6 May 2025 Charlotte Katie Mae Avis · Prevention of Future Deaths report Dorset
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Concerns raised 2 Hazardous road layout at Loscombe Crossroads View source Continuing risk of road traffic collisions at Loscombe Crossroads View source
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AI-generated summary
Charlotte Katie Mae Avis · 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
Charlotte Katie Mae Avis died at the scene after her car was struck head-on by a vehicle that had lost control and crossed into the opposite carriageway on 1 December 2022. The report raises concerns about the layout of Loscombe Crossroads and the number of collisions and fatalities at the site, with concern that future deaths could occur.
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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 Dorset Council; that does not assign responsibility.
PFD Monitor interpretation Hazardous road layout at Loscombe Crossroads
Wider context from the report “(1) Evidence has been provided that between 01.01.2014 and 24.03.2025 there have been 8 road traffic collisions at the site of Charlotte’s death which is referred to as Loscombe Crossroads, near Sherborne, Dorset. Those collisions have resulted in slight, serious and fatal injuries being sustained by those involved. There have been 4 fatalities from 3 of the collisions in a 4 year period. These fatalities occurred on 21.01.2020, 01.12.22 and 20.02.24.The last of these fatalities occurred after Charlotte’s death.
(2) Although the speed of the road was reduced by Dorset Council on 11th October 2024 from 70mph to 60mph, I have concerns around the layout of the road and the number of collisions in the area, and that there could be future deaths that occur.
” 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 Dorset Council; that does not assign responsibility.
PFD Monitor interpretation Continuing risk of road traffic collisions at Loscombe Crossroads
Wider context from the report “(1) Evidence has been provided that between 01.01.2014 and 24.03.2025 there have been 8 road traffic collisions at the site of Charlotte’s death which is referred to as Loscombe Crossroads, near Sherborne, Dorset . Those collisions have resulted in slight, serious and fatal injuries being sustained by those involved. There have been 4 fatalities from 3 of the collisions in a 4 year period . These fatalities occurred on 21.01.2020, 01.12.22 and 20.02.24.The last of these fatalities occurred after Charlotte’s death.
(2) Although the speed of the road was reduced by Dorset Council on 11th October 2024 from 70mph to 60mph, I have concerns around the layout of the road and the number of collisions in the area , and that there could be future deaths that occur .
” 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 feasibility study for introducing average speed cameras on the A30 between Yeovil and Sherborne, collaborating with relevant stakeholders including Dorset Police.
Verbatim wording from the response “2. Records show a high number of collisions along the entire length of the A30 dual carriageway between Yeovil and Sherborne, with many vehicles significantly exceeding the speed limit. Therefore, we are conducting a feasibility study to introduce Average Speed Cameras to ensure compliance with the recent change in speed limit to 60mph. This work will involve close collaboration with stakeholders, including Dorset Police.” Source location Response from Dorset 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 Reduce the speed limit at the relevant road site from 70mph to 60mph.
Verbatim wording from the response “(2) Although the speed of the road was reduced by Dorset Council on 11th October 2024 from 70mph to 60mph, I have concerns around the layout of the road and the number of collisions in the area, and that there could be future deaths that occur.” Source location Response from Dorset Council
Open published response
12 Feb 2024 Natalie Christina Mountford · Prevention of Future Deaths report Dorset
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Concerns raised 3 Failure to robustly log and action direct reports of water leaks onto highways View source Failure to investigate flowing water during highway inspections View source Recurring collision hazard from ice on a steep, curved road section View source
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AI-generated summary
Natalie Christina Mountford · 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
Natalie Christina Mountford was struck by a vehicle while assisting at an earlier collision on an icy road and died at the scene from her injuries. The report raised concerns about repeated collisions at the location, the failure to investigate flowing water during highway inspections, and the absence of a robust process for logging and acting on reports of water leaks onto 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 Dorset Council; that does not assign responsibility.
