From the archives: The Baby Murders

A Maclean’s special report from 1984 on the investigation into infant deaths at the Toronto Hospital for Sick Children

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Elizabeth Tracy Mae Wettlaufer has been charged with eight counts of first-degree murder, accused of killing eight patients at long-term care homes in Ontario. But it’s not the first time that Canada’s medical system has come under such scrutiny, with shocking revelations. In 1984, Maclean’s reporter Arthur Johnson wrote about the investigation into the deaths of babies at Toronto’s Hospital for Sick Children and the charges laid on Susan Nelles. (The charges were eventually stayed; later theories suggested that the real culprit was actually a toxin that leeched from rubber.) Read the full story below.

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The administrators at Toronto’s prestigious Hospital for Sick Children were alarmed, and the nurses were frightened. Something had gone terribly wrong in the cardiac ward, and no one knew why. Throughout 1980 and early 1981 babies died in unprecedented numbers at Canada’s foremost children’s hospital—and the death rate seemed to be accelerating. The administrators ordered studies into the unexpected deaths, and nurses held anxious meetings after work to discuss their fears and apprehensions. Still, everyone hesitated to use the unthinkable word, “murder.” Finally, a father’s shouting, wall-pounding grief after his son had died unexpectedly on March 12, 1981, set in motion a series of startling inquiries that would prove conclusively that someone—or possibly more than one person—had murdered some of the babies by injecting them with enough of the heart drug digoxin to kill several adults. But, after one of the most exhaustive and dramatic criminal investigations in Canadian history, the question still remains: who did it? The search for the answer to the mystery has captured international attention. Investigators hope that this week’s long-awaited appearance before a judicial inquiry by nurse Susan Nelles— she was charged with four of the murders and then discharged at a preliminary hearing—will help them to find an answer to a case that has baffled police for three years.

Tragedy: Nelles’s arrest on March 25, 1981, was the beginning of a murder case without parallel in Canada. Her discharge at the conclusion of a preliminary hearing one year later was a sensational development in a tragedy that unfolded in a criminal court and was debated in almost every living room in the country. Since then, the case, amplified by intense and constant media attention, has been marred by bitter accusations and protests from those involved. The nurses insist that they have been subjected to trial by public inquiry. The hospital’s administrators worry that the publicity will damage the institution’s reputation. And the families demand to know why their babies died.

The source of the relentless interest was the compelling horror of the crime. No more helpless or innocent victims could be imagined. The babies ranged in age from nine days to 11 months. Some were seriously ill when admitted to the internationally renowned hospital. But some were expected to improve. Instead, while they were being treated on wards 4A and 4B of the cardiac unit, the babies suffered heart failure, could not be resuscitated and died. Police cite the death of Laura Woodcock on June 30, 1980, as the first suspicious case. The last was Justin Cook, three months old, who died on March 22, 1981. In all, investigators examined a total of 43 suspicious deaths. Autopsies on some of the babies showed levels of digoxin in their bodies 30 or 40 times higher than safe levels. Some of the babies had not even been prescribed digoxin. It seemed beyond comprehension that mass murder could have occurred in a world-famous institution devoted to healing children. That it could have gone undetected for nine months seemed beyond reason.

Exhaustive: The investigation has been controversial. Some of the world’s foremost medical and legal experts studied the baby killings during four exhaustive investigations, including one that the hospital itself conducted. Yet every probe seemed to raise serious questions about the hospital’s diligence in investigating the deaths and the police department’s competence in finding the killer. While hospital administrators and nurses became suspicious about the mysterious deaths as early as Sept. 5, 1980, an internal hospital investigation concluded that the deaths were natural among infants with serious heart and other medical problems. Nelles’s lawyers charged that Metro Toronto police made a hasty decision to charge her because she refused to answer their questions without a lawyer present. On Dec. 14, 1982, six months after Nelles had been discharged, Ontario Attorney General Roy McMurtry declared that police had additional information on the case and were pursuing new leads. But on Feb. 9, 1983, Police Chief Jack Ackroyd said that there was not enough evidence to justify laying new charges.

