There are countless factors that can lead to your death.
As Senior Coroner,
I deal with nearly 4,500 fatalities a year.
NARRATOR: The coroner can make any enquiries necessary
to find a cause of death.
Can you explain what you've brought and then take me through it, please?
We need to be alert to the fact
that there could be something more sinister in this.
With unprecedented access,
we follow the coroner's full investigation.
It does make you realise how fragile life is.
Let's start and just work our way up.
Forensic medicine is all about being very suspicious.
From the moment of arrival in the mortuary,
to the final conclusion of the inquest.
WOMAN:All rise.
ADELEY:I'm sorry you're attending under these circumstances,
and I appreciate that the evidence that you'll hear today
may be distressing.
As a family, how do you face the person that killed your mum?
If you die here, if it's violent, unnatural
or of an unknown cause, it's my job to find out how.
PHONE RINGS
In Southport, two pedestrians have died
after being struck by a vehicle shortly after getting off a bus.
Emergency services have identified them
as friends Grace Foulds, who was 85 years old,
and Marie Cunningham, aged 79.
Excuse me, sir, have you got a moment? Yeah, sure.
I've been informed of a case involving two ladies,
been out shopping in town, come back, got off a bus,
crossing the road, and they've been struck by a vehicle.
Sadly, both ladies have died of their injuries in hospital. OK.
Can we get hold of the relevant police file, please?
We'll have a look at it
and see what information they've got regarding the collision.
Yes, sir. I'll pick it up from there.
OK. Thanks a lot.
Lancashire Senior Coroner Dr James Adeley
will want to find out whether the two women were easily visible
as they crossed the road
and what the actions of the driver were.
What may initially present as a simple collision
could have hidden factors at play.
Road traffic collisions are a common death
that coroners investigate.
You've got the human factors.
You can have a driver who may not be paying attention.
They may be using a mobile phone.
There may be other problems that contribute
from their point of view.
You've equally got, what was the pedestrian doing?
because some pedestrians will cause their own collision
by walking out into the road without looking.
So there are all these factors that need to be investigated.
Marie Cunningham's sons, Steve and Terry,
are visiting the site of the collision
to try to understand the circumstances
of their mum's death.
So, we're on Lulworth Road here. This is the scene of the crash.
Mum and Grace would have got off on... at that bus stop...
Yeah. ..on the right-hand side.
Would've crossed over the road.
Mum lived just over the other side of the road, in the flats there.
Grace lived just behind you, in the flats.
She was walking her across the road
so she could get home safely,
before heading back across this road herself.
You know, she was quite comfortable at crossing roads.
She was a very fit, agile 79-year-old.
So we are completely confused
as to why a car and a driver would hit two women
crossing a road of this size.
The driver must have saw them.
The family have lost sleepless nights thinking about it,
because you can't... understand what has happened.
Thinking about how much of an impact did she have.
It feels actually surreal.
Even walking down the other night,
it didn't feel like it was my legs walking down the road,
seeing an area where... your mum has died.
I don't think people understand that feeling.
When you come back here,
all that happens when you close your eyes for the night
is you visualise what happened.
No CCTV footage available.
You just visualise, so your mind runs away with...
Yeah. What happened, yeah, absolutely.
Yeah, yeah, yeah.
There is something fundamentally wrong.
You can feel it. We just don't know what that is.
But there is a desire here as a family
to find out what it is and get to the truth.
The Senior Coroner's investigation
will now want to hear from any witnesses
who saw what happened on the day
the two friends, Marie Cunningham and Grace Foulds, tragically died.
I walked to the front of the car,
and I saw a lady who was on her back.
And there was shopping sprawled all over the road,
and I now know this lady's called...
Now I know she's called Grace.
NARRATOR: Lancashire Senior Coroner Dr James Adeley
is investigating the deaths of two women
killed in a road traffic collision -
Marie Cunningham and Grace Foulds.
Grace is survived by a son, Victor, and her daughter, Caroline.
So, Mum grew up in Malta.
She met my father in 1957,
and they fell in love straight away.
He was a British soldier, and he was stationed over in Malta.
My father's parents were from Southport,
so it seemed like the natural choice to settle in Southport.
She became a great member of the community.
Everybody knew her...
MALTESE ACCENT: "Everybody loves me!"
That was her accent, that's how she used to speak.
Religion meant a lot to her,
and I think it helped her when she became a widow.
Mum was fiercely independent.
She had lots of friends.
Her social life was just... better than mine.
Although she did make time for her grandchildren.
She was a wonderful grandmother, Very, very important to her.
It was about half past five at night,
and my husband got a phone call from my brother, saying,
"Mum's in hospital. Can you go and see what it is?"
And we get into a room,
and my young sister-in-law's in there,
and she's in floods of tears.
There's police there, so, you know, what's going on?
My mother is dead.
I had to go and formally identify her.
She looked at peace. She looked restful.
She was still warm.
SHE SIGHS
So I tried to say goodbye.
You try to keep happy... memories.
It would have been easier to find my mum
passed away in her chair, in her... home.
