Failings found in death of Jack Last from AstraZeneca jab

Jack Last, from Stowmarket, died from a blood clot in his brain caused by a reaction to the Oxford AstraZeneca Covid-19 vaccination.

A new report released by Suffolk and North East Essex Integrated Care Board has today said he was incorrectly classified as living with his parents when he was invited to be vaccinated on March 20, 2021. 

Following an independent investigation by Facere Melius on behalf of the ICB, they found Mr Last was contacted at the time due to a previous mention of COPD - that was no longer active - on one of his parents' GP records.

This classified them as eligible for their vaccine and led to Jack being included in the extended group as his records contained their home number.

A coroner concluded in 2022 he died as a result of a blood clot to the brain caused by his body's reaction to the vaccine (Image: Contributed)

This was despite living in his home, which he moved into in 2018.

A family statement said it was "heartbreaking" to learn of the errors which led to him being invited to receive the vaccination early.

They said Mr Last had previously told his surgery, Mendlesham Medical Practice, he was registered at a different address. 

Mr Last was first contacted to receive the vaccine on March 20, 2021, before being administered his first jab on March 30, 2021, days before new guidance would be issued.

On April 7 - the day after Mr Last started feeling ill - National Health Service England (NHSE) guidance updated to say that while the benefits of the AstraZeneca vaccine outweighed the risk of adverse events for individuals over 30, people aged under 30 and without underlying health conditions should be offered an alternative. 

MORE: Family's tribute to 'always smiling' Jack after tragic death aged 27

Had he not been invited to received the AstraZeneca vaccine when he did, Mr Last would have been in a cohort which would have seen him offered him either Pfizer or Moderna vaccines, the report said.

Mr Last first visited West Suffolk Hospital on April 9, 2021 (Image: Newsquest)

The report also explained what was happening at the time surrounding the vaccination process.

Prior to Mr Last's invitation for his vaccine, The Suffolk GP Federation agreed to expand the criteria for vaccine eligibility to include those eligible for the vaccine for those who were caring for individuals in cohort six of the vaccination. 

The purpose of this extension of eligibility was to reduce the risk of infection in immunosuppressed people by vaccinating those most likely to transmit the virus to them.

Only 400 people in Suffolk fitted this eligibility criteria, but the delivery service for the vaccine in the county had capacity to deliver 4,000 doses. 

One day before Mr Last received his text, it was agreed to expand the criteria to those living with cohort 6 eligible patients. 

After this was agreed, people eligible were identified by GP lists stating they were cohabiting. Searches were carried out by matching individuals to landline numbers. 

Mr Last's medical record had the same landline number as his parents, one of whose records showed them as meeting the criteria for cohort 6. This parent had received their vaccine on March 19 with the general population of their age group.

When moving into his own home, his GP practice gave him a standard form to update his contact details. 

However, this form had no facility for ensuring the removal of any pre-existing telephone numbers from his electronic records. This is why his parents' landline number remained present. 

Advisers recommend NHS England should review its current guidance to include a check for out-of-date telephone numbers.

Mr Last first started feeling ill during the week commencing Monday, April 5, 2021. 

Follow the change in the guidance, Mr Last's family told him to seek medical advice.

He contacted 111 on Friday, April 9, 2021, and was later told by a clinical adviser to visit West Suffolk Hospital in Bury St Edmunds. 

Later that day, a plain CT scan was performed on Mr Last by an out of hours service outsourced to a separate company. 

The radiologist reported on the CT scan that there was no acute abnormalities in his brain.

This was later found to be inaccurate. 

The report says: "It would also have been advisable to send Jack straight away to another hospital or centre that could provide the CT venogram he needed, rather than waiting until the next day."

A CT venogram was performed the following day and demonstrated a blood clot, delaying treatment by 15 hours. 

The report concluded while this delay was unlikely to have changed the outcome for Mr Last, it was still a missed opportunity. 

When his condition deteriorated, he was transferred to Addenbrooke's Hospital in Cambridge. 

Advisers to Facere Melius said he received an appropriate and high standard of care before he died on April 21.

Four recommendations have been made following the investigation.

These include:

- NHS England, should consider developing guidance for GPs on when to move active diagnosis codes to ‘resolved’ codes

- NHS England should review its current guidance to include a check for out-of-date or decommissioned telephone numbers.

- The Department of Health and Social Care should consider developing an MOU between national agencies, royal colleges, and professional bodies to ensure that guidance on newly emerging diseases are co-ordinated and published as widely and as quickly as possible.

- : All Integrated Care Boards should seek to assure themselves that every practice has implemented the requirements of the Data Provision Notice.

Medical Director of the Suffolk and North East Essex ICB, Dr Andrew Kelso, said: “Our thoughts remain with the family of Jack and have been throughout this very tragic case.

“On behalf of all system partners, we are truly sorry for what has happened and for the loss, heartbreak and distress they must be experiencing.

“Due to the seriousness of what happened, we immediately commissioned an independent review to fully understand what led to this tragedy and to identify learning.  We also wanted to give the family all the answers to their questions.

“This independent review allowed the system to look at the incident from beginning to end, without the restrictions of organisational boundaries and without prejudice.”

 Dr Ewen Cameron, chief executive of the West Suffolk NHS Foundation Trust, said: “We continue to offer our deep and heartfelt condolences to Mr Last’s family and friends as they navigate this extremely difficult and painful time.

“We have engaged fully with the system-wide investigation, alongside carrying out robust internal review processes to scrutinise the circumstances of Mr Last’s tragic death and recognise there are things we could have done better.

“We have already acted upon learning for West Suffolk NHS Foundation Trust in the report, particularly around increasing our provision for out of hours radiological reporting.”