28 Jun 2019 Feni Lee · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 4 Failure to ensure incoming clinical correspondence is reviewed and actioned by a GP View source Ineffective redirection of post between co-located GP practices View source Insufficiently thorough review of repeat medication View source Failure to identify and address hospital loss to follow-up during medication review View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Feni Lee · 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
Feni Lee, who had Behçet’s syndrome, took an excessive quantity of colchicine over a two-week period in September 2017 and died in hospital on 17 September 2017 after developing severe side effects, including liver necrosis. The concerns included the thoroughness of the medication review, the failure to address her loss to hospital follow-up, and delays and ineffective processes for redirecting correspondence between two GP practices.
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 Bexley Medical Group; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure incoming clinical correspondence is reviewed and actioned by a GP
Wider context from the report “(3) You informed the inquest that there are two GP practices at Erith Health Centre on Pier Rd. They are based in the same building and the receptionists from both practices work in close proximity. The letter from Guys relating to the outpatient clinic on 20 October 2015 was appropriately sent to Erith Health Centre on Pier Rd but had the name of a GP from the other practice. You accepted that there was considerable delay in this letter being forwarded to your practice and that it was scanned onto your system some 2 to 3 months after it was sent. You also accepted that it was placed onto your system without being seen or actioned by a GP.
My concern is that there does not appear to be an effective means whereby post is re-directed between the two GP practices. I am therefore copying this report to the other GP practice, which I understand to be the practice of ████████ and ████████
” 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 Bexley Medical Group; that does not assign responsibility.
PFD Monitor interpretation Ineffective redirection of post between co-located GP practices
Wider context from the report “(3) You informed the inquest that there are two GP practices at Erith Health Centre on Pier Rd. They are based in the same building and the receptionists from both practices work in close proximity. The letter from Guys relating to the outpatient clinic on 20 October 2015 was appropriately sent to Erith Health Centre on Pier Rd but had the name of a GP from the other practice. You accepted that there was considerable delay in this letter being forwarded to your practice and that it was scanned onto your system some 2 to 3 months after it was sent . You also accepted that it was placed onto your system without being seen or actioned by a GP.
My concern is that there does not appear to be an effective means whereby post is re-directed between the two GP practices. I am therefore copying this report to the other GP practice, which I understand to be the practice of ████████ and ████████
” 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 Bexley Medical Group; that does not assign responsibility.
PFD Monitor interpretation Insufficiently thorough review of repeat medication
Wider context from the report “(1) You informed the inquest that Bexley Medical Group has a system whereby all medication obtained by repeat prescription is reviewed annually. You could not say exactly when the review of Ms Lee’s medication took place (at that time it was not documented) but said it would have been towards the end of 2016. You said the review looked at the need for ongoing medication and the dose. There were a number of features that do not appear to have been taken into account at this review:
a. Colchicine is an unlicensed usage of a drug used to treat a rare disorder. It was being prescribed by the GP under instructions from a specialist hospital clinic.
b. There had been no instructions from Guys as to what should be prescribed since January 2016.
c. The instructions from Guys in January 2016 do not mention colchicine. No inquiry was made with Guys to check whether the intention was for it to be continued as part of the treatment, and yet it continued to be given by the GP as a repeat prescription.
d. The dosage being given on repeat prescription does not match any of the recent instructions from Guys about its use.
e. Ms Lee had mental health problems and was a vulnerable person.
I therefore have concerns about the thoroughness of this medication review.
(2) Towards the end of 2016 it would have been obvious that Ms Lee had been lost to follow up at the hospital, and so the drug review appears to have been a lost opportunity to rectify this.
” 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 Bexley Medical Group; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and address hospital loss to follow-up during medication review
Wider context from the report “(1) You informed the inquest that Bexley Medical Group has a system whereby all medication obtained by repeat prescription is reviewed annually. You could not say exactly when the review of Ms Lee’s medication took place (at that time it was not documented) but said it would have been towards the end of 2016. You said the review looked at the need for ongoing medication and the dose. There were a number of features that do not appear to have been taken into account at this review:
a. Colchicine is an unlicensed usage of a drug used to treat a rare disorder. It was being prescribed by the GP under instructions from a specialist hospital clinic.
b. There had been no instructions from Guys as to what should be prescribed since January 2016.
c. The instructions from Guys in January 2016 do not mention colchicine. No inquiry was made with Guys to check whether the intention was for it to be continued as part of the treatment, and yet it continued to be given by the GP as a repeat prescription.
d. The dosage being given on repeat prescription does not match any of the recent instructions from Guys about its use.
e. Ms Lee had mental health problems and was a vulnerable person.
I therefore have concerns about the thoroughness of this medication review.
(2) Towards the end of 2016 it would have been obvious that Ms Lee had been lost to follow up at the hospital, and so the drug review appears to have been a lost opportunity to rectify this.
” 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 Implement medication reviews for patients without a review for over 12 months, using EMIS searches, clinician prompts, and recall monitoring for higher-risk medicines.
Verbatim wording from the response “We have started implementing our plan to carry out medication reviews in all patients, who have not had a review for over 12 months. Our new software EMIS, which was installed in June 2018, is able to support searches of any outstanding medication review.
We have reviewed over 86% of patients taking four or more drugs, and 63% of patients taking one to three drugs.” Source location 2019-0224-Response-by-Bexley-Medical-Group
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 Contact mental health patients who miss hospital outpatient appointments to establish reasons and support attendance.
Verbatim wording from the response “Our administrators and receptionists will contact patients with mental health problems, who do not attend hospital outpatient appointment to establish the reasons and support them in keeping up with their appointments.” Source location 2019-0224-Response-by-Bexley-Medical-Group
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 Route all correspondence to GPs to ensure an audit trail and accountability.
Verbatim wording from the response “We also discussed the issues with actioning letters and we will ensure that all correspondence is work flowed to the GPs to ensure proper audit trail and accountability.” Source location 2019-0224-Response-by-Bexley-Medical-Group
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations