A nurse died three days after being discharged from hospital with a diagnosis of acid reflux, with a coroner warning that lessons must be learned. Paula Ivers, 47, had attended Tameside General Hospital with severe chest pain that was spreading to her back, but medics failed to diagnose a tear in the body's main artery – the aorta – which ultimately led to her death.
Discharged with acid reflux diagnosis
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.
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. She was sent home with a diagnosis of gastroesophageal reflux disease – more commonly known as acid reflux – and a prescription for omeprazole.
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 – a tear in the wall of the body's main artery – 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."
The coroner said doctors did not take into account the severity of her pain and her family history of early cardiac death. The inquest into her death in November heard that her father had died "of a cardiac case" aged in his early to late 40s when she was young.
Family's tribute and calls for awareness
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."
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."
