On January 23, 1986 at 10:22 a.m., 18 year-old Erin Shannon suffered a massive and fatal cardiac arrest during a D&E abortion at the Ottawa Civic Hospital. She was 18 weeks pregnant. The inquest into her death was held in Ottawa on April 14, 15, and 16. Sue Hierlihy was in attendance and the following is her account of the testimony presented at the inquest and an analysis of the Coroner’s Jury recommendations.
A Coroner’s Inquest in Ontario is called to enquire into and determine the answers to the following question: who died, when, where, the cause of death, and by what means the deceased met his or ser death. The answers to these five questions were easily determined within the first three hours of the three-day inquest into the death of Erin Shannon. Who, when and where were obvious; by what means was established as during the course of a therapeutic abortion; the cause of death was shown to be Amniotic Fluid Embolism. A rare complication of abortion and childbirth.
The remaining two and a half days of testimony revolved around the abortion practices of the Ottawa Civic Hospital and attempted to answer the nagging question of how Erin Shannon could already have been on the operating table at the same time the Therapeutic Abortion Committee was supposedly meeting to approve her abortion.
Erin Shannon was first seen by a physician in the Emergency Room of the Queensway-Carleton Hospital in Ottawa on December 3, 1985. she complained of urinary frequency and lower back pain. Although she was 10 weeks pregnant at the time, she was unaware of her condition, and it remained undiagnosed. She was given a prescription for ampicillin for a urinary tract infection and sent home.
Dr. Irving Solway
Erin next saw her own family physician, Dr. Patrick Cross, on January 10, 1986. He immediately diagnosed her condition, and confirmed it with a pregnancy test. Erin had had a history of amenorrhea (irregular menstrual periods), but guessed that her last period had been in September. An ultrasound at the Riverside Hospital on January 13 confirmed her pregnancy at 17 weeks. She returned to Dr. Cross on January 16, at which time they discussed her options. He told her of facilities available to help her, and stressed the lateness of her pregnancy and the dangers of abortion. Over the next several days there were several conversations between Dr. Cross and Erin’s mother. Each time he stressed his opposition to abortion. By January 20, Mrs. Shannon and Erin were adamant – Erin had chosen abortion.
Dr. Cross’ secretary made an appointment for Erin with Dr. Irving Soloway, a man known in Ottawa for doing late term abortions. The appointment was for January 22, and Dr. Cross’ secretary was told (by Soloway’s office) to tell Erin to bring $200 with her to the appointment, as well as a letter from Dr. Cross requesting the abortion for the Therapeutic Abortion committee (TAC) meeting. Dr. Cross refused to supply this letter.
Erin and her mother reached Dr. Soloway’s downtown office at 9:30 a.m. on January 22. After a short interview, Dr. Soloway proceeded to insert eight laminaria tents to dilate Erin’s cervix sufficiently for the surgical portion of the abortion, which he informed her would take place the next day. Laminaria tents are match-like sticks of seaweed which expand, thereby dilating the cervix over a number of hours. Dr. Soloway’s receptionist accepted $120 for the laminaria insertion, a procedure not covered by the Ontario medicare plan. Consent forms and the application for the abortion had been signed earlier. Erin and her mother filled the prescription for tetracycline prescribed by Dr. Soloway and then went to the Ottawa Civic Hospital for blood and urine tests.
Dr. Soloway then wrote an unaddressed and undated letter which stated,
“Re Erin Shannon
This young girl is pregnant and cannot carry on because of psycho social reasons and I therefore strongly recommend a TA for this patient.”
This handwritten letter, written in what can only be described as hieroglyphics, was the basis of the approval by the TAC.
In her testimony, Erin’s mother expressed surprise at the procedures which took place in Dr. Soloway’s office. She stated that she thought that Erin would be examined by the doctor, who would then set a date for the abortion. As things turned out, she couldn’t have been more wrong.
Erin and both of her parents were at the Ottawa Civic Hospital at 7 o’clock the next morning. She had experienced some yellowish fluid discharge the afternoon before, but a phone call to Dr. Soloway’s nurse had confirmed this as normal. She was admitted to the Surgical Day Care Unit when it opened at 8 a.m.
The SDCU pre-op admitting nurse who cared for Erin before her abortion testified that “app’d” (approved) was handwritten beside Erin Shannon’s name when she checked the O.R. sheet between 8 and 8:30 a.m. At 10:05, Erin was taken into the operating room and at 10:22 she went into cardiac arrest, just as the abortion was completed. After various resuscitative measures, she was pronounced dead at 10:53 a.m.
To the best of anyone’s recollection, the regularly-scheduled weekly meeting of the Ottawa Civic Hospital TAC took place at approximately 10 o’clock that morning. And therein lay the source of the problem for the jury: how could Erin Shannon have been in the O.R. at 10:05 and been marked “approved” at 8:30 if the TAC did not meet to discuss her case until 10 o’clock?
