Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0197, written 17 Apr 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Apr 2025 |
|---|---|
| Reference | 2025-0197 |
| Deceased | Peter Westwell, Mary Cunningham, Grace Foulds, Anne Ferguson |
| Coroner | James Adeley |
| Coroner area | Lancashire and Blackburn with Darwen |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO OF STATE FOR TRANSPORT 1 CORONER , SECRETARY I am Dr James Adeley, HM Senior Coroner for the coroner area of Lancashire and Blackburn with Darwen 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 24 March 2022 I commenced an investigation into the deaths of: Mary Frances Cunningham, aged 79 years whose investigation concluded at the end of the inquest on 17 April 2025. The cause of death was multiple injuries and the conclusion of the inquest was Road Traffic Collision; Grace Foulds, aged 85 years whose investigation concluded at the end of the inquest on 17 April 2025. The cause of death was multiple injuries and the conclusion of the inquest was Road Traffic Collision; Anne Elizabeth Ferguson aged 75 years whose investigation concluded at the end of the inquest on 17 April 2025. The cause of death was multiple injuries and the conclusion of the inquest was Road Traffic Collision; and Peter Anthony Westwell aged 80 years whose investigation concluded at the end of the inquest on 17 April 2025. The cause of death was spinal column chest injuries and the conclusion of the inquest was Road Traffic Collision; 4 CIRCUMSTANCES OF THE DEATHS The four fatalities shared the same feature that the driver's sight was well below the standard required to drive a car with each driver had obtained a driving licence from the DVLA. Anne Ferguson was killed by a driver who was unable to see was driving due to severe bilateral cataracts that had developed over the previous 8 to 12 years. During this time the driver had never sought an optical assessment. A month before the collision, the driver attended a visual assessment with an optometrist and informed her that he did not drive. Consequently, the optometrist did not tell the driver that he should immediately stop driving. The driver drove every day for the next month before colliding with Anne Ferguson causing her death. The driver input necessary to avoid the collision was minimal. There were no other contributory factors to the collision other than the driver's very poor eyesight. The driver had repeatedly failed to self-report his condition, of which he was aware, on several licence applications to the DVLA. The DVLA, at the time of the collision, still licensed the driver to drive a car. Mary Cunningham and Grace Foulds died in a double fatal due to a driver who was unable to see due to severe bilateral keratoconus. In 2019 the driver was informed that his sight did not meet the legal standards for driving, after which the driver got into his car and drove home. The driver underwent corneal grafting to his right eye after which, never having been informed by any clinician involved in his care that his vision met the legal standards for driving, he self-assessed that his vision in his right eye was now sufficient for him to drive. It would have been obvious that the driver that the vision in his right eye remained worse than his left eye, which even with the contact lens was insufficient to meet the legal standards for driving. There were no other contributory factors to the collision other than the driver's very poor eyesight. The driver had repeatedly failed to self-report his condition, of which he was aware, as he considered that his obligation was only advisory rather than mandatory. The DVLA, at the time of the collision, still licensed the driver to drive a car. Peter Westwell was killed by a driver who had a long history of severe bilateral eye disease. In 1999 the driver was only able to reach the visual standard required to drive using glasses. However, in all subsequent police interviews and statements he always denied the need for glasses. In 2003 the driver had a right retinal detachment resulting in the loss of almost all detailed vision in the central field. In 2013 the driver developed wet macular degeneration in his left eye resulting in significant compromise to his central field of vision and at this time this vision did not meet the legal standards for driving. The driver was told on two separate occasions that he should not drive before he began to inform optometrists that he was a non-driver. The driver had repeatedly failed to self- report his condition, of which he was aware, on multiple licence applications to the DVLA. The DVLA, at the time of the collision, still licensed the driver to drive a car. 