The death of Nelia Laroza has led the Ontario Nurses Association to renew calls for the province to ensure hospitals are meeting SARS safety directives for medical personnel.

"Nurses believe this death could have been prevented," said Carolyn Edgar, president-coordinator of the nurses' union at North York General.

Laroza, 51, of Markham, was infected the week before public health officials discovered a second wave of the disease.

She was infected at North York General Hospital where, according to interviews with a dozen nurses and one doctor, warning bells related to a second SARS outbreak were repeatedly raised in April and early May. Nurses and doctors, concerned that possible SARS cases were being discounted, were ignored, according to senior nursing officials.

"(Laroza) didn't want to spread it to anybody. She was very careful with her mask and she was very worried about her family," said nurse Emma Gonzales, a colleague of Laroza. "It is hard for me to let go. I was hoping so much she would recover."

Laroza died Sunday in the early evening. Her husband, two children and other family members had just visited her.

She had battled SARS symptoms — fever, fatigue, muscle ache and breathing difficulties — since mid-May, when she and 15 other nurses on 4 West, the orthopedic floor, were infected.

Her husband, Emil, has been shattered by the experience. "She was his heart," said Laroza's niece, Hazel Corda.

So far, the second SARS wave has claimed 14 lives, after 25 died in Toronto's first outbreak.

Laroza's nursing career spanned more than 20 years, the last 13 at North York General. Prior to that, she worked at Riverdale Hospital and a hospital in her native Philippines.

Laroza came from a big family with a long health-care and nursing background. Her hobbies included sewing, and she made her own nurse's uniforms.

Her son, Kenneth, 16, was the Father Michael McGivney Catholic Academy student who was quarantined after showing SARS symptoms. He attended the school until May 23, and officials were notified on May 28. Subsequently, more than 1,500 students and staff were ordered into quarantine until June 3.

Colleagues said Laroza couldn't believe that she had infected her son, despite all her precautions. She would pace the floor in her isolation room, wondering how it happened.

Laroza also leaves a daughter, Grace, 23. A funeral service will be held at 10 a.m. Friday at Ogden Funeral Home on Kennedy Rd. The viewing will be on Thursday between 7-9 p.m.

In interviews yesterday, family and colleagues stressed that Laroza was meticulous in following SARS precautions.

Laroza "was very scared that SARS was a lot more serious than most people had predicted and she had isolated herself from any family gathering," Corda said. "She just wanted to make sure everyone was safe (from SARS)."

Dr. Colin D'Cunha, Ontario's commissioner of public health, said he was saddened that Laroza died. "She is someone in my view who has paid the ultimate sacrifice." Dr. Andrew Simor, chief microbiologist at Sunnybrook hospital, said her death is not surprising. "Certainly health-care workers have been at the highest risk of getting of SARS and many have died around the world."

He estimated just under half the 23 SARS victims who are still hospitalized are health-care workers, and about a quarter are others who got it in hospital.

In some good news for the beleaguered North York hospital, a friend and nursing colleague of Laroza has recovered, though she had been as sick as Laroza. A doctor and health-care aide with SARS remain in serious condition in North York General.

Laroza's death "has hit us hard," said Adeline Falk-Rafael, president of the Registered Nurses Association of Ontario. "She is one of us. She has lost her life in the line of duty."

Falk-Rafael said the death adds an urgency to the inquiry by Mr. Justice Archie Campbell into the handling of the SARS outbreaks. That inquiry is just getting under way and will involve Campbell and his team interviewing people involved in the outbreaks.

"Did even one person become infected unnecessarily in this second wave of SARS? Were some decisions made for political and economic reasons? Were all decisions made for health reasons?" said Falk-Rafael, referring to the controversy over the dramatic lessening of infection protection when the first outbreak appeared to be on the wane in April and May.

How did Laroza get infected?

According to Toronto Public Health, SARS came to her wing, 4 West, on April 2. Nobody spotted the signs until it was too late.

A 96-year-old patient with a fractured pelvis was transferred down from the geriatric ward on the eighth floor. It's believed the man had SARS and was starting to show symptoms that day.

Public health officials have been pursuing the theory that the 96-year-old man was earlier infected by an eighth-floor geriatric ward nurse, who was infected by her mother, who had been a patient at Scarborough Grace Hospital, where the first SARS outbreak occurred in March.

However, the eighth-floor nurse has denied that she brought SARS to North York General. In an interview, she said she cannot be the link because she never visited her ill mother at Scarborough Grace and her mother never showed symptoms of SARS, despite being in a room at Grace beside a man thought to be a "super-spreader" from the first wave of SARS.

However SARS entered North York General, it appears that it lingered on 4 West, surviving through several 10-day incubation periods. How it did that is a mystery, experts say.

Dr. Bonnie Henry, of Toronto Public Health, said Laroza likely became ill in mid-May. Henry said the nurse was discovered to be a SARS case around May 22, when public health officials were beginning their investigation of the new outbreak at North York General.

Nurses have told the Star that they spotted pockets of SARS-like symptoms throughout the hospital in April and May. The nurses brought their concerns to hospital doctors, but those concerns were discounted because experts could find no connection or "epi-link" between sick patients and known SARS patients. The growing outbreak of respiratory infections was discounted as routine sickness.

In the case of the 96-year-old man, four members of his family came down with SARS-like symptoms. But they were discounted by hospital doctors as SARS cases.

At the same time, on the seventh-floor psychiatry ward, three patients with SARS-like symptoms were also discounted as SARS cases. Health officials say they ruled these cases out because there was no obvious link to known SARS cases.

Contributing to the outbreak was a gradual slackening of precautions, such as the wearing of masks by health-care workers. As Toronto struggled out of the first outbreak, the feeling in many hospitals was that the concern was over. As politicians lobbied the World Health Organization to end its damning travel advisory, hospitals like North York responded with varying degrees of precautions. Some nurses and doctors insisted on wearing masks, gowns and glasses. Others took no precautions at all.

One of the issues raised by the Ontario Nurses Association has been if the masks fit properly.

North York General spokesperson Ingrid Perry Peacock said that "since we have come through this we have had masks on appropriately and have provided mask training and fitting for all our staff."

Perry Peacock said she did not know if fitting of the masks was an issue in Laroza's death.

Perry Peacock said staff are working with the labour and health ministries on such issues as mask fitting and training.

All staff in the hospital, not just health-care workers, must wear a mask at all times. "We are required to use them from the time we enter the front door," said Perry Peacock. "We may take our masks off to eat lunch, but we sit at least two metres apart."

North York General Hospital vice-president Keith Rose said the hospital will undergo a health ministry audit next week. He expects the facility, which is all but closed, to begin a phased reopening next Monday.

It has been almost 20 days since the last new SARS case in Canada.

With files from Peter Small and Frank Calleja