The other nurses who cared for the babies on the cardiac ward before they died have also come under close scrutiny since McMurtry ordered an inquiry under Mr. Justice Samuel Grange on April 21, 1983. And nursing staff testimony in recent weeks has been particularly sensational. Late last week Nelles made a surprise appearance. As she sat for five minutes in the audience at the back of the hearing room with John Sopinka, her lawyer, the only television camera in the room was trained on her face. And when she left, reporters and camera crews mobbed her. But recent testimony at the inquiry has turned the focus of media attention on a new subject: Phyllis Trayner, leader of Nelles’s nursing team. On Feb. 13 fellow nurse Bertha Bell testified that she saw Trayner inject an unidentified drug into the buritrol (intravenous feeder bottle) of baby Allana Miller around midnight on March 20, 1981. The baby, who had been assigned to Nelles, died at 3:27 a.m. The autopsy showed a large amount of digoxin in her body. According to Bell’s testimony, the baby’s chart and nursing notes did not record an injection administered by Trayner. A police lawyer said that Bell’s information would have changed the course of the police investigation if she had given it when police charged Nelles three years ago. But Bell added that police did not seem interested when she tried to tell them in April, 1981, that Nelles had not even been in the hospital when another baby died from a digoxin overdose. A second nurse, Kathy Coulson, testified that, before Nelles was arrested, she suspected that Trayner was involved in the baby deaths. And other nurses said that Trayner became so obsessed with the deaths that colleagues found it difficult to work with her.

The testimony regarding Trayner has led groups like the Canadian Civil Liberties Union to charge that the inquiry is becoming a trial without the safeguards of the judicial process.

Grange has made it clear that his mandate does not include using the word “murder” during the inquiry or when he reports to McMurtry. Indeed, the province’s Public Act prohibits him from making any finding of civil or criminal wrongdoing. Still, the Ontario Court of Appeal ruled late last week that Grange can name anyone he finds to have administered digoxin overdoses to the babies. The judgment confirmed an earlier ruling by the divisional court that allowed Grange to name names. Ian Scott, a lawyer for the hospital, had argued that Grange was empowered to conduct “an inquiry to find a killer.” Said Scott: “If there is a killer and Mr. Justice Grange knows who it is, we want that name. We have an obligation to ensure that that person does not return to work.” Lawyer Sopinka complained that although witnesses were giving opinions at the inquiry about who was responsible for the deaths, those people who had been named were not allowed an immediate chance to reply. Said Sopinka: “These are personal opinions without factual basis.”

Testify: As Nelles takes the stand this week, she will be able to offer her version of events on the cardiac ward for the first time. The small, slight nurse did not testify at her preliminary hearing. On the advice of her lawyers she has made few public statements and has refused most requests for interviews. After her discharge the hospital placed her on paid leave for roughly 2 1/2 years, but since late last year she has worked in the hospital’s dialysis unit.

Since last fall Nelles has offered the benefit of her experience in a series of talks to chapters of the Registered Nurses’ Association of Ontario. She told one group of nurses in Ajax, outside Toronto, on Nov. 22, “I was hurt by a couple of nurses who made completely subjective statements about me on the witness stand.” Still, Nelles told the group that the experience also had a positive effect: it made her more empathetic. Said the nurse: “I’m not so quick in judging my colleagues. I keep my thoughts more to myself than I did in the past.”

For Phyllis Trayner the Grange inquiry could be much more of an ordeal. The hospital gave her paid leave after Nelles’s arrest, as it did for Nelles, but Trayner has been on maternity leave since giving birth earlier this year. A study by the Atlanta Centers for Disease Control in g Georgia reported that Trayner had been on the cardiac ward during or shortly before all of the 28 most suspicious baby deaths. Commission counsel Paul Lamek is likely to question her about her colleagues’ comments about her preoccupation with the deaths, and he will certainly ask her to comment on the allegation about administering a drug that was never recorded.

But, once the nurses have finished testifying, the focus of the inquiry will shift to the conduct of the police investigation of the deaths and the manner in which they charged Nelles. Some nurses have already testified that the investigating officers appeared uninterested in evidence that pointed away from Nelles as the murder suspect. It was only when Judge David Vanek discharged Nelles on May 21, 1982, 14 months after the last suspicious baby death, that police resumed a full-scale investigation at the hospital and conducted a second round of interviews of doctors, nurses and others on the cardiac ward. And hospital administrators will likely be questioned about the diligence of their efforts before Nelles’s arrest to uncover the reasons for the deaths.

