Closing Address by Frank Gomberg
at the Lisa Shore Inquest

February 9, 2000

On October 21, 1998, Sharon Shore and Bill Shore made a decision that will haunt them for the rest of their lives. The decision that they made was to take their beloved daughter Lisa to the Hospital for Sick Children in order to stop or at least reduce her pain. Lisa was crying out in pain and she looked to her mommy and her daddy to help her. Sharon and Bill did what any loving, frantic parent would have done. They did what you would have done, what I would have done. They took Lisa to the Hospital for Sick Children, reputedly the best children's hospital in the world.

Sharon and Bill placed Lisa's care and her life in the hands of the doctors and the nurses at the hospital. They put their trust in the hospital. That trust was cruelly betrayed and Lisa is dead forever. Nothing that any of us can do will bring Lisa back. There's not enough morphine in the world to stop Sharon's pain and Bill's pain and their son Devon's pain and their son Aron's pain and Grandmother Barbara's pain and Grandmother Mary's pain.

What can you do about all of this? Why are we here? You are here to help ensure that a human tragedy like this never happens again; so that 5 jurors like you don't have to look into the pain-filled faces of grief-stricken parents again some day. You're here to help prevent another tragedy like this one and I know from listening to your questions over the last few weeks that that is exactly what you are going to do.

I am not going to review the evidence at any great length although I could do that. I'm not going to do it because I am convinced that you know it as well as I do. I do not want to bore you or waste your time. If I do re-iterate some points that are already firmly entrenched in your minds, then I apologize for that in advance.

I will also briefly talk to you about your "fact finding function" which is a little legalistic and somewhat boring. I will warn you before I do that, so that you will at least know that it is coming.

This case is not a difficult one. The facts should have been easy to figure out, particularly to anyone at Sick Kids — if they wanted to figure them out. Once the facts are laid bare, the conclusions which emerge are fairly obvious. Unfortunately, what happened here was that the Hospital for Sick Children embarked on a campaign of deception, confusion, and outright corruption of the truth. To call what went on a smokescreen and a cover-up is exactly right. If it looks like a duck and quacks like a duck, there is a very good chance it is a duck — except if you ask Ruth Doerksen, Anagaile Soriano, Mary Douglas or Carol Warren. They would have you believe that a yellow quacking winged bird is something other than a duck. I know that you haven't been fooled — not in the least! Witnesses like Jennifer Stinson, the pain nurse, and Susan Anderson, the Kidcom expert, and Pauline Matthews from the Emergency Department were truthful and forthright. Contrast that with the evidence of Anagaile Soriano and Ruth Doerksen. The difference is like night and day.

Examples of the hospital's morally bankrupt attempt to mislead and tell half-truths are the answers to the questions I asked on behalf of the Shore family in my letter of December 11, 1998.  I signed the letter and as I stand before you, I'm proud to say that when I sign something, I take full responsibility for it. The Hospital's abject failure to take responsibility is a theme or a subtext that runs through this inquest. My letter of December 11, 1998 was necessary because no answers were forthcoming from Sick Kids up to that time. Sick Kids shouldn't have needed my letter to provoke an investigation into Lisa's treatment. Surely, the highly unexpected death of an otherwise healthy 10-year-old, should give rise to some curiosity on the part of the medical and nursing hierarchy at Sick Kids, particularly since nurses Doerksen and Soriano continued caring for other kids and continue to do so to this very day! But Sick Kids waited for a letter from me and then waited some more after getting my letter from the coroner, Dr. Reingold. By the way, the reason I didn't send the letter directly to Sick Kids was that it was apparent that without the help of the coroner's office no answers would ever be forthcoming. Sick Kids then spent over a month drafting and crafting a very lawyerly, anonymous response to our questions. Not only were the answers carefully constructed but they were cleverly sent with a letter from Marion Stevens <added note: the Risk Manager. This "covering letter" talks about reviewing and editing the responses but doesn't say who is responsible for the answers. The author of the grossly inaccurate answers is the prolific "anonymous". Well, the shirking of responsibility for the authorship of the answers to the family's questions is directly in keeping with Sick Kids' attempts to shirk responsibility on most issues in this case.

