On 7 December 2015 the final report of Sheriff Beckett QC's Fatal Accident Inquiry (FAI) into the deaths of John Sweeney, Lorraine Sweeney, Erin McQuade, Stephenie Tait, Gillian Ewing and Jacqueline Morton was published. The six were pedestrians in Glasgow city centre on 22 December 2014 when a Glasgow City Council bin lorry veered out of control, mounted a pavement and crashed, killing them and injuring a further 15 people in the vicinity.
Council employee Henry (Harry) Clarke was at the wheel of the lorry when he lost control, having suffered an episode of neurocardiogenic syncope, a temporary loss of consciousness resulting in a faint.
Sheriff Beckett identifies 8 reasonable precautions, which, if taken, could have prevented the accident. All relate to Mr Clarke's previous medical history, and specifically, an earlier faint suffered by Mr Clarke in 2010.
Sheriff Beckett also makes 19 recommendations to doctors, Glasgow City Council, local authorities in general, the DVLA and the Secretary of State for Transport.
In addition to implications for medical professionals, the DVLA and Glasgow City Council, the findings will also be of interest to other local authorities and employers where people regularly drive in the course of their work.
The circumstances of the incident were examined through a fatal accident inquiry (FAI) held at Glasgow Sheriff's Court.
It was established that, prior to his employment with Glasgow City Council, Mr Clarke, aged 58, worked for First Glasgow as a bus driver. In April 2010 he suffered a fainting episode whilst driving a bus.
He resigned from First Glasgow whilst suspended from his duties and later secured employment with Glasgow City Council.
On 22 December 2014 Mr Clarke was driving the Council bin lorry, accompanied by two crew members, who were responsible for collecting the refuse. He had begun his shift at 6am and was due to finish at 3.30pm. No concerns were identified in relation to Mr Clarke in the course of that day.
As it was driving along Queen Street in Glasgow city centre, the crew felt the lorry veer to the left and saw that Mr Clarke was slumped in his seat. He failed to respond to shouted warnings and the lorry gained speed before mounting the pavement and colliding with pedestrians, before striking a wall and coming to a halt around 19 seconds later.
Mr Clarke and the two crew members sustained minor injuries. Six pedestrians were killed and an additional 15 were injured.
Sheriff Beckett identified a number of precautions which may have prevented the deaths, centred on the previous fainting episode experienced by Mr Clarke in April 2010.
Five of these precautions related to Mr Clarke personally. It was identified that Mr Clarke could have told doctors the truth about the fainting episode and given an accurate account of his history in medical and occupational health questionnaires. He also could have notified the DVLA and refrained from continuing to drive buses and seeking further employment in the same area.
It was also identified that the doctors concerned could have advised Mr Clarke to notify the DVLA and clarified with him the circumstances of the 2010 faint.
Sherriff Beckett also identified that the deaths may have been avoided if First Glasgow had provided a "full, accurate and fair employment reference" to Glasgow City Council.
Sheriff Beckett identified 19 recommendations to reduce the chance of reoccurrence of such an incident.
The specific recommendations to Glasgow City Council include:
- It should not let drivers commence work before references are checked
- It should carry out an internal review of its employment processes with a view to improving checks on medical and sickness absence information
- It should provide crews with basic information about the steering and braking controls of vehicles
- It should, where possible, identify routes in which, in the event of an incident, the number of people at risk would be minimised
More general recommendations for local authorities and other refuse collectors were:
- To seek, wherever practical, to have automatic emergency braking systems (AEBS) fitted to vehicles
- To take into account in risk assessment the potential for the presence of exceptional numbers of pedestrians at particular times
Sheriff Beckett also made recommendations to doctors, the DVLA and Secretary of State for Transport around fitness to drive.
The findings of the report are primarily concerned with the fitness of an individual to drive. Sheriff Beckett comments that "the most effective measure to prevent such an occurrence would be to seek to avoid drivers becoming incapacitated at the wheel. Responsibility in that regard lies with drivers themselves and DVLA."
However, employers should be mindful of the precautions and recommendations, particularly in relation to the need to carry out checks before allowing drivers to start work, giving consideration to the fitting of AEBS to vehicles, and factoring into risk assessments the issue of the risk to pedestrians along driver routes.