The Pediatric Cardiac Surgery Inquest Report



Monitoring within the HSC

The evidence discussed in Chapters Six through Nine gives rise to the following findings regarding issues of monitoring of the HSC's Pediatric Cardiac Surgery Program in 1994.


The evidence suggests that the formal and informal monitoring of issues at the HSC failed to identify the problems with the Pediatric Cardiac Surgery Program in a timely fashion.


The evidence suggests that Drs. Blanchard and Bishop, the department heads responsible for the program at the relevant time, as well as the cardiologist, and the surgeon, did not adequately monitor surgical performance and results of the PCS program, on either a case-by-case or collective basis, particularly in the early startup period of 1994.


The evidence suggests that Drs. Blanchard and Bishop, the cardiologist and the surgeon also did not appreciate the significance of the poor level of communications and the poor interpersonal relationships between the surgeon and others that very quickly developed, and continued throughout the year.


The evidence suggests that Drs. Blanchard and Bishop were slow to respond effectively to concerns that were raised by program staff in the spring of 1994.


The evidence suggests that Drs. Bishop, Blanchard, and Craig should have informed their respective vice-presidents, in writing and in detail, of the anaesthetists' withdrawal of services in May 1994.


The evidence suggests that the Pediatric Cardiac Surgery Program should not have been allowed to return to full service in September 1994.


The evidence suggests that Dr. Odim's membership on the panel of surgeons that reviewed each surgical death for the Children's Hospital Standards Committee had the potential for a serious conflict of interest when the death involved one of Dr. Odim's patients.

As the numerous findings in this section indicate, there was a generally a failure of monitoring of issues and problems at the HSC in 1994.

There was no tracking of common indicators that might point to matters of concern, such as the duration of cardiopulmonary bypass times, the duration of total circulatory arrest times, the volume of blood loss, the number of units of blood and blood components transfused. According to the evidence, there were no plans in place to develop such a database at the time that the program was suspended. While a database was eventually developed, and showed times for such details as cardiopulmonary bypass, total circulatory arrest and cross-clamping, the database provided only a list of details for each individual patient. While data were collected for each child, they were not collected and analysed for patients as a group. As a result, it was not possible to track trends.

Nor was there any attempt to collect data from the Pediatric Cardiac Surgery Program and compare the results of the Winnipeg program with any others, and make some evaluation of the program's performance.

There was no debriefing setting in which members of the surgical team could debate and discuss pre-operative issues, intra-operative care (including surgical procedures and post-operative care) and outcomes. The M & M Rounds were mentioned as a possible setting for such discussions, but they dealt with cases long after the operation. (This was usually several weeks after the autopsy had been completed.) In addition, the M & M Rounds were clearly intended as teaching and learning opportunities for staff in the hospital generally and were open to individuals not involved in the case, such as medical students. These rounds were not intended as a forum for a full and frank discussion of the details of each procedure. These factors meant, in the medical culture of the time, that the M & M rounds provided limited opportunity where related concerns, such as communication between personnel, could easily be discussed.

In addition, the medical culture of the HSC unfortunately reflected the concept of the surgeon as the supreme and infallible captain of the ship. This meant that what should have been the collective concern about the team's ability to handle certain cases turned into highly charged conflicts centring on the surgeon. Once framed in that manner, it became difficult to have open discussions or successfully resolve the issues.

Furthermore, despite formal policies, it is clear that the use of incident reports was not an engrained element of the HSC culture. Hospital staff observed many serious and alarming events in 1994. Indeed, many staff members began keeping private accounts of these events. However, only one incident report was filed for the cases under review during the entire year. Problems and complications during operations were often not charted, recorded or reported to the Standards Committee.

The Standards Committee structure that the HSC depended upon was simply not capable of addressing and evaluating important questions in a timely fashion. The Standards Committee process did not, in most instances, begin to review a death until an autopsy had been completed.

Finally, often in 1994, managers ignored pertinent information that was brought to their attention and, at best, simply tolerated the bearers of bad news. Lamentably, the responsibility for dealing with this information was never clearly delineated.



Current Home - Table of Contents - Chapter 10 - Monitoring within the HSC
Next Monitoring outside the HSC
Previous Monitoring of issues and problems within and 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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