Toronto hospital baby deaths

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The Toronto hospital baby deaths were multiple alleged poisonings of babies at Toronto's Hospital for Sick Children that occurred between June 1980 and April 1981, when charges of murder were laid against a nurse at the hospital. The story was a major news event throughout the year, and ended with the nurse being exonerated. Although suspicion was cast on other people, no further charges were ever laid.

Later analysis suggests that the tests and methodologies that pointed to poisoning were flawed, and may have been generating false positives. Specifically, chemicals used in the manufacture of everyday medical items may have contributed to the test indicating high levels of the alleged poison. It was also demonstrated that a "wave" of similar alleged poisonings were occurring at that time.

Initial accusations[edit]

During an investigation of baby deaths in the cardiac unit of the Hospital for Sick Children, abnormally high levels of the heart medication digoxin were found in as many as 43 of the infants. The levels were measured using a newly introduced testing method known as HPLC, and the levels were high enough to suggest that it was the cause of death.

A police investigation followed during which time it was found that a nurse that the hospital had been working shifts during the times that 23 of the deaths occurred. Susan Marguerite Nelles (born in Belleville, Ontario),[1] was arrested and charged in March 1981 with murdering four babies. The deaths then stopped.

During the case that followed, it was discovered that Nelles had not actually been on duty during the noted times, having swapped shifts with other nurses who had access to the same medication. Although the deaths ended after Nelles' arrest, the hospital had introduced restrictions for access to digoxin and had implemented a policy that kept infants in intensive care longer. Total deaths between the two units remained identical.[clarification needed]

Nelles asked for legal counsel when she was arrested. Her request was interpreted by the investigating police officers to be an indication of her guilt, but the court later ruled that such requests should not be interpreted as evidence of guilt. The court also ruled that the Crown lacked evidence to convict Nelles. The government eventually paid for Nelles' legal costs after she sued the province's Attorney-General, Roy McMurtry for malicious prosecution.

Inquiry and aftermath[edit]

A Royal Commission, led by Justice Samuel Grange, found that eight infants had been murdered. Although another nurse, Phyllis Trayner,[2] fell under scrutiny, no one was charged. Moreover, the experimental test that detected digoxin may have given false results for other chemicals.

Nelles has since remained in the medical care world after her trial. In 1992 she became Director of the Belleville Dialysis Unit of Kingston General Hospital. She also counsels nurses on legal issues and on dialysis. In 1999, Nelles received an honorary degree from Queen's University in Kingston, Ontario (from which she had graduated with a Bachelor of Nursing Science degree in 1978) for her work in promoting integrity in the nursing field.[1] She helped establish the Nelles Scholarship for Queen's Nursing Science Students in memory of her father, Dr James Nelles and brother Dr David Nelles.[3]

As of 2005, only Nelles had been charged with a crime involving the baby deaths.[4]


As per 2010 article,[5] there is some question as to whether any of the infants were murdered – but perhaps killed by a substance called MBT (mercaptobenzothiazole) that was used in the manufacture of the syringes used to medicate the babies and can mimic digoxin in autopsies. To quote from the epilogue, "Today, no one can even say with certainty whether any crimes were ever committed on the pediatric cardiac ward."

Gavin Hamilton, M.D., of London, Ontario, published a book, The Nurses are Innocent – The Digoxin Poisoning Fallacy,[6] proving that very high blood digoxin levels should be expected in autopsy samples. He described an epidemic of baby poisoning occurring at the same time as the Toronto baby deaths (in Hammersmith Hospital, London, England),[7] caused by a cumulative toxin leached from pharmaceutical rubber (syringes, ampoules, and I.V. apparatus).[8] Babies anywhere in the world who received multiple injections (such as the seriously ill Toronto babies) were exposed to this contaminant, MBT. In the FDA's National Center for Drug Analysis, MBT was proven to give falsely high digoxin readings by HPLC testing,[9] the method used by the Toronto Centre for Forensic Sciences during the criminal investigation.


  1. ^ a b "World leader in alternative energy technology amongst honorary degree recipients". Queen's University. 20 May 1999. Retrieved 2007-07-16. 
  2. ^ Michele Mandel (March 5, 2011). "Sick Kids Cold Case Getting Colder". Toronto Sun ( Retrieved October 22, 2011. 
  3. ^ "Susan Nelles Scholarship". 
  4. ^ Commissioner: Samuel G. M. Grange (1984). "Report of the Royal Commission of Inquiry into Certain Deaths at the Hospital for Sick Children and Related Matters". Toronto: Ontario Ministry of the Attorney General. 
  5. ^ Peter Bowal and Kelsey Horvat (September–October 2011). "A Famous Case Revisited: Whatever Happened To ... The Prosecution of Susan Nelles" (PDF). LawNow. Retrieved October 22, 2011. 
  6. ^ Gavin Hamilton, M.D. (November 2011). The Nurses are Innocent – The Digoxin Poisoning Fallacy. Dundurn Press. ISBN 978-1459700574. 
  7. ^ Meek JH, Pettit, Pettit BR. (1985). Avoidable accumulation of potentially toxic levels of benzothiazoles in babies receiving intravenous therapy. The Lancet 326:1090-1092.
  8. ^ Bethune, Brian (2011-12-22). "The baby killer at Toronto’s Sick Kids was rubber - Books". Retrieved 2013-05-27. 
  9. ^ Reepmeyer JC, Juhl YH. (1983). Contamination of injectable solutions with 2-mercaptobenzothiazole leached from rubber closures. J Pharm Sci. Nov;72(11):1302-1305.

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