Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0214, written 2 May 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 May 2025 |
|---|---|
| Reference | 2025-0214 |
| Deceased | Rosemary MacAndrew |
| Coroner | Beth Brown |
| Coroner area | Nottingham and Nottinghamshire |
| 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: 1. Secretary of State for Transport 1 CORONER I am Beth Brown, Assistant Coroner for the coroner area of Nottingham and Nottinghamshire. 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 4 November 2024 an inquest was opened into the death of Rosemary MacAndrew, aged 64. The inquest concluded on 28 April 2025. I made a determination at inquest that she died as a result of a road traffic collision. 4 CIRCUMSTANCES OF THE DEATH Rosemary MacAndrew died on 5 July 2024 at Waitrose, Newark, Nottinghamshire, as a result of chest injuries, sustained in a Road Traffic Collision, when she was a pedestrian in the carpark of the store. She was struck by a motor car that was reversing at speed and became trapped beneath the vehicle. The motor vehicle was being driven by an 89- year-old male who was not able to account for the manner in which the vehicle was driven. It was suspected by paramedics who attended the scene that the driver may have had a neurological event whilst driving the vehicle. In the two years preceding the collision his mobility had reduced, he reported back and leg pains to his GP, and in October 2023 he presented to the local Emergency Department with neurological symptoms, suspected to be as a result of a TIA. In the months preceding the collision he had seen his GP with itching and pains in his legs. He died eight months after the collision of dementia and gangrene in both feet. As the guidance currently stands, none of the above conditions present prior to the collision were notifiable to the DVLA pursuant to the ‘Assessing Fitness To Drive: a Guide for Medical Professionals’. The above conditions would have been self-reportable by the driver if he considered they could affect his driving safety. No such self-referral had been made. 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. 1 The MATTERS OF CONCERN are as follows. – The UK population is of increasing age and the number of older drivers is increasing rapidly. The current system for vehicle licensing relies largely upon the self-awareness of a driver and their willingness and\or ability to self-report medical conditions to the DVLA. I am concerned that older drivers with vulnerabilities, including age, decreasing mobility and cognitive decline pose a risk of future deaths through compromised driving ability thereby creating a risk of deaths in the future. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 01 July 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: 1. Rosemary MacAndrew’s family. 2. The Driver’s GP I have sent a copy of the report to the Nottinghamshire Police Serious Collision Investigation Unit as I believe they may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response and all interested persons who, in my opinion, should receive it. 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. 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. 9 Dated: 2 May 2025 Beth Brown HM Assistant Coroner For Nottingham and Nottinghamshire 2
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.
Beth Brown HM Assistant Coroner Nottingham and Nottinghamshire 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: 1 July 2025 Dear Beth, 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 inquest you conducted into the death of Rosemary MacAndrew. 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 Rosemary MacAndrew’s death and would like to express my sincere condolences to her family. I have considered your report and its recommendations very carefully. Your report raises concerns about the risks to road safety posed by the current driver licensing system which is based on drivers self-declaring medical conditions. The current driver licensing arrangements are underpinned by the Road Traffic Act 1988, which makes it a legal requirement on all drivers to inform the Driver and Vehicle Licensing Agency (DVLA) if at any time they develop a medical condition that may affect safe driving. The current arrangements balance the risks that an individual poses to road safety with personal mobility and are designed to be fair and proportionate to all drivers who remain fit and competent to drive, regardless of their age. When drivers reach the age of 70, they must renew their licence and then do so at most every three years thereafter. The driving licence renewal process provides a timely reminder to individuals to consider their health in the context of driving. Drivers are encouraged to discuss any concerns about their driving fitness with their own medical professionals. The DVLA is responsible for ensuring that drivers with medical conditions meet the required medical standards of fitness to drive and will investigate those who notify a medical condition. This investigation involves obtaining information from the driver and or their doctor or healthcare professional or asking the driver to attend a medical examination or driving assessment. The law states that the DVLA must have reasonable grounds to initiate medical investigations into anyone holding or applying for a driving licence. In practice, this means that an applicant or driver must notify the DVLA of a medical condition before an assessment of their medical fitness to drive can begin. However, the DVLA can also investigate where a notification of a health condition has been made by a third party, for example the police, healthcare professionals, family or friends. This recognises that there may be occasions where a driver lacks insight into their ongoing ability to drive safely. Healthcare professionals play a vitally important role in the driver licensing process by providing advice to their patients about the implications of their condition, the effect of any treatment or medication they are receiving and when they must inform the DVLA. To support healthcare professionals, the DVLA publishes guidance called “Assessing fitness to drive: a guide for medical professionals”. The DVLA also provides a dedicated email service for healthcare professionals to contact one of its doctors for either case-specific advice or general guidance. While healthcare professionals are not legally obliged to notify the DVLA about a patient who may be medically unfit to drive, guidance issued by the regulatory bodies does state that they should consider the safety of their patient and the public and notify the DVLA in certain circumstances. This aims to ensure that individuals who are potentially unfit to drive or lack self- awareness into their condition are identified and appropriately assessed by the DVLA. The General Medical Council provides guidance to doctors regarding circumstances where it is justifiable to breach patient confidentiality. This guidance advises that doctors do not have to seek a patient’s consent to contact the DVLA if they do not feel it is “safe and practicable to do so”. The guidance also states that doctors should still “make every reasonable effort” to persuade patients to contact the DVLA voluntarily. To ensure that the DVLA is notified about drivers who have conditions that may impair their insight into their health and driving abilities, my Department will continue to engage with healthcare professionals and their regulatory bodies to understand if there may be circumstances where doctors and health care professionals could be encouraged or supported in notifying the DVLA when appropriate. 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 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 may become more prevalent. Following the Sheriff’s determinations from a Fatal Accident Inquiry (FAI) into the death of in Scotland, the DVLA has initiated discussions with the Secretary of State for Transport’s Honorary Medical Advisory Panel on driving and psychiatric disorders to consider the challenges that impairment of cognitive function presents in the context of the medical licensing process. The panel met on 8 May 2025 to discuss the expert papers and recommendations made at the FAI. The DVLA will continue to work closely with the panel to consider this important issue. The Government takes road safety very seriously and we are focused on ensuring that only those who are fit and safe to drive hold a valid driving licence. My Department will continue to work with healthcare professionals, driving organisations and regulatory bodies to enhance the safety of our roads and ensure that those who pose a risk to road safety are appropriately identified and assessed. The Department is also developing its Road Safety Strategy and will set out more details in due course. Best wishes, MINISTER FOR THE FUTURE OF ROADS
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