Inquest turned into all-out probe, coroner says

February 11, 2000

Case hurt by lack of disclosure, jury told

By Harold Levy
Toronto Star Staff Reporter

LISA SHORE

The inquest into the death of 10-year-old Lisa Shore at the Hospital for Sick Children had to turn into a full investigation to get at the truth because so few facts were known when it began, Coroner Jim Cairns has told the jury.

Cairns also acknowledged yesterday there were serious communication problems between the hospital and his office, and vowed that they would not recur.

Dr. Morton Reingold, the investigating coroner, had testified that the lack of information provided to him by the hospital was enough to ``undermine and impair'' his investigation.

Lisa died of respiratory and heart failure on the morning of Oct. 22, 1998. Her parents had taken her to the hospital the evening before because she was in pain from a non-life-threatening condition. A doctor had ordered she be monitored against the possible deadly effects of morphine.

``I indicated that this inquest would be unusual,'' Cairns told the jurors before releasing them to begin their deliberations.

``It became an investigation of the death.''

Patrick Hawkins, lawyer for the hospital and its nurses, told the jurors earlier in the inquest that he had advised his clients not to give statements to the coroner's investigators, as was their right.

Outside court, family lawyer Frank Gomberg said he was shocked that the only two people to volunteer statements to the investigators were Lisa's parents, Sharon and Bill Shore.

Cairns, who is also Ontario's deputy chief coroner, explained that efforts to establish the truth about Lisa's death made the inquest ``much more adversarial than usual,'' but added, ``it was necessary.

``This inquest was extremely important to bring out the facts. The first time many people said anything about the death was on the witness stand . . . under oath . . . (and) that aspect was extremely revealing.

``I do not think the appropriate place to find these things out is at the inquest. You were probably wondering what bombshell will we hear today.''

Cairns specifically mentioned a bombshell that burst shortly after the inquest began in November, when the hospital unexpectedly blamed Lisa's death on a respiration and heart monitor in what Gomberg called a bid to deflect responsibility from its staff.

That caused a lengthy delay in the hearing to allow the monitor's manufacturer to retain counsel. The hospital withdrew the allegation when the inquest resumed.

Other bombshells included revelations that:

Ruth Doerksen, the nurse responsible for Lisa's care, had viewed certain computerized doctor's orders about an hour after Lisa died, and printed them out of a hospital computer five days later. She took them home, where they remained sealed until she was ordered to bring them to court.

Both nurses who cared for Lisa that day made extensive notes, which they took home, sealed in envelopes and later provided to their lawyer but not to the coroner.

Doerksen dictated an account of her treatment of Lisa on an audiotape - later erased - as nurses are required to do to pass on information from shift to shift. None of the nurses who testified - including Doerksen, her colleague Anagaile Soriano and nursing educator Mary Douglas - mentioned the tapes' existence, until Doerksen was recalled by the jurors after another nurse mentioned that taping reports was standard practice.

The hospital did not investigate Lisa's death. Jean Reeder, chief of nursing, said she only became aware there were ``nursing issues'' toward the end of February, 1999.