The Pediatric Cardiac Surgery Inquest Report



Delays in the autopsy reports

Autopsies were conducted on nine of the 12 children who died in 1994. In the cases of Gary Caribou and Vinay Goyal, the families requested that there be no autopsy. In the case of Daniel Terziski, a miscommunication led to a situation where an autopsy that should have been performed was not performed.

In the nine cases where autopsies were carried out, the autopsy itself was performed within a short period of time (generally within 48 hours), but there were extremely long delays between the autopsy and the completion of the autopsy report. The Baumann family had to wait over five months, while several other families had to wait over four months for the reports to be completed. In the Still and Piller cases the reports were completed quickly. However, it is also apparent that other autopsy reports were completed only because of the pressure that mounted following the closure of the program in February 1995.

It appears from the evidence that five autopsy reports were completed in February 1995, within a ten-day period following the closing of the program. If the program closure had not generated intense demand from the parents for these reports, then it would appear to be reasonable to assume there might have been further delays in completing those reports.

Dr. Susan Phillips, the Chief Pediatric Pathologist at the HSC, testified that during 1994 she believed pediatric pathology to have been understaffed. She pointed to efforts that she had made to have a third pathologist appointed to assist her and Dr. Joseph de Nanassy. However that position was not filled.

In 1994 Phillips and de Nanassy did 197 autopsies. They also examined 2,271 pediatric surgical specimens. These are specimens removed from living children, usually during operations. In general, the specimens must be examined and reported on within 24-48 hours.

The Fatality Inquiries Act states that, where an autopsy has been ordered by the Chief Medical Examiner, an autopsy report must be submitted to the Chief Medical Examiner's Office within 30 days of the autopsy. There is no deadline if an autopsy is not ordered by the CME. Phillips testified that she understood that requirement to mean within 30 days of the completion of all tests, not 30 days after conducting the initial autopsy. She pointed out that many tests results do not come back until well after the 30-day period. She stated that it was her goal to have the autopsy reports to the CME within three months of conducting the initial autopsy. Using that as a standard, the HSC met this deadline in six of nine cases.

However, the Act itself is clear: a report is be submitted within 30 days of the autopsy. It is also clear that this report must be comprehensive enough to allow the CME to make the crucial decision as to whether to proceed with further investigation or even to order an inquest.

One of the factors that seems to have contributed to the ongoing disputes that existed within the program was the lack of specific information about, or disagreements over, what had occurred. The pathologist's report is one tool that can be used to help resolve such disputes and questions. Unfortunately, the delay in the autopsy reports meant that decision-makers lacked access to valuable information. The narrowing of the cannula sites in the Tena Capili case should have been made known by October before the operations on Erica Bichel, Ashton Feakes, Jesse Maguire, and Erin Petkau were undertaken.

In his testimony to the Inquest, Markesteyn indicated that his office was not able to enforce speedier completion of autopsy reports.



Current Home - Table of Contents - Chapter 9 - Delays in the autopsy reports
Next The College of Physicians and Surgeons
Previous The Quality Assurance Committee
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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