Ontario mom wants mandatory prescription-error reporting across Canada after son, 8, dies
Months after Melissa Sheldrick’s eight-year-old son Andrew died from ingesting a prescription issued in error, the Mississauga, Ont., mother is on a mission to have mandatory medication reporting systems instituted across Canada.
“We can’t undo what has happened. We know that and we have come to accept that as a family. However, putting another family through this is not acceptable,” Sheldrick told Global News.
She said after Andrew turned five years old, he was diagnosed with a sleep disorder that “altered his behaviour.” He was then given prescriptions to help address his condition.
“We started him on a medication that was prescribed and it turned him around 180 degrees,” Sheldrick said, adding her son was a “bundle of energy.”
“He giggled the most when he was up to no good and it is sound, and light, and laughter that we really miss in this house.”
Fast-forward to March of this year, the family was preparing to go to Montreal for March Break. Sheldrick said she picked up the medication from the pharmacy on March 12 in the evening and gave Andrew a dose shortly after.
“We picked it up on Saturday, brought it home, put it in the fridge … the label on the bottle was right. The bottle said it was for Andrew at this address, and it said it was Tryptophan,” she said.
Sheldrick said when she found her son in bed on Sunday morning, panic set in.
“We had no idea this could even happen. I remember the paramedic holding me up just saying sometimes this just happens with kids and you need to be prepared for that,” she said.
Sheldrick said she and her husband were called by the police for a meeting with the coroner, and that’s when they were told the medication issued for Andrew wasn’t Tryptophan.
“It was completely Baclofen, which is a muscle relaxant – a very powerful muscle relaxant often given to patients with M.S. and he was given three times the lethal dose for an adult,” she said.
“So it would have stopped his breathing, it would have just stopped everything in his body… quickly.”
Sheldrick has launched a lawsuit against the pharmacy. But the incident has prompted her to speak out and call for better tracking of prescription dispensing-related errors. She said she recently met with Ontario Health Minister Dr. Eric Hoskins, who said the province is committed to change.
“Let’s look at different models that do exist in other parts of Canada or indeed the world, that we can put in place; measures to minimize, if not eliminate that risk from happening in the future,” Hoskins told Global News, adding he is committed to working with the College of Pharmacists on the issue.
Sheldrick described her meeting with Hoskins as “extremely positive” and said the Health Ministry is also working with the Institute For Safe Medication Practices to find a way to put safe guards in place for increasing patient safety.
She said she is taking her campaign nationally and hopes to meet with Prime Minister Justin Trudeau and federal Health Minister Dr. Jane Philpott.
Errors in dispensing pharmaceutical drugs in Canada are not uncommon, but Nova Scotia is the only province that requires mandatory reporting of prescription-related errors.
Sheldrick said she hopes Ontario, as well as the other provinces and territories, will follow Nova Scotia’s lead.
“We’ve heard from people from coast to coast to coast – from across the world – wondering why this isn’t even in place already?”
Amit Negandhi, a pharmacist from Newfoundland, said tracking programs should be done across Canada.
“I am very curious as to what happened in [Sheldrick’s] son’s case because that was big,” he said.
“If we had a mandatory error-reporting system, that would help that.”
Angie Seth contributed to this report
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