Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0076, written 7 Feb 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Feb 2025 |
|---|---|
| Reference | 2025-0076 |
| Deceased | Kenton Beasley |
| Coroner | Joseph Turner |
| Coroner area | West Sussex, Brighton and Hove |
| Category | Suicide (from 2015) |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive, the Driver and Vehicle Licensing Agency 1 CORONER I am Joseph TURNER, Area Coroner for the coroner area of West Sussex, Brighton and Hove 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 20 May 2024 I commenced an investigation into the death of Kenton Clete BEASLEY aged 54. The investigation concluded at the end of the inquest on 29 January 2025. The conclusion of the inquest was that: On 19th May 2024 Police were called to an address in Ashurst, Steyning by ambulance services where Kenton Beasley had sadly been found hanging. He was confirmed to be deceased at the scene and 3rd party involvement was ruled out. Notes indicating intent were found nearby; he had suffered with his mental and physical health for many years. 4 CIRCUMSTANCES OF THE DEATH I concluded that Mr Beasley had sadly taken his own life, due to a severe deterioration in his mental health. A significant contributing factor to that had been his inability to secure long term employment in the transport sector (he had been an HGV driver and transport manager). As a result he had resorted to underpaid and exploitative work, and had been forced to borrow money from friends, leading to a sense of shame and remorse. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) There was a lengthy and unnecessarily protracted period (8 Sep 23 – 12 Mar 24) in which Mr Beasley was attempting to renew his licence, which meant he was unable to secure professional HGV driver employment. The following individual events and consequent frustrations exacerbated Mr Beasley’s poor mental state: • DVLA wrote to his GP on 11 October 2023 and the GP surgery responded with the • • • information they believed was required on 18 October 2023. In a call from Mr Beasley to DVLA of 30 Nov 23 it was apparently confirmed that DVLA had all the necessary information and a ‘DVLA Doctor’ decision would be forthcoming soon. It then transpired that was not the case and more or different information was required. There was then a further delay in securing another GP appointment. Despite that second GP appointment being booked for 10 Jan 24, the DVLA questionnaire was never received by the GP. Regulation 28 – After Inquest Template Updated 15/10//2024 TG Despite a GP letter sent after that appointment confirming no concerns at Mr Beasley’s physical or mental health in terms of fitness to drive, this was rejected because it did not contain the information in questionnaire format. It appears to have taken the intervention of his then MP, Greg Clarke, to unlock the impasse There was a delay in booking a further GP appointment in Feb 24. The above was compounded by the fact that, even once his licence was renewed on 12 Mar 24, this was only for 12 months (to 11 Mar 25) - hence secure long-term employment was not offered. Mr Beasley was further distressed at the prospect of having to repeat the renewal process. In the period Sep 23-Mar 24, whilst verbally informed that he was able to drive under s.88 RTA 1988, the online checker was showing his licence to have expired, hence over 20 potential employers refused to hire him, notwithstanding his attempts to explain s.88. Mr Beasley had been unable to find out the reason for the delay, nor was he informed until late in the process what the original reason for removal of his licence had been. It eventually transpired that this arose due to a previous attempt at self-harm over twenty years earlier, since and despite which he had driven professionally for many years. It was never made clear why this was so. He was frequently unable to get through via the telephone advice service. Mr Beasley had attempted telephone contact on multiple occasions, but calls went unanswered and unattended. Even though an individual medical caseworker was assigned, Mr Beasley’s experience was that contact was still difficult and sporadic and he was constantly chasing rather than being kept informed. On some occasions when he made telephone contact he was in tears of frustration but no vulnerable customer protocol appears to have been followed, nor was there any attempt to expedite his application or provide a fuller explanation as to the delay. 6 ACTION SHOULD BE TAKEN In my opinion 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, namely by April 04, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons – wife (sister) (sister) I have also sent it to who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. Regulation 28 – After Inquest Template Updated 15/10//2024 TG I may also send a copy of your response to any person who I believe may find it useful or of interest. 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: 07/02/2025 Joseph TURNER Area Coroner for West Sussex, Brighton and Hove Regulation 28 – After Inquest Template Updated 15/10//2024 TG
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.
