Inquest into the Death of Jared Charles OLSEN

41y · Male·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

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.