Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Mark Athias · 28 Jan 2022 · Kevin McLoughlin, West Yorkshire (East)
“The catheter care plan had identified the need for his fluid intake and output to be monitored. The contemporaneous records kept were, however, inadequate.”
judiciary.uk/…/mark-athias-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Mark Athias (28 Jan 2022) · stated timescale: 2022
“The nursing home did not have sterile replacement catheters in stock, despite being aware that Mr [name redacted] had difficulties with his catheter, which had necessitated it being replaced twice in the previous weeks. The mistakes made in ordering placements had not been detected by managers in the nursing home.”
judiciary.uk/…/2022-0024-Response-from-Exemplar-Health-Care_Pub…
Stated action 2 · response to Mark Athias (28 Jan 2022) · stated timescale: 2022
“after Mr [name redacted]' death, weekly stock checks were implemented at Copperfields in order to ensure a sufficient level of stock is maintained at all times.”
judiciary.uk/…/2022-0024-Response-from-Exemplar-Health-Care_Pub…
Stated action 3 · response to Mark Athias (28 Jan 2022) · stated timescale: February 2022
“The EMAR system also has a Dashboard that flags an alert in the event any stock is running low. The levels of stock are therefore no longer dependent on visual assessment although, as explained by Ms , weekly visual stock checks still take place”
judiciary.uk/…/2022-0024-Response-from-Exemplar-Health-Care_Pub…
3 further stated actions are listed on the full chain page.
What recurred
- 20 Jan 2023 · Sophia Ayuk · Graeme Irvine · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Mark Athias · 28 Jan 2022
“The catheter care plan had identified the need for his fluid intake and output to be monitored. The contemporaneous records kept were, however, inadequate.”
Later · Sophia Ayuk · 20 Jan 2023
“Instructions given to monitor and record Ms [name redacted] food and fluid intake were not adequately followed.”
What happened next
No web check of the stated actions has been published for this chain.