The Pediatric Cardiac Surgery Inquest Report



The department heads meeting of October 28

On October 28, Blanchard, Postl, Craig and Wiseman met. At this meeting, Postl summarized the discussions he had conducted with the individuals involved in the Pediatric Cardiac Surgery Program.

According to notes taken by Blanchard at the time, Craig said that pediatric cardiac anaesthesia was "remarkably naive & feel besieged. Reluctantally [sic] to see selves as a major part of problems." (Exhibit 66, HSC 68) Craig said he did not recall making these comments. He did say that he believed the department was to a measure insulated from the larger politics of the HSC. He also testified that he did recognize that, as a result of their actions in May, the pediatric cardiac anaesthetists did feel as if they were being portrayed as villains.

Blanchard said that it was at this meeting that he realized that "there were serious concerns in the nursing realm as well." (Evidence, page 36,625) Blanchard explained that he knew in May that the nurses had concerns, but he believed they were largely "in the realm of compassion, of caring, of grief, you know, that sort of thing." (Evidence, page 36,625) Despite this evidence of discord, Blanchard testified that he believed at the time that it was proper to allow the program to continue at full activity.

At the end of the meeting, he distributed copies of Odim's letter to the two other department heads and to Wiseman, with instructions that they not distribute it further. Craig testified that, when he read the letter, he was disappointed and wondered if the Wiseman Committee's efforts at team building were not doomed to failure.

In his testimony, Wiseman said that the letter was disturbing in a number of respects. He was now open to Odim's recommendation of an external review.

But an external review, because of the need for-my sense was that there was still a need for cardiac surgical expertise in the perspective of a review, which I didn't, I couldn't offer. And as you know, in terms of a genuine peer, there wasn't one in the city. (Evidence, page 40,712)

In his testimony, Postl commented that the letter disturbed him as well.

I remember reading it and being surprised at the intensity of the comment, some of the negativity that was expressed. I think that's my memory. I was a little surprised at that. (Evidence, page 35,488)

During the autumn, Postl began reviewing the surgical results from the Pediatric Cardiac Surgery Program and concluded that the numbers were not satisfactory. He testified that he raised the issue with Giddins. In their discussion, Giddins pointed to the small number of cases that were under review and suggested that the surgical results were consistent with the results during the period when Duncan was the surgeon. Giddins told Postl that some very difficult cases had actually gone very well. Giddins said that an improvement could be expected over time, as in Duncan's case.

This suggests that Giddins believed that Odim was progressing along a learning curve, and that events in the operating room needed to be looked at from that perspective. This was not the first time that Giddins and others had used this approach to rationalize the results that the program was exhibiting.

To repeat what has been said elsewhere in this report, it is simply not appropriate to allow patient care to be compromised while a surgeon gains experience. If it was felt results would not be as good as they ought to have been because Odim was progressing along a learning curve, greater care ought to have been taken in case selection to ensure that he did not take on cases that were beyond his level of skill and experience. That was never done.



Current Home - Table of Contents - Chapter 8 - The department heads meeting of October 28
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Previous The meeting of the anaesthetists on October 19
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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