Eleventh Christmas Without You, 2017

So many just don’t comprehend!
Those who do have experienced the same!

When your parents die, you have lost your past.
Memories of your youth are what you hold on to.

When your child passes, you have lost your future.
Memories, yes, but what was yet to come has expired too!

So at present, I merely exist.

Christmas’ are to be better than the first,
Instead each one is followed by the worst!

Four were the members of our family,
Now in solitude we remain at three.

At this time of year, I am so unhappy; that’s my life!
Love you, Terra.
Love you Brandy,
Love you Paulette.

Institutional Betrayal== Breach of Trust

















THE HOSPITAL --under jurisdiction of Liberal Minister of Health

THE CHIEF CORONER'S OFFICE--appointed by Liberal majority government and --under jurisdiction of Liberal Minister of Corrections and is a member of the CPSO and CMPA!

From: Dirk.Huyer@ontario.ca
To: awkilby@hotmail.com
CC: Julia.Noonan@ontario.ca
Subject: Terra Dawn Kilby
Date: Sat, 28 Jun 2014 16:33:44 +0000

Dear Mr. Kilby,

Thank you very much for coming to see Ms. Noonan and me on June 26. While we may not agree on some things, I do believe it was a positive meeting in that both of us had an opportunity to discuss the death investigation and many other issues leading up to the death of your daughter. Please extend my appreciation to your family members who attended as well -- their questions and perspectives positively added to our discussion.

Regarding the e-mails that you sent following our meeting, I am not going to revisit what we already discussed around sarcasm, personal addresses etc. You and I provided our views on that and I respectfully am putting that in the past.

Moving forward, as I told you, I will not be engaging in further dialogue about the death investigation of your daughter, her medical treatment or the decision not to hold an inquest.

At this time, I will address your point about "necrosis of tissue surrounding the resection that broke down" as it is an issue I did not focus upon in our meeting. I am of the opinion that the tissue necrosis arose as a complication of the surgical procedure, specifically the staple line. Based upon the information available the exact physiologic process that caused the tissue necrosis to occur cannot be determined. There was no evidence in the post mortem examination report to indicate that an acute infective process was directly involved.

Again, I am pleased to have met you and your family in person and appreciate the time and effort you have dedicated in finding more answers regarding the tragic death of your daughter. I understand that our meeting may not have provided the result you hoped for but I do think it was an open, candid conversation.

Take care,

Dirk Huyer

Dirk Huyer MD

Chief Coroner for Ontario

Forensic Services and Coroner’s Complex
25 Morton Shulman Avenue,

Toronto, Ontario,

M3M 0B1




With respect to Based upon the information available the exact physiologic process that caused the tissue necrosis to occur cannot be determined. There was no evidence in the post mortem examination report to indicate that an acute infective process was directly involved.”

“…appreciate the time and effort you have dedicated in finding more answers regarding the tragic death of your daughter.”

This is because of an inept death investigation and not wanting to dig deeper to explain the above! Why should I be finding the answers?

I think Dr. Huyer's own words supports my assertion of a faulty, biased death investigation.

THE DEATH INVESTIGATIVE OVERSIGHT COUNCIL--appointed by Liberal majority government and --under jurisdiction of Liberal Minister of Corrections --has Chief Coroner or Deputy sitting on this council!


THE HEALTH PROFESSIONS APPEAL AND REVIEW BOARD--appointed by Liberal majority government --under jurisdiction of Liberal Minister of Health

THE ONTARIO OMBUDSMAN--appointed by Liberal majority government

THE ONTARIO PATIENT OMBUDSMAN--appointed by Liberal majority government

THE ONTARIO PROVINCIAL POLICE--under jurisdiction of Liberal Minister of Corrections

THE INDEPENDENT POLICE REVIEW DIRECTOR--appointed by Liberal majority government and --under jurisdiction of Liberal Minister of Corrections

THE LIBERAL MINISTER OF HEALTH and is a member of the CPSO and CMPA!






Without a doubt; a Conspiracy exists,
Self-protecting Officials; such hypocrites!

If you were a MPP’s daughter; it would cause a fit,
Because you’re mine; they don’t give a shit!

For years we have yearned for justice,
The lack of moral integrity merely disgusts us!

Government institutions that won’t expose,
The Medical negligence concealed by those!

Medical Immunity granted; regardless of guilt,
Preserving Ontario Health Care’s patchwork quilt!

