Key Points
- Paula Ivers, a 47-year-old children’s nurse from Denton, Greater Manchester, passed away at home on 8 March 2024, three days after visiting Tameside General Hospital with chest pain.
- Paula was discharged from the hospital’s Same Day Emergency Care facility having been diagnosed with gastro-oesophageal reflux disease, often referred to as acid reflux, and was prescribed omeprazole.
- Her cause of death established through a post mortem examination was haemopericardium, a collection of blood in the sac around her heart and an aortic dissection secondary to cystic medial degeneration.
- The coroner, Christopher Morris, concluded his narrative finding and stated Paula Ivers’ death was contributed to by neglect due to an undiagnosed and untreated aortic dissection.
- At the inquest, the coroner noted that despite no CT angiogram being carried out prior to discharge, it is likely that it would have led to establishing the diagnosis.
- The coroner made Preventing Future Deaths reports for NHS England and Tameside and Glossop Integrated Care NHS Foundation Trust with concerns regarding chest pain evaluation and family history record keeping.
- The Trust accepted the coroner’s findings and offered an apology stating that Paula Ivers was not provided with the quality of care she deserved.
Tameside (Manchester Mirror) October 16, 2026 — A devoted NHS children’s nurse died three days after being sent home from Tameside General Hospital with a diagnosis of acid reflux, despite chest pain later found to be caused by an undiagnosed tear in her aorta, an inquest has concluded.
Paula Ivers, 47, from Denton, attended the accident and emergency department at Tameside General Hospital in Ashton-under-Lyne at about 10.30am on 5 March 2024 after experiencing worsening chest pain since the previous evening. As reported by the Manchester Evening News, the pain was radiating to her back and shoulders.
Ms Ivers, a mother of one, was assessed in A&E before being referred to the hospital’s Same Day Emergency Care unit. She underwent an ECG, a chest X-ray and blood tests; most results were normal, although her heart rate was raised and she had slightly increased C-reactive protein, a marker of inflammation.
She was discharged at about 3pm the same day with a diagnosis of gastro-oesophageal reflux disease and a prescription for omeprazole. Three days later, on 8 March 2024, she was found collapsed on her bedroom floor by her young daughter and was later pronounced dead.
What Did The Inquest Find?
The inquest, concluded at South Manchester Coroners’ Court in Stockport on 17 June 2026, heard that Ms Ivers died from complications of an undiagnosed and untreated aortic dissection. Coroner Christopher Morris recorded a narrative conclusion and found that neglect contributed to her death.
A post-mortem examination established that she died from haemopericardium, a dangerous accumulation of blood in the sac surrounding the heart, alongside an aortic dissection caused by cystic medial degeneration, a condition affecting the wall of the aorta.
An aortic dissection is a time-critical medical emergency in which a tear forms in the wall of the aorta, the body’s main artery. ITV Granada Reports reported that the condition ultimately led to a fatal cardiac arrest.
The coroner found that the medical team did not consider the possibility of an aortic dissection and did not carry out a CT angiogram, a scan used to examine blood vessels. In his Prevention of Future Deaths report, he stated that had the investigation been conducted, it was probable that the underlying condition would have been recognised, allowing transfer to a specialist centre for emergency surgery.
As reported by ITV Granada Reports journalist Anna Youssef, the coroner said that, because aortic dissection is relatively rare and both doctors involved were “relatively inexperienced”, it did not occur to them that it could be the cause of Ms Ivers’ symptoms.
What Happened At Tameside Hospital?
The inquest heard that Ms Ivers was triaged in A&E before being sent to the Same Day Emergency Care unit, which treats patients assessed as not requiring admission to hospital. She was seen by a junior doctor and, for the first time, asked about her family medical history.
She told medics that her father had died from a cardiac arrest at the age of 45. Despite this history, and despite her reported chest pain, she was not given a CT scan, which ITV reported is the most common way to diagnose an aortic dissection.
Her case was discussed with the unit’s clinical lead, who had been a fully qualified GP for just over a year. She was then diagnosed with acid reflux and advised to buy Gaviscon before being sent home.
The Manchester Evening News reported that the coroner noted the medical team failed to consider the intensity of Ms Ivers’ pain and her family history of early cardiac events. He also raised concerns that the possibility of aortic dissection was not taken into account and that no CT angiogram was performed before discharge.
What Did The Coroner Say?
Coroner Christopher Morris issued Prevention of Future Deaths reports to NHS England and Tameside and Glossop Integrated Care NHS Foundation Trust, which runs Tameside General Hospital. He said lessons needed to be learned to help prevent similar deaths.
According to the Manchester Evening News, the coroner raised concerns about the assessment of patients presenting with chest pain, including the absence of routine blood-pressure checks in both arms and failures to document relevant family medical histories.
