| 1. Name of deceased | Lisa Shore |
| 2. Date and time of death | October 22, 1998 @ 0620-0700 |
| 3. Place of death | Hospital for Sick Children - Toronto |
| 4. Cause of death | Caused by probable complex drug interaction leading to cardiac and respiratory arrest |
| 5. By what means | Homicide |
JURY RECOMMENDATIONS CONCERNING THE DEATH OF LISA SHORE
The following recommendations are not presented in any particular order
of priority:
MANUFACTURER and HOSPITAL (HSC) - RE: RESEARCH
1. RECOMMEND a study be undertaken to examine interactions
between morphine/Gabapentin/other therapeutic drugs. The results of these
studies should be widely disseminated to the medical and hospital
communities.
HOSPITAL (HSC)- RE: KIDCOM
2. RECOMMEND for computerized information systems such as Kidcom, automated warning technology should be explored and implemented. For example, when "suspended" 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 the Kidcom orders are activated.
3. RECOMMEND the standard order set within the Kidcom system for patients on parenteral opioids, whether by PCA pumps or any other method of delivery, should include a line which the physician can delete if not applicable. This automatic entry should state "Warning: patient is on other concurrent medications that may potentiate adverse side effects. Increased vigilance is advised."
4. RECOMMEND when a patient is discharged or expired, any suspended orders in the Kidcom system should print automatically and form part of the patient's permanent record.
5. RECOMMEND that Kidcom be programmed so that when a new patient is admitted to a ward through Emergency Department, that the ward computer lock-out access to patient care update until Kidcom Patient Doctor's Order is activated, i.e. Progress Notes, History, etc. cannot be accessed until Kidcom Doctor's Order is activated.
6. RECOMMEND that Kidcom Print Request Tapes be stored for eighteen (18) months and be made available for Coroner's investigation.
7. RECOMMEND, as per Paediatric Review Committee Final Report, that "the Kidcom orders were not read/opened on admission to the ward, or during the night: the committee recommends that HSC investigate the frequency with which orders are not accessed from the Kidcom system and the average delay between children being admitted and the orders being accessed."
8. RECOMMEND that all Shift Change - Nursing Notes be inputted
on Kidcom.
HOSPITAL (HSC) - RE: EDUCATION
9. RECOMMEND all nurses and doctors should be educated or re-educated to ensure they know that Kidcom monitoring orders and PCA monitoring protocols begin at initiation of opioid therapy and restart again from the moment of admission to the ward. The Kidcom orders should be changed to reflect this.
10. RECOMMEND the Kidcom Orientation Program for both nurses and doctors be revised to accommodate changes. The revised Orientation Program to be presented to all doctors and nurses in hospital.
11. RECOMMEND annual education sessions for all nurses, doctors, and nurse educators who care for patients on parenteral opioids should be mandatory. These sessions should cover:
12. RECOMMEND that when doctors prescribe PCA pump use in the Emergency Department, that they document on handwritten Emergency Room Doctor's Orders, any variation in monitoring aside from Protocol.
13. RECOMMEND that all nurses be made aware that doctors monitoring orders or other mandatory monitoring protocols are never discretionary and must be followed at all times unless:
a) The orders are clearly erroneous, and authorization is obtained from
the doctor to make change,
b) Authorization is obtained from the
doctor, or
c) The level of monitoring is to be greater than that
ordered by the doctor.
HOSPITAL (HSC)- RE: CHARTING
14. RECOMMEND that a laminated Sedation Scale be posted on a wall in each of the patient's room
15. RECOMMEND 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.
16. RECOMMEND that the hospital should formally adopt the Electronic Monitoring Guidelines - see Exhibit #68, attached. Further that the Nursing Flow Chart be redesigned to include appropriate columns marked: "Corimetric Monitor" - "High/Low Heart Rate" setting and "Apnea" setting; "Pulse Oximeter Monitor"; "Other Monitor". Also that the chart have columns marked: "Sedation Scale", and "Pain Scale", and, that there be a space allocated for the registering of monitor serial numbers. "See PCA Protocols for Sedation Scale and Pain Scale Guidelines" is to be clearly marked on the chart. This chart to be used with all patients on PCA Pumps, and opioids. See attached.
17. RECOMMEND that periodic spot checks to audit Nursing Flow
Charts be conducted throughout the hospital to assess the thoroughness of
Nurse charting to Doctor's orders, with particular attention being paid to
monitoring. The audits to be conducted by a Nursing Review Committee.
