Agreed Statement of Facts

1. Anagaile Soriano graduated with a BScN from Ryerson Polytechnical University in 1998 and became a member of the College of Nurses (the “College”) the same year. While at Ryerson, Ms Soriano was on the Dean’s list and received high academic grades.

2. She was hired as a full-time registered nurse by The Hospital for Sick Children (“HSC”) in May of 1998 on Unit 5A/B, an Orthopedic, Ear Eye and Nose, and General Surgery Unit; she completed her orientation in July of 1998.

3. Ms Soriano was very active in continuing nursing education both through inservices at the Hospital and at academic institutions. Although she was a novice nurse, she was well regarded by her superiors and peers at HSC and has no prior disciplinary history.

Background - Ruth Doerksen

4. Ruth Doerksen graduated from Ryerson Polytechnical Institute in 1984 with a Diploma in Nursing. She became a member of the College in 1985 and completed her BScN in 2003.

5. Ms Doerksen initially worked for a nursing agency following graduation. In October 1984, she was hired as a full time registered nurse at HSC and worked in a variety of areas, including Burns and Plastics, Pediatric Medicine, Cardiology, Emergency and Unit 5A/B.

6. Ms Doerksen was very active in continuing nursing education both through inservices at HSC and at academic institutions. Ms Doerksen has no prior

disciplinary history and was well regarded by her peers and other health care professionals.

Unit 5A

7. Unit 5A was a surgical unit for Ear, Nose and Throat; Orthopedics, and short stay surgical clients. It contained 20 single bed rooms and a 4 patient Constant Care Room where those requiring more frequent monitoring, including clients with airway problems and young babies, were placed.

8. The Constant Care Room was staffed with one nurse. Staffing for the rest of the Unit depended on the number of beds occupied. In general, each staff nurse was assigned 4 or 5 patients, depending on client needs.

9. Additionally, on the day shift, there was a Resource Nurse who did not have a patient assignment, a Clinical Educator, and a Unit Manager. As well a ward clerk was assigned to unit 5A on days and evenings until 8pm to perform various clerical duties at the nursing station including the processing of orders, obtaining equipment and the paging and receipt of calls from physicians and others.

10. The staffing on the night shift consisted of staff nurses who had a client assignment. The night Resource Nurse carried a full client assignment as well as administrative duties.

11. On the evening of October 21/22, 1998, due to a lower than usual client census, there were three nurses assigned to Unit 5A. Ms Doerksen was the Resource Nurse and, in addition, had an assignment of initially four and then five clients after the transfer of client L.S. Nurse MF was assigned to the Constant Care Room, which required the presence of one nurse at all times. Ms Soriano was assigned to care for four clients. During breaks, Ms Soriano and then Ms Doerksen cared for nine clients. Ms Doerksen first covered the break for nurse MF and then took her own break, while Ms Soriano looked after both her clients and those of Ms Doerksen. Subsequently, Ms Doerksen covered the nine clients when Ms Soriano took her break from approximately 0430 hours to 0600 hours.

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Patient Controlled Anesthesia (“PCA”)

12. PCA is a method of administrating an analgesic, such as morphine, intravenously. A PCA machine allows a client to self-administer analgesia by pressing a hand-held button. When the button is pushed by the client, the pump delivers a pre-determined dose of analgesia as long as it is within pre-set limits.

13. Unit 5A was one of the units in the hospital approved for use of PCA pumps. Nurses on unit 5A were trained to care for clients receiving morphine, including morphine administered via PCA pumps and were accustomed to monitoring such patients, particularly post surgical patients transferred to the unit from the post anesthetic recovery room.

14. PCA monitoring standards in effect at the HSC at the time required the recording of a baseline heart rate, respiratory rate, blood pressure, sedation score and pain score and then hourly for four hours:

a) on initiation of narcotic administration; and

b) after any increase in drug dose or infusion rate.

Thereafter, during the continuation of PCA narcotic administration, respiratory rate and sedation scale were to be taken every hour, and heart rate, blood pressure and pain score taken every four hours.

15. The nursing practice on Unit 5A at the time was to monitor most patients on a PCA with the assistance of a Corometric monitor.