Safe, sound.
Not on a cold...
..I don't know - dirty road, I suppose.
I don't know, just... terrible. Yeah.
Just terrible.
It's not gonna bring her back, you know,
but it'd just be nice to know exactly what did happen.
In the investigation into the deaths
of Marie Cunningham and Grace Foulds,
a witness has emerged who helped the women
and spoke to the driver.
I've been a nurse for 44 years,
mainly in the community in Southport.
There's a lady that we go to just off Lulworth Road.
She was my last visit of the day.
When I saw on the left-hand side, erm...
a car, a white car, with its hazard lights on,
and a gentleman by the side of it, waving his arms,
I just said, "Are you all right?"
And he just said to me, exact words were,
"She just walked out in front of me."
So, I walked to the front of the car,
and I saw a lady who was on her back.
And there was shopping sprawled all over the road,
and I now know this lady's called... I now I know she's called Grace.
She was motionless.
When you see somebody collapse, your training just kicks in,
you know what to do.
But there was no response at the time,
so I was very concerned about this lady's health.
I went to the back of the car, and there was another lady,
who was actually on her side and her head was on the kerb,
and I thought, "Gosh, two of them."
The lady at the back of the car, who I now know is called Marie,
she seemed to be, erm... severely injured,
and also she had a severe head injury.
I just sat talking to her, held her hand.
I realised that lady was conscious,
so I thought my priority was then Grace.
The emergency services came. They took over CPR.
PARAMEDIC:Now, just... Yeah, try and hold it.
The end of it? Yeah.
SIRENS
I wasn't hopeful that there was gonna be
a good outcome from this at all.
It looked very bleak.
SIRENS
Marie Cunningham was brought into Aintree Hospital's A&E,
where she was given a CT scan,
but she died that same evening, only hours after the crash.
Radiologist Dr Beardmore reviews the scan.
So, this is a scan of Marie Cunningham,
she's been brought into hospital,
and this is the initial scan that's been done,
to try and identify what injuries she's sustained.
Looking at it from the top in the head,
you can see there's a skull fracture on the left side.
She's also got some haemorrhage or some blood
around the side of the brain,
and also in the spaces around the brain.
Working down, I suspect that she's also got a cervical spine fracture,
and then the other injuries that she's sustained
is she's got multiple fractures of the ribs.
Working down to the abdomen,
there is a lot of blood in the pelvis,
and he's got multiple fractures through both sides of the pelvis.
You know, if a car hits a pedestrian,
these are the types of injuries that we sometimes face,
and, you know, are usually significant,
and sometimes life-threatening, as in this case.
Marie Cunningham was the mother of four children,
sons Steve and Terry,
and daughters Lynn and Sue.
My mum and dad, they were hard-working people, weren't they?
They wanted to better their life for us, didn't they?
She grew up in Liverpool,
Scotland Road area, proper Scousers. TERRY:Oh, yeah.
She was the matriarch, wasn't she?
She used to worry about everybody. Yeah.
Dad died 14 years ago. Mum was devastated.
She was just broken-hearted.
It took her a while, didn't it, to rebuild her life?
You know, with encouragement from everybody in the family,
she did, she pushed herself.
Mum was very independent, very busy, and very fit.
Her calendar was chocker. All the time.
My mum and Grace were really good friends.
They'd go to St Joseph's Church every Sunday.
Then they'd go and have a coffee and put the world to rights,
have a laugh, have a cry.
What's happened? How can something like that happen?
Why do two people get killed
on a main road in Southport at half four?
How can it happen? How can that happen?
Marie's son Terry went to investigate
within hours of the crash.
I did pull up at the side of the road,
and the police were still outside.
The bus shelter light was so bright...
Mm. ..and the post box.
I don't think I'll ever get that image...
And then we got talking about who it was,
how much pity we felt for him, because as a driver,
I couldn't even put myself in his shoes...
No. ..to kill two people.
At the scene,
witness Shirley was taken aback by the attitude of the driver.
The driver didn't come to any of the ladies,
which was a bit of a surprise.
He was on his phone,
and then he walked over the other side of the road.
So, it was like, he didn't come out and say,
"Is she all right? Is she all right?"
But I just presumed that was shock that can make you do strange things.
I think if it was me, I'd be hysterical,
and, yeah, be beside myself, but very calm, extremely calm.
RADIO CHATTER
I came in and went in the bath and just couldn't stop crying.
It's something that I'll never, ever forget.
I've thought about it for quite a while.
How did it happen?
Something went wrong that day.
I think a lot of people had their own speculation
of what must have happened.
I've been guilty of it myself, just surmising that...
They'd walked out. And they're doddery...
Yeah. ..and they can't hear,
and they couldn't see, a car coming, and all that kind of stuff.
But then you're like, "No, you don't know my mum." Yeah.
WHISPERS:I'll make you a brew.
You'll get answers, hopefully.
You'll get them answers.
Merseyside Police, who attended the scene,
spoke to the driver of the vehicle involved in the collision.
Mr Jones was approached by one of the witnesses
on the call to the emergency services
and asked what had happened.
