Inquest into the Death of Jared Charles OLSEN
Deceased
Jared Charles OLSEN
Demographics
41y, male
Date of death
2015-03-05
Finding date
2017-09-29
Cause of death
Fulminant sepsis (Klebsiella pneumoniae) with multi-organ failure complicating severe pancytopenia following the administration of 6-Mercaptopurine in a man with acute severe exacerbation of chronic colitis (Crohn's) and TPMT deficiency
AI-generated summary
A 41-year-old man with newly diagnosed severe Crohn's colitis was prescribed 6-mercaptopurine (6-MP) after only 5 days of hospital treatment. He had a homozygous TPMT gene deficiency (present in ~0.3% of population) that rendered him unable to metabolise the drug safely. A TPMT test was ordered but results were not communicated to treating clinicians. Additionally, critical post-discharge full blood count monitoring was not arranged effectively. The patient developed fatal bone marrow aplasia, sepsis and multi-organ failure. Key failures included: absence of written 6-MP prescribing policy; electronic test results not reaching the treating team; failure to implement post-discharge blood monitoring with the GP; and inadequate communication systems. The death was likely preventable had either the TPMT results been acted upon on 19 February 2015, or full blood count results obtained on 24-25 February 2015 when bone marrow toxicity would still have been reversible.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Homozygous TPMT gene deficiency preventing normal drug metabolism
- Absence of written hospital policy for safe 6-MP prescribing
- TPMT test ordered but results not communicated to treating clinicians
- Electronic test results system failure (iCM) with no alert mechanism
- Lack of post-discharge monitoring systems for full blood counts
- Failure to communicate discharge plan effectively to general practitioner
- Discharge summary mailed but did not reach GP
- Patient vulnerability due to mental health condition (depression, anxiety)
- Inadequate supervision of junior staff in transit lounge
- Reliance on patient to arrange own follow-up blood tests
- Absence of IBD clinical nurse specialist at time of discharge
Coroner's recommendations
- That FSH put in place internal robust systems for tracking lists of patients in iCM for whom tests have been ordered and received, including for discharged patients, that facilitate conveyance of results to the ordering clinician and consultant in charge, and highlight urgent/abnormal results
- That the Department of Health consider whether an operational directive is required to support governance within public hospitals regarding systems for tracking test results, particularly for discharged patients, with alert regarding need for robust systems to facilitate conveyance of abnormal results to ordering clinician and consultant in charge
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