Dhananji Dona

I am Emma Serrano, Area Coroner, for the Area Coroner for Staffordshire.

On the 3 rd October 2024, I commenced an investigation into the death of Mrs Dhananji Denawakage Dona. The investigation concluded  at the end  of the  inquest on 20 January 2026. The conclusion of the inquest was a short form conclusion a natural cause, with a neglect rider. The cause of death was: 1a. Septic shock and Disseminated Intravascular Coagulopathy I b Urine infection and Septic Miscarriage

i)    Mrs Dona attended the Royal Stoke University Hospital, Stoke on Trent. She  was  pregnant  and  had  noticed  bleeding  and  was  suffering  from abdominal pain.   She was suffering from SEPSIS as well as miscarrying. There was a delay in her assessment in the A&E department, and the SEPSIS screening tool was not used. ii)   There is a specific National Early Warning Score matrix for prenatal women. This was not used in the A&E department as, despite national guidance to say this should be used in all departments of a hospital, it was only used in the maternity department of the Hospital. iii)  This led to a delay in her diagnosis and treatment of the SEPSIS. iv)  She continued to deteriorate whilst in hospital and, passed away on the 2 October 2024. v)   Evidence heard at inquest was that, earlier diagnosis and treatment for SEPSIS would have meant that Mrs Dona would have survived.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows.

1. That although the specialist National Early Warning Score matrix for prenatal women, should be used within the whole of the hospital, it still was not, and there were no plans to introduce this within a reasonable timescale.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.