The baby killer at Toronto's Sick Kids was rubber - Macleans.ca

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

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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.