“Ms Heath was noted to be warfarin resistant and alternative medication regimes were not…”

The coroner’s concerns

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. 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. 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. 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. 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. 4 4 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 have a medical review or a haematology referral. 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. 10. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: 1. Care Quality Commission I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. SIGNATURE 5 5

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0284

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0