Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0127, written 7 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Mar 2024 |
|---|---|
| Reference | 2024-0127 |
| Deceased | Richard Collins |
| Coroner | Rachael Griffin |
| Coroner area | Dorset |
| Category | Road (Highways Safety) related deaths |
| Organisation named | Dorset Healthcare University NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Rt Hon Victoria Atkins MP, Secretary of State for Health and Social Care 2. 1 CORONER Chief Executive Officer for NHS England I am Rachael Clare Griffin, Senior Coroner, for the Coroner Area of Dorset 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 the 23rd March 2022, an investigation was commenced into the death of Richard Andrew Collins, born on the 16th January 1966. The investigation concluded at the end of the Inquest on the 29th February 2024. The medical cause of death was: Ia Traumatic injuries The conclusion of the Inquest was road traffic collision . 4 CIRCUMSTANCES OF THE DEATH At approximately 20.45 hours on the 9th February 2022 Richard, who had a diagnosis of bipolar affective disorder, abandoned his vehicle on the verge of the eastbound carriageway of the A421 in Bedfordshire. Following this he was walking about half a metre into the carriageway of lane one of the eastbound carriageway of the A421 about 1.15km west of the roundabout junction with the A421 towards Bedford, when he was struck by the left front side of an articulated later in a collapsed and found a short time unresponsive condition on the grass verge on the side of the A421 and despite resuscitation attempts his death was confirmed. lorry. He was 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 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: 1. During the inquest evidence was heard that: i. There is a legal duty upon a driving licence holder to inform the DVLA of any illness or injury, both physical and mental, that would have a likely impact on safe driving ability. In addition to this, as detailed at page 9 of the DVLA Assessing fitness to drive - a guide for medical professionals Assessing fitness to drive: a auide for medical orofessionals - GOV.UK (www.gov.uk), doctors and other healthcare professional should: advise the individual on the impact of their medical condition for safe driving ability advise the individual on their legal requirement to notify DVLA ofany relevant condition notify DVLA directly of an individual's medical condition or fitness to drive, where they cannot or will not notify DVLA themselves ii. iii. iv. 9th December and Prior to his death Richard had been detained under section 2 of 20th the Mental Health Act 1983 between December 2021 following a relapse of his mental health and his presentation with symptoms of hypomania. He remained a voluntary patient until his discharge on the 7th January 2022. He was advised of his duty to notify the DVLA of his illness by the treating consultant during his admission, however the DVLA were not notified prior to his death and so a full driving licence remained in force . Following his release from hospital Richard was under the care of the community mental health team. On the 13th January 2022 his mother contacted his care coordinator, a mental health nurse, and advised that he had purchased a car and had driven it the previous day. On the 31st January 2022 he was assessed under the Mental Health Act 1983 following the police exercising their powers under section 136 of that Act, however was not deemed to require detention. Between the date of his release from hospital and his death Richard had a number of contacts with representatives from the secondary mental health services. No medical professional discussed Richard's driving or notification to the DVLA with him after his discharge there being opportunities to do so. His driving licence remained in force and consideration was not given to its medical revocation prior to his death. from hospital, despite 2 v. Dorset Healthcare University NHS Foundation Trust (DHUFT), who provide the secondary mental health care services in Dorset, did not have a local written policy in place at the time of Richard's death in relation to assessing patient's fitness to drive and contacting with the DVLA. Since Richard's death DHUFT have implemented a written policy which is accessible to all employees of the trust including mental health practitioners and nurses as well as doctors. This has been well received and felt to be very clear. This provides guidance around the duties upon medical professionals and to support decisions where an individual's ability to drive safely is brought into question. The trust have also changed their practice as a result of the learning from Richard's death. For example, DHUFT have a checklist for all inpatient meetings which now includes the DVLA requirements so that they are considered at every discussion with, or about, the patient. vi. Although there is current guidance from the General Medical Council (GMC) and the DVLA to medical professionals about assessing fitness to drive and notifying the DVLA of concerns, I have not been made aware of any national guidance for NHS trusts on the issue of local trust guidance or policy which could help to ensure awareness of, and compliance with the legal duties relating to the medical revocation of driving licences. 2. I have concerns with regard to the following: i. Whilst considerable work has been undertaken within the secondary mental health services in Dorset, I am concerned that there may be similar issues or missed opportunities nationally within other trusts which could lead to the lack of revocation of driving licences on medical grounds, putting the patients and other road users at risk of death. 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or 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, 2nd May 2024. 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. 8 COPIES and PUBLICATION 3 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) Richard's Family (2) Dorset Healthcare University NHS Foundation Trust (3) Chief Constable of Dorset Police (4) Chief Constable of South Yorkshire Police (5) Dorset Council (6) Driver of the articulated lorry I am also under a duty to send the Chief Coroner a copy of your response. I have also sent a copy of this report to the following persons for their awareness: a) The Rt Hon Mark Harper MP, Secretary of State for Transport b) Julie Lennard, Chief Executive Officer for the DVLA 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 Dated Signed Rachael C Griffin 7th March 2024 4
2 responses 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.
