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Staff reporter thestar.com
Sharon Shore was asleep in a chair only few feet from her daughter when the 10-year-old died in a Sick Children's Hospital bed on Oct. 21, 1998. On Thursday, with tears running down her face, she listened to Deputy Chief Corner Jim Cairns announce that Lisa Shore's death was a homicide, caused by a complex drug reaction that caused her heart and respiratory system to fail. This was the finding of a five-person jury that heard two weeks of testimony and deliberated for another two weeks. Shore said she felt vindicated.
''The truth is out now,'' she said at a press conference after the announcement. ''The hospital is solely responsible for our daughter's death . . . On a personal level, however, nothing changes. My daughter is still gone.'' According to the inquest, which began hearing evidence last November, Lisa was admitted to the hospital with pain caused by a chronic disorder relating to a broken leg. A doctor administered morphine, after which she was to be checked on regularly by nurses and be hooked up to a monitor that measures breathing and heart rates.
The hospital said all the proper procedures were carried out but the question remained as to why no alarms sounded when Lisa was dying. The jury, by ruling that the death was a homicide as opposed to an undetermined or accidental death, agreed that Lisa had been killed by another person, Cairns said. But he explained that homicide was a finding of fact, not of fault or legal responsibility. Throughout the inquest, there was considerable focus on Ruth Doerksen, the nurse who cared for Lisa the night she died. According to Doerksen, Lisa was attached to a monitor. Sharon Shore, however, says she never saw her daughter hooked up to the machine.
Shore inquest recommendations
After the death, Doerksen printed out the doctor's orders and took them home, where they remained sealed until she was ordered to bring them to court. The Hospital for Sick Children says the institution is shocked by the verdict and would have agreed with a ruling of accidental or undetermined death as opposed to homicide. ''Everyone acknowledges the errors that we made,'' said Alan Goldbloom, the hospital's vice-president for clinical and academic affairs. ''However, the feeling of everyone here is that the errors were human and not intentional.'' Goldbloom apologized to the Shore family. ''No words can express how sorry we are about this tragedy. We offer our deepest apologies for the mistakes made and we will have to live with this forever.'' Along with the verdict, the jury provided 35 recommendations aimed at preventing similar deaths and allowing investigations into suspicious deaths to run smoother. The main recommendations cover the transfer of information between doctors and nurses with a focus on the computer system the two groups use. They also relate to nurse training in the use of morphine and making access to well-documented records easier for parents and investigators. The inquest was wrought with confusion and accusations of cover-ups, prompting Cairns to admit during proceedings that there were serious communication problems between the hospital and his office, making the investigation difficult. The hospital did its best to cover up the truth, said Frank Gomberg, the Shore's lawyer. ''The hospital not only failed to take care of Lisa, but it then tried to hide the truth. This strikes at the very integrity of the Hospital for Sick Children.'' Goldbloom said the hospital has taken the incident seriously and already has implement changes to procedures as a result. He says the use of monitors is now mandatory when a child is receiving narcotic medications; a special education program has begun for nurses treating patients with chronic pain, and a program is being developed for staff regarding their roles when a coroner is investigating a death. Despite these changes the hospital may still have a fight on its hands. Bill and Sharon Shore are pressing for a criminal probe of the circumstances surrounding Lisa's death and are asking for a public inquiry to be conducted by the province. They also are asking that Doerksen, as well as another nurse on duty, Anagaile Soriano, be fired. The two nurses currently are on paid leave and will remain on leave until the chief nurse at the hospital has reviewed records of the inquest and come to a decision, Goldbloom said. |
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