Billy Warwick-Jones
10 Sept 2021 · Coroner Lydia Brown · West London
This report repeats 1 earlier warning, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. unwell driver with untreated urinary tract infection causing delirium
“The driver of the vehicle that caused this death was unwell with a urine tract infection. He had previously been treated for a urine tract infection. There is no evidence to suggest that he or his family were advised that he may demonstrate symptoms of confusion, agitation or delirium as a consequence of this and they would render him unfit to drive.”
2. lack of testing and instruction for older drivers regarding sudden confusion or delirium
“There appears to be insufficient testing and instruction of the older population with regards to road safety, which led to this tragic outcome. While there are guidelines for driving with dementia or mild cognitive impairment produced by the General Medical Council, there appears to be nothing specific to other sudden onset confusion or delirium which is a well recognised and common symptom in the elderly when physically unwell.”
3. need for more frequent testing and reporting duties
“Consideration should be given to more frequent, rigorous testing and to consider the duties that should be placed on the driver, their medical practitioners and also family members/carers to report changes in presentation or health to the Driver and Vehicle Licensing Agency.”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“The DVLA appears to have limited mechanisms for drivers to be formally medically reviewed for the purpose of being medically fit to drive.”
This report
“Consideration should be given to more frequent, rigorous testing and to consider the duties that should be placed on the driver, their medical practitioners and also family members/carers to report changes in presentation or health to the Driver and Vehicle Licensing Agency.”
Closely relatedConfidence 0.90 · high
This report
“Consideration should be given to more frequent, rigorous testing and to consider the duties that should be placed on the driver, their medical practitioners and also family members/carers to report changes in presentation or health to the Driver and Vehicle Licensing Agency.”
Later report
“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.”
Identical hazardConfidence 0.90 · high
This report
“Consideration should be given to more frequent, rigorous testing and to consider the duties that should be placed on the driver, their medical practitioners and also family members/carers to report changes in presentation or health to the Driver and Vehicle Licensing Agency.”
Later report
“Drivers may not self-report medical conditions due to a variety of reasons. This can be due to due to a lack of understanding, insight, or simply because someone has not explicitly told them what to do or how to do it”
Responses
2021-0305-Response-from-Department-for-Transport.pdf ↗· Department for Transport
Stated action
“the DVLA has published guidance for medical professionals which can be accessed on Gov.uk. The DVLA also provides a dedicated and confidential telephone line for health professionals to contact one of its doctors for case-specific advice or general guidance.”
2021-0305-Response-from-GMC.pdf ↗· Department for Transport
Stated action
“we have contacted the Royal College of General Practitioners (RCGP) to alert them to these issues, so they can consider how best to raise awareness of this particular case and its implications with their members.”