Doctors failed to respond to the concerns of nurses just hours before a young mum-of-three died in hospital, an inquest heard.

Sian Hollands, 25, died shortly before 10pm on Sunday, November 15, 2015 at Darent Valley Hospital after going into cardiac arrest.

The former drug addict was admitted to A&E the day before with chest and abdominal pains, shortness of breath, and she had recently had surgery after an ectopic pregnancy, all of which are symptoms of the pulmonary embolism given as the medical cause of death.

Consultant Dr Kamran Khan told the inquest at Gravesend's Old Town Hall earlier this week that he was not made aware of all of her symptoms because he did not have access to ambulance records or notes taken by nurses.

But yesterday the inquest heard from agency nurse Emeleen Sarenas, who said she first made Dr Khan aware of Miss Hollands' symptoms and her 'patient at risk score' at 10.30am on the day she died - 20 minutes before he saw the patient himself.

Miss Hollands continued to feel unwell throughout the morning and afternoon and an ECG scan was taken at 1pm. She was then given oxygen after her risk score escalated at 2pm.

Ms Sarenas said she raised her concerns at 12pm, 1pm, 2pm, 2.25pm, 2.30pm, and 3.30pm, which was when Dr Khan saw Miss Hollands for the last time and said she could be discharged if her condition improved when she woke up.

But she still felt unwell and refused to leave the hospital, spending the rest of the afternoon sat up in a chair waiting to see a doctor in the medical short stay area.

Amanda Fry was a senior nurse on the hospital's integrated discharge team, responsible for helping patients with mobility issues get home.

She saw Miss Hollands at 5.15pm, who was asking for an ambulance to take her home and help her up the stairs to get to her third-floor flat in Priory Hill, Dartford.

"She didn't look right and I was unhappy with her condition," she said.

"She said she was unwell, she was dizzy, lethargic, had shortness of breath, and chest pains.

"After 40 years of nursing if my alarm bells ring I escalate it."

Miss Hollands was deemed not to be in a fit condition for a stairs assessment and Ms Fry reported her concerns to consultant Dr Peter Varasteanu, who had taken over the entire A&E department from Dr Khan.

It was her understanding that Miss Hollands would be seen at 5.30pm, but she was not.

Nurse Caterina Ponte began her shift on the short stay ward at 7pm. She said Miss Hollands told her that she was not feeling well and was asking when she was going to be seen by a doctor.

"The respiratory rate was increased, she was pale and sweating and asking for ice, and had chest pain," she said.

"The handover said the plan was to discharge her but she was still insistent to see the doctor. She didn't look right."

All witnesses giving evidence on Wednesday noted how busy the hospital's A&E department was during the weekend Miss Hollands was there, with one of its wards under-staffed.

Miss Hollands was not seen by Dr Varasteanu until 7.15pm and was transferred to the resuscitation room at 7.45pm, where her condition continued to deteriorate and she went into cardiac arrest.

Dr Varasteanu told the inquest that he "did not recall" being asked to see Miss Hollands before then and admitted he was "surprised" to hear she was still in A&E, having been on duty when she was admitted on the Saturday.

Both Dr Varasteanu and Dr Khan said pulmonary embolism would have been high on their list of possible diagnoses if they had been aware of all of her symptoms when they saw her during the day.

They also acknowledged Miss Hollands had been "labelled" a heroin addict and that there had been a failure to properly consider a diagnosis other than withdrawal.

Sian was on a methadone programme to help keep her off heroin but had not taken her medication for three days.

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 tomorrow — 501 days after Sian’s death.