Lacey Heath

Date:23 July 2026 

H.M Area Coroner 
Ms Sonia Hayes 
SEAX House 
Victoria Road South 
Chelmsford 
Essex 
CM1 1QH 

Dear Ms Hayes,  

Regulation 28 Report to Prevent Future Deaths – Miss Lacey Carol Anne Heath 

I write further to your Prevention of Future Deaths Report, dated 28 May 2026, following 
the conclusion of the Inquest touching on the death of Miss Heath. 

We have considered your concerns and now set out our formal response to each matter 
using your numbering as follows. 

Matters of Concern 

1.  Ms Heath was noted to be warfarin resistant and alternative medication regimes 
were  not  successful  in  keeping  Ms  Heath  within  a  therapeutic  range  for  her 
required lifelong requirement to have anticoagulation to prevent a significant 
risk of death. The GP and hospital clinicians trailed different combinations of 
appropriate therapy which included additional injections when required. This 
was not considered to be clinically appropriate long-term. 

We  recognise  the  importance  of  clinically  appropriate  plans  being  in  place  for  our 
patients.  Therefore,  we  are  implementing  a  high-risk  anticoagulation  pathway  for 
patients with persistent sub-therapeutic INR, suspected warfarin resistance, complex 
anticoagulation  requirements  or  repeated  instability  despite  appropriate  dose 
adjustment.  

The pathway  will  define  criteria for senior clinical  review,  frequency  of  INR testing, 
escalation thresholds and documentation requirements. This is due for completion by 
the end of July 2026.  

Patients  with  prolonged  sub-therapeutic  INR  or complex  anticoagulation needs  will 
be  identified  promptly  and  receive  documented  senior  review.  There  will  be  an 
approved  pathway,  staff  communication,  sample  audit  of  high-risk  cases  and 
evidence of escalation decisions recorded in the clinical record. 

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 To  maintain  oversight  and  sustainability,  the  divisional  governance  team  will 
undertake a monthly audit of high-risk anticoagulation cases for the first three months 
following implementation; thereafter there will be a quarterly audit.  

Any  issues  detected  in  the  audits  will  be  reported  through  Pathology  Governance 
group and Broomfield Quality and Safety Hospital Group. Exception reporting at the 
site  level  feeds  up  directly  into  trust-wide  board  ensuring  oversight  at  a  Senior 
Leadership Level.  

2.  Due to the complexity of her case, Ms Heath’s anticoagulation was under the 
care  of  the  acute  hospital  team.  Alternative  anticoagulation  medication  had 
resulted in high INR readings and significant risks associated with bleeding. 

By  the  end  of  August  2026,  we  will  have  conducted  a  complete  review  of  the 
anticoagulation service escalation process for complex patients under hospital care.  

We plan to introduce a documented requirement for complex cases including high INR 
readings, bleeding risk, recurrent instability or failed alternative regimes to be reviewed 
by a senior clinician and, where appropriate, haematology. This will establish a clear 
escalation route for complex anticoagulation patients.  

An  updated  standard  operating  procedure  will  be  devised  to  reflect  this  approach, 
which will include clearly defined senior review criteria.  

Communication  of  the  new  process  will  be  undertaken  will  all  anticoagulation  staff. 
There  will  be  a  quarterly  governance  audit  of  complex  anticoagulation  cases  and 
escalation of any compliance concerns.  

Any audit exceptions will be reviewed through the hospital site governance assurance 
groups, and appropriate actions will be assigned where documentation or escalation 
is incomplete or below the expected standard.  

3.  Ms  Heath’s  experienced clinical  team  did  not  consider  that there  had been a 
sufficient  trial  of  Warfarin  and  recommended  at-home  monitoring  to  permit 
daily  readings  to  be  taken  to  manage  the  significant  risks  associated  with 
anticoagulation and to find an individualised dose for Ms Heath. Clinicians were 
not concerned about medication non-compliance and that the difficulties were 
clinical. 

