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The Drug They Wouldn't Stop
The Charted Defense Newsletter | Michael Coleman MD
A malpractice case involving a young child illustrates how recognition and response failures—rather than the initial prescribing decision—can drive catastrophic outcomes and large verdicts. In 2016, while being treated for Burkitt lymphoma at Children’s Hospital the child was started on allopurinol for tumor lysis syndrome prophylaxis, a routine therapy. Within days he developed progressive skin sloughing, a hallmark of Stevens-Johnson syndrome (SJS), yet multiple clinicians documented the worsening rash over approximately nine days without discontinuing the drug or obtaining a dermatology consult. When another physician finally recognized the likely diagnosis and stopped allopurinol, roughly 30% of the child’s body surface area was involved; he died the next day. In 2024 a jury returned a reported $35 million verdict against the University System Board of Regents. The case highlights recurring malpractice patterns: documented warning signs without action, diffusion of responsibility in team-based care, delayed escalation, and inadequate documentation of clinical reasoning. The broader lesson for physicians is that litigation risk often arises not from the initial treatment decision but from failures in monitoring, recognizing complications, and clearly documenting risk assessment, escalation plans, and response when warning signs appear.
Sources
Case Sources
* The Augusta Press (May 8, 2024). “Augusta jury awards $35 million verdict.” https://theaugustapress.com/augusta-jury-awards-35-million-verdict/
* GeorgiaMalpractice.com (Scott McMillen). “10 of the Largest Medical Malpractice Verdicts in Georgia History.” https://georgiamalpractice.com/10-of-the-largest-medical-malpractice-verdicts-in-georgia-history/
* Childers, Schlueter & Smith, LLC. SJS Practice Area. https://cssfirm.com/practice-areas/personal-injury/medical-malpractice/stevens-johnson-syndrome/
* AboutLawsuits.com: $6M California allopurinol-SJS verdict; $21M Bartlett v. Mutual Pharmaceutical SJS verdict.
Legal Sources
* Georgia Tort Claims Act, O.C.G.A. § 50-21-23 et seq. https://law.justia.com/codes/georgia/2020/title-50/chapter-21/article-2/section-50-21-23/
* Mutual Pharmaceutical Co. v. Bartlett, 570 U.S. 472 (2013).
Medical Literature
* Yang CY et al. “Allopurinol Use and Risk of Fatal Hypersensitivity Reactions.” JAMA Intern Med. 2015;175(9):1550-7.
* Ko T et al. “A prospective study of HLA-B*5801 genotyping in preventing allopurinol-induced severe cutaneous adverse reactions.” Clin Transl Allergy. 2014;4:O4.
* Cairo MS et al. “A Clinical and Economic Comparison of Rasburicase and Allopurinol.” Clin Lymphoma Myeloma Leuk. 2017;17(3):173-178.
* Cheung CMT et al. “SJS and TEN in Hong Kong.” Hong Kong Med J. 2024;30(2):102-109.
* Huang YS et al. “Drug-induced liver injury associated with severe cutaneous adverse drug reactions.” Liver Int. 2021;41(11):2671-2680.
* Bathini L et al. “Initiation Dose of Allopurinol and the Risk of Severe Cutaneous Reactions.” Am J Kidney Dis. 2022;80(6):730-739.
* Noe MH, Micheletti RG. “Diagnosis and management of SJS/TEN.” Clin Dermatol. 2020;38(6):607-612.
* Hasegawa A, Abe R. “Recent advances in managing SJS and TEN.” F1000Research. 2020;9:612.
* Chang CJ et al. “Pharmacogenetic Testing for Prevention of SCAR.” Front Pharmacol. 2020;11.
Regulatory Sources
* NCBI Medical Genetics Summary: Allopurinol Therapy and HLA-B*58:01 Genotype. https://www.ncbi.nlm.nih.gov/books/NBK127547/
* CPIC Guideline for Allopurinol and HLA-B (2013/2015). Hershfield MS et al. Clin Pharmacol Ther. 2013;93(2):153-158. Saito Y et al. Clin Pharmacol Ther. 2016;99(1):36-37.
* Allopurinol: Pediatric drug information. UpToDate (2026).
* Allopurinol: ClinicalKey AI clinical summary. Elsevier ClinicalKey (2026).
The Charted Defense provides educational content for physicians. Nothing in this newsletter constitutes legal advice, patient-specific medical advice, or a definitive statement of adjudicated findings. Case details are drawn from publicly available reporting with attribution. Where court-primary documents have not been obtained, this limitation is noted. Laws vary by jurisdiction. Discuss specific legal questions with qualified counsel. Discuss specific clinical questions with qualified colleagues.
Michael Coleman, MD is a practicing hospitalist, Hospital Medicine Program Director at US Acute Care Solutions (South Division), based at Highlands Medical Center in Scottsboro, Alabama. He is currently pursuing a Juris Doctor degree to deepen his expertise at the intersection of medicine and law. Michael has personally been named as a defendant in a medical malpractice lawsuit — an experience that profoundly shaped his understanding of how litigation impacts physicians.
Where medicine meets the law — an MD’s journey to JD.
