An inquest has heard that a grandmother died from a painful illness after increasing the dose of her Mounjaro injection. Caroline Savage, 73, from Wortwell, Norfolk, suffered "sudden and severe pain" after being advised to increase the amount she was taking on a private prescription.
Cause of Death
The hearing was told Mrs Savage died from faecal peritonitis, a leaking of faecal matter into the abdominal cavity, caused by a perforation of part of her intestines. Norfolk's Coroner Court also heard that her family were concerned that hospital doctors may have been too quick to attribute her symptoms to the drug.
Mrs Savage had been taking Mounjaro for around four months to lose weight and manage symptoms of lipoedema, a painful build-up of fatty tissue. Her private prescribing doctor, Dr Harvinder Chahal, said she was warned that possible side effects included abdominal pain and constipation.
Hospital Visit
In October 2024, her weight had fallen from 128kg (20st) to 18st, and she reported feeling well. She was advised to complete the two remaining 7.5mg doses in her existing pen before increasing to 10mg. However, on the morning of October 18, 2024, she began suffering abdominal pain, and an ambulance was called at 1.30pm.
She was taken to the Norfolk and Norwich Hospital's emergency department at about 2.45pm but stayed in an ambulance because the department was too busy. A senior clinical fellow in emergency medicine initially suspected pancreatitis, a known but rare complication from weight-loss medication, but blood results did not indicate this. He concluded she did not require admission or a CT scan.
Advanced clinical practitioner Laura Rea said Mounjaro's recognised side effects, including abdominal pain and bloating, formed a reasonable working diagnosis without evidence of a surgical emergency. Dr Olmo-Ferrer, a consultant in emergency medicine, also reviewed Mrs Savage and carried out a focused ultrasound to rule out an abdominal aortic aneurysm. He said she appeared comfortable enough to be discharged with pain relief and advice.
Death and Aftermath
Mrs Savage was discharged at about 6.30pm but collapsed at home just after midnight. Her husband Jeremy, a former Tory councillor, heard a thud and found her unresponsive on the floor. He called an ambulance and attempted CPR, but she could not be saved. A post-mortem examination found she had died from faecal peritonitis.
The hearing was told there is no established evidence that Mounjaro can cause this condition, but possible links were discussed. The drug slows the speed food moves from the stomach to the intestine, and constipation is a known side-effect. If someone already unknowingly had diverticular disease, the side effects could raise pressure in the intestines, increasing the risk of inflammation and perforation, but no exact figure could be put on this risk.
Inquest Proceedings
During the inquest, held before area coroner Yvonne Blake, Mrs Savage's use of Mounjaro and whether hospital staff carried out enough investigations before sending her home were discussed. Her family argued she was discharged without a proper diagnosis, questioning why no surgical review, CT scan, or further investigation was undertaken. The hospital carried out a review of her care after her death.
Consultant Dr Hussain Hommad told the inquest that her presentation, blood tests, observations, and ultrasound findings were all normal at the time she was assessed. He said the outcome was extremely difficult to predict, and clinicians had acted appropriately based on the information available.
The family's barrister, Jasmine Leng, submitted that Article 2 of the European Convention on Human Rights, the right to life, should be considered over what they described as systemic failures in communication, documentation, and clinical decision-making. She argued clinicians repeatedly assessed Mrs Savage's pain shortly after morphine had been administered and may not have taken this into account when deciding whether further investigations were needed.
Solicitor Alison Brockhurst, representing the Norfolk and Norwich University Hospitals NHS Foundation Trust, argued Mrs Savage's death was from natural causes and the high threshold for engaging Article 2 had not been met. She accepted record-keeping "wasn't as good as it could have been" but said evidence showed detailed discussions had taken place between clinicians in person and that appropriate processes had been followed.
Coroner Ms Blake said she required further time to consider the legal submissions before deciding whether Article 2 should apply. She adjourned that decision and said she would later return to deliver her narrative conclusion.
