CAROLINE ALPHONSO
The Globe and Mail
Wednesday, February 2, 2000

Toronto -- The mother of a 10-year-old child who died at the Hospital for Sick Children told a coroner's inquest yesterday that she never saw a key piece of equipment meant to monitor her daughter's heart rate and breathing.

"With complete and utter sureness, there was no monitor in the room," said Sharon Shore, whose daughter Lisa died in 1998.

The alarms on the machine sound much like a household smoke detector and Mrs. Shore, who slept in her daughter's hospital room, said she would have been screaming for a nurse if any alarms had gone off.

Mrs. Shore's testimony directly contradicts that of two nurses who said they attached Lisa to a monitor that would sound alarms if the morphine she was given had any adverse effects.

Nurse Ruth Doerksen told the inquest last month that she turned off the alarm that monitors Lisa's breathing that night after it sounded several false alarms. However, Ms. Doerksen said, she left on an alarm that would sound if the girl's heart rate exceeded or fell below set limits.

The second nurse, Anagaile Soriano, testified Monday before the five-person jury that she heard an alarm sound, but said she wasn't sure it came from Lisa's room.

Yesterday, Dr. Morton Reingold, the coroner who investigated Lisa's death, gave testimony similar to that of Mrs. Shore. He told the inquest that he was unaware there was a monitor in the room when he was called to the hospital the day Lisa died.

When a coroner is called to investigate, a hospital's usual practice is to turn over any evidence. But Dr. Reingold said he wasn't notified of the monitor.

Another controversial revelation from the inquest is the duty nurses' testimony that, contrary to hospital policy and the file that accompanied the child to the ward, they did not check the orders entered by the emergency-room doctor on the hospital's computer.

The orders contained detailed information that would have led to close monitoring of the girl during her first few hours on the ward.

The hospital told the coroner's office and the Shore family that, until Jan. 26, 1999, it was unaware of the orders.

Still on the stand, Dr. Reingold said he was shocked when Frank Gomberg, a lawyer for the Shore family, told him Ms. Doerksen made a computer printout of the doctor's orders and took it home five days after Lisa's death. She turned the printout over to her lawyer recently.

"[The hospital] didn't volunteer information that he needed to do a comprehensive investigation," said Mr. Gomberg, charging that the inquest is being treated like an investigation instead of an opportunity to prevent more deaths.

A hospital spokesman said the institution will not comment until the inquest is over.

Lisa died at the hospital Oct. 22, 1998, eight hours after being admitted for chronic leg pain. She was found dead in her bed a few hours after being given morphine.

Mrs. Shore fell asleep in Lisa's room and woke up after doctors found the girl dead during their morning rounds.

"The big issue is: These nurses didn't do their job and Lisa should be alive today had there been competent nurses at the job," she said during a break yesterday.

Mr. Gomberg said the family will file a complaint with the College of Nurses of Ontario after the inquest.