28 Jan 2022 Mark Anthony Athias · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 7 Failure of managers to detect inadequate monitoring records View source Unavailability of sterile replacement catheters in stock View source Delayed managerial detection of missing handover records View source Failure to detect mistakes in ordering replacement catheters View source Failure to conduct sufficiently frequent checks that required records exist and are preserved View source Inadequate contemporaneous records of fluid intake and output View source Failure to preserve handover records View source See 4 more concerns
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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Mark Anthony Athias · Prevention of Future Deaths report
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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.
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× 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 Exemplar Health Care Services Limited; 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 Exemplar Health Care Services Limited; 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 Exemplar Health Care Services Limited; 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 Exemplar Health Care Services Limited; 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 Exemplar Health Care Services Limited; 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 Exemplar Health Care Services Limited; 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 Exemplar Health Care Services Limited; 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