He believed they had stepped off the pavement to his near side,
so from his left-hand side, leaving him with no time to react.
It's a natural line of enquiry that you've got to cover
as to whether the pedestrians that are in the carriageway
have run into the road or walked into the road
and have left the driver with little reaction time
to take evasive action.
The CCTV from the bus that they'd alighted from
was able to show us that the ladies, despite their age
and the misconceptions that may be associated with that
in terms of their mobility, there was no issue surrounding that.
Both were mobile ladies.
In terms of the footage of the collision itself,
this comes from a property that overlooks Lulworth Road.
Now, admittedly that footage, it's really quite grainy.
However, what we can see from that footage
is that they cross fully over the opposing side of the road
to which Mr Jones is travelling in.
And then having crossed the centre white lines,
get three quarters away
across the side of the road that Mr Jones is travelling in,
when he strikes them
and only brakes having impacted with both of them.
From the footage that we can see,
the headlights of Mr Jones's Audi illuminate both ladies
as they're crossing the road,
raising that question of how and why he's not seen them.
So, the initial accounts that we had at the scene
that Glyn Jones had provided to various witnesses
were that the ladies had stepped off the pavement
to his left-hand side
and left him very little time to react.
Whereas the CCTV footage that we've now gathered
conclusively shows us
that the ladies had actually travelled from his right-hand side.
And it's clear to me that Glyn Jones's account
doesn't match up with the circumstances of the incident,
and therefore, he's been correctly been placed under investigation
for that offence and needs to be interviewed about it.
DISTANT SIRENS
In Langho, Lancashire, emergency services attend the scene
of another collision between a vehicle and a pedestrian.
The driver of the car is uninjured.
But the pedestrian is in a very serious condition.
Despite the best efforts of paramedics,
the pedestrian dies at the scene.
Lancashire Police have contacted us.
A road traffic collision that's happened
on Whalley Road at Langho. OK.
Early indications are there's two people involved,
an 80-year-old pedestrian and an 80-year-old car driver. OK.
The pedestrian has been crossing the road
and has been struck by the car.
Sadly, the pedestrian has died at the scene.
I assume we'll get a request for the police
for a Home Office postmortem,
and subsequently, we'll get the police file?
I've no doubt, yes.
I've been in initial consultation with Sergeant Helen Parkinson,
the senior investigation officer. OK.
Thank you. Thanks, Jason.
The pedestrian in the collision
has been identified as Peter Westwell,
a grandfather from Langho, Lancashire.
I've known Peter for over 20 years, the father of my neighbours.
Peter was a real gentleman.
He was a lovely man, very active.
He loved going out and walking.
I'd often see Peter walking about in his red anorak,
full of life and fit as a fiddle.
Very young for his age, very with it,
a sharp sense of humour, and yeah, a nice man.
Very much a family man,
and very, very proud of his grandchildren.
Peter's friend Wendy remembers
that he'd previously had some health issues.
If we can go back to lockdown, Peter had been really poorly.
And he'd actually had a bleed on his brain.
And he'd been in hospital, and actually, he'd nearly died.
And I know he spent some time in recuperation
and in a rehabilitation centre before he could come home.
The family had to encourage Peter to stop driving.
And it was really sad at the time, cos that was his independence.
But he always followed the rules and always did what he was told.
And that's why this case is so upsetting.
That day of the tragedy,
Peter was walking because he couldn't drive.
Peter probably had years yet to live,
years to enjoy his grandchildren growing up,
and I think that's the saddest thing about the whole event.
So, we now appear to have two road traffic collisions
where you have an older driver who has not seen a pedestrian,
not braked before the collision, resulting in a fatality.
And this begins to make you realise
that there may be a wider issue here that needs looking into.
We will have to look at both the driver and the pedestrian
to see what has gone on,
and whether or not there are health concerns,
or just an error of judgment that has occurred to cause this death.
In the case of Peter Westwell,
who was hit by a car while crossing the road,
PC Abby McTomlinson was the first police officer
at the scene of the collision.
So, I was on an early shift.
The driving conditions on the day were dry, it was sunny.
We pulled up alongside the roadside
and immediately seen an ambulance in the middle of the road,
a number of witnesses, vehicles.
We've seen the subject vehicle, which is Mr Pemberton's car.
He was the driver at the time,
and then unfortunately, we've seen Mr Westwell laid out
in the middle of the road
receiving medical treatment from ambulance.
We immediately went to speak to the driver who was involved.
He said that the pedestrian, Mr Westwell,
had walked out in front of his vehicle,
and that was at the point of contact.
So, our initial interaction with Mr Pemberton
was quite strange, quite bizarre.
He showed no sort of compassion for the victim
who was laid out on the roadside.
Mr Pemberton's main concerns with us and main questions with us
was what was gonna happen with his car, would he get a new car?
So, Mr Westwell was pronounced deceased
at the roadside by ambulance,
which then would change the nature of the investigation.
Dr Adeley has been made aware that the victim in this crash,
Peter Westwell, had some previous medical issues.
