Dorset
Coroner Area
Reports: 84
Earliest: Aug 2013
Latest: 30 Mar 2026
94% response rate (above 63% average).
Oliver Roberts
All Responded
2026-0184
30 Mar 2026
National Police Chiefs' Council
College of Policing
Devon and Cornwall Police
+2 more
Emergency services related deaths (2019 onwards)
Mental Health related deaths
Concerns summary (AI summary)
There is a lack of practical guidance for police officers on applying their powers to obtain communications data under the Investigatory Powers Act 2016, especially regarding urgent Grade 2 requests.
Noted
(AI summary)
• The College of Policing provides eLearning training for investigators on the national ‘College Learn’ platform.
• These learning packages “Introduction to Communications Data,” sit within the Digital Media Investigators (DMI) modules.
• This training is available for all police officers and staff across England and Wales.
James Fitzpatrick
All Responded
2026-0087
12 Feb 2026
Dorset Healthcare University NHS Founda…
National Institute for Health and Care …
General Medical Council (GMC)
+1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Disputed
(AI summary)
• The GMC met with the Nursing and Midwifery Council (NMC) to discuss alignment across their respective pieces of guidance.
• The GMC and NMC explored opportunities for future collaborative working to develop some joint messaging highlighting the expected standards for communication within and across the multi-disciplinary team. • Dorset Healthcare University NHS Foundation Trust undertook a review to determine whether any national guidance was in development regarding community and mental health handover processes.
• The Trust awaits the response from NICE, GMC, and NMC, and any guidance that is issued in this area.
• The Trust has reviewed its own local arrangements and additional action in relation to this is set out in section 3.
Leonardo Machado
Partially Responded
2025-0611
5 Dec 2025
Department for Business and Trade
Department for Education
Department for Transport
+2 more
Road (Highways Safety) related deaths
Concerns summary (AI 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.
Noted
(AI summary)
HSE acknowledges the concerns around the rental of food delivery licenses to under 18s, lone working, and road safety but states road traffic accidents are generally a police matter. HSE notes actions being taken by other government departments and the food delivery industry to tighten controls.
Amber Walker
All Responded
2025-0528
21 Oct 2025
Department of Health and Social Care
Other related deaths
Concerns summary (AI 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.
Noted
(AI summary)
The Department of Health and Social Care references NICE guidance on epilepsy, the Epilepsy Self-Management Programme, and the Clive Treacey Checklist regarding SUDEP risk assessment. They note that medical schools and royal colleges set their own curricula and that doctors are responsible for keeping their clinical knowledge up to date.
Leonardo Machado
All Responded
2025-0476
18 Sep 2025
Deliveroo
Home Office
Just Eats
+1 more
Road (Highways Safety) related deaths
Concerns summary (AI 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.
Noted
(AI summary)
Uber Eats uses industry-leading account-sharing detection technology, including real-time identity verification software requiring couriers to take selfies that are compared with their profile photo and monitors for suspicious behaviors that may indicate attempts to circumvent their security controls. Deliveroo has strengthened checks and processes to ensure rider accounts are only used by authorized individuals, including biometric checks and identity verification, and has a dedicated team investigating potential account sharing with minors; they also terminate agreements with riders who allow unregistered substitutes to use their accounts. Just Eat has introduced enhanced checks to ensure substitutes meet requirements set for all couriers, requiring pre-registration, biometric checks, and document submission to prove age and right to work; random biometric screening checks are also performed. HSE acknowledges concerns about rental of permits, employment of minors and lone working, but notes that road traffic accidents are generally a police matter. They highlight existing guidance and legislation, and ongoing work between government and the food delivery industry to improve security checks.
Gemma Weeks
All Responded
2025-0428
19 Aug 2025
Secretary of State for Education
Secretary of State for Health And Socia…
Secretary of State for the Home Departm…
Alcohol, drug and medication related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
The Department of Health and Social Care is increasing the number of drug treatment places and providing targeted grants to improve drug and alcohol services. They are also launching a national media campaign focusing on the harms caused by ketamine. The Department for Education is piloting a teacher training grant, starting early 2026 and the Oak National Academy is developing new RSHE resources to support schools with the delivery of the updated RSHE curriculum, available from autumn 2025. The Home Office has requested an updated harms assessment of ketamine from the ACMD, including advice on whether it should be moved to Class A, and expects to receive the report by the end of 2025.
