England, November 20, 2025: Paula Ivers, a 47-year-old with over 24 years of experience as a pediatric nurse, tragically died in March 2024 after her life-threatening aortic dissection that was misdiagnosed as indigestion at Tameside Hospital in Greater Manchester, England. An inquest into her death has revealed multiple missed opportunities that could have prevented this fatal outcome.
An inquest held on Monday, November 17, 2025, at Manchester South Coroners' Court in Stockport examined the circumstances surrounding her death, as per People.
In March 2024, Ivers experienced severe chest pain that she described as worse than childbirth, as per ITV News.
Following her GP's advice, her partner Simon Norbury drove her to the Accident and Emergency department at Tameside Hospital in Ashton-under-Lyne. According to Manchester Evening News, she was struggling to breathe during the car journey and had packed an overnight bag, anticipating admission.
Despite the severity of her symptoms and significant family history of cardiac disease that included her father's death from cardiac arrest in his early 40s, Ivers underwent standard triage procedures including blood tests, an ECG, and a chest X-ray.
She was subsequently transferred to the Same Day Emergency Care Unit, a facility designed for patients not requiring hospital admission.
The inquest at Stockport Coroner's Court revealed that Dr. Osama Ahmed, a consultant in emergency medicine, reviewed her ECG trace without physically examining her. He then diagnosed her with gastroesophageal reflux disease.
As per Metro, medical staff told the couple it was indigestion, advising them to purchase Gaviscon on their way home.
According to NHS, Gaviscon is generally used to treat heartburn (acid reflux) and indigestion.
The inquest uncovered several alarming gaps in Ivers' assessment and care:
Blood pressure was not measured on both arms, a standard protocol for suspected aortic conditions
The patient's significant family cardiac history was not adequately considered in the clinical decision-making
No documentation existed regarding the rationale for classifying her as "low risk"
Dr. Ahmed later admitted under questioning from Coroner Christopher Morris that Ivers was not actually low-risk and should not have been suitable for the Same Day Emergency Care Unit
Despite CT scans being the most common way to diagnose the deadly aortic dissections, Dr Ahmed did not order one.
Over the following three days, Ivers continued to experience excruciating pain and struggled to sleep. Her sister Lesley, also a nurse, received texts from Paula expressing that she still had "horrendous pain" and desperately wanted it to go away, as per Manchester Evening News.
On March 8, 2024, Ivers was discovered collapsed on her bedroom floor by her nine-year-old daughter.
She was pronounced dead, and a post-mortem examination confirmed the cause of death as aortic dissection, a time-critical medical emergency caused by a tear in the aorta's inner layer.
Aortic dissection is a life-threatening condition characterized by the tearing of the aortic wall, creating a false lumen that can compromise blood flow to vital organs. Without prompt surgical treatment, mortality rates are extremely high. 1
Key red flags for aortic dissection include:
Sudden, severe chest pain
Pain radiating to the back or between shoulder blades
Blood pressure differences between arms
An abrupt, transient, severe increase in blood pressure
Family history of cardiovascular disease
Dr. Ahmed acknowledged during the inquest that while aortic dissection is not a common condition, he now realizes Ivers should have been hospitalized immediately.
Paula Ivers dedicated more than two decades to caring for children as a pediatric nurse. Her sister Lesley described her as "caring, smart, determined and loyal," someone who "lit up a room whenever she was around."
In a statement as per Manchester Evening News, Lesley Ivers expressed the cruel irony of the situation: "Paula was a fierce advocate and defender of the NHS, yet when she needed it most, she was let down in the worst way possible."
The inquest, has been adjourned until June 2026 due to staff shortages in the U.K. amid doctors' strikes, the coroner said, as noted by ITV News.
1. Levy D, Sharma S, Farci F, et al. Aortic Dissection. [Updated 2024 Oct 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441963/
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