 I'm going to talk now, this part of my presentation, about the way the Victorian licensing system works and a bit about our little driving clinic over at St Vincent's, but also there's a few little tales about the legal involvement in this and about the legal significance of driving assessment. I guess one of the risks of my job is that you tend to think like a lawyer after a while and so I've got to cover a few little issues that we've all got to think about because there is a legal responsibility in the sorts of work we do and in the interpretation of the outcomes. So licensing in Australia is a state responsibility, so you know, there's several different jurisdictions, they've all got different laws, they're basically similar and there is a push for uniform legislation. I mean that book of guidelines that you've all got there is actually an Australia-wide federal effort and it's meant to apply everywhere but there are some little minor differences between various jurisdictions and you know for instance in some states they have compulsory reporting by medical practitioners and in some states they have age-based assessments and other various things, but most of the regulations are pretty similar, so there are some little minor differences but obviously I'm going to talk mainly about the Victorian situation. Here in Victoria VicRoads is God, VicRoads is the ultimate organisation that says yes or no and all of us might give advice to VicRoads or might send in reports and do assessments and do tests on people but ultimately it's VicRoads that has the final say as to whether or not a person gets a licence, how long they get it for, whether there's any conditions on it, when it needs to be reviewed and all the rest of the paraphernalia that goes with licensing. There's no specific legislative requirements about impairments, there used to be a regulation in Victoria about visual acuity and but that's that's all been lifted now in difference to the national standard so in fact there's no legislative regulation regarding impairments. VicRoads has got discretion about licensing conditions, they have a legislative requirement to satisfy themselves that a person's fit to drive but there's no law that says what that fitness to drive is. There are the guidelines which have got a certain legal status or otherwise which I'll talk about in a minute but ultimately it's up to VicRoads and VicRoads decisions can be subject well firstly to internal review if people want to appeal them and ultimately people have got recourse to the magistrates court and every year VicRoads gets a few cases where they've got to go to court and I guess argue or defend their decisions. There's other authorities that issue different kinds of driving permits as a Victorian taxi directorate which has jurisdiction over taxi permits, bus drivers, driving instructors and there's WorkSafe which has jurisdiction over people who drive dangerous goods, explosives, petrol tankers, things like that. Oddly enough there's no similar law for people that drive cranes and forklifts and other industrial devices like that. There used to be years ago but now it's really up to the employer to be satisfied that a person's fit to operate a crane and there's no specific law about it which is sometimes a bit scary I've got to say. We can see people, for instance it's in Vincent's who've got terrible epilepsy, tell them not to drive a car but there's nothing to stop them getting a job as a forklift or crane driver, pretty terrifying. So the way the system works is that VicRoads gets a source of information about somebody and I'll talk in a minute about what that might be and VicRoads has a licensed review department which is staffed mainly by clerical people who process this information but they have several medical case managers that have other nursing or occupational therapy backgrounds that act as a sort of a second line referral level inside VicRoads. When VicRoads gets a notification that somebody might have a medical problem they will generally send a form out to that person so they go and get a medical review, go and get a medical opinion from your doctor or a report, send it back to us, you've got X amount of time to do that and then they will make a decision based on the medical report that they get about a person's fitness to drive. If they find that it's a quite an easy straightforward decision that's fine, there's a set of guidelines that VicRoads has internally based on the book that their internal review people use. If it's a difficult case or a complicated case or there's multiple conditions or certain difficult conditions they will send it to us at the Victoria Institute of Forensic Medicine where we review cases in file form for VicRoads and send them back written opinions or advice about things and we also have an expert committee which are a bit more later and once that opinion gets back to VicRoads, VicRoads makes a decision and then the driver if they've been knocked back obviously has an avenue to ask for a review or appeal. The sources of information that VicRoads have are many and varied. There's no compulsory age based review in Victoria but once a person becomes known to VicRoads Mental Review then they get into the review system and they may or may not need to have regular reviews after that. One source of information is on the initial application form so people apply for a learner's permit or for a licence