The Hospital for Sick Children is an icon in this city, this province,
this country. That it is a world-class facility which has saved and enriched
thousands of young lives goes without saying.
But this well-deserved reputation for excellence is the very
reason why much more needs to be said and done about the tragic death at
Sick Kids of 10-year-old Lisa Shore.
As the coroner's jury into Lisa's death ruled Thursday, she likely
died of "complex drug interaction leading to cardiac and respiratory arrest"
after being admitted in October, 1998 with a rare, non-life-threatening
condition arising from an earlier broken leg.
She was put on morphine. The monitor that was supposed to detect
heart or respiratory failure was turned off.
Because of this, the jury ruled that Lisa's death was "homicide"
- a judgment some, including the hospital, find harsh.
It is not. This jury is to be congratulated for its candour.
Too often inquest juries return predictable verdicts and recommendations
that wind up gathering dust.
This jury, having heard the often shocking and disturbing facts
surrounding Lisa's death, determined that it was not just a case of terrible
bad luck, simple human error or unavoidable accident.
Their use of the word "homicide," which was not recommended by
the inquest's lawyer, was nonetheless clear and deliberate.
It doesn't mean anyone at the hospital murdered Lisa. It means
the jury believed someone was directly responsible for her death.
Such a verdict necessitates a police investigation. There are
too many unanswered questions here, both about possible negligence leading
up to Lisa's death and about the hospital's behaviour - characterized by
her family as a "cover-up" - after the fact.
The jury's recommendations also require further action - particularly
the one calling on the hospital to respond "quickly, accurately and openly"
to relatives following a patient's death.
Surely, this should go without saying!
Sick Kids, while expressing shock at the "homicide" ruling, has
offered a "profound" apology to the Shores. But that is not enough. A full
public accounting of what happened and when is in order. This could be
done via a public inquiry, or the hospital could come forward and take
the initiative publicly and on its own.
We expect nothing less of an institution of its great stature.
