Mr Locksley Burton · Prevention of Future Deaths report

On 7th October 2020 an inquest into the death of Mr Locksley Burton was opened. He died on 24th April 2020 in King’s College Hospital, London. (case ref: 4160929) The inquest was concluded on 29th July 2022, heard before me with a narrative conclusion delivered.

The medical cause of death was:
1a Systemic sepsis
1b Covid-19 (coronavirus) pneumonia and osteomyelitis of the left heel (joint causes)
1c
II Type 2 diabetes mellitus, peripheral vascular disease, dementia, multiple myeloma

The circumstances of death were:
Mr Burton was an 80 year old disabled right leg amputee with dementia, bipolar disorder, diabetes and other conditions, who received nursing care and support in a residential home from May 2019. He was seen weekly or fortnightly in the hospital diabetic foot clinic until 2020 when, in the pandemic, visits became monthly, unknown to the GP. He developed an infection on his left foot. The podiatrist stressed the importance of changing dressings and of keeping the wound dry, but Mr ████████ was not always compliant with its being inspected and dressed in the nursing home. The staff tried, but could not find ways to keep the wound clean and dry. When he became lethargic, blood tests were done which identified that he was anaemic and had an infection. It was assumed that this was non-specific, but his wound was not inspected by the visiting GP on 2nd April. He was given antibiotics, and tested positive for Covid (for which he had high risk) on 11th, despite precautions taken by the nursing home. He was admitted to hospital on 15th April where his wound was found to be necrotic and gangrenous. It was locally debrided but he was unfit for surgery and died at 20.00 hours on 24th April 2020.

The conclusion as to the death was:
He died of mixed natural causes. It cannot be determined, had it been possible to provide better supervision and management of his wound, whether that would have led to a different outcome.

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.