Dhananji Dona

Emma Serrano 
Area Coroner  
Stoke on Trent and  
North Staffordshire Coroners Service 
Stoke Town Hall 
Kingsway 
Stoke-on-Trent  
ST4 1HH 

Dear Coroner, 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

9th March 2026 

Re: Regulation 28 Report to Prevent Future Deaths – Dhananji Denawakage 
Dona who died on 2nd October 2025.   

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated  21st 
January 2026 concerning the death of Dhananji Denawakage Dona on 2nd October 
2025. In advance of responding to the specific concerns raised in your Report, I would 
like  to  express  my  deep  condolences  to  Mrs  Dona’s  family  and  loved  ones.  NHS 
England is keen to assure the family and yourself that the concerns raised about Mrs 
Dona’s care have been listened to and reflected upon.   

Your Report raises concerns that although the specialist National Early Warning Score 
(NEWS) matrix for prenatal women should be used within all departments of a hospital, 
it still was not in this case, and there were no plans to introduce this within a reasonable 
timescale. Your report does not specify Mrs Dona’s gestation, but references that she 
had miscarried.  

NHS England has developed the national Maternity Early Warning Score (MEWS) in 
direct response to findings from the Confidential Enquiries into Maternal Deaths in the 
UK, which have consistently highlighted the need for a dedicated, standardised early 
warning system for pregnancy and the postnatal period. These enquiries show that 
delayed recognition and escalation of clinical deterioration remain important, recurring 
themes. 

Currently,  the  National  Early  Warning  Score  2  (NEWS2)  is  the  mandated  scoring 
system  used  across  the  NHS  for  detecting  deterioration  in  adults  who  are  not 
pregnant. NEWS2 is widely implemented in care settings outside of acute maternity 
services.  However,  physiological  parameters  in  pregnancy  differ  significantly  from 
those of the non‑pregnant population. Normal ranges for heart rate, blood pressure, 
respiratory  rate  and  oxygen  saturation  change  during  pregnancy  and  the  early 
postpartum period. 

Applying non‑pregnant thresholds to pregnant women can therefore: 

•  Delay early recognition of deterioration 
•  Generate unnecessary false‑positive escalations 

                                                                                                                       
 
 
 
 
 
 
 
  
 •  Create variation and risk in the clinical response 

To address this, NHS England has developed MEWS as a separate scoring tool using 
evidence‑based,  pregnancy‑specific  thresholds,  which  more  accurately  reflect 
physiological  changes  from  conception  to  four  weeks  postpartum.  This  ensures 
deterioration can be recognised and escalated appropriately and consistently. 

The national MEWS matrix removes variation by providing a single, standardised tool 
for  use  across  England  in  all  care  settings  where  a  woman  may  present,  including 
those  outside  maternity  units  (e.g.  emergency  departments,  general  wards, 
ambulance service environments). 

In October 2025, when Mrs Dona passed away, there was no published NHS England 
guidance on the use of the national MEWS in non‑maternity clinical areas due to initial 
focus being on implementation in acute maternity services. 

The National Institute for Health and Care Excellence (NICE) had previously published 
a Medtech Innovation Briefing (MIB205) in February 2020. This briefing clearly stated 
that NEWS2 should not be used for pregnant women, as the physiological changes of 
pregnancy make NEWS2 inappropriate and potentially misleading for this population. 

However, this important caution is not clearly articulated in either: 

•  NICE Clinical Guideline CG50 (2020) Acutely ill adults in hospital: recognising 
and responding to deterioration https://www.nice.org.uk/guidance/cg50 ; or 
•  The revised NICE Guideline NG255 (2025) Suspected sepsis in pregnant or 
recently pregnant people: recognition, diagnosis and early management 
https://www.nice.org.uk/guidance/ng255 . 

NICE has confirmed that it plans to review the use of Modified Obstetric Early Warning 
Scores  (MEOWS)  and  consider  making  recommendations  on  it  within  guideline 
NG255.  The  current  guideline  version  addresses  the  management  of  suspected 
sepsis both outside and inside acute hospital settings. NHS England will engage with 
NICE throughout the guideline update process to ensure that considerations regarding 
the  use  of  MEWS  /  MEOWS  in  non‑maternity  care  environments  are  appropriately 
reflected. This updated guidance is expected to be published in February 2027. 

MEWS implementation forms part of wider national commitments to improve maternity 
and neonatal safety. 

In March 2023, NHS England published the  Three‑Year Delivery Plan for Maternity 
and Neonatal Services. MEWS implementation is a key requirement within Theme 4: 
Standards and structures that underpin safer, more personalised, and more equitable 
care. 

NHS  England  has  developed  national  digital  specifications 
the 
implementation of the national MEWS across both maternity and non‑maternity clinical 
environments.  These  specifications  are  designed  to  ensure  consistency  and 
interoperability across electronic patient record (EPR) systems, reducing variation in 
how deterioration is recognised, recorded, and escalated. 

to  support 

 Draft versions of the specifications have already been circulated to digital suppliers via 
the NHS Futures platform ahead of their planned formal publication in Spring 2026. 
This early dissemination aims to enable suppliers and organisations to begin aligning 
or configuring their systems in preparation for national rollout, thereby supporting safer 
and  more  consistent  digital  recognition  of  deterioration  in  pregnant  and  recently 
pregnant women across all care settings. 

