Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0224, written 28 Jun 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Jun 2019 |
|---|---|
| Reference | 2019-0224 |
| Deceased | Feni Lee |
| Coroner | Philip Barlow |
| Coroner area | London Inner (South) |
| Category | Community health care |
| Organisation named | Oxleas NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (4)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT iS BEING SENT TO:
4. EER fe Bextey mecicat Group, 174 King Harole’s Way,
Bexleyheath DA7 5RB
1 | CORONER
1am Philip Barlow, assistant coroner, for the coroner area of inner South London
2 | CORONER’S LEGAL POWERS
| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3 {| 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 Behcet's 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.
4 | CIRCUMSTANCES OF THE DEATH
Up until January 2016 Feni Lee was being seen as an outpatient by a
specialist at Guys Hospital (Guys), for the management of Behcet’s syndrome. As part
of her treatment Ms Lee had been prescribed colchicine. Colchicine is an unlicensed but
recognised treatment to control ulceration in Behcet's syndrome. Ms Lee failed to attend
further appointmenis at Guys after January 2016 and so her last appointment at Guys
was on 6 January 2016. Colchicine continued to be prescribed by Bexley Medical Group
as a repeat prescription up until her death in September 2017.
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. ~
(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.
| therefore have concerns about the thoroughness of this medication review.
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.
(2
~
(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. | am therefore copying this report
to the other GP practice, which | understand to be the practice o
an
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you and your
GP practice, Bexley Medical Group, have the power to take such action.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 27 August 2019. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.
COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:
(1) Ms Lee’s family, c/o Leigh Day solicitors
(2) Oxleas NHS Trust
| have also sent it to:
(3)
(4) fF consultant in oral medicine, Guys & St thomas’ NHS Trust
nd Erith Health Centre, 50 Pier Rd, Erith, Kent DA8
who may find it useful or of interest.
| am also under a duty fo send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.
9 | 28 June 2019 Philip Barlow
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (2)
NOTE: This form is to be used before an inquest.
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Bexley Medical Group Practice Code: G83053 King Harold’s Way Surgery Hurst Place Surgery Erith Health Centre 171 King Harold’s Way 294a Hurst Road 50 Pier Road Bexleyheath Bexiey Erith Kent DA7 5RF Kent DAS 3LH Kent DA8 1RQ Tel: 020 8303 1127 Tel: 020 8300 2826 Tel: 01322 334237 Our ref: SM/ps 14" August 2019 Coroner's Report Response by Bexley Medical Group Mr Barlow, Assistant coroner, Inner South London Dear Mr Barlow, Re: Feni Lee Thank you for your report, which we received on 5th July 2019. The practice has discussed your findings at two separate clinical meetings. First, on 26" June 2019 at our main site, King Harold’s Way, with our clinicians in attendance. Second; on 5h 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 drugs, and 63% of patients taking one to three drugs. All clinicians have been instructed to undertake medication reviews opportunistically and they are prompted to do so ona daily basis by our management team. tn particular, patients on Colchicine and Azathioprine have been contacted for an 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
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