Simon Moore
All Responded
2025-0404
5 Aug 2025
Network Rail
Suicide (from 2015)
Concerns summary (AI 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.
Action Planned
(AI summary)
Network Rail is developing industry guidance on welfare communications and has set up an Industry Working Group on Welfare Communication. The SWR investigation report was considered at the NR SPAD Recommendations and Review Panel.
Sheldon Jeans
All Responded
2025-0376
25 Jul 2025
Department of Health and Social Care
HMP Guys Marsh
HMPPS
+1 more
Alcohol, drug and medication related deaths
State Custody related deaths
Concerns summary (AI 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.
Noted
(AI summary)
HMP Guys Marsh has developed its Incentivised Substance Free Living (ISFL) unit, provides comprehensive staff information on illicitly brewed alcohol, and ensures in-cell medication safes are available and fit for purpose. Oxleas NHS Foundation Trust has committed to introducing regular assurance checks for all prisoners in receipt of IP medication. Oxleas NHS Foundation Trust will be developing and distributing new health promotion materials to the prison population at HMP Guys Marsh focusing on safe storage and proper disposal of medication. They have published a local In-possession Medication Compliance procedure outlining bi-monthly in-cell compliance checks. HMPPS has developed and disseminated materials focused on illicitly brewed alcohol (IBA), including the Drugs in Prison and Probation (DiPP) guide. The healthcare provider at HMP Guys Marsh, Oxleas NHS Foundation Trust, has committed to introducing regular assurance checks for all prisoners in receipt of IP medication, and in-cell lockers will be replaced if damaged. The Department acknowledges concerns about medication held in prisoners' possession, but states that national NHS policies for prisoners are the same as those used in the community. They believe existing processes, contractual monitoring, and learning from serious incidents are sufficient, and that national guidance could further complicate the issue.
Jairus Earl
All Responded
2025-0349
10 Jul 2025
Department of Health and Social Care
Home Office
Child Death (from 2015)
Suicide (from 2015)
Concerns summary (AI 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.
Action Planned
(AI summary)
The NPCC highlights the importance of personal responsibility on license holders for the security of firearms. The NPCC commenced delivery of an additional two-day course for Firearms Licensing Enquiry Officers focusing on domestic abuse, family turmoil, mental health and wellbeing in June 2025. The Home Office alerted all police forces to the issue of information sharing regarding shotgun license holders, and it is possible for police to check if an individual is a firearm or shotgun certificate holder. They will also engage with the DHSC directly regarding police access to health information. The Department will explore broadening access to relevant medical information of others residing at licence-holders' addresses and engage with GP representatives. They will work with them to ensure that operational guidance relating to the existing Digital Firearms Marker policy remains fit for purpose and considers ongoing learnings.
Colin Lovett
All Responded
2025-0265
30 May 2025
Department of Health and Social Care
HMPPS
Alcohol, drug and medication related deaths
State Custody related deaths
Concerns summary (AI 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.
Disputed
(AI summary)
HMPPS does not believe it's necessary or appropriate to require all operational prison staff to undertake specific diabetes awareness training. However, following discussion with the Governor, the healthcare provider at The Verne has provided a diabetes awareness and guidance document which has been disseminated to all staff. NHS England will share the details of this case and concerns raised with all regional health and justice commissioning teams, along with links to NICE guidance and the National Diabetes Audit.
Charlotte Avis
All Responded
2025-0213
6 May 2025
Department for Transport
Dorset Council
Road (Highways Safety) related deaths
Concerns summary (AI 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.
Noted
(AI summary)
Dorset Council plans to implement a temporary traffic regulation order prohibiting certain turns at the Loscombe Crossroads. They are also conducting a feasibility study to introduce average speed cameras on the A30 between Yeovil and Sherborne. The Department for Transport acknowledges the concerns but states that decisions about road layout and safety are the responsibility of the local traffic authority (Dorset Council).
