Nurse dies three days after discharge with missed aortic dissection diagnosis

Paula Ivers, a 47-year-old mother and children’s nurse, presented to Tameside General Hospital’s A&E on March 5 with acute chest pain that spread to her back. After an ECG, chest X-ray and blood tests, clinicians noted a raised heart rate and a slight rise in C-reactive protein but found no other abnormalities, leading to a discharge diagnosis of gastro-oesophageal reflux disease and a prescription for omeprazole. The coroner highlighted that doctors did not factor in her father’s early cardiac death nor perform a CT angiogram that could have detected an aortic dissection.

Ivers collapsed at her Denton home three days later and died from haemopericardium caused by an aortic tear. The inquest determined that neglect contributed to her death and issued a Prevention of Future Deaths notice urging NHS England and Tameside and Glossop Integrated Care NHS Trust to improve chest-pain assessment, including blood-pressure checks in both arms and thorough family-history recording. The Trust apologized, acknowledged the findings, and said it had already taken steps to strengthen patient-safety processes.