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Thestar.com
> News | | Dec. 9, 2000. 12:46 AM | | Inquest called into 2nd Sick Kids death | | Coroner orders probe because case resembles that of girl who died on same ward two years earlier | Harold Levy and Sonia Verma
STAFF REPORTERS | Ontario's chief coroner has ordered an inquest into the death of 17-year-old Sanchia Bulgin at the Hospital for Sick Children. This is the second inquest called into the death of a patient on Ward Five A/B - the unit that cares for general surgery and orthopedic patients - in the past 15 months. Sanchia died Sept. 14 after undergoing non-life-threatening surgery to remove her gall bladder. Unmonitored by doctors and nurses, the teenager, who had sickle-cell anemia, bled to death in Ward Five A/B. The hospital accepted responsibility for the teen's death one month ago, several weeks after The Star reported the coroner's office was conducting an investigation. At that time, hospital senior vice-president Alan Goldbloom said Sick Kids did not believe an inquest into the girl's death was necessary because it ``is able to find out all of the information pertaining to the death.'' Yesterday, spokesperson Cyndy DeGiusti said the hospital will respect the coroner's decision. ``We've been co-operating with the coroner's office so far and will continue to do so,'' she said. Ontario's chief coroner, Dr. James Young, ordered the inquest because the circumstances surrounding Sanchia's death closely resembled those of 10-year-old Lisa Shore, who died in the same ward on Oct. 22, 1998, his legal counsel said. ``Dr. Young felt a public examination of the circumstances was required, given that there had been an inquest a few months before involving Lisa Shore in these circumstances,'' Al O'Marra said yesterday. Lisa was found dead in her bed on Ward Five A/B less than 12 hours after her mother brought her to emergency for relief from pain in her leg caused by a non-life-threatening condition. The five-member jury at the Shore inquest heard evidence her nurses failed to monitor her for the possible deadly effects of the morphine she was given to kill pain, and allegations from the Shore family of a hospital cover-up. The jury, which by law cannot assess blame, sent shock waves through the hospital in February when it declared Lisa's death a ``homicide'' - defined as the killing of one person by another.
`I'm appalled that another child has died under what appear to be similar circumstances'
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The jury also made a series of recommendations, including stringent monitoring of a patient's vital signs. An internal Hospital for Sick Children committee that reviewed Sanchia's death found serious problems, including:
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.''
No direct communication among any of the key physicians and surgeons caring for Sanchia, 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 Sanchia before her 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.) O'Marra said the decision to order an inquest into the death at the hospital was made just hours before Young received a letter written on behalf of Sanchia's mother, Stephanie Bulgin, calling for such a hearing. Bulgin says she hopes the inquest will result in concrete changes to patient care at the hospital. ``My main reason for wanting an inquest called is to allow everything that was bad in this case to turn out to be for the better for other children and parents at the Hospital for Sick Children,'' she said yesterday after learning of the coroner's decision. ``In the Lisa Shore case, many recommendations were given from the inquest that were not carried out in my daughter's case and I pray this inquest moves those in charge at the hospital . . . to not only say they will make changes but to make sure that what they say will actually be done.'' Lisa's mother Sharon also welcomed the inquest with mixed emotions. ``While on one hand I welcome the inquest, on the other hand I'm appalled that another child has died under what appear to be similar circumstances,'' she said. Bulgin's lawyer, Frank Gomberg, who also represented Sharon Shore at the inquest looking into Lisa's death, said he intends to raise several questions at the inquest, including:
Why nurses did not report life-threatening blood pressure and breath rates to doctors five hours before Sanchia died so they could be acted on.
Why nurses never took Sanchia's blood pressure again during this five-hour period.
Why a doctor on rounds failed to examine Sanchia shortly before she died in spite of the life-threatening readings posted on her door. The inquest will likely begin next spring. |
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