Fatality inquiry report into death of 8-year-old girl makes 3 recommendations

A fatality inquiry into the death of an eight-year-old girl who overdosed on a sleep-aid drug at an Edmonton group home has led to three recommendations for doctors.

Nevaeh Michaud died on Jan. 5, 2014, at Ayesha's Light, a Mill Woods group home operated by Mariam's Footsteps. A medical examiner determined her body had toxic levels of trichloroethanol — a metabolite of the sedative chloral hydrate.

"From the evidence before the inquiry, I conclude that Nevaeh's death was caused by an accumulation of trichlorethanol resulting from receiving a therapeutic dose of chloral hydrate," Alberta provincial court Judge Elizabeth A. Johnson wrote in the report.

Johnson adopted three recommendations from Michael Rieder, a clinical pharmacologist and professor who gave expert testimony during the inquiry:

• Chloral hydrate is not an appropriate sleep aid for long-term use in children, but can be used as a short-term measure;
• The drug should be prescribed for a defined period of time, without an automatic refill order;
• Chloral hydrate therapy should be monitored regularly and include "considerations as to when therapy should be weaned/stopped."

The College of Physicians and Surgeons of Alberta (CPSA) accepted the recommendations but is urging doctors to consider recent medical literature suggesting chloral hydrate not be used to treat insomnia in children because of significant side effects.

In a 2014 article for the journal Neurology Clinical Practice, University of Michigan doctors and sleep scientists Barbara Felt and Ronald Chervin wrote that current medical literature suggests limiting medications for child sleep problems.

Though chloral hydrate is still sometimes used to treat children with trouble sleeping, "safety, side effects, and tolerance concerns should substantially limit its use," they wrote. 

"We are concerned that the process used to reach these recommendations did not follow the principles and steps to develop best practice recommendations and not all the available evidence was considered prior to issuing them," CPSA registrar Scott McLeod wrote in an Aug. 30 letter to the Justice and Solicitor General's fatality inquiry co-ordinator.

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The college has shared the report, its recommendations and further guidance on the drug with its approximately 11,000 members.

"What we expect physicians to do is really always look for the latest evidence," CPSA chief of staff Shawn Knight told CBC News.

"Clinical guidelines, to some degree, say, 'this is what you're supposed to do for all patients,' " he said. "These are very complex situations and physicians truly need to look at each person and look at the benefit versus the risk."

Nevaeh's case was complex. The inquiry heard that in addition to difficulty sleeping, she had significant physical and cognitive disabilities. 

Treatment options are limited for children with such challenges, Rieder told the court.

After Nevaeh tried several other medications, the inquiry heard, her doctor prescribed chloral hydrate in the fall of 2013, calculating the dosage based on her weight. She was given a nightly dose, as well as an additional amount if she woke up in the night. 

Rieder told the court that Nevaeh's regular dose was generous for a child and her "as-needed" dose, which records suggest was administered almost every night, was within the range of doses used for adults.

No charges were laid as a result of her death.

"It's important that we all learn from this situation, as it was tragic," said Jeff Whissell, deputy registrar of the Alberta College of Pharmacy (ACP).

Similar to the doctors' group, the ACP is informing its members of the case and about chloral hydrate.

The recommendations are a starting point, Whissell said.

"We would encourage all pharmacies to rely on evidence and form guidelines and principles to ensure good practice when they're trying to meet the needs of their patients."