We have had a report that Peter Westwell has had
some form of haemorrhage on his brain.
We don't know the extent of this or when it occurred,
but it is the sort of thing that may affect
your ability to function,
your perception of hazards around you.
So we will need to understand
how this relates to the collision itself.
The pathologist, when they look at the brain,
will be able to tell you
whether that bleed was affecting Peter Westwell
at the time of the collision.
Pathologist Richard Shepherd has performed
more than 20,000 autopsies...
..and reviews Peter Westwell's postmortem.
Looking at the vehicle,
we know that this was effectively a head-on collision.
The car hit the pedestrian
as the pedestrian was standing, moving across the road.
Just looking at the bodywork of the car,
we can see significant damage to the lower bumper, with cracks.
But the major points of impact here
are clearly with the bonnet of the car,
which is crumpled back and folded in,
and with the windscreen,
which is glazed and damaged in two places.
Dr Richard Shepherd then moves on to look
at Peter Westwell's injuries.
The crucial findings in Peter's case
are the damage that's been caused essentially to his chest,
but also secondarily to his head.
And what we found were extensive fracturing
predominantly to the left side of his body.
All of the ribs on the left side were fractured,
but more crucially was the damage to his spine.
And what has happened,
his spine has being tipped backwards by this blow,
and when you tip someone backwards, that force can break the spine.
Crucially, though, of course, in a sense, it's not just the bone.
It's the spinal cord that runs down the middle,
and here you can see the yellow, with the spinal nerves coming out.
It's that damage that causes the real problems.
Just the blow causes all the nerves to stop working.
And of course, breathing, heart rate,
everything is controlled through that bit,
and this is why the spinal fractures were so important
in the cause of Peter's death.
Peter Westwell's friend Wendy was concerned
that a previous brain injury may have affected him
on the day of the incident
and could have contributed to his death.
I served in the police for 30 years, and I served my last seven years
as assistant chief constable with Lancashire.
In my experience, I know when you're investigating,
whether it's a road traffic collision or a death,
a sudden death of someone,
that you have to take all the circumstances into account,
and I was concerned at the time
that maybe Peter's brain injury had contributed.
It needed to be ruled out.
When we performed the examination,
we saw that there had been a previous bleed
around the surface of the brain.
And we know that that was an old injury,
and it was nothing to do with the incident.
We don't expect this, from his past medical history,
to have affected him,
and there's nothing to suggest that it did so.
From the moment Peter was struck,
the injuries he received were non-survivable.
We know that through the investigation,
it has been proven that Peter had done nothing wrong
in these circumstances.
But now we need to understand, why on earth did that ever happen?
The investigation into Peter Westwell's death
begins to shift towards looking at whether the driver was at fault.
Lancashire Police discover some concerning video evidence.
As part of the investigation, we did house-to-house CCTV trawl.
The first clip that we come to
shows Mr Westwell walking towards the collision site,
walking along Whalley Road, walking absolutely fine.
He's very visible, yeah, his bright red jacket.
The next footage is the Honda Jazz travelling along Whalley Road.
You can see here straight away, see from the speed of it,
it immediately looks a lot faster than all the other cars.
Whalley Road is a 30-mile-an-hour limit,
and Mr Pemberton was travelling at 48 miles an hour.
Having established the driver was speeding,
the police also managed to obtain some footage
from another driver on the road.
Mr Westwell can quite clearly be seen already.
He's started to cross the road, plenty of time.
He's not stumbling, and then unfortunately,
you can just see the other car coming at pace.
You can see inevitably what's gonna happen, unfortunately.
The other car just never slowed down.
There's no braking.
It was quite clear that the error had fallen
on the part of the Honda driver.
Helen Parkinson then directs her team to make further enquiries.
Following a fatal collision, or any serious collision,
we will do four preliminary tests.
The first thing we did was do the breath test,
and that came back zero.
That was negative.
We then conduct a drug wipe, and that was negative.
A fit test and an eyesight test.
The eyesight test's legal requirements are
to be able to read a numberplate from 20 meters away.
Officers from Helen's team visit the driver, Neil Pemberton,
to conduct the eyesight test.
We're then gradually moving closer, ask him again to read it.
A little bit closer, asked him again to read it.
Unfortunately, he couldn't give us the correct number plate
until he was only two and a half metres away
from the car numberplate.
Which is very, very worrying indeed.
So, we then looked at his medical records,
and we could see that he was under an ophthalmologist,
certainly from 2013,
where he suffered several medical issues with his eyes.
He had wet macular degeneration and also a detached retina,
and he was basically blind in one eye,
and was struggling with his vision in his other eye.
And the first time he was told not to drive was in 2013.
He'd been driving for nine years after he'd been told
his eyesight was not good enough to drive.
Dr Adeley will now have to look into what role poor eyesight played
in the crash which led to the death of Peter Westwell.
But whilst investigating his death,
the coroner is alerted to another road traffic collision
with concerning similarities.
The police have notified us of a further road traffic collision
of an older pedestrian who's been struck by an older driver.
Assisted by her neighbours,
emergency services have identified the pedestrian as Anne Ferguson.
