Deaths of children linked to syrup commission:Dr. Praveen Soni received ₹8.90 per Coldrif prescription

The deaths of 26 children shocked the nation after they consumed a toxic cough syrup called Coldrif in Madhya Pradesh. The children first experienced kidney failure, followed by the shutdown of other vital organs. Ultimately, the poison affected their brains, leading to death. The syrup, sold at Rs 89 per bottle, was prescribed by Dr. Praveen Soni, who received a 10 percent commission for every prescription, amounting to just Rs 8.90 per bottle. For all the prescriptions he wrote for the affected children, Dr. Soni reportedly earned approximately Rs 230, a small sum for a catastrophic loss of life. Despite repeated warnings from parents about their children’s deteriorating condition, Dr. Soni continued prescribing the syrup, showing complete disregard for patient safety. At the same time, government authorities and drug inspectors failed to intervene, highlighting systemic negligence. Dainik Bhaskar spoke to experts and tried to understand this entire system, that from the making of this poisonous medicine to its reaching children, which characters of our system have been equal partners in this crime. Read the report… Government promises action, but accountability lags On October 4, Chief Minister Mohan Yadav promised strict action against all responsible parties. However, 18 days later, there has been little progress in identifying those truly accountable. In response, the government suspended three bureaucrats and transferred the Drug Controller, but experts argue that this is merely a superficial response. The real question remains: Who were the real culprits behind these deaths? A deep dive into the chain of events, from production to prescription, reveals multiple points of failure in both private and government systems. From Tamil Nadu to Madhya Pradesh: A poisonous journey The primary villain in this tragedy was Ranganathan, owner of Shrisan Pharma, a company previously banned in Tamil Nadu for failing to meet quality standards. Ignoring this ban, Ranganathan simply changed the factory’s name and location and resumed production. The factory’s chemical analyst, K. Maheshwari, replaced the safe propylene glycol with diethylene glycol, a highly toxic industrial solvent used in paints, brake fluid, and antifreeze. Once ingested, this chemical destroys the kidneys and liver, eventually affecting the brain. Adding to the negligence, batch SR-13 was released without proper quality testing or verification of lab reports. This lethal batch was distributed through a network of stockists, reaching super-stockists in Jabalpur, then Chhindwara stockist New Apna Pharma, and eventually medical stores across the city. Children suffer while commission drives prescriptions Every district is legally required to have drug inspectors collect random samples of medicines and test them. In Chhindwara, no such inspections occurred, allowing the toxic syrup to circulate freely. Dr. Praveen Soni prescribed Coldrif for children suffering from coughs, ignoring obvious warning signs such as vomiting, abdominal pain, swelling, and reduced urine output — all classic indicators of kidney failure. Parents repeatedly returned, desperate for help, but Dr. Soni continued prescribing the same toxic syrup, telling them: Now take your child to another doctor. He later admitted to receiving a 10% commission per bottle, turning a child’s life into a mere ₹8.90 transaction. Government records indicate that 594 bottles of this batch were distributed in Chhindwara, earning Dr. Soni a total of Rs 5,286 — a paltry sum in exchange for countless lives. Parents faced financial ruin while saving children Desperate to save their children, parents resorted to loans, selling jewelry, and mortgaging land, traveling over 125 kilometers to hospitals in Nagpur. Tragically, most returned home with their children’s bodies instead of cure. It was only after Nagpur doctors identified a pattern — all children with kidney failure had been prescribed Coldrif syrup — that the Chhindwara system began to respond. On September 26, Nagpur Medical College officially confirmed via kidney biopsy reports that the children’s kidneys were damaged due to toxic effects of the syrup. This prompted Chhindwara Collector Sheelendra Singh to call an emergency health department meeting. Delayed ban and administrative negligence Pediatrician Dr. Pawan Nandurkar recommended an immediate ban on Coldrif based on biopsy results and expert advice. On September 29, Chhindwara administration froze the syrup’s sale and sent samples for testing in Bhopal. Shockingly, two days later, State Health Minister Rajendra Shukla cleared the syrup, claiming no official report linked the syrup to deaths, thereby refusing a statewide ban. Meanwhile, Health Department Principal Secretary Sandeep Yadav dismissed media reports highlighting children’s deaths. Officials prepared statements refuting Bhaskar’s reporting, though public pressure prevented them from implementing it fully. Tamil Nadu report confirms poison content On October 3, the Tamil Nadu government’s investigation confirmed the syrup contained 48% toxic chemical, compelling the Chief Minister to order a state-wide ban. Despite this confirmation, Principal Secretary Yadav continued to deflect responsibility, blaming the Tamil Nadu government for approving the syrup without proper quality testing. Systemic negligence exposed Negligence reached its peak when samples sent from Chhindwara to Bhopal on September 30 were not tested until October 4, as the drug department and labs were on holidays. Drug Controller Dinesh Maurya admitted that no testing occurred during Dussehra holidays, while officers attended festival celebrations. Only after the Tamil Nadu report gained media attention did Bhopal labs confirm 46% poison content in Coldrif syrup in a report released midnight, October 5.
Police action and legal proceedings The Madhya Pradesh Police Special Investigation Team (SIT) arrested factory owner Ranganathan and chemical analyst K. Maheshwari in Tamil Nadu. Dr. Praveen Soni was also taken into custody. His bail application was rejected by the lower court. He appealed to the High Court, with a hearing scheduled for October 27. Dr. Soni’s lawyers argued he merely prescribed the syrup, did not manufacture it, and thus should not be considered an accused. Government lawyers countered that he knew Coldrif, a fixed-dose combination (FDC), was not for children under four, yet continued prescribing it in exchange for a 10% commission, which he admitted. The court denied bail, noting: Even after knowing the dangers, the doctor continued administering the syrup to young children, violating December 18, 2023 guidelines. The crime is serious, the investigation is ongoing, and the accused may tamper with evidence. Experts cite failures at every level Dr. Pankaj Shukla, former Additional Director of the National Health Mission and ex-CMHO, said: Every stage of this case reflects negligence. Shrisan Pharma released Coldrif without quality testing, and local drug inspectors and controllers failed in monitoring. Stockists also distributed the syrup without verifying lab reports. Experts highlighted that India’s Drugs and Cosmetics Act, 1940, is outdated and does not adequately regulate modern medicine production, distribution, or quality checks. Ethical enforcement and stringent laboratory testing are urgently needed to prevent future tragedies.