Girl's death spurs new hospital rules, probe told

Toronto's Hospital for Sick Children revamped its procedures for monitoring children who are being given morphine following the death of Lisa Shore, a coroner's jury has been told. 

The jurors also heard yesterday that nurses tested the 10-year-old girl's blood pressure only once after she was admitted to the hospital's orthopedic ward in the early hours of Oct. 22, 1998 - instead of hourly, as a doctor had instructed - and that an emergency pager message to a doctor went unanswered and was not followed up quickly. 

Lisa died suddenly of respiratory and heart failure on Oct. 22, 1998 (the cause of which remains unclear), after going to the hospital the evening before for help with pain from a broken leg. 

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

The jury already has learned that orders to monitor Lisa, entered into a computer by a doctor in the emergency ward, were never received by nurses on the ward to which she was eventually transferred, as the orders had been suspended until she arrived on the ward. 

Mary Douglas, a nursing educator, testified yesterday that after Lisa's death, the computer system used to convey doctors' orders was changed so nurses now receive a hard copy of the orders, even when they have been suspended. 

Douglas said that as a result of the hospital's review of its practices, an oxygen saturation monitor - a device that measures the oxygen level in the blood - must be used on every child receiving morphine, and 13 new monitors have been purchased. 

Other improvements include reviewing dosage guidelines for morphine; requiring two nurses to ensure that the proper dose is being administered; and education sessions on how to monitor patients receiving morphine for pain control. 

``I am very glad that those changes have been made, and based on those changes, that no other child will lose their life because of this situation,'' Sharon Shore, Lisa's mother, said outside the inquest yesterday. 

``However, at the same time, I am inexpressibly sad that all of these things which a medical institution of Sick Kids' stature should have had in place, weren't in place, and that maybe the reputation of Sick Kids, at the time of Lisa's death, was not as well deserved as it should have been.'' 

Douglas also testified that a nurse waited an hour and 15 minutes before paging a doctor who had not replied after the nurse called to advise that Lisa's rate of breathing had dropped considerably. 

Although Douglas said the hospital had heightened monitoring of Lisa while she was on the ward, she conceded under cross-examination by the Shore family lawyer that there was no indication in hospital records of any monitoring of Lisa's pain or sedation, in spite of the doctor's orders.