Hospital 'missed opportunities' to diagnose mother found unconscious under coat in 8-hour A+E wait
A coroner has concluded that a mother-of-two from Derbyshire who waited more than eight hours to be seen at hospital died from natural causes - but that the hospital "missed opportunities" to diagnose a bleed on her brain sooner.
Inga Rublite, 39, suffered “significant, irreversible” brain damage after she was found unconscious under her coat after waiting in a crowded A&E waiting room at the Queen’s Medical Centre (QMC) in Nottingham on 20th January this year.
The inquest was told that Inga, who was originally from Latvia, died two days later from a brain aneurysm which caused a “massive bleed” on her brain, and it could not be contained with surgery.
Inga had called 111 on the 19th January with a sudden headache, neck pain, and blurry vision, feeling “as though hit by a brick”.
She then spoke to a clinician on the phone and was advised to go to hospital, where she arrived at about 10.30pm that night.
Staff called out in A&E three times for Ms Rublite in the early hours of 20th January, and rang her mobile phone with no answer - but her twin sister Inese Briede said there was no missed call on her phone.
Nottinghamshire coroner Elizabeth Didcock said:
“There were three opportunities for the headache to be recognised as something more dangerous than it was thought to be.”
At 6.50am, staff registered Ms Rublite as discharged, thinking she had left of her own accord.
Ten minutes later staff found her “tucked behind a door with a coat tucked over her face, seemingly asleep”, but when they looked closer, she appeared to fit.
According to Luke Derby, an emergency department matron, Ms Rublite had been sat in the main waiting area where it was “reasonable” that staff would have walked past, but she would “not be physically seen” by the person calling for her.
Mr Derby said: “We have moved the chairs where Inga was sat because they have poor visibility from the navigator’s desk. They have been moved so people can’t sit there.”
Mr Derby also confirmed that it was “not unusual” to see patients with coats over their heads, especially during night shifts.
The inquest heard the waiting room was overcrowded because the emergency department’s maximum capacity was exceeded that night.
Ms Didcock said: “I’m aware from the investigation report that there was significant crowding and additional numbers of people.
“I’m aware that is the background to it and has been for some time.”
“There was an opportunity missed to see how she was"
Robert Jamieson, A&E consultant at the QMC, said:
“As soon as you start to put all these targets in and look at the number of staff to do that, it becomes unachievable.
“We are competing with needing observations done every two hours.
“The constant barrage of needing to do the next thing with the next person means that these things that seem so obvious don’t happen.
“There was an opportunity missed to see how she was, how the pain was, and how she appeared, but that didn’t happen.
“Unfortunately, Inga was sat there, and she was missed.
“We have talked about lots of options and the investigation has talked about lots of options in terms of checking who’s in the area and managing the space.”
Inga's twin Inese Briede has travelled more than a thousand miles from her home in Latvia to find out how her sister died.Inese has been to the QMC for herself and seen patients' frustrations, and has described her heartbreak at losing her "best friend".
Inese says although they lived in different countries, they were always on the phone to each other, providing support and encouragement.
Inese says "There are times when I forget about this, we were so used to chatting anytime that we wanted to, there are moments when I just take my phone, I want to send her some messages, I want to make a video call and then I have to stop.
"Then it comes to me and it's so hard. It feels like every month that goes by it's so miserable".
"We accept there were missed opportunities in Inga’s care"
Dr Manjeet Shehmar, Medical Director at Nottingham University Hospitals NHS Trust (NUH) said:
“We would like to offer our sincere condolences to the family of Inga for their loss.
"Although due to the nature of the bleed on the brain the outcome is unlikely to have been different, we accept there were missed opportunities in Inga’s care and are truly sorry that we did not meet the standards we strive to deliver.
"We recognise there are times when our hospitals are under extreme pressure which can impact patient experience.
"Our teams continue to work hard to maintain safe services and improve flow across our sites.
"We apologise to patients who experience delays in their care, and continue to prioritise patients with the highest level of need.
"We have completed an investigation in order to assess and implement learning, and as a result have introduced changes in our Emergency Department to ensure we can deliver better care to patients and support our staff to do this in the future.
"We fully accept the coroner's findings, and are determined to take all action possible to improve our care.”
Tim Slater, Deputy Director of Operations at East Midlands Ambulance Service said:
“I offer my deepest condolences to Inga Rublite’s family, who we understand have faced a deeply difficult time.
“EMAS has not been formally involved in the ongoing inquest, however we are currently conducting an investigation into a 999 call which was made to us on 19 January 2024 relating to Ms Rublite.
“We take all concerns relating to EMAS very seriously, so we encourage any family members with concerns to contact our Patient Experience team, to allow them to investigate and respond to them in full.”