On the night of November 26, 2025, a nurse at the Children’s Clinical University Hospital (BKUS) in Riga, Latvia, prepared an infusion bag for a young oncology patient’s treatment the following day. She labeled it sodium bicarbonate, the medication the child’s doctor had ordered. Prosecutors say what was actually in the bag was potassium chloride — a drug that, given the wrong way, stops a heart. The child died. This week, the nurse who prepared that bag was sentenced to prison for it.
What the court found
Riga City Court sentenced Jeļena Ugurenko on September 28, 2026, to two and a half years’ imprisonment after she pleaded guilty to negligent performance of her professional duties resulting in a patient’s death. The case had been sent to trial by the Rīga Pārdaugava Prosecutor’s Office in April 2026, roughly five months after the child died. The court also banned Ugurenko from practicing medicine for four years. According to Latvian Television and Latvian Public Media, Ugurenko admitted guilt and expressed regret; her defense described the case as “a fateful coincidence of circumstances.”
The victim’s family had sought 500,000 euros in non-pecuniary damages as part of the criminal proceeding. The court declined to award it, ruling that compensation at this stage would be premature and that the family could pursue it through a separate civil case.
Two drugs that should never be confused
Sodium bicarbonate and potassium chloride are both common hospital infusion additives, but they do almost opposite things in a crisis. Sodium bicarbonate buffers acid in the blood. Potassium chloride, given as a rapid or concentrated IV push rather than a slow, diluted infusion, can stop the heart within minutes — it’s the same drug used in lethal-injection protocols for exactly that reason. It is one of a short list of medications every U.S. hospital pharmacy classifies as “high-alert” and is supposed to store, label, and double-check separately from everything else on the shelf. Latvian authorities have not detailed whether BKUS had an equivalent safeguard in place at the time, or where in the preparation process the two drugs were switched.
I don't know a nurse who hasn't had a near-miss with a high-alert drug — the vial that looked like the other vial, the label you read fast because the unit was slammed. Most of us catch it before it leaves our hands. This case is the nightmare version of that same ordinary moment, and the sentence doesn't undo it for the family or for the nurse who has to live with it. What actually prevents the next one isn't punishing harder after the fact — it's independent double-checks on potassium chloride specifically, every time, built into the workflow so it doesn't depend on any one person's attention on any one shift. If your unit still pulls potassium chloride the same way it pulls saline, that's the thing to fix today, not after your own version of this story.
The case echoes similar high-alert medication prosecutions elsewhere, including in the United States, where nurses have faced criminal charges after fatal mix-ups involving the exact same class of drug. Patient-safety advocates have long argued those prosecutions punish individuals for failures in systems that were supposed to catch the error before it reached the bedside — a debate this case will likely reopen in Latvia.