Lisa, 10, was dead. But high-tech equipment didn't sound alarm because it wasn't turned on, inquest told

Lisa Shore's mother kept a silent overnight vigil as the 10-year-old lay in her room at the Hospital for Sick Children. 

A team of doctors came by at 7:20 a.m. on Oct. 22, 1998, to check the girl, admitted the day before with excruciating leg pain. 

Her mother, Sharon Shore, spent the night in a bedside chair, ready to offer comfort and love. 

``I asked (Lisa's mother) how Lisa slept,'' Dr. Melanio Catre testified at a coroner's inquest yesterday. 

``She responded that she slept well.'' 

Then Catre looked at Lisa and realized something had gone horribly wrong. 

The child was dead. 

Alarm bells should have sounded during the night from high-tech monitoring equipment attached to the girl but the equipment wasn't turned on, said Catre, then a senior pediatrics resident at the hospital. 

Lisa's mother and father, Bill, sat quietly during the testimony on the second day of an inquest before Ontario deputy coroner Dr. Jim Cairns. 

Lisa had been admitted to the hospital with recurring leg pain, a rare condition previously diagnosed as reflex sympathetic dystrophy. 

The pain had been bothering her ever since she broke the leg six months earlier. 

At Sick Kids, she was given morphine after a doctor's warning about the drug's potentially life-threatening risk failed to reach emergency department nurses, the jury heard. 

A monitor that tracked vital signs was attached and plugged in but not turned on, Catre said. 

The monitor would have set off a loud sound if it had been activated. 

``Is it a noticeable alarm?'' asked Margaret Browne, a lawyer for the coroner's office. 

``Very noticeable,'' Catre replied. 

``Do the children in that ward normally have these alarms?,'' Browne continued. 

``Yes,'' Catre said. 

The jurors also heard that warnings from Dr. Markus Schily about morphine's possible deadly effects on the child were never seen by nurses in the emergency ward where the drug was administered. 

The doctor's warnings were filed electronically and a printout included with her chart was not transferred from the emergency department to her room. 

The warnings were not accessible to the emergency department team who injected her with the painkiller, Pauline Matthews, an emergency room nurse, testified. 

``Did you hear anything going off?,'' Browne asked Matthews. 

``No.'' 

``Nothing?'' 

``Nothing.'' 

Frank Gomberg, a lawyer for Lisa's parents, asked Matthews if it was unusual for the emergency team not to see a doctor's instructions. 

Schily had also left a note on the chart reminding nurses to check the computer. 

``I have no access, no access whatsoever,'' Matthews said. 

Pressed on the point, Matthews expanded, ``If she stayed there (in the emergency ward) for three days, I'd have no access to it.'' 

The inquest continues Friday.