Work to improve detection of sepsis in pregnant women is being affected by a digital system delay, hospital bosses have been told, meaning staff may have to resort to using sheets of paper until the situation is resolved.

Royal Stoke University Hospital has been told by a coroner to take action to reduce the risk of future deaths following the inquest of Dhananji Denawakage Dona.

The 33-year-old was 15 weeks pregnant when she was admitted to Royal Stoke after she began suffering heavy bleeding and severe abdominal pain. She died just hours later from septic shock.

Staffordshire Area Coroner Emma Serrano concluded at an inquest last month that she died as a result of natural causes – contributed to by neglect.

Ms Serrano issued a report to prevent further deaths following the inquest, raising concerns that a specialist National Early Warning Score matrix for prenatal women – used nationally to identify potential sepsis cases – was not being used in the hospital's A&E department and there were "no plans to introduce this within a reasonable timescale".

On Wednesday (February 11), health campaigner Ian Syme questioned the hospital board on work to put the matrix in place across all departments.

He said: "Perusing UHNM (University Hospitals of North Midlands NHS Trust) board papers from the previous three years, 'sepsis' as a word is highlighted thousands of times and 'sepsis screening', 'sepsis awareness', 'sepsis treatment' (and) 'sepsis teams' highlighted hundreds of times; UHNM Board is obviously sighted on sepsis awareness, sepsis screening and sepsis treatment in its various departments.

"A Staffordshire Area Coroner Prevention of Future Deaths Report (PFD) sent to UHNM and NHSE (NHS England) emphasises grave concerns regarding sepsis screening of a pregnant lady. The decision at the conclusion of this inquest included a neglect rider.

advertisement

"There is a specific national early warning score matrix for prenatal women that must be used in all hospital departments, yet despite this the matrix was not used in UHNM's A&E/ED (emergency department) portal. That specific matrix (was) only implemented in UHNM's Maternity Unit.

"Has UHNM now, as a matter of urgency, reviewed its implementation of the aforementioned matrix and is UHNM Board now assured that this specific matrix is being implemented in all hospital departments when required?

"If not, what inhibits the implementation of that specific matrix throughout UHNM's departments?"

UHNM's chief nurse Ann-Marie Riley said: "It was always the intention to implement it, but the company could not update the system in a timely way. It is going to be a protracted process.

"We have a working group now, which is looking at a digital solution. It is likely we will go to paper, but there is a risk to paper that a single sheet can be lost."

Speaking after Wednesday's meeting, Mrs Riley added: "We fully accept the coroner's findings and would like to express our apologies and deepest sympathies with Mrs Denawakage's husband and their daughter.

"Since this incident and in line with the Maternity and Newborn Safety Investigation Programme recommendations, we have taken steps to improve the safety and quality of emergency and maternity care.

"We will continue to work closely with our clinical teams, national partners and where possible, with Mrs Denawakage's family, to make sure these changes lead to safer care for the communities we serve."

advertisement