On 21s October 2016 commenced an investigation into the death of Sian Marie Hollands]. The investigation concluded at the end of the inquest on 10"Aprl 2017] The conclusion of the inquest was The death of Sian Holland was due_to the failures ofthe doctors at Darent Valley_Hospital to examine,diagnose and treat her for_pulmonar embolism following her_admission to the hospital_The medical cause of death was Bilateral Pulmonary Thromboemboli CIRCUMSTANCES @F THE DEATH Sian Hollands became unwell on 14/11/2015 Her friend called an ambulance and she was taken to Darent Valley Hospital A & E, 18.38_She had complained of breathlessness_chest pain and feeling that she was withdrawing Trom opiates asshe had not had methadone Sian had also had surgery for an ectopic pregnancy at Ashford and St Peter's Hospital on 26.10,15 Sian was seen by an A & E doctor at 19.57 After_taking_her_history_and_examining_her the doctor_arranged for_her to have fluids and blood tests and then discussed her care with an A & E consultant and medical registrar She_ remained in hospital for treatment with diazepam Inthe early_hours of 15.11.15 Sian complained of chest pain and wanted to seea doctor_The doctors were busy but advised she should have an ECG which she refused She_was seen at 10 3Oby an A & E consultant who felt she was suffering from withdrawal and prescribed her methadone TShewas reviewed aqain in the_aiternoon but was_sleeping and therefore deemed suitable for discharge_ Sian was_seen by a physiotherapist who was unable to assess_her mobility as requested because_of shortness of breath and chest pain when trying to walk The_physiotherapist asked that she be_reviewed again by a doctor_ Sian_was reviewed at approximately 1900 by the A & E consultant and who concluded that she may have a pulmonary embolus and transferred to resus for ongoing care_ Sian suffered a cardiac arrest and death was confrmed at 21.52

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.