Doctors failed a young mum-of-three who died hours after being discharged from hospital, a coroner ruled.
Sian Hollands died suffered a heart attack and died after doctors discharged her from hospital.
The 25-year-old collapsed on her way out of the building and was rushed into intensive care but medics could not save her.
A&E consultants failed to spot signs of the blood clot, despite ambulance paramedics having noted chest pains, stomach pains, and shortness of breath, all of which were present throughout Sian’s time in hospital.
Both Dr Leila Mohamed and Dr Kamran Khan who saw Sian when she was admitted to Darent Valley Hospital in Kent said they did not have access to the ambulance notes and that the patient was only complaining of abdominal pain.
But agency nurse Emeleen Sarenas picked up on Sian’s symptoms when she started looking after her on the morning of November 15, 2015, and spoke with Dr Khan before he assessed her for the first time at 10.50am.
Dr Khan initially denied being aware of Sian’s chest pain and shortness of breath but Sian’s medical notes showed his handwriting scrawled on the other side, proving that he not read them in full.
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 pain was put down to withdrawal rather than a pulmonary embolism, first when Sian was admitted the evening before she died, then by another consultant on the Sunday.
Dr Angela Feazy, who was brought in from Tunbridge Wells Hospital as an independent expert to look into the death said it was a “serious failure” to not consider possibilities other than withdrawal.
She said during questioning by barrister Edward Ramsay, representing Sian’s family: “All of her symptoms were compatible with a diagnosis of pulmonary embolism.
“There seems to have been an acceptance that she was suffering from withdrawal and other symptoms were not considered.”
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.
Yesterday (Mon) a coroner at Gravesend’s Old Town Hall concluded that Sian’s death was due to failures of doctors to examine, correctly diagnose, and treat her for a pulmonary embolism following admission to hospital.
Coroner Roger Hatch said: “Had they done so, on the balance of probability, she would not have died.”
The inquest was originally due to start on January 30, but was called off after two days as it emerged that Dr Khan needed legal representation, having disputed the trust’s admission that his decision to discharge her was a mistake.