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Undetected Medical Toxicity Leads to Child’s Death

When a child or any patient is being seen by multiple doctors and specialists, someone must supervise the overall treatment plan.

Doctors and specialists must work together and communicate for any such treatment plan to be effective.

Unfortunately for one young boy and his family, lack of communication between his pediatrician and specialists resulted in cardiac arrest and death for the boy, with medication toxicity implicated as cause.

The five-year-old boy, who suffered from ADD and sleep disorder, was referred to a behavioral specialist for severe behavioral complaints. The specialist started him on 500 mg of clonidine at bed time.

His parents were told to closely monitor the child for side effects, including blood pressure and pulse. The specialist sent a consult letter containing this information to the pediatrician who later stated he never received it.

Five months later, the child was referred to a sleep specialist, who started him on 1500 mg of chloral hydrate, to be taken at bedtime. The child was seen by the sleep specialist twice and the specialist recorded 11 telephone communications with his parents, including discussions on medication risks.

When the sleep specialist saw the child four months later, he learned that the family had switched the sleep medication several times, alternating between chloral hydrate, Benadryl and hydroxyzine.

The family had switched medications because they felt the choral hydrate was causing a rash, which is a known common side effect of the drug. The specialist asked the family to list any visible changes or side effects from the medication. He also asked that any future medication changes be approved only after clinical consultation.

Over the next several months, the child’s behavior and sleep issues only worsened. The pediatrician suggested the child be given a second dose of chloral hydrate when he woke up during the night. The family then began administering two doses during the night.

Six months after the second appointment with the sleep specialist, the patient underwent surgery for a benign brain tumor. While the child was being prepared for anesthesia, the parents were told the child was on a “whopping dose” of the chloral hydrate, but this concern was not communicated to the pediatrician.

After the surgery, the child was placed on steroids, and initially showed improvement in behavioral and sleep issues.

Upon the child’s discharge from the hospital, the neurologist re-started both prescriptions for clonidine and chloral hydrate. The pharmacy department questioned the pediatrician about the high dose of chloral hydrate that had been prescribed for the child. Not having much experience with this medication, the pediatrician reviewed a pediatric dosage text, but never consulted the sleep specialist who had initiated the medication.

Several months later, the child collapsed at home immediately following a second dose of chloral hydrate, and died of a cardiac arrest. Although an acute overdose was not identified as the cause of death, evidence of elevated concentrations of clonidine and chloral hydrate was found in the body.

The parents sued the pediatrician, the behavioral specialist, and the sleep specialist, because the physicians failed to:

• make them aware of the cardiac side effects of the medications (clonidine and chloral hydrate).
• monitor the child for medication side effects.
• provide access to appropriate specialty care because of gate-keeping for the managed care organization.

The parents had a strong medical malpractice case that was settled for $500,000 based on the following factors:

The pediatrician was unfamiliar with some of the medications he had prescribed. When required to refill medications prescribed by another physician, the prescribing physician should learn the recommended dosage and any side effects. When increasing the medication dosage, the physician should communicate with the specialist who prescribed the medication. Any pharmacy concerns regarding dose, strength or frequency should serve as a red flag and warrant full review.

The patient was never monitored for medication toxicity. Primary physicians must be familiar with serious side effects of medications so they will know if a monitoring plan is needed and can provide the necessary follow-up.

Lack of direct communication between the pediatrician and the specialists.
Patients can assist in relaying information from other providers, but relying on patients for critical information is never appropriate. It is the responsibility of primary care providers and specialists to ensure that the handoff of vital information reliably occurs.

For more on medical safety issues, see the library of articles by Daytona Beach medical malpractice attorney.

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