Dorset
Coroner Area
Reports: 84
Earliest: Aug 2013
Latest: 30 Mar 2026
94% response rate (above 63% average).
Cheralyn Clulow
All Responded
2021-0009
12 Jan 2021
Dorset Police
Alcohol, drug and medication related deaths
Police related deaths
Concerns summary (AI summary)
Police lacked appropriate fire drop keys and training for emergency access to communal properties, causing delays in attending a deceased person's address.
Action Planned
(AI summary)
Dorset Police officers will soon be issued with keys and fobs to allow for quick access to communal properties, with a system in place to compensate for properties where this is not achievable. A reminder on police powers of entry will be circulated to all frontline officers.
Brandon-Robert Collins-Hayward
All Responded
2021-0088
1 Dec 2020
Royal College of Obstetricians and Gyna…
Child Death (from 2015)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Absence of national guidance for postnatal home visits to include basic newborn observations and for medical assessment of babies when mothers are admitted with potential sepsis creates future death risks.
Action Planned
(AI summary)
NICE guidelines on postnatal care and neonatal infection were being updated to address concerns about monitoring mothers/babies after discharge and assessing babies when mothers are admitted with infection. The Royal College of Paediatrics and Child Health will continue to advocate for adequate resources in child health. NICE updated its guidance for postnatal care (NG194) to include a recommendation addressing the assessment of the baby where the mother has symptoms or signs of sepsis. The scope of its updated guidance for Neonatal infection (NG195) also covers late neonatal infection.
Katrina O’Hara
All Responded
2020-0051
3 Mar 2020
College of Policing
Crime, Policing and Fire Service
National Police Chief’s Council
Other related deaths
Concerns summary (AI summary)
Outdated police policy led to a high-risk 999 call being downgraded, and officers failed to recognise the increased danger to the victim when the perpetrator expressed suicidal intent. The victim was also left without a replacement phone after hers was seized for evidence.
Noted
(AI summary)
The NPCC has undertaken a major refresh of the National Contact Management Strategy since 2015, with revised principles and practice that cover the issue of inappropriate channel selection. The report will be raised at the next meeting of the National Contact Management Steering Group. The Home Office is working to pilot and evaluate approaches to identifying and tackling high risk offenders, including adding suicide indicators to the list of potential risk indicators. Work is ongoing to review findings from domestic homicide reviews and academic research with a view to more accurately identifying key characteristics and risk factors for domestic homicides.
Beryl Fricker
All Responded
2020-0024
28 Jan 2020
BCP Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Poor street lighting at a wide, busy junction in a residential area created inadequate illumination for all road users, increasing collision risks for pedestrians and vehicles.
Action Planned
(AI summary)
BCP Council will assess pedestrian provision at the Upwey Avenue/Lake Road junction, considering a central refuge island or narrowing the junction mouth. However, funding for recommended schemes is limited and timescales cannot be provided at present.
Brenda Drew
All Responded
2019-0421
10 Dec 2019
Royal Pharmaceutical Society
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
The deceased received unrequested, repeat prescriptions for high-dose Oramorph. The GP surgery failed to formally review this potent medication for several months, raising concerns about prescribing oversight.
Action Taken
(AI summary)
The RPS highlights existing guidance for pharmacy teams covering prescription requests to GPs, published in 2015 and available on their website. They also updated and published a Prescribing Competency Framework in 2017 covering safe prescribing of repeat medicines.
Douglas Oak
All Responded
2019-0352
24 Oct 2019
Association of Ambulance Chief Executiv…
St John Ambulance
College of Policing
+4 more
Other related deaths
Concerns summary (AI summary)
There is a critical lack of national guidance for Ambulance Services on using chemical sedation for patients with Acute Behavioural Disturbance, despite its effectiveness for safe treatment and transport.
Noted
(AI summary)
The Department of Health and Social Care acknowledges the report but states that a response will be delayed due to an upcoming General Election. They will contact the office to agree on a new deadline once a new administration is in place. The College of Policing and NPCC are working with forces and medical service partners to address concerns related to Acute Behavioural Disturbance, including raising awareness and consistency in recognition and response. The Chair of the NPCC will write to all Chief Constables to bring the content of the PFD to their attention. Joint guidance between ambulance services and police forces is in development, overseen by a joint committee. AACE will share operational considerations with the National Directors of Operations Group (NDOG) for ambulance services, and will discuss the report at future meetings. St John Ambulance is providing additional Continuous Professional Development training around Acute Behavioural Disturbance. They have also raised the topic for inclusion in the latest version of the First Aid Manual.
