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Medical Mistake Costs Child His Life

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Mom shares tragic story of 3-year-old son's death from an accidental overdose.

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Mom•Logic: When did Sebastian go in for a medical test, and when did you sense something was wrong?

Luisa: On October 10th, 2007, we brought Sebastian in for a hormone deficiency test. Before the test, they gave me a sheet detailing what to expect. I was told the test was simple and to bring some toys for Sebastian to play with. They said he'll have an IV, they were going to draw some blood, and the test last four hours. There was nothing lethal, and nothing to be concerned about.

During the test, Sebastian was supposed to have 5.75 grams of Arginine, which is an amino acid that stimulates the pituitary gland. I was in the room with the nurse when the medicine arrived from the pharmacy. There were two bottles of the drug, and I questioned the nurse because it seemed like a lot of medicine for a 3-year-old. I had a mother's intuition or instinct that something just wasn't right. The nurse checked and thought she was doing the right thing, but she was wrong. She ended up giving him 60 grams of Arginine, more than 10 times of the prescribed dosage. The nurse started doing the test and as a Mom, I questioned her, but trusted what she told me.

During the test, Sebastian was having bad headaches. I started getting worried and I didn't like it. It was hard for Sebastian to tell me how bad he felt or how he was hurting because he was just a little boy. The nurse assured me it's normal for kids to have headaches or an upset stomach so we continued with the test. Sebastian was feeling worse, so my husband called the doctor who was on call that day. The doctor never looked at Sebastian or the medicine--she looked at the charts, saw the nurse, and told us if we stopped the test, we would have to bring him back next week and do it all over again. We just wanted to get it over with and we trusted the doctor, so we kept going.

At the end of the test, we took Sebastian home. By that point, he had so much medicine in him that he was knocked out. He was conscious and would respond if you asked him something, but otherwise, he didn't walk, talk, and it was like he passed out. We thought he'd get better at home, but he was nauseous. By midnight, he wasn't getting better. He actually looked worse. His mouth was purple, and he had purple under his eyes. We called the doctor's "after hours" number and they said to give him fluids because he was probably dehydrated. They said if things didn't seem better to take him to the emergency room. I knew something was wrong, so we took him to the ER at midnight. It took forever for him to be seen. He didn't get admitted until 5 a.m. They had no idea what was wrong, even though I explained he had the test done earlier that day. They just kept giving him fluids for dehydration.

After finally being admitted into a room, Sebastian had a few seizures while my husband and I were with him. The nurses and doctors weren't concerned. He was in the hospital all day Tuesday. The endocrinologist came into the room to see him. I told her about the bottles of medicine and she never mentioned it could be an overdose. Instead, they thought he was having a reaction from the medicine.

Sebastian wasn't getting any better and we were desperate for answers. We never thought he was going to pass away. At 11 pm, his doctor came by once more before she left for the night. He was lying there sleeping and had a stable heart rate. She thought he was fine until he had another seizure--she realized something was wrong and sent him to ICU. I was relieved that he was going into ICU because I figured he'd be under good care. It turned out Sebastian's brain was swelling from the overdose, and it was too late. His brain cells were swelling and he was dying. I kept saying, "What's wrong? How can we fix this?" Nobody would tell me anything. They took him for a CT scan and it was misread. They said there was no swelling and there was. On Wednesday morning, Sebastian passed away. My husband and I were called into a room and we were told it was an overdose. They said it was their mistake, and they were so, so sorry.

Mom•Logic: After learning your son passed away from a medical mistake, how did you find the strength to want to help others?

Luisa: When this happens, you go into a phase where you're in shock and it's not really happening. During that period, a lot of doctors made us realize that this happened because there isn't a children's hospital near us in Florida, and it was caused by numerous misunderstandings and miscommunications. There were so many things that went wrong. It wasn't just the overdose. From there, we started analyzing the situation and understood the only way we could honor Sebastian's memory is to not let this go under the table. It's so painful, and it's so, so ugly to lose a child like this. It's unnecessary and I wouldn't want another mom to go through something so horrible as this. I feel this ruined my whole life. I have another son who is 1 ½ years old and he was affected, and always will be. It's not fair, and other parents shouldn't go through this.

Mom•Logic: What is the Sebastian Ferraro Foundation?

Luisa: We created a foundation in his name and to honor his memory. You can have hate, but there is nothing that will bring him back, so the only thing we can do at this point is to honor his memory. The foundation has short-term goals that surround safety issues. The hospital is creating a comprehensive patient safety program. Our long-term goal is to create, as Sebastian's legacy, a free-standing, state-of-the-art Children's Hospital in Gainesville.

Mom•Logic: What advice or message do you want to send to Moms?

Luisa: From my experience, you need to follow your instinct. As a mom, it's the main thing. You should question everything and don't just say "yes" because you don't want to seem picky or difficult. You need to make sure the doctor is doing the right thing and they're double-checking. Don't be afraid to ask questions. No one knows your child better than you, and I wish I had asked more questions. You're paying for the doctor's service, so don't be afraid. Ask questions until you feel comfortable. It could be a matter of life or death.

Click on an image to view Sebastian's Photo Gallery


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14 comments so far | Post a comment now
Anonymous March 18, 2008, 2:09 PM

FYI incase anyone reading this needs a childrens hospital before you can get one built up in Gainsville there are several that I have had to travel to in southern florida and yes being on the road for hours with a very angry screaming baby sucks but your story has reaffirmed that my long travels to bring my daughter to a childrens specific hospital is what is best for her. I am so sorry that the doctors and support staff that cared for your son screwed up the way they did, and I will pray for you and your family.


SugarPlumFairy March 18, 2008, 5:12 PM

This story is so sad!! Yes, I will definitely feel free to ask more questions.

Hospitalworker May 5, 2008, 11:15 PM

Nurses EVERYWHERE make mistakes, this could happen anywhere!

paloma esquivel August 12, 2008, 5:53 PM

I wouldn,t say I know how you feel cause i dont but God Bless you for being strong and giving others courage to step up and ask more ? i have 4 boys and I would lose it if something were to happen to my babies.

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