Louis Thorold

PFD Report All Responded Ref: 2023-0311
Date of Report 18 August 2023
Coroner Simon Milburn
Response Deadline est. 2 November 2023
All 2 responses received · Deadline: 2 Nov 2023
Coroner's Concerns (AI summary)
The self-certification process for driving licence renewal for drivers aged 70+, without independent medical scrutiny, risks allowing individuals with undiagnosed conditions like dementia to continue driving.
View full coroner's concerns
During the inquest I heard evidence that drivers who reach 70 years of age and are therefore required to reapply for their driving licence at that point(and thereafter every 3 years) do so via an online self-certification process and that there is no need for independent medical scrutiny or input unless there is an issue which is specifically drawn to the attention of a medical practitioner. In this case one of the drivers involved in the road traffic collision was driving with undiagnosed dementia which effected their cognitive ability to perceive hazards on the road.
Responses
Cambridge County Council Local Authority / Fire Service
12 Oct 2023
Action Planned
Cambridgeshire County Council implemented a reduced speed limit of 40mph and improvements including a pedestrian crossing and enhanced walking/cycling provision on the A10. The County Council and the Cambridgeshire and Peterborough Combined Authority are developing an Outline Business Case to implement strategic enhancements of the A10 corridor, with route safety as a key consideration; due to report in Summer 2024. (AI summary)
View full response
Dear Mr Milburn,

Response to Regulation 28 Report regarding Louis Stephen James THOROLD Cambridgeshire County Council has considered the Regulation 28 report regarding the tragic circumstances surrounding the death of Louis Thorold and, in particular, the questions regarding the Council’s ‘Settlement Policy’. Your letter questioned whether the policy had been correctly applied (i.e., whether the location in question should be set at 30mph). Since the collision, the County Council, in collaboration with Cambridgeshire Constabulary and developers Urban and Civic, have implemented a reduced speed limit in this area to 40mph, and has overseen the delivery of improvements associated with the Waterbeach New Town development, including a pedestrian crossing, and enhanced walking and cycling provision on the A10. A separate note was provided to the inquest outlining these changes. Implementing Safe Speeds is a key pillar of the approach taken by the Cambridgeshire and Peterborough Vision Zero Partnership, of which the County Council is a member. The Partnership has developed a Speed Strategy, which alongside wider guidance and policies, assists in identifying the most appropriate speed for any given route1. This letter sets out the rationale for the current 40mph speed limit at Car Dyke Road. This rationale is informed by national and local policy and guidance. However, the County Council and the Cambridgeshire and Peterborough Combined Authority (CPCA) are presently developing an Outline Business Case to implement strategic enhancements of the A10 corridor. Route safety is a key consideration in the development of the business case. In July 2023 the officer Project Board confirmed that the following four packages should be developed within the Outline Business Case:

1 Vision Zero Speed Strategy

Date: 12th October 2023

Chief Executive’s Office Box ALC2609 New Shire Hall Emery Crescent Enterprise Campus Alconbury Weald Huntingdon PE28 4YE

PRIVATE AND CONFIDENTIAL Mr S. Milburn Cambridgeshire and Peterborough Coroner Service Lawrence Court Princes Street Huntingdon PE29 3PA

Chief Executive

• Package 2b: Online dualling between the A14 and Waterbeach
• Package 3b: Dualling between A14 and Ely (without the Waterbeach Bypass)
• Package 4: Offline dualling between the A14 and Waterbeach with a single carriageway route to Ely
• Package 7: focuses on public transport, and includes the Stretham Park and Ride

Currently, the packages are only at concept stage, so the specific improvements are yet to be designed. However, by managing both the strategic and local movements through the A10 corridor using proposed infrastructure including dualling, junction improvements and active travel measures the packages are being designed to improve road safety. For example, by addressing the current congestion issues shunt type collisions and those associated with turning movements will be addressed. The current timeline is that the Outline Business Case, which will include the results of stakeholder engagement and two periods of statutory consultation, will be completed in summer 2024 with a specific package of improvements identified for further development subject to further funding. Speed / Settlement Policy The Regulation 28 report refers to the County Council speed policy, with respect to settlements. This policy states:

The County Council will work towards the introduction of a 30mph speed limit in the developed parts of all settlements in the County where appropriate in relation to the nature of the street frontage, activity, environment, and density. Where suitable and affordable, complementary features may be required to encourage drivers to travel at an appropriate speed. Each location will be considered on its own merit. For speed limit purposes the following definitions will apply: I. A settlement will be ‘20 properties fronting onto a length of public highway over a distance of 600m’.

II. The extent of a settlement will be ‘The point at which full frontage development begins’, or ‘at the first property fronting a road entering a settlement, on which there is at least 3 properties/100 metre length of road, prior to the point at which full frontage development begins’.

