5 Dec 2024 William Albert Nairn Lardner · Prevention of Future Deaths report Dorset
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Concerns raised 3 Lack of a stable safe public footpath along Hurn Court Lane View source Limited public transport access to the airport View source Lack of pedestrian pathway and crossing facility at Parley Lane Parking View source
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AI-generated summary
William Albert Nairn Lardner · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 30 June 2023, 16-year-old William Albert Nairn Lardner was struck by a vehicle that went through a red light while he was crossing Parley Lane near Bournemouth Airport, sustaining traumatic injuries that led to his death. The report raises concerns about unsafe pedestrian access around the airport, including the absence of footpaths and crossing facilities, limited public transport, and safety issues identified after the death that remained unaddressed.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a stable safe public footpath along Hurn Court Lane
Wider context from the report “(5) Parley Lane is a busy single carriageway semi-rural road with a national speed limit and BCP Council has responsibility for the road as the local highway authority. Hurn Court Lane is owned by the airport who therefore have responsibility for it. There is no public footpath along Hurn Court Lane after turning off Parley Lane to access the airport. Please see attached photograph at JGL/4. This results in pedestrians walking in the road or on the grass section next to the road on Hurn Court Lane to get to the airport terminal. This is dangerous as it is not a stable, safe public pathway and could lead to people falling into the road or being struck by vehicles , especially as people pull suitcases along. The airport has erected signs stating these is no pedestrian access, however, these are widely ignored.
(6) A site visit and assessment in July 2023 by Dorset Police Road Casualty Reduction Officer and the Senior BCP Council Safety Officer following Billy’s death highlighted some fundamental safety issues. At this time no action has been taken around these safety issues, although matters have been discussed. Accordingly, the safety issues remain the same 17 months on from the site assessment, with a likely increasing number of passengers using the airport going forward.
(7) I, therefore, have concerns that there could be future deaths given the manner in which users are accessing the airport and the lack of public transport and pedestrian access available.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Limited public transport access to the airport
Wider context from the report “(3) There is limited access to the airport by public transport. There is no access by train and there is one bus service from central Bournemouth to the airport. This bus service only operates Monday to Friday with a total of 5 journeys a day : 2 inbound journeys which are from Westover Road, Bournemouth to the Airport, one between 05.50 and 06.31 hours and then the other between 06.35 to 07.22 hours and 3 outbound journeys from Bournemouth Airport to Westover Road, Bournemouth between 13.53 to 14.25 hours, 16.20 and 17.20 hours and 18.00 to 18.49 hours. This service focuses on providing a service for staff working at the neighbouring Aviation Business Park, however, does also serve the main passenger terminal. Previously, the airport was served by an hourly bus service, however this was stopped.
(4) Many people access the airport on foot, either being dropped off and/or picked up on Parley Lane where there is no layby or drop off zone or by using nearby car parks and walking on foot to the airport. One such car park is at the Adventure Wonderland site and is known as Parley Lane Parking (Parley Lane Parking | Bournemouth Airport Parking). This is 0.9 miles from the airport, on the opposite side of Parley Lane which offers cheaper rates than Bournemouth Airport to park. There is no pathway on the side of the road at Parley Lane Parking and no crossing facility, so people will either walk along the road or have to cross the road to access the footpath. Please see attached photograph at JGL/5.
(5) Parley Lane is a busy single carriageway semi-rural road with a national speed limit and BCP Council has responsibility for the road as the local highway authority. Hurn Court Lane is owned by the airport who therefore have responsibility for it. There is no public footpath along Hurn Court Lane after turning off Parley Lane to access the airport. Please see attached photograph at JGL/4. This results in pedestrians walking in the road or on the grass section next to the road on Hurn Court Lane to get to the airport terminal. This is dangerous as it is not a stable, safe public pathway and could lead to people falling into the road or being struck by vehicles, especially as people pull suitcases along. The airport has erected signs stating these is no pedestrian access, however, these are widely ignored.
(6) A site visit and assessment in July 2023 by Dorset Police Road Casualty Reduction Officer and the Senior BCP Council Safety Officer following Billy’s death highlighted some fundamental safety issues. At this time no action has been taken around these safety issues, although matters have been discussed. Accordingly, the safety issues remain the same 17 months on from the site assessment, with a likely increasing number of passengers using the airport going forward.
