Family welcomes inquest findings following three-year fight after preventable death of young mother Tanya McCartney

Tanya, a 25-year-old mother from Chesterfield, died on 19 May 2023 from bilateral lobar pneumonia, less than 24 hours after being discharged from Chesterfield Royal Hospital NHS Foundation Trust.

The inquest heard that Tanya attended hospital on 18 May 2023 after becoming increasingly unwell with breathing difficulties, chest pain, a painful and swollen throat, a high temperature and other concerning symptoms. She had been referred to A&E by her GP, who was sufficiently concerned about her condition to send her to hospital for urgent assessment.

Evidence obtained during subsequent investigations included expert opinion that showed Tanya was displaying signs suggesting possible sepsis and should have remained in hospital for monitoring and intravenous antibiotic treatment. However instead of being admitted, she was given the option of being discharged home with oral antibiotics, which she agreed to.

On the 19 May Tanya collected her car from the GP surgery and returned home. She then became acutely unwell with confusion and difficulty recognising her partner, and 11-month-old son. She then sat on the sofa, where her lips started to turn blue and she stopped breathing. Her partner called an ambulance and performed CPR before paramedics arrived, but sadly Tanya could not be saved.

The Trust's internal investigation concluded that Tanya’s discharge was appropriate and an initial inquest into her death was closed. However, following a rigorous legal fight led by Tanya’s family and the Clinical Negligence team at law firm Slater and Gordon, which involved obtaining independent expert medical evidence, the Trust reversed its position. The inquest was reopened following an admission of liability in the medical negligence claim, where it was accepted that the decision to discharge Tanya from hospital on the 18 May 2023 was inappropriate.

In August 2025, the Trust issued a formal letter of apology to the family, admitting that Tanya should have been admitted for further observations, investigations and intravenous antibiotics. The Trust has acknowledged that, had this happened, Tanya would, on the balance of probabilities, have survived.

Anita Davies, Assistant Coroner for Derby and Derbyshire, delivering a narrative verdict, acknowledged that Chesterfield Royal Hospital’s decision to discharge the young mother contributed to her death.

Anita Davis said: "At the point of discharge no clear source of infection has been identified, she had a very high CRP result coupled with a high heart rate, temperature and respiratory rate and three hours before discharge her vital signs had been significantly outside of normal range and merited further monitoring and investigation. Given the clinical picture the Trust accepts that Tanya should have been admitted for further observations and intravenous antibiotics. The Trust accepts that had she been admitted and given intravenous antibiotics, on the balance of probabilities she would have survived. I therefore find that had Tanya been admitted on the 18 May and given appropriate intravenous antibiotics it is more likely than not that she would have survived. The decision not to admit Tanya to hospital on the evening of the 18 May, but rather to offer her a choice between admission or return home, contributed to the death."

Tanya had only recently returned to work as a Mental Health Care Assistant following maternity leave and had hoped to train as a mental health nurse. She leaves behind her young son, Marcus, who was just 11-months old when she died. Now aged 4, he is being raised by his grandmother and has no memories of his mother.

Natasha Johnson, Tanya's mother, said: "Nothing will ever make up for losing my daughter, but we want to thank the coroner for finally having examined the circumstances of her death properly. Every day Marcus asks questions about his mummy. One day he will want to understand what happened to her. We owed it to him, and to Tanya, to keep fighting until the truth came out.

"We welcome the verdict today, which finally puts into official words what our family has known since the terrible day Tanya was taken from us. Getting to this point has been an exhausting, painful battle. From the beginning, our family struggled to understand how Tanya could go to hospital desperately unwell and then die the very next day. We have waited a long time to find out the truth about what happened and why she died.

"While the hospital has accepted that, had Tanya been admitted for antibiotic treatment she would probably have survived, hearing that is devastating. Those are words no family should ever have to hear.

"Listening to the coroner formally acknowledge the failures in Tanya's care brings us some closure, but it does not lessen the absolute heartbreak we live with every single day. Tanya was only 25 years old. She was beautiful, funny, a loving daughter, sister and granddaughter but, above all, she was an incredible mum, who lived for her little boy. Marcus has now spent most of his life without his mother and asks why his mummy is in heaven and that is something we will never come to terms with.

"We can only hope that the Trust takes the coroner's words to heart so that no other mother has to know their child's death was entirely preventable. We hope Tanya’s death and the lessons identified have led to meaningful change to help ensure that no other family experiences the pain and heartbreak that we have endured."

The family is represented by solicitor Rebecca Dowse, our medical negligence specialist.

Rebecca said: "Tanya McCartney’s death was a devastating and avoidable tragedy involving a young woman whose condition was treatable. She was just 25 years old, a loving mother to her young son, and had her whole life ahead of her.

The inquest's narrative verdict, which acknowledged the Trust's admission that discharging Tanya was inappropriate, is a stark reminder of the tragic consequences of incorrect clinical decision-making. We now know it was not just inappropriate to discharge Tanya; it was a fatal error that the Trust has been forced to account for.

"Tanya's family has shown extraordinary determination in pursuing answers. They have had to endure not only the devastating loss of a much-loved daughter and mother, but also years of uncertainty while trying to understand how such a tragedy could occur. Today’s findings from the coroner are an important acknowledgement of the concerns that Tanya’s family have fought for so long to have properly examined. While we welcome the Trust’s eventual admissions and the procedural changes implemented since this tragedy, it should never require a grieving family to launch a legal battle simply to obtain the truth.

"We hope the conclusions reached today provide Tanya’s family with some measure of accountability and the answers they have sought for so long. It is now vital the findings from this case, together with the learning identified by the Trust, are acted upon and embedded in practice, so that the failures identified can be prevented in the future and are not repeated."

Since Tanya's death, the Trust has introduced several changes and learning measures, including strengthened oversight of higher-risk patients within the Emergency Department, improvements to referral and handover procedures, and the introduction of a new electronic patient record system.