Study interaction of 2 drugs: Jury

35 recommendations put forward by coroner's probe

A study should be undertaken to examine interactions between two drugs that Lisa Shore was on when she died last October at the Hospital for Sick Children.

 The five-person coroner's jury inquiring 10-year-old Lisa's death urged -- as the first of their 35 recommendations -- that "a study be undertaken" to examine interactions between morphine, Gabapentin and other therapeutic drugs.

 Initially, it was thought the little girl may have died from a morphine overdose, but since her levels of the painkiller were found to be normal, the jury has pointed to the possibility of a complex drug interaction between morphine and Gabapentin, an anti-convulsant drug.

 The jury also recommended:

 That automated warning technology "should be explored and implemented" for the hospital's computerized system for doctor's orders called Kidcom.

 The inquest heard that Lisa's nurses had never seen strict orders for vital signs and other monitoring ordered by the child's admitting doctor -- because they hadn't checked the Kidcom computer system where the orders were filed.

 'VITAL SIGNS'

 And they failed to see a handwritten note "see Kidcom orders" written by a doctor in the little girl's chart.

 "When ... Kidcom orders are entered in Emergency for an incoming admission, a page or other audible warning should sound regularly, such as every five minutes, on the destination ward, and stop only when Kidcom orders are activated," the jury recommends. 

 They also recommended that "for patients admitted to wards from Emergency, nurses must review the Emergency nursing notes, doctors orders, flow charts and vital sign assessments, and should initial all documents as evidence that they have been reviewed."

 The jury also suggested a doctor "must ask for all specific vital signs and scales in any telephone consultation with nursing staff," something that would, if done, possibly reveal when doctor's orders are not being followed. They also recommended that a relief staff nurse be added to all "long night or long day," 12-hour shifts worked by nurses.

 The jury recommended that "when the family of a deceased patient -- whether on its own or through a lawyer -- requests detailed information about the circumstances of the child's death, every effort should be undertaken to respond quickly, accurately and openly."  Inquest jury cuts to the truth -- Heather Bird