The Pediatric Cardiac Surgery Inquest Report



From Lindsay to Williams and Roy

The plan to have Dr. Bill Lindsay review the Pediatric Cardiac Surgery Program had to be abandoned on January 2, 1995. On that date, it was learned that Lindsay would not be taking up his position as the head of cardiovascular and thoracic surgery and cardiology for both the HSC and St. Boniface General Hospital until February 1995. Dr. Robert Blanchard assumed the responsibility of finding someone who could conduct a more immediate review. It was obvious that, with the decision to suspend the program pending a review, time was of the essence.

Because the decision to bring in outside reviewers had financial implications, it required and received the approval of HSC President Rod Thorfinnson. Interestingly, the decision to bring in external reviewers was not taken to the Medical Advisory Committee, which met in both January and February.

Dr. Bill Williams, head of cardiovascular surgery at the Toronto Hospital for Sick Children, and Dr. Larry Roy, a cardiac anaesthetist from the same hospital, were contracted to conduct the review. It was to be conducted with very tight timelines. On January 9, a notice was sent out to all the doctors involved in the program, asking for written submissions that could be sent to Williams and Roy by January 13. The doctors involved began preparing the information they wished the reviewers to see.

On the other hand, the nurses were not informed of the appointment of Williams and Roy, and they were not at that time asked to prepare any written submissions. This was an amazing oversight, given the degree to which the events within the program had affected them individually and collectively and the degree to which they had struggled to bring problems within the program to the attention of the authorities in the hospital. It was, however, sadly in keeping with the way that nurses had been treated throughout the process.

In his submission to Williams and Roy, Dr. Murray Kesselman said that the main issues for the pediatric intensive care unit with the pediatric cardiac surgery program had been confusion over supplies that the surgeon required for bedside care, controversy over sedation and pain relief (analgesia) and post-operative complications.

In her submission, Dr. Molly Seshia noted that the neonatal intensive care unit had not received any protocols from Odim. The NICU nurses early in 1994 had drafted a protocol, but it was still awaiting Odim's input. In a separate memorandum, she asked that Williams and Roy look into such matters as bypass times, mortality rates, complication rates and the quality of diagnostic, anaesthetic and post-operative care.

Giddins's submission was less concerned with addressing problems he saw with the program than with giving Williams and Roy information about what had occurred. Giddins identified three separate phases to the events of 1994. The first phase, from February to March 1994, was marked by what he termed 'understandable' issues, as the team members familiarized themselves with each other. He wrote:

While I had felt that pre-op discussions had been detailed, academic, and fruitful from an early stage, the intra-op 'network' is obviously more intricate - needing greater time to develop. As acting medical director, I must of course take major responsibility for case selections during this and later periods. (Exhibit 20, Document 284)

His admission that he had a 'major responsibility' for case selection was an appropriate and professionally responsible act, considering the fact that case selection had been such a major concern during 1994.

The second period, that of the crisis of confidence, took place in April and May. Of this period he wrote:

The anesthesia service in particular appeared uncomfortable with their role in the cardiac OR, and therefore a moratorium was placed on anything other than palliative (closed) procedures and simple open cases (ASD's). By August, the team (as it was now referred to) had proceeded to 'medium' risk procedures (non-infant VSD's), with good success. Vocalization of frustration that there weren't more of these 'medium-risk' cases around! By mid-September, it was felt appropriate by all to proceed to essentially 'all-comers' (understanding that complex situations - particularly neonatal - would be subject to transfer out). (Exhibit 20, Document 284)

The suggestion that "complex situations - particularly neonatal - would be subject to transfer out," however, has to be considered in the face of the fact that none of the "complex neonatal cases" that the team faced in the fall of 1994 were even considered for transfer.

The final crisis of confidence came, he said, in December. In summarizing the situation in Winnipeg, Giddins made the following observations:

There are, no doubt, weaknesses in the current makeup of the section of Cardiology. As a smaller pediatric centre and heart program, all staff (medical, nursing, technical) have had to be flexible. As the only cardiologist here for the 9 months before the arrival of Dr. Ward in July, it was impossible to provide any more than a consultation service to the hospital. Since his arrival, things have been little better, considering the inevitable medical 'backlog' that had developed. This has had direct effects on everything from our ability to get acquainted with transesophageal echo techniques to being more involved at the critical care bedside. While Dr. Ward is extremely accomplished, this is still his first staff appointment. Both of us would be considered junior in many centres. We have done our best to help short of direct bedside management, which with our current clinical demands would be impossible. (Exhibit 20, Document 284)

On January 12, 1995, Odim forwarded a letter to Williams, describing his perception of the issues at the hospital. A portion of that letter simply reprinted excerpts from his September 26 letter outlining the May 17 withdrawal of services. Odim then summarized the Wiseman Committee experience. He stated that among the issues dealt with at that time were the mortality and morbidity rate, a lack of confidence in the surgeon, communication issues, the learning curve that the surgeon and cardiologist faced, proper decorum in the OR and the issues facing a pediatric cardiac surgery program in a small market. He concluded by saying:

Clearly, I have had some difficulty establishing myself as the captain of the ship. This is further unmasked by the lack of local leadership in cardiac surgery, cardiology, and anesthesia. (Exhibit 20, Document 286)

Ullyot prepared the anaesthetists' submission. It highlighted concerns about case selection, surgical results, and the program review and case review process. Her submission noted that the Wiseman Committee had not fully addressed the concerns that had led the anaesthetists to withdraw their services. It also emphasized the lack of an overall strategy for the program's development and called for a review of the number of anaesthetists required for the program. Finally, her report stated that the nurses must be involved in the review process.

