The Pediatric Cardiac Surgery Inquest Report



Chapter 10 - Findings and Recommendations


The preceding chapters have recounted the events surrounding the deaths of 12 children during or after pediatric cardiac surgery at the Winnipeg Health Sciences Centre in 1994. While each of these children died under very specific circumstances, common issues have arisen from the evidence presented to this Inquest. They point to the conclusion that the serious organizational and personnel problems experienced by the Health Sciences Centre's Pediatric Cardiac Surgery Program during 1993 and throughout 1994 may have contributed to the deaths of some of these children. This leads to a central finding of this Inquest:


The evidence suggests that, during 1994, the Pediatric Cardiac Surgery Program at the Health Sciences Centre did not provide the standard of health care that it was mandated to provide and which parents believed, and had a right to expect, that their children would receive.

While some of the problems that the program faced related to the abilities and conduct of specific individuals, other problems were largely systemic in nature. These systemic problems related to the structure of the HSC, in particular to hospital policies and procedures governing staffing, leadership, teamwork, communication, decision-making and quality assurance. Weaknesses in all of these areas led to problems in the procedures and outcomes of the program. As a further result of systemic failures, the issues surrounding the abilities and conduct of certain team members, and the performance of the surgical team itself, were not dealt with in a timely or effective manner.

This chapter is devoted to setting out those findings and recommendations that are essential for ensuring that the situations that occurred in this program in 1994, and the manner in which these children died, will not be repeated. They include, among other things, the question of whether or not the HSC should continue to attempt to maintain a Pediatric Cardiac Surgery Program.

The overall objective of these recommendations, however, is to prevent a similar situation from arising at the HSC as occurred in 1994. The evidence suggests that this objective can best be met by strengthening program planning, establishing appropriate preventive measures and improving risk management.

The evidence also makes it clear that improving interpersonal and team communications and devoting resources to building and maintaining a properly functioning surgical team are keys to any similar future programs.

Meeting the latter objective requires that the culture of health-care institutions must change. It is particularly important that medical professionals provide parents with more information than was done in these cases. Also of particular importance is that nurses not be treated by doctors and hospital administrators as undertrained subordinates, whose concerns can be readily dismissed as emotional responses to tragic outcomes.

The ubiquitous nature of human error in a medical setting must also be accepted and better understood, and its occurrence no longer treated as a moral failing. Methods must be developed to reduce the frequency of medical and human errors within hospitals, trap such errors as they occur and reduce their impact.

The thrust of the recommendations in this chapter is not punitive. The need is to improve the health-care system so as to prevent the recurrence of events that occurred in 1994. It is necessary to accept that the health-care system will not improve if people act solely on the basis of a fear of consequences for themselves or their careers. Instead, the recommendations are intended to establish a structure within which highly skilled and talented people can establish a health-care team that continually works together to provide a high standard of care. All of the comments and recommendations in this chapter are intended to fulfil this objective.

However, there are recommendations that do call upon appropriate existing agencies to examine this report with a view to determining if any disciplinary or other action is required for those whose performance and actions may not have met the appropriate standard for the positions they held.

This rest of this chapter is made up of eight sections. They include findings and recommendations with regard to:

Each section contains findings, explanatory text and recommendations. The findings and recommendations flow from information already presented in previous chapters. For this reason, the explanatory text has been kept to a minimum.



Current Home - Table of Contents - Chapter 10 - Introduction
Next The loss and recruitment of program staff before 1994
Previous Chapter 10 - Findings and Recommendations
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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