Further to this, NHS England published the Maternal Care Bundle (MCB) in January 
2026.  This  sets  out  evidence‑based  standards  across  five  key  clinical  areas  to  be 
implemented nationally by March 2027. MEWS is an essential component of Element 
2: Pre‑hospital and Acute Care.  

This element requires: 

•  The implementation of the national MEWS across all settings for women who 

are, or have been, pregnant within the previous four weeks 

•  Timely obstetric and/or obstetric physician review  in accordance with MEWS 

escalation timeframes based on total score and clinical concern 

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking place around the Reports to Prevent Future Deaths. All reports received are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures that key learnings and insights around events, such as the sad death of Mrs 
Dona, are shared across the NHS at both a national and regional level and helps us 
to  pay  close  attention  to  any  emerging  trends  that  may  require  further  review  and 
action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director 
NHS England

Royal Stoke University Hospital 
Executive Suite 
Springfield 
Newcastle Road 
Stoke-on-Trent 
Staffordshire 
ST4 6QG 

17 March 2026 

STRICTLY PRIVATE & CONFIDENTIAL 
Ms Emma Serrano 
Area Coroner 
Stoke-on-Trent and Staffordshire 

Dear Ms Serrano 

Dhananji Denawakage DONA 

Further to your letter dated 21 January 2026, I am pleased to provide a response under paragraph 7 of Schedule 5 of 
the  Coroners  and  Justice  Act  2009  and  Regulations  28  and  29  of  the  Coroner’s  (Investigations)  Regulations  2013, 
addressing your concerns surrounding the death of Dhananji Denawakage Dona. 

Recorded Circumstances of the Death 
“Mrs Dona attended the Royal Stoke University Hospital, Stoke on Trent.  She was pregnant and had noticed bleeding 
and was suffering from abdominal pain.  She was suffering from SEPSIS as well as miscarrying.  There was a delay in 
her assessment in the A&E department, and the SEPSIS screening tool was not used.   

There is a specific National Early Warning Score matrix for prenatal women.  This was not used in the A&E department 
as, despite national guidance to say this should be used in all departments of a hospital, it was only used in the maternity 
department of the Hospital. 

This led to a delay in her diagnosis and treatment of SEPSIS. 

She continued to deteriorate whilst in hospital and passed away on the 2 October 2025. 

Evidence heard at inquest was that earlier diagnosis and treatment for SEPSIS would have meant that Mrs Dona would 
have survived.” 

Concerns 
During the course of the inquest, you felt that evidence revealed matters giving rise for concern. In your opinion, matters 
for concern are as follows. 

“That although the specialist National Early Warning Score matrix for prenatal women, should be used within the whole 
of the hospital, it still was not, and there were no plans to introduce this within a reasonable timescale.”  

You reported this matter under Paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 
29 of the Coroner’s (Investigations) Regulations 2013.  In your opinion, action should be taken to prevent future deaths.  

Action Taken 
The University Hospitals of North Midlands NHS Trust has taken the issues highlighted during the inquest seriously and 
indeed, I am grateful that you have raised your concerns to which a response is provided below.  

Across the UK, the national direction for maternity safety is being driven by the Saving Babies’ Lives Care Bundle and 
includes  national  maternity  safety  initiatives,  which  emphasise  early  identification  and  escalation  of  maternal 
deterioration. As part of this, the national Maternity Early Warning Score (MEWS) has been mandated for adoption across 

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 all NHS Trusts (by March 2027) to ensure consistent, standardised monitoring of pregnant, and recently pregnant, women 
in every clinical setting.  

Nationally,  progress  has  been  slower  than  intended  due  to  delays  in  digital  supplier  readiness  and  variation  in  local 
electronic patient record capabilities. UHNM is on a similar trajectory to other Trusts across the UK. NHSE is responsible 
for the safety improvement programme across England.  

The current digital systems used across UHNM are unable to support the introduction of the new National Maternal Early 
Warning  Score  (MEWS).  We  have  engaged  with  our  supplier  colleagues,  System  C,  and  with  regional  and  national 
colleagues regarding options; they have confirmed the inability of our current systems to be adapted to accommodate 
the MEWS. 

However, in response to the Regulation 28 received, and the national directive to implement the national MEWS, UHNM 
have established an operational group to develop a Trust wide approach which is appropriate for all applicable clinical 
areas.  

‑

In  the  short-term,  a  paper
based  MEWS  process  will  be  rolled  out  across  the  organisation  ensuring  that  this  is  fully 
implemented by the national directive timeframe of March 2027. This roll-out will be supported by appropriate training 
and will be aligned with national guidance and local governance processes. Clearly, as this safety critical pathway must 
be  implemented  consistently  and  reliably  across  all  areas  of  the  organisation  where  pregnant  patients  may  present 
(including the Emergency Department, Acute Medicine, Surgical areas, and any outpatient or assessment settings), it is 
essential that a robust, Trust wide training programme is delivered prior to implementation. This will ensure that staff 
across all clinical environments understand the escalation framework, associated clinical triggers and the governance 
requirements linked to MEWS. 

Our longer-term strategy will look at progressing work to explore the development of an in-house digital solution to 
support implementation of the MEWS, whilst also awaiting the provider of the existing digital observations platform to 
complete the required software updates; we will endeavour to implement whichever appropriate digital solution is 
available first.  

I do hope that the above information provides assurance that the Trust has  taken the concerns raised at the inquest 
seriously and that you are content with the response that has been provided.  

Should you wish to discuss any aspect of this report further, please do not hesitate to contact me directly. 

Yours sincerely 

Chief Executive 

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