Dorset

Concerns summary A lack of national and local written guidance for patient handovers between staff and wards leads to incorrect or incomplete information being transferred, risking patient care.

Concerns summary Insufficient oversight of 'rental' food delivery licenses to underage individuals places children in vulnerable lone working situations, increasing their risk of road traffic collisions and harm.

Concerns summary Doctors are reluctant or presume others have discussed SUDEP with epilepsy patients, despite its critical importance. There's a lack of universal use of SUDEP checklists and inadequate medical training on the subject.

Concerns summary A lack of oversight regarding the 'rental' of food delivery licenses to children under 18 places them in vulnerable lone-working situations, increasing their risk of road traffic collisions and harm.

Concerns summary Public and young people lack understanding of ketamine's severe dangers, exacerbated by its Class B classification suggesting lower risk, leading to increased usage, addiction, and devastating health complications.

Concerns summary A lack of communication protocol meant critical welfare information from a distressed train driver was not relayed from the signaller to the attending Driver Manager, hindering timely mental health assessment.

Concerns summary The absence of clear national and local policies on managing illicitly brewed alcohol ("hooch") and governing prisoner-held medications creates significant safety risks within the prison estate.

Concerns summary Significant gaps in shotgun licence regulation, including no requirement to declare multiple properties or movement, and less stringent application criteria compared to firearms, create a risk of future deaths.

Concerns summary Prison staff lack essential diabetes training and understanding of critical attacks. Non-24/7 healthcare and poor awareness among staff risk delayed care and future deaths for insulin-dependent prisoners.

Concerns summary A specific crossroads has a history of numerous serious and fatal collisions, and concerns remain regarding the road layout despite a speed limit reduction, indicating a risk of future deaths.

Concerns summary No formal process exists for prisons to share critical in-prison behavioural and mental health information with sentencing courts. Additionally, national guidance is lacking for ensuring continuity of care for released prisoners with mental health needs.

Concerns summary Ketamine is easily accessible, perceived as less harmful by teenagers, and its highly addictive nature causes severe, irreversible bladder damage (ketamine cystitis), trapping users in a cycle of dependence.

Concerns summary Denture adhesive gel poses an unadvertised choking hazard, particularly for vulnerable elderly individuals, and lacks essential warnings on its packaging or leaflet about this significant risk.

Concerns summary Systemic failures in mental health care transfer protocols, university staff training, hospital discharge planning, and patient information sharing policies created significant risks for a vulnerable student.

Concerns summary A potentially deformed surgical jig, lacking quality control and auditing, may have caused incorrect hip screw insertion, compounded by the loss of the defective jig preventing proper investigation.

Concerns summary The provided text is incomplete and does not contain discernible coroner's concerns regarding future deaths.

Concerns summary Limited public transport and expensive drop-off charges at Bournemouth Airport force passengers to walk along dangerous, unpaved, high-speed roads. This creates significant pedestrian safety risks, especially for those with luggage.

Concerns summary A High Intensity Use Care Plan was not shared with ambulance services or other hospitals. Upon admission, there were delays in accessing the patient's record, preventing adherence to her care plan and leaving staff unaware of her significant self-harm history.

Concerns summary The dangerous practice of roadwork crews urinating between LGV axles risks fatal injuries. Despite a previous death, no industry-wide safety notices or publicity have addressed this ongoing hazard.

Concerns summary There is open, unwarned access to a dangerous wooded area with a significant drop, posing an ongoing risk of serious injury due to lack of barriers or warning signs.

Concerns summary A high-risk mental health patient was inappropriately transferred to a prison with limited healthcare and no effective handover. The absence of a national directory for prison healthcare facilities exacerbated risks for prisoners with complex needs.

Concerns summary Dorset County Hospital lacks out-of-hours interventional radiology, forcing patients needing urgent, life-saving interventions to be transferred, which creates potentially critical treatment delays.

Concerns summary A critical "Professionals Checklist" for identifying self-neglect risks, including declining medication, was not used by adult social care practitioners, leading to missed multi-agency risk management opportunities.

Concerns summary Secondary mental health services failed to discuss DVLA notification regarding driving fitness with a high-risk patient, exacerbated by the absence of a local policy for assessing driving ability.