A children's nurse who was sent home from hospital and told she had acid reflux died just three days later, after doctors failed to consider a life-threatening condition behind her chest pain, a coroner has warned.
Paula Ivers, 47, died at her home in Denton on March 8, 2024, after attending Tameside General Hospital with severe pain in her chest that was spreading to her back. The mum-of-one had been discharged with a diagnosis of acid reflux, but medics had failed to diagnose a tear in the body's main artery - the aorta - which ultimately led to her death.
Coroner raises concerns over chest pain assessment
Now, a coroner has 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.
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."
Inquest 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."
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.
Family history and missed diagnosis
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.
The coroner said the possibility of an aortic dissection was not considered by doctors, and no CT angiogram - which checks for narrowed or blocked arteries - was carried out before she was discharged.
Tragically, 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, the inquest into her death heard.
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.
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 Same Day Emergency Care unit with a diagnosis of Gastroesophageal Reflux Disease. Ms Ivers's 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. It assured the coroner that the Trust has "taken the concerns outlined in the Prevention of Future Deaths Notices issued seriously and have carefully considered the actions required in responses".
Concerns raised to national health leaders
The coroner also raised concerns to national health leaders after the court heard evidence from the Clinical Lead of SDEC about factors he considers have contributed to increased attendances to the Trust's urgent care services.
Firstly, Mr Morris raised concerns about evidence heard that some patients are unable to get a timely GP appointment. He then raised concerns 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.
The health service said it would "continue to support providers in implementing the national urgent and emergency care and SDEC guidance", adding that patient safety and timely access to clinical expertise would be "at the centre" of these arrangements.
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."
