Phenergan Supp given to toddler; child dies

The only problem I've ever had with phenergan was with an elderly patient and it was given IV. My pediatrician didn't like phenergan for his patients so we often ended up with Tigan suppositories. My question is this... if mom thought that it was a 50mg Phenergan suppository, why did she allow them to give it to her child? Not blaming the mom here but just wondering.

Frankly that is what I was thinking too.