Parents say complaint 'swept under the rug' after B.C. pharmacy error leads to overdose for 5-year-old

The physical effects of Eli Wilson's clonidine overdose lasted for more than a day. A full 16 hours after taking the medication, video taken by his parents shows the autistic five-year-old falling asleep while standing.

Eli recovered after a night in hospital, but it would take months and thousands of dollars for mom and dad Lindsay and Brent to confirm what they had suspected.

Someone at the Goldstream Forbes Pharmacy in Victoria, B.C., had made a mistake while compounding the sleeping medication in February 2021.

Eli's clonidine was more than 14 times stronger than his prescribed dose, a lab report shared with CBC shows.

"I burst into tears," Lindsay Wilson remembers.

Her husband recalls their pediatrician telling saying they'd dodged a bullet.

"As bad as it was, it could have been much, much worse," Brent Wilson said.

Hoping for accountability, the Wilsons filed a complaint with the College of Pharmacists of B.C.

In a letter from the college's inquiry committee later that year, they learned the pharmacy didn't have any standard policies or procedures for compounding medications, and the dispensing pharmacist didn't perform an accurate final check of the drug.

Despite these findings, the inquiry committee decided there would be no punitive measures for the pharmacists, and nothing about what happened was made public.

"It's completely swept under the rug," Lindsay Wilson said. "If a new customer … is going to do their due diligence, there's no record of this anywhere."

When the college's decision was upheld as "justifiable and reasonable" by the Health Professions Review Board last week, the Wilsons decided it was time to speak out. They believe the college has failed in its responsibility to protect the public.

"I think it's important that people are aware, so they can ask questions of their pharmacists and then make good decisions for themselves," Brent Wilson said.

Pharmacists Ennreet Aujla, who was the manager for Goldstream Forbes at the time, and Quin Andrew, who'd prepared the medication, were both named in the complaint.