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Mother’s ‘living hell’ after son dies despite 15 GP visits in under four months

PUBLISHED: 14:40 22 November 2020 | UPDATED: 10:31 23 November 2020

Lisa Middlemass with her son Luke Baker, who died despite visiting doctors 15 times in three-and-a-half months. PHOTO: Lisa Middlemass

Lisa Middlemass with her son Luke Baker, who died despite visiting doctors 15 times in three-and-a-half months. PHOTO: Lisa Middlemass

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A grieving mother said she is in “living hell” after her 27-year-old son “died for no reason” despite 15 visits to doctors in just three-and-a-half months.

Luke Baker, who died despite visiting doctors 15 times in three-and-a-half months. PHOTO: Lisa MiddlemassLuke Baker, who died despite visiting doctors 15 times in three-and-a-half months. PHOTO: Lisa Middlemass

Luke Baker had been treated for aspiration pneumonia during an overnight stay in hospital after being knocked unconscious following a fall from his bicycle in July 2019.

Mr Baker visited GPs at the Andaman surgery, in Lowestoft, and used the out-of-hours service more than a dozen times with a range of physical and mental health complaints in the months before his death on November 10, 2019.

His mother, Lisa Middlemass, said: “We lived together in Lowestoft and you cannot imagine how awful it is without him.

“Every day I wake up it is a living hell to think he died for nothing.

Luke Baker, who died despite visiting doctors 15 times in three-and-a-half months. PHOTO: Lisa MiddlemassLuke Baker, who died despite visiting doctors 15 times in three-and-a-half months. PHOTO: Lisa Middlemass

“People should hear what a terrible failure this was.

“Week after week when he came out of hospital, he was going back to the doctors complaining of coughing up brown phlegm and saying he felt really ill.

“They thought he had tonsilitis and he had several courses of antibiotics, but they didn’t do any investigations. They should have done a chest x-ray and taken samples.”

An inquest into Mr Baker’s death heard evidence from Dr Susan Lock, senior partner at the Andaman surgery, who said Mr Baker’s chest appeared clear during consultations.

Mrs Middlemass said: “People must think ‘why didn’t you take him to hospital’, but because he was on medication for anxiety and depression, I think that masked the symptoms and kept him going.

“The evening before he died, he got up and walked to the Chinese takeaway and ate it - That’s why I wasn’t thinking he was literally about to die.

“The next day I thought he was late getting up so I went up to knock on the door and I found him dead.”

Both mother and son had worked at M&H Plastics in Beccles before his death.

She said: “He was the loveliest person and my best friend. We are all heartbroken.

“He would do anything for anyone. He was a genuinely nice person.

“So many people from work went to his funeral, but I have had to give up my job because I would find it too difficult to face everyone who knew Luke.”

Declining health ‘should have been investigated’ - Independent review

An inquest into the death of the 27-year-old was adjourned following the discovery of a letter sent from NHS England and NHS Improvements.

The letter, a response to a complaint submitted by Mrs Middlemass, explained a review of Mr Baker’s care was carried out by an independent GP clinical advisor.

It states: “Since the accident, Luke went to his own GP surgery a total of 12 times, mainly with physical illness and sometimes with anxiety and depression.

“He also attended the out-of-hours service twice and was admitted overnight to the hospital.

“Although Luke’s mother says he repeatedly told GPs about his breathing problems, this was not mentioned in the notes.

“Luke saw or spoke to doctors 15 times in a three-and-a-half month period before his death.

“In my experience, a person who consults so many times in a short space of time, who would not normally do so, should be fully investigated.

“In Luke’s case, this was even more important given his history of aspiration pneumonia.

“The response by the Practice, although comprehensive in the detail of the consultations, does not, in my opinion, set out the course of events that illustrates the declining health of a fit, young man and the appropriate actions in light of this decline.”

A further review, by NHS England’s Performance Management Team was also recommended to ensure the advisor’s concerns are addressed.

The inquest, on October 22 at Suffolk Coroner’s Court, heard evidence from Dr Lock, who said: “Luke’s death was a complete shock to all of us at the surgery and none of us could have forseen it.

“Visits to the GP and out-of-hours service with complaints of temperature and coughs revealed his chest was clear apart from on one occasion on July 31. There was no evidence of a chest infection found.

“Having looked through Luke’s notes, I cannot see how his death could have been prevented. He didn’t have any indication he was as ill as he was.

A blood test had been arranged in late September, which Mr Baker did not attend, while another had been arranged at an appointment on October 30 for two weeks later, just days after his death.

The inquest also heard Dr Lock had been unaware of Mr Baker’s accident and stay at the JPUH following a change in computer system at the practice.

She said: “It felt precarious at the time because we were dealing with a delay in getting letters from the hospital and trying to access the patients records easily without going into another system, so it was really cumbersome.

“It takes time to adjust to a new system but unfortunately the volume of patients we have to see doesn’t change and the expectation of us to treat people to a high standard doesn’t change. It was a very difficult time and it was unfortunate Luke’s accident happened at that time.

“Because of the change, I hadn’t realised until had passed away that he had had the accident.”

The inquest was adjourned for assistant coroner Tim Deeming to consider the NHS England and NHS Improvement findings, with no date currently set for the hearing to resume.

Speaking after the inquest, Mrs Middlemass said: “I didn’t know until the inquest that the doctor didn’t know about his accident. It shocked me to my core.

“It is not good enough. Clearly people are going to die if they can’t get the records and Luke did die.

“It is just such incompetence and somebody needs sacking for this.

“His beautiful life has been cut short and my life is ruined forever.

“I don’t want this brushed under the carpet. My son died for no reason.”


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