Nurse missed vital doc orders

Coroner's inquest

Ruth Doerksen testified before a coroner's inquest that she never saw orders from the emergency physician who admitted Lisa to the Hospital for Sick Children until around 10 a.m. on Oct. 22, 1998. Lisa had already been found dead in her room about 7 a.m.

The girl had been given emergency care at the hospital the previous night for acute leg pain caused by a rare, chronic condition known as reflex sympathetic dystrophy.

The emergency doctor had placed strict orders for Lisa's care up on the ward on a Sick Kids computer system called KIDCOM, which is routinely used for such orders.

But Doerksen only referred to written orders that came up from emergency with the patient, and she did not see a line on those orders that told nurses to see the KIDCOM electronic system for fuller instructions.

Since the girl was on morphine, the doctor had ordered that Shore be monitored carefully for the first four hours. He'd ordered that both a sedation scale and pain scale be done, as well as heart rate, blood pressure and respiration rate, "every hour for the first four hours," said family lawyer Frank Gomberg. But many of these tests were not done, because Doerksen hadn't seen the orders in the hospital computer.

"All of these things probably would have saved her life," Gomberg said.

And Gomberg also said yesterday the inquest had been "hijacked" because Sick Kids failed to disclose to the coroner the existence of the doctor's orders until Jan. 26, 1999 -- a full three months after Lisa's death.