NATALIE SOUTHWORTH and SUSAN BOURETTE
The Globe and Mail
Friday, February 25, 2000

Toronto -- The parents of a Toronto girl are demanding a criminal investigation after an inquest ruled that her death at the Hospital for Sick Children was a homicide. The ruling was only the second in 10 years to apply the term to a death at an Ontario hospital.
 

The coroner's jury found that someone at the hospital caused the death of 10-year-old Lisa Shore in the fall of 1998.

"It is a finding of fact, not of fault, or legal responsibility," deputy chief coroner Dr. Jim Cairns said yesterday after reading the findings of the four-month-long inquest.

The finding of homicide does not imply blame or intent on the part of the hospital or its staff, but it does recognize that the little girl's death was the result of human error.

Police are reviewing the case to see if criminal charges should be laid.

The jurors made the finding even after the coroner's counsel, Margaret Browne, argued that the death should be classified as accidental or undetermined.

The dead girl's parents, Bill and Sharon Shore, said they felt vindicated after the ruling.

"The truth is out there. The Hospital for Sick Children was wholly responsible for our daughter's death . . . The nurses had a big part in that responsibility," Ms. Shore said.

Lisa's parents said they will not be satisfied until the two nurses who cared for her, now on paid leave from the hospital, are fired. The couple have also filed a disciplinary complaint against the nurses, Ruth Doerksen and Anagaile Soriano, with Ontario's College of Nurses.

Dr. Alan Goldbloom, senior vice-president of clinical and academic affairs at the Hospital for Sick Children, said the hospital staff "are deeply saddened by the tragedy of Lisa's death. Clearly the Hospital for Sick Children failed Lisa Shore. We are profoundly sorry."

It was the first time the hospital had apologized to the family outside of the inquest.

The jury has asked the hospital to consider 35 recommendations and demanded an update in eight months. The recommendations include calls for better training in drug treatment for recent nursing graduates, extra staff on long shifts, and better regulation of breaks for nurses working 12-hour shifts.

Dr. Goldbloom said that while all of the recommendations will be studied carefully, the hospital does not agree with the jury's decision.

Lisa died at the hospital on Oct. 22, 1998, eight hours after being admitted for chronic leg pain. She suffered from reflex sympathetic dystrophy, a rare, non-fatal condition, and was attached to a morphine pump to control the pain. Because of her condition, Lisa was also on a medication known to heighten the sedative effects of morphine.

Dr. Goldbloom said that because the hospital thought Lisa's death could possibly have been caused by an overdose of morphine, staff did not pursue a thorough internal investigation.

At the inquest, however, the jury heard that many instructions were ignored by nurses assigned to Lisa's care.

Ms. Doerksen testified that she had not looked for the doctor's orders in the computer. The court also heard that Lisa was not attached to a machine that would have monitored her respiration. The machine is used to alarm nurses if breathing decreases to a dangerous level.

The Shore's lawyer, Frank Gomberg, said his clients are pushing for a criminal investigation as well as a public inquiry. He said that the hospital not only failed to take care of Lisa but tried to hide the truth.

Police looked into the possibility of laying criminal charges after Lisa's death but could find no basis for such charges. In light of yesterday's ruling, however, "the police will take a fresh look . . . and consult with us," Paul Culver, Toronto's senior Crown attorney, said.

Criminal proceedings would proceed only if startling new evidence was found in the inquest record, he said. But Mr. Culver added that the burden of proof is much higher in a criminal case: Guilt must be found "beyond a reasonable doubt," whereas in an inquest, guilt is based on the balance of probability.

The Hospital for Sick Children said it has already implemented a number of changes.

"I'm sure this inquest has raised questions in the minds of many parents. Having said that, I feel we can reassure parents that we are committed to the absolute highest standard of care," Mr. Goldbloom said.