PFD report

Mark Anthony Athias · Prevention of Future Deaths report

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Issued 28 Jan 2022•West Yorkshire Eastern

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
7

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
12

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised7

  1. Failure of managers to detect inadequate monitoring records
    Part of recurring concern: Insufficient care home management capacity and oversightPart of recurring concern: Unreliable recording of fluid balance information
  2. Unavailability of sterile replacement catheters in stock
    Part of recurring concern: Failure to ensure essential clinical equipment and supplies are available and serviceablePart of recurring concern: Unreliable availability of urinary catheters for required care
  3. Delayed managerial detection of missing handover records
    Part of recurring concern: Failure to reliably preserve handover records
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.9

  1. Action

    Preserve handover records through electronic monthly files, printed management-office copies, archiving and monthly completeness checks.

    Stated by Exemplar Health CareStated completedThe respondent said that this action was complete when they made their response on 31 January 2022.
  2. Action

    Implement monthly audits of supplementary and care files, with findings discussed with unit managers.

    Stated by Exemplar Health CareStated completedThe respondent said that this action was complete when they made their response on 31 January 2022.
  3. Action

    Provide EMAR training to staff and access to continuous EMAR support and an out-of-hours management contact system.

    Stated by Exemplar Health CareStated completedThe respondent said that this action was complete when they made their response on 31 January 2022.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Existing management oversight, quality assurance and governance processes are considered sufficient to ensure records are kept, retained and reviewed for trends.

    Stated by Exemplar Health CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Insufficient care home management capacity and oversight; Unreliable recording of fluid balance information.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure to ensure essential clinical equipment and supplies are available and serviceable; Unreliable availability of urinary catheters for required care.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure to reliably preserve handover 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. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Insufficient care home management capacity and oversight; Unreliable availability of urinary catheters for required care.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

Yes — Failure of care and safety auditing to identify deficiencies.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unreliable recording of fluid balance information.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure to reliably preserve handover records; Failure to retain safety-critical source records and evidence; Unreliable handover of care information and responsibility.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Preserve handover records through electronic monthly files, printed management-office copies, archiving and monthly completeness checks.

Verbatim wording from the response

“You heard evidence from Ms ████████ that Exemplar Health Care had changed its system to use word templates across the entire organisation. It is therefore no longer possible for documents such as handovers to be overwritten. In addition, each handover is now saved electronically in a specific month document file and a copy is printed off and retained in the management office at Copperfields in paper form with a date tracker.”

Source location

2022-0024-Response-from-Exemplar-Health-Care_Published
Page 4 · response
Published 31 January 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement monthly audits of supplementary and care files, with findings discussed with unit managers.

Verbatim wording from the response

“9. Copperfields has implemented monthly auditing of supplementary and care files and findings are discussed with individual unit managers.”

Source location

2022-0024-Response-from-Exemplar-Health-Care_Published
Page 5 · response
Published 31 January 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide EMAR training to staff and access to continuous EMAR support and an out-of-hours management contact system.

Verbatim wording from the response

“Copperfields delivered shared learning with the nursing staff following Mr Athias' death which highlighted the other avenues available to access catheters in the community. In addition, following the implementation of the EMAR system at Copperfields in February 2022, all staff were provided with several weeks of EMAR training and have access to 24 hours a day support from the EMAR team. The nurses and management team have been trained to review the stock”

Source location

2022-0024-Response-from-Exemplar-Health-Care_Published
Page 2 · response
Published 31 January 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Digitise EQA governance and establish team-leader accountability, daily management reviews, clinical walkarounds, take-twenty meetings and electronic quality-assurance tracking.

Verbatim wording from the response

“In addition to these management changes, specific steps have also been taken to ensure greater management overview, and quality assurance, of record keeping and documentation. During Mr Athias' residence at Copperfields the relevant governance processes (EQA- External Quality Assurance) were paper based. However, the majority of the EQA processes have now been moved to a digital platform.”

Source location

2022-0024-Response-from-Exemplar-Health-Care_Published
Page 3 · response
Published 31 January 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement layered catheter-stock controls, including weekly checks, resident-level supplies, minimum backup stocks, daily records and handover sign-off.

