Sick Kids failed to disclose doctor's orders, coroner says 

Toronto's Hospital for Sick Children failed to disclose crucial medical records shedding light on the death of Lisa Shore to the investigating coroner for about three months, an inquest was told yesterday. 

Deputy Chief Coroner Dr. Jim Cairns, who is presiding over the inquest into Lisa's death, told the jury yesterday that the investigating coroner had assumed that he had received a ``full chart'' from the hospital. 

But Cairns said that ``it wasn't until January'' - three months after Lisa's Oct. 22, 1998 death - that the hospital disclosed to the coroner the detailed orders entered by Dr. Markus Schily, a pain doctor, into the hospital's computerized information system. 

Ten-year-old Lisa died at the hospital about 12 hours after she had been brought to the emergency ward for help with pain from a broken leg. 

Sharon Shore, her mother, pushed for an inquest to find out why a young girl who suffered from no life-endangering illnesses was found dead shortly after her admission for pain relief. 

The orders required nurses to hook her up to a corometric monitor which would sound a shrill alarm if Lisa's heart or breathing fell below set levels. 

The orders also required them to monitor Lisa's heart, respiration and blood pressure every hour for the first four hours of care after transfer from the emergency ward and to measure the extent of her pain and sedation. 

Frank Gomberg, a lawyer for the Shore family, was upset by the late disclosure of the orders to the family. 

``I finding it shocking that, when the hospital knew on Jan. 26 that the records it gave the family in early November were incomplete, it took no steps to supplement those incomplete records with these critical orders,'' he told the Star. 

The family only learned about the orders in mid-April, 1999 when meeting with Cairns who gave them a copy. 

The jury has heard evidence that the nurses were never aware of Schily's orders because they never checked Kidcom, the high-tech patient record system developed by the hospital in 1993, as hospital policy requires. 

Carol Warren, a systems information trainer at the hospital, testified yesterday that the nurses treating Lisa were trained in using Kidcom, had access to the system and should have used it to access the doctor's orders. 

The failure to disclose the record meant that the investigating coroner, Dr. Morton Reingold, began his investigation without knowing that the orders existed and were not followed by nursing staff. 

Reingold has not yet testified. 

Although a corometric monitor was observed in Lisa's room at the time doctors discovered she was dead, leads that should have been attached to her were curled up on top of it and the monitor was turned off.