Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0642, written 20 Nov 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Nov 2024 |
|---|---|
| Reference | 2024-0642 |
| Deceased | Dorothy Nias |
| Coroner | Emma Hillson |
| Coroner area | Cornwall and the Isles of Scilly |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Information Classification: CONTROLLED Information Classification: CONTROLLED REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretary of State for Transport Great Minster House Horseferry Road London SW1P 4DR Chief Executive Driver and Vehicle Licensing Agency Longview Road Morriston Swansea 1 CORONER I am Ms Emma Hillson, Assistant Coroner for the coroner area of Cornwall and the Isles of Scilly. 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 9 November 2023, I commenced an investigation into the death of Dorothy Jennifer Nias aged 90. The investigation concluded at the end of the inquest on 20 November 2024. I recorded the cause of death as I a) Lower Respiratory Tract Infection I b) Multiple Injuries 1 Information Classification: CONTROLLED Information Classification: CONTROLLED 1 c) Road Traffic Collision II Frailty My conclusion as to the death was as follows: Road Traffic Collision 4 CIRCUMSTANCES OF THE DEATH On Wednesday 14 June 2023 Dorothy Nias was driving an automatic transmission vehicle owned by her since April 2017. She was driving downhill on a dual carriageway section of road on the A39 at Devoran, Truro approaching a roundabout with a speed restriction of 50mph. On approach she moved into lane 2 continuing at speed before mounting the roundabout, travelling across to the other side where she hit a lamp post causing her vehicle to rotate and land in the opposite direction of travel. The lamp post then fell but did not cause any further injury or incident. Miss Nias later stated that she had confused her brake and accelerator pedals and, in an attempt to prevent hitting the vehicles in front of her in lane 1, she moved to lane 2. There was no evidence of any vehicle defect. There were no other vehicles involved and no evidence of any other feature that caused or contributed to the collision. It was a dry and fine day. As a result of the collision she sustained multiple injuries and did not regain her mobility with a gradual deterioration in her condition. She died on 6 November 2023. 5 CORONER’S CONCERNS During the course of the investigation, the evidence has 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. It was clear from the evidence that there were concerns raised by family members to Miss Nias regarding her ability to continue to drive having had a number of minor incidents prior to this collision. Despite encouragement to use alternative means of transport she was described as independent and chose to continue. The accident was caused by confusion between her brake and accelerator pedals in an automatic transmission vehicle, allowing her speed to increase without restriction and as a result she was unable to negotiate the roundabout leading to the collision. At present there is no upper age limit for drivers. Drivers over 70 are required to apply for a new licence every 3 years and there is no requirement for there to be any form of medical check or assessment to confirm fitness to drive. The applicant must make a self-declaration. 2 Information Classification: CONTROLLED Information Classification: CONTROLLED Between the years of 2019 and 2023 there was a total of 221 fatal collisions recorded within the Devon and Cornwall Police force area. There were 3,145 serious collisions and 15,868 slight injury casualties. Of the above collisions, 28 fatal collisions had a contributory factor of a person aged 70 or over. 310 serious collisions and 1,058 slight injury collisions. Of the above 28 fatal collisions 14 deaths were people of 70 years or older. 132 people of the 310 serious collisions were 70 or older and 604 people from the slight injury collisions were of the same age bracket. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 15 January 2025. 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Miss Dorothy Nias’ family. I have also sent it to: Chief Constable of Devon and Cornwall Police – Forensic Collision Department I am also under a duty to send the Chief Coroner a copy of your response and all interested person who in my opinion should receive it. 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. 3 Information Classification: CONTROLLED Information Classification: CONTROLLED 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 20 November 2024 Signature Emma Hillson Assistant Coroner for Cornwall and Isles of Scilly 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.