So many individuals paid through our taxes,
Failing us all; what a bunch of asses:

--with regard to Terra Dawn Kilby Those who should be held accountable by the newly elected Conservative government in 2018

Premier of Ontario --Premier Wynne, Premier McGuinty,

Ontario Minsters of Health --Dr. E. Hoskins, D. Matthews, Rick Bartolucci

Ontario Ministers of Corrections --Yasir Naqvi, Madeleine Meilleur

Ontario Members of Provincial Parliament --majority of them from 2006 to the present

Defeat the above who in are still present in the next election 2018

CPSO -- Angela Bates Manager Committee Support Area Investigations and Resolutions--then Director, Regulatory Affairs at Retirement Homes Regulatory Authority no longer there and presently founded her own company SIGNAL REGULATORY SOLUTIONS angela.bates@signalregulatory.com , Sandra Keough Investigator

HPARB --Chair Janice Vauthier--should be replaced and not be appointed to any Ontario government position, Past Chair Linda Lamoureux---now Executive Chair of Safety, Licensing Appeals and Standard Tribunals of Ontario,--should be replaced and not be appointed to any Ontario government position, Lori Coleman Registrar--should be replaced and not be appointed to any Ontario government position, Anna Dunscombe--should be replaced and not be appointed to any Ontario government position

Third Appeal Chair Tom Kelly, Members Stephen Jovanoviorc and Brenda Petryna--these three should never be allowed to serve on any Ontario appeal/review board

Ontario Ombudsman --Paul Dube Ombudsman--should be replaced and not be appointed to any Ontario government position, A Marin-Ombudsman, Investigator Lorraine Boucher- Investigator--should be replaced and not be appointed to any Ontario government position, Fran Cappe-Investigator,

Humber River Hospital --CEO B. Collins--now CEO of the hospital--should be replaced and not be appointed to any Ontario government position, past CEO Rueben Devlin,

Ontario Chief Coroner’s Office --Dr. D. Huyer,--should be replaced and not be appointed to any Ontario government position Dr. A. McCallum--now head of Onge,--should be replaced and not be appointed to any Ontario government position '

Dr. A. Lauwer--now CEO of Ross Memorial Hospital in Lindsay, Ont--should be replaced and not be appointed to any Ontario government position

DIOC --Joseph C.M. James (Chair), Emily Musing (Vice-Chair), John Pearson (Vice-Chair), William (Bill) McLean, David Williams, Dorothy Cynthia (Cindy) Prince, Denise St-Jean, Fiona Smaill, Lidia Narozniak, Lori Marshall, Lucille Perreault, William (Bill) J Shearing, Michael Pollanen, Fiona Foster Manager of DIOC

--All should be replaced and not be appointed to any Ontario government position

Ontario Patient Ombudsman --Christine Elliott, Investigator Marie Claire Muamba --authority and mandate should be expanded especially in light of the Ontario Ombudsman, P Dube's inaction

Ontario Provincial Police --Commissioner J.V.N. (Vince) Hawkes,

Inspector Bradley McCallum--should be investigated with regard to inadequate handling of my submission for Breach of Trust complaint vs Chief Coroners past and present and he should be replaced

OIPRD -- Director Gerry McNeilly

Terra Dawn Kilby
"An Angel In Our Lives"
April 22/78 to July 21/06





Mr Shanoff who wrote the two articles in the Sunday Toronto Sun sent me this from a woman who contacted him. --a very knowledgeable nurse

"I read with interest your article in the Sunday Sun October 13, 2013. titled “Why did woman die after routine surgery?”. I applaud you for bringing the circumstances surrounding this case to public attention. I feel it is a pity that innocent people must bare their hearts and their private lives in such a public fashion to get the attention they deserve and also to expose the injustice that permeated their lives.

As a former ICU nurse, who spent most of my nursing years in large academic teaching hospitals, I could say the reason for the woman’s death is a no brainer! However, not having seen the hospital records, I speak cautiously.

Several indicators from nursing records points to a “foul odour” and “purulent discharge” Both of these observations strongly point to an underlying infective process going on beneath the skin surface. Purulent discharge, as observed in this case, means the pus from the infection is significant enough in quantity that it is draining out wherever it can, which, after surgery, is usually through the operative incision. This is one of the VERY basic and elementary observations after any surgery. AND the procedure once the discharge has been observed, is to “swab” (do a culture of) the discharge, so that microbiology can determine the type of bacteria responsible. The microbiology / bacterial report then identifies which antibiotics would be best used to combat the infective process, so that appropriate antibiotics can then be ordered by the physician/surgeon. “Cultures” used to take a few days to process, but currently, preliminary results can be obtained the same day. Even without microbiology testing, surgeons have been educated to know what types of bacteria are most prevalent in certain situations.

I see no mention at all that the woman was started on antibiotics either on the 15th of July, the day the nursing records indicated the purulent drainage was first observed. or, at any point in time prior to the woman’s discharge. If this is the case would negligence be a good word to use here? It is a standard of Nursing Practice, to report such findings as “discharge” immediately to the Surgeon and obtain an order for antibiotics. If the hospital utilized the “Pathways” model of post-op care, then there should have been “standing orders” in place to give direction. Regardless, there is absolutely no excuse for antibiotics not being ordered immediately when discharge was first observed.

It would seem to me that having had this discharge for 5 days…. at least for 5 days that it was observable…… where was the surgeon doing his post-operative checks on his patients? It is also a well know fact that abdominal infections are a dangerous game to play. It is also well known that by the time the infective process is observable on the surface of the skin at the incision, there is much more going on “inside”, beneath the skin surface. You are only seeing what is “overflowing”, so to speak.