(7) I, therefore, have concerns that there could be future deaths given the manner in which users are accessing the airport and the lack of public transport and pedestrian access available .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Lack of pedestrian pathway and crossing facility at Parley Lane Parking
Wider context from the report “(4) Many people access the airport on foot, either being dropped off and/or picked up on Parley Lane where there is no layby or drop off zone or by using nearby car parks and walking on foot to the airport. One such car park is at the Adventure Wonderland site and is known as Parley Lane Parking (Parley Lane Parking | Bournemouth Airport Parking). This is 0.9 miles from the airport, on the opposite side of Parley Lane which offers cheaper rates than Bournemouth Airport to park. There is no pathway on the side of the road at Parley Lane Parking and no crossing facility, so people will either walk along the road or have to cross the road to access the footpath. Please see attached photograph at JGL/5.
(5) Parley Lane is a busy single carriageway semi-rural road with a national speed limit and BCP Council has responsibility for the road as the local highway authority. Hurn Court Lane is owned by the airport who therefore have responsibility for it. There is no public footpath along Hurn Court Lane after turning off Parley Lane to access the airport. Please see attached photograph at JGL/4. This results in pedestrians walking in the road or on the grass section next to the road on Hurn Court Lane to get to the airport terminal. This is dangerous as it is not a stable, safe public pathway and could lead to people falling into the road or being struck by vehicles, especially as people pull suitcases along. The airport has erected signs stating these is no pedestrian access, however, these are widely ignored.
(6) A site visit and assessment in July 2023 by Dorset Police Road Casualty Reduction Officer and the Senior BCP Council Safety Officer following Billy’s death highlighted some fundamental safety issues. At this time no action has been taken around these safety issues, although matters have been discussed. Accordingly, the safety issues remain the same 17 months on from the site assessment, with a likely increasing number of passengers using the airport going forward.
(7) I, therefore, have concerns that there could be future deaths given the manner in which users are accessing the airport and the lack of public transport and pedestrian access available.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consult on reducing the Parley Lane speed limit from 60 to 40 mph.
Verbatim wording from the response “The speed limit review has been completed and the reduction of the speed limit from 60 to 40mph is currently being consulted upon. The intent is to have implemented the 40mph speed limit by July 2025. An assessment for a vehicle activated sign shall follow when the speed limit has been reduced to 40mph.” Source location Response from BCP Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess the location for a vehicle-activated sign after the speed limit is reduced to 40 mph.
Verbatim wording from the response “The other two actions were to review the speed limit on Parley Lane including assessing the location for a vehicle activated sign and to check the operation of the pedestrian facilities on the crossing facilities at the junction of Hurn Court Lane and Parley Lane.” Source location Response from BCP Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Re-check the operation of pedestrian crossing facilities at the Hurn Court Lane and Parley Lane junction.
Verbatim wording from the response “The other two actions were to review the speed limit on Parley Lane including assessing the location for a vehicle activated sign and to check the operation of the pedestrian facilities on the crossing facilities at the junction of Hurn Court Lane and Parley Lane.” Source location Response from BCP Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the 40 mph Parley Lane speed limit by July 2025.
Verbatim wording from the response “The speed limit review has been completed and the reduction of the speed limit from 60 to 40mph is currently being consulted upon. The intent is to have implemented the 40mph speed limit by July 2025. An assessment for a vehicle activated sign shall follow when the speed limit has been reduced to 40mph.” Source location Response from BCP Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the review of the Parley Lane speed limit.
Verbatim wording from the response “The other two actions were to review the speed limit on Parley Lane including assessing the location for a vehicle activated sign and to check the operation of the pedestrian facilities on the crossing facilities at the junction of Hurn Court Lane and Parley Lane.” Source location Response from BCP Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support the airport in progressing construction of a footway into the airport.
Verbatim wording from the response “Although the council is not responsible for the provision of a pavement (footway) beyond the speed limit signs it does recognise that the provision of a pavement (footway) up to and into” Source location Response from BCP Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Investigate with the airport whether to reinstate the previous bus service or increase bus-service frequency.
Verbatim wording from the response “The Council shall work with the airport to investigate if/how the previous service could be reinstated, or the frequency of bus services to the airport increased. This may need to be facilitated by the securing of funding from new development(s) at/in the vicinity of the airport.” Source location Response from BCP Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provision of a footway beyond the speed-limit signs is outside the council’s highway responsibility.
Verbatim wording from the response “BCP Council response, action and timescale: Note: the site description in point 3 refers to Hurn Court Lane north of the junction, however, the photo shows Hurn Court Lane south of the junction. This response is regarding Hurn Court north. The council responsibility for the highway ends approximately 15 metres north (from the signalised junction) along Hurn Court Lane towards the Airport where the speed limit signs are located. Up to this point there is a pavement (footway).” Source location Response from BCP Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Private landowners are responsible for providing walking and cycling facilities on land beyond the council highway extent.
Verbatim wording from the response “BCP Council response: As per reply to item 5 above. The land to the north of the signalised junction beyond the 20mph speed limit signs is the responsibility of private landowners who are responsible for the provision of any walking and cycling facilities on their land. The following plan (Fig.4.) and street view (Fig.5) show the council highway extent.” Source location Response from BCP Council
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3 May 2024 Neville Stephen Abbott · Prevention of Future Deaths report Dorset
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Concerns raised 1 Lack of knowledge and use of the Professionals Checklist for assessing potential self-neglect View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Neville Stephen Abbott · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Neville Stephen Abbott, who lived alone and was known to Adult Social Care and Community Mental Health Services, was found deceased at home on 8 February 2022. He had schizophrenia and atrial fibrillation, and declined prescribed anticoagulant medication. The report raises concerns that Adult Social Care practitioners did not use the Professionals Checklist to assess potential self-neglect or consider convening a Multi-Agency Risk Management Meeting.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge and use of the Professionals Checklist for assessing potential self-neglect
Wider context from the report “i. The lack of knowledge of, and use of the “Professionals Checklist” by ASC practitioners risks adults known to ASC not being assessed where there is a potential risk of self-neglect, including the perhaps less obvious aspects of self-neglect such as declining prescribed medication. Consequently, the requirement to consider calling a MARM, mandated by the “Professional Checklist”, in order to share information, assess risk and to formulate a plan to mitigate risk, may be missed.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a mandatory staff webinar on self-neglect, checklist use, risk assessment, management escalation and the Multi-Agency Risk Management framework.
Verbatim wording from the response “c. Based on the above instruction, we will also be holding a mandatory webinar for all staff on 26 June 2024. The purpose of this webinar is to further highlight what constitutes self-neglect, to highlight the guidance that is available in the Safeguarding Adults Board (SAB) Procedures and our own guidance, including the requirement to use the Self-Neglect Checklist. We will remind practitioners that they are required to undertake a Risk Assessment if a person ‘declines an assessment, services or support’ and to discuss this issue with their line manager. We will promote the use of the MARM framework in supporting the formulation of a multi-agency risk assessment and management plan.” Source location Response from BCP Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update Managing Risk and Engagement Guidance to include the Self-Neglect Checklist requirement.
Verbatim wording from the response “a. On 6 June, we instructed all operational staff in ASC via email to complete the Self-Neglect Checklist when they are allocated a person who appears to find engaging with services challenging. We will update our own ‘Managing Risk and Engagement Guidance’, to include this information.” Source location Response from BCP Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate awareness of the Self-Neglect Checklist and Multi-Agency Risk Management framework through management and frontline staff channels.
Verbatim wording from the response “k) Prompted discussion within Locality and Acute Hospital Services to raise awareness of the Self-Neglect checklist, MARM framework and to encourage their use were discussed at the service managers planning meeting. This has led to service managers discussing in their team managers meeting and further cascading to front line staff. This included raising awareness of available self-neglect/hoarding training and MARM Training.” Source location Response from BCP Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Instruct Adult Social Care operational staff to complete the Self-Neglect Checklist for allocated people who find engaging with services challenging.
Verbatim wording from the response “a. On 6 June, we instructed all operational staff in ASC via email to complete the Self-Neglect Checklist when they are allocated a person who appears to find engaging with services challenging. We will update our own ‘Managing Risk and Engagement Guidance’, to include this information.” Source location Response from BCP Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make the Self-Neglect Checklist prominent on the updated Adult Social Care intranet.
Verbatim wording from the response “b. The Self-Neglect Checklist is now much more prominent on our updated Adult Social Care intranet site, to help raise awareness in the future.” Source location Response from BCP Council
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8 Feb 2023 Stephen Robert Wood · Prevention of Future Deaths report Dorset
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Concerns raised 1 Lack of knowledge and/or understanding of when to report road obstructions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Stephen Robert Wood · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 30 May 2021, Stephen Robert Wood was riding his motorcycle when it entered a 60-metre stretch of grass covering the carriageway, causing him to fall into the path of an oncoming car. He sustained numerous significant and unsurvivable injuries and died. The principal concern was a lack of knowledge about when road obstructions should be reported, meaning hazards may not be removed or warnings provided to other road users.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge and/or understanding of when to report road obstructions
Wider context from the report “2. I have concerns with regard to the following:
i. That there is a lack of knowledge and/or understanding as to when people should report an obstruction in the road. I would request that consideration is given to making all road users aware of the dangers of obstructions in the road and to encourage them to report any hazards to the local Police force or Local Authority so that it can be removed as soon as possible, or at least other road users be warned of the hazard to prevent a future death.
” Open source report
21 Jul 2022 Gaia Kima Pope-Sutherland · Prevention of Future Deaths report Dorset
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Concerns raised 12 Failure of Mental Health teams to provide assessment information directly to GPs View source Lack of policy for handling sexual harassment or assault in DHUFT inpatient units View source Lack of police officer knowledge of life-threatening illnesses and their behavioural impact View source Failure to flag key information on DHUFT RiO records View source Ambiguity in Dorset Police policies for welfare concerns, missing persons, and call handling, grading and deployment View source Lack of DHUFT policy for contact with patients’ families View source Failure to create, complete and store Dorset Police records appropriately View source Delay in AMHP feedback of Mental Health Act assessment information to GPs View source Lack of staff knowledge of Dorset Police welfare, missing persons, and call handling policies View source Lack of resourcing of epilepsy services View source Ambiguity and inconsistency in access to Community Mental Health care processes View source Lack of communication between neurology and psychiatric teams View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Gaia Kima Pope-Sutherland · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Gaia Kima Pope-Sutherland, who had epilepsy and mental health conditions, left her aunt’s address in a psychotic state on 7 November 2017 and was later found deceased on 18 November 2017. The jury concluded that she probably died from hypothermia between 15.59 on 7 November and 10.00 on 8 November 2017. Principal concerns included under-resourcing and poor communication between epilepsy, neurology and mental health services, as well as issues concerning police training, missing-person policies and record keeping, and communication and information sharing within mental health services.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Failure of Mental Health teams to provide assessment information directly to GPs
Wider context from the report “x. As per paragraph 1(xiii) above, when a Mental Health Act assessment is undertaken, there is a possibility that information may not be fed back to the GP in the best way or in a timely manner, if it is not fed back by those from the Mental Health team, and I therefore request that consideration is given to the DHUFT representatives forwarding information, directly to the GP, rather than through the discharging team at the acute hospital . This may include their RiO record notes, or their assessment notes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Lack of policy for handling sexual harassment or assault in DHUFT inpatient units
Wider context from the report “vi. As per paragraph 1(ix) above, the occurrence of sexual harassment or assault whilst an inpatient at one of DHUFT’s inpatient units could have a detrimental effect on a person’s mental health which could have fatal consequences. I request that consideration is given to a policy being put into place to provide guidance to staff as to how to deal with this situation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Lack of police officer knowledge of life-threatening illnesses and their behavioural impact
Wider context from the report “iii. As per paragraph 1(iv) above, there could be future deaths due to the lack of knowledge Police Officers in England and Wales have around life threatening illnesses , such as epilepsy and mental health illness, and I request that consideration is given by the College of Policing to providing national training to all staff across all police forces, on illnesses such as epilepsy and mental health illness, and the impact they have on individuals and their behaviour. I also request consideration to be given to these topics forming part of the syllabus for the College of Policing induction training for Police Officers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Failure to flag key information on DHUFT RiO records
