This is the statement that I would have given had I been allowed to address the panel at the College of Nurses of Ontario disciplinary hearing of Ruth Doerksen and Anagaile Soriano.  I was advised by counsel for the College that I was not a party, and therefore had no right to participate in the hearing. 

 

-Sharon Shore, Sept. 19, 2005

 

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Thank you for giving me the opportunity to speak. I would like to talk about two things: the evidence before you on the Agreed Statement of Facts, which only minimally reflects the events that actually happened on the night in question, and the penalty that you will be imposing on the basis of those facts.

 

I want to make it clear to everyone that I stand here to speak for my daughter Lisa. You need to know that her name is Lisa Shore, not the anonymous L.S. that repeatedly appears in the Agreed Statement of Facts. It has been 7 years since Lisa died, and 5 ½ years since I first filed complaints against these two nurses. These past few years were not spent investigating my complaints; they were spent arguing, haggling, and negotiating to prepare the antiseptic document that’s now in front of you.  

 

It is ironic that I, who am not a party to the proceedings, stand before you as the only person here who is willing to speak the truth. After Lisa died, the Hospital for Sick Children, these nurses, and their lawyers first tried to do everything possible to cover up and conceal. When that didn’t work, they tried their best to shoot the messenger – me.  The nurses’ lawyers have gone to the Crown Attorney’s office to complain about me, accusing me of obtaining information illegally. They have sent me lawyer’s letters threatening legal action. They have sent lawyer’s letters attempting to shut down my web site. They have spoken to other parties and had them send me letters threatening legal action. They blame me for being the cause of all their problems, when all I am doing is speaking the truth they are trying so hard to hide.

 

The College is self-regulating, which means it is in charge of policing its own. To me, this incomplete and inaccurate Agreed Statement of Facts and Joint Submission on Penalty seems more like the College is in charge of protecting its own.

 

In paragraph 56 of the Agreed Statement of Facts, the College says that it is not alleging that any omission or commission on the part of these nurses caused Lisa’s death. The College may not be saying it, but I am. For the record, the omissions and commissions of Ruth Doerksen and Anagaile Soriano did cause Lisa’s death. There are two expert nursing reports that say so. And a coroner’s inquest jury, having heard these nurses testify under oath about the nursing care they gave Lisa, decided that her death was a homicide.

 

The College and these nurses are so intent on whitewashing what happened that they’re even playing word games about the cause of Lisa’s death. Paragraph 55 of the Agreed Statement of Facts says that experts thought that Lisa’s death “was caused by an unknown drug interaction precipitated by cardiac arrhythmia or an electrical conduction difficulty resulting in cardiac arrest”. That’s like describing the person who was shot to death as dying from blood loss. It may be technically true, but there wouldn’t have been any blood loss if there hadn’t been a bullet hole to cause the blood loss. Maybe Lisa did have a cardiac arrhythmia or electrical conduction difficulty as she was dying – but she sure as hell didn’t have one when she came in to the hospital a few hours earlier. And that “unknown drug interaction” occurred because the hospital gave Lisa a lot of morphine. Even these nurses know the dangerous side effects of morphine, the most serious of which is respiratory depression. The first sign that Lisa was in trouble that night was respiratory depression. Once the nurses ignored that, and Lisa’s body started shutting down, nothing else mattered. To say that Lisa died from cardiac arrhythmia or electrical conduction difficulty is more than misleading, it is an overt attempt to deflect all responsibility from the nurses who stand before you.

 

The truth is that while Lisa was a child in pain, she was not a child who was sick. She had gone to school the day before she came to the hospital. She came to the hospital because she was in terrible pain, and that was the only thing wrong with her. If Lisa had stayed home on October 21, 1998, if she had never gone near the Hospital for Sick Children, she would still be alive. Lisa Shore died because she went to the hospital for Sick Children, and because Ruth Doerksen and Anagaile Soriano neglected her and abandoned her. Afterwards, they lied about what they had done to cover it up, and kept on lying even while they testified under oath at the coroner’s inquest.

 

Let’s talk about the doctor’s orders. The Agreed Statement of Facts, in paragraph 24, says that the doctor “entered on the Doctor’s Orders Sheet the following for pain control”. While this Agreed Statement of Facts mentions the first few lines of the doctor’s orders, it doesn’t mention the rest of them – the ones about how frequently vital signs were to be taken, the two different vital signs monitors that were to both be used, and the requirement that the doctor be contacted if Lisa’s breathing fell below a certain level. The Agreed Statement of Facts neglects to mention that these two nurses never read those doctor’s orders. It neglects to mention that the nurses did not follow those orders. It neglects to mention that another doctor also gave orders for Lisa’s intravenous solution, and that those orders were also never read and never followed.