Some surgical procedures are best handled with antibiotics given prophilactically prior to surgery, especially when the risk of infection is high (such as is the case with certain abdominal surgeries). Optimal post operative care and surgical ouycome is sometimes contingent on good pre-operative care. For both agencies, the CPS and the HPARB to give minimal attention to the fact that antiobiotics were NOT given, is totally inexcusable.. It is almost like they are denying the contribution this makes to the post-operative infective process…..like they are excusing themselves from antibiotics having any responsibility or role in the woman’s health… or lack of it. Malpractice? Whatever it is, this is inexcusable, both for the two review boards and for the surgeon..

Further to the infective process ongoing in this woman’s abdomen, the infection sometimes does NOT stop here. It is also a basic concept in medicine and very elementary, that infective processes, when untreated or not affectively treated, can evolve into septicemia (infection in the blood) and septic shock (where your body starts to shut down from the infection) ….. and death. This is the NO BRAINER ! This is where I fail to see how both agencies, the College and the Review Board, don’t seem to be paying any attention, whatsoever, to rudimentary medicine !!

I am also dismayed at the length of time it took for this surgeon to complete the Hospital Discharge Summary and I also assume that the operative records are included in this five month delay. Every hospital has policies governing the length of time physicians have to complete paperwork before hospital privileges are revoked…. Which means that doc cannot practice in that hospital. Health Record Departments are very diligent in constantly reminding the offenders of unfinished paperwork and of consequential impending suspensions. Five months is a long time. Was this period of time within the framework of that hospital’s policy…. Or was his privileges suspended which prompted him to complete the operative records and then have his privileges re-instated? My biggest concern with incomplete or absence of prompt record keeping is that the margin of error increases exponentially as time passes.

I am also troubled by the reactions of the College and the Review Board. The shrugging -off of responsibility back and forth speaks to me of not wanting to address this issue and get to the bottom and be forthcoming with answers.,,,, or not wanting to give answers. Often in cases where there is compelling evidence of mismanagement and allegations of mismanagement, this behavior by The College is repeated. Is this a “big name” or prominent surgeon that is involved in this case, and both agencies are trying to minimize the impact on his career and reputation? Who is covering for who here? Having worked in the system for 46 years, I feel confident in saying that this is not an uncommon practice amongst physicians and also not an uncommon practice by the College. If you look at other “worst scenario” cases where there have been complaints or questions asked of the College, how many times have complaints been dismissed when the evidence is pretty compelling? The “Old Boys Network” is still alive and kicking even in this era of supposed accountability.

I also question the reason Humber River Regional Hospital would “create a memorial garden with a plaque in Terra’s name”. This is again not the “normal” or usual practice after a patient dies expectedly or unexpectedly, whether inside its doors or without. What does the hospital know that they are not telling….. or even worse, not admitting to
. A friend of mine received a card and gift basket after being hit in an accident. Legally, this is an admission of guilt. Are we seeing the same admission of guilt here? Is this the hospital’s way of offering an “olive branch” to cloud the truth. I believe there is more to this than meets the eye.

I have many opinions about the Legal system in this great land of ours, but this may be the only way this poor father is going to get any answers to his questions. Docs are terrified of legal action, but it usually gets their attention. What is needed is a careful and shrewd lawyer who is knowledgeable in medical practice; that is, has available the academic knowledge with acceptable and competent medical practices required for this case, Armed with knowledge, should he delve into available information on this woman’s case, I am assured the answer should come pretty quickly.


No, the father has a very valid and heartfelt point of view when it comes to finding answers to his daughter’s death. Money does not bring your child back, and this reflects my own thoughts after I lost my son tragically at the same age. To lose a child, no matter the cause, is very painful, and for many years to come. The pain is magnified many times over, when negligence and stupidity is at the root of the cause of death. I admire his persistence and his thinking. However, in spite of our best hopes and well intended thinking, legal action may be the only way to eventually find the answer he seeks. My heart goes out to this father. I truly hope that some of the things I have said, will be of help in finding his answers; and maybe some day bring relief and comfort to his heavy heart."


--Look on right side under "Blog Archive" (oldest to newest)


College of Physicians and Surgeons - Stories of Failure

What is especially interesting in this recent Star (last week Feb/2016)article is the following:

“We are not a public organization. . . Our accountability is to our members,” said the College’s executive director, Dr. Francine Lemire" CPSO


We already know the CPSO is corrupt and HPARB from the article where it stated "it looks like HPARB just threw up their hands and said we give up"



But for the Ombudsman's Office to swallow such garbage leaves the citizens of Ontario with no where to go.