I'm not going to go through the 22 responses one by one. Your ability to read the answers is as good as mine.

The opening paragraph says that Lisa's vital signs were noted upon admission to 5A. It doesn't say that her blood pressure was significantly lower at 1:45am than it was at 12:40am in Emergency.

Paragraphs 1 and 2 refer to heart rate settings of 50-60 at the low rate and 160-180 for the high rate "as appropriate for Lisa's age". Come on — do you think that is honest?

"The nurses checked Lisa hourly through the night". Do you think that is an honest answer?

Answer 5 talks about the PCA Nursing Resource Manual. The implication is that the directives in the manual were followed. That implication was and is a blatant lie.

Answer 5 also says "the monitoring orders were placed on the hospital computer system (Kidcom)". That was true — but they conveniently forgot to mention that no one ever activated those orders! Do you think that is honest?

There is a sentence which reads that the sedation scale and pain scales "were not recorded although there is an assessment of level of consciousness in the patient record". The implication is that the sedation scales and pain scales were done but not recorded. That is just too misleading for me and I'm sure for you too.

Answer 6 refers to the blood pressures and suggests that not taking the ordered blood pressures was "possibly an attempt not to awaken Lisa once she had begun to rest." But this too is a blatant, bald-faced lie.

According to Nurse Doerksen she woke Lisa to take her oral temperature at 5:00am. Why didn't she take her blood pressure then — a blood pressure that probably would've saved her life? Doerksen's answer to this question asked by Dr. Cairns was "I don't know".

I suggest to you that the hospital engaged in a cover-up, in a misguided orgy of deception which was intended to disguise, distort and bend the truth so that it would remain forever hidden. What the hospital did before you, the jury, was to continue its campaign of deception. If the hospital really wanted to answer the family's questions truthfully it could've and should've written a letter like this one:

Jan. 28, 1999

Sharon and William Shore
Thornhill, Ont.

Dear Mr. and Mrs. Shore,

The Hospital for Sick Children has conducted a thorough investigation of the circumstances surrounding the unexpected death of your daughter, Lisa Shore, who was in our hospital for treatment of pain arising from a non-life threatening condition. I am now able to respond accurately to the questions posed by Frank Gomberg in his letter of December 11, 1998.

