Coroner's Finding: Raines, Edward John

CORONERS COURT OF SOUTH AUSTRALIA DISCLAIMER - Every effort has been made to comply with suppression orders or statutory provisions prohibiting publication that may apply to this judgment. The onus remains on any person using material in the judgment to ensure that the intended use of that material does not breach any such order or provision. Further enquiries may be directed to the Registry of the Court in which it was generated.

INQUEST INTO THE DEATH OF EDWARD JOHN RAINES [2025] SACC 15 Inquest Findings of her Honour Coroner Giles 20 May 2025

CORONIAL INQUEST Examination of the cause and circumstances of the death of an 86-year-old man, Edward Raines, who was involved in a collision on the Karoonda Highway. The inquest examined the circumstances in which Mr Raines came to be driving given that he had been identified as not competent to hold a licence by a police officer approximately three weeks earlier.

Held:

1. Edward John Raines, aged 86 years of Mindarie, died at Halidon on 12 April 2019 as a result of multiple injuries.

2. Circumstances of death as set out in these findings.

Recommendations made.

Counsel Assisting: MR M KIRBY Interested Party: DEPARTMENT FOR INFRASTRUCTURE AND TRANSPORT & SOUTH AUSTRALIA

POLICE Counsel: MR B LU - Solicitor: CROWN SOLICITOR Witness: SGT M WRIGHT & MR S GILBERT Counsel: MS B LU – Solicitor: CROWN SOLICITOR Hearing Date/s: 25/03/2025-26/03/2025 Inquest No: 10/2023 File No/s: 0747/2019

INQUEST INTO THE DEATH OF EDWARD JOHN RAINES [2025] SACC 15 Introduction and reason for inquest Mr Edward John Raines was born on 27 October 1932 and died on 12 April 2019 in a motor vehicle collision. He was 86 years of age.

The collision occurred at approximately 1:15pm on Friday 12 April 2019 on Karoonda Highway, Halidon. The collision involved a 1998 gold Daihatsu Pyzar sedan registration number WFC253, driven by Mr Raines, and a prime mover of semi-trailer configuration, namely a 2015 white Volvo prime mover SB13KU, towing a Freightliner semi-trailer SY45AJ, which was fully laden with hay.

The collision occurred when Mr Raines, who was travelling in a southerly direction along Karoonda Highway, failed to properly negotiate a left-hand bend in the roadway, causing his car to cross onto the incorrect side the road. At that time, a semi-trailer prime mover was proceeding in a northerly direction on Karoonda Highway and negotiating a righthand bend when the two vehicles collided head-on, with the point of impact being driver’s side to driver’s side.

Mr Raines sustained fatal injuries and was declared deceased at the scene.

The death of Mr Raines was a ‘reportable death’ as defined in the Coroners Act 2003 (SA). A reportable death includes deaths by ‘unexpected, unnatural, unusual, violent or unknown cause’. An inquest was held to explore the circumstances of Mr Raines’ death.

A circumstance of Mr Raines’ death was that he had been witnessed by a police officer driving in a dangerous manner approximately three weeks prior to the fatal collision. The SAPOL officer who witnessed the driving on that earlier occasion, Sergeant Mark Wright, later that day sent a form to the Department for Transport and Infrastructure (DIT) suggesting that DIT require Mr Raines to undergo a medical assessment to determine his fitness to drive. Whilst DIT had sent a letter to Mr Raines to set into motion a medical assessment to determine his fitness to drive, as at the date of the fatal collision that medical assessment had not yet occurred, and Mr Raines was still driving. The dangers associated with Mr Raines’ driving led to a tragic outcome for Mr Raines, but also had potential to cause significant harm or death to other road users.

The reason for the inquest was to explore the delay that exists between DIT issuing a letter to a driver requiring them to have a medical assessment to determine their fitness to drive, and any action being taken if that is not acted upon. The inquest also considered whether SAPOL and/or DIT have, or should have, the ability to suspend a driver in the interim until DIT can be satisfied by medical assessment that the driver is in fact safe to drive.

[2025] SACC 15 Coroner Giles Evidence at inquest Two witnesses were called to give evidence at the inquest: Sergeant Mark Wright - In 2019 Sergeant Wright was stationed at the Berri Police • Station and was at the relevant time the Traffic Manager for the Murray Mallee Local Service Area. Sergeant Wright first encountered Mr Raines on Friday 22 March 2019 when he witnessed him driving in what he considered to be a dangerous manner. Sergeant Wright’s next encounter with Mr Raines was when he attended at the scene of the fatality on 12 April 2019.

Mr Stuart Gilbert - At the time of giving evidence Mr Gilbert was the Director of • Regulation for DIT, a position he had held for just over 5 years. He had been employed by DIT (or its predecessor) since the mid-1980s.

In addition to the oral evidence of those witnesses, affidavits were received into evidence from the following people: Ms Tammy-Lee Hissey, daughter of Mr Raines • Dr Neil Langlois, Consultant Forensic Pathologist, Forensic Science SA (FSSA) • Lauren Geirer, Forensic Scientist, FSSA • Stephen Trobbiani, Forensic Scientist, FSSA • Graeme Morris, civilian witness • Catherine Jansse, civilian witness • Craig Dunkin, civilian witness • Kenton Millikin, driver of the prime mover • Justin Cooper, Brevet Sergeant, SAPOL • Samuel Petters, Senior Constable, SAPOL • Paul Zilm, Brevet Sergeant, SAPOL • The Court also received into evidence the SAPOL Major Crash Investigation Unit fatal collision report.

In this Finding I shall not summarise all the evidence tendered or heard at the inquest but refer to it only in such detail as appears warranted by its forensic significance and the interests of narrative clarity. It should not be inferred from the absence of reference to any aspect of the evidence that it has not been considered.

