A coroner has said lessons must be learned after a nurse died three days after being discharged from hospital with a misdiagnosis of acid reflux. Paula Ivers, 47, attended Tameside General Hospital with severe chest pain that was spreading to her back, but doctors failed to diagnose a tear in the body's main artery, the aorta, which ultimately led to her death.
Ms Ivers died at her home in Denton on March 8, 2024. She had been discharged with a diagnosis of gastroesophageal reflux disease, more commonly known as acid reflux, and a prescription for omeprazole. A coroner warned that lessons must be learned to prevent future deaths, raising concerns over how patients with chest pain are assessed in hospital and whether vital family medical history is noted.
Family's tribute to 'loving' nurse
Ms Ivers' loved ones said her "needless" death has "left a huge void" in the family. Lesley Ivers, 51, described her sister as "loving, kind and generous".
"For almost 25 years Paula devoted her life to the NHS," she said. "One of the hardest things to come to terms with is that when she needed help from the service she gave so much to, she was badly let down."
Coroner finds neglect contributed to death
At an inquest into Paula's death, Coroner Christopher Morris concluded that her death was contributed to by neglect. In a Prevention of Future Deaths (PFD) report issued to NHS England and Tameside and Glossop Integrated Care NHS Trust, which runs Tameside General, he said doctors had not considered the possibility of a life-threatening aortic dissection and had not carried out a scan that could have spotted it.
The report said: "Had this investigation been undertaken, it is likely the underlying condition which ultimately led to Ms Ivers's death would have been identified leading to her transfer to a specialist centre for emergency surgery which she probably would have survived."
Ms Ivers visited the hospital's A&E on March 5, 2024, after suffering chest pain since the previous evening, which was getting worse. She was given an ECG, a chest X-ray and blood tests, before being sent to the hospital's Same Day Emergency Care (SDEC) unit.
Missed family history and scan
While most of her test results came back normal, her heart rate was high and she had a slightly raised level of C-reactive protein, a marker of inflammation. The coroner said doctors did not take into account the severity of her pain and her family history of early cardiac death. The inquest heard that her father had died "of a cardiac case" aged in his early to late 40s when she was young.
The coroner said the possibility of an aortic dissection was not considered by doctors, and no CT angiogram was carried out before she was discharged. Three days later, Ms Ivers was found collapsed on the floor of her bedroom by her young daughter at their home in Denton and later pronounced dead.
A post-mortem examination found Ms Ivers died as a consequence of haemopericardium, a build-up of blood in the sac surrounding the heart, and an aortic dissection caused by cystic medial degeneration, a condition affecting the wall of the aorta.
Trust apologises and pledges action
The inquest concluded on June 17, 2026, where the coroner recorded a narrative conclusion stating Ms Ivers died as a consequence of complications arising from an undiagnosed, and therefore untreated, aortic dissection three days after her discharge from a hospital SDEC unit with a diagnosis of Gastroesophageal Reflux Disease. Her death was contributed to by neglect.
While the coroner acknowledged the "significant amount of work" the NHS Trust had done following its investigation into Ms Ivers' care, he raised concerns about how patients with chest pain are assessed, including the failure to routinely record blood pressure in both arms and the lack of the recording of significant family medical history. The Trust issued an apology to the court in its delays in responding to prevention of future deaths reports following the inquests into Ms Ivers and four other patients.
The coroner also raised concerns to national health leaders after hearing evidence from the Clinical Lead of SDEC about factors he considers have contributed to increased attendances to the Trust's urgent care services. He raised concerns about evidence heard that some patients are unable to get a timely GP appointment, and about the lack of a national requirement which he says "mandates early substantive face-to-face review by an experienced doctor" before deciding whether a patient is streamed into either A&E or a SDEC unit.
Responding, NHS England said changes to the GP contract for 2026/27 explicitly require requests identified as clinically urgent by a GP practice to be dealt with on the same day. It also acknowledged there was no national requirement for a face-to-face review, adding national guidance was in place to support safe assessment and appropriate clinical decision-making.
Ms Ivers' family have since instructed medical negligence lawyers to look into the circumstances relating to her death. Lesley told law firm Irwin Mitchell: "Our family will never be the same, but Paula's daughter will grow up knowing how much Paula loved her and how proud she was of her."
"Paula's compassion, professionalism, and kindness touched so many lives. Our focus is now on ensuring there is more awareness of aortic dissection and that medical professionals realise the importance of not only a timely diagnosis but also appropriate treatment."
"Paula was a great advocate of the NHS, so we don't want others to be put off seeking help. Rather, we want to honour Paula's memory by seeing lasting improvements in patient care."
