Hospital reviews ED staffing after woman found dying under a coat
Posted 13 August 2024 - 16:00
Coroner accepts emergency department was excessively busy but orders hospital's trust to provide progress report on risk of preventable deaths
A hospital trust is reviewing nursing staff numbers in its emergency department (ED) after a woman was found dying under her coat among 76 other patients waiting to be seen.
Inga Rublite experienced a brain haemorrhage in the ED waiting room of the Queens Medical Centre in Nottingham after attending the hospital with a sudden severe headache and blurred vision on 19 January.
A report into her death by assistant coroner for Nottinghamshire Elizabeth Didcock found that the ED was ‘excessively busy’ and there was immense pressure on the team of three nurses, two clinical support workers and one ED assistant. The report also says three ED medics were off sick, creating a shortage of doctors across the whole department.
The unit, which usually has a capacity of 36 patients, had 76 patients waiting to be seen when Ms Rublite arrived at 10.30pm.
Coroner says emergency department was significantly overcrowded that night
At the inquest, which concluded on 31 July, Dr Didcock said there had been missed opportunities by nursing staff to escalate Ms Rublite’s care and refer her for a CT scan. She said an initial triage had missed significant symptoms, including a headache affecting her ability to stand or move her head.
If these had been identified and she had been assessed by a senior doctor, a bleed on the brain would have been suspected, she said. However, Dr Didcock added: ‘I appreciate that time for triage assessment is limited, the UTU [urgent treatment unit] was significantly overcrowded that night, and there were limited doctors and nurses staffing the UTU.’
The whole ED was overcrowded with long ambulance waits, and waits to be seen in all areas, ‘necessitating staff moving from UTU to help cover the majors and other ED areas,’ she said.
Observations were taken of Ms Rublite at 2.07am, when she was reported to be ‘alert and awake’, but the coroner found her ‘persisting and escalating symptoms of a brain haemorrhage were not recognised’.
Trust says it is ‘determined to take all action possible to improve our care’
Her name was called at 4am, 5.26am and 6.50am but there was no response and she was assumed to have left the ED and was discharged. However, at 7am an ED nurse coming on shift found her lying on the floor under her coat, where she had earlier vomited and experienced a seizure. Despite emergency treatment by staff she died two days later in the intensive care unit.
The coroner said Nottingham University Hospitals NHS Trust had addressed nursing and medical staffing levels, but it must provide a progress report of further actions by the end of November so she could be satisfied that the risk relating to the prevention of future deaths had been resolved.
The trust’s medical director, Manjeet Shehmar, 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 fully accept the coroner's findings, and are determined to take all action possible to improve our care.’
Actions pledged by Nottingham University Hospitals NHS Trust
- Removal of chairs with restricted view for staff in the area where Inga Rublite was sitting
- Ongoing review into the numbers and allocation of nursing and medical staff within the ED
- Introduction of a public address system in the waiting room when calling patients
- Review of initial assessment process (triage)
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