00:00:06
within weeks of opening her medical
00:00:08
clinic dr kathleen holland had seven
00:00:11
infants who stopped breathing and had
00:00:13
seizures severe enough to require
00:00:15
emergency resuscitation in her office
00:00:18
considerably more than what most
00:00:20
pediatricians see in an entire year
00:00:24
when one of the children died
00:00:27
local health officials demanded answers
00:00:29
[Music]
00:00:42
[Applause]
00:00:44
[Music]
00:00:50
[Applause]
00:00:57
[Music]
00:00:58
kerrville texas is a quiet little
00:01:00
community just an hour's drive from san
00:01:02
antonio
00:01:04
although kerrville is primarily a
00:01:06
retirement community
00:01:08
dr kathleen holland saw a business
00:01:10
opportunity
00:01:12
she opened what was only the second
00:01:14
pediatric clinic in kerrville
00:01:17
reed and patty mcclellan were excited by
00:01:19
the prospect of a female pediatrician
00:01:22
coming to town a lot of mothers do want
00:01:24
to take their kids particularly if it's
00:01:25
a girl to a to a female doctor
00:01:28
and this was a young doctor a
00:01:30
progressive doctor
00:01:31
somebody that seemed to kind of breathe
00:01:32
a fresh a little bit of fresh air into
00:01:34
the medical community there and had
00:01:37
training in the latest techniques the
00:01:39
mcclellan's daughter chelsea was one of
00:01:41
dr holland's first patients when she
00:01:43
opened her practice in 1982.
00:01:47
chelsea was 15 months old
00:01:49
chelsea arrived on the very first day of
00:01:52
practice mom called reporting that she
00:01:55
was breathing funny and had done so
00:01:57
again
00:01:58
previously two months ago
00:02:01
just moments after dr holland finished
00:02:03
the evaluation chelsea stopped breathing
00:02:06
and had to be rushed by ambulance to the
00:02:09
sid peterson memorial hospital
00:02:11
there emergency room doctors revived
00:02:14
chelsea
00:02:15
but tests could not reveal what caused
00:02:18
the incident
00:02:21
just one month later
00:02:23
chelsea visited dr holland's office
00:02:25
again this time for a routine
00:02:28
vaccination
00:02:33
after being given the shot
00:02:35
chelsea stopped breathing turned blue
00:02:37
and had a seizure
00:02:39
once again the child was rushed to
00:02:41
peterson memorial hospital where she was
00:02:44
stabilized
00:02:47
later that day
00:02:48
chelsea was taken by ambulance to san
00:02:50
antonio to be evaluated by specialists
00:02:54
dr holland was following the ambulance
00:02:57
in her own car
00:02:58
along the way chelsea went into cardiac
00:03:01
arrest the ambulance pulled off the road
00:03:04
so dr holland could assist in the
00:03:06
resuscitation
00:03:07
[Music]
00:03:11
i jumped into the ambulance and
00:03:14
started doing
00:03:16
cpr and asked them where the closest
00:03:19
facility was which was comfort and so we
00:03:21
pulled into the closest facility and
00:03:24
unfortunately she did not respond to all
00:03:27
of the efforts
00:03:28
uh to bring her back and so after about
00:03:30
20 minutes or more in the hospital as
00:03:33
well as all of the efforts on route
00:03:37
she was pronounced dead
00:03:39
the autopsy concluded that chelsea died
00:03:43
of cardiac arrest attributed to sudden
00:03:46
infant death syndrome which usually
00:03:48
occurs in children under one year of age
00:03:52
chelsea had been premature and had some
00:03:54
breathing problems at birth
00:03:56
but by all accounts medical accounts she
00:03:58
had outgrown that problem
00:04:00
and sids is something that afflicts kids
00:04:03
who are younger i mean certainly doctors
00:04:05
can speak about that more
00:04:06
authoritatively but
00:04:07
generally you don't have kids dying of
00:04:09
sids at the age of 15 months
00:04:14
over the next several weeks dr holland
00:04:17
had more emergencies
00:04:19
a five-month-old girl started choking
00:04:22
and was unable to breathe and she too
00:04:25
had to be rushed to the hospital
00:04:30
a few days later yet another child had a
00:04:33
seizure which required emergency
00:04:35
treatment
00:04:36
in the first month of practice
00:04:39
dr holland had seven children who
00:04:41
suddenly and unexpectedly stopped
00:04:43
breathing had seizures and required
00:04:46