16. The Corometric monitor in use on the unit at the time was designed for children under the age of two, particularly those at risk of SIDS (Sudden Infant Death Syndrome). It had a digital readout of both heart rate and respiratory rate. The monitor would normally be positioned toward the door so that the readouts would be readable by the nursing staff from the hallway. The monitor had a loud heart rate alarm that could be set to sound if it exceeded various parameters and could not be deactivated. The monitor also had a loud apnea alarm that could be set to various settings including deactivation in which case there would still be a heart rate and respiratory rate readout but the apnea alarm would be deactivated. The Corometric monitor had a history of false apnea alarms particularly with older children. It is no longer in use at the hospital.

Client L.S.

17. In 1998, L.S. was a 10-year-old physically active girl who loved swimming, roller blading, biking, and playing with animals, her friends, and her two younger brothers. She suffered a spiral fracture to her right tibia on February 11^th, 1998, when playing in the school yard. Her right leg was put in a cast at North York General Hospital. L.S. subsequently began complaining of severe pain in her right leg and had her cast split at the ER of HSC on February 13^thand replaced on February 17^th. L.S. was re-admitted to HSC on February 17, 1998 for

management of increasing right leg pain, including a continuous lumbar epidural insertion of analgesic. She was hospitalized at HSC on another occasion, and then at the Boston Children’s Hospital. She was diagnosed as having reflex sympathetic dystrophy (“RSD”), a complex regional pain syndrome. L.S. was prescribed a number of medications, including Gabapentin, an antiseizure medication and Amitriptyline, an antidepressant medication, to treat her RSD.

18. L.S. also continued to be seen by the pain clinic of HSC where, on or about September 9th 1998, L.S. was prescribed an additional anti-seizure medication, Carbamazepine, for her RSD.

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Events of October 21-22, 1998

19. On October 21, 1998, L.S. was experiencing increased pain in her right leg. At approximately 2150 hours, L.S. was brought to HSC by her parents where she was triaged by the nurse in the Emergency Department as a stable non-urgent patient.

20. L.S. was assessed in the Emergency Department by Dr. S., who was a Fellow with HSC’s anaesthesiology Pain Service (“Pain Service”) at approximately 2350 hours.

21. Prior to coming to HSC, L.S. was given her daily dose of 400 mg of Carbamazepine at 1900 hours. While in the Emergency Department, L.S. was given her other usual medications by her mother with the approval of Dr. S. This included 1400 mg of Gabapentin at 2220 hours and 75 mg of Amitriptyline at 2300 hours.

22. Because Pain Service could not admit patients directly, (they had no admitting privileges), arrangements were made between Orthopaedics and Pain Service to admit L.S. as an orthopaedic patient but on the understanding that Pain Service would take responsibility for her care and that the orders would be written by Pain Service and not by orthopaedics. This arrangement was unusual.

23. Dr. S developed a plan of care for L.S. She would be admitted to the ortho service for pain control, she would be put on a PCA , and her pain management would be decided upon by Anaesthesia Pain Service, including an assessment for an epidural in the morning. L.S. was to be cared for in the Emergency Department until her pain was under control (about 5 on a scale of 1 to 10) and then transferred to an inpatient unit.

24. Dr S. ordered on the Doctor’s Orders Sheet the following for pain control:

10 mg morphine

Incremental doses 2 mg IV Until pain free (pain scale about 5)

IV PCA device

50 mg morphine in 50 mg saline = 1 mg=1cc

Bolus 1.5 mg, lockout interval 6 minutes, Total Dose= 20 mg in 2 hours

25. At approximately 2350 hours L.S. was given a stat dose of 2 milligrams of morphine IV. Her vital signs recorded at that time were: pulse 88, respirations 16 and pain scale 8/10.

26. At approximately 0015 hours, Dr. S., with the assistance of an emergency department nurse, set up the PCA . L.S. self-administered 10.5 mg of morphine via the PCA between 0040 hours and 0107 hours.

27. At approximately 0040 hours, L.S. was given a further dose of morphine 2 mg IV by the emergency room nursing staff. The vital signs recorded at this time were: pulse 90, respirations 14, blood pressure 106/84, pain scale 7.

28. The total amount of morphine administered to L.S in the emergency department prior to her transfer to Unit 5A was 14.5 mg morphine.

