Dorset
Coroner Area
Reports: 84
Earliest: Aug 2013
Latest: 30 Mar 2026
94% response rate (above 63% average).
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.
Kathryn Richmond
Partially Responded
2017-0401
17 Nov 2017
Ambulance Association
Department of Health and Social Care
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The ambulance service's non-staggered shifts meant multiple ambulances were unavailable for calls during simultaneous meal breaks, critically reducing resources and delaying emergency response.
Noted
(AI summary)
The Department of Health notes the concerns and states that ambulance services are aware of the need to stagger meal breaks and regularly review their rostering systems and that AACE will ensure that the National Directors of Operations Group (NDOG) is made aware of these concerns.
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.
Keward Guy Domonic Harding
Historic (No Identified Response)
2013-0190
16 Aug 2013
Community Mental Health Team
Community health care and emergency services related deaths
Concerns summary (AI summary)
An urgent mental health assessment was significantly delayed for over two weeks, potentially preventing detection of a decline in physical health that could have been treated.
Jordan Buckton
Historic (No Identified Response)
2013-0187
14 Aug 2013
Dorset Healthcare University NHS Founda…
National Offender Management Service
State Custody related deaths
Concerns summary (AI summary)
Prison staff lacked awareness of a prisoner's self-harm history due to information sharing failures. Additionally, there was inadequate follow-up after prescribing anti-depressants and a mental health course was discontinued due to staff shortages.