A hospital trust has apologised after “human failings” meant opportunities to properly diagnose a happily married beauty therapist were missed which would have saved her life.

Lucy Cziraki, 36, passed away after collapsing at her home in Tonbridge – just days after she was discharged from hospital.

An inquest into her death concluded on Friday (June 13) at Oakwood House in Maidstone, where area coroner Catherine Wood heard of the failures that led to her death on October 4, 2023.

It was heard how Lucy’s husband, Steven, was woken up at 6am and saw her in “severe pain”. He went out to retrieve some morphine and when he returned she had collapsed.

Emergency services attempted to resuscitate her but were sadly unsuccessful.

A post-mortem conducted by Dr Chambers recorded the medical cause of death was likely to be hemopericardium, which refers to blood in the pericardial sac, and can be caused by a ruptured aortic aneurysm, particularly a type A aortic dissection.

It is a life-threatening condition where the aorta – the body’s largest artery through which oxygen and nutrients travel from the heart to organs throughout your body – ruptures, causing massive internal bleeding.

Ms Wood told the hearing: “At the time, she was living life to the full and was happily married. This was a tragic death of a young woman that has affected a number of lives.”

The court heard how the 36-year-old had underlying health complications and had been in and out of hospital for treatments, including a visit to King’s College Hospital in London.

She had previously been diagnosed with vasculitis, a condition that causes the immune system to attack healthy blood vessels.

On September 29, 2023, Lucy had significant chest pain which was “radiating to her back”.

She was taken by her husband, who she had recently wed, to Tunbridge Wells Hospital, formerly known as Pembury Hospital, and assessed by Dr Elias.

He ordered a CT aortogram scan, a non-invasive technique that provides images of the aorta, allowing clinicians to detect and diagnose a variety of conditions, including aneurysms and blockages.

However, the court heard not all of Lucy’s details were made available and included on the CT request form, which would have been viewed by the radiologist who conducted the screening.

It was believed the abnormality wasn’t picked up on the imaging due to a non-gated CT scan taking place.

Whereas, a gated CT scan minimises the motion of the heart and is vital for cardiac imaging, especially when assessing the coronary arteries and surrounding structures.

Dr Elias indicated during the evidence stage of the inquest the image came up negative but he was still concerned about Lucy.

He referred her for a repeat blood test and “felt it was appropriate” to keep her at the hospital.

A Maidstone and Tunbridge Wells NHS Trust clinician, who was working from another country at the time, reviewed the scans.

She would have looked at clinical referrals first but didn’t have access to all of Lucy’s health history.

Ms Wood stated that aortic dissection shouldn’t have been ruled out straight away.

She added: “This condition was not unheard of. It doesn’t occur very often, but it is still known. It gave false reassurance.”

Lucy was then seen by several other healthcare professionals, all of whom were “misled” by the CT scan images, which showed everything was stable.

They believed it could have been an inflammatory problem or a flare-up of her vasculitis.

The court was told it appeared Lucy’s pain had subsided from the previous day and she was “eating and seemed happy to be going home”.

She was discharged from hospital on October 1 and just three days later passed away at home.

“Had all evidence been made available to each clinician, we might be in a different position – we wouldn’t be sitting here today.”

Ms Wood recorded that her death was by natural causes but provided a narrative conclusion.

She said that “human failings” had allowed Lucy’s death to happen and had further imaging or a different scan been available, it may have shown an aortic aneurysm.

Lucy would have then had an emergency referral to Kings College Hospital, where she’d undergone surgery and most likely survived.

The area coroner added: “Had all evidence been made available to each clinician, we might be in a different position – we wouldn’t be sitting here today.

“I want to turn to the family and offer my sincere condolences. It was a tragic loss of a young life.

“I’m sure she’d be proud of how you have coped admirably. All we can do is learn and move forward.”

Ms Wood recognised that Maidstone and Tunbridge Wells NHS Trust had made several changes in its practice to avoid such an event happening again.

In January last year, it launched the West Kent Community Diagnostic Centre – a multi-million-pound facility near Maidstone Hospital with advanced X-rays, CT, MRI, DEXA and ultrasound scans.

A spokesperson for Maidstone and Tunbridge Wells NHS Trust said: “Our thoughts remain with Lucy’s family and friends and we are very sorry her care fell short of the high standards our teams work hard to provide.

“Following a thorough review of Lucy’s care, the trust took steps to address the issues identified.

“We are fully committed to learning, developing and improving our services following any recommendations from the coroner.”

“Following a thorough review of Lucy’s care, the trust took steps to address the issues identified.”

A King’s College Hospital NHS Foundation Trust spokesperson added: “We would like to offer our deepest condolences to Cziraki’s family and loved ones following their loss.”

Ceilidh Robertson, Leigh Day senior associate solicitor who represented Lucy’s family, commented: “This Inquest has been incredibly difficult for all those involved.

“The process has facilitated a thorough investigation into Lucy’s death and found that she would likely still be alive had she received different care.

“It is encouraging that the coroner has decided to issue a prevention of future deaths report to the Department of Health and I sincerely hope that action is taken and lessons are learned so that no other families have to experience such a devastating loss.”

According to the Aortic Dissection Charitable Trust, aortic dissection is a treatable condition and has a better than 80% survival rate when it’s diagnosed and treated on time.

Yet, as of 2022, 50% of people who are struck by this condition, die.