Pregnant Mother's Tragic Death Ruled 'Gross Failure of Care' at NHS Hospital
A devastating inquest has concluded that a 33-year-old pregnant mother suffered an avoidable death due to what the coroner described as a 'gross failure of care' at a major NHS hospital. Dhananji Dona, who was 15 weeks pregnant, died from septic shock after experiencing what her husband called 'hours without being seen' in the emergency department.
Critical Delays in Emergency Assessment
The tragedy unfolded at Royal Stoke University Hospital on October 1, 2024, when Dhananji arrived at 11.30am suffering from heavy bleeding and severe abdominal pain. Her husband, Lasitha Arachige, told the inquest that despite repeatedly emphasising the seriousness of her condition, they faced extensive delays before receiving proper medical attention.
'After two hours I spoke to the registration staff emphasising my wife's condition,' Mr Arachige testified. 'Despite telling the triage staff about my wife's heavy bleeding and pain, she was not physically examined or referred to a doctor.'
Systemic Failures Identified in Investigation
Maternity investigator Louise Armitage conducted a thorough review of the incident, uncovering eleven separate factors that contributed to Dhananji's death. Among the most alarming findings was that the pregnant woman waited two hours and three minutes for a triage assessment - dramatically exceeding the recommended 15-minute timeframe for urgent cases.
The investigation revealed multiple systemic problems:
- Pregnant women were not treated as a priority within the emergency department
- Sepsis assessment tools were not properly utilised
- Observation requirements for pregnant patients were not complied with
- Cultural awareness gaps may have affected how seriously symptoms were taken
Cultural Factors and Clinical Oversight
Mrs Armitage's report highlighted that Dhananji's Sri Lankan background may have influenced her care. 'We 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,' she stated. 'That meant clinical signs and symptoms were not taken seriously as staff perceived that she looked well.'
Medical Professionals Confirm Preventable Nature of Death
Gynaecologist Dr Gourab Misra, who oversaw Dhananji's surgery after she was finally rushed to theatre, accepted the investigation's findings. He commented: 'It's more likely than not that if this lady was provided with more timely sepsis intervention, she would have survived.'
The coroner, Emma Serrano, delivered a damning verdict, concluding that Dhananji died from natural causes contributed to by neglect. 'My view is that this is a gross failure of care,' she stated. '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.'
Coroner Issues Prevention of Future Deaths Report
In response to the tragedy, Coroner Serrano issued a prevention of future deaths report, urging the hospital to implement the modified obstetric warning score system. This would ensure that pregnant patients receive more frequent and appropriate observations in emergency settings.
'Based on the evidence, I am of the view that had she been treated in a timely fashion, she would have survived,' the coroner concluded, highlighting the preventable nature of this devastating loss.
The case has raised serious questions about emergency care protocols for pregnant women within the NHS and the importance of timely intervention for sepsis, a condition where minutes can mean the difference between life and death.
