A coroner has found that a Lurgan woman who died after a heart attack should have been taken to hospital by ambulance staff who attended her home hours earlier. Elizabeth O'Hagan, 54, died at the Royal Victoria Hospital in Belfast on 12 October 2021, three days after first calling for help with chest pain.

At an inquest held at Laganside Courts in September and October 2025, Coroner Maria Dougan ruled that the initial ambulance crew ought to have conveyed Mrs O'Hagan to Craigavon Area Hospital for further assessment. She found that had this occurred, Mrs O'Hagan would more likely than not have survived.

The inquest heard that Mrs O'Hagan called 999 at around 10.55am on 9 October 2021, after developing central chest pain, shortness of breath, dizziness and nausea. She had received news earlier that morning that her father had died in England.

Paramedic Shirley Hewitt and Associate Ambulance Practitioner Samuel Wright attended her home at 11.19am. They carried out an assessment, recorded an elevated blood glucose level, performed a 12-lead ECG and administered GTN spray and aspirin. The ECG was interpreted as showing normal sinus rhythm. Mrs O'Hagan was not taken to hospital.

The coroner found that the assessment of Mrs O'Hagan's chest pain was inadequate and poorly documented. No formal pain score was recorded and a repeat ECG was not performed despite continuing symptoms. The coroner also found that the ambulance crew failed to adequately consider the possibility of Acute Coronary Syndrome, despite Mrs O'Hagan's significant risk factors including diabetes and smoking.

A key issue was the advice given about hospital attendance. Mrs O'Hagan's husband, John O'Hagan, told the inquest that the crew said the ECG showed no signs of a heart attack and suggested her symptoms were likely a panic attack. Paramedic Hewitt maintained she recommended hospital attendance, but the coroner preferred Mr O'Hagan's account.

The coroner concluded that Mrs O'Hagan was not clearly informed that a cardiac event had not been ruled out and that further hospital investigations were needed. She found that had Mrs O'Hagan been fully advised, she would likely have agreed to go to hospital.

At around 2.20pm that afternoon, Mrs O'Hagan collapsed at her daughter's home. She suffered a cardiac arrest and was resuscitated by ambulance crews, but sustained severe hypoxic brain injury due to prolonged lack of oxygen. She died three days later after life support was withdrawn.

Expert cardiologists agreed that Mrs O'Hagan would still have suffered a cardiac arrest even if she had been taken to hospital earlier, but that being in hospital would have allowed much faster resuscitation and defibrillation. The first cardiac arrest in the community lasted approximately 36 minutes.

Coroner Dougan found that earlier conveyance would have materially improved Mrs O'Hagan's prospects of survival. She preferred the evidence of one expert who estimated the chances of survival at slightly greater than 50%, concluding on the balance of probabilities that Mrs O'Hagan would have survived without fatal brain injury.

The inquest also heard that the Northern Ireland Ambulance Service (NIAS) accepted findings from a Serious Adverse Incident review and has implemented changes, including a new electronic patient record system that prevents retrospective alterations. Training on cognitive bias has also been introduced.

The coroner extended condolences to Mrs O'Hagan's family. The inquest heard she was a teacher, a mother and grandmother, and an organ donor whose donations helped three people.