Source · Prevention of Future Deaths

Feni Lee

Ref: 2019-0224 Date: 28 Jun 2019 Coroner: Philip Barlow Area: London Inner (South) Responses identified: 1 / 2 View PDF

An inadequate medication review failed to address unlicensed drug use and a vulnerable patient's needs, compounded by severe delays in internal post redirection between GP practices for critical hospital correspondence.

Date 28 Jun 2019

56-day deadline 27 Aug 2019

Responses identified 1 of 2

Community health care and emergency services related deaths

Coroner's concerns

AI summary

View full coroner's concerns

You informed the inquest that Bexley Medical Group has a system whereby all The Way; Guys Guys Group 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 the dose. There were a number of features that do not appear to have been taken into account at this review: 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_ There had been no instructions from Guys as to what should be prescribed since January 2016. 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: The dosage being given on repeat prescription does not match any of the recent instructions from Guys about its use_ Ms Lee had mental health problems and was a vulnerable person_ 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 review appears to have been a lost opportunity to rectify this_ (3) You informed the inquest that there 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 ofa 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_ am therefore copying this report to the other GP practice, which understand to be the practice o] and

Responses

1 respondent

Bexley Medical Group Other

14 Aug 2019 PDF

Action Taken

The practice has started implementing a plan to carry out medication reviews in all patients who have not had a review for over 12 months. The practice has discussed the report with Riverside Medical Practice and they have agreed to send letters via email and in person. (AI summary)

View full response

Dear Mr Barlow, Re: Feni Lee Thank you for your report; which we received on Sth July 2019. The practice has discussed your findings at two separate clinical meetings. First, on 26th June 2019at our main site, King Harold' s with our clinicians in attendance: Second; on 5th July 2019 with Sharon Herbert Erith Health Centre manager), at the branch surgery, Erith Health Centre. The practice has agreed the following action plan:
1. Medication reviews 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 and 63% of patients taking one to three drugs Way Way, drugs,

AlI clinicians have been instructed to undertake medication reviews opportunistically and they are prompted to do So on daily basis by our management team: In particular, patients on Colchicine and Azathioprine have been contacted for urgent medication review. A recent search shows that we have two patients on Colchicine and they have both been contacted. We also have 27 patients on Azathioprine, who are monitored by administration staff using EMIS searches and a recall system is now in place:
2. Discussion with neighbouring practice regarding correspondence letters and mail Bexley Medical Group has discussed the report with our neighbouring practice Riverside Medical Practice: They are aware of our concerns about passing on any hospital correspondence regarding our patients. They have agreed to send letters via email as well passing them in person: 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:
3. To enhance and strengthen communication between Surgery and Hospital Secretaries: 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 Kind regards, Bexley Medical Group an

Report sections

Investigation and inquest

On 27 September 2017 commenced an investigation into the death of Feni Lee, age 34, The investigation concluded at the end of the inquest on 21 June 2019. The conclusion of the inquest was as follows: Medical Cause of Death: 1a) multi-organ failure 1b) colchicine overdose Feni Lee had Behcets syndrome for which she was receiving repeat prescriptions of colchicine from her GP; In September 2017 she took an excessive quantity of colchicine over a two week period because she was feeling unwell. She developed severe side effects, including liver necrosis, and was admitted to Queen Elizabeth Hospital where she died on 17 September 2017 _ The narrative conclusion was that Feni Lee died after taking excess colchicine for Behcet's syndrome without intention of self harm.

Circumstances of the death

Up until January 2016 Feni Lee was being seen as an outpatient by specialist at Hospital (Guys) , for the management of Behcets syndrome. As part of her treatment Ms Lee had been prescribed colchicine. Colchicine is an unlicensed but recognised treatment to control ulceration in Behcets syndrome Ms Lee failed to attend further appointments at Guys after January 2016 and so her last appointment at was on 6 January 2016. Colchicine continued to be prescribed by Bexley Medical as a repeat prescription up until her death in September 2017 .

Copies sent to

Oxleas NHS Trust and drug are have also sent it to: and rith Health Centre, 50 Pier Rd, Erith; Kent DA8

Inquest conclusion

Medical Cause of Death: 1a) multi-organ failure 1b) colchicine overdose Feni Lee had Behcets syndrome for which she was receiving repeat prescriptions of colchicine from her GP; In September 2017 she took an excessive quantity of colchicine over a two week period because she was feeling unwell. She developed severe side effects, including liver necrosis, and was admitted to Queen Elizabeth Hospital where she died on 17 September 2017 _ The narrative conclusion was that Feni Lee died after taking excess colchicine for Behcet's syndrome without intention of self harm.

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Shared signals

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Report details

Reference: 2019-0224
Date of report: 28 June 2019
Coroner: Philip Barlow
Coroner area: London Inner (South)

Responses identified

Responses identified 1 of 2

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 27 Aug 2019.

Sent to

Erith Health Centre, 50 Pier Rd, Erith, Kent DA8

Bexley Medical Group

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.