Toronto’s Hospital for Sick Children, generally referred to as simply “Sick Kids,” is considered one of the prime pediatric hospitals in the world. Sick Kids is nestled in the heart of Toronto’s medical district, a dense neighborhood of hospitals attached by old underground tunnels. Everyone in Toronto is aware of Sick Kids. Most kids have visited it for one reason or another.
On June 30th, 1980, 18-day-old Laura Woodcock died unexpectedly in Sick Kid’s cardiac ward. Within the following two months, more than twenty babies died in the exact ward, leading a group of worried nurses to raise red flags with the hospital’s cardiologists. The hospital quietly started its investigation but attempted to avert harming the “morale” of staff with accusations or suspicion.
The rate of baby demises over the next year was 625% higher than normal. It proceeded until March 1981, when 3-month-old Justin Cook died and his dad demanded an autopsy. The autopsy showed high levels of the drug digoxin in the infant’s system. The coroner then found that another recently died baby had a big amount of digoxin in her body– 13x more than would be deemed safe. This was the finding that eventually led the hospital to reach the police, and then things appeared to get even more bizarre.
The investigation discovered that digoxin was not regulated in the hospital and was freely available. While the inquiry went on, another baby died with high levels of digoxin in their system. The hospital eventually put digoxin under strict control. Numerous babies in a different ward became sick; it was discovered that these babies had high levels of epinephrine in their systems– a drug that was not even in use on that ward.
Lead cardiac nurse Phyllis Traynor discovered heart medication tablets in her salad in the Sick Kids cafeteria. Another nurse discovered medication capsules in her soup. Police raided nurses’ lockers and poured over nurse schedules. All nurses on the cardiac ward were put on temporary vacation, and all patients were transferred to various wards.
Police inferred that there were between 32-43 (totals vary based on the report) suspicious baby deaths and attempted to discover 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. Of the dubious baby deaths, Nelles had been present for more than half. Nelles had also been Justin Cook’s only nurse– she was with him when he passed away.
The police questioned Nelles about the deaths; Nelles rejected 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 killing of four infants.
The strange deaths seemed to stop.
An initial inquiry (similar to a US grand jury) decided that there was not sufficient evidence to charge Nelles with any killing, and the charges were dropped.
Inquiries and investigations into the deaths proceeded, putting up more questions than answers. Lead cardiac nurse Phyllis Trayner had been present for most of the baby demises on the ward; two nurses ultimately reported seeing Trayner performing unauthorized injections in babies that later died. The Grange Inquiry, an official inquiry into 36 of the suspicious deaths, asserted that at least 8 of the babies had been killed. It also discovered that Nelles had been targeted by police because she rejected to speak without a lawyer.
Other things noted in the inquiry:
Most of the deaths occurred between 12 a.m. and 6 a.m.
Some of the babies were critically and/or terminally ill, while others were anticipated to make full recoveries.
The cardiac doctors strongly believed that the casualties were the result of the illnesses (not outside forces)
Original reports of high digoxin levels were dismissed as they were believed to simply be mathematical mistakes.
Research has indicated that there may be a substance (“Substance X”) that responds to certain antibodies and builds a false positive in tests for digoxin.
Digoxin redistributes in the corpse after death, sometimes “multiplying”.
Substances identical to digoxin may form in the body after demise.
Medication mistakes can and do happen in hospitals; some of the cases being examined were a result of a documented medication (digoxin) mistake.
A number of the dead children did not have autopsies or post-mortem tests conducted (this required parental consent, which was sometimes not given).
Various of the kids did not die from a digoxin overdose.
Number of the kids could have passed away from digoxin toxicity OR other natural causes– there was an indication to support both.
Some of the kids DID have apparent evidence of a digoxin overdose– one (Kristin Inwood) was noted to have “the increased level of serum digoxin ever recorded.”
The nurses met jointly at one of their homes to examine the casualties after being put on leave.
Although Nelles was the main nurse for the four newborns she’d been accused of murder, she was relieved for breaks by Trayner. There was no proof to indicate 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 killings had been committed at Sick Kids after all. In “The Nurses are Innocent,” Hamilton formulates that the actual culprit was a chemical discovered in rubber called MBT. At the time of the casualties, rubber was being used in everything– including IV lines and disposable syringes. MBT was leeching into the systems of these small, susceptible babies and resulting in anaphylaxis and death. According to Hamilton, the chemical can be blundered for digoxin in post-mortem tests.
So why did unusual casualties unexpectedly surge in 1980? This was when single-use, pre-filled medication syringes were being introduced. The notion for these syringes was that they would lessen medication mistakes by already having the meds measured out. They could also be stocked for up to three years. Hamilton says that this directed to more MBT leaking into the medication over time. At the exact time of the Toronto deaths, both Australian and British research was indicating that MBT build-up and cumulative exposure could be disastrous in babies.
When I was growing up, the Susan Nelles case was frequently used as an instance of how an overzealous inquiry can go wrong and harm honest people. After charges were dropped, Nelles expended years battling to be exonerated in the public’s impression as well. She tried to sue the Crown prosecution forever bringing penalties against her (this ended up being unsuccessful mainly because Canada wouldn’t allow the precedent). Amazingly, Nelles returned to the medical field and came to be a well-respected and successful nurse–she even has a scholarship named after her. You don’t hear extremely about the baby casualties anymore; it appears to have faded from Toronto’s collective memory. (This case has stayed in my mind because although it occurred 9 years before I was born, my mum was a Toronto nurse at a different hospital at the time. One of her good friends was on Nelle’s nursing team at Sick Kids, and she realized Nelles as an acquaintance.)
I’m uncertain about this case and could argue either way on some things– but I lean toward rubber being the cause, and I believe there was never sufficient evidence to justly charge anyone with killing. The police focus on Nelles appears unfair and I think sympathy for what she went through. Still, it’s ridiculous. One thing I’ll never forget is the total WTF moment of nurses discovering heart medication capsules in their cafeteria food (particularly since I worked in that cafeteria during my time at college!). And even if rubber resulted in a surge in deaths, it’s tough to account for the casualties stopping so abruptly in March 1981. Did the hospital unexpectedly ban rubber that month? I doubt it. Maybe other changes halted the deaths: Strict supervision of digoxin, more oversight of nurses. But then we are again left with the notion of a nurse (or nurses) deliberately overdosing on patients.
What do you think? Was killing behind the weird baby deaths at Sick Kids? Was it a cover-up among the nurses? Was there more than one murderer? Or was it something more innocent?.