HOSPITAL (HSC)- RE: MONITORS
18. RECOMMEND that a committee be struck to recommend age and weight appropriate settings of corometric monitors; including high and low heart rate; and pulse oximeter monitor. Recommend that these settings then be posted on all monitors.
19. RECOMMEND that the attending nurse on the ward of admission
be responsible for handing out preprinted "Facts On" brochures to
parent(s), regarding monitors, and for holding verbal discussion with
parent(s) to ensure the parent(s) feel included in the care.
HOSPITAL (HSC) - RE: PAGING/COMMUNICATION
20. RECOMMEND that when nurse paging doctor for urgent need consultation, that the nurse is not to allow a lapse of more than five (5) minutes to pass before repaging. If second attempt to page is not successful within five (5) minutes, nurse must then consult alternative source.
21. RECOMMEND that all failed attempts to communicate through pages be documented on Nurses Flow Chart and in Kidcom Progress Notes.
22. RECOMMEND that a doctor must ask for all specific vital
signs and scales in any telephone consultation with nursing staff.
HOSPITAL (HSC) - RE: "CLINICAL JUDGEMENT"
23. RECOMMEND that a committee be formed and made responsible
for defining the term "Clinical Judgement". The committee to be
responsible for defining the terms, parameters and limitations of
application. The committee to be comprised of both nurses and doctors. The
committee being held responsible for the dissemination of information to
all hospital staff.
HOSPITAL (HSC) - RE: STAFFING
24. RECOMMEND that when new graduate nurses are hired by HSC that they have comprehensive training through Pain Service Department in care and monitoring of patients on opiate drug treatment, and that they are on the Preceptor Program for a minimum six (6) month term.
25. RECOMMEND that a Relief Staff Nurse be added to all LN (Long Night) and LD (Long Day) shifts at the HSC.
26. RECOMMEND that nursing breaks on any twelve (12) hour shift
be regulated so that nurses take breaks at appropriate times throughout
shift, and that a Relief Staff Nurse be responsible for covering off for
nurses on break, only. No Relief Staff Nurse (or any other nurse on
shift) is to be responsible for more than five (5) patients at one time.
HOSPITAL (HSC) - RE: CORONER'S CASE
27. RECOMMEND that the hospital appoint a team of doctors and nurses to act as Coroner Co-ordinators of all events in the situation of a Coroner's Case. That team to be responsible for securing the room of the deceased to include: all items on recommended "Coroner's Check List"; arranging for all personnel involved in the deceased's care to write a summary of events; and for those persons to remain on the Ward, available for a discussion with the Coroner.
28. RECOMMEND that when an unexplained or unexpected death occurs, all persons who had any responsibility for the patient's care, including relieving nurse, in the previous twelve hours must be available, at the hospital, for an interview with the Coroner when he attends at the hospital, on his initial visit, to investigate the death.
29. RECOMMEND in cases of unexplained or unexpected death
occurring in a hospital, the Coroner should direct that the contents of
all recycling and shredding bins at the nursing station be preserved, as
well as all documents, audio and videotapes, audit trail records, incident
reports, nursing notes, and any other information relating to the patient
who died. This direction should be quickly and clearly conveyed to the
hospital employees by the Investigating Coroner, and by the above
recommended hospital appointed coroner's team.
HOSPITAL (HSC)/CORONER'S OFFICE - RE: CORONER'S CASE
30. RECOMMEND 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. In cases of
unexplained or unexpected deaths, a member of the hospital's Medical
Ethics committee must be included in any discussion of, meeting with, or
written response to the family or to a Coroner looking into the child's
death.
CORONER'S OFFICE - RE: PAEDIATRIC/PEER REVIEW COMMITTEE
31. RECOMMEND that where nursing issues are relevant in a
Coroner's Case, that a Nursing Representative from the Regulatory Body of
the nursing profession be added to the Paediatric/Peer Review Committee.
CORONER'S OFFICE - RE: CORONER'S CASE
32. RECOMMEND that when an unexplained or unexpected death occurs in a hospital, the Coroner's Office should designate one Coroner - who is not affiliated with the hospital - to be the liaison between the hospital and the family. This responsibility should continue at least until the conclusion of any Coroner's investigation or inquest.
33. RECOMMEND that a standard form be used as a "Coroner's Checklist" to be completed during the Coroner's initial visit. The Coroner's Checklist to include the following items:
OFFICE OF THE CHIEF CORONER
34. RECOMMEND that a report be issued within eight (8) months, regarding the implementation of the Lisa Shore Inquest - Jury Recommendations
35. RECOMMEND that a copy of the Jury Recommendations be sent to: