Girl's hospital death 'a homicide'

Inquest negligence verdict 'vindicates' Lisa Shore's parents

Parents' Struggle ... Bill and Sharon Shore say they feel 'vindicated' after a coroner's inquest determined their daughter Lisa died of negligence at the hands of Sick Kids hospital last October.

A coroner's jury stunned a packed inquest courtroom yesterday by handing down a verdict that 10-year-old Lisa Shore died by "homicide" at the Hospital for Sick Children.

 However, the verdict does not mean the jury feels the little girl was murdered, but instead that she died because of negligence.

 Coroner Dr. James Cairns, who has been conducting the inquest into the Thornhill child's death last Oct. 22, cautioned those in the courtroom that the jury's verdict is a finding of fact.

 "It is not a finding of fault or legal responsibility," Cairns said.

 The three-woman, two-man jury found that Lisa probably died by "complex drug interaction leading to cardiac and respiratory arrest."

 The child had been taken to the hospital the evening before her death for treatment of severe pain.

 In addition to their factual verdict on cause of death, the jury handed down 35 recommendations on how such deaths could be prevented in future.

 At a press conference following the verdict, the child's mother, Sharon Shore, said she was "elated" when she heard the jury's decision.

 Some members of the family began to cry when the "homicide" verdict was read out by Cairns.

 "What it did is it vindicated us," she told reporters.

 Saying she was "absolutely thrilled" by the jury's verdict, Shore added she feels the nurses involved "should be terminated; they should have been terminated right at the beginning."

 Shore family lawyer Frank Gomberg said the jury's decision "strikes at the very integrity of the Hospital for Sick Children. 

 "The hospital not only failed to take care of Lisa, but it then tried to hide the truth," he said. 

A TRAGEDY UNFOLDS

A five-person coroner's jury found yesterday that Lisa Shore's hospital death in October 1998 was a homicide. Here is a chronology of the events leading up to her death and the aftermath: Oct. 21, 1998 at 7 p.m. -- Lisa's parents take her to the Hospital for Sick Children because of pain from a rare, non-life-threatening chronic disorder, known as reflex sympathetic dystrophy, due to a broken leg suffered six months earlier.  Oct. 22 at 1:45 a.m. -- After being treated in Sick Kids' emergency department, Lisa is admitted to the orthopedic ward. She is given morphine for her leg pain and Dr. Markus Schily orders that she be monitored hourly against possible deadly effects of the drug. The orders also required nurses to hook Lisa up to a corometric monitor, which would sound an alarm if her heart rate or breathing falls below set levels. This is also the last time Lisa's blood pressure and temperature are taken, according to her chart. Oct. 22 at 2 a.m. -- Lisa's mother, Sharon Shore, falls asleep at her daughter's bedside. Oct. 22 at 4 a.m. -- In a phone call from a nurse, Schily is told Lisa's vital signs are good. Schily told the nurse to recheck Lisa's vital signs and call him back if there were any problems. He wasn't called back. Oct. 22 at 6 a.m. -- The last time a nurse checks on Lisa. Oct. 22 at 7:18 a.m. -- In a routine round of staff checks, doctors awaken Lisa's mother and together they find her 10-year-old girl had died from respiratory and heart failure during her sleep. The corometric monitor was in the room but leads that should have been attached to Lisa were curled up on top of it and the monitor was turned off.  Oct. 22 at 10 a.m. -- Lisa's nurse Ruth Doerksen first sees Schily's orders, according to her testimony. Doerksen later prints them out and takes them home, where they remained sealed until she was ordered to bring them to court last month. Jan. 26, 1999 -- For the first time the hospital discloses to the coroner Schily's detailed orders to nurses, which leads to the calling of an inquest into Lisa's death. October 1999 -- The hospital quietly settles a civil suit with Lisa's family. The details are not released. Nov. 8, 1999 -- The inquest investigating Lisa's death opens. Nov. 12, 1999 -- The inquest is delayed two months so the coroner can grant standing to the manufacturer of corometric heartbeat and breathing monitors after hospital staff imply equipment failure may have led to Lisa's death. The hospital later recants that suggestion. Feb. 8, 2000 -- The hospital issues an apology to Lisa's family. Jean Marie Reeder, chief of nursing, admits there was "inadequate nursing care" but cites an ongoing Sick Kids' nursing shortage.

 And Gomberg said the family is calling for a public inquiry to be conducted by the province.

 "The inquest process was necessarily adversarial because the Shores wanted the truth and the hospital did its best to hide the truth," said Gomberg.

 "This calculated attempt to defeat public scrutiny warrants a public inquiry by the province of Ontario into the hospital administration and the ethical framework in which its nurses operate," he said.

 Gomberg said the inquiry is necessary to remove the "taint of the shameful coverup engaged in by the Hospital for Sick Children."

 And Gomberg told reporters the Shores have never felt anyone at Sick Kids "set out in a culpable way to kill Lisa."

 But he said the family's position is that they were "woefully, woefully negligent."

 And Gomberg said there's a "very good possibility that some charges could be laid, I don't know what charges."

 Two hospital nurses have been suspended with pay pending the outcome of the investigation.

 The lawyer called on Chief-designate Julian Fantino to order a full investigation into the little girl's death. Among other things, he said the police should investigate whether there was criminal negligence, or whether people testifying at the inquest committed perjury.

 OBSTRUCTION

 He also said the cops should investigate the possibility of obstruction of justice in the case.

 "The point is, the police did no investigation in this case and they ought to have ... and I call on the outgoing chief of police and ...(incoming) Chief Fantino, to direct that a proper investigation be done so that we can figure out what happened," Gomberg said.

 Meanwhile, police spokesman Const. Devin Kealey said detectives from the force's homicide squad will be meeting with the crown attorney's office to go over the recommendations.

 "It will be up to the crown to decide which way we go from there," Kealey said.

 Hospital for Sick Children senior vice-president Dr. Alan Goldbloom said they're "shocked at the verdict."

 "We recognize that the jury was expressing its outrage at the death of Lisa Shore," said the pediatrician.

 And Goldbloom pointed out that the coroner's lawyer at the inquest recommended the jurors rule the death either accidental or undetermined -- not a homicide.

 Apologizing several times to the Shore family for the death of their daughter, Goldbloom said: "We are very deeply saddened by the tragedy of Lisa Shore's death.

 "Clearly, the Hospital for Sick Children failed Lisa Shore and failed the Shore family. We will live with this forever," Goldbloom said.

 "We are profoundly sorry for what has happened," he added.

 -- With files from Scot Magnish  Study interaction of 2 drugs: Jury Inquest jury cuts to the truth -- Heather Bird