Anne's friend and neighbour, Madeleine,
went straight to her side after the crash.
Everybody knew Anne. Everybody knew Anne.
I first met Anne when she moved in 14 years ago.
We just... got on, because she got on with anybody.
Anne looked after her husband, who had to have 24-hour care.
She did everything.
I used to take her out to give her a bit of freedom,
and also for a laugh.
God, we used to laugh.
She'd been to her doctors for her prescription,
and she were coming back across t'road.
I saw her out the window... across the road.
By the time I'd come downstairs here,
I'd heard the bang.
So I run out.
And I knew it were Anne by her coat, the coat she had on.
And her trolley was outside my house.
The handle was up the side of my house.
And the wheels were in next door's garden.
So I just went up to her
and knelt down at the side of the road with her...
..and held her hand, gripped my hand.
I said, "I'm here, and I'm stopping."
But I think I knew...
..when the ambulance, when the two ambulance girls come,
and I looked at their faces, and they took her in the ambulance.
But I never thought I'd never speak to her again.
At first, every time I went out t'house
I didn't want to go out...
..cos I could picture...
I mean, I still can picture her stood at t'window.
WHISPERS:I don't know.
It'll always be there, she'll always be there.
The sad thing was that a little bit later...
..her husband... committed suicide in the nursing home...
..because he couldn't live without her.
We just don't know how it happened.
We just thought he hadn't seen her.
The coroner is now looking into the deaths
of four pedestrians -
Grace Foulds and Marie Cunningham in Southport...
..as well as Peter Westwell,
and now Anne Ferguson in Lancashire.
This is beginning to show a worrying collection of cases
in a relatively short period of time
in a relatively small area,
which has to be more than a coincidence,
and requires us now to look at whether or not we are unusual,
or this is a wider problem on British roads.
NARRATOR: In the case of Grace Foulds and Marie Cunningham,
two friends killed whilst crossing the road
outside their homes in Southport,
Dr James Adeley needs a pathologist's findings
to further his investigation.
Road traffic collisions are investigated
with a number of pieces of evidence.
This is a collision between a pedestrian and a car,
so you are interested in which way the pedestrian was facing.
How did the car hit them?
What then happened to the pedestrian?
And the pathologist's report can give you a lot of information
as to the orientation of both the vehicle
and the pedestrian when they're hit.
Pathologist Dr Richard Shepherd
examines the notes from the postmortem.
Grace had suffered extensive injuries
with the contact with the vehicle and with the road.
Even in hospital, they were unable to save her life,
despite advanced resuscitation techniques.
We also noticed that there was a skull fracture.
There's damage to the brain.
There's fracturing of the upper cervical spine -
a very common site of injuries
for pedestrians in road traffic collisions.
There are multiple fractures to the ribs.
Because of the multiple rib fractures,
the lungs are often penetrated by the fractured ends,
and Grace had those penetrating injuries,
causing her lungs to collapse.
Marie had an injury that resulted in a fracture of the skull,
bleeding around the surface of the skull.
She had bleeding internally, within her brain,
and that's a very serious complication of a head injury.
There was also fractures of her spine,
fractures at the ribs of the left side of her chest,
and there was fracturing of her pelvis.
The skull fracture associated with bleeding
around and within the brain
is a very, very serious injury in anyone,
but particularly an elderly individual.
The postmortem also points to a vital piece of information
regarding the circumstances of the collision.
Assessing direction of travel and point of impact
can be very difficult.
But in this case, the weight of the injuries
seems to be to the left side of both ladies,
which suggests that the vehicle was coming from their left.
And on an English road,
that means they would have crossed one carriageway
over the centre line
and now be in the second half of the road
at the time they were struck.
In Southport, in the hours after the collision
which killed Marie Cunningham and Grace Foulds,
Merseyside Police officers question driver Glyn Jones.
The investigating officer in this case was asked to go and conduct
an eyesight test with Mr Jones
in the days following the collision.
I think it's fair to say that the performance was extremely poor.
And therefore it's a failure
on the basis that he's performed that poorly.
The investigating officer in this case asked Mr Jones
to give him details of his GP and who his opticians were,
and Mr Jones refused to provide those details to the officer.
Having seized the driver's mobile phone,
police tracked down the details of his GP,
who told them Jones had been phoning to ask them
not to co-operate with the investigation.
He believed that information shouldn't be shared
and that he wasn't best pleased
with the police applying for that information.
When I hear that, it just highlights to us
that we're on the right pathway, aren't we?
The evidence that we're gathering is starting to aggravate Mr Jones,
which suggests to me that we're starting to uncover things
that he doesn't want us to know about.
In the ten years or so prior to the collision,
he'd been told on multiple occasions
by multiple professionals and experts
that he shouldn't be driving.
KNOCKING
We had sufficient evidence in this particular case
to feel confident that we could put a file
to the Crown Prosecution Service and obtain a charge.
Glyn Jones, the driver who killed Grace Foulds and Marie Cunningham,
was charged with two counts of causing death by dangerous driving.
