Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0259, written 11 May 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 May 2026 |
|---|---|
| Reference | 2026-0259 |
| Deceased | Tung Tran |
| Coroner | R Brittain |
| Coroner area | Inner North London |
| Source | judiciary.uk record |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REPORT TO PREVENT FUTURE DEATHS REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 1. CORONER I am Richard Brittain, Assistant Coroner, for the coroner area of Inner London North. 2. DATE OF REPORT 11 May 2026 3. CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3. THIS REPORT IS BEING SENT TO 1. The chair of the British Viral Hepatitis Group, British Association for the Study of the Liver (BASL) 2. Director of Public Health Programmes, UK Health Security Agency (UKHSA) You are under a duty to respond to this report within 56 days of the date of this report, namely by 6 July 2026. I, the coroner, may extend the period if an appropriate application is made. 4. YOUR RESPONSE Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports - Courts and Tribunals Judiciary. 5. SUMMARY OF CORONER’S CONCERN Having heard evidence relating to Mr Tran’s death, I am concerned that: 1. There is a lack of national guidance regarding which services should be responsible for the monitoring and prescribing in relation to hepatitis B reactivation prevention; 2. There is a large population of patients who are found to have hepatitis B infection through opt-out screening in Emergency Departments but there is a lack of specialised commissioning to maintain subsequent engagement with services. I heard that this differs from the position with regards to hepatitis C and HIV services, even though these patient populations are smaller. 6. ACTION SHOULD BE TAKEN In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action. 7. INVESTIGATION AND INQUEST On 2/10/25, an investigation was commenced into the death of Tung Thanh Tran, aged 41 years. I heard the subsequent inquest on 13/3/26. The medical cause of death was determined to be: 1.a. Acute liver failure 1.b. Sepsis (unknown source) 1.c. Hepatitis B reactivation owing to cessation of medication 2. Immunosuppression for renal transplantation Mr Tran died at Royal Free Hospital, London on 12/9/25 Inquest Conclusion Mr Tran died of complications arising from reactivation of a viral illness, which arose from inadvertent discontinuation of necessary medical treatment. 8. CIRCUMSTANCES OF DEATH Mr Tran had a background history of renal transplant in 2013 and was diagnosed with chronic hepatitis B as part of this process. After a period of disengagement from services, Mr Tran was discharged from hepatology but continued to receive viral reactivation prophylaxis (Entecavir) from renal transplant services. Supply of medication changed to home delivery in early 2025 but the Entecavir was inadvertently discontinued, as 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. 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 was too unwell to be considered for liver transplant and sadly died on 12 September 2025. 9. CORONER’S CONCERNS During the course of the inquest I heard evidence giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: 1. There is a lack of national guidance regarding which services should be responsible for the monitoring and prescribing in relation to hepatitis B reactivation prevention; (concern directed to BASL) 2. There is a large population of patients who are found to have hepatitis B infection through opt-out screening in Emergency Departments but there is a lack of specialised commissioning to maintain subsequent engagement with services. I heard that this differs from the position with regards to hepatitis C and HIV services, even though these patient populations are smaller (concern directed to UKHSA) 10. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: 1. Mr Tran’s family 2. The Royal Free Hospital I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. SIGNATURE
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
The British Association for the Study of the Liver (BASL)
Secretariat Office c/o Executive Business Support Ltd
Stowe House, St Chad’s Road, Lichfield, Staffordshire WS13 6TJ
The British Association for the Study of the Liver
Stowe House
St Chad’s Road
Lichfield
Staffordshire
WS13 6TJ
6th July 2026
Mr Richard Brittain
Assistant Coroner, for the coroner area of Inner London North
London Borough of Camden
5 Pancras Square
London N1C 4AG
Sent by email
Dear Mr Brittain,
Re: Prevention of Future Deaths Report
The British Viral Hepatitis Group (BVHG) is a sub-group of the British Association for the Study of the
Liver (BASL). BASL is a charitable specialist society dedicated to advancing knowledge and
understanding of liver diseases and to the optimal care of patients with those diseases. These aims
are principally achieved through dissemination of research and sharing of clinical expertise and
through the promotion of opportunities for collaboration in liver research. BASL does not lead the
development or publication of clinical guidelines.
There are two groups of patients requiring antiviral therapy when undergoing immunosuppressive
treatment:
• The first is those patients with a diagnosis of chronic hepatitis B (CHB) defined by the
presence of a positive hepatitis B surface antigen (HBsAg) on two occasions 6 months apart.
These CHB patients are usually managed in specialist hepatology services and the
responsibility of monitoring and prescribing lies with these services.
• The second group is those patients who are HBsAg negative but hepatitis B core antibody
(HBcAb) positive. These patients are at risk of hepatitis B reactivation in the setting of
immunosuppressive treatment. There are many different specialties who prescribe
immunosuppressive regimens, including (but not limited to) haematology, oncology, and
non-liver organ transplant services. Guidance regarding the need for antiviral therapy for
such patients is provided by the relevant specialist societies and frequently also in local NHS
Trust guidance. There is variation between NHS Trusts as to whether this monitoring and
prescribing is delivered by the treating team or whether specialist hepatology services are
involved.
Limited Company No: 5017662. Registered Charity No: 1106320
The British Association for the Study of the Liver (BASL)
Secretariat Office c/o Executive Business Support Ltd
Stowe House, St Chad’s Road, Lichfield, Staffordshire WS13 6TJ
•
In line with the educational role of BASL and BVHG 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. We will use this forum to highlight
the risks of gaps in monitoring and prescribing of antiviral treatment for participants to take
back to their local services.
Additionally, we will continue to highlight the role of health inequalities and access to care that also
appears to have impacted the outcome in this case as we recognise these as being major issues for
people living with viral hepatitis infections more widely.
Yours sincerely,
BASL President
Limited Company No: 5017662. Registered Charity No: 1106320
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