From early October, news across India has been filled with reports of the deaths of twenty-three children in Madhya Pradesh and Rajasthan after consuming cough syrup. Behind those headlines lies a story that has not been understood fully and has not been examined properly. This is the sixth case of diethylene glycol poisoning recorded in India. The question remains, has the Drug Controller General of India learned anything from the past?
To understand what really happened, I spoke with three people who see this system from different sides: a medicine manufacturer, a teacher at the central level who trains drug inspectors, and a paediatrician. Their names have been kept anonymous. What they said shows how this tragedy could have been prevented if lessons from earlier cases had been taken seriously. Read till the end to see how failure at every level turned a preventable error into another national disaster.
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What is MP and Rajasthan case of “Death of children due to Cough Syrup case” ?
In Rajasthan, the first death was reported on September 22 in Sikar when a five-year-old child died after taking a cough syrup containing dextromethorphan. Two more children died in Bharatpur after consuming the same formulation. A two-and-a-half-year-old who took ambroxol fell critically ill. Investigations later confirmed nine child deaths across the state [source: OC Academy1]. The Rajasthan Medical Services Corporation Limited, which handles medicine procurement, had sourced the syrups from Kaysons Pharma even though the company had failed forty-two quality tests in the past. The government initially cleared the manufacturer and blamed doctors and pharmacists. After public pressure, Kaysons Pharma was blacklisted. Health Minister Gajendra Singh Khinvsar said the deaths were caused by other illnesses and not by contaminated medicine [Source: DrugsControl Media Services. Rajasthan Cough Syrup Crisis2].
In Madhya Pradesh, fourteen children died between September 4 and 26 after consuming the cough syrup Coldrif. The syrup was made by Sresan Pharmaceuticals in Tamil Nadu. Tests at the Tamil Nadu Drug Testing Laboratory found 48.6 percent diethylene glycol in the syrup, a highly toxic chemical that damages the kidneys [Source: DrugsControl Media Services 3]. The doctor involved, Praveen Soni, continued prescribing Coldrif even after children developed renal complications. Two drug inspectors, Sharad Jain and Gaurav Sharma, were suspended for negligence [Source: TNN. Cough syrup deaths 4]. The case led to nationwide scrutiny of cough syrup safety and the regulation of pharmaceutical manufacturing.
For detail information about the case, check out our YouTube video.
2025 Tragedy Timeline
What is DEG Poisoning?
Diethylene glycol, or DEG, was found in the Coldrif cough syrup consumed by children in Madhya Pradesh. Cough syrups usually contain polyethylene glycol (PEG) as an excipient to improve solubility, texture, and stability. The connection between PEG and DEG lies in production. During the manufacture of PEG, DEG often appears as an impurity. Its presence means contamination.
In the Coldrif samples, DEG was detected at 48.6 percent, nearly forty times higher than the permissible limit. A trainer of drug inspectors said, “It is certain that industrial-grade PEG was used. That is why the DEG level was so high.”
DEG is a toxic industrial chemical used in brake fluids and paints. When consumed, it is converted by the liver into harmful compounds that destroy kidney tissue and cause acute renal failure.
This is not the first DEG poisoning incident in India. It is the sixth.
1972 – Madras (Chennai): Use of DEG in paracetamol elixir caused the deaths of 15 children. The supplier’s licence was cancelled. No criminal prosecution followed.
1986 – J.J. Hospital, Mumbai: Fourteen patients died due to DEG contamination. Justice was not served. Only administrative reforms were suggested.
1988 – Bihar: Eleven children died after taking contaminated cough syrup. No one was convicted.
1998 – Gurugram and Delhi:33 children died after consuming DEG-contaminated syrup.
2019 – Jammu and Kashmir:12 children died. Legal proceedings remain incomplete.
2025 – Madhya Pradesh and Rajasthan: 14+ children in Madhya Pradesh and nine in Rajasthan died after consuming contaminated cough syrup.
