CAROLINE ALPHONSO
The Globe and Mail
Thursday, February 10, 2000

Toronto -- The Hospital for Sick Children admitted that it made mistakes that resulted in the death of a 10-year-old girl, but it did not cover up what happened, a coroner's inquest heard yesterday.

In his final summation to the jury into the death of Lisa Shore, hospital lawyer Patrick Hawkins admitted there were "honest human errors" made by hospital staff.

"We're not here to point the finger and we're not here to blame people," he said at the inquest.

The Shore family lawyer, Frank Gomberg, said in his summation that the hospital "embarked on a campaign of deception, diffusion and outright corruption of the truth."

A juror, Lawrence Dillon, had earlier said the hospital was creating a "smoke screen" to hide facts by releasing documents of questionable accuracy slowly or not at all.

The five-person jury also has to determine the cause of Lisa's death and issue recommendations.

Mr. Hawkins submitted to the jury that the cause should either be accidental death or undetermined. Mr. Gomberg called for a finding of homicide, although the inquest is not able to lay criminal charges.

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

Lisa's mother, Sharon Shore, said she fell asleep in the hospital room and woke up after doctors on their morning rounds found the child dead.

Since November, jurors have heard testimony from doctors, nurses, the investigating coroner and other experts as to that night's events.

Yesterday, Mr. Gomberg presented 13 recommendations for the jury to consider. The Shore family's recommendations include an automated warning message on Kidcom, the hospital's computer system, when doctors' orders left with nursing staff are not acted upon.

Neither Ruth Doerksen nor Anagaile Soriano, the nurses on duty that night, carried out the orders written by an emergency-room doctor, as required by the hospital, the inquest heard.

The orders called for intensive monitoring of Lisa for adverse reaction to morphine. The hospital denied such orders existed until Jan. 26, 1999, three months after Lisa died.

Mr. Gomberg also recommended that patient flow sheets and progress reports note when monitors to measure a patient's heart rate and breathing are used. The inquest heard contradictory testimony as to whether there was a monitor in Lisa's hospital room and, if there was, whether it was on.

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

Mrs. Shore testified that she didn't see a monitor in the room, contradicting the two nurses on duty who said they attached Lisa to a monitor.

Ms. Doerksen told the inquest that she turned off the alarm on a breathing monitor 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, Ms. Soriano, testified that she heard an alarm sound, but said she wasn't sure it came from Lisa's room.

Another recommendation submitted to the jury was that all nurses should be made aware that doctors' monitoring orders or other protocols must be followed unless they have errors.

Mrs. Shore said outside the inquest that the staff who cared for Lisa failed to perform their duties.

"If you have people who do not follow the rules no matter how many rules there are in place, you cannot prevent a death like this from happening again," Mrs. Shore said.

Margaret Browne, the coroner's counsel, will make her final summation today. Deputy coroner Dr. Jim Cairns will then instruct the jury.