Family of boy who died after prescription error told health minister is ‘all in’ for change

The mom of an eight-year-old boy who died after a pharmacy switched his sleep medication for a toxic dose of another drug says she is encouraged by what she heard in a face-to-face meeting with Ontario Health Minister Eric Hoskins earlier this week.

“We had a great meeting,” Melissa Sheldrick told Go Public.

“He was very honest, he was kind and respectful, I believe he was genuine in his want to help us with this, seeing where the gaps are and trying to fill some of those gaps and to improve patient safety.”

Sheldrick, her husband and daughter met with Minister Hoskins on Tuesday at the family’s request.

“We’re certainly considering her proposals,” Minister Hoskins told CBC News.

“I was very appreciative to have the opportunity to meet with the Sheldrick family. Obviously, I expressed my deep sorrow at the loss of their son particularly under these circumstances. It’s unimaginable.”

Melissa Sheldrick

Melissa Sheldrick and her family met with Ontario Health Minister Eric Hoskins on Tuesday to talk about improving medication safety. (CBC)

After Andrew’s death, the family started a petition to get the Ontario government to enact mandatory medication error reporting.

That petition now has more than 20,000 signatures. The goal is 25,000.

Judging from what what was said in Tuesday’s meeting, Sheldrick says she is convinced the Minister is already on board.

“He is committed to maintaining transparency throughout this and being accountable. His quote was ‘I’m all in,’ and so he is going to help us move forward with this,” Sheldrick told Go Public.

Andrew Sheldrick

The Sheldrick family says they are willing to work with the health minister to ‘help in any way that we can’ to prevent medication error deaths like Andrew’s. (Supplied by the Sheldrick family)

Andrew Sheldrick died on March 12 after his mom gave him what she thought was his usual dose of medication for a sleep disorder.

A report by Ontario’s Office of the Chief Coroner concluded Andrew had not taken Tryptophan, the sleep medication he’d been prescribed, but Baclofen, a muscle relaxant drug used to treat muscle spasms caused by conditions such as multiple sclerosis.

The coroner found the boy had almost three times the dose of Baclofen in his system that would be toxic to an adult, and no trace of the sleep drug Tryptophan.

The report concluded an independent compounding pharmacy in Mississauga had made a mistake and substituted one drug for the other.

Minister Hoskins first learned about Andrew Sheldrick’s story when Go Public brought it to his attention in late October.

At the time, he vowed to look into changes. He repeated that commitment this week.

“I am more than willing — I’m anxious — to find additional measures that will speak to transparency and accountability that can reduce the risk of this kind of tragedy happening ever again,” he said.

According to an update on the Sheldrick’s petition page, Hoskins told them he had begun conversations with the Ontario College of Pharmacists (OCP) and the Institute for Safe Medication Practices (ISMP) and has a commitment from both to develop “high level protection policies and regulations” to govern prescription error monitoring.

As Go Public also reported in October, Minister Hoskins reiterated his plan to study Nova Scotia’s medication error tracking system.

Nova Scotia is the only province that requires pharmacists to report all errors to The Institute for Safe Medication Practices (ISMP) Canada.

Minister Hoskins said the province will also study pharmacist workload to see if that is a contributing factor in prescription errors.

Andrew Sheldrick

There is currently no requirement to report errors to a formal body except when a pharmacy is inspected by its governing college. Andrew Sheldrick, 8, died after a Missisauga pharmacy dispensed a toxic dose of muscle relaxant instead of his usual medication for a sleep disorder. (Supplied by the Sheldrick family)

When asked when changes will be implemented, Hopkins didn’t offer details but said “it shouldn’t take long.” He told CBC News he wants to ensure the Sheldrick family has confidence that the province proposals “will have a real impact.”

To date, there is no requirement to report errors to a formal body except when a pharmacy is inspected by its governing college.

Typically, each Ontario pharmacy is inspected every two to four years and error reports are not public.

ISMP Canada is now investigating what happened in Andrew Sheldrick’s case and their report’s findings will be used to improve the system, according to Julie Greenall, ISMP Canada’s Director of Projects and Education.

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