Excerpt from NOT GUILTY
by George Sullivan
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Mystery at Sick Kids
March 12, 1981, bgan as a routine Thursday at Toronto's Hospital for Sick Children, a century-old institution known throughout the world for its year in, year out success in the care of young patients. But events that day were to trigger a real-life horror story for the parents of dozens of infants being treated at the hospital. They also were to cause a skilled and experienced nurse to be suddenly arrested and wrongfully accused of the horrendous crime of killing four sick babies in her care.
Twenty-four-day-old Kevin Pacsai died at Sick Children's Hospital that March day in 1981. While the baby's death was sudden and unexpected, to hospital authorities it was considered a natural death. Little Kevin had been admitted to the hospital the day before and assigned to Ward 4B, a section set aside for the treatment of young children with heart problems. He was in good condition when he arrived. Nurse Susan Nelles, who had been a member of the hospital's staff for a year and a half, and who was known to be a thoughtful and vigilant caregiver, was assigned to watch over Kevin.
Late that night, Kevin had periods where his heart beat irregularly, sometimes faster than normal, other times slower. But otherwise Kevin appeared in stable condition to nurse Nelles. Twice during the night he had hungrily taken his bottle.
At 9:30 that night, Nelles gave Kevin a dose of a drug called digoxin in an amount that had been ordered for him. A relatively mild drug, digoxin is derived from foxglove, a common plant whose leaves have been used for centuries in brewing a tea used to strengthen the heartbeat. Today digoxin is widely used when a patient's heart is weak and has trouble pumping blood through the body.
As 2:30 the next morning, a Code 25 alarm blared on the hospital's fourth floor, signaling an emergency. A baby's heart had stopped beating. Nurse Nelles was a member of the emergency team. After she checked to see that Kevin was resting comfortably, she rushed to answer the alarm. Despite the frantic efforts of nurse Nelles and the other members of the cardiac arrest team, the baby could not be saved.
When Nelles went back to check on Kevin, she found that his condition had changed. An hour earlier, he had been active and alert. Now he was listless. And she noticed that his heartbeat was irregular again.
Nelles was worried. She called Dr. Colm Costigan, who was in charge of the emergency team. When Dr. Costigan arrived and examined the infant, he confirmed that Kevin's condition had changed for the worse. He arranged to have the baby transferred to the hospital's intensive care unit.
Later that morning, the device monitoring Kevin's heartbeat sent out an ear-piercing alarm. Kevin's heartbeat had slowed dramatically. Nothing could be done to control it as it plunged downward. Kevin died at 10:10 on the morning of March 12, 1981.
From Not Guilty: Six Times When Justice Failed, copyright © 1999 by George Sullivan.
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