Home / Health / Coroner Demands Safety Changes After Sepsis Death
Coroner Demands Safety Changes After Sepsis Death
26 Jan
Summary
- Woman's death deemed preventable due to delayed sepsis diagnosis.
- Hospital trust failed to use sepsis screening tools.
- Coroner calls for urgent safety improvements at the hospital.
A recent coroner's report has mandated safety improvements at a hospital trust following the preventable death of a patient. Dhananji Denawakage Dona was admitted to Royal Stoke University Hospital in Stoke-on-Trent while pregnant, presenting with bleeding and abdominal pain.
The area coroner for Staffordshire, Emma Serrano, determined that Dona was suffering from sepsis and a miscarriage. Her findings indicated a significant delay in her assessment within the A&E department, and crucially, a sepsis screening tool was not utilized.
University Hospitals of North Midlands, which manages the facility, has been contacted for comment regarding the report's conclusions. Dona's condition deteriorated, leading to her death on October 2, 2024.
The coroner's report emphasized that a specialized early warning score matrix for prenatal women, intended for hospital-wide use, was still not implemented. Furthermore, there were no plans to introduce this critical system within a reasonable timeframe, prompting the coroner's call for action to prevent future deaths.