PFD Monitor interpretation Failure to robustly log and action direct reports of water leaks onto highways
Wider context from the report “iii. There would appear to be no process in place at Wessex Water to log and action reports made directly to staff of water leaks onto a highway , or if a process is existent it would appear not to be robust . The risk is that such reports may be “lost”, with the necessary work not undertaken , leaving water flowing from a leak on the highway, with the subsequent risk outlined above.
” 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 Dorset Council; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate flowing water during highway inspections
Wider context from the report “ii. The presence of flowing water in a road is not considered and/or investigated by Dorset Council Highways Officers when conducting a highway inspection , leading to a risk that remedial action to stem the flow may not be taken , further leading to the continued presence of flowing water on a road. The presence of water itself could cause or contribute to a road traffic collision, but if the water were to freeze in sub-zero temperatures, the risk of a collision increases further;
” 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 Dorset Council; that does not assign responsibility.
PFD Monitor interpretation Recurring collision hazard from ice on a steep, curved road section
Wider context from the report “i. This section of the B3091 appears to be an accident “black spot” , with previous collisions likely to have occurred as a consequence of the presence of ice on the road, combined with a steep incline and a bend in the 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 Dig out existing and additional drainage ditches to assist water flow at the identified location.
Verbatim wording from the response “On the 4 January 2023 a joint site visit was conducted by qualified Road Safety Auditors from the team during which it was identified that water flowing out of the road surface over the middle of the carriageway (leading to the possible build-up of ice/slush) was a likely contributing factor. The water appeared to be emanating from a Wessex Water (WW) trench reinstatement and therefore contact was made with WW to ensure that they would take action to address the risk with their asset. The auditors were notified by Dorset Police that water on the road was an active line of enquiry and that investigators from the Serious Collisions Investigation Team were in contact with WW. The auditors noted that as a precaution the local Highways Team would be digging out the existing and some additional drainage ditches to assist water flow.” Source location Response from Dorset 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 Resurface the road and adjust its camber so naturally occurring surface water enters the existing drainage system efficiently.
Verbatim wording from the response “As part of the site investigation consideration was given to the tragic road death which occurred near to this location on the 19 December 2017. It was noted that after this collision (2017) the road was resurfaced with the roads camber being adjusted to improve the ride quality and to ensure that any naturally occurring surface water entered the existing drainage system in an efficient manner. These works were complete in September 2018.” Source location Response from Dorset 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 Review winter-service policy measures concerning water on the highway during precautionary salting operations, completing the review by September 2024.
Verbatim wording from the response “Dorset Council sets out its plan for managing the highway network during winter in its ‘Winter Service Policy and Operational Plan’. This policy is reviewed annually, and we will commit to reviewing the measures and actions set out in this policy with regards to the presence of water on the highway network encountered during precautionary salting operations. This review will be complete, and any identified amendments implemented, by September 2024.” Source location Response from Dorset 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 Review the highway safety policy document within six months to ensure its guidance on flooding, surface water and slippery fluids is sufficiently robust.
Verbatim wording from the response “In addition to this hazards which may affect the safety and/or the serviceability of the highway network can be identified through various routine highway maintenance operations such as cyclical maintenance activities e.g. gully emptying and through ad-hoc inspections undertaken in response to public enquiries.” Source location Response from Dorset 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 Conduct joint site visits with Dorset Police after every fatal collision, assess highway-condition factors, and take necessary mitigating action.
Verbatim wording from the response “We work with partners to reduce serious collisions and after every fatal road traffic collision the Road Safety Team conduct a joint site visit with Dorset Police to consider any factors regarding the condition of the highway which could have contributed to the collision and take any necessary mitigating action to maintain the highway to a safe standard to prevent future collisions.” Source location Response from Dorset 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 Review the B3091 between Sturminster Newton and Shaftesbury within three months to consider additional proportionate improvements.
Verbatim wording from the response “I will commit my team to review the B3091 between Sturminster Newton and Shaftesbury within the next three months to consider whether there are any additional proportionate improvements required.” Source location Response from Dorset Council
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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 Wessex Water is responsible for addressing risks arising from water appearing to originate from its trench reinstatement or asset.
