Published: 11:22, 10 April 2017
Doctors failed a young mother-of-three who died hours after being discharged from hospital, a coroner has ruled.
Sian Hollands, 25, died of a pulmonary embolism at Darent Valley Hospital shortly before 10pm on Sunday, November 15, 2015, after going into cardiac arrest.
A&E consultants failed to identify signs of the blood clot, despite ambulance paramedics having noted chest pains, abdominal pains, and shortness of breath, all of which were present throughout Miss Hollands' time in hospital.
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Now, coroner Roger Hatch says she probably would have survived had she been treated properly.
Today, he concluded: "The death of Sian Hollands was due to failures of doctors at Darent Valley Hospital in Dartford to examine, correctly diagnose, and treat her for a pulmonary embolism following admission to hospital.
VIDEO: Sian's family speak after the inquest
"Had they done so, on the balance of probability, she would not have died."
The former drug addict of Priory Hill in Dartford had also had surgery at St Peter’s Hospital in Ashford on October 26 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 therefore put down to withdrawal, first by Dr Leila Mohamed when Miss Hollands was admitted the evening before she died, then by Dr Kamran Khan on the Sunday.
Both told the inquest at Gravesend’s Old Town Hall last month that they did not have access to the ambulance notes and that the patient was only complaining of abdominal pain.
However, agency nurse Emeleen Sarenas did pick up on Miss Hollands’ symptoms when she started looking after her on Sunday morning and spoke with Dr Khan before he assessed her for the first time at 10.50am.
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 has admitted seven failings, 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.
Speaking after the inquest, mum Nicola Smith said: "She was just left and labelled. We as a family are absolutely heartbroken.
"It's been really hard, especially for Marne, the little one - she misses her mummy terribly.
"Being judged, labelled, and ignored is what cost my daughter her life."
She said she thought the hospital had learned lessons from her daughter's death and hoped to see significant changes, but added that she was pursuing a civil claim and will seek advice on whether charges can be brought against certain doctors.
Speaking before the verdict was delivered in an interview with our sister paper, the Dartford Messenger, she said: “She had lots of her own problems but she thought she was a crusader who could help other people. She’d forget the problems she had and go on a mission to help someone else.
“The number of people that came forward after she died, that she’d met through different walks of life, they all said the same thing, which is that she had a good heart."
The inquest was originally scheduled for Monday, January 30, but was called off after two days as it emerged that Dr Khan required legal representation, having disputed the Trust’s admission that the decision he made to discharge her was a mistake.
A statement issued by Dartford and Gravesham NHS Trust said: "We continue to extend our sincere condolences to the family and friends of Sian Hollands.
"We apologise to the family that Sian did not receive the level of care that she was entitled to expect when she came into A&E in November 2015.
"The inquest has highlighted a number of failings in the way that her care was delivered. We will be complying fully with the direction that the Coroner has given.
"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.
"The actions we have taken include, changing our system for recording vital observations to the National Early Warning System (NEWS) so that we can better recognise how severely a patient is deteriorating and escalate appropriately.
"Staffing levels in the Emergency Department have been increased. We now have more doctors in the department providing clinical support over the full 24 hour period.
"A General Manager with a senior nursing background provides support to the staff and clinicians during weekdays between 8am and 8pm. At weekends there is extended Matron cover. Matrons are experienced emergency department nurses who take a leadership role in the department to ensure safety.
"New protocols have been introduced to measure and react to surges in demand in the department and there are plans in place to maintain patient safety and flow.
"Throughout this time we have worked with Sian’s family to make improvements. We were happy to welcome them to the department at the end of last year to show them how things have changed."