First, it is important to note that speeds are not informed by a single, blanket policy. The latest policy with regards to settlements, as set out above, does highlight that there are other considerations, primarily relating to the nature of the route in terms of physical characteristics and demand. The route at Car Dyke Road does not present as a logical 30mph, as it takes the form of a primary road, and the surrounding land use context is not significantly developed. Whilst we recognise the number of frontages over the extended length of the route, it cannot be considered as ‘full frontage’ development in this location. The properties are set back from the road, in some cases not visible from the road and they are well spaced out. This section does not, therefore, meet the criteria to be classed as a settlement.

Chief Executive

National Speed Guidance The County Council’s speed limit policy is based upon the DfT Circular 1/13, Setting Local Speed Limits and gives characteristics of a road together with the appropriate speed limit. The table below sets out the DfT Speed limits for single carriageway roads with a predominant motor traffic flow function, such as the A10.

There are safety implications with installing an artificially low speed limit. Speed limits should be easy to determine and should encourage self-compliance, i.e., the visual clues should tell a driver what the appropriate speed is, and it will feel natural as they are driving. Changing the speed limit and introducing nothing but a change in signage is very unlikely to ensure driver compliance on its own. If all speed limit signage were taken away, the driver should instinctively know what the speed limit is from the environment: a driver will choose different speeds for a rural road through open countryside and a built-up road through a town centre. The A10 is a primary route and was designed and built as a national speed limit road. There are some junctions, accesses, and bends. Where a speed limit is set below the natural limit, compliance is likely to be low unless drivers can see the reason for the reduced limit. Compliance with the previous 50mph speed limit was good. Since the reduction in speed limit to 40mph the compliance is low, with a vehicle average speed being recorded as 47mph. Department for Transport Circular 1/13 states that speed limits should not be used to attempt to solve the problem of isolated hazards such as a single road junction or reduced forward visibility (e.g., at a bend). Cambridgeshire County Council has sought the view from the police regarding safe speeds in this location. Cambridgeshire Constabulary does not support a reduction in the speed limit to 30mph, commenting that:

“whilst the circumstances surrounding the fatality were tragic, it was not speed related and a change in speed limit would be unlikely to have changed the outcome. The collision history at the location prior to and after the revised speed limit of 40mph was

Chief Executive

put in place was benign. There is no evidence to suggest this location would be a cause for focus for road safety measures’.2

Data The current speed limit is 40mph at the location. A one-week speed survey was conducted between Tuesday 19th and Monday 25th September 2023 using automatic traffic counting equipment. This is the preferred method of gathering speed data as drivers are less inclined to react to the presence of automatic counters unlike speed detection guns which can cause alarm and result in drivers braking. During the survey period 92,889 vehicle movements were recorded. The data showed that there is already a lack of compliance under the existing 40mph limit (52.5mph average velocity for the first 85% of vehicles). The average speed recorded across the one-week period was 44.1mph. It should be noted that this is an all-day average which includes peak times when average speeds are likely to be reduced due to the high volume of traffic. The lowest average speed recorded during the sample period was 31mph which occurred during peak flow on Monday and Tuesday between 16.00 and
17.00 hours. Whilst the highest average speed was 57mph on Thursday between 03.00 and 04.00 hours. It is also noted that the average daily speed peaks at 47 and 48 mph for Saturday and Sunday respectively, indicating that speeds are likely to be higher at weekends. Taking all of this data into consideration, a further speed limit reduction would be unlikely to be adhered to under the current road and development environment. Summary Cambridgeshire County Council is committed to reducing Deaths and Injuries on all of our roads for all road user types.

We recognise Safe Speeds as a fundamental pillar of the Safe Systems approach endorsed by the County Council and its Vision Zero partners. At the present time, based on (i) the nature of the route, (ii) observed vehicle speeds, (iii) national and local policies and (iv) comments from Cambridgeshire Police support, we do not propose to reduce the speed further. However, speeds on the A10 will remain under review, and road safety forms a key component of the A10 Outline Business Case (due to report in Summer 2024), which has potential to change the physical nature of the route. As part of the agreed planning mitigated for the Waterbeach New Town, a range of measures have been secured to provide enhanced services and facilities for non- motorised road users, including a railway station, off-road walking and cycling and equestrian routes, and bus services. Furthermore, with the Greater Cambridge Partnership, we are developing segregated mass transit and adjacent non-motorised routes which will contribute to the safety and sustainability of the network in the area.

2
– Cambridgeshire Constabulary Traffic Management Officer

Chief Executive
Department for Transport Central Government
5 Jan 2024
Action Planned
The Department for Transport acknowledges the concerns about drivers over 70 and notes that drivers must self-declare medical conditions. The DVLA recently published a Call for Evidence on driver licensing for people with medical conditions, with the results currently being analyzed. RoSPA has developed an older drivers website with information and advice. (AI summary)
View full response
Dear Mr Milburn,

Thank you for your report of 18 August 2023 made under the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, following the inquest you conducted into the death of Louis Steven James Thorold.

I was very sorry to learn of the circumstances of Louis Thorold’s death and would like to express my sincere condolences to his family.

I have considered your report and its recommendations very carefully and although our roads are some of the safest in the world, I would like to assure you that we are not complacent about road safety. I must stress that one road death is one too many and the Driver and Vehicle Licensing Agency (DVLA) is focused on ensuring that only those who meet the required medical standards are granted a licence.

You set out your concerns that if drivers beyond the age of 70 continue to drive without independent medical scrutiny of their continued ability to drive then there is a risk of deaths occurring in similar circumstances and you asked that the department take action to prevent future deaths.

The current driving licence arrangements are underpinned by a legal requirement that all drivers, of any age, must inform the DVLA if at any time they develop a medical condition that may affect safe driving. All drivers must meet the appropriate health standards for fitness to drive and a licence will only be issued to those who meet those standards.

When applying for or renewing a driving licence, applicants must self-declare whether they have any medical conditions. The DVLA will investigate drivers who notify a relevant medical condition by obtaining information from them and where appropriate from their medical professionals. From the Secretary of State The Rt Hon Mark Harper MP

Great Minster House 33 Horseferry Road London SW1P 4DR

The DVLA will also investigate notifications from third parties, including concerned family, neighbours, or health care professionals. This is in recognition of the fact there may be times when individual drivers do not notify the DVLA appropriately or where a health condition affects their insight into their driving safely.

The DVLA takes road safety very seriously and wants to make sure that licence holders are fit and safe to drive. Drivers are encouraged to discuss any concerns about their driving fitness with their own medical professionals.

Although there is no legal obligation on medical professionals to notify the DVLA about a patient who is medically unfit to drive, they do have a duty of care to their patient and to the public to report when they have concerns and their patient is unwilling or unable to notify the DVLA. The guidelines issued by the General Medical Council (GMC) were updated in April 2017 and highlight a doctor’s duty to disclose information to the DVLA where the patient has failed to do so.

In regard to older drivers, it is recognised that health can deteriorate in later life and driving licences expire at age 70 and are then renewed at least every three years. Applicants renewing a licence from age 70 must declare that they meet the legal eyesight standards for safe driving and confirm whether they have any relevant medical conditions which may affect safe driving. These regular renewals provide a timely reminder for drivers to consider their health in the context of driving.

We have considered whether any changes to this policy are justified and proportionate. Driver licensing arrangements are designed to be balanced and proportionate for all drivers, and we are of the view that the current process for drivers renewing their licence at 70 strikes the appropriate balance between fairness, road safety and the individual. There is little evidence to suggest that introducing a stricter regime which includes mandatory testing or medical examination would improve road safety. For this reason, we do not propose to change the current approach.

The DVLA recently published a Call for Evidence (CfE) on driver licensing for people with medical conditions. The CfE ran for 12 weeks and was an early stage request for input into a review of the legislative framework. Evidence has been gathered from members of the public and a range of experts across organisations. The CfE closed on 22 October and the responses are currently being analysed.

The full information regarding the CfE is available via https://www.gov.uk/government/consultations/driver-licensing-for-people- with-medical-conditions-call-for-evidence

The CfE is looking to identify areas where policy or legislative changes may be able to improve outcomes for all drivers and other road users. Once the outcomes to the CfE have been analysed the DVLA will be in a position to provide an update to Ministers.

The Department for Transport does recognise that older people must be able to maintain the skills and confidence required to remain safe and effective drivers. With funding from my department, the Royal Society for the Prevention of Accidents (RoSPA) has developed an older drivers website www.olderdrivers.org.uk/. The website contains information to help older people to continue to drive for as long as they are safe to do so. It includes details on driving assessments and refresher training. It also provides advice on making the decision to retire from driving, if an individual is no longer able to drive safely. Driver education schemes are also provided by local authorities, and these are an effective way of providing support for older drivers and ensuring they remain fit and competent to drive.

I can assure you that our policies are kept under constant review and reducing the numbers of those killed and injured on our roads is a key priority for the Department.
Sent To
  • Cambridge County Council
  • Department for Transport
Response Status
Linked responses 2 of 2
56-Day Deadline 2 Nov 2023
All responses received
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections
Investigation and Inquest
On 24.01.21 I commenced an investigation into the death of Louis Steven James THOROLD (age 5 months 18 days). The investigation concluded at the end of the inquest on 26.07.23. The conclusion of the inquest was that Louis died as the result of a ‘road traffic collision’. The medical cause of Louis’ death was ‘multiple traumatic injuries’.
Circumstances of the Death
Louis died at 1701hrs on 22.01.21 at Addenbrookes Hospital in Cambridge. Postmortem examination revealed that he died as a result of multiple severe traumatic injuries. At around 1551hrs earlier that day the driver of a car travelling north on the A10 Ely Road at Landbeach turned right across the southbound carriageway where it was struck by an approaching van. The van left the carriageway to the nearside as a result of the impact and struck Louis and his mother as she pushed him in his pushchair along the pavement. The van came to rest in a ditch on the far side of the pavement trapping Louis underneath. He was extricated by a passer-by and treated at the scene. Sadly, Louis went into cardiac arrest and despite prolonged attempts at resuscitation and transfer to hospital he died of his injuries.

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.