In January 1982, babies became ill in a separate department, it was later found epinephrine, which was not supposed to be on that ward, had somehow been substituted for vitamin E, there had been non-fatal unauthorized digoxin administration to other babies, and another death was, contrary to what the hospital said at the time, caused by unauthorized administration of digoxin. In September 1981, team leader nurse Phyllis Trayner (died 2011) found heart drug capsules in food she was eating and another nurse found the capsules in her soup.