Verbatim wording from the response

“You were provided with written evidence from Nurse ████████ that she recognised that the catheter stock was insufficient during an out of hours shift on 2 July 2021, and she requested that further catheters be ordered. Unfortunately, due to a communication error this request was not actioned. ████████ explained that, following Mr Athias' death, she personally reviewed all incidents across the Exemplar Health Care organisation and found no evidence of a similar incident occurring, either before or since. She explained that the lack of sterile catheter was therefore an unfortunate, one-off communication error. Ms ████████ also explained that, shortly after Mr Athias' death, weekly stock checks were implemented at Copperfields in order to ensure a sufficient level of stock is maintained at all times. This new system is working well.”

Source location

2022-0024-Response-from-Exemplar-Health-Care_Published
Page 2 · response
Published 31 January 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deliver catheter-care refresher training and shared learning on fluid-intake recording and alternative catheter access routes.

Verbatim wording from the response

“Copperfields delivered shared learning with the nursing staff following Mr Athias' death which highlighted the other avenues available to access catheters in the community. In addition, following the implementation of the EMAR system at Copperfields in February 2022, all staff were provided with several weeks of EMAR training and have access to 24 hours a day support from the EMAR team. The nurses and management team have been trained to review the stock”

Source location

2022-0024-Response-from-Exemplar-Health-Care_Published
Page 2 · response
Published 31 January 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Update the catheter policy to require sufficient stocks for planned, unplanned and emergency catheter changes.

Verbatim wording from the response

“You heard evidence from ████████, Head of Quality for Exemplar Health Care Services that following Mr Athias' death Exemplar Health Care's catheter policy was updated to reflect the importance of retaining sufficient stocks of catheters in all Exemplar Health Care homes. You were provided with a copy of the updated policy and your attention was drawn to the following paragraph:”

Source location

2022-0024-Response-from-Exemplar-Health-Care_Published
Page 1 · response
Published 31 January 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement EMAR stock visibility, low-stock alerts and daily or weekly dashboard monitoring with remote clinical oversight.

Verbatim wording from the response

“Following Mr Athias' death, Exemplar Health Care has also implemented an Electronic Medication System ("EMAR"). This means that stock level is visible on the EMAR system at all times and stock levels can be viewed by the nurses on EMAR laptops, and remotely by Clinical Nurse Managers, Heads of Care, the Registered Home Managers and the central support service 24 hours a day. This has resulted in far more overview of stock at all levels of seniority and removes the risk of a communication error leading to an absence of equipment such as occurred in Mr Athias' case.”

Source location

2022-0024-Response-from-Exemplar-Health-Care_Published
Page 2 · response
Published 31 January 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deliver workshops and coaching on creating, implementing and monitoring unambiguous care plans and comprehensive records across all service users.

Verbatim wording from the response

“Further workshops and coaching sessions have also been undertaken by various experienced Quality Managers in order to support staff to create, implement and monitor more thorough and unambiguous care plans. In the first instance this support was focussed on the documentation for service users who utilised catheters, however the workshops have now been undertaken in relation to all service users and included general sessions on record keeping and documentation. You heard evidence from Ms ████████ that significant management change has now taken place at Copperfields since Mr Athias' death. A new Registered Home Manager and new Clinical Nurse Manager are now in place. In addition, a second full time Clinical Nurse Manager and a full time Head of Care have been employed.”

Source location

2022-0024-Response-from-Exemplar-Health-Care_Published
Page 3 · response
Published 31 January 2022

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing management oversight, quality assurance and governance processes are considered sufficient to ensure records are kept, retained and reviewed for trends.

Verbatim wording from the response

“I have detailed above the relevant management structure changes and quality assurance systems in place to ensure that all record keeping is appropriate and accurate. In summary:”

Source location

2022-0024-Response-from-Exemplar-Health-Care_Published
Page 4 · response
Published 31 January 2022

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing electronic, visual and dashboard stock controls remove the risk of communication errors causing catheter shortages.

Verbatim wording from the response

“Following Mr Athias' death, Exemplar Health Care has also implemented an Electronic Medication System ("EMAR"). This means that stock level is visible on the EMAR system at all times and stock levels can be viewed by the nurses on EMAR laptops, and remotely by Clinical Nurse Managers, Heads of Care, the Registered Home Managers and the central support service 24 hours a day. This has resulted in far more overview of stock at all levels of seniority and removes the risk of a communication error leading to an absence of equipment such as occurred in Mr Athias' case.”

