Concerns raised 13 Inadequate clinical records of the patient’s presentation, INR results and medication dose View source Lack of General Practitioner funding for at-home anticoagulation testing supplies View source Unavailability of at-home anticoagulation monitoring for daily readings and individualised dosing View source Failure to apply for funding for at-home anticoagulation monitoring View source Failure to clarify the nature and clinical impact of reported illness in records View source Use of alternative anticoagulation medication associated with high INR readings and bleeding risk View source Insufficient trial of Warfarin View source Failure to provide medical review or haematology referral for prolonged non-therapeutic INR View source Failure to consider learning difficulties when providing anticoagulation care View source Unaffordability of at-home anticoagulation monitoring View source Failure to achieve a therapeutic INR for a prolonged period View source Failure to explain available funding to the patient View source Failure of alternative anticoagulation regimes to maintain a therapeutic range View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lacey Carole Anne HEATH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lacey Carole Anne HEATH died on 16 February 2025 after collapsing at home and suffering cardiac arrest en route to hospital. The death followed thrombosis and complete stenosis of her mechanical aortic valve in the context of sub-therapeutic anticoagulation. Concerns included difficulty maintaining therapeutic anticoagulation, lack of access to affordable at-home monitoring, absence of a funding application, insufficient medical review or haematology referral, and inadequate clinical records.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate clinical records of the patient’s presentation, INR results and medication dose
Wider context from the report “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 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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of General Practitioner funding for at-home anticoagulation testing supplies
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of at-home anticoagulation monitoring for daily readings and individualised dosing
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to apply for funding for at-home anticoagulation monitoring
Wider context from the report “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 a 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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to clarify the nature and clinical impact of reported illness in records
Wider context from the report “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 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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Use of alternative anticoagulation medication associated with high INR readings and bleeding risk
Wider context from the report “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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient trial of Warfarin
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide medical review or haematology referral for prolonged non-therapeutic INR
Wider context from the report “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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to consider learning difficulties when providing anticoagulation care
Wider context from the report “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 a 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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unaffordability of at-home anticoagulation monitoring
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to achieve a therapeutic INR for a prolonged period
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to explain available funding to the patient
Wider context from the report “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 a 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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of alternative anticoagulation regimes to maintain a therapeutic range
Wider context from the report “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.
” Open source report
Concerns raised 1 Lack of commissioned specialist services for safely reducing and withdrawing from prescribed dependency-forming medications View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Paul Barry · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Paul Barry died at Broomfield Hospital from fatal complications of community-acquired pneumonia, with excessive codeine use contributing to his death. The principal concern was the lack of a commissioned specialist service to help patients and GPs safely reduce or withdraw from prescribed dependency-forming medication, creating a risk of avoidable future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of commissioned specialist services for safely reducing and withdrawing from prescribed dependency-forming medications
Wider context from the report “Notwithstanding the positive finding that the specific medication prescribed by Mr Barry’s GP had not been the source of the excessive codeine taken prior to admission to hospital, compelling evidence was received at the inquest from a Partner at the GP Practice (with a particular specialism in this area of dependency-forming medications) that there remains no specialist commissioned service available for GPs to which they might refer their patients to manage reduction of their intake of prescribed dependency-forming medications . This is in contrast to the availability of commissioned services for patients who are dependent on illicit drugs and/or alcohol.
The evidence confirmed that reduction or cessation of dependency-forming medications needs to be very carefully managed due to the risk of withdrawal symptoms and, in the context of the unchallenged evidence received, requires specialist input and training to maximise the prospects of success and to avoid potentially fatal consequences . The evidence, again unchallenged, was that the continuing absence of such a commissioned service gives rise to the risk of avoidable future deaths .
The long-standing and continuing lack of commissioned services in primary or secondary care for assisting people to safely reduce and withdraw from such prescribed medication was confirmed in her evidence by the Director of Pharmacy and Medicines Optimisation within the Mid and South Essex Integrated Care Board (the ICB). This witness helpfully set out important steps currently proposed and/or being taken to educate clinicians and service users alike of the dangers of opiate based prescription medications (alongside their relatively limited benefits in most, though not all, cases) with a view to reducing the size of the cohort of patients at risk of becoming dependent/addicted in the medium and longer term. However, this does not - absent a commissioned service to which GPs and patients may turn for specialist advice and assistance - address the immediate and on-going risk of future deaths to those currently dependant on/addicted to these medications, with the numbers of such patients having significantly increased in the post-COVID 19 period as a consequence of lengthy delays to, for example, chronic pain-relieving surgery.