Richard Hallett
All Responded
2019-0189
6 Jun 2019
Duchy of Cornwall
Road (Highways Safety) related deaths
Concerns summary (AI summary)
A lack of road markings at junctions and permitted parking obstructing sightlines created dangerous driving conditions, leading to confusion about right of way and reduced visibility.
Action Planned
(AI summary)
The Duchy of Cornwall will install two additional parking bollards on each approach to the junction on Lower Blakemere Road, to deter parking in the immediate vicinity. They have submitted the proposals to Dorset Council Highways Department for approval with a longstop of 31 October 2019.
Richard Phillips
All Responded
2019-0165
20 May 2019
Dorset Council Highways Department
Road (Highways Safety) related deaths
Concerns summary (AI summary)
A known problem of water running and freezing on a road descent created hazardous icy conditions, contributing to a fatal collision and highlighting unresolved road safety issues.
Action Taken
(AI summary)
Dorset Council has resurfaced the section of the B3091 where the accident took place, adjusting the camber to improve ride quality and drainage. They will continue to inspect the section regularly and monitor the surface water situation over the winter period.
Branko Zdravkovic
All Responded
2019-0047
13 Feb 2019
Home Office
State Custody related deaths
Concerns summary (AI summary)
Detainee healthcare staff were incorrectly advised to use ACDT procedures instead of statutory Rule 35(2) reports, and lacked a formal system to inform the Home Office, impeding Article 2 obligations.
Action Planned
(AI summary)
The Home Office will write to all parties in IRCs by the end of April 2019 to reiterate the requirements for sharing information on detainees being managed under ACDT procedures. They will use learning from the HMPPS pilot to improve suicide and self-harm prevention guidance and procedures.
Rowan Lloyd
All Responded
2018-0380
11 Dec 2018
Dorset Highways Department
Road (Highways Safety) related deaths
Concerns summary (AI summary)
A busy road junction, frequently used by school children, lacks safe pedestrian crossings, cycle lanes, or barriers, leading to obscured views and high risk for pedestrians and cyclists.
Action Taken
(AI summary)
Dorset Council completed the proposed hatched lining on footways on the A354 approaches to signals, and a pre-feasibility study of the signalled junction between Portland Road, Merley Road and Langton Avenue has been completed. A redundant lighting column on Merley Road is hoping to be completed later this month.
Bartholomew Coleman
All Responded
2018-0250
10 Jul 2018
Network Rail
Railway related deaths
Concerns summary (AI summary)
The railway line is easily accessible from a bridge with a low wall, showing signs of frequent public use and alcohol consumption, without adequate warning of danger.
Action Planned
(AI summary)
Network Rail is planning to apply mitigation measures (wire mesh panels with base plated fence posts fixed to the top of the parapet walls) to further deter access to the track below, with an anticipated completion date of the end of September 2018. They will also erect a warning sign of the dangers presented.
John Hill
All Responded
2018-0195
25 Jun 2018
Dorset Police
Home Office
Suicide (from 2015)
Concerns summary (AI summary)
Firearms licensing checks failed to include crucial enquiries with family members, missing vital information about the applicant's suicidal intentions before a certificate was granted.
Action Planned
(AI summary)
The Home Office will encourage "professional curiosity" through new accreditation standards for Firearms Enquiry Officers being developed by the College of Policing. They intend to consult on draft statutory guidance to the police on firearms licensing, inviting the police to consider any wider family members when they are likely to be relevant. Durham Constabulary outlines that the Home Office is preparing to go to public consultation on their guidance to forces on issuing firearms certificates later this year, and they will endeavour to include the lessons learned from Mr Hill's death, in particular, for FEO's to ensure that they examine the domestic and family circumstances of an applicant should this appear to be relevant under Section 27 of the Firearms Act 1968. CFOA has disseminated information about the dangers posed by emollient creams to all fire and rescue services through internal communications channels, and will promote safety warnings relating to these creams through their own safety campaign weeks and online/press channels.
Rosemary Scott
All Responded
2018-0172
5 Jun 2018
Dorset County Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Failure to measure venous blood gases due to a missing reminder system for the Sepsis Six Pathway, and an insufficient number of machines for PEEP therapy, compromised respiratory support.