Verbatim wording from the response “On the 4 January 2023 a joint site visit was conducted by qualified Road Safety Auditors from the team during which it was identified that water flowing out of the road surface over the middle of the carriageway (leading to the possible build-up of ice/slush) was a likely contributing factor. The water appeared to be emanating from a Wessex Water (WW) trench reinstatement and therefore contact was made with WW to ensure that they would take action to address the risk with their asset. The auditors were notified by Dorset Police that water on the road was an active line of enquiry and that investigators from the Serious Collisions Investigation Team were in contact with WW. The auditors noted that as a precaution the local Highways Team would be digging out the existing and some additional drainage ditches to assist water flow.” Source location Response from Dorset Council
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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 inspections and policy guidance already address flooding, surface water and slippery fluids as highway safety hazards.
Verbatim wording from the response “In addition to this hazards which may affect the safety and/or the serviceability of the highway network can be identified through various routine highway maintenance operations such as cyclical maintenance activities e.g. gully emptying and through ad-hoc inspections undertaken in response to public enquiries.” Source location Response from Dorset Council
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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 Resources and practicability constrain winter service, so ice and snow cannot be prevented or cleared across all network routes at all times.
Verbatim wording from the response “There is no positive statutory duty placed upon a highway authority to drain a highway; however, section 41(a) of the Highways Act (1980) places a duty upon highway authorities to ensure, so far as is reasonably practicable, that safe passage along a highway is not endangered by snow or ice.” Source location Response from Dorset 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.
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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 Dorset 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
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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 Introduce a Dorset Road Safe website link identifying whom to contact about road obstructions and debris, with information highlighting associated dangers.
Verbatim wording from the response “• Commitment 2
Dorset Road Safe’s Partnership website will introduce a clear link around who to contact in respect of an obstruction/debris on the road. There will also be a section devoted to highlighting the associated dangers to road users.” Source location Response from Dorset 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 Review partner websites and contact details, then establish clear, cross-referenced public reporting links and urgent and non-urgent obstruction-reporting guidance.
Verbatim wording from the response “• Commitment 1
Websites for Dorset Police, the respective Local Authority for Dorset and BCP, along with National Highways, will all review and ensure there is a clear link to enable reporting of obstructions and debris on the road by the public.” Source location Response from Dorset 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 Dorset Council, BCP Council and National Highways have good existing arrangements for the public to report road obstructions and debris.
Verbatim wording from the response “Partnership colleagues in both Councils and National Highways have good existing arrangements for the Public to report issues on the road.” Source location Response from Dorset Council
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19 Jan 2023 Derek Larkin · Prevention of Future Deaths report Dorset
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Concerns raised 3 Lack of access to patients’ prescribed medication and medication review information View source Lack of interoperability between Adult Social Care and NHS information systems View source Lack of access to GP-held information about medication management concerns 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
Derek Larkin · 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
Derek Larkin was found deceased at home on 2 June 2021 after returning from a care home, and a post-mortem examination demonstrated an overdose of prescription morphine. The report raises concerns that Adult Social Care did not have sufficient information about his prescribed medication, medication management, or concerns raised by family and healthcare professionals, including because its computer system could not communicate with the NHS SystemOne system.
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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 Dorset Council; that does not assign responsibility.
PFD Monitor interpretation Lack of access to patients’ prescribed medication and medication review information
Wider context from the report “There is no evidence that the Dorset Council Adult Social Care computer system Mosaic can communicate with the NHS SystemOne. The Adult Social Care team would benefit from having information about the medication being prescribed to a patient, with the patient’s consent, and when that medication was last reviewed. Dorset Council Adult Social Care would benefit from information held by a current or former GP practice as to a patient’s medication and how to manage any particular concerns raised by health care professionals or family where a patient is able to independently manage his medication.
” 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 Dorset Council; that does not assign responsibility.
PFD Monitor interpretation Lack of interoperability between Adult Social Care and NHS information systems
Wider context from the report “There is no evidence that the Dorset Council Adult Social Care computer system Mosaic can communicate with the NHS SystemOne. The Adult Social Care team would benefit from having information about the medication being prescribed to a patient, with the patient’s consent, and when that medication was last reviewed. Dorset Council Adult Social Care would benefit from information held by a current or former GP practice as to a patient’s medication and how to manage any particular concerns raised by health care professionals or family where a patient is able to independently manage his medication.
