If that is what happened, yes I agree that they are wrong and grossly negligent. What I find hard to believe is there is a department that would allow Ketamine to be given without monitoring capnography. Capnography would have alerted them that he stopped breathing within 15-30 seconds. The only details that are provided are too much medication was given and he died. Not monitoring capno would have made this an open and shut case.
The other reason I don’t jump on it’s their fault is because we follow something called “just culture” which says when an error is made we have to look at the totality of the circumstances and we console human error, coach reckless behavior and punish negligence. I wasn’t involved in any case reviews and I wasn’t on the jury. I don’t know the full circumstances so I’m going to remain impartial and let the jury’s verdict speak for itself.