Investigators confronted indications of murder at the Hospital for Sick Children more by accident than by design. As revealed by testimony, the suspicion arose on March 12, 1981, when Dr. Paul Tepperman, one of Metro Toronto’s 20 coroners, received a telephone call from a concerned member of the hospital staff. Dr. Rodney Fowler, a senior cardiologist at Sick Kids, had just had an emotion-charged meeting with Kevin Garnett, whose 24-day-old son, Kevin Pacsai, had died that day on the cardiac ward. The child had undergone tests for an abnormally rapid heartbeat, and doctors planned to release him in two days. The grief-stricken Garnett questioned the baby’s sudden death and beat the walls of Fowler’s office with his fists. That shook Fowler’s belief that the baby had died of natural causes. Fowler then called Tepperman to ask whether or not the coroner wanted to investigate the death.

Concerned: Tepperman replied that, whenever a family expresses concern about a death, a coroner can launch inquiries. After noting some details Tepperman ordered that an autopsy be conducted at the hospital. The results revealed no abnormal circumstances. But four days later Fowler called Tepperman to report that his own research indicated that baby Kevin had a digoxin level about 13 times higher than the normal level for a baby being treated with the drug. Then, on March 20, Tepperman received a call from Dr. James Maneer, a staff pathologist at the hospital, who became concerned after hearing about the high digoxin levels recorded in the baby’s autopsy. Before that infant’s death Maneer had done an autopsy on four-month-old Janice Estrella after she had died on the cardiac ward on Jan. 11. The results revealed such a high level of digoxin that he thought the laboratory had made a mistake.

Tepperman concluded that it was not a mere coincidence that two sudden deaths had occurred on the same ward involving high levels of digoxin. He was also concerned that the hospital had waited two months before informing him of Estrella’s death. In fact, Tepperman was so disturbed that he made several attempts to reach his supervisor, Ontario’s chief coroner, Ross Bennett. He finally made contact the next day, Saturday, March 21. Bennett suggested a meeting with hospital officials and officers from the Metro police homicide squad. But when Bennett informed hospital officials later that day of his concerns about the two deaths, he said, “It seemed we were not telling them anything new.”

He was also surprised to learn that the hospital had already done a study of 20 deaths on the cardiac ward. Hospital officials said that they had ordered the investigation because of a morale problem among nurses on the ward. Tepperman was not convinced. In an interview he said, “It indicated a lot more was going on than we knew.” That night one-year-old Allana Miller died on the cardiac ward with a digoxin level of 72. At 4:56 the next morning three-monthold Justin Cook, who had been in the same room as Allana Miller, died. Homicide detectives then began examining the records of all deaths on the ward in previous months. By Sunday, March 22, laboratory tests revealed that Cook had a digoxin reading of 100—and that the drug had never been prescribed for him. Suddenly, police suspected murder.

Interview: To allow for time for questioning the homicide detectives decided to give the nursing team on the unit a three-day leave. The nurses were due back on the night of Wednesday, March 25. That day teams of policemen went to the homes of each of the five nurses to interview them.

When a team headed by Sgt. Jack Press arrived at Susan Nelles’s apartment, the officers identified themselves as policemen from the coroner’s office. However, her roommate, a law student, advised her not to answer any questions without consulting a lawyer if she faced questioning. Officer Press cautioned Nelles that any statement she made would be taken down in writing and could be used in evidence against her. Then, according to Nelles’s lawyer, Austin Cooper, Press said: “Okay, Justin Cook died of an overdose of digoxin, a drug he wasn’t supposed to have. We believe you gave him the drug and we would like to know why. Do you wish to give any explanation for his being given digoxin?” Nelles replied, “I think I want to speak to a lawyer.” Press then arrested her on a first-degree murder charge in the death of Justin Cook. A few days later police also charged Nelles with murdering the Pacsai, Estrella and Miller babies.

Charged: One year later Nelles stood trial at a preliminary hearing that for 44 days focused on testimony by many of her colleagues. Cooper, Nelles’s trial lawyer, submitted that the charges had been a horrible mistake. “Who kills little babies anyway without motive?” he asked. “An innocent person has been charged,” Cooper told Judge Vanek. But Crown Attorney Robert McGee maintained that Nelles, alone, of the cardiac ward nursing team, had shown signs of “aberrant behavior.” He pointed to the evidence of nurse Marie Mandel, who said that Nelles had referred to the fact that four or five deaths had occurred in a period of seven or eight days. Nelles, she said, had commented, “Not a bad record, huh?” And another nurse testified that after one baby died most of the nurses were crying, but Nelles had “a sort of smile.” In the end, Vanek discharged her by stating: “There is no direct evidence of any act on the part of Susan Nelles tending to show that she was involved in poisoning these babies by overdoses of digoxin; no evidence either of any suspicious or untoward conduct, of consciousness of guilt or coverup; and all of her actions are perfectly consistent with the due and proper performance of her regular duties as a registered nurse.”

