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A health trust has released a staff training video urging them to take a less judgmental approach when dealing with patients.
It comes four years after the death of Sian Hollands, a mother of three and former drug addict from Dartford, who died after consultants at Darent Valley Hospital failed to identify the signs of a blood clot.
The 25-year-old was admitted to the hospital on November 14, 2015 suffering from chest pains, abdominal pains, and shortness of breath.
The following day, she was discharged but died shortly before 10pm from a pulmonary embolism after going into cardiac arrest.
Doctors who saw to Miss Hollands, who was on a methadone programme, put her symptoms down to drug withdrawal.
Nicola Smith, Sian's mother, made the video for Dartford and Gravesham NHS Trust to mark four years since her daughter's death.
She said: "On the November 15 2015 my family's life changed due to the tragic death of my daughter Sian.
"I continually fought for someone to listen, I had numerous meetings with the hospital but seemed to hit a brick wall.
"After lots of meeting and endless paperwork I was finally blessed with meeting the chief nurse Siobhan and the new chief executive Louise Ashley finally I was heard.
"I have worked alongside the hospital to make a video to make staff stop and think so that something can be learnt from my daughter's unnecessary death.
"It's been a long four years and we miss Sian every day but I will continue to get Sian's story heard.
"Sian left behind three beautiful children who miss her terribly. All we ask as a family is please be non-judgemental."
Trust chief executive Ms Ashley said: "Whilst I know that all our staff come to work do the best for their patients, sometimes we do not get it right.
"In the case of Sian we made judgements about her previous lifestyle choices and it interfered with our clinical decision making.
"Unfortunately we can’t go back and change what happened on that night in November 2015, but thanks to the extreme courage and determination of Nicola - Sian’s mum - and her family, we can all learn lessons so that Sian’s story is never repeated.
"I would like to thank Nicola for working with our chief nurse to make this training video.
"We will be using it to educate staff in the importance of getting the facts right, making non-judgemental decisions and being honest and open with families even when we are not proud of the care we have given.
"Our mistakes that night changed the life story of Sian’s children and family forever and for that I am truly sorry but our commitment is that by working together with Nicola we can learn important lessons and improve the care we deliver for all our patients."