  1. Dr. Schily, the Pain Service fellow, entered specific monitoring orders into the hospital's computer system, known as "Kidcom". Dr. Schily did this in the Emergency Department at 11:48pm. These Kidcom orders were initially placed in "suspended" mode, and were supposed to be "activated" by Ruth Doerksen or Anagaile Soriano, the nurses on Ward 5A that night. This was not done. I enclose a copy of the suspended Kidcom orders, which should have been included in the hospital records that were sent to you.
  2. The Kidcom orders required that Lisa be placed on a pulse oximeter, which measures the amount of oxygen in the blood. Because the nurses never activated the Kidcom orders, and because the nurses never looked at the Kidcom orders, this was not done.
  3. The Kidcom orders required that Lisa's vital signs — heart rate, respiratory rate, and blood pressure — be taken hourly for the first four hours after arrival on Ward 5A. The heart rate and respiratory rate were taken frequently, but the blood pressure was taken only once, at 1:45am.
  4. The Kidcom orders also required that a formal sedation scale and a formal pain scale be done hourly for the first four hours after arrival on Ward 5A. This was not done.
  5. Even if the nurses did not know about the Kidcom orders, it was mandatory that at a minimum, they follow the monitoring protocols clearly set out in the nursing manual. I enclose a copy of the manual, Patient–Controlled Analgesia (PCA) Nursing Resource Material, for your review. These protocols provided for almost identical monitoring as was ordered by Dr. Schily, including sedation scale, pain scale and blood pressure. The nurses did not follow the mandatory protocols. As such, appropriate monitoring was not done.
  6. Lisa's blood pressure should have been taken as ordered, even if she was asleep.
  7. The Kidcom orders mandated that Lisa be attached to a corometric monitor, a device that will sound an alarm when a problem is detected with breathing or heart rate. Based on Lisa's hospital records, it is unclear whether a corometric monitor was applied. If it was applied, it is unclear whether it was ever turned on. It is clear that no alarms sounded when Lisa's breathing and heart stopped. Nurse Doerksen says that a corometric monitor was attached and working throughout the night, but that she turned off the apnea (i.e. breathing) part of the alarm because it rang three or four times and was making a terrible racket. I understand that Mrs. Shore disputes this because she was sleeping in the room and heard no alarms. Without trying to figure out who is right, disabling the apnea part of the alarm is completely unacceptable.
  8. Dr. Schily spoke with Nurse Soriano at 4:05am. Dr. Schily says that he was assured that all Lisa's vital signs and oxygen saturation were good, and that Lisa was arousable. Nurse Soriano says that she reported Lisa's respiration as 8,10, that Lisa's heart rate was in the '100's, and that she was arousable. I cannot resolve this discrepancy. What is clear is that Lisa's condition required immediate medical intervention including the administration of Narcan. This was not done.
  9. The increase in Lisa's heart rate from 72 beats per minute at 1:45am to 134 beats per minute at 4:15am was a "red flag" that should have alerted the nurses that immediate medical intervention was critical.
  10. Nurses Doerksen and Soriano made detailed notes in the week following Lisa's death. I enclose copies for your review.
  11. Dr. Wright's Death Summary contained several inadvertent errors. I enclose a corrected Death Summary which I believe to be accurate.

It is clear that Lisa Shore did not receive appropriate care while at the Hospital for Sick Children in the early hours of October 22, 1998. On behalf of the Hospital, I apologize to the Shore family for this unspeakable tragedy. I enclose a list of the changes we have made or are in the process of making. I hope that the changes we have implemented and will continue to implement as a result of our thorough investigation will ensure that a tragedy like this never happens again.

Yours truly,

If a picture is worth 1,000 words then this case can be summarized by 3 pictures:

  1. The doctor's orders in Emergency
  2. The lost in space suspended "Kidcom" orders that Nurse Doerksen saw as part of the patient care plan on October 22, 1998
  3. The flow sheet for October 22, 1998.

Let's spend a few minutes talking about these 3 pictures.

1. The doctor's orders

I'm not going to review these orders with you other than to say that they specifically said, "See Kidcom orders". The Kidcom orders required a pulse oximeter and a corometric monitor and lots of other manual monitoring. You see, Lisa was on morphine and as Dr. Schily said, morphine is a potentially deadly drug. Morphine is a very good painkiller but it has potentially lethal side effects. Dr. Schily knew that only too well. That's why he made detailed and appropriate orders at 11:48pm on October 21, 1998. No-one has suggested that there was anything wrong with these orders, nor could they; the orders were bang on correct. You see Dr. Schily knew that Lisa was being exposed to a danger. He was prepared to expose her to that danger knowing that she would be carefully watched; if she got into trouble then the effects of morphine would be reversed and the danger would be eliminated. The metaphor is getting into an airplane to go parachuting. The owner of the parachute school knows that jumping out of an airplane is a very dangerous thing. He tells the instructor to pack the main parachute and to pack a back up chute in the parachutist's jumping equipment. The main chute is like the oximetry device. The back up chute is like the corometric monitor. The new parachutist jumps out of the plane relying on the instructor and the school. Unfortunately, there were no parachutes in place. Who would jump out of a plane without a parachute? Who would have their child go on morphine with no oximetry, and no corometric monitor? To ask the question is to answer it — no one! Mr. Hawkins will suggest that what happened here was a terrible series of very human errors. I completely disagree. I'm not suggesting that anyone set out to kill Lisa or that anything sinister was done to cause her death. What I am suggesting is that there was a callous disregard for protocol and procedure and an almost inconceivable disregard of prompts, any of which if reacted to, would have saved Lisa. When the nurses failed to activate Dr. Schily's orders and when Nurse Soriano failed at 4:05am to convey the seriousness of Lisa's condition to Dr. Schily, they signed Lisa's death warrant. There were still opportunities for a reprieve however. Both Dr. Smith and Dr. McLeod testified that Lisa would probably have survived and would probably not have had any brain damage if Narcan had been administered even as late as 6:00am. There was no reprieve however, because the nurses weren't doing their jobs.