 

Ruth Doerksen and Anagaile Soriano admitted at the coroner’s inquest that they hadn’t looked at those doctors’ orders. Even the Hospital for Sick Children, which knew about it and initially withheld that information from us, eventually admitted it. Even with these nurses’ complete lack of competent nursing care, had Lisa been placed on the appropriate vital signs monitors as the doctor had ordered, those monitors’ alarms would have gone off when Lisa’s vital signs started deteriorating, and she would have been saved. Had the nurses followed the doctor’s order to give Lisa a 2/3 – 1/3 intravenous solution instead of deciding on their own to give her only normal saline, she might have been better hydrated and better able to fight off the deadly side-effects of morphine. She might have survived a little longer, maybe long enough so that the doctors who came to check on her the next morning might have saved her.

 

At the coroner’s inquest, a nurse from the Emergency Department testified that children coming up to the ward from the Emergency Department always have doctors’ orders in the computer system. Members of this panel, whether you are a nurse or not, you must know how important it is for nurses to follow doctors’ orders. Would you want any of your loved ones to be a hospital patient where the nurse decides on her own how to treat you – or to not treat you, as is the case here? Ruth Doerksen had 15 years of experience at the hospital, and five years with its computer system. Do you honestly think she just forgot to go to the computer to read the doctors’ orders? That would be like a police officer going on patrol in a high crime district and forgetting to strap on his or her gun.  How can a nurse take care of a patient without knowing what the doctor ordered? The answer is that she cannot.

 

Not reading the doctor’s orders is much worse than “failing to adequately assess”, as the Agreed Statement of Facts alleges. It more clearly explains how these two nurses are responsible for Lisa’s death.

 

Let’s talk about monitoring some more, because that too is damning information that has been omitted from this Agreed Statement of Facts. There are three different versions of events – the one the nurses testified to under oath, the one that’s being presented to you here, and the truth.

 

What you need to know before I describe these different versions to you is that when Lisa was found dead, she was hooked up to a monitor. This monitor has two alarms, one for heart rate and one for respiration. You can turn off the breathing alarm, but you can’t turn off the heart rate alarm unless you turn off the machine entirely. If you pull the plug out, or if a patient twists and gets disconnected from the monitor, the alarm will go off. When Lisa died, no alarm sounded. After Lisa’s death, all the hospital’s monitors were found to be working properly. The only possible explanation for the monitor’s alarm not having gone off when Lisa died was that it was not turned on in the first place.

 

Version #1, from inquest testimony[1]:

Ruth Doerksen acknowledged that she did not put Lisa on the oximetry monitor the doctor had ordered. Although she did not document anything on her initial nursing note about any monitors, she claimed that she did attach the second kind of monitor, called a Corometric, to Lisa, as had been ordered. She said that it repeatedly sounded false alarms, so she had to keep returning to Lisa’s room to fix it. Eventually, she said, she turned off one of its two alarms altogether. She told the inquest that she left the Constant Care Room[2] where she was assigned to do this, even though Anagaile Soriano and another nurse both testified that one is not allowed to leave the Constant Care Room under any circumstances.

Doerksen testified that she did not know where I, Lisa’s mother, was during the many times she allegedly came into the room to shut off the false alarms. Can any of you imagine being in a hospital room with your child, with alarms going off, and not being there beside your child in a panic, waiting for the doctors and nurses to come running?

During the time that Ruth Doerksen was in the Constant Care Room, Anagaile Soriano was responsible for Lisa’s nursing care. However, Soriano could not explain why she didn’t specifically remember an alarm going off in Lisa’s room. She could not explain why, when Ruth Doerksen allegedly left the Constant Care Room to turn off a false alarm, she passed right by Soriano, who claimed to be sitting on or around the nursing station right near Lisa’s room. Does any of that sound logical or believable?  I suggest to this panel that had any of the Hospital for Sick Children’s nurses really abandoned its most vulnerable patients, the ones who required round-the-clock monitoring in the Constant Care Room, even the hospital might have been a little concerned. It wasn’t concerned, because it knew the whole monitor story was made up, and it knew that Ruth Doerksen had never really left those Constant Care patients unattended.

