Toronto -- An inquest into the death of a 10- year-old girl at the Hospital for Sick Children heard for the first time yesterday evidence that should have been revealed before the inquiry started, the deputy chief coroner said.

Dr. Jim Cairns made his remarks as the nurse who cared for LisaShore at the hospital said that she saw the child's computer records twice in the days after she died.

Dr. Cairns said that it took the coroner's office three months and some prodding to obtain these records and the family had to wait several months longer for them. He told the inquiry yesterday that he had no idea the nurse had seen the records until he heard her give her testimony.

"Many of the witnesses are giving evidence we are hearing for the first time. This makes it difficult for counsel to know where it leads us," Dr. Cairns told jurors at the inquest into why Lisa died at the hospital Oct. 22, 1998, eight hours after being admitted for chronic leg pain.

Frank Gomberg, lawyer for the Shore family, was much blunter with his criticism in the court.

"This is shocking. . . . It's outrageous I should have to do a police investigation in a courtroom," he said as nurse Ruth Doerksen revealed she first read orders entered on a computer by the emergency room doctor hours after Lisa died.

A few days after the girl's death, Ms. Doerksen said, she printed out a copy of Lisa's records and took them home to study carefully.

Ms. Doerksen was the charge nurse on the floor when Lisa was admitted at about 1 a.m. During two days in the witness box, Ms. Doerksen testified that on the night Lisa was brought to the hospital, she did not check the orders entered on the computer by the emergency room doctor who first saw Lisa, although the file that accompanied the child to the ward stated "check Kidcom," the hospital's computer.

Lisa was receiving morphine, a potent drug that can depress breathing, and the doctor's orders contained detailed information that would have led to close monitoring of the girl during her first few hours on the ward.

The jury has heard that several of the checks, including monitoring of her blood pressure and sedation were ordered but never done.

The inquiry also heard contradictory evidence about whether Lisa was attached to a machine designed to measure her heart rate and breathing. Ms. Doerksen said she attached Lisa to the machine, but turned off the alarm that monitors breathing when it sounded several false alarms. However, she said she left on the alarm that would sound if the girl's heart rate exceeded or fell below set limits.

When doctors checked on Lisa at 7:15 the next morning, they found the girl dead in her bed and that the machine had been turned off.

The machine and the alarm, which sounds much like a household fire detector, were demonstrated to the jury yesterday. The girl's mother, who stayed by Lisa's bedside that evening, will testify that she never heard the false alarms, Mr. Gomberg said, and he challenged Ms. Doerksen's assertion that she had attached the machine.

The coroner also cautioned nurses who have packed the courtroom that they had been observed coaching the witness by shaking or nodding their heads before she answered and that such behaviour was "entirely inappropriate."

The inquest continues today.