and there's a question or there's a series of questions on those forms asking about medical conditions, certain specific conditions like epilepsy and diabetes etc whether they're taking any medication and things of that sort. So those things if they're disclosed on the application form they then lead to an automatic medical review. VicRoads gets an enormous number of notifications from the police if the police turn up at a crash and you know they do a breath test on someone and they're satisfied that they're not drunk or there's no drugs involved and they think there might have been some issue of impairment then they will automatically notify VicRoads and so the whole same medical review process happens. They also get I guess Dobbins from various people, doctors, health professionals, family, general public. Sometimes they need to be taken with a bit of a bit of a grain of salt. One of the things you'll learn about working in this field is that there's a lot of high emotions concerning driving and people will dob people in for all sorts of capricious reasons. I don't think health professionals do that but certainly next door neighbours and family and anonymous will do that. You certainly get concerned family especially with older drivers who will send notification into VicRoads because they want something done about someone who's obviously got some cognitive problems. There is a bit of law that says that it's compulsory for drivers to report themselves so there's actually a regulation of the Road Safety Act that says that anybody who's got a condition that might have a long term chronic effect on their ability to drive must notify VicRoads of this and people have gone to trouble in the courts after crashes etc. who haven't done this. It's a contentious issue. There's also section 27 of the Road Safety Act that's the section that protects all of us and it says that if a health professional or in fact if anybody notifies VicRoads about a driver who's potentially unsafe and does it in good faith not out of a sort of spite or anything but if we do it as part of our normal professional activities then we can't be sued by the driver. Even if they lose their license whatever might happen to them we can't be sued because we've acted professionally in good faith. This is a pretty reassuring bit of law really because there are many cases where doctors and other people will see people who could be dangerous. We've got lots of phone calls asking about this and I'm sure VicRoads gets even more than we do. But there is no compulsory reporting by health professionals so if you or me or anybody sees somebody who is dangerous we don't have to report. There's no bit of law that says we have to report. But I think that we have a moral obligation to do it and I like to talk about the Coroners Court test which is how would you feel in the witness box of the Coroners Court if you didn't report. And all your notes were there and it said that this person has epilepsy or whatever and you hadn't notified or done anything about it. In all areas of medicine it's something that I certainly appreciate working in the field of forensic medicine is that information is really really important and you must keep notes about all the sort of stuff. It's your best protection in the long run. If you've had to take action or you've seen someone and there's some disaster down the track you must keep adequate notes. Ultimately it's the only thing that will save your skin really. So the medical guidelines are a wonderful effort every few years to review these and to produce these but they are not law. They're not legally binding. There have been court cases in Australia not in Victoria but in New South Wales there was one really well known court case involving a driver with epilepsy where the legal status of the guidelines was questions in court and there was issues about whether or not this person would get into trouble because their condition fitted in to odds and the guidelines are otherwise. So they are an important document and courts tend to examine documents very intensively and argue about them. So even though we can depart from what's in these guidelines, they are only guidelines. They're not law. You'll be very careful doing that and we sometimes do it on really really top quality expert advice but it's something that should be done very very carefully and very very circumspectly because you know if something nasty happens courts have a way of inquiring into things in great detail and they will look at these guidelines even though they're not part of established law. Licensing conditions really you know all sorts of conditions can be put under people's licenses and VicRoads of course has the ultimate say into what those conditions are going to be. Some of them are really easy and straightforward. Someone needs to wear glasses. Obviously they have to wear glasses if they've got a condition that results in poor night vision then they can have a license restricted to daytime only, automatic transmissions, all those things regular reviews are a condition. They can be put on a license. Some of them not so straightforward and you know we see all sorts of weird and wonderful conditions mooted for people. You know distances is probably a fair income restriction but you know things like restricting people to specific routes or specific streets or just to do left-hand turns not really very practical. We had