emergency hospitalization some of them
00:04:49
were indeed life threatening had
00:04:51
ambulances coming in on more than a
00:04:53
weekly basis that was totally
00:04:54
astonishing it was totally unprecedented
00:04:56
in kerrville they don't even have very
00:04:58
many young families with children so
00:05:00
ultimately other doctors who were just
00:05:02
watching this blizzard of activity got
00:05:04
very suspicious and started asking
00:05:06
questions and those suspicions led
00:05:09
medical investigators to reopen their
00:05:12
inquiry into chelsea mcclellan's death
00:05:17
[Music]
00:05:19
in the first month of practice
00:05:21
dr kathleen holland had seven children
00:05:24
who experienced seizures and breathing
00:05:27
problems in her office severe enough to
00:05:30
require hospitalization
00:05:32
one of those patients 15 month old
00:05:35
chelsea mcclellan died of cardiac arrest
00:05:38
on the way to the hospital
00:05:40
administrators at peterson memorial
00:05:42
hospital asked dr holland to attend a
00:05:45
formal meeting to discuss the situation
00:05:48
i was considered a prime suspect
00:05:52
and my practice obviously
00:05:54
fell back as a result
00:05:58
it strained put a great strain on my
00:06:00
marriage at the time
00:06:03
and
00:06:05
financially
00:06:07
things were falling apart
00:06:08
[Music]
00:06:10
during the meeting dr holland reviewed
00:06:12
each of the cases for the committee she
00:06:15
said all of the incidents could be
00:06:17
explained by the children's medical
00:06:19
histories chelsea was born premature and
00:06:21
had a history of breathing problems even
00:06:24
before coming to me
00:06:25
one member of the committee asked dr
00:06:27
holland
00:06:28
if she used the drug succinyl choline in
00:06:31
her practice
00:06:33
succinylcholine is a powerful muscle
00:06:35
relaxant which can cause respiratory
00:06:37
failure in large doses
00:06:40
it's so powerful it's sometimes used in
00:06:43
lethal injections for executions
00:06:46
dr holland said she had a vial in her
00:06:48
office but had never used it
00:06:51
they also asked dr holland if she
00:06:54
trusted her employees
00:06:56
dr holland said she did
00:06:59
that night after office hours
00:07:02
dr holland spoke with her nurse janine
00:07:05
jones
00:07:06
dr holland described jones's behavior
00:07:09
that night
00:07:10
as suspicious there was a lull in the
00:07:12
conversation and
00:07:15
the next thing she said was oh by the
00:07:16
way i found that missing vial of such no
00:07:18
choline
00:07:19
and i said what missing pile of sucks no
00:07:22
culling
00:07:23
i told you before i lost a vial of
00:07:26
succino choline and ordered a
00:07:27
replacement for it and i found the
00:07:29
missing bottle so now we have two vials
00:07:32
dr holland suspected it was more than a
00:07:35
mere coincidence that her nurse
00:07:37
mentioned the exact same drug
00:07:39
doctors asked her about in the meeting
00:07:42
i'm just sitting there and i'm absorbing
00:07:44
all of this
00:07:46
and i'm putting it in perspective with
00:07:48
the the emergency
00:07:51
the
00:07:52
meeting regarding my emergencies
00:07:55
the next morning dr holland went to the
00:07:57
refrigerator and found the two vials of
00:08:00
succinyl choline
00:08:01
both appeared to be full but in one of
00:08:04
the caps
00:08:05
she noticed two tiny needle marks
00:08:09
and at that point in time my whole world
00:08:12
collapsed
00:08:14
and i remember being emotionally just in
00:08:16
turmoil that morning just absolutely in
00:08:19
turmoil
00:08:20
dr holland immediately turned the vials
00:08:23
over to the authorities dr holland was
00:08:25
within our circle of suspicion
00:08:28
dr holland
00:08:30
was very defensive
00:08:31
in our investigation
00:08:34
because she felt
00:08:36
that as a captain of the ship so to
00:08:38
speak that she was responsible for this
00:08:40
child's death
00:08:42
and bear in mind at that time she was
00:08:44
anticipating a flood of lawsuits from
00:08:46
parents
00:08:48
janine jones was also under suspicion
00:08:51
jones was a
00:08:52
year 33-year-old licensed vocational
00:08:54
nurse divorced with two children who had
00:08:57
come to kerrville after leaving a job in
00:09:00
