I have strong, albeit mixed emotions about this case. On one hand, it all seems so simple, cut and dried sitting here discussing it in retrospect. But hindsight is always 20/20.
I think this child's death represents a multi-level failure on the part of many different individuals,
to notice something was wrong. And that, unfortunately, happens all the time to, I'd imagine, thousands of children every year. Not every case will be as spectactular and sensational as this one, for sure but it's a sad fact: parents hurt and neglect their children. A lot. Too frequently. People don't always notice. I'd say that at least half the time, no one notices.
In this particular case, I want to say the majority of the blame lies with the parents. They seem, to me anyway, to want to substitute pharmacotherapy for parenting. That's how the article reads anyway. But then again, we don't know what these parents were going through. It sounds like they had issues of their own and other children with problems. I doubt they were trying to kill their child. More likely, they were ill-equipped to deal with the stresses of life and parenthood and viewed medication as a way to take a short-cut, if you will.
I'd also question a doctor who'd prescribe these types of medications in this quantity to a four-year old for behavioral reasons. But it is not unprecedented. There are some very young children with some major problems...so it's unusual but not unheard of. I've seen it...my pharmacy is within walking distance of two major child psych clinics.
It sounds like the pharmacists were aware of the refill too soon issue, but if there was a reasonable explanation it's hard to say that you or I would have done any differently, given the circumstances.
See how there are so many sides to this? It is a tragedy, for sure. One that will change the way every person involved in it views the world, probably for the rest of their lives. But no one will pay a price as big as that child, an innocent child who died a horrific death because all of the adults, all of the people who were supposed to protect her, let her down.
And now, I'm officially: