The deaths and treatment errors reported in the study of Lim et al are indeed distressing.1 However, some important questions remain unanswered. First, the authors do not state who was responsible for the children's treatment and who prescribed—or did not prescribe—the medication in question. Second, there is no solution-oriented discussion of the problem as the authors' analysis was inadequate.

For example, it remains unclear whether paediatricians or other doctors were responsible for these deaths or lay people, therapists or non-medical practitioners. If the treatment was not prescribed by doctors, it is quite conceivable that the persons giving the treatment lacked the necessary knowledge for treating children and for distinguishing dangerous situations from harmless symptoms. If this was the case, the problem would not be …