Inquest Touching the Death of Caroline Savage

The inquest into the death of Caroline Savage, aged 73, took place before Area Coroner Yvonne Blake in the Norfolk Coroner’s Court. The Coroner handed down her conclusion on 24 August 2026.

On 18 October 2024, Caroline was taken by ambulance to the Norfolk and Norwich University Hospital (‘NNUH’) following sudden onset of severe abdominal pain, arriving at the hospital at 13.40. The ambulance was held in a queue outside the hospital due to hospital overcrowding.

Caroline remained on the ambulance with paramedics for almost all of her time in hospital. She was visited by two NNUH doctors and one NNUH Advanced Clinical Practitioner. Throughout her stay in the ambulance, she remained in severe abdominal pain, which was contemporaneously documented by the ambulance crew. The paramedics gave Caroline oxygen, three doses of morphine and one dose of paracetamol, to manage her pain. By coincidence, each of the three assessments of Caroline by NNUH clinicians took place shortly after she had received pain relief.

Although Caroline remained in severe abdominal pain, the acute abdominal pathway was not activated. Therefore, whilst Caroline received an abdominal ultrasound scan, she was not referred for a CT scan as mandated by the pathway.

She was discharged from hospital and sent home at 18.24. A final set of clinical observations was not performed before her discharge, which would have been good medical practice. Although the doctors did not identify the cause of her pain, her discharge summary recorded a potential diagnosis of “?pancreatitis // Side effects of medication” (a reference to Mounjaro, which Caroline had been taking without complication).

The post-mortem investigation concluded that Caroline died of 1a. Faecal peritonitis and 1b. Perforated sigmoid diverticular disease.

In her summing up, the Coroner found that there had been no evidence that too much Mounjaro had caused Caroline’s symptoms and, during her narrative conclusion, the Coroner identified that the record-keeping of NNUH had been ‘sparse’.
Caroline’s family are grateful for the Coroner’s decision to issue a Prevention of Future Deaths report. The Coroner plans to ask NNUH to address the poor standard of record-keeping; how communication and clinical handovers between paramedics and hospital staff take place; and NNUH staff’s understanding of when a patient’s care is transferred from paramedics to NNUH doctors. The Coroner also intends to ask NNUH whether a specific record can be made when a patient has been provided morphine out-of-hospital (eg. by paramedics).

Caroline’s family hope this will encourage the Trust to make much-needed and important changes. It is the family’s belief that NNUH clinicians too readily attributed Caroline’s symptoms to her Mounjaro dosage without adequately exploring other possible explanations for her severe pain. Although the paramedics who stayed with Caroline throughout her stay in hospital had created a continuous set of observations and pain scores, it does not seem that these records were available or properly considered by the clinicians who treated and then discharged Caroline. By comparison, the standard of record-keeping by NNUH was poor. The family feel that the NNUH clinicians assessing Caroline failed to appreciate the significance of her symptoms, including the severity of her pain. Treating clinicians discharged Caroline without performing a final set of clinical observations, and in part on the basis that Caroline’s pain had resolved. However, on each occasion that Caroline had been seen by NNUH clinicians, she had only just received morphine, which would have obscured her true pain levels. There is no record that any of the NNUH clinicians considered the timing of their

assessment (shortly after the administration of morphine) as part of their assessment of her pain levels. The family feel that NNUH clinicians discharged Caroline without an accurate understanding of the nature and cause of her pain, and that there were missed opportunities to more thoroughly investigate Caroline’s symptoms.

The family have commented:

“Caroline was a loving wife, mother and grandmother who was full of life and energy. She had struggled in recent years with the consequences of lipoedema — an under-recognised condition that causes a painful build-up of fat in the limbs which does not respond to diet or exercise. But after finally accessing specialist care and treatment, including Mounjaro weight-loss medication, she was feeling positive and excited about her future.
She was deprived of that future, years she had hoped to spend playing with her grandchildren and enjoying retirement with her friends and husband. She was also deprived of the opportunity to say goodbye to her loved ones, dying hours after having been discharged from hospital, where her symptoms had been attributed to side effects of weight-loss medication.
She is very much missed and so much more so in these circumstances. We have found the hospital to be evasive and unwilling to change. This process has been devastating but it was important to give a voice to Caroline and we hope that no other family face a loss in similar circumstances.”

Jasmine Balmer of Ashtons Legal says:

“This case has highlighted the real-time danger of failures in communication between multiple agencies providing care in an emergency setting. After an afternoon in an ambulance outside hospital, Caroline was discharged hours before her death, without a safe diagnosis and without investigations that she should have had access to. We continue to see ambulances queuing outside hospitals holding patients who require emergency care. To protect patient safety, we need robust processes in place to ensure effective communication and clear on-ground allocation of responsibility between paramedics and treating clinicians. I am proud of the family’s determination to get answers for Caroline. It is vital that the Trust now reflects and delivers on lessons learned to prevent future deaths”.