The Pediatric Cardiac Surgery Inquest Report




Life is a precious and fragile gift. The gift to the parents of the children who were the subject of these proceedings lay in what they could be. Born with the burden of a defective heart, they yet stood on the threshold of possibility. For reasons beyond their control, however, their possibilities were not to be realized.

The events surrounding their deaths have been examined in considerable detail and the findings and recommendations that seem appropriate have been set out. But for the families, that may never be the end of it.

The evidence suggests that some of the children need not have died. The Paediatric Death Review Committee of the College of Physicians and Surgeons, in its annual report for 1994, classified four of the twelve cases (without identifying which cases) as being possibly preventable with improved medical management. I believe that that number could be even higher.

The evidence from these proceedings suggests that the deaths of Jessica Ulimaumi, Vinay Goyal, Marietess Capili, Jessie Maguire and Erin Petkau involved some form of mismanagement, surgical error or misadventure and were all at least possibly preventable or preventable. The operations on Daniel Terziski and Erica Bichel involved procedures that were probably outside the ability of the surgeon and the team to attempt and ought not to have been done in this province. The operation on Shalynn Piller was outside the permitted parameters applicable to the team at the time of the operation and also ought not to have been done in this province.

The deaths of Gary Caribou, Alyssa Still and Ashton Feakes are still surrounded by more questions than answers. Only the death of Aric Baumann from a fatal and untreatable disease has been acceptably explained.

Much of the time involved in the writing of this Report has been spent in determining what occurred and when and how. To a certain extent there remains the question of why. To that there are no easy answers. The best that this report and the hearings could do is to uncover the events of that year and reveal what went on. To the extent that there are reasons for what occurred, they are offered in this and preceding chapters.

Yet we are faced with the fact that the parents of these children have been left with a great burden: the loss of a child. Parents are not supposed to outlive their children. Those parents have no choice but to try to adapt to that situation.

For some of them, this proceeding may have provided a catharsis, but for others it has not. Some of the families feel the obligation to take the matter of their children's deaths further, through other types of proceedings and actions. For some of the families, a belief in a Higher Power has allowed them to come to terms with what has happened. For others, there is nothing, I suspect, that will bring them peace. If they can find any solace in this report, it is in the knowledge that the details of the tragic events of 1994 have finally been brought to light.

However, there is something that must be stated clearly.

From all of the facts and evidence that have been uncovered, there is one that stands out. The deaths of these children were not the result of any failing on the part of the parents. There was nothing that these parents did that they ought not to have done. There was nothing that they did not do that they should have done. Faced with the situation that each of them saw, they did what they believed was best for their child and they acted on the basis of the best information that they were able to obtain.

Yet of all those who have been involved in this sad proceeding, the parents will continue to carry the greatest burden.

For that, we owe them the commitment to do all that we can to ensure that this does not happen again.



Current Home - Table of Contents - Chapter 10 - Conclusion
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Previous Referral to the College of Physicians and Surgeons of Manitoba
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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