Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0167, written 19 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Mar 2026 |
|---|---|
| Reference | 2026-0167 |
| Deceased | James Coates |
| Coroner | Robert Cohen |
| Coroner area | Cumbria |
| 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.
Miss K J Gomersal LLB | Senior Coroner | Cumbria
HM Coroner's Courts, Allerdale House, Workington, Cumbria CA14 3YJ
Tel: 0300 303 3180 | Email: hmcoroner@cumbria.gov.uk | Web: hmcoronercumbria.org.uk
Case Ref: 12890429
24 March 2026
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 HM Assistant Coroner 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 29 August 2024 an investigation commenced into the death of James Scott COATES.
The investigation concluded at the end of the inquest. The conclusion of the inquest was:
Road Traffic Collision
The medical cause of death was:
1a Burns
1b Road Traffic Collision
1c
II
4) CIRCUMSTANCES OF THE DEATH
I recorded the following matters in relation to Mr Coates' death:
Mr Coates was 39 years old. He lived in Tyne and Wear and worked in Barrow-in-Furness.
On 20th August 2024, at approximately 22:28, Mr Coates was driving his car along Park
Road in Barrow. It was dark. Park Road is a rural road, without overhead lighting. It is subject
to the national speed limit. Mr Coates drove toward a left-hand bend. 75% of the Cats Eye
reflectors leading into that bend were not functioning. As Mr Coates entered the bend his
speed was in the region of 90 mph. He was not able to maintain full control of the vehicle at
that speed, and it crossed into the oncoming carriageway, where a head on collision with
another vehicle occurred. In that collision Mr Coates sustained unsurvivable injuries; his
death was confirmed at the roadside at 23:20. Mr Coates had also used cannabis prior to the
collision, and it is likely that this had an adverse impact on his ability to control the vehicle.
An additional feature of the evidence was that Mr Coates suffered from epilepsy and was
used cannabis every day. According to the evidence I heard, both his epilepsy and cannabis
use should have been reported to the DVLA but neither was. In fact, Mr Coates medical
records confirmed that several months after he was diagnosed with epilepsy he accepted to
clinicians that he had not informed the DVLA of his condition. He was reminded to do so but
did not follow that advice. It appears that he was never even advised to tell the DVLA of his
cannabis use. For the avoidance of doubt, I did not find that epilepsy caused or contributed to
the collision.
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. –
I previously sent you a Prevention of Future Deaths Report (in relation to the deaths of Neil
Errington and Gareth and Patricia Evans) highlighting my concern that the expectation that
drivers would self-report their conditions (which arises as a matter of legislation) was not
being followed.
The evidence in this inquest provides further cause for concern. Once again, the evidence is
that a person with potentially significant conditions never notified the DVLA, and that his
doctors did not draw it to the DVLA's attention because legislation places the onus on licence
holders and not their doctors. I remain of the view that this is insufficiently robust to ensure
that drivers with serious conditions are not having their licenses properly reviewed.
6) ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you the Secretary
of State 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 20th May 2026. 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 each interested person.
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.
24 March 2026
Signature
Robert Cohen HM Assistant Coroner for
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.
RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 Please do not include any living persons’ names in this document, in accordance with the Chief Coroner’s PFD Publication Policy (2026). THIS RESPONSE IS BEING SENT TO: Mr Robert Cohen The Senior Coroner, Mr Robert Cohen for the Coroner Area Cumbria in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following an inquest into the death of Mr Scott Coates that concluded on 1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, , Minister for Local Transport provides this response within 56 days (plus any extension granted) of the date of the Report to Prevent Future Deaths. 2. DATE OF RESPONSE TBC 3. CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified in the report are as follows: The reliability and safety of the current self-declaration system and the risk that some drivers may not inform the Driver and Vehicle Licensing Agency (DVLA) of relevant medical conditions that may affect their fitness to drive. 3. DETAILS OF ACTION TAKEN, how has the concern been addressed. The actions being taken by my Department and the DVLA to address the issues raised in this Prevention of Future Deaths Report include reviewing the self declaration forms for notifying the DVLA of a medical condition, raising public awareness of the legal duty to notify medical conditions to the DVLA and the consequences of not doing so and reinforcing the existing General Medical Council guidance which advises doctors when to notify the DVLA where a patient continues to drive despite being advised to notify the DVLA. ‑ I can confirm that the DVLA is engaging with healthcare professionals and has delivered a series of educational sessions to encourage clinicians to notify the DVLA directly where a patient is unable or unwilling to do so themselves. Further engagement with regulatory bodies, clinical networks and healthcare professionals will continue to better understand any concerns or issues that may be preventing notifications being made to the DVLA by doctors and driving licence holders. 4. DETAILS OF PROPOSED Please note that any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. FURTHER ACTION The work to review and improve the self-declaration forms and associated processes is ongoing and timescales will continue to be considered alongside wider organisational changes already underway. Driver licensing for those with medical conditions is a highly complex area involving an extensive range of conditions, medical standards, legal and operational requirements and wide a range of stakeholders. It is important that any changes are considered and introduced carefully to ensure they are safe, workable and sustainable. SIGNATURE MP, MINISTER FOR LOCAL TRANSPORT.
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