A 47-year-old nurse who dedicated nearly 25 years of her life to caring for others died just three days after doctors sent her home from a hospital with an acid reflux diagnosis, missing a life-threatening tear in her body’s main artery.
Paula Ivers, a mother of one from Denton, England, sought emergency treatment at Tameside General Hospital on March 5, 2024, after experiencing severe chest pain that spread into her back.
Despite the intensity of her symptoms and a family history of early heart-related death, doctors diagnosed her with gastroesophageal reflux disease, commonly known as acid reflux, and prescribed medication.
Three days later, her young daughter discovered her collapsed on her bedroom floor. Ivers was pronounced dead on March 8.
Now, more than two years after her death, an official investigation has concluded that serious failures in her medical care contributed to the tragedy.
British coroner Christopher Morris determined that Ivers died from an undiagnosed aortic dissection, a dangerous condition in which a tear develops in the inner wall of the aorta, the major artery carrying blood from the heart to the rest of the body.
The condition can quickly become fatal if it is not identified and treated.
According to the coroner’s findings, Ivers had been experiencing worsening chest pain since the evening before she visited the hospital.
Doctors performed an electrocardiogram, commonly called an EKG in the United States, along with a chest X-ray and blood tests.
Most results were normal, although her heart rate was elevated and blood tests showed a slightly increased level of C-reactive protein, a marker associated with inflammation.
She was transferred to a same-day emergency care unit before being discharged with a prescription for omeprazole, a medication used to reduce stomach acid.
But investigators later determined that doctors had failed to consider aortic dissection as a possible explanation for her symptoms.
They also failed to adequately account for the severity of her pain and her family’s medical history.
Ivers’ father had died from a heart-related condition in his 40s, a detail the coroner said should have been considered during her assessment.
Crucially, doctors did not order a CT angiogram, a specialized imaging scan that can reveal problems in major blood vessels.
The coroner concluded that such a scan likely would have identified the tear and allowed Ivers to be transferred to a specialist hospital for emergency surgery.
He found that she probably would have survived if the condition had been diagnosed and treated.
An autopsy revealed that Ivers died after blood accumulated around her heart, a complication of the aortic dissection that prevented her heart from functioning properly.
The underlying tear was associated with cystic medial degeneration, a weakening of tissue within the aortic wall.
At the conclusion of the inquest on June 17, 2026, Morris formally determined that neglect contributed to her death.
The findings have devastated Ivers’ family, particularly because she had spent most of her adult life working for Britain’s National Health Service.
Her sister, Lesley Ivers, described Paula as a loving, generous and compassionate woman who devoted herself to helping patients.
“For almost 25 years Paula devoted her life to the NHS,” Lesley said.
She explained that one of the family’s greatest struggles has been accepting that Paula died after seeking help from the same health system she had served for decades.
The tragedy has also prompted action beyond the family’s individual case.
In a formal report issued August 26 and published in October, the coroner warned that additional deaths could occur unless hospitals improve how they evaluate patients experiencing chest pain.
He raised concerns about the failure to consistently document important family medical history, the absence of routine blood pressure measurements in both arms and the way patients are directed into urgent care services.
The report also questioned whether patients should receive an early, in-person assessment by an experienced physician before decisions are made about which emergency service should treat them.
The Tameside and Glossop Integrated Care NHS Foundation Trust has since acknowledged serious shortcomings in Ivers’ treatment.
In civil proceedings brought by the family, the hospital operator admitted that it failed to consider an aortic dissection, did not carry out appropriate investigations and discharged Ivers without adequately explaining her symptoms.
The trust also acknowledged that appropriate testing would likely have led to emergency surgery and that Ivers probably would have survived.
The family’s attorneys are now working toward a financial settlement.
NHS England has also responded to the broader concerns, pointing to existing emergency care guidance and measures intended to improve timely access to medical assessments.
For Americans, the case highlights an important distinction between ordinary acid reflux and potentially life-threatening cardiovascular emergencies.
Acid reflux can cause burning discomfort in the chest, but aortic dissection may cause sudden, severe chest or back pain and can sometimes resemble other medical conditions.
Not every patient experiences the same symptoms, and some may have pain without the classic warning signs.
Sudden, severe or unexplained chest or upper-back pain should be treated as a medical emergency, particularly when accompanied by fainting, weakness, trouble breathing or other concerning symptoms.
For Ivers’ family, the tragedy has become a mission to prevent others from experiencing a similar loss.
Her sister said the family does not want Paula’s death to discourage people from seeking medical help. Instead, they hope it will encourage hospitals to recognize dangerous symptoms earlier and provide appropriate treatment.
The family is also determined to make sure Paula’s daughter grows up knowing how deeply her mother loved her.
