Tower Bridge Care Centre

Private and voluntary organisations · Residential care home

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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
Published responses: 100%
Concerns addressed: 3
Stated actions: 3

Concerns and recipient responses

Statements from Tower Bridge Care Centre linked to the concerns in each report. Select any concern, action or position to view the source wording.

29 Jul2022
Inner South London
Concerns raised5
1. Failure to communicate reductions in clinic attendance and dressing changes to the GP
2. Lack of a process for managing patients who decline necessary potentially life-threatening care and may lack capacity
3. Failure to make alternative arrangements and revise the care plan when clinic attendance changes
1. Prescribing antibiotics without examining the patient
2. Failure to maintain adequate wound inspections and dressing changes when diabetic foot clinic attendance changes
Actions described in response 2
1. Action
  Continue participating in monthly multidisciplinary meetings with clinical, social care, mental health, palliative care and pharmacy professionals.
2. Action
  Review each resident’s clinical risks through monthly Key Clinical Indicators exception reports, including wounds and escalation processes.
Respondent positions 2
1. Position
  The Home disputes that the GP was unaware of the reduced clinic attendance or wound-dressing changes, stating the GP was informed.
  Disputes the concern
1. Position
  The Home disputes that Mr Burton probably lacked capacity, stating he was assessed as having capacity throughout his residence.
  Disputes the concern
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 Tower Bridge Care Centre; 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 Tower Bridge Care Centre; 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 Tower Bridge Care Centre; 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 Tower Bridge Care Centre; 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 Tower Bridge Care Centre; 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
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue participating in monthly multidisciplinary meetings with clinical, social care, mental health, palliative care and pharmacy professionals.

Verbatim wording from the response
“Throughout the pandemic ‘lockdowns’ and since, the Home has continued to engage with the regular Monthly Multi-Disciplinary Meetings. During the pandemic, these were a blend of virtual and in-person meetings. As the Home Manager for the Home, I review the Clinical Risks of each resident through our monthly Key Clinical Indicators exception reports. These include wounds and the escalation process. Mr Burton’s wound deterioration and his presentations were discussed at these meetings.”

Source location
Response from The Kind Care Company
Page 3 · response
Published 29 September 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review each resident’s clinical risks through monthly Key Clinical Indicators exception reports, including wounds and escalation processes.

Verbatim wording from the response
“Throughout the pandemic ‘lockdowns’ and since, the Home has continued to engage with the regular Monthly Multi-Disciplinary Meetings. During the pandemic, these were a blend of virtual and in-person meetings. As the Home Manager for the Home, I review the Clinical Risks of each resident through our monthly Key Clinical Indicators exception reports. These include wounds and the escalation process. Mr Burton’s wound deterioration and his presentations were discussed at these meetings.”

Source location
Response from The Kind Care Company
Page 3 · response
Published 29 September 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The Home disputes that the GP was unaware of the reduced clinic attendance or wound-dressing changes, stating the GP was informed.

Verbatim wording from the response
“As the Coroner has correctly concluded, the pandemic was the reason that the DFC reduced its attendance. The GP was made aware of this during his attendances at the Home during the relevant period. We do note however that it was a period of unprecedented uncertainty and many services, the DFC included, were running a reduced service and attempting to adapt to the changing status of contact with individuals requiring care during this period.”

Source location
Response from The Kind Care Company
Page 2 · response
Published 29 September 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The Home disputes that Mr Burton probably lacked capacity, stating he was assessed as having capacity throughout his residence.

Verbatim wording from the response
“It is important to note that Mr Burton was deemed to have capacity on admission and throughout his time at the Home. Mr Burton had been diagnosed with a personality disorder, but this did not affect any decision on his capacity. Mr Burton had no formal diagnosis of dementia and he was regularly reviewed by staff at the Home and external professionals. Mr Burton was also under the care of the South London and Maudsley Trust’s Care Home Intervention Team (CHIT). His presentations in relation to non-compliance with personal care and assessment of his cognition were assessed by the CHIT, initially in December 2019 and as relevant after this date. The CHIT consulted with staff at the Home and with Mr Burton’s daughter. Mr Burton’s daughter is recorded as advising that Mr Burton's significant behavioural issues were not reflective of a diagnosis of dementia.”

Source location
Response from The Kind Care Company
Page 2 · response
Published 29 September 2022
Open published response

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 raised5

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

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

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

Prescribing antibiotics without examining the patient

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

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Actions described in response 2

Respondent positions 2