It was acknowledged by all that no alarms sounded when Lisa died. Ruth Doerksen could not explain why the other alarm on a supposedly working monitor – the one that could not be shut off – did not sound. Nor could she explain why she never documented anything about this or why she never reported it to anyone higher up. Think about it: a nurse has a patient who has just unexpectedly and mysteriously died, and the monitor that was supposed to warn of impending danger did not go off. Can you imagine a nurse not documenting it, and not reporting it to anyone? When Ruth Doerksen wrote up her nursing notes after Lisa died, she never said anything about an alarm having failed to sound. What if the monitor was broken? Would any competent nurse not say anything and let that defective monitor get used on another child? Of course not – because the whole story was invented by her to cover up the truth, that Lisa was never, ever attached to a working monitor. When Doerksen testified at the inquest, she was asked to explain these inconsistencies, and she had no answer.

 

Version #2, the Agreed Statement of Facts before this panel:

There was a Corometric monitor. These monitors were not designed for use on children older than two <does anyone care that this implies that the Hospital for Sick Children was using defective equipment for its patients?>. Ruth Doerksen failed to ensure the monitor was properly set and functioning.

There is no mention anywhere in the Agreed Statement of Facts that oximetry monitoring was ordered by the doctor but never done.

 

The truth:

Two monitors were ordered for Lisa. Neither was ever used. There were no false alarms. There were no alarms at all, because there were no monitors ever attached to Lisa and turned on. I was with Lisa, awake, during the time that Ruth Doerksen claimed to have come into the room repeatedly to turn off false alarms. No one came into the room. The mothers in the adjacent rooms both stated that no alarms went off that night within earshot, and that they would have heard them if they had. One of them even pointed out that multiple alarms went off on subsequent nights as every child on the floor was placed on a monitor after Lisa’s death.

 

It is true that when Lisa was found dead, she was attached to a monitor that was not turned on. Let me explain how that happened. The Agreed Statement of Facts doesn’t mention that Ruth Doerksen told the inquest jury that she hadn't done the required 7:00am check on Lisa – although she did it for her other 4 patients. According to her testimony, she somehow “forgot” about Lisa. Can any of you imagine a nurse forgetting one of her 5 patients – the one who had arrived from Emergency five hours earlier, the one about whom they called the doctor only three hours earlier, at 4:00am?  I suggest that it is far more likely that Ruth Doerksen did check on Lisa at 7:00am, and that’s when she found she was dead, and that’s when she hooked her up to the monitor. She couldn’t turn it on, because once she turned it on the monitor would not register a heart beat and an alarm would sound. I would have woken up and caught her in the act.

 

Ruth Doerksen told the inquest jury that she was going to do the 7:00am check, the one she had forgotten to do, at 7:15am when she accompanied the doctors on their rounds. But I saw her when she came into the room, and all she did was stand by the door. She never approached Lisa to take her vital signs – because she already knew Lisa was dead.

 

There is yet another inconsistency that has conveniently been omitted from the Agreed Statement of Facts, one which brings into question the accuracy of the nursing data that Ruth Doerksen actually did chart. She wrote on the nursing flowsheet that she awoke Lisa at 5:00am to take her temperature. Since Lisa did not have a fever or any infection, taking a temperature was not required according to the doctors’ orders, hospital protocols, or good nursing practice. What was required, however, was that her blood pressure be taken. The Hospital for Sick Children said that the reason she hadn’t taken Lisa’s blood pressure was “possibly an attempt not to awaken Lisa once she had begun to rest”[3]. So Ruth Doerksen awakened Lisa at 5:00am to take her temperature, but didn’t want to wake her at 5:00am to take her blood pressure, a measurement that might have saved her life. When asked to explain this apparent contradiction at the coroner’s inquest, she replied, “I have no answer for that”.

 

Another area in which the Agreed Statement of Facts is somewhat deficient is its description of the hospital’s then-existing PCA monitoring standards. It says what those standards were, but doesn’t explicitly state that those standards were not adhered to. It doesn’t say that the nurses admitted under oath that they were familiar with those standards, and it doesn’t tell you that they had no answer when asked why they didn’t follow them for Lisa.

 

The “failure to assess” and “failure to monitor” that you see in the Agreed Statement of Facts are really much more than that. Ruth Doerksen and Anagaile Soriano did not need doctors’ orders to know how frequently they were supposed to take Lisa’s vital signs, and which vital signs they were supposed to take, because they knew the hospital protocols. There is no plausible explanation for this except that their neglect was intentional.

