An inquest is investigating the death of a 73-year-old grandmother who developed faecal peritonitis, a condition causing intestinal perforation, after increasing her dosage of the Mounjaro weight loss drug. Caroline Savage, from Wortwell, Norfolk, was privately prescribed Mounjaro approximately four months before her death.
Savage, who weighed 128kg (20 stone) in July 2024, had turned to Mounjaro after failing to lose weight through diet and exercise. She was also using the drug to manage symptoms of lipoedema. Her private prescribing doctor, Dr. Harvinder Chahal, confirmed she was warned of potential side effects, including abdominal pain and constipation. By October, her weight had reduced to 114kg (18 stone), and she had reportedly experienced no significant side effects.
She was advised to finish her existing 7.5mg doses before increasing to 10mg. However, on October 18, Savage began experiencing acute and constant abdominal pain. An ambulance was called, and she was taken to Norfolk and Norwich Hospital's rapid assessment and treatment area. Due to the emergency department being busy, she remained in the ambulance, where she was assessed by a senior clinical fellow. The initial concern was pancreatitis, a rare but known complication of weight-loss medications. However, this was ruled out by her blood test results.
Further examination led to the conclusion that admission or a CT scan was not required. An advanced clinical practitioner noted that recognized side effects of Mounjaro, such as abdominal pain and bloating, presented a reasonable working diagnosis in the absence of signs pointing to a surgical emergency. A consultant in emergency medicine also reviewed Savage, ruling out an abdominal aortic aneurysm with an ultrasound. He determined she was well enough to be discharged with pain relief, with no clinical indication for a CT scan or referral. Savage left the hospital around 6:30 p.m.
Just after midnight, her husband, Jeremy Savage, discovered her unresponsive on the floor. Despite his attempts at CPR, she could not be revived. The coroner's court heard that Savage died from faecal peritonitis, caused by a perforation of her intestines.
While there is no established evidence linking Mounjaro directly to faecal peritonitis, the inquest explored possible connections. The drug is known to slow the digestive process, and constipation is a common side effect. The hearing was informed that in individuals with pre-existing, undiagnosed diverticular disease, the side effects of Mounjaro could potentially increase pressure within the intestines, raising the risk of inflammation and perforation.
Ms. Savage's family, represented by barrister Jasmine Leng, argued that she was discharged without a proper diagnosis and questioned the lack of surgical review, CT scan, or further investigation. The family's legal team submitted that potential systemic failures in communication, documentation, and clinical decision-making at the hospital might warrant engagement of Article 2 of the European Convention on Human Rights, which concerns the right to life. They also suggested that clinicians may not have adequately factored in her pain levels after morphine administration when assessing the need for further investigation.
Representing the Norfolk and Norwich University Hospitals NHS Foundation Trust, solicitor Alison Brockhurst acknowledged that record-keeping was not ideal but maintained that appropriate procedures were followed and that detailed discussions had occurred between clinicians. The trust argued that Savage's death was from natural causes and did not meet the threshold for engaging Article 2. The coroner has reserved her decision on whether Article 2 applies and will deliver a narrative conclusion at a later date.