A “lack of national guidance” on monitoring and prescribing for hepatitis B reactivation poses a “significant risk of future deaths”, a coroner has warned.
In a prevention of future deaths report published earlier this month, assistant coroner for Inner London North Richard Brittain noted that Tung Tran, 41, died in September 2025 of complications from a hepatitis B reactivation caused by “inadvertent discontinuation of necessary medical treatment”.
“Inadvertently discontinued”
The report said Tran was diagnosed with hepatitis B after a renal transplant in 2013 and, “after a period of disengagement from services”, was “discharged from hepatology but continued to receive viral reactivation prophylaxis, Entecavir, from renal transplant services”.
It added that Tran’s medication supply changed to home delivery in early 2025, but Entecavir was “inadvertently discontinued”, with the “presumption that hepatology would continue to prescribe this”.
Tran “appears to have understood this to have been an intentional change of his medication”, Brittain said.
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“He attended his local hospital in August 2025 with signs of acute liver disease from reactivation of hepatitis B and was transferred to the Royal Free Hospital,” he added.
“He was too unwell to be considered for liver transplant and sadly died on September 12, 2025″.
According to the report, an inquest into Tran’s death found the medical cause to be acute liver failure, sepsis, hepatitis B reactivation “owing to cessation of medication” and immunosuppression for renal transplantation.
Lack of commissioning and guidance
Brittain highlighted to the British Viral Hepatitis group at the British Association for the Study of the Liver (BASL) a concern that “there is a lack of national guidance regarding which services should be responsible for monitoring and prescribing in relation to hepatitis B reactivation prevention”.
He also directed a concern to the UK Health Security Agency, noting that although a “large population” of patients are found to have hepatitis B through opt-out screenings at emergency departments, “there is a lack of specialised commissioning to maintain subsequent engagement with services”.
And he said that “unless action is taken to address” the concerns, there is “a significant risk of future deaths”.
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In its response, the BASL said it “does not lead the development or publication of clinical guidelines”.
It added that there “is variation between NHS Trusts” as to whether monitoring and prescribing for patients at risk of hepatitis B reactivation in the setting of immunosuppressive treatment is “delivered by the treating team or whether specialist hepatology services are involved”.
“We have previously and will again incorporate the risks of hepatitis B reactivation and its prevention and management into our webinar and conference programmes in this coming year,” it said.
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It comes after a coroner raised concerns earlier this year over prescribing errors at HMP Thameside following the death of an inmate.
And it follows a coroner warning GPs of the risk of propranolol overdose after the death of a man who took a “significant amount” of the drug.