Let's talk about driving a car for a minute. Have you ever driven through a stop sign by mistake? Even though Constable Culleton is here I have to confess to having gone through stop signs many times in my life. I've never gone through 2 in a row. For sure I've never gone through 3 in a row. 4 in a row would be impossible. 5 in a row would be outrageous.

At 12:00am Nurse Doerksen took a call from Emergency saying that Lisa would be coming up to Ward 5A. That was prompt #1 to eventually activate the Kidcom. Well they went through that stop sign!

At about 1:30am Nurse Soriano took a phone call from Emergency saying that Lisa would be coming up to Ward 5A. That was prompt #2 to activate the Kidcom. Well they went through that stop sign!

At about 1:45 Lisa arrived on Ward 5A. That was prompt #3 to activate the Kidcom. Another stop sign!

When Lisa arrived on Ward 5A her emergency chart arrived with her, including the emergency flow sheet, the detailed emergency progress notes and more importantly, Dr. Schily's specific note — "see Kidcom orders". That was prompt #4 to activate the Kidcom. They went through that stop sign too!

Now Lisa is on Ward 5A and there are apparently no orders. Not to worry, there's a PCA nurses manual to follow. The nurses failed to follow the mandatory orders in the manual. Unbelievably, they also went through that stop sign!

Lisa's vital signs and in particular a highly elevated pulse rate from 3:20am was a stop sign. They went through that stop sign too! Attributing a high pulse rate to pain without going back to see how much pain Lisa was in in the Emergency department (when her pulse was stable at about 90) is another stop sign. They zipped right through that stop sign!

Failing to figure out why Lisa was so cold at 5:00am was another stop sign. They went through that one too! On and on it goes. You can probably identify other stop signs that I've missed. I suggest to you that this was no accident. This was neglect. This was intended to be benign neglect because these nurses didn't think that Lisa had a problem. However, the benign neglect had very malignant consequences because too many stop signs were violated.

2. The lost in space suspended orders

Do you think that these orders were really "lost in space"? Do we really have to paint by numbers here? Nurse Doerksen saw the orders as part of the patient care plan on October 22, 1998. Marta Papa also saw them. They then conveniently disappeared and no one else saw them that day, even though Lisa had died. Obviously, whoever threw them out should've been on high alert to retain them.

Can you believe it — the nursing care plan for a recently dead patient who died most unexpectedly was tossed out! 5 days later Nurse Doerksen printed the suspended orders up and took them home where they remained for 15 months, until I asked for them in open court in front of you. Come on!

And yet until January 26, 1999 no one at the hospital thought to look carefully for doctors orders that were obviously made because someone at the hospital had to reverse at least the medication orders made by Dr. Schily. No one at the hospital thought to try to find the orders. Did they want to find them is the question? The answer is a resounding "No". Sitting on these Kidcom orders for 3 months and hiding them from the coroner and from the family is just one more example of the moral bankruptcy of those who ought to have been getting to the bottom of this tragedy.