Wider context from the report “viii. As per paragraph 1(xi) above, information could be lost on lengthy RiO records held by DHUFT if there is a significant number of records, and I therefore request that consideration is given to a guidance document dealing with how and what information should be flagged on RiO which could be provided to all staff at DHUFT. I would further request consideration is given to training staff how to record information, so it is flagged on the record.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in Dorset Police policies for welfare concerns, missing persons, and call handling, grading and deployment
Wider context from the report “iv. As per paragraphs 1(v-vi) above, there could be future deaths that occur as a result of current Dorset Police policies around concern for welfare reports, missing persons reports, and the call handling, grading and deployment of resources and I request that consideration is given to a thorough review of these policies to reduce ambiguity and prevent future deaths. I would further request that consideration is given to providing a comprehensive training package to all Police Officers and control room staff within Dorset Police, around the missing persons policy, concern for welfare policy, and for control room staff only, the call handling, grading and deployment policy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Lack of DHUFT policy for contact with patients’ families
Wider context from the report “vii. As per paragraph 1(x) above, there is no specific policy in place within DHUFT around how to engage with the family or dealing with the Think Family approach. A lack of contact with family members , who know the patient best, could lead to information gaps, which could lead to future deaths. I request that consideration is given to a policy being created around contact both to, and from, a patient’s family.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Failure to create, complete and store Dorset Police records appropriately
Wider context from the report “v. As per paragraphs 1(vii-viii) above, there is currently a risk that Dorset Police records are not being created, completed or stored in an appropriate way . This could result in a lack of detail, or incorrect information being recorded and relied upon , which could lead to a future death. I therefore request that consideration is given to reviewing how all Dorset Police records are held, to ensure integrity of the information, and that consideration is given to providing a training session on record keeping for all Dorset Police staff, across all areas of the Force.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Delay in AMHP feedback of Mental Health Act assessment information to GPs
Wider context from the report “xi. As per paragraph 1(xiv) above, in respect of the feeding back of information to the GP by the AMHP which is detailed at paragraph 2.10 of Standard Operating Procedure for the flow of information following Mental Health Act assessments, I would request that consideration is given by Dorset County Council, BCP Council and DHUFT to reducing this timeframe from 7 days to 72 hours . Although this is a decision for Dorset County Council and BCP Council, the document is a DHUFT document and so will require their consideration too.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge of Dorset Police welfare, missing persons, and call handling policies
Wider context from the report “iv. As per paragraphs 1(v-vi) above, there could be future deaths that occur as a result of current Dorset Police policies around concern for welfare reports, missing persons reports, and the call handling, grading and deployment of resources and I request that consideration is given to a thorough review of these policies to reduce ambiguity and prevent future deaths. I would further request that consideration is given to providing a comprehensive training package to all Police Officers and control room staff within Dorset Police, around the missing persons policy, concern for welfare policy , and for control room staff only, the call handling, grading and deployment policy .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Lack of resourcing of epilepsy services
Wider context from the report “i. As per paragraphs 1(i-iii) above, there could be future deaths locally and across the country due to the lack of resourcing of epilepsy services . I request consideration is given to a review of the nursing resources in epilepsy care locally in Dorset Epilepsy Service, and generally nationally across England and Wales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Ambiguity and inconsistency in access to Community Mental Health care processes
Wider context from the report “ix. As per paragraph 1(xii) above, I would request that consideration is given to providing training to all staff on the access to Community Mental Health services which could also cover the processes regarding discharge planning from the care of the mental health teams.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Lack of communication between neurology and psychiatric teams
Wider context from the report “ii. Further I am concerned that there could be future deaths as a result of the lack of communication between neurology and psychiatric teams and request that there is consideration as to how to ensure effective lines of communication between the 2 disciplines.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue applying the 72-hour requirement for distributing completed Mental Health Act assessment reports.
Verbatim wording from the response “• The AMHP must then complete their full (or final) report within 2 hours of completing their assessment (or by the end of their shift if they are an out of hours worker) and again distribute this to the receiving Ward (if relevant), the Mental Health Legislation office, General Practitioner, Care Co-ordinator, the Medics involved in the assessment and the AMHP Lead within 72 hours.” Source location Response from BCP Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss with Approved Mental Health Professionals how to succinctly share information with GPs, highlighting information of immediate relevance.
