4 negligences behind children’s deaths in MP:Officer on pilgrimage, syrup samples locked in labs; delayed action by doctor

The deaths of 11 children in Chhindwara, Madhya Pradesh, after consuming contaminated cough syrup have exposed alarming negligence at multiple levels of the state’s health and drug control system. While Tamil Nadu acted within 24 hours to identify and ban the toxic medicine, Madhya Pradesh took five days even to confirm the poison- by which time several young lives had already been lost. After reports came out, the Tamil Nadu government banned production and sale of this product at Sri Sun Pharmaceuticals. All this happened within 24 hours. Meanwhile, the state of MP’s system was such that when suspicious medicine samples were sent from Chhindwara to the Bhopal lab, the Drug Authority kept testing samples of other medicines instead of examining Coldrift and Nextra DS syrup. Know step by step, what negligence occurred at which level First negligence- a major delay The accident began in early September. On September 2, four-year-old Shivam Rathore died in Chhindwara’s Parasiya block. His death was dismissed as routine. Over the next 15 days, five more children died, all showing signs of kidney failure. Yet, neither the health department nor the local administration connected the dots. It was only after six deaths that the administration became alert and on September 20 set up a separate ward at Parasiya Civil Hospital. By then, precious time had been lost. Second negligence- Biopsy revealed the cause, but action delayed When four children were referred to a hospital in Nagpur, doctors there conducted kidney biopsies. The report clearly linked kidney damage to toxic chemicals present in a cough syrup — ‘Coldriff’ — given to all the affected children. Despite this decisive evidence, local health authorities in Chhindwara took three more days to ban the medicine. On September 29, the sale of Coldriff was finally prohibited in Chhindwara — but not in the rest of Madhya Pradesh. Supplies continued unchecked through the super-stockist in Jabalpur, meaning the same poisonous syrup remained available across the state. Third Negligence: Lab chose other medicines, then went on holiday On September 30, samples of the suspected syrups — ‘Coldriff’ and ‘Nextra DS’ — were sent from Chhindwara to the state drug laboratory in Bhopal. But the lab analysts began testing other medicines first — including Alto-E, Voxam DS and D-Frost — and released their reports the very next day, October 1. The crucial testing of Coldriff and Nextra DS was pushed aside. As the state faced a mounting crisis, the lab shut for Navami, Dussehra and Gandhi Jayanti holidays. Children continued to die even as the laboratory remained locked. This was found in Madhya Pradesh government report
Coldrif has been confirmed to contain 46.2% Diethylene Glycol (DEG). Meanwhile, Nextro-DS and Meftol P syrup reports were found ‘OK’. These two have been declared as standard quality cough syrups. Fourth Negligence: Government doctor continued distributing poison through private clinic Adding to the major loss, a government paediatrician posted at Parasiya Civil Hospital, Dr. Praveen Soni, continued prescribing Coldriff from his private clinic even after the biopsy report had indicated the syrup’s role in kidney failure.His wife’s medical store reportedly kept selling the medicine. When interacting with Dainik Bhaskar team, Dr Soni shifted responsibility to the drug inspector, saying, “I have prescribed this syrup for years and saw good results. We cannot collect samples — that’s the drug inspector’s job.” Dr Soni was arrested late on October 4 after the MP government’s test results became public. Officials on leave amid crisis Even as the crisis deepened, key officials in Madhya Pradesh were unavailable. The state’s Deputy Controller and licensing authority, Shobhit Koshta, went on a pilgrimage to Rameswaram on October 1 after merely writing a letter to the Tamil Nadu government requesting an investigation into the manufacturer. As he went on leave, the drug laboratory in Bhopal remained closed for holidays. When asked why testing was delayed, MP’s Drug Controller Dinesh Kumar Maurya said, “We test samples in the order we receive them. We could not test during Dussehra holidays.” Lives lost to apathy The step-by-step account of this incident highlights glaring failures in vigilance, accountability and urgency. From ignoring early deaths, delaying action despite clear biopsy evidence, failing to prioritise testing, allowing festive holidays to hold up lab work, to a doctor continuing to prescribe the fatal syrup- each layer of negligence contributed to the death toll. The Chhindwara incident underlines the need for stronger state-level drug regulation and a faster public-health response mechanism to prevent avoidable loss of innocent lives.