It has become—and is likely to remain—the murder case that will not die. Ontario Supreme Court Justice Samuel Grange probed the mystery during 191 days of testimony beginning in June, 1983, and a further three months of deliberation before he released his 288-page report last month on the deaths of 36 babies at the Hospital for Sick Children in Toronto between June, 1980, and March, 1981. Grange concluded that someone had killed eight babies by administering overdoses of digoxin, a drug used to control irregular heart rates. Grange also found that 13 other deaths were either “highly suspicious” or “suspicious.” But police have laid no new charges of murder since the case against nurse Susan Nelles, originally accused of murdering four of the babies, was dismissed in May, 1982. Last week, when the hearing’s transcripts became public, police announced that they had assigned three officers to review the case. But a substantial group of scientists, doctors and nurses continues to question Grange’s conclusions. They say that the scientific data on which they were based is not dependable enough to prove that anyone killed the babies.
Grange’s critics say that the testing for digoxin was inadequate and that new studies indicate some of the methods used to detect the drugs are unreliable. Declared James Russell, a professor in the department of surgery at the University of Alberta, in Edmonton: “The conclusions are outrageous. There is no scientific evidence that proves murder was committed.” Added Russell, who has worked as a researcher in the field of clinical chemistry for 17 years: “It is entirely possible that none of the babies died from digoxin poisoning.” During the period of the baby deaths the standard laboratory technique used to determine the amount of digoxin in a patient’s blood was a process known as radioimmunoassay (RIA). That method depends upon the interaction between special proteins and digoxin to detect the drug and measure the amount in the sample being checked. Using RIA a technician combines a patient’s blood or tissue sample with animal antibodies known to bind with digoxin molecules. Then, if the first test detects digoxin, the technician clears the sample of substances similar to digoxin which could raise the actual reading produced. This second process is known as High Pressure Liquid Chromatography (HPLC).
The Centre of Forensic Sciences in Toronto used both methods to test blood and tissue taken from 21 of the 36 babies who died. And Grange concluded that the results of those tests “went a long way to satisfying” him that murder had
been committed—with digoxin as the fatal drug. Grange said he found it significant that the RIA and HPLC tests had not only detected high levels of digoxin in several of the babies but also indicated the presence of the drug in the bodies of four other infants who were not supposed to have been given it.
But some scientists argue that both methods sometimes mistake other compounds for digoxin. Dr. Steven Soldin, a biochemist at the Hospital for Sick Children and one of the country’s leading experts in digoxin research, for one, says that the test results are not always reliable. In October, 1984, Soldin published a paper in the professional journal Clinical Biochemistry entitled,“Are Immunoassays for Digoxin Reliable?” His conclusion: they were not. The paper described a series of experiments beginning in July, 1983, by Soldin and a team of researchers at the hospital. They discovered that RIA tests could not clearly distinguish between digoxin and more
than 25 substances found naturally in the body, including such hormones as cortisone and progesterone. Soldin noted that the compounds which gave “digoxin-like” readings never reached the high level found in the blood and tissue
samples of the babies who died at the hospital. It was for that reason that Grange rejected his evidence.
Other experts also question the validity of the standard tests. Dr. David Seccombe, a medical biochemist at Vancouver’s Shaughnessy Hospital, has conducted experiments on a daily basis since 1982 analysing the blood from newborn children and pregnant mothers. He has found that RIA tests can label at least six nondigoxin compounds as digoxin. Said Seccombe: “With the commonly used system of testing we cannot separate digoxin from digoxin-like substances. With our state of knowlege I do not think that you can conclude that what they found was digoxin.”
But Douglas Lucas, the director of the Centre of Forensic Sciences, rejects that belief. Said Lucas: “Part of the criticism after the Grange report was released comes from the fact that those scientists did not understand what was done. As for the analytic data, everyone who
looked at it who was considered an expert concluded that the testing method was state of the art.”
