Inquest into the Death of Jared Charles OLSEN

Inquest into the Death of Jared Charles OLSEN

Delivered on :29 September 2017

Delivered at : Perth

Finding of : State Coroner Fogliani

Recommendations :Yes

That Fiona Stanley Hospital put in place its own internal robust systems for tracking lists of patients in iCM for whom tests have been ordered and received, including for patients that have been discharged, that those systems facilitate the conveyance of test results to the attention of the clinician who ordered the test and the consultant in charge of the patient’s treatment, and that those systems highlight urgent and/or abnormal test results.

And

That the Department of Health consider whether an operational directive or instruction is required to support governance within public hospitals regarding the implementation of systems for tracking test results, particularly where patients have been discharged.   Such operational directive or instruction would include an alert to public hospitals regarding the need for robust systems to be in place to facilitate the conveyance of an abnormal laboratory result to the attention of the clinician who ordered the test and the consultant in charge of the patient’s treatment..

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased died at Fiona Stanley Hospital on 5 March 2015 after suffering complications from sepsis, brought on by a serious adverse reaction to a medication that had previously been prescribed to him at that hospital. The deceased was 41 years old.

The focus of the inquest was the deceased’s first admission at Fiona Stanley Hospital and traversed his diagnosis, the initial treatment with steroids to treat his inflammation, the decision to prescribe the 6-MP medication, the steps taken to address his consent to treatment, the timing of medical tests undertaken to detect his enzyme activity, the reasons as to why the test results were not ascertained by Fiona Stanley Hospital clinicians, the plans for his follow up medical care after discharge, and the reasons as to why those plans failed in their implementation.

The State Coroner found the deceased was treated for Crohn’s colitis with the immunosuppressant medication 6-MP, a cytotoxic drug and he was unable to metabolise it because he had two non-functioning copies of the TPMT gene. This led to 6-MP toxicity and profound bone marrow suppression, ultimately resulting in his death.  The State Coroner concluded that Fiona Stanley Hospital missed a number of opportunities to detect and avert the possibility of 6-MP toxicity in the deceased, and that it is likely that the deceased’s death could have been prevented if the 6-MP had been withdrawn at certain points.

The State Coroner found a series of events led to significantly abnormal test results being received electronically at Fiona Stanley Hospital, with no clinician becoming aware of them. The State Coroner commented that the inquest highlighted the risk for patients when too much reliance is placed on electronic communications in an environment where clinicians routinely work on rotation and in team environments.

The State Coroner found that there were risks for patients when critical post discharge care arrangements with GP’s are planned, which have no adequate system in place to check on whether the GP has become aware of his or her function.

The combination of the absence of a policy addressing the safe prescription of 6-MP (which includes monitoring for toxicity), and  the absence of an adequate system in place for tracking lists of patients in iCM for whom tests have been ordered, caused the State Coroner to conclude that there were systemic failures at Fiona Stanley Hospital.  The State Coroner commented that the deceased’s care at Fiona Stanley Hospital was deficient and fell below the standards that should ordinarily be expected of a public hospital.

The State Coroner made two recommendations in regards to the proactive conveyance of abnormal test results to the attention of the appropriate treating clinicians.

The State Coroner noted since the deceased’s death Fiona Stanley Hospital and PathWest have developed a number of procedures in support of improved communication, and the avoidance of a fragmented system of care. They have included the imperative for health professionals to speak with each other in certain cases to ensure that vital information has been passed on, that it has been received, noted and understood, that appointments are kept, that patients are contacted, and that the chain of clinicians involved in a patient’s care operates in a more integrated fashion.

Catch Words : 6-Mercaptopurine (6-MP) : Communication of test results : Discharge arrangements from hospital : Follow Up with GP :Misadventure.

Last updated: 17-Nov-2017

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