Source location

2022-0024-Response-from-Exemplar-Health-Care_Published
Page 2 · response
Published 31 January 2022

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The catheter stock failure was an isolated communication error, with no evidence of similar incidents occurring before or since.

Verbatim wording from the response

“You were provided with written evidence from Nurse ████████ that she recognised that the catheter stock was insufficient during an out of hours shift on 2 July 2021, and she requested that further catheters be ordered. Unfortunately, due to a communication error this request was not actioned. ████████ explained that, following Mr Athias' death, she personally reviewed all incidents across the Exemplar Health Care organisation and found no evidence of a similar incident occurring, either before or since. She explained that the lack of sterile catheter was therefore an unfortunate, one-off communication error. Ms ████████ also explained that, shortly after Mr Athias' death, weekly stock checks were implemented at Copperfields in order to ensure a sufficient level of stock is maintained at all times. This new system is working well.”

Source location

2022-0024-Response-from-Exemplar-Health-Care_Published
Page 2 · response
Published 31 January 2022

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Electronic storage, printed copies and monthly checks ensure handovers cannot be overwritten and remain accessible.

Verbatim wording from the response

“You heard evidence from Ms ████████ that Exemplar Health Care had changed its system to use word templates across the entire organisation. It is therefore no longer possible for documents such as handovers to be overwritten. In addition, each handover is now saved electronically in a specific month document file and a copy is printed off and retained in the management office at Copperfields in paper form with a date tracker.”

Source location

2022-0024-Response-from-Exemplar-Health-Care_Published
Page 4 · response
Published 31 January 2022

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Establish weekly governance review of trends from audits, incidents and near misses, with periodic reporting to the organisational compliance team.

    Stated by Exemplar Health CareStated completedThe respondent said that this action was complete when they made their response on 31 January 2022.
  2. 2

    Increase management capacity by appointing new home and clinical managers, an additional full-time clinical nurse manager and a full-time head of care.

    Stated by Exemplar Health CareStated completedThe respondent said that this action was complete when they made their response on 31 January 2022.
  3. 3

    Implement weekly EMAR feedback and monthly organisational compliance feedback for care homes.

    Stated by Exemplar Health CareStated completedThe respondent said that this action was complete when they made their response on 31 January 2022.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Establish weekly governance review of trends from audits, incidents and near misses, with periodic reporting to the organisational compliance team.

Verbatim wording from the response

“In addition, Copperfields has a weekly governance meeting where trends can be monitored and further actions undertaken in response to any audit findings, untoward incidents or "near miss" events. These trends are also recorded as part of the clinical statistics for Copperfields which are reported every period to the Exemplar Health Care compliance team. The compliance team is therefore able to review any trends across the whole of the organisation and identify any anomalies for an individual care home.”

Source location

2022-0024-Response-from-Exemplar-Health-Care_Published
Page 5 · response
Published 31 January 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Increase management capacity by appointing new home and clinical managers, an additional full-time clinical nurse manager and a full-time head of care.

Verbatim wording from the response

“Further workshops and coaching sessions have also been undertaken by various experienced Quality Managers in order to support staff to create, implement and monitor more thorough and unambiguous care plans. In the first instance this support was focussed on the documentation for service users who utilised catheters, however the workshops have now been undertaken in relation to all service users and included general sessions on record keeping and documentation. You heard evidence from Ms ████████ that significant management change has now taken place at Copperfields since Mr Athias' death. A new Registered Home Manager and new Clinical Nurse Manager are now in place. In addition, a second full time Clinical Nurse Manager and a full time Head of Care have been employed.”

Source location

2022-0024-Response-from-Exemplar-Health-Care_Published
Page 3 · response
Published 31 January 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement weekly EMAR feedback and monthly organisational compliance feedback for care homes.

Verbatim wording from the response

“3. Exemplar Health Care has implemented weekly EMAR feedback on each home.”

Source location

2022-0024-Response-from-Exemplar-Health-Care_Published
Page 4 · response
Published 31 January 2022

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026