A 77-year-old Tasmanian woman who died from an artery tear had been sent home from hospital a day earlier with painkillers after staff didn't correctly diagnose her condition.
Care provided to Helen Mary Badcock at Launceston General Hospital was "not of an acceptable standard" according to coronial findings published on Monday.
She was taken to the hospital by ambulance on Christmas Day 2020 after suffering significant pain and numbness in her right leg while at home with her daughter and granddaughter.
Ambulance paramedics were unable to find a blood pressure on her right side.
Mrs Badcock's condition was reviewed, and her altered leg and foot sensation recorded, at the hospital where a CT scan of her lower back was undertaken.
It showed degenerative spinal disease with very mild canal stenosis, a narrowing of the gap between vertebrae.
"Mrs Badcock was discharged, staff apparently concluding that her presentation was in some way attributable to the mild spinal degeneration indicated in the CT scan," coroner Simon Cooper wrote.
"Unfortunately this conclusion was not correct, as Ms Badcock had suffered a type I aortic dissection."
Mr Cooper said the aortic dissection should have been apparent because of an inability to obtain a blood pressure on Mrs Badcock's right side.
He said it was something ambulance paramedics noticed and recorded, but hospital staff did not.
"Mrs Badcock was discharged home with painkillers, where she died from an aortic dissection in the evening of the following day," Mr Cooper wrote.
Her medical records from the hospital contained no record of blood pressure measurements in both arms and nothing with regard to pulse deficits, unlike the records of Ambulance Tasmania.
Mr Cooper wrote there was no record of "anything in the nature of cardiovascular examination" being carried out.
"Mrs Badcock showed obvious signs that she was likely to have been suffering from an aortic dissection when she was at the (hospital)."
"I think it is clear that staff at the (hospital) did not understand the significance of the blood pressure difference, and thus missed an opportunity to diagnose the underlying cause for her presentation."
Mr Cooper said there was no evidence of systemic issues around misdiagnosis of aortic dissection at the hospital.
"However, that is not the point. Considering the evidence as a whole, I conclude that care received by Mrs Badcock ... was not of an acceptable standard."
