Recipient

Alexandra View Care Centre

First report 10 Dec 2020•Latest report 10 Dec 2020

Recipient record

Reports, concerns and published responses

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

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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

10 Dec2020
Sunderland
Concerns raised7
1. Lack of clarity about required observation frequency for residents at risk of falls
2. Lack of a deadline for completing policy and procedure review with associated training
3. Failure of fitted sensor mats to activate an alert when a resident is out of bed
1. Failure to conduct rapid learning exercises to identify ongoing risks to other residents
2. Failure of resident alert arrangements to alert staff before routine checks
3. Lack of a clear policy for handling residents’ potentially hazardous personal property
4. Lack of clarity about whether a resident’s room door should be open
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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

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

Reports, concerns and published responses

Reports over time

Concerns raised7

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

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

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

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

Failure of resident alert arrangements to alert staff before routine checks

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

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