Hospital staff missed a number of opportunities to correctly diagnose the condition of a young mum-of-three who died just hours after being discharged, an inquest heard.

Former drug addict Sian Hollands, died on Sunday, November 15, 2015 at Darent Valley Hospital after going into cardiac arrest.

The 25-year-old had been taken into A&E by ambulance the day before, just weeks after she had been released from prison and suffered an ectopic pregnancy. She was on a methadone programme to keep her off heroin.

Dartford and Gravesham NHS Trust has accepted seven failures that contributed to her death, and during an inquest this week Dr Kamran Khan admitted that Sian’s poor health was not properly picked up on.

The medical cause of her death given by pathologist Dr Ann Fleming was a pulmonary embolism, a hard to identify clot preventing blood reaching the lungs, but this was not considered by Dr Khan or nurses during their assessments.

Instead they had put her condition down to the fact that she had not had her daily dose of methadone for three days when she was admitted.

Speaking on behalf of Sian’s family, barrister Edward Ramsay said: “A heroin addict comes into A&E — it must be withdrawal. There was a failure to consider other possibilities.”

Dr Khan admitted that was the case, but insisted he had not considered pulmonary embolism because he was not aware of Sian complaining of chest pain, which he acknowledged would have made “all the difference”.

He said he was told about her methadone programme and ectopic pregnancy, but said Sian only complained to him of abdominal pain when he first saw her at 10.50am on the Sunday.

He told the hearing at Gravesend’s Old Town Hall on Tuesday that his initial assessment was that she was dehydrated or suffering from withdrawal, insisting that he had not been told of any chest pain.

Sian had complained of chest pain overnight and earlier in the morning, and it had been noted by ambulance paramedics, alongside shortness of breath and difficulty walking.

Dr Khan said: “If I had been shown the ambulance records and shown the nurse’s notes, pulmonary embolism would have been high on the list of considerations.”

On the first day of the hearing, Dr Leila Mohamed, a nurse who looked after Sian on the Saturday, told the hearing that she also had not seen the notes taken by the ambulance crew.

She admitted she had no experience of dealing with patients having withdrawal from methadone or heroin, but defended her assessment of Sian.

“You can tell from looking at a patient if they look well or unwell — you don’t just rely on numbers and figures,” she said.

“She told me she had no chest pain. The patient knows best. Dehydration and methadone withdrawal could both have explained her symptoms. She did not present me with any symptoms or signs of a pulmonary embolism.”

At 1pm on the Sunday, Dr Khan was informed that Sian, of Priory Hill in Dartford, was still complaining of abdominal pain and prescribed paracetamol. The next time he saw her was at 3.30pm and she was asleep. He took the decision to discharge her on the condition that she felt well enough when she woke up.

Mr Ramsay said that the documents required to assess Sian properly “were not in a proper state”, and Dr Khan had therefore failed to consider symptoms that added up to a high ‘patient at risk score’.

Sian’s partner Carl Alleyne spent time with her in hospital on the day she died and was told by nurses that her tests “had come back fine” and she was being sent home because “they needed the bed space”.

Sian, who mum Nicola Smith said had been “in such high spirits” just days before falling ill, never left the hospital. Having left her bed for a wheelchair, Sian started to burn up and Mr Alleyne was told to fetch ice from the on-site Costa Coffee.

By the time he returned, Sian had been taken behind a curtain to a resuscitation room and Ms Smith was also called to the hospital. Sian went into cardiac arrest and was pronounced dead shortly before 10pm.

The week-long inquest, which originally opened on January 30 this year but was pushed back after it emerged that Dr Khan required legal representation, continues today and is scheduled to conclude on Friday — 501 days after Sian’s death.