29. At approximately 0105 hours, the emergency department nurse recorded in the nursing notes that L.S. was up to bathroom, that her pain had increased to 8 and that her mother stated “her pain will never be 5 on a PCA pump. She needs to be upstairs sleeping”. At Mrs. S’s request, the emergency department nurse paged Dr. S., who agreed that L.S. could be transferred to the floor with a reported pain level of 8.

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Transfer to Unit 5A

30. At approximately 0105 hours, the emergency department nurse called Unit 5A and gave report to Ms Soriano, who was working on the unit. She reported that the patient being transferred was a 10 year old girl, admitted for pain management and that she had been given some Morphine in Emergency Department by way of bolus and was coming to the floor with a PCA pump. It was further reported that she was a stable patient that was being transferred to 5A to get some sleep and to have her pain treated with an epidural the next day. Finally, it was reported that she was being admitted through Orthopaedics but under the management of Pain Service.

31. At approximately 0145 hours, L.S. was transferred to Unit 5A by transport personnel and her mother. L.S. was received by Ms Doerksen, her assigned nurse. Ms Doerksen settled L.S. into a room for the night with the assistance of Ms Soriano. Prior to the evening of October 21, 1998, neither Ms Doerksen nor Ms Soriano had any prior contact with or information about L.S.

32. While Ms Doerksen attached L.S. to a Corometric monitor, she failed to ensure that the Corometric monitor was properly set and functioning.

33. Ms Doerksen assessed and documented the following vital signs on the flow sheet (attached as Appendix 1) at 0145 hours:

Temperature: 36

Pulse: 72

Respirations: 16

Blood pressure: 90/60

Ms Doerksen checked the IV site and documented the total amount absorbed. She also checked the PCA pump and documented the number of demands and goods as well as the total amount of morphine absorbed.

34. At no time after her transfer to Unit 5A did L.S. make any further demands for morphine; all morphine received by L.S. was administered in the emergency department.

35. Ms Doerksen recorded her observations in a progress note at 0150 hours:

Admitted to 5A via emergency. PIV (peripheral intravenous) insitu and infusing well. PCA started and using appropriately. Child in no obvious pain when moving from stretcher to a bed. No voiced c/o (complaints) although mom states not to place blanket over right leg as LS can not tolerate it. Child asleep on stretcher and settled to sleep as soon as moved over to bed. Mom at bedside and staying overnight. Vital signs stable.

36. Ms Doerksen recorded the following observations of L.S. on the hospital’s computerized record keeping system at 0205 hrs.

patient general description: -- chronic r hip pain

Gabapentin, 400 400 600, TID

Carbamazepine, 200, BID

Amitriptyline, 75, QHS

Apical Heart Rate: 72BPM

Respiratory Rate: 16

Temperature: 36.1, PO

Weight/KG: 40

Physical findings: Healthy looking ten year old girl with in no obvious distress. Holds R leg straight when moving about in bed

37. Ms Doerksen relieved the nurse in the Constant Care Room at approximately 0215 hours and then took her break. Ms Soriano assumed care for L.S during Ms Doerksen’s absence. In addition to caring for Ms L.S. during this time, Ms Soriano attended to the care needs of eight other patients including assessments, observations, interventions, treatments, and medications.

38. Ms Soriano assessed and documented the following vital sign at 0230 hours:

Respirations: 14

Ms Soriano checked the IV site and documented the total amount absorbed. She also checked the PCA pump and documented the number of demands and goods as well as the total amount of morphine absorbed.

39. Ms Soriano assessed and documented the following vital sign at 0245 hours:

Respirations: 12

Ms Soriano checked the IV site and documented the total amount absorbed. She also checked the PCA pump and documented the number of demands and goods as well as the total amount of morphine absorbed.

40. Ms Soriano documented the following assessments and intervention at 0250 hours:

Chest dry good a/e [air entry], took morphine PCA away

Respirations: 8, 10

41. Following the removal of the morphine, Ms Soriano paged Dr. S. at 0250 hours and got no response to the page.

42. Ms Soriano documented the following assessments at 0320 hours:

Asleep

Pulse: 120

Respirations: 12

Ms Soriano checked the IV site and documented the total amount absorbed.