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 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: 1. The licensing system for class I drivers is the laxest in Europe for the following reasons: (cid:127) The UK is only one of five European countries to use a licence plate test (see below) for visual acuity testing (cid:127) The UK and is only one of three countries to rely upon self-reporting of visual conditions affecting the ability to drive (cid:127) The UK is the only country to issue a driving licence without any visual check for a continuous period of time that may be as much as 53 years A driver's visual acuity is only checked at the time of the driving test by reading a number plate at 20 m. A driver may then hold a licence until 70 years of age during which time there is no check that they meet the visual legal standards to drive a car. During this time a driver is required to self-monitor and self-refer visual conditions to the DVLA. During this time a variety of ocular diseases may develop, some of which are silent and of which the driver of which the driver may not be aware that that they are suffering from a disease that would compromise the driver's ability to comply with the legal standards to drive a car. 2. At 70 years of age and every three years thereafter, a driver self-reports on a licence application that they can read a number plate 20 m and have not been informed that their vision falls beneath the legal limit for driving. Over the age of 70 the incidence of diseases that affect the eye rises sharply and not all can be detected by the driver unless they undergo an ophthalmic assessment. There is no question of the renewal application as to whether or not the driver's visual fields are sufficient to meet the legal standards for driving. Visual fields can only be assessed by an ophthalmic assessment using specialist equipment. 3. Self-reporting of visual conditions permits drivers to lie about their current driving status to those performing an ophthalmic assessment and avoid warnings not to drive. Drivers may also admit they drive but then ignore instructions not to drive and fail to notify the DVLA. In such circumstances, when the DVLA becomes aware, the DVLA does not refer such cases to the police for prosecution and consequently drivers can lie without sanction. All three drivers in this case either lied concerning the driving status wilfully misinterpreted questions to avoid driving advice not to drive, adopted fictions of their visual performance to allow them to drive, prioritised their own enjoyment and independence over the lives of other road users and repeatedly obtained licences from the DVLA due to a defective self-reporting system that does not confirm the driver meets the visual legal standards for driving and is open to abuse. 4. Self-reporting of visual conditions affecting the driver's ability to meet the legal standards required to drive a car is unfit for purpose the following reasons: (cid:127) Surveys of optometrists in the UK have reported that over half of the optometrists reported seeing a patient in the last month who, despite being told their vision was beneath the driving standard, indicated they would continue to drive. This would suggest approximately 56,000 drivers a year undergo a sight test confirms they do not reach the visual legal threshold to drive a car but will continue to do to so: (cid:127) An independent survey of the public produced the following results: (cid:127) 19% have had a collision either as a driver, passenger, pedestrian or cyclist with a motorist whom they believed had poor vision 29% of motorists said they would continue to drive despite knowing their vision is below the legal standard 33% of motorists would continue to drive as normal if visual test showed their vision had fallen beneath the legal standard 26% said they are concerned about someone they know driving despite having poor vision (cid:127) (cid:127) (cid:127) (cid:127) (cid:127) Doctor/optometrist-patient medical confidentiality is an entrenched aspect of UK medical practice and is only rarely breached and this only occurs after protracted patient negotiations during which time a driver continues to drive their car. Unless there were to be some form of requirement for a driver's visual assessment that is believed the legal limit to be communicated to the DVLA, this safeguard by which the DVLA may be notified of a driver continue to drive against advice produces only a minimal number of cases each year. This is already known to the DVLA. (cid:127) Between 2019 and 2023 there has been a collapse of drivers self- reporting the four major conditions of diabetic retinopathy, cataracts, glaucoma and macular degeneration resulting in a 70 to 76% reduction in notifications. As the diseases are unchanged, the patient cohort is unchanged and the DVLA have not altered their processes, the DVLA have no explanation for this substantial reduction in driver self-reporting over such a short period. This was not attributed to Covid during the inquest. In view of the importance of retaining a licence, the ease of licence renewal by either online or postal methods and the length of time since the Covid epidemic, Covid would be an unlikely explanation of the collapse drivers who may have a degree of mild cognitive impairment or dementia may not be sufficiently self-aware to recognise visual deficiencies that compromise their ability to drive. (cid:127) (cid:127) The UK's population is ageing with the number of drivers over the age of 70 increasing by approximately 250,000 drivers each year. As the changes to the eye and diseases that affect the eye predominantly affect those over 70, any existing problems will worsen in the medium term. 5. The 20 m licence plate test is a rough and ready roadside assessment of visual acuity. The 20 m licence plate test is unfit to accurately assess visual acuity to confirm that a driver meets the legal standard and makes no assessment of visual fields that are also a