Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0203, written 9 Oct 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Oct 2020 |
|---|---|
| Reference | 2020-0203 |
| Deceased | Brian Griffiths |
| Coroner | Colin Phillips |
| Coroner area | Swansea and Neath Port Talbot |
| Category | Road (Highways Safety) related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. -=hief Constable of South Wales Police Email: 1 CORONER I am Colin Phillips, acting senior coroner, for the coroner area of SWANSEA and NEATH PORT TALBOT 2 CORONER'S LEGAL POWERS I 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. 3 INVESTIGATION and INQUEST On 3rd October 2019 I commenced an investigation into the death of Brian Griffiths aged 66. The investigation concluded at the end of the inquest on 7th October 2020. The conclusion of the inquest was Road Traffic Collision and the medical cause of death was 1a Right Tibia/Fibular fracture and Vascular Injury. 1b Crush in"u CIRCUMSTANCES OF THE DEATH 4 The deceased was Brian Griffiths and he died on the 2nd October 2019 at ITU Morriston Hospital Morriston Swansea. On 30th September 2019 a vehicle whilst leaving the Tesco Express store on Bryn Mor Road Gowerton and Petrol Station forecourt unexpectedly accelerated , veered out of control and collided with Mr Griffiths causing catastrophic injuries. The vehicle pinned Mr Griffiths to the cash machine from which he was withdrawing cash. The driver was elderly ( aged 91 years) and could provide no explanation for his driving. The driver panicked and was unable to engage reverse gear in a vehicle which he was unfamiliar with and which he was using because his own vehicle had been written off in a collision which had previously occurred in the same location. Mr Griffiths was freed by members of the public who intervened and came to his assistance. There was no mechanical fault in the vehicle. Mr Griffiths was taken to Hospital but died despite surgical intervention. There was no concerns with the medical care or treatment. 1 5 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. - On 29th April 2019 ( 5 months prior to the fatal collision) the driver had been involved in another collision at the same location of the Tesco Petrol station in the Gower. The collision was damage only and the road traffic officer dealt with the collision by way of SI70 ( exchange of details). The other driver involved was later treated for whiplash but this was not disclosed at the scene. No D751 medical referral was considered by the road traffic officer but no medical factors were disclosed or identified that would support the submission. There is no obligation to submit the form based only on the fact that the driver was elderly. An opportunity was missed at the time of the collision in April 2019 for an independent assessment of the driving ability of the driver. I was informed at the Inquest that there are a number of police forces which have elderly person driver referral schemes / fitness to drive which can be used as an alternative to a prosecution for minor driving offences or collisions. Dyfed Powys have a scheme that has been running for 4 years after an initial pilot and it has been used as a successful tool to take unsafe elderly drivers off the road The schemes involves a cognitive test and also a driving test to assess the standard of an individual's driving. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 4th December 2020. 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. 2 8 COPIES and PUBLICATION I have sent ) -epo r t to the Chief Coroner and to the following Interested wife of the deceased. I have also sent it to Brake the road Persons Mrs safety charity w o may find it useful or of interest. I 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. 9 SIGNED BY CORONER Colin Phillips 3
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.
CADW DE CYMRU‘N DDIOGEL « KEEPING SOUTH WALES SAFE PencadlysHeddlu | Police Headquarters Heol y Bont-faen Cowbridge Road Penybont Bridgend CF3I 3SU CF31 3SU Mewn argyfwng ffoniwch 999 In an emergency always dial 999 fel arall, ffoniwch 101 for non-emergencies dial 101 Gwefan: www.heddlu-de-cymru.police.uk Website: www.south-wales.police.uk 26 November 2020 Colin Phillips ~ Senior Coroner Dear Mea . Pn, | write in reply to your letter dated 9 October 2020 to Chief Constable Jukes (former Chief Constable of South Wales Police), regarding the inquest into the death of Brian Griffiths. Mrffllasked me to respond to your letter on his behalf, in my capacity as Assistant Chief Constable with responsibility for Roads Policing in South Wales Police. The circumstances that you describe in your letter, concerning the death of Brian Griffiths, are as recorded by South Wales Police. As you outline, the first collision involving the same driver (aged 91 years) occurred on 29 April 2019 and was dealt with by way of Section 170 of the Road Traffic Act 1988 (exchange of details). A D751 Medical Referral was not made on that occasion as the submission criteria was not met. However, in June 2019 the same driver applied for the renewal of his driver’s licence and on 10 July 2019, the Driver and Vehicle Licensing Agency confirmed that he passed the required medical standards for safe driving and renewed the licence. This process did not involve medical tests but did follow the process required for an elderly driver and his General Practitioner signed through the license renewal, confirming medical fitness to drive, without requiring additional tests to be undertaken. Therefore, in the circumstances of this matter, the driver's medical fitness to drive was subject of review between 29 April 2019 and 30 September 2019. Mae Heddlu De Cymru yn croesawu derbyn gohebiaeth yn Gymraeg a Saesneg. Byddwn yn ateb gohebiaeth a dderbynnir yn Gymraeg yn Gymraeg ac ni fydd gohebu yn Gymraeg yn arwain at oedi. South Wales Police welcomes receiving correspondence in Welsh and English. Any correspondence received in Welsh will be answered in Welsh and corresponding in Welsh will not lead to a delay in responding. £) © swpolice Prif Gwnstabl | Chief Constable South Wales Police is committed to ensuring and improving the safety of road users within the force area and identifying opportunities for early interventions for those whose driving is found to fall below the required standard. Therefore, prior to receiving your letter, the South Wales Police Serious Collision Investigation Unit (SCIU) had already engaged with colleagues in Dyfed Powys Police to fully understand the elderly person referral scheme that they have in place, to inform a review as to how South Wales Police could establish a scheme of a similar nature. In addition, Inspector BB pea of SCIU, has also engaged colleagues in Criminal Justice Services, the Motoring Unit and the Wales Mobility Driver Assessment Service, who facilitate the running of the courses, to discuss the implementation of the scheme in South Wales. The timescales for implementation of the scheme in South Wales Police is May 2021, however the relevant departments and agencies are working to deliver it earlier, if possible. The death of Brian Griffiths was, and remains, a tragedy and | would like to take this opportunity, on behalf of South Wales Police, to express my sincerest condolences to his wie Yours sincerely Assistant Chief Constable Mae Heddlu De Cymru yn croesawu derbyn gohebiaeth yn Gymraeg a Saesneg. Byddwn yn ateb gohebiaeth a dderbynnir yn Gymraeg yn Gymraeg ac ni fydd gohebu yn Gymraeg yn arwain at oedi. South Wales Police welcomes receiving correspondence in Welsh and English. Any correspondence received in Welsh will be answered in Welsh and corresponding in Welsh will not lead to a delay in responding. Heddlu De Cymru © ©O swpolice Prif Gwnstabl | Chief Constable South Wales Police
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