Nine-stone man died from anorexia weeks after doctors' 'human error'

A nine-stone man who suffered from anorexia died weeks after "human error" meant doctors failed to inform his GP he had been discharged from hospital.

Luke Mason, who had suffered with anorexia since he was 17, was referred to the eating disorder service in January 2022, with a weight of 8st 7lb, after his condition worsened following the death of his older brother. But the referral was rejected, with no explanation recorded, an inquest into Luke's death at Blackpool Town Hall heard.

Then, in October 2022, Luke was admitted to the Royal Preston Hospital after blood tests undertaken by his GP showed he had low potassium levels. Subsequent tests highlighted no concerns and Luke, from Freckleton, Lancashire, was discharged.

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But "human error" meant doctors failed to send a discharge summary to Luke's GP, which would have allowed him to be further monitored in the community, the inquest heard. This was a "missed opportunity", Assistant Coroner Louise Rae said, although she added she could not conclude that Luke's outcome would have been any different if the summary had been sent.

On January 30 2023, Luke, aged 30, was found unresponsive in bed by his mum Carol at their home in Clitheroes Lane. He weighed 9st and the pathologist who undertook a post mortem said Luke "didn't look like a healthy gentleman for his age".

The cause of Luke's death was given as pneumonia and anorexia with a form of hepatitis, caused by anorexia and alcohol, listed as a contributory factor.

At the inquest held today (Thursday October 3), the Assistant Coroner, Ms Rae, heard there was no documented reason why Luke had been rejected by the eating disorder service in January 2022.

In October 2022, before he was admitted to the Royal Preston Hospital, Luke had told his GP that he would accept a referral to the eating disorder service. But as Luke's GP, Dr Hannah Todd, was not aware he had been discharged from hospital, no referral was made.

"While Dr Todd received a summary from the emergency department, this only informed her that he was being admitted to the hospital," Ms Rae said. "She didn't receive a discharge summary and she was not aware Luke had returned to the community.

"This was a missed opportunity to monitor him and send that referral and a discharge summary should have been sent.

"The best person to make that referral was Dr Todd and had she known he had been discharged she would have made it. However, had the referral been made, with his BMI, it is probable that Luke would have been triaged as non-urgent and it is unlikely he would have been seen prior to his death in January 2023.

"I therefore cannot find that, had a referral been made in October, that it would have changed the outcome given the 12-week waiting time for non-urgent referrals. A discharge summary should be sent to every patient's GP. In this case it wasn't sent due to human error but I can't say that this would have led to a different outcome."

The inquest heard that the trust which runs the Royal Preston Hospital carried out a review of Luke's care following his death. Changes have since been made to ensure discharge summaries are sent for every patient.

In her conclusion the coroner said: "Luke Mason died from a combination of naturally-occurring disease and hepatitis caused by a combination of anorexia and alcohol."