Marta Vento
All Responded
2025-0137
11 Mar 2025
College of Policing
HMPPS
National Police Chiefs’ Council
+2 more
Mental Health related deaths
Other related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
NHS England required ICBs to review community mental health services by September 2024. NHS England understands that NHS Dorset would actively support the expansion of this work to support sharing of mental health care plans. The DCR Partnership is looking to have the capability to share information with others using the NRL from March 2026 onwards. The College of Policing acknowledges concerns about the lack of a bespoke risk assessment tool for violence in MOSOVO units. They will consult with the NPCC Lead for MOSOVO and relevant subject matter experts to improve guidance and direction and will liaise with Dorset Constabulary to ensure they are fully sighted on current guidance. The NPCC will request the College of Policing to review APP and training material to highlight violence risk assessment more strongly within risk management plans; they have also reiterated a request for a full review of the ARMS process. NHS Dorset supported a learning event led by NHSE regarding mental health needs, and will work with SWAST to enable access to the Dorset Care Record. They have also opened a risk on the system risk register to scrutinise the accessibility of information across system partners. HM Prison and Probation Service acknowledges concerns about sharing risk information from prison with sentencing courts and highlights the establishment of immediate release pathfinders in three prisons to develop multi-agency approaches. They will task the Safety Group in HMPPS to consider this specific area when reviewing the Prison Safety Policy Framework later in 2025-26.
Philip Jones
All Responded
2025-0111
27 Feb 2025
Care Quality Commission
Fixodent
Product related deaths
Concerns summary (AI 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.
Noted
(AI summary)
Procter & Gamble expresses condolences, states its products comply with regulations and are safe when used as directed, and maintains a post-market surveillance system; they are not proposing changes to the product or packaging but will continue to monitor adverse events and respect the coroner's perspective about risk assessments in care homes. The CQC will feature the incident on its Learning from safety incidents webpage to raise awareness and share learning with providers, advising providers to consider denture adhesive gel in risk assessments and care planning, referencing HSE's COSHH Risk Assessment and CQC's Regulation 12.
Joshua Leatham-Prosser
All Responded
2025-0110
27 Feb 2025
Home Office
Alcohol, drug and medication related deaths
Concerns summary (AI 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.
Noted
(AI summary)
The Home Office acknowledges the concerns about ketamine's classification and potential harm, notes that it will continue to work with partners to discourage misuse and alert people about the dangers of ketamine, and has commissioned the ACMD to provide an updated harms assessment of ketamine.
Alexander Channing
All Responded
2025-0052
31 Jan 2025
Arts University Bournemouth
Devon Partnership NHS Trust
Dorset Healthcare NHS Foundation Trust
Suicide (from 2015)
Concerns summary (AI 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.
Noted
(AI summary)
The Arts University Bournemouth confirms that a full-day training session on EUPD and personality disorders was delivered to 17 members of Student Services staff on January 6, 2025. Devon Partnership NHS Trust acknowledges the concerns regarding patient transfers and information sharing, referencing existing procedures and policies but not committing to new actions. Dorset HealthCare is seeking to strengthen its relationship with Devon Partnership Trust to ensure that there are effective and comprehensive discharge pathways between the two organisations. Learning will be shared within the Learning and Review Groups at the next meeting which is scheduled for April 2025.
Reginald Smith
All Responded
2025-0037
21 Jan 2025
Stryker (UK) Ltd
British Orthopaedic Association
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Disputed
(AI summary)
Stryker disputes that the Gamma Nail Distal Targeting System could become deformed with repeated use if properly maintained. They assert the incident rate for adverse events is extremely rare and their risk mitigation is sufficient. The BOA has drafted generic advice for trauma and orthopaedic surgeons on the need for vigilance regarding the condition and preparation of any jig used, and adherence to operative technique documentation. It also plans to draft guidance as to the number and orientation of intraoperative imaging and post-operative ‘check’ X-rays, with publication expected by the end of May.
David Haw
Partially Responded
2024-0698
20 Dec 2024
Department for Transport
Offshore Racing Council
Royal Yachting Association
Other related deaths
Concerns summary (AI summary)
The provided text is incomplete and does not contain discernible coroner's concerns regarding future deaths.
Noted
(AI summary)
The RYA will work with Organising Authorities to establish trends around support boats and to support Organising Authorities in managing risks associated with their events, continuing to raise awareness of responsible behavior. The Department for Transport acknowledges the concerns raised in the PFD report but states that existing legislation and guidance are sufficient, placing responsibility on local authorities and vessel operators to ensure safety. They will continue to review evidence on alcohol limits and PFD use, but do not plan to introduce national mandates.
