A judge looking into the deaths of 12 babies after heart surgery at a Winnipeg hospital has concluded at least nine of them could have survived.
Manitoba Justice Murray Sinclair ruled that five of the babies' deaths were preventable, while four others were "possibly preventable" in a 502-page report released on Monday.
Sinclair led an inquest that reviewed the deaths of 12 babies in 1994 at the Health Sciences Centre General Hospital in Winnipeg.
The hospital issued a formal apology on Monday to the families of the 12 children who died.
Dr. John Horne of the Health Sciences Centre also apologized to the nurses whose warnings about the program went ignored.
The report ruled that two deaths were likely not preventable.
It made no conclusive ruling in the death of Shalynn Piller, who died at 14 days old on Aug. 3, 1994.
"The program continually undertook cases that were beyond the skill and experience of the surgeon and his team," Sinclair concluded, referring to Dr. Jonah Odim, the chief surgeon at the centre of the problems.
Odim, an American who now works in California, had little experience before coming to Winnipeg. Some surgical staff considered him incompetent and refused to work with him.
Odim said friction and animosity on the heart team hindered performance. He also said parents expected too much for their very sick children.
The working tension forced the hospital to close the unit at one point, only to restart it after a review. None of the problems were publicized. But doctors and nurses knew and they sent their own children out of Manitoba for treatment.
In 1994, the pediatric cardiac unit at the hospital was shut down and the inquest called after 12 children one in four of the unit's patients died within 10 months.
"If I had known the program was having difficulties, I never would have brought my daughter there," said Ben Capili.
His two-year-old daughter Maritess died after an artery that carried blood to her brain was sewn shut during a botched operation.
Capili's story is tragically typical of the problems uncovered by experts called in to look at what had been going on in the unit.
Sinclair found that some procedures should not have even been attempted.
The report made 36 recommendations. Among them are:
- improve the way the Health Sciences Centre recruits specialists
- increase the pay of pediatric cardiac surgeons to better or equal those who operate on adult patients
- create a patient's rights handbook that talks about informed consent
- improve monitoring inside and outside the hospital to avoid another situation like this developing.
Horne says the hospital has already corrected some of the problems.
He says nurses are now represented on physician interview panels. References are now scrutinized for doctors applying for positions. And pediatric cardiac surgery has been reintroduced in Manitoba, but only as part of a regional program in Western Canada.
Children with serious heart problems now go to Edmonton or Vancouver for treatment.
Manitoba's Health Minister, Dave Chomiak, says his department will work quickly to implement Sinclair's recommendations.
The inquest involved almost three years of testimony from close to 100 witnesses, and 10,000 pages of written evidence. It cost $2.4 million.
The parents of the children who died more than six years ago are finally getting some answers but they're not expecting much to come out of the inquest.
They wanted a full inquiry, which could find blame, but the Manitoba government rejected that. Sinclair's inquest can only make recommendations to fix problems.
Some of the parents are suspicious of the timing of the release of the report, coming on election day when most people are concentrating on that.