Pregnant mum-to-be’s ‘avoidable’ dying after tragic chain of hospital failures
An inquest heard that medics at the Royal Stoke University Hospital showed a ‘gross failure of care’ when tending to 33-year-old Dhananji Dona, who could have been saved
The Royal Stoke University Hospital(Image: )
A mum-to-be suffered an “avoidable” death from which she could have been saved if hospital staff acted in a timely manner, an inquest has heard. The Royal Stoke University Hospital was slammed for its ‘gross failure of care’ after Dhananji Dona, from Trent Vale, sadly passed away on 1 October 2024.
The 33-year-old was 15 weeks into her pregnancy when she started experiencing heavy bleeding and intense abdominal pain. She was rushed to hospital at 11.30am – but later succumbed to septic shock.
Her husband, Lasitha Arachige, shared his heartbreaking account at the inquest: “We waited for hours without being seen. When I enquired about the delay, I was told it was a busy day and that we would be called soon.
“After two hours I spoke to the registration staff emphasising my wife’s condition and we were admitted. Despite telling the triage staff about my wife’s heavy bleeding and pain, she was not physically examined or referred to a doctor.
“At around 3pm, a doctor took a blood test, administered saline, and performed a Covid test. He did not examine my wife physically or explain the results. Her scan at 4.45pm showed unclear results and she was transferred to A&E. My wife’s condition worsened with continued heavy bleeding and severe pain. I informed the nurses several times about her deterioration, but my concerns were ignored,” reports Stoke on Trent Live.
“At 8.45pm the staff reacted to the severity of the bleeding, rushing her to the resuscitation department. After the foetus was removed, my wife was taken to theatre to control the bleeding. Unfortunately, I was later informed that my wife had passed away due to an infection and complications from the bleeding.”
Maternity investigator Louise Armitage was tasked with looking into the incident to pinpoint any potential system breakdowns. Her investigation revealed 11 factors that played a part in Dhananji’s tragic demise.
She found that Dhananji had been left waiting for a triage assessment for two hours and three minutes, far exceeding the recommended wait time of just 15 minutes. Mrs Armitage also discovered that pregnant women weren’t given priority status within the A&E department.
Moreover, the probe highlighted that the A&E department had failed to properly using sepsis assessment tools or sticking to observation guidelines for expectant mothers.
Mrs Armitage said: “We found that compliance with the sepsis screening tool was low. Thanks to pressures facing staff, the tool was not seen to be effective within the emergency department. That meant the sepsis screening tool was not complete and that the sepsis care pathway was not commenced while the triage assessment was underway. This contributed to a three hour and 25 minute delay of the treatment of sepsis.”
Medics also failed to use a crucial warning system that could have saved her life.
The report also suggested that the patient’s Sri Lankan background may have played a role in her death. Investigator Mrs Armitage said: “We also found the clinical knowledge of cultural differences, including of how people from different ethnic backgrounds may present, behave and appear when unwell may have impacted Dhananji’s care. That meant clinical signs and symptoms were not taken seriously as staff perceived that she looked well.
“We’re really trying to understand pregnant women from different backgrounds and why it is that there is such a big difference in how many women are dying from ethnic minority groups. We worked alongside the family in this instance. We understand that within their culture they try to bear their pains as to not be a burden. Staff believed she looked well despite her medical observations, which impacted on the assessment of how unwell she was.”
Mrs Armitage presented an eight-step action plan to the Royal Stoke to enhance its care. Suggestions included reducing triage waiting times, ensuring accurate sepsis screenings, and monitoring the modified obstetric warning score within the emergency department.
Gynaecologist Dr Gourab Misra, who performed Dhananji’s surgery after she was urgently taken to theatre, acknowledged the investigation’s findings. He remarked: “It’s more likely than not that if this lady was provided with more timely sepsis intervention, she would have survived.”
Rebecca Fernyhough, professional lead for quality operations at the Royal Stoke, confirmed that the trust had begun implementing the safety recommendations from the investigation. However, she noted that not all of the proposed changes had been enacted yet.
Mrs Fernyhough said: “The use of the modified obstetric warning score has not yet been implemented in the emergency department. This is because there are national modifications being made to the system, so our action plan is to wait until these changes are rolled out before the system is introduced. The deadline for implementation is March 27.”
Coroner Emma Serrano determined that Dhananji’s death was due to natural causes, but was also contributed to by neglect.
She stated: “My view is that this is a gross failure of care. It is a total and complete failure of care. She should have been assessed within 15 minutes and she was not. When she was assessed, sepsis was not recognised and the correct tools were not used. Therefore there was a delay in administering treatment. Based on the evidence, I am of the view that had she been treated in a timely fashion, she would have survived.”
The coroner issued a report to prevent future deaths, urging the hospital to adopt the modified obstetric warning score system for more frequent monitoring of pregnant patients.