In his judgment Vanek said, “We are dealing with an aberrant, twisted, warped personality, someone who poisons babies at a hospital with digoxin, and strange things might be expected to happen.” Indeed, witnesses at the preliminary hearing related bizarre stories of threatening telephone calls and strange marks made on doors and lockers. Nurse Elizabeth Radojewski testified that nurses feared a lunatic was loose in September, 1981, when Trayner found pills in her bowl of soup and nurse Sui Scott discovered them in her salad at the hospital. In fact, the pills were propanolol, a heart drug that is supposed to regulate the rhythm of the heart. Trayner testified that in August and September, 1981, she found crosses drawn with what seemed to be red lipstick on her hospital locker, apartment door and car.

But other evidence emerged at the hearing that was much more disturbing. The Crown described 16 other mysterious baby deaths in the cardiac ward and said the cases were “carbon copies” of the four murders with which Nelles had been charged. And as police continued to investigate, the count of possible murders rose.

Vanek’s contention that a crazed murderer had been loose in the hospital’s cardiac ward was reinforced by a team of expert medical researchers from the Centers for Disease Control in Atlanta, which conducted a detailed analysis of the circumstances surrounding the deaths. According to the CDC report, released in February, 1983, of 36 deaths at the hospital’s cardiac wards between July, 1980, and March, 1981,18 were suspicious. The CDC reported that the 18 deaths might have been caused by digoxin poisoning, could not be explained adequately or were unexpected and inconsistent with the babies’ medical records. Of the 18 deaths, the CDC found, digoxin overdoses “probably” caused seven. As well, the report said that Trayner was on ward duty when all 28 of the most suspicious deaths occurred.

Even if the Grange investigation does not eventually point to a killer, the Hospital for Sick Children will never be the same. The facility, which has won an international reputation for the quality of its medical care and its research achievements, has been shaken to its foundations. The hospital was criticized by the Atlanta report and by an earlier inquiry into its procedures by Ontario Supreme Court Justice Charles Dubin for failing to spot the epidemic of deaths on the cardiac wards. After the Nelles hearing, Kenneth Rowe, the hospital’s assistant administrator, explained why the deaths had gone unreported for so long. “It is not normal for a hospital to think foul play has been expected,” he said. Still, as a result of Dubin’s recommendations, executive director Douglas Snedden said that the hospital made numerous changes in its procedures. Among them: a unit-dose system for dispensing all drugs in the hospital’s pharmacy; a statistical review of hospital deaths; and identification tags for staff and visiting family members.

For nurses, the numerous investigations have been a series of agonizing trials. Frances Kitely, the lawyer representing the Registered Nurses’ Association of Ontario at the Grange inquiry, told a meeting in Hamilton, Ont., in January that nurses had become the “sacrificial lambs” in the affair. And Alison Lehman, the RNAO’s liaison officer at the inquiry, declared in an interview last month that nurses had suffered because of an inept police investigation. The remark drew an angry demand for an apology from Metro police lawyer Percival. He did not get one.

Mystery: Partly as a result of the intense media coverage, the expectations for Grange and his inquiry are enormous. But, given the inconclusive findings of all the previous investigations, it is unlikely that Grange will be able to state categorically what happened. But Grange appears to be the last hope for a solution to the mystery. Said Supt. George Thompson, who is monitoring the inquiry for the Metro Toronto police department: “Everyone is looking for the key and the answer.”

But greater understanding can never compensate the parents of the dead children for their tragic loss. Still, the inquiry promises to dispel some of the uncertainty that has haunted the mothers and fathers for three years. Betty Gionas of Mississauga, Ont., spent months trying to find out if her daughter Barbara had been murdered after the child died on March 9, 1981, at the age of two months on the cardiac ward. She still is not sure. Gionas has gleaned two lessons from the tragedy: “Doctors have to be more aware of things that go wrong repeatedly and take steps earlier. Parents have to be more aware and check up on doctors and nurses.” As Judge Grange prepares his report on the unsettling affair on the cardiac wards, he may be writing the final chapter in Canada’s most widely followed murder mystery. The conclusion of his inquiry will mean the end of three years of painful publicity and criticism for the hospital and its staff. And for the parents of the dead children, he may be able to answer some of their troubled questions. But, unlike the situation in a fictional whodunit, the identity of the killer may never be known.

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