February 25, 2000  Jury's verdict on girl who died at Sick Kids Lisa's death called homicide Parents call for police investigation and public inquiry By Harold Levy and Jennifer Quinn  Toronto Star Staff Reporters KEN FAUGHT/TORONTO STAR DAUGHTER MOURNED: Lisa Shore's classmates signed her school desk and chair for her parents, Bill and Sharon, after the girl died at Sick Kids Hospital in 1998. The death of 10-year-old Lisa Shore, who died less than 12 hours after she was brought to the Hospital for Sick Children with pain in her leg, has been called a homicide by a coroner's jury.  Jurors stunned the coroner's courtroom with their verdict, which was contrary to a request from Crown Attorney Margaret Browne that they find Lisa's death was either accidental or undetermined.  The girl's family immediately called for a public inquiry and a police investigation.  Homicide, as used by a coroner's jury - which by law cannot assess blame - is based on the neutral dictionary definition: the killing of one human being by another.  Coroner Jim Cairns explained yesterday that a homicide verdict is ``a finding of fact rather than one of legal responsibility,'' and that it is not within the jurisdiction of jurors to determine if the killing of one person by another ``is culpable or non-culpable.''  But the verdict ``means that the Hospital for Sick Children has got a serious systemic problem that they had better address,'' said the family's lawyer, Frank Gomberg, ``because to link the word homicide with the words Hospital for Sick Children, to my knowledge, has never ever been done before.''  Homicide verdict extremely rare Persistence pays off for couple Sick Kids has seen scandals before The Star's view The world-famous hospital ``failed Lisa and the Shore family by not doing any investigation and by obstructing the coroner's investigation,'' Gomberg said. ``This was an unacceptable attempt to avoid public scrutiny.''  Lisa's mother, Sharon Shore, said she was ``absolutely thrilled'' to hear the jurors call her daughter's death a homicide, ``because this meant the truth was out there . . . that, as we have been saying from the very beginning, the Hospital for Sick Children was wholly responsible for our daughter's death.''  Toronto Police spokesperson Constable Devin Kealey said homicide investigators will meet with the crown attorney's office to discuss the verdict.  The Hospital for Sick Children already has reached an out-of-court settlement in a civil suit brought by the Shore family. Sharon Shore has said the money is mainly being used to pay for the family's lawyer, ``so the truth can come out.''  Lisa died on Oct. 22, 1998, after being admitted the night before seeking relief from recurring pain in her leg, a rare condition previously diagnosed as reflex sympathetic dystrophy, triggered by a broken leg.  The coroner's jury heard testimony from Dr. Markus Schily that he prescribed morphine on a self-controlled pump for Lisa's pain, and left specific orders for nurses to monitor the little girl for the potential life-threatening dangers of morphine. Schily testified he was shocked after Lisa's death to learn that his orders never reached the nurses who cared for Lisa, despite the note he left on her chart reminding nurses to look at his orders in the computer.  Lisa was found dead at 7:15 a.m. the next morning when doctors came by on their morning rounds.  One member of the three-woman, two man jury said yesterday the inquest was a gruelling experience.  ``I am so sorry that she died and I am still so emotional,'' said Angelina Santa Ana.  ``I would tell (Sick Kids) to be more careful relating to the nurses. They just have to follow the doctors' orders. If that was followed, then maybe this wouldn't happen.''  During the 20-day inquest, which began last November, jurors grew visibly upset at the evidence given by the hospital's witnesses.  They heard conflicting evidence about the use of a corometric monitor, which sounds alarms when breathing and heart rates fail. Nurse Ruth Doerksen, who was primarily responsible for Lisa's care, testified she had the child hooked up to the device, but later disconnected the respiration unit after it sounded repeated false alarms.  Lisa's mother, who spent the night in her daughter's hospital room, testified she neither saw such a machine, nor heard the repeated alarms Doerksen spoke of.  Gomberg told reporters yesterday the homicide verdict indicated the jurors did not believe Doerksen's testimony.  While the hospital eventually agreed that if a monitor was attached to Lisa, someone had turned it off, Gomberg suggested in his closing arguments that Doerksen wheeled the monitor into Lisa's room only after she discovered that her charge had died.  Jurors also heard about the disappearance of important nursing notes following Lisa's death and the erasure of an audiotape containing a verbal record of Lisa's care.  Yesterday, Dr. Alan Goldbloom, Sick Kids' vice-president of academic and clinical development - and the person responsible for patient care - apologized repeatedly to the Shore family.  ``I want to say to the members of the Shore family that no words can possibly express how sorry and devastated all of us are by this tragedy,'' a subdued Goldbloom said. ``People who devote their careers to this institution are here to help children and support families.  ``When we failed to do that, it's devastating for all of us,'' he added.  ``We offer (the Shores) our deepest sympathies and we apologize for the mistakes that have been made. We're terribly sorry - we will all live with this forever.''  Doerksen and Anagaile Soriano, the other nurse responsible for Lisa's care, were placed on paid leave when the inquest began last November. They will remain off work until the hospital's probe into the case is complete, Goldbloom said.  But Goldbloom - who rejected the idea that a public inquiry and police probe of Lisa's death are necessary - insisted there was no cover-up and that the hospital wants to make certain that a tragedy like Lisa's death never happens again.  Still, he conceded, ``we're not satisfied with the way we handled it.  ``I think that any gaps were honest ones, and I think that when you begin any legal, or quasi-legal process, a lot of people feel very constrained by what they can or can not say.''  The coroner's jury made 35 recommendations, including:  In cases of unexplained or unexpected death occurring in a hospital, the investigating coroner should direct that the contents of all recycling and shredding bins at the nursing station be preserved for the investigation, along with audio and videotapes and any other information relating to the patient who died.  Every effort should be made ``to respond quickly, accurately and openly'' when relatives ask for information about their child's death.

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