Sure Coroner Reingold didn't do a great job. His notes were lousy and he should've asked more questions. However, nothing that Dr. Reingold did caused Lisa's death and his failure to sequester a corometric monitor had nothing to do with anything because there was no corometric monitor ever used! Pointing the finger at Dr. Reingold is just one more example of the ethical malaise that afflicted and continues to afflict Sick Kids in this case.

The orders were the "game plan" for taking care of Lisa. Because the nurses say they never saw the orders and because there was no adherence to the PCA nursing protocols, Lisa was truly jumping out of an airplane with no parachutes on her back. They gave her the morphine and they pushed her out of the airplane!

3. The flow sheet

I'm not going to take you through the flow sheet as I'm sure that you can see it in your dreams or nightmares. Certainly Sharon and Bill can. Dr. Robin Williams was the moral conscience of the inquest. She looked at the flow sheet and at the treatment and was highly critical of both. Dr. Williams said that there were many, many signs of problems including a significantly elevated heart rate and a low blood pressure at 1:45 compared to what it had been in the Emergency Department. The respirations were also depressed. These were all red flags "that ought to have gone up, that ought to have alerted the nurses to what was going on even with the vitals they took". In a nutshell, Dr. Williams was highly critical of the monitoring that was done. In other words much more ought to have been done. However, even what was done ought to have sounded the proverbial alarm and it didn't.

Findings of fact

Dr. Cairns is going to talk to you about the law and I'm not going to get into that as that is his responsibility. I will talk to you briefly about what lawyers, judges and coroners call findings of fact. This is the part of my address that is somewhat boring and I apologize. Dr. Cairns will tell you that a fact is only a fact when you find it to be a fact. I may express my opinion to you about what a witness said and Ms. Browne, Mr. Hawkins, Mr. Krkachovski, Ms. Posno and Dr. Cairns himself can also do so. With the greatest of respect to Dr. Cairns, it doesn't matter what Dr. Cairns thinks about the facts any more than it matters what I think or what Ms. Browne thinks or what Mr. Hawkins thinks. What is crystal clear is that Mr. Hawkins and I agree to disagree on the facts. You must determine the facts. You do that by looking at a witness and assessing her demeanour in the witness box. Was she being candid? Was she trying to help? Did she concede obvious points in cross-examination? Did it look like she was being truthful? How does her evidence accord or diverge from the evidence of other witnesses? Does the evidence make sense? Is it logical? Is it internally consistent? One example of what I say is an internal inconsistency is Nurse Doerksen's evidence that she woke Lisa at 5:00am to take her temperature while at the same time saying that she didn't want to awaken Lisa to take her blood pressure.

Another example of an inconsistency is the completeness of Nurse Soriano's personal notes and her failure to mention a corometric monitor in them. Nurse Soriano didn't add her own nurses' note to the hospital record. She didn't do that because she wasn't prepared to lie on that point at that time. She did say in her evidence that she heard one alarm from a corometric monitor but she doesn't know if it came from Lisa's room. Does that make sense? Lisa was Soriano's patient at that time and the alarm sounds just as Doerksen comes out of the constant care room to pick up some papers. You heard on Monday from nurse Phillibert and yesterday from nurse Nguyen that a nurse cannot even come out of the constant care room to respond to a Code. But, Doerksen comes out to pick up some papers. Doerksen would have you believe that she goes to Soriano's patient, abandoning the 3 kids in the constant care room. She does this to turn off an alarm and in doing so disables 50% of the corometric monitor. She turns off an alarm designed to be loud enough to be heard by nurses in other patient rooms and down the hall at the nurse's station. Does that make sense to you? Sharon Shore is sleeping and sleeps right through the initial start up cycling sounds of the monitor plus 3 or 4 loud alarms. Doerksen hears all of these alarms from outside Lisa's room but Sharon hears none of them. Does that sound right?

