Show Notes
A grieving father, an unlocked digoxin cabinet at SickKids, and two impossible blood levels - how did that expose them?
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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