Alexandra View Care Centre

Private and voluntary organisations · Nursing home

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First report 10 Dec 2020•Latest report 10 Dec 2020

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 Alexandra View Care Centre linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Sunderland

    AI-generated summary

    Edward Mallaby · 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

    Edward Mallaby died after a boxed television fell onto him in his room at Alexandra View Care Home, causing injuries, bedbound status and pneumonia. Concerns included the handling and secure storage of potentially hazardous personal property, failure or absence of alerts when he was out of bed, unclear observation arrangements, and the lack of a rapid learning exercise or deadline for policy and training review.

    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 View Care Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clarity about required observation frequency for residents at risk of falls

    Wider context from the report

    “4. Although the deceased had a falls risk assessment, it was not clear whether he was subject to hourly or half hourly observations, or whether the door to his room was to be open or not. ”
    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 View Care Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a deadline for completing policy and procedure review with associated training

    Wider context from the report

    “6. A full review of policy and procedure with associated training was apparently underway but without a deadline for completion. ”
    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 View Care Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of fitted sensor mats to activate an alert when a resident is out of bed

    Wider context from the report

    “2. If a sensor mat was fitted it then it did not activate to alert staff that the deceased was out of bed. ”
    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 View Care Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to conduct rapid learning exercises to identify ongoing risks to other residents

    Wider context from the report

    “5. There appeared to be no rapid learning exercise to ensure that other residents were not at any ongoing risk. ”
    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 View Care Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of resident alert arrangements to alert staff before routine checks

    Wider context from the report

    “3. Staff only discovered the deceased “with the TV Box on the top of his legs” on a routine check rather than by a sensor mat or personal alarm call. ”
    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 View Care Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a clear policy for handling residents’ potentially hazardous personal property

    Wider context from the report

    “1. There was no clear policy with the handling of residents’ personal property which may be hazardous. In particular, if the television could not be immediately fitted or stored securely, then the family should be told to arrange another time for it to be delivered and/or remove it. ”
    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 View Care Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clarity about whether a resident’s room door should be open

    Wider context from the report

    “4. Although the deceased had a falls risk assessment, it was not clear whether he was subject to hourly or half hourly observations, or whether the door to his room was to be open or not. ”
    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