From inquest to insight.

BACKGROUND In March 1995, The Chief Medical Examiner, Province of Manitoba, ordered an inquest into the deaths of 12 children who died in 1994 while undergoing or shortly after having undergone cardiac surgery at Health Sciences Centre in Winnipeg, Manitoba, Canada. The inquest spanned over five years, and resulted in almost 50,000 pages of transcript, including the testimony of more than 80 witnesses (Sinclair 2000). Justice Sinclair found that the Pediatric Cardiac Program did not provide the standard of care that it was mandated to provide, as he determined that at least five of the deaths were preventable. In response to the 516-page report issued by Judge Murray Sinclair, the former Minister of Health, the Honourable Dave Chomiak, established a Review and Implementation Committee to review the recommendations from the inquest and determine (1) what actions had already been taken to address the recommendations, (2) what future actions should be taken and (3) the implications of the recommendations for the broader health system. A learning process began, which would have a ripple effect throughout the Manitoba health system for years to come. The Review and Implementation Committee, chaired by Professor Paul Thomas, issued a report in May, 2001, entitled Report of the Review and Implementation Committee for the Report of the Manitoba Pediatric Cardiac Surgery Inquest containing 53 recommendations which sought to “identify institutional arrangements and procedures that would provide Manitobans with a stronger guarantee of competent, safe and ethical healthcare in the future” (Manitoba Health 2001).