Doctors said our two-year-old son had a cold. A day later he was dead… because of a decimal point, lawsuit claims
A little boy died after his medical care team at a well-reputed Florida hospital made a critical dosing error with one of his medications, a new legal complaint claims.
University of Florida Health Shands in Gainesville, Florida, is facing a wrongful death lawsuit filed by the family of two-year-old De’Markus Page.
Page, an active and happy toddler described as a picky eater, began persistently crying, suffering from bouts of diarrhea, and ultimately stopped eating entirely for several days before his parents brought him to AdventHealth Ocala Hospital in March 2024.
Doctors diagnosed him with a rhinovirus/enterovirus—common cold viruses—and dangerously low potassium, a condition known as hypokalemia that can cause severe muscle weakness, fatigue and, in extreme cases, life-threatening heart rhythm problems.
His condition was deemed serious enough to require more advanced care, leading to his transfer to UF Health Shands.
There, a new evaluation showed his electrolyte levels were dangerously unstable, with potassium once again plummeting to a critical low, the lawsuit alleges.
According to the legal complaint filed on behalf of De’Markus’ parents, the staff did not grasp the critical nature of his needs and was overlooking essential protocols, including constant vital sign monitoring.
As part of his treatment, Page was supposed to receive 1.5 millimole (mmol) of potassium phosphate twice per day to get his potassium levels back to a healthy baseline.
After his picky eating turned into a complete loss of appetite, accompanied by constant crying and diarrhea, his parents brought two-year-old boy De’Markus Page to the hospital in March 2024. There, he was diagnosed with a common cold virus
However, according to the complaint filed by his parents, on his second day in the hospital, a doctor allegedly ‘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.’
This massive dose, far exceeding typical pediatric limits and potentially fatal even for an adult, triggered a catastrophic chain of events, according to the lawsuit.
An excess of potassium disrupts the electrical signals that regulate the heartbeat, which can cause the heart to stop suddenly.
The lawsuit alleged the overdose caused De’Markus to suffer a sudden hyperkalemic cardiac arrest. Furthermore, the complaint states that during the resuscitation, medical staff took more than 20 minutes to successfully intubate him – insert a breathing tube – leaving his brain deprived of oxygen long enough to inflict irreversible damage.
UF Shands has not returned the Daily Mail’s request for comment. The teaching hospital also has not yet responded to the legal complaint with a legal filing from its legal team.
The oxygen deprivation resulted in what the lawsuit describes as a catastrophic and irreversible brain injury, along with severe damage to other organs. He showed no neurological improvement after two weeks on life support, and his parents made the decision to withdraw it.
He was pronounced dead on March 18, 2024. The official cause of death, as cited in the lawsuit, is the result of the hyperkalemic cardiac arrest and subsequent anoxic brain injury.
While UF Shands has not responded to a Daily Mail request for comment, it has told other outlets that it does not comment on ongoing litigation.
Despite arriving with dangerously low potassium, he was not placed in intensive care. The next day, a decimal error changed his dose from 1.5 mmol to 15 mmol, causing his potassium to spike to fatal levels and triggering cardiac arrest
Page was healthy and active prior to his hospitalization, with minor speech and developmental issues. According to the legal complaint, he was suspected to ‘have some level of autism,’ but was never formally diagnosed.
‘He remained underweight in the 30th percentile for his age due to his being a picky eater,’ the complaint said.
It added: ‘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.’
When De’Markus Page arrived at the UF Health Shands emergency department on March 2, 2024, he was admitted to a general pediatric floor. The lawsuit contends that his condition necessitated admission to an intensive care unit (ICU), where he would have received the continuous heart monitoring and critical-care oversight his unstable electrolytes required.
The next day, March 3, a catastrophic error occurred, according to the complaint. One of his doctors allegedly entered a new medication order, deleting a critical decimal point.
This changed the dosage of an oral potassium supplement from 1.5 mmol to 15 mmol, a 10-fold increase.
Potassium is the mineral that keeps the heart’s rhythm steady, a precise charge in every beat. But at a level 10 times beyond what his small body could handle, that essential salt became a deadly toxin.
The overdose flooded De’Markus’s system, jamming the delicate electrical signals that tell the heart when to contract.
His heart essentially froze in a state called hyperkalemic cardiac arrest. The heart’s electrical circuitry shorted out and the organ stopped pumping blood effectively, causing sudden collapse and, without immediate intervention, death.
Page’s family is now seeking damages exceeding $50,000 for medical bills, funeral expenses, and other losses
The lawsuit alleges the error went unnoticed by supervising physicians and that the hospital’s pharmacy system issued but then overrode a ‘Red Flag’ warning about the excessive dose.
As a result, De’Markus received the ten-fold overdose twice in one day, once in the afternoon and again in the evening, for a total of two massive, erroneous doses, the complaint said.
With no continuous monitoring in place, his potassium levels spiked to a fatal degree, causing him to go into cardiac arrest around 9 pm.
The emergency response was allegedly botched, the parents claim in the lawsuit. It says it took at least 20 minutes and multiple failed attempts for doctors to successfully insert a breathing tube, leaving his brain deprived of oxygen. He was resuscitated but had sustained catastrophic, irreversible brain damage.
After two weeks on life support with no improvement, he was removed from support and died on March 18, 2024.
The boy’s mother, Dominique Page, told local outlet WCJB: ‘It’s been extremely difficult since the passing of my son because to this day, I still have not known what happened.
‘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.’
The legal complaint does not say explicitly how the family learned the details of their son’s death, though it could have been through a mix of their own observations, information from hospital staff and a subsequent, formal investigation, like the pre-suit inquiry required by Florida law.
The family is seeking more than $50,000 in damages to cover funeral and medical costs, lost earnings and other losses.
