Man, 27, died from blood clot after he was wrongly given Covid vaccine as report reveals 'human error'

Jack Last and a youngster
-Credit: (Image: PA Media)


A review has discovered that a man died from a blood clot after experiencing an adverse reaction to a Covid-19 vaccine he was mistakenly given. Jack Last, 27, died in hospital in April 2021 following his inoculation with the AstraZeneca (AZ) vaccine, which he had been invited to receive a month prior.

However, an investigation by NHS Suffolk and North East Essex Integrated Care Board (ICB) revealed that Mr Last was only invited due to an error in records held by the Suffolk GP Federation, which incorrectly listed him as living with his parents. The report, released on Tuesday, also highlighted a missed opportunity to provide Mr Last with the necessary X-rays and treatment at West Suffolk Hospital in Bury St Edmunds.

At the time of his vaccination, it was known that the AstraZeneca vaccine could, in rare instances, cause side effects in individuals of his age group, including blood clots in veins and arteries. The report concluded that Mr Last's death was "a consequence of a combination of system shortcomings, human error, and tragic unfortunate timing".

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An old illness diagnosed in one of Mr Last's parents years before the vaccination programme, which was not active at the time, remained on the GP record of the Suffolk GP Federation. This led to him being included among those deemed eligible for the Covid-19 vaccine as their clinical condition was described as "at-risk".

A mistake that registered Mr Last's personal phone number as his parents' landline granted him household contact status, thus qualifying him for the vaccine.

Mr Last was administered the AZ vaccine on March 30 2021, just before the guidelines on vaccination were altered and alternative vaccines were suggested for his age group.

The report stated: "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."

A week later, Mr Last started feeling unwell, experiencing severe headaches, vomiting, and light sensitivity.

After visiting West Suffolk Hospital, a radiologist reported no brain abnormalities following a plain CT head scan. However, a review revealed minor abnormalities that were overlooked, which could have detected a blood clot in his brain.

A subsequent scan the next day clearly identified a blood clot, resulting in a treatment delay of approximately 15 hours. While this likely did not alter Mr Last's outcome, it was a missed opportunity to initiate the correct treatment sooner, according to the report.

He was then transferred to Addenbrooke's Hospital in Cambridge, where the report found the treatment he received to be appropriate and of high quality. Mr Last's condition worsened and he succumbed to vaccine-induced thrombocytopenia on April 20 2021.

Dr Andrew Kelso, Medical Director of the Suffolk and North East Essex ICB, expressed his condolences stating: "Our thoughts remain with the family of Jack and have been throughout this very tragic case."

He continued with an apology: "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."

Acknowledging the gravity of the incident, he said: "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."

Dr Kelso emphasised the thoroughness of the inquiry, noting: "This independent review allowed the system to look at the incident from beginning to end, without the restrictions of organisational boundaries and without prejudice."