The baby killer at Toronto’s Sick Kids was rubber

The real culprit for a wave of deaths in the early 1980s was a compound found in seals on IVs and syringes

Baby killer turns out to be rubber

QMI Agency

In April 2010 a story concluded in a Dutch courtroom, much like a similar one burned into the memories of Canadians of a certain age. Nurse Lucia de Berk was cleared of seven murder convictions that had put her in prison, supposedly for life, in 2004. After the unexpected death of a baby cardiac patient—determined by autopsy to be a case of deliberate poisoning with the heart drug digoxin—de Berk was arrested. Deaths previously ruled natural were relabelled because de Berk was present. Prosecutors took as proof of guilt indications that fell far short of evidence—in her diary de Berk confessed to a “very great secret,” which she later said was her unscientific interest in tarot cards—and ignored the fact she wasn’t present for some of the “murders.”

In short, it’s a close replay of Toronto nurse Susan Nelles, the deaths of dozens of babies at the city’s Hospital for Sick Children during 1980 and 1981, and the resulting Grange inquiry after the bogus case against Nelles collapsed. But the real parallel remains unknown to most Canadians even now: it’s not that the wrong person was fingered for murder, but that no murders were committed at all.

That’s the conclusion meticulously and persuasively argued by retired physician Gavin Hamilton in The Nurses Are Innocent. Between June 1980 and March 1981, baby deaths spiked 625 per cent at Sick Kids’ cardiac unit—43 cases in all. Autopsies belatedly performed as death inexorably followed upon death seemed to show poisonous levels of digoxin. Investigators focused on Nelles, because she was (apparently) on duty for 24 of the deaths, and because she had the temerity to ask for a lawyer. Later, the Grange inquiry managed to cast a lifelong cloud of suspicion over another nurse, Phyllis Trayner (now dead), while ruling eight of the deaths as murders.

So what really happened to those children? A cluster of factors, according to Hamilton. They were very sick, and it took only the tiniest of nudges—natural or deliberate—to push them across death’s threshold. And that push was coming with increasing force. MBT, a chemical compound in the rubber seals used in IV lines and disposable plastic syringes, was leeching into the contents of those devices, bringing chances of life-threatening anaphylactic shock—which is how Hamilton, a radiologist from London, Ont., encountered it—and of death by accumulated toxins. The problem grew, unseen, as the era of unit-dose syringes dawned around 1980. Designed to eliminate overdose errors, prepackaged unit doses had three-year shelf lives—all the longer for the MBT to leech into the contents.

The smallest, most fragile patients, the cardiac babies, were most at risk: more injections, more transfusions, more poison, more chances of crossing the threshold. And if circumstances were cruelly conspiring against the children, so too were they taking aim at the accused nurses. The tests used to measure the digoxin levels in the autopsied babies were less than useless. They consistently misread MBT as digoxin, and failed to take into account that digoxin in the hearts of cardiac patients spreads through the body postmortem, giving a false reading of how much was present during life.

Then there was the Charles Smith factor. The persuasive, incompetent and now disgraced pathologist began his career at Sick Kids in 1980. It’s impossible to evaluate Smith’s exact role in a murder investigation that arose because of findings made in the hospital’s autopsy rooms, but Hamilton is sure it was significant: “I smell him,” he says in an interview, “I smell his presence.”

Hamilton has reason to. Something was compelling authorities to bull ahead when they should have known better. At the same time the Sick Kids deaths happened, Australian researchers warned of MBT’s lethal cumulative effects, especially in infants. Most disturbingly, a 1980 to 1983 study at London, England’s Hammersmith Hospital found “potentially toxic” levels of MBT in 91 babies. By the theory promulgated by Toronto Crown prosecutors, their suspected grim reaper must have been active in hospitals worldwide. And so it was: MBT, rubber’s killer compound.




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The baby killer at Toronto’s Sick Kids was rubber

  1. Editors:  The compounds were leaching into the contents of the syringes.  Leeching is another matter entirely.

  2. So it wasn’t the nurses, has the true culprit been prosecuted with same level of zeal as the nurses were? Were the incompetent prosecutors taken to task for their actions? Were lessons learned and proper protocols followed for all future products?
    No, no and no. I seem to recall a Montreal doctor daring to reveal the inadequate protocols in use at that time for testing drugs, and the practices of drug companies hidden from the light of day. Packaging a known drug in a toxic manner due to lack of testing is surely no different that releasing an improperly tested drug.
    Still to this day a drug company can continue testing despite results until a test shows a positive result, and then bury their property (many negative test results) and publish the positive one. And then off to market they go!
    Another facet of capitalism’s benefits, that society must be the real test of the unknown, because to properly test a product would cut into profit margins.

    • I think you are a bit confused.  The single dose syringes were not made by pharmaceutical companies and have been in use for years in adult and pediatric applications without incident.  That is likely why they were not on the radar when the babies died and the tests revealed digoxin poisoning.   I agree.  The police and pathologists rushed to judgement but you cannot blame the pharmaceutical companies either.  They had no evidence whatsoever to believe that the product was unsafe and it isn’t unsafe for anyone by very sick babies.  Afterall, if this product is used in all IV lines and syringes, just think how many people have been exposed to it without reacting. 

      • I think you are a bit confused…”has the true culprit been prosecuted with same level of zeal as the nurses were” … which words in that sentence look the most like ‘pharmaceutical companies’ to you?

        “At the same time the Sick Kids deaths happened, Australian researchers
        warned of MBT’s lethal cumulative effects, especially in infants.”… does that say AT THE SAME TIME? Gee that must mean it WAS KNOWN… when “The problem grew, unseen, as the era of unit-dose syringes dawned around 1980″ and “Between June 1980 and March 1981, baby deaths spiked 625 per cent at Sick Kids”
         
        It sure sounds like the problem was known and had been researched when the NEW unit dosage syringes were available for public use. I like the use of the word ‘unseen’.

        So in conclusion, the single dose syringes had NOT been in use for years, had been researched and the problem found and identified, the evidence had been published, the product had not been tested by the supplier and the evidence of the Australian study was ignored by the supplier.

        • Pardon me, I was referring to the case of the Dutch nurse which occured 20 years after the Canadian baby deaths.  Apparently the Australian research was not widely noted. There are no indications that followup studies to verify the results were ever done.   Even a book explaining what really happened in 1980/81 took 30 years to come out.  I think it easy to stand back now and say “it is so obvious” but when the same product has been used for years in other syringes and IVs and only a very small number of at risk individuals are affected….and when the toxicity tests lead you to something altogether different, it was a difficult puzzle to unravel.

  3. families of the nurses so sue the heck out of them for causing so much grief to them.

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