RICK MADONIK/TORONTO STAR

WANT ANSWERS: Sharon and Bill Shore, top, came to an inquest yesterday to hear why their 10-year-old daughter Lisa, below, died after being admitted at the Hospital for Sick Children with recurring leg pain.

Death inquest opens after family settles with Sick Kids

The inquest investigating the death of 10-year-old Lisa Shore at the Hospital for Sick Children opened yesterday, but the hospital has already quietly settled a civil suit with the family. 

Frank Gomberg, the family's lawyer, refused to comment on the details but did confirm a settlement was reached last month. 

Lisa died Oct. 22, 1998, after being admitted for recurring leg pain, a rare condition previously diagnosed as reflex sympathetic dystrophy - chronic burning pain - brought on by a broken leg. 

Yesterday, the first day of testimony, the jury heard from Dr. Markus Schily, who prescribed morphine on a self-controlled pump for Lisa's pain when she came to the hospital the night before she died. 

After her death, Schily was shocked to discover that his many specific orders - to guard against the potential life-threatening dangers of morphine - never reached the nurses who cared for Lisa, he testified.  Schily left a note on Lisa's chart reminding nurses to look at his orders in the computer. 

But all those orders on the computer - including monitoring vital signs once an hour, calling him if anything changed dramatically and hooking Lisa up to machines to monitor her breathing and the oxygen level in her blood - have the word ``suspended'' in front of them. 

Based on information he later received from computer specialists, those words mean his orders were never seen, Schily testified. 

Lisa's charts, entered as exhibits, show her vitals were not monitored once an hour and tests were not done to determine whether she could be awakened easily, Schily testified. 

And the information Schily was given when staff paged him at 4 a.m. to tell him Lisa's respiration rate had dropped was inadequate and led him to believe she was doing all right, he testified. 

``I assumed everything was fine.'' 

But sitting in coroner's court yesterday, looking at Lisa's charts, Schily said it is now clear to him the girl was far from fine when he received that call and wasn't being monitored as he had asked. 

Her chart shows a pulse of 134 at 4:15 a.m., above normal, and shows her blood pressure and temperature hadn't been taken since 1:45 a.m., but Schily said he recalls being told Lisa's vitals were all fine. He also said he was told Lisa was easily wakened, though he testified those tests were never done. 

``I assumed she was being properly monitored,'' he said of the 4 a.m. phone conversation, when he told the staff to remove the pain medication pump from the room because of Lisa's decreased respiration.

 Schily flew in from Israel of his own accord to testify and help the Shores find out what happened to Lisa. 

Dressed in business suits and taking notes, Sharon and Bill Shore came to the inquest seeking those answers. 

But Sharon Shore, who was in the room with her daughter, believes she already knows what happened. 

`She had a reaction to the morphine,'' Shore said. ``And all the things that can be done to reverse this reaction were available and there, but that the people who were taking care of her did not do the things they should have done in order to save her.'' 

Shore also said her daughter was not hooked up to any of the monitors Schily ordered - monitors that would have beeped when her breathing or heart rate dropped, waking Sharon, who was sleeping beside Lisa, not realizing she was in any danger. 

Lisa was found dead at 7:15 a.m., when staff did routine rounds. 

What haunts the Shores is that their daughter wasn't in danger when they took her to the hospital. They only hoped to stop her pain. 

``She didn't have a life-threatening condition. She was in pain . . . she could have been in pain at home. Eventually she would have gotten better,'' Sharon Shore said. 

With the civil suit already settled, and the knowledge that the truth surrounding Lisa's death may not make living without her any easier to bear, Shore said she has another reason to be at the inquest. 

The truth may help others. 

``A lot of things went wrong at the hospital. Whether they are indicative of the way things work at that hospital is maybe something the public should be demanding to find out. Certainly enough things went wrong that our daughter died,'' Shore said. 

Shore said she wants the hospital ``to acknowledge its role and be accountable and make sure changes are made so that everybody knows that the hospital is a good place, a safe place to go, so that this never happens to another child.''