LAWRENCE DILLON: Juror surprises Shore family lawyer.

Inquest juror points finger at Toronto hospital

An inquest juror in a highly unusual move accused Toronto's Hospital for Sick Children of covering up the circumstances of the death of a 10-year-old girl and creating a ``smokescreen'' to hide the truth. 

He then offered his theory of how Lisa Shore came to die. 

Outside court, Shore family lawyer Frank Gomberg said in his 20-year career, he had never heard such comments from an inquest juror. 

The statements were made while jurors grilled a witness - whom they had asked to be returned to court to answer their questions - for more than an hour and a half. 

``I have never, ever heard a juror refer to a hospital or to any major institution, and suggest in court and on the record that it is engaged in a cover-up and a smokescreen,'' Gomberg said in an interview. 

Lisa had been brought to the hospital by her mother on the evening of Oct. 21, 1998 for relief from a non-life-threatening chronic pain disorder. 

Less then 12 hours later, she was found dead in her hospital bed. ``I don't know if I can ask this,'' juror Lawrence Dillon told Dr. Jim Cairns, the presiding coroner. ``To me this sounds like a cover-up. We've been given a smokescreen.'' 

Dillon and four other jurors have been hearing testimony from nurses, doctors and other hospital officials since the inquest began in November. 

At the time Dillon asked his question, Mary Douglas - a nursing educator from the hospital who in earlier testimony had defended the treatment given to Lisa by her nurses - was in the witness box. 

The jurors had asked that Douglas be returned to court so they could question her. 

Unlike criminal trials, jurors at inquests in Ontario are allowed to question witnesses directly. 

Dillon continued his comments even after Cairns ruled Douglas did not have to answer. 

``I do realize that the Hospital for Sick Children is well known and unblemished,'' he said. ``And I hope this situation is an isolated case and covers the whole iceberg.'' 

Dillon said he was specifically troubled by the nurses' testimony on what was or wasn't done, partial entries made by nurses in Lisa's flow chart and how ``we heard of circumstances in which people supposedly lied to one another.'' 

None of the other jurors took issue with his comments. 

The inquest has already heard evidence that:  Ruth Doerksen, the nurse responsible for Lisa's care, had viewed certain computerized doctor's orders about an hour after Lisa died. The coroner's office did not learn about these orders until January, 1999.  Both Doerksen and Anagaile Soriano, the nurses who cared for Lisa after she was admitted early on Oct. 22, made extensive notes, which they took home, sealed in envelopes and later provided to their lawyer. These notes only emerged at the inquest.  The nurses claimed they had attached Lisa to a monitor that would sound an alarm if her breathing or heart rate fell below pre-set levels. Dr. Morton Reingold, the investigating coroner, testified that if he had known that, he would have seized the monitor in Lisa's room. 
  
That monitor, which was not mentioned in any nurse's notes made before Lisa died, ended up in circulation at the hospital and could not be studied by the coroner. 

Reingold has testified that not having early access to the relevant information ``would interfere with my investigation'' to the extent that it would be ``undermined and impaired.'' 

In another highly unusual development at yesterday's inquest, Dillon asked Cairns if he could tell the inquest what he thought had actually happened to Lisa ''that night.'' 

Although Cairns said it would not be appropriate at this stage of the inquest, he allowed Dillon to use a hypothetical example. 

In this example, Dillon talked about a patient, like Lisa, who is sent for pain relief from the emergency ward to the orthopaedic ward - where nurses are used to treating patients for such injuries as broken bones. 

``They take her and put her in a room, give her an aspirin, assuming that she will be gone (discharged) tomorrow, not realizing how critical a patient she is,'' he said. ``So there is no or little care given to that patient. 

``She has pain, so put her in her room and basically forget her,'' Dillon continued. 

Both Doerksen and Soriano had earlier admitted they failed to access emergency room doctors' orders requiring them to monitor Lisa intensively against the potentially deadly effects of morphine - and that the girl probably would have been saved if she had been monitored properly. 

As well, both nurses acknowledged they failed to follow much of the hospital's own nursing protocol, which called for intensive monitoring.