A children's nurse who was sent home from hospital and told she was suffering from acid reflux passed away just three days later, after doctors failed to identify 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 presenting at Tameside General Hospital with severe chest pain that was radiating through to her back. The mum-of-one had been discharged with a diagnosis of acid reflux, yet medics had overlooked a tear in the body's main artery - the aorta - which ultimately proved fatal.
Coroner issues stark warning
A coroner has now issued a stark warning that lessons must be learnt to prevent further deaths, raising serious concerns about how patients presenting with chest pain are assessed and whether crucial family medical history is being properly recorded.
Ms Ivers' family described her "needless" death as having "left a huge void" in their lives. Her sister Lesley Ivers, 51, described her as "loving, kind and generous", reports the Manchester Evening News.
"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 findings
During 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 operates Tameside General, he said medics had failed to consider the possibility of a life-threatening aortic dissection - a tear in the wall of the body's main artery - and had not performed a scan that could have detected 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."
Hospital visit and missed diagnosis
Ms Ivers attended the hospital's A&E on March 5, 2024 after experiencing chest pain since the night before, which was worsening. She underwent an ECG, a chest X-ray and blood tests, before being transferred to the hospital's Same Day Emergency Care (SDEC) unit.
While the majority of her test results returned normal, her heart rate was elevated and she had a marginally raised level of C-reactive protein, an indicator of inflammation. She was discharged with a diagnosis of gastroesophageal reflux disease - more commonly referred to as acid reflux - and a prescription for omeprazole.
The coroner said doctors failed to 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 noted that the possibility of an aortic dissection had not been considered by medical staff, and that no CT angiogram — a scan used to detect narrowed or blocked arteries — was performed prior to her discharge.
Tragically, three days later, Ms Ivers was discovered collapsed on her bedroom floor by her young daughter at the family home in Denton and was subsequently pronounced dead, the inquest heard.
Post-mortem and conclusion
A post-mortem examination revealed that Ms Ivers died as a result of haemopericardium, a dangerous accumulation of blood in the sac surrounding the heart, alongside an aortic dissection caused by cystic medial degeneration, a condition which affects the wall of the aorta.
The inquest concluded on June 17, 2026, with the coroner recording a narrative conclusion stating that 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 undertaken following its investigation into Ms Ivers' care, he expressed concerns regarding the way in which patients presenting with chest pain are assessed, highlighting the failure to routinely measure blood pressure in both arms and the absence of recorded significant family medical history. The Trust offered an apology to the court for its delays in responding to prevention of future deaths reports following the inquests into Ms Ivers and four other patients.
It reassured 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".
The coroner also wrote to national health leaders after the court received evidence from the Clinical Lead of SDEC regarding factors he believes have contributed to a rise in attendances at the Trust's urgent care services.
Mr Morris firstly raised concerns about evidence heard that some patients are unable to secure a timely GP appointment. He went on to highlight the absence of a national requirement which he says "mandates early substantive face-to-face review by an experienced doctor" before determining whether a patient is directed into either A&E or an SDEC unit.
Response from NHS England
In response, NHS England stated that amendments to the GP contract for 2026/27 explicitly require requests identified as clinically urgent by a GP practice to be addressed on the same day.
It also conceded there was no national requirement for a face-to-face review, noting that national guidance was already in place to support safe assessment and appropriate clinical decision-making. The health service confirmed it would "continue to support providers in implementing the national urgent and emergency care and SDEC guidance", stating that patient safety and prompt access to clinical expertise would remain "at the centre" of these arrangements.
Ms Ivers' family have since instructed medical negligence solicitors to investigate the circumstances surrounding 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."
