Parents say the complaint was “swept under the rug” after a mistake at BC pharmacy led to a 5-year-old overdose
The physical effects of Eli Wilson’s clonidine overdose lasted more than a day. A full 16 hours after taking the medication, video taken by his parents shows the autistic five-year-old falling asleep standing up.
Eli recovered after a night in the hospital, but it would be months and thousands of dollars before Mom and Dad confirmed to Lindsay and Brent what they suspected.
Someone at Goldstream Forbes Pharmacy in Victoria, BC made a mistake in February 2021 while assembling the sleeping drug.
Eli’s clonidine was more than 14 times more potent than his prescribed dose, a lab report shared with CBC shows.
“I burst into tears,” recalls Lindsay Wilson.
Her husband recalls their pediatrician saying they had dodged a bullet.
“As bad as it was, it could have been much, much worse,” said Brent Wilson.
Hoping for accountability, the Wilsons filed a complaint with the College of Pharmacists of BC
In a letter from the college board of inquiry later that year, they learned that the pharmacy did not have standard policies or procedures for drug mixing, and the dispensing pharmacist did not perform an accurate final inspection of the drug.
Despite these findings, the investigative committee decided there would be no punitive action against the pharmacists and nothing about what happened was made public.
“This is being swept under the rug completely,” said Lindsay Wilson. “When a new customer … does their due diligence, there’s no record of it anywhere.”
When the college’s decision was upheld as “justified and reasonable” by the Health Professions Review Board last week, the Wilsons decided it was time to speak out. They believe the college has failed in its responsibility to protect the public.
“I think it’s important for people to be aware of this so that they can ask their pharmacists questions and then make good decisions for themselves,” said Brent Wilson.
“No Evidence of Bad Intent”
Pharmacists Ennreet Aujla, then manager of Goldstream Forbes, and Quin Andrew, who prepared the drugs, were both named in the complaint.
Attorney Elyse Sunshine represented the pharmacists throughout the complaints process and told CBC her clients are barred from speaking about certain cases due to patient confidentiality.
“Product safety and handling procedures are of paramount importance and all of our pharmacies have staff training on safe and accurate dispensing,” Sunshine said in an email.
The College did not respond to requests for comment.
In the letter to the Wilsons, the investigating committee says it decided against punitive action because “the mitigating factors seemed to indicate that there was no pattern or unethical behavior and no evidence of bad faith.”
Under BC’s current Health Professions Act, consent-resolved complaints like this one can only be made public if they are deemed to be “serious matters.” The government has promised that will change with the new Healthcare Professions and Professions Act, which has yet to be passed.
CLOCK | 5-year-old struggles to stay awake 16 hours after overdose:
Eli Wilson has autism, a seizure disorder, and trouble sleeping. He takes clonidine every night because sleep deprivation can make his seizures worse, and because he can’t swallow pills it’s necessary to make a liquid, his parents say.
Eli unknowingly took the overdose on the night of February 27, 2021.
When the habitual early riser wasn’t out of bed by 8 a.m. the next morning, his parents worried something was wrong.
“It was more than just a deep sleep. We tried to wake him up but we couldn’t,” said Lindsay Wilson.
Eli’s heart rate was 55 beats per minute, much slower than his normal resting rate of 90. His parents watched as he passed out over the bathroom sink and stood in front of the open refrigerator.
Eli doesn’t speak, so he couldn’t share what was going on, leaving his parents wondering if he was having a seizure. They spent much of the day talking to their pediatrician about what to do, saying she suspected a clonidine overdose at an early age.
While his wife was taking Eli to the emergency room, Brent Wilson said he called the pharmacy to alert them and ask for a clonidine test. Staff called three labs before telling the Wilsons they couldn’t find anyone to test the drug, college records show.
In the end, the Wilsons paid $5,250 out of pocket for a lab they found themselves, plus the cost of flying a helicopter to Vancouver to keep it refrigerated.
“It shook our confidence”
When the Wilsons filed their complaint, they had hoped to see something like a recent ruling from New Brunswick, where a pharmacist was publicly reprimanded, fined, and suspended for an error in the composition of clonidine for giving gummy candy to a child doses that were 1,000 times the prescribed amount.
“Our BC college wasn’t even in the ballpark,” said Brent Wilson.
Instead, the pharmacists agreed to hire an outside expert to help develop policies and procedures, take medication error prevention courses, conduct training with pharmacy staff, and write an essay about what went wrong.
The Health Professions Review Board broadly concurred with that resolution, although it said the college should have told the Wilsons that Aulja was a member of the college’s investigative committee at the time of the complaint. However, she withdrew from all panels of the committee during the decision, which the board felt was sufficient to prevent a conflict of interest.
Eli’s overdose had a lasting impact on his family. His parents say he was afraid to go to his bedroom for more than a month afterwards and his twin sister insisted on sleeping next to him for the next year.
“It really shook our confidence,” said Brent Wilson. “Every time we open a new recipe, we get nervous.”
They have now switched pharmacies and are starting on a tiny dose each time they start a new bottle of clonidine.
“Every time we do that, we hold our breath a little bit,” he said.
