Locksley Burton

King's College Hospital 
NHS  Foundation Trust 

Chief Executive 
King's College Hospital 
Denmark Hill 
London  SES  9RS 
020 3299 4939 
www.kch.nhs.net 

HM  Senior Coroner Andrew Harris 
London  Inner South  District 
1 Tennis Street 
London  SE1  1YD 

BY EMAIL ONLY 

23  September 2022 

Dear Sir, 

Inquest into the  death of Mr  Locksley Burton 

We write  in  relation  to  the  Regulation  28  Report to  Prevent Future  Deaths dated 29 th 
July 2022  in  connection with  the  inquest of Mr Locksley Burton. 

We  are  very  sorry  that  Mr  Burton  died  in  these  circumstances  at  King's  College 
Hospital during the Covid-19 pandemic. We have apologised to his family for the care 
he  received  at King's and  offer our heartfelt condolences. 

In  your  report  you  have  identified  concerns  which  we  set  out  below  (in  bold)  and 
respond  to  each  in  turn  in  as far as  they relate to  King's  College Hospital Trust: 

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. 

Following  the  beginning  of the  first  lockdown,  on  the  23rd  March  2020,  there  was  a 
reduction  of  patients  seen  by  the  Diabetic  Foot  Clinic  from  fifty  to  approximately 
twenty-five  per  day.  However,  there  is  no  evidence  from  Silhouette  (which  is  the 
Diabetic  Foot Clinic's  records  system)  that  Mr  Burton  was  seen  less  frequently  than 
clinically  indicated.  Mr  Burton  was  seen,  as  planned  on  the  26th  March  2020,  in  the 
Diabetic Foot Clinic.  His  right  and  left feet were  treated  with  a plan  to  review in  three 
to  four weeks' time.  The  review timescale was  based  on  clinical  history,  observations 
and  clinical judgement taken  on  the  day.  There  is  no  evidence that this  decision  was 
made due to  the impacts of the Covid-19 pandemic. The decision was made based on 
the  clinical judgement of an  experienced  podiatrist who knew the patient well. 

The  Diabetic Foot Clinic continued  to  operate throughout the  Pandemic offering face-
to-face  appointments.  Patients  were  prioritised  on  the  basis  of  clinical  need  and 
continued  to  be seen  in-person  at the frequency that was  required. 

An Academic Health Sciences Centre for London 

Pioneering better health for all 

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 There  was  no  evidence  at  inquest  that  alternative  arrangements  and  revised 
care plan was  made. 

As  described  above,  there  was  no  need  for  a  new  care  plan  or  alternative 
arrangements to  be  made  by the  Tr:st,  as  Mr Burton's  dfabeticfeei were  stable  and 
he was given a further follow-up  appointment to  be seen  in  the Diabetic Foot Clinic. 

1 

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. 

There  would  only  be  communication  to  the  GP  from  the  Diabetic  Foot  Clinic  if there 
had  been  significant change  to  the  ulcers  or the  management plan,  neither of which 
was  the  case.  An  increase  in  the  time  between  outpatient  appointments  would  not 
necessarily  result  in  the  GP  being  written  to.  There was  no  change  in  the frequency 
of the dressings and  so  the  GP .did  not need to  be  informed. 

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. 

Mr Burton was well known  to the  King's College Hospital Diabetic Foot service, having 
been treated since 2016.  During this time he  had  continually expressed  a strong wish 
not to  undergo a major amputation  of his  left foot despite this  being  recommended  at 
that time and  on  several occasions afterwards. 

When  Mr Burton  presented  to  the  Trust  on  16th  April  2020,  his  foot  was  found  to  be 
unsalvageable  and  therefore  an  amputation  may  have  been  an  appropriate  clinical 
course  of  action.  Mr  Burton  continued  to  express  wishes  not  to  have  a  major 
amputation.  However,  at  that  time  Mr  Burton  was  not  considered  a  fit  surgical 
candidate  for  a  major  amputation,  and  this  was  the  reason  why  surgery  was  not 
progressed.  Mr Burton's clinical notes do show that he was, at times,  confused during 
this  final  admission.  If  Mr  Burton's  clinical  condition  had  improved  and  surgical 
intervention  (i.e.  amputation)  was  considered  in  his  best  interests,  then  a  formal 
capacity  assessment  would  have  been  indicated  here.  It  may  also  have  been 
appropriate to  involve an  Independent Mental Capacity Advocate (IMCA). 

We do recognise that documentation in  relation to a mental capacity assessment could 
have been clearer in  Mr Burton's medical records. All clinical staff at the Trust currently 
take  a Mental Capacity Act (MCA)  and  Consent training  module at  induction,  and  the 
Trust's "Mental Capacity Act Policy" clearly lays out expectations for all staff in  relation 
to  capacity assessments. 

In the last three months, we have increasedJhe rangE:iof learning andJrajoingayailable 
for our clinicians  in relation. to  conse11f and  the  MCA fhrougI21frJoternal and external 
. 
legaTp-affrie-rs-:ine-frusfl1a~s~alreadyl1elcfthree consent seminars with  clinicians. 

An Academic Health Sciences Centre for London 

Pioneering better health for all 

I  I 

I 01

• 

I  KING'S  HEALTH  PARTNERS 

 In  conjunction  with  the  Corporate  Medical  Director  for  Quality  and  Governance, we 
have e~-~c:!?J~sb~~~.~a  ~~~group foJ  improving .cons~ntan.d MCA.as~~ssrr1~~ts.  We 
are working alongside the Director of Nursing for Vulnerable People and  the Associate 
Director  of  Nursing  for  Mental  Health  to  establish  an  improvement  plan.  This  will 
include evaluation  of the  consent and  MCA training  programmes to  ensure that these 
are effectively supporting  staff in  delivering  best practice. 

The  Trust's  consent  policy  has  been  reviewed  and  updated  to  make  it  easier  for 
clinicians  to  follow,  and  seek  additional  support  as  appropriate.  In  September 2022, 
we  also  initiated  a Trust-wide  consent  audit  through  our  Clinical  Governance  Leads 
forum;  the  results  of which  will  be  reviewed  through  the  Patient  Safety  Committee 
which  is  chaired  by the  Chief Medical Officer. 

To  examine  the  current  collaborative  multi-disciplinary  arrangements  and 
ensure they are appropriate and safe. 

Communication  with  the  GP  would  have  taken  place  if there  had  been  a  significant 
change  in  the  condition  or management of Mr Burton's diabetic foot.  Had  there  been 
a deterioration  identified  at his  Diabetic  Foot Clinic  appointment,  the  GP  would  have 
been  written  to  and  any  requirement  for  district  nurse  support  or other  primary  care 
intervention would  have  been  outlined  in  the  clinic  letter.  It would  then  be  for the  GP 
to communicate to the relevant primary care team.  As there was no significant change 
in  Mr Burton's management,  there was no  necessity to  communicate this to the GP as 
Mr  Burton  remained  under  the  care  of  the  Diabetic  Foot  Clinic  and  had  a  future 
appointment booked. 

Thank you  for raising  these  points  and  for giving  us  an  opportunity to  respond.  I trust 
that this  letter provides you  with  an  assurance  that we  have  seriously considered  the 
points raised  in  your report. 

Yours sincerely, 

Chief Executive 

An Academic Health Sciences Centre for London 

Pioneering better health for .c,11 

KING'S  HEALTH  PARTNERS

Royal College of 
General Practitioners 

Honorary Secretary of Council 

Mr Andrew Harris 
Senior Coroner - London  Inner South jurisdiction 

20 September 2022 

Dear Mr Harris 

Regulation 28 Report to  Prevent Future Deaths - touching on the death of Mr Locksley Burton 

I write as  Honorary Secretary for the Royal  College of General  Practitioners (RCGP),  in  response 
to your Regulation  28 report dated 29 July 2022, regarding the very sad  death of Locksley 
Burton.  Firstly,  may I offer my sincere condolences to Locksley's family. 

The  circumstances raise  issues with communication from secondary care to primary care, an 
issue that the RCGP  is  working to improve with our colleagues across all  specialities.  In addition, 
the RCGP continues to work with NHS England and  NHS  Improvement to improve the 
communication links between primary and  secondary care. 

I trust that this reply is  helpful and  if you  have any questions, please do not hesitate to contact 
me. 

Yours Sincerely 

RCGP  Honorary Secretary

FOA:  Mr Andrew Harris, Senior Coroner,  London  Inner South  jurisdiction 

. Dear Sir 

Re:  Regulation  28  Report to Prevent Future Deaths 

Further to the inquest touching the death of Mr Locksley Burton, as heard on 7 October 2022, 
and the corresponding  Regulation 28  Report to Prevent Future Deaths of 29 July 2022, please 
find attached the response on behalf of Tower Bridge Care Home,  1 Aberdour Street,  London, 
SE1  4SH. 

The Learned Coroner identified the following matters of concern: 

"  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 

11 

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. 

The Learned Coroner requested that Kings College Hospital, QHS GP Care Home Service and 
Tower Bridge Care Home provide a response to enable him to  understand the current 
collaborative multi-disciplinary arrangements. As Home Manager for Tower Bridge Care Home 
(the Home), I am  providing the following response: 

The Diabetic Foot Clinic (DFC) is  run  by Kings College Hospital, with 8am to 5pm clinic hours. 
The DFC will send the Home a letter for clinic attendance and advise the Home on  clinic 
appointments. The Home will then book transport,  and either a carer or a family member attends 
with the resident.  In the circumstances of Mr Burton's care,  his daughter preferred to  be in 
attendance at the appointments. Where she was not available, staff would attend with  Mr Burton 
instead. 

Due to  their clinical expertise and  knowledge of the individual, the DFC decides the frequency of 
appointments dependent on  presentation.  However, if the Home considers that an  appointment 
needs to be made, staff from the Home would go through the GP and the GP would make the 
contact. 

