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.
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
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 Dorset County 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 Dorset County 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 Dorset County 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 Dorset County 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 Dorset County 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 Dorset County 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 Dorset County 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 Dorset County 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 Dorset County 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 Dorset County 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 Dorset County 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 Dorset County 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
25 Mar 2019 Christopher William Gibbs · Prevention of Future Deaths report Dorset
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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 Dorset County 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 Dorset County 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
31 Jan 2018 Aaron George Nordass-Lacey · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Inadequate signage directing cyclists where the cycle lane ends View source Failure to control excessive vehicle speeds on Barrack Road View source Failure to prevent pedestrians and cyclists from crossing Barrack Road dangerously 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.
×
AI-generated summary
Aaron George Nordass-Lacey · 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
Aaron George Nordass-Lacey died on 13 October 2016 after falling from his bicycle on the A35 Barrack Road, Christchurch, and being struck by a motor vehicle. The principal concerns relate to the safety of pedestrians and cyclists on Barrack Road, including road-crossing behaviour, vehicle speeds, barriers, and unclear cycle-lane signage.
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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 County Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate signage directing cyclists where the cycle lane ends
Wider context from the report “1. During the inquest evidence was heard that:
i. The road where the incident occurred that lead to Aaron’s death, the A35 Barrack Road, Christchurch, Dorset is a road which has a speed limit of 30 miles per hour. Evidence was given that people regularly drive at excessive speeds on this road. The location of the incident is near to a school and evidence was given that people, especially school children, do not always use the designated crossing just prior to the junction of Clarendon Road and Barrack Road. Evidence was given that school children often flood out of the school and run into the road. Evidence was given that this was perceived to be a danger and that there could be the death of a person in the future.
ii. The placement of barriers along this section of road would assist in reducing the access to the road and encouraging pedestrians to use the crossing to cross the road safely, reducing the potential dangers and risk to life. It was also suggested that a fixed speed camera may assist in regulating the speed of vehicles that use the road.
iii. Evidence was also given in relation to the cycle lane along Barrack Road. The cycle lane along Barrack Road heading towards Christchurch is on the footpath and is a shared cycle lane and footpath. The cycle lane comes to an end just before the junction of Clarendon Road and evidence was given by the Collision Reduction Team Manager that the expectation is that when the cycle lane comes to an end, cyclists will cross the road and use the cycle path on the footpath on the other side of the road. Although there is a sign at the end of the cycle lane it is not clear that the expectation is for the cyclist to cross over the road at the crossing . The lack of signage is therefore very confusing and could lead to a further collision .
2. I have concerns with regard to the following:
i. The safety of pedestrians and cyclists who use Barrack Road, Christchurch where the incident that led to Aaron’s death occurred. I would therefore request that there is a review of the safety measures in place and consideration is given to the erection of barriers along the pavement and also along the central reservation to discourage pedestrians and cyclists from crossing the road in a dangerous manner.
ii. I would also request that a review is undertaken regarding the signage given to cyclists at this location and consideration be given to having a fixed speed camera at this location.
” 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 County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to control excessive vehicle speeds on Barrack Road
Wider context from the report “1. During the inquest evidence was heard that:
i. The road where the incident occurred that lead to Aaron’s death, the A35 Barrack Road, Christchurch, Dorset is a road which has a speed limit of 30 miles per hour. Evidence was given that people regularly drive at excessive speeds on this road . The location of the incident is near to a school and evidence was given that people, especially school children, do not always use the designated crossing just prior to the junction of Clarendon Road and Barrack Road. Evidence was given that school children often flood out of the school and run into the road. Evidence was given that this was perceived to be a danger and that there could be the death of a person in the future.
ii. The placement of barriers along this section of road would assist in reducing the access to the road and encouraging pedestrians to use the crossing to cross the road safely, reducing the potential dangers and risk to life. It was also suggested that a fixed speed camera may assist in regulating the speed of vehicles that use the road.
iii. Evidence was also given in relation to the cycle lane along Barrack Road. The cycle lane along Barrack Road heading towards Christchurch is on the footpath and is a shared cycle lane and footpath. The cycle lane comes to an end just before the junction of Clarendon Road and evidence was given by the Collision Reduction Team Manager that the expectation is that when the cycle lane comes to an end, cyclists will cross the road and use the cycle path on the footpath on the other side of the road. Although there is a sign at the end of the cycle lane it is not clear that the expectation is for the cyclist to cross over the road at the crossing. The lack of signage is therefore very confusing and could lead to a further collision.
2. I have concerns with regard to the following:
i. The safety of pedestrians and cyclists who use Barrack Road, Christchurch where the incident that led to Aaron’s death occurred. I would therefore request that there is a review of the safety measures in place and consideration is given to the erection of barriers along the pavement and also along the central reservation to discourage pedestrians and cyclists from crossing the road in a dangerous manner.
ii. I would also request that a review is undertaken regarding the signage given to cyclists at this location and consideration be given to having a fixed speed camera at this location.