43. Ms Soriano assessed and documented the following vital signs at 0400 hours:

Pulse: 130

Respirations: 12

Ms Soriano checked the IV site and documented the total amount absorbed.

44. Ms Soriano documented the following at 0405 hours after she paged and then spoke by telephone with Dr. S.:

very drowsy, pain service aware of RR [respiratory rate] and sedation

Pulse: 120

Respirations: 12

45. Dr. S. did not return to the hospital to further assess L.S.

46. Ms Soriano documented the following intervention and assessments at 0415 hours:

HOB [head of bed up]

Pulse: 134

Respirations: 10

Ms Soriano checked the IV site and documented the total amount absorbed.

47. Ms Soriano assessed and documented the following at 0420 hours:

Respirations: 16, 12

48. When Ms Doerksen returned to the floor at approximately 0430 hours she received report from Ms Soriano on the nine patients on the floor. In reporting on L.S., Ms Soriano told Ms Doerksen that she had earlier had a concern about L.S.’s decreased respirations, and her sedation level. She reported that she had spoken to Dr. S. to make him aware of L.S. status and that he had said to take away PCA access (which Ms Soriano had already done) and to keep a close eye on her. Ms Soriano advised Ms Doerksen that L.S.’s respirations had recovered and were no longer a concern. She also told Ruth that L.S. had not used the PCA at all since coming to the unit.

49. Ms Doerksen documented the following assessments at 0500 hours:

Asleep

Temperature: 35.7 po [by mouth]

Pulse: 126

Respirations: 16

Ms Doerksen checked the IV site and documented the total amount absorbed.

50. Ms Doerksen documented the following assessments at 0600 hours:

Asleep

Pulse: 126

Respirations: 14

Ms Doerksen checked the IV site and documented the total amount absorbed.

51. Both Ms Soriano and Ms Doerksen, if they testified, would have said that after 0405 hours, they made clinical observations about L.S. which they did not document and that satisfied them that L.S. was stable and sleeping.

52. Shortly after 0700 hours, Ms Doerksen and a number of doctors entered L.S.’s room. L.S.’s vital signs were absent. A code was called, but she could not be resuscitated and was pronounced dead.

53. Ms Doerksen made the following progress note at 09:00 hours:

Received pt. from ER @ 01:45 hr. PIV in situ and infusing well at 20 cc/hr PCA had been started in ER. Vital signs stable, Afebrile on arrival to unit PO36 - 72-16-BP 90/60. child moved from ER stretcher to bed with assistance, No complaint of pain when moving corometric monitor applied since arrival to unit and insitu throughout the night - child settled to sleep and was asleep all night except when woken by nurse for vital signs. Mom at bedside, settled to sleep. Nurse covering for writer at break, called pain service @ 04:05 as respirations ( down symbol) to 8-10 min. Pain service advised to take button away which was done. Child has not used PCA since arrival to unit at 0:145 At 0:600 respiration 14, HR 126.

Entered room at 0715 with physicians (orthopaedic service) child not breathing, code 25 called, CPR initiated - by orthopaedic resident (Dr. Yee). oxygen applied by RN while writer ran for narcan in med room when checked pt at 0600, monitor in situ (error Ruth Doerksen) on and functioning, Pt. sleeping, mom asleep in room.

54. Following L.S.’s death, a post mortem examination disclosed no cause of death. Further, toxicology reports indicated that all medications received by L.S. were within therapeutic range, except for Gabapentin, which had higher levels.

55. Expert opinions from toxicologists and pathologists opined that death was caused by an unknown drug interaction precipitated by cardiac arrhythmia or an electrical conduction difficulty resulting in cardiac arrest. Prior to L.S.’s death, there was no documented history of an interaction from the combination of drugs prescribed to L.S.

56. The College is not alleging that any omission or commission on the part of Ms Doerksen or Ms Soriano caused L.S.’s death.

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ADMISSIONS

Soriano Admissions

57. Ms Soriano admits that she failed to maintain the standards of practice of the profession, as alleged in Allegation #1 of the Notice of Hearing dated November 5, 2001, in that:

i) Having determined that there were indications that Ms L.S. was experiencing respiratory depression at approximately 0250 hours she failed thereafter to: