The Pediatric Cardiac Surgery Inquest Report




Putting together a report of this magnitude and managing the process that led up to it, is an impossible task for one person. Many people contributed to this report and to that process.

Christina Kopynsky, Q.C., and Don Slough fulfilled their role as Crown counsel in the Inquest proceedings admirably. They reviewed all documents, interviewed and organized the calling of all the witnesses, prepared 'will-says' for counsel for the various parties summarizing anticipated witness testimony, and prepared excerpts from the exhibits and transcripts for hearings. Additionally, they each participated in the management of Inquest staff. They fulfilled their public responsibilities in a highly professional manner.

Donna Jorgerson and Debby Tack undertook the duties of court clerk for the Inquest hearings. They managed the thousands of pages of exhibits that were filed and operated the courtroom computer and projector. They also contributed to the smooth operations of the proceedings.

Thomas Fone and Paul Cech-Manek, Sheriff Officers, provided courtroom security.

Lanyse Guay was seconded from the Chief Medical Examiner's office for a short while as a Medical Investigator. She was replaced by Betty Owen-Nordrum, RN, who organized the medical charts so that they made sense to non-medical people. She also prepared case summaries from the charts of each of the twelve children, participated in interviewing witnesses, assisted counsel for all the parties with locating medical and other information when asked, and found material needed for the final report. She coordinated the preparation of the diagrams and medical drawings used in the report, as well as helped in proof-reading it. Her contribution was immeasurable.

Kathy Bhola kept the office organized, running the Inquest's administrative operations, maintaining records, and performing numerous other tasks. She would be an asset in any organization. Tera Cooper, Krista Sommer, and Agatha Kostefko were the Inquest's administrative assistants.

Dr. Jan Davies taught us all about human error and human factors analysis. Much of the information and material in this report on those subjects is a result of her work. She also assisted in proof-reading the final draft of the report.

Dr. Glenn Taylor provided invaluable assistance in the diagrams and drawings used in the report, especially with those drawings intended to represent the hearts and anomalies of each of the twelve children.

Cindy Chuckree created the illustrations that appear in this report.

Law students Kelly Moar and Rachel Charette read and summarized thousands of pages of documents and transcripts, and researched numerous legal issues. Jock Bates did the copy-editing, and the staff of Manitoba Culture, Heritage and Tourism - Information Resources Division supervised the printing and web-site development.

The firm of Finlayson Reid Reporting Services provided transcripts for the Inquest on a daily basis.

The professional expertise and patience of Steven Rosenberg, Debbie Crump and the staff of Doowah Design, who undertook the design and layout of the Report, is also gratefully acknowledged.

Finally, Doug Smith performed two important roles for the Inquest - those of researcher and writer. Armed with a remarkable ability to flesh out a series of ideas, thoughts and concepts into a highly polished written state, he put in countless hours reading transcripts and documents to become familiar with the material and to check sources, facts and quotations. His ability to digest and understand huge amounts of detail and information is impressive, but more importantly, his dedication to completion of a task, even one as enormous as this, was inspiring. I was very fortunate to have been able to convince him to work with me on this.

While all of the people mentioned played a role in the development of this report, its contents including any errors are my responsibility.

Associate Chief Judge Murray Sinclair



Current Home - Table of Contents - Acknowledgements
Next Chapter 1 - Introduction to the Issues
Previous Introduction
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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