Terra Dawn Kilby --- A Father's Memories
An Angel In Our Lives, Terra Dawn Kilby November 2014

A tribute to the life of my daughter who died due to the negligence of a surgeon at Humber River Regional Hospital, Toronto, Ontario, Canada. Covered up by Humber River Regional Hospital, the CPSO, HPARB, Chief Coroner's Office of Ontario, the DIOC, Ontario's Ombudsman and the entire Provincial Liberal Party!

TERRA DAWN KILBY April 22, 1978 - July 21, 2006. College’s Decision “The routine use of antibiotics prior to bowel surgery is an important aspect of care that was NEGLECTED by Dr. Klein in this case.”…




HPARB's Decisions Kilby vs Laz Klein.
First Decision:
Second Decision:

Third Decision:

The Letter I Sent to the Chief Coroner's Office Outlining My Numerous Concerns
Coroner's Comments.doc

Death Investigative Oversight Council's Decision

2 years after my initial request and after both Chief Coroner and Deputy Chief Coroner left the OCC.
DIOC Decision Aug 2013.doc
The Chief Coroner's Office, the College of Physicians and Surgeons of Ontario, the Health Professions Appeal and Review Board, the Death Investigative Oversight Council, the Liberal government and Ms Deb Matthews and Premier Wynne apparently agree that it is perfectly within the accepted Standard of Care to:
--have open abdominal surgery without the mandatory antibiotic prophylaxis

--having not had the above, accepted that there was no need for antibiotics when the abdominal incision was oozing purulent liquid and was so infected that all staples were removed

--when test results showed "many gram negative bacilli", still it was quite acceptable to provide no antibiotics

And the College/HPARB totally ignored Dr. Andrew McCallum's letter to the College when he was Eastern Ontario Coroner. In it he states that infection was a contributing factor in Terra's death.
One must also wonder how on earth the Chief Coroner's death investigation failed to note the lack of antibiotics plus other issues contained within the hospital records and yet I have numerous pieces of correspondence from both Dr. Lauwers and Dr. McCallum stating they saw no issues with respect to the Standard of Care???

THE OMBUDSMAN'S OFFICE has allowed the College and HPARB to establish the above as precedence for future complaints/appeals made to both of them.





Gan Reporter to appeared July 21, 2015
Terra Dawn Kilby
“An Angel In Our Lives”
April 22, 1978 – July 21, 2006

Tears still appear when we think of you.
Visits to your grave site we often do.
Loving memories convey serenity too!

Our precious daughter, Terra Dawn;
It’s been nine years since you’ve been gone.
Within our hearts you still belong!

July Twenty-first is a time of sorrow.
Additional years, I wish we could borrow.
Maybe then, we’d not feel hollow!

Today, messages guided to heaven above.
Channeled to you on the wings of a dove.
Expressing our heartfelt, everlasting love!


Wednesday, 29 June 2011

No Accountability or Transparency in Ontario--Dr. Laz Klein/Dr. Bert Lauwers/Dr. Andrew McCallum/

"Defamation is comprised of two subcategories between libel (libel refers to written defamatory statements)and slander(broadcasting of spoken defamatory words)

Proving a Claim in Libel and/or Slander
"the statement must be false!"

Defences to Actions in Libel and Slander
"The first defence is the defence of truth. The defence can be made that the statement was truthful and therefore there was nothing false about the statement, meaning therefore, that the statement was not defamatory."


"The second defence to an allegation of libelous statement is that the statements made were made as a fair comment. The defence of fair comment would be considered by the Court in situations where, by looking at the statement made, the facts and the situation, a conclusion can be made that the statements made were in actuality a fair commentary on the situation at hand and that the comments were fair and were not malicious."

"The defence of qualified privilege arises normally in situations where the individual publishing these statements will escape any liability if it can be proven that the public good could be furthered in open debate. 

It is obvious that the Coroner's Office did not want negligence perhaps incompetence shown, which would involve a fellow member of the medical profession and certainly the standards were not met.

My 28 year old daughter is dead!!!!!!!!!  And no one within Ontario will supply me with answers to my very serious concerns; not even those people who supposedly investigated!!!!

During the year 2009 to Feb 2010 ---- six deaths at this same hospital involving the same department with very similar situations-- bled to death.    This year a patient went in for a hysterectomy---was in her hospital room ---- started bleeding ---- bled to death before they could get to OR.----    Also, apparently an expert from a medical university was called in to assess the procedures within the operating room involving this same department team.    My daughter  bled to death 12 hours after being released from Humber River Regional Hospital.

Just think, if the Chief Coroner's Office had of granted a public inquest, or a regional coroner's review or have The Patient Safety Death Panel look into this matter it would have indeed saved lives.

Please help me find some justice for the death of my 28 year old daughter.
Please feel free to forward this to any of your friends who may wish to help, as well.
IN MEMORY OF TERRA DAWN KILBY --Trying to bring Transparency and Accountability Within Ontario's Health Care Institutions.

--See Face Book groups "Missing Terra Dawn", "Ontario Chief Coroner's Lies, Deceit and Immoral" and "Ontario Needs a Health Ombudsman" for more relevant information.