one recently where somebody advised that this you know elderly gentleman could only drive two or three k's and he's saying but look there's no petrol station within two or three k's I'll have to get someone else to take my car to get it filled up. So you know these things have to be practical they have to be enforceable. So you know if a police officer happens to pick up somebody and you know interrogates their computer and sees what conditions are on a license it's got to be something practical that you know actually will have a positive bearing on on their safety. You know we've had people say well you know someone can only drive on the roads bounded by page 47 B3 of the Melways etc and that's also a problem because a driving license is a legal document that says Vic Rhodes certifies that this person is fit to use the Victorian road system as it is. Warts and all with road works, detours, bad weather you know signal breakdowns, signs all the things that we find on the road. Vic Rhodes is saying that this person who's got this bit of plastic knows how to use that system and is able to deal with the unexpected and so that's going to be born in mind when thinking about whether or not a person can have a driver's license. It's not enough just to say well I can drive from head of the doctor's surgery or from head of the shops they've got to be able to deal with the unexpected in case something happens. We've done a lot of work about medical reviews and you know what people do have or what sort of medical conditions people do have that actually come to grief. I was fascinated to hear that study that Chris was talking about earlier on today about driving assessments for inpatients and the lack of. It's certainly something that we are quite familiar with that there's not much knowledge of doctors out there whether they're hospital doctors or GPs or specialists even about driving unless they happen to practice in certain fields where there's a lot of issues with this. So for instance neurologists to deal with epilepsy will certainly be familiar with it but you know other other specialists might not be and GPs might not get a Vic Rhodes form very often you know they might work in an area where there's not very many older people and they might get a Vic Rhodes form once a month or once every couple of months and they don't really have their skills maintained in thinking about driving so if somebody comes in who's just been diagnosed with diabetes and put an insulin they don't think instantaneously well you know this is going to be an issue. What we've done over the years we've done a couple of studies because we work in close conjunction with the coroner's court we've had the opportunity to look through coroner's files from time to time and the first of these studies we did back in 96 where we we got all of the coroner's files on people that died behind the wheel who were over the age of 70 over a two year period what was encouraging about this was that these people constituted just over 10% of all the dead drivers in that period that's about the same as their proportion of the population so the number of people over 70 or about 10% of the population about 10% of the dead drivers that was encouraging because it said there's not more of them getting killed than you'd expect so these people are not getting killed just because they're older they're getting killed at the same rate as everybody else which you know perhaps you can think of as being comfortable I suppose if we'd done a similar I would like to think that if we'd done a similar study of people between 18 and 25 we'd probably find it was a higher proportion of those 42 drivers that we found only two of them actually known to Vic Rhodes and what was also encouraging was that neither of those actually one of those died in a collision that was totally somebody else's fault even though this person had lots and lots of medical problems none of those had contributed to the crash the other one was a man who'd been sent a request for medical report because they thought it because they thought he might be risk of a stroke because he had been having transient is scheming attacks in fact he had a stroke but but before he could get a medical appointment but the other 40 weren't known to Vic Rhodes and what was interesting about looking at coroner's files is that you do get autopsy results toxicology you get medical reports from their doctors and all that sort of information we found of those 42 there were three that killed their spouse you know the husband and wife had been driving together I think they're all male drivers and the female spouse was killed it's not uncommon in that age group then for only the husband to have a driver's license and this is a powerful argument we think against putting in a condition of having a navigator or having a co-pilot for people who are just got early dementia we don't think that's a protection we think that just puts the co-pilot at risk and even though in some countries like in Canada they do espouse having co-pilots we don't believe in it and we don't we don't let people drive that way on the autopsy and on the medical reports there was a high instance of unreported illnesses and especially cardiovascular disease now I suppose if you were topsy anybody over the age of seven you're going to find a degree of cardiovascular disease so it's hard to know how important it is but when you looked