Thirteen Times Too Many: Babies Dying Inside Toronto's Trusted Hospital
The blood of a dead baby showed a digoxin level thirteen times normal at Toronto’s premier children’s hospital, and that result sat in a file for two months while more children died-twenty deaths in roughly two months, the death rate jumping from about one per week to five. How did a world-class hospital respond by calling it a “morale problem,” leaving a drug cabinet unlocked, and keeping critical autopsy results from the coroner?
In this episode, we lay out the sequence of events inside the Hospital for Sick Children between June 30, 1980 and March 1981, following nurses’ warnings, internal investigations, withheld autopsy findings, and the coroner’s entry after a distraught parent’s reaction-what finally pulled outside authorities into the ward and what questions still remained?
Person: Janice Estrella
Person: Kevin Pacsai
Person: Kevin Pacsai
Location: Hospital for Sick Children, Toronto
Period: June 30, 1980-March 22, 1981
- Digoxin concentration in one dead baby measured at 13 times the normal level.
- Approximately 20 children died within roughly two months on the cardiac ward.
- Baseline death rate was about one death per week, which rose to about five per week.
- Janice Estrella’s autopsy result sat in a hospital file and was not disclosed to the coroner until March 20, 1981-nearly two months after it was obtained.
- Kevin Pacsai, age three weeks, died on March 12, 1981, prompting the coroner’s immediate involvement.
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