requirement. The European Council of Optometry and Optics in 2011 stated in respect of the 20 m licence plate test "this practice is unacceptable as the licence plate is not performed under control conditions and the results are not directly comparable with the underlying European standards which specify an assessment of visual acuity" and that member states using the licence plate test "should do more to improve their system of addressing drivers' vision". The UK took no action during the nine years it remained a member of the European Union. The Association of Optometrists and the College of, optometrists both expressed the views of their organisation that the licence plate test was a poor proxy for a sight test both in terms of the information provided and the fact that it provided no visual health check to detect undiagnosed ocular and general diseases that may affect a driver's ability to drive. The Secretary of State for Transport already supports the drivers over the age of 60 should take advantage of the free NHS sight tests to ensure that their vision meets the legal standards for driving. However, research shows that drivers, for unspecified reasons, are not taking up these tests. 6. The latest government figures record 1624 fatalities, 28,087 life changing serious injuries and 103,266 slight injuries accounting for 60,000 hospital admissions a year. Due to the Stats 19 data recording parameters, it is likely this is a substantial underestimate the actual number of road collisions from the National Travel Survey being approximately 600,000 and from the Department of Work and Pensions Compensation Recovery Unit 446,976. Data collection is further complicated by historical IT issues between constabularies resulting in a non- standardised reporting software. According to the Department for Transport uncorrected defective eyesight only occurred in 56 of the 15,355 road deaths recorded between January 2014 and January 2023, or 0.224% of all deaths. The evidence given at the inquest inferred that this figure was a significant underestimate of eyesight as a contributory factor in collisions for the following reasons: (cid:127) (cid:127) (cid:127) other factors such as speed, wearing a seatbelt, using a mobile device or drink/drugs are easily ascertainable whereas defective vision is more difficult to detect, there must be a suspicion that it relates to an offence before a test can be made and the Stats 19 contributory factors usually are completed shortly after a collision when the full circumstances, including sight, may not be known the College of Optometrists stated that the visual aspects of collisions are difficult to disentangle from other contributory factors different constabularies approach to roadside testing is substantial such that over the same 10 year period Essex Constabulary remove the licences from 350 drivers was Bedfordshire, Cambridgeshire, Cleveland, Derbyshire, Durham, Gloucestershire, Gwent, Hertfordshire, Leicestershire, Staffordshire, Warwickshire and West Murcia constabularies between them only remove the licences of 112 drivers the number of prosecutions for causing death by dangerous driving due to eyesight issues extrapolated from 34 constabularies give a figure of 95 deaths as opposed to the official figure of 56 for the same period (cid:127) Estimates of drivers continuing to drive with vision that does not meet the legal standards from safety initiatives and older driver safety experts range from 1.7% to 5%. This equates to an active driving population site does not meet the legal limit of between 720,000 and 2.1 million licence holders. Lincolnshire, Yorkshire, South (cid:127) Any assurances given by the Secretary of State should bear in mind the limitations of the government statistics in their reply. 7. During the course of the inquest the following observations were offered by various bodies regarding mandatory site testing: (cid:127) (cid:127) The view of the National Police Chief's Council was expressed by as that it was "much better not to let the risk Commander (drivers with defective sight) onto the road and better for the police if the risk wasn't there in the first place". Commander went on to express the view of the NPCC that they would "fully support mandatory sight tests, but this was a decision for those in government" the College of Optometrists clinical adviser, explained that self-monitoring and self-referral was open to abuse by drivers who lie, the 20 m number plate test was both inadequate as a visual assessment of acuity and visual fields and that given the importance of the independence conferred by car driving there was considerable pressure on drivers to minimise any perceived visual deficits (cid:127) the Association of Optometrists explained that the current system was flawed and the DVLA should require proof of eyesight before granting a driving licence. During the course of the inquest, it also became apparent that the Secretary of state for Transport has been forwarded to reports by the Older Drivers' Task Force in 2016 and 2021 recommending mandatory site testing. The Older Drivers' Task Force is a body partly funded by the Department for Transport. The above information is provided to assist the Secretary of State for Transport and is not a recommendation by the Coroner to the Secretary of State. 