Staff at a Nottingham hospital missed two chances to treat a woman found dying under a gown in a busy emergency department, a coroner has concluded.
An inquest into the death of 39-year-old Inga Rublite found she died of natural causes but medical staff failed to recognise “persistent and escalating symptoms of a brain haemorrhage” as she waited more than eight hours in emergency rooms.
According to Dr Elizabeth Didcock, assistant coroner for Nottinghamshire, Rublite should have been assessed by a senior doctor and had a head scan when she arrived at the Queens Medical Centre (QMC) just after 10.30pm on January 19 this year.
When Rublite was next examined by a nurse, around 2 a.m., and she reported having severe pain, she should have reported it to a doctor, she said.
“(Rublite) had persistent and escalating symptoms of brain haemorrhage that were not being recognised,” Didcock said, adding that the unit was “excessively busy” that night. “There were 76 patients that needed to be seen, and there were generally fewer medical staff on the unit.”
Didock concluded that Rublite had suffered a second severe hemorrhage in the brain shortly before her discovery, which resulted in her death. “Had she been admitted for close monitoring, as she should have been, she would still have suffered (a) second rapid and devastating hemorrhage.”
Rublite, a mother of two, arrived at the ER with severe headaches, blurred vision, high blood pressure, and nausea. She spent several hours in the waiting room overnight, and after failing to respond to her name being called three times, she was classified as discharged, with staff assuming she had left.
She was found at 7am, unresponsive and slumped in front of her chair with her face covered by a coat, after vomiting and having a seizure. She had suffered a massive brain haemorrhage and was declared inoperable. She died two days later, on 22nd January.
Her twin sister, Inese Briede, said she believed her sister “had essentially died in that waiting room”. She added: “Nobody did anything for her. And by the time they found her, it was too late. I just couldn’t believe they took her off the waiting list when she wasn’t answering. Did anybody look for her? Did anybody check the CCTV to see if she had left?”
Rublite grew up in Latvia with her sister and the couple moved to the UK in 2004 after finishing school. Rublite lived and worked in Nottingham, where she had two sons, now aged 13 and 11.
Briede, who now lives in Latvia, said she and her sister were close and would spend several hours a day on the phone. On Jan. 19, during a break at the distribution center of the warehouse where she worked, Rublite was on a video call with her sister when she suddenly had a severe headache that she described as “being hit by a brick.”
She finished her shift and went home, where she slept for five hours before seeking medical help by calling 911. At around 9:45pm she was advised to go to the emergency room, but was told an ambulance would take several hours. A neighbour drove her to the hospital.
Didcock said things “went wrong from the start” for Rublite when a quick three-minute triage assessment by a nurse failed to reveal the full extent of her symptoms.
There were no senior doctors available for the nurse to consult as they had been diverted to other areas due to an influx of patients from an ambulance backlog. A CT scan was not requested for Rublite.
Staff last saw her at 2am, when she said her pain had become severe. Her name was not called again until 4:30am, and then she was called again at 5:26am and 6:50am.
Rublite was out of sight of the main office, but in a busy hallway where staff likely passed her several times.
On Wednesday, the investigation stated that she may have been missed because the staff is used to homeless people sleeping in the waiting room.
“Although she wasn’t directly visible from the desk, she wasn’t in a remote corner, there were people around and they were walking past,” said Dr John Walsh, deputy medical director at Nottingham University Hospitals NHS Trust. “On those particular weekend nights there can be a number of people sleeping with coats and blankets on, and I don’t think the staff who were coming through would have realised that there was a very sick lady underneath.”
He said there is no “clear standard procedure in response” to a patient who does not respond when his name is given, but that the hospital is making changes to prevent a similar incident.
The chairs Rublite was sitting in had been moved and staff now had to report back within 30 minutes if patients were unresponsive. In addition, patients sleeping under their coats were disturbed to check on them.
The number of doctors deployed in the Emergency Department was increased from three to five and a loudspeaker system for calling out names would be installed.
Walsh said Rublite’s death had “hit the staff very hard” and that they were working under difficult circumstances to manage the rising demand from patients. “It’s not because of malpractice or the fact that she was ignored. We have caused her harm as a result of the delay, there is no doubt about that,” he said.
Dr Manjeet Shehmar, Medical Director at Nottingham University Hospitals Trust, said: “We would like to offer our sincere condolences to Inga’s family for their loss. While it is unlikely that the outcome would have been different due to the nature of the brain haemorrhage, we recognise that opportunities were missed in Inga’s care and we sincerely regret that we fell short of the standards we strive to achieve.
“We recognise that there are times when our hospitals are under extreme pressure, which can impact the patient experience. Our teams continue to work hard to maintain safe services and improve flow across our sites.”