1. Driver and Vehicle Licensing Agency (DVLA)

I am Jessica Swift, Assistant Coroner for the City of Kingston Upon Hull and the East Riding of Yorkshire. 

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. 

On 8 August 2019 an inquest was opened into the deaths of Geoffrey Stewart Toase and Michael William Midgley. 
The inquest concluded on 2 August 2024, the conclusion reached was the short form conclusion of road traffic collision.   

On 3 August 2019, Mr Toase and Mr Midgley had arranged to spend the day riding their motorcycles around Yorkshire, they were accompanied by two associates.
  
At around 3:45pm, whilst travelling down the A166 Garrowby Hill, Mr Toase and Mr Midgley were involved in a head on collision with a car that was travelling from the opposite direction. That car was located wholly on the wrong side of the carriageway at the point at which it collided with Mr Toase and Mr Midgley.  

The driver of the car involved had a number of health-related conditions, including Type 1 Diabetes Mellitus, controlled by insulin injection. As a result of the diabetes, the driver of the car was required to reapply to the DVLA for a license every 3 years. 
 
At the time of the collision, the driver of the car was, on the balance of probability, suffering a hypoglycaemic episode which had compromised their ability to drive in an appropriate manner.  
Emergency services attended the collision scene swiftly, but the injuries suffered by both Mr Toase and Mr Midgley were such that nothing could be done to save them and they were both declared deceased at the incident scene.    

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 heard evidence from two representatives of the DVLA at the inquest, including a DVLA employed Doctor. That Doctor gave evidence about their role in the medical review and decision to re-issue a license to the driver of the car involved in the fatal collision. That evidence gave rise to the following concerns:  
a) DVLA Doctors are not actively encouraged by the DVLA to request further information about an applicant’s medical history.  
b) The  DVLA  does  not  generally  seek  further  information  from  any  identified Speciality  Doctor  that  may  be  involved  in  an  applicant’s  medical  care  and treatment;  any  requests  for  further  information  are  usually  directed  to  an applicant’s General Practitioner (GP). 
c) The forms sent to an applicant’s GP by the DVLA for the purpose of obtaining further information are largely tick box in nature and do not provide sufficient scope for the GP to provide more detailed information and this therefore does not allow for a full assessment to be conducted by the reviewing DVLA Doctor.  
d) Current  DVLA  working  practices  do  not  appear  to  allow  DVLA  Doctors  to consider the interplay between different medical conditions an applicant may be suffering with.  
e) There is no apparent system in place to verify the accuracy of the information provided  by  an  applicant  within  their  medical  self-declaration  and  that  this information is generally accepted by the DVLA without question. 
f) The information provided by an applicant within their medical self-declaration is no  longer sent to their GP by  the DVLA alongside any request for further information, which limits any scope for the GP to identify if the information contained within a medical self-declaration is accurate.  
g) The  DVLA  Doctor   involved  in  this  case  gave  evidence  that  they  felt “constrained” by the DVLA guidance, standards and working practices they are required to work to.  
h) The decisions made by DVLA Doctors when considering to re-issue a license are  not  subject  to  any  form  of  audit  procedure  to  ensure  accuracy  and consistency of decision-making. 

In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) has the power to take such action. 

You are under a duty to respond to this report within 56 days of the date of this report, namely by 7 October 2024. I, the Coroner, may extend this 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.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:  

Family of Mr Toase and Mr Midgley; 
The driver of the car involved in the collision (via his legal representatives).
 
I have also sent it to the following who may find it useful or of interest:

Department for Transport
 
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. 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. 
Your response will also be shared with the above named Interested Persons.