Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0227, written 11 Sep 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Sep 2017 |
|---|---|
| Reference | 2017-0227 |
| Deceased | Henry Prow |
| Coroner | Emma Carlyon |
| Coroner area | Cornwall and the Isles of Scilly |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS Henry Prow, deceased. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: DVLA and The Department of Transport DVLA Chief Executive — Mr Oliver Morley, Chief Executive’s Office, DVLA, Swansea, Wales, SA6 7JL Secretary of State for Transport — Mr Chris Grayling, Department for Transport, Great Minster House, 33 Horseferry Road, London, SW1P 4DR CORONER | am Dr E Emma Carlyon the Senior Coroner for Cornwall and the Isles of Scilly. CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST Henry Prow (date of birth 22.11.1957) of Orchard View, Lower Carblake, Cardinham, Bodmin died in a single vehicle road traffic collision on 12" August 2016. His death was referred to the Cornwall and Isles of Scilly Coroner. After a post mortem, an Investigation was opened on 18" August 2016 and an inquest opened on 6" December 2016. The Inquest hearing took place on 2" June 2017 at Truro Municipal Buildings. The cause of death was established as 1a) Multiple injuries; 2) Diabetes; Renal, hepatic and vascular disease. CIRCUMSTANCES OF THE DEATH Henry Prow was returning from a weekly routine medical appointment at Derriford Hospital on 12"" August 2016 in his Vauxhall Insignia VRN [i He had multiple medical and physical disabilities which required him to drive an automatic car with assisted steering. He was driving along the A38 Dobwalls by-pass at around 66 mph when he failed to reduce his speed for unknown reasons on approaching the Twelvewoods Roundabout resulting in the car colliding with the curb by the separation barrier at around 12.36 pm. As a result of this collision, the car left the ground and rotated about its longitudinal axis and then collided with the cheveroned sharp deviation of route sign and posts on the roundabout. Mr Prow received fatal injuries from the collision and died at the scene. He was not wearing a seat belt or using the required assisted steering at the time of the collision. A medical event prior to the collision could not be excluded. Mr Prow suffered from significant medical problems including severe diabetic nephropathy with vascular disease, left hemiplegia due to CVE, liver transplant for primary sclerosing cholangitis and hepatitis C, type II diabetes and was on antidepressants. This caused him to have no use of his left arm, limited use of his left leg and limited movement and feeling in his right foot. It is understood that_a condition of his licence was to have the vehicle modified to allow the vehicle ancillary controls to be operated by the driver using one hand while driving. He had held a driving licence since 1978. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — At the inquest concerns were raised by the police and a friend as to the criteria required by the DVLA and Department of Transport for the issuing and surrendering of driving licences and the terms and conditions for ensuring appropriate modification of driver’s vehicles. Mr Prow had been a very fit and active man and worked as a training instructor in the Army for 3 years. As a result of his deteriorating poor health he lost his mobility and he was keen not to lose his driving license which would reduce his independence. At inquest it was considered that the collision was possibly preceded by Mr Prow having a medical issue/event. The DVLA appears to have limited mechanisms for drivers to be formally medically reviewed for the purpose of being medically fit to drive. In particular in cases where drivers have deteriorating health or fluctuating health (of which they may not have insight) as in the case of Mr Prow. It is understood that at present the treating GP/doctors or the driver themselves have a duty to advise the DVLA of medical issues which can affect a person’s ability to drive. A driver’s voluntary surrender of a driving licence (especially in a rural area with little public transport) may have a serious detrimental effect on their health and social/employment situation making it unrealistic expectation on the driver in many cases. There was concern, that the driver's GP/doctors could have a conflict of interests in such situations as they would have a duty to inform the DVLA of medical issues which could result in the surrender of the driving licence which could/would result in deterioration of the patient/doctor relationship e.g. such as patients withholding significant medical information with their doctors for fear of losing their licence. There were also concerns that there appeared to be no mechanism for ensuring the required modification to the vehicles were still relevant to the vehicle that they were driving at the time (he had changed cars since requirement made and his health had deteriorated) and were appropriately in place and used . ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action. To review the manner in which licences are issues and surrendered on health grounds and the method and criteria for assessing this e.g. the consideration of independent medical assessment or a compulsory medical at time periods. To review the mechanism for ensuring the required modification to vehicles are still relevant to the vehicle and to the medical issues of the driver and that these modifications were fitted and used appropriately. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 6"" November 2017. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the followj Interested Peraons: TT (Brother), | have also sent it a of the Serious Collision Investigation Team, Devon and Cornwall Police who may find it useful or of interest. | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. [DATE] [SIGNED BY CORONER] 41/09/2017 Cugaloeth Erne Cortyen
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
