Lisson Grove Health Centre

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First report 27 Feb 2019•Latest report 27 Feb 2019

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

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.

  1. Inner West London

    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
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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