Inquest into the Death of Jared Charles OLSEN

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

1. 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
2. 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