Hospital agrees machine didn't malfunction 

Shortly after the inquest into the death of 10-year-old Lisa Shore at Toronto's Hospital for Sick Children resumed yesterday following a lengthy delay, the coroner dropped a bombshell on the jurors. 

Dr. James Cairns, deputy chief coroner of Ontario, told them the heart and breathing monitor, which was supposed to sound a shrill alarm and warn nurses if the child's vital signs faltered, had been turned off. 

Just how the corometric monitor came to be turned off is expected to be the subject of great controversy in the remaining weeks of the inquest. 

When the inquest broke off in November, after only a few days, the hospital had maintained the monitor had somehow malfunctioned. 

The new position, given to the jurors by Cairns, had been agreed on by lawyers for all parties at the inquest, including the hospital. 

The monitor was meant to catch the possibly deadly effects of morphine, which an emergency ward doctor had prescribed to counter the unbearable pain from a broken leg that caused Lisa to be brought to the hospital on Oct. 21, 1998. She died the next day. 

As Cairns told the jurors, ``You can accept that if a monitor was in Lisa's room at 7 a.m. (on Oct. 22), then it either was not attached to Lisa and turned off, or it was attached to Lisa and turned off.''

 Doctors at Boston's Children's Hospital had diagnosed Lisa as suffering from reflex sympathetic dystrophy, a rare condition marked by chronic burning pain that often starts with a minor injury, such as a fracture. 

Early in the inquest, the jury was told that a doctor's orders to nursing staff to use an instrument that would detect the amount of oxygen in Lisa's blood, as well as the backup corometric monitor, never reached her nurses. 

Yesterday, the jurors heard that minutes after the girl died, nurse Ruth Doerksen told another nurse she had turned off the alarm on the corometric monitor that would indicate breathing problems. 

Nursing educator Mary Douglas said a weeping Doerksen told her she had turned the apnea breathing alarm off but didn't know why, and ``had never done that before.'' 

Douglas testified Doerksen told her Lisa was fine when she checked her at 6 a.m., about 1 1/2 hours before doctors discovered she was dead, and kept asking why the alarm didn't go off. 

Doerksen has not yet testified at the inquest. 

But Frank Gomberg, a lawyer for the Shore family, told the jury he understands Doerksen will testify that she turned the alarm off because it kept sounding. 

Pressed by Gomberg on whether it is preferable to make a note in the hospital record when a child is attached to a corometric monitor, Douglas replied that this is now done ``for legal reasons.'' 

In other testimony yesterday, Stephan Bauer, the facility's manager of medical engineering, said the hospital did not preserve a monitor found in Lisa's room when it was discovered she had died. 

Bauer explained no one realized the monitor was significant until the next day, and by then it had been cleaned and returned to circulation in the hospital. 

Hospital records do not mention that Lisa was placed on a monitor or which monitor had been put in her room.