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