Recipient

Copperfields

First report 28 Jan 2022•Latest report 28 Jan 2022

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Nursing home. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

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.

28 Jan2022
West Yorkshire Eastern
Concerns raised7
1. Failure of managers to detect inadequate monitoring records
2. Unavailability of sterile replacement catheters in stock
3. Delayed managerial detection of missing handover records
1. Failure to detect mistakes in ordering replacement catheters
2. Failure to conduct sufficiently frequent checks that required records exist and are preserved
3. Inadequate contemporaneous records of fluid intake and output
4. Failure to preserve handover records
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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

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

Reports, concerns and published responses

Reports over time

Concerns raised7

Failure of managers to detect inadequate monitoring records

Unavailability of sterile replacement catheters in stock

Delayed managerial detection of missing handover records

Failure to detect mistakes in ordering replacement catheters

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

Inadequate contemporaneous records of fluid intake and output

Failure to preserve handover records