James Astley

I am Alison Mutch, Senior Coroner, for the coroner area of South Manchester

On 25 th January 2024 I commenced an investigation into the death of James  Astley. The investigation concluded on the13th August 2024 and the conclusion was one of Narrative: Died from natural causes contributed to by dehydration  and poor nutritional status. The medical cause of death was 1a) Urosepsis,  vascular dementia II) Frailty, dehydration, poor nutritional status.

James Astley had dementia and was immobile. His nutritional status declined  significantly from November 2023. In December his swallow deteriorated and  led to him becoming increasingly frail. On 2nd January he was started on  antibiotics. On 3rd January he was seen again by a GP and found to have  deteriorated further. He was admitted to Tameside General Hospital where he was treated for urosepsis and dehydration. Despite treatment he continued to deteriorate due to his frailty. He died at Tameside General hospital on 22nd  January 2024.

During the course of the inquest the evidence revealed matters giving rise to  concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. –

1. The inquest heard evidence that Mr Astley was at significant risk due to poor nutrition and fluid intake. However the MUST documentation was not correctly completed and the overall quality of fluid and nutrition  charts was poor. As a consequence he became increasingly frail and the risk to his overall wellbeing and physiological reserves continued.
2. Overall documentation at the home was limited and lacked detail

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.