A grandmother developed sudden pain and died after increasing the dose of her Mounjaro weight loss jab, an inquest has heard.
Caroline Savage, 73, had been privately prescribed the popular drug for around four months before being advised to raise the amount she was taking.
She then fell ill and was rushed to Norfolk and Norwich Hospital where she was assessed by senior doctors and discharged at around 6.30pm.
But Ms Savage collapsed at home a few hours later and died just after midnight.
An inquest at Norfolk’s Coroner Court heard the grandmother died from faecal peritonitis – a leaking of faecal matter into the abdominal cavity – caused by perforation of part of her intestines.
Mounjaro’s gastrointestinal side effects were suggested as a ‘reasonable working diagnosis’ on her admission to hospital and links to the weight loss drug were explored at the inquest.
But Ms Savage’s family suggested doctors who treated her in hospital may have been too keen to attribute her symptoms to the drug.
They argued her symptoms should have prompted further investigation instead of being dismissed as side effects.
Grandmother Caroline Savage, pictured, developed sudden pain and died after increasing the dose of her Mounjaro weight loss jab, an inquest has heard
In response, solicitor Alison Brockhurst, representing the Norfolk and Norwich University Hospitals, accepted record keeping ‘wasn’t as good as it could have been’ but insisted appropriate pathways had been followed.
Ms Savage, from Wortwell, in Norfolk, failed to lose weight through diet and exercise, weighing 128kg (20 stone) in July 2024, so turned to Mounjaro.
She was also taking the drug in a bid to ease symptoms associated with lipoedema.
The grandmother was warned at the time that possible side effects included abdominal pain and constipation, her private prescribing doctor Dr Harvinder Chahal said.
The treatment appeared to be going well and Ms Savage’s weight had fallen to 114kg (18 stone) by October and she reported no significant side effects.
She was advised to complete the two remaining 7.5mg doses in her existing pen before increasing to 10mg.
But on October 18, Ms Savage complained of acute and constant abdominal pain and an ambulance was called at 1.30pm.
She was rushed to Norfolk and Norwich Hospital’s rapid assessment and treatment area at about 2.45pm but remained in the ambulance because the emergency department was too busy.
The grandmother was assessed by a senior clinical fellow in emergency medicine who said his initial concern was pancreatitis, a known but rare complication associated with weight-loss medication.
This was ruled out after her blood results arrived and, following examination, the doctor concluded she did not require admission or a CT (computed tomography) scan.
Advanced clinical practitioner Laura Rea said Mounjaro’s recognised side effects, including abdominal pain and bloating, formed a reasonable working diagnosis in the absence of any evidence pointing towards a surgical emergency.
Dr Olmo-Ferrer, a consultant in emergency medicine, also reviewed Ms Savage and carried out a focused ultrasound to rule out an abdominal aortic aneurysm.
He said she appeared comfortable enough to be discharged with pain relief, adding there was no clinical indication for a CT scan or a referral, and the grandmother left the hospital at about 6.30pm.
Just after midnight, her husband Jeremy, a former Tory councillor, heard a thud and found his wife unresponsive on the floor.
He called an ambulance and attempted CPR but she could not be saved.
While there is no established evidence that faecal peritonitis can be caused by Mounjaro, possible links were discussed at the hearing.
The drug slows the process by which food moves from the stomach to the intestine, and constipation is a known side-effect.
The hearing was told that if someone already unknowingly had diverticular disease – a condition that affects the intestine – the side effects from Mounjaro could increase pressure in the intestines and therefore the risk of inflammation and perforation.
Ms Savage’s family, represented by barrister Jasmine Leng, argued she had been discharged without a proper diagnosis and questioned why no surgical review, CT scan or further investigation was undertaken before she was sent home.
Following her death, the hospital carried out a review of her care.
Consultant Dr Hussain Hommad told the inquest her presentation, blood tests, observations and ultrasound findings were all within normal limits at the time she was assessed.
He said diverticular perforation was extremely difficult to predict and clinicians had acted appropriately based on the information available.
Although Mounjaro has since become associated with increased risks of gallstones and bowel obstruction, he said its use alone does not currently lower the threshold for carrying out CT imaging.
The family’s barrister submitted that Article 2 of the European Convention on Human Rights – the right to life – should be engaged because of potential systemic failures in communication, documentation and clinical decision-making at the hospital.
Ms Savage pictured with her husband Jeremy. She had been privately prescribed the popular drug for around four months before being advised to raise the amount she was taking
She argued clinicians repeatedly assessed Ms Savage’s pain shortly after morphine had been administered and may not have factored this in when deciding whether further investigations were needed.
Solicitor Alison Brockhurst, representing the Norfolk and Norwich University Hospitals NHS Foundation Trust, argued Ms Savage’s death was from natural causes and the high threshold for engaging Article 2 had not been met.
She accepted record keeping ‘wasn’t as good as it could have been’ but said evidence showed detailed discussions had taken place between clinicians in person and that appropriate pathways had been followed.
Ms Blake said she required further time to consider the legal submissions before deciding whether Article 2 should apply.
She adjourned her decision and said she would return to deliver her narrative conclusion.
