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.
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
After a Royal Commission
on the deaths concluded at least eight infants had been murdered,
suspicion fell on another nurse. No one was charged.
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
In the end the government
paid Susan Nelles legal bills.
Nelles Appellant v. Her Majesty The Queen in right of Ontario
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.
PO Box 6166
Olympia, WA 98507
Copyright Kari Sable 1994-2006