Ms Emma Hillson HM Assistant Coroner Coroner for Cornwall & the Isles of Scilly H.M. Coroner’s Office Pydar House Pydar Street Truro Cornwall TR1 1XU fffffffff Driver and Vehicle Licensing Agency Interim Chief Executive Longview Road Morriston Swansea SA6 7JL Phone: Email: Website: 01792 382139 lynette.rose@dvla.gov.uk www.gov.uk/dvla Your Ref: Date: 14 January 2025 Dear Ms Hillson, Thank you for your letter of 22 November 2024 and your report made under the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, following the inquest you conducted into the death of Miss Dorothy Jennifer Nias. I also acknowledge your notification that the DVLA is an Interested Person in these proceedings. I was deeply saddened to hear about the circumstances surrounding Miss Nias’ passing and would like to extend my condolences to her family. My team has worked with Department of Transport colleagues on this matter and a full and substantive reply to your report, agreed on behalf of both Interested Persons, will be sent by the Secretary of State for Transport. Yours sincerely Interim Chief Executive Find out about DVLA’s online services Visit: www.gov.uk/dvla
From the Parliamentary Under Secretary of State Great Minster House 33 Horseferry Road London SW1P 4DR Tel: 0300 330 3000 E-Mail: lilian.greenwood@dft.gov.uk Web site: www.gov.uk/dft Our Ref: 14 January 2025 Emma Hillson HM Assistant Coroner Coroner for Cornwall & the Isles of Scilly H.M. Coroner’s Office Pydar House, Pydar Street Truro, Cornwall TR1 1XU Dear Ms Hillson, Thank you for your letter of 22 November 2024 and your report made under the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, following the inquest you conducted into the death of Miss Dorothy Jennifer Nias. I understand that this report has also been sent to the Chief Executive of the Driver and Vehicle Licensing Agency (DVLA) and this reply covers both approaches. I am grateful for the opportunity to consider and respond to the concerns you have raised. I was very sorry to learn of the circumstances that led to Miss Nias’s death and would like to express my sincere condolences to her family. I can assure you that my department takes road safety very seriously and ensuring only drivers who are medically fit to hold a driving licence is a priority. The current driver licensing arrangements take into account the risks that an individual poses to road safety and are designed to be fair and proportionate to all drivers who remain fit and competent to drive, regardless of age. All drivers must renew their licence at the age of 70 and at most every three years after that. As health can deteriorate with age, the driving licence renewal process from the age of 70 onwards provides a timely reminder to drivers to consider their health in the context of driving. When they renew their licence, applicants must make a legal declaration as to whether they are suffering from a ‘relevant’ or ‘prospective’ disability’ that is likely to cause their driving of a vehicle to be a source of danger to the public, or because of its progressive nature, may become such a disability in the future. Those who notify a medical condition will be investigated by the DVLA and a driving licence will only be issued if a driver can meet the appropriate medical standards for driving. In addition, existing licence holders of any age are required by law to notify the DVLA if they become aware that they are suffering from a relevant or prospective disability, or if such a disability has become more acute since the licence was issued. I can confirm that Miss Nias at no time reported any medical conditions to the DVLA. Miss Nias most recently applied for her driving licence to be renewed in 2020 and no medical conditions were declared at that time. In 2023, the DVLA carried out a call for evidence about driver licensing for people with medical conditions. The call for evidence sought views on the current legislative basis for assessing fitness to drive and what changes may be made. This was an important first step in gathering a wide range of views and evidence that may support future changes to the legal framework. The DVLA is considering the research and evidence provided and the need for any further research that may be required to inform potential changes to the legislative framework governing driver licensing for those with medical conditions. This will include the process of self-declaration. There are no plans for changes to the current driver licensing requirements while the analysis of the call for evidence responses continues. My department works closely with many organisations and local authorities that offer training and assessments for older drivers with the aim of helping them to keep driving safely. Mobility Centres conduct assessments for drivers, passengers and wheelchair or scooter users and help find solutions to enable more people to keep driving or retain mobility. Drivers can undergo a thorough assessment of their cognitive ability and driving, including assessment by an occupational therapist. The centre will advise on any adaptions that may help the individual to continue driving safely, or it may recommend that the individual ceases driving. I am very grateful for you bringing your concerns to my attention. Best wishes, MINISTER FOR THE FUTURE OF ROADS
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