Royal Stoke: Delay in sepsis detection system for pregnant women
Coroner's report prompts urgency in addressing prenatal care
Royal Stoke University Hospital is experiencing delays in improving sepsis detection systems for pregnant women, causing staff to potentially rely on paper documentation.
The issue follows a coroner's directive to take action to reduce future death risks after the inquest of Dhananji Denawakage Dona, who died from septic shock at 15 weeks pregnant.
Staffordshire Area Coroner Emma Serrano concluded at the inquest last month that her death was due to natural causes, contributed to by neglect.
A report has been issued by Ms Serrano to prevent further fatalities, raising concerns about the absence of a specialist National Early Warning Score matrix for prenatal women in the hospital's A&E department.
Sepsis detection in various departments of University Hospitals of North Midlands NHS Trust (UHNM) has been highlighted through board papers.
However, on 11th February, health campaigner Ian Syme questioned the delay in applying the matrix across all departments, emphasizing the urgency due to previously highlighted concerns in the coroner's report.
Although UHNM's Maternity Unit has implemented the matrix, it remains absent in the A&E department.
Chief Nurse Ann-Marie Riley acknowledged that system updates were delayed, stating: “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.”
To address the issue, a working group is now exploring digital solutions; however, paper documentation may be used temporarily despite risks of information loss.
Mrs Riley expressed her apologies and sympathies to Mrs Denawakage’s family, adding, “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 Mrs Denawakage’s family to make sure these changes lead to safer care for the communities we serve.”
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