Gainesville, FL – A Florida family has filed a lawsuit claiming their 2-year-old son, De’Markus Page, died after medical staff at UF Health Shands administered ten times the intended dose of potassium phosphate due to a missing decimal point in the prescription.
The lawsuit, filed on November 6, accuses the hospital, along with several doctors, pharmacists and supervising staff, of failing to notice the fatal error despite warning alerts issued by the facility’s own pharmacy system.
How the Child’s Medical Emergency Began
According to the lawsuit, De’Markus was first taken to another medical facility on March 1, 2024, after persistent crying, diarrhea and decreased appetite. He was diagnosed with rhinovirus and enterovirus, common causes of respiratory illness, but doctors also found low potassium levels, prompting IV treatment and concerns that he required a higher level of care.
Upon transfer to UF Health Shands, medical teams determined that his potassium levels were “dangerously low” and continued treatment to stabilize him.
The Fatal Decimal Error
The lawsuit states that during the treatment process, a doctor mistakenly entered a potassium phosphate dose of 15 mmol instead of 1.5 mmol, an error caused by omitting a decimal point. This meant De’Markus received ten times the correct dosage.
The filing claims that multiple colleagues, supervising physicians and pharmacists failed to catch the mistake, even after the hospital’s system issued a Red Flag warning identifying the dose as excessively high. Despite the alert, the medication was reportedly administered in two consecutive doses, leading to a rapid and fatal spike in potassium.
Cardiac Arrest and Lack of Timely Response
According to the lawsuit, the overdose caused De’Markus’ potassium to climb to a fatal level, triggering cardiac arrest. The complaint further alleges that medical staff did not respond quickly enough during the emergency and that the child went at least 20 minutes without breathing, resulting in irreversible brain damage and “catastrophic” injury to multiple organs.
He remained on life support for two weeks without improvement and died on March 18, 2024.
Mother Says She Was Never Given Answers
De’Markus’ mother, Dominique Page, told reporters she has spent months seeking clarity from the hospital about what happened.
“It’s been extremely difficult since the passing of my son because to this day, I still have not known what happened,” she said. “I was never told. When I asked, it was always a vague, ‘I do not know. I do not know.’ I still have nightmares about what happened.”
The family’s attorneys referenced details from publicly available reports and filings, including statements first noted in coverage by USA Today, which highlighted the lawsuit’s claims of a preventable medication error and lack of intervention from hospital staff.
Hospital Declines to Comment on the Lawsuit
UF Health Shands officials have stated they cannot comment on pending litigation. The case underscores ongoing concerns surrounding hospital medication safety, supervision practices and the potential for catastrophic consequences when multiple layers of oversight fail.
Growing Attention on Patient Safety in Pediatric Care
Medical dosing errors in children can be particularly dangerous due to smaller body weight, more precise dosing requirements and the heightened impact of even minor miscalculations. Patient safety groups note that decimal-related medication errors are among the most common avoidable mistakes, which is why many hospitals rely on automated alerts, pharmacist oversight and multiple checks before medication is given.
The lawsuit argues that these safeguards were present but ignored, contributing to the toddler’s death.
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