SAcommunity

Coroner's Finding: SMORDOWSKI Edmund

Deceased

Edmund Smordowski

Demographics

63y, male

Date of death

2012-06-16

Finding date

2016-09-19

Cause of death

blunt head and chest trauma from motor vehicle collision

AI-generated summary

Edmund Smordowski, a 63-year-old cyclist, was struck from behind by an 83-year-old driver, Kevin Rice, and died from blunt head and chest trauma. The collision occurred because Rice was unable to maintain his vehicle within the marked lane, and was driving erratically despite a clear road with visible cyclist. Rice had failed two practical driving assessments that year but was permitted a third test after 50 minutes of instruction and minimal further lawful driving. He narrowly passed the third test and his licence was reinstated by the Registrar, who failed to appreciate that Rice had demonstrated incompetence in two egregious failures and had not adequately remedied identified faults. The coroner identified critical procedural failures in licence reinstatement processes: different assessors were used across three tests (preventing proper contextualisation of deteriorating performance), inadequate medical input was sought from his GP between tests, eyesight testing was unreliable, and the Registrar applied an incorrect legal standard—looking for evidence of incompetence rather than requiring positive proof of competence after demonstrated failure. Had assessment protocols been more rigorous and consistent oversight exercised, this death would likely have been prevented.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

general practiceophthalmology

Error types

proceduralsystemcommunication

Contributing factors

driver Rice's erratic and unsafe driving behaviour, including failure to maintain vehicle within lane
driver Rice's inability to drive at reasonable speed and habitually driving well below speed limit
driver Rice's failure to keep proper lookout
inadequate practical driving assessment protocols: three different assessors used instead of same assessor for consecutive tests
same route used repeatedly in three tests, allowing familiarity advantage
insufficient instruction between failed tests (50 minutes total over two months)
no evidence of remediation of demonstrated faults before licence reinstatement
Registrar applied incorrect legal standard in reinstatement decision—seeking evidence of incompetence rather than requiring positive proof of competence
inadequate medical review—no updated fitness certificate sought from GP between second test and reinstatement
unreliable eyesight testing by general practitioner with untestable methodology
no requirement for driver to demonstrate improvement through training before third test

Coroner's recommendations

Serial practical driving assessments conducted pursuant to section 80 of the Motor Vehicles Act 1959 which have involved failure or failures should be conducted by the same assessor
Serial practical driving assessments conducted pursuant to section 80 of the Motor Vehicles Act which have involved failure or failures should be conducted over different routes
Serial practical driving assessments conducted pursuant to section 80 of the Motor Vehicles Act which have involved failure or failures should invite particular scrutiny by the Registrar, especially in cases where the driver has demonstrated a propensity to drive habitually at unreasonably slow speeds with potential to create danger
The Registrar should be reminded that where a driver's licence has been suspended due to demonstrated incompetence, the onus under section 80(2a)(e) of the Motor Vehicles Act is on the driver to satisfy the Registrar of competence to drive
Where an assessor's report recommends driving only accompanied by a motor vehicle instructor, further practical assessment should only be permitted if: (a) the driver demonstrates receipt of such instruction, and (b) the instructor furnishes a report containing description of instruction provided, issues addressed, and an opinion on competence considering not only performance during instruction but known history
Where a licence has been suspended following a failed practical driving assessment, a further Certificate of Fitness should be sought from the person's medical practitioner before licence reinstatement, and the eyesight certificate should be completed by a specialist

Full text

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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

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