A trainer of drug inspectors explained that DEG contamination can only be detected through gas chromatography. According to him Most manufacturing units in India do not have this testing facility. “If proper testing had been done, these deaths would not have happened,” he said.
This raises the next question: who should be held responsible? which brings us to the next topic…………
Who should be held responsible for the deaths of the children?
There are many faces responsible for the deaths in this case. The doctor, the manufacturer, and the Drug Controller General of India.
First, the doctors. In both Rajasthan and Madhya Pradesh, doctors prescribed medicines that carry clear warnings against use in children below five years. Dextromethorphan and ambroxol are specifically listed by the Indian Academy of Pediatrics as unsuitable for that age group. Coldrif, which was widely prescribed, contains dextromethorphan, chlorpheniramine, and phenylephrine.
The Central Drugs Standard Control Organisation has repeatedly warned that this combination should not be given to young children because their safe and toxic doses are too close.
In Madhya Pradesh, Dr Praveen Soni continued to prescribe Coldrif even after children began developing kidney problems. When he was arrested, the Indian Medical Association, a body of forty lakh doctors, protested against his arrest. Dr Soni said he had prescribed the medicine to children for years. His statement itself shows how guidelines were ignored. He worked in a government-run Community Health Centre at day, but most of the children who died had been treated at his private clinic. It was there that he could prescribe branded drugs.
“Why did he prescribe a branded medicine from such a small area, that too one made in Tamil Nadu? Clearly there was an external force, possibly a medical representative, who influenced him.” – A teacher who trains drug inspectors .
A paediatrician added, “Even if the doctor prescribed the syrup, children should not have died. That means the medicine itself was unsafe.”
The manufacturer’s role is equally serious. A medicine maker from Himachal said, “The manufacturer should have tested both the raw material and the finished product before sending it to the market.”
The company did not test. The syrup was sold. Two drug inspectors in Madhya Pradesh were later suspended for knowing about the adulteration but failing to act.
The first report from the CDSCO claimed that no diethylene glycol or ethylene glycol was detected. The Tamil Nadu Drug Testing Laboratory found the opposite. The DEG concentration in Coldrif was 48.6 percent.
A teacher who trains drug inspectors said, “This is the fault of the Drug Controller General of India. This is not the first time India has faced DEG poisoning. We have lost children six times now. If it happened once or twice, it was a mistake. If it happened the third or fourth time, it was a crime. But the fifth and sixth make it a habit, a habit of taking lives. What is the DCGI doing? They must create strict laws and enforce them properly.”
Another medicine manufacturer explained how the reporting system itself is weak. “Every month, a drug inspector must submit ten samples. Nine are taken from manufacturers and retail pharmacies and one from cosmetics. These are sent for testing. If any sample fails, it is reported by the CDSCO as NSQ, not of standard quality.”
That weakness allows manipulation. The Drug Controller II in Rajasthan, Rajaram Sharma, was found to have changed definitions in official data and is now facing criminal charges.
The teacher who trains inspectors said, “This can change only if the production of PEG is strictly regulated. The DCGI should act.”
The cases in Madhya Pradesh and Rajasthan show why testing every medicine is essential. If a drug carries a warning that it should not be given to children below four, no child should die after taking it. Yet they did.
In Rajasthan, a doctor tried to reassure parents that the cough syrup was safe. To prove it, he and two ambulance staff members drank it themselves. Within hours, they fell ill. The incident revealed how fragile trust in the system has become.
A paediatrician explained that many posts for drug inspectors posts remain vacant. Those who are appointed often handle more than one district and work under pressure. Sampling becomes random, not scientific. Manufacturers, driven by profit, push their products into the market without giving enough attention to safety.
That is why, in our own work, we send each batch for independent testing before sale. Only after those results are cleared do we release any product. Testing is not a formality. It is the line that separates safety from tragedy.
Checkout: SayaCare’s strict Testing Policy for every medicine batch.
The story of the cough syrup deaths in Madhya Pradesh and Rajasthan is not only about one batch or one company. It reflects how a chain of neglect can take lives. The doctor prescribed what should not have been prescribed. The manufacturer sent out medicine that was never properly tested. The regulators failed to detect it before it reached children.
