Sick Children's hospital investigated why infants were dying in their cardiac unit. An experimental testing technique indicated the infants were poisoned with digoxin, a fast acting difficult to trace heart medication. A police investigation focused on Susan Nelles, the nurse scheduled on duty at the time of deaths. After her arrest the deaths in the cardiac unit sharply dropped.
The case collapses
Nelles had not been on duty for several of the deaths, she shifts with other nurses. All of the staff had access to the same fast acting poisons that Nelles did. The fact Nelles asked for legal counsel when confronted with the accusation as proof of her guilt was also held against against her. The court ruled a fundamental legal is not to be construed as evidence of guilt. The deaths ceasing in Nelles absence was explained by the hospital's new policy of restricting on access to digoxin. A preliminary dismissed the action due to lack of evidence of Nelles involvement.
After a Royal Commission on the deaths concluded at least eight infants had been murdered, suspicion fell on another nurse. No one was charged.
Faults in the commission's theories exposed
Deaths in the cardiac care increased, the total hospital death rate of infants did not. Previously the hospital moved infants out of intensive care earlier than in the past. After Nelles arrest the policy was reversed to keep infants in intensive care longer. The total deaths rate during similar periods of time and circumstances between the two units were almost identical. The digoxin found in the deceased babies may never have been present. The test, an experimental method, detected byproducts of digoxin after it broke down in the body, gave false results to other chemicals and labeled them as by products of digoxin as well. It impossible to determine if digoxin was used.
The nurses working on the ward blamed the hospital's policies. They also knew the test being used to find digoxin was experimental. Their solidarity never wavered. And
In the end the government paid Susan Nelles legal bills.
Ms. Nelles retained John Sopinka as her counsel in launching a civil suit against Ontario's attorney general and Metro Toronto Police alleging malicious prosecution.
There is a tragedy to that story that is seldom noticed. Her father, a doctor, died in the midst of it all of a heart attack. No one can escape the conclusion that Susan Nelles experiences profoundly changed and nearly ruined her life, and killed her father.
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