At court, Glyn Jones was found guilty
and jailed for seven years and four months.
When we found out that his eye condition was so severe,
that legally, he wasn't even able to see his steering wheel,
I think it was just shock, wasn't it?
We just... We didn't realise it was so bad.
He was unfit to drive. He knew he was unfit to drive.
He got into a car on numerous occasions,
and he rolled those dice every single time he went in that car.
He had the opportunity at the side of the road
to say it was his fault, but he chose not to do that.
The barrister gave the guilty plea on his behalf.
He never spoke, never looked at the family once,
never showed any kind of remorse in any way, shape or form
as he was sat in the dock.
The trial gave us the decision.
But what it didn't uncover was
why was this such an accident waiting to happen
in the way that it did.
His car would have been MOT'd,
and his car would have been safe to drive,
but the driver wasn't safe to drive the car.
And that's where change really needs to happen.
In the case of Peter Westwell,
who was killed by 80-year-old driver Neil Pemberton
in a car crash in Langho, Lancashire,
senior investigating officer Helen Parkinson
is bringing her findings to the attention
of Senior Coroner Dr James Adeley.
Right, what have we got here, please?
So, this is the police prosecution file,
in relation to a gentleman called Mr Neil Pemberton,
who has recently been sentenced
for causing death by dangerous driving of Mr Peter Westwell. Right.
He's recently been sentenced to 32 months in prison
for causing death by dangerous driving
by the fact that he had incredibly poor eyesight.
Fine.
Can you explain what you've brought and then take me through it, please?
So, there's an awful lot of... Medical records.
Medical records, yeah.
Can we have a look at the footage, please?
Yes, absolutely.
WOMAN ON VIDEO:'Right, OK. tell me what you can see.'
'That's nine metres.'
MAN ON VIDEO: 'That's how I can see it.'
'Right, go on. Move a bit further forwards
'so you can really see it for me
'and read the whole number plate out.'
'Tell me when you can read it.'
I can read that.
'There is an H.' I know.
U. You've got it.
You've got it. What's that?
'2.5 metres.'
2.5 metres? Mm-hm.
It's a painful watch, isn't it? That is... concerning.
With this, the principal concern coming out of this case
is that you have got an increasingly elderly population...
Yes.
..who, up until today in reading this report,
I didn't know what the requirements were for sight. Yes.
Most people aren't even aware of the requirements for this,
and all of this is you assure the DVLA
on a voluntary basis? Mm-hm.
So the question then starts to become,
is this safe, or is there an ongoing problem?
With the police prosecution of Peter Westwell's driver
having now concluded, the inquest can now take place.
Dr Adeley moves forward with his investigation.
We will ask Richard Booth, who is a consultant optometrist,
and ask him for an opinion
as to how compromised the sight of these drivers was.
Dr Adeley will want to examine this vital evidence
about the state of the drivers' vision
as he prepares for the inquests.
Optometrist Richard Booth first examines
the records of Neil Pemberton,
the driver who killed Peter Westwell.
I realised that it was 1999,
was the last time that he met the eyesight requirement for driving.
He had a retinal detachment in one eye
and age-related macular disease in the other.
Neil Pemberton told the optician that they no longer drove.
They told the hospital in some cases
that they no longer drove.
They completed the form, because he was over the age of 70,
which is done every three years,
saying there was no problem with his eyes
and he never had any eye disease or anything.
But it relies on the honesty,
and it's just too easy to self-certify
that you meet the eyesight requirement.
He would have known, there was no question about it,
that he was well outside the requirement for driving.
In my opinion, he would have been able
to be registered partially-sighted, which is rather frightening.
It's probably about the worst case there that I've seen.
I was then approached to look at the case of Glyn Jones,
who had a road traffic collision and killed two pedestrians.
Those pedestrians were Marie Cunningham and Grace Foulds,
killed as they crossed the road in Southport.
The condition Glyn Jones had was keratoconus.
Keratoconus is a misshaped cornea.
Instead of being spherical, it is conical,
and therefore everything becomes very distorted.
Which means that the furthest he could see clearly
would have been about 5cm away from his eye,
which is about that.
He knew from the last eye examination he had
prior to the collision
that his eyesight didn't meet the requirement.
It's just totally irresponsible.
He was under the age of 70,
so he didn't actually need to complete a form
saying what his eyesight was like.
However, it falls to the driver who has defective eyesight
is to notify the DVLA.
With evidence mounting that the issue
of poor eyesight in drivers is not sufficiently regulated,
Coroner Dr Adeley decides to contact the DVLA,
which issues driving licences.
The cases of Marie Cunningham and Grace Foulds
have similarities to Peter Westwell,
due to drivers who have been told not to drive
due to their eyesight but have continued to do so.
'Coroners have a responsibility to identify risks
'where people may lose their lives
'and draw this to the attention of authorities
'who have the power to deal with this.'
You can have a very simplified test to cover most things.
If we removed the self-assessment reporting
and had it authenticated by a professional,
it would be quite easy and quick to do.
And I think it's likely to have the effect
of reducing road traffic collisions in total.
