Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2025-0031, written 30 Dec 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Dec 2024 |
|---|---|
| Reference | 2025-0031 |
| Deceased | Ian Harris |
| Coroner | John Ellery |
| Coroner area | Shropshire, Telford & Wrekin |
| 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.
JOHN ELLERY H.M. SENIOR CORONER FOR SHROPSHIRE, TELFORD & WREKIN AREA H.M. Coroner’s Service Guildhall Frankwell Quay Shrewsbury Shropshire SY3 8HB Coroner's Office: Email: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Driver and Vehicle Licensing Agency Head of Strategy and Policy Longview Road Morriston Swansea SA6 7JL 1 CORONER I am John Ellery, H.M. Senior Coroner, for the coroner area of Shropshire, Telford & Wrekin. 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 28 August 2024 I commenced an investigation into the death of Ian Paul HARRIS The investigation concluded at the end of the inquest on the 14 January 2025. The conclusion of the inquest was that the cause of death for the late Mr. Harris was due to a road traffic collision, including the medical cause of death of multiple traumatic injuries. 4 CIRCUMSTANCES OF THE DEATH On the 23 August 2024 the late Mr. Harris was driving a motor car on the A483 at Sweeney, Oswestry, Shropshire when it was in collision with an oncoming Heavy Goods Vehicle. Mr. Harris lost control of his vehicle and drifted across into the part of the oncoming vehicle due most likely to a medical condition. 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. • The medical condition of the deceased was known. He was known to have suffered blackouts and was also in addition to a car driving licence, the holder of an HGV licence. The deceased had informed his own GP that he was no longer driving and had notified DVLA. Neither appear to have been correct. Additionally, in order to renew his HGV licence, the deceased completed a form DP4 on the 19 August 2024 which was accompanied by a Medical examination report of the same date. • For whatever reason the deceased did not seek the medical report from his own GP, who would have known about his medical condition and who therefore would not have been able to support the application. Instead the deceased went to an independent GP and that GP completed the medical examination report based solely on what the deceased had told him (and without disclosing his medical condition) without having access to his medical records. • A statement from DVLA relating to this inquest tells us that a driver is recommended to have their own GP complete the examination and the D4 medical report but there is no obligation on drivers to see their own GP. • The concern is if a driver is prepared to provide inaccurate information to the DVLA there is nothing to prevent him doing the same to an independent GP who has no means of checking the accuracy of the information given to them. It then raises the question, what is the purpose and value of a driver being able to provide information to an independent GP who is not in a position to confirm its accuracy? • In my view, consideration should be given as to whether a report from the driver’s own GP should be required or, if not, an independent GP should be able to have access to the medical records themselves. • 4 days after completing the 2 forms the fatal accident occurred, with additional injury and loss to others. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 14 March 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. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the family of the deceased and the other interested persons; DAC Beachcroft LLP, OCL Solicitors & JMW Solicitors LLP. I have also sent it to West Merica Police Road Traffic Investigation Unit who 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 Send to: John Ellery H.M. Senior Coroner Shropshire, Telford & Wrekin 16 January 2025 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.
John Ellery H M Senior Coroner Shropshire, Telford & Wrekin Guildhall Frankwell Quay Shrewsbury Shropshire SY3 8HB Driver and Vehicle Licensing Agency Head of Strategy and Policy Longview Road Morriston Swansea SA6 7JL Email: Website: Our Ref: Your Ref: www.gov.uk/dvla 2 Date: 22 April 2025 Dear Mr Ellery Thank you for your report of 17 January 2025 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 Ian Paul Harris. Please accept my apologies for the delay in responding, this was due to the original letters and follow ups not being received by the relevant people. I was very sorry to learn of the circumstances of Mr Harris’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 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. Failure to do so is an offence. 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 called “Assessing fitness to drive: a guide for medical professionals”, which is available online at Assessing fitness to drive: a guide for medical professionals - GOV.UK. The guidance is based on legislation and advice from the Secretary of State for Transport’s Honorary Medical Advisory Panels. The medical panels provide the DVLA with expert medical advice about relevant medical conditions and their impact on driving. The guidance advises members of the medical profession on the medical standards that must be met by individuals to hold licences to drive various categories of vehicles. The medical 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. 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 it is an offence to make a false declaration. They driver must also submit a D4 medical report which must be completed following an examination which must be carried out by a doctor registered and licensed to practice by the General Medical Council in the UK or registered within the EU. The DVLA recommends that drivers ask their own GP to complete the D4 medical report as the GP will have access to medical records and could provide medical information that may be required. However, it is not a legal requirement for drivers to ask their own GP to carry out the examination and complete the D4 report. Making it a requirement for a driver’s own GP to carry out the examination and complete the form may have significant impacts on drivers and the transport industry in terms of time and costs. Also, GPs are not obliged to complete D4 medical reports as this is classed as private work and is not carried out on the NHS. We are aware of a number of private companies that offer this service to drivers and where this is the case, and as only GPs are likely to have access to the full medical records, the examining doctor must be satisfied that they have sufficient information about a driver’s medical history and should not sign a D4 report where there is any doubt. I can confirm that the information provided to the DVLA on Mr Harris’s D4 medical reports did not raise any health concerns which would have required the DVLA to conduct medical investigations into his fitness to drive. I am grateful to you for bringing your concerns to my attention. I can assure you that we are not complacent, we take road safety very seriously and are focused on ensuring that only those who are fit to drive are granted a licence. The DVLA will continue to work closely with all relevant stakeholders to raise awareness of the impact medical conditions may have on fitness to drive and continue to explore any potential options for further improvements. Yours sincerely Head of Strategy and Policy Find out about DVLA’s online services Visit: www.gov.uk/dvla
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