I have issued a complaint against the Chief Coroner's Office of Ontario with respect to their investigation into Terra's death. Terra bled to death 12 hours after being released from hospital July21, 2006. I have been trying for five years to merely bring out the truth. No malpractice suit, I don't want money. I want changes.
They denied my request for a public inquest, denied my request in having Terra's death looked into by the Patient Safety Death Panel and denied my request for an Eastern Ontario Coroner's review.

All of their decisions were based on their own independent, unnamed expert whose report ignored completely many medical concerns contained within Terra's hospital records.

What are they trying to keep hidden?? Are they afraid that others will question perhaps their own loved one's death and the coroner's investigation, thus opening up a floodgate of more complaints against the Chief Coroner's Office of Ontario?

What I sent to the Death Investigative Council was more than 75 pages.

Now, we will see how this new council judges my complaint if I ever get a response from them.

What I have learned since Terra's death:

1. The Chief Coroners Office of Ontario have never granted an inquest into a death that may implicate the care or lack thereof by a surgeon or hospital. This office is fully funded by Ontario's taxes. The Chief Coroner's final opinion for public inquests can not be overturn! Dr Lauwer's makes over $300,000 dollars per year with approximately 4- 6 weeks paid holidays. Dr. McCallum, our Chief Coroner makes over $400,000 with the same number of weeks paid holidays.  THESE TWO LEFT THE CHIEF CORONER'S OFFICE BEFORE MY COMPLAINT WAS DEALT WITH BY THE DIOC.

2. We the taxpayers of Ontario pay 85% of all doctor's malpractice insurance.
The Malpractice Insurer has THREE BILLLION DOLLARS set aside to defend doctors!!! That is why malpractice suits have been on the decline.

3. The College of Phys & Surgeons are totally inept at investigating themselves. Since 1994, they have received well over 30,000 complaints from Ontario Citizens and only 377 have been confirmed and dealt with by the College. I have won my first appeal at the Health Professions Appeal and Review Board. This Board sent the College's decision back to them ( it has been over 400 days since this was done) for a new decision as it was deemed "unreasonable". I have a second complaint submitted to the College and it has been over a year with no response.(the College's unnamed expert also fails to comment on the important issues and sidesteps the crucial concerns)

Looking at the comment below certainly questions whether this College should continue to be self-regulated.  They have difficulty finding a suitable opinion provider???   I feel very sorry for all those citizen who have submitted complaints in the past who probably didn't have thorough and expertise investigations.

"I apologize for the length of time this has taken, but it can take some time to locate a suitable opinion provider who is willing to do the work; and these are physicians who invariably have full-time practices."

Yours truly,

Angela Bates
Manager, Committee Support
College of Physicians and Surgeons of Ontario

Although I find the College's opinion provider to be very evasive he/she did make some interesting comments:

Words like "possible", "assumed",  "seemed", "perhaps" do not appear to show a competent, confident assessment by the College's expert.

"The discharge summary was dictated by Dr. Klein five months later on December 30th 2006. Given the gravity of this case, I would have expected a prompt discharge summary from Dr. Klein."

"On reading the ambulance call report from July 20th, it sounds as if T.D.K. was in at least hypovolemic shock and possibly septic shock."

"Her haemoglobin in the Emergency department in Kingston was 82 but her platelet count was only 24000. She has a very high lactate consistent with shock but her albumin was only 10 suggestive of profound sepsis and her INR was 6.0, again suggestive of sepsis."

"The autopsy results were felt to be indicative of hemorrhagic shock as a cause of death, but in my opinion the cause of death was likely a combination of septic shock with secondary hemorrhagic shock superimposed on this."

" If the patient did have an anaerobic infection around the anastomosis, DIC could result and could cause bleeding. The expert noted that the patient's serum albumin was only 10 at Kingston General, something that "does not happen overnight", but indicates profound protein loss and poor protein intake."

Terra bled out and died less 12 hours after being released from hospital!!!  So something was amiss and could have been picked up if the surgeon or a doctor saw her the day of her release!!!!
" It is best for a surgeon to see a patient the morning of discharge; or at least, for nursing staff to document the patient's status. As well, the expert clarified that if there were signs of sepsis or hypovolemia on the morning of discharge, these may have shown themselves if the surgeon or nursing staff had assessed the patient that morning."     Note from AWK-- Terra was not seen by her surgeon or any doctor for over 24 hours prior to her release.

"Perhaps a consideration for intraabdominal sepsis as the cause of the diarrhea could have been given more credence."
"He noted that he would have expected a more thorough analysis of the situation in the surgeon's notes."

"Her haemoglobin in the Emergency department in Kingston was 82 but her platelet count was only 24000. She has a very high lactate consistent with shock but her albumin was only 10 suggestive of profound sepsis and her INR was 6.0, again suggestive of sepsis."

 Terra did not have the following done which is mandatory for all bowel surgery!!!

" I do not see any record that she received preoperative or post operative antibiotics."

