Published: 10:20, 21 September 2017
A doctor who failed to diagnose the condition of a young mum-of-three who died just hours after he discharged her from hospital has been referred to a medical practitioners tribunal.
Earlier this year a coroner ruled that Dr Kamran Khan was among those who failed to examine, correctly diagnose, and treat 25-year-old Sian Hollands for a pulmonary embolism following admission to Darent Valley Hospital in November 2015, despite her complaining of several symptoms.
Roger Hatch concluded the inquest at Gravesend Old Town Hall by saying that Miss Hollands would probably not have died if she had been treated properly and now Dr Khan, who still works at the hospital, has been referred to a tribunal by the General Medical Council (GMC).
Miss Hollands' mum, Nicola Smith, said: "I am so happy that I finally may get some justice."
The inquest in April heard how Dr Khan first came into contact with Miss Hollands, of Priory Hill, Dartford, on Sunday, November 15, 2015, on the morning after she had been admitted to A&E.
The former drug addict had undergone surgery at St Peter’s Hospital in Ashford just weeks earlier after suffering an ectopic pregnancy, further increasing the chance of a pulmonary embolism.
She was on a methadone programme to keep her off heroin, but had not taken her medication for three days when she was admitted to A&E.
Her condition was put down to withdrawal, first by Dr Leila Mohamed when Miss Hollands was admitted, then by Dr Kamran Khan, who told the inquest that they did not have access to the ambulance notes and that the patient was only complaining of abdominal pain.
Dr Khan initially denied being aware of Miss Hollands’ chest pain and shortness of breath and said a pulmonary embolism would have been high on his list of considerations if he had been, but the inquest heard that this information was available to him.
Evidence emerged in the form of Miss Hollands’ medical notes, which had Dr Khan’s handwriting scrawled on the other side, proving that he not read them in full.
Dr Khan had already admitted that Miss Hollands was “labelled” as an an addict and that diagnoses other than withdrawal were not seriously considered as a result.
The evidence was provided by Dr Angela Feazy, a doctor from Tunbridge Wells Hospital brought in as an independent expert to look into Miss Hollands’ death.
“All of her symptoms were compatible with a diagnosis of pulmonary embolism,” she said during questioning by barrister Edward Ramsay, representing Miss Hollands’ family.
“There seems to have been an acceptance that she was suffering from withdrawal and other symptoms were not considered.”
When asked by Mr Ramsay whether it was a “serious failure” to consider possibilities other than withdrawal, she said it was.
Dartford and Gravesham NHS Trust admitted seven failings following Miss Hollands' death, including a failure to consider different diagnoses, a failure to recognise a deteriorating patient, and a failure to pass on key information during the handovers between consultants.
A spokesman said: "We have looked closely at our procedures in the emergency department and produced a detailed action plan to help prevent this type of serious incident from happening again."
Police made initial inquiries into whether any criminal offences had taken place, but no charges were brought.
No date has yet been set for Dr Khan's tribunal.
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