From Maria Caulfield MP Parliamentary Under-Secretary of State for Mental Health and Women's Health Strategy 39 Victoria Street London SW1H 0EU Rachael Griffin Senior Coroner For the Coroner Area of Dorset BCP Civic Centre Bourne Avenue Bournemouth BH2 6DY 20 May 2024 Dear Mrs Griffin, Thank you for the Regulation 28 report to prevent future deaths about the death of Mr Richard Andrew Collins. I am replying as Minister with responsibility for Mental Health and Women’s Health Strategy. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Collin’s death, and I offer my sincere condolences to his family and loved ones. I can only begin to imagine the effect that this will have had on his loved ones and, whilst I know that it will come as little comfort to them, I nevertheless hope they will accept my heartfelt condolences. Your report raises the concern that there may be missed opportunities nationally within Trusts that could lead to the lack of revocation of driving licences on medical grounds, and that this could put patients and other road users at risk. You raised that you had not been made aware of any national guidance for NHS Trusts on the issue of local Trust guidance or policy which could help raise awareness of and compliance with the legal duties related to the medical revocation of driving licences. In preparing this response, Departmental officials have made enquiries with NHS England and have been informed that it is not within the remit of NHS England to issue guidance on the revocation of driving licences. As your report states, there is existing national guidance issued by the General Medical Council (GMC) on this issue (Patients’ fitness to drive and reporting concerns to the DVLA or DVA) which outlines the following (section 4): “The driver is legally responsible for telling the DVLA or DVA about any such condition or treatment [that might mean they are unfit to drive]. Doctors should therefore alert patients to conditions and treatments that might affect their ability to drive and remind them of their duty to tell the appropriate agency. Doctors may, however, need to make a decision about whether to disclose relevant information without consent to the DVLA or DVA in the public interest if a patient is unfit to drive but continues to do so.” The General Optical Council also issue similar guidance. The GMC are responsible for setting the standards doctors and those who train them need to meet. It is expected that all doctors use their professional judgement to apply the standards set by the GMC in their day-to-day practice. Trusts are expected to have due regard to existing guidance from organisations such as the GMC and Royal Colleges, and to develop their own local policies. We note that in this case, Dorset Healthcare University NHS Foundation Trust (DHUFT) did not have a local policy in place at the time of Richard’s death. The GMC guidance refers to the guidance (General information: assessing fitness to drive) also issued by the DVLA, referenced in your Report, which sets out the responsibilities for doctors and other healthcare professionals, as well as how they can get in touch with the DVLA: Medical condition notification: assessing fitness to drive - GOV.UK (www.gov.uk). As a result of the concerns highlighted in your Report, colleagues from each of the seven NHS regions will be asked to raise awareness of the GMC and DVLA guidance with their systems and providers. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MARIA CAULFIELD MP
Rachael Clare Griffin
Coroner’s Office for the County of Dorset
Town Hall
Bournemouth
BH2 6DY
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
29 April 2024
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Richard Andrew Collins
who died on 9 February 2022.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 7
March 2024 concerning the death of Richard Andrew Collins on 9 February 2022. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Richard’s family and loved ones. NHS England are
keen to assure the family and the coroner that the concerns raised about Richard’s
care have been listened to and reflected upon.
Your Report raises the concern that there may be missed opportunities nationally
within Trusts that could lead to the lack of revocation of driving licences on medical
grounds, and that this could put patients and other road users at risk. You raised that
you had not been made aware of any national guidance for NHS Trusts on the issue
of local Trust guidance or policy which could help raise awareness of and compliance
with the legal duties related to the medical revocation of driving licences.
It is not within the remit of NHS England to issue guidance on the revocation of driving
licences. As your Report states, there is existing national guidance issued by the
General Medical Council (GMC) on this issue (Patients’ fitness to drive and
reporting concerns to the DVLA or DVA) which outlines the following (section 4):
“The driver is legally responsible for telling the DVLA or DVA about any such condition
or treatment [that might mean they are unfit to drive]. Doctors should therefore alert
patients to conditions and treatments that might affect their ability to drive and remind
them of their duty to tell the appropriate agency. Doctors may, however, need to make
a decision about whether to disclose relevant information without consent to the DVLA
or DVA in the public interest if a patient is unfit to drive but continues to do so.”
The General Optical Council also issue similar guidance. The GMC are responsible
for setting the standards doctors and those who train them need to meet. It is expected
that all doctors use their professional judgement to apply the standards set by the
GMC in their day-to-day practice. Trusts are expected to have due regard to existing
guidance from organisations such as the GMC and Royal Colleges, and to develop
their own local policies. We note that in this case, Dorset Healthcare University NHS
Foundation Trust (DHUFT) did not have a local policy in place at the time of Richard’s
death.
The GMC guidance refers to the guidance (General information: assessing fitness to
drive) also issued by the DVLA, referenced in your Report, which sets out the
responsibilities for doctors and other healthcare professionals, as well as how they
can get in touch with the DVLA: Medical condition notification: assessing fitness to
drive - GOV.UK (www.gov.uk).
As a result of the concerns highlighted in your Report, colleagues from each of the
seven NHS regions will be asked to raise awareness of the GMC and DVLA guidance
with their systems and providers.
I would also like to provide further assurances on national NHS England work taking
place around the Reports to Prevent Future Deaths. All reports received are discussed
by the Regulation 28 Working Group, comprising Regional Medical Directors, and
other clinical and quality colleagues from across the regions. This ensures that key
learnings and insights around preventable deaths are shared across the NHS at both
a national and regional level and helps us pay close attention to any emerging trends
that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
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