wick ) 47 18" 2018 From the Parliamentary RES under Secretary of State Jesse Norman MP Department Great Minster House for Transport . 33 Horseferry Road London SW1P 4DR Tel: 0300 330 3000 Dr Emma E Carlyon Email: jesse.norman@dft.gsi.gov.uk Senior Coroner for County of Cornwall The New Lodge Penmount , Truro 15 JAN 2qdp TR4 9AA Web site: www.gov.uk/dft Thank you for your letter and report of 7 September following the inquest you conducted into the death of Mr Henry Prow. | was sorry to read of the circumstances of Mr Prow’s death and | can assure you that | have considered your report and its recommendations very carefully. Your report suggests that the process for issuing and surrendering driving licences on health grounds and the criteria used for assessing fitness to drive for those with health conditions should be reviewed. The current driver licensing process is underpinned by a legal requirement that all drivers must inform the DVLA at any time of a medical condition that affects safe driving. The required health standards for driving are based on the views of medical experts from across Europe and are provided for in law. The detail of these standards is informed by the opinion of eminent experts on a number of honorary medical advisory panels which consider health and driving. All drivers must meet the appropriate health standards for driving and the DVLA will investigate those who notify a medical condition. Such investigations usually involve obtaining information from the driver and possibly their doctor or specialist. The DVLA will only issue a licence to those who meet the required standards. Your reports suggests that when deciding whether someone is medically fit to drive, consideration should be given to using independent medical assessment. | can confirm that in more complex cases, the DVLA already uses independent medical or driving assessments before deciding whether to issue a driving licence. The DVLA can also issue a licence of limited duration when required, as in Mr Prow’s case, to allow someone's fitness to drive to be closely monitored on a regular basis. The length of the licence issued is based on the advice of medical experts and will depend on the medical condition concerned. After reviewing Mr Prow’s records, officials have confirmed that he had been in regular contact with the DVLA about his medical conditions. Mr Prow's driving licence had been regularly reviewed since 2001. Mr Prow had also notified the DVLA outside of the driving licence renewal process when he suffered a stroke in 2011 and when he had laser treatment on his eyes in 2013. In January 2014, the DVLA arranged for Mr Prow’s visual acuity and field to be tested. Mr Prow’s health met the appropriate standards and a driving licence, valid for three years, was issued on 18 February 2014. Mr Prow also had a driving assessment following a discussion with Motability Operations Ltd regarding the possible termination of the lease of his vehicle due to a lack of mobility following the stroke. The assessment recommended that Mr Prow should drive a car with automatic transmission and modified steering. The current process focuses on those drivers who have a medical condition. It is designed to be fair and proportionate without penalising those drivers with disabilities who continue to drive safely. There is little evidence to suggest that introducing a stricter regime which includes mandatory medical or practical driving assessments would improve road safety. To impose such a requirement without the appropriate evidence would be overly bureaucratic and potentially very costly. Britain’s roads are some of the safest in the world and our road safety record compares favourably with other countries with stricter and more intrusive driver licensing regimes. You have also suggested that there should be mechanisms in place to ensure that any required modifications to a vehicle are still relevant and are fitted and used appropriately. By law, drivers must ensure that they are able to control a vehicle safely and be able to meet any conditions or restrictions on their licence. Drivers who require adaptations to their vehicle and whose licence is noted with the appropriate code can only legally drive a vehicle fitted with the specified adaptations. The police are responsible for enforcing compliance with the requirements of any restricted driving licence. There are a number of businesses and charitable organisations that provide advice on vehicle adaptation solutions for people with limited mobility. Driving Assessment Centres can also be a first point of contact to offer advice to drivers on driving aids and adaptations. Vehicle dealerships will also be aware of accredited manufacturers and installers and can offer advice about available vehicles and suitable adaptations. Every time a driver renews their entitlement they are asked to confirm whether they require special controls to be able to safely control a vehicle and what these are. These would be checked and recorded on any subsequent driving licences issued. However, | can confirm that the DVLA is currently reviewing how restrictions imposed on driving licences as a result of a medical condition or disability are communicated to drivers, particularly when they change their cars. | note the concern you have expressed that GPs may have a conflict of interest in notifying the DVLA of their patient's medical condition. Medical professionals, and GPs in particular, play an important role in the driver licensing process by advising their patients of the implications of their condition on driving, the effect of any treatment or medication and whether they should notify the DVLA. As | have outlined, drivers are legally responsible for notifying the DVLA if they have a medical condition. However, the General Medical Council (GMC) has revised its guidance to doctors on reporting concerns to the DVLA. The revised guidance states that doctors do not need to seek a patient’s consent to contact the DVLA if they do not feel it is safe and practical to do so. The GMC advises doctors to alert patients to conditions and treatments that might affect their ability to drive and remind them of their duty to tell the DVLA. Doctors may, however, decide to disclose relevant information without consent to the DVLA, in the public interest, if a patient is unfit to drive but continues to do. This can be done via a dedicated “doctor to doctor’ telephone line or by email to one of the DVLA’s qualified doctors. | am grateful to you for bringing this case to my attention and for the recommendations you have made. | hope the information in this letter reassures you that the appropriate processes in place for addressing the issues you have raised. However, | can assure you that these processes are kept under review and where improvements are identified, these are put in place. ; bse JESSE NORMAN
See every Prevention of Future Deaths report matching Road (Highways Safety) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.