Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0507, written 12 Aug 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 Aug 2024 |
|---|---|
| Reference | 2024-0507 |
| Deceased | Geoffrey Toase and Michael Midgley |
| Coroner | Jessica Swift |
| Coroner area | Kingston Upon Hull and the East Riding of Yorkshire |
| Category | Road (Highways Safety) 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Driver and Vehicle Licensing Agency (DVLA) 1 CORONER I am Jessica Swift, Assistant Coroner for the City of Kingston Upon Hull and the East Riding of Yorkshire. 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 8 August 2019 an inquest was opened into the deaths of Geoffrey Stewart Toase and Michael William Midgley. The inquest concluded on 2 August 2024, the conclusion reached was the short form conclusion of road traffic collision. 4 CIRCUMSTANCES OF THE DEATH On 3 August 2019, Mr Toase and Mr Midgley had arranged to spend the day riding their motocycles around Yorkshire, they were accompanied by two associates. At around 3:45pm, whilst travelling down the A166 Garrowby Hill, Mr Toase and Mr Midgley were involved in a head on collision with a car that was travelling from the opposite direction. That car was located wholly on the wrong side of the carriageway at the point at which it collided with Mr Toase and Mr Midgley. The driver of the car involved had a number of health-related conditions, including Type 1 Diabetes Mellitus, controlled by insulin injection. As a result of the diabetes, the driver of the car was required to reapply to the DVLA for a license every 3 years. At the time of the collision, the driver of the car was, on the balance of probability, suffering a hypoglycaemic episode which had compromised their ability to drive in an appropriate manner. Emergency services attended the collision scene swiftly, but the injuries suffered by both Mr Toase and Mr Midgley were such that nothing could be done to save them and they were both declared deceased at the incident scene. 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:– I heard evidence from two representatives of the DVLA at the inquest, including a DVLA employed Doctor. That Doctor gave evidence about their role in the medical review and decision to re-issue a license to the driver of the car involved in the fatal collision. That evidence gave rise to the following concerns: a) DVLA Doctors are not actively encouraged by the DVLA to request further information about an applicant’s medical history. b) The DVLA does not generally seek further information from any identified Speciality Doctor that may be involved in an applicant’s medical care and treatment; any requests for further information are usually directed to an applicant’s General Practitioner (GP). c) The forms sent to an applicant’s GP by the DVLA for the purpose of obtaining further information are largely tick box in nature and do not provide sufficient scope for the GP to provide more detailed information and this therefore does not allow for a full assessment to be conducted by the reviewing DVLA Doctor. d) Current DVLA working practices do not appear to allow DVLA Doctors to consider the interplay between different medical conditions an applicant may be suffering with. e) There is no apparent system in place to verify the accuracy of the information provided by an applicant within their medical self-declaration and that this information is generally accepted by the DVLA without question. f) The information provided by an applicant within their medical self-declaration is no longer sent to their GP by the DVLA alongside any request for further information, which limits any scope for the GP to identify if the information contained within a medical self-declaration is accurate. g) The DVLA Doctor involved in this case gave evidence that they felt “constrained” by the DVLA guidance, standards and working practices they are required to work to. h) The decisions made by DVLA Doctors when considering to re-issue a license are not subject to any form of audit procedure to ensure accuracy and consistency of decision-making. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) has 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 7 October 2024. I, the Coroner, may extend this period. Your response must contain details of action taken or proposed to be taken, setting out 2 the timetable for action. Otherwise, you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Family of Mr Toase and Mr Midgley; The driver of the car involved in the collision (via his legal representatives). I have also sent it to the following who may find it useful or of interest: Department for Transport 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. She may send a copy of this report to any person who she 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. Your response will also be shared with the above named Interested Persons. 9 Jessica Swift Assistant Coroner for the City of Kingston Upon Hull and the East Riding of Yorkshire 12 August 2024 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.
Jessica Swift Assistant Coroner City of Kingston Upon Hull & East Riding of Yorkshire Coroner’s Service The Guildhall Alfred Gelder Street Hull HU1 2AA Driver and Vehicle Licensing Agency Head of Strategy and Policy Longview Road Morriston Swansea SA6 7JL www.gov.uk/dvla Phone: Website: Your Ref: Our Ref: Date: 4 October 2024 Dear Jessica Swift, Thank you for your report of 12 August 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 inquest into the deaths of Geoffrey Stewart Toase and Michael William Midgley. I was very sorry to learn of the circumstances of Mr Toase and Mr Midgley’s deaths and I would like to express my sincere condolences to their families. I have considered your report and its recommendations carefully and I can assure you that the Driver and Vehicle Licensing Agency (DVLA) 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 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. Where a driving licence holder or applicant is suffering from a relevant or prospective disability, driving licences may be issued for a shorter period so that fitness to drive can be regularly reviewed. This helps to ensure that drivers continue to meet the required medical standards for driving. 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 medical panels provide the DVLA with expert medical advice about relevant medical conditions and their impact on driving and this feeds into the guidance provided. The guidance specific to diabetes is based on legislation and the advice provided by the Secretary of State for Transport’s Honorary Medical Advisory Panel on Driving and Diabetes Mellitus. The DVLA’s Drivers Medical team assesses all driving licence applications against the required standards. A medical questionnaire will be sent to the applicant in the first instance, asking them for more information about their condition. The applicant is also asked to provide authorisation for their healthcare professional to release information from their medical records to the DVLA. If further information is required, the DVLA will write directly to the relevant doctor and/or consultant managing the care and treatment of the applicant. This information is requested in the form of a questionnaire which is designed to be completed from medical records. Other registered healthcare professionals can also provide information to the DVLA where it is appropriate to do so. It is for the individual practice or hospital team to decide which appropriately registered healthcare professional is best placed to complete the questionnaire. Healthcare professionals can also contact the DVLA’s doctors directly if they have any concerns about their patient driving. Where more information is needed to establish fitness to drive, the DVLA may also request a medical examination and/or driving assessment. If the investigation finds that a driver has a relevant disability and cannot meet the medical standards, an existing licence will be revoked or an application refused. As outlined above, the DVLA can also issue a licence for a shorter period, typically between one and five years, allowing driving fitness to be more regularly monitored. Any applications referred to the DVLA’s doctors are usually more complex and often involve multiple medical conditions. A reviewing DVLA doctor wishing to carry out a full assessment can decide to write to the nominated healthcare professional to request any further information on the applicant’s health that they may consider relevant. The DVLA’s doctors take a holistic clinical view of each case and consider the impact that multiple medical conditions could have on fitness to drive in order to make a licensing decision. Particularly complex cases are sometimes referred to one of the expert members of the relevant medical panel to review and on occasion, cases may be discussed at the relevant medical panel meeting. All drivers have a legal responsibility to notify the DVLA of the onset or worsening of a relevant medical condition. It is an offence not to do so and drivers who fail to notify or make a false declaration can be fined up to £1,000. Drivers are encouraged to discuss any concerns about their ongoing driving fitness with their own healthcare professionals and to notify the DVLA where appropriate. The DVLA takes road safety very seriously and the UK’s roads are among the safest in the world. However, we are not complacent and our processes and policies are kept under review. Last year the DVLA issued a call for evidence to gather a wide range of views and evidence that may support future changes to the legal framework which underpins the current medical driver licensing process in Great Britain. The responses are currently being analysed. I am grateful to you for bringing your concerns to my attention. I can assure you that we take 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 Head of Strategy and Policy Find out about DVLA’s online services Visit: www.gov.uk/dvla
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