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recurance

James Astley

10 Sept 2024 · Coroner Alison Mutch · South Manchester

This report repeats 2 earlier warnings. See the linked reports.

The coroner's concerns

  1. 1. poor nutrition and fluid intake

    “poor nutrition and fluid intake”
  2. 2. MUST documentation not correctly completed

    “MUST documentation was not correctly completed and the overall quality of fluid and nutrition charts was poor”
  3. 3. overall documentation at the home was limited

    “Overall documentation at the home was limited and lacked detail”

Linked reports

Repeats an earlier warningAnthony Slack1 Dec 2020 · 3 years 9 months earlier
Identical hazardConfidence 0.90 · high

Earlier report

“The documentation available at the inquest from the home was limited in detail. As a result, it was difficult to understand what observations had been undertaken by care home staff who were monitoring him.”
Original on judiciary.uk ↗

This report

“Overall documentation at the home was limited and lacked detail”
Full chain: Inaccurate and inconsistent care plan entries and record keeping
Repeats an earlier warningJohn Dickinson22 Jul 2021 · 3 years 2 months earlier
Identical hazardConfidence 0.90 · high

Earlier report

“(1) The record keeping was inconsistent and lacked detail on general wellbeing.”
Original on judiciary.uk ↗

This report

“Overall documentation at the home was limited and lacked detail”
Full chain: Inaccurate and inconsistent care plan entries and record keeping

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error