The Pediatric Cardiac Surgery Inquest Report



The role of the President
and vice-presidents

In their testimony, several of the vice-presidents indicated that they were surprised by the information that they had received at this meeting. Wright had been kept briefed by Postl of his concerns and knew in late November or early December that he had been thinking of closing the program. Wright testified that, when she took on her new responsibilities on June 1, she was briefed by Dr. Agnes Bishop, the outgoing head of pediatrics. Bishop had told Wright that there had been problems with the Pediatric Cardiac Surgery Program, but a multidisciplinary committee was looking at the issue. Wright said that she may have briefed Thorfinnson about this matter at the end of June, but it would have been simply to say that a committee had been set up to deal with problems. Wright said that she had not seen the Wiseman Committee interim report when it was prepared in the summer of 1994, but had been briefed about its contents. The one report from her mentioning the program in 1994 that went to the Board of Directors of the HSC simply indicated that a new surgeon had been hired and that the program was providing full service.

VanDeVelde-Coke testified that before the meeting she had not known about either the withdrawal of the anaesthetists from the program or the existence of the Wiseman Committee.

Sutherland said that he felt the department heads should have informed him of the events of May 1994. He did add, however:

These three department heads, Dr. Bishop, Dr. Blanchard and Dr. Craig, were three of the people on whose judgment I relied on greatly. They were excellent department heads, and had good insight, good wisdom. And if they came to me and said, Ian, we have got a problem, and this is how I have dealt with it, and, in fact, looking at how they dealt with it in terms of setting up a committee of individuals who were involved in delivering the health care, and getting them to review it, and getting their buy in to re-establishing it, I don't think I could have done any better than that. (Evidence, page 38,437)

In his testimony, Thorfinnson said that before the summer of 1994, he had been made aware there were some problems in the program, but had been assured that they were being addressed. He was not certain how he had been given this information, but thought it might well have been from Wright. Thorfinnson testified that, with the benefit of hindsight, the details of the anaesthetists' action should have been brought both to his attention and to the attention of the Board of Directors. Again, he indicated, it would have been unlikely that either he or the board would have taken any action other than to allow the Wiseman Committee to do its work. Thorfinnson also said that he thought the matter ought to have been addressed by the MAC. He did not think it would have been appropriate to have been brought up at the Nursing Council. While nurses were involved in the program, it was in his opinion a medical and surgical issue, not a nursing issue.

Thorfinnson testified that Blanchard spoke to him about the program's problems twice in 1994, once in early December and once following the decision to stop performing surgery pending a review. At the first meeting with Blanchard, Thorfinnson said, Blanchard had said there were concerns with surgical outcomes and that he was monitoring the program. Thorfinnson testified that he asked if there were problems with Odim's competency, a question that Blanchard indicated that he could not answer. In terms of the manner in which the issues were reported to the Vice-Presidents and the President, Thorfinnson said:

It has become I think very clear to the vice-presidents and no doubt to the people who report to them that any activity of this magnitude should be reported up very quickly. And that's the major impact of that reporting mechanism. (Evidence, page 46,522)

Blanchard testified that he met with Odim on February 13 and informed him that the program was being shut down for at least six months. He also told him that if the program were to be revived, Odim would no longer be the surgeon. Blanchard advised Odim to seek another appointment and requested that he resign immediately. Blanchard testified that Odim indicated that he would resign. However, Odim never submitted a resignation. He testified that he told Blanchard he needed time to consider whether or not to resign. He said that he spoke with Blanchard by telephone later that night and told him that he did not intend to resign. Blanchard did not pursue the matter, but Odim did not participate in any more pediatric cardiac surgery at the HSC after that date.

On February 14, 1995, the HSC issued a news release that read in full:

The Health Sciences Centre announced today that the Pediatric Cardiac Surgery Program will undergo an intensive six-month review to ensure that the best possible cardiac care service is available to young Manitobans and their families. This decision was made because patient outcomes have not achieved standards which the hospital hoped for when the program was re-introduced in February 1994.

An external review of the Pediatric Cardiac Surgery Program was commissioned by the Health Sciences Centre in January 1995. The report of the external reviewers highlighted a number of areas in which the program could be improved, including staffing patterns, resource allocation and the meeting of outcome objectives. Fundamentally, the review questioned whether, in a population of about one million people, there are sufficient numbers of children requiring heart surgery to maintain the clinical expertise required.

In the course of the next six months, the Health Sciences Centre will consider a variety of steps which might be taken to optimize the activities of the program. Such steps might include more formalized links with other centres where pediatric cardiac surgery is performed, reallocation of financial resources in support of the program and revisions to program staffing patterns.

Patients requiring pediatric cardiac surgery have been transferred to Saskatoon or Toronto since Christmas 1994 and will continue to be transferred until the Centre's review has been completed. This practice, which has been routinely followed in the past, will ensure that Manitoba's children continue to have prompt access to the full spectrum of pediatric cardiac services during the six month review period. (Exhibit 43)

Not surprisingly, this news release generated a considerable degree of coverage. That coverage was not without its negative impacts.



Current Home - Table of Contents - Chapter 9 - The role of the President and vice-presidents
Next The parents
Previous Responding to the report
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
Search the Report
Table of Contents