Mark Athias

Exemplar
HealthCare 

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Mr Kevin McLoughlin 
Senior Coroner for West Yorkshire (East) 
HM Coroner's Court 
71  N orthgate 
Wakefield 
WFl  3BS 
Via email: HMCoroner@Wakefield.gov.uk 

24 March 2022 

Dear Mr McLoughlin 

Mark Anthony Athias Inquest 

I am writing to you in response to your Regulation 28 report dated 28 January 2022, following 
the inquest into the death of Mark Anthony Athias, which you conducted on 27 January 2022. 
First, and on behalf of all the staff at Exemplar Health Care and particularly Copperfields Care 
Home, I would like to say how deeply saddened we all were by Mr Athias' tragic death. 

Your report raises five matters that cause you concern and I shall take each in turn. 

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 the previous weeks. The mistakes made in ordering placements had not 
been detected by managers in the nursing home. 

You heard evidence from 
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: 

, Head of Quality for Exemplar Health Care Services 

gel, 

"It is essential to ensure that the home retains sufficient stocks ofcatheters,  lubricating 
sterile catheter packs,  drainage systems,  securing systems and stands. 
Ensure sufficient stock levels are available· to accommodate both planned and unplanned 
replacement andfactor in emergency changes i. e.  ifthe catheter is known to be 
problematic" 

 explained that, at the time of Mr Athias' placement at Copperfields, all of the care 

documentation was paper based. This meant stock was ordered by a tally system, with the need 

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 for the nurses on duty to ensure that a visual observation was undertaken, and stock ordered or, if 
the observation was undertaken out of hours, then the need for further stock to be ordered was 
communicated in the unit diaries in order for it to be ordered the following day. 

You were provided with written evidence from Nurse 
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. 

that she recognised that the catheter 

 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 
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. 

 also explained that, shortly after Mr Athias' death, 

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 CO!Jllllunication error leading to an absence of equipment such as occurred 
in Mr Athias' case. 

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 
central support team to undertake a weekly dashboard review as a further check on stock levels 
across the organisation. 

, weekly visual stock checks still take place. The EMAR system also enables the 

In addition to the wider organisational changes explained above, Copperfields has put in place a 
"3  step check" system in order to ensure monitoring of catheters as follows: 

1.  Each resident with a catheter in situ has stock located within their room which is 
visually checked on a daily basis by the team leaders. This means that the team 
leaders can reassure themselves that there are enough catheters for each individual 
resident (rather than relying on a general level of stock for all residents). 

2.  A back up stock of catheters is stored in the storeroom with a minimum of three 

catheters for each resident. 

3.  Stock level is recorded in each unit's individual diary and this is reviewed on a 

daily basis as part of the daily handover.  The written record requires sign off after 
each catheter check and so an individual Registered Nurses take personal 
responsibility for the accuracy. 

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 

 levels on EMAR on a daily basis.  The Copperfields staff also have access to an on-call system to 
the home management staff 24 hours a day should any issues arise. 

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. 

Exemplar Health Care has protocols for recording fluid balance (including input and output), and 
a supporting fluid and nutrition policy. These policies were in place at the time of Mr Athias' stay 
at Copperfields; however, it is recognised that Mr Athias' contemporaneous records were not 
consistently kept, and this had not been recognised by the management team at the time. 

 that specific catheter related training was delivered at 

You heard evidence from Ms 
Copperfields by an experienced Quality Manager following Mr Athias' death. Ms 
explained that the feedback following this training was that the nursing staff at Copperfields were 
knowledgeable and informed in respect of catheterisation and catheter care but were very pleased 
to undertake appropriate refresher training.  In addition, the importance of recording fluid intake 
as well as output was highlighted to the care team in a shared learning presentation, emphasising 
what steps were to be taken in order to prevent any future similar occurrences. 

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 anddocumentation. 
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. This is to ensure that there is additional management resource 
in order to  support the home and, particularly, to ensure that there is a Clinical Nurse Manager on 
site at weekends and out of hours.  I set out in an appendix to this letter the previous and current 
management structure at Copperfields. 

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- Exemplar Quality 
Assurance) were paper based. However, the majority of the EQA processes have now been 
moved to a digital platform. 

