Dear Sir Re: Regulation 28 Report to Prevent Future Deaths Further to the inquest touching the death of Mr Locksley Burton, as heard on 7October 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 was made. 11 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.

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.

Dear Sir, Inquest into the death of Mr Locksley Burton We write in relation to the Regulation 28 Report to Prevent Future Deaths dated 29th 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. I An Academic Health Sciences Centre for London Pioneering better health for all

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 1 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. 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. . I 01 I I
• I KING'S HEALTH PARTNERS An Academic Health Sciences Centre for London Pioneering better health for all

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.