February 25, 2000  Hospital `failed Lisa' By Jennifer Quinn  Toronto Star Staff Reporter The Hospital for Sick Children apologized repeatedly yesterday for the death of 10-year-old Lisa Shore, and said it will probe the actions of nurses charged with her care.  What happened Feb. 11, 1998: Lisa breaks her leg and experiences excruciating shooting pain, later diagnosed as a nervous condition triggered by the injury. It is not life-threatening. Oct. 21, 1998, 9:30 p.m: Sharon Shore brings Lisa to the emergency room. The admitting doctor attaches Lisa to a self-administered morphine pump. Orders for nurses to intensively monitor her are entered into Kidcom the hospital's computerized information system. Oct. 22, 1998, 1:37 a.m: Lisa is brought to Ward 5A and placed under the care of nurses Ruth Doerksen and Anagaile Soriano. They later say they attached her to a vital-signs monitor, which the Shores dispute. 1:37 a.m. to 7 a.m.: Nurses check Lisa's pulse. They admit they did not read the doctor's orders or follow the protocol for patients on morphine, including checking blood pressure hourly, monitoring breathing, and documenting pain and sedation. Experts testify Lisa probably would not have died had she been properly monitored. 7:15 a.m.: Sharon Shore wakes up just as doctors find Lisa dead. Their efforts to revive her fail. ``Clearly, the Hospital for Sick Children failed Lisa Shore and failed the Shore family, and we will live with this forever,'' Dr. Alan Goldbloom, vice-president of academic and clinical development, said yesterday. ``It's a tragic day. No caregiver wants to be in the position of explaining a child's death. We all spend our careers working to prevent that.  ``We are profoundly sorry for what has happened, and we are determined to do everything humanly possible to ensure that such a tragedy never happens again.''  The 10-year-old girl died at the hospital in October, 1998, after seeking treatment for extreme pain. A coroner's inquest was called into her death. The three-woman, two-man jury yesterday declared Lisa's death a homicide - meaning she died as a result of the actions of another person.  The verdict ``devastated'' the staff at Sick Kids, Goldbloom said, noting that the hospital believed Lisa's death was accidental, a result of human error. ``We recognize that the jury was expressing its outrage at the death of Lisa Shore, and we are shocked at the verdict,'' Goldbloom said, noting that the coroner's counsel suggested the jurors rule the death accidental or undetermined.  ``Regrettably, human error did occur in Lisa Shore's case,'' Goldbloom told reporters. ``Nobody has ever managed to eliminate all human error, but we're determined to take every step necessary to minimize it.''  Among the steps Goldbloom says the hospital already has taken:  It has hired 100 nurses, improving the nurse-to-patient ratio on its wards.  It has modified its patient-care information system so that doctors' orders are printed automatically on the ward as soon as a patient is admitted.  It is changing policies around ``unexpected events'' so they can be investigated thoroughly and the hospital can account for what staff did.  Its protocols for the management of pain have been rewritten and education for nurses has been ``enhanced.''  All children receiving morphine will have their heart rate and breathing monitored at all times.    Goldbloom said the actions of nurses responsible for Lisa's care will be probed by the hospital's chief of nursing, who will ``also be seeking the advice of the College of Nurses of Ontario, which is the body responsible for the standards and practices of the profession.'' That probe will likely take a few weeks, he said.  A hospital spokesperson recorded a message for staff yesterday on the Sick Kids' public affairs telephone line. ``For the record, the hospital fully co-operated with the coroner's office,'' the message said. ``We did our best to provide, to the best of our ability and to the best of our knowledge, what information was necessary to facilitate an open and fair investigation of Lisa's death.''

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