Sharon and Bill take Lisa to the hospital for pain relief and now Sharon sleeps through piercing alarms when she told you that if she'd heard any alarms at all, she'd have run into the hall screaming for a nurse! Isn't that what you would do? Your daughter's or your granddaughter's breathing or heart may have stopped as evidenced by this shrill alarm. What the hospital would have you believe is that Sharon simply kept sleeping. That is just the craziest thing I've heard in my 20 years around the courts.

You can believe all, part or none of what a witness says. In making your determination you can consider what other witnesses have said.

In other words, do you believe what Nurse Soriano said or what Dr. Schily said about their 4:05 telephone conference? I suggest that Dr. Schily's version is much more credible. Once you find that Nurse Soriano is not to be believed on her version of what took place with Dr. Schily, you may choose to disbelieve her evidence about hearing one alarm coming "maybe" from Lisa's room and "maybe not". You can disbelieve her evidence about hearing cycling sounds from a corometric monitor while she was standing near the door. You can disbelieve her evidence that there was a corometric monitor attached and functioning during the night.

If there was a corometric monitor then why didn't the apnea alarm sound? Because it was turned off — how convenient! Why didn't the cardiac part of the monitor sound when Lisa's heart rate went below 50 to 60? The hospital has 3 answers:

1) We don't know — see their letter

2) Mr. Bauer tried to concoct an explanation in Nov. 99 — which got Mr. Krkachovski involved in this inquest. This Bauer — Sick Kids theory was later dropped in favour of an agreement that "if there was a monitor in the room, it was not on when Lisa arrested".

3) The whole monitor was turned off by persons unknown.

Well I have a better and simpler and very credible explanation. Ruth Doerksen and Anagaile Soriano were not very concerned about Lisa and they had no reason to suspect that anything bad would happen to her. A corometric monitor was never attached to Lisa while she was alive.

Sometime between 6:30am and 7:00am, after sorting and stapling the nine patient care plans, nurse Doerksen went in to check Lisa and found her dead. Nothing could be done for Lisa but Nurse Doerksen could make a bad situation a little better for herself. She ran and grabbed a corometric monitor and put it on the shelf near the door. She ran out and did rounds with the doctors. The doctors found Lisa dead. Nurse Doerksen couldn't have saved Lisa at 6:45am or at 6:55am or at 7:05am but she could save her career and that's exactly what she tried to do.

Where there's a conflict between Nurse Soriano and Dr. Schily I'd ask you to accept Dr. Schily's evidence and to reject Nurse Soriano's. It makes no sense to believe that Dr. Schily would just go back to sleep if he was told even half of what Nurse Soriano says she told him.

Dr. Schily says that he was told that Lisa's vital signs were "good" and that her respiration rate was just above 10 per minute. She was arousable. He told Nurse Soriano to look up saturation and carefully check sedation, respiration and all other vital signs. Doesn't that make sense? I asked Dr. Schily whether he'd have rushed to the hospital if he thought his orders hadn't been followed. He said yes. Doesn't that sound sensible?

Nurse Soriano paged Dr. Schily at 2:50am and didn't page him again for an hour and fifteen minutes. Does that make sense?

In my respectful submission, you should reject Nurse Soriano's testimony in favour of Dr. Schily's. Nurse Soriano's testimony is simply not credible.

In the same way you should reject Nurse Doerksen's testimony where it conflicts with Sharon Shore's.

Nurse Doerksen was highly evasive and might even have been coached from the audience. What she said made very little sense. I would urge you to conclude that no corometric monitor was ever turned on that night — just as Sharon Shore said. That means a lot to Sharon and Bill because it would vindicate what Sharon has been saying for 15 months and put the lie to the Hospital's disgraceful "cover up" once and for all.

Before concluding with our suggested recommendations let me say that even if I said nothing to you about recommendations, Sharon and Bill are thoroughly convinced that whatever recommendations you do make are good enough for them.

