On Sunday, March 13, eight-year-old Andrew Sheldrick was found dead by his father in their Ontario home.
Though they were told that they couldn’t have done anything to save him, Andrew’s parents had no idea what happened to their little boy. They didn’t know for over four months.
Finally, in July, they received their answer from a coroner’s report. It concluded that Andrew had not taken his regularly prescribed sleep medication, tryptophan. They were horrified to find that he had three times the toxic dose of baclofen, a muscle relaxant, in his system instead. This was all due to one pharmacy’s tragic mistake.
Because Andrew had parasomnia, a sleep disorder that caused him to wake up multiple times during the night, it was necessary for him to take tryptophan so he could get proper rest.
He had been taking the medication since it was prescribed to him in October 2014 without any problems or bad side effects. It turns out that at Floradale Medical Pharmacy Ltd., the Mississauga pharmacy he regularly got it from, an unidentified pharmacist had prepared the wrong medication for him.
Floradale is a compounding pharmacy, which means that it mixes personalized medications for each patient. Andrew took a liquid form of tryptophan because he had trouble swallowing pills, so his parents weren’t able to tell the difference when a liquid form of baclofed was accidentally given to them instead.
The heartbroken family has filed a lawsuit against the pharmacy and its owner and manager, Amit Shah. Andrew’s mother, Melissa Sheldrick, has also started a petition demanding that Ontario’s health minister enact mandatory medication error reporting to The Institute for Safe Medication Practices (ISMP). The only Canadian province that requires it is Nova Scotia.
ISMP is currently in the process of investigating the circumstances that led to Andrew’s death. When the report is completed, the Ontario Coroner’s Office will decide whether it should be made public or not.
The Sheldrick family has also made a complaint to the Ontario College of Pharmacists, which is able to punish the people responsible for this entirely avoidable tragedy. Parents should never have to worry that their children’s prescribed medications might accidentally kill them.