Precisely this issue was highlighted in a previous PFD Report from 14th November 2019 issued by the former Senior Coroner in this jurisdiction. The response from the (then) Clinical Commissioning Group had indicated an intention to roll-out a Prescribed Opioid Dependence Local Enhanced Service in early 2020, but this was not implemented due to the COVID 19 pandemic.
Since then, including at the date of Mr Barry’s death in November 2023 and through to today, there remains no such, or similar, commissioned service across Essex or, it appears, consistently across England and Wales with only rare pockets around the country where such a service is commissioned.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Offer accredited dependence-forming-medication e-learning on opioid reduction in chronic pain and cognitive behavioural therapy for persistent pain to primary care practices.
Verbatim wording from the response “Concurrent to this, regionally funded accredited Dependence Forming Medications (DFM) e-learning on ‘Reducing opioids in chronic pain’ and ‘Cognitive Behavioural Therapy for persistent pain’ training was offered to all practices through a locally commissioned Medicines Optimisation Local Enhanced Scheme in 2023-24.” Source location Response from Mid and South Essex Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Procure and implement a Community Musculoskeletal Service opioid reduction and discontinuation pathway providing structured deprescribing support and coordination with GPs.
Verbatim wording from the response “A new Opioid Reduction/Discontinuation Pathway is planned within the Community Musculoskeletal (MSK) Service, currently in procurement and due for implementation in February 2026.” Source location Response from Mid and South Essex Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and disseminate guidelines for acute and chronic non-malignant pain management, including opioid tapering guidance for chronic non-cancer pain.
Verbatim wording from the response “As further support for clinicians treating patients who are prescribed dependence forming medications, the ICB has developed and disseminated comprehensive guidelines for the management of acute and chronic non-malignant pain, including specific guidance on Opioid Tapering for Chronic Non-Cancer Pain. These resources provide a structured framework for identifying at-risk patients and supporting safe withdrawal.” Source location Response from Mid and South Essex Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work up a business case to scale the Aegros primary-care-network model across the Integrated Care Board, including clinician upskilling for deprescribing and dependency prevention.
Verbatim wording from the response “The ICB Executive Committee has endorsed a proposal to work up a business case to scale up the Aegros Primary Care Network (PCN)-based model across the ICB, aiming to deliver this service affordably while maintaining a primary care focus and upskilling clinicians to both deprescribe and prevent new cases of dependency.” Source location Response from Mid and South Essex Integrated Care Board
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Limited resources constrain the pace and scale of developing services for dependence-forming medication support.
Verbatim wording from the response “The Mid and South Essex Integrated Care Board (ICB) is committed to improving patient safety and outcomes across all areas of care. However, as with all healthcare systems, we must continually balance a wide range of competing priorities, including urgent and emergency care, mental health, cancer services and cardiovascular disease. While the issue of dependence-forming medications remains a significant concern, and we are taking meaningful steps to address it, the pace and scale of service development are inevitably influenced by the need to allocate limited resources across multiple areas of critical need. Nonetheless, we fully recognise the risks highlighted in your report and remain committed to reducing harm and improving support for patients affected by medication dependency.” Source location Response from Mid and South Essex Integrated Care Board
Open published response
Concerns raised 3 Failure of primary and secondary care systems to provide timely access to definitive medication and concordance records View source Insufficient time for responsible clinicians to consider medical records before mental health reviews View source Reliance on patients’ accounts of current medication without routine verification View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Fiona May Humberstone · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Fiona May Humberstone, who had longstanding mental health conditions, alcohol misuse and chronic pain, died at home from an inadvertent overdose of prescribed Oromorph taken with other medication. The concerns included mental health clinicians relying solely on patients’ accounts of their medication and inadequate access to accurate, up-to-date prescribing information between primary and secondary care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of primary and secondary care systems to provide timely access to definitive medication and concordance records
Wider context from the report “(2) Further, oral evidence from a senior EPUT witness confirmed that the Trust could not, as electronic systems were presently configured, readily access information held by GP practices regarding individual patients (and vice versa) . It appeared that this evidence was provided by way of an explanation as to why accurate and up to date medication/prescribing information was not routinely obtained by clinicians in advance of reviews of patients. Absent any other system for ensuring swift and accurate information transfer between primary and secondary care providers , then the continuation of a state of affairs where a consultant psychiatrist is undertaking a review of a mental health patient but does not have access to a definitive record of the medication presently being taken by that patient (and/or their concordance with prescribed medication) gives rise to a conspicuous risk of future deaths. The EPUT witness suggested that this was a matter for the Clinical Commissioning Group (CCG) to address.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient time for responsible clinicians to consider medical records before mental health reviews
