It came as Prof Paul Marks ruled that 33-year-old Hayley Gascoigne who collapsed and died at Hull Combined Court last January died from natural causes.
In evidence heard on Wednesday, a paramedic claimed he did not cut away Hayley Gascoigne's dress and place defibrillation pads on her to protect her "modesty,".
Gary Long was the first to arrive at Hull Combined Court after Hayley Gascoigne, 32, suddenly went into cardiac arrest in the concourse following family court proceedings last January.
Hull Coroners Court heard Mr Long admit to mistakes, including failing to recognise that the mother-of-four's heart had a shockable rhythm.
He said: "I find that hard to explain and I can't understand it myself."
The paramedic, 60, who retired last November, told the hearing that he had put "dots" on Ms Gascoigne, who was wearing a dress and leggings, to check her heart's electrical activity, but did not follow it up with pads, to shock the heart.
"What I should have done is cut the dress and put the pads on," he told the hearing.
"It was a mistake, I put the dots on Hayley because I was thinking of her modesty."
The inquest heard that the first paramedic to arrive in the concourse, Gary Long, 60, made serious errors, including failing to recognise the mother-of-four had a shockable heart rhythm.
A serious incident report by Yorkshire Ambulance Service said his actions, including failing to put defribillation pads on her and leaving cardiac drugs in his car, fell far short of the expected standard.
After the incident Mr Long never returned to frontline duties and he retired last November.
'Diminished survival chances'
However Prof Marks agreed with independent expert Dr Francis Morris who told the hearing that if a shock was delayed any more than four minutes, the chances of someone surviving were “diminished significantly.”
Mr Long took five minutes to arrive at Ms Gascoigne’s side following the 999 call and would have needed 90 seconds to make a correct assessment, remove her clothes and attach the defribillation pads.
Prof Marks said: “Having accepted Mr Morris’s evidence and the incontrovertible evidence of admitted failing, the timing does not show there was a missed opportunity, that had it been taken would have avoided Hayley’s death.”
Ms Gascoigne, who worked as a carer at a home for people with cerebral palsy, had been “visibly upset” following the conclusion of family court proceedings .
Mr Morris said acute emotional distress could provoke an arrythmia, or irregular heart-beat.
“We are increasingly recognising broken heart syndrome,” he said.
Speaking afterwards her parents Terry and Kate Gascoigne said they felt Hayley, of Baildon Road, Scunthorpe, would have had a better chance of living if those involved had acted with greater urgency, adding: “We sincerely hope lessons will be learned.”
They said: "Hayley's collapse in court was horrific and it gets no easier to bear when you consider that so much more could have been done to try and save her.
"She could still be with us today - a mother to her four children, our beautiful girl."
Their lawyer Nick Gray, of Williamsons Solicitors, said an “unacceptable amount of time” passed before serious attempts were made to revive her.
He said they found the lack of a public access defibrilliator at Hull Combined Court "extraordinary", adding: “These are a proven lifesaver and you would have thought a court, of all places, would have one.”
Paramedic 'did not cut away dress due to modesty'
The inquest heard that Ms Gascoigne from Baildon Road, Scunthorpe, became "really upset" when her case at court had concluded.
She went to the toilet but when she came back to join family members she complained of feeling dizzy and sick. She later died in Hull Royal Infirmary.
In a statement her sister Charlotte Jones said: "Her eyes rolled back and she seemed to become rigid."
The hearing heard how her family urged Mr Long - who took four minutes from arriving at her side to starting treatment - to "hurry up."
A security officer and a retired nurse had already given her CPR, and police officers who were at court for a different case became involved.
Detective Chief Inspector Tony Cockerill said Mr Long appeared uncomfortable with the situation and he felt he should intervene, offering to give chest compressions.
He said: "I could tell, through experience of having dealt with medical colleagues for many years, that something did not appear right.
"Just from the expression on his face, something was not how it should be."
He told coroner Prof Paul Marks how he had overheard a female paramedic, who later arrived at the scene, ask whether Mr Long had brought his kit.
DCI Cockerill claimed the paramedic responded with words to the effect of: "I left it in the car. I'm sorry. I thought it was just some kind of fit."
The court heard from Dr Ian Richmond, who carried out the post-mortem examination, how Miss Gascoigne's death appeared to have been caused by a failure in the heart's left ventricle, which in turn was the result of the hypertensive heart disease.
It is known as a "silent killer" as there are no symptoms necessarily associated with it.
He confirmed that she had otherwise appeared to be a "healthy lady" at the time of her death.
Asked by counsel for Mr Long, Laura Addey whether the medical episode could have happened at any time, he replied: "Yes sadly it could."