A coroner has issued a stark warning about the absence of national guidance for monitoring patients with past hepatitis B infections, following the death of a 41-year-old North London man from liver failure. Mr Tung Tran died at the Royal Free Hospital in Camden in September 2025 after his antiviral medication was inadvertently discontinued when he switched to home delivery.
Inquest findings reveal medication error
An inquest concluded in March 2026 that Mr Tran's death was caused by acute liver failure, sepsis, immunity issues related to a kidney transplant, and the reactivation of hepatitis B. He had been diagnosed with the bloodborne virus after a renal transplant in 2013 and was prescribed Entecavir to suppress the virus. However, when he switched to home delivery in 2025, the medication supply was stopped due to confusion over which hospital department was responsible for issuing the prescription.
According to Assistant Coroner Richard Brittain for Inner North London, the drug was “inadvertently discontinued” because of a lack of clarity between departments. “There was a presumption that hepatology would continue to prescribe this. Mr Tran appears to have understood this to have been an intentional change of his medication,” the coroner's report stated.
National guidance gap identified
Mr Brittain raised concerns that national guidance does not clearly specify which hospital departments should monitor and prescribe drugs to prevent dormant infections from returning. He noted that despite a “large population” of patients diagnosed with hepatitis B through routine screenings, there is insufficient specialised commissioning to ensure discharged patients remain in contact with clinical services.
The coroner's report was sent to the Royal Free Hospital, the British Association for the Study of the Liver (BASL), and the UK Health Security Agency (UKHSA). In a response dated July 6, the BASL President stated that the association does not lead on developing clinical guidelines but noted that chronic hepatitis B patients are “usually” managed by specialist hepatology services.
Response from health bodies
The Local Democracy Reporting Service contacted UKHSA, which directed inquiries to NHS England. NHS England did not respond in time for publication. In February 2026, NHS England published an evaluation of its hepatitis B testing programme, which found “high uptake and a positive impact in finding people who are undiagnosed with a bloodborne virus.” However, the report acknowledged that there is no national registry for the virus to track illness patterns, monitor treatment, or plan localised healthcare.
A spokesperson for the Royal Free London said: “We would like to apologise and to share our heartfelt condolences with Tung Tran’s family. Following our investigation, we have introduced a number of measures to ensure patients whose anti-viral medication is switched to home delivery continue to receive it.”
Impact and next steps
Mr Tran was admitted to his local hospital in August 2025 with signs of acute liver disease from the reactivation of hepatitis B. He was transferred to the Royal Free but was too unwell for a liver transplant, dying on September 12, 2025. The coroner's warning highlights a systemic flaw that could affect other patients with dormant hepatitis B infections, emphasizing the need for clear national protocols to prevent similar tragedies.
