http://bmj.com/cgi/content/full/323/7322/1148/c
BMJ 2001;323:1148 ( 17 November )
David Spurgeon Quebec
Three families whose children died seven years ago in Winnipeg’s paediatric
cardiac surgery unit, in a situation reminiscent of that at the cardiac surgery
department of the Bristol Royal Infirmary in England, fear that recommendations
from the inquest have been watered down
The findings of the inquest were not published until last December, six years
after the deaths of the children (BMJ 2000;321:1433). Paul Thomas,
professor of political science at the University of Manitoba, was then given
four months to devise a plan to implement the inquest’s 36 recommendations. He
produced a report last spring.
Saul Simmonds, lawyer for the three families who are protesting about the
report, said that the 51 recommendations in Professor Thomas’s report
"could have been written by the doctors. They’ve all circled their
wagons" (Canadian Medical Association Journal 2001;165:1242).
The inquest and Professor Thomas’s report relate to the deaths of 12 infants
who died after paediatric cardiac surgery in 1994 at the Winnipeg Health
Sciences Centre. Mortality was 29% among high risk cases compared with a norm
of 11%.
The parents endured 30 months of testimony and then waited three months for
the inquest report. The cardiac programme has since been shut down. There are
similarities to the inquiry into the deaths of babies from cardiac surgery at
the Bristol Royal Infirmary, which was published last summer, six years after
the last baby died, and 13 years after high mortality was first noted (28 July,
p 181). Both showed a flawed system that included mismanagement and surgical
inadequacies.
In the Winnipeg case, because parents were not given enough
information—particularly about the surgeon’s relative inexperience—the judge
who presided over the inquest, Justice Murray Sinclair, recommended that all
hospitals provide patients with information about physicians’ education,
experience, complaints lodged, and disciplinary action taken against them.
Professor Thomas’s report supports the creation of physician profiles, but he
said the programme would be expensive and might deter physicians from moving to
Manitoba.
Professor Thomas said that many of Justice Sinclair’s recommendations are
idealistic and that he didn’t test their feasibility. He called Manitoba
"a have-less province," where health costs consume 40% of the
provincial budget. "I know it sounds crass, but we have to be politically
and economically realistic," Professor Thomas is quoted as saying.
Mr Simmonds and the families are angry about this. Mr Simmonds criticised,
for example, Professor Thomas’s advocacy of inhospital disclosure-protection
policies, rather than legislation on whistleblowing suggested by the inquest
report. In response, Professor Thomas said that new evidence from the Bristol
case shows that whistleblowing legislation does not work. "We don’t want
symbolic gestures," Professor Thomas told the Canadian Medical
Association Journal. "We want to implement things that work."
Professor Thomas said that he appreciated the parents’ frustration because
they believe no one has been held accountable for their children’s deaths. He
has demanded that all the people affected by his recommendations—government
departments, the regional health authority, the hospital, the nurses’
association, the College of Physicians and Surgeons, and the medical
examiner—must implement them as soon as possible, and report their progress by
next spring.
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