Two mothers want probe of hospital


Sat Nov 11, 2000 - Updated at 07:31 AM

Thestar.com > Entertainment/Life > Health

Nov. 10, 2000. 11:36 EDT

Their children died in the same ward two years apart

Harold Levy
STAFF REPORTER

The mothers of two young girls who died unexpectedly, two years apart, in the same ward at the Hospital for Sick Children are both calling for a public inquiry.

Their calls for an independent inquiry are supported by the foreperson of the coroner's jury that in February returned a verdict of homicide after a 20-day inquest into the death of one of the girls, 10-year-old Lisa Shore.

Lisa's mother, Sharon Shore, wrote to Health Minister Elizabeth Witmer in April and asked her to order a public inquiry into her death.

On Oct. 22, 1998, Lisa Shore was brought to Sick Kids by her mother because of pain in her leg, which had been broken earlier that year. The girl was admitted and attached to a morphine pump.

Less than 12 hours later, as her mother dozed beside her, Lisa was found dead in her bed on Ward Five A/B, the unit that cares for general surgery and orthopedic patients.

The five-member coroner's jury heard evidence that Lisa's nurses failed to monitor her for possibly deadly effects of the morphine.

``We are learning that the events surrounding my daughter's death were not isolated events,'' Shore wrote in her April letter to Witmer. ``We are learning that there are significant problems at the hospital which directly impact on patient care.''

In light of the death of 17-year-old Sanchia Bulgin on Sept. 14, also on Ward Five A/B, Witmer should call a public inquiry ``before any more children unnecessarily die,'' Shore said yesterday.

Bulgin, 17, who suffered from sickle cell anemia, died after undergoing surgery to remove her gallbladder.

The Hospital for Sick Children accepts the blame for her death, and deputy chief coroner Dr. Jim Cairns is probing Bulgin's death.

An internal committee struck by the hospital to review Bulgin's death acknowledged that nurses did not complete taking the teen's vital signs or recognize the seriousness of changes in her vital signs, and that they did not identify the fact that she was going into shock.

However, Stephanie Bulgin, Sanchia's mother, told The Star a public inquiry was necessary ``because the last inquest did nothing to save my daughter's life.''

Gail Allegri, jury foreperson in the Shore case, said yesterday that she was ``profoundly disturbed'' to learn of Bulgin's death and renewed her call for a public inquiry.

``I believe a full inquiry is the only way to determine what actually happened on the day Lisa died,'' she wrote in a letter to Witmer in June.

``We must do everything in our power to uncover the truth and ensure that no other child passes away needlessly because we failed to draw lessons from Lisa's death.''

Shore believes the problems at Sick Kids are deeply rooted and a public inquiry is needed to make the hospital safe for all patients.

`I know there are good people there, but the good people are afraid to do anything about the bad'

``I would look at the reasons why so many qualified nurses have left Sick Kids or been laid off or fired, at morale, and at why nurses and doctors are afraid to come forward to reveal problems,'' she said. ``It is my belief that the hospital has covered up other cases where children have unnecessarily died or have been seriously harmed by the hospital.

``An inquiry needs to ferret out what's going on there, why it is allowed to go on, and to have the ability to make the changes to insure that the hospital becomes a safe place for all children,'' Shore added. ``This is not a blanket condemnation of the hospital. I know there are good people there, but the good people are afraid to do anything about the bad.''

Witmer's press secretary, Barry Wilson, said yesterday it would not be appropriate for the ministry to comment on the possibility of a public inquiry while a coroner's investigation is under way.

``This is indeed a tragic and sad situation and our condolences go out to the family and friends,'' Wilson said. ``We are advised that the coroner's office is currently investigating this incident and, as such, we will await their findings.''

It appeared to be business as usual at the hospital yesterday, but a nurse, who asked not to be identified, told The Star the Bulgin case was ``on everybody's mind.''

``I think the nurses are pretty terrified,'' the nurse said. ``It's particularly bad on Ward Five A/B, where the two girls died.''

Parents who ask Sick Kids' staff about the situation are being given a letter written by Dr. Alan Goldbloom, vice-president of academic and clinical development, said hospital spokesperson Helen Simeon.

``You may have heard some stories in the media about the unexpected death of a child at the Hospital for Sick Children,'' the one-page letter begins. ``I wanted to provide you with some information on the case to clarify what you may have read.''

The letter assures parents that unspecified recommendations of an internal review committee are being implemented as quickly as possible, ``to make sure that patients get the best possible care.''

Meanwhile, a number of issues remain up in the air.

A prosecutor is currently studying a report on the Shore case prepared by a member of Toronto's homicide squad to determine whether criminal charges should be brought against the hospital and staff members.
The Ontario College of Nurses meets next week to discuss an investigation by its own investigators in response to a complaint brought by Sharon Shore against six nurses. The college can order a public disciplinary hearing.
Cairns, who has the authority to order an inquest into Bulgin's death, expects to conclude his investigation by mid-December.
The compensation that will be made to the Bulgin family by the hospital has yet to be determined. Lawyer Frank Gomberg, who represents Stephanie Bulgin, doubts a lawsuit will be necessary because the hospital has already admitted liability.

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