Errors meant Covid jab given to clot victim - report

A man who died after being given a Covid-19 vaccination should not have received the jab, according to an independent review.

Jack Last, 27, died from a blood clot after receiving the AstraZeneca vaccine in 2021. The following year, an inquest found he died as a “direct result” of the inoculation.

A review into his death, published today, found admin errors meant Mr Last was wrongly offered the vaccine months before he should have been and that staff at his local hospital in Suffolk failed to spot how ill he was after he received the jab.

In a statement, his sister Jasmine said: “It’s unbearable to think that due to these events, Jack has lost his right to a full and happy life at such a young age”.

The report, which was commissioned by the Suffolk and North East Essex Integrated Care Board, concludes that “Jack’s death was a consequence of a combination of system shortcomings, human error and tragic unfortunate timing”.

Dr Andrew Kelso, medical director of the care board, said: “On behalf of all system partners, we are truly sorry for what has happened. Our thoughts remain with the family of Jack and have been throughout this very tragic case.”

Mr Last, from Stowmarket, Suffolk, was invited to receive the Covid-19 vaccine in March 2021.

At the time, the rollout of the vaccine in the UK was prioritising all adults aged 16 to 64 with underlying health conditions.

The Suffolk GP Federation, a collective of surgeries in the county, was sent a large batch of the AstraZeneca vaccine with a short expiry date. The surgeries ran out of people to vaccinate within the eligible cohorts so expanded the criteria to include those who were living with vulnerable people to ensure vaccines weren’t wasted.

However, an error in the medical records of one of Mr Last’s parents indicated they suffered from chronic obstructive pulmonary disease (COPD), a lung condition that causes breathing difficulties, which would have made them vulnerable.

The telephone number on his medical records also suggested Mr Last was living with his parents and that he was therefore eligible for the vaccine.

He had, the report from healthcare investigators Facere Melius found, moved out of his parents’ home and had told his GP of his new personal details in 2019.

He received a text message inviting him to book an appointment and was given the AstraZeneca (AZ) vaccine on 30 March, 2021.

By the time he had received the jab, reports had already emerged in Europe of the AZ vaccine being linked in rare cases to blood clots. It wasn’t until a week after he’d been inoculated that the advice was changed to recommend that people under 30 should not be given the AZ vaccine if an alternative was available.

Mr Last, who was described by his family as happy and healthy with a love of keeping fit and exploring, fell ill within a week of getting the vaccine.

He went to his local A&E at West Suffolk Hospital, in Bury St Edmunds, on 9 April complaining of severe headaches having phoned NHS 111.

His blood tests were abnormal and the consultant ordered a specialised scan to see if Mr Last had a vaccine-induced thrombosis (VITT) - an emerging condition at the time linked to the AZ vaccine.

However, the radiologist did not have the technical expertise to perform such a scan, the report found. Instead, a regular CT scan was performed which identified a blood clot in his brain. This wasn’t spotted by the radiologist, whose report said he had no brain abnormalities.

It wasn’t until the following day that the specialist scan was performed. It correctly identified the blood clot, linked to the AZ vaccine.

The report found the failure to accurately diagnose the problem delayed his treatment by 15 hours.

“Although it is not clear if this delay would have changed the outcome for Jack, this was still a missed opportunity to have started the medication regime as early as possible,” the report concluded.

Shortly afterwards, Mr Last was transferred to specialist care at Addenbrooke’s Hospital in Cambridge. His treatment there, the report said, was “appropriate and of a high standard”. However, Jack died on 20 April, 2021. The 2022 inquest found he died from a blood clot as a direct result of his reaction to the AZ vaccine.

“If Jack had not been invited to have the AZ vaccine early,” the report said, “he would have been in a much later cohort (starting 8 June, 2021), by which time people under 30 were to be offered Pfizer or Moderna vaccines.”

Data from the Office for National Statistics shows, until July 2023, the deaths of 63 people in England “involved” the adverse effects of a Covid-19 vaccine, with 55 of those being “due” to the vaccine.

In a statement, Mr Last’s sister Jasmine described her brother as happy, healthy, witty and entertaining. Before he received the vaccine “he hadn’t had a single day sick from work. He was very rarely unwell. Then suddenly he was not fine”.

“It all happened so quickly, it still struggles to hit home at times that we are never going to see him again,” she added.

“Shortly after receiving his jab, the reports of Oxford AstraZeneca injections causing deaths were starting to gain attention, but by this time it was too late, Jack had already had the injection. We hope a lesson in accurate medical data keeping will be learnt from this.”

The report makes four recommendations, including ensuring that patients’ medical records are updated and accurate, and only include current, active telephone numbers.