Finding into death of Graeme Harold Griffiths

65y · Male·Severe neutropenic sepsis and multi-organ failure secondary to severe mucositis and probable DPD deficiency in the setting of T3 rectal carcinoma

A 65-year-old man with stage 3 rectal cancer died from severe neutropenic sepsis and multi-organ failure secondary to probable dihydropyrimidine dehydrogenase (DPD) deficiency when treated with capecitabine chemotherapy. He developed severe mucositis and systemic toxicity within days of commencing treatment. While the coroner found the clinical management appropriate by 2015 standards, the case highlights that DPD deficiency testing was not routine practice in Australia at the time, nor was a specific antidote available. The coroner noted emerging international practices in pre-treatment DPD testing and recommended that oncology groups consider adopting this as standard care, and that governments expedite access to the newly-available antidote Vistogard.