Coroner Concludes Delayed Diagnosis Contributed to Tragic Deaths of Mother and Baby
A pregnant mother died at a Birmingham hospital just days after her daughter was stillborn, with a coroner stating that both were more likely to have survived if medical staff had acted more swiftly. Tammy Mackenzie, aged 41, passed away at Heartlands Hospital on August 6, 2023, following a series of critical delays in her treatment.
Missed Opportunities in Diagnosis and Treatment
An inquest heard that Tammy, who was 28 weeks pregnant, was admitted to the emergency department at Heartlands Hospital on July 26, 2023, suffering from severe abdominal pain and vomiting. Despite recommendations for an MRI scan on both July 26 and 27, the crucial diagnostic procedure was not carried out until July 30. This scan ultimately confirmed a small bowel obstruction, a condition that had been previously missed during earlier hospital admissions.
Assistant Coroner Ian Dreelan highlighted that Tammy had a complex pregnancy and had experienced similar symptoms dating back to May of that year. She was admitted to Heartlands Hospital between July 7 and July 11, where she received conservative treatment for constipation before being discharged. The coroner emphasised that there were missed opportunities to identify and treat the obstruction earlier, which could have altered the tragic outcome.
Rapid Deterioration and Surgical Interventions
Following the delayed MRI scan, medical staff attempted non-surgical treatments, including inserting a nasogastric tube and administering Gastrografin. However, Tammy's condition deteriorated rapidly after being transferred to a surgical ward on August 1. An emergency caesarean section was performed, but her daughter, Khloe, was stillborn. During subsequent surgery, the small bowel obstruction was identified and treated, but Tammy was transferred to intensive care where she failed to respond to treatment over the next 48 hours.
A further laparotomy was conducted on August 3, but her condition continued to decline. Intensive care treatment was withdrawn on August 6, and Tammy died later that day. The medical cause of death was recorded as multiple organ failure, strangulated small intestine, and abdominal adhesion.
Coroner's Findings and Family's Grief
In his conclusion, Mr Dreelan stated that Tammy's death was due to natural causes, contributed to by missed opportunities to diagnose the small bowel obstruction. He referenced an internal post-incident review which found that, on the balance of probabilities, an earlier MRI scan would have led to a quicker diagnosis and treatment while Tammy was more stable. "Tammy and her daughter were more likely to have survived under those circumstances," the coroner affirmed.
Addressing Tammy's family, Mr Dreelan expressed his deepest condolences, acknowledging the profound loss they have endured. Tammy's mother, Jacqueline, described her daughter as a "happy-go-lucky person who laughed a lot" and said she misses her terribly. The family attended the inquest seeking answers, believing that delays in diagnosis and surgery played a significant role in the tragedy.
This case underscores critical issues in maternal healthcare and the importance of timely diagnostic interventions in complex medical situations.