"I did not find any record of any postoperative antibiotics being administered."

"The expert found no evidence in the record that any antibiotics had been prescribed perioperatively. He stated that it is the standard of practice with bowel surgery to administer antibiotics, either orally or intravenously, approximately 2 hours prior to surgery so that the drugs are circulating before the incision is made." 

Yet this expert states:

"Overall, I feel that Dr. Klein met the standards of practice in his management." 

 "Her (meaning my daughter) preoperative care, operative care and post operative care seemed appropriate" 
You have got to be kidding!!!!
4. Hospitals remain secretive and non-transparent. I might add that this particular hospital is constructing a memorial garden in Terra's name. Without acknowledging the surgeon's/hospital's responsibility , they offered to do this----I think that says something in itself.

5. Premier McGuinty and his Ministers have done nothing for me. Suggestion--- Provincial Election this fall-- why should the Liberals receive your vote???

If you wish to provide some assistance, all I would ask of you is to write to this committee expressing your interest in this process to ensure that The Chief Coroner's Office is held accountable for their flawed investigation by omission of relevant factors which may have contributed to her death and therefore failed to protect other Ontario citizens from perhaps encountering the same fate in a hospital.

You may wish to e-mail the others named below.

Subject title -- Kilby vs Ontario's Chief Coroners Office

Death Investigation Oversight Council
25 Grosvenor Street. 1st floor
Toronto, Ontario, M7A 1Y6

Subject title for the College of Phys & Surgeons "Kilby vs Klein"

abates@cpso.on.ca; Manager, Committee Support College of Physicians and Surgeons of Ontario

lthurling@cpso.on.ca President of the College

Andrea Horwath     ahorwath-co@ndp.on.ca

Tim Hudak             tim.hudakco@pc.ola.org

Dalton McGuinty   dmcguinty.mpp.co@liberal.ola.org
Kathleen Wynne    kwynne.mpp.@liberal.ola.org

Deb Matthews       dmatthews.mpp.co@liberal.ola.org
Minister who oversees hospitals and the College of Phys & Surg

M. Meilleur              mmeilleur.mpp.co@liberal.ola.org
Minister who oversees the Chief Coroner's Office of Ontario

Now we have at least four systemic factors within Terra's care at HRRH:

1. No anti-biotic prophylaxis given at time of major open abdominal surgery! -- No anti-biotics given at any time!

2. Dietary needs not met --- only receiving 687 calories per day on liquid diet with no supplemental nutrition given, thus a starvation diet producing nutritional deficiencies.

3. Many gram negative bacillia present and left untreated causing damage to the reconstructed colon

4. Many PMN's indicating a bacterial infection ignored by the surgeon and left untreated causing damage to the reconstructed colon

Yet Dr Lauwers (Chief Coroners Office of Ontario) insists there are NO systemic issues factoring into Terra's colon resection breakdown and causing her death????????

Do You Smell Something ODD??

Also, his independent medical expert failed to mention any of the four above items that were indicated within the medical charts and records belonging to Terra which he was to study.

Plus:  The incision was oozing purulent fluid upon released from hospital.  Her abdomen went from flat to rounded to large upon her release.

So many issues that Dr Lauwers from the Chief Coroner's Office refused to comment on, including his so-called unnamed expert.

Chief Coroner of Ontario
26 Grenville Street
Toronto, Ontario M7A 2G9
Dear Dr. McCallum:
I was recently visited by a constituent, Mr. Arnold Kilby, to discuss his concerns surrounding the circumstances of his daughter's death in July of 2006.  I understand that you are personally familiar with Mr. Kilby and his concerns and that your office rejected the need for an inquest into his daughter's death.
Mr. Kilby, understandably, is quite passionate about determining the real cause(s) of his daughter's death and insuring that, if mistakes were made, that they not be repeated and jeopardize other lives.  During his visit, Mr. Kilby laid out a very persuasive case, raising legitimate questions that, apparently, have never been answered. As a layman I can't speak to many of the issues he raised, but two jumped out at me as very legitimate causes for concern in the way his daughter was dealt with.
The first was the decision to operate without purging the colon for fear of infection; and the second was the nursing charts indicating a persistent "foul odour" at his daughter's incision, an odour that was still present upon her release from hospital and should indicate, to the least trained eye, that infection is present.
After reviewing Mr., Kilby's extensive file, I believe his daughter's death merits reconsideration from your office with respect to the death meriting an inquest. There remains far too many unanswered questions surrounding Terra Kilby's untimely passing, questions that only your office can secure answers to.

I urge you to give every possible consideration to calling an inquest into Terra's death.
Kind regards.  Sincerely,
R. Runciman

Comments from The Chief Coroner's Office's unnamed expert????
The operative procedure was carried out according to the appropriate standard and good decision making is evident. The postoperative care was appropriate.

There were no clinical indications for a CT scan or other investigation. It is not unusual for patients to be discharged without having had a solid bowel movement.

