LOUISE ELLIOTT
Canadian Press
Friday, November 10, 2000

Toronto's Hospital for Sick Children is taking "full responsibility" for the death of a teenager during a routine operation in September.

Seventeen-year-old Sanchia Bulgin's death, just a few hours after surgeons removed her gallbladder, "should have been a preventable one," said Dr. Alan Goldbloom, senior vice-president of clinical and academic affairs at the hospital.

"We've identified errors during her care here both at the [physician] level and at the nursing level."

In particular, Dr. Goldbloom said staff failed to identify internal bleeding in Ms. Bulgin's abdomen after surgery, and said they didn't take quick action when her condition began to deteriorate.

"Intervention should have been made more quickly," he said.

Staff did not check her blood count before surgery -- crucial in Ms. Bulgin's case because she suffered from sickle-cell anemia.

"Sanchia was a child with complex problems, and not everybody was fully up-to-date on her status," he said.

Dr. Goldbloom said the death did not result from errors during surgery. Ms. Bulgin died Sept. 14 after being taken from a postsurgery room to Ward Five A/B, the unit that cares for general surgery and orthopedic patients.

The ward was the subject of an inquest into the sudden death of 10-year-old Lisa Shore in 1998. The coroner's jury in that case found that Lisa's death was a "homicide."

But while Dr. Goldbloom said the ward tends to be staffed by newer, more inexperienced nurses, he said there was no connection to Lisa Shore's death.

"This is the ward where most of our surgical patients go. I don't believe there's any more to it than that."

But the province's deputy chief coroner said yesterday that the two deaths had at least one thing in common.

"Both deaths do involve issues of quality of monitoring by nurses," said Dr. Jim Cairns, whose department is now conducting a separate investigation.

Since Ms. Bulgin's death, the hospital has appointed a nurse-educator to the ward, Dr. Goldbloom said, and additional nursing support. Dr. Cairns said his findings will not be available for several weeks, but added his recommendations will "include at least what they've indicated" in the hospital report. Dr. Cairns's report will go to the pediatric-death review committee, which assists the coroner in investigating unexplained children's deaths across Ontario.

After the review is completed, a ruling will be made on whether to hold a coroner's inquest, he said.

The hospital has asked physicians involved in the case to review hospital protocols.

Lisa Shore was found dead in her bed on Ward Five A/B on Oct. 22, 1998, less than 12 hours after her mother had taken her to emergency for relief from pain caused by a non-life-threatening condition.

The five-member jury heard evidence that Lisa's nurses failed to monitor her for possible deadly effects of the morphine she was given and about allegations from the Shore family of a hospital cover-up.

The jury, which by law cannot assess blame, sent shock waves through the hospital when it found that Lisa's death was a "homicide" -- defined as the killing of a person by another. Toronto's homicide squad launched an investigation, but prosecutors have not indicated whether charges will be laid.