Inquest Finds Delayed Diagnosis Contributed to Tragic Deaths of Mother and Baby
An inquest has heard that a mother died just days after losing her baby in a stillbirth, with both tragedies potentially preventable if doctors had acted more swiftly. The hearing revealed that critical delays in performing an MRI scan may have cost both lives at Heartlands Hospital in Birmingham.
Timeline of Missed Opportunities
Tammy Mackenzie, a 41-year-old pregnant woman, passed away at Heartlands Hospital in Bordesley Green, Birmingham, on August 6, 2023. Her death followed surgery to address a small bowel obstruction that had gone undiagnosed for too long. Her daughter, Khloe, was stillborn at 28 weeks during an emergency caesarean section as Tammy's health deteriorated rapidly.
The inquest detailed that Tammy had been experiencing abdominal pain and vomiting since May 2023, leading to multiple hospital admissions. On July 26, medical staff recommended an MRI scan to investigate her symptoms thoroughly. However, this crucial diagnostic procedure was not carried out until four days later, on July 30. The scan finally revealed the small bowel obstruction that had been causing her distress.
Coroner's Findings and Internal Review
Assistant coroner Ian Dreelan, presiding over the Birmingham and Solihull inquest, ruled that Tammy's death resulted from natural causes but was contributed by missed opportunities to diagnose the underlying condition of a small bowel obstruction. The official medical cause of death was recorded as multiple organ failure, strangulated small intestine, and abdominal adhesion.
An internal hospital review presented during the inquest concluded starkly that if the MRI scan had been performed sooner, the surgical option could have been undertaken while Tammy was in a more stable condition. This timely intervention would have significantly increased the likelihood of survival for both Tammy and her unborn daughter.
Family's Anguish and Hospital's Response
Tammy's mother, Jacqueline, emotionally described her daughter as happy-go-lucky and expressed how she misses her terribly. The family's grief is compounded by the knowledge that earlier action might have averted this double tragedy.
The sequence of events showed Tammy was initially treated for constipation in early July and discharged after a four-day hospital stay. She was readmitted two weeks later when the MRI was recommended, but the delay persisted. After the obstruction was discovered, her condition worsened, leading to an emergency laparotomy on August 1. Despite transfer to intensive care and a second surgery, Tammy did not respond to treatment and died on August 6 after her care was withdrawn.
Coroner Dreelan offered his condolences, stating, Words can't express my condolences to the family sufficiently for the loss you have suffered. I hope, in some very small part, the conclusion of this process allows you to move forward in some way. The University Hospitals Birmingham NHS Trust has been contacted for comment regarding the inquest's findings.
