
It began quietly on a rainy August afternoon in Madhya Pradesh. It was around 3 pm on August 16, when six-year-old Divyansh Yaduvanshi developed a fever. His temperature read 100 degrees Fahrenheit – mild enough to seem harmless, yet enough to worry his father, Prakash Yaduvanshi, a small farmer from Duddi village in Parasia tehsil of Chhindwara district.
The next morning, Prakash took his son to Dr Pravin Soni in Parasia, about five to six kilometres from their village. A well-known child specialist, Dr Soni’s clinic was the first stop for most parents in the region. After a brief examination, he prescribed Indiclav tablets and a cold syrup named Coldrif – to be given twice and four times a day, respectively.
No one in this quiet corner of the country could have imagined that the syrup – manufactured by Sresan Pharmaceuticals in Tamil Nadu – contained diethylene glycol, a toxic industrial solvent used in brake fluid and antifreeze. Within weeks, Coldrif would be linked to one of the worst medical tragedies the region had ever seen.
Over the next seven weeks, 17 children, including Divyansh, died and six more were hospitalised in neighbouring Nagpur, Maharashtra – all with the same symptoms, all with one common medicine on their prescriptions: Coldrif.
Doctors in Nagpur had raised the alarm about suspected diethylene glycol poisoning as early as September 22. Yet, the Madhya Pradesh government denied any link between the syrup and the deaths until October 3, when Tamil Nadu’s drug testing laboratory confirmed the syrup contained 48.6 percent diethylene glycol and flagged more than 364 manufacturing violations at Sresan Pharmaceuticals. The delay proved deadly – children continued taking the contaminated syrup even as families sold land and jewellery to fund treatments in a desperate race against poison. What it also exposed was public health infrastructure struggling to tackle a crisis.
Now, amid mounting outrage, the Madhya Pradesh government has arrested one doctor who prescribed the medicines and acted against three officials. But all of this is being seen as a kneejerk response.
The tragedy echoes a chillingly similar episode in Gambia in 2022, where 66 children died after consuming cough syrup tainted with diethylene glycol, manufactured by an Indian firm.
Sajid added, “The lab assistant gave us a small container and told us to bring his urine when he was ready. We went back to the hospital. We waited, but he didn’t pass urine the entire night.”
The next morning, his parents grew worried and informed Dr Soni. Even the doctor found it alarming. He advised the family to take Adnan to Chhindwara District Hospital. But fearing poor facilities there, the family instead went to Dr Pravin Nahar’s private hospital in the city.
After some tests, Dr Nahar informed the family that Adnan’s creatinine levels were very high and his kidneys were not functioning properly. The family decided to rush him to Nagpur, about two hours from Chhindwara. On August 29, Adnan was admitted to NSH Hospital, where doctors confirmed that both kidneys had been severely damaged and dialysis was immediately required.
Sajid said, “Adnan was okay for the first three dialysis sessions. But after the fourth, his condition deteriorated, and doctors put him on a ventilator.”
From August 30 to September 6, Adnan remained on the ventilator. The family, by then, had exhausted their savings. They were unable to afford the increasing hospital bills, after which they shifted him to Government Medical College, Nagpur. He died the next day.
‘She was my only child’
Mahesh Daheriya, 34, a resident of Belgaon village, recalls the last days of his daughter Vidhi Dehariya, who would have turned three on October 5 but died just weeks before her birthday.
Mahesh said, “On the morning of August 29, she developed a fever. I wasn’t at home then, so my elder brother took her to Dr Pravin Soni, the doctor we usually consult. He gave her some medicine, and for the next two or three days, she seemed fine.”
But the fever returned, and the family went back to Dr Soni, who asked them to continue the medicines. On September 3, however, Vidhi did not urinate the entire day. Her parents rushed her back to the doctor, who ordered blood tests and referred her to Dr Pravin Nahar. The next day, Dr Nahar informed the family that her kidneys were failing. The family then took Vidhi to Civil Hospital in Chhindwara, but her condition worsened. That same day, they made the urgent trip to Government Medical College in Nagpur. Vidhi died the next day.
“She was my only child. I tried my best, but I couldn’t save her. At that time, nobody knew what was happening with the children in Parasia. We didn’t know the danger was the medicine,” said Mahesh.
The first casualty is not even recognised
Prakash Yaduvanshi recalled that when his six-year-old son didn’t improve after the first visit, he took him back to Dr Soni on August 20. The doctor advised continuing the same medicines. “But his condition worsened. On the night of August 22, he began vomiting repeatedly. We panicked and took him to another doctor, Akash Shrivastav, in Chhindwara,” Prakash said.
Dr Shrivastav found Divyansh critical and referred him to Vivanta Hospital, where he was given injections and glucose. His condition deteriorated further. By August 24, he had stopped passing urine. “Doctors said his kidneys were failing and referred us to Colors Hospital in Nagpur,” Prakash said. “Tests there confirmed both kidneys were damaged. He underwent seven dialysis sessions, but nothing changed. On August 28, he was put on a ventilator.”
By September 1, Divyansh had stopped responding. “I had already borrowed Rs 7 lakh for his treatment,” Prakash said. “I asked the doctors to discharge him so we could move him to a government hospital. I had no money left. When they removed the ventilator the next day, he was gone. He had been breathing only because of the machine.”
