James Baxter: Prevention of future deaths report

Other related deaths

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Date of report: 12/04/2024

Ref: 2024-0194

Deceased name: James Baxter

Coroner name: Ian Wade

Coroner Area: Berkshire

Category: Other related deaths

This report is being sent to: Department for Transport

The Right Honourable Mark Harper MP, Secretary of State for Transport
I am Ian Wade KC, Assistant Coroner for the Coroner area of Berkshire
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
On 5th September 2022 I commenced an investigation into the death James Ferris Baxter aged 78. The investigation was discontinued by the issue of coronial Form B on 31st January 2023, without inquest.
Mr Baxter was a qualified and lawfully licensed passenger carrying coach driver. He held a valid Category D licence authorising him to drive a PCV, issued on 3rd December 2021. He died on 4th September 2022 at Junction 15 of the M25 motorway, while driving a single deck Mercedes Benz coach. It has been determined by post mortem that he died from an acute right coronary artery thrombosis secondary to plaque rupture, due to severe ischaemic heart disease.  This was a natural cause of death. He was at the wheel and actually driving, with 25 passengers on board, when he suffered this medical episode causing the coach to crash. A passenger managed to take over control of the moving coach which was brought to a stop by collision with a safety barrier, causing some minor injury to some passengers and minor damage to the vehicle.
The MATTERS OF CONCERN are as follows.
As Mr Baxter was over 65 years old, he was required under current regulations pursuant to the Road Traffic Act 1988 and associated legislation to apply to have his Category D licence renewed annually using a Form D47P, and to have supplied a medical examination report in Form D4.

My investigation has revealed that Mr Baxter’s registered GP was never asked by Mr Baxter to examine him for the purposes of the renewal of his Category D licence, nor to submit a Form D4. Mr Baxter was medically examined by an appropriately qualified medical practitioner offering such an examination commercially to holders of HGV and PCV licences. A test was undertaken in the approved manner and was accompanied by a completed and duly signed Form D4, dated 2nd October 2021.

Mr Baxter was diagnosed with Type 2 Diabetes Mellitus in 2007, and with Hypertension in 2011, and he was prescribed suitable medications for these conditions. His medical history showed that he was obese and gaining weight in 2020 with a noted increase over time in his HbA1c, leading his GP to note that his diabetes was poorly controlled. In itself, this history does not make it clear that Mr Baxter was medically unfit to hold a Category D licence. However, aged 78, with chronic and poorly controlled diabetes and high blood pressure, the circumstances in which he would develop ischaemic heart disease and be at risk of suffering a serious coronary episode, of the sort he suffered on 4th September 2022, appeared to be established.

I received evidence that DVLA does commission functional cardiac stress testing for those with known cardiovascular disease, or those with symptoms suspected to be related to cardiac disease but this arises only in cases where such conditions are declared. Apparently there is no mechanism in place to diagnose asymptomatic individuals with these tests, but the evidence in the investigation indicated that a risk-based stratification system (for example a Q-Risk score) which takes account of age and comorbidities, rather than just cardiac symptoms, was feasible to reduce the risk of incidents of this type, thereby prompting consideration of stress testing. Alternatively a periodic stress test related to age was suggested as a means of ameliorating risk. Evidence was also provided indicating that on the D4 form there should be a provision to fill in HbA1c and cholesterol results produced within the previous 3 months as obtained by the applicant from a GP.
In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely 20th June 2024. I, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
I have sent a copy of my report to the Chief Coroner and to [REDACTED}
(next of kin), Thames Valley Police Roads Policing, Ryminster Medical Services Limited (trading as D4Drivers UK), and Westbus Coach Services Ltd
I am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.
912th April 2024