committee. Despite this, there was no recommendation for any additional or improved pre-operative meetings that would involve pediatric cardiac surgery team members other than the cardiologist and the surgeon.

Communication had clearly been flagged as a serious issue; yet nothing was put into place to address issues of communication on an ongoing basis. No debriefing sessions were held after difficult cases, a small step that would have gone a long way to addressing any concerns that arose intra-operatively.

The concerns expressed by the PICU and NICU staff, about procedures being performed in their units for which they were ill-prepared, had not been addressed. Preparation of the cardiac bins-which had begun as early as April-had not been completed.

The Wiseman Committee's interim report would have left the department heads, to whom it was sent, with the impression that all matters of concern had been addressed and resolved during meetings of the committee. Unfortunately, this was a false impression.



Current Home - Table of Contents - Chapter 8 - September 7 - the return to full program
Next Craig's meeting with the anaesthetists
Previous Preamble
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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