By the end of September 2026, a robust process for home INR monitoring will be in 
place.  Prior to home monitoring proceeding, we will conduct a detailed assessment 
of patient suitability, any training needs, equipment requirement, general support and 
governance, and follow-up arrangements as necessary. This new process will ensure 
that decisions to recommend, decline or defer self-testing are clearly recorded with the 
rationale, and always discussed with the patient and, if possible, their family or carers.  

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 4.  Ms Heath could not afford to fund the at home monitor as this was financially 
prohibitive for her being on a low income. The monitor was expensive and there 
is  no  obligation  for  General  Practitioners  to  fund  the  testing  strips  and 
incidentals required to facilitate testing. As this would be a lifelong commitment 
for  a  woman  who  was  only  34  years-old,  Ms  Heath  was  not  able  to  take  the 
advice  of  her  expert  clinical  team  and  was  compelled  to  have  alternative 
prescribing  that  was  not  successful  in  keeping  her  INR  within  therapeutic 
range. 

By  the  end  of  September  2026  we  will  have  a  process  for  escalating  cases  where 
recommended  anticoagulation  monitoring  equipment  or  consumables  may  be 
clinically required but financial barriers are identified. This will include signposting to 
available  funding  routes,  individual  funding  consideration,  charitable  support  or 
commissioner discussion where applicable.  

Where financial barriers for clinically recommended monitoring are identified, they will 
be escalated and documented.  We plan to introduce funding and escalation guidance 
that  will  be  communicated  to  relevant  staff.   To ensure  the new process  is working 
effectively, we plan to complete audits of funding applications. 

5.  No application for funding was made on behalf of Ms Heath by the Trust nor 
was this explained to Ms Heath who a very quiet, shy lady who always relied on 
her very loving family to assist her with appointments and could not advocate 
for herself. There was no consideration if Ms Heath had any learning difficulties 
and it was noted that there was developmental delay in her medical records. 
Evidence at the inquest was Ms Heath experienced this as clinicians not caring 
about  her  and  she  became  very  despondent  about  the  failure  to  achieve  a 
therapeutic range.  

By  the  end  of  October  2026,  we  plan  to  introduce  a  prompt  within  the  high-risk 
anticoagulation pathway requiring clinicians to consider whether the patient may need 
additional communication support, family/carer involvement, reasonable adjustments 
or  advocacy  where  records  or  presentation  suggest  vulnerability,  developmental 
delay, difficulty self-advocating or reduced understanding of risk. 

This  will  ensure  that  patients  who  may  have  additional  communication  or  support 
needs are recognised and supported in risk discussions and decision-making. This will 
be  by  way  of  a  pathway  prompt,  staff  briefing,  audit  of  high-risk  cases  for 
documentation of support needs, family/carer involvement and agreed follow-up plans. 

The  effectiveness  of  this  prompt  and  pathway  will  be  monitored  by  the  Patient 
Experience and Learning Disability teams and reported to the Pathology Governance 
group. 

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 6.  Ms Heath did not manage to achieve a therapeutic INR for a protracted period 
of time putting her at increased risk of developing complications and did not 
have a medical review or a haematology referral.  

A defined trigger will be set  for medical review and/or haematology referral when  a 
patient INR remains outside therapeutic range for a prolonged period; when repeated 
appointments are not attended during a high-risk period; or when treatment instability 
persists  despite  appropriate  intervention.  This  will  include  a  requirement  for 
documented clinical rationale where referral is not made.  

This  will  allow  patients  with  prolonged  poor  INR  control  to  receive  timely  medical 
review and specialist input where indicated.  

The  referral and  escalation  criteria  will  be  updated  along  with a  referral log,  clinical 
record audit and governance review of any cases breaching trigger thresholds. 

7.  There was an absence of appropriate medical records recorded for Ms Heath to 
understand her clinical presentation other than very basic information on the 
INR platform on INR results and medication dose. Evidence was these records 
are not compliant with the requirements of healthcare regulators and led to a 
lack  of  appreciation of  Ms  Heath’s  concerns  and the  complexity  of  her  case. 
One  entry  stated  Ms Heath  had been “unwell” with  no clarification or  further 
information on what the problem was and/or how this may have impacted on 
her condition. 