The standard of proof to be applied in making coronial findings is the civil standard, the balance of probabilities. In considering making findings which imply or express criticism of individuals, I am guided by the principles enunciated in Briginshaw v Briginshaw1 and I shall not make such a finding unless the evidence leads me to a comfortable level of satisfaction that the finding should be made.

1 (1938) 60 CLR 336

[2025] SACC 15 Coroner Giles Mr Raines’ background Mr Raines was a father to eight children, and a grandfather and great-grandfather. He lived in a caravan on the property of his daughter, Tammy-Lee Hissey, for 27 years. The property was on the Karoonda Highway in Mindarie.

Ms Hissey provided an affidavit to the Court.2 She stated that her father needed some extra assistance in the months leading up to his death. She noticed he had lost some weight and was becoming unsteady on his feet and had begun to have falls. He was beginning to forget things and his personal hygiene was beginning to become challenging.

Mr Raines reportedly only drove his vehicle once a fortnight into Berri for shopping.

Mr Raines reportedly wore prescription glasses from the age of about 16 years old, including for driving. He had a medical history including hypercholesterolaemia, hypertension, osteopenia and prostate cancer.

The fatal collision Karoonda Highway is a semi-rural highway, which extends generally north-south between Loxton to the north and Murray Bridge to the south. In the vicinity of the collision scene, Karoonda Highway has two lanes, one southbound and one northbound.

It was constructed of bitumen and generally in a reasonable state of repair. At the time of the fatal collision, the speed limit for that section of road was signposted at 100 kilometres per hour (km/h).

Mr Raines was the driver and sole occupant of the Daihatsu sedan. The other vehicle involved in the collision was the Volvo prime mover. Whilst there were no independent witnesses to the actual collision, a number of civilians observed Mr Raines’ driving in the lead up to the collision.

Mr Graeme Tonkin Mr Tonkin from Queensland observed Mr Raines’ vehicle driving slowly along the Karoonda highway in a generally southerly direction, driving over onto the dirt shoulder of the road and also across the white lines in the centre of the road. Mr Tonkin quickly overtook Mr Raines, not feeling safe driving behind him. As he passed, he observed Mr Raines driving hunched forward close to the steering wheel. Mr Tonkin soon observed Mr Raines rapidly approaching from behind. In his estimate Mr Raines was travelling at about 110 km/h. Mr Raines overtook Mr Tonkin, without slowing down, causing two vehicles coming in the opposite direction to swerve to their left to avoid colliding with him. Mr Tonkin then saw Mr Raines drive away, increasing the distance between them. Mr Tonkin saw Mr Raines cross the centre lines onto the wrong side of the road on about six more occasions. Mr Raines’ vehicle was lost to view, but shortly after Mr Tonkin came upon the collision where Mr Raines had collided head-on with a truck coming from the opposite direction.3 Ms Catherine Janssen Ms Janssen from Loxton was driving north along the Karoonda Highway. As she drove up a slight incline, she was forced to brake heavily and veer off to the side of the road to 2 Exhibit C1a 3 Exhibit C5

[2025] SACC 15 Coroner Giles avoid Mr Raines’ vehicle which had drifted over onto the wrong side of the road and was rapidly approaching her. She did not see Mr Raines make any effort to avoid her or correct his path.4 Mr Craig Dunkin Mr Dunkin was driving a Toyota Prado towing a large camper trailer from Adelaide in a northerly direction along the Karoonda Highway, having just passed through Halidon. As he drove around a right-hand bend he observed Mr Raines’ vehicle coming towards him, on the wrong side of the road across double white lines. Mr Dunkin was forced to veer off the road to the left to avoid Mr Raines, who gave no indication that he had even seen Mr Dunkin’s vehicle.5 Mr Kenton Millikin Mr Millikin was the driver of the truck that was involved in the collision with Mr Raines.

He was driving a Volvo prime mover with a semi-trailer loaded with hay bales along the Karoonda Highway in a northerly direction when he observed Mr Raines’ vehicle approaching. He initially thought Mr Raines was on the wrong side of the road but could not be sure as he was observing Mr Raines’ vehicle from around a bend and slightly over a crest. Mr Millikin deactivated the cruise control and the exhaust brakes and covered the foot brake. As Mr Raines rounded the bend of the road towards Mr Millikin, it was clear he was entirely on the wrong side of the road. Mr Millikin steered left off the road to avoid Mr Raines’ vehicle, but was unable to completely leave the roadway due to a one metre drop-off on the side of the road. He observed Mr Raines steer to the left, back towards the correct lane, however it was too late to avoid a collision. The front right corner of each vehicle struck the other, and Mr Millikin’s truck rolled and came to a stop on the highway. Mr Millikin was able to extricate himself from his truck through the front windscreen, shaken by the collision but not seriously injured.

Mr Raines’ vehicle suffered catastrophic damage to the front right side. Mr Raines was located deceased in the driver’s seat.6 Cause of death A post mortem examination was conducted at Forensic Science South Australia by forensic pathologist, Dr John Gilbert. Dr Gilbert identified the cause of death as ‘multiple injuries’. I so find.

Dr Gilbert opined that it was possible that Mr Raines’ aberrant driving might have resulted from ischaemic heart disease. However, Mr Raines’ driving history, the observations of Sergeant Wright on 22 March 2019, the observations of other drivers on this day, and the opinion of his daughter that he was never a very good driver, would suggest that his driving on this day was not the result of any acute heart issue, and was not an isolated incident.

Toxicology did not detect any alcohol or drugs in either driver.7 4 Exhibit C6 5 Exhibit C7 6 Exhibit C8 7 Exhibits C3 and C4

[2025] SACC 15 Coroner Giles SAPOL Major Crash Investigation Senior Constable Petts of the Heavy Vehicle Enforcement Section of SAPOL attended the collision scene and examined the semi-trailer involved and conducted an examination of the work diary used by the driver, Mr Millikin. Senior Constable Petts concluded that Mr Millikin was not driving beyond his requirements for work safety, fatigue was not an issue, nor was the truck overloaded.8 Troy Sage is a qualified mechanic who was at the relevant time a Vehicle Examiner attached to the SAPOL Major Crash Investigation Section. He carried out an examination of both vehicles involved in the collision and concluded that both vehicles had been in a reasonable condition prior to the collision. He could find nothing mechanically wrong that would have caused or contributed to the collision.

Brevet Sergeant Zilm conducted the major crash investigation and crash reconstruction.

He collated data from road markings, vehicle positions and debris, as well as witness statements. The approximate point of impact between the vehicles was in the approximate centre of the northbound lane.9 The road condition was fair and dry. Brevet Sergeant Zilm concluded that the collision occurred when Mr Raines’ vehicle crossed onto the incorrect side of the road when negotiating the left bend, and into the path of Mr Millikin’s prime mover. I so find.

Mr Raines’ driving in March 2019 On 22 March 2019, some weeks before the fatal collision, Mr Raines’ driving came to the attention of Sergeant Mark Wright of SAPOL. Sergeant Wright gave evidence at the inquest and described his interaction with Mr Raines on this occasion as follows: ‘….I was travelling, the section of the road is called Bookpurnong Road in Loxton, it's on the outskirts of the township. I was travelling south into the township. It's an 80-kilometre zone bitumen road. That Saturday, a junction there is where there is a BP On The Run, a service station. So as I was approaching that service station, heading south towards the township of Loxton, travelling at 80 km/h, doing the speed limit, I saw Mr Raines' vehicle.

He was on my left, where the service station was. He was - I could see him at the end of the forecourt, what's known as the forecourt, at the end of a BP - of a service station, which sort of borders the edge of the road. So basically, as I was driving, I could see him at the edge of that forecourt about to turn left onto Bookpurnong Road. As I got closer, probably within, you know, 30 metres, maybe closer, from memory, Mr Raines drove out, pulled out onto Bookpurnong Road to turn left to go further south, so he pretty much pulled in front of me, caused me to brake heavily, I had to swerve so that I didn't cause a T-bone collision.

Otherwise, I would have collected him probably somewhere near the driver's side or near the rear of his car. So braked heavily, avoided the collision, and Mr Raines continued further down the road where I proceeded to stop him.’10 His evidence was that he travelled behind Mr Raines for approximately one kilometre, with his lights activated in an attempt to get Mr Raines to pull over, before Mr Raines complied.11 Sergeant Wright’s impression was that Mr Raines simply had not realised 8 Exhibit C10 9 Exhibit C12 at [46] 10 Transcript, page 13 11 Transcript, page 19

[2025] SACC 15 Coroner Giles that he was behind him, attempting to pull him over, until just before he obeyed that direction.12 Sergeant Wright’s evidence was that once Mr Raines had pulled over, he had a conversation with him about what had occurred. As far as Sergeant Wright was aware, he had not had any prior dealings with Mr Raines. He described Mr Raines as looking a bit dishevelled and untidy. He said that he explained to Mr Raines that the reason that he had stopped him was because he had pulled out in front of him and nearly caused a collision. Mr Raines stated that he had had not seen Sergeant Wright’s car when he pulled out. Mr Raines showed Sergeant Wright his licence, which Sergeant Wright noted had some medical conditions endorsed on it. Sergeant Wright also observed that Mr Raines was wearing glasses at this time. This interaction lasted for about 10 to 15 minutes.

Sergeant Wright cautioned Mr Raines for failing to give way. In addition, Sergeant Wright decided he would submit a form known as a PD596 referral for Mr Raines. A PD596 is a form entitled ‘Referral for a medical review for SA driver’s licence’ that is used by SAPOL officers to refer drivers to DIT if an officer is concerned that a medical condition is affecting a driver’s fitness to drive.

Sergeant Wright explained that he completed the PD596 at the end of his shift that day and that his reason for doing so was: ‘I guess the main thing is his inability to recognise that I was coming towards him down the road and I guess the judgement of him not being able to determine the distance and travelling time of another vehicle coming towards him. Having some - once I realised - he had some medical conditions as well, there's a possibility that maybe that medical condition could have contributed to his reaction time or the way he perceives the traffic on the road.

I guess just generally him being unaware of my position on the road and then the position after that where it took him some time to recognise a police vehicle behind him even with

• even though I was in an unmarked car - with all the lights and everything flashing they are still very quite prominent on the road. And when you see someone - you know generally as a rule - you know I've stopped lots of people over time in an unmarked police vehicle with the lights going and most people are fairly respondent within a quick point of time so.’13 Sergeant Wright expressed that the driving he observed by Mr Raines was ‘absolutely a danger to the road’.14 Yet, despite that, he formed the view that the driving he observed by Mr Raines did not satisfy the elements of the offence of ‘driving in a manner dangerous’. Sergeant Wright’s evidence was that, having formed the view that Mr Raines had not committed an offence for which immediate suspension of his licence was a potential consequence, he had no power or authority to immediately prevent Mr Raines from driving,15 but if he did have that power, he probably would not have let Mr Raines drive home.16 Sergeant Wright did not see Mr Raines on the road again until the day of the fatal collision. On that day, 12 April 2019, Sergeant Wright was tasked to a fatal collision on 12 Transcript, page 19 13 Transcript, page 18 14 Transcript, page 24 15 Transcript, page 29 16 Transcript, page 30

[2025] SACC 15 Coroner Giles Karoonda Highway and he arrived at 2:45pm. When he arrived, he observed a prime mover with a single flatbed trailer attached carrying large square bales of hay. The trailer was tipped on its left side with the hay remaining secured by strapping and the prime mover remained upright on its wheels. Approximately 30 metres southwest of this vehicle was a gold Daihatsu sedan registration WFC253 lying on its driver’s side.

Sergeant Wright identified this as the vehicle belonging to Mr Raines. Mr Raines was present in the front of the vehicle, obviously deceased. Sergeant Wright assumed Forward Commander responsibilities at the scene and assisted with the removal of Mr Raines from the vehicle.

Registrar of Motor Vehicles - power to ensure fitness to drive The Registrar of Motor Vehicles has functions and powers which aim to ensure that drivers are medically fit to drive, and capable of driving safely.

In accordance with Section 80 of the Motor Vehicles Act 1959, the Registrar may require a driver to undergo tests, or to furnish evidence of their ability or fitness to drive in certain circumstances.

Section 80 of the Motor Vehicles Act 1959 reads as follows: ‘Ability or fitness to be granted or hold licence or permit (1) If in the opinion of the Registrar it is desirable that the ability or fitness of an applicant for the issue or renewal of a licence or learner's permit, or of the holder of a licence or learner's permit, to drive a motor vehicle, or a motor vehicle of a particular class, should be assessed, the Registrar may require the person to undergo such assessments or to furnish such evidence of ability or fitness to drive as the Registrar directs.

(1a) The Registrar may, with the approval of the Minister, direct that all applicants for the issue or renewal of a licence or learner's permit who are of a particular class, or all holders of a licence or learner's permit who are of a particular class, must undergo such assessments, or furnish such evidence as to ability or fitness to drive a motor vehicle, or a motor vehicle of a particular class, as the Registrar may require.

(1b) The Registrar may, in directing a person to undergo an assessment under this section, require that the assessment be undertaken at a particular location or by a particular person or body determined by the Registrar.

(2) For the purposes of this section, an assessment undertaken to assess a person's ability or fitness to drive a motor vehicle, or motor vehicle of a particular class, must comply with guidelines published or adopted by the Minister by notice in the Gazette and the results of such an assessment must be applied by the Registrar in accordance with any policies published or adopted by the Minister by notice in the Gazette.

[2025] SACC 15 Coroner Giles (2a) If—

(a) a person fails to comply with a requirement of the Registrar under this section; or

(b) the Registrar is satisfied—

(i) after considering the results of assessments or evidence required under this section; or (ii) from information furnished to the Registrar by a health professional or from any other evidence received by the Registrar, that a person is not competent to drive a motor vehicle or a motor vehicle of a particular class, the Registrar may—

(c) refuse to issue a licence or permit to the person; or

(d) refuse to renew the person's licence or permit; or

(e) suspend the person's licence or permit for such period as the Registrar considers necessary in the circumstances of the case, or until the person satisfies the Registrar, in such a manner as the Registrar directs, that the person is competent to drive a motor vehicle; or

(f) remove a classification assigned to the person's licence, or substitute for a classification assigned to the person's licence another classification.

(3) The Registrar may issue to any person who has been required to undergo assessments, or to furnish other evidence of ability or fitness to drive a motor vehicle, a temporary driving permit authorising that person, subject to such conditions and restrictions as may be specified in the permit, to drive motor vehicles.

(4) A temporary driving permit has, subject to any conditions and restrictions specified in the permit, effect as a licence.

(5) A person must not contravene any condition or restriction of a temporary driving permit.

Maximum penalty: $1 250.’ As at March and April 2019, DIT had policy in place called ‘Licencing Topic 38 – Medical Review’.17 That policy stated that licence holders were required to undertake a medical examination and provide a certificate of fitness in the following circumstances: On the initial issue of a learner’s permit or driver’s licence, where the applicant • has declared a medical or physical condition or that they are taking medication that may impair driving; Generally, where the applicant or holder of a learner’s permit or driver’s licence • is taking medication for treatment of a medical condition; Where the holder of a driver’s licence is aged 70 years or more.

• The policy stated that ‘licence holders aged 70 years or more are required to submit a certificate of fitness each year’. The policy further states that ‘essentially, the determination of a person’s fitness to drive rests with the medical practitioner’.

17 Exhibit C20

[2025] SACC 15 Coroner Giles Where a medical test is required, section 80(2) of the Motor Vehicles Act outlines that the tests must be undertaken as outlined in guidelines approved and published by the Minister.

Guidelines for Assessing Fitness to Drive The guidelines for Assessing Fitness to Drive (AFTD) contain the medical standards for licensing and clinical management guidelines and is published by Austroads. Austroads is governed by a Board consisting of senior executive representatives from each of its member organisations, including each State and Territory in Australia, the Commonwealth, and New Zealand. The AFTD are accepted and used in all Australian States. The National Transport Commission undertakes reviews of the guidelines periodically. The guidelines for AFTD have been approved and gazetted by the Minister in South Australia for the purpose of the Motor Vehicles Act 1959 (SA).18 The guidelines for AFTD allow medical practitioners to establish the relevance of certain medical conditions and the impact these conditions have on a person’s ability to drive.

They also assist licensing authorities in making licensing decisions. The guidelines for AFTD set out the steps involved in assessing a person’s fitness to drive, including specific considerations for the assessment of people with multiple medical conditions or agerelated change.

Mr Raines’ licence history Since 2006 Mr Raines had annually submitted medical certificates to DIT to verify his medical fitness to drive, as mandated for drivers over the age of 70.19 Mr Gilbert’s evidence was that documentation held by DIT suggested that Mr Raines was very compliant with that requirement and indicated he would attend the same clinic in Loxton in September/October each year to obtain his certificate.

From 2006 until 2018 Mr Raines was assessed by a medical practitioner as being fit to hold a driver’s licence.

The final medical assessment to determine fitness to drive prior to Mr Raines’ death was on 3 September 2018. The Medical Practitioner’s Declaration (MPD) from this consultation, completed by Dr L Mackinnon of Loxton, records that Mr Raines met the relevant driving standard, that he did not require a practical driving test, that glasses or contacts were not required for driving, and that his licence should not be subject to a condition.20 This is a curious outcome given that the MPD from 12 months prior stated that Mr Raines did require glasses or contacts for driving, and recommended a condition that he must wear corrective glasses when driving. In fact, that had been the outcome of each of the fitness to drive medical assessment for Mr Raines since 2014.

However, the fact that the MPD of 3 September 2018 stated that Mr Raines did not require glasses or contacts for driving, and that he did not need a condition on his licence of such, appears to have been of no consequence. When Sergeant Wright pulled Mr Raines over on 22 March 2019, he noted he was wearing glasses and recorded on the PD596 that 18 Motor Vehicles Act section 80(2) - South Australian Government Gazette, No. 92, 29 September 2003, p. 3661 19 The evidence of Mr Gilbert was that earlier certificates had possibly also been provided, but that DIT were able to locate certificates from 2006 onwards (Transcript, page 38) 20 Exhibit C21

[2025] SACC 15 Coroner Giles Mr Raines’ licence, which was valid until 1 September 2020, had a condition that he wear corrective lenses. Thus, despite what was recorded in the MPD of 3 September 2018, that condition remained on Mr Raines’ licence, and he seemingly continued to wear glasses when driving. I am also satisfied that Mr Raines was wearing glasses at the time of the fatal accident as Mr Craig Dunkin21 described seeing Mr Raines wearing ‘black rimmed glasses’ as he avoided a collision with him shortly before the fatal accident.

Ultimately, the inquest did not focus on the previous assessments of fitness to drive or the adequacy of those previous assessments, as Mr Raines had not had an assessment for more than seven months prior to his death. It is not helpful to speculate whether any new medical conditions may have presented, or previously identified medical conditions deteriorated since that time. Indeed, it is a possibility that any deterioration in his health post his last assessment was significant, given his daughter’s description of his general decline over the months leading up to his death. This illuminated the issue of what occurs when it comes to the attention of SAPOL that a person with a current certificate of fitness to drive from a medical practitioner may no longer be fit to drive.

Of note, the evidence revealed that Mr Raines had likely not undertaken a practical driving assessment since first obtaining his licence. The MPD form contains a box which states ‘requires a practical driving assessment’ with a ‘yes’ or ‘no’ tick box option. In relation to the MPD provided to DIT for Mr Raines from 2006 onwards, ‘no’ was ticked on every occasion. The evidence from Mr Gilbert was that if the medical practitioner does not recommend a practical driving assessment, then DIT does not mandate one at any other time for a licence holder, unless they are over the age of 85 and looking for a class of licence to drive a vehicle other than a car (which Mr Raines was not). Indeed, there was nothing to suggest that Mr Raines had had a practical driving assessment at any time other than when he first got his driver’s licence.

Powers of SAPOL officers when observing driving of concern Although SAPOL is not expressly permitted, or required, under section 80 to refer drivers to DIT for the purpose of requiring the driver to undergo a medical assessment or produce evidence of their ability or fitness to drive, the PD596 serves as the mode of communication of concern about an individual’s medical fitness to drive from SAPOL to DIT if an officer is concerned that a medical condition is affecting a driver’s fitness to drive.

SAPOL officers are required to complete a PD596 where: a driver who is of or above 70 years of age is at fault in a collision (not including • property only collisions reported online); or it is suspected that a medical episode or other medical condition might have caused • or contributed to a collision (regardless of a person’s age).

SAPOL officers may also complete and submit a PD596 referral if they suspect a person’s medical condition is affecting that person’s driving fitness, as Sergeant Wright did in relation to Mr Raines.

21 Exhibit C7

[2025] SACC 15 Coroner Giles Whilst police officers have the power to suspend a person’s driver’s licence in certain circumstances, that does not include a situation where they suspect a person’s medical condition is affecting that person’s fitness to drive. In the circumstances where a police officer may issue an immediate suspension of licence, such as in respect of speeding and drink/drug driving offences under the Road Traffic Act 1961 and the Criminal Law Consolidation Act 1935, the prerequisite to the exercise of the power is, typically, that the SAPOL officer believes or suspects that a relevant offence has been committed. For example, if a driver submits to a drug screening test which indicates the presence of a prescribed drug in the person’s blood or oral fluid, the SAPOL officer is able to form a reasonable suspicion that a relevant offence has been committed. It is clear that, based on the General Order, Immediate Loss of Licence dated December 2018 that as the time of his interaction with Mr Raines on 25 March 2019, Sergeant Wright did not have the power to issue an immediate loss of licence.22 Process following submission of a PD596 to DIT in March/April 2019 As at March 2019, DIT had a policy in place called Licencing Topic 38 – Medical Review.23 The following sets out the procedure at that time once a PD596 was sent from SAPOL to DIT.

SAPOL would email the PD596 directly to DIT Licence Regulation. The Senior Regulation Officer (SRO) would triage the emails received to that inbox each day as they were received.

The SRO would assess all received PD596 forms.

Upon review of the PD596, the SRO would place a message on the relevant client's record in the Transport Regulation User Management Processing System (TRUMPS)24 and the record would be frozen to prevent the client from transacting any business with DIT.

A letter was created and sent to the client requesting them to contact Licence Regulation within seven days of the date of the letter to advise the details of their treating doctor (first letter).

If the client did not respond to the letter within seven days, a further letter (second letter) was sent to the client providing them with a further seven days from the date of the letter to advise the details of their treating doctor.

If the client responded to either letter and provided Licence Regulation with details of their treating doctor, a letter would be sent to both the client and their treating doctor requesting a certificate of fitness be completed and provided within 14 days of the date of the letter. A blank certificate of fitness and a copy of the PD596, with the details of the reporting police officer and any witness details redacted, was provided with the letter to the client's treating doctor only.

22 Exhibit C25 23 Exhibit C20 24 An IT system which stores the register of drivers’ licences and vehicle registrations, among other things. It is used to process applications, calculate fees and it has business rule validations to ensure compliance with legislative and policy requirements.

[2025] SACC 15 Coroner Giles If the client did not respond to the second letter, a further letter (third letter) was sent to the client advising that if they did not provide the details of their treating doctor within seven days of the date of the letter their driver's licence would be suspended. The suspension would not be lifted until the completed certificate of fitness was provided.

If the client did not respond to the third letter, a further letter would be sent to the client advising that the suspension of their driver's licence would commence 10 days from the date of the letter.

If a certificate of fitness was received within the requested timeframe, the following actions were taken by the SRO: An entry was made in the client's record in TRUMPS and their record was • unfrozen, allowing them to transact any business with DIT.

If the certificate of fitness indicated the client was not fit to drive, their driver's • licence was suspended and the client and the treating doctor were advised by letter.

If the certificate of fitness indicated the client was medically fit, but required a • practical driving assessment, the client was notified by letter providing the steps to undertake the assessment.

If the certificate of fitness indicated the client was medically fit, the client was • notified by letter that no further action was required.

If the certificate of fitness indicated that the client was medically fit, subject to • ongoing review due to medical conditions, the client was notified by letter.

The SRO maintained a spreadsheet where the client's details were recorded for the purpose of monitoring those clients who had not responded to their letters.

All letters sent by Licence Regulation as part of this process were sent by Australia Post’s regular mail service to the client’s nominated postal address as recorded on the client’s record in TRUMPS.

Actions taken regarding the PD596 submitted by Sergeant Wright The PD596 completed by Sergeant Wright was received by DIT on 25 March 2019.

Within 24 hours of its receipt DIT sent a letter to Mr Raines indicating that they had received a report from SAPOL raising concerns about his fitness to drive and requiring him to provide contact details for his treating doctor.

This letter was sent via regular mail. DIT utilises regular mail as its primary method of communication, primarily due to the fact that DIT does not have email addresses for all clients and, in any case, not all clients possess an email address. In fact, Mr Gilbert gave evidence that DIT holds email addresses for fewer than 48% of drivers aged over 70 years.

I do observe that relying solely on regular mail to convey important messages, such as a requirement to undergo a medical assessment or an associated license suspension, may present several issues. Mail sent via regular post can be subject to delays in delivery, or sometimes even loss, such that the intended recipient may not receive the message in a timely manner, or at all. Furthermore, there is no guaranteed confirmation that the recipient has received or read the letter.

[2025] SACC 15 Coroner Giles At the scene of the fatality, Sergeant Wright located in Mr Raines’ vehicle a letter from DIT stating that he needed to have a medical assessment to assess his fitness to drive.

Thus, whilst I am satisfied that Mr Raines clearly received the letter from DIT, there is no evidence upon which I can be satisfied as to the date of receipt of that letter.

As at the date of the fatal accident, 12 April 2019, 17 days had passed since Sergeant Wright had issued the PD596, and 16 days since DIT sent the first letter to Mr Raines.

DIT has no record of a response to that letter from Mr Raines.25 According to the DIT process in place at the time, once seven days passed from the first letter with no contact from Mr Raines, a second letter should be sent. DIT has no record of a second letter being sent to Mr Raines.26 I am satisfied that a second letter was not sent to Mr Raines, despite the fact that 17 days had elapsed since the first letter.

It is unhelpful to speculate on how events might have unfolded had a second letter been sent to Mr Raines. It remains unknown when Mr Raines received the first letter, whether he had sufficient time to act upon it and, had a second letter been sent, when it may have arrived or been opened by him.

As a result of the process in place as at March and April 2019, there was a minimum period of 31 days between sending of the first letter and the suspension of a licence in circumstances where the licence holder failed to provide a medical certificate confirming their fitness to drive. Mr Raines’ case clearly illustrates that, in some instances, that timeframe may be surpassed. During this period the licence holder would be permitted to continue driving. That is a significant period of time to have a driver on the road in circumstances where SAPOL have flagged their concerns about that person’s fitness to drive. In some circumstances, such a driver may place themselves and other road users at risk of death and/or serious injury each time they get behind the wheel while awaiting completion of the medical review process.

Was it appropriate for Mr Raines to be driving in the interim?

Section 80 of the Motor Vehicles Act does, and did as at March and April 2019, vest in the Registrar the power to suspend a driver’s licence in various instances. In particular, in accordance with Section 80(2a)(b)(ii), if the Registrar is satisfied from information furnished to the Registrar by a health professional or from any other evidence received by the Registrar that a person is not competent to drive a motor vehicle or a motor vehicle of a particular class, the Registrar may do a number of things including suspending the person’s licence or permit for such period as the Registrar considers necessary in the circumstances of the case, or until the person satisfies the Registrar, in such manner as the Registrar directs, that the person is competent to drive a motor vehicle.

Within the ambit of that section of the Act, it was open to the Registrar to review the PD596 submitted by Sergeant Wright and suspend Mr Raines’ licence until the Registrar was satisfied in such manner as the Registrar directs, that Mr Raines was competent to drive a motor vehicle. That could have entailed suspension pending a medical assessment, or a practical driving assessment, or both. Whilst Mr Gilbert agreed that the 25 Exhibit C24 26 Exhibit C24

[2025] SACC 15 Coroner Giles legislation gives the Registrar the discretion to take such action, his evidence was that it is not something that is done by DIT in accordance with its policy position.27 The evidence provided by Sergeant Wright to DIT about Mr Raines’ driving ability should have caused concern to any reader about Mr Raines continuing to drive for a period of a medical review playing out. Sergeant Wright recorded on the PD596, under the heading ‘SAPOL Recommendation’, that he ‘formed the opinion that Raines is not a competent driver, cannot react quickly and has no perception of his driving surrounds’.28 Had DIT explored this concern further with Sergeant Wright, it may be that the threshold for a decision by the Registrar under section 80(2A)(ii) would have been satisfied, if indeed it was part of the policy of DIT at the time to contemplate whether any interim action needed to be taken pending the outcome of a medical review. As it was not, those concerns of Sergeant Wright were simply taken on board as a reason to refer Mr Raines for a medical fitness to drive assessment, which occurred. Consideration was not given to whether his licence should be suspended in the interim, despite the fact that information suggested that he posed a risk to himself or others by continuing to drive, simply because DIT policy was such that that was not the way the process worked.

While I am not definitively stating that Mr Raines’ licence should have been temporarily suspended pending a medical assessment—and I acknowledge that more evidence than what Sergeant Wright recorded on the PD596 would be needed to inform such a decision—I am of the view that the Registrar does have the legislative power to suspend a licence upon receipt of concerns reported by the police, until the Registrar is otherwise satisfied of that person’s fitness to drive. However, the DIT process at the time for responding to PD596 notices did not (and still does not) involve a consideration of whether any interim measures need to be taken while the medical review process following submission of a PD596 unfolds.

Changes to the PD596 process since Mr Raines’ death The process that occurs within DIT upon receipt of a PD596 has gone through various changes since the time of Mr Raines’ death. The procedure currently followed by Licence Regulation staff when processing a PD596 is detailed in the document entitled ‘How to process a Referral for Medical Review For SA Driver's Licence (SAPOL)’.29 This process was implemented in June 2023.

Under this process, SAPOL emails the PD596 referral directly to Licence Regulation. A Licence Regulation Coordinator or Team Leader then triages incoming emails daily to assess whether each case involves what is considered to be a high-risk or low-risk client.

The risk assessment is based on the information available at the time. For example, a low-risk case may involve a minor incident such as a car park bump or scratch, with no prior medical concerns. In contrast, a high-risk case may involve serious factors such as injury, risk to life, mental health concerns, significant vehicle damage, prior medical issues on record, or if the client holds a heavy vehicle licence.

Once triaged, the PD596 referral is allocated to a Licence Regulation team member for action. The team member reviews the PD596 and places a message on the client's record 27 Transcript, page 55 28 Exhibit C18 29 Exhibit C19, SDS-1

[2025] SACC 15 Coroner Giles in the TRUMPS system. The client’s record is then frozen to prevent them from transacting with DIT until a certificate of fitness is provided. If the client holds a Passenger Transport Driver Accreditation, a notification is also sent to DIT’s Passenger Transport Accreditation team to inform them of the medical review requirement. Licence Regulation then generates a letter advising the client that they are required to undergo a medical assessment and have their treating doctor complete a certificate of fitness. A blank certificate of fitness form is enclosed with this letter.

If the client is assessed as low risk, the PD596 is not included with the letter. These clients are required to return the completed certificate of fitness within 28 days of the letter's date.

For high-risk clients, the letter includes a redacted version of the PD596 which outlines only the offence, particulars of the incident, a brief description and the doctor’s details (if available). This redaction ensures that irrelevant or sensitive information, such as personal details or witness information, is not shared with the treating doctor. These clients are also required to return the completed certificate of fitness within 28 days of the letter's date.

Licence Regulation staff use a spreadsheet to track client responses. Clients are listed on either a high-risk or low-risk follow-up sheet. This enables staff to monitor compliance.

When a completed certificate of fitness is received within the required timeframe, the client’s record in TRUMPS is updated and the freeze is lifted. This allows them to resume transactions. If the certificate states that the client is not currently fit to drive, their licence is suspended, and they are notified by letter. If the client is deemed fit or fit subject to ongoing medical review, they are advised accordingly.

If DIT does not receive a certificate of fitness within the specified timeframe, a suspension notice is sent to the client advising that their licence will be suspended 10 days from the date of the letter. The suspension remains in effect until the certificate is received. All correspondence issued by Licence Regulation as part of this process continues to be sent via regular post to the client’s postal address on file in TRUMPS, and each letter is signed by a delegate of the Registrar of Motor Vehicles.

Of note is that under the 2019 process, it would be a minimum of 31 days between DIT notifying someone of the requirement to undergo a medical assessment and their licence being suspended if a certificate of fitness to drive was not received by DIT. Under the new process, that minimum timeframe has now increased to 38 days. These additional days represent an increase in the amount of time a potentially unsafe driver may remain on the road, heightening the risk to both themselves and other road users. In my view, this amplifies the need for DIT to consider whether any interim measures need to put in place for the protection of the driver and other road users.

[2025] SACC 15 Coroner Giles Summary of findings Mr Raines died in a collision which occurred at approximately 1:15pm on Friday 12 April 2019 on the Karoonda Highway, Halidon.

The collision involved a 1998 gold Daihatsu Pyzar sedan registration number WFC253, driven by Mr Raines, and a prime mover of semi-trailer configuration, namely a 2015 white Volvo prime mover SB13KU, towing a Freightliner semi-trailer SY45AJ.

Mr Raines was observed by multiple road users to be driving in an unsafe manner in the minutes leading up to the fatality.

Mr Raines caused the collision which resulted in his death.

There were no roadway or weather conditions which contributed to the accident and both vehicles were mechanically sound.

Mr Raines’ cause of death was multiple injuries.

Mr Raines had been observed driving in a dangerous manner approximately three weeks prior by Sergeant Mark Wright.

