Jamie Lee Poole · Prevention of Future Deaths report

On 17/07/2017 I commenced an investigation into the death of Jamie Lee Poole, aged 27. The investigation concluded at the end of the inquest on 9th March 2021. The conclusion of the inquest was a narrative conclusion of: ‘A recognised complication of immunosuppressant treatment for a lifesaving kidney transplant’. The cause of death recorded at inquest was:-

1a) Cerebral oedema.
1b) Electrolyte disarray with calcium and magnesium deficiencies.
II) Renal failure due to Henoch-Schoenlein purpura.

Jamie Lee Poole was diagnosed with IgA nephropathy, which causes kidney failure, which required the lifesaving surgery of a kidney transplant in 2011. After the transplant she was placed on a dose of immunosuppressant (tacrolimus) to prevent rejection of the transplanted kidney. One of the known side effects of the use of the medication is that it can cause low levels of magnesium within the body. Her kidney function again started to deteriorate in October 2016. She was managed for this within the community. Omezaprole was introduced in Jamie Lee Poole’s prescription medication, as part of the management of the reoccurrence of her kidney failure. A known side effect of this medication is that it can cause low levels of magnesium within the body. She was admitted to the Royal Stoke University Hospital on 27 June 2017 with low levels of magnesium and low calcium and was treated for correction of electrolyte disturbance. On the 28 June 2017 between 6:20 and 6:30 in the morning she was found on the floor having collapsed. It was discovered that she had significant swelling on her brain. This was caused by a lack of oxygen to the brain, which was either caused by a heart problem or a seizure, which on balance would have been caused by the low levels of magnesium. She was transferred to the intensive care unit at the Royal Stoke University, Stoke-on-Trent where she passed away on the 2 July 2017. She passed away due to acute cerebral oedema and acidosis. This was caused by low levels of magnesium and calcium.

(1) Transplant patients are put on strong immunosuppressive medication to prevent rejection of the transplanted organ. The medication, tacrolimus in Jamie Lee Poole case, has a common known side effect of reducing magnesium levels within the body. This can be life threatening. Despite this, it is not standard practice to regularly test transplant patients magnesium levels. I heard evidence at inquest that, whilst the Trust providing care for Jamie Lee Poole, has now remedied this, and routinely test post-transplant patients’ for magnesium levels, this is not the case in other areas. The evidence that I heard was that, whether these levels were tested routinely and regularly, was very much dependant on trust area. In one area, patients may be tested routinely for this in others they would not.