a pediatric intensive care unit in san
00:09:02
antonio she was sort of rough and ready
00:09:05
personality she was very coarse
00:09:07
rough
00:09:08
she cursed like a sailor
00:09:11
she talked about sex a lot even though
00:09:12
she wasn't
00:09:13
an attractive woman
00:09:16
she
00:09:17
kind of liked to you know mix it up and
00:09:19
give people a hard time the two vials of
00:09:23
succinyl choline were sent to the
00:09:25
forensic lab for testing although the
00:09:27
vial with the two needle holes appeared
00:09:29
to be full
00:09:30
tests indicated that 80 percent of the
00:09:33
vial had been filled with water
00:09:36
a large dose of succinyl choline could
00:09:39
have caused chelsea mcclellan's death
00:09:41
unfortunately it was considered to be
00:09:44
untraceable it's the type of drug that
00:09:47
after injection into the body it rapidly
00:09:50
disappears and it's not traceable in its
00:09:53
original form because suctional choline
00:09:56
is made up of succinic acid and choline
00:09:59
which are natural elements in the human
00:10:01
body
00:10:02
and without hard scientific evidence
00:10:05
all investigators had were dr holland's
00:10:08
suspicions and janine jones denials
00:10:12
[Music]
00:10:17
district attorney ron sutton was
00:10:19
beginning to suspect that 15 month old
00:10:22
chelsea mcclellan and some of the other
00:10:24
children in dr holland's pediatric
00:10:26
clinic had been intentionally injected
00:10:30
with succinylcholine
00:10:32
a powerful muscle relaxant
00:10:34
every child
00:10:35
who is of a non-talking age that came
00:10:38
into this clinic
00:10:40
with a potentially
00:10:42
serious medical problem suddenly had a
00:10:44
seizure if the child was a talking age
00:10:47
child
00:10:48
or some other problems just a sniffle or
00:10:51
something like that didn't get it but if
00:10:53
they had a potentially serious problem
00:10:55
and a non-talker
00:10:56
they got it
00:10:58
a vial of succinyl choline in dr
00:11:00
holland's office appeared to be full
00:11:03
but had two needle holes in the cap and
00:11:06
had been refilled with water
00:11:08
the prime suspect was dr holland's nurse
00:11:11
janine jones
00:11:13
since she was in the ambulance with
00:11:15
chelsea mcclellan when she went into
00:11:17
cardiac arrest and died
00:11:20
while all this was going on in kerrville
00:11:22
there were similar suspicions about
00:11:24
janine jones in san antonio just one
00:11:28
year earlier death rates rose
00:11:31
dramatically in the pediatric intensive
00:11:33
care unit at bexar county hospital while
00:11:36
janine jones was working there
00:11:39
dr vincent demaio the chief medical
00:11:41
examiner for bear county heard
00:11:44
suspicions about janine jones from some
00:11:46
of his medical colleagues after a while
00:11:49
it became common knowledge and it became
00:11:52
a kind of a morbid joke
00:11:55
that if you were going to have deaths in
00:11:56
the pediatric care unit it was always on
00:11:59
the shift that
00:12:00
janine jones was working
00:12:03
dr demaio passed this information on to
00:12:06
deputy district attorney nick rothy who
00:12:09
discovered that the death rates dropped
00:12:11
as soon as janine jones left the
00:12:14
hospital
00:12:15
we could tell
00:12:16
that
00:12:17
when jones left
00:12:19
those peak numbers dropped immediately
00:12:22
the month she left the day after she
00:12:24
left
00:12:25
things just leveled out and stayed level
00:12:27
they were level going in and then just
00:12:29
peaked right there
00:12:31
and then the minute she left i'd say
00:12:32
almost a minute i mean today to the day
00:12:36
they went back to what
00:12:37
normal levels
00:12:39
officials in san antonio called in the
00:12:42
centers for disease control in atlanta
00:12:44
georgia the premier medical
00:12:46
investigation agency in the world
00:12:49
dr gregory istri was the epidemiologist
00:12:52
assigned to analyze the death rates in
00:12:55
the intensive care unit the fact that
00:12:57
the deaths appear to have been declining
00:13:00
in the late 1970s in 1980 early 1981 and
00:13:05
then seemed to go up again in 1981-82
00:13:08
and the fact that that increase was
00:13:10
almost exclusively on the evening shift
00:13:13
