FATAL ERRORS: Sanchia Bulgin, 17, died after gallbladder surgery.

An internal hospital report, dated Oct. 24, that was provided to Sanchia Bulgin's family only acknowledged serious ``problems'' in the care provided her by both doctors and nurses.

But yesterday, in a news release, hospital senior vice-president Alan Goldbloom said, ``The hospital has taken full responsibility for the death of Sanchia Bulgin.''

Bulgin, who had sickle cell anemia, was having her gallbladder taken out. Children with sickle cell anemia are prone to gallstones and sometimes must have their gallbladder removed as a result.

She died Sept. 14 after being brought from a post-surgery room to Ward Five A/B, the unit that cares for general surgery and orthopedic patients.

The same ward was the subject of an inquest into the sudden death of 10-year-old Lisa Shore in 1998.

The coroner's jury in that case found that Lisa's death was a ``homicide,'' after a stormy inquest in which one of the jurors publicly accused the hospital of a cover-up.

The deputy chief coroner, Dr. Jim Cairns, who is probing Bulgin's death, says his investigation is important ``because a child has died, and it is the second child that has died on the same ward.''

Cairns said he is exploring some of the same issues in the two cases.

The Star has obtained a copy of the report of an internal review committee struck by the hospital ``to investigate the events leading up to the unexpected death of Sanchia Bulgin, and to identify any human error or systems problems that contributed to this unexpected and tragic event.''

• No direct communication among any of the key physicians and surgeons caring for Bulgin, from the time of her first hospitalization in June until her death. ``Because of this poor communication, Sanchia was not adequately prepared for her operation.''
• Failure of the hospital's hematology and anesthesia departments to properly evaluate Bulgin before the operation: ``Sanchia had complex medical problems and should not have gone to the operating room without a recent detailed medical evaluation.''
• Lack of recognition of the severity of her condition: ``There was a lack of understanding among the nurses about sickle cell disease, and what its implications are.'' (Sickle cell anemia is an inherited blood disease in which abnormal red cells reduce the blood's capacity to carry oxygen).
• Inadequate nursing clinical judgment: ``Nurses did not obtain complete vital signs or recognize the seriousness of changes in the observed vital signs, and thus did not identify developing shock in this patient nor a need to request help from the surgical house staff.''
• Poor communication among nurses: ``Nurses failed to pass on key clinical findings to new nurses assuming care of Sanchia . . . Documentation of clinical nursing observations and interventions was incomplete.''
Stephanie Bulgin, who gave the internal review report to The Star, said her daughter was supposed to go into the hospital for the surgery, stay overnight and return home the next morning.

``The reason she had to stay was so that they could monitor her and make sure that she did not go into a sickle cell crisis,'' she said in an interview.

A sickle cell crisis, which can be caused by factors such as infection, can attack or damage various parts of the body.

Bulgin believes her daughter would still be alive if doctors had talked to each other before operating on her, and if nurses had properly carried out the most basic nursing functions.

``Sanchia would have had a huge file from her many stays at the hospital, if only the doctors had taken the time to read it,'' she said.

``And if nurses had been reading her vital signs regularly, as they are supposed to do, they would have seen she was failing and called for help.''

Lawyer Frank Gomberg, who also represented the Shore family, said he was ``horrified'' to learn that the Bulgin family's worst fears about their daughter's death had been confirmed by the hospital.

``The hospital has admitted responsibility for Sanchia's death,'' he said. ``There's no doubt in my mind at all after reading the hospital's own report that its negligence caused this girl to unnecessarily die.

``We fully expect the hospital to pay damages to the family without the necessity of a lawsuit.''

Goldbloom told The Star the hospital does not believe an inquest into Sanchia's death is necessary because the hospital ``is able to find out all of the information pertaining to the death.''

But, he added, ``That is a coroner's decision.''

He said some changes recommended by the internal review committee have already been implemented.