'Human error and tragic timing' meant Suffolk man was wrongly given AstraZeneca Covid-19 vaccine
"System errors" meant a man who died after being given the AstraZeneca Covid-19 vaccine was wrongly invited to have the jab, an independent report has found.
Jack Last, 27, an engineer from Stowmarket in Suffolk, developed a "throbbing headache" six days after receiving the AstraZeneca jab in March 2021.
He died from a blood clot to the brain at Addenbrooke's Hospital in Cambridge on 20 April 2021, with an inquest finding he died as a "direct result" of getting the vaccine.
On Tuesday, a review undertaken on behalf of the NHS Suffolk and North East Essex Integrated Care Board said he was invited to get the vaccine months before he should have been.
'Catastrophic errors' and 'missed opportunities'
The review by Facere Melius concluded Mr Last's death was as a result of "system shortcomings, human error and tragic unfortunate timing."
The 27-year-old was invited to receive the vaccination before he should have been due to out of date records at his GP practice showing his parents had a clinical condition and Mr Last was still living with them. Neither of these were true.
If Mr Last had not been invited to have the AstraZeneca vaccine early, he would have been in a later cohort where under-30s were offered the Pfizer or Moderna vaccines.
The review also found a radiologist failed to identify a blood clot on Mr Last's brain during a CT scan on 9 April 2021, resulting in a delay of treatment of around 15 hours.
The review said this was a "missed opportunity", despite it being unclear if the delay would have changed Mr Last's fate.
In a statement, his family said: "Jack was a happy, healthy, carefree 27 year old.
"Before Jack had his Oxford AstraZeneca COVID-19 injection, he hadn’t had a single day sick from work.
"It all happened so quickly, it still struggles to hit home at times that we are never going to see him again.
"The report details the many horrendous and ultimately catastrophic errors from the moment Jack arrived at West Suffolk Hospital.
"We hope a lesson in accurate medical data keeping will be learnt from this, particularly if in national emergencies medical data is shared with other agencies."
Recommendations
The report made several recommendations to the NHS and government, with its first being for NHS England to develop guidance for GPs on when to mark conditions as "resolved" - this followed Mr Last's parents not having COPD taking off their records.
The second recommendation was for NHS England to review its guidance on checking for out-of-date phone numbers.
The third recommendation was for the Department of Health and Social Care to ensure multiple agencies were in contact to ensure guidance on newly emerging diseases is published "as widely and as quickly as possible".
After Mr Last was invited for his second vaccination following his death, the final recommendation was for all integrated care boards to ensure every GP practice has implemented the Data Provision Notice.
'Truly sorry'
Dr Andrew Kelso, Medical Director of the Suffolk and North East Essex Integrated Care Board, 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.
“Hopefully by doing this work and by trying to understand what happened, we can at least mark his death in some way, show some proper respect for Jack and do everything we can to learn from the errors that happened."
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