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A man who died three weeks after receiving the AstraZeneca COVID-19 vaccine received the jab despite not being eligible for it, an independent investigation has found.
An investigation into failings surrounding the death of Jack Last, a 27-year-old young man who died in April 2021 from blood clots linked to the Oxford-AstraZeneca vaccine, found that the 27-year-old was mistakenly called in early by his GP to be vaccinated and did not receive the vaccine, which is considered safer for under-30s.
The report concluded that his death was the result of “a combination of systems failures, human error and tragic and unfortunate timing.”
His family have blamed the NHS for “numerous mistakes” that took the life of a healthy, vibrant young man.
They said: “Sharing Jack’s horrific ordeal is something we must do to highlight the many mistakes that took his life… Jack suffered extensive internal injuries throughout his body, hemorrhages and a blood clot on the brain, and passed away after several painful days.”
The report said those failings included a “lack of urgency” in ordering a head CT scan to check for a possible blood clot, and then misdiagnosing the scan after it was performed.
A three-year investigation into his death, carried out by consultancy Facere Melius, found that Suffolk General Practitioners’ Union was forced to increase the number of people receiving the AstraZeneca jab amid concerns about vaccine wastage at the height of the pandemic.
The report said general practice services in Suffolk were actively expanding vaccination invitations and doing their best to encourage people to get the Covid-19 vaccine.
Just days before the vaccinations began, on March 30, the GP service received a “large delivery of AstraZeneca vaccines which are due to expire within the next few days”.
Mr Last was not eligible for the vaccine as he was not clinically vulnerable and did not live with people who were, but he was encouraged to get vaccinated and received the AstraZeneca vaccine.
The investigation report found inaccurate GP practices records for Mr Last’s family and no tests were carried out when they attended the vaccination centre, meaning Mr Last was vaccinated just before a warning was issued about the jab for under-30s.
“If Jack had not been offered the AstraZeneca vaccine early on, he would have been in a much later cohort (starting 8 June 2021), by which time people under 30 would have been offered the Pfizer or Moderna vaccines,” the report said.
At the time, the government continued to publish MHRA guidance saying the benefits of Covid-19 vaccines “continue to outweigh any risks”, with reports of blood clots at less than one in a million people.
Six days after receiving the vaccine, Mr Last became ill and experienced “severe headaches and occasional vomiting and visual disturbances”.
However, a head CT scan that confirmed the blood clot was not reported by the hospital’s radiologist and he did not receive treatment until the day after he was admitted. He suffered devastating brain injuries and died on April 20, 2021.
A post-mortem examination concluded that the Oxford-AstraZeneca vaccine triggered an excessive immune response, causing blood clots in multiple parts of the body.
At the time, the hospital had restrictions in place to prevent the spread of COVID-19, and the family was restricted from visiting their son a few days before he died.
The family said: “We think one of the reasons Jack wasn’t taken seriously at the hospital was because the ‘safe and effective’ mantra was repeated so often it seemed like the truth, so anything to the contrary was viewed as offensive – as if he wanted to infect others with COVID-19 or was being deliberately picky.”
“The report details a number of horrific and ultimately tragic mistakes made, from the moment Jack arrived at West Suffolk Hospital. Something went wrong at every turn from his admission and Jack never seemed to get a chance to rest.”
Dr Andrew Kelso, medical director for Suffolk and North East Essex Integrated Care Board, said: “Our thoughts are with Jack’s family and have continued to do so throughout this extremely tragic incident.
“On behalf of all our system partners, I sincerely apologize for what happened and for the loss, grief and distress they may be experiencing. This independent investigation has allowed the system to investigate the incident from start to finish, without bias and without being constrained by organizational boundaries.”
The Suffolk Grand Prix Association has been contacted for comment.
