JOHN BARBER

Friday, February 25, 2000

It happens. Planes fall from the sky. Healthy children die mysteriously in hospitals.

We accept it when it happens, partly because every remote accident affecting somebody else is one more lucky escape for us. We understand.

A few hours after a coroner's jury declared 10-year-old Lisa Shore was a victim of homicide, the legendary institution that . . . failed her reached out to the public and begged desperately for any available scrap of that understanding.

In return it got a stony stare.

Already tarnished by the strange and sordid Olivieri-Apotex affair, the Hospital for Sick Children has exposed itself again, as if gripped by another spasm of involuntary self-revelation. The sight is, again, disturbing.

Lisa Shore's death is disturbing. A relatively healthy girl was brought to the emergency room with leg pain. She was admitted to the hospital and died overnight, with a morphine drip in her arm and her mother sleeping by her side.

The circumstances surrounding her death are disturbing. Neither Ruth Doerksen nor Anagaile Soriano, the nurses responsible for Lisa that night, consulted the orders for Lisa's care written by the emergency-room physician who admitted the girl. They left many of the recommended procedures undone.

The ignored orders included a note to monitor Lisa intensively in the expectation that she might experience an adverse reaction to morphine -- something the pain medication she was already taking exposed her to.

Contrary to the testimony given by the two nurses, however, Lisa's mother testified that there was never a heart-rate or breathing monitor attached to the girl that night. She died without anyone knowing.

It happens. Mistakes are made. We understand. The hard part to understand is what the Hospital for Sick Children did after Lisa Shore died.

We'll leave the description up to Frank Gomberg, the Shore family lawyer, whose harsh views on the hospital's role were dramatically vindicated yesterday, as soon as the jury accepted his argument that Lisa died as a result of homicide.

"The hospital did everything in its power to prevent the truth from coming out," Mr. Gomberg said yesterday. "They played with the truth and did everything they could to sweep the incident under the rug."

The hospital made stupid mistakes in the aftermath of Lisa's death and then refused to own up to them, according to Mr. Gomberg, deciding instead to withhold key evidence from the Shore family and the inquest.

The fabled institution's performance "makes me want to throw up," Mr. Gomberg said. The whole place, he concluded, is rotten.

Among the several incidents of alleged obstruction and evasion that the lawyer highlighted yesterday, two stand out.

For three months after Lisa's death, the hospital denied the existence of any doctor's orders to monitor her for an adverse reaction to morphine. The orders emerged only when one of the nurses revealed she had copied them onto her home computer.

The inquest learned only last week that nurses on an outgoing shift had tape-recorded notes and observations about Lisa's care to the incoming nurses, Ms. Doerksen and Ms. Soriano. The tape had been accidentally erased, according to the hospital.

"That's why the jury found homicide. They couldn't take it any more," Mr. Gomberg said.

"No one is suggesting they intended to kill her," he said. "They did not intend to kill her. But when you put somebody on morphine without a monitor, it's the same as pushing them out an airplane without a parachute. They die."

Hospital spokesman Dr. Alan Goldbloom dodged the question of the nurses' fate at a news conference yesterday, saying only that their actions will be reviewed. He also regretted the "confusion" that resulted in the jury's view that his hospital obstructed its work.

And he begged for forgiveness. "Clearly, the Hospital for Sick Children failed Lisa Shore and failed the Shore family, and we will live with this forever," he said. "We are profoundly sorry . . ."

Understand?