Not As Straightforward As It Seems
“Toronto’s Hospital for Sick Children, commonly referred to as simply ‘Sick Kids,’ is considered one of the top pediatric hospitals in the world. Sick Kids is nestled in the heart of Toronto’s medical district, a dense neighborhood of hospitals connected by old underground tunnels. Everyone in Toronto is familiar with Sick Kids. Most children have visited it for one reason or another.
On June 30, 1980, 18-day-old Laura Woodcock died unexpectedly in Sick Kid’s cardiac ward. Within the next two months, more than twenty babies died in the same ward, leading a group of concerned nurses to raise red flags with the hospital’s cardiologists. The hospital quietly began its own investigation but tried to avoid hurting the ‘morale’ of staff with accusations or suspicion.
The rate of baby deaths over the next year was 625% higher than normal. It continued until March 1981 when 3-month-old Justin Cook died and his father demanded an autopsy. The autopsy revealed high levels of the narcotic digoxin in the infant’s system. The coroner then discovered that another recently deceased baby had a huge amount of digoxin in her body, 13x more than would be considered safe. This was the discovery that finally led the hospital to contact the police, and then things seemed to get even more bizarre.
The investigation found that digoxin was not regulated in the hospital and was freely accessible. While the investigation went on, another baby died with high levels of digoxin in their system. The hospital finally put digoxin under strict control. Several babies in a different ward became sick; it was found that these babies had high levels of epinephrine in their systems– a narcotic that was not even in use on that ward. Lead cardiac nurse Phyllis Traynor found heart medication tablets in her salad in the Sick Kids cafeteria. Another nurse found medication capsules in her soup. Police raided nurses’ lockers and poured over nurse schedules. All nurses in the cardiac ward were put on temporary leave, and all patients were transferred to different wards.
Police determined that there were between 32 and 43 suspicious baby deaths and tried to find common links between them.
Susan Nelles was a 25-year-old nurse in the Sick Kids pediatric ward. She was one of a small team led by Phyllis Traynor. Nelles had been present for more than half of the suspicious baby deaths. Nelles had also been Justin Cook’s only nurse, she was with him when he died.
The police questioned Nelles about the deaths; Nelles refused to answer questions without a lawyer present, apparently on the advice of a friend in law school. Police arrested Nelles and charged her with the murder of four infants.
Afterward, the strange deaths seemed to stop.
A preliminary inquiry, similar to a US grand jury, decided that there was not enough evidence to charge Nelles with any murder, and the charges were dropped.
Inquiries and investigations into the deaths continued, raising more questions than answers. Lead cardiac nurse Phyllis Trayner had been present for most of the baby deaths on the ward; two nurses eventually reported seeing Trayner performing unauthorized injections in babies that later died. The Grange Inquiry, an official inquiry into 36 of the suspicious deaths, stated that at least 8 of the babies had been murdered. It also found that Nelles had been targeted by police because she refused to speak without a lawyer.
Other things noted in the inquiry:
Most deaths occurred between 12 am and 6 am.
Some of the babies were critically and/or terminally ill, while others were expected to make full recoveries.
The cardiac doctors strongly believed that the deaths were the result of the illnesses, not outside forces.
Original reports of high digoxin levels were ignored as they were thought to be mathematical errors.
Research has suggested that there may be a substance, ‘Substance X,’ that reacts to certain antibodies and creates a false positive in tests for digoxin.
Digoxin redistributes in the body after death, sometimes ‘multiplying.’
Substances similar to digoxin may form in the body after death.
Medication errors can and do occur in hospitals; some of the cases being investigated were a result of a documented medication, digoxin, error.
A number of the deceased children did not have autopsies or post-mortem tests performed, these required parental consent, which sometimes was not given.
A number of the children did not die from a digoxin overdose.
A number of the children could have died from digoxin toxicity or other natural causes as there was evidence to support both.
Some of the children did have clear evidence of a digoxin overdose– one (Kristin Inwood) was noted to have ‘the highest level of serum digoxin ever recorded.’
The nurses met together at one of their homes to discuss the deaths after being put on leave.
Although Nelles was the primary nurse for the four infants she’d been charged with murdering, she was relieved for breaks by Trayner. There was no evidence to suggest Nelles had been alone with 2 of the 4 patients when they died.
In 2011, retired doctor Gavin Hamilton published a book with a new argument: no baby murders had been committed at Sick Kids after all. In ‘The Nurses are Innocent,’ Hamilton proposes that the real culprit was a chemical found in rubber called MBT. At the time of the deaths, rubber was being used in everything, including IV lines and disposable syringes. MBT was leeching into the systems of these small, vulnerable babies and causing anaphylaxis and death.
According to Hamilton, the chemical can be mistaken for digoxin in post-mortem tests. So why did unusual deaths suddenly surge in 1980? Apparently, this was when single-use, pre-filled medication syringes were introduced. The idea for these syringes was that they would reduce medication errors by already having the meds measured out. They could also be stored for up to three years. Hamilton says that this led to more MBT leaking into the medication over time. At the same time as the Toronto deaths, both Australian and British research was showing that MBT build-up and cumulative exposure could be fatal in babies.
After charges were dropped, Nelles spent years fighting to be exonerated in the public’s view as well. She attempted to sue the Crown prosecution forever bringing charges against her, this ended up being unsuccessful primarily because Canada wouldn’t allow the precedent.
Amazingly, Nelles returned to the medical field and became a well-respected and successful nurse. She even has a scholarship named after her. You don’t hear very much about the baby deaths anymore; it seems to have faded from Toronto’s collective memory despite never being officially solved.”