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Investigation and inquest
On 14th July 2021 I commenced an investigation into the death of Alexander (Alex) Lee Reid, 22/12/1992. The investigation concluded at the end of the Inquest on 10/11/2023. The conclusion of the Inquest was a narrative conclusion reflecting Alex's death linked to his having received the Oxford Astra Zeneca vaccination against Covid-19, the medical cause of death being 1a) Cerebral Venous Sinus Thrombosis 1b) Covid-19 Vaccine-Induced Immune Thrombotic Thrombocytopenia.
Circumstances of the death
Alex was invited to receive his Covid vaccination earlier than his age alone would have entitled him to do so. Alex received his first dose of the Oxford Astra Zeneca vaccine on 21/03/2021. On 07/04/2021, official advice was given that persons aged under 30 should not receive the Oxford Astra Zeneca vaccination as their first vaccination. Those who had by that date received it as their first vaccination were advised to receive it as their second. Alex did so on 18/05/2021. He died on 29/06/2021. He was 28.
Coroner’s concerns
(1) When Alex was invited to receive his vaccination early, he did not understand why, and no-one was able to tell him.
(2) The inquest heard expert evidence that the combined vaccination monitoring and recall specification designed to identify vulnerable people for the purposes of inviting them to receive their Covid vaccinations early had identified Alex as vulnerable from an incorrect BMI of 68.97 recorded in his GP records on 06/02/2004. The mistake was due to the relevant clinician recording Alex's height as 145cm and his weight as 145kg, giving a BMI of 68.97 for an 11 year old boy whose previously recorded BMI aged 9 had been 14.88.
(3) The inquest heard expert evidence that to have built a system that would validate multiple data items in an individual's GP records for the purposes of ensuring that individuals were not incorrectly identified as vulnerable would not have been feasible within the constraints and context of the Covid-19 programme.
(4) The inquest heard expert evidence that an easier and more appropriate option would be to embed validation rules in general practice IT systems that would check such information at the time of data entry.
(5) If the obviously erroneous BMI had not been recorded or had been challenged at the point of entry by the relevant IT system, Alex would not have been classed as vulnerable, would not have been offered a vaccine before guidance was published that the under 30’s should not receive the Oxford Astra Zeneca vaccine, and would not have died when he did.
(6) The consequences of the data input error in this case give rise to a concern that more might be done by way of specification design to allow for the correction of or challenge to potential data input errors at the point of entry, with consequential improvements in the reliability of such data and the safety of patients and reducing the risk of other deaths occurring in similar circumstances in the future.
Information checked against the published report and official responses