8. The Secretary of State, prior to the commencement of the inquest, confirmed in writing that she endorsed the comments of previous Secretaries set out in previous replies to Prevent Future Deaths reports. In response to PFD report concerning Louis Thorold, a five-year-old crushed to death by a driver with cognitive impairment, the then Secretary of State replied "I must stress that one road death is one too many and the Driver and Vehicle Licensing Agency (DVLA) is focused on ensuring that only those who meet the required medical standards are granted a licence". For the reasons given above, the current system for "ensuring" drivers meet the visual legal standards is ineffective, unsafe and unfit to meet the needs of society as evidenced by the deaths of Mary Cunningham, Grace Foulds, and Ferguson and Peter Westwell where the DVLA continued to provide licences to drivers who had failed to meet the legal sight requirements. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and 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 12 June 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 and how such action has been audited to ensure any changes are effective. 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: the families of Mary Cunningham, Grace Foulds, Anne Ferguson and Peter Westwell NPCC the drivers who cause the above deaths I have also sent a copy to the following organisations who may find it useful or of interest: Secretary of State for Health concerning the pressure that road collisions placed on the NHS Road safety charity's including RoadPeace, RoSPA and Brake 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] 17th April 2025 [SIGNED BY CORONER]
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.
From the Parliamentary Under Secretary of State Great Minster House 33 Horseferry Road London SW1P 4DR Tel: 0300 330 3000 E-Mail: Web site: www.gov.uk/dft Our Ref: 10 June 2025 Dr James Adeley HM Senior Coroner Lancashire and Blackburn with Darwen 2 Faraday Court Faraday Drive Fulwood Preston PR2 9NB Dear Dr Adeley, Thank you for your report made under the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, following the inquests you conducted into the deaths of Mary Frances Cunningham, Grace Foulds, Anne Elizabeth Ferguson and Peter Anthony Westwell. I am responding as Minister for the Future of Roads, and am grateful for the opportunity to consider and respond to the concerns you have raised. I was very sorry to learn of the tragic circumstances that led to these deaths and would like to express my sincere condolences to the families of those involved. I have considered your report and its recommendations very carefully. Your report raises concerns regarding the effectiveness and safety of the system of self-declaration for ensuring that drivers meet the necessary vision standards required for safe driving. All drivers have an ongoing legal responsibility to ensure that they meet the vision standards for driving, wearing glasses or corrective lenses if needed. Drivers must declare their medical fitness when they apply for and renew a driving licence and must notify the DVLA of any medical condition that may affect their fitness to drive at any time during the validity of their licence. Drivers are also encouraged to regularly check their own vision by reading a number plate from a distance of 20 metres. The number plate test is currently the baseline assessment for visual acuity as it is straightforward, cost effective and easily administered, making it a practical and functional assessment of vision in real time. Its simplicity provides drivers with a good indication that they can meet the required visual acuity standards for driving and scan information accurately from a distance. I acknowledge that there are concerns about the efficacy of the number plate test and the DVLA will continue to work closely with the Secretary of State for Transport’s Honorary Medical Advisory Panel on visual disorders and driving to discuss the points raised in your report and consider possible alternatives. Driving with uncorrected vision can have far-reaching consequences that affect personal safety, motor insurance status and the safety of other road users. It is therefore essential for drivers to prioritise regular eye examinations and take corrective measures to ensure they meet the necessary vision standards for driving. The Government fully supports the NHS’s recommendation that adults have their eyes tested every two years. As you are aware, it is a legal requirement for all drivers to inform the DVLA if at any time they are no longer able to meet the vision standards for driving or they develop a medical condition that may affect visual field. The DVLA is legally required to investigate such notifications and arrange for a formal vision test where necessary, to establish whether the eyesight standards can be met. Eye healthcare professionals, including optometrists and ophthalmologists, play a vital role by advising their patients whether they meet the vision standards for safe driving and when they need to inform the DVLA about an eye condition. To support healthcare professionals, the DVLA publishes guidance on GOV.UK called “Assessing fitness to drive: a guide for medical professionals”. The DVLA also provides a dedicated email for healthcare professionals to contact one of its doctors for either