Lacey Heath
28 May 2026 · Coroner Sonia Hayes · Essex
This report repeats 3 earlier warnings. See the linked reports.
The coroner's concerns
1. inadequate anticoagulation management
“Ms [name redacted] was noted to be warfarin resistant and alternative medication regimes were not successful in keeping Ms [name redacted] within a therapeutic range for her required lifelong requirement to have anticoagulation to prevent a significant risk of death”
2. financial barrier to monitoring
“Ms [name redacted] could not afford to fund the at home monitor as this was financially prohibitive for her being on a low income”
3. lack of funding advocacy
“No application for funding was made on behalf of Ms [name redacted] by the Trust nor was this explained to Ms [name redacted]”
4. inadequate medical documentation
“There was an absence of appropriate medical records recorded for Ms [name redacted] to understand her clinical presentation”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“[the deceased]'s medical records at TCT were neither comprehensive nor easy to understand and did not conform to the expected standard”
This report
“There was an absence of appropriate medical records recorded for Ms [name redacted] to understand her clinical presentation”
Identical hazardConfidence 0.90 · high
Earlier report
“Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023”
This report
“There was an absence of appropriate medical records recorded for Ms [name redacted] to understand her clinical presentation”
Closely relatedConfidence 0.85 · high
Earlier report
“Evidence was heard that the mental health crisis staff do not appear to have appropriate access to the primary care mental health System One records and there is a risk that vital information is not being shared.”
This report
“There was an absence of appropriate medical records recorded for Ms [name redacted] to understand her clinical presentation other than very basic information on the INR platform on INR results and medication dose.”