CopperfieldsIncludes reports addressed to a minister or senior office-holder acting for this organisation.

Private and voluntary organisations · Nursing home

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First report 28 Jan 2022•Latest report 28 Jan 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

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

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

  1. Addressed to: Manager, Copperfields Nursing Home.

    West Yorkshire Eastern

    AI-generated summary

    Mark Anthony Athias · 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

    Mark Anthony Athias had multiple physical and mental health issues, including recurring urinary infections and problems with a long-term catheter. After difficulties with his catheter on 2 July 2021, he was admitted to hospital, where his condition deteriorated and he died on 6 July 2021. Concerns included a lack of sterile replacement catheters, inadequate monitoring records, and a missing handover record, with risks arising from deficient record keeping.

    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 Copperfields; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of managers to detect inadequate monitoring records

    Wider context from the report

    “2. The catheter care plan had identified the need for his fluid intake and output to be monitored. The contemporaneous records kept were, however, inadequate. This hindered any assessment of his urinary problems. The managers in the nursing home had not noticed the inadequacy of such records. ”
    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 Copperfields; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of sterile replacement catheters in stock

    Wider context from the report

    “1. The nursing home did not have sterile replacement catheters in stock, despite being aware that Mr Athias had difficulties with his catheter, which had necessitated it being replaced twice in previous weeks. The mistakes made in ordering replacements had not been detected by the managers in the nursing home. ”
    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 Copperfields; that does not assign responsibility.

    PFD Monitor interpretation

    Delayed managerial detection of missing handover records

    Wider context from the report

    “3. The handover record for 2 July 2021 was missing, having allegedly been overwritten. The managers in the nursing home did not appreciate this until an Adult Safeguarding Investigation was underway. ”
    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 Copperfields; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to detect mistakes in ordering replacement catheters

    Wider context from the report

    “1. The nursing home did not have sterile replacement catheters in stock, despite being aware that Mr Athias had difficulties with his catheter, which had necessitated it being replaced twice in previous weeks. The mistakes made in ordering replacements had not been detected by the managers in the nursing home. ”
    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 Copperfields; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to conduct sufficiently frequent checks that required records exist and are preserved

    Wider context from the report

    “4. In order to ensure instructions were complied with, and without checks to ensure the contemporaneous records required to be kept were actually being maintained, there is a risk deficient record keeping could continue. 5. Managers of nursing homes should make checks sufficiently often to ensure the records required to be kept actually exist, and that they are preserved, so as to facilitate an analysis of trends in the medical condition of patients in the care of the nursing home ”
    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 Copperfields; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate contemporaneous records of fluid intake and output

    Wider context from the report

    “2. The catheter care plan had identified the need for his fluid intake and output to be monitored. The contemporaneous records kept were, however, inadequate. This hindered any assessment of his urinary problems. The managers in the nursing home had not noticed the inadequacy of such records. ”
    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 Copperfields; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to preserve handover records

    Wider context from the report

    “3. The handover record for 2 July 2021 was missing, having allegedly been overwritten. The managers in the nursing home did not appreciate this until an Adult Safeguarding Investigation was underway. ”
    Open source report
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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