GAY ABBATE

Tuesday, May 22, 2001

Sanchia Bulgin and Toronto's Hospital for Sick Children knew each other well.

Over 15 years, the girl went to the hospital numerous times for treatment for sickle-cell anemia and other medical problems.

So it never entered Stephanie Bulgin's mind that her 17-year-old daughter might bleed to death there after undergoing a routine gallbladder operation.

Tomorrow, the world-renowned hospital goes under the microscope as a coroner's inquest begins probing the events surrounding Sanchia's death on Sept. 14, 2000. The coroner's jury will make recommendations that may prevent similar deaths.

Ms. Bulgin, who has two other daughters, aged 4 and 10, said in an interview she hopes that something positive will come out of Sanchia's death.

"I pray that through this inquest recommendations will be implemented. It's important to not only say but do," she said.

This is the second inquest into an unexpected death on the hospital's Ward Five A/B, the unit that takes care of general surgery and orthopedic patients.

Ten-year-old Lisa Shore was admitted on Oct. 22, 1998, because of leg pain caused by a non-life-threatening medical condition brought on by a broken leg. Less than 12 hours later she was dead.

During this inquest, some parties with standing are expected to explore the issue that Sanchia had sickle cell anemia, one of the manifestations of sickle cell disease. It is an inherited disorder that affects red blood cells.

The disease is more common in people of African descent and those living in the Mediterranean area.

Children with sickle cell anemia are prone to gallstones, which is what brought Sanchia to the hospital.

The Sickle Cell Association of Ontario is one of the groups with standing at the inquest.

After Sanchia's death, the hospital accepted full responsibility, saying the death could have been prevented. The hospital then set up a review committee to look into the circumstances. The committee identified problems at both the physician and nursing levels, including:

Sanchia was not adequately prepared medically for the operation because physicians and surgeons caring for her did not talk to each other about her condition.

She was not medically evaluated before the operation. In particular, no blood work was done, which was crucial in her case because of anemia.

Nurses looking after her lacked knowledge about sickle cell disease and its implications.

Nurses did not obtain complete vital signs in the hours preceding Sanchia's death.

Nurses attributed alarms on monitors hooked up to Sanchia to equipment malfunction.

Lawyer Frank Gomberg, who is representing the Bulgin family at the inquest, said he plans to raise questions about these problems and the fact that Sanchia was not monitored during the last five hours of her life.

Although the five selected jurors will hear the first witness today, the inquest has already dealt with one contentious issue: whether to grant standing to Lisa Shore's mother, Sharon Shore. Standing would allow her to question witnesses and to raise issues.

Chief coroner James Young denied her standing, saying that involving the family from a previous inquest is risky because "the inquest could descend into a second inquest into the same death with the other parties not present or protected." He also said it would lengthen the inquest, which is expected to take at least three weeks.

Unlike in Sanchia's case, the hospital never admitted responsibility in Lisa's death. Instead, it settled with the Shore family for an undisclosed amount before the inquest.

There are other similarities between the two deaths other than the ward on which they occurred. The same type of monitor was use to check the oxygen level in both patients' blood even though the equipment was known to be faulty. And hospital staff failed to monitor both girls properly.

The coroner's jury in Lisa's death made a finding of homicide. But the finding carried no legal consequences, unlike it would have in a court of law.

Sanchia had been sick most of her life. When she was six years old, she was in the hospital with a severe infection that required abdominal surgery, which resulted in cardiac arrest and subsequent brain injury. Ms. Bulgin said her daughter died because she was not monitored properly.