Source · Prevention of Future Deaths

James Coates

Ref: 2026-0167 Date: 19 Mar 2026 Coroner: Robert Cohen Area: Cumbria Responses identified: 1 / 1 View PDF

The current system relies inadequately on drivers self-reporting medical conditions to the DVLA, as doctors are not required to report, risking unreviewed licenses for seriously ill drivers.

Date 19 Mar 2026
56-day deadline 20 May 2026
Responses identified 1 of 1
Road (Highways Safety) related deaths

Coroner's concerns

AI summary
The current system relies inadequately on drivers self-reporting medical conditions to the DVLA, as doctors are not required to report, risking unreviewed licenses for seriously ill drivers.
View full coroner's concerns
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.

Responses

1 respondent
Department for Transport Central Government
PDF
Action Taken

The DVLA has delivered a series of educational sessions to healthcare professionals to encourage direct notification of medical conditions. The Department for Transport and DVLA are also reviewing self-declaration forms, raising public awareness of the duty to notify, and reinforcing GMC guidance for doctors. (AI summary)

View full response
[Page 1] 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.

[Page 2]
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 FURTHER ACTION 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. 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

[Page 3] 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.

Report sections

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
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.

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Report details

Reference
2026-0167
Date of report
19 March 2026
Coroner
Robert Cohen
Coroner area
Cumbria

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 20 May 2026.

Sent to

Department for Transport

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