My last posting of May - May 29th. I thought since there have been a few deaths recently related to medication errors, I would repost this. This is what happens when people jump to conclusions and investigations are not carried out properly.
It is easy to point fingers at the suspect, but what happens when you actually are innocent and everyone assumes you are guilty? There but for the grace of god......
Here is a young nurse's story - the one that rocked our nursing world back in the early 1980s.
When I was a young nurse back in 1981-1982, a Canadian court case shocked the nursing community. It was enough to have every nurse in Canada take stock of their vulnerability.
It was discovered that there was a higher than average death rate in a certain Pediatric Cardiac Unit at Toronto's Sick Kids Hospital. Up to 46 babies died "suspiciously". An MD told his friends, then went to the police - "Someone's killing our kids" he claimed.
You can read all about it if you google "Susan Nelles nurse". She was accused of murdering 4 babies. All the evidence was circumstantial. Yet, she was arrested and hauled away by the police and incarcerated until the judge exonerated her due to insufficient evidence almost a year later. The biggest part of the prosecutors case rested on her close vicinity to the Unit plus the above MD's observation that she wasn't sufficiently grief stricken - according to his standards - while she was doing end of shift paperwork in the am on the deceased baby's chart.
Turns out that she wasn't even there for 3 out of the four suspected "homicides" ....and the MD had no clue what the RN was like, never having spent more than a few moments with her. Also, it was found that the test that detected digoxin - the suspected killer - was not only experimental, but flawed. Yet, because of the proceedings, her reputation was damaged and it caused stress to her family - enough stress that her father, an MD , died of cardiac arrest during the proceedings.
Her legal costs back then exceeded $200K which was the price of 3 average homes.
She lost almost a year of her life, spent under a microscope and denied a normal life. The newspapers reported extensively on it and people were ready to play judge and jury, calling for "justice" to be rendered on this nurse.
She was stripped of dignity, privacy and her reputation. You can still find her name in thesis', newspaper articles online and general hits.....1,710 google results for "Susan Nelles nurse"....her notoriety just won't die. In March 1991 the Halifax Chronicle Herald reported that she was still "haunted" by the accusations of murder that had been made against her.
Circumstantial Evidence.
Imagine - you could end up in Jail for a good chunk of time because coincidence sets you the wrong place at the wrong time ( although not as many times by a long shot as another nurse who was later under suspicion but no charges laid).
Then, because you have a law student as a roommate, and she suggests you should see a nurse liability lawyer because of the "talk" about the unit and gives you a couple of phone numbers, and when the police come to question you - you mention that you wish to contact a lawyer first and you pull out those handy phone numbers - the police think you are exhibiting "suspicious behavior".
Then an MD that flies through your unit once in a while feels compelled to testify about your "lack of grief" and the "scene of the crime" has been disposed of due to hospital inattention despite all the suspicions.
Oh, but you say - that was almost 30 years ago.
Think it couldn't happen today?
Take a look at Lucy De Berk, the Dutch RN that was recently - in this past decade - incarcerated for 6 1/2 years, convicted of serial murders (7) with the "proof" based on incorrect statistical data, wrongly analysed and wrongly interpreted by a statistician.
There were no eyewitnesses or evidence found. Only the statistical improbability of babies dying on her shift. In the end, all the deaths were attributed to "natural" causes. No evidence whatsoever. Just stats and somebody's say-so.
But, the damage remains. It took a physical toll on De Berk. She suffered a stroke while incarcerated. It also took a toll on her personal life. As a newspaper reports: "On Wednesday the Arnhem court is expected to conclude the case by declaring her innocent of the murders, a course of action urged on the court by the public prosecutors.
It should bring to an end one of the worst miscarriages of justice in Dutch history, but will it clear her name? Many Dutch people appear unpersuaded." The public don't see the injustice of it all. She will still have to deal with this - probably for the rest of her life.
The thought that a nurse that is innocent can be hauled up before the courts and judged by society, still gives me a chill. I am fairly careful in what I say out loud in the hospital. I might think some things......who doesn't.....but what comes out of my mouth in a hospital setting is fairly measured.
I am uber-careful with my charting, drugs and such. But how do you protect yourself when you have done nothing wrong?
Interestingly enough, through the whole process, who was the most to blame for the accusations?
Points to be pondered:
1. Although the deaths increased in the Cardiac unit, the overall deaths in the hospital did not. Why? Apparently babies were being moved out of the ICU before they should have been and put on the Cardiac Unit.
After Nelles arrest, the hospital changed the policy to keep the patients in ICU longer post operative. So, statistically speaking, post arrest - there was a dramatic decrease in the deaths on the Cardiac Unit itself, but overall - no change. The hospital had just redistributed the deaths to the ICU, but in the process- further incriminated Nelles.
2. The supposed presence of digoxin may well have never existed. In the Nelles case, the tests the courts relied on to detect digoxin in the deceased and exhumed babies were experimental and was proved to show false positives. It was actually impossible to test whether digoxin was even present.
