Dorset

Coroner Area
Reports: 83 Earliest: Aug 2013 Latest: 12 Feb 2026

93% response rate (above 62% average).

Response Status
Responded 77 Historic 5 Pending 1
AI Classification
Action Taken 0%
Action Planned 50%
Noted 50%
Disputed 0%
Based on 2 classified responses
Top Categories
Other related deaths (19) Road (Highways Safety) related dea… (18) Alcohol, drug and medication relat… (16) Suicide (from 2015) (14) State Custody related deaths (13)
Quarterly Trend
Category Breakdown
How does this area compare?
vs South West average: +2 reports · +29pp response rate
vs national average: 0 reports · +31pp response rate
Clear 5 results
Ryan Merna
Historic (No Identified Response)
2022-0102 5 Apr 2022
Dorset Healthcare University NHS Founda…
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Other related deaths
Concerns summary The forensic team failed to adequately probe and document disclosures regarding a perpetrator's living situation and weapon possession, hindering risk assessment and police notification.
Kristiyan Danailov
Historic (No Identified Response)
2019-0315 23 Sep 2019
Chemical Business Association Department for Environment Food and Rural Affairs +1 more
Other related deaths
Concerns summary Insufficient identity checks and obstacles exist to prevent vulnerable individuals from purchasing hazardous items online, indicating a lack of industry awareness about associated risks.
Amanda Spark
Historic (No Identified Response)
2018-0109 19 Apr 2018
Dorset University NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Concerns arose regarding a patient's decision to change her medication regime while under crisis team care, implying potential issues with medication management and oversight.
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.