Dorset
Coroner Area
Reports: 83
Earliest: Aug 2013
Latest: 12 Feb 2026
93% response rate (above 62% average).
Colin Hodge
All Responded
2017-0042
28 Feb 2017
Dorset Highways Departments
Road (Highways Safety) related deaths
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.
Liam Day
All Responded
2016-0402
14 Dec 2016
British Mountaineering Council
Royal Yachting Association
Other related deaths
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.
Wayne Cornlouer
All Responded
2016-0356
12 Oct 2016
HMP Portland
State Custody related deaths
Suicide (from 2015)
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.
Richard Westgate
All Responded
2015-0050
16 Feb 2015
Civil Aviation Authority
British Airways
Other related deaths
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.
Daniel Jones
All Responded
2014-0049
3 Feb 2014
Dorset Highways Management
Road (Highways Safety) related deaths
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.
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
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
National Offender Management Service
Dorset Healthcare University NHS Founda…
State Custody related deaths
Concerns 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.
Andrew Nixon
All Responded
2022-0165
Somerset NHS Foundation Trust
Mental Health related deaths
Suicide (from 2015)
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.
Action taken summary
NHS Somerset has issued new staff briefings and posters on consent and confidentiality, updated clinical risk training content, and established a policy requiring co-produced safety plans shared with