Lacey Carole Anne HEATH · Prevention of Future Deaths report

On 21 February 2025, I commenced an investigation into the death of Lacey Carole Anne HEATH, aged 34 years that concluded on 13 May 2026.

The medical cause of death was:

1a Prosthetic Aortic Valve Thrombosis with Sub-Therapeutic Anti-Coagulation

2 Turners Syndrome

Lacey Carole Anne HEATH died on 16 February 2025 at Lynfields, London Road, Witham of Prosthetic Aortic Valve Thrombosis with Sub-Therapeutic Anti-Coagulation en-route following a collapse at home. Miss Heath had Turner’s Syndrome and had a bicuspid valve and was at higher risk of developing cardiac problems. Miss Heath underwent successful surgical replacement of her Aortic Valve, aortic root and ascending aorta in May 2019 and was prescribed anticoagulation. Miss Heath was a medically complex patient with warfarin resistance. There was difficulty maintaining anticoagulation within a therapeutic range that was managed by the local hospital that were not resolved with medication changes. In January and February 2025 anticoagulation was noted to be sub-therapeutic. Miss Heath was found on the morning of 16 February 2025 with rapid respiration and unresponsive. Miss Heath went into cardiac arrest en-route to hospital and ambulance crew stopped and commenced resuscitation with escalation to critical care support. HEMS continued with advanced life support upon arrival, but Miss Heath had complete stenosis of her mechanical valve with thrombosis that caused the cardiac arrest that was irreversible

Conclusion

Miss Heath was at significant risk of developing thrombus on her mechanical aorta valve as a recognised complication of necessary medical treatment. The risk increased when required anticoagulation was sub-therapeutic, and that contributed to her death.

Lacey Carole Anne HEATH died on 16 February 2025 at Lynfields, London Road, Witham of Prosthetic Aortic Valve Thrombosis with Sub-Therapeutic Anti-Coagulation en-route following a collapse at home. Miss Heath had Turner’s Syndrome and had a bicuspid valve and was at higher risk of developing cardiac problems. Miss Heath underwent successful surgical replacement of her Aortic Valve, aortic root and ascending aorta in May 2019 and was prescribed anticoagulation. Miss Heath was a medically complex patient with warfarin resistance. There was difficulty maintaining anticoagulation within a therapeutic range that was managed by the local hospital that were not resolved with medication changes. In January and February 2025 anticoagulation was noted to be sub-therapeutic. Miss Heath was found on the morning of 16 February 2025 with rapid respiration and unresponsive. Miss Heath went into cardiac arrest en-route to hospital and ambulance crew stopped and commenced resuscitation with escalation to critical care support. HEMS continued with advanced life support upon arrival, but Miss Heath had complete stenosis of her mechanical valve with thrombosis that caused the cardiac arrest that was irreversible

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 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.

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 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.