Mum and Stillborn Daughter Might Have Survived with Earlier MRI Scan, Inquest Concludes
A "happy-go-lucky" mother tragically died just days after giving birth to her stillborn daughter via emergency caesarean section, with an inquest hearing that both might have survived if medical staff had acted more promptly.
Double Tragedy at Birmingham Hospital
Tammy Mackenzie, aged 41, passed away at Heartlands Hospital in Birmingham on August 6, 2023, following a series of medical complications that began when she arrived at Bordesley Green Hospital's emergency department on July 26. She was experiencing severe abdominal pain and vomiting, symptoms that had plagued her intermittently since late May that year.
The inquest, led by Assistant Coroner Ian Dreelan, revealed that Tammy was 28 weeks pregnant when her condition deteriorated rapidly, necessitating an emergency C-section. During this procedure, her daughter Khloe was delivered stillborn. The coroner's investigation focused on whether earlier intervention could have prevented this devastating outcome.
Missed Opportunities in Diagnosis
Medical records showed that an MRI scan was recommended for Tammy on July 26, with the recommendation reiterated the following day when she was admitted to the maternity unit. However, the scan was not performed until July 30, four days later. This delay proved critical.
The MRI eventually confirmed that Tammy had a small bowel obstruction, a condition that had not been properly identified earlier. Treatment began on July 31 with the insertion of a nasogastric tube and administration of Gastrografin, but her condition continued to worsen.
On August 1, Tammy underwent an emergency laparotomy alongside the C-section. During this surgery, the small bowel obstruction was finally identified and treated, but by then it was too late to save baby Khloe.
Coroner's Findings and Family's Anguish
Assistant Coroner Dreelan concluded that Tammy's death resulted from natural causes, but was "contributed to by missed opportunities to diagnose the underlying condition of small bowel obstruction." He revealed that an internal post-incident review had determined that, on the balance of probabilities, both Tammy and her daughter "were more likely to have survived" if the MRI had been carried out sooner.
The coroner explained: "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."
Tammy's medical cause of death was recorded as:
- Multiple organ failure
- Strangulated small intestine
- Abdominal adhesion
Following the surgery, Tammy was transferred to intensive care but failed to respond to treatment. Doctors performed another laparotomy on August 3, but her condition continued to deteriorate. Life support was withdrawn on August 6, and she died later that day.
A Family's Heartbreak
Tammy's mother, Jacqueline, spoke of her profound loss, saying she misses her "happy-go-lucky" daughter "terribly." The family believes that the late diagnosis and subsequent delayed treatment played a significant role in Tammy's death.
Addressing the family during the inquest, Mr Dreelan expressed his condolences: "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."
This tragic case highlights ongoing concerns about maternal healthcare and timely diagnosis within the NHS, particularly in complex pregnancy cases where multiple symptoms may obscure underlying conditions.
