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Coroner’s reportPrevention of future deaths · 2025-0572

“I heard evidence in this inquest concerning the requirement of drivers' to self-notify…”

Dated 12 Nov 2025, from the coroner for Birmingham and Solihull. Sent to 4 organisations or people.

A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.

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Replies were due by 7 Jan 2026. A reply may have been sent and not yet published.

Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.

  1. Report dated12 Nov 2025
  2. Deadline7 Jan 2026
  3. Published on judiciary.uk14 Nov 2025
  4. Today23 Oct 2026

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Responses from each recipient

Responses from each recipient
Sent toResponse
Department for TransportResponse publishedPublished on judiciary.uk in November 2025.
DVLADeadline passedNo response published on judiciary.uk so far. The 56-day deadline was 7 Jan 2026. A reply may have been sent and not yet published.
General Medical CouncilNamed in the report as “The General Medical Council”Response publishedPublished on judiciary.uk in November 2025.
General Optical CouncilNamed in the report as “The General Optical Council”Response publishedPublished on judiciary.uk in November 2025.

The coroner’s concerns

– 1. I heard evidence in this inquest concerning the requirement of drivers' to self-notify the DVLA of any medical conditions that may interfere with their driving. The evidence in this inquest was that the driver of the vehicle that caused the fatal road traffic collision - due to an unexpected medical event at the wheel - had a number of health issues. As it could not be proven which medical condition caused him to suffer the medical event, it could not be said that he should (or even could) have regulated his driving accordingly. 2. Furthermore, the driver’s medical records were ambiguous as to whether he had been explicitly told to notify the DVLA of his health conditions. 3. The evidence was that the driver played "fast and loose" with the DVLA but that he had not committed any crime. 4. The issue of drivers failing to self-refer their health issues to the DVLA for assessment is a serious and persisting issue. From the Courts and Tribunals Judiciary website for Prevention of Future Deaths (https://www.judiciary.uk/?s=&pfd_report_type=&post_type=pfd&order=relevance), I am aware of at least 6 PFD reports being issued in the past 3 years (References - Ref: 20250523 (3 deaths); Ref: 2025-0196; Ref: 2024-0507; Ref: 2025-0031; Ref: 2025-0214; Ref: 2024-0127). 5. Following scrutiny of those reports, it is apparent that the DVLA and Department of Transport previously called for evidence in 2023 seeking views on the current legislative basis for establishing whether a person was medically fit to drive. At that time, officials were considering that evidence and considering policy options as part of the government’s road safety strategy which was being developed and the details would be provided, “in due course”. 6. Two years later from that call for evidence, and still no national strategy has been announced. I understand that in August 2025 His Majesty's Government announced that a new Road Safety Strategy would be published in the Autumn of 2025. However, we are now in the depths of November and there is no sign currently of any Road Safety Strategy being published. 7. I am aware that the DVLA publishes guidance on GOV.UK called “Assessing fitness to drive: a guide for medical professionals” to support healthcare professionals (https://www.gov.uk/government/publications/assessing-fitness-to-drive-a-guide-formedical-professionals). What is unclear, however, is whether a) that guidance is well known amongst medical professionals, and b) whether that process is an effective mechanism for doctors to report patients with health issues, as there does not appear to be any published statistical evidence on the issue. 8. I am also aware that The General Medical Council (GMC) and the General Optical Council (GOC) offer guidance about notifying DVLA when the person cannot or will not exercise their own legal duty to do so. Again, it is unclear whether a) that guidance is well known amongst medical professionals, and b) whether that process is an effective mechanism for doctors to report patients with health issues, as there does not appear to be any published statistical evidence on the issue. 9. 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. There are then those who are reckless and knowingly avoid notifying the DVLA of a health condition when explicitly told to do so - either through arrogance, pride or through fear of losing employment. The end result is the same: people are dying needlessly on our roads due to people who, legally, should not be on our roads. 10. There is a risk of future deaths occurring where drivers do not self-refer their conditions to the DVLA, or where medical professionals do not report those health issues to protect the wider public. 11. It is not for I, as Coroner, to tell you what action should be taken. However, it is part of my judicial function to bring this matter to your attention so that you – individually and collectively – can consider what steps can and should be taken to reduce the risk of deaths occurring in the future.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source
judiciary.uk, Prevention of Future Deaths reports, 2025-0572
Added to Minute Book
8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0

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