An 84-year-old woman presented to the emergency department with a sudden onset of chest pain, shortness of breath and vomiting. She had a medical history of hiatus hernia, gastro-oesophgeal reflux disease and asthma only, but had several recent courses of oral steroids to treat her asthma. Initially she was hypoxic, tachycardic and normotensive. ECG was normal, chest X-ray showed a hiatus hernia and right middle zone consolidation. Inflammatory markers were normal. CT angiogram was performed to exclude aortic pathology, for which it was negative. It did however show a large hiatus hernia which had perforated and was communicating with the left lung. The patient deteriorated clinically and became hypotensive and more hypoxic. She was transferred to the intensive care unit but died 36 hours later as she was too unwell to undergo any exploratory surgery.