Stonham Aspal man, Jack Last, 27, died after a receiving a Covid-19 AstraZeneca vaccine ‘too early’, report finds
A series of ‘system errors’ led to the death of a man after he was wrongly given a Covid-19 vaccine, a new report has found.
The report into the death of Jack Last, from Stonham Aspal, found that the 27-year-old was invited to receive an AstraZeneca vaccination earlier than he should have been.
The independent investigation was carried out by Facere Melius on behalf of the NHS Suffolk and North East Essex Integrated Care Board (ICB).
The report was commissioned by the ICB to understand what happened and how system partners managed his care, and to ensure any relevant lessons were learned.
It concluded that Mr Last’s death, in April 2021, occurred because of ‘system errors’ which led to him being invited to receive a Covid-19 vaccination in March 2021 earlier than he should have been because of information contained in his GP practice’s electronic records system.
Jack Last, an agricultural and field engineer, was invited to receive the vaccination because he was incorrectly classified as living with his parents, giving him household contact status.
This was due to errors in how the Suffolk GP Federation (GP Fed) searched for household contacts of eligible patients.
One of his parents had a previous illness that was not active at the time, but the presence of the illness code on their GP record led to them being classified as eligible for a vaccination.
These factors resulted in Mr Last being included in the extended group of people eligible for a Covid-19 vaccine.
In fact, Mr Last was not living with his parents at the time and his parent’s issue had been resolved.
Mr Last received the AstraZeneca (AZ) vaccine on March 30 2021, shortly before guidance on giving the AZ vaccine changed.
An alternative to AZ vaccine was recommended for under-30s, given the newly-emerged data on rare but adverse reactions in this cohort.
The main side-effect was by then known to be vaccine-induced thrombocytopenia and thrombosis (VITT).
This was also just a day before the advice from NHS England to those responsible for administering the delivery of the Covid-19- was published.
This made it necessary for those in the recently extended eligibility criteria called to receive the vaccine to provide documentary proof of their ‘household contact’ status. Jack would not have met this criterion.
The GP Fed, which was providing the vaccine delivery in Jack’s area, was ‘doing its best’ to maximise the number of people being vaccinated against this deadly virus.
If Mr Last had not been invited to have the AZ vaccine early, he would have been in a much later cohort, starting June 8, 2021, by which time people under 30 were to be offered Pfizer or Moderna vaccines.
It was also be noted, however, that VITT-like cases have emerged around and soon after the time of Jack’s death in some people after they received these alternative vaccines.
After experiencing adverse side effects to the AZ vaccine, Mr Last went to West Suffolk Hospital in Bury St Edmunds.
His blood test results were abnormal so a CT venogram was ordered.
However, reporting was unavailable out of hours and a plain CT head scan was performed.
The results of the plain CT scan were normal - but a review demonstrated subtle abnormalities that could have identified a blood clot in his brain.
This was not identified in the report, and he was misreported as having no brain abnormalities.
A CT venogram was performed the following day and ‘clearly demonstrated’ a blood clot, therefore, there was a delay in treatment of approximately 15 hours.
The report concludes that while this delay is unlikely to have changed the outcome, this was still a missed opportunity to have started the correct medication regime as early as possible, and/or to have transferred him immediately to a hospital that could have undertaken the CT venogram and provided the expert specialist treatment he needed.
When Mr Last’s condition deteriorated, he was transferred to Addenbrooke’s Hospital in Cambridge.
The treatment he received there was assessed by the Facere Melius clinical expert advisers to this investigation to be ‘appropriate and of a high standard’.
Despite the best efforts of the teams treating him there, his condition continued to worsen.
Mr Last died on the morning of April 20, 2021.
Medical director of the Suffolk and North East Essex ICB, Dr Andrew Kelso, who said that Mr Last’s death was both ‘tragic and preventable’, 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.”
An inquest was held into Mr Last’s death in December 2022, where the coroner concluded that Jack died of a blood clot to the brain caused as a direct result of his body’s reaction to the Oxford AstraZeneca Covid-19 vaccination.
Before his death Jack had been a healthy and physically fit young man of 27, described by his family as an adventurer.
He had previously spent six months working in the Antarctic with the British Antarctic Survey. He took part in many sporting activities with his friends.
At 18 he gained his UK private pilot’s licence, and regularly flew around East Anglia and beyond. He later obtained his US pilot’s licence and did some flying over California.
The inquest found his death was a consequence of a combination of ‘system shortcomings, human error, and tragic unfortunate timing’.
The Facere Melius report added ‘it should be acknowledged that this was still a very turbulent time’ at the height of the Covid-19 pandemic, and the NHS and hospitals and their staff were under ‘enormous pressure’ because of the high infection rates, and many people became critically ill with the virus
What also contributed, it said, to this ‘challenging environment, locally and nationally’, when Mr Last became ill was that VITT was a newly emerging condition, and clinicians and public health organisations were still learning about it.