Wider context from the report “(3) Issues regarding the necessity for access to (and adequate time for the consideration of) medical records including prescriptions and concordance with medication in advance of mental health reviews undertaken by responsible clinicians has been raised in relation to mental health related death in Essex previously. I am concerned that the evidence from FH’s inquest indicates that such matters remain unresolved .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Reliance on patients’ accounts of current medication without routine verification
Wider context from the report “(1) In her statement provided for the purposes of the inquest, FH’s consultant psychiatrist listed the medications prescribed to FH at the time of her death but made no reference to the Oromorph. During the course of her oral evidence she confirmed that, at the time of her last review of FH in April 2020, she was entirely unaware that she had been prescribed this powerful morphine-based pain killer for a number of months. She also confirmed that had she known of the prescription for that medication it would have affected her risk assessment, given LH’s continuing misuse of alcohol. She told the court that it was (and remains) her usual practice to rely entirely on the information regarding medication (including dosage and frequency) provided by the patient, even in telephone only consultations. She stated that she would only rarely (and certainly not routinely) check the accuracy of the account provided by obtaining a list of medication from the GP or other clinical records.
Although not causative in respect of FH’s death, I am concerned that the practice of relying entirely on a patient’s account of current medication , in circumstances where significant mental health issues are often involved (including where there is chronic substance and/or alcohol misuse) gives rise to a serious risk of future deaths. As was accepted by the witness, any risk assessments, care plan reviews or further prescribing of (or alteration to) a medication regimen may in such circumstances be predicated upon incomplete, inaccurate and potentially dangerously misleading information . In my view the risk of future deaths is clear.
” Open source report
Concerns raised 2 Inadequate training and education for general practitioners and GP practices in care for patients dependent on prescribed opiates View source Lack of specialised assistance and referral agencies for general practitioners supporting patients dependent on prescribed opiates View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Joanna Clare Alice Flynn · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joanna Clare Alice Flynn, aged 31, was found slumped over her bed on 26 May 2019 after last being seen on 23 May 2019. The inquest returned an Open conclusion against a background of long-standing prescribed opiate addiction, with concerns about the lack of specialised support and referral pathways for patients needing help to withdraw from addictive prescription drugs, as well as GP training and education.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate training and education for general practitioners and GP practices in care for patients dependent on prescribed opiates
Wider context from the report “The General Practitioner who gave evidence told the court that there was a lacuna in the healthcare provided for patients such as the deceased in terms of giving assistance for weaning off addictive prescription drugs such as opiates. It was clear that General Practitioner’s require highly specialised assistance in order to help such patients and agencies within the healthcare system to which to refer them. This was all lacking in this particular sad set of circumstances. The court was informed about a proposed pilot scheme – a substance misuse Locally Enhanced Service for people with dependence to prescribed opiates. There was no assurance that this had commenced or indeed yet been funded. I would like an assurance that this hopeful initiative has got off the ground and indeed I would like to have information about any other initiatives to endeavour to address this dreadful problem. I would also like to hear what strides have been taken to improve training and education for general practitioners and GP practices in this worrying area of care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Essex Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of specialised assistance and referral agencies for general practitioners supporting patients dependent on prescribed opiates
Wider context from the report “The General Practitioner who gave evidence told the court that there was a lacuna in the healthcare provided for patients such as the deceased in terms of giving assistance for weaning off addictive prescription drugs such as opiates . It was clear that General Practitioner’s require highly specialised assistance in order to help such patients and agencies within the healthcare system to which to refer them . This was all lacking in this particular sad set of circumstances . The court was informed about a proposed pilot scheme – a substance misuse Locally Enhanced Service for people with dependence to prescribed opiates. There was no assurance that this had commenced or indeed yet been funded . I would like an assurance that this hopeful initiative has got off the ground and indeed I would like to have information about any other initiatives to endeavour to address this dreadful problem. I would also like to hear what strides have been taken to improve training and education for general practitioners and GP practices in this worrying area of care.
” Open source report
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Request correction
Addressed to NHS Mid and South Essex Integrated Care Board, now represented here by NHS Essex Integrated Care Board.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations