Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0523, written 16 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Oct 2025 |
|---|---|
| Reference | 2025-0523 |
| Deceased | Martin Evans, Patricia Evans and Neil Errington |
| Coroner | Robert Cohen |
| Coroner area | Cumbria |
| 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.
Miss K J Gomersal LLB | Senior Coroner | Cumbria
Fairfield, Station Road, Cockermouth, Cumbria CA13 9PT
16 October 2025
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: The Secretary of State for Transport
1) CORONER
I am Robert Cohen for Cumbria
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3) INVESTIGATION and INQUEST
On 17 February 2023 I commenced an investigation into the death of Martin Gareth EVANS.
The investigation concluded at the end of the inquest . The conclusion of the inquest was a
narrative in the following terms:
Gareth Evans was 70 years old. On 13th February 2023 he was a front seat passenger in a
vehicle driven by his wife. They were travelling on Stainburn Bypass, Great Clifton. Another
vehicle collided with Mr and Mrs Evans' car. The collision was caused by the driver of the
other vehicle having an episode of syncope. He had had previous similar episodes. In the
collision Mr Evans sustained devastating injuries which caused his death. His death was
confirmed at the roadside at approximately 20:18.
The medical cause of death was:
1a Multiple injuries
1b
1c
II
Also on 17th February 2023 I commenced an investigation into the death of Patricia Mary
EVANS. The investigation concluded at the end of the inquest . The conclusion of the inquest
was a narrative in the following terms:
Pat Evans was 68 years old. On 13th February 2023 she was driving a vehicle, accompanied
by her husband. They were travelling on Stainburn Bypass, Great Clifton. Another vehicle
collided with Mr and Mrs Evans’ car. The collision was caused by the driver of the other
vehicle having an episode of syncope. He had had previous similar episodes. In the collision
Mrs Evans sustained devastating injuries which caused her death. Her death was confirmed
at the roadside at 20:18.
The medical cause of death was:
1a Multiple injuries
1b
1c
II
On 19 May 2022 I commenced an investigation into the death of Neil ERRINGTON. The
investigation concluded at the end of the inquest . The conclusion of the inquest was a
narrative in the following terms:
Neil Errington was 50 years old. On 2nd May 2022 Mr Errington was driving. Another vehicle
collided with Mr Errington's car. This was caused by the driver of the other vehicle having a
seizure. In the collision Mr Errington sustained devastating head injuries. He was transported
to the Royal Victoria Infirmary, Newcastle Upon Tyne. Mr Errington had emergency surgery
was but remained in critical condition. A decision was taken to withdraw Mr Errington's life
support and he died, in hospital, at 2:18 on 12th May 2022.
The medical cause of death was:
1a Blunt Head Injury
1b
1c
II
I elected to hear these three inquests in succession because they raised common issues.
This Regulation 28 report addresses those issues.
4) CIRCUMSTANCES OF THE DEATH
Each of these three deaths occurred when a driver had a medical episode which caused
them to lose control of their vehicle. In each case the drivers had been aware of their
propensity to experience such episodes. In each case the drivers had been advised not to
drive. Each of the drivers was subsequently convicted of causing death by dangerous
driving.
In the course of the three inquests I heard evidence from doctors and officials at the DVLA on
the manner in which drivers who have medical impairments are licensed.
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. –
(1) The DVLA witnesses confirmed to me that the scheme created by section 94 of the Road
Traffic Act 1988 requires that 'licence holders' notify the DVLA if they suffer from a relevant or
prospective disability. In turn the DVLA place the emphasis on the expectation that licence
holders will themselves honestly inform the DVLA of their condition. Although medical
professionals can inform the DVLA of a patient's unfitness to drive, the DVLA proceed on the
basis that notifications will not usually come via this route.
In each of these three inquests the drivers responsible for the collisions had repeatedly lied to
the DVLA about their fitness to drive. I was told that this was 'disappointing' but not wholly
surprising.
I am aware that HM Senior Coroner for Lancashire and Blackburn with Darwen addressed a
PFD report to you (ref: 2025-0196) on April 24th 2025 in which a death had been caused by a
driver who, by reason of their condition, lacked the necessary insight to self-refer to the
DVLA.
Each of these cases illustrate the problem with expecting that those who have medical
impairments should self-refer to the DVLA. There will be cases where, despite repeated
advice not to drive, a person is unable or unwilling to inform the DVLA of their situation. My
concern is that this risks future deaths. I consider that whilst self-referral remains the default
position, more drivers will be able to continue driving whilst endangering lawful road users.
6) ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you the Secretary
of State for Transport 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 12th December 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 Interested Persons.
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.
16 October 2025
Signature
Robert Cohen HM Assistant Coroner for Cumbria
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.
Mr Robert Cohen H M Senior Coroner for Cumbria Fairfield Station Road Cockermouth Cumbria CA13 9PT fffffffff Driver and Vehicle Licensing Agency Director of Strategy, Policy and Communications Strategy, Policy and Communications Directorate Longview Road Morriston Swansea SA6 7JL Your Ref: Our Ref: Date: 10 December 2025 Dear Mr Cohen Thank you for your report of 16 October 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 inquests you conducted into the deaths of Neil Errington, Martin Gareth Evans and Patricia Mary Evans. I was very sorry to learn of the tragic circumstances surrounding the deaths of Mr Errington and Mr and Mrs Evans and would like to express my sincere condolences to their families. 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 system is 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 their ability to meet the medical standards for 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 current driver licensing system relies on self-declaration, supported by medical evidence where it is available. While I understand the concern that decisions may be made based on incomplete medical records, there are practical difficulties in requiring doctors to confirm whether a patient’s records are or appear to be complete. The way in which medical records are recorded and held is not uniform across the devolved health services in GB and in the various health regions. While medical records are transferred when an individual changes GP practice, how soon the new practice has access to those records can vary. Clinicians also then typically only have access to records within their own practice or local NHS systems and may be unable to verify whether a patient has received treatment elsewhere although there are often summaries of clinical information where a patient has received hospital treatment elsewhere. This will be particularly difficult if the patient has been treated abroad unless this has been disclosed by the patient and formally documented by the GP in medical records. Even where medical records appear complete, they may still lack relevant information if the individual has not recently consulted their GP or reported symptoms. Therefore, no meaningful action could be taken based solely on the absence of medical information. However, the DVLA will review the content of the medical questionnaires it sends to clinicians to consider whether additional prompts or questions could be included which may identify inconsistencies or gaps in the medical records. The DVLA’s medical standards are outlined in the guidance Assessing Fitness to Drive, which is informed by legislation and expert advice from the Secretary of State for Transport’s Honorary Medical Advisory Panels. The guidance is used to help determine whether individuals with medical conditions should hold a driving licence. The guidance is primarily aimed at healthcare professionals to guide them about how their patient’s condition may affect their ability to drive safely and when the DVLA must be notified. The guidance covers a wide range of medical issues and a key part involves evaluating the likelihood of a person experiencing a sudden disabling even, which could impair their ability to control a vehicle. To manage this risk, the DVLA uses risk thresholds to guide decisions about when it is safe for someone to resume driving. For car and motorcycle (Group 1) drivers, if the acceptable risk of such an event is assessed to be lower than 20% over the next 12 months, the individual may be issued with a driving licence after six months. If the risk exceeds 20%, a longer period of not driving, typically 12 months, is required. The risk threshold is stricter for drivers of buses and lorries at less than 2% per year. This enables the DVLA to make an informed and proportionate decision about whether the individual can safely return to driving. Individuals with conditions that could cause a sudden loss of control, like blackouts or loss of consciousness, must not drive. When the DVLA revokes a driving licence on such grounds, the decision can be reviewed if new medical information becomes available. This evidence can be provided in a report from a relevant medical specialist and should include their confidence in the diagnosis, whether any episodes occurred while driving, the presence of warning signs, known triggers and an opinion on the likelihood of recurrence, which the DVLA will assess against its risk thresholds. I note the concerns you have expressed that current guidance may not provide sufficient clarity on how clinicians should estimate this risk. In response to your report, we will review the guidance to consider if it can be made clearer, more consistent and better aligned with clinical practice. This will include exploring the development of structured tools to support risk assessment and clearer expectations for specialist reports. I am grateful to you for bringing your concerns to my attention. I can assure you that we take road safety very seriously and we are focused on ensuring that only those who are fit to drive are granted a licence to do so. Road safety measures have not been reviewed for more than a decade, and the Department for Transport is developing a Road Safety Strategy which will include a broad range of polices and will set out more details in due course. The DVLA will continue to work closely with clinicians to raise awareness of the impact medical conditions may have on fitness to drive and continue to explore any potential options for further improvements. Detailed timelines have yet to be finalised, as reviewing existing processes and policy development in such an important area is inherently complex and involves a wide range of stakeholders. However, I can assure you that this work is being treated as a priority. Yours sincerely Director of Strategy, Policy and Communications 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 Web site: www.gov.uk/dft 9 December 2025 Mr Robert Cohen HM Assistant Coroner for Cumbria Fairfield Station Road Cockermouth Cumbria CA13 9PT Dear Mr Cohen 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 Neil Errington, Gareth Evans and Patricia Mary Evans. I am replying as the Minister responsible for road safety and I 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 surrounding the deaths of Mr Errington and Mr and Mrs Evans and I extend my sincere condolences to their families. I have considered your report and the concerns you have raised very carefully. Your report raises concerns about the effectiveness and safety of the self-declaration process for notifying medical conditions that may affect driving and the potential for drivers to not notify the Driver and Vehicle Licensing Agency (DVLA) of a medical condition. All drivers must ensure they meet the required medical standards for driving at all times and are legally required to tell the DVLA about the onset or worsening of a condition that could affect this. While the legal responsibility to notify the DVLA rests with the driver, the DVLA will also act on information provided by the police, healthcare professionals, friends, relatives or neighbours and such notifications are treated as a high priority. When a notification is received the DVLA will initiate an investigation. This may include gathering information from the driver, obtaining information from their doctor, commissioning a medical examination or requiring a driving assessment. Only drivers who can meet the required medical standards will be issued with a licence. Healthcare professionals play a crucial role in the licensing process and should advise patients on how their condition or treatment may impact their fitness to drive and when the patient is required to inform the DVLA. To support healthcare professionals, the DVLA publishes guidance called ‘Assessing Fitness to Drive – a guide for medical professionals’, which is available on GOV.UK. The DVLA also offers a dedicated email service through which healthcare professionals can seek case-specific or general advice from the DVLA’s team of doctors. While healthcare professionals are not legally obliged to notify the DVLA about a patient who has a medical condition that may affect their fitness to drive, guidance from the relevant regulatory bodies advises medical professionals that they can notify the DVLA of a patient’s medical condition in the interests of the safety of the patient and the wider public. The General Medical Council (GMC) provides guidance to doctors regarding circumstances where it is justifiable to notify the DVLA of a patient’s medical condition. The guidance advises that where doctors are aware that an individual has not understood their advice or has chosen to continue driving despite their advice, a notification to the DVLA in the public interest does not breach patient confidentiality. 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 recognise that some drivers wilfully ignore medical advice and will not notify the DVLA and continue driving. This can have potentially devastating consequences. Officials will carry out a comprehensive review of the self-declaration forms and consider ways to further raise awareness of the importance of notifying conditions to the DVLA and the potential far reaching consequences of failing to do so. Officials will also continue to engage with healthcare professionals and their regulatory bodies to reinforce the importance of notifying the DVLA if their patient lacks the capacity or willingness to inform the DVLA of their condition themselves. My department also recognises that the volume and complexity of driving licence applications for those with one or more medical conditions is increasing, reflecting both an ageing population and a strong desire among drivers to maintain the independence that driving provides. We are reviewing the evidence already gathered alongside the findings from recent inquests. As part of this work consideration will be given to the process of self- declaration. Thank you for raising these important issues. 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. Road safety measures have not been reviewed for over a decade and my department is developing a Road Safety Strategy which will include a broad range of polices and will set out more details in due course. I am sure you will appreciate that policy development in such an important area as this is inherently complex and involves a wide range of stakeholders. I can assure you this work is being treated as a priority and we are committed to delivering meaningful improvements to road safety and to preventing further avoidable tragedies. Best wishes, MINISTER FOR THE FUTURE OF ROAD
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