” 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 Dorset Council; that does not assign responsibility.
PFD Monitor interpretation Lack of access to GP-held information about medication management concerns
Wider context from the report “There is no evidence that the Dorset Council Adult Social Care computer system Mosaic can communicate with the NHS SystemOne. The Adult Social Care team would benefit from having information about the medication being prescribed to a patient, with the patient’s consent, and when that medication was last reviewed. Dorset Council Adult Social Care would benefit from information held by a current or former GP practice as to a patient’s medication and how to manage any particular concerns raised by health care professionals or family where a patient is able to independently manage his medication.
” 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 health professionals about medication, its use, storage and risks at assessment and review points, including options appraisal and safe-management planning.
Verbatim wording from the response ““Liaison with Health professional/prescriber for reviews of medication, options appraisal and confirmation of risks and safe management”” Source location Response from Dorset 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 Obtain written confirmation from health professionals of medication-specific risks and how to manage them safely for named individuals.
Verbatim wording from the response ““Liaison with Health professional/prescriber for reviews of medication, options appraisal and confirmation of risks and safe management”” Source location Response from Dorset 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 Full integration of Mosaic and SystemOne is constrained because separate data controllers own and regulate systems that are not designed to communicate.
Verbatim wording from the response “SystemOne (a health service record keeping system) and Mosaic (Dorset Council’s social care record keeping system) are not designed to communicate with one another and are owned and regulated by separate organisational data controllers under the General Data Protection Regulation (GDPR) and Data Protection Act 2018.” Source location Response from Dorset Council
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2 Feb 2022 Carol Patricia Cole · Prevention of Future Deaths report Dorset
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Concerns raised 1 Failure to ensure PPNs reach GPs for Dorset Council residents 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
Carol Patricia Cole · 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
Carol Patricia Cole was found collapsed and unresponsive at home on 15 May 2020 after being prescribed medication and having a history including depression, unstable personality disorder and previous overdoses. The inquest concluded that her death was suicide. Concerns were raised that processes for sharing Public Protection Notices in the Dorset Council area may have resulted in the GP not receiving information about concerns regarding her mental health, creating a missed opportunity for assessment, support or treatment.
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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 Dorset Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure PPNs reach GPs for Dorset Council residents
Wider context from the report “iii. In Dorset there are 2 Local Authorities that cover the County, BCP Council and Dorset Council. If MASH receive a PPN about a resident in the BCP Council area the current arrangement is that MASH send the PPN directly to the GP as required. If they receive a PPN about a resident in the Dorset Council area the current process is that they do not send it directly to the GP but send it directly to the Dorset Adult Access team at Dorset Council, who will then send it to the GP .
iv. At the time of her death Carole resided within the Dorset Council area. A PPN was submitted to MASH regarding Carole on 25.4.20 which raised concerns regarding her mental health. The MASH team determined the PNN should be shared with the Dorset Adult Access team to share with the GP in line with the process.
v. At the Inquest the representative from the GP surgery confirmed there was no record of the PNN being received by them , which led to a missed opportunity for Carole to be assessed by her GP.
vi. The process currently in place, which I understand has been agreed by both Dorset Council and Dorset Police, of preventing the MASH team from sending the PNN directly to the GP, may result in the GP not being informed of the contents of the PPN which may result in a person not receiving an assessment, support or treatment. I am not aware of a reason why the MASH team cannot send it directly to the GP, as they do for those residents in BCP council area, to avoid such missed opportunities to take action which may lead to a future death.
2. I have concerns with regard to the following:
i. There could be missed opportunities to share PPNs relating to residents within the Dorset Council area with agencies or professionals due to the current processes in place between Dorset Police and Dorset Council which could lead to a future death. I therefore request that Dorset Police and Dorset Council review their current processes in place regarding the sharing of PPNs by MASH, especially to General Practitioners for the residents within the Dorset Council area.