or in the evening hours
00:13:15
made us think that there really was
00:13:17
something unusual that was going on
00:13:19
there the rise in the intensive care
00:13:22
death rates coincided with the dates
00:13:24
janine jones worked there
00:13:26
and jones worked the 3 to 11 shift
00:13:29
but there were more than 200 individuals
00:13:32
who passed through the pediatric
00:13:34
intensive care unit doctors nurses aides
00:13:38
ward clerks therapists technicians and
00:13:41
medical residents
00:13:42
dr istri began his investigation by
00:13:45
assigning each employee a number he
00:13:48
charted which of the 200 individuals
00:13:50
were on duty at the time of the 30
00:13:53
suspicious deaths and the 50 or so
00:13:56
unexplained medical emergencies
00:13:59
nurse 32 had a significant and quite
00:14:03
extraordinarily high risk of deaths to
00:14:06
patients when nurse 32 was working
00:14:08
compared to when nurse 32 was not
00:14:10
working
00:14:12
in fact
00:14:13
that risk was
00:14:15
10 times higher
00:14:17
the risk of death was 10 times higher
00:14:19
when she was working compared to when
00:14:21
she was not working and the identity of
00:14:23
nurse number 32 nurse 32 was janine
00:14:27
jones
00:14:28
is janine jones
00:14:31
prosecutors found evidence that
00:14:33
supervisors in the intensive care unit
00:14:36
strongly suspected janine jones was
00:14:39
somehow involved in these mysterious
00:14:42
deaths so they conducted a study
00:14:44
began to focus on janine jones
00:14:47
but decided what to do would be to
00:14:49
eliminate the lvns
00:14:52
from the staff and only staff the unit
00:14:54
with registered nurses thus getting
00:14:58
janine out of the picture
00:15:00
dr holland
00:15:01
asked hospital staff down there if
00:15:04
janine would be a good choice for her to
00:15:06
ask to come to kirby with her and they
00:15:08
said yes that she would be a good choice
00:15:11
and a good nurse for her therefore san
00:15:13
antonio got rid of janine sent her to
00:15:15
kirby
00:15:17
the suspicious deaths in the intensive
00:15:19
care unit stopped after janine jones
00:15:22
left
00:15:23
and the incident's mysteriously
00:15:26
resurfaced in the medical practice where
00:15:28
jones was next employed
00:15:35
prosecutors were convinced that 15 month
00:15:38
old chelsea mcclellan had been murdered
00:15:41
by an intentional injection of succinyl
00:15:44
choline
00:15:45
a powerful muscle relaxant
00:15:47
but they had no way to prove it since
00:15:50
there were no toxicology tests sensitive
00:15:53
enough to find succinylcholine in the
00:15:55
human body but prosecutors heard about a
00:15:58
forensic scientist in philadelphia
00:16:01
dr frederick readers who was conducting
00:16:04
research on drugs like
00:16:06
succinylcholine
00:16:08
chelsea mcclellan's autopsy samples were
00:16:10
sent to dr readers who took them to the
00:16:13
karolinska institute in sweden
00:16:16
there an experimental protocol permitted
00:16:19
chelsea's tissues to be analyzed with
00:16:21
gas chromatography
00:16:23
this process heats and separates the
00:16:26
various molecules in the samples then
00:16:29
measures the speed at which they
00:16:31
separate from one another
00:16:33
in a scientific first
00:16:35
traces of succinylcholine were
00:16:37
discovered in chelsea mcclellan's
00:16:39
embalmed tissues we have the hypothesis
00:16:42
of our finding that we are reasonably
00:16:45
certain that this child was administered
00:16:49
sectional calling
00:16:50
at or around the time of her death order
00:16:54
at or around the time of her onset of
00:16:58
the symptoms and signs
00:17:01
that then led to her death jeanine jones
00:17:05
was charged with the murder of chelsea
00:17:07
mcclellan
00:17:09
and pleaded not guilty
00:17:13
prosecutors believe that janine jones
00:17:15
first injected chelsea mcclellan with
00:17:17
succinylcholine in the examining room
00:17:21
while dr holland was busy with chelsea's
00:17:23
mother
00:17:24
and later injected chelsea again in the
00:17:28
ambulance
00:17:29
causing her death
00:17:33
the discovery of succinyl choline in
00:17:36
chelsea mcclellan's tissues
00:17:38
the diluted vial with the needle holes
00:17:40
found in dr holland's office
00:17:43
and the fact that janine jones was alone
00:17:46
with each of the infants at the time of
00:17:48
their seizures
00:17:50
all told a story
00:17:53
the last witness i believe that
00:17:54
testified in the in the kirbyo case in
00:17:56
georgetown
00:17:58
testified that she went up to janine
00:18:01
standing outside of sid peterson
00:18:02
hospital
00:18:04
and janine had said you know what this
00:18:06
place needs or at some point she said is
00:18:08
that what this place needs is a
00:18:10
pediatric intensive care unit
00:18:13
and uh and obviously she would want to
00:18:15
be the head nurse
00:18:17
and this other person said i think it
00:18:18
was another nurse
00:18:21
said well but janine we don't have any
00:18:23
critically ill children like that out
00:18:25
here
00:18:26
and janine
00:18:28
said
00:18:29
yes you do you just need to know go out
00:18:31
and find them
00:18:32
on february 16 1984
00:18:36
janine jones was found guilty of the
00:18:39
merger of chelsea mcclellan
00:18:41
by injection of succinal choline
00:18:44
and was sentenced to 99 years in prison
00:18:48
in a later trial
00:18:50
janine jones was also convicted of one
00:18:53
count of injury to a child while working
00:18:55
at bear county hospital in san antonio
00:18:59
specifically for injecting an infant
00:19:02
with 22 000 units of heparin a near
00:19:05
fatal dose
00:19:07
for that crime janine jones was
00:19:09
sentenced to an additional 60 years in
00:19:12
prison what had happened what janine was
00:19:14
doing was injecting these children with
00:19:16
a drug called heparin and which is a
00:19:18
blood thinner and and because it's a
00:19:21
blood thinner these children's little
00:19:23
wounds wouldn't coagulate and
00:19:24
consequently they started oozing
00:19:27
blood from all these stick marks janine
00:19:30
jones began creating havoc in the
00:19:32
intensive care unit in san antonio
00:19:35
because of what prosecutors believe was
00:19:38
her contempt for some of the doctors and
00:19:41
registered nurses who worked there she
00:19:43
was still in lvn she didn't have the
00:19:45
education they had and she wasn't going
00:19:46
to go as far as they were going to go
00:19:48
and i think she resented that
00:19:50
and when janine jones left san antonio
00:19:54
she continued her rampage in kerrville
00:19:58
there's so many people that that could
00:19:59
have indeed stopped janine jones at some
00:20:02
point could have done the right thing
00:20:03
and failed to do it it's really a story
00:20:06
about the medical
00:20:08
bureaucracy it's a story about
00:20:11
medical politics
00:20:13
it's a story about institutions that
00:20:15
fail to do what they should do
00:20:17
for all the wrong reasons
00:20:19
that that are afraid of
00:20:20
bad publicity and scandal
00:20:23
um and litigation and so allow janine
00:20:25
jones to go off and and harm kids and
00:20:28
curve all and murder chelsea mcclellan
00:20:30
that's what makes it a a terrible a
00:20:32
truly tragic tale
00:20:34
[Music]
00:20:36
dr holland says she relied on the
00:20:39
positive employment reference bear
00:20:41
county hospital provided for jeanine
00:20:43
jones before hiring her
00:20:45
despite a broken marriage numerous
00:20:48
lawsuits and near bankruptcy
00:20:50
dr holland stayed in kerrville texas to
00:20:53
rebuild her practice
00:20:55
she says it has taken years to regain
00:20:59
the trust of the community
00:21:01
in february of 1984
00:21:03
the practice was down to seeing four
00:21:05
patients a week
00:21:09
my
00:21:10
husband
00:21:12
divorced me
00:21:14
before the
00:21:15
year 1982 was closed
00:21:18
um
00:21:19
while those who had worked with me
00:21:21
before knew
00:21:22
of
00:21:25
my own character and knew that that i
00:21:27
wasn't involved my professional
00:21:29
reputation was totally gone
00:21:32
especially in this town
00:21:35
and so
00:21:37
i found myself
00:21:38
at rock bottom
00:21:40
but i knew i hadn't
00:21:43
i knew i hadn't
00:21:45
participated in that crime
00:21:48
and i knew that and i knew god knew that
00:21:51
and
00:21:53
i
00:21:54
just made a decision that i wasn't going
00:21:56
to quit and i wasn't going to leave
00:21:58
i had nothing to run from
00:22:02
[Music]
00:22:12
[Music]
00:22:33
you
