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The College of Nurses of Ontario, as one of its little information brochures sternly announces, enforces "a strict no-scent policy" within its central Toronto head office, with the result that visitors are advised to refrain from wearing perfume or aftershave.

Curious that, because there was something decidedly off about the odour emanating from the proceedings that unfolded there yesterday.

The occasion was the disciplinary hearing of two registered nurses, Ruth Doerksen and Anagaile Soriano, respectively the former charge nurse and a rookie on duty on the ward where, almost seven years ago, a little girl named Lisa Shore died unexpectedly at the Hospital for Sick Children.

When all was said and done,

Ms. Doerksen and Ms. Soriano, now 45 and 29 respectively, each pleaded guilty to a single count of professional misconduct for failing to properly assess and monitor the sunny 10-year-old child who was their patient.

It was a plea bargain, both as defensible and as baldly coarse, as any other.

The two nurses admitted their guilt on the one count, the college dropped other charges against them and joined in asking the five-member disciplinary panel to assign each a sentence of a month's suspension -- which itself was promptly suspended.

Taken in isolation and on its face, it was arguably reasonable.

The nurses, after all, had endured what Ms. Soriano's lawyer, Liz McIntyre, called a form of "triple jeopardy" in that their conduct was examined at length in a coroner's inquest, the subject of criminal charges (withdrawn after the prosecutor's case collapsed during the preliminary hearing) and ultimately saw the two women suspended (albeit with pay) for 43 months by the hospital.

In essence, Ms. McIntyre and Marlys Edwardh, Ms. Doerksen's lawyer, argued that their clients had suffered enough, and although college prosecutor Linda Rothstein didn't buy in for that reason, she said that since protection of the public is the point of any penalty, and since the nurses have gone through probably more retraining and monitoring than the college would have imposed in any case, it was the right decision.

There was a modicum of blunt talk in that room, most of it coming from Ms. Rothstein, who most recently so distinguished herself at the long-running Toronto computer-leasing inquiry.

"Ruth Doerksen and Anagaile Soriano failed to do enough to adequately assess Lisa Shore," Ms. Rothstein said, "and failed to get her the help she needed" when there were "warning signs she was experiencing respiratory depression. The message for the profession," she said, "is, 'If in doubt, get help.' "

It was also left to Ms. Rothstein to speak a difficult truth: "It is not appropriate to penalize harshly because the consequences are heartbreaking."

Certainly, the modern view is that, as with airline pilots and other professionals for whom perfectly human mistakes may see horrendous results, the better course is to create an atmosphere where what Ms. McIntyre called "the blame and shame game" yields to an environment where all can admit their failures and then set about learning from them such that they won't happen again.

That atmosphere didn't exist on Oct. 22, 1998, when Lisa died, and it didn't exist at the coroner's inquest, where, by most accounts, the hospital was in a state of high denial and presented as hopelessly disorganized or deliberately obfuscating the nature of what had happened.

It is worth noting that despite the plethora of proceedings, the only group of people who have ever heard Ms. Doerksen and Ms. Soriano and all the others testify about the night Lisa died were the inquest jurors. They heard the little girl's mother, Sharon, who was in her daughter's room all that awful night, contradict what the two nurses said -- most critically about a monitor that could have saved Lisa's life.

Mrs. Shore said Lisa was never hooked up to this monitor, which issues loud alarms if either breathing or heart rates drop below a certain level. The nurses said Lisa was, but that Ms. Doerksen had turned off the respiratory warning because it was repeatedly sounding false alarms.

Yet the heart-rate alarm, which can't be turned off, failed to sound when Lisa died.

All that the disciplinary panel heard on this issue yesterday was that Ms. Doerksen failed to make sure the monitor was properly set and working.

Similarly, lurking in the background to the care Lisa got, or didn't, on the last night of her life was that she had been to the hospital before. She had broken her right leg in a playground accident earlier that year, but the searing pain she suffered afterwards was the subject of disagreement, with some doctors pronouncing it the result of nerve damage called reflex sympathetic dystrophy, and one Boston physician suggesting it was psychological in origin, and others perhaps suspicious.

It shouldn't have mattered a whit: The child was in pain, but it was hardly a life-threatening condition.

Yet this is something with which many Canadians who have logged time in hospital wards watching over vulnerable loved ones can identify, and will know instinctively may be true.

Patients do acquire reputations, good or bad, among staff and so do the kin who do battle on their behalf. Any advocate who has crossed this line, and becomes known as a pain in the butt, will be familiar with the difficulty that may follow, from getting the attention of a nurse to the speed with which granny's diaper is changed.

The only reference in the agreed statement of facts given to the committee yesterday is that neither nurse had any prior contact with or information about Lisa Shore -- which is accurate enough perhaps, but doesn't preclude the reputation business.

Thus, Mrs. Shore yesterday described as "antiseptic" not only the agreed statement of facts, but the proceeding itself.

She had hoped to address the committee, but could do so only in the form of a "victim-impact statement" in which she would be forbidden to criticize the nurses. As Ms. Rothstein said, "She did not feel she could honestly, fully and fairly express her views within those parameters."

In the result, Mrs. Shore, who is now articling with a Toronto law firm, a career switch inspired by what she saw of the system after Lisa's death, sat quietly in the hearing room yesterday with her husband, Bill, her mom and her sister.

They got to hear all about the nurses' trauma these past years, and listen to Ms. McIntyre as she told the panel that the fact Lisa died "is not a circumstance that is relevant to you in the consideration of penalty today," and to Ms. Edwardh when she said, "No one knows better than Ms. Doerksen and Ms. Soriano what the cost of this incident has been."

Mrs. Shore, enormous eyes shiny with tears, could have argued that one into the ground before she ever studied a word of the law.

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