Children’s nurse, 47, dies three days after NHS sent her home with acid reflux misdiagnosis

Paula Ivers, 47, was sent home with a diagnosis of acid reflux – and died three days later

A children’s nurse who was discharged from hospital and informed she was suffering from acid reflux passed away merely three days later, after medical staff overlooked a potentially fatal condition causing her chest pain, a coroner has cautioned.

Paula Ivers, 47, died at her Denton home on March 8, 2024, having presented at Tameside General Hospital with acute chest pain radiating to her back. The mother-of-one had been sent home with an acid reflux diagnosis, yet doctors had missed a tear in the aorta – the body’s primary artery – which proved fatal.

A coroner has now issued a warning that lessons must be learnt to avert future deaths, highlighting concerns regarding the assessment of patients presenting with chest pain in hospitals and whether crucial family medical histories are properly documented.

Ms Ivers’ family said her “needless” death has “left a huge void” amongst them. Lesley Ivers, 51, remembered her sister 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.”

During an inquest examining Paula’s death, Coroner Christopher Morris determined that her death was contributed to by neglect. In a Prevention of Future Deaths (PFD) report directed at NHS England and Tameside and Glossop Integrated Care NHS Trust, which operates Tameside General, the coroner stated that medical staff had failed to consider the possibility of a fatal aortic dissection – a rupture in the wall of the body’s primary artery – and had not conducted a scan capable of detecting it.

The report stated: “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.”

Paula had chest pain

Ms Ivers attended the hospital’s A&E department on March 5, 2024 following chest pain that had begun the previous evening and was intensifying. She underwent an ECG, a chest X-ray and blood tests before being referred 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 showed a marginally increased 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 noted that doctors failed to take into consideration the intensity of her pain and her family history of premature 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 a child.

The coroner noted that medical staff had not considered the possibility of an aortic dissection, and no CT angiogram – a scan used to detect narrowed or blocked arteries – had been performed prior to her discharge from hospital.

Three days later, Ms Ivers was discovered collapsed on her bedroom floor by her young daughter at their Denton home and was subsequently pronounced dead, the inquest into her death was told.

A post-mortem examination revealed Ms Ivers died from haemopericardium, an accumulation of blood in the sac surrounding the heart, and an aortic dissection resulting from cystic medial degeneration, a condition that affects the aortic wall.

The inquest concluded on 17 June 2026, with the coroner delivering a narrative conclusion that Ms Ivers died from complications arising from an undiagnosed, and consequently untreated, aortic dissection three days following her discharge from a hospital Same Day Emergency Care unit with a diagnosis of Gastroesophageal Reflux Disease. The coroner determined that Ms Ivers’s death was contributed to by neglect.

While the coroner recognised the “significant amount of work” undertaken by the NHS Trust following its investigation into Ms Ivers’ care, he expressed concerns regarding the assessment of patients presenting with chest pain, including the failure to routinely measure blood pressure in both arms and the inadequate recording of relevant family medical history. The Trust offered an apology to the court for its tardiness in responding to prevention of future deaths reports following inquests into Ms Ivers and four other patients.

It gave assurances to 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 raised concerns with national health leaders after the court heard testimony 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 initially raised concerns over evidence suggesting that some patients are unable to secure a timely GP appointment. He then highlighted the absence of a national requirement which he says “mandates early substantive face-to-face review by an experienced doctor” prior to determining whether a patient should be directed to either A&E or an SDEC unit.

‘Our family will never be the same’

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 that no national requirement existed for a face-to-face review, noting that national guidance was 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”, emphasising 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.”

What the trust said

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 fully acknowledges the findings of the Coroner and has carefully considered the concerns raised. We have already taken a number of actions to strengthen our processes and improve patient safety, and we remain committed to learning from this tragic case to help prevent similar events in the future.”

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