Recipient

Downshaw Lodge

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First report 10 Sep 2024•Latest report 10 Sep 2024

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Residential care home. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Downshaw Lodge linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Manchester South

    AI-generated summary

    James Astley · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    James Astley had dementia, was immobile, and became increasingly frail following worsening nutrition, fluid intake, and swallowing difficulties. He was admitted to hospital with urosepsis and dehydration and died there on 22 January 2024. The concerns included incorrectly completed MUST documentation, poor-quality fluid and nutrition charts, and limited, insufficiently detailed documentation at the care home.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Downshaw Lodge; that does not assign responsibility.

    PFD Monitor interpretation

    Poor quality of fluid and nutrition charts

    Wider context from the report

    “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 ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Downshaw Lodge; that does not assign responsibility.

    PFD Monitor interpretation

    Limited and insufficiently detailed documentation

    Wider context from the report

    “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 ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Downshaw Lodge; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to correctly complete MUST documentation

    Wider context from the report

    “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 ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026