A pregnant woman who waited hours without being properly assessed at an A&E department in Stoke-on-Trent died from an avoidable infection after what a coroner described as a “total and complete failure of care.”
Dhananji Dona, 33, was 15 weeks pregnant when she was admitted to Royal Stoke University Hospital at 11.30am on October 1, 2024, suffering heavy bleeding and severe abdominal pain. She later died from septic shock. An inquest heard that she waited for hours in the emergency department without being examined by a doctor.
Her husband, Lasitha Arachige, told the hearing that staff repeatedly told him the department was busy. Despite explaining the seriousness of his wife’s condition, she waited more than two hours before being triaged and was not physically examined or referred to a doctor at that stage.
He said a doctor eventually took blood and Covid tests and administered fluids around three and a half hours after arrival, but again did not carry out a physical examination or explain the results. Her condition continued to deteriorate throughout the afternoon and evening, with ongoing heavy bleeding and pain, despite repeated warnings to nursing staff.
It was not until 8.45pm that staff reacted to the severity of her condition and rushed her to resuscitation. After the foetus was removed, she was taken to theatre to control the bleeding, but later died from infection-related complications.
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An independent maternity investigation identified 11 factors contributing to her death, including excessive delays in triage, failure to recognise sepsis, and inadequate monitoring of pregnant patients. The review found Dhananji waited more than two hours for triage, far exceeding the recommended 15 minutes, and that pregnant women were not treated as a priority in the emergency department.
The investigation also noted that staff failed to properly use sepsis assessment tools and that cultural factors may have played a role. It found that clinicians may have underestimated the severity of her condition because she appeared outwardly well, despite serious underlying symptoms.
A senior gynaecologist involved in her care accepted the findings and said it was more likely than not that Dhananji would have survived if sepsis had been identified and treated earlier.
Coroner Emma Serrano concluded that Dhananji died from natural causes contributed to by neglect. She ruled that the case represented a gross failure of care, stating that timely assessment and treatment would have saved her life. The coroner has issued a prevention of future deaths report, urging the hospital to improve monitoring and early warning systems for pregnant patients.
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