The individual team leaders have been trained that they are responsible for ensuring that there are 
no gaps in the supplementary documentation, that all documentation is complete before the end 
of their shifts and that this is reported to the unit managers, who in turn report it in a daily "take 
20 meeting". This is then documented in the EQA electronic record. 

Quality assurance reviews are also undertaken by: 

1.  A daily manager walk around; 
2.  A clinical manager walk around which is undertaken daily ; and 

 
 3.  A daily "take twenty" meeting this involves the Home manager, Clinical Nurse 

Manager and the Unit Manager or registered general nurse managing the unit on 
the day. 

The results of these quality assurance reviews can be reviewed remotely on the EQA systems, 
which can be access via PC, Laptop, Tablet or smart phone. The EQA processes enable managers 
to monitor in "real time" (either remotely or in person) the supplementary records and any 
"actions required" as these are now recorded digitally. 

3. The handover record for 2nd  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. 

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. 

In the management office, three months of paper copies are saved in files for each unit. After the 
three-month period has elapsed the paper copies are archived in the storage room. Prior to 
archiving, a monthly check takes place to ensure that there are no missing days and the individual 
checker this is completed by the Home Manager and Clinical Nurse Manager who signs to 
confirm that they have been reviewed and all relevant paper copies are present. 
This method ensures that all documentation is accessible both electronically and in paper form 
and there is no longer any possibility of a document such as a handover being overwritten, and 
the content lost. 

4. In order to ensure instructions were complied with, and without checks to  ensure that 
contemporaneous records required to be kept were actually being maintained, there is a 
risk deficient record keeping could continue. 

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: 

1.  Exemplar Health Care has introduced an electronic system which is accessible 

remotely and allows oversight from the central clinical team. 

2.  Exemplar Health Care has implemented a daily clinical walk around by a nurse 

which provides quality assurance and traceability. This walk around is then signed 
off by the Home Manager or Head of Care. 

3.  Exemplar Health Care has implemented weekly EMAR feedback on each home. 
4.  Exemplar Health Care has implemented a monthly compliance feedback. 
5.  Shared learning has taken place at Copperfields. 
6.  Defensible documentation training has taken place at Copperfields. 
7.  A 24-hour management structure is now in place at Copperfields. 
8.  It is now explicitly part of the team leaders' roles that they are responsible for 

reviewing and quality assuring supplementary records. 

 9.  Copperfields has implemented monthly auditing of supplementary and care files 

and findings are discussed with individual unit managers. 

10. Daily electronic saving of handovers takes place and printed copies are stored in 

the Copperfields management office. 

11. Daily monitoring of EMAR dashboards for stock levels takes place. 

Exemplar Health Care is confident that the processes outlined above have resulted in all clinical 
instructions being followed, appropriate record keeping being undertaken and regular, appropriate 
quality assurance taking place. 

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 conditions of patients in the care of the nursing home. 

I have set out above the various processes that have been implemented to ensure that the 
management team at Copperfields, and across Exemplar Health Care, review and quality assure 
records. I am confident that appropriate records are being kept and retained. 
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. 

I would like to take the opportunity to assure you that Exemplar Health Care seeks to learn from 
all untoward incidents and absolutely recognises that Mr Athias 1 death was the most serious type 
of such incidents. As outlined in the evidence of Ms 
 during the inquest and in the summary 
above, Exemplar Health Care has already taken learning from Mr Athias' extremely sad death and 
will continue to do so. 

Yours sincerely 

Home manager 

 
 Appendix 1 
Figure 1 - Previous management structure at Copperfields 

Regional Director 

Regi~tered  Home 

Mdnager 

I 
Clinical Nur!.e Manager 

CNM 
I 
I 

I 

I 

Unit Manager 

Unit M,mager 

Unit manager 

I 

I 

/ 

Tearn leader x1 

Team  leader xl 

Team leader xl 

Figure 2 - Current management structure at Copperfields 

Rt>giPOdl  dirertor 

Rt"gisterPd  Manager 

Copper fields 

.---------.------- --------.------.

Head of Care 

Clinic al Nutst>
ManagN (CNM)

Clinical Nur~e 
Manager (CNM) 

I 

Unit Manager 

Unit Manager 

Unit Manage-,

lt>am leadE'rs 

Night Manager 

Night 

Team Leaders