A summary of the Determination by Sheriff John Beckett QC, following a Fatal Accident Inquiry held at Glasgow into the deaths John Kerr Sweeney, Lorraine Sweeney, Erin Paula McQuade, Stephenie Catherine Tait, Gillian Margaret Ewing, and Jacqueline Morton.
A fatal accident inquiry into the death of six people who died when a bin lorry mounted a pavement in Glasgow city centre and collided with a number of pedestrians after the driver fainted at the wheel has found that there were reasonable precautions which could have been taken whereby the accident might have been avoided.
Sheriff John Beckett QC also made a total of 19 recommendations which, if followed, may reduce the chance of a recurrence of such an accident.
John and Lorraine Sweeney, Erin McQuade, Stephenie Tait, Gillian Ewing, and Jacqueline Morton, all died on 22 December 2014 as a result of sustaining multiple injuries after being struck by the bin lorry driven by Henry Clarke, who suffered an episode of neurocardiogenic syncope, causing him to temporarily lose consciousness so that he was unable to control the movement and direction of the vehicle.
The inquiry heard that in the course of his previous employment with First Bus, Mr Clarke had lost consciousness while sitting at the wheel of his bus at a bus stop, but the sheriff found that following the incident on 7 April 2010 he “deliberately misled” doctors as to the location and nature of what had happened to him.
“Mr Clarke deceived all three doctors in the hope that he would be able to return to work sooner rather than later so that he would not lose his job with First… None of the doctors who saw Mr Clarke advised him to notify DVLA of this event and he did not do so,” Sheriff Beckett said.
The Sheriff also found that Mr Clarke made inaccurate and untrue declarations in his online BUPA Health Declaration form, having successfully applied for a job as a minibus driver with Glasgow City Council (GCC) in December 2010, and that he lied on another BUPA Health Declaration form when he applied for promotion to the position of HGV driver in December 2011.
When he submitted an application for renewal of his group 2 licence in December 2011, Mr Clarke also “deliberately concealed relevant information from DVLA”, not least in relation to the incident of 7 April 2010, the Sheriff found.
He concluded that Mr Clarke “repeatedly lied in order to gain and retain jobs and licences”.
The Sheriff identified a total of eight reasonable precautions whereby the accident might have been avoided:
For Mr Clarke to have told the whole truth to Dr McKaig, Dr Lyons and Dr Langan about what had occurred on 7 April 2010.
For Dr Lyons to have advised Mr Clarke to notify DVLA given what he was told on 8 April following the incident on 7 April 2010.
For Dr Langan to have clarified with Dr Lyons the circumstances of Mr Clarke’s faint on 7 April 2010 before concluding that he had suffered a simple faint.
For Mr Clarke to have provided true and accurate information in completing an occupational health questionnaire in connection with his application for employment with Glasgow City Council in December 2010.
For First Glasgow to have provided a full, accurate and fair employment reference to Glasgow City Council in respect of Mr Clarke’s application for employment.
For Mr Clarke to have provided true and accurate information about his medical history on BUPA medical questionnaires in December 2011.
For Mr Clarke to have disclosed the incident of 7 April 2010 in DVLA form D47 and to Dr Willox in December 2011.
For Mr Clarke, after fainting at the wheel of his bus on 7 April 2010, to have refrained from continuing to drive buses and to have refrained from seeking further employment as a group 2 driver in the absence of his having told the truth to doctors and without having acted upon the advice which would have been forthcoming, and thereafter without making his relevant medical history known to Glasgow City Council to the extent required in its recruitment, appointment and promotion processes.
Sheriff Beckett’s 19 recommendations are as follows:
Doctors generally, and general practitioners in particular, should take steps to ensure that medical notes are made and kept in such a way as to maximise their ability to identify repeated episodes of loss of consciousness, loss of or altered awareness, in the case of patients who are or may become drivers.
When a doctor is advising an organisation employing a driver as to that driver’s fitness to drive following a medical incident whilst driving, that organisation should provide all available information about the incident to the doctor and the doctor should insist on having it prior to giving advice to the organisation and the driver.
Glasgow City Council, when employing a driver, should not allow employment to commence before references sought have been received.
Glasgow City Council should carry out an internal review of its employment processes with a view to ascertaining potential areas for improvement in relation to checking medical and sickness absence information provided by applicants, for example by having focussed health questions within reference requests for drivers and obtaining medical reports in relation to health related driving issues from applicants’ GPs.
Glasgow City Council should provide its refuse collection operators with some basic training to familiarise them with the steering and braking mechanisms of the vehicles in which they work.
Local Authorities and any other organisations which collect refuse, when sourcing and purchasing refuse collection vehicles which are large goods vehicles, should seek to have AEBS fitted to those vehicles wherever it is reasonably practicable to do so.
Local Authorities and any other organisations which collect refuse, and which currently have large goods vehicles without AEBS but to which AEBS could be retrofitted, should explore the possibility of retrofitting with the respective manufacturer.
Glasgow City Council should seek to identify routes between refuse collection points which, so far as is reasonably practicable, minimise the number of people who would be at risk should control be lost of a refuse collection lorry.
The potential for the presence of exceptional numbers of pedestrians at particular times should be taken account of as part of route risk assessment in refuse collection.
The Driver and Vehicle Licensing Agency (DVLA) should satisfy itself as to precisely what the categorisation is intended to mean and to achieve in the loss of consciousness/loss of or altered awareness section of the guidance contained in its “At a Glance Guide to the Current Medical Standards of Fitness to Drive” (“at a glance”).
Having done so, DVLA should then ensure that the meaning is made clear to those who apply the guidance in practice.
DVLA should consider if a flow chart could be provided to guide doctors through the categorisations contained in the loss of consciousness/loss of or altered awareness section of “at a glance”.
DVLA should consider whether the section of “at a glance” on loss of consciousness/loss of or altered awareness gives sufficient weight to the absence of prodrome [symptoms experienced in advance of an episode] given its significance for road safety.
DVLA should consider whether the section of “at a glance” on loss of consciousness/loss of or altered awareness gives sufficient weight to a medical event occurring at the wheel of a vehicle and its consequences.
DVLA should change its policy on notification from third parties so that relevant fitness to drive information from ostensibly reliable sources, such as the police, can be investigated whether or not it comes in written form.
DVLA should redouble its efforts to raise awareness of the implications of medical conditions for fitness to drive amongst the medical profession.
The Secretary of State for Transport should instigate a consultation on how best to ensure the completeness and accuracy of the information available to DVLA in making fitness to drive licensing decisions with a view to making legislative change.
Part of this exercise should involve considering increasing the penalties and altering the mode of prosecution for contravention of section 94 of the Road Traffic Act 1988.
The Secretary of State for Transport should instigate a consultation on whether it is appropriate that doctors should be given greater freedom, by the General Medical Council, or an obligation, by Parliament, to report fitness to drive concerns directly to DVLA.
The Sheriff further highlighted three matters for consideration:
Occupational health doctors performing D4 examinations and providing advice to employers on applicant drivers, and employers of drivers who facilitate their staff applying for renewal of group 2 licences without the involvement of GPs, should consider whether to require the applicant to sign a consent form permitting release by any GP of relevant medical records to the occupational health doctor.
DVLA and the Department for Transport should consider how best to increase public awareness of the impact of medical conditions on fitness to drive and the notification obligations in that regard.
DVLA, the Crown Prosecution Service and Crown Office and Procurator Fiscal Service should review whether there are policies in place which prevent or discourage prosecution for breaches of sections 94 and 174 of the Road Traffic Act 1988. If there are such policies, consideration should be given by DVLA and the prosecuting authorities to whether they are appropriate where the current fitness to drive regime is a self-reporting system which is vulnerable to the withholding and concealing of relevant information by applicants.
In making that last observation, the Sheriff explained (at para 476) that it was no part of his function in the inquiry to comment on prosecution decisions in particular cases, but he was referring to general evidence given in the inquiry to the effect that there have been no prosecutions of drivers who have failed to notify or have given false information to DVLA.
In his written Determination, Sheriff Beckett said: “It may well be that the single most useful outcome of this Inquiry would be to raise awareness of the dangers involved in driving if subject to a medical condition which could cause the driver to lose control of a vehicle. Media outlets reporting on the issuing of this Determination, would be performing a valuable service to the public if they include the following information in their reporting:
“‘Guidance, including a list of relevant conditions, can be found on the DVLA website: www.gov.uk/driving-medical-conditions. Drivers can contact DVLA if they are not sure what to do. They can consult their doctor if they are in doubt or if they are in need of advice’.”
The Sheriff also recorded his personal expression of sympathy to the families and friends of the six people who lost their lives.
He added: “The whole country was deeply shocked by what happened on 22 December 2014, but for the families of six people who died, the consequences extend beyond shock to the pain of permanent loss. As it neared its conclusion, the Inquiry heard some detail of just how important and valuable those six people were to their families, their friends and the wider community.
“It cannot have been easy to listen to the evidence, but many relatives of those who died steadfastly attended the Inquiry demonstrating their love, loyalty and commitment for those they have lost. I am aware that others chose to keep in touch with the progress of the Inquiry in other ways and I can understand why they would do that.
“Relatives in court managed to maintain composure, dignity and respect in circumstances which must at times have been very difficult indeed. I pay tribute to the way that they conducted themselves throughout the Inquiry.”