NATALIE SOUTHWORTH
The Globe and Mail
Tuesday, January 18, 2000

Toronto -- New testimony has shed light on one of the mysteries surrounding the sudden death of 10-year-old Lisa Shore at the Hospital for Sick Children two years ago.

At a coroner's inquest that resumed yesterday, a registered nurse educator testified that the nurse responsible for Lisa's care on the night she died had turned off an alarm that warns when patients stop breathing. Another alarm that goes off when the heart stops beating may still have been on.

Mary Douglas, who trains nurses at the hospital, told the inquest she consoled Lisa's nurse, Ruth Doerkson, minutes after the Toronto girl died.

"She was crying. She kept asking questions. 'What went wrong? What did I miss?' She said, 'I turned the apnea [breathing] alarm off. I never do that. I don't know what [sic] I did that. Maybe I shouldn't have done that,' " recalled Ms. Douglas.

Ms. Douglas said she went into Lisa's room and verified the alarm was shut off.

Ms. Douglas testified that Ms. Doerkson last checked Lisa's breathing at 6 a.m., more than an hour before she was found with no sign of breathing.

Lisa died Oct. 22, 1998, after being admitted to the hospital the previous evening because of chronic pain in her leg. Lisa suffered from reflex sympathetic dystrophy, a rare, non-fatal condition, and was attached to a morphine pump to control the pain. Because of her condition, Lisa was on a medication known to heighten the sedative effects of morphine.

The inquest adjourned in November after the hospital's manager of patient-care equipment services testified on behalf of the hospital that corometric monitors, which check both heartbeat and breathing, can read a false heartbeat even when there is none. That means no alarm would have sounded to indicate Lisa was in danger.

The theory sparked an uproar and was immediately attacked by lawyers who had not been forewarned about the testimony by the hospital's lawyers. The inquest was delayed until the manufacturer of the machines, G. E. Marquette Medical Systems, had reviewed the case.

Yesterday, Van Krkachovski, counsel for the company, said the controversial theory had "fallen by the wayside," as other testimony had come to light suggesting the alarm was not turned on when Lisa died. What has yet to become clear in testimony is whether only the breathing alarm was turned off or whether the entire machine was. That would have kept the heart alarm from sounding.

All parties, including the hospital, agreed to disregard the false-reading testimony.

Later in the day, Ms. Douglas testified that a number of changes, many involving the monitoring of patients, have been implemented at the hospital since Lisa's death. But Ms. Douglas said the new requirement that nurses record whether their patients are attached to corometric monitors is medically pointless. "The value is for legal purposes," she said matter-of-factly, silencing the courtroom. Sharon Shore, Lisa's mother, started to cry, and the counsel for the coroner, Margaret Browne, raised her eyebrows.