Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0194, written 12 Apr 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Apr 2024 |
|---|---|
| Reference | 2024-0194 |
| Deceased | James Baxter |
| Coroner | Ian Wade |
| Coroner area | Berkshire |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Reading Town Hall Blagrave Street Reading Berkshire RG1 1QH DX 40124 Reading Castle Street REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Right Honourable Mark Harper MP, Secretary of State for Transport 1 CORONER I am Ian Wade KC, Assistant Coroner for the Coroner area of Berkshire 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. http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 5th September 2022 I commenced an investigation into the death James Ferris Baxter aged 78. The investigation was discontinued by the issue of coronial Form B on 31st January 2023, without inquest. 4 CIRCUMSTANCES OF THE DEATH Mr Baxter was a qualified and lawfully licensed passenger carrying coach driver. He held a valid Category D licence authorising him to drive a PCV, issued on 3rd December 2021. He died on 4th September 2022 at Junction 15 of the M25 motorway, while driving a single deck Mercedes Benz coach. It has been determined by post mortem that he died from an acute right coronary artery thrombosis secondary to plaque rupture, due to severe ischaemic heart disease. This was a natural cause of death. He was at the wheel and actually driving, with 25 passengers on board, when he suffered this medical episode causing the coach to crash. A passenger managed to take over control of the moving coach which was brought to a stop by collision with a safety barrier, causing some minor injury to some passengers and minor damage to the vehicle. 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows. – 1) As Mr Baxter was over 65 years old, he was required under current regulations pursuant to the Road Traffic Act 1988 and associated legislation to apply to have his Category D licence renewed annually using a Form D47P, and to have supplied a medical examination report in Form D4. 2) My investigation has revealed that Mr Baxter's registered GP was never asked by Mr Baxter to examine him for the purposes of the renewal of his Category D licence, nor to submit a Form D4. Mr Baxter was medically examined by an appropriately qualified medical practitioner offering such an examination commercially to holders of HGV and PCV licences. A test was undertaken in the approved manner and was accompanied by a completed and duly signed Form D4, dated 2nd October 2021. 3) Mr Baxter was diagnosed with Type 2 Diabetes Mellitus in 2007, and with Hypertension in 2011, and he was prescribed suitable medications for these conditions. His medical history showed that he was obese and gaining weight in 2020 with a noted increase over time in his HbA1c, leading his GP to note that his diabetes was poorly controlled. In itself, this history does not make it clear that Mr Baxter was medically unfit to hold a Category D licence. However, aged 78, with chronic and poorly controlled diabetes and high blood pressure, the circumstances in which he would develop ischaemic heart disease and be at risk of suffering a serious coronary episode, of the sort he suffered on 4th September 2022, appeared to be established. 4) I received evidence that DVLA does commission functional cardiac stress testing for those with known cardiovascular disease, or those with symptoms suspected to be related to cardiac disease but this arises only in cases where such conditions are declared. Apparently there is no mechanism in place to diagnose asymptomatic individuals with these tests, but the evidence in the investigation indicated that a risk-based stratification system (for example a Q-Risk score) which takes account of age and comorbidities, rather than just cardiac symptoms, was feasible to reduce the risk of incidents of this type, thereby prompting consideration of stress testing. Alternatively a periodic stress test related to age was suggested as a means of ameliorating risk. Evidence was also provided indicating that on the D4 form there should be a provision to fill in HbA1c and cholesterol results produced within the previous 3 months as obtained by the applicant from a GP. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 20th June 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. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to (next of kin), Thames Valley Police Roads Policing, Ryminster Medical Services Limited (trading as D4Drivers UK), and Westbus Coach Services Ltd 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 [DATE] 12th April 2024 [SIGNED BY CORONER] 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.