Such scientists as Soldin and Seccombe insist that the controversy could have been avoided if investigators had relied more directly on Mass Spectrometry (MS), a more specific method of testing. In that test, molecules in blood or tissue are bombarded (usually by electrons), causing them to fragment. Technicians can then positively identify specific molecules by their fragmentation
patterns, because each pattern is as distinct as an individual fingerprint. Said Soldin: “It is the most definitive testing method we have available. If it had been used, we would have known that digoxin was present where it was never prescribed.”
The method was used on three occasions to test samples from three of the babies who died under suspicious circumstances. But Grange did not rely heavily on the test evidence when he made his final judgment.
Instead, he wrote, “It is doubtful how useful [the MS method] is in digoxin testing because of that drug’s high molecular weight and because the process is lengthy and expensive.” Grange said he reached that conclu-
sion after a panel of 10 experts in the field told him that the Forensic Science Centre’s methods of testing ( RIA and HPLC ), “produced the best and most reliable results.” As a result, he ruled that further testing using MS would be unproductive.
But Catherine Costello, a member of the panel that advised Grange on the usefulness of further MS testing, said the panel’s objection to MS was not that it was not accurate or could not be performed but that by the spring of 1984
there were no reliable tissue samples from the dead babies available. Said Costello: “If it had been done at the time of the deaths, they would have had an open-and-shut case.” She further criticized the quality of tests that were done. Said Costello, associate director at the Mass Spectrometry Facility at the Massachusetts Institute of Technology in Cambridge: tests were inconclusive. In one case, the spectrum produced was of such poor quality that it was impossible to say whether digoxin was present or not. In the other case, there was only a partial spectrum scanned. The people doing the testing did not seem to know enough I about mass spectrome-
try.” But Lucas said: “We did not represent them to be good spectrums, but that was because of the quality of the samples. They were done by highly qualified mass spectrascopists.”
Dr. Peter Macklem, physician in chief of Montreal’s Royal Victoria Hospital, has also criticized the Grange report’s use of evidence based on levels of digoxin found in the bodies of nine exhumed babies. Declared Macklem: “Nobody really knows whether or not digoxin builds up in the body after death. There have been no animal studies with which to compare the results. The legal system just did not accept the criteria that scientists demand.”
Macklem first publicly entered the controversy over digoxin levels in September, 1984, when he spoke to a meeting of the Canadian Society for Clinical Investigation in Montreal. His argument was both dramatic and macabre: only by exhuming a control group of babies who had not died of digoxin overdoses could scientists expect to reach an accurate conclusion. He made the same point before the inquiry last September but conceded that his suggestion was impractical for ethical reasons.
Critics have also objected to the significance placed on the times of the deaths. Said Dr. Albert Burton, a biochemist at the University of British Columbia in Vancouver: “Twenty-nine of the 36 deaths occurred between 1 a.m. and 5 a.m. This fact fits in less with the theory of murder in the night than it does with biological factors. Cortisol, an important hormone, regulates a great many body functions, and it falls to a low ebb during the night. At this time, the body’s resistance is lowest and its vulnerability highest.”
The criticism of the Grange inquiry conclusions is welcomed by the six nurses who worked or supervised on wards 4A and 4B during the time the babies died. Said Gail Paech, president of the Registered Nurses Association of Toronto, speaking for the nurses: “We are not at all satisfied with the Grange report. A variety of experts testified as to how digoxin works on the body. Grange acknowledged some and disregarded others. There is no question that there is a sense of bitterness.”
For his part, Grange has refused any further comment on the inquiry. But the reaction from the nurses has brought its own criticism. Said Paul Lamek, counsel for the Grange inquiry: “How do they explain that [the deaths] happened on one ward under one team of nurses, at one time of night?” Yet, for some, other questions remain. Added Soldin: “All the possibilities that were present before the Grange inquiry still exist today. The book has been closed prematurely.”
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