# Woman Burned Alive by Medication: Pharmacist Found Guilty

Source: https://www.youtube.com/watch?v=9tUvzQYWWXw
Recap page: https://rapidrecap.app/video/9tUvzQYWWXw
Generated: 2025-11-12T02:06:20.02+00:00

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## Quick Overview

The pharmacist in the case where a woman suffered severe injuries from Lamictal (lamotrigine) titration was found not guilty because the expert testimony presented by the defense suggested that following the manufacturer's guidelines, which state the dose should not exceed 50mg daily for the first four weeks for patients not taking valproate, would have virtually eliminated the risk of Stevens-Johnson Syndrome (SJS), implying the error was in the prescribing, not the dispensing.

**Key Points:**
- The patient lost her medical malpractice appeal after suffering severe injuries, including permanent disability and scarring, from Stevens-Johnson Syndrome (SJS) after taking Lamictal.
- The initial prescription started at 25mg daily for one week, followed by 50mg daily for three weeks, which the expert witness testified was an incorrect titration schedule, leading to the SJS.
- A 2017 analysis shows the incidence of SJS with Lamictal is 0.04% for most adults, but factors like age, race, and co-infections (like HIV) increase this risk.
- The prescribing nurse practitioner increased the dose to 100mg daily on Day 18 (Week 2.5), skipping the manufacturer's recommended 50mg maximum for Weeks 3 and 4 for patients not taking interacting drugs.
- An expert medical doctor testified that the incorrect titration caused the SJS and that it was completely avoidable if the prescription was written correctly or if the pharmacist had verified the schedule.
- The jury found the pharmacist not guilty, despite the expert testimony suggesting the pharmacist should have called the prescriber to correct the titration schedule, which would have avoided the entire situation.

![Screenshot at 00:57: The video displays a prescription bottle for Lamictal \(lamotrigine\) as the speaker introduces the drug associated with the severe adverse event.](https://ss.rapidrecap.app/screens/9tUvzQYWWXw/00-00-57.png)

**Context:** This video analyzes a medical malpractice case where a woman developed the life-threatening Stevens-Johnson Syndrome (SJS) after being prescribed the anticonvulsant/mood stabilizer Lamictal (lamotrigine) for bipolar disorder. The core issue revolves around the rapid dose escalation detailed in the initial prescription (25mg for one week, then 50mg for three weeks) which deviated from standard manufacturer guidelines, a deviation that experts testified was the direct cause of the severe rash and subsequent permanent disability.

## Detailed Analysis

The speaker reviews the case of a woman who suffered severe, life-altering injuries, including permanent disability and scarring, due to Stevens-Johnson Syndrome (SJS) allegedly caused by the incorrect titration of Lamictal prescribed for bipolar disorder. The initial prescription called for 25mg daily for one week, then 50mg daily for the next three weeks. The speaker notes that according to the manufacturer's guidelines for patients not taking interacting medications, the dose should not exceed 50mg daily until Week 5. The dose was increased to 100mg daily on Day 18 (Week 2.5), violating this safety guideline. An expert medical doctor testified that this incorrect titration caused the SJS and that it was entirely avoidable. The pharmacist who filled the prescription reportedly did not counsel the patient on the risks or verify the dosage change with the prescriber. The jury ultimately found the pharmacist not guilty, despite evidence suggesting that had the pharmacist called the prescriber or supervising physician, the error would have been corrected, avoiding the patient's injuries. The speaker expresses frustration that such errors occur, noting that the required slow titration is critical for this drug.

### Case Background

- Woman developed SJS from Lamictal rapid titration
- Lost medical malpractice appeal
- Suffered permanent disability and scarring

### Lamictal Titration Error

- Initial script was 25mg (Wk 1), then 50mg (Wk 2-4); manufacturer guideline recommends 50mg max until Week 5 for this patient group

### Expert Testimony

- Medical doctor testified that the incorrect titration caused SJS and was completely avoidable; expert pharmacist stated virtually no chance of problem if guidelines were followed

### Pharmacist Liability

- Expert testified pharmacist should have called the prescriber to fix the titration schedule or refused to fill the incorrect prescription; pharmacist did not counsel patient on risks or verify dose increase.

![Screenshot at 00:00: Woman in distress on a vertical video complaining about losing her medical malpractice appeal, stating 'JUSTICE WAS NOT SERVED'.](https://ss.rapidrecap.app/screens/9tUvzQYWWXw/00-00-00.png)
![Screenshot at 00:57: Visual display of a Lamictal prescription bottle being introduced by the speaker.](https://ss.rapidrecap.app/screens/9tUvzQYWWXw/00-00-57.png)
![Screenshot at 02:09: Screenshot of a 2017 analysis showing the incidence of SJS with Lamictal is 0.04% for most adults.](https://ss.rapidrecap.app/screens/9tUvzQYWWXw/00-02-09.png)
![Screenshot at 03:32: Display of the incorrect Lamictal titration schedule \(25mg for 1 week, then 50mg for 3 weeks\) compared to the manufacturer's table.](https://ss.rapidrecap.app/screens/9tUvzQYWWXw/00-03-32.png)
![Screenshot at 05:06: Text overlay highlighting the timeline of events, including Day 0 \(First Prescription\), Day 18 \(Dose Increased\), Day 24 \(Second Prescription\), and Day 29 \(Admitted to ICU\).](https://ss.rapidrecap.app/screens/9tUvzQYWWXw/00-05-06.png)
![Screenshot at 07:09: Excerpt from court documents detailing expert testimony that the incorrect titration caused SJS and was avoidable.](https://ss.rapidrecap.app/screens/9tUvzQYWWXw/00-07-09.png)
![Screenshot at 08:24: Excerpt from court documents showing that the pharmacist should have called the prescriber to explain the problem, which would have avoided the entire situation.](https://ss.rapidrecap.app/screens/9tUvzQYWWXw/00-08-24.png)