MD's orders 'lost'

Lisa, 10, not monitored hourly, inquest told

Nurses at Toronto's Hospital for Sick Children apparently never saw the orders in a computer system, the opening day of an inquest heard yesterday.

Lisa, 10, of Thornhill, died Oct. 22, 1998 after being admitted the previous evening in severe pain.

After breaking her leg six months earlier, she had been diagnosed at Boston's Children's Hospital with reflex sympathetic dystrophy, a rare condition marked by chronic, burning pain.

At the inquest, an enlarged copy of Dr. Markus Schily's missed orders sat on an easel near the six jurors.

Schily indicated several times he was shocked when he heard later his computerized orders apparently were never transmitted from the hospital's emergency department to the orthopedic ward where Lisa spent her final hours.

Schily, 40, an anesthesiology resident at Sick Kids at the time, testified he had also flagged the orders he left on a computer system called Kidcom, which was routinely checked by nurses.

Schily said he wrote "see Kidcom orders" on Lisa's ward chart before he left the hospital, hours before the girl died after getting the morphine.

Another painkiller with sedative effects, amitriptyline, had been given to Lisa by her parents as part of her bedtime routine.

When Dr. Jim Cairns, Ontario's deputy chief coroner, asked Schily to clarify what his handwritten chart note meant, he replied: "It clearly means: Look, check in the computer after my notes ... I wanted to prevent someone from thinking (the written chart) is all that's needed."

Nurses have not yet testified at the inquest.

Outside coroner's court Schily's lawyer, Anne Posno, would not let him say whether following the Kidcom orders would have saved Lisa's life.

"The nurses did not get them," Posno said. "We can't tell you what happened."

Frank Gomberg, the lawyer for Lisa's parents Bill and Sharon Shore, said outside court the family had reached a settlement with the hospital.

Schily, who took a hospital post in Israel last summer, testified that morphine had been prescribed for Lisa because an epidural block had failed and she had received morphine before.

Schily said he had been told Lisa's vital signs were good in a phone call from a nurse at 4 a.m. the day Lisa died. But he's since found out nurses had not followed his Kidcom orders to closely monitor Lisa's pulse, blood pressure and blood-oxygen levels, and to keep a self-inflating bag, oxygen or suction device at her bedside.

"Taking into consideration what I know now, I'm very unhappy about the lack of information," Schily said in a reply to one of the six jurors. Asked whether that meant nurses or hospital staff, he replied: "Yes, I would have expected more."

Schily said under questioning by Patrick Hawkins, a lawyer acting for the hospital, that he didn't recall seeing a Kidcom training book caution that ward nurses should be telephoned about any orders in the Kidcom system.

Schily said his notation on Lisa's chart, plus the fact he had mentioned his Kidcom monitoring orders to a nurse accompanying Lisa to emergency, should have been enough.

Schily testified he never heard a telephone page at 2:50 a.m., as claimed by nursing staff, and would expect repeat pages in such a case.

Just after 4 a.m., he said, he told a nurse to recheck Lisa's vital signs and call him back about any problems. But there were no more pages or calls, he said. The inquest continues.