“With harrowing prose, the author details the surgical ineptitude, patriarchal culture, and dysfunctional hierarchy that led to the deaths of twelve children … If there’s a take away from this devastating story, it’s that if a nurse says Take Your Baby and Run, you have every reason to listen.” –Leighton Schreyer, Literary Review of Canada, Bookworm #20
“Youngson’s attention to detail in this hospital nightmare is impressive, and her sympathy for the parents of these dead babies and kids is demonstrably genuine and lasting. Her play-by-play of the operations she saw is so intimate you risk weeping as these little bodies die on the operating table or shortly after.” — Barry Craig, Winnipeg Free Press
Take Your Baby and Run listed in Quill & Quire’s Fall Nonfiction Preview
Take Your Baby and Run featured in 46 works of Canadian nonfiction to read in fall 2023 on CBC Books
“Enhanced for the reader with a truly informative Foreword by Lanette Siragusa RN., MN, “Take Your Baby And Run: How nurses blew the whistle on Canada’s biggest cardiac disaster” will prove to be of particular and special value to readers with an interest in systemic medical malpractice. Part memoir, part medical malfeasance whistle-blowing, and essential reading for medical reform activists.” — Andrea Kay, Midwest Book Review
by Lanette Siragusa
Author Carol Youngson and I have never met yet, our paths must have unknowingly crossed multiple times over the course of our careers.
Manitoba is a “big small town” and as graduates of the same school and one-time employees of the same hospital, Carol and I have no doubt shared many similar experiences throughout our careers. I was honoured to write this foreword to her book documenting a dark period in Manitoba’s healthcare history.
Carol’s book details her extraordinary experiences as lead operating room cardiac nurse during the catastrophic series of events that led to the untimely deaths of twelve young children. After three decades, Carol’s account offers readers an insider’s view of the tragic events and her own personal and professional struggles to support her patients and teammates amid the intense frustration she felt as her voice—and the voices of her colleagues—were muted. Although I do not know Carol personally, I feel a deep connection to her passion and her commitment.
Clinical providers are educated for careers dedicated to serving people during their most vulnerable moments. We train so we can manage high-risk, fast-paced, life and death situations. We develop skills in specialized areas and we learn to build bonds of trust with our patients and their loved ones. We do these things because they enable us to function proficiently as part of an integrated healthcare team. Most importantly, we commit ourselves to these efforts because we care and we want to make a difference in the lives of others.
In 1994, I was a third-year nursing student completing my clinical rotation on a pediatric medical unit at Health Sciences Centre Winnipeg’s Children’s Hospital. I was young, full of energy and optimism for the future. I was also blissfully unaware that just a few floors below me, in the operating room theatre within the same Manitoba hospital, a disaster was unfolding and a growing sense of dread was beginning to build amongst those closely involved with the pediatric cardiac surgery program.
Three years later, intense media coverage and the longest public inquiry in the history of our province had revealed the devastating details of how twelve children lost their lives undergoing cardiac surgery at HSC Children’s. The inquiry’s heart-wrenching account highlighted system failures and warning signs unheeded for too long.
By this time, I was a graduate, a registered nurse, and a mother of a newborn baby boy diagnosed with a cardiac condition. While I had previously followed media reports on the ongoing public inquiry with shock and disbelief, it had been from the distance of an outsider. Now, as I sat by my baby’s bedside in the Pediatric Intensive Care Unit, I related on a personal level. After multiple invasive tests and interventions, we both had eyes swollen from crying and were exhausted. He was connected to so many monitors and machines that it was difficult for me to get close enough to comfort him. I was terrified to put my faith and trust in the experts who, although professional and kind, were strangers to me. I felt powerless to make him better and helpless as I watched my baby suffer.
I made choices for my child out of fear that there could be lingering dysfunctions within the now defunct pediatric cardiac surgery team. So many questions and scenarios went through my mind and I couldn’t help but think of the parents of those twelve babies who came before mine—their fear, disappointment, pain, and fortitude to carry on.
Now, thirty years later, Carol Youngson’s remarkable story reminds us of that dark time in our history. While Carol had graduated in 1969, at the height of the feminist movement, and was an expert nurse by 1994, she and her nursing colleagues functioned within a pervasive, patriarchal culture.
Within this context existed a hierarchy of power and professional siloes that proved to be key contributors to the crisis that was created.
