Alexander House Health Centre

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First report 23 Sep 2015•Latest report 23 Sep 2015

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
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
4

Described in responses

Concerns and recipient responses

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

  1. Manchester West

    AI-generated summary

    Dorothy Delaney · 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

    Dorothy Delaney was found collapsed at her care home on 11 June 2015 after being prescribed Rivaroxaban for atrial fibrillation and Clopidogrel for previous transient ischaemic attacks. She was diagnosed with a large intracerebral haemorrhage and died later that day. The principal concern was that both anticoagulant and antiplatelet medications were prescribed without individual specialist advice, increasing the risk of haemorrhage.

    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 House Health Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to obtain individualized specialist advice for patients prescribed anticoagulation and antiplatelet medication together

    Wider context from the report

    “vi. Following Mrs Delaney’s diagnosis of atrial fibrillation and the subsequent prescription of Rivaroxaban, no specialist advice was sought regarding the appropriateness of continuing to prescribe both Clopidogrel and Rivaroxaban together. Evidence was given at the inquest that advice is not sought on an individual basis for patients at Alexander House Health Centre who are prescribed both Clopidogrel and Rivaroxaban as they rely on advice previously sought in respect of other patients in similar circumstances. 2. I therefore have concerns that there are patients under the care of Alexander House Health Centre who are being prescribed both anticoagulation therapy and antiplatelet medication at the same time, which increases the risk of a haemorrhage occurring, in circumstances where specialist advice has not been sought, taking into account the individual patient’s previous medical history and circumstances. ”
    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Produce a practice protocol for prescribing anticoagulant and antiplatelet medicines together.

    Verbatim wording from the response

    “Although I was not able to find any protocol or guidance on this issue, as I have feedback from our local Haematology Department, I decided to produce a protocol for our practice for future prescribing of anticoagulant with antiplatelet agents. Furthermore I have reviewed all the patients who are on combined treatment. I have looked at their medical records and checked the suitability of the patient to be on both groups of medication. In any patient, if I was not sure, I have liaised with secondary care to clarify the matter.”

    Source location

    2015-0402-Alexander-House-Health-Centre
    Page 2 · response
    Published 23 September 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review all patients receiving combined anticoagulant and antiplatelet treatment, checking documented suitability and consulting secondary care when uncertain.

    Verbatim wording from the response

    “Although I was not able to find any protocol or guidance on this issue, as I have feedback from our local Haematology Department, I decided to produce a protocol for our practice for future prescribing of anticoagulant with antiplatelet agents. Furthermore I have reviewed all the patients who are on combined treatment. I have looked at their medical records and checked the suitability of the patient to be on both groups of medication. In any patient, if I was not sure, I have liaised with secondary care to clarify the matter.”

    Source location

    2015-0402-Alexander-House-Health-Centre
    Page 2 · response
    Published 23 September 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Change prescriptions to single anticoagulant treatment where appropriate after discussing the decision with each patient.

    Verbatim wording from the response

    “I felt on reviewing their records, most of the patients could be managed by a singly anticoagulant agent instead of combined treatment, as per our local Haematology guidance. Accordingly I made the”

    Source location

    2015-0402-Alexander-House-Health-Centre
    Page 2 · response
    Published 23 September 2015

    Open published response
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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