Coroner calls for national guidance on hepatitis B after 41-year-old man’s death at Royal Free hospital

A coroner has warned there is a dangerous lack of guidance around monitoring people with past hepatitis B infections, following the death of a North London man from liver failure.

Tung Tran, 41, died in September 2025 at London’s Royal Free Hospital due to several causes: acute liver failure, sepsis, immunity issues linked to a kidney transplant and the return of hepatitis B, an inquest concluded in March.

After he was diagnosed with the bloodborne virus following his renal transplant in 2013, doctors prescribed Tran drugs to stop it from re-emerging. But when he switched to home delivery in 2025, his medication supply stopped.

In August that year, Tran came to his local hospital with signs of acute liver disease from the reactivation of hepatitis B. He was then transferred to the Royal Free but was too unwell to be considered for a liver transplant. Tran died on 12 September 2025.

Following an inquest, Richard Brittain, assistant coroner for Inner North London, said the specific drug meant to keep the hepatitis B at bay, Entecavir, had been “inadvertently discontinued” because of confusion around which hospital department was supposed to issue Tran the prescription.

“There was a presumption that hepatology would continue to prescribe this. Tran appears to have understood this to have been an intentional change of his medication,” the coroner’s report stated.

In light of this, the assistant coroner raised concerns over a lack of clarity in national guidance around which hospital departments are responsible for monitoring and prescribing drugs to stop dormant infections from returning.

Despite the “large population” of patients diagnosed with hepatitis B through routine screenings, Brittain added that there was not enough specialised commissioning to ensure discharged patients stayed in contact with clinical services.

The assistant 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 its response dated 6 July, the BASL President said it did not lead on developing or publishing clinical guidelines, but clarified that chronic hepatitis B patients were “usually” managed by specialist hepatology services, who were responsible for monitoring and prescriptions. The Local Democracy Reporting Service (LDRS) contacted the UKHSA for comment, but the agency directed us to NHS England (NHSE) instead.

NHSE did not respond in time for publication. In February 2026, the administrative body published an evaluation of nearly three years of its hepatitis B testing programme, finding it “demonstrated high uptake and had a positive impact in finding people who are undiagnosed with a bloodborne virus”. However, the report noted that there is currently no national registry for the virus to track illness patterns, monitor treatment and 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.”

Tung Tran: Prevention of future deaths report.

Please support The Fitzrovia News. Consider helping us cover our costs by visiting our secure payment page.