” Open source report
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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 Seek approval to align a partnership review of Adult MASH PPN sharing with the Children’s MASH review.
Verbatim wording from the response “iii) Share learning from the Regulation 28 report at Dorset’s Safeguarding Adult Review in April 2022 and seek approval to align a full partnership review of PPN sharing within Adult MASH with the Children’s MASH review which will take place in July 2022.” Source location 2022-0033-Response-from-Dorset-Council_Published
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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 Amend Dorset Police and Dorset Council PPN-sharing processes to align with BCP processes.
Verbatim wording from the response “i) Amend the current process of sharing PPNs between Dorset Police and Dorset Council to align with BCP processes. This requires work to ensure the MASH has adequate capacity and access to up-to-date information about a person’s GP. To have immediate impact on the current process, Dorset Council will fund additional staffing resources to MASH to assist with the sharing of PPNs to GPs to allow time for a wider system review of MASH to be completed. The plan is to complete recruitment by end of May 2022.” Source location 2022-0033-Response-from-Dorset-Council_Published
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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 Review current PPN-sharing processes with Dorset Police and BCP Council to identify improvements.
Verbatim wording from the response “The request was made that Dorset Police and Dorset Council review their current processes in place regarding the sharing of PPNs by MASH, especially to General Practitioners for the residents within the Dorset Council area. We reviewed the current PPN process with Dorset Police and Bournemouth, Christchurch and Poole (BCP) Council between 16/02/2022 and 16/03/22. This involved members of the operational management team at Dorset Council and Bournemouth, Christchurch and Poole (BCP) Council and Dorset Police Public Protection Unit meeting to analyse current steps in the process. This identified the following areas of improvement:” Source location 2022-0033-Response-from-Dorset-Council_Published
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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 Amend the Adult Access Team process to forward PPNs to relevant agencies regardless of Adult Social Care involvement.
Verbatim wording from the response “iv) Amend Dorset Council’s internal process so that the Adult Access Team forward PPNs to relevant agencies or professionals regardless of whether the person is known or not known to Adult Social Care. This was immediately actioned and implemented on 25/02/22.” Source location 2022-0033-Response-from-Dorset-Council_Published
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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 Fund and recruit additional MASH staff to support sharing PPNs with GPs, with recruitment planned by the end of May 2022.
Verbatim wording from the response “i) Amend the current process of sharing PPNs between Dorset Police and Dorset Council to align with BCP processes. This requires work to ensure the MASH has adequate capacity and access to up-to-date information about a person’s GP. To have immediate impact on the current process, Dorset Council will fund additional staffing resources to MASH to assist with the sharing of PPNs to GPs to allow time for a wider system review of MASH to be completed. The plan is to complete recruitment by end of May 2022.” Source location 2022-0033-Response-from-Dorset-Council_Published
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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 Meet with Dorset Police, BCP and health partners, including GP safeguarding leads, to discuss PPN-sharing processes and improvements.
Verbatim wording from the response “ii) A meeting has been arranged between Dorset Council, Dorset Police MASH, BCP and health partners including GP safeguarding leads in April 2022 to discuss current PPN sharing processes, including what is working well and areas for improvement. This was the earliest opportunity to do so, so that all parties could be represented.” Source location 2022-0033-Response-from-Dorset-Council_Published
Open published response
20 May 2019 Richard Geoffrey Phillips · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 2 Failure to maintain the road and its verges View source Failure of surface-water drainage on the road stretch 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
Richard Geoffrey Phillips · 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
Richard Geoffrey Phillips died at the scene after a car lost control on ice while he was riding his motorcycle on the B3091 on 19 December 2017. The concerns identified included poor drainage of surface water, ice forming on the carriageway, and the maintenance and condition of the road and its verges.