You have to answer 5 questions prior to making your recommendations

1) Name of deceased:
Lisa Shore

2) Date and time of death:
October 22, 1998
6:30am to 7:00am

3) Place of death:
Hospital for Sick Children, Toronto

4) Cause of death:
Drug interaction leading to respiratory and cardiac arrest

5) By what means:
Homicide caused by the administration of a large dose of morphine without appropriately monitoring the life threatening consequences of morphine including:
— Increased heart rate
— Decreased respiratory rate
— Decreased blood pressure
— Decreased temperature

February 9, 2000

Recommendations of the Shore family resulting from the inquest into their daughter Lisa's death at the Hospital for Sick Children on October 22, 1998

The recommendations:
<NOTE 1:  The following originally included reasons and rationales giving rise to each recommendation.  As a result of the objection of Patrick Hawkins, lawyer for the hospital, these rationales had to be deleted before giving them to the jury.  The jury did hear them read, however.

Recommendation 1:
For computerized information systems such as Kidcom, automated warning technology should be explored and implemented. For example, when "suspended" Kidcom orders are entered in Emergency for an incoming admission, a page or other audible warning should sound regularly, such as every five minutes, on the destination ward, and stop only when the Kidcom orders are activated.

Recommendation 2:
The standard order set within the Kidcom system for patients on parenteral1 opioids, whether by PCA pumps or any other method of delivery, should include a line which the physician can delete if not applicable. This automatic entry should state "Warning: patient is on other concurrent medications that may potentiate2 adverse side effects. Increased vigilance is advised."

Recommendation 3:
When a patient is discharged or expired, any suspended orders in the Kidcom system should print automatically and form part of the patient's permanent record.

Recommendation 4: <see note 2
All nurses and doctors should be educated or re-educated to ensure they know that Kidcom monitoring orders and PCA monitoring protocols begin at initiation of opioid therapy and restart again from the moment of admission to the ward. The Kidcom orders should be changed to reflect this.

Recommendation 5:
That all nurses be made aware that doctors monitoring orders or other mandatory monitoring protocols are never discretionary and must be followed at all times unless
a) The orders are clearly erroneous,
b) Authorization is obtained from the doctor, or
c) The level of monitoring is to be greater than that ordered by the doctor.

Recommendation 6: <see note 2
For patients admitted to wards from Emergency, nurses must review the Emergency nursing notes, doctors orders, flow charts, and vital sign assessments, and should initial all documents as evidence that they have been reviewed.

Recommendation 7:
Use of corometric monitors and pulse oximeters, when ordered by doctors or mandated by policy, must be marked on patient's flowsheets and nursing progress notes, including time attached, time removed, settings, and actions taken when alarms sound. In this regard the hospital should formally adopt the Electronic Monitoring Guidelines — see Exhibit 68.

Recommendation 8: <see note 2
Yearly education sessions for all nurses and doctors who care for patients on parenteral opioids should be mandatory. These sessions should cover
a) the mechanism and actions of morphine and other opioids,
b) interactions with other classes of medications, and
c) review of normal and abnormal parameters for vital signs assessment

Recommendation 9:
When an unexplained or unexpected death occurs, all persons who had any responsibility for the patient's care, including relieving nurses, in the previous twelve hours should be removed from patient care until a thorough investigation by the coroner's office or other independent party has been completed.

Recommendation 10:
When an unexplained or unexpected death occurs in a hospital, the coroner's office should designate one coroner — who is not affiliated with the hospital — to be the liaison between the hospital and the family. This responsibility should continue at least until the conclusion of any coroner's investigation or inquest.

Recommendation 11:
In cases of unexplained or unexpected death occurring in a hospital, the coroner should direct that the contents of all recycling and shredding bins at the nursing station be preserved, as well as all documents, audio and videotapes, audit trail records, incident reports, nursing notes, and any other information relating to the patient who died. This direction should be quickly and clearly conveyed to hospital employees by the investigating coroner.