He also communicated concerns to national health leaders after hearing evidence from the clinical lead of the Same Day Emergency Care unit about pressures on urgent care services. The coroner noted evidence suggesting that some patients were unable to secure timely GP appointments, and said there was no national requirement for an early, thorough face-to-face assessment by an experienced doctor before a patient was directed to A&E or a Same Day Emergency Care unit.
How Has The NHS Responded?
Tameside and Glossop Integrated Care NHS Foundation Trust accepted the coroner’s findings. In a statement reported by ITV Granada Reports, a Trust spokesperson said: “We accept the coroner’s findings and offer our deepest apologies that Paula did not receive the standard of care she should have.”
The Manchester Evening News reported that the Trust apologised to the court for delays in responding to future-death reports following inquests involving Ms Ivers and other patients. It told the coroner that it had taken the concerns seriously and had carefully considered the actions required in response.
NHS England said that, from the 2026-27 contract, urgent requests identified by GP practices will explicitly be required to be addressed on the same day. It acknowledged that there is no national requirement for in-person reviews, but said national guidance exists to support safe assessments and appropriate clinical decision-making.
NHS England added that it would continue to support providers through national urgent and emergency care and Same Day Emergency Care guidance, stating that patient safety, timely access and clinical expertise should remain “at the forefront” of those efforts.
What Has Paula Ivers’ Family Said?
Ms Ivers’ sister, Lesley Ivers, who is also a nurse, said her sister had dedicated nearly 25 years to the NHS. In a statement reported by the Manchester Evening News, she said:
“One of the hardest realities to accept is that when she sought assistance from the very service she devoted herself to, she was severely let down.”
Speaking outside South Manchester Coroners’ Court after the inquest conclusion, Lesley Ivers said, as reported by ITV Granada Reports: “She was deeply failed by the very system to which she devoted her life.”
She added that Paula “deserved far better, both as a patient and a professional who gave so much to others”, and said her daughter had been left “utterly devastated and traumatised” by her mother’s death.
The family described Paula as “loving, kind and generous”. Through law firm Irwin Mitchell, they said their focus was on raising awareness of aortic dissection and ensuring medical professionals recognise the importance of timely diagnosis and appropriate treatment.
“We want to ensure that others are not deterred from seeking help,” the family said. “Instead, we aim to honour Paula’s memory by advocating for lasting improvements in patient care.”
What Legal Action Is Under Way?
Ms Ivers’ family has instructed medical negligence solicitors to investigate the circumstances surrounding her death. Irwin Mitchell senior associate solicitor Nicola Ashton, representing the family, said the finding of neglect and the issuing of two Prevention of Future Deaths reports were “deeply significant”.
“It confirms the family’s concerns and, they hope, will lead to real change so no other family has to go through this,” Ms Ashton said, according to ITV Granada Reports. She said the family’s priority had been to seek answers and ensure meaningful change resulted from Paula’s death.
The Manchester Evening News reported that the Trust accepted that relying on an acid-reflux diagnosis without excluding aortic dissection, failing to consider the condition, not conducting appropriate tests, and discharging Ms Ivers without a diagnosis that could reasonably explain her pain constituted breaches of duty. It also accepted that, had the condition been considered and proper investigations undertaken, she would have been transferred for emergency surgery and would probably have survived.
Background Of The Development
Paula Ivers had worked as a paediatric nurse for more than 24 years. Her family said she spent nearly 25 years working for the NHS and was known for her compassion, professionalism and kindness.
She attended Tameside General Hospital on 5 March 2024 after experiencing what ITV described as crushing chest pain, which she told her partner was worse than childbirth. She was discharged later that day with acid reflux and died at home on 8 March 2024.
The inquest was heard over two days at South Manchester Coroners’ Court in Stockport. It concluded on 17 June 2026, with the coroner recording that Ms Ivers died from complications of an undiagnosed and untreated aortic dissection and that neglect contributed to her death.
Prediction: What This Means For Patients
For patients in Tameside, Greater Manchester and across the NHS, the case is likely to increase scrutiny of how chest pain is assessed, particularly where symptoms include pain spreading to the back or shoulders and where there is a relevant family history. The coroner’s concerns focused on blood-pressure checks in both arms, documentation of family history, and the use of appropriate imaging such as CT angiography.
For NHS staff, the Prevention of Future Deaths reports may lead services to review their chest-pain pathways, escalation procedures and the involvement of experienced clinicians in decisions to discharge patients from urgent-care settings. The coroner specifically highlighted the absence of a national requirement for an early, thorough face-to-face assessment by an experienced doctor before referral decisions are made.
For families, the development may reinforce the importance of clearly reporting severe, persistent or worsening chest pain and any relevant family medical history when seeking urgent care. The case also highlights the potential consequences when a serious vascular condition is not considered among possible causes of chest pain.
For the wider NHS, NHS England’s response indicates that same-day handling of urgent GP-identified requests will form part of the 2026-27 contract. However, the service said existing national guidance already supports safe assessment and clinical decision-making, meaning the practical effect will depend on how local NHS providers implement and monitor those standards.