NARRATOR: Senior Coroner Dr James Adeley
is investigating a number of road traffic collisions,
including the death of Anne Ferguson,
a pedestrian who died whilst crossing the road
in the town of Whitworth.
Lancashire Police's Serious Collision Investigation Unit
went to the scene of the crash
involving a van driver called Vernon Law.
You can see Anne cross the road.
She has a good vantage point for crossing the road.
She's able to see both sides of the road.
Starts crossing the road, it's clear in both directions.
Literally, she was just over a metre from the pavement.
She very nearly got all the way across.
Had he slowed down slightly,
she would have been able to get across.
From watching and analysing the CCTV,
Mr Law never pressed his brakes,
so clearly he never saw Mrs Ferguson,
despite her being in his sight for over five seconds.
Pathologist Richard Shepherd reviews Anne Ferguson's postmortem.
In trying to understand complex incidents like this,
it's so useful to have CCTV footage, and that's what we have here.
The impact is clearly very severe.
She's instantly scooped off her feet.
She strikes the vehicle hard,
and then she's thrown forwards by the front of the vehicle.
And it's obvious from the moment
that you see her body responding to this
that there are severe fractured limbs.
So, she's got multiple fractures of the ribs,
and there were multiple fractures of Anne's spine.
One in the neck, one in the upper chest
and one in lower chest.
The one in the lower chest is particularly important.
And actually, that's often where the most energy,
the most force from the vehicle is delivered,
because there, the spine had moved, and the spinal cord was cut through,
causing it completely to stop working.
I'm sure that this was an immediately fatal impact.
And if there has to be a good thing,
it's that she would actually have known nothing about this.
Police officers at the scene
conducted a number of tests on the driver.
PARKINSON:Mr Law passed the drug wipe.
He passed the breath test.
OFFICER ON VIDEO:So, the next thing I need to go through with you
is an eyesight test,
to make sure that you meet the minimum standards
for driving a vehicle.
Unfortunately, as we've seen again, he failed the eyesight test.
Not quite.
Mr Law couldn't read the number plate
until he was only six metres away.
So, following the failure of the eyesight test,
it was clear this is an avenue
that we needed to investigate further.
So we contacted his opticians.
And it turns out just a month earlier,
prior to the collision,
Mr Law had gone and had an eyesight test
where he was diagnosed with cataracts in both eyes.
Cataract is where there is opacity in the lens,
so as the lens inside your eye ages,
it starts to go slightly yellow, usually.
It's like looking through a filter.
And it becomes quite distorted, the vision, mainly blurred... blur.
You would be susceptible to bright lights,
so headlights would become a problem.
Mr Law had cataracts in both eyes.
One eye was particularly poor.
It was virtually sort of hand movements or light perception,
a very dense cataract.
It's frightening that he managed to survive, really,
in everyday life with eyesight like that.
He shouldn't have been driving.
He shouldn't have been driving for at least a decade
and probably slightly longer than that,
and with the result that it has ended in a fatality.
On speaking to the optometrist that he spoke to
because of how bad his eyesight was,
they asked him if he was a driver of a vehicle, to which he said no.
I think that's probably because
he feared that he may lose his licence,
hence the reason he lied.
And unfortunately, he selfishly chose driving,
which cost Mrs Ferguson her life.
Obviously, at the moment, we're relying on people to declare
these medical issues to the DVLA themselves.
And this clearly isn't working, people are choosing to lie,
people choosing to ignore the advice,
and that decision just needs taking out of their hands.
Afternoon, sir. Have you got a moment?
Yeah, sure.
The prosecution's been completed into the death of Anne Ferguson.
Driver Vernon Law has been sentenced,
and obviously, he's got serious eye conditions.
So similar to the cases we have? Yes, sir, it is.
OK. Could you get the police prosecution file,
the judge's sentencing remarks
and anything else that might assist us
in evaluating this case?
And we'll have a look when it's all together.
The common factor in these four deaths
is an older driver with an eyesight problem
who continues to drive,
posing risks to all other road users.
This is likely to not be simply in my area.
This is replicated across the UK.
These are significant numbers of people who are dying,
and the system that allows these drivers to continue to drive
needs examination in court.
NARRATOR: Because Senior Coroner Dr James Adeley
is now investigating four deaths
involving drivers with defective eyesight,
he makes an unusual and important decision -
to bring the cases together in a joint inquest.
Deaths of a number of different people
in different incidents being combined into one inquest
is actually quite rare.
The first part of the inquest deals with how these people died,
the collisions that led to their deaths,
and the eyesight of the specific drivers involved.
The second part of the inquest deals with the system
by which drivers' sight is assessed,
and how safe this is to ensure
that people who also use the road do not get injured or killed.
'We can't avoid what we've gone through.
'History is history now.'
But if anything comes out of this that avoids other families having
to go through the grief, the trauma,
the emotions that we've gone through
by losing a parent or a loved one,
then the whole process is worth it from start to finish.
'This current process is not working,
'and people are dying.'
The population is more elderly now,
and unless they get to grips with the process,
there will be more fatalities.
