Mistaken substitution of medication leads to child's death

THE BALTIMORE SUN

HAMPTON, Va. -- Megan McClave didn't want to take her medicine.

It tasted "yucky" she said, and the 8-year-old spit it out. On the second try, she managed to take about half.

Megan kissed her father good night and slipped off to sleep.

By morning, July 18, she was dead.

Her mother, Johnda McClave Thompson, who lives in Westminster, said Megan was born in West Virginia but the family moved to Randallstownwhen she was less than a year old.

"I just want people to know what happened to her, to know these things can happen and watch out," said Mrs. Thompson. "This should never happen again."

"This," say authorities in Virginia, was mistaken substitution of medications that led to the child's death.

A few days before her death, Megan's tonsils had been removed.

Megan, still a little woozy, was home resting with her mother, who had arrived from Maryland to be with her after the operation.

Her father, Michael a foreman for the CSX railroad, drove to the Rite Aid drugstore in Oyster Point, Va. to fill the prescription for Megan's painkiller.

Demerol liquid, it said. Take "2-3 tsp." every four hours as needed for pain. Mr. McClave waited as the pharmacistfilled the prescription.

'Generic substitute'

A few minutes later, the pharmacist returned to the counter. They didn't have Demerol, he said; what he'd provided was a generic substitute.

Like Megan's prescription, the label stuck on the bottle read: "Take 2 to 3 teaspoonfuls by mouth every 4 hours as needed for pain."

The label also said "Roxanol" and in smaller letters "morphine sulfate."

According to the toxicology reports, Megan Colleen McClave died July 18 from "morphine toxicity due to ingestion of Roxanol."

Instead of dispensing Demerol -- the drug written on Megan's prescription -- authorities say Kent Lee Schafer doled out Roxanol, a powerful morphine-based mixture typically used to relieve the chronic and often crippling pain of cancer patients.

In a two-teaspoon dose Megan got about 200 milligrams of morphine, some six to 20 times the typical adult dosage, said William Cooke, chairman of the pharmacology department at Eastern Virginia Medical School in Norfolk.

Medical experts say the drug shut down her respiratory system. But the primary problem, said the Tidewater District's deputy chief medical examiner, Faruk Presswalla, was morphine poisoning.

"I've never heard of anything like this," said Irwin Reich of the Philadelphia College of Pharmacy and Science. "To think Roxanol is the same as Demerol is inexcusable. They're completely different."

Roxanol is morphine. Demerol is a brand name for a drug called meperidine. Both drugs are painkillers, but they are not interchangeable.

Mr. Schafer's license has been suspended by the Virginia Board of Pharmacy.

Medicine for a sore throat

Friday evening, six or eight hours after her surgery, Megan complained that her throat hurt. Her father measured out a dose of the painkiller and spooned some into her mouth.

Megan spit it onto the floor. "It tastes yucky, daddy," she said.

Saturday, Megan spent the day with her mother. Megan and her 13-year-old sister, Bethany, lived with their father, and Megan looked forward to seeing her mother.

The next afternoon, the pain returned, stronger this time. Mr. McClave decided to try the prescription painkiller again.

He put a couple of teaspoons in a glass of 7-Up and stirred. Megan drank about half.

A little while later, she threw up. Her stomach hurt too, and she seemed quiet and drowsy.

'She seemed better'

Around 7 p.m., Megan nestled into her father's bed to watch TV with him. "It was the first time we'd really spent any time together since the surgery," says Mr. McClave. "She seemed to be doing a little better."

After Megan fell asleep, he read for about an hour and then slept. He woke at 4 a.m. and went to work.

He felt a little uneasy about leaving Megan, but he expected this day to go like most others during the summer. The girls would get up and go to the Winers, the neighbors who watched them during the day.

At 8:30 a.m., Mr. McClave called his daughters. He let the phone ring, but no one answered. He hung up and called his neighbors to see if Bethany and Megan were already there. Not yet, said Geretta Winer.

He said he guessed the girls were in bed and he planned to call later.

At 9:17, his pager began screeching: "It had my phone number, and then '911' after it."

He ran to a phone. At his house, Geretta's husband, Richard, snatched up the receiver.

"You need to get back here right away," Mr. Winer told him.

Bethany had found Megan just after 9 a.m. She lay motionless in her father's bed. Her face was blue and looked a little bloated.

Bethany couldn't wake her. Terrified, she called the Winers, who sprinted over to the house. They called 911 and tried CPR.

It was useless. Megan was dead and may have been for hours.

Mr. McClave turned onto his street to find the neighborhood lit up by the flashing lights of police and emergency vehicles.

"I could see it on everybody's face when I got there," he said. "An officer stepped in front of me, and Richard came over to say, 'Let's go back across the street.' "

There, Mr. Winer delivered the news: Megan was dead. Mr. McClave collapsed in the Winers' living room.

Across the street, paramedics loaded Megan's body into an ambulance for an autopsy.

A pretty casket

Torn by grief, Mr. McClave sleepwalked through the task of planning his daughter's funeral. The one thing he did pay attention to was the type of casket.

"It was especially important that I pick out something pretty," he said. "I knew it was the last thing I'd ever get her."

All the while, he worried about Bethany and wondered if Megan's mother would hold up.

When Mrs. Thompson arrived in Hampton the day of her daughter's death, she raced through the house searching for Megan.

When she couldn't find her, Mrs. Thompson became hysterical and began shattering things in the bathroom. Her ex-husband feared she might have a nervous breakdown.

A few days later, at a cemetery near his boyhood home of Flatwoods, Ky., Mr. McClave stood with his family and buried his youngest daughter.

Early results of the autopsy had ruled out complications with the tonsillectomy, a hemorrhage or a heart attack. Hampton police, who investigate every suspicious death, had ruled out foul play.

Aunt's detective work

Mr. McClave's aunt had a few ideas. Like her nephew, Janice Miller is a long-time train company employee. Ms. Miller, who lives in Kentucky, admits she "doesn't know anything" about medications.

Nevertheless, she had been thinking about Megan's painkiller for days after the child's burial.

Ms. Miller checked a layman's medical guide. The Demerol entry read: "a pleasant tasting, banana-flavored liquid."

That puzzled her, because she knew Megan had said her painkiller was "yucky." She told Mr. McClave's mother, her sister, of her suspicion but thought it was premature to say anything to Mike McClave.

A week after Megan's funeral, Mrs. Miller returned to Hampton with Mr. McClave and his mother.

On Tuesday, Aug. 2, Mr. McClave left the house, and the women settled down to detective work.

"We were looking for anything that would help us understand what in God's name had happened," Ms. Miller says.

They found the painkiller in a kitchen cabinet. Ms. Miller put a drop on her finger.

When she touched it to her tongue, a "horrible, bitter" taste exploded in her mouth. She poured a little in a spoon -- "about a quarter-teaspoon" -- and swallowed.

"I wanted to see what would happen," she says.

Thirty minutes later, an invisible band squeezed her head.

"I was sicker than I'd ever been in my life," she says. "I felt clumsy, I was dizzy and there was this God-awful nausea."

Another hospital trip

Hours passed, and her symptoms worsened. Finally, Mr. McClave put her into the car and raced to the emergency room. Before leaving, he grabbed the Roxanol and left a message with the Hampton police.

"My God, what if she dies too?" he said he was thinking. "It's got to be the medicine."

Doctors at the emergency room said Ms. Miller was suffering from morphine poisoning. They hooked her up to an IV and pumped her full of medication to counteract it.

Mr. McClave showed them the bottle of Roxanol, explaining it had been prescribed for his daughter's post-operative pain. He said the doctor told him Roxanol isn't typically given to children.

And, says Mr. McClave, the doctor told him Roxanol is not a generic form of Demerol.

Around 3 a.m., Ms. Miller was able to leave the hospital. Several hours later, Hampton Detective Randy Gnatowsky returned Mr. McClave's call from the night before.

After hearing the story, Detective Gnatowsky sent a crime scene technician for the Roxanol. It would be weeks before anyone would officially link the bottle to Megan's death.

But to Mr. McClave and his family, that was merely a formality.

They were sure morphine had killed Megan. They also knew that morphine hadn't been part of the original prescription. Someone had made a terrible mistake.

No record of trouble

Mr. Schafer got his license in 1966, just out of the University of Colorado School of Pharmacy. He passed the state exam and started a practice in the small town of Wray. He stayed in Colorado, said officials there, about 15 years.

In 1981, he left the state. The Colorado Pharmacy Board has no record of his ever getting into trouble.

In 1987, Virginia granted him a license. According to the National Association of Boards of Pharmacy, Virginia and Colorado are the only states in which Mr. Schafer holds a license.

Virginia pharmacy board officials say that, until Megan McClave's death, Mr. Schafer had never been investigated. After looking into that case, the board suspended his license pending a formal hearing.

The hearing had been scheduled Sept. 28, but his attorney asked that it be delayed. The pharmacist, board officials say, may be considering an agreement offered by the board.

Under its terms, Mr. Schafer would acknowledge the mistake -- something board documents show he has already done -- and accept an indefinite suspension.

The agreement would allow him to petition the board at any time to have his license reinstated. But he would have to prove he was again qualified to practice in Virginia.

Unacceptable

To Megan's family, the board's offer is unacceptable.

"I try to have compassion for the man, but that was our little girl," says Ms. Miller. "You can't say, 'Oh, it was just a mistake.' "

Regaining his license may not be Mr. Schafer's biggest problem. The Newport News Commonwealth's Attorney's office is reviewing the case to see if he should be prosecuted.

Mike McClave thinks involuntary manslaughter charges are appropriate.

"I don't want this man to go to prison," he said, "but I do want him prosecuted. I want him to be found guilty of what he's done."

Mr. Schafer won't talk about the incident, referring all questions to his attorney.

The lawyer, Jeffrey DeCaro, who also represents Rite Aid, said the company is investigating the death.

Mr. DeCaro also said Rite Aid plans to hire a medical examiner to review the autopsy findings. Rite Aid may contest the medical examiner's conclusion that morphine was the primary cause of death, he said.

As torn up as Mr. McClave is, his ex-wife may be worse.

"For me, every day is bad, but some are 'better' than others," he says. "I don't think she has any 'better' days. She's destroyed."

Johnda Thompson admits as much. She sees no reason to live, she says, and occasionally considers suicide. The only thing stopping her, she says, is fear that taking her own life would keep her out of heaven.

And right now, heaven's the only place she wants to be. After all, she says, that's where Megan is.

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