We are reviewing documentation standards within the anticoagulation service, and we 
will implement a structured clinical note template for contacts, missed appointments, 
patient-reported  symptoms  such  as  “unwell”,  risk  discussions,  escalation  decisions, 
advice given and follow-up plan by the end of October 2026. This will explore system 
functionality for persistent alerts or pinned critical risk information. 

Clinical records will show clear evidence of the patient’s presentation, risks, advice, 
escalation  and  follow-up.  Critical  risk  information  will  then  remain  visible  to  staff 
reviewing  the  case.  There  will  be  an approved note template,  staff  briefing,  sample 
documentation audit and outcome of clinical system review. 

Monthly  documentation  audits  will  be  undertaken  for  the  first  three  months  after 
implementation, followed by quarterly intervals. Results and improvement actions will 
be monitored through the Pathology Governance group and included in service quality 
reports. 

We are currently in the process of introducing a new single electronic patient record 
(‘EPR’) system across our trust. This EPR will replace/integrate with current systems 
services in all areas and will be for all our hospital sites. 

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 This system will provide real-time and accurate information on a patient’s history to 
support  clinical  decision  making.  Clinicians  will  have  the  ability  to  add  and  access 
information  to  support  quicker  and  personalised  care  for  our  patients,  reducing  the 
need for paper-based processes and multiple systems.  

The system is currently in its testing stage, expected to run through the remainder of 
the year. As per current timelines, the system is expected to go live in June 2027. 

Once established, the addition of the new EPR will be twofold: 

1.  The observations will be in the new EPR for all encounters across the trust from 

the date it goes live 

2.  All new electronic notes will be visible within the notes 

In the interim we will use our current INR monitoring system, INRstar, to conduct INR 
checks.  

Following implementation of the new EPR there will be further consideration as to its 
use and its suitability and combability.  

If I can assist any further with these matters, please do not hesitate to contact me.  

Yours sincerely, 

Chief Executive 
Mid and South Essex NHS Foundation Trust                           

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Ms Sonia Hayes 
Essex and Thurrock Coroner’s Service 
Essex County Council 
Seax House 
Victoria Road South 
Chelmsford 
CM1 1QH 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

9th July 2026  

Dear Ms Hayes, 

Re: Regulation 28 Report to Prevent Future Deaths – Lacey Carole Anne Heath 
who died on 16th February 2025.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 28th 
May 2026 concerning the death of Lacey Carole Anne Heath on 16th February 2025. 
In advance of responding to the specific concerns raised in your Report, I would like 
to express my deep condolences to Ms Heath’s family and loved ones. NHS England 
is keen to assure the family and yourself that the concerns raised about Ms Heath’s 
care have been listened to and reflected upon.   

Your Report raises the following concerns: 

1.  Although  Ms  Heath’s  experienced  clinical  team  recommended  an  at  home 
monitor  be  utilised  to  attempt  to  achieve  a  therapeutic  INR  range  due  to  the 
complexities of her case, NICE Guidance on anticoagulation states that at home 
monitor  is  not  funded  by  the  NHS  and  there  is  no  obligation  for  General 
Practitioners  to  fund  the  testing  strips  and  incidentals  required  to  facilitate 
testing. This means patients, such as Ms Heath who was on a low income, are 
prohibited  from  using  this  tool  to  attempt  to  achieve  a  therapeutic  range  with 
appropriate oral medications. 

2.  No application for funding was made on behalf of Ms Heath by the Trust nor was 
this explained to Ms Heath. There was no consideration if Ms Heath had any 
learning difficulties and it was noted that there was developmental delay in her 
medical records.  

3.  Ms Heath was at increased risk of developing complications with her INR results, 
but  this  was  not  escalated  and  so  her  clinic  appointment  with  INR  testing 
remained the same. 

