Inquiry Into The Fatal Accidents And Sudden Deaths Inquiry (scotland) Act 1976 Into The Deaths Of John Kerr Sweeney, Lorraine Sweeney, Erin Paula Mcquade, Stephenie Catherine Tait, Gillian Margaret Ewing And Jacqueline Morton
| Jurisdiction | Scotland |
| Judge | Sheriff J Beckett QC |
| Neutral Citation | [2015] FAI 31 |
| Court | Fatal Accident Determinations (Scotland - United Kingdom) |
| Date | 07 December 2015 |
| Docket Number | B757/15 |
| Published date | 07 December 2015 |
SHERIFF COURT OF GLASGOW AND STRATHKELVIN
[2015] FAI 31
B757/15
Under the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976
DETERMINATION
By
Sheriff John Beckett QC
in the Fatal Accident Inquiry into the deaths of
John Kerr Sweeney
Lorraine Sweeney
Erin Paula McQuade
Stephenie Catherine Tait
Gillian Margaret Ewing
Jacqueline Morton
GLASGOW, 7 DECEMBER 2015
The Sheriff, having heard and considered all of the evidence, and the submissions of parties, finds and determines that:
1. In terms of section 6 (1) (a) of the Fatal Accidents and Sudden Deaths Inquiries (Scotland) Act 1976
1.1 John Kerr Sweeney, born 15 April 1946 and who resided in Dumbarton, died at Queen Street, Glasgow at 2.29pm on 22 December 2014.
1.2 Lorraine Sweeney, born 2 March 1945 and who resided in Dumbarton, died at Queen Street, Glasgow at 2.29pm on 22 December 2014.
1.3 Erin Paula McQuade, born 27 September 1996 and who resided in Dumbarton, died at Queen Street, Glasgow at 2.29pm on 22 December 2014.
1.4 Stephenie Catherine Tait, born 10 February 1985, who resided in Glasgow, died at Queen Street, Glasgow at 2.29pm on 22 December 2014.
1.5 Gillian Margaret Ewing, born 2 February 1962, who resided in Cyprus and Edinburgh, died at Queen Street, Glasgow at 2.29pm on 22 December 2014.
1.6 Jacqueline Morton, born 30 May 1963, who resided in Glasgow, died at Queen Street, Glasgow at 2.29pm on 22 December 2014.
2. In terms of section 6 (1) (b) of the Act
2.1 The cause of the death of John Kerr Sweeney was sustaining multiple injuries in a road traffic collision (pedestrian).
2.2 The cause of the death of Lorraine Sweeney was sustaining multiple injuries in a road traffic collision (pedestrian).
2.3 The cause of the death of Erin Paula McQuade was sustaining multiple injuries in a road traffic collision (pedestrian).
2.4 The cause of the death of Stephenie Catherine Tait was sustaining multiple injuries in a road traffic collision (pedestrian).
2.5 The cause of the death of Gillian Margaret Ewing was sustaining multiple injuries in a road traffic collision (pedestrian).
2.6 The cause of the death of Jacqueline Morton was sustaining multiple injuries in a road traffic collision (pedestrian).
2.7 The cause of the accident resulting in the deaths of John Kerr Sweeney, Lorraine Sweeney, Erin Paula McQuade, Stephenie Catherine Tait, Gillian Margaret Ewing and Jacqueline Morton was the loss of control of Glasgow City Council bin lorry registered number SB62 NKD by its driver, Henry Campbell Clarke, while he was driving northwards on Queen Street, as a result of which the lorry mounted the pavement on the west side of Queen Street and collided with a number of pedestrians.
2.8 Mr Clarke lost control of the lorry when he suffered an episode of neurocardiogenic syncope whereby he temporarily lost consciousness (he fainted) so that he was unable to control the movement and direction of the lorry.
3. In terms of section 6 (1) (c) of the Act
the reasonable precautions, if any, whereby the death and any accident resulting in the death might have been avoided;
3.1 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.
3.2 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.
3.3 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.
3.4 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.
3.5 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.
3.6 For Mr Clarke to have provided true and accurate information about his medical history on BUPA medical questionnaires in December 2011.
3.7 For Mr Clarke to have disclosed the incident of 7 April 2010 in DVLA form D47 and to Dr Willox in December 2011.
3.8 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.
4. Section 6 (1) (d) of the Act
the defects, if any, in any system of working which contributed to the death or any accident resulting in the death;
I make no findings under this section.
5. In terms of section 6 (1) (e) of the Act
any other facts which are relevant to the circumstances of the death.
In my narrative of facts I set out facts relevant to the circumstances of the deaths. Not all of the facts narrated have direct relevance, but they are relevant to the recommendations which I am making.
Recommendations
I make the following recommendations:
5.1 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.
5.2 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.
5.3 Glasgow City Council, when employing a driver, should not allow employment to commence before references sought have been received.
5.4 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.
5.5 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.
5.6 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.
5.7 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.
5.8 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.
5.9 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.
5.10 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”)
5.11 Having done so, DVLA should then ensure that the meaning is made clear to those who apply the guidance in practice.
5.12 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.”
5.13 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 given its significance for road safety.
5.14 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.
5.15 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.
5.16 DVLA should redouble its efforts to raise awareness of the implications of medical conditions for fitness to drive amongst the medical profession.
5.17 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.
5.18 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.
5.19 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.
Matters for consideration:
I suggest that the following matters ought to be given consideration by those concerned.
6.1 Occupational health doctors performing D4 examinations and providing advice to employers on applicant drivers, and...
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