Sister of woman who died under coat in ER says hospital system is broken

The twin sister of a woman who died under a gown in an overcrowded Nottingham emergency department says her story shows “the whole hospital system is broken” as she fears more people will die from overcrowding and mistakes.

Inga Rublite, 39, died after she was found unconscious on the floor under a coat, more than eight hours after arriving at the emergency department of Queens Medical Centre in Nottingham on January 19.

Her name was called three times by hospital staff, but when Rublite did not respond, they assumed she was gone and released her from the system. She was found collapsed on the floor by staff arriving on duty at 7am.

She had suffered a brain haemorrhage and an inquest concluded in July that she had died of natural causes and would likely still have died of a “catastrophic haemorrhage” even if she had been treated more quickly.

Her twin sister, Inese Briede, said her family disagrees with the investigation’s findings, saying there is no way to know for sure whether Rublite would have died if she had been seen by a doctor earlier.

“The inquest said she died of natural causes. Yes, I understand that an aneurysm is a natural cause, but the way she waited and the way she was treated there … No, I still see that as negligence,” she said. “I believe that every person and every body is different, and you can’t be 100 percent certain that she would have died anyway.”

During the inquiry, Dr John Walsh, deputy medical director at Nottingham University Hospitals NHS Trust, outlined a number of steps being taken to prevent a similar situation happening again.

Examples include moving chairs in the waiting room so that they are always in view of staff, increasing the number of doctors on duty, and introducing a stricter procedure for following up on patients who do not respond when their name is called.

Briede said: “Any change the hospital makes for patients is a good change, but I just don’t see it being enough. The hospital needs to look at everything, it’s not just a few steps that need to be taken.”

She said she was shocked at how accustomed staff had become to overcrowded spaces and that this was happening in hospitals across the country.

“The whole hospital system is not working properly. And they need to figure it out, because problems with the system, these mistakes, are still causing what they already caused with Inga,” she said. “But I do have sympathy for the staff. It’s because of overcrowding, that’s not how you should treat a patient.”

The investigation found that there were 61 patients in the ER waiting room the night Rublite arrived, well over the maximum capacity of 38. Doctors had been deployed elsewhere in the hospital to help clear patients from the line of ambulances.

When Rublite arrived, there was no experienced physician available to make a decision on Rublite’s treatment. This was cited as a major reason why a CT scan was not ordered, which would have diagnosed the bleeding in her brain.

Briede said one of the most disturbing moments of the investigation was when staff said Rublite might have been mistaken for a homeless person. In the winter, Rublite often comes to the ER waiting room to sleep under her coat. That could explain why she was missed so much.

“That was a big shock when I heard that. I thought, she never looked like a homeless person. And even if a homeless person goes in, they need to be treated,” Briede said. “I know English is not my first language, and there were some points where I listened to the research and thought, did I get that right?”

She said Rublite’s family, who live in Latvia, are still struggling to come to terms with her death, as are her two sons, aged 13 and 11, who live with their father in England.

“The family still can’t believe she’s gone. Because it was so sudden and every time we talk about Inga, we just say she should have been saved, and they could have saved her,” Briede said. “We can’t believe that you can sit in the hospital and no one does anything for you.”

Dr Manjeet Shehmar, Medical Director at Nottingham University Hospitals NHS 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 have completed a study to assess and implement lessons learned. As a result, we have implemented changes in our emergency department to ensure we can provide better care to patients and support our staff to do so in the future.”