February 25, 2000  PETER POWER/TORONTO STAR LONG ROAD: Bill and Sharon Shore head to a news conference yesterday following the inquest into their daughter's death. `Unusual' inquest a low point for Sick Kids Hearing into death of Lisa Shore was tense, adversarial By Harold Levy  Toronto Star Staff Reporter SISTERLY LOVE: Lisa Shore, who was 10 when she died at the Hospital for Sick Children in 1998, hugs her brothers Devon, now 11, and Aron, now 8, in this family photo. Sharon Shore says she did what any mother would have done for a child in agony.  She brought her 10-year-old daughter Lisa to one of the leading children's hospitals in the world. She stayed with her in the emergency ward, where doctors prescribed morphine and left instructions for nurses to monitor Lisa against the possibly deadly effects of the drug. Then Shore went with her to the ward, where she slept on a couch beside her daughter.  When Shore woke up just after 7 a.m., as doctors on their rounds entered the room, Lisa was dead in her bed.  The questions began immediately, but few answers came.  ``Nobody wanted to talk to us,'' Shore said in an interview. ``Nobody would acknowledge that anything was done in error. We were told several times that Lisa received conscientious nursing care.''  Sharon and Bill Shore kept asking questions, and their persistence led to one of the most unusual inquests Toronto has ever seen. For the 20 days of testimony, the atmosphere in the drab coroner's hall was alternately adversarial, tense and dramatic as lawyers clashed, jurors grilled witnesses, the hospital was accused of a cover-up and a senior nurse made an emotional apology from the witness stand.  Even the presiding coroner admitted he found the Shore inquest ``unusual.''  ``You were probably wondering what bombshell will we hear today,'' Dr. Jim Cairns told jurors in his closing comments.  Lisa was the Shores' only daughter, a sunny girl who loved swimming, in-line skating and playing in the park with her brothers, Devon 11, and Aron, 8.  `Nobody wanted to talk to us. Nobody would acknowledge that anything was done in error. . . . I'm very grateful that we had the inquest, because without it - without the power of the coroner's office and coroner's subpoenas - we would not have been able to compel these people to talk.'  - Sharon Shore, mother of Lisa ``Art was her passion, cartooning, silk painting, drawing and working with clay, and she was tremendously talented,'' Sharon said. ``She wanted to be an architect, cartoonist or veterinarian when she grew up.''  On Feb. 11, 1998, Lisa broke her leg at school.  She appeared to be recovering well after a cast was applied, but two weeks later she woke up screaming, complaining of constant shooting pains in the area of the break.  Doctors in Boston diagnosed Lisa with reflex sympathetic dystrophy, a condition often caused by an extremely mild event, such as a sprain or fracture, in which something that normally isn't painful - like a touch or a gust of wind - results in agony.  The Shores brought Lisa to Sick Kids for pain relief several times after the diagnosis. On several occasions morphine was prescribed, and each time, Lisa left the hospital alive and well.  So what went wrong the last time?  The Shores launched their search for answers by requesting Lisa's medical records from the hospital. They pored over them with a team of friends and relatives with medical expertise, including an intensive care nurse, a kidney specialist and a fifth-year psychiatry resident.  Together with a lawyer, they drafted a letter containing 24 questions, which they asked Dr. William Lucas, the regional coroner, to forward to the hospital. The letter, sent in December, 1998, addressed many aspects of Lisa's care, including why an alarm did not sound when her heart stopped beating.  The hospital's replies didn't satisfy the Shores.  ``Our persistent questions, coupled with the hospital's failure to provide us with reasonable answers, prompted the coroner to order the inquest,'' Sharon said.  The hospital's lawyer later told the inquest he had advised his clients - including the nurses who cared for Lisa - not to make statements to the coroner's investigators, as was their right. The coroner also told jurors that his office had received so little information from the hospital that he had been forced to use the inquest as ``an investigation'' to get to the truth.  The difficulty establishing the facts about Lisa's death made the inquest ``much more adversarial than usual,'' Cairns said.  ``This inquest was extremely important to bring out the facts,'' he added. ``The first time many people said anything about the death was on the witness stand . . . under oath . . . (and) that aspect was extremely revealing.''  The inquest went off the rails within a few days of its start last November, when the hospital attempted to blame a crucial piece of equipment for Lisa's death.  A corometric monitor contains two alarms - one for breathing and one for the heart rate - that sound with the intensity of a smoke detector so they can be heard at the nurses' station down the hall. According to the orders given by the doctor treating Lisa, the alarm was to be turned on to monitor her reaction to the morphine.  The hospital lawyer shocked the inquest by suggesting Lisa might have lived if the monitor had not malfunctioned - an allegation that forced the coroner to adjourn the hearing to give the manufacturer time to get a lawyer.  