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Thestar.com
> News > Editorials | | Nov. 12, 2000. 06:49 EDT | |
| | Troubling parallels | | Two years ago, 10-year-old Lisa Shore died in the care of Toronto's Hospital for Sick Children. A coroner's jury later called the death ``homicide'' - a finding of fact, not blame, that devastated the hospital and its staff. On Sept. 14, 17-year-old Sanchia Bulgin died in the same ward of the hospital. The hospital has accepted full responsibility. But there are too many other similarities between the two cases to let the matter end there. It was not simply the same ward that was involved, but the same problems showed up. For example, in the Shore case, the inquest heard evidence that a corimetric monitor was turned off because it sounded repeated false alarms. In Sanchia Bulgin's case, an internal inquiry by Sick Kids says, the same type of monitor was used and, two hours before her death, the monitor registered low or ``not available'' readings for oxygen in her blood. However, these readings were ``initially felt to be due to monitor dysfunction.'' ``Equipment malfunction appears to be a common interpretation because of frequent problems associated with the use of the corimetric for an older child,'' the report said. Other similarities are just as troubling. Sick Kids' internal review cites poor communication between doctors and nurses, incomplete records, a lack of understanding among nurses as to the nature of Sanchia's ailment, a failure of nurses to obtain complete vital signs or recognize the need to call surgical staff for help. There is one important difference. After Lisa Shore's death, her parents were unable to get answers from the hospital on why their daughter had died. The hospital was roundly criticized by the coroner's jury for this. After Sanchia Bulgin's death, the hospital sent her parents a copy of the findings of its inquiry. That is to be commended. But it's not enough. Regrettably, this requires a new look by the coroner, to determine if this death came from a whole new set of failings - or the same failings, uncorrected. |
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