Recommendation 12:
When the family of a deceased patient — whether on its own or through a lawyer — requests detailed information about the circumstances of the child's death, every effort should be undertaken to respond quickly, accurately, and openly. In cases of unexplained or unexpected deaths, a member of the hospital's Medical Ethics committee must be included in any discussion of, meeting with, or written response to the family or to a coroner looking into the child's death.

Recommendation 13: <see note 2
Further studies should be undertaken to examine interactions between morphine and Gabapentin. The results of these studies should be widely disseminated to the medical and hospital communities.

NOTE 2:  Counsel for all parties, including the hospital, reviewed our recommendations prior to presenting them to the jury, and requested several changes.  Since ours were the only ones put forward, we felt it was more important to get them submitted rather than quibble over the wording, and so we agreed to most of the changes.  However, we would like people to know some of our recommendations as originally put forward:

#4:  "and doctors" was added. We do not feel that this recommendation is applicable to doctors; Dr. Schily clearly understood the protocols.  Nurses Doerksen, Soriano, and Douglas did not.  Back to recommendation 4

#6:  We were requested to add the words "and doctors" to the recommendations.  We refused.  The specific point of this recommendation is to ensure that ward nurses who receive patients from emergency read the patient's emergency records — which clearly was not done in Lisa's case.  It was not intended to add additional paperwork and meaningless rules for all parties.Back to recommendation 6

#8:  "and doctors" was added. We do not feel that this recommendation is applicable to doctors; Dr. Schily clearly understood the protocols.  Nurses Doerksen, Soriano, and Douglas did not. Back to recommendation 8

#13  This recommendation was added by the Hospital for Sick Children.  Although we welcome any additional studies on drug interactions, we believe that Lisa first and foremost suffered a known adverse side-effect of a high (but therapeutic) dosage of morphine, which could have been easily reversed.  We do not dispute the possibility that the gabapentin may have affected Lisa, but feel that her system went haywire as a result of respiratory depression, which then caused the other medications she was on to interact in strange ways.  The hospital is using the possibility of "some unknown reaction" as a desperate attempt to relieve themselves of any responsibility for Lisa's death.  They want everyone to believe that she died from some unknown drug reaction, and maybe they made a few human errors along the way, but nothing they did contributed to her death.  The truth is that Lisa had an adverse drug reaction because the hospital gave her a large dose of morphine and failed to monitor her.  Even without any concurrent medications, 14.5mg of morphine in 1 1/4 hours for a 10 year old was a high enough dosage that it alone could have caused a respiratory depression and death.  Lisa died because of negligent nursing care, not because of gabapentin. Back to recommendation 13

1 Parenteral: through any route other than by mouth

2 Potentiate: to augment or increase the potency or action

On behalf of Sharon and Bill I want to thank you

Juror's names omitted

for paying such close attention to the evidence.

Mr. Hawkins will make some points in his closing with which I completely and utterly disagree. The rules are such that I cannot stand up and respond to Mr. Hawkins after he finishes and sits down. When Mr. Hawkins does make these points, you have to respond in your minds as you'd expect me to respond. You must furnish my responses to Mr. Hawkins because I am not allowed to.

It has been an honour to appear before you on behalf of the Shores. Lastly, I also want to briefly address a point Mr. Hawkins made when he was cross-examining Sharon Shore.

Before Lisa died, I had never met Sharon or Bill or Lisa. In March 1999 my brother married Sharon's first cousin. I was asked to get involved in this case by Sharon's father Phil, immediately after Lisa died. I had a few meetings with Phil and the family before Phil had a fatal heart attack in November 1998, about 30 days after his most beloved granddaughter Lisa died. I don't think Sharon and Bill are relatives but I'd love it if they were. They have become my friends and I'm proud to have been their lawyer. They pursued the truth with integrity, great courage and tenacity.

They have been helped by Dr. Cairns and Ms. Browne. They are now turning the story of Lisa's last night on earth over to you. I know that you will not fail them.

On behalf of Sharon and Bill I thank you. If Lisa were here, she would thank you too.


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