4.  Hospital Medical records were not compliant with the requirements of healthcare 
regulators  and  led  to  a  lack  of  appreciation  of  Ms  Heath’s  concerns,  the 
complexity  of  her  case  and  the  ongoing  risk  to  Ms  Heath.  Staff  used  an 
electronic platform to record INR and medication dose and have no other place 
to record anticoagulation records within the anticoagulation clinic. Evidence was 
these records are not compliant with the requirements of healthcare regulators 
and led to a lack of appreciation of Ms Heath’s concerns and the complexity of 

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 her case. One entry stated Ms Heath had been “unwell” with no clarification or 
further information on what the problem was and/or how this may have impacted 
on her condition. 

Concern 1 and 2: Funding for home monitoring for anticoagulation 

Funding responsibility for at-home INR monitoring, can sit across different parts of the 
system  depending  on  the  clinical  pathway  and  who  held  responsibility  for  ongoing 
anticoagulation management. From an anticoagulation perspective, commissioning of 
services is the responsibility of Integrated Care Boards (ICBs).  

INR machines are not prescribable on an NHS primary care prescription, and may or 
may  not  be  included  within  routine  anticoagulation  service  specifications.  Most 
commonly, patients are asked to provide their own INR machine, and then the strips 
and  other  consumables  are  provided  by  the  NHS  on  prescription  via  the 
anticoagulation service directly or via their GP. However, this will vary by ICB.   

This case is exceptional, however, as there was a clear clinical need for an INR home 
testing  machine.  As  such  an  approach  for  funding  should  have  been  made  by  the 
anticoagulation  service  to  the  ICB  for  this  individual,  if  not  routinely  included  in  the 
service specification. 

While at-home INR monitoring is not routinely commissioned, an Individual Funding 
Request (IFR) process exists to enable consideration of funding in cases of clinical 
exceptionality. In circumstances such as Ms Heath’s, an IFR application could have 
been  submitted  by  the  responsible  specialist  clinician  to  support  access  to  non-
routinely commissioned interventions where there is evidence of exceptional clinical 
need. However, no application was made in this case.  

We are aware you have also directed your Report to Essex ICB who will be providing 
a detailed response. They have, however, informed the NHS England East of England 
regional team that whilst they do not routinely commission at-home INR testing they 
are always happy to receive IFR requests for exceptional cases.  

Essex  ICB  have  contacted  providers  to  reinforce  the  role  of  the  IFR  process  in 
supporting  access  to  non-routinely  commissioned  interventions  where  standard 
policies do not meet the needs of clinically complex patients. They have reiterated that 
requests  must  be  made  prospectively  by  the  responsible  clinician,  and  they  must 
ensure  that  patients  are  appropriately  supported  to  understand  available  options 
where treatments fall outside routine commissioning. 

The  ICB  will  continue  to  work  with  provider  organisations  to  promote  consistent 
understanding and application of the IFR process, supporting equitable access to care 
and reducing the risk of similar circumstances arising in future. 

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 Concern 3: Lack of escalation  

We  note  that  you  have  also  addressed  your  Report  to  Mid  &  South  Essex  NHS 
Foundation Trust, who would be best placed to answer this concern as it relates to the 
practice of specific practitioners.  

Concern 4: Medical Records Non-Compliance 

We  note  that  you  have  also  addressed  your  Report  to  Mid  &  South  Essex  NHS 
Foundation Trust, who would be best placed to answer this concern as it relates to 
practice of specific practitioners.  

It is not clear from the Report which staff were non-compliant with keeping accurate 
medical records, but both the General Medical Council’s Good Medical Practice and 
Nursing  and  Midwifery  Council’s  Standards  detail  what  is  required  of  doctors  and 
nurses when keeping contemporaneous records.  

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking place around the Reports to Prevent Future Deaths. All reports received are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures that key learnings and insights around events, such as the sad death of Ms 
Heath’s, are shared across the NHS at both a national and regional level and helps us 
to  pay  close  attention  to  any  emerging  trends  that  may  require  further  review  and 
action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director  
NHS England  

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