Man 'let down' by GPs after undiagnosed pneumonia death, mother claims
- Credit: Archant
A 27-year-old was "let down" by his GPs after an undiagnosed battle with pneumonia, despite making repeated visits to his GP in the months before his death, his mother has claimed.
Luke Baker spoke to doctors 15 times in the months leading up to his death in November 2019 over a number of issues, but died after his prescription medication worsened the effects of pneumonia.
An inquest into Mr Baker's death was adjourned in October 2020 after his mother Lisa Middlemass began reading a letter 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.
Assistant coroner Tim Deeming resumed the hearing on Tuesday, June 22, where Mrs Middlemass claimed her son had been "let down" by his GPs.
The 27-year-old made 12 visits to the Andaman Surgery in Lowestoft in just three-and-a-half months after a fall off his bicycle knocked him unconscious and resulted in a stay at the James Paget University Hospital to treat aspiration pneumonia.
Dr Catherine Kouame, a GP at the surgery, told the resumed hearing these were for a number of reasons including chest and throat infections and medication reviews.
She added Mr Baker did not only attend with breathing problems or a persistent cough.
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She said: "There were an array of complaints. It wasn't just that he had a continuous cough and sometimes when he came in he wasn't coughing.
"As a clinician who treated Luke, I believe this was a sad and unfortunate accident."
Mrs Middlemass, however, refuted her son's death was an accident, with Dr Kouame adding she was "really, really sorry for what happened."
Dr Susan Lock, senior partner at the Andaman Surgery in Lowestoft, was recalled to Ipswich Coroner's Court this week, despite giving evidence last year.
Previously, she told the hearing a change in computer system meant she was unaware of his accident and battle with pneumonia.
Returning to Ipswich Coroner's Court this week, Dr Lock said: "I think the change in computer system impacted on the care of a lot of our patients.
"NHS were promising it in early February when we were all there, but it was delayed and came in August when two clinicians were on annual leave.
"It involved turning off our previous system for two weeks and I can't even remember how we fudged through that fortnight.
"There was difficulty recording things or accessing notes, and took twice as long but we had the same number of patients and the same expectations of quality to deal with.
"We were meant to greet the system running but were on the backfoot all day."
Mr Baker, who worked at M&H Plastics in Beccles before his death, was found dead at his Lowestoft home on November 10, 2019, with a post-mortem finding evidence of prescribed medication in his blood, although they were unable to say how long Mr Baker had had pneumonia.
Assistant coroner Tim Deeming noted no blood test had been carried out.
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.
Recording a narrative conclusion, Mr Deeming said: "Luke died from widespread bilateral pneumonia, which developed as a consequence of aspiration on the background of raised morphine concentration and alongside other medication in his blood."