Overview
- University Hospitals Birmingham NHS Foundation Trust said it has implemented a number of changes to improve safety following the case.
- Assistant coroner Ian Dreelan concluded there were missed opportunities to diagnose small bowel obstruction, contributing to the death.
- An MRI was advised on July 26 and reiterated on July 27 but occurred on July 30, confirming a small bowel obstruction.
- Tammy Mackenzie, 41, underwent an emergency laparotomy and Caesarean on August 1 at 28 weeks; her daughter Khloe was stillborn and Ms. Mackenzie died on August 6.
- The internal post-incident review told the inquest that an earlier MRI would likely have led to earlier treatment and increased the chances of survival for both mother and baby.