case-specific advice or general guidance. Notifications received from healthcare professionals are treated as a priority. The DVLA also investigates notifications from others who may have concerns, including the police, relatives and friends. This recognises that there may be occasions where a driver lacks awareness of the potential effect of their vision on their ability to drive safely. Police officers also play an essential role in maintaining road safety by conducting roadside number plate reading tests when they suspect a driver has impaired vision. As you are aware, the DVLA also prioritises notifications from the police. Where the DVLA is informed by the police that a driver has failed to read a number plate from 20 metres at the roadside, immediate action is taken to revoke the driving licence. Although the self-declaration process for notifying medical conditions to the DVLA is intended to empower drivers to take personal responsibility for their fitness to drive, I understand that there may be circumstances where drivers may not fully recognise the deterioration in their vision or the implications that a visual impairment may have on their driving abilities. Officials will conduct a comprehensive review of the self-declaration forms and the customer facing information to ensure it communicates the importance of regular eyesight testing as clearly as possible. The review will also look to highlight the importance of notifying conditions to the DVLA and the potential far reaching consequences of failing to meet the vision standards. As you are aware, the drivers involved in these tragic incidents wilfully chose to ignore the advice of their healthcare professionals, did not inform the DVLA and continued to drive despite being aware that their vision did not meet the required standards for driving. While eye healthcare professionals are not legally obliged to notify the DVLA about a patient who is no longer able to meet the vision standards for driving, they are advised by their regulatory body, the General Optical Council, in its guidance to consider the safety of their patient and the public and notify the DVLA without the patient’s consent if it is in the public interest to do so. However, I recognise that this may be challenging where there are concerns about confidentiality and the ethical implications of disclosing sensitive health information without a patient’s consent and where drivers dishonestly declare themselves to be non-drivers. I also acknowledge that this often involves protracted negotiations between healthcare professionals and their patients before a notification is made to the DVLA. My Department will work with eye healthcare professionals and their regulatory bodies to identify and aim to address any concerns and issues that may be preventing them from notifying the DVLA when it is in the public interest to do so. My officials have advised that the STATS19 system for collecting and reporting road traffic collision data is unable to capture detailed information that identifies the causes of collisions. Many vision-related conditions may not manifest in ways that are immediately apparent following a road traffic collision. My Department will work with the Standing Committee on Road Injury Collision Statistics (SCRICS) to review and improve the collection and collation of STATS19 data. Officials will also continue to engage with police forces to develop a more standardised approach to roadside eyesight testing at the scene of the accident or shortly after to ensure that all relevant data is captured and reported accurately. DVLA officials are also considering why there has been a reduction of notification of diabetic retinopathy, cataracts, glaucoma and macular degeneration between 2019 and 2023, with a view to understanding the cause and identifying what action may need to be taken. 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 establishing whether an individual is medically fit to drive and what may be improved and changed. The DVLA is considering the research and evidence provided and the additional research needed. The DVLA will also consider the evidence presented during the inquest hearing, to inform potential changes to the law that governs driver licensing for those with medical conditions. Work in this area is ongoing and includes consideration of the process of self-declaration and the challenges posed by an ageing population where certain conditions, including vision conditions, may become more prevalent. Consideration is also being given to policy options as part of the Government’s Road Safety Strategy, which is being developed and the details of which will be provided in due course. Thank you for raising these important issues. I recognise that good vision is crucial for safe driving. I can assure you that the Government takes road safety very seriously and we are focused on ensuring that only those who are fit and safe to drive are issued with a driving licence. My Department will continue to work closely with the police, healthcare professionals, driving organisations and regulatory bodies to enhance the safety of our roads and ensure that those who do not meet the medical standards for driving are appropriately identified, managed and assessed. Best wishes, MINISTER FOR THE FUTURE OF ROADS
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