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An NHS trust has changed how it monitors patients on anticoagulants, following the death of a patient.
This came in response to a ‘Prevention of future deaths’ report (PFD), published online on 6 August 2026 and written by coroner Sonia Hayes.
The PFD revealed that Lacey Heath, aged 34 years — who had Turner’s syndrome and a bicuspid valve — died of prosthetic aortic valve thrombosis with sub-therapeutic anticoagulation on 16 February 2025, following a collapse at home.
Heath was deemed a complex patient who, following an aortic graft, required life-long anticoagulation and was at higher risk of developing cardiac problems, the coroner wrote.
The report also noted that Heath had warfarin resistance, and her clinical team had “struggled” to find a therapeutic anticoagulation drug regimen, adding that the team “did not consider that there had been a sufficient trial of warfarin and recommended at-home monitoring to permit daily anticoagulation readings”.
However, the at-home monitor was expensive and “there is no obligation for general practitioners to fund the testing strips and incidentals required to facilitate testing”, the coroner continued.
“[Heath] was compelled to have alternative prescribing that was not successful in keeping her INR [international normalised ratio] within therapeutic range,” it added.
The patient had been unable to achieve a therapeutic INR for a protracted period of time, and between January 2025 and February 2025 — shortly before her death — her anticoagulation was noted to be sub-therapeutic, the report noted.
In a response to the coroner’s report, published on 23 July 2026, Mid and South Essex NHS Foundation Trust and its integrated care board (ICB) said it was “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 would allow patients with prolonged sub-therapeutic INR or complex anticoagulation needs to be identified promptly and receive documented senior review, the trust said.
It also committed to reviewing its anticoagulation service escalation process for complex patients under hospital care by the end of August 2026.
The trust added that this would “establish a clear escalation route for complex anticoagulation patients”, including where home monitoring may be clinically required, but financial barriers for the patient have been identified.
The trust also said it would establish a “defined trigger” for medical reviews and/or haematology referrals when certain criteria are met, including if a patient’s INR remains outside the therapeutic range for a prolonged period.
Responding to concerns raised by the coroner about a lack of “appropriate medical records”, the trust said it was reviewing documentation standards for the anticoagulation service.
It added that it is also in the process of introducing a new single electronic patient record system across the trust — expected to go live in June 2027 — which will “provide real-time and accurate information on a patient’s history to support clinical decision-making”.
Katherine Stirling, consultant pharmacist in anticoagulation and thrombosis at Leeds Teaching Hospitals NHS Trust, commented: “All healthcare professionals looking after patients on vitamin K antagonists (VKAs) should have guidance in place regarding when to cover high thrombotic-risk VKA patients, who present with a low INR, with an injectable quick-acting anticoagulant, such as a low molecular weight heparin.
“They should also know who and where to escalate to for patients who are not responding to usual measures and their INRs remain out of range.
“Self-testing of the INR can improve the time in therapeutic range for patients. In this case, the access to the self-testing machine due to its cost seemed to have been an issue.
“Services could consider applying for local charity funding to buy self-testing machines and testing strips for low-income patients who may benefit but would otherwise not be able to afford the machines,” she added.
In its response to the coroner’s report, published on 9 July 2026, NHS England said that while self-testing machines are not routinely commissioned, in the event of a clear clinical need, “an approach for funding should have been made by the anticoagulation service to the ICB for this individual”.
“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,” NHS England added.
NHS England added that the ICB had since “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”.