Also, hospital policy dictated that bodies be cleaned off, IV tubing dumped and bedding around the baby sent to laundry etc....therefore perhaps critical evidence discarded - evidence that may have cleared Nelles immediately.
3. The Dutch Nurse? Statistics and psychology drove this case. De Berk's conviction - and even the 'proof' that there were any murders at all – let alone by whom – were almost entirely based on flawed data and flawed interpretation.
Apparently the traces of toxins found in the bodies of the deceased in this case could have been residual from treatments done. There was no evidence linking De Berk to any of the deaths except she was on shift at the time of expiration - and the stats showed that there were more deaths on her shift by chance than could be statistically proved possible.
4. Convinced she was guilty, the police and the managers of the Juliana Children's Hospital assembled a compendium of "data" in which it seemed every death became unnatural when it had occurred during, or after, a shift in which she had worked. For one of the alleged murders, it was established on appeal she had not even been in the hospital for three days around the time it occurred.
Their saving grace?:
1. The nurses working with Nelles all supported Nelles throughout, testifying opposite of what the MD did....which was a major factor in the judge dismissing all charges. Their solidarity in blaming hospital policy went far to exonerate Nelles. No thanks to the one
MD (Dr Fowler) who seemed insistent on pushing his theory of guilt by facial expression.
2. The determination of a statistical mathematician at a Leiden University that believed De Berk was innocent, was the driving force behind clinching an overturn in De Berk's case. Finally an expert was brought in to debunk the theories in the prosecutors argument - the flawed testing.
It is easy to point fingers at the suspect, but what happens when you actually are innocent and everyone assumes you are guilty? There but for the grace of god......
Here is a young nurse's story - the one that rocked our nursing world back in the early 1980s.
When I was a young nurse back in 1981-1982, a Canadian court case shocked the nursing community. It was enough to have every nurse in Canada take stock of their vulnerability.
It was discovered that there was a higher than average death rate in a certain Pediatric Cardiac Unit at Toronto's Sick Kids Hospital. Up to 46 babies died "suspiciously". An MD told his friends, then went to the police - "Someone's killing our kids" he claimed.
You can read all about it if you google "Susan Nelles nurse". She was accused of murdering 4 babies. All the evidence was circumstantial. Yet, she was arrested and hauled away by the police and incarcerated until the judge exonerated her due to insufficient evidence almost a year later. The biggest part of the prosecutors case rested on her close vicinity to the Unit plus the above MD's observation that she wasn't sufficiently grief stricken - according to his standards - while she was doing end of shift paperwork in the am on the deceased baby's chart.
Turns out that she wasn't even there for 3 out of the four suspected "homicides" ....and the MD had no clue what the RN was like, never having spent more than a few moments with her. Also, it was found that the test that detected digoxin - the suspected killer - was not only experimental, but flawed. Yet, because of the proceedings, her reputation was damaged and it caused stress to her family - enough stress that her father, an MD , died of cardiac arrest during the proceedings.
Her legal costs back then exceeded $200K which was the price of 3 average homes.
She lost almost a year of her life, spent under a microscope and denied a normal life. The newspapers reported extensively on it and people were ready to play judge and jury, calling for "justice" to be rendered on this nurse.
She was stripped of dignity, privacy and her reputation. You can still find her name in thesis', newspaper articles online and general hits.....1,710 google results for "Susan Nelles nurse"....her notoriety just won't die. In March 1991 the Halifax Chronicle Herald reported that she was still "haunted" by the accusations of murder that had been made against her.
Circumstantial Evidence.
Imagine - you could end up in Jail for a good chunk of time because coincidence sets you the wrong place at the wrong time ( although not as many times by a long shot as another nurse who was later under suspicion but no charges laid).
Then, because you have a law student as a roommate, and she suggests you should see a nurse liability lawyer because of the "talk" about the unit and gives you a couple of phone numbers, and when the police come to question you - you mention that you wish to contact a lawyer first and you pull out those handy phone numbers - the police think you are exhibiting "suspicious behavior".
Then an MD that flies through your unit once in a while feels compelled to testify about your "lack of grief" and the "scene of the crime" has been disposed of due to hospital inattention despite all the suspicions.
Oh, but you say - that was almost 30 years ago.
Think it couldn't happen today?
Take a look at Lucy De Berk, the Dutch RN that was recently - in this past decade - incarcerated for 6 1/2 years, convicted of serial murders (7) with the "proof" based on incorrect statistical data, wrongly analysed and wrongly interpreted by a statistician.
There were no eyewitnesses or evidence found. Only the statistical improbability of babies dying on her shift. In the end, all the deaths were attributed to "natural" causes. No evidence whatsoever. Just stats and somebody's say-so.
But, the damage remains. It took a physical toll on De Berk. She suffered a stroke while incarcerated. It also took a toll on her personal life. As a newspaper reports: "On Wednesday the Arnhem court is expected to conclude the case by declaring her innocent of the murders, a course of action urged on the court by the public prosecutors.
