Recipient

Alexandra Court - CleveleysIncludes reports addressed to a minister or senior office-holder acting for this organisation.

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First report 2 Nov 2015•Latest report 2 Nov 2015

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 Alexandra Court - Cleveleys linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to: Manager/proprietor, The Alexandra Court Care Home.

    Blackpool and the Fylde

    AI-generated summary

    Jean Dorothy Gillespie · 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

    Jean Dorothy Gillespie was residing in a care home for respite care when her prescribed Pyridostigmine ran out, with the last dose administered on 25 April 2015. She developed symptoms attributable to myasthenia gravis, was taken to hospital, and died on 8 May 2015. The report raised concerns that care staff did not know about her condition or the urgency of replacing the medication, and that care home records did not document the condition, its symptoms, or the medication's purpose.

    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 Alexandra Court - Cleveleys; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of care home records to document conditions, symptoms and medication purposes

    Wider context from the report

    “1. The inquest heard that a senior member of the care staff with responsibility for administering medication to residents and for re-ordering supplies of medication did not know that the deceased suffered from myasthenia gravis, nor was this a condition she had heard of before. 2. When supplies of the necessary medication were about to expire she did seek to re-order supplies. When they did not materialise she did not appreciate the urgency the situation demanded until symptoms became evident. 3. I am concerned that irrespective of whether this is a care home rather than a nursing home that staff with responsibility for administering and / or re-ordering supplies of medication for potentially life threatening conditions are aware of the conditions and what the medication is prescribed for so that staff can then react accordingly. 4. Further, consideration of the care home records made no reference to the name of the condition, the symptoms that can materialise, nor what the prescribed medication was for. A member of staff previously unfamiliar with this patient who may have responsibility for administering her medication would not have been able to familiarise themselves with the necessary knowledge from a perusal of the care home records and I am concerned there is a risk of future deaths were this situation to be replicated. ”
    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 Alexandra Court - Cleveleys; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of staff awareness of conditions and medication purposes

    Wider context from the report

    “1. The inquest heard that a senior member of the care staff with responsibility for administering medication to residents and for re-ordering supplies of medication did not know that the deceased suffered from myasthenia gravis, nor was this a condition she had heard of before. 2. When supplies of the necessary medication were about to expire she did seek to re-order supplies. When they did not materialise she did not appreciate the urgency the situation demanded until symptoms became evident. 3. I am concerned that irrespective of whether this is a care home rather than a nursing home that staff with responsibility for administering and / or re-ordering supplies of medication for potentially life threatening conditions are aware of the conditions and what the medication is prescribed for so that staff can then react accordingly. 4. Further, consideration of the care home records made no reference to the name of the condition, the symptoms that can materialise, nor what the prescribed medication was for. A member of staff previously unfamiliar with this patient who may have responsibility for administering her medication would not have been able to familiarise themselves with the necessary knowledge from a perusal of the care home records and I am concerned there is a risk of future deaths were this situation to be replicated. ”
    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 Alexandra Court - Cleveleys; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to recognise the urgency of unavailable medication supplies

    Wider context from the report

    “1. The inquest heard that a senior member of the care staff with responsibility for administering medication to residents and for re-ordering supplies of medication did not know that the deceased suffered from myasthenia gravis, nor was this a condition she had heard of before. 2. When supplies of the necessary medication were about to expire she did seek to re-order supplies. When they did not materialise she did not appreciate the urgency the situation demanded until symptoms became evident. 3. I am concerned that irrespective of whether this is a care home rather than a nursing home that staff with responsibility for administering and / or re-ordering supplies of medication for potentially life threatening conditions are aware of the conditions and what the medication is prescribed for so that staff can then react accordingly. 4. Further, consideration of the care home records made no reference to the name of the condition, the symptoms that can materialise, nor what the prescribed medication was for. A member of staff previously unfamiliar with this patient who may have responsibility for administering her medication would not have been able to familiarise themselves with the necessary knowledge from a perusal of the care home records and I am concerned there is a risk of future deaths were this situation to be replicated. ”
    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