Is it an emergency?
Posted on
in Ipswich and East Suffolk News
An independent report has today been published into the tragic death of a 27-year-old man who was wrongly given the AstraZeneca vaccination.
Read the report Suffolk and NE Essex Investigation Final Published Version Sept 2024.pdf
The independent investigation into the death of Jack Last in April 2021 was undertaken by Facere Melius on behalf of the NHS Suffolk and North East Essex Integrated Care Board (ICB).
It was commissioned by the ICB to understand what happened and how system partners managed his care, and to ensure any relevant lessons were learned.
The report concluded that Jack’s death occurred because of system errors which led to him being invited to receive a COVID-19 vaccination in March 2021 before he should have been.
Jack was invited to receive the vaccination because he was incorrectly classified as living with his parents, thereby giving him household contact status.
This came about due to errors in how the Suffolk GP Federation (GP Fed) searched for household contacts of eligible patients.
One of Jack’s 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 Jack being included in the extended group of people eligible for a COVID-19 vaccine.
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.
After experiencing adverse side effects to the AZ vaccine, Jack 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. Therefore, a plain CT head scan was performed.
The results of the plain CT scan were normal, however, a review demonstrated subtle abnormalities that could have identified a blood clot in Jack’s brain. This was not identified in the report, and Jack 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 for Jack, 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 Jack’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 Jack there, his condition continued to worsen. Jack died on the morning of 20 April 2021.
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.”