Eloise Palfrey West Sussex, Brighton & Hove Coroner Service Parkside Chart Way Horsham RH12 1XH Driver and Vehicle Licensing Agency Chief Executive Longview Road Morriston Swansea SA6 7JL fffffffff Date: 24 October 2025 Dear Ms Palfrey, Thank you for your letter of 10 February 2025 on behalf of the area coroner, Joseph Turner, to the former Chief Executive of the Driver and Vehicle Licensing Agency (DVLA), enclosing a Regulation 28 report following the inquest into the death of Mr Kenton Clete Beasley. I am responding as Chief Executive of the DVLA. Please accept my sincere apologies that a response was not sent sooner, this was unfortunately due to an oversight. I was very sorry to learn of the circumstances that led to Mr Beasley’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 we take such matters very seriously. The DVLA is responsible, on behalf of the Secretary of State for Transport, for ensuring that only those who can meet the required medical standards are issued with a driving licence. The law places a legal obligation on a driver to tell the DVLA if a new medical condition develops or if an existing medical condition gets worse. When notified about a medical condition, the DVLA must assess whether the individual can meet the required medical standards for driving. The medical standards are set out in the DVLA’s guidance: Assessing fitness to drive: a guide for medical professionals. The standards are based on legislative requirements and advice from the expert members of the Secretary of State for Transport’s Honorary Medical Advisory Panels. Reflecting the additional road safety risk, the medical standards are substantially higher for drivers of lorries and buses (Group 2) than for drivers of cars and motorcycles (Group 1), due to the size and weight of the vehicle and the length of time a professional driver typically spends at the wheel during the course of their occupation. Medical investigations can range from the consideration of information provided by the driver or applicant to a more detailed investigation which can include information provided by medical professionals, reports or examinations. If the driver is found to be suffering from a relevant or prospective disability this can result in their licence being revoked, a long-term driving licence (valid until the licence holder reaches the age of 70) being issued or a short period licence being issued, so that drivers whose ongoing health needs to be monitored can be regularly reviewed. These arrangements are designed to be balanced and proportionate for all drivers, balancing road safety and allowing individuals to continue to drive while they remain well. 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 doctor 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 a person’s fitness to drive. Although Mr Beasley’s medical fitness to drive was first considered by the DVLA in 2002, his ongoing ability to meet the required standards had been regularly reviewed since 2018 when he notified us of a deterioration in his health. Mr Beasley applied to renew his licence in September 2023 and the DVLA followed the usual process of obtaining information from his GP. Following a telephone call from Mr Beasley on 30 November 2023, a DVLA doctor reviewed the information received from his GP but we were unable to make a licensing decision based on the information received. Our doctor then asked for an examination to be undertaken by Mr Beasley’s GP and for copies of any clinically relevant letters from the previous three years. Mr Beasley telephoned the DVLA on 11 December 2023 and one of our doctors reviewed the case but was not able to progress it as Mr Beasley had not had the required examination with his GP. On 16 January 2024, the DVLA received a letter from Mr Beasley’s MP enclosing an email that he had sent to them. From this letter, it was evident that the GP had unfortunately not received our original request from 30 November 2023. On 25 January 2024, the DVLA’s original request from 30 November 2023 was re-sent to the GP. We received the completed examination report and supporting information from Mr Beasley’s GP on 21 February 2024 and a decision was made that he could have a one-year licence to drive both Group 1 and Group 2. However, when this licence was being produced it was discovered that the photograph, which must be renewed every 10 years, had expired so the actual licence could not be issued. We wrote to Mr Beasley on 22 February 2024 confirming that he would be issued with a licence when he renewed the photograph as required. This letter included the relevant forms to do this. Mr Beasley’s completed photocard renewal form was received at the DVLA on 8 March 2024 and his new licence issued on 11 March 2024. Having considered the timeline and the DVLA’s actions during the time in question, I recognise that it took some time to complete medical enquiries in Mr Beasley’s case. However, I am sure you will appreciate that we must be satisfied that those who are issued with a driving licence can meet the required health standards and I am content that the steps taken in this case were necessary and proportionate. We always endeavour to deal with customers professionally and sensitively and our communications are tailored to the needs of the individual where appropriate. On both occasions Mr Beasley telephoned the DVLA, the call handlers escalated his case to a DVLA doctor to be reviewed. Unfortunately, the most significant delay in processing Mr Beasley’s application was between November 2023 and January 2024 when the correspondence sent by the DVLA was not received by the GP. I am grateful to you for bringing your concerns to my attention and I hope this reply explains the position. Yours sincerely, Chief Executive Find out about DVLA’s online services Visit: www.gov.uk/dvla
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