29 Jul 2022 Mr Locksley Burton · Prevention of Future Deaths report Inner South London
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Concerns raised 5 Failure to communicate reductions in clinic attendance and dressing changes to the GP View source Lack of a process for managing patients who decline necessary potentially life-threatening care and may lack capacity View source Failure to make alternative arrangements and revise the care plan when clinic attendance changes View source Prescribing antibiotics without examining the patient View source Failure to maintain adequate wound inspections and dressing changes when diabetic foot clinic attendance changes View source See 2 more concerns
Responses linked to these concerns
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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.
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× 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
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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
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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
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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
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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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations