Winnipeg inquest recommendations watered down, parents say

Seven years after 12 children died in Winnipeg's pediatric cardiac surgery debacle, 3 of the families involved fear the recommendations from the resulting inquest have been “watered down” in the report on their implementation.

The inquest report, which was nearly 6 years in the making (CMAJ 2001;164 [3]: 393), contained 36 recommendations on everything from whistle-blower legislation to the need for widely available physician profiles. Paul Thomas, a professor of political science at the University of Manitoba, had only 4 months to devise a practical plan to implement the recommendations.

Saul Simmonds, the lawyer for the 3 families, says the 51 recommendations in Thomas' plan “could have been written by the doctors. They've all circled their wagons.”

The inquest and the 2 reports that emerged from it relate to pediatric cardiac surgery that took place in 1994 at Winnipeg's Health Sciences Centre. Twelve infants died, for a mortality rate of 29% among high-risk cases; the norm was 11% (CMAJ 1998;159:1285-7). The parents endured 30 months of inquest testimony, then waited 3 years for the inquest report. The process took so long that some of the recommendations are redundant. In fact, the pediatric cardiac program has been shut down — these patients now transferred to Alberta.

Thomas says many of Judge Murray Sinclair's recommendations are “pretty pure and idealistic.” In the original inquest report, he says, Sinclair “didn't test the feasibility of his recommendations,” given Manitoba's “finite resources and other practical limitations.”

“We are a have-less province. Health is 40% of our provincial budget. I know it sounds crass, but we have to be politically and economically realistic.”

Simmonds and his clients are angry at this “glossing over.” He says whistle-blower protection for staff who disclose alleged wrongdoing is a prime example. Instead of implementing legislation, as suggested by Judge Sinclair, Thomas advocates in-hospital disclosure-protection policies that would be reviewed in 5 years. Simmonds says such policies have “no teeth,” but Thomas counters that new evidence from a similar inquest in Bristol, England (CMAJ 2001;165 [5]: 628) indicates that whistle-blower legislation doesn't work. “We don't want symbolic gestures,” Thomas told CMAJ. “We want to implement things that work.”

Thomas also called for a broader, systemic change in the “culture of error,” with the emphasis switching from secrecy to disclosure (CMAJ 2001; 165 [8]:1083).

One of the more contentious recommendations calls for physician profiles, which would include data on a physician's education, work experience, complaints lodged and disciplinary action. Thomas' report supports the creation of profiles, but he agrees that the program would be expensive and might deter physicians from moving to the province.

Thomas says he appreciates the parents' frustration, because in their view no one has been held accountable for the deaths of their children. He says the bottom line is accountability, but instead of blaming a few people he's holding 7 organizations, which must implement his recommendations, accountable. All 7 — 2 government departments, the regional health authority, hospital, nurses' association, College of Physicians and Surgeons and medical examiner — must report their progress by next spring.

The college is prepared to support the call for making physician profiles available to patients or their guardians, but it is concerned about the proposed inclusion of all complaints made to it.

Figure. Fifteen-month-old Ashton Feakes was 1 of 12 infants whose deaths following cardiac surgery in Winnipeg resulted in a lengthy inquest. Photo by: Canapress