Birmingham Hospital Trust Implements Safety Changes Following Tragic Maternal Death
The University Hospitals Birmingham NHS Foundation Trust has confirmed it has implemented significant safety changes following the tragic death of a pregnant mother under its care. Tammy Mackenzie, a 41-year-old expectant mother, died at Heartlands Hospital in Birmingham on August 6, 2023, just days after her daughter was stillborn.
Inquest Reveals Missed Opportunities in Care
An inquest into Tammy's death heard this week that both mother and baby were "more likely to have survived" if medical staff had acted more promptly. The hearing revealed there had been "missed opportunities" to diagnose and treat a small bowel obstruction that ultimately proved fatal.
Tammy had been 28 weeks pregnant when she was admitted to Heartlands Hospital's emergency department on July 26, 2023, presenting with abdominal pain and vomiting. Following surgery at the Bordesley Green hospital, her condition deteriorated rapidly, leading to an emergency C-section during which her daughter, Khloe, was stillborn.
Family Seeks Answers Through Inquest Process
Tammy's family attended the inquest seeking answers about the circumstances surrounding her death. They believe delays in both diagnosis and surgical intervention contributed to the double tragedy. Assistant coroner Ian Dreelan concluded that Tammy's death resulted from natural causes "contributed to by missed opportunities to diagnose the underlying condition of small bowel obstruction."
Addressing the family directly during the hearing, Mr Dreelan stated: "An internal, post-incident review concluded that, on the balance of probability, had the MRI been actioned sooner, referring a diagnosis of small bowel obstruction, the non-surgical treatment would have been initiated earlier, and the surgical option could've been performed while Tammy was more stable and, Tammy, and her daughter, were more likely to have survived."
Hospital Trust Responds with Safety Improvements
Following the inquest's conclusion, a spokesperson for University Hospitals Birmingham NHS Foundation Trust expressed the organisation's deepest condolences to Tammy's family. The trust acknowledged the findings and confirmed that comprehensive changes have been implemented to prevent similar tragedies in future.
The trust stated: "The loss of both a mother and her baby is a profound tragedy, and our thoughts remain with everyone affected. An internal review was carried out following the patient's death and we have taken forward the learning to strengthen our processes and improve the safety and quality of care. A number of changes have already been implemented to reduce the risk of such circumstances occurring again."
The hospital trust emphasised its ongoing commitment to providing safe, compassionate care and ensuring that lessons from this case are embedded across all its services. The implemented changes represent a direct response to the internal review conducted after Tammy's death, with the specific aim of improving diagnostic processes and treatment pathways for similar cases in future.
This tragic case highlights the ongoing challenges within maternity services and the critical importance of timely diagnosis and intervention in emergency obstetric situations. The trust's response demonstrates the NHS's commitment to learning from adverse incidents and continuously improving patient safety standards across its hospital network.
