Jack Last, from Stonham Aspal, was sent second Covid-19 vaccination invitation more than two months after he died

The parents of a 27-year-old man who died after he was given a Covid-19 vaccine suffered further distress when he was sent a vaccination invite after his death.

An independent investigation into the death of Jack Last, from Stonham Aspal, near Stowmarket, said a letter inviting him to come forward for a second vaccine was sent to his home, more than two months after he died.

Jack died in April 2021 of a blood clot to the brain after he received an AstraZeneca (AZ) vaccination earlier than he should have.

In the report published at the end of the investigation by healthcare consultancy, Facere Melius, it said: “It was very upsetting for Jack’s parents to see this invitation, and they have asked for an explanation as to why it happened.”

Jack, who worked as an agricultural and field engineer, received a first dose of the AZ vaccination on March 30, 2021.

He was invited to receive the vaccination because he was incorrectly classified as living with his parents, giving him household contact status.

A week later, on Tuesday, April 6, Jack started to feel unwell suffering from a severe headache and disturbed vision.

On April 9, he attended the emergency department at West Suffolk Hospital in Bury St Edmunds, and was admitted to hospital for tests.

His blood test results were abnormal so a CT venogram was ordered.

However, reporting was unavailable out of hours and a plain CT head scan was performed.

The results of the plain CT scan were normal - but a review demonstrated subtle abnormalities that could have identified a blood clot in his brain.

This was not identified in the report, and he was misreported as having no brain abnormalities.

Jack remained at the hospital until April 11, when following a significant deterioration in his health he was transferred to Addenbrooke’s Hospital, in Cambridge.

He remained at Addenbrooke’s Hospital until he died on April 20, 2021.

Within the report, a statement from Jack’s family spoke of: “Many horrendous and ultimately catastrophic errors from the moment Jack arrived at West Suffolk Hospital.”

“It appears that at every turn since he checked in something went wrong, and Jack just couldn’t catch a break,” said his family.

They believe staff at the hospital in Bury St Edmunds were ‘at times unkind to Jack’ and ‘he was not taken seriously to begin with’.

The family statement said: “Two staff members at West Suffolk Hospital, involved early on in Jack’s care, wrote a short paper on Jack’s case and published it without our knowledge.

“We note at the end of the report it states ‘Jack died peacefully in his sleep’, for the purpose of accuracy, as you will read in this report, this was not the case.

“Jack died following days of agony, with immense internal damage throughout his body,

bleeding and clots in his brain, with part of his skull removed.

“We hope that even one part of this report does not happen to someone else.

“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.”

Dr Ewen Cameron, chief executive of the West Suffolk NHS Foundation Trust, said: “We continue to offer our deep and heartfelt condolences to Mr Last’s family and friends as they navigate this extremely difficult and painful time.

“We have engaged fully with the system-wide investigation alongside carrying out robust internal review processes to scrutinise the circumstances of Mr Last’s tragic death and recognise there are things we could have done better.

“We have already acted upon learning for West Suffolk NHS Foundation Trust in the report, particularly around increasing our provision for out-of-hours radiological reporting.”

Findings from the independent investigation

The investigation found a doctor, who it referred to as ‘Dr D’ was the medical registrar for the AAU and involved in Jack’s care at West Suffolk Hospital.

Dr D was working a day shift over the weekend of 10-11 April, and approached Jack for his permission to write a case report about his condition and treatment for the British Medical Journal (BMJ)

He said the report looking at Vaccine-Induced Immune Thrombotic Thrombocytopenia would make a useful contribution to clinical learning.

Jack agreed and signed the BMJ consent form.

The case report, co-authored by Dr D and Dr B, was accepted for publication on May 29, 2021, and published on June 16, 2021.

In October 2021, as part of the ongoing response to COVID-19 and as part of a wider strategy to improve data quality the Secretary of State for Health and Social Care directed NHS Digital to investigate and implement ways in which to improve the quality, accuracy, and timeliness of death notifications.

This was because historically there had been an approximate 20 per cent discrepancy in death notifications reported by clinical settings, those reported by the Office of National Statistics, and the General Register Office.

Jack received the AstraZeneca vaccine, shortly before guidance on giving the AZ vaccine changed.

An alternative to AZ vaccine was recommended for under-30s, given the newly-emerged data on rare but adverse reactions in this cohort.

The main side-effect being blood clots.