MD `shocked' that nurses ignored orders 

Lisa Shore might be alive today had her condition been monitored by staff at Toronto's Hospital for Sick Children, a coroner's jury has heard. 

That probability was raised yesterday by child autopsy specialist Dr. Charles Smith at the inquest probing the 10-year-old girl's death. 

It was also raised by Dr. Stuart MacLeod, former dean of Hamilton's McMaster University medical school. He is a pharmacologist as well as a medical . 

Lisa had been placed on a self-administered morphine device to relieve pain from a non-life-threatening disorder after being admitted to the hospital in the early hours of Oct. 22, 1998. 

But the jury has heard that morphine is a powerful narcotic that can fatally restrict breathing and damage the heart - and that nurses did not read a doctor's order to attach two monitors to Lisa which would sound alarms if her respiration and heart rate deteriorated. 

Smith, described by coroner Dr. Jim Cairns as ``independent'' even though he works at the hospital, said an autopsy revealed that Lisa had water in her lungs and a slightly swollen brain, which were consistent ``with a young person who dies after a respiratory depression.'' 

``Swelling of the brain (because of lack of oxygen) doesn't occur simultaneously. It doesn't just occur,'' he told the jury. ``It (the dying process) may have been five, 10, 15 minutes, or even longer.'' 

Asked by Frank Gomberg, a lawyer representing the Shore family, whether her condition could have been reversed, Smith replied: ``That's how I read this autopsy report. Yes.'' 

MacLeod testified he was ``shocked'' that the doctor's orders - including the requirement that her blood pressure be taken hourly - had not been read by the nursing staff and were therefore not carried out. 

He also said Lisa may have been saved had she been given a drug to reverse the adverse effects of the morphine while there was still time. ``You can't be sure, (but) it's a high probability of that occurring,'' he said.