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Home » Blog » Inquest Probes Nurse’s Fatal Misdiagnosis
Life

Inquest Probes Nurse’s Fatal Misdiagnosis

Maria DelGattia
Last updated: November 19, 2025 8:19 pm
Maria DelGattia
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A 47-year-old nurse from England died three days after being told her “crushing” chest pain was indigestion, an inquest has heard, raising urgent questions about how heart symptoms in women are assessed.

Contents
What HappenedWhy Women’s Heart Symptoms Get MissedGuidelines and the Reality on the GroundVoices From the CaseA System Under ScrutinyWhat Could Change

According to evidence presented to the coroner, the mother of one was found collapsed on her bedroom floor by her 9-year-old daughter following the initial diagnosis. The case centers on what signs were missed, why the diagnosis went wrong, and whether earlier intervention might have changed the outcome. It also adds to growing concern that women’s cardiac symptoms are too often dismissed or mislabeled.

What Happened

The nurse sought help after reporting severe chest pain described as “crushing.” She was advised it was likely indigestion, then deteriorated and died three days later. The inquest is examining the timeline of care, the advice given, and any gaps in assessment.

“Crushing” chest pain was recorded before a diagnosis of indigestion was given.

Coroners’ courts do not attribute blame. They examine facts and can issue prevention of future deaths reports if they identify patterns or risks. This hearing will look at whether standard protocols for chest pain were followed and if red flags were overlooked.

Why Women’s Heart Symptoms Get Missed

Research in the UK has shown that women often present with heart attack symptoms that can be mistaken for digestive issues, anxiety, or muscle strain. Classic signs like severe chest pressure can occur, but so can subtler symptoms such as jaw pain, nausea, or breathlessness.

A University of Leeds and British Heart Foundation study found women were about 50% more likely than men to receive a wrong initial diagnosis after a heart attack. That gap delays treatment and increases risk. Advocates say this case fits a familiar pattern: symptoms dismissed as indigestion, then a rapid and tragic turn.

  • Indigestion-like discomfort can signal a heart attack.
  • Women may have chest pain, but also nausea, jaw or back pain, or unusual fatigue.
  • Persistent, severe, or “crushing” pain needs urgent assessment.

Guidelines and the Reality on the Ground

National guidance advises treating ongoing chest pain as a medical emergency. That includes prompt ECG testing and troponin blood tests to check for heart damage. In busy settings, however, atypical presentations can slip through, especially if a patient is younger, female, or has few known risk factors.

Clinicians often balance many possibilities at once. But experts warn that assigning chest pain to reflux without ruling out cardiac causes carries high stakes. Inquests have repeatedly highlighted how small delays add up: a missed ECG, a discharged patient, a return with worse symptoms.

Voices From the Case

Family members described their shock at the loss and the distress of a child discovering her mother at home. The coroner’s questions focused on the initial assessment, including the nature of the pain and whether emergency protocols were triggered.

“The description of severe, ‘crushing’ chest pain is a red flag that typically warrants urgent cardiac testing,” one line of questioning suggested.

Clinicians involved in the case are expected to describe their decision-making, the patient’s presentation, and whether alternative diagnoses were considered. The hearing may also explore staffing levels, triage processes, and follow-up advice.

A System Under Scrutiny

This case reflects a wider issue. Cardiology groups have long urged public awareness that heart attacks are not just a “male” problem. Women are more likely to wait before seeking care and more likely to be misdiagnosed at first contact.

Hospitals across England have introduced high-sensitivity troponin tests and faster pathways for chest pain. But implementation varies. Experts say consistent use of checklists and repeat testing can catch cases that look like indigestion early on.

What Could Change

The inquest could recommend better training on women’s cardiac symptoms, clearer safety-netting advice, and stronger triage rules for severe chest pain. It may also encourage audits of how often indigestion is recorded before a cardiac diagnosis is made.

Public health messages remain simple. If chest pain is severe, pressure-like, or keeps returning, call emergency services. Do not drive yourself to hospital. Tell clinicians if the pain spreads to the arm, jaw, or back, or if you feel clammy, sick, or short of breath.

This case is a stark reminder that heart disease does not fit tidy stereotypes. A nurse with “crushing” chest pain deserved the fastest route to testing. The inquest will determine what happened and what needs fixing, but the lesson is already clear: take chest pain seriously the first time. Watch for the coroner’s findings and any formal recommendations aimed at preventing another loss like this.

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