2-year-old died after hospital missed a decimal point in medication dosage, leading to overdose, lawsuit says

GAINESVILLE, Fla. (WCJB/Gray News) – A family in Florida is suing a hospital after they say their 2-year-old son was accidentally given a fatal dose of potassium phosphate, leading to his death.

The lawsuit filed Nov. 6 lists UF Health Shands in Gainesville, Florida, as the defendant, along with several doctors, pharmacists and other medical professionals at the hospital.

According to the lawsuit, 2-year-old De’Markus Page died on March 18, 2024.

The lawsuit says De’Markus was first brought to another hospital by his mother on March 1, 2024, due to his persistent crying, diarrhea and decreased appetite.

He was diagnosed with rhinovirus and enterovirus, which are often the cause of respiratory illnesses like the common cold.

However, De’Markus was also found to have a low potassium level, which the emergency department began IV treatments for.

After evaluating De’Markus further, medical staff at the hospital decided he needed a higher level of care and transferred him to UF Health Shands.

After arriving at UF Health Shands, doctors found De’Markus’ potassium level to be “dangerously low,” the lawsuit says, which they began treatment for.

However, the following day, the lawsuit says a doctor mistakenly entered the incorrect amount of potassium phosphate to be given to De’Markus.

The lawsuit says the doctor made a critical error by leaving out a decimal point in the dosage. The correct amount was supposed to be 1.5 mmol, but 15 mmol was entered – 10 times the amount De’Markus should have been given.

The lawsuit claims that several other supervising physicians, colleagues and pharmacists failed to catch and correct the mistake, despite the hospital’s pharmacy system issuing a “Red Flag” warning that alerted them to the excessive dosage.

“Because of these errors, De’Markus received two consecutive doses of a massive overdose of oral potassium phosphate,” the lawsuit states.

De’Markus’ potassium levels rose to a fatal level, which caused him to go into cardiac arrest.

The lawsuit also alleges that medical professionals failed to respond to De’Markus’ cardiac arrest in a timely manner, and he went without breathing for at least 20 minutes.

The lawsuit says the lack of oxygen caused De’Markus to suffer irreversible brain damage, as well as “catastrophic” damage to other organs.

He spent the next two weeks on life support and showed no signs of improvement. He was taken off life support and died on March 18, 2024.

“It’s been extremely difficult since the passing of my son because to this day, I still have not known what happened,” Dominique Page, De’markus’ mother, told WCJB. “I was never told. When I asked, it was always a vague, ‘I do not know. I do not know.’ I still have nightmares about what happened.”

WCJB reached out to UF Health Shands officials for comment, who say they cannot comment on pending litigation.

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