There was no evidence of any hemorrhagic event subsequently nor change in vital signs that would have merited repeat laboratory investigations Discharge on July 20,2006 was therefore clinically appropriate.
At all times the record would indicate that she received an appropriate standard of care. In spite of the outcome, I find no area of concern with respect to the standard of care that she received. 
Correspondence from Chief Coroner's Office

Excerpts from March 4, 2009 letter denying an inquest by Dr Lauwers
“The Office of the Chief Coroner has not received any other expressions of interest in an inquest examining Terra's death from the public.”
I have no idea why Dr. Lauwers would mention this, as according to the Coroner’s act a family has the right to request such an inquest.  There is no mention that I would have to go to the public for support. The Coroners Act specifically states that the family of a deceased person may request an inquest. This request should be made to the investigating coroner.”
Ultimately, the expert concluded that, "While the patient suffered the most devastating complication of an operation, and specifically one of the most common complications of bowel resection, at all times the record would indicate that she received an appropriate standard of care. In spite of the outcome, I find no area of concern with respect to the standard of care that she received".
A. E. Lauwers, MD, CCFP, FCFP
"The circumstances and facts related to the death of Terra are well known. In addition, valuable jury recommendations are in my opinion, highly improbable. The sudden, unexpected and unanticipated hemorrhage, which occurred at her parents' home was not foreshadowed by any clinical indicators. The suture edge suddenly released and Ms. Kilby tragically, rapidly exsanguinated. This fact makes it highly unlikely that a jury could ever make recommendations directed to the avoidance of death in similar circumstances in the future. As such, I am declining the Kilby Family's request for an inquest examining Terra Dawn Kilby's death.."
“There has been a great deal of scrutiny of your daughter's case. As part of that scrutiny, an expert review was obtained from an independent surgical consultant. Based on my review of the independent expert reviewer's opinion, I conclude that there are no omissions or commissions during your daughter's treatment that contributed to or caused your daughter's death."
All of this information is set out very clearly in the expert reviewer's report.
 Andrew McCallum, MD, FRCPC Chief Coroner for Ontario
But his report has omitted much relevant information so the expert reviewer’s report is not thorough and clear.

"While I realize that you have many remaining questions, I am not in a position to respond. You may wish to speak with your daughter's caregivers regarding these questions. However, I can state that our investigation did not reveal an issue in care that led to your daughter's tragic death. This was the opinion of our expert independent consultant. Thus, I can add nothing more at this juncture.”
Andrew McCallum, M.D., FRCPC

  I can state that our investigation did not reveal an issue in care that led to your daughter's tragic death. This was the opinion of our expert independent consultant. Thus, I can add nothing more at this juncture.”
Andrew McCallum, M.D., FRCPC

"The Patient Safety Review Committee's mandate is to look at systems issues contributing to a death. As there were no systems issues contributing to your daughter's death identified by our investigation, it would not be appropriate to refer her case to that committee.
At this juncture, the investigative mandate of the Office of the Chief Coroner is concluded."
Andrew McCallum, MD, FRCPC Chief Coroner for Ontario
"I have been advised that you contacted our Regional Office in Kingston, Ontario today requesting a Regional Coroner's Review be conducted with respect to Terra's death.
Regional Coroner's Reviews are not ensconced in legislation. They are conducted at the discretion of the Deputy Chief Coroners and Regional Supervising Coroners. These are generally conducted when a death investigation reveals the presence of systemic issues that contributed to the death in question, and where it could be anticipated that the review would lead to recommendations which would prevent deaths in similar circumstances in the future. Given the information provided by the expert opinion our office obtained of your daughter's tragic death, a Regional Coroner's Review would not be indicated.
In conclusion, the Office of the Chief Coroner's investigative mandate has been met in Terra's case and there is nothing further that we can offer you. Please accept our deepest condolences for your tragic loss."
A.     E. Lauwers, MD, CCFP, FCFP
NOTE:   The Chief Coroner’s Office does not have the authority to deny a request sent to the Regional Coroner for a death review but apparently did so.   I know they would influence the Eastern Ontario Coroner into denying my request but it should have been up the Eastern Ontario Coroner to do so.  Regional coroner reviews are held on a case-by-case basis at the discretion of the Regional Coroner.”  So, the Chief Coroner’s Office should be admonished for overstepping his authority!
"As previously stated by Dr. McCallum in his letter of July 8, 2009, all the information that .our office can provide has been conveyed to you in previous correspondence. The investigative mandate of the Office of the Office of the Chief Coroner is concluded.
To that end, our office will not be in a position to return phone messages to you in the future."
Sincerely,  A.E. Lauwers, MD, CCFP, FCFP 
So, the Chief Coroner’s Office has refused to answer any questions I have of them with regard to my daughter's death which they supposed investigated thoroughly.
I am an Ontario citizen whose daughter passed away suddenly, whose death was investigated by them and they won't answer questions.   Why???  and How can they be allowed to do this???

From my MPP when he spoke in parliament.

