The Pediatric Cardiac Surgery Inquest Report



Inappropriate staffing levels

Small surgical units must always struggle to find a balance with staffing issues. The team members must not be overworked, thereby putting patient care at risk. At the same time, each team member must be involved in a sufficient number of cases to maintain an appropriate skill level. There are no hard and fast rules on these issues. The evidence suggests that in 1994 staffing levels were stretched throughout the HSC. However, staffing issues in Cardiology, Surgery, Anaesthesa and Pathology proved to be of particular significance.


The evidence suggests that Drs. Blanchard and Bishop, the department heads responsible for the program at the relevant time, appear to have failed to recognize fully the implications of only one cardiologist being at the Variety Children's Heart Centre for most of 1994. Steps should have been taken to limit the number of patients seen at the centre, on the basis of Giddins's workload alone.


The evidence suggests that the fact that, throughout the existence of this program, there was only one surgeon who was on constant call, also placed a high degree of pressure on the surgeon.


The evidence suggests that shortages in the Department of Pathology also contributed to the fact that autopsy reports were not completed in a timely manner.


The evidence suggests that an appropriate balance had not been struck between the number of anaesthetists providing anaesthetic care to the program and the number of cases in which each anaesthetist participated.

Evidence was presented to the Inquest that, after spending all night at the bedside of a patient, Duncan was asked by Collins not to undertake a surgical procedure the next morning. On the other hand, there was evidence that Odim went into the operating room to perform a surgical procedure, on very little sleep, after spending the entire night in the ICU.

In contrast, while there were issues relating to staff shortages, there was also an issue with regard to whether there were too many anaesthetists providing service to the program. While there was no evidence presented to this Inquest to suggest that care suffered as a result, legitimate questions were raised throughout 1994 about the number of anaesthetists providing coverage to the Pediatric Cardiac Surgery Program.

The concept of the ability to develop and maintain skill levels is the same for an anaesthetist as for a surgeon, and for that reason, the number of anaesthetists providing coverage for the program should relate to the number of cases available. Williams and Roy, for example, said that the ideal number of anaesthetists should be between two and three anaesthetists for a program the size of Winnipeg.



It is recommended that: Any restart of the Pediatric Cardiac Surgery Program be initiated only after the relevant department heads jointly review staffing levels and assure themselves that they are appropriate to avoid overwork and fatigue and maintain appropriate skill levels. This applies to every discipline involved in the program.

More specifically:

Any restart of the Pediatric Cardiac Surgery Program be initiated only at a time when pediatric cardiology is staffed appropriately.

If the number of cardiologists in the Pediatric Cardiac Surgery Program is reduced following a restart, the program should reduce the level of service it provides.

Any new Pediatric Cardiac Surgery Program have provisions for relief for the pediatric cardiac surgeon. This could involve protocols for referral of patients out of province or arrangements to bring other surgeons into Manitoba.

The Department of Surgery for the HSC establish guidelines and protocols for surgeons that help in the decision as to when to operate if fatigued: for example, after being on call. These guidelines and protocols could be similar to those used by anaesthetists.

The Department of Pathology be properly staffed so as to be able to comply with reasonable guidelines for the completion of autopsies and autopsy reports as set out later in this chapter.

The Department of Anaesthesia ensure that the program has an appropriate number of anaesthetists. This number would have to take into account the need for anaesthetists to be involved in a sufficient number of cases to enable them to obtain a requisite level of experience, as well as ensuring that they are able to provide appropriate coverage for all cases.



Current Home - Table of Contents - Chapter 10 - Inappropriate staffing levels
Next Treatment of nurses
Previous Administrative issues
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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