HC-One 

Registered office: Southgate House, Archer Street, Darlington, County Durham, DL3 6AH 
Incorporating HC-One Limited, registered in England No. 07712656; Meridian Healthcare Limited, 
registered in England No. 01952719; HC-One Beami.5h Limited. registered in England No. 05217764 

 
 The relevant GP from QHS GP Care Home Service attends the service three times a week 
(Tuesdays,  residents on the Ground and  First floors; Thursday,  residents  on  the  Second and 
Third  Floors;  Friday,  for any additional urgent enquiries). When the GP attends the service, they 
are provided with  the relevant list of which individuals require review.  One of the Home's nurses 
will accompany the GP throughout their visit and the GP provides their instructions after review of 
each  patient. Any prescriptions are then emailed to  Boots Pharmacy, which delivers the relevant 
prescriptions to the Home. This continued throughout the pandemic. 

As the Coroner has correctly concluded, the pandemic was the reason that t~~eeDFCJ~duced  it§~~ 
attendance'. The GP was made aware qf this during his attendances at the Home during the 
relevanfperfod. 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. 

Although  Mr Burton had made it clear throughout his time in the Home that he only wanted the 
DFC to change his dressings, there is evidence within  Mr Burton's notes of the Home's staff 
worl<ing with his behaviours and there is record  of staff changing  his dressing, taking 
photographs, updating his Wound Care Plan, the @hometeam changing his dressings and 
confirming that there were noted deteriorations.  In  addition,  Mr Burton was still engaging with 
dermatology and Tissue Viability Nurse appointments during this period  and  attended the 
Hospital to have a blood transfusion.  He and the Home were therefore continuing to engage with 
his care needs. At this time, the GE-ebJ:lQQ@~nlnf9[DlEidJ:>J-1bJHlelerioration gfj\11_rJ3urtQO'~ WQJJJ)d 
and Mr Burton was on  antibiotics. We are unable to comment on whether the GP made contact 
with the DFC as a result of receiving this information. 

The first formal confirmation of a reduced  DFC  service was received  by the Home on  7 April 
2020. Attempts were made to  contact the  DFC once the wound was noted to be deteriorating. 

In April,  Mr Burton was identified as having deterioration to his wound,  continued to be on 
antibiotics for potential infection and was subsequently identified  as Covid positive. This 
information was recorded  in  his notes and Mr Burton's care was adapted accordingly. 

It is important to  note that Mr Burton was ~e!17e<:iJo-h9ve i;;apacity 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. 

!IC-One 

Registered office: Southgate House, Archer Street. Darlington, County Durham, DL3 6AH 
Incorporating HC-One Limited, registered in England No.  07712656; Meridian Healthcare Limited, 
registered in England No.  01952719; HC-One Beamish Limited, registered in England No. 05217764 

 
 In general terms,  in  circumstances where a resident declined necessary potentially life-
tt1reatening  care and  where there were concerns in relation to whether the resident lacked 
capacity,  the process would  be to  refer the resident back to their GP,  involve social services and 
other professionals and  record  that this  has happened.  All these steps were taken  in  relation to 
Mr Burton, including (as above) the involvement of CHIT. Residents who have capacity have the 
right to decline treatment even if it is life threatening. 

The principles of Mental Capacity Act apply to  residents  in  Care Homes. We would  note that, 
during  his hospital stay,  Mr Burton  made it clear that he did  not want another amputation and that 
the decision was for him to be comfortable.  The Consultants upheld his wishes not to have 
another surgery. 

Current collaborative multi-disciplinary arrangements 

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. 

Monthly Multi-Disciplinary Meetings have continued.  Attendance comprises the Home's Home 
Manager,  Deputy Home Manager,  Clinical  Lead and  Unit Manager of the  unit,  in conjunction with 
the Consultant Geriatrician,  GP, Advanced  Nurse Practitioner,  and Dietician (in-person),  and the 
social worker,  CHIT Team,  palliative team, and pharmacist Uoining onfine). 

In  September 20,22'. through  agreement with the Consultant Geriatrician from  Guys and St 
Thomas' 14osp1tal I  the H~f1]ELaJ§QJtlt[QQLf~<3q a~e~kJYJE;\/!€;'(( gf51£ih~Hs_k_r§§icl~nisj¥b ich  tak:ecs 
place ollfsTaeof the 111onthly Multi:O]sQiQlinary Meetings.  The Home identifies residents with  high 
needs and  reports to the Consultant Geria-trician who then visits to  have a face-to-face  review 
with the residents  and the staff in the Home.  Actions needed to  be taken  are then  escalated by 
people assigned for the particular action. 

We hope that the above addressed the coroner's concerns,  as raised  Regulation 28 Report to 
Prevent Future Deaths of 29 July 2022. 

We would like to reiterate our condolences to  Mr Burton's family for their loss. 

Yours sincerely, 

HC-One 

Registered office: Southgate House, Archer Street, Darlington, County Durham, DL3 6AH 

Incorporating HC-One Limited, registered in England No.  07712656; Meridian Healthcare Limited, 
registered in England No.  01952719; HCOne Beamish Limited, registered in England No. 05217764