The report of the coroner, Jacques Ramsay, which will be made public today confirms, a little boy aged 23 months, Ghali Chorfi, died at the CHU Ste-Justine on December 10, 2016 due to an overdose of drugs.
TVA has learned that although the cause could not be determined with certainty, the coroner believes that the only possibility is that a nurse had given him inadvertently an injection of potassium instead of saline solution intended to flush the vein after the injection of a drug to prevent stomach ulcers.
Three weeks earlier, the little boy had undergone a bone marrow transplant to combat the cancer. He had a neuroblastoma, a cancer of stage 4 on one of his kidneys.
Everything was done well, as the related VAT News in march 2017.
Placed in isolation, he took over the forces and was amused when it all happened. He has done a first cardiac arrest and was resuscitated. He was transferred to the intensive care unit, but died a few hours later in the arms of his mother.
The autopsy report documented significant oedema, congestion and haemorrhages in the lungs.
The mother-of-Ghali, Hadil El Amrani, says he is satisfied with the coroner’s report and hope that this will prevent further tragedies.
The coroner recommends that the CHU Ste-Justine to follow-up the changes already put in place since the accident on the use of the syringes which should be prepared at the hospital pharmacy.
He also wants the hospital’s awareness of other institutions for the implementation of safe practices in handling of the potassium and that the department of Health is warning the CISSS and the CIUSSS for them to adopt a policy to prevent it from happening again.