Recipient

Lisson Grove Health Centre

First report 27 Feb 2019•Latest report 27 Feb 2019

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Lisson Grove Health Centre linked to the concerns in each report. Select any concern, action or position to view the source wording.

27 Feb2019
Inner West London
Concerns raised6
1. Failure to correlate the medication list with the active problem list
2. Lack of a system to address harmful medication interactions and redundant treatment
3. Inadequate recording and coding of relevant medical history on the active problem list
1. Insufficient supervision of administrative staff
2. Lack of a clear system for identifying harmful medication interactions
3. Inadequate medication review systems
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

Theresa Margaret Feehan · 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

Theresa Margaret Feehan, who had severe oxygen- and steroid-dependent allergic asthma, was found deceased at home on 12 March 2018. The court recorded aspiration pneumonia and ingestion of amitriptyline and dihydrocodeine as the medical cause of death, with natural causes combined with side effects of prescribed medication. Concerns included inadequate medication review, incomplete medical-history recording, poor correlation between medication and problem lists, insufficient systems for identifying harmful medication interactions, and inadequate supervision of administrative work.

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 Lisson Grove Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to correlate the medication list with the active problem list
Wider context from the report
“3. That there appears to be little correlation between the medication list and the active problem list such that it would make it difficult for a reviewing doctor to understand why a patient was on a particular medication and thus challenge its continuation or dosage appropriately, thus putting patients at risk. ”
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 Lisson Grove Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Lack of a system to address harmful medication interactions and redundant treatment
Wider context from the report
“4. That there appears to be no clear system for identifying medications which may interact to the detriment of the patient or no system to address such issues should they arise such as reducing or stopping redundant treatment thus putting patients at risk. ”
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 Lisson Grove Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Inadequate recording and coding of relevant medical history on the active problem list
Wider context from the report
“2. That the recording and coding of relevant medical history on the active problem list is inadequate thus putting patients at risk ”
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 Lisson Grove Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Insufficient supervision of administrative staff
Wider context from the report
“5. That administration systems within the practice should be audited to determine whether they are adequate and the work of the administrative staff sufficiently supervised, such that patients are not put at risk. ”
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 Lisson Grove Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Lack of a clear system for identifying harmful medication interactions
Wider context from the report
“4. That there appears to be no clear system for identifying medications which may interact to the detriment of the patient or no system to address such issues should they arise such as reducing or stopping redundant treatment thus putting patients at risk. ”
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 Lisson Grove Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Inadequate medication review systems
Wider context from the report
“1. That the system of medication review within the practice is inadequate putting patients at risk. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised6

Failure to correlate the medication list with the active problem list

Lack of a system to address harmful medication interactions and redundant treatment

Inadequate recording and coding of relevant medical history on the active problem list

Insufficient supervision of administrative staff

Lack of a clear system for identifying harmful medication interactions

Inadequate medication review systems