Sergeant Wright formed the view that, as of that date, Mr Raines was not a competent driver.

Sergeant Wright advised DIT of his concerns about Mr Raines’ fitness to drive by submitting a PD596 that afternoon.

DIT responded to the receipt of the PD596, in accordance with their policy in place at that time, by sending Mr Raines a letter advising him to provide his doctor’s details as he was required to undergo a medical assessment to assess his fitness to drive.

Mr Raines had received this letter by 12 April 2019.

DIT did not receive any response to that letter from Mr Raines.

That letter was located in Mr Raines’ vehicle at the time of the fatality.

Recommendations Pursuant to Section 25(2) of the Coroners Act 2003 I am empowered to make recommendations that in the opinion of the Court might prevent, or reduce the likelihood of, a recurrence of an event similar to the event that was the subject of the inquest.

One potential recommendation that was explored through the inquest was whether SAPOL should have the power to temporarily suspend a licence following observation of concerning driving until DIT is satisfied of the person’s fitness to drive. I received into evidence a submission30 on behalf of the Commissioner of Police addressing this. SAPOL were opposed to any such legislative change, noting that it would require police officers to assess whether a driver is medically impaired—a determination they are neither trained 30 Exhibit C23

[2025] SACC 15 Coroner Giles nor equipped to make, particularly based on brief interactions or second-hand information. SAPOL also expressed concern over the lack of procedural safeguards, including the potential for appeals or court reviews of immediate suspensions, which could strain resources and increase court appearances and prosecutorial workloads.

Additionally, SAPOL noted the risk of civil claims from drivers who lose employment due to suspension, particularly in light of 2024 data indicating that a significant number of suspensions may later be withdrawn. SAPOL submitted that the current process is preferable, that is, that SAPOL submit a PD596 in defined circumstances allowing the Registrar or Licensing Regulation Manager at DIT to make informed decisions, including referrals for medical assessment or the imposition of licence conditions such as driving restrictions.

Given that the discretion exists for DIT to temporarily suspend a driver’s licence pending receipt of a medical certificate of fitness to drive, it seems that there is no need for SAPOL to have that power, particularly in light of the concerns raised by SAPOL as detailed above. A PD596 notification can serve as a means of SAPOL communicating to DIT concerns they have about a driver’s fitness to drive. The Registrar can then consider that information pursuant to Section 80 (2a)(b)(ii) in making a decision about what action needs to be taken, including suspending the person’s licence or permit for such period as the Registrar considers necessary in the circumstances of the case, or until the person satisfies the Registrar, in such manner as the Registrar directs, that the person is competent to drive a motor vehicle. I note that the guidelines for Assessing Fitness to Drive seem to contemplate that this could occur, as those guidelines specifically state that ‘the driver licensing authority will consider reports provided by health professionals, police, and members of the public, as well as crash involvement and driving histories’.31 As it is not current practice within DIT to consider, following receipt of a PD596, whether interim action needs to be taken prior to the medical assessment of fitness to drive being completed, I recommend that the Minister for Infrastructure and Transport reconsider their current practice, and incorporate into their policy within DIT that consideration be given to whether the Registrar should exercise their discretion to suspend a person’s licence pending the receipt of a medical certificate of fitness to drive in circumstances where SAPOL raises concerns about a driver’s competence.

To address the issue the delay between when a driver is advised they need to provide a medical certificate of fitness to drive, and when a person’s licence is suspended for noncompliance, Counsel Assisting urged me to make a recommendation that the agencies collaborate to enable faster sharing of information to promptly identify high-risk drivers in need of assessment, and to enable more rapid and efficient communication between DIT and their clients. In relation to information sharing, when SAPOL comes into possession of email addresses, telephone numbers, alterative addresses and the like, that should be shared with DIT to ensure they have the most current an expeditious means of contacting a client when required in relation to important licensing matters. Counsel for DIT submitted that the only recommendation I should make is that SAPOL and DIT consult with each other and review their processes with a view to expediting and improving the current PD596 process. The evidence of Mr Gilbert was that he agreed it would be ‘good to improve on that timeframe’32 and that discussions to attempt to do so 31 Assessing Fitness to Drive 2022, page 26 32 Transcript, page 60

[2025] SACC 15 Coroner Giles are underway with SAPOL.33 I am of the view that reducing that timeframe is of importance. I therefore make the following recommendation directed to the Minister for Police and the Minister for Infrastructure and Transport: That SAPOL and DIT consult and review their processes with a view to expediting and improving the current PD596 process. Part of that consultation should be improved processes for information sharing.

Counsel Assisting urged me to make a recommendation that DIT amend its current policy to require a mandatory practical driving assessment for all drivers over the age of 85 years, regardless of the class of licence held. I was advised by DIT that 1500 licence holders in South Australia that would be included in that criteria. The desirability or feasibility of such a change was not explored in any detail, nor with any expert during the course of the inquest. Therefore, in the absence of further information, I decline to make this recommendation.

Finally, it is my view that DIT should transition from relying solely on postal communication to utilising email addresses, or a combination of both, when communicating critical information about fitness to drive and licence suspension.

Electronic communication provides a faster, more reliable and traceable method of communication. Particularly in relation to suspension notices, it is my view that if electronic communication is not feasible (for example, due to the lack of a client’s email address), then police should be tasked with personally delivering the notification to ensure that the individual is properly notified, and public safety is upheld. I appreciate there are some challenges involved in process changes such as this, and as this issue did not directly arise in this inquest (as Mr Raines had at some point received the hardcopy letter he was sent), I will not make a prescriptive recommendation on this topic. However, I urge DIT to contemplate ways to move beyond regular post.

Keywords: Motor Vehicle Collision; Fitness to Drive 33 Transcript, page 60