Thursday, February 24, 2000
The saga of Lisa Shore
A coroner's jury will deliver a verdict today into the
death in 1998 of a 10-year-old girl at the Hospital for Sick Children.
The cause of her death is known, the reason is not
Mark Gollom
National Post
Photo
From Family Web Site, Used With Permission
Lisa Shore broke her leg in a school accident. Six
months later she was admitted to hospital suffering pain in her leg. Less
than a day later, she was dead.
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On Oct. 21, 1998, 10-year-old Lisa Shore was admitted to the Hospital
for Sick Children suffering from severe pain to her leg.
It was not a life-threatening condition but rather a chronic disorder
relating to a broken leg she had suffered months earlier.
On Oct. 22, just hours after Lisa had been admitted, the young girl
was dead.
Today, jurors of a coroner's inquest will deliver a verdict in the girl's
death, ending an investigation that has been wrought with controversy and
accusations of cover-ups and smoke screens.
"The kid got abysmal care, the nurses were not disciplined and they
continue to work there," the Shores' lawyer, Frank Gomberg, said yesterday.
"There is a major issue whether they told utter lies and the hospital as
an institution attempted to cover up what happened."
What isn't at issue is the cause of Lisa's death. An autopsy revealed
the girl most likely died of respiratory depression caused by the effects
of morphine. Although not conclusive, the hospital does not contest the
explanation.
The jury will decide the culpability of the hospital, ruling the death
as either accidental, undetermined or a "homicide."
Patrick Hawkins, the hospital's lawyer, has argued that Lisa was the
victim of "honest human mistakes."
Mr. Gomberg argues the negligence of the nursing staff led to Lisa's
death and is akin to a homicide.
The Shores' ordeal began six months before the death of their daughter,
when Lisa broke her leg playing at school. Her leg was set in a cast, but
she continued to be burdened by intense pain. Doctors at the Hospital for
Sick Children were unable to diagnose the problem and instead recommended
she receive psychological counselling.
Three months later, the Shores travelled to Boston's Children's Hospital,
where physicians diagnosed her problem as reflex sympathetic dystrophy
syndrome. According to the National Institute of Health, the rare disorder
is characterized by severe burning pain that can occur after a fracture.
The cause of the disease is unknown but is thought to be a result from
damaged nerves.
Doctors were able to provide some relief for Lisa. But on Oct. 21 she
was taken to the Hospital for Sick Children complaining again of severe
pain.
According to the inquest, Lisa came into the emergency room that evening
and was attended to by Dr. Markus Schily, who administered morphine and
put Lisa on a morphine pump.
He then input his orders into a computer system of the emergency room
on how Lisa should be monitored. Nurses are obligated to check the system
when the patient is admitted into a room.
Among numerous orders, Lisa was to have her vital signs checked hourly
and, most importantly, she was be put on a Colometric monitor -- a device
that measures heart and breath rate.
Nurses were also ordered to do a pain and sedation scale every hour
to check Lisa's pain and to gauge her drowsiness from the morphine.
On Lisa's chart, Dr. Schily also wrote to check the computer for the
orders.
But when Lisa was transferred to a room, the nurses never tapped into
the computer to check the orders. If the orders are not checked on the
computer, the protocol manual tells nurses what to do if a child is on
a morphine pump. The nurses did not check the manual, nor did they check
Lisa's vital signs hourly.
Lisa eventually fell asleep, heavily drugged on morphine. Her mother,
Sharon, by her bedside, also fell asleep.
According to Ruth Doerksen, Lisa's nurse, the girl was attached to the
Colometric monitor.
When the monitor is initially hooked up, it goes through cycling noises,
including loud beeps, to show it is working. Mrs. Shore claims she never
heard those noises and never saw the machine attached to her daughter.
Ms. Doerksen testified that she left the room and heard the alarm sound
from the breathing rate part of the monitor, which sounds like a smoke
detector. She said she came in to reset the button and stop the alarm from
sounding. She said the alarms sounded three more times and she eventually
turned it off. Mrs. Shore said she was never once woken up by the alarms.
Ms. Doerksen said she checked on Lisa at 6 a.m. and the girl was fine.
A little after 7 a.m., Mrs. Shore was awakened when doctors making their
rounds entered her daughter's room. There, they discovered Lisa was dead.
Although a civil suit was settled between the Shores and the hospital,
a coroner's inquest was launched in November.
At the beginning of the inquest, Mr. Gomberg raised the question why
neither alarm from the monitor went off when Lisa died.
The hospital acknowledged the breathing part had been turned off. As
to why the heart-rate alarm did not sound, the hospital initially had no
answer.
Officials then offered a theory that a dying or dead child can still
give out certain waves that can be read by the machine as a heart beat.
The inquest was adjourned and preparations were made to have the manufacturer
of the machine come to testify.
The hospital eventually agreed that the machine had not been turned
on. Mrs. Shore contests that Lisa was ever hooked up to the monitor.
Mr. Gomberg, in his closing argument, suggested Ms. Doerksen discovered
the orders between 6:30 a.m and 7 a.m., found Lisa dead then grabbed the
monitor and put it in Lisa's room.
The inquest also uncovered a number of problems with the hospital's
approach to the investigation
Ms. Doerksen never mentioned she dictated an account of her treatment
of Lisa on a tape recorder -- which eventually was erased -- until another
nurse testifying spoke of the procedure.
As well, Ms. Doerksen printed out the doctor's orders from the computer
five days after Lisa's death and took them home with her, but the coroner
had to wait three months to receive the printout from the hospital.
Ms. Doerksen and the other nurse to treat Lisa, Anagaile Soriano, both
made extensive notes that only came to light at the inquest and not the
initial investigation.
Jurors also claimed that nurses were being guided in their testimony
by colleagues in attendance.
At one point during the inquest, one of the jurors accused the hospital
of engaging in a "cover up" and that the jurors had been given a "smoke
screen" of events.
During the inquest, the hospital's head nurse apologized to Lisa's family
while on the stand, admitting the facility had failed the Shores as an
institution.
But Mrs. Shore was unforgiving.
"An apology is meaningless without the act behind it. The only act the
hospital could have taken is immediate termination of those nurses.
"It seemed the hospital really didn't care about Lisa," she said. "Her
death was meaningless to them."
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