The unlocked digoxin cabinet that sent thirteen infants to death
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カートに追加できませんでした。
しばらく経ってから再度お試しください。
ウィッシュリストに追加できませんでした。
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ほしい物リストの削除に失敗しました。
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ポッドキャストのフォローに失敗しました
ポッドキャストのフォロー解除に失敗しました
The unlocked digoxin cabinet that sent thirteen infants to death
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The unlocked digoxin cabinet that sent thirteen infants to death
In this episode we lay out the unfolding crisis at the Hospital for Sick Children in 1980-81: a cardiac ward reorganization, a widely accessible supply of digoxin, and a sudden rise in infant mortality that clinicians noticed before police were involved. What patterns and decisions kept questions unanswered as families demanded explanations?
Person: Kevin Pacsai
Location: Hospital for Sick Children, Toronto
Date: June 30, 1980 (ward reorganization) - March 1981 (police arrival)
Topic: unexpected spike in infant cardiac deaths and digoxin access
Event: two infants with exceptionally high digoxin blood concentrations (one 13× normal)
- Administrators split the cardiac unit into two adjacent wards on June 30, 1980, a routine logistical change before the deaths rose.
- During summer 1980-spring 1981, digoxin was stored unsecured and accessible to any staff on the cardiac ward.
- Senior cardiologists recognized a sharp increase in mortality (from about one death per week to five) but deliberately delayed escalation citing ward morale.
- Dr. Paul Tepperman received autopsy blood results showing the highest digoxin level of his career, then, days later, another result nearly as extreme (thirteen times normal).
- The case produced a five-year investigation and a public inquiry with a 200-page report, yet no criminal convictions were reached.
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