Jack Last died after the NHS mistakenly administered AstraZeneca’s Covid vaccine, a report says

An independent review has now concluded that the decision to classify the parent's clinical condition as a lung disease was “erroneous” and that Last therefore “should not have been invited to be vaccinated”.

NHS records showed that one of his parents had chronic obstructive pulmonary disease (COPD), which meant he was classified as a high-risk patient.

However, the report states: “A review of the GP's records by the expert clinical consultant found that there were no further investigations or active treatment for COPD after 2016. They further concluded that there was no clear evidence of COPD and the respiratory specialist classified the parents' chronic cough as more likely to be asthma.”

In addition, Last was believed to be living with relatives because the local NHS group's system matched people using their landline numbers, despite Last's request that this information be removed from his file.

When Last was invited to be vaccinated, Clinical Commissioning Groups (CCGs) were “struggling to use their remaining AZ vaccine stock” and there was a national target to limit wastage, the inquiry said.

“Documentary evidence”

The last time the vaccine was received was on March 30, 2021. The following day, NHS England published updated guidelines stating that “household contacts” of people with “severe immunosuppression” would need to provide “documentary proof of their address.”

The report concluded that Last “would have been considered unsuitable” if these checks had been required when he was vaccinated.

The engineer may have been one of the last younger patients to receive the AstraZeneca vaccine, as just over a week later, official advice was to offer people under 30 an alternative vaccine due to concerns about blood clots.

The report also identified “failures” in Last’s care at the West Suffolk NHS Foundation Trust.

“Abnormal values”

The review found that blood tests identified “abnormal values” and that the “indicators were identified as warning signals [red flags]“ for a rare side effect called vaccine-induced immune thrombocytopenia and thrombosis (VITT).

At this point, a conversation with a hematologist should have taken place, the report said, according to an expert advising the investigation.

They said that “despite Jack's severely abnormal blood test results… the physician on duty expressed little clinical suspicion as to the possible underlying cause of Jack's condition.”

An ultrasound examination was “not urgent” and a radiologist falsely stated that there were “no acute abnormalities”. This statement later turned out to be incorrect.

Hematologists were asked at the end of March to be “vigilant” for possible VITT cases.

The report found that a specialist treating Last “failed to specifically address” some of his test results and that “treatment” did not begin until a special scan confirmed a blood clot in his brain.

“Therefore, the opportunity was missed to start Jack on the only treatment that might have had the potential to slow the progression of the disease,” the report said.

“Although it is not clear whether this delay would have changed the outcome for Jack, it was still a missed opportunity to start medication for VITT as early as possible.”

Last died on April 20, 2021.