The Operating Room environment is unlike any other, requiring at least three different healthcare professionals (anesthesiologist, nurse, and surgeon), dressed in matching attire, working in close proximity within a confined space for hours on end. With patients that are unconscious under anesthesia, the surgery team relies on protocols, technology, and skill to remove body parts, stop bleeding, repair damage, and save lives. There are multiple surgical specialties and every procedure, no matter how minor, carries some degree of risk.
Within the Operating Room theatres, every person has a defined role in order to fulfil a specific purpose. Concise communication is required, along with the ability to stay calm under pressure when things don’t go as planned.
Looking back, it would be easy to point a finger and blame one villain. But in complex organisms like healthcare, the most wicked problems are multifactorial and thus, intricate and complex to solve. Judge Murray Sinclair, who presided over the Pediatric Cardiac Surgery Public Inquest, astutely acknowledged the many flaws that contributed to the deaths of the twelve children, including human error, unclear accountabilities, organizational structure, system processes, and overall culture. Like the Swiss Cheese Model of accident causation, multiple holes had to perfectly align in order to produce this magnitude of error.
The recommendations Sinclair delivered ensured safeguards were put into place to mitigate future risks of this nature, including revamping the Informed Consent process, passing whistleblower legislation and creating Nursing Practice Councils, where nurses can safely raise and formally escalate concerns without fear of retribution in the spirit of continuous improvement.
Clinicians who worked at the hospital during this time acknowledge how our health system changed after this event. Three decades later, the lessons that were learned will never be forgotten. For some, these lessons involved the need for critical evaluation, transparency of information, clear communication, mentorship, and careful selection of new medical recruits in order to ensure safety when establishing a high-risk, low-volume clinical service. For nurses in particular, it highlighted the worth of their role and the need to value and respect all individuals within a team. In healthcare, this also includes patients and their families. Strengthening collaboration and trusting partnerships within team-based models of care remains an ongoing priority of focus for healthcare organizations today.
As I embark upon my latest role as Chief Executive Officer within a complex provincial healthcare organization (that includes HSC Children’s), I am humbled by the teams around me—their expertise, dedication and intentions to serve others well. Every day, they deliver excellent patient care that often goes unnoticed, and I trust them to guide my decisions and actions with their knowledge, evidence, and experiences. The magnitude of the challenges we face within healthcare can, at times, be daunting and overwhelming. And it can be tough to hear the issues raised by our teams; however, as leaders we owe it to our people and the populations we serve to listen, problem solve together, and make the necessary decisions related to factors within our control.
Enabling high-functioning teams is the key to unlocking the magic of quality care. Carol’s story offers a powerful reminder to all of us in healthcare to put our egos aside, be accountable for our individual actions, and base every decision on what is best for our patients and their families.
Today, my child and thousands of others have benefitted from the advocacy and learning of those who came before us. Manitoba children are now transferred out of province for pediatric cardiac surgical procedures, to centralized locations in a select few neighbouring provinces. In locations where a higher volume of specialized procedures are performed, team expertise is enhanced, risks are lowered, and better health outcomes are realized. In my own family’s care experience, our visit to Edmonton’s Stollery Children’s Hospital, 1,500 kilometres away, was completely coordinated through the Variety Children’s Heart Centre. As a parent, I benefited from the trust and confidence I was able to have in the process and the surgical team. Thanks to Justice Sinclair’s recommendations, every detail was taken care of for us, dramatically reducing the stress we felt and allowing us to solely focus on our loved one.
Carol’s book is a personal account of her own experience; however, it is worth reflecting on how everyone connected to this tragedy was required to carry their own burdens and find individual ways to cope and heal over time. For all those involved in the clinical care, the administration, and the public inquiry, this could not have been easy. But it was especially difficult for the parents and loved ones of the children involved and it is them we must keep top of mind well into the future as we pursue continuous improvement and give meaning to the lives lost and the grief endured.
For those who work in the broader healthcare sector, I encourage you to read this story of courage in the face of adversity thoughtfully. Let Carol’s struggle be our inspiration well beyond the scope of pediatric cardiac surgery. Despite all we have learned in Manitoba, similar tragedies continue to occur in other jurisdictions where safeguards are lacking. This book serves as a reminder for all of us working within healthcare, everywhere, to stay grounded in our core principles, be brave enough to speak truth to power, value each member of your team, and always put patients first.
May we continue to forever honour the lessons that were learned, the burdens that were carried, and the hearts that were broken.
-Lanette Siragusa, RN, MN
Winnipeg, July 2023