Criminal-negligence charges against two Toronto nurses in the death of 10-year-old Lisa Shore collapsed yesterday amid tears, applause and allegations of inadequate police work and tampered-with evidence.
A courtroom packed with 70 nurses and members of their families erupted in joy after the Crown conceded that the evidence against nurses Ruth Doerksen and Anagaile Soriano had eroded beyond repair.
Prosecutor Hank Goody said that some Crown witnesses jolted his case with unexpected testimony, while new information arose to tarnish the credibility of others.
Ontario Court Judge Ramez Khawly praised Mr. Goody for his fairness and said the case epitomizes how justice can go awry when the need to make a sound criminal case is overcome by a rush to assign blame.
The dramatic announcement ended just short of the halfway point in a preliminary inquiry that had been scheduled to run for 10 weeks.
Lisa was found dead in her bed at the Hospital for Sick Children on Oct. 22, 1998. She had been on morphine all night to lessen the pain of a non-fatal condition affecting her leg - reflex sympathetic dystrophy. In 2001, an inquest jury delivered a verdict of "homicide," and Toronto Police arrested the two overnight nurses.
Although both women were visibly relieved yesterday, they expressed bitterness toward the police and news-media outlets that gave a megaphone to those demanding criminal charges.
"We've been angry for a long time," said Ms. Doerksen, who said she may never return to nursing. "We were not asked any questions from the very beginning - right up to this day."
Ms. Doerksen said the criminal charges compounded the continuing trauma of wondering whether she could have done something to save Lisa's life.
Ms. Soriano, 25, said it still amazes her that just four months after entering nursing, Lisa's death and its aftermath changed her life forever. "I'm going to be very anxious going back," she said. "What am I supposed to do? Am I going to be paranoid? Overcautious?"
Judge Khawley reflected yesterday that when a child's life is cut short, "the determination to affix blame can unleash forces that become difficult to control."
He likened the case to two locomotives hurtling toward one another on the same track - one representing vengeance and the other justice - until they collide.
The Crown was left to sift through the wreckage, including "documents withheld and tampered with," Judge Khawly said. "I can say this with truth: There are no winners in this."
Defence lawyers Marlys Edwardh and Elizabeth McIntyre cited several examples of the sort of evidence that sank the prosecution: •Police at one point said an assessment of Lisa's condition made at a Boston hospital bore no relevance to the case against the nurses. But when the defence obtained the assessment, it was relevant; •A doctor who was phoned at home by Ms. Soriano shortly before Lisa died unexpectedly took responsibility in his testimony for erring in the morphine dosage he had approved; •An expert report that could have cleared up allegations that the nurses had tampered with a "flow sheet" on Lisa's treatment was suppressed. •The seemingly damning allegation at the inquest that the nurses had not read computerized treatment instructions turned out to be a relatively innocent act.
It was the third time in two decades that charges against nurses have collapsed at the preliminary-hearing stage. The others involved nurses Susan Nelles and Gita Proudman.
Ms. Edwardh and Ms. McIntyre criticized authorities for persistently scapegoating nurses. "How many times do we have to do this?" Ms. McIntyre asked. "It's the blame game. The media pick up on the perception that somebody must be blamed.
"It's all too easy to blame the nurses," she said. "This is a real problem for the nursing profession. What has happened as a result of these cases is that nurses are terrified that when something goes wrong, they are going to be subjected to these kinda of criminal proceedings. Things do happen in hospitals. We do have deaths in hospitals."
Several of those caught up in the case cited Lisa's mother - Sharon Shore - and her lawyer as a major force behind the criminal charges.
Ms. Edwardh said the two nurses were placed under a magnifying glass at the inquest, yet doctors escaped with much less scrutiny and some hospital protocols went unexamined.
She said the nurses relied on hospital lawyers to represent their interests. When the inquest proceeding morphed into an exercise in blame-laying, Ms. Edwardh said, the nurses felt defenceless.
"The inquest was hijacked by private interests," Ms. McIntyre added. "An inquest is not supposed to be a finding of liability, but this case was translated into a homicide investigation."
The lawyers blasted the Toronto Police for laying charges prematurely instead of conducting an additional investigation, leaving two conscientious nurses vulnerable to imprisonment and ruined careers.
"In our view, that was very, very wrong," Ms. Edwardh said. "When you walk into a hospital, it's not like you are going down to the tavern. It is a very complex world. An inquest cannot be a substitute for a criminal investigation."
Said Ms. McIntyre: "If they had taken 10 steps back and looked at the totality of the case, it becomes crystal clear that there is nothing close to criminal liability."
Police and prosecutors in the case declined to be interviewed yesterday.