'It's been a long time coming,
'and it's about time somebody did something.'
It's gonna be a long day, a lot to process.
Hi, my name's Wendy Walker. Hi, Wendy.
I'm here with the Westwell family. Hi.
Hopefully, this inquest will bring that closure,
and now the family will be able to focus
on the happy memories of Peter as that hiker and fisherman,
and happier memories for the family to look back on.
Drivers from the collisions have been called by Dr Adeley
to give evidence at court.
Neil Pemberton, the driver who killed Peter Westwell,
appears remotely.
The driver from the Southport case, Glyn Jones,
is brought in from prison.
This is the man that killed my mum. This is the man that killed Grace.
As a family, how do you face the person that killed your mum?
This is gonna be a hard day.
You accept that at the time of the collision,
your eyesight was beneath that required by the DVLA to drive a car?
Yes.
You've just been told not to drive.
Why wouldn't you notify the DVLA
that your sight is so compromised that you can't drive?
There was no need for me to do that,
in the way I interpreted the Highway Code.
In terms of this,
at no point have you been told that you were safe to drive.
No. As I've said, sir, I made an error of judgment.
You say that, "I did not suffer with any difficulties
"with my eyesight prior to the collision."
Is that correct?
That's correct, yeah.
So the fact that you have a retinal detachment
with serious implications for your sight,
and wet macular degeneration,
you do not consider to be difficulties with your eyesight?
No.
Your lack of eyesight played no part in this collision?
No.
And your speed played no part in this collision?
No.
Today just reinforced the fact that people can't be responsible
for assessing whether they're safe or not.
It's amazing how many people actually think
that they're OK to drive, and they're simply not.
A representative from the DVLA -
the organisation which issues driving licences -
is called to give evidence.
Do you think self-reporting is working for visual complaints?
I think on the whole, it does.
Yes, I think the vast majority of people
fulfil their legal obligation to tell us
in terms of medical standards, generally,
and vision is included in that.
And on what do you base that?
Well, it's, erm...
Because you've just said you've got no evidence.
Well, again, it's a lack of evidence
to show that they aren't, if you like.
Well, there's a lack of evidence to show that they are.
You just don't know, do you?
Well, the answer is obviously "Yes, I don't know."
Yes, OK. If the question is,
"Do I know that everybody's telling us,
"or the vast majority of people that tell us?"
I can't sit here and give you a stack of evidence
that says they are.
Don't you think that within a system that relies upon self-reporting,
knowing whether or not it's working,
when there are four fatalities in this court alone,
would be important?
Yes.
And yet you don't.
After hearing all the evidence,
Dr Adeley makes it clear for the official record
that he believes that the system used
to regulate driving licences should now be re-examined.
Firstly, a system that continues to grant driving licences
to drivers who were aware of their visual defects,
who go on to cause the death of a person,
is not, in my view, safe,
as is amply demonstrated by the four deaths in this inquest.
I consider that the current system of self-reporting is ineffective
and an unsafe system,
and unfit to meet the needs of society.
My condolences are and remain
with the families who have lost loved ones
due to collisions caused by drivers
with each of them knowing that their vision was defective
and their inability to see pedestrians
resulted in these four deaths.
There was no reason at all for them to have been run down, you know -
these two women crossed that road every day, once, twice a day.
They were just out, ready to go home.
It just shouldn't... just shouldn't have happened.
Sorry.
Never in the world did I think he couldn't see proper...
..and he shouldn't have been on the road.
I mean, how many more accidents could he have caused?
Surely, it's not just a case of ticking a form off.
They should have to have their eyes tested.
So something has to change.
Mum's beautiful life was taken from us
in the most cruel and senseless way.
Our mum and her friend were killed
by the selfish, reckless actions of Glyn Jones,
an obnoxious, self-righteous man
who chose to ignore repeated medical advice
telling him that his eyesight failed the legal limit to drive.
This tragedy was not inevitable. It was entirely avoidable.
People who can't see to drive mustn't be getting behind a wheel.
The tragic irony of this is that Peter had stopped driving.
We probably all know somebody who shouldn't be driving,
and that's the reason that this needs to be regulated.
The evidence at this inquest suggests
that there is a systemic problem
where drivers continue to drive who have defective eyesight,
who have been told they should not be driving.
In this country, we have a system that allows you
to take a rudimentary sight test aged 17.
And then there are no checks on your ability to see to drive
until you are 70, when you self-report
that you are still able to reach the standards for driving.
This is clearly unsafe.
As a result, I will be writing to the Secretary of State for Transport
with a Prevent Future Deaths report,
because there is clearly a risk of continuing avoidable deaths,
so that someone can review the system and take action.
This has been the most difficult two weeks of your life,
having to hear decision makers avoid taking ownership and responsibility,
and looking to an easy route to a solution,
with unrefutable evidence that the system is broken.
We don't want to stop people driving.
We just want to put steps in place that people can drive safely.
LYNN:I think they'd be proud of what we've done.
My mum would be really proud of us, and we're only doing this for her.