Published: 22:37, 31 March 2017
A young mum-of-three who died just hours after being discharged from hospital may still be alive if doctors hadn’t missed multiple opportunities to correctly diagnose her condition, an inquest heard.
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.
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 heroine, 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 this week 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 on Friday 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.
Friday’s 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.”
The inquest in full
She added that there were multiple opportunities to make the diagnosis and that had it been made earlier in the day - “on the balance of probability” - Miss Hollands may not have died.
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.
Nurse Ms Sarenas told the inquest that she had raised her concerns numerous times throughout the afternoon as a prescription of methadone had failed to improve Miss Hollands’ condition, but Dr Khan chose to discharge her at 3.30pm while she was asleep, on the condition she felt better when she woke up.
When she did she continued to feel unwell and former partner Carl Alleyne refused to take her home. She was moved from her trolley into a chair in the medical short stay unit because the department was said to be extremely busy and bed space was needed.
Despite her condition the plan to send her to her home was still in place until she was seen by Amanda Fry from the hospital’s integrated discharge team at 5.15pm.
“She didn’t look right and I was unhappy with her condition,” she said.
“After 40 years of nursing if my alarm bells ring I escalate it.”
She reported her to consultant Dr Peter Varasteanu, who had taken over from Dr Khan, but he did not go to see Miss Hollands until 7.15pm.
He said he “did not recall” being asked to see Miss Hollands before then but like Dr Khan admitted that she had been labelled as an addict and that she must be suffering from withdrawal.
At 7.36pm he identified pulmonary embolism as the possible diagnosis - the first time it had been since she was admitted to the hospital - and she was taken to the resuscitation room at 7.45pm.
She went into cardiac arrest shortly after 8pm and was pronounced dead at 9.52pm.
Coroner Roger Hatch will deliver his verdict on Monday, April 10 - 511 days after Miss Hollands’ death.
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.