If the nurse caring for 10-year-old Lisa Shore had followed a doctor's orders and the girl had been properly monitored, she might still be alive today, an inquest has heard. 

``There are so many what-ifs,'' said Dr. Robin Williams, representing the pediatric review committee, a group of doctors who study the circumstances of children's deaths for the chief coroner's office. 

Williams testified yesterday at the inquest into Lisa's death. The committee, which studies about 70 deaths a year, spent many hours trying to determine what caused her death and how the health-care system can be changed to prevent similar deaths. 

Lisa was admitted to the Hospital for Sick Children in the early hours of Oct. 22, 1998, with a non-life-threatening chronic pain disorder. She had been given morphine for leg pain before she was found dead just after 7 a.m. 

An emergency room doctor wrote orders to ensure Lisa did not suffer breathing difficulties while being administered morphine. The orders were never read by Lisa's nurse, and the girl was not properly monitored while she slept, the inquest was told. 

``Many things went wrong. The nurse at the bedside did not follow the doctor's orders,'' Williams told the inquest. 

``Even at 4 a.m. there was still lots of time for intervention, the committee felt,'' she said. 

Around that time, the nurse checked Lisa's breathing and pulse several times. 

``Obviously there was some concern,'' said Williams, noting numerous readings were taken. ``What is unfortunate is that more wasn't done. 

``The monitoring (around 4 a.m.) that was done - there were significant red flags there that did not result in action.'' 

The committee concluded Lisa may have reacted to the combination of morphine and other prescribed medications she was taking for pain. 

``If the drug interaction was the cause of death - which we believe it was - the removal of the morphine would have prevented this outcome.'' 

Outside the inquest, Frank Gomberg, lawyer for the Shore family, said he is pleased with the committee's findings. ``Their findings are exactly what the family had been saying for months and months,'' he said. 

``Enough experts have made it quite clear . . . the primary reason why Lisa is not here is because she did not receive the proper nursing care,'' said Sharon Shore, Lisa's mother. ``And I am waiting for the hospital to acknowledge that.'' 

The inquest continues Monday.