Feb 24, 18:09 est Recommendations of Shore inquest  By Louise Surette Staff reporter thestar.com After two weeks of deliberations, a five-person inquest jury released its verdict today in the death of Lisa Shore. The 10-year-old Thornhill girl died at Toronto's Sick Children's Hospital in October, 1998.  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 of pain in her leg, which she had broken earlier that year.  She was given morphine for leg pain, and a doctor ordered that she be monitored for any adverse reaction to the drug. Lisa's mother fell asleep and woke up seconds after doctors found the girl dead while making their morning rounds.  The jury made 35 recommendations aimed at preventing similar deaths.  The main ones cover the transfer of information between doctors and nurses with a focus on the computer system the two groups use.  The panel also recommended that:  - Patient information be stored on a computer system for 18 months and made available to coroners;  - When a patient is discharged or dies, doctors' orders be printed out automatically and added to the patient's permanent record;  - All shift-change notes be put on record and that training on the use of the computer system be mandatory for nurses and doctors;  - Better rules governing the way doctors are paged be implemented. There should be a gap of no more than five minutes between the first and second attempts to page a doctor. If the second attempt is unsuccessful, the nurse must try again within five minutes;  - Nursing graduates receive comprehensive training in monitoring patients receiving opiates;  - Nursing breaks on any 12-hour shift be spaced efficiently;  - When an unexplained death occurs, all documents and people who had any responsibility for patient care must be available for interviews by the coroner;  - When the family of a deceased patient requests information about the circumstances of the patient's death, every effort be undertaken to respond quickly, accurately and openly.

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