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Vision Of Hope Rises From Tragedy

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By RON WORD, The Associated Press

Published: March 8, 2008

GAINESVILLE - It's a parent's worst nightmare.

Horst and Luisa Ferrero took their intelligent, healthy and happy 3-year-old, Sebastian, in for a medical exam last October.

The 25-pound boy was small for his age and doctors had recommended that he take a routine test to determine if he might be a candidate for growth hormone therapy to give him a boost.

Two days later he was dead, killed by a series of medical errors including a massive drug overdose accidentally administered to him.

But rather than be bitter, Sebastian's parents have taken their grief and formed the Sebastian Ferrero Foundation and plan to give it the $850,000 settlement they received from Shands Healthcare at the University of Florida.

Its goal is to promote patient safety programs - the Institute of Medicine estimates that as many as 98,000 people die each year in U.S. hospitals because of medical injuries - and plant the seed for a stand-alone children's hospital in Gainesville.

Sebastian's parents, who are developers, think that if he had been treated at such a hospital, the cascade of mistakes that led to his death might have been avoided, or at least caught before they turned fatal.

'A Routine Test'

Their goal is to build a $300 million, 125-bed state-of-the-art hospital within five years. They estimate they must raise about 10 percent of the money - $30 million - with the remainder coming from bonds.

Although their son died after being treated at Shands University of Florida hospital and Shands AGH, both in Gainesville, the boy's parents hope the new hospital would be operated by Shands. It operates a children's hospital within the UF hospital.

"It will depend how involved the community gets and how committed UF and Shands are to make this a reality," said Debbie Joseph, the foundation's executive director.

Sebastian's death came after a three-day nightmare that began when his parents took him to the University of Florida Pediatric Outpatient Clinic for the growth hormone stimulation test suggested by his physician.

"We never thought there was a risk involved," said his father, 33. "This was something preventable and this was something simple. This was a routine test."

Sebastian's 32-year-old mother told him about the test. It would feel like a mosquito bite, she said, and bought him a portable Thomas the Train set to entertain him.

The test involved the infusion of the amino acid arginine into his veins. Normally, both the drug and the test are safe. His physician prescribed a dose of 5.75 grams, but the prescription processed by the Shands Medical Plaza's outpatient pharmacy was 60 grams.

Before the test, Luisa asked a nurse if the dose was correct. The dose dispensed by the pharmacy was two large bottles. The nurse checked the chart and assured her that everything was OK.

It took about 30 minutes for the arginine to drip into Sebastian and he developed a severe headache and appeared to be in extreme pain. Horst stopped the procedure and asked a doctor to examine his son.

After checking the chart, but not the child, the test resumed.

"Continuing the test was a critical mistake," the family said in a chronology of the errors and deficiencies surrounding the boy's death. "It should have been stopped to try to reverse the outcome."

Concerns Were Ignored

After the infusion, Sebastian stayed in the clinic for four hours, although some of his symptoms indicated he was having problems.

After arriving home, he was vomiting and having seizures, and his parents took him to the Shands AGH emergency room. Their concerns that his sickness was caused by the arginine test were ignored.

They spent four hours in the crowded emergency department, waiting in the hallway for Sebastian to be seen.

About 6:30 a.m., he was admitted to Shands AGH and treated for dehydration.

It wasn't until 24 hours after he first came to the emergency room that his parents persuaded doctors to check him more closely. Sebastian had a seizure and he was sent to the pediatric intensive care unit. A CT scan was misread because there was no pediatric radiologist on duty, the Ferreros said.

A decision was made to transfer Sebastian to the intensive care unit at Shands at the University of Florida. By the time he arrived, he was brain-dead.

"We had just hours to be able to ... to try to figure out what was happening and to try to fix the problem," Horst Ferrero said. "It took three days to figure out what was wrong - by then it was too late."

They soon learned from their physician that the overdose was the cause of Sebastian's death.

Shands immediately admitted its errors caused Sebastian's death and its investigation uncovered another arginine overdose. The mother of a 5-year-old boy stopped a test when her son jumped off the couch screaming, "My brain is on fire."

Shands implemented a series of changes, including the establishment of an infusion center featuring specially trained nurses. It will order its own medication and fill its own prescriptions, said Mike Gold, the UF College of Medicine's senior associate dean for clinical affairs. The hospital also will increase its training and oversight.

Gold is not as optimistic as the Ferreros on when the new children's hospital will open.

"Accomplishing that will take a number of years, if not a decade," Gold said.

"I have admiration for the Ferreros. I cannot imagine a worst tragedy than for a parent to lose a child. But they are taking what happened to Sebastian and trying to make the world a better place."

The Ferreros, who have another son who is 18 months old, still marvel at Sebastian, who spoke English, Italian and Spanish and was a loving, active and caring child.

"He would light up any room he would enter. He was just so alive," his father said.

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