Verbatim wording from the response “We are also in the process of discussing with AMHP's how they could succinctly share information with GP’s, and in particular highlighting that information which is of most immediate relevant to them.” Source location Response from BCP Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage with Dorset Healthcare Trust to agree amendments to the Pan-Dorset Standard Operating Procedure for information distribution.
Verbatim wording from the response “We are actively engaging with Dorset Healthcare Trust to agree the necessary amendments to the Pan-Dorset Standard Operating Procedure. We are of the view that the Standard Operating Procedure standard for distributing information is too slow and we will continue to apply the requirement of 72 hours.” Source location Response from BCP Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing AMHP requirements and quality assurance arrangements already require recording and sharing assessment outcomes within specified timescales.
Verbatim wording from the response “The BCP Council Approved Mental Health Professionals (AMHP) Service uses the Mental Health Act 1983 (amended 2007) and the Code of Practice to inform practice standard, which are monitored through an AMHP Quality Assurance Framework.” Source location Response from BCP Council
Open published response
20 May 2021 Wilfred Roy Breakell · Prevention of Future Deaths report County of Dorset
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Concerns raised 1 Lack of a barrier between the highway and the storm drain View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Wilfred Roy Breakell · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Wilfred Roy Breakell died at Royal Bournemouth Hospital from multiple cervical spine fractures sustained when he fell into a storm drain while riding his bicycle. The report raised concern that there was still no barrier between the highway and the storm drain, creating a risk to cyclists and vehicles leaving the highway.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a barrier between the highway and the storm drain
Wider context from the report “Although there is now wooden fencing that runs from the end of the paved footpath in a northerly direction (adjacent to the pedestrian crossing), there is still no barrier between the highway and the storm drain where there is no paved area ; that is, from the start of the exit from the A338 to the paved footpath adjacent to the pedestrian crossing. The evidence I heard at the Inquest from the investigating police officer is that cyclists use the A338 and the Blackwater Junction exit. There remains a risk that if a cyclist left the paved highway for any reason, he or she would be at risk of falling into the storm drain. In addition, if a vehicle lost control at the exit, that vehicle is at risk of leaving the highway and falling into the storm drain. A barrier between the highway and the storm drain would reduce that risk.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install permanent timber post-and-rail fencing beside the slip road and storm drain.
Verbatim wording from the response “I am aware that following what happened on the morning of Sunday 17 May 2020 you remain concerned that there is a risk that future deaths will occur, unless action is taken to extend the existing timber post and rail fencing along the slip road to prevent cyclists falling into the storm drain.” Source location 2021-0165-Response-from-BCP-Council_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Additional fencing is not appropriate because recurrence risk is low and the fencing could cause more injuries than it prevents.
Verbatim wording from the response “(i) There remains a low risk that a similar event will re-occur at this location.
(ii) The small level difference from the slip road surfacing down into the ditch is in highway design terms deemed insufficient to require protecting in the event of a vehicle leaving the carriageway.
(iii) If the post and rail fencing is extended, it is as likely to cause injury to occupants of any vehicle that fails to negotiate the bends as to protect them from it. A known cause of injury and death to road users from vehicles, including motorcycles and cyclists leaving the highway and striking posts, barriers or other obstructions that are not passively safe. There is a risk therefore that a timber barrier here could create an additional safety hazard.” Source location 2021-0165-Response-from-BCP-Council_Published
Open published response
17 Feb 2020 Lorraine Anne Molyneaux and James Anthony Lewis · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Lack of a suitable pedestrian crossing near the bus stops and entrance to Turbary Retail Park View source Insufficient street lighting between Mountbatten Roundabout and Clock Garage Roundabout View source Failure to ensure street lighting is working between Mountbatten Roundabout and Clock Garage Roundabout View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Lorraine Anne Molyneaux and James Anthony Lewis · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 16 October 2019, Lorraine Molyneaux was struck by a motorcycle while crossing Ringwood Road near Turbary Retail Park and died at the scene. The motorcyclist, James Anthony Lewis, had consumed alcohol, suffered significant traumatic head injuries and died on 22 October 2019. Concerns related to repeated pedestrian collisions at the location, the distance of crossings from nearby bus stops and the adequacy and operation of street lighting.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a suitable pedestrian crossing near the bus stops and entrance to Turbary Retail Park
Wider context from the report “i. The deaths of Lorraine and James now bring the total fatalities to 3 in the same location and in similar circumstances since September 2018. I have concerns that there could be future deaths at this location if action is not taken.
ii. I therefore request that a review is undertaken of the pedestrian crossings and the layout of Ringwood Road outside of Turbary Retail Park . I request that consideration is given to the placing of a pedestrian crossing closer to the bus stops and the entrance to Turbary Retail Park as soon as possible to avoid future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient street lighting between Mountbatten Roundabout and Clock Garage Roundabout
Wider context from the report “iii. I further request that the street lighting between Mountbatten roundabout and Clock Garage Roundabout is reviewed in relation to the amount of lighting and to ensure that the current lighting is working.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure street lighting is working between Mountbatten Roundabout and Clock Garage Roundabout
Wider context from the report “iii. I further request that the street lighting between Mountbatten roundabout and Clock Garage Roundabout is reviewed in relation to the amount of lighting and to ensure that the current lighting is working .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a joint fatal-collision investigation and site visit with the Dorset Police Road Casualty Reduction Officer.
Verbatim wording from the response “BCP Council carries out joint investigations into fatal road traffic collisions in conjunction with the Dorset Police Road Casualty Reduction Officer. With regards to the incident on Ringwood Rd, the site was visited by three officers at 10.00hrs on Tuesday 26th Nov 2019 (see Appendix A).” Source location 2020-0033-Response-from-BCP-Council-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prioritise crossing design work within the Transforming Cities Fund requirements to support the anticipated road-layout adjustment.
Verbatim wording from the response ““To consider the installation of a controlled crossing at this location. Transforming Cities Fund (TCF) bid submitted to DfT on 28 November (2019). Ringwood Road is on a TCF route where treatment may be considered. This may be in the form of a controlled crossing or the installation of a new signalised junction with pedestrian facilities. Any works at this location to be discussed with TCF programme manager”.” Source location 2020-0033-Response-from-BCP-Council-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the lighting design and establish whether illumination levels meet requirements for the road layout.
Verbatim wording from the response “Your report also raised that there were concerns raised by one witness about the perceived level of street lighting and the fact that some of the lanterns were not working.” Source location 2020-0033-Response-from-BCP-Council-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Identify the crossing location as a funding priority and submit a Transforming Cities Fund bid for treatment there.
Verbatim wording from the response “As you have clearly indicated in your report, BCP Council has identified this location as a priority for the funding of a crossing facility following a previous incident in September 2018 which involved the death of a pedestrian crossing the road at this location. The Fatal Accident report that followed the site visit recommended the following remedial action:” Source location 2020-0033-Response-from-BCP-Council-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Carry out a prioritised additional day-and-night survey to measure actual illumination levels at the location.
Verbatim wording from the response “As a part of our normal working practice and in order to carry out a full and detailed check of the actual illumination levels on site we are required to visit the location during the day to measure and mark out several light calculation points on the road and footway then followed up with a visit during the hours of darkness for measurement to be made by use of a light meter.” Source location 2020-0033-Response-from-BCP-Council-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing lighting levels and sensor operation are considered adequate; illumination will not normally be improved unless specifically recommended by a safety report.
Verbatim wording from the response “The Council has carried out a careful review of the lighting design at this location and this has determined that the lighting levels meet or exceed those required for this type of road layout. The lighting at this location is triggered by light sensor and these sensors appear to have been working satisfactorily at the time of the incident and indeed since that time. We are aware of some lighting defects on Ringwood Road but some distance from the incident. Although not material to this incident this may possibly account for the suggestion that some lighting was not operational.” Source location 2020-0033-Response-from-BCP-Council-Redacted
Open published response
28 Jan 2020 Beryl Fricker · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 1 Lack of adequate street lighting at the Lake Road and Upwey Avenue junction View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Beryl Fricker · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Beryl Fricker was struck by a Toyota Yaris while crossing Upwey Avenue in Poole at dusk on 20 November 2018 and died of her injuries in hospital on 30 November 2018. The principal concern was poor street lighting at the junction of Lake Road and Upwey Avenue, particularly its wide and poorly illuminated middle section, which could affect pedestrians, cyclists and other road users.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate street lighting at the Lake Road and Upwey Avenue junction
Wider context from the report “i. Upwey Avenue is a wide junction, with the nearest street lamps some distance from the junction itself. As a consequence the middle of the junction appears to be the least well illuminated section of that stretch of road . The surrounding area is residential and there are a number of local schools, including infant and secondary schools, so there is likely a significant number of pedestrians, cyclists and other road users travelling along Lake Road.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a detailed light-meter survey of the junction and investigate whether illumination improvements are sensible and safety-justified.