” 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 County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent pedestrians and cyclists from crossing Barrack Road dangerously
Wider context from the report “1. During the inquest evidence was heard that:
i. The road where the incident occurred that lead to Aaron’s death, the A35 Barrack Road, Christchurch, Dorset is a road which has a speed limit of 30 miles per hour. Evidence was given that people regularly drive at excessive speeds on this road. The location of the incident is near to a school and evidence was given that people, especially school children, do not always use the designated crossing just prior to the junction of Clarendon Road and Barrack Road . Evidence was given that school children often flood out of the school and run into the road . Evidence was given that this was perceived to be a danger and that there could be the death of a person in the future.
ii. The placement of barriers along this section of road would assist in reducing the access to the road and encouraging pedestrians to use the crossing to cross the road safely, reducing the potential dangers and risk to life. It was also suggested that a fixed speed camera may assist in regulating the speed of vehicles that use the road.
iii. Evidence was also given in relation to the cycle lane along Barrack Road. The cycle lane along Barrack Road heading towards Christchurch is on the footpath and is a shared cycle lane and footpath. The cycle lane comes to an end just before the junction of Clarendon Road and evidence was given by the Collision Reduction Team Manager that the expectation is that when the cycle lane comes to an end, cyclists will cross the road and use the cycle path on the footpath on the other side of the road. Although there is a sign at the end of the cycle lane it is not clear that the expectation is for the cyclist to cross over the road at the crossing. The lack of signage is therefore very confusing and could lead to a further collision.
2. I have concerns with regard to the following:
i. The safety of pedestrians and cyclists who use Barrack Road, Christchurch where the incident that led to Aaron’s death occurred . I would therefore request that there is a review of the safety measures in place and consideration is given to the erection of barriers along the pavement and also along the central reservation to discourage pedestrians and cyclists from crossing the road in a dangerous manner.
ii. I would also request that a review is undertaken regarding the signage given to cyclists at this location and consideration be given to having a fixed speed camera at this location.
” Open source report
3 Feb 2014 DANIEL WARWICK JONES · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 2 Failure to provide sufficiently conspicuous warning and directional signage at A356 junctions View source 60 mph speed limit at or around road junctions 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
DANIEL WARWICK JONES · 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
Daniel Warwick Jones died from multiple injuries in a road traffic collision while riding a motorcycle on the A356, where his motorcycle collided with a motorcar turning right into a side-road junction. The inquest heard concerns that road users were unaware of the junction warning signage and road markings, and that signage, overtaking restrictions and speed limits at or near junctions may require consideration.
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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 County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide sufficiently conspicuous warning and directional signage at A356 junctions
Wider context from the report “The court heard evidence from the car driver and her passenger, a rider of another motorcycle who was out with the deceased, two further independent witnesses and finally the Police Officer who conducted the accident investigation. It became clear from a number of witnesses who used the road on a regular basis that they were aware that there was a junction at this point but were unaware of the roadside warning triangle sign to indicate a junction or of the white arrow painted on the road surface to direct traffic travelling in the same direction as the deceased to pull into the nearside carriageway .
This road is subject to 60 mph speed limit. Consideration needs to be given to improving the signage at this junction . Either by marking double white lines on the A356 to tell users that they must not overtake or improving the size and position of warning triangles indicating there is a junction , or both of those improvements together with anything further that would prevent a further accident at this junction.
Further whether the speed limit at or around junctions on this road need to be reduced. The Police Officer who is an experienced road traffic officer who has to provide accident reports to the Coroners and other Courts was of the view that the signage at all junctions along the A356 may need to be considered .
The inquest of course only heard evidence in connection with this junction.
” 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 County Council; that does not assign responsibility.
PFD Monitor interpretation 60 mph speed limit at or around road junctions
Wider context from the report “The court heard evidence from the car driver and her passenger, a rider of another motorcycle who was out with the deceased, two further independent witnesses and finally the Police Officer who conducted the accident investigation. It became clear from a number of witnesses who used the road on a regular basis that they were aware that there was a junction at this point but were unaware of the roadside warning triangle sign to indicate a junction or of the white arrow painted on the road surface to direct traffic travelling in the same direction as the deceased to pull into the nearside carriageway.
This road is subject to 60 mph speed limit . Consideration needs to be given to improving the signage at this junction. Either by marking double white lines on the A356 to tell users that they must not overtake or improving the size and position of warning triangles indicating there is a junction, or both of those improvements together with anything further that would prevent a further accident at this junction.
Further whether the speed limit at or around junctions on this road need to be reduced . The Police Officer who is an experienced road traffic officer who has to provide accident reports to the Coroners and other Courts was of the view that the signage at all junctions along the A356 may need to be considered.
The inquest of course only heard evidence in connection with this junction.
” 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 Erect additional “Side Road Ahead” warning signs with distance plates on both approaches to the junction.
Verbatim wording from the response “The County Council will erect additional 'Side Road Ahead' warning signs on the offside, on both approaches to the above junction, along with distance plates at the first of the existing deflection arrow road markings. A 'SLOW' road marking will also be laid for eastbound traffic on the nearside.” Source location 2014-0049-Response-by-Dorset-County-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 Lay a “SLOW” road marking for eastbound traffic near the junction.
Verbatim wording from the response “The County Council will erect additional 'Side Road Ahead' warning signs on the offside, on both approaches to the above junction, along with distance plates at the first of the existing deflection arrow road markings. A 'SLOW' road marking will also be laid for eastbound traffic on the nearside.” Source location 2014-0049-Response-by-Dorset-County-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 The national speed limit remains appropriate for the A356 because its class, conditions and collision record do not justify a lower limit.
Verbatim wording from the response “The road is subject to the national speed limit since this is appropriate to the class and conditions generally found along the A356. Lower limits are used to protect communities from traffic travelling at unreasonable speeds in built-up areas. 50mph limits are used on some routes or sections of road with a poor collision record but this does not apply in the case of the A356 in Dorset.” Source location 2014-0049-Response-by-Dorset-County-Council
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations