“A succession of mistakes,” says Benício’s father, who died from the adrenaline in his veins

The parents of the boy Benício Xavier de Freitas, aged 6, who died after receiving a bad dose of adrenaline in his vein, denounce a succession of errors in the care of their son at the Santa Júlia Hospital, in Manaus (AM). The child, who would have been 7 on Christmas Day, died on November 23.

In an interview with Fantático, the child’s parents, Joice Carvalho and Bruno Freitas, said the child had a dry cough and fever and that laryngitis was suspected. The decision to take him to the hospital came from his mother, as she thought his throat was very inflamed. However, the family spent 14 hours inside the health center, from where the boy emerged lifeless.

“No father, no mother takes their child to the hospital to die. Especially the way Benício died. This succession of mistakes, this negligence that we saw,” said the father, who spent most of the care at his son’s side.

The condition was not serious

During the examination at the hospital on November 22, Benício’s condition was not considered serious. According to the mother, during the consultation, the doctor asked to evaluate the child and told her that she would take adrenaline, without explaining what that would look like.
A month before the treatment, Benício had been treated in the same hospital, in the same condition. The mother says that Benício was treated with adrenaline by inhalation in the first situation.
The doctor who treated Benício was Juliana Brasil Santos. Juliana’s prescription listed pure, undiluted adrenaline, administered intravenously, in three doses totaling 9 milligrams.
After the application, Benício’s condition suddenly worsened. The boy died after six consecutive cardiac arrests.

Bad medicine

According to pediatrician Márcio Moreira, from the Albert Eintein Hospital, “as it is a case of laryngitis, we regularly use inhaled adrenaline. We inhale adrenaline and hope for rapid improvement, even if it is temporary.”

Adrenaline, produced by the body and also synthesized as medicine, is recommended for inhalation in mild conditions. The injectable version, in the vein, is used in serious situations, such as cardiorespiratory arrest, and administered in very small doses, slowly, generally in intensive care.

Still according to Benício’s mother, she did not question the doctor’s prescription, because she was certain that the adrenaline would be used by inhalation. The mother said she only asked when she saw the injectable serum.

“Where’s the adrenaline inhalation? It’s always been an inhalation.” According to her, the nursing technician Raíza Bentes replied that she had never done it intravenously either, but that it would be indicated in the medical prescription.

The parents claim that shortly after receiving the adrenaline, Benício became pale and complained of heart pain. Joice recalls: “Then I started to despair. My husband told me: ‘Run and call the doctor’.”

Raíza attacked the doctor. “I informed her that I had administered the medication and that the child had reacted. (…) I said it was adrenaline. And then she took it and said ‘ok'”, says the nursing technician.

In WhatsApp messages to another doctor, Juliana wrote: “I was the one who made a mistake with the prescription.” Later, in a report to the hospital, he reiterated that he had “prescribed incorrectly”.

Deterioration of health

Benício was rushed to the red emergency room. His parents say he was conscious but having difficulty breathing.

Four hours later, the boy was transferred to intensive care. He spent time with his father, had a meal and, a few hours later, was intubated. “I told him inside: ‘Come on, my son. Let’s go. Improve your oxygenation’. I prayed a lot,” says Bruno.

Benício had six cardiac arrests and could not resist. “It’s an immense pain that I will carry with me for the rest of my life,” says the father. “According to what we analyze, verify, observe, it is a succession of errors,” emphasizes Bruno.

Investigation

Police are investigating failed intubations and a lack of control by the unit pharmacist. According to delegate Marcelo Martins, there is “a structural, sequential error in the protocols, in the care. (…) And then we see that Benício had no chance,” he said. The investigator believes the boy was the victim of a homicide.

“Certainly, homicide. The doctor simply issued a medical prescription and did not review it, which would be a simple double-check procedure. The nursing technician could also have done the double-check. And that would have avoided this outcome,” says Martins.

The president of the Amazonas Regional Pharmacy Council, Reginaldo Silva Costa, says: “Certainly, the pharmaceutical professional would have identified the overdose and would have asked the prescribing professional to review his prescription.”

The nursing technician defends herself by asserting that she only followed the medical prescription. Raíza Bentes has been working as a technician for seven months. She was suspended by the Regional Nursing Council and remains free.

In a statement, her defense claims that she will only speak once the investigations are completed and that she followed the prescription as prescribed by the hospital nurses.

Juliana Santos Brasil has been released from the hospital. In court, she presented a video alleging that the electronic prescribing system had exchanged, without her knowledge, inhaled adrenaline for intravenous adrenaline. However, as the hospital’s technology session highlights, without the doctor’s intervention, the system is not capable of doing anything in an automated manner.

The doctor is free

The doctor obtained a preventive habeas corpus so as not to be arrested during the investigations. His lawyer, Felipe Braga, reiterated that there was a system failure in the subsequent proceedings. “It was a multiplicity of factors, from the moment when there was a break in double or triple checks, to the absence of the pharmacist,” specifies the lawyer. “I don’t consider she made a mistake.”

The hospital’s medical director, Guilherme Macedo, says that “the entire management is involved in developing action plans so that the hospital avoids similar situations with a tragic outcome like this.”