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recurance

Dhananji Dona

21 Jan 2026 · Coroner Emma Serrano · Staffordshire

The coroner's concerns

  1. 1. lack of use of National Early Warning Score matrix for prenatal women across hospital

    “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”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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