The Pediatric Cardiac Surgery Inquest Report



Human and Medical Error

In performing its mandate, an inquest has a responsibility to determine if changes are needed in the way that institutions and organizations go about their activities, so as to prevent such deaths from recurring. That requirement calls upon judges who preside at inquests in this province to consider the question of medical error and institutional responsibility. While it does not permit inquest judges to declare on the question of culpability (as has been discussed elsewhere), it does permit judges to identify and discuss individual and institutional error.



Current Home - Table of Contents - Chapter 10 - Human and Medical Error
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Previous Monitoring outside the HSC
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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