An expectant mother tragically lost her life due to inadequate care provided by a prominent hospital, as determined by an inquest. Dhananji Dona, aged 33, experienced severe bleeding and abdominal pain at 15 weeks into her pregnancy. Despite being admitted to the Royal Stoke University Hospital on October 1, 2024, she succumbed to septic shock. Her husband, Lasitha Arachige, shared during the inquest that they faced significant delays at the hospital without receiving prompt attention.
Following an investigation, it was revealed that 11 factors contributed to Dhananji’s untimely death, leading the coroner to conclude that she encountered a “complete failure of care.” Despite being rushed to the hospital from Trent Vale, near Stoke-on-Trent, Dhananji faced prolonged waiting times without adequate medical attention. Her condition worsened as she continued to bleed heavily and experience intense pain, with her husband’s concerns being disregarded by the medical staff.
The investigation further highlighted systemic issues, including the prolonged wait time for a triage assessment and the failure to prioritize pregnant women in the emergency department. Additionally, cultural factors related to Dhananji’s Sri Lankan background were identified as potential contributors to her tragic outcome. Gynaecologist Dr. Gourab Misra, who oversaw her surgery, acknowledged that timely sepsis intervention could have potentially saved her life.
Coroner Emma Serrano attributed Dhananji’s death to natural causes exacerbated by neglect, emphasizing the significant lapses in care she experienced. The coroner’s report recommended the implementation of a modified obstetric warning score system to ensure more frequent monitoring of pregnant patients, aiming to prevent similar tragedies in the future.
