Toronto hospital baby deaths

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The Toronto hospital baby deaths, believed to be homicides, occurred in the Cardiac ward of the Hospital for Sick Children between July 1980 and March 1981. They ended when the police were called in and the digitalis-type medication used for the killings (digoxin) began to be kept under lock and key. Three nurses were at the center of the investigation, and an apparent attempt to poison nurses' food. One of the nurses, Susan Nelles, was charged with four murders, but the prosecution was dismissed a year later on the grounds that she could not have been responsible for a death not included in the indictment, which the judge deemed a murder. A conspiracy between multiple nurses was regarded by the judge as not credible. The lead detective resigned. An official government inquiry discounted claims by the hospital's own former chief of pediatrics that the deaths were not homicides and not proven to be due to digoxin. A second suspect was not prosecuted. The case is officially one of unsolved murders.

Deaths[edit]

The Cardiac ward of the Hospital for Sick Children began what was subsequently found to be a several-fold increase in mortality in 30 June 1980.[1] Within two months twenty patient deaths led to a group of nurses approaching the unit's cardiologists, but they kept investigation limited and in-house to prevent a "morale problem".[2] The excess deaths continued but it was not until March 1981 that a bereaved father's extreme distress led to the coroner being brought in and detecting suspiciously high levels of a heart regulating medication digoxin, a powerful form of digitalis, in a dead baby.[3][4] Eight days later he was told an autopsy by the hospital had already found 13 times the normal concentration of the same heart drug in another dead baby.[5] The medication had not been subject to any security measures.[6][7] Police were called in and began to search staff lockers when another baby died from digoxin poisoning on 22 March 1981. Examination of work logs and other nurses' subjective impression that a colleague had inappropriate reactions to the deaths led to the arrest and charging with murder of a nurse, who was released on bail[8] In January 1982 babies became ill in a separate department, it was later found epinephrine (which was not supposed to be on that ward) had somehow been substituted for vitamin E, there had been non-fatal unauthorized digoxin administration to other babies, and another death was, contrary to what the hospital said at the time, due to unauthorized administration of digoxin.[9] In September 1981, team leader nurse Phyllis Trayner (died 2011)[10] found heart drug capsules in food she was eating and another nurse found the capsules in her soup.[11][12]

'There was no dioxin poisoning and no Toronto cardiac baby murders'

Gavin Hamilton’s 2011 Dundurn Press book, “The Nurses are Innocent – The Digoxin Poisoning Fallacy” documents, meticulously, the technical reasons for the high autopsy digoxin levels in the Toronto baby deaths.

1. Living heart cells concentrate digoxin up to 1,000 times the therapeutic blood levels. Heart cells die 10 minutes after death and release concentrated digoxin into blood in the heart chambers. Autopsy digoxin blood samples are taken from the heart chambers and nearby large vessels hours (even days) after death.

2. At the time of the baby deaths, Reepmeyer and Juhl, at the US Centre for Drug Analysis, found falsely high digoxin assays in digoxin unit dose syringes. The samples were contaminated by MBT (mercapto-benzothiazole), a chemical catalyst used to manufacture the pharmaceutical rubber of disposable plastic syringes, routinely used around the world. 50% of syringes showed significant MBT contamination. MBT was being measured immunologically as digoxin by RIA tests and by the highly-rated HPLC test methods. The HPLC test uses the RIA method for the final stage of analysis. The RIA test was used at the THSC and the HLPC test was used by the Centre for Forensic Sciences during the Grange Royal Inquiry,, because the HPLC was considered as the gold standard in digoxin testing.

3. At the time of the THSC baby deaths, 91 babies on a London Hammersmith Hospital neonatal ward showed “potentially toxic” MBT blood levels from pharmaceutical rubber parts of disposable syringes, the rubber seals of drug ampoules and from 3 sites in IV administration sets. They used an uncommon term for MBT, calling it BTT (benzo-thiazole-thiolate), a chemically correct term, but which concealed its true nsature from researchers looking into the hazards of MBT. If these neonatal babies were tested for digoxin by RIA, they would have shown falsely high digoxin readings, even when they hadn’t received any digoxin doses.

4. MBT becomes bound to plasma proteins, preventing MBT elimination by the kidneys. This makes MBT a cumulative toxin, which increases the blood MBT concentration with each MBT-contaminated injection.The THSC babies were on the ward with the most seriously ill babies, who would be receiving multiple injections and multiple exposures to toxic MBT. Justice Grange was disturbed that the ill babies could not be resuscitated; that was because resuscitation attempts required multiple injections that would have contained more MBT and thus caused even more poisoning.

5. In a Lancet letter in 1990, “Medical rubber anaphylaxis,” radiologist, G. Hamilton, documented two series of allergic reactions (including life-threatening anaphylaxis) in his patients (1983 and 1987) from MBT contamination of x-ray dyes he injected. Brian Bethune, in a December 22, 2011 Mackleans Magazine book review of “The Nurses are Innocent” said it all in his title: The baby kiiller at Toronto’s Sik Kids was rubber.