William Lardner
All Responded
2024-0670
5 Dec 2024
BCP Council
Bournemouth International Airport Ltd
Road (Highways Safety) related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
BCP Council will work with the airport to investigate improving bus service provision and will investigate potential funding opportunities for speed reduction measures. They also describe historical context and responsibilities. Bournemouth Airport (BOH) states the accident did not occur due to their actions. However, they are working to improve bus service links and will construct a pedestrian footpath alongside Hurn Court Lane.
Emma Sanders
All Responded
2024-0646
26 Nov 2024
NHS Dorset
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI 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.
Noted
(AI summary)
NHS England acknowledges the concerns and provides context on the Summary Care Record (SCR), the Royal College of Emergency Medicine (RCEM) guidance, and the National Record Locator (NRL), and states reports are discussed by the Regulation 28 Working Group. NHS Dorset will enforce the use of the Dorset Care Record in line with contractual commitments in 2025/2026 and will monitor progress of the issue directly via their Corporate Risk Register. They will also share the Regulation 28 Report with NHS partners and wider system partners at the Pan Dorset Mortality Group.
Sunnah Khan and Joseph Abbess
All Responded
2024-0538
10 Oct 2024
Department for Education
Child Death (from 2015)
Other related deaths
Action Planned
(AI summary)
The Department for Education will consider how best to complement swimming and water safety lessons already delivered through the PE curriculum, to ensure that all pupils are taught about water safety, including the water safety code. The Department will also commit to supporting the 2025 RLSS UK's annual Drowning Prevention Week.
Thomas McAuley
All Responded
2024-0426
2 Aug 2024
Health and Safety Executive
Accident at Work and Health and Safety related deaths
Concerns summary (AI 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.
Noted
(AI summary)
The HSE acknowledges the coroner's concerns regarding welfare provision and workplace transport safety on construction sites, but asserts that existing legislation and guidance are sufficient and well-known within the industry. They will continue to raise awareness through stakeholder engagement and inspections.
Fredrick Dunbavin
All Responded
2024-0396
23 Jul 2024
Seascape Homes and Property Limited
Other related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
Seascape Homes and Property Limited has had a HHSRS assessment carried out, extended the existing metal key clamp barrier along the boundary, and installed 'No Access & fall risk' signs.
Frazer Williams
Partially Responded
2024-0294
31 May 2024
Department of Health and Social Care
HMP Guys Marsh
HM Prisons and Probation Service
+2 more
State Custody related deaths
Suicide (from 2015)
Concerns summary (AI 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.
Noted
(AI summary)
NHS England is responding to 'The Long Wait' HMIP report, and is working with HMPPS nationally and regionally to support the ACCT process. HMP Guys Marsh issued guidance to healthcare staff and relevant training was provided to induction and reception staff who conduct first night interviews. NHS England South West region supported the development of e-learning training for healthcare staff on safeguarding in secure and detained settings. Unilink will raise the issue of prisoner transfer information with the Ministry of Justice to explore the possibility of sharing relevant information to better manage and redirect communications. The response is a cover letter forwarding the PFD response, but contains no details itself. The Department of Health and Social Care acknowledges concerns about mental health treatment equity in prisons and delays in transferring mentally unwell prisoners. They mention the Mental Health Bill, which will introduce a 28-day statutory time limit for transfers from prison to hospital, and that they expect other recipients of the report to address concerns around national guidance, ACCT processes and engagement with family members.
Christine Booker
All Responded
2024-0285
28 May 2024
Dorset County Hospital NHS Foundation T…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Noted
(AI summary)
The hospital states it does not provide a 24/7 emergency service for specialist interventional radiology for embolization, this is a specialised service commissioned by NHS England; The hospital states that the regulation 28 notice should be addressed to NHS England as the service commissioner. NHS England acknowledges the concerns regarding out-of-hours interventional radiology at Dorset County Hospital, but states a full service would likely be unsustainable. They believe the concerns are more appropriate for the Trusts to address and are seeking further details, while also highlighting national work on PFD reports.
Neville Abbott
All Responded
2024-0247
3 May 2024
BCP Council
Other related deaths
Concerns summary (AI 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.
Action Taken
(AI summary)
BCP Council has made changes to the way in which they support people who find it difficult to engage with support services. A deep dive audit will be undertaken in June and July into cases where self-neglect is mentioned in case records and they will publish Mental Capacity Act practice guidance in August, and will continue to operate monthly peer group drop-ins for practitioners.