A man died from a blood clot after having an adverse reaction to a Covid-19 jab he was wrongly given, a review has found.
Jack Last, 27, died in hospital in April 2021 after he was given the AstraZeneca (AZ) vaccine, which he was invited to receive a month earlier.
But a report commissioned by NHS Suffolk and North East Essex Integrated Care Board (ICB) found Mr Last was only invited because he had been incorrectly classified as living with his parents on records held by the Suffolk GP Federation.
The report, published on Tuesday, also found there was a missed opportunity to give Mr Last the appropriate X-rays and treatment while he was at West Suffolk Hospital in Bury St Edmunds.
It was known at the time of his jab that the AstraZeneca vaccine, in rare cases, could have side effects on those in his age group, including blood clots in veins and arteries.
The report concluded Mr Last’s death was “a consequence of a combination of system shortcomings, human error, and tragic unfortunate timing”.
A previous illness diagnosed to one of Mr Last’s parents years before the vaccination programme, which was not active at the time, also remained on the GP record of the Suffolk GP Federation.
This meant he was included among those deemed eligible for the Covid-19 vaccine as their clinical condition was described as “at-risk”.
An error that classed Mr Last’s own telephone number as that of his parents’ landline gave him household contact status, which also made him eligible for the vaccine.
Mr Last received the AZ vaccine on March 30 2021, shortly before guidance on giving the jab changed and alternative vaccines were recommended for his age group.
The report said: “If Jack 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.”
Mr Last began to feel unwell a week later and had severe headache, vomited and was sensitive to light.
After going to West Suffolk Hospital, he was reported by a radiologist as having no brain abnormalities after he underwent a plain CT head scan.
However, a review demonstrated there were slight abnormalities that were missed which could have identified a blood clot in his brain.
A further scan the following day clearly identified a blood clot, meaning there was a delay in treatment of approximately 15 hours.
This was unlikely to have changed Mr Last’s outcome but was a missed opportunity to have started the correct treatment sooner, the report found.
He was then transferred to Addenbrooke’s Hospital in Cambridge, with the report finding the treatment he received there to be appropriate and of a high standard.
Mr Last’s condition deteriorated and he died of vaccine-induced thrombocytopenia on April 20 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.”
