Staff at a hospital in Nottingham missed two opportunities to treat a woman found dying under a coat in a crowded emergency department, a coroner has concluded. An inquest into the death of Inga Rublite, 39, found she died of natural causes but medical staff failed to recognise “persistent and escalating symptoms of brain haemorrhage” as she waited in A&E for more than eight hours. Dr Elizabeth Didcock, an assistant coroner for Nottinghamshire, said Rublite should have been assessed by a senior doctor and sent for a head scan when she arrived at Queens medical centre (QMC) just after 10.30pm on 19 January this year. When Rublite was next assessed by a nurse, at about 2am, and reported to be in severe pain, this should have been escalated to a doctor, she said. “[Rublite] had persistent and escalating symptoms of brain haemorrhage that were not recognised,” said Didcock, adding that the department was “excessively busy” that night. “There were 76 patients waiting to be seen, and reduced medical staff generally across the department.” Didock concluded Rublite suffered a second severe bleed on the brain shortly before she was found, which caused her death. “If she had been admitted for close monitoring, as she should have been, she would still have had [a] second rapid and devastating bleed.” Rublite, a mother of two children, arrived at A&E with a severe headache, blurred vision, high blood pressure and nausea. She spent several hours in the waiting area through the night, and after she failed to respond to her name being called three times she was classed 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, having vomited and had a seizure. She had suffered a severe brain haemorrhage and her condition was declared inoperable. She died two days later, on 22 January. Her twin sister, Inese Briede, said she thought her sister “basically died in that waiting room”. She added: “No one was doing anything for her. And by the time they found her, it was too late. I just couldn’t believe that they had taken her off the waiting list when she didn’t answer. Did anyone look for her? Did anyone check the CCTV cameras to see if she had left?” Rublite grew up in Latvia with her sister, and the pair 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 talk on the phone for several hours a day. On 19 January, while on a break at the warehouse distribution centre where she worked, Rublite was on a video call with her sister when she developed a sudden severe headache which she said felt like “being hit by a brick”. She finished her shift and went home where she slept for five hours before seeking medical help by calling 111. At about 9.45pm she was advised to go to A&E but was told an ambulance would take several hours. A neighbour drove her to the hospital. Didcock said things “went wrong from the beginning” for Rublite, when a brief three-minute triage assessment by a nurse failed to uncover 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. She was last seen by staff at 2am, at which point she said her pain had become severe, but her name was not called again until 4.30am; then she was called again at 5.26am and at 6.50am. Rublite’s seat was not in view of the main desk, but was in a busy passageway where staff would have walked past her multiple times. On Wednesday the inquest heard that she might have been missed because staff were accustomed to homeless people sleeping in the waiting area. “Although she wasn’t directly visible from the desk, she wasn’t in a remote corner, people were around and passing by,” said Dr John Walsh, the deputy medical director at Nottingham University hospitals NHS trust. “Those particular evenings at weekends there may be a number of people asleep with coats and blankets on them, and I guess that staff passing by didn’t appreciate that underneath was a very sick lady.” He said there was no “no clear standard operating procedure in response” to a patient not responding to their name being called, but the trust was making changes to prevent a similar incident. The seats where Rublite sat had been moved, and staff now had to escalate concerns within 30 minutes if patients did not respond, while those sleeping under coats would be disturbed to check on their wellbeing. The number of doctors allocated to that area of A&E had been increased from three to five, and a loudspeaker system for calling names was to be introduced. Walsh said Rublite’s death had “hit staff very hard” and they were working under challenging circumstances to manage rising patient demand. “It is not because of malpractice or the fact she was ignored. We have harmed her as a result of the delay, there is no doubt about that,” he said. Dr Manjeet Shehmar, the medical director at Nottingham University hospitals trust, 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.”