Susan Nelles and a Nurse's Nightmare
Susan Nelles was a pediatric nurse who was wrongfully charged with murdering infants.
Unexplained Deaths
Babies in the cardiac ward of Toronto's world-renowned Hospital for Sick Children were dying in what seemed like mysterious circumstances. Was a homicidal caregiver killing them?
There was an apparent spike in the unexplained deaths of vulnerable infants.
Death of a Baby
Laura Woodcock was born on June 12, 1980, but she failed to thrive. She was transferred to Toronto's Hospital for Sick Children (known as Sick Kids) suffering from jaundice, a lung infection, and a minor heart defect. None of these conditions were deemed to be life threatening.
Initially, she was treated with antibiotics and digoxin, a drug “used to improve the strength and efficiency of the heart, or to control the rate and rhythm of the heartbeat (Mayo Clinic).” However, the digoxin treatment was quickly stopped.
Six days after admission to Sick Kids, Laura Woodcock's condition rapidly worsened and she went into cardiac arrest. Resuscitation efforts failed and the baby died at the age of 18 days. According to the Royal Commission of Inquiry:
“The pathologist was unable to give an explanation for the sudden death of the infant. The Coroner's Investigation Statement, nevertheless, contained the following statement: 'Upon my investigation I was satisfied that death was due to natural causes.'”
At the time, this was thought to be an individual tragedy. Nothing more. But over the next nine months, the cardiac wards at Sick Kids saw a 625% increase in child mortality rates.
Sick Kids is one of the world's leading pediatric hospitals.
Digoxin Deaths
According to a University of Calgary report: “Early meetings among hospital staff concluded the problem was not serious.” But then, four-month-old Janice Estrella died in January 1981.
The infant arrived at Sick Kids in December 1980 in very poor condition with a major heart defect. Surgery to correct the problem was successful and the child was placed in intensive care and given digoxin, among other medications. The digoxin was halted and Janice Estrella, while seriously ill, was stable.
The later Royal Commission of Inquiry described subsequent events:
“At 2:40 a.m. on January 11, the baby was observed to be gasping, with a rapidly declining respiratory rate and bradycardia (slow heart rate). Little heart beat could be heard. The cardiac arrest team was called but the baby could not be resuscitated. She was pronounced dead at 3:22 a.m.”
Blood samples showed the child had a higher level of digoxin in her than a therapeutic dose would account for.
Three months later, 23-day-old Kevin Pacsai was admitted to Sick Kids for investigation of an uneven heartbeat. He was doing quite well when, in the early hours of March 12, 1980, his nurse, Susan Nelles, noticed a rapid downward change in his condition.
Nelles had difficulty getting a physician to look at the little boy, but eventually he was transferred to the intensive care unit where he died a few hours later. The autopsy found no cause of death other than digoxin toxicity.
The deaths of babies Estrella and Pacsai convinced the coroner that something was dreadfully amiss and police were called in to investigate.
Digoxin is widely prescribed to heart patients.
Nurse Nelles Charged With Murder
Babies continued to die. One of them, 12-week-old Justin Cook, also had a high level of digoxin in his blood, and the night he passed away he was under the care of Susan Nelles.
All members of the Ward 4A nursing team were suspended and interviewed by police who, by then, had focussed their attention on Susan Nelles. On the advice of her roommate, a law school student, she retained legal counsel. She was the only nurse to lawyer up, and this led police to be suspicious.
That University of Calgary report notes: “Three days after baby Cook’s death, she was arrested and charged with the murder of ... four babies. The suspicious baby deaths then stopped. Nelles volunteered little information in the police interview which further convinced the police of her guilt.”
She maintained her innocence, and there were holes in the police case.
During one infant death for which she was charged, Nurse Nelles had been off work for several days. She was not the only member of Sick Kids staff with access to digoxin and she had an unblemished record as a dedicated pediatric nurse.
When the case against Susan Nelles came up for a preliminary hearing at Ontario’s Provincial Court, it was thrown out for lack of evidence and all charges were dropped.
Nelles then pursued lawsuits against several provincial legal entities for malicious prosecution. These were settled by the defendants and Nelles was awarded her costs.
The Grange Inquiry and Aftermath
In 1983, a royal commission was set up to inquire into the baby deaths at Sick Kids. The result was largely inconclusive. Susan Nelles was exonerated and it was noted that accused persons should be free to hire legal counsel without raising the suspicions of investigators.
Justice Samuel Grange, who headed up the inquiry, ruled that 15 baby deaths were “suspicious.” But although another nurse was named as a person of interest, nobody has ever been charged with the baby deaths. And, it turns out, those deaths may have been accidental.
In the early 1980s, a chemical known as MBT-2 was used in the rubber tubing of intravenous lines and syringes, but it was found to leach out and contaminate medications.
Also, MBT-2 mimicked digoxin in postmortem examinations. It seems highly likely that the infants dying at Sick Kids were getting a lethal overdose of MBT-2 and not digoxin at all.
This is the conclusion of Dr. Gavin Hamilton in his 2011 book The Nurses Are Innocent. He notes that babies in intensive care at Toronto's Hospital for Sick Children were already in a very fragile state. The smallest amount of MBT-2 poisoning would be enough to tip them over into catastrophic organ failure.
Bonus Factoids
- In 2004, nurse Lucia de Berk in the Netherlands was sentenced to life in prison for the deaths of seven babies from digoxin overdoses. Under Dutch law, she faced no possibility of parole. Newspapers called her the “angel of death” and “the murder nurse.” Her conviction was based largely on statistical improbability—prosecutors calculated that the odds of numerous babies dying on Ms. De Berk's shifts at three hospitals were one in seven billion. The deaths were deemed an “impossible coincidence” and the nurse was found guilty as charged. Then, statistician Richard Gill examined the prosecution's numbers and found they were wonky. After six years in prison, Ms. De Berk was exonerated. Science.org notes: “Her case is now considered one of the worst miscarriages of justice in the Netherlands.”
- In Italy, nurse Daniela Poggiali was also convicted of murdering two of her patients largely because of faulty statistical evidence. She spent seven years in custody before being found not guilty by the country's Supreme Court in 2023.
- In 2015, Susan Nelles Pine established a scholarship at her alma mater, Queen's University, to assist a pediatric nursing student.
Sources
“Report of the Royal Commission into Certain Deaths at the Hospital for Sick Children and Related Matters.” The Honourable Mr. Justice Samuel G. M. Grange, 1984.
“Whatever Happened To ... The Prosecution of Susan Nelles.” Peter Bowal and Kelsey Horvat, prism.ucalgary.ca, September/October 2011.
“The Baby Killer at Toronto’s Sick Kids Was Rubber.” Brian Bethune, Maclean's magazine, December 22, 2011.
“Unlucky Numbers.” Cathleen O'Grady, science.org, January 19, 2023.
This content is accurate and true to the best of the author’s knowledge and is not meant to substitute for formal and individualized advice from a qualified professional.
© 2024 Rupert Taylor