:  Excellent Care For All Act, 2010
        Second Reading
            Tuesday, May 4, 2010
Mr. Steve Clark: 
I am pleased to rise to provide some comments to the member for Scarborough-Rouge River.  I listened to his comments about quality and value, and also about accountability in this Excellent Care for All bill.

On Friday, I met with one of my constituents, Arnold Kilby from Lansdowne, whom I think has e-mailed every member of this Legislature hundreds and hundreds of times with a concern about the system.  His daughter, Terra Dawn Kilby, passed away in 2006, 12 hours after her release from a Toronto-area hospital.  He has many unresolved issues with respect to the care she received in that hospital.  I know that he’s written to the Minister of Health and Long-Term Care and also to the Minister of Community Safety, expressing his concerns that the system let her down; that there wasn’t an accountable system; that he can’t seem to get answers on the fact that there should be things put in place at the hospital and in the health care system that make the government accountable for what happens at these facilities; and the fact that, in his case, with his daughter Terra Dawn, he still, three years after her death, cannot get answers from this government or from the hospital involved.  You know, it’s not an issue of taking the government to court.  All he wants is a bill that puts some accountability back in the system that would ensure what happened to him and his family never happens again.

I’ve looked at this Bill 46.  I looked at Hansard from yesterday, at what the minister said, and I don’t see that this bill has that accountability for Arnold Kilby, that it has that accountability with a hospital so that it adequately addresses his concerns.  I would like someone to address that at some point in the future

Why should I need, or have to go outside Ontario and Canada's Borders to get the answers I seek? 

Excerpts below from experts outside of Ontario and Canada

Dear Mr. Kilby: Of course I will be happy to review your materials and give you an opinion. It is always disappointing to hear that other surgeons are not willing to take the time to offer opinions regarding cases that may have been mismanaged. ....... I would believe it to be a grave mistake to have NOT prepared a patient's bowel if there was any chance the bowel would need to be entered during the surgery. ......If indeed her abdomen was distending, and her pulse rate rising over an observable period of time, then the really important issue was why was she not rushed back into the operating room when it was clear that an intra-abdominal catastrophe was occurring?

Dear Mr Kilby
......I think there are a lot of problems with this case and you have a strong case to proceed. ......Bleeding from a stapled anastomosis that leads to hemorrhage shock and death seems a little unusual. I see negligence in this case

Dear Mr Kilby
......I find it difficult to justify what appears to be a "whitewash" of the patient's cause of death. The points you have raised are--in my opinion--legitimate reasons to question the validity of classifying her death as "natural" and would support your complaint of inadequate investigation. ........She unmistakably died of surgical complications that were arguably survivable with less flawed management.

Dear Mr Kilby

I recognize that there were serious complications, and probably unnecessary complications, with your daughter’s care. From what I have read I believe that the standard of care was not met which caused your daughters demise. .....this case which appears to be or at least border on malpractice.

Dear Mr Kilby

I have concerns that the nurses documented for Terra's abdominal exam that her abdomen was "large" for the last several days of her stay in the hospital. More importantly, they document for a number of days prior to her discharge that there was a foul smelling odor and that the wound was "oozing copious amount of purulent discharge" during this entire time as well is very concerning. .....

This doesn't happen with a superficial wound infection. These things happen when there is an anastomotic breakdown and leakage through the wound and possibly into the peritoneal cavity.

Mr Kilby
I am concerned about the description of the abdominal examination progressing from "rounded" to "large" The nutritional aspect is contributory ......supplemental nutrition should reasonably have been considered.
Mr Kilby

I am going to respectfully disagree with the Coroner.

If you take a look at the charts, it seems to me that nurses and doctors are talking about two different patients.

Doctors are talking about a stable patient who is afebril , and her wound is healing , and their plan is to discharge the patient within 1-2 days.

On the other hand, nurses are talking about a patient who has a fluctuating vital signs [particularly her Temperature], patient is refusing food while she is stating to nurses that she is hungry, and she tells nurses that she does not have pain but nurses are giving her pain medications anyway, and finally patient's abdomen is going from flat to round and large.

Don't you think, these people either did not know what they were talking about or something serious was happening to the patient?  May be the thing that was happening was not septic shock but it was ileus, may it was not ileus but it was leaking from perforated site. Something was definitely wrong. It is easy to conclude that both nursing and medical care provided to patient was inadequate and below the standard of care. The definition of negligent malpractice in law is " failure to meet the standard of practice by health care professionals" and " omission of act that the fiduciary relationship of a nurses and physician with their patient, obligate them to do for their patients"

Inadequate and meaningless physician progress note. Physician must write their progress note in SOAP system [ CPSO requires that all physician's note to be written in SOAP method.  S: subjective, means what patient is telling me  O: Objective, what I observe  , A: assessment, vital signs and physical assessment,  P: Plan, what I am going to do for this patient in order to address her complaints and her abnormal physical findings]

Ultimate responsibility lies with Terra's surgeon!