A Tasmanian coroner has not recommended any changes despite finding the level of care at Launceston General Hospital given to a woman was "unacceptable".
On Christmas Day in 2020, Helen Mary Badcock was at her home in Deloraine when she developed significant pain in her abdomen and numbness in her right leg.
Her daughter called an ambulance and paramedics found the 77-year-old to be alert and not distressed.
In his findings, coroner Simon Cooper said attending paramedics made a note that they "were unable to find blood pressure on her right-hand side".
Ms Badcock was taken to the Launceston General Hospital where staff carried out a CT scan of her spine, showing degenerative spinal disease.
Hospital staff determined her presentation to the hospital was due to the mild spinal degeneration and she was discharged.
Instead, Ms Badcock had suffered a tear in the inner layer of the aorta, the large blood vessel of the heart.
"The fact that Ms Badcock had suffered an aortic dissection should have been apparent because of the inability to obtain a blood pressure on her right side — something ambulance paramedics noticed and recorded, but staff at the Launceston General Hospital did not," he noted.
Medical records for Ms Badcock from the LGH contain no record of blood pressure measurements in both arms and nothing with regard to pulse deficits.
There was also no record of anything in the nature of a cardiovascular examination occurring.
Mr Cooper said Ms Badcock showed "obvious signs that she was highly likely to have been suffering from an aortic dissection when she was at the LGH".
The findings were sent to the LGH for comment and Mr Cooper said in return he received the results of a review commissioned in relation to the death of Ms Badcock and another patient.
He found the review of the case failed to amount to evidence of a "systemic issue of misdiagnosis of aortic dissection".
But when considering the evidence as a whole, Mr Cooper concluded that the care received by Ms Badcock was "not of an acceptable standard".
Despite the findings, Mr Cooper said the circumstances of Ms Badcock's death "are not such as to require me to make any comments or recommendations".
In a statement, LGH executive director of medical services Peter Renshaw extended his "sincere condolences" to Ms Badcock's family and noted that there had been "hospital-wide learning and staff education" following investigations into the patient's death and treatment provided.
