A pregnant woman ‘waited for hours without being seen’ at an A&E department in Stoke-on-Trent despite heavy bleeding and pain – she tragically died later
10:41, 24 Jan 2026Updated 10:49, 24 Jan 2026
A pregnant woman waited hours before being seen by a doctor at A&E – she died hours later(Image: )
An expectant mother suffered an avoidable death after a major hospital demonstrated a “gross failure of care”, an inquest ruled.
Dhananji Dona was just 33 years old when she started suffering heavy bleeding an severe abdominal pain at 15 weeks pregnant. She was admitted to the Royal Stoke University Hospital at 11.30am on October 1, 2024, but tragically died later from septic shock. Her heartbroken husband Lasitha Arachige told an inquest she “waited for hours without being seen” at the hospital’s A&E department.
An investigator later uncovered 11 factors that contribute to Dhananji’s death and a coroner concluded the 33-year-old faced a “complete failure of care”.
An inquest ruled Dhananji Dona faced a ‘gross failure of care’ before her death(Image: Stoke Sentinel/BPM Media)
READ MORE: Nurses describe ‘horrific sight’ before ‘rare’ event led to dad’s death at Cambridge hospitalREAD MORE: Footballer killed by flesh-eating virus after paramedics ‘missed opportunity’
Dhananji, from Trent Vale, outside Stoke-on Trent, was rushed to the hospital but her husband told the inquest she faced a long wait before being seen. He said: “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.”
The husband said 3.5 hours after they arrive at A&E a doctor took a blood test, did a Covid test and administered saline but “did not examine my wife physically or explain the results”, according to StokeOnTrentLive.
He said: “Her scan at 4.45pm showed unclear results and she was transferred to A&E Green. 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.
“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 reviewed the incident to look for any possible systemic failures – she uncovered 11 factors contributing to Dhananji’s death. She said the woman waited two hours and three minutes to receive a triage assessment, well over the recommended waiting time of 15 minutes.
Mrs Armitage also discovered that pregnant women were not treated as a priority within the emergency department. The emergency department had failed to utilise sepsis assessment tools properly or comply with observation requirements for pregnant women.
The report also highlighted that Dhananji’s Sri Lankan background may have contributed to her death. Mrs Armitage added: “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.”
Gynaecologist Dr Gourab Misra oversaw Dhananji’s surgery after she was rushed to theatre. He accepted the findings of the investigation, commenting: “It’s more likely than not that if this lady was provided with more timely sepsis intervention, she would have survived.”
Coroner Emma Serrano concluded that Dhananji died as a result of natural causes – contributed to by neglect. She said: “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 prevention of future deaths report – urging the hospital to implement the modified obstetric warning score system so that pregnant patients are observed more frequently.