Dorset

Concerns summary Outdated police policy led to a high-risk 999 call being downgraded, and officers failed to recognise the increased danger to the victim when the perpetrator expressed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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns summary The A338, a 10-mile arterial route with consistent speed limits and no exits, presents inherent risks due to its design of straight sections and open sweeping bends.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns summary Illicit prescription drug transfer in prison is facilitated by chaotic medication dispensing, lack of swallowing checks, and an ongoing drug problem despite previous warnings.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns summary Significant risks in deep water soloing include dangerously cold sea temperatures, lack of essential safety equipment like lifejackets or communication devices, and unawareness of rapid hypothermia.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns summary Family/carers were not fully involved in mental health risk assessments or care planning, and there was no clear criteria for conducting a Carer's Assessment, limiting protective factors.