“Dozens of children died over a month, but the administration did nothing,” he said. “Government hospitals are useless — even veterinary ones are better. The poor like us have no choice but private hospitals. When our children die, nobody cares.”
Divyansh’s name has not been included in the district administration’s official list of deceased children, making his family ineligible for the Rs 4 lakh compensation announced by Chief Minister Mohan Yadav. “The chief minister came to Chhindwara on Monday, but I wasn’t allowed to meet him because my son’s name wasn’t on the list. I’ve submitted an application and hope they add it,” Prakash said.
Divyansh was declared dead on September 2 — the first casualty in what is now known as the Coldrif deaths.
The pattern emerges
In the days that followed, news trickled in of other children dying in villages across Parasia tehsil, all with the same symptoms: vomiting, stoppage of urine, kidney failure. For weeks, no one suspected the syrup. In the surrounding villages of Parasia, parents continued giving Coldrif to their children, prescribed by trusted doctors, unaware of what was coming.
In Newton village of Parasia, five-year-old Adnan Khan fell ill just days after Divyansh. His uncle, Sajid Khan, 53, recalls the sequence of events. “There was viral fever going around in Parasia. Adnan developed a fever on August 21, so we took him to Dr Pravin Soni, whom we usually visit whenever any child in our family falls ill…He examined him and prescribed Anset MD, Meftal P 100, and Coldrif syrup, asking us to give four doses of 4 ml each day.”
On August 25, Adnan complained of a stomach ache, so the family took him back to Dr Soni, who prescribed more medicines. Two days later, the symptoms turned severe. On August 27, Adnan began vomiting repeatedly – nearly eight to 10 times that day. The family rushed back to Dr Soni, who admitted him to his Jeevan Jyoti Hospital. He advised blood and urine tests. But at the pathology laboratory, Adnan couldn’t urinate.
Ironically, the Controller of Food and Drug Administration (FDA) of Madhya Pradesh, Dinesh Kumar Maurya, had already written to Tamil Nadu’s drug regulator on October 1, requesting action against Sresan Pharmaceuticals, the manufacturer in Kanchipuram. Maurya noted that drug inspectors from Madhya Pradesh and the CDSCO sub-zone in Indore were already conducting a joint investigation.
The Tamil Nadu Directorate of Drugs Control completed its probe within 36 hours and banned the contaminated batch, but Madhya Pradesh authorities delayed releasing their own report even as the death toll mounted.
Between September 26 and 28, joint teams from the Central Drugs Standard Control Organization (CDSCO) and the MPFDA had collected samples of 19 medicines from Chhindwara – all of these, including Coldrif, were prescribed to victims. CDSCO took six samples, while MPFDA collected the remaining 13. By October 1, CDSCO had submitted its reports on all six samples, confirming they met quality standards. In comparison, MPFDA moved slowly, submitting reports on only three of the 13 samples by October 3 – none of which included Coldrif.
Meanwhile, Tamil Nadu acted decisively: within 36 hours of the October 1 alert, it tested the same syrup and banned Coldrif on October 3. The MPFDA, despite collecting its sample on September 26, did not release its test report for nine days. Only on October 4, after Tamil Nadu’s ban, did Madhya Pradesh release its report on Coldrif.
The damning laboratory report
The report from the Tamil Nadu drug testing laboratory confirmed that the syrup was highly adulterated, stating, “The sample is found to be adulterated since it contains diethylene glycol (48.6 percent w/v), which is a poisonous substance that may render the contents injurious to health.”
The report further observed that Sresan Pharmaceuticals had failed to comply with Good Manufacturing Practices (GMP) at any stage of production. A huge number of non-compliances were noticed. Over 364 deficiencies were recorded, including 39 critical and 325 major deficiencies. It cited gross negligence, including storage and distribution under unhygienic and extreme conditions risking product quality, use of non-pharmaceutical grade propylene glycol without testing for diethylene glycol and ethylene glycol concentration, absence of air filtration systems to prevent contamination, no pest control measures, use of non-pharma-grade solvents, and no systems to prevent microbial proliferation.
While the Madhya Pradesh government apparently remained in slumber for weeks as children continued to die, it has now acted swiftly against Dr Pravin Soni. An FIR was filed against him and Sresan Pharmaceuticals at the Parasia police station on October 5, following which Dr Soni was arrested from his home in the middle of the night by the Chhindwara police.
His arrest is viewed by some as an attempt to find a scapegoat. The Indian Medical Association (IMA) has objected to the arrest, stating that doctors only prescribe medicines and are not responsible for their manufacturing or quality testing. The responsibility to ensure drug safety lies with the drug controller and the government. The IMA also warned it would intensify protests if the doctor is not released.
A day after the arrest, the Madhya Pradesh government suspended Deputy Drug Controller Shobhit Kosta and two drug inspectors, Gaurav Sharma and Sharad Kumar Jain, from their duties. Meanwhile, the State Food and Drug Controller, Dinesh Kumar Maurya, has been transferred.
Newslaundry reached out to MP Health Minister and Deputy CM Rajendra Shukla for comment. This report will be updated if a response is received.
This story was originally published in Newslaundry and has been republished here with permission.