A Florida hospital faces allegations of causing the death of a 2-year-old boy due to administering a potassium phosphate dose that was ten times higher than prescribed. This tragic error reportedly stemmed from the removal of a crucial decimal point in the boy’s medical records. Additionally, the lawsuit claims that hospital staff failed to promptly respond when the child suffered cardiac arrest, delaying resuscitation efforts for over 20 minutes.

“Such a loss is unimaginable for any parent,” stated attorney Jordan Dulcie of Searcy Law, speaking to Law&Crime about the circumstances surrounding the death of young De’Markus Page.

The Page family has filed a lawsuit against UF Health Shands Children’s Hospital in Gainesville. This establishment, affiliated with the University of Florida, is being accused of “wrongful death medical negligence” linked to the incident that occurred in March 2024.

The lawsuit details that De’Markus was initially under care for a viral infection at AdventHealth Ocala before being transferred to Shands in early 2024. The complaint describes him as an “active toddler” with minor developmental delays and a possible autism spectrum disorder.

His family notes that De’Markus was underweight, in the 30th percentile for his age, as he was a selective eater. This dietary issue made him particularly susceptible to fluid and electrolyte imbalances, a common risk factor when young children encounter typical viruses that affect their food and fluid intake.

Upon De’Markus’s admission to Shands, the hospital staff ordered “oral potassium phosphate” at a dose of “1.5 mmol” to be administered twice daily, according to the lawsuit.

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.