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Tung Tran

11 May 2026Coroner: R BrittainArea: Inner North London

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Coroner

I am Richard Brittain, Assistant Coroner, for the coroner area of Inner London North.

Legal Powers

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DATE OF REPORT 11 May 2026

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.

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.

Action Required

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.

Action Required

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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.

Investigation and Inquest

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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

  1. 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.

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