Blanchard prepared a lengthy submission that is worth quoting in detail.

My own perspective is generic and necessarily non-technical. A serious error on my part when Jonah arrived was failure to anticipate the potential for difficulties in introducing a new surgeon without a senior mentor or team-builder. When Kim Duncan joined our program in July 1986, [Jary] Barwinsky had been carrying on a modest program of closed cardiac surgery at the Children's Hospital and served to introduce Kim into the system and assist him. More important, George Collins was the father-figure for the entire Variety Heart Program at the Children's Hospital and was a major influence in helping Kim Duncan over the rough spots, especially at the beginning of his activities here. After Kim Duncan left in August 1993, the program was discontinued pending the recruitment of a Paediatric Heart Surgeon. When Jonah arrived, there was no cardiac surgeon with any interest or recent activity at the Children's Hospital and George Collins was no longer with us. Unfortunately, we left Jonah to fend for himself in a new environment with different procedures than he had previously experienced. He did not know our team and the team did not know him. To make matters worse, Jonah has not, it appears, established strong links with easy communication among some of the key players, especially Anesthesia. From my perspective, the anesthetists behaved in an adversarial fashion without making allowances for the situation of a new junior surgeon who should have been the director of the team. It appeared to me that, when things appeared to go wrong, the anesthetists and some nursing staff were ready to believe that this was entirely the fault of inadequate surgical management.

Nonetheless, communications were not established from either side to try to sort these things out and I, at least, was not aware of the serious nature of the problem until the anesthetists unilaterally boycotted the program. We then set up a series of meetings chaired by Dr. Nathan Wiseman, Director of the Paediatric Surgical Services. His report is attached along with my response to it that may have been too optimistic. During this period I interviewed those who have worked with Jonah as assistants or colleagues and was told that he is technically capable, if somewhat slow. He has also been considered to be knowledgeable. The Anesthetists and staff at the General Hospital (Adult) have found his operative procedures to be on par with our average adult cardiac surgeons. I am not capable of judging his surgical skills nor surgical judgement directly. I tried to get Jonah to work more closely with another new recruit whose primary activity is adult cardiac surgery, Andrew Hamilton. Unfortunately, Jonah has not always availed himself of this individual's assistance and support and one is left wondering why he did not do this. My direct discussions with Jonah lead me to believe that he is open and willing to work things out. (Exhibit 29, Document 391)

He concluded the letter by stating:

From my perspective, the problems are as follows:

  • A junior solo paediatric heart surgeon without a mentor.
  • Jonah seems not to be sufficiently clear and direct in communications.
  • When things go wrong in the operating room, it is reported Jonah appears to become flustered at times.
  • There may be problems in judgement, both for case selection and in the conduct of some problems when things are not progressing as anticipated. I have no direct indication of this, but from interviewing Jonah I wonder whether he always scans the whole horizon of possibilities.
  • Jonah maintains a dignified and calm exterior. Perhaps this is misinterpreted by some of the nursing staff as lack of caring. My own reading of Jonah is that he is a dedicated and caring individual who certainly is willing to work hard to develop a good program. It would appear, however, that he is somewhat reluctant to ask for help, advice, or moral support when it is needed.
  • There are probably too many Anaesthetists.
  • There are two Critical Care Units dealing with a small volume of difficult post-operative patients.
  • We failed to spend time at the beginning to work through the whole system, using simulations and trial runs. (Exhibit 29, Document 391)

On January 13, 1995, Blanchard sent a memorandum to sixteen doctors involved in the program, advising them that Williams and Roy would be present at the HSC on January 25 and urging them to make themselves available on that day.

However, once again the nurses were left out of the loop. They had not been given advance notice to prepare submissions to the Williams and Roy Committee; nor were they given the same notice that doctors received of the impending visit. The director of pediatric patient services, Isobel Boyle, belatedly received notice of the Williams and Roy process. When she brought her concerns to the head of the Department of Pediatrics, Dr. Brian Postl, she said he indicated that the nurses had to be involved in the process. It fell to Irene Hinam and Carol Youngson to organize the nurses' response. Hinam approached both the NICU and PICU nurses and assisted them in preparing reports (Exhibit 20, Documents 278 M, 278 N, 278 O).

Their report stressed:

  • Lack of preparation at the start of the program;
  • Poor planning;
  • Odim's poor understanding of hospital protocols;
  • Poor communications with nurses and families;
  • Lengthy operations;
  • Increased need for heart pacing;
  • Deaths of children who were not high-risk;
  • Monitoring lines falling apart;
  • Post-operative bleeding;
  • Concern over longer than expected stays in ICU; and
  • Poor morale.

On January 25, 1995, Williams and Roy met from 0730 hours to 1900 hours with individuals involved in the program. From their itinerary, while it would appear that they met with operating-room nurses, it does not appear that they spoke with any of the NICU or PICU nurses.



Current Home - Table of Contents - Chapter 9 - From Lindsay to Williams and Roy
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Previous Chapter 9 - Table of Contents
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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