Testimony on this point ranged from the ludicrous to the absurd. In the end the standard answer was “I don’t remember.” Successive witnesses dredged up by the Civic Hospital to enlighten the jury succeeded only in contradicting themselves and each other under oath. During cross-examination, several witnesses finally agreed that there “could have been” a “special” meeting of the TAC the afternoon before, on January 22, but no one could remember when (or even where) this meeting would have taken place. When faced with the earlier testimony of Dr. Soloway, that he did not even deliver his letter and the Request for Abortion to the hospital until the evening of January 22, no explanation could be given at all.
However, the fact that the TAC Certificate issued for Erin Shannon is definitely dated January 23 was easily explained. The date of the regularly-scheduled weekly meeting is always inserted on every certificate by the secretary of the TAC, regardless of when the ‘actual’ meeting takes place or when the ‘actual’ approval is given. The fact that this is a legal document (required by the Criminal Code) which should be dated at the same time that it is signed does not seem to matter.
The one person who was not called to testify was the morning nurse who supposedly wrote “app’d” beside Erin Shannon’s name on the O.R. sheet sometime before 8:30 that morning. She was conspicuous by her absence (the reasons for which never came out in court), and the jury and spectators were left to wonder what her testimony would have revealed. As well, Dr. Soloway and others had testified that Erin’s was the fourth or fifth abortion of the morning; no one questioned when the others were approved.
The testimony of the Chairman of the TAC, Dr. Jane Chambers, was indeed revealing. Aside from being unable to recall when she approved Erin Shannon’s abortion, Dr. Chambers was candid in her explanation of the abortion practices of the Ottawa Civic Hospital.
The present members of the TAC are all women: three radiologists and two general practitioners. They were appointed by the Medical Director of the hospital, and not the hospital Board of Directors as specified in the Criminal Code. Weekly meetings are held Thursday mornings at 10 o’clock in the office of the TAC secretary. Meetings take 20 to 30 minutes during which time 30 to 40 applications are routinely approved. In 1985, approximately 2,000 abortions were performed at the Civic Hospital. No applications for abortion were refused.
The form used at the Ottawa Civic Hospital is a single sheet of paper divided into thirds. The top third is the “Application for Abortion” made by the patient. It includes the patient’s name, address and date of birth, date of application, and signature lines for the patient and a witness. ‘LMP’ (last menstrual period) also appears on this part of the form; on Erin Shannon’s form this was blank. The referring doctor is listed as Dr. Cross, in spite of his objections to the abortion.
The middle third is the ‘Certificate of the Therapeutic Abortion Committee.’ It states:
“The Therapeutic Abortion Committee of the Ottawa Civic Hospital has considered the above case on (date) and approved/rejected termination of this pregnancy. The Committee also recommends consideration of: Sterilization, Contraceptive counselling, Psychiatry, Other”
Signature lines are provided for two members of the TAC. The date on Erin Shannon’s form, filled in by the TAC secretary as outlined above, is January 23, 1986.
This simplistic ‘certificate’ would not seem to comply with the Criminal Code requirement that the TAC “…has by certificate in writing stated that in its opinion the continuation of the pregnancy of such female person would or would not be likely to endanger her life or health…” (Section 251(4) (c). The TAC is also required to provide a copy of the certificate to the doctor performing the abortion (Section 251(4) (d). This is not done at the Ottawa Civic Hospital.
The bottom third of the form is ‘For Medical Records Only’. It includes the date of the procedure (in this case blank), type of abortion (here checked as D&C and Suction although the procedure actually used was D&E), post-operative complications (remarkably blank), age and marital status of the patient, gestational age (18 weeks) and ‘reason’ listed as ‘Psych.’, ‘Social’, Economic.’ And ‘Med.’ In Erin Shannon’s case the first three ‘reasons’ were checked off.
This one piece of paper and Dr. Soloway’s undated, unaddressed, handwritten, one-sentence letter contained all of the information provided to the TAC considering Erin Shannon’s case.
Dr. Chambers testifies that it was the practice of the Civic TAC to approve abortion applications simply on the recommendation of the doctor performing the operation. It is not the place of the Committee to question the applications, according to Dr. Chambers. All abortions up to 20 weeks of pregnancy are approved for ‘psycho social’ reasons; if a woman has seen a doctor, her desire for an abortion qualifies, because refusal “could be bad for her health.” After 20 weeks of pregnancy ‘medial’ reasons are considered (for example, an ‘abnormal’ fetus). She estimated the number of abortions performed at the Civic between 16 to 20 weeks of pregnancy to be 5 percent, or 100 per year.
The coroner gave up
Dr. Chambers was at a loss to explain when this particular abortion certificate was signed, despite the fact that her signature was on it. She simply reiterated that it must have been before Erin entered the O.R. because that is the way the system works. The other doctor who signed the certificate was not called to testify, nor was the third member of the Committee present sat the ‘meeting,’ whenever and wherever it took place. The question was never resolved, as the lawyers and the coroner gave up in utter frustration.