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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 Dorset Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain the road and its verges
Wider context from the report “2. I have concerns with regard to the following:
a) The collision investigation officer from Dorset Police expressed concern in relation to the poor drainage of surface water on this particular stretch of road. My attention was drawn to four draining gullies within 150 metres of the scene, two on each side of the road. As the water flows down the southbound side of the road it does not flow into the gulley but due to the camber of the road the water crosses over the centre of the road and flows down the centre of the road before flowing on to the opposite carriageway. On the nearside of the opposite carriageway is another drainage gulley which contains a gridded metal drain which was (at the time) largely obscured and overgrown by grass. The water once again bypasses this gulley. It is this surface water which has frozen at the time of the accident. At least 2 of the gullies which could drain the water away from the carriageway appear redundant. The positioning of these gullies are questionable.
b) Maintenance of the road and its verges.
” 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 Dorset Council; that does not assign responsibility.
PFD Monitor interpretation Failure of surface-water drainage on the road stretch
Wider context from the report “2. I have concerns with regard to the following:
a) The collision investigation officer from Dorset Police expressed concern in relation to the poor drainage of surface water on this particular stretch of road . My attention was drawn to four draining gullies within 150 metres of the scene, two on each side of the road. As the water flows down the southbound side of the road it does not flow into the gulley but due to the camber of the road the water crosses over the centre of the road and flows down the centre of the road before flowing on to the opposite carriageway . On the nearside of the opposite carriageway is another drainage gulley which contains a gridded metal drain which was (at the time) largely obscured and overgrown by grass . The water once again bypasses this gulley . It is this surface water which has frozen at the time of the accident. At least 2 of the gullies which could drain the water away from the carriageway appear redundant . The positioning of these gullies are questionable .
b) Maintenance of the road and its verges.
” 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 Resurface the B3091, adjusting the road camber to improve drainage and reduce surface water.
Verbatim wording from the response “The accident took place on the section of the B3091 that has subsequently been resurfaced.” Source location 2019-0165-Response-by-Dorset-Council
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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 Clean the drainage system serving the affected highway section.
Verbatim wording from the response “The drainage system has been cleaned recently but we will react to any blockages that are reported to us by the public or staff locally.” Source location 2019-0165-Response-by-Dorset-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 resurfacing improvements are considered sufficient, so no further work is planned at this location for the time being.
Verbatim wording from the response “The highway in question is affected by run off from neighbouring properties and springs. As a result of these issues there will always be some surface water on the carriageway but the improvements we have made will reduce it as much as is reasonably possible.” Source location 2019-0165-Response-by-Dorset-Council
Open published response
Concerns raised 3 Lack of a clear boundary between the pavement and roadway at the junction View source Narrow entrance to Howards Lane causing cars to cut the corner View source Failure to maintain the pavement and roadway at the junction in a safe state of repair 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
Reverend Colin Hodge · 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 19 January 2016, Reverend Colin Hodge stumbled on an uneven pavement at a junction in Wareham and fell against a turning vehicle, then struck his head. He was taken to hospital and died on 25 January from an inoperable head injury. Concerns included the poor state of repair and lack of a clear boundary between the pavement and roadway, with vehicles sometimes cutting the corner.
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 Dorset Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear boundary between the pavement and roadway at the junction
Wider context from the report “(2) At the time of the incident, the pavement and roadway were all of one level .
(3) Evidence from the witnesses indicated that this junction was of concern for two reasons; Firstly that pedestrians would walk straight across as there was no clear boundary between the pavement and the road ; Secondly, as the entrance to Howards Lane is narrow, cars would sometimes cut the corner.
” 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 Dorset Council; that does not assign responsibility.
PFD Monitor interpretation Narrow entrance to Howards Lane causing cars to cut the corner
Wider context from the report “(2) At the time of the incident, the pavement and roadway were all of one level.
(3) Evidence from the witnesses indicated that this junction was of concern for two reasons; Firstly that pedestrians would walk straight across as there was no clear boundary between the pavement and the road; Secondly, as the entrance to Howards Lane is narrow, cars would sometimes cut the corner .
” 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 Dorset Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain the pavement and roadway at the junction in a safe state of repair
Wider context from the report “(1) The evidence from the witnesses who were all from the Wareham area, was that the pavement and road way at the junction of the High Street and Howards Lane was in a poor state of repair .
” Open source report
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Addressed to Dorset County Council, now represented here by Dorset Council.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations