Inset: De'Markus Page (J Brown Funeral and Cremation Services). Background: UF Health Shands Children's Hospital in Gainesville, where De'Markus Page's family said a fatal mistake by staff took his life last year (Google Maps).
A Florida hospital has been accused of killing a 2-year-old boy with an "exceedingly high" dose of potassium phosphate — 10 times the dosage he was ordered to receive — after staff deleted a "critical decimal point" from his chart, a lawsuit says. The hospital also didn't notice that the boy went into cardiac arrest and waited more than 20 minutes before trying to save him, his family alleges.
"No parent should have to lose a child like this," attorney Jordan Dulcie, of Searcy Law, told Law&Crime on Tuesday about the death of De'Markus Page.
Page's family is suing UF Health Shands Children's Hospital in Gainesville — a teaching hospital for the University of Florida — for "wrongful death medical negligence" in connection with De'Markus' death in March 2024.
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According to the legal complaint, De'Markus was being treated for a virus at AdventHealth Ocala hospital before being transferred to Shands in early 2024. He is described as an "active toddler" who experienced minor speech and developmental delays and was "suspected of having some level of autism," the complaint says.
"He remained underweight in the 30th percentile for his age due to his being a picky eater," De'Markus' family alleges. "His nutritional challenges made De'Markus far more vulnerable to incurring fluid and electrolyte deficits should he contract the normal viruses and illness of early childhood that impact a child's oral intake."
While being treated at Shands, hospital staffers initially put in an order for "oral potassium phosphate" to be administered to him at "1.5 mmol," or millimole, twice a day upon his arrival, according to the complaint.
On the second day of his hospitalization, a doctor "unconscionably entered an incorrect order for De'Markus' oral potassium phosphate medication to be given at a dosage 10 times the level ordered the previous day," the complaint charges. This allegedly happened after the doctor "failed to recognize or blatantly ignored the fact" that De'Markus' potassium level had returned to normal that morning.
"[The doctor] errantly placed the new 11:01 am order for oral potassium phosphate to be administered at 10 times the previous dosage, deleting a critical decimal point in the prior day's dosage of 1.5 mmol — now ordering the liquid supplement to be given at 15 mmol twice a day," the complaint says. "This exceedingly high level of potassium would be administered to De'Markus … with no rationale, and in addition to two other routes of potassium administration he was already receiving in the way of intravenous KCL and Pedialyte — and to an underweight 2 year old who had a normal morning potassium level."
De'Markus' family says the original potassium phosphate order was calculated based on his size, weight, and the "lab results and electrolyte needs" from his first day in the hospital. Staff allegedly failed to catch and correct the mistake and complications soon began.
A lack of "proper emergency equipment on the general pediatric floor" and "no blood monitoring of his electrolytes" in place led to De'Markus going into a "hyperkalemic state and suffering hyperkalemic cardiac arrest," according to the complaint.
Hospital staff, however, didn't notice what was happening for "at least 20 minutes" and "fumbled with a timely and successful intubation" of De'Markus' airway, the complaint says, noting how there were allegedly "at least two to three botched attempts" by doctors to establish a "patent airway" for him.
"De'Markus was reported to have a spontaneous return of circulation and cardiac activity, but the anoxic damage already done to his brain and other vital organs was catastrophic," the complaint states. "Unfortunately, having sustained the massive anoxic damage … De'Markus went on to endure a horrific and protracted hospital course over the next two weeks as a neurologically obtunded, ventilator-dependent patient in the pediatric intensive care unit."
De'Markus succumbed to his "anoxic brain injury" a little over two weeks after he was transferred to Shands, his family says. "De'Markus ultimately was determined to be brain dead and passed away in his mother's arms," Searcy Law said in a press release sent to Law&Crime on Tuesday. "This tragic case highlights serious concerns about patient safety, pediatric care protocols, and the oversight of the most vulnerable children with special needs in hospital settings like Shands Children Hospital."
"What this family has endured is unimaginable and the worst part is that it was entirely preventable," Dulcie, the family's attorney, said. "I'm committed to holding the University of Florida Shands Children's Hospital fully accountable and presenting this case to a jury to avoid this tremendous grief from happening to another family."
Hospital officials did not respond to Law&Crime's request for comment Tuesday.