It should bring to an end one of the worst miscarriages of justice in Dutch history, but will it clear her name? Many Dutch people appear unpersuaded." The public don't see the injustice of it all. She will still have to deal with this - probably for the rest of her life.
The thought that a nurse that is innocent can be hauled up before the courts and judged by society, still gives me a chill. I am fairly careful in what I say out loud in the hospital. I might think some things......who doesn't.....but what comes out of my mouth in a hospital setting is fairly measured.
I am uber-careful with my charting, drugs and such. But how do you protect yourself when you have done nothing wrong?
Interestingly enough, through the whole process, who was the most to blame for the accusations?
Points to be pondered:
1. Although the deaths increased in the Cardiac unit, the overall deaths in the hospital did not. Why? Apparently babies were being moved out of the ICU before they should have been and put on the Cardiac Unit.
After Nelles arrest, the hospital changed the policy to keep the patients in ICU longer post operative. So, statistically speaking, post arrest - there was a dramatic decrease in the deaths on the Cardiac Unit itself, but overall - no change. The hospital had just redistributed the deaths to the ICU, but in the process- further incriminated Nelles.
2. The supposed presence of digoxin may well have never existed. In the Nelles case, the tests the courts relied on to detect digoxin in the deceased and exhumed babies were experimental and was proved to show false positives. It was actually impossible to test whether digoxin was even present.
Also, hospital policy dictated that bodies be cleaned off, IV tubing dumped and bedding around the baby sent to laundry etc....therefore perhaps critical evidence discarded - evidence that may have cleared Nelles immediately.
3. The Dutch Nurse? Statistics and psychology drove this case. De Berk's conviction - and even the 'proof' that there were any murders at all – let alone by whom – were almost entirely based on flawed data and flawed interpretation.
Apparently the traces of toxins found in the bodies of the deceased in this case could have been residual from treatments done. There was no evidence linking De Berk to any of the deaths except she was on shift at the time of expiration - and the stats showed that there were more deaths on her shift by chance than could be statistically proved possible.
4. Convinced she was guilty, the police and the managers of the Juliana Children's Hospital assembled a compendium of "data" in which it seemed every death became unnatural when it had occurred during, or after, a shift in which she had worked. For one of the alleged murders, it was established on appeal she had not even been in the hospital for three days around the time it occurred.
Their saving grace?:
1. The nurses working with Nelles all supported Nelles throughout, testifying opposite of what the MD did....which was a major factor in the judge dismissing all charges. Their solidarity in blaming hospital policy went far to exonerate Nelles. No thanks to the one
MD (Dr Fowler) who seemed insistent on pushing his theory of guilt by facial expression.
2. The determination of a statistical mathematician at a Leiden University that believed De Berk was innocent, was the driving force behind clinching an overturn in De Berk's case. Finally an expert was brought in to debunk the theories in the prosecutors argument - the flawed testing.
Conclusion:
Sometimes, in the process of finding answers for the public, Management may use you as a scapegoat. You hope that your hospital will back you when the time comes, but don't count on it.
As both these nurses above found out - Nurses, in the eyes of the management, when under fire - are expendable.
This isn't the only conclusion you can draw from this .... but the obvious message seems pretty clear to me.
******************************************
A little post script here: Apparently, according to the published report in the Ottawa Citizen, the prosecutors stated that if the judge had found sufficient evidence to proceed to trial in the Susan Nelles case, they would have dropped the case because the outcome would not have been in their favor - and they didn't want to put Ms Nelles through the pain and suffering of a drawn out trial.
Does anyone really understand that kind of reasoning???......
nurseXY said...
Wow.
Just...wow.
Just...wow.
newnurseinthehood said...
This is so messed up. Dr. Fowler sounds a massive douche. Wow, someone didn't cry at work? Yeah, sounds pretty heartless.
A NURSE said...
Definitely a travesty of justice.
And I agree about MD Fowler. If you clicked on the link and read the actual transcript of the questioning....he is majorly a douche. I tried to google his name but nothing comes up. Perhaps he is not "of this earth" at this time. It sure is quite the mark to leave on this earth...the only reference to him is that record of his statement.....his douchebagness on display for posterity.
And I agree about MD Fowler. If you clicked on the link and read the actual transcript of the questioning....he is majorly a douche. I tried to google his name but nothing comes up. Perhaps he is not "of this earth" at this time. It sure is quite the mark to leave on this earth...the only reference to him is that record of his statement.....his douchebagness on display for posterity.
1 comment:
Exactly. When I saw the headlines about the events at Seattle Childrens this past month my thoughts were: I cannot judge. I have no idea what the circumstances were. I am positive Childrens has a pyxxis. I am positive they have fail-safes in place. How can we know what truly went on that particular day?
People are so quick to judge. Here in America we're supposed to presume innocence until proven guilty. HA! Tell that to masses and/or the media.
There but for the grace of God go I.
Post a Comment