When the inquest resumed in January, the hospital retracted the allegation and admitted that if Lisa had been attached to a monitor by her nurses, someone had turned it off.  Things went downhill from there for Sick Kids.  The hospital had told the coroner's office and the Shore family that it was unaware of the existence of certain doctor's orders until January, 1999. But when Ruth Doerksen, the key nurse responsible for Lisa's care, took the stand, she testified she saw a patient-care report containing these orders two hours after Lisa died and she printed them from a hospital computer five days later and took them home.  In another low moment, the doctor who prepared a summary of Lisa's death, as required by law, apologized from the witness stand for the serious errors it contained. Dr. James Wright admitted he had not read Lisa's nursing chart before preparing the summary and relied totally on the information the hospital's staff had given him.  Chief nurse Jean Reeder admitted that the hospital did not investigate Lisa's death internally because she was not aware that there were ``nursing issues'' until four months after Lisa died. She also apologized for the hospital's failure to communicate in a timely manner with Lisa's parents.  The Shores were there for every day of the inquest - Sharon at the table with family lawyer Frank Gomberg and Bill sitting to one side of the courtroom with their family and supporters. Hospital staff, including nurses and administrators, and their supporters sat on the other.  At one point, while Doerksen was testifying, Cairns looked toward the hospital section and said jurors had complained that witnesses were being ``coached'' by people in the audience. He said this behaviour - suggesting answers by shaking or nodding of the head - was ``inappropriate'' and would not be tolerated.  Things heated up even further in the final days of the inquest, when a juror stunned the courtroom with criticism of the hospital.  ``I don't know if I can ask this,'' Lawrence Dillon told Cairns. ``To me this sounds like a cover-up. We've been given a smokescreen.''  The Shores' lawyer then pressed Doerksen, suggesting that she and nurse Anagaile Soriano covered up their role in Lisa's death by lying about attaching her to a monitor, an allegation both nurses flatly denied.  Doerksen had testified she recorded on audiotape a summary of her care for Lisa - standard procedure when ending a shift. Gomberg questioned how she could have done that without first consulting the patient-care plan, which contained the doctor's orders the nurses had failed to access.  ``I suggest you saw the patient-care plan between 6:15 a.m. and 7 a.m.,'' Gomberg told Doerksen, referring to the time just before doctors found Lisa dead.  ``Mr. Gomberg, you can suggest anything you want,'' she replied.  ``I suggest that sometime after you saw that plan, you went into her room and saw Lisa dead, went out of the room, got a corometric monitor and put it on the shelf,'' Gomberg continued.  Later, Dillon questioned chief nurse Reeder.  ``So there was no investigation of the nurses (by the hospital)?'' the juror asked. ``Doesn't that seem odd?''  ``Yes, it does,'' Reeder replied.  The jury foreperson, Gail Allegri, said she was troubled by Reeder's testimony that she believed both Doerksen and Soriano were telling the truth, although no one from the hospital had questioned them.  ``How can you sit there and attest to the absolute honesty of nurses when we have had such conflicting testimony and (so many) errors?'' Allegri continued.  ``In my professional judgment and years of experience, I do believe that they are telling the truth,'' Reeder replied.  The atmosphere was so strained that by the time Reeder apologized to the Shores on the stand, telling them, ``We failed you as an institution . . . we are terribly sorry'' - it was angrily rejected by the family.  ``What I heard was insincere . . . something said on the stand so they can say they actually did the right thing,'' Sharon Shore said. ``But if it takes a coroner's inquest and 15 months of lies and cover-up to get an apology which is totally worthless, then I have no use for that kind of apology.''  So why did Lisa die?  That may have to remain a mystery. Medical experts testified that, by itself, the morphine she was given could not have caused her death, nor could any of the three other drugs she was given that night.  The best guess is that she died of an adverse reaction between morphine and gabapentin, one of the other drugs. But Shore says the precise cause of death is secondary to the fact that Lisa's life probably could have been saved, as several experts testified, if she had been monitored by the nurses as required.  ``The signs were staring them in the face from the outset,'' Shore said. ``If only they had done their jobs and looked for them.''  The Shores have established a Web site in Lisa's memory - http://www.lisashore.com - displaying photos of their daughter and some of her silk paintings.  ``I'm very grateful that we had the inquest, because without it - without the power of the coroner's office and coroner's subpoenas - we would not have been able to compel these people to talk,'' Sharon Shore said.  ``The sad thing is that not every family in similar circumstances would have the resources and professional assistance to go this far.''

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