Coroner's Finding: RAPHAEL Daniel Buddy

20y · Male·closed head injury

A 20-year-old man on a stationary scooter was struck from behind by a van while waiting to turn right at a traffic junction in poor visibility. The driver was monocular (one eye only) due to diabetic complications and failed to detect the scooter despite its lights being illuminated. Critical failures in driver licensing procedures were identified: the registrar did not properly consider the driver's monocularity when renewing his licence in 2004, did not seek information about his commercial driving task, and did not examine his poor driving history. His eyesight was tested only by confrontation screening, not sophisticated perimetry testing despite significant laser treatment to his retina. These procedural failures meant that restrictions appropriate to night driving may not have been imposed, potentially preventing the fatal collision.