Every time a diethylene glycol tragedy happens, the response is the same. Officials suspend a few people, order inquiries, and issue new guidelines. But nothing changes on the ground. Factories still use industrial-grade solvents. Testing remains limited. Data can still be manipulated.
India has now faced six confirmed cases of DEG poisoning over five decades. Each one was preventable. The pattern shows that the system reacts only after lives are lost. The cost of that delay is counted in the deaths of children whose families believed they were giving them medicine, not poison.
The lesson is not new. Medicine must be tested, rules must be enforced, and accountability must be real. Unless that happens, the next tragedy will not be an accident. It will be another expected repetition of the same failure.
Mahak Phartyal completed her bachelor's in pharmacy from Veer Madho Singh Bhandari Uttarakhand Technical University. She previously worked as a Medical Writer at Meril Life Sciences, where she wrote numerous scientific abstracts for conferences such as India Live 2024 and the European Society of Cardiology (ESC). During her college years, she developed a keen research interest and published an article titled “Preliminary Phytochemical Screening, Physicochemical and Fluorescence Analysis of Nyctanthes arbor-tristis and Syzygium cumini Leaves.”
Mahak Phartyal completed her bachelor’s in pharmacy from Veer Madho Singh Bhandari Uttarakhand Technical University. She previously worked as a Medical Writer at Meril Life Sciences, where she wrote numerous scientific abstracts for conferences such as India Live 2024 and the European Society of Cardiology (ESC). During her college years, she developed a keen research interest and published an article titled “Preliminary Phytochemical Screening, Physicochemical and Fluorescence Analysis of Nyctanthes arbor-tristis and Syzygium cumini Leaves.”
5 thoughts on “Cough Syrup or Killer? The Madhya Pradesh and Rajasthan Tragedy Explained”
This is such a heartbreaking situation, and it’s infuriating to see that history is repeating itself. The failure to act on past tragedies is clear, but what struck me most in this post is the lack of accountability across the board—from manufacturers to regulators. If the system had been more transparent and proactive, these deaths could have been prevented.
I like Sayacare’s reports but I think they only test for reported ingredients in the medicines(if they are under or above limits of QA) and not the other contaminants right?
Or do you also test for contamination?
Hello Anoosha,
Thank you for your question.
We conduct assay testing to verify the purity and potency of the active ingredient. While the assay can indicate if the purity is lower than expected, it does not identify the specific contaminant. If the purity falls below the acceptable range, we do not include those medicines in our inventory and return the batch to the manufacturer.
Aap logo contamination testing aur heavy metals testing wagera bhi Kiya kijiye..tab logo ka trust aur badhega apke brand par… I hope aap is advice pr jarur vichar karenge
Hi Mukesh Kumar,
Thank you for your suggestion!
We will introduce contamination and heavy metals testing in future to further strengthen trust in our brand.
This is such a heartbreaking situation, and it’s infuriating to see that history is repeating itself. The failure to act on past tragedies is clear, but what struck me most in this post is the lack of accountability across the board—from manufacturers to regulators. If the system had been more transparent and proactive, these deaths could have been prevented.
I like Sayacare’s reports but I think they only test for reported ingredients in the medicines(if they are under or above limits of QA) and not the other contaminants right?
Or do you also test for contamination?
Hello Anoosha,
Thank you for your question.
We conduct assay testing to verify the purity and potency of the active ingredient. While the assay can indicate if the purity is lower than expected, it does not identify the specific contaminant. If the purity falls below the acceptable range, we do not include those medicines in our inventory and return the batch to the manufacturer.
Aap logo contamination testing aur heavy metals testing wagera bhi Kiya kijiye..tab logo ka trust aur badhega apke brand par… I hope aap is advice pr jarur vichar karenge
Hi Mukesh Kumar,
Thank you for your suggestion!
We will introduce contamination and heavy metals testing in future to further strengthen trust in our brand.