This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thecharteddefense.substack.com/subscribe
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By The Charted DefenseThe Charted Defense Newsletter | Michael Coleman MD
A malpractice case involving a young child illustrates how recognition and response failures—rather than the initial prescribing decision—can drive catastrophic outcomes and large verdicts. In 2016, while being treated for Burkitt lymphoma at Children’s Hospital the child was started on allopurinol for tumor lysis syndrome prophylaxis, a routine therapy. Within days he developed progressive skin sloughing, a hallmark of Stevens-Johnson syndrome (SJS), yet multiple clinicians documented the worsening rash over approximately nine days without discontinuing the drug or obtaining a dermatology consult. When another physician finally recognized the likely diagnosis and stopped allopurinol, roughly 30% of the child’s body surface area was involved; he died the next day. In 2024 a jury returned a reported $35 million verdict against the University System Board of Regents. The case highlights recurring malpractice patterns: documented warning signs without action, diffusion of responsibility in team-based care, delayed escalation, and inadequate documentation of clinical reasoning. The broader lesson for physicians is that litigation risk often arises not from the initial treatment decision but from failures in monitoring, recognizing complications, and clearly documenting risk assessment, escalation plans, and response when warning signs appear.
Sources
Case Sources
* The Augusta Press (May 8, 2024). “Augusta jury awards $35 million verdict.” https://theaugustapress.com/augusta-jury-awards-35-million-verdict/
* GeorgiaMalpractice.com (Scott McMillen). “10 of the Largest Medical Malpractice Verdicts in Georgia History.” https://georgiamalpractice.com/10-of-the-largest-medical-malpractice-verdicts-in-georgia-history/
* Childers, Schlueter & Smith, LLC. SJS Practice Area. https://cssfirm.com/practice-areas/personal-injury/medical-malpractice/stevens-johnson-syndrome/
* AboutLawsuits.com: $6M California allopurinol-SJS verdict; $21M Bartlett v. Mutual Pharmaceutical SJS verdict.
Legal Sources
* Georgia Tort Claims Act, O.C.G.A. § 50-21-23 et seq. https://law.justia.com/codes/georgia/2020/title-50/chapter-21/article-2/section-50-21-23/
* Mutual Pharmaceutical Co. v. Bartlett, 570 U.S. 472 (2013).
Medical Literature
* Yang CY et al. “Allopurinol Use and Risk of Fatal Hypersensitivity Reactions.” JAMA Intern Med. 2015;175(9):1550-7.
* Ko T et al. “A prospective study of HLA-B*5801 genotyping in preventing allopurinol-induced severe cutaneous adverse reactions.” Clin Transl Allergy. 2014;4:O4.
* Cairo MS et al. “A Clinical and Economic Comparison of Rasburicase and Allopurinol.” Clin Lymphoma Myeloma Leuk. 2017;17(3):173-178.
* Cheung CMT et al. “SJS and TEN in Hong Kong.” Hong Kong Med J. 2024;30(2):102-109.
* Huang YS et al. “Drug-induced liver injury associated with severe cutaneous adverse drug reactions.” Liver Int. 2021;41(11):2671-2680.
* Bathini L et al. “Initiation Dose of Allopurinol and the Risk of Severe Cutaneous Reactions.” Am J Kidney Dis. 2022;80(6):730-739.
* Noe MH, Micheletti RG. “Diagnosis and management of SJS/TEN.” Clin Dermatol. 2020;38(6):607-612.
* Hasegawa A, Abe R. “Recent advances in managing SJS and TEN.” F1000Research. 2020;9:612.
* Chang CJ et al. “Pharmacogenetic Testing for Prevention of SCAR.” Front Pharmacol. 2020;11.
Regulatory Sources
* NCBI Medical Genetics Summary: Allopurinol Therapy and HLA-B*58:01 Genotype. https://www.ncbi.nlm.nih.gov/books/NBK127547/
* CPIC Guideline for Allopurinol and HLA-B (2013/2015). Hershfield MS et al. Clin Pharmacol Ther. 2013;93(2):153-158. Saito Y et al. Clin Pharmacol Ther. 2016;99(1):36-37.
* Allopurinol: Pediatric drug information. UpToDate (2026).
* Allopurinol: ClinicalKey AI clinical summary. Elsevier ClinicalKey (2026).
The Charted Defense provides educational content for physicians. Nothing in this newsletter constitutes legal advice, patient-specific medical advice, or a definitive statement of adjudicated findings. Case details are drawn from publicly available reporting with attribution. Where court-primary documents have not been obtained, this limitation is noted. Laws vary by jurisdiction. Discuss specific legal questions with qualified counsel. Discuss specific clinical questions with qualified colleagues.
Michael Coleman, MD is a practicing hospitalist, Hospital Medicine Program Director at US Acute Care Solutions (South Division), based at Highlands Medical Center in Scottsboro, Alabama. He is currently pursuing a Juris Doctor degree to deepen his expertise at the intersection of medicine and law. Michael has personally been named as a defendant in a medical malpractice lawsuit — an experience that profoundly shaped his understanding of how litigation impacts physicians.
Where medicine meets the law — an MD’s journey to JD.
This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit thecharteddefense.substack.com/subscribe