A man who died at Fiona Stanley Hospital (FSH) after having an adverse reaction to an anti-inflammatory drug would likely still be alive if results of his blood tests had been checked by doctors, the WA Coroner has found. Jared Olsen died in March 2015, less than a month after he was given the drug 6-mercaptopurine (6-MP) to treat his inflammatory bowel disease (IBD). The drug is known to cause adverse side effects in some people, including bone marrow toxicity. National medical standards require patients prescribed with 6-MP to undergo screening tests for the enzyme TPMT, which is needed to metabolise the drug. At the time of Mr Olsen’s admittance FSH did not have a policy regarding the safe prescription of the drug, although doctors did order a TPMT screen. However when the hospital’s electronic database generated the request for the test, it did so under the name of an intern on Mr Olsen’s treatment team. The test revealed Mr Olsen had severely low levels of TPMT, but when the results were released electronically none of the treating clinicians became aware of that fact. In her findings WA Coroner Ros Fogliani said if doctors had been aware of Mr Olsen’s TPMT levels any time soon after he was prescribed 6-MP, his bone marrow impairment would likely have been reversible. She said Mr Olsen’s death was a result of systemic failures within FSH, but did not make any adverse comments against the clinicians involved. In her findings Ms Fogliani recommended FSH install robust systems for tracking test results of discharged patients, and ensuring those results were provided to consultants in charge of the patient’s treatment. She also recommended such a system highlight urgent or abnormal test results. Ms Fogilani also recommended the Department of Health consider whether similar measures should be adopted across the public health system.