Verbatim wording from the response “In order to carry out a full and detailed assessment of the actual illumination levels on site using light meters, we are required to visit the location during the day to measure and mark out several light calculation points on the road and footway, and then follow up with a visit during the hours of darkness. Unfortunately, the streetlighting team haven’t been able to carry out the required site inspections due to the weather conditions. This is because the inclement conditions we have experienced recently have meant the road surfaces were still fairly wet in the evenings, and this factor can easily influence the ambient lighting levels we measure.” Source location Response from BCP Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Required lighting inspections could not yet be completed because wet road surfaces would affect measured ambient lighting levels.
Verbatim wording from the response “In order to carry out a full and detailed assessment of the actual illumination levels on site using light meters, we are required to visit the location during the day to measure and mark out several light calculation points on the road and footway, and then follow up with a visit during the hours of darkness. Unfortunately, the streetlighting team haven’t been able to carry out the required site inspections due to the weather conditions. This is because the inclement conditions we have experienced recently have meant the road surfaces were still fairly wet in the evenings, and this factor can easily influence the ambient lighting levels we measure.” Source location Response from BCP Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Other factors may explain the collision, and improved street lighting may not have prevented it.
Verbatim wording from the response “There are other possible explanations for the failure of the driver to see Beryl Fricker crossing the road which are unrelated to lighting levels. For example, the driver's visibility of the pedestrian could have been inhibited by the vehicle’s A-pillar rather than the lighting levels, and changing the lighting would not have prevented it.” Source location Response from BCP Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing junction lighting meets the applicable British Standard and is considered standard and appropriate for the location.
Verbatim wording from the response “BCP Council’s policy is that it illuminates subsidiary roads and footpaths to lighting class P4 in accordance with BS5489-1:2013 (Code of practice for the design of road lighting). The Council Streetlighting Engineer has checked the current street lighting provision at the Upwey Avenue Lake Road junction by way of producing a lighting report using specialist design software.” Source location Response from BCP Council
Open published response
Concerns raised 2 Lack of cycle lanes on both sides of the carriageway View source Lack of warning signs alerting drivers to the potential presence of cyclists View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Christopher William Gibbs · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher William Gibbs was cycling home from work on the A338 on 3 October 2017 when he was struck from behind by a courier van and died at the scene. The report raised concerns about the lack of cycle lanes and warning signs for cyclists on the fast, busy and unlit dual carriageway, as well as debris making the edge of the carriageway unsafe for cycling.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Lack of cycle lanes on both sides of the carriageway
Wider context from the report “2. I have concerns with regard to the following:
I. There is no cycle lane on either side of the carriage way.
II. There are no warning signs to drivers making them aware of the potential presence of cyclists. Warning signs at the east bound carriageway near the Blackwater junction and westbound carriageway soon after the Ashley Heath roundabout would prompt such consideration by drivers in what would then be an unremarkable 10 mile drive. Such information would hopefully be at the fore front of drivers minds as they commenced this 10 mile section of his/her journey.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bournemouth, Christchurch and Poole Council; that does not assign responsibility.
PFD Monitor interpretation Lack of warning signs alerting drivers to the potential presence of cyclists
Wider context from the report “2. I have concerns with regard to the following:
I. There is no cycle lane on either side of the carriage way.
II. There are no warning signs to drivers making them aware of the potential presence of cyclists. Warning signs at the east bound carriageway near the Blackwater junction and westbound carriageway soon after the Ashley Heath roundabout would prompt such consideration by drivers in what would then be an unremarkable 10 mile drive. Such information would hopefully be at the fore front of drivers minds as they commenced this 10 mile section of his/her journey.
” Open source report
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Addressed to Bournemouth Borough Council, now represented here by Bournemouth, Christchurch and Poole Council.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations