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

9th March 2026

• 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

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 to support 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.

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.

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

. 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.