Coroner says hospital didn't reveal enough

The lack of information given to a coroner probing the death of 10-year-old Lisa Shore was enough to ``undermine and impair'' his investigation, he told an inquest jury yesterday. 

Dr. Morton Reingold also told jurors that the disclosure of the details of the girl's death was ``much less than you would expect from a world-class institution like Sick Kids.'' 

But he also acknowledged that there was no evidence the lack of disclosure was intentional. 

Reingold was dispatched to the Hospital for Sick Children by the coroner's office at about 8:30 a.m. on Oct. 22, 1998, to probe the death of the child, who had been admitted for pain control a few hours earlier. 

His job was to examine Lisa's body, interview witnesses, seize any equipment that might shed light on her death and prepare a report that the coroner's office would use to determine if an inquest should be ordered. 

Yesterday, Reingold said he was surprised to hear for the first time about certain revelations that had emerged during the inquest. What he heard left him ``very disturbed,'' he said. 

These revelations include the fact that:  Ruth Doerksen, the nurse responsible for Lisa's care, had viewed certain computerized doctor's orders about an hour after Lisa died. The coroner's office did not learn about these orders until January, 1999.  Both of the nurses who cared for Lisa that day made extensive notes, which they took home, sealed in envelopes and later provided to their lawyer. These notes only emerged at the inquest.  The nurses claimed they had attached Lisa to a monitor that would sound an alarm if her breathing or heart rate fell below pre-set levels. If Reingold had known that, he says he would have seized a monitor that was in Lisa's room. 
  
That monitor, which was not mentioned in any nurse's notes made before Lisa died, ended up in circulation at the hospital and could not be studied by the coroner. 

Reingold told Shore family lawyer Frank Gomberg that not having early access to the relevant information ``would interfere with my investigation'' to the extent that it would be ``undermined and impaired.'' 

But asked by hospital lawyer Patrick Hawkins whether he had information ``that the disclosure issue was anything but inadvertent,'' Reingold replied that he had no reason to believe that anything was done intentionally on that morning. 

As expected, Sharon Shore, who had slept in her daughter's room, contradicted evidence by nurses Doerksen and Anagaile Soriano that they had attached Lisa to a functioning monitor. 

Shore took particular issue with Doerksen's testimony that she had turned off a breathing alarm on the monitor because it rang falsely three or four times, and she wanted Lisa to sleep. 

Asked whether she would have checked with nursing staff if an alarm on a monitor had sounded, she replied, ``I would have been in the hallway screaming for a nurse long before anyone made it to the room.'' 

The inquest continues today, when jurors will visit the hospital and examine its ``Kidcom'' computer system.