6. In the April 2013 issue of the Uppsala Reports, the WHO .Drug Monitoring Centre in Sweden reviewed “an important book,” ending the discussion with these exact words:

“it illustrates a risk to patients using medication that is little-known or discussed, Drs. Hamilton and Napke argue that it reveals the systemic failure of government health protection agencies to protect citizens from a known allergenic and toxic chemical, MBT, a worldwide contaminant of injections for 30 years, with medical journals aiding and abetting the process by refusing to publish informative articles on public health issues related to MBT contamination of injections”. A cursory internet search for MBT as an accelerant in the rubber industry shows that it is still widely used: wherever we are, we should be alive to possibilities of unusual anaphylactic reactions/toxic effects!“[13]

Police investigation and inquiry[edit]

Susan Nelles was arrested and charged with murder, but a judge acquitted her at the preliminary hearing stage and the case never went to trial, partly because she had not been on duty when one death the judge decided was an additional murder occurred, and more than one nurse being involved in a series of motiveless murders strained credulity.[14][15] The exonerated nurse did not believe that there had been any murders, and in a 2011 interview she reiterated that the 1985 inquiry report had been incorrect in stating that many deaths during a rise in mortality on the ward (from one a week to five) had been deliberate homicides.[16][17] Data from the investigation was sent to the US Centers for Disease Control and Prevention, which discovered that Traynor was the only person who had been on duty for all 29 cases of death being looked at.[18] In 1984 two nurses testified they had seen Traynor making a 21 March 1981 unauthorized injection into the IV of a baby who died three hours later.[19] A commission of inquiry listed eight of the baby deaths as murder, with another 13 as highly suspicious.[20] Later reports mention a total of thirty-two babies and three children.[21] Traynor, who denied any impropriety in her behavior on the ward, was questioned in televised inquiry hearings, and resigned after the inquiry's report was published.[22] Although chemical interaction between digoxin and rubber tubing used in its administration was used to question whether the deaths were the result of foul play, the case is officially listed as one of unsolved murders. [23][24]

See also[edit]

References[edit]

  1. ^ The Encyclopedia of Serial Killers P 120-121, Michael Newton (2006)
  2. ^ The Encyclopedia of Serial Killers P 120, By Michael Newton (2006)
  3. ^ The Encyclopedia of Serial Killers P 120, By Michael Newton (2006)
  4. ^ "Tepperman said he was first called to the hospital on March 12, 1981 because Kevin Garnett, father of Kevin Pacsai, 'was unusually upset' over the death of his three-week-old son that day. It wasn't until March 20, 1981, eight days later, that he was told about an autopsy in January on Janice Estrella, who had a digoxin level in her bloodstream that was the highest he had ever heard of".
  5. ^ The Encyclopedia of Serial Killers P 120-121, Michael Newton (2006)
  6. ^ UPI Progress slow in babies' hospital deaths, July 27, 1982 retrieved 12/30/17
  7. ^ Dead babies remain a mystery, QMI Agency, March 6, 2011 Retrieved 24/12 2017
  8. ^ The Encyclopedia of Serial Killers P 120, By Michael Newton (2006)
  9. ^ SickKids: The History of the Hospital for Sick Children, By David Wright, The Hospital for Sick Kids
  10. ^ [Dead babies remain a mystery, QMI Agency, March 6, 2011 http://www.stcatharinesstandard.ca/2011/03/06/dead-babies-remain-a-mystery] Retrieved 24/12 2017
  11. ^ Encyclopedia of serial Killers, Brian Lane 1992
  12. ^ Dead babies remain a mystery, QMI Agency, March 6, 2011 Retrieved 24/12 2017
  13. ^ Hamilton, Gavin (November 2011). The Nurses are Innocent - The Digoxin Poisoning Fallacy. Dundurn Press. ISBN 978-1-4597-0059-8.
  14. ^ SickKids: The History of the Hospital for Sick Children,By David Wright, The Hospital for Sick Kids
  15. ^ Dead babies remain a mystery, QMI Agency, March 6, 2011 Retrieved 24/12 2017
  16. ^ Dead babies remain a mystery,QMI Agency,2011 March 6 Retrieved 24/12 2017
  17. ^ The Encyclopedia of Serial Killers P 120, By Michael Newton (2006)
  18. ^ [Dead babies remain a mystery, QMI Agency, Sunday, March 6 http://www.stcatharinesstandard.ca/2011/03/06/dead-babies-remain-a-mystery] Retrieved 24/12 2017
  19. ^ The Encyclopedia of Serial Killers P 120, By Michael Newton (2006)
  20. ^ The Encyclopedia of Serial Killers P 120, By Michael Newton (2006)
  21. ^ Dead babies remain a mystery, QMI Agency, Sunday, March 6 Retrieved 24/12 2017
  22. ^ [Dead babies remain a mystery, QMI Agency, Sunday, March 6 http://www.stcatharinesstandard.ca/2011/03/06/dead-babies-remain-a-mystery] Retrieved 24/12 2017
  23. ^ [Dead babies remain a mystery, QMI Agency, Sunday, March 6 http://www.stcatharinesstandard.ca/2011/03/06/dead-babies-remain-a-mystery] Retrieved 24/12 2017
  24. ^ The Encyclopedia of Serial Killers P 120, By Michael Newton (2006)

External links[edit]