PFD report

Mrs Dhananji Denawawake Dona · Prevention of Future Deaths report

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Issued 21 Jan 2026•Staffordshire and Stoke-on-Trent

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
11

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Failure to use the specialist National Early Warning Score matrix for prenatal women throughout the hospital
    Part of recurring concern: Unreliable clinical Early Warning Score systems for deterioration
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.9

  1. Action

    Disseminate draft MEWS digital specifications to suppliers through the NHS Futures platform ahead of formal publication.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 January 2026.
  2. Action

    Publish the Maternal Care Bundle setting national maternity safety standards, including MEWS implementation across relevant care settings.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 January 2026.
  3. Action

    Develop national digital specifications supporting consistent implementation of MEWS across maternity and non-maternity electronic patient record systems.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 January 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Current digital systems cannot support introducing the national Maternal Early Warning Score because they cannot be adapted to accommodate it.

    Stated by University Hospitals of North Midlands NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to use the specialist National Early Warning Score matrix for prenatal women throughout the hospital

Wider context from the report

“1. 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. ”

Is this part of a recurring concern?

Yes — Unreliable clinical Early Warning Score systems for deterioration.

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Disseminate draft MEWS digital specifications to suppliers through the NHS Futures platform ahead of formal publication.

Verbatim wording from the response

“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.”

Source location

Response from NHS England
Page 3 · response
Published 26 January 2026

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Publish the Maternal Care Bundle setting national maternity safety standards, including MEWS implementation across relevant care settings.

Verbatim wording from the response

“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.”

Source location

Response from NHS England
Page 3 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop national digital specifications supporting consistent implementation of MEWS across maternity and non-maternity electronic patient record systems.

Verbatim wording from the response

“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.”

Source location

Response from NHS England
Page 2 · response
Published 26 January 2026

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Publish the final MEWS digital specifications in Spring 2026.

Verbatim wording from the response

“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.”

Source location

Response from NHS England
Page 3 · response
Published 26 January 2026

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop the national Maternity Early Warning Score using pregnancy-specific thresholds for deterioration recognition and escalation.

Verbatim wording from the 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.”

Source location

Response from NHS England
Page 2 · response
Published 26 January 2026

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Explore developing an in-house digital solution to support maternal early warning score implementation.

Verbatim wording from the response

“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.”

Source location

Response from Royal Stoke University Hospital
Page 2 · response
Published 26 January 2026

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop a Trust-wide maternal early warning score approach suitable for all applicable clinical areas.

Verbatim wording from the response

“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.”

Source location

Response from Royal Stoke University Hospital
Page 2 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Roll out a paper-based maternal early warning score process organisation-wide, supported by training and aligned with national guidance and local governance, by March 2027.

Verbatim wording from the response

“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.”

Source location

Response from Royal Stoke University Hospital
Page 2 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Establish an operational group to coordinate a Trust-wide maternal early warning score approach.

Verbatim wording from the response

“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.”

Source location

Response from Royal Stoke University Hospital
Page 2 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Current digital systems cannot support introducing the national Maternal Early Warning Score because they cannot be adapted to accommodate it.

Verbatim wording from the response

“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.”

Source location

Response from Royal Stoke University Hospital
Page 2 · response
Published 26 January 2026

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Engage with NICE during its guideline update to reflect MEWS and MEOWS considerations in non-maternity care environments.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 26 January 2026.
  2. 2

    Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share relevant learning across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 January 2026.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    NHSE is responsible for the national safety improvement programme across England.

    Stated by University Hospitals of North Midlands NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Engage with NICE during its guideline update to reflect MEWS and MEOWS considerations in non-maternity care environments.

Verbatim wording from the response

“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.”

Source location

Response from NHS England
Page 2 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share relevant learning across national and regional NHS services.

Verbatim wording from the response

“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.”

Source location

Response from NHS England
Page 3 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

NHSE is responsible for the national safety improvement programme across England.

Verbatim wording from the response

“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.”

Source location

Response from Royal Stoke University Hospital
Page 2 · response
Published 26 January 2026

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026