A recent coronial investigation into the death of a woman with insulin dependent diabetes after a car accident, highlights some important lessons for doctors.
The investigation emphasised the importance for GPs to seek input from the patient’s specialist for some health conditions before certifying fitness to drive. It also highlighted the key role treating doctors play and the challenges in broaching discussions with patients around fitness to drive and documentation of these discussions.
The patient’s GP completed a medical certificate in October 2019 indicating she met the criteria for a conditional licence, with a review period of five years. Insulin dependent diabetes was listed as the condition.
Her driver’s licence had previously been suspended and she had reported a suicide attempt shortly after this. It is not clear from the coroner’s findings when these events occurred. Tragically, the 57-year-old died in March 2020 after driving her car off the road in Queensland. The evidence indicated there was no driver input to avoid the collision prior to impact. This was consistent with a person experiencing a hypoglycaemic event and losing consciousness while driving. The report from the patient’s insulin pump indicated she had a low blood sugar episode at the time of the accident.
Her insulin pump also indicated that in the month prior to the accident she had 16 hypoglycaemic events, with a hypoglycaemic episode earlier on the morning of the accident. According to the pump settings, she would have had to ignore at least three alarms prior to her hypoglycaemic episode on the day of the accident.
Fitness to drive standards
A doctor’s role in assessing a patient’s fitness to drive is outlined in Austroads and National Transport Commission’s Assessing Fitness to Drive for commercial and private vehicle drivers medical standards. The fitness to drive standards provide information about a broad range of conditions and their impact on assessing a patient’s fitness to drive, and outline when further specialist assessment is required.
In the case of diabetes mellitus, the standards state a patient who has reduced hypoglycaemic awareness should be under the care of a specialist such as an endocrinologist, who should be involved in assessing their fitness to drive. A conditional licence may be considered (for private drivers), taking into account the specialist’s opinion, the nature and extent of driving involved and the driver’s self-care behaviours. However, under the fitness to drive standards any patient who has a persistent reduced awareness of hypoglycaemia is generally not fit to drive unless they experience early warning symptoms or have an effective management strategy for their condition where there are no early warning symptoms.
No record of patient discussion
The coroner found that based on the fitness to drive standards, the characteristics of the patient’s diabetes would have necessitated input from an endocrinologist to determine her fitness to drive, and the review period should have been two years, not five.
The coroner was also critical of the GP and endocrinologist for not documenting any discussion with the patient about her fitness to drive.
“I could find no evidence of discussions about safety to drive in the notes of the attending GP or the attending endocrinologist. This is concerning as the endocrinologist has previously completed paperwork to the effect that [the patient] was unfit or potentially unsafe to work due to her diabetes, and yet driving does not appear to have been discussed,” the coroner said.
The coroner concluded the patient’s history of severe hypoglycaemia and poor awareness, made her ineligible for a conditional licence. Ultimately, the coroner found this decision should have been made by the endocrinologist, not the GP.
However, the coroner acknowledged that doctors may sometimes feel uncomfortable about having frank conversations with patients about difficult subjects such as fitness to drive.
“Proximity in care of a patient and maintaining trust in a therapeutic relationship can mean such difficult subjects are not always broached to the full extent they could be. I note in this case that [the patient] reported a suicide attempt shortly after her licence was suspended. This would identify this as a sensitive topic,” the coroner said.
"One path around this apparent obstruction is identifying an independent clinical service to assess drivers,” the coroner noted.
This case highlights the importance for doctors to consider the fitness to drive standards carefully when assessing a patient’s fitness to drive and check whether there are any features of the patient’s condition which require specialist input before making an assessment. It not only emphasises the importance of having frank discussions about fitness to drive, but also acknowledges the difficulties this can raise in the context of maintaining a continued, trusting treating relationship.
Ultimately, it is up to the licensing authority to determine whether a patient is fit to drive, based on the treating doctor’s clinical assessment. However, if a doctor clears someone fit to drive against the standards and the driver has an accident, the doctor may be open to criticism. Therefore, it is necessary to document the clinical assessment appropriately, including the advice and information given to the patient about their fitness to drive and review period.
If you need guidance on your reporting obligations in relation to fitness to drive assessments, please visit Avant’s Medico-legal Advisory Service website, contact us on firstname.lastname@example.org or call 1800 128 268, 24/7 in emergencies.
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