A children's nurse died three days after being discharged from hospital with an acid reflux diagnosis, when doctors missed a fatal tear in her aorta, a coroner has warned.
Paula Ivers, 47, attended Tameside General Hospital with acute chest pain radiating to her back on March 5, 2024. She was sent home with a diagnosis of gastroesophageal reflux disease and a prescription for omeprazole. Three days later, she was found collapsed at her Denton home and pronounced dead.
Coroner Christopher Morris concluded that neglect contributed to her death. In a Prevention of Future Deaths report, he stated that medical staff failed to consider the possibility of an aortic dissection and did not perform a CT angiogram before her discharge.
Missed fatal condition
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."
A post-mortem revealed Ms Ivers died from haemopericardium and an aortic dissection resulting from cystic medial degeneration. The inquest, concluded on 17 June 2026, heard that her father had died of a cardiac case in his early to late 40s when she was a child.
The coroner noted that doctors failed to take into consideration the intensity of her pain and her family history of premature cardiac death. He also raised concerns about the assessment of patients presenting with chest pain, including the failure to routinely measure blood pressure in both arms and inadequate recording of family medical history.
Family's response
Lesley Ivers, 51, remembered her sister as "loving, kind and generous". She said: "For almost 25 years Paula devoted her life to the NHS. 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."
The family have instructed medical negligence lawyers. 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."
Trust response
A spokesperson for Tameside and Glossop Integrated Care NHS Trust said: "We would like to express our sincere condolences to the family and loved ones of Paula Ivers following the conclusion of the inquest into her death. We are deeply sorry for the shortcomings in the care provided and for the distress this has caused."
The Trust acknowledged the coroner's findings and said it has taken actions to strengthen processes and improve patient safety. NHS England stated that amendments to the GP contract for 2026/27 require clinically urgent requests to be addressed on the same day, and confirmed it would continue to support providers in implementing national urgent and emergency care guidance.
