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A coroner in North London has called for more national guidance on which services should be responsible for monitoring and prescribing medication to prevent hepatitis B becoming active again after the death of a patient whose treatment was inadvertently discontinued.

Tung Thanh Tran, 41, died at the Royal Free Hospital in September 2025 after being diagnosed with chronic hepatitis B following a renal transplant in 2013.

An inquest into his death heard he was discharged from hepatology but continued to receive the viral reactivation prophylaxis entecavir from renal transplant services.

By the start of 2025, the medication was being delivered to his home but was then “inadvertently discontinued as there was a presumption that hepatology would continue to prescribe” it.

In his report, sent to the British Association for the Study of the Liver (BASL) and the UK Health Security Agency (UKHSA), the coroner for Inner North London Richard Brittain said Tran appeared “to have understood this to have been an intentional change of his medication”.

Tran was admitted to his local hospital in August 2025 with signs of acute liver disease from reactivation of hepatitis B and transferred to the Royal Free Hospital, where he died on September 12, 2025.

“He was too unwell to be considered for liver transplant,” Brittain noted in his report. He recorded the cause of death as acute liver failure, sepsis (unknown source), hepatitis B reactivation owing to cessation of medication and immunosuppression for renal transplantation.

“Mr Tran died of complications arising from reactivation of a viral illness, which arose from inadvertent discontinuation of necessary medical treatment,” the report concluded.

Brittain told BASL that Tran’s death gave rise to concerns about “a lack of national guidance regarding which services should be responsible for the monitoring and prescribing in relation to hepatitis B reactivation prevention”.

Brittain also told the UKHSA: “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.”

The report was also sent to Tran’s family and the Royal Free Hospital.