Noted
(AI summary)
The Trust states it is not possible to implement a blanket prompt for venous blood gas measurements. The Trust has 6 PEEP machines, though some were out of service at the time of the incident. Loan units were rented.
Joanne Richardson
All Responded
2018-0134
8 May 2018
Dorset Healthcare University Hospital N…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Critical communication failures between mental health services meant a high-risk assessment by one team was not shared with the Community Mental Health Team, compromising informed patient care.
Action Taken
(AI summary)
Administrators now check both electronic patient information systems for referrals, and read-only access is available to administrators and team leads. A new referral inbox is used to share urgent risk information. The need to act on information has been reinforced within the CMHT, and learning has been disseminated to all CMHTs.
Aaron Nordass-Lacey
All Responded
2018-0028
31 Jan 2018
Dorset County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Excessive vehicle speeds, inadequate pedestrian barriers, and confusing cycle lane signage contribute to dangerous road crossing practices by pedestrians and cyclists on Barrack Road.
Action Taken
(AI summary)
Dorset Council has already implemented several safety improvements, including installing a coloured band on a signpost, and has issued work orders to remove a redundant deflection arrow and relocate a cycle route sign, to be completed by the end of April 2018. Cycle safety training is regularly delivered to schools.
Colin Hodge
All Responded
2017-0042
28 Feb 2017
Dorset Highways Departments
Road (Highways Safety) related deaths
Concerns summary (AI summary)
A junction's poor state of repair and lack of clear pavement/roadway boundaries encourage pedestrians to cross unsafely and drivers to cut corners, posing significant collision risks.
Action Taken
(AI summary)
Dorset County Council installed kerb stones on 19 August 2016 to define the edge of the footway and address concerns with the footway surface; they will also erect a marker post (bollard) in the footway to prevent vehicles from overrunning the footway at Howard's Lane.
Liam Day
All Responded
2016-0402
14 Dec 2016
British Mountaineering Council
Royal Yachting Association
Other related deaths
Concerns summary (AI summary)
The deceased died of hypothermia after deep water soloing; he was not wearing appropriate safety equipment and the dangers of low temperatures in coastal waters were not fully appreciated.
Action Planned
(AI summary)
The RYA has refreshed the safety information pages on its website and will be highlighting this safety information to its members through various electronic communications and in the RYA's annual Safety Advisory Notice. The BMC will make climbers aware of the risks of dangerously low temperatures in coastal waters, including Cold Water Shock, in their guidance and will raise this with guidebook writers. They will also emphasize the importance of not deep water soloing alone and suggest climbers tell others of their plans and expected return time.
Wayne Cornlouer
All Responded
2016-0356
12 Oct 2016
HMP Portland
State Custody related deaths
Suicide (from 2015)
Concerns summary (AI summary)
An emergency coding system for medical emergencies was not initially in Night Orders, raising concerns if all staff are now aware of its recent inclusion and proper use.
Action Taken
(AI summary)
A notice to staff was re-issued on 28 September 2016 reminding staff about emergency codes and ambulance requests; the local emergency code protocol has been distributed and displayed. The induction programme for new staff is being updated to include guidance on the local emergency protocol and all existing staff will receive a personal briefing.
Richard Westgate
All Responded
2015-0050
16 Feb 2015
British Airways
Civil Aviation Authority
Other related deaths
Concerns summary (AI summary)
Aircraft cabin air contains organo-phosphate compounds harming occupant health and impairing flight control. There is no real-time monitoring of these compounds or consideration for individual genetic susceptibility.
Noted
(AI summary)
The CAA acknowledges the coroner's concerns but states that expert studies have not found a definitive link between cabin air quality and health issues. They will cooperate with EASA's ongoing investigations into cabin air quality and review their position in due course. British Airways notes the concerns but states that they have been fully dealt with by government and regulatory bodies. BA follows existing guidance and legislation and monitors research in this area.
Daniel Jones
All Responded
2014-0049
3 Feb 2014
Dorset Highways Management
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Insufficient road signage, including warning triangles and white arrows, at a specific junction on the A356 creates a hazard, necessitating improved signage or reduced speed limits.
Action Planned
(AI summary)
Dorset County Council will erect additional 'Side Road Ahead' warning signs on the offside to alert those overtaking to the presence of the junction ahead at Toller Lane. The existing deflection arrows and thickened centre line will have a 'SLOW' road marking laid opposite the new sign for eastbound traffic.