 

Sounds unbelievable, doesn’t it? But let me clarify some things. Point number 31 says that neither Ms. Doerksen nor Ms. Soriano had any prior contact with or information about Lisa. That is patently false. When Lisa came to the hospital in October 1998, to be neglected and left to die, every doctor and nurse on that ward who had been there when Lisa was there a few months earlier (which includes Ruth Doerksen but not Anagaile Soriano) knew about her, knew about the child they thought was faking her pain. At the coroner’s inquest, Ruth Doerksen testified that while she hadn’t been Lisa’s nurse before the night of October 21, 1998, she did know of her. The Agreed Statement of Facts is not correct. Knowing that Ruth Doerksen did know about Lisa, knowing the attitude of the doctors and nurses on the ward, gives you a motive for why Lisa was ignored. It helps you to understand why Lisa was neglected and left to die.

 

The College’s ostensible mandate is to protect the public from bad nurses and bad nursing. How can it possibly do so, when it is content with untruths, half-truths, and omissions of material information as presented to it in this Agreed Statement of Facts?

 

I know that the College is not allowed to refer to inquest testimony. But there is nothing stopping the College from asking the same questions again at a hearing that were asked at the inquest. I expected I would have opportunity to testify in detail about the things I have spoken about here as well as others. I was confident that once you heard these two nurses testify, you would be able to see, just as the inquest jurors had, their lies, evasions, and inconsistencies. I knew you would be able to determine who was telling the truth and who was not. It is my submission to this panel that the Agreed Statement of Facts should not be accepted, and that there should be a contested hearing held in its place.

 

 

 

I’d also like to address the panel on the penalty. The Joint Submission on Penalty proposed by the College and the nurses is that the nurses receive one month suspensions, with the suspensions themselves to be suspended. In other words, they’ll go right back to work tomorrow, just as they have been doing all along.

 

I was told that this is pretty typical of the penalty given by the College where nurses have been found to have failed to monitor and assess their patient. Matter of fact, the College even told me earlier this year how it considers sexual abuse to be much more serious than these charges are. If this is true, then in my opinion the government should not allow nursing to be a self-regulating profession. Doctors and nurses lose their licenses for having sex with their patients, but get no penalty at all for neglecting patients and leaving them to die?  

 

I checked this month’s issue of College’s newsletter, the Standard[4]. I’d like to summarize for this panel some of the discipline decisions and penalties reported there.

1)      Nurse forced patient to clean up her own feces, held patient by hand or back of neck to force her to do so. Penalty: 4 month suspension. Nurse had shown no remorse. The Panel noted that the client was vulnerable and that the member’s actions compromised the client’s dignity.

2)      Nurse verbally, physically, and/or emotionally abused patient who was a senior, and cognitively impaired. Penalty: 3 month suspension.

3)      Nurse collected $1300 in sick benefits under false pretences/forgery. Penalty: three month suspension. The panel noted that “the penalty reflected the seriousness of the member’s actions and demonstrates that such behaviour will not be tolerated. It reinforces the values of honesty, integrity and professionalism that form the cornerstones of the nursing profession”.

4)      Nurse administered medication to other nurses without a prescription/ misappropriation of property/obstruction of an employer’s investigation. Penalty: three month suspension.

 

In the next issue, it should say: Failing to read or follow doctors’ orders, intentionally neglecting a 10-year-old child and thereby allowing her to die, and attempting to conceal the truth: One month’s suspension. Patient was a vulnerable member of society, and there is no demonstrated remorse, so the suspension is suspended to allow the members to return to work to care for other children.

 

I think the public needs to know that the College considers the property offence of stealing $1300 to be far worse than neglecting a child and allowing her to die. As they say in the criminal justice system, this “shocks the conscience of the community”. It certainly shocks everyone who knows the truth about what these nurses did.

 

My understanding was that penalties got reduced where nurses were remorseful. There is no remorse expressed in this Agreed Statement of Facts, because there has never been any expressed by these nurses. Quite the opposite; this Agreed Statement of Facts represents the first time in the seven years since Lisa’s death there has been any forthright admission they did anything wrong. So what is the basis for suspending the suspension?

 

The Hospital for Sick Children and its nurses and lawyers have spent the past few years telling the world that systems problems led to Lisa’s death, attempting to convince everyone that these two nurses did nothing wrong. The hospital has already demonstrated that supporting its nurses is more important to it than the safety of its patients. As I read the Agreed Statement of Facts, it appears that the College of Nurses of Ontario feels exactly the same way.

 

  

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