Dr. Soloway’s testimony was gruesome but enlightening. For many years he has had a reputation as Ottawa’s premier abortionist. By his own estimation, he performs 500 abortions per year, and specialized in late term procedures.
Dr. Soloway was frank in his assertion that the insertion of the laminaria tents was part of the abortion; in fact he would not have performed the procedure without them. He detailed the necessity to dilate the cervix as much as possible due to the “relatively big” size of the fetus at 18 weeks. He went on to describe the “crushing instruments” with “big jaws and teeth” used to “break up the fetus and take it out bit by bit.”
He expounded on the merits of the D&E procedure, explaining that, although it is not an easy operation, he has perfected his technique over the years. Asked why he performs so many late term abortions, he stressed his own expertise in the procedure, combined with reluctance on the part of other abortionists to perform abortions when the fetus is so big. In his opinion, other doctors do not like looking at the results.
The expert witness called by the Coroner was Dr. Paul McKenzie, an abortionist from the Kingston General Hospital. He outlined the workings of the TAC at his hospital, which are similar to those of the Civic with three major exceptions. Although the definition of ‘psycho-social reasons’ is the same in both hospitals, counselling services are made available to the patient through the Kingston hospital. The TAC at the Kingston General does not actually ‘meet,’ but the signatures are obtained by taking the applications around to the various doctors once a week. The original copy of the certificate is then attached to the patient’s pre-op chart. Dr. McKenzie stated that the Kingston General Hospital performed up to 650 abortions in 1985 and did not refuse any requests.
In the area of counselling, it is interesting to note that with the exception of Dr. Cross, each person involved in the care of Erin Shannon felt that it was someone else’s responsibility to counsel her. The nurses in the SFCU do not initiate any discussion or counselling procedures.
The TAC obviously thinks the surgeon has counseled the patient, as Mrs. Shannon found out too late. Dr. Soloway felt that counselling was not his role as Erin would not have come to him for the abortion if she did not want one.
As anyone who has ever been near a hospital knows, even a short hospital stay involves more forms and notes than an RCMP security check. There are countless admission forms, consent forms, nursing notes, O.R. sheets, test results, physician’s records, case histories, etc. The Civic Hospital provided in evidence no less than 22 pieces of paper with Erin Shannon’s name on them, recording what should have been a four-or-five-hour hospital stay.
There is a good and valid reason for this. When dealing with patients’ lives, each person involved wants to legally ensure that their actions are recorded, and rightly so. It is curious, therefore, to note that regarding abortion, the one operation routinely performed at the Civic Hospital that is subject to Criminal Code provisions, there is no safety mechanism by which nurses and doctors can ensure that they are not participating in an illegal abortion. No one sees the signed Certificate except the TAC members, their secretary, and eventually a medical records clerk. The handwritten notation “app’d,” assed to the O.R. list at the admitting desk after a phone call from the TAC secretary is the only proof medical staff have of the approval. Unless they check this copy of the O.R. sheet themselves, which the anesthetists and O.R. nurses do not routinely do, they simply assume that if the patient is in the O.R. her abortion has been approved. That’s a good degree of trust, even among professionals, when the penalty for being wrong could be life imprisonment.
In addition to answering the five questions previously mentioned, a Coroner’s Jury in Ontario may make recommendations respecting any matter arising out of the inquest. However, they are not allowed to make or infer any findings of criminal or legal responsibility. Any recommendations of the jury are forwarded to the appropriate officials, however they are simply recommendations and have no force of law.
Illegal five ways
In this case the jury’s recommendations (see box above) centered around the cause of death, Amniotic Fluid Embolism, and tightening the Criminal Code to ensure proper operation of Therapeutic Abortion Committees according to the spirit as well as the letter of the law.
There are five different ways in which Erin Shannon’s abortion might be found to be illegal. First and foremost, the abortion was admittedly begun 24 hours prior to Erin’s appearance in the operating room. The insertion of the laminaria, described by Soloway as the first step in the two-step D&E procedure, took place in his office before he even wrote to the Therapeutic Abortion Committee. There is no known medical use of laminaria at 18 weeks of pregnancy except in connection with abortion. Secondly, the TAC Chairman could not prove that the abortion certificate was signed before the surgical portion of the abortion took place. Thirdly, the TAC itself is improperly appointed according to the provisions of the Criminal Code.
Further, the TAC certificate does not say anything about the continuation of the pregnancy being a danger to anyone’s health.
Lastly a copy of it was not provided to any qualified medical practitioner let alone the one performing the abortion.
Despite the obvious breaches of Section 251 of the Criminal Code, the Ottawa Police ad the local Crown Attorney are not intending to lay criminal charges against anyone involved in this case. The current wisdom seems to be that no jury will convict a gaggle of ‘reputable physicians’ on a bunch of ‘technicalities.’ So much for the Abortion Law. So much for Justice.