By Susan Carr

On December 13, 2006, 4-year-old Rebecca Riley died from an overdose of clonidine administered by her parents, who have been charged with first-degree murder. Prosecutors allege the parents routinely misused multiple drugs that had been prescribed to treat attention deficit hyperactivity disorder and bipolar disorder in their three young children.

Based on reports published in The Boston Globe, this does not sound like a case of premeditated harm or murder. Rather, this sounds like a particularly gruesome sort of medication error, with a long list of individuals involved and harmed in various ways.

Rebecca's family exhibited the stereotypic symptoms of a "troubled family:" poverty, lack of education, psychiatric disorders, restraining orders, and allegations of sexual abuse. The Rileys had been known to the Massachusetts Department of Social Services (DSS) since 2002. Rebecca died despite receiving care from a board-certified psychiatrist practicing at one of Boston's respected medical institutions and a DSS investigation in the summer of 2006. A state senator summarized the case as if describing James Reason's Swiss cheese model of error, saying, "The state, the child's parents, the psychiatrist, and the pharmacies that filled the girl's prescriptions all share some responsibility for her fate. You've got four levels that could have caught something, and the confluence of misses that created a window for tragedy."

Many people question whether the physician's diagnoses and treatments were appropriate. The DSS has been criticized for not recognizing that Rebecca's parents were mismanaging their children's medications and for not getting the children out of danger. The department is trying to appoint a panel of physicians to perform independent reviews of medical treatments for families in DSS care. Disturbingly, they report difficulty in finding physicians who are willing to serve, which they attribute to the physicians' fear of liability and reluctance to second-guess their medical colleagues.

This case reveals the web of responsibility that exists around patients who depend on others to manage their medical care — especially children, the elderly, and in this case, whole families who are unable to care for themselves. With hindsight, it is obvious that everyone in this case needed a better understanding of the risks inherent in the combination of Rebecca's medications and family situation. In a perfect world, Rebecca's physician and DSS caseworkers would have recognized that it was inappropriate to give her parents responsibility for managing those risks.

Cramer, M. (2007, Febraury 8). DSS dropped inquiry before girl, 4 was found dead. The Boston Globe.

Cramer, M. (2007, February 9). DSS seeking medical experts. The Boston Globe.

Cramer, M., & Mishra, R. (2007, February 7). Girl fed fatal overdoses, court told. The Boston Globe.