QHS GP Care Home Service

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First report 29 Jul 2022•Latest report 29 Jul 2022

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 QHS GP Care Home Service linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Inner South London

    AI-generated summary

    Mr Locksley Burton · 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

    Mr Locksley Burton, an 80-year-old disabled right leg amputee with dementia and other conditions, died in hospital on 24 April 2020 from mixed natural causes including systemic sepsis, Covid-19 pneumonia and osteomyelitis of the left heel. Concerns included inadequate wound inspections and dressing changes after diabetic foot clinic attendance was reduced, insufficient communication and care planning, and no demonstrated process for managing refusal of potentially life-threatening care where capacity was probably lacking.

    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 QHS GP Care Home Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate reductions in clinic attendance and dressing changes to the GP

    Wider context from the report

    “Mr Burton did not receive adequate inspections of his wound and changes of dressings when the attendance at the diabetic foot clinic ceased to be weekly or fortnightly. The pandemic was a likely reason for this, but there might be other reasons in future for such changes. There was no evidence at inquest that alternative arrangements and revised care plan was made. The GP did not know of the reduction in clinic attendance or reduction in changes of dressing and assumed others were inspecting the wound and prescribed antibiotics without an examination being done. No witness was able to demonstrate any process of managing a patient who declined necessary potentially life threatening care and probably lacked capacity to make the decision. ”
    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 QHS GP Care Home Service; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a process for managing patients who decline necessary potentially life-threatening care and may lack capacity

    Wider context from the report

    “Mr Burton did not receive adequate inspections of his wound and changes of dressings when the attendance at the diabetic foot clinic ceased to be weekly or fortnightly. The pandemic was a likely reason for this, but there might be other reasons in future for such changes. There was no evidence at inquest that alternative arrangements and revised care plan was made. The GP did not know of the reduction in clinic attendance or reduction in changes of dressing and assumed others were inspecting the wound and prescribed antibiotics without an examination being done. No witness was able to demonstrate any process of managing a patient who declined necessary potentially life threatening care and probably lacked capacity to make the decision. ”
    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 QHS GP Care Home Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to make alternative arrangements and revise the care plan when clinic attendance changes

    Wider context from the report

    “Mr Burton did not receive adequate inspections of his wound and changes of dressings when the attendance at the diabetic foot clinic ceased to be weekly or fortnightly. The pandemic was a likely reason for this, but there might be other reasons in future for such changes. There was no evidence at inquest that alternative arrangements and revised care plan was made. The GP did not know of the reduction in clinic attendance or reduction in changes of dressing and assumed others were inspecting the wound and prescribed antibiotics without an examination being done. No witness was able to demonstrate any process of managing a patient who declined necessary potentially life threatening care and probably lacked capacity to make the decision. ”
    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 QHS GP Care Home Service; that does not assign responsibility.

    PFD Monitor interpretation

    Prescribing antibiotics without examining the patient

    Wider context from the report

    “Mr Burton did not receive adequate inspections of his wound and changes of dressings when the attendance at the diabetic foot clinic ceased to be weekly or fortnightly. The pandemic was a likely reason for this, but there might be other reasons in future for such changes. There was no evidence at inquest that alternative arrangements and revised care plan was made. The GP did not know of the reduction in clinic attendance or reduction in changes of dressing and assumed others were inspecting the wound and prescribed antibiotics without an examination being done. No witness was able to demonstrate any process of managing a patient who declined necessary potentially life threatening care and probably lacked capacity to make the decision. ”
    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 QHS GP Care Home Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain adequate wound inspections and dressing changes when diabetic foot clinic attendance changes

    Wider context from the report

    “Mr Burton did not receive adequate inspections of his wound and changes of dressings when the attendance at the diabetic foot clinic ceased to be weekly or fortnightly. The pandemic was a likely reason for this, but there might be other reasons in future for such changes. There was no evidence at inquest that alternative arrangements and revised care plan was made. The GP did not know of the reduction in clinic attendance or reduction in changes of dressing and assumed others were inspecting the wound and prescribed antibiotics without an examination being done. No witness was able to demonstrate any process of managing a patient who declined necessary potentially life threatening care and probably lacked capacity to make the decision. ”
    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