Process a ‘whitewash’: Shore
acts of “ omission or commission” that caused Lisa’s death. But the two nurses acknowledged they failed to adequately assess, monitor or provide adequate nursing care to Lisa and failed to adequately document her condition and care. The nurses were suspended by the hospital after the coroner jury’s verdict from March 2000, to November 2003, before being allowed to return to work under close supervision. The nurses will not have to serve the one-month suspension because the disciplinary panel found more time off work was not warranted. They were also reprimanded and the suspension will be recorded in the college’s register.
Shore alleged key information about Lisa’s care was omitted from the agreed statement of facts and called the entire process a “ whitewash.” She vowed to continue her efforts to tell the public her view of what happened at the hospital the night of Oct. 22, 1998. “ There is nothing else after this except for me to stand up and speak the truth in as many places and as loudly as I can, and I intend to do that.” College prosecutor Linda Rothstein told the panel Shore had not been allowed to participate in the hearing on the advice of an independent lawyer. She added Shore had declined to file avictim impact statement when told limits could be placed on it by the college.
Rothstein defended the agreement with the nurses’ lawyers, saying Doerksen and Soriano had acknowledged their misconduct, shown remorse, had not intentionally harmed Lisa, had not been the subject of any other complaints and had voluntarily taken courses to improve themselves.
Outside the hearing, Shore distributed a seven-page statement she said she would have given had she been allowed to address the disciplinary panel.
“ The college is self- regulating, which means it is in charge of policing its own,” she said in the statement. “ To me, this incomplete and inaccurate statement of facts and joint submission on penalty seems more like the college is protecting its own.” Lawyer Marlys Edwardh, who represents Doerksen, said both nurses feel bad that they have not been able to apologize to the Shore family.
“ Mrs. Shore is very angry still,” Edwardh said after the hearing. “ To watch her, even during the course of this submission, she rejects what the college has done, she rejects what the nurses have done in remediation and it is quite clear that she rejects even the ( college’s) description of what happened as non- intentional.
“ You can’t give a meaningful apology to someone who you know will only reject it,” Edwardh continued. “ But do both Ms. Doerksen and Miss Soriano at the very core of their being feel the tragic loss of Lisa — and would they love to say that to the Shores if they would hear it?
“ Yes. But can they hear it? No.” Edwardh said she was “ very pleased with the penalty result. It was the right one. It focused on protection of the public. I think the public should be satisfied that both nurses have gone through remediation and are excellent, competent nurses.”
Margaret Keatings, vice president of professional practice at the Hospital for Sick Children, told reporters yesterday that while the circumstances surrounding Lisa Shore’s death were “ incredibly tragic,” the two nurses had gone through extensive re- education and monitoring.
“ I would have to say that right now I think that they are two of the safest nurses we have working at the Hospital for Sick Children,” Keatings said.
Lisa died after being admitted the previous night with recurrent pain in her leg, a rare condition previously diagnosed as reflexive sympathetic dystrophy, triggered by a broken leg. The coroner’s jury heard testimony from Dr. Markus Schilly that he prescribed morphine on aself- controlled pump for Lisa’s pain, and left specific orders for nurses to monitor her for the potential life- threatening dangers of morphine. The jurors heard conflicting evidence about the use of a corometric monitor, which sounds alarms when breathing and heart rate fail.
Doerksen, who was primarily responsible for Lisa’s care, testified she had the child hooked up to the device, but later disconnected the respiration unit after it sounded repeated false alarms.
Shore, who spent the night in her daughter’s room, testified that she neither saw such a machine, nor heard the alarms. The jury made 35 recommendations, including changes to the hospital’s computerized information system that would cause a warning to be sounded where a nurse failed to access a doctor’s computerized orders.