Coroner Warns of Hepatitis B Guidance Gaps

A coroner has raised concerns about insufficient national guidance for monitoring individuals with previous hepatitis B infections, following the death of Tung Tran, 41, at the Royal Free Hospital. Mr Tran died in September 2025 from acute liver failure, sepsis, immunity issues linked to a kidney transplant, and the reactivation of hepatitis B.

Medication Discontinuation and Health Complications

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Mr Tran was diagnosed with hepatitis B after receiving a kidney transplant in 2013. He was prescribed medication to prevent the dormant virus from returning. However, when his prescription was switched to a home delivery service in 2025, his supply was inadvertently halted. This discontinuation occurred due to confusion between hospital departments regarding who was responsible for issuing the prescription. The assistant coroner's report stated that Mr Tran appeared to believe the change in medication was intentional.

In August 2025, Mr Tran presented at his local hospital with symptoms of acute liver disease, a consequence of the hepatitis B re-emergence. He was subsequently transferred to the Royal Free Hospital, but his condition was too severe for him to be considered for a liver transplant. He passed away on 12 September 2025.

Call for National Guidance and Reporting

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Following the inquest, Richard Brittain, assistant coroner for inner north London, issued a prevention of future deaths report. He highlighted a lack of clarity in national guidelines concerning which hospital departments should monitor and prescribe medication to prevent dormant infections from reactivating. The coroner noted that despite a significant number of patients diagnosed with hepatitis B through routine screenings, there is insufficient specialised commissioning to ensure continuity of care for discharged patients.

The assistant coroner's report was sent to the British Association for the Study of the Liver (BASL) and the UK Health Security Agency (UKHSA). BASL indicated that while chronic hepatitis B patients are typically managed by specialist hepatology services responsible for monitoring and prescriptions, they do not lead on developing national clinical guidelines. The UKHSA directed inquiries to NHS England.

NHS England published an evaluation of its hepatitis B testing programme in February 2026. The report indicated high uptake and a positive impact in identifying individuals with undiagnosed bloodborne viruses. However, it also noted the absence of a national registry for the virus, which hinders the tracking of illness patterns, monitoring of treatment, and planning of localised healthcare services.

Hospital Response and Future Measures

A spokesperson for the Royal Free Hospital offered condolences to Mr Tran's family and stated that the hospital has implemented new measures. These changes are designed to ensure that patients whose antiviral medication is switched to home delivery continue to receive their prescriptions without interruption.