Alexander Court Care CentreIncludes reports addressed to a minister or senior office-holder acting for this organisation.

Private and voluntary organisations · Nursing home

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First report 14 Jul 2016•Latest report 14 Jul 2016

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

Concerns and recipient responses

Statements from Alexander Court Care Centre linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to: ████████, Nursing Director, Alexander Court Care Centre.

    London (East)

    AI-generated summary

    Mr Harold Goulding · 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

    Mr Harold Goulding suffered two falls at a care home on 5 and 6 November 2015, followed by a subdural haematoma, seizure and cardiac arrest; he died on 10 November 2015. The concerns included communication failures between the anticoagulation clinic, GP and care home, and the GP not checking the care home’s medication administration record, meaning he was unaware that Mr Goulding was receiving warfarin.

    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 Alexander Court Care Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to notify relevant healthcare providers of changes in a care home resident’s General Practitioner

    Wider context from the report

    “1. The evidence revealed a breakdown of communication between the anti-coagulation clinic, the General Practitioner and the Care Home. The Care Home had registered Mr Goulding with a new General Practitioner but did not notify the anti-coagulation clinic of the details of the new General Practitioner. The community pharmacist therefore continued to provide reports to the old GP. 2. The General Practitioner provided the lead in relation to the administration of medication at the care home. The General Practitioner did not however consider the Medication Administration Record held by the home. The staff providing evidence from the care home agreed that it would reduce risk in the future, if a system is in place to ensure that the General Practitioner attending for new resident reviews, considers and approves the medication set out within the Medication Administration Record. This would not only provide assurance to the Care Home staff in relation to medication that they are administering, but would also ensure that GPs are fully aware of the medication that residents are currently receiving. It was further agreed that in order to reduce future risk, the Care Home staff should take the lead in ensuring that any other health agencies providing care to new residents are informed when the home registers new residents with a new General Practitioner, so that information can be correctly shared. ”
    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 Alexander Court Care Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of General Practitioners to review and approve care home residents’ Medication Administration Records

    Wider context from the report

    “1. The evidence revealed a breakdown of communication between the anti-coagulation clinic, the General Practitioner and the Care Home. The Care Home had registered Mr Goulding with a new General Practitioner but did not notify the anti-coagulation clinic of the details of the new General Practitioner. The community pharmacist therefore continued to provide reports to the old GP. 2. The General Practitioner provided the lead in relation to the administration of medication at the care home. The General Practitioner did not however consider the Medication Administration Record held by the home. The staff providing evidence from the care home agreed that it would reduce risk in the future, if a system is in place to ensure that the General Practitioner attending for new resident reviews, considers and approves the medication set out within the Medication Administration Record. This would not only provide assurance to the Care Home staff in relation to medication that they are administering, but would also ensure that GPs are fully aware of the medication that residents are currently receiving. It was further agreed that in order to reduce future risk, the Care Home staff should take the lead in ensuring that any other health agencies providing care to new residents are informed when the home registers new residents with a new General Practitioner, so that information can be correctly shared. ”
    Open source report
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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