Ian Wade Assistant Coroner Berkshire Coroner's Office Reading Museum and Town Hall Blagrave Street Reading RG1 1QH Dear Mr Wade, From the Secretary of State Rt. Hon Louise Haigh MP Great Minster House 33 Horseferry Road London SW1P 4DR Tel: 0300 330 3000 E-Mail: Web site: www.gov.uk/dft Our Ref: 17 July 2024 Thank you for your report of 12 April 2024 made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, following the investigation you conducted into the death of James Ferris Baxter. I was very sorry to learn of the circumstances of Mr Baxter’s death and would like to express my sincere condolences to his family. I have considered your report and its recommendations carefully and I can assure you that the Department takes such matters very seriously. The current driver licensing arrangements are underpinned by a legal requirement that all drivers, of any age, must inform the Driver and Vehicle Licensing Agency (DVLA) at any time if they develop a medical condition that may affect safe driving. All drivers must meet the appropriate medical standards for driving and a licence will only be issued to those who meet those standards. These arrangements are designed to be balanced and proportionate for all drivers, balancing road safety and the mobility of individuals. The medical standards relating to fitness to drive are set out in the DVLA’s guidance: Assessing fitness to drive: a guide for medical professionals. The guidance is based on both domestic legislation and advice from the Secretary of State for Transport’s Honorary Medical Advisory Panels. The guidance advises members of the medical profession on the medical standards that need to be met by individuals to hold licences to drive various categories of vehicles. The health standards for drivers of lorries and buses are substantially higher than for drivers of cars and motorcycles due to the size and weight of the vehicle and the length of time a professional driver typically spends at the wheel. The medical panels provide the DVLA with expert medical advice about relevant medical conditions and their impact on driving. Drivers of lorries and buses are required to renew their driving entitlement every five years from the age of 45 and then annually from the age of 65. When renewing their licence, a driver must make a declaration regarding their health and submit a D4 medical report following an examination which must be carried out by a doctor. The DVLA recommends that drivers ask their own GP to complete the D4 medical report, given that the GP will have access to the medical records and could provide medical information that may be required. However, there is no obligation for drivers to see their own GP and to make it a requirement may have impacts on drivers and the transport industry in terms of time and costs. In addition, a number of private companies offer this service to drivers and where this is the case, the examining doctor should be satisfied that they have sufficient information about a driver’s medical history and should not sign a D4 where there is any doubt. After the age of 45, and in accordance with the requirements for lorry and bus licensing, Mr Baxter submitted several D4 medical reports which were completed by his own GP. The only medical conditions declared on these reports were diabetes treated with low-risk medication, and hypertension. At no point was the DVLA advised that Mr Baxter had ischaemic heart disease. In November 2020 Mr Baxter applied to renew his lorry and bus entitlement. He submitted a D4 medical report which was completed by a doctor other than his GP. On this occasion the doctor completing the D4 notified DVLA of Mr Baxter’s diabetes and added that Mr Baxter was not on anti-hypertensive treatment but was taking two other types of medication, one for renal protection and one for hypercholesterolaemia (high cholesterol). The additional information supplied was unrelated to his diabetes. The DVLA most recently issued a driving licence to Mr Baxter in December 2021, around nine months before the incident. The application and D4 submitted at that time which again was completed by a doctor other than his GP detailed that all medication remained the same except with the addition of medication for prostate issues which was unrelated to his diabetes. Based on all the evidence available at the time, Mr Baxter was relicensed by the DVLA. The information provided to the DVLA on Mr Baxter’s D4 medical reports did not raise any health concerns which would have required the DVLA to conduct further medical investigations into his fitness to drive. Mr Baxter’s D4 medical reports provided information about the medication he was taking, but it was only the medication used to treat diabetes that was relevant in terms of assessing his fitness to drive. I have noted your suggestions regarding the possibility of adding Hbac1 and cholesterol readings as standard to the D4 forms, as a way of screening for risk of heart-related conditions. Currently, the DVLA can only act on information received from licence holders and/or healthcare professionals about known medical conditions. The DVLA issued a Call for Evidence late last year to gather views on the legislative framework that governs driver licensing for people with medical conditions. There were 486 responses in total which are currently being examined. I am very grateful for you bringing your concerns to my attention. Please be assured that my department takes road safety very seriously and we are focused on ensuring that only those who are fit to drive are granted a licence to do so. Yours sincerely, Rt Hon Louise Haigh MP SECRETARY OF STATE FOR TRANSPORT
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