at their doctor's records you certainly found that quite a lot of people were on medication and had conditions that should have resulted in a notification of vicarades even though vicarades might have let them drive or they might have asked for further information that people who'd had heart attacks people who'd had angina all of those things would have got vicarades to request a bit more information and satisfy themselves about fitness but none of these people were known to vicarades there's a lot of prescription drug use that wasn't mentioned on doctor's reports so people you know if they come to us and have to have an autopsy they get toxicology investigation so we do a very thorough testing for all sorts of drugs and medications and so forth causes a bit of excitement in the study we did in 2010 but not in 2000 but not in 1996 but we found a big incidence of drugs that weren't known to their doctors or weren't mentioned to their doctors and you know whether people are getting them from other doctors whether they're you know getting together and someone says look I've got this wonderful tablet for my arthritis won't you try you can laugh but I can remember my old mum saying things like that you know Mr. So-and-so is taking this pill why can't I have it so you know you can imagine them having a bit of a chat about this so you know there there are issues of prescription drugs that you know people might not know taking when we repeated the study in 2010 we got very similar results you got a couple of fascinating bits of toxicology found a couple of old cannabis users so there are you know there's a few oldies that still like to have a bit of a puff and we found one bloke we found one old bloke that had some methyl amphetamine in his blood and we got very excited and then we discovered that it was a better bollock product of a particular drug used for Parkinson's disease so you know dope things don't don't get up that far but you know the bottom line is though that there are there are a lot of medical conditions out there that don't get reported this then leads us to thinking about well you know what what are the responsibilities of doctors and can you get into trouble over these sorts of cases criminal liability of doctors or other health professionals is not covered in the fitness to drive legislation so that section of the Road Safety Act protect you being from being sued by the patient or by the driver but doesn't protect you from being charged with something nasty if somebody has a crash so there is a potential liability if medical advice is found to be negligent or if a if an OT assessment is found to be improper for instance or any other kind of assessment and there have been civil suits brought against doctors I don't know about other professionals they have been civil suits brought for damages if somebody's been driving had a crash damaged somebody else or damaged some property or killed somebody the other party can has actually had to go at the doctor for giving that advice even though the doctor themselves might not have satisfied the criteria for a criminal charge and this was the case that really you know got people going on this this was a case in tooth in 2006 where a doctor was threatened with a manslaughter charge over a bus crash where the driver killed himself and a couple of passengers the driver was told not to drive buses by the doctor but didn't take medical advice fact after that a lot of people stopped giving advice here in Victoria we have an expert committee that works with us at the Institute of Professors of Neurology and Ophthalmology that give us advice about this but in other states I think they have yet to find a way around this problem we found here in Victoria that collision investigators are going for Vicrods files very frequently much more so than ever before and they're starting to wonder about the effects of medical conditions and of the people that have given advice so it's important to think about this the Victorian police who investigate crashes are very tough about this sort of stuff talked about our role I just want to talk a little bit about the St. Vincent's Clinic we started this up in 2004 it began as a neurology clinic just looking at epilepsy and driving but it's since been extended to every other condition so we see diabetics people with all sorts of acquired disabilities people with dementia people with congenital things like muscular dystrophy and so on it's staffed by forensic physicians like me from the Institute and we are only really resourced enough to see three or four patients a week we only do one session a week we'd love to be able to do more in fact we had an offer to set up a clinic at one of the other rehab hospitals in Melbourne where they have OTs on staff which would have been terrific but we just haven't got enough resources to do this in the first couple of years we saw all sorts of patients from 16 to 91 cars learners permits taxis heavy vehicles we only really knock back 3% on the spot most of them we assessed as being fit to drive we don't have this clinic to stop people from driving we have this clinic to keep people on the road we sent about a third of them off for further tests including OT assessments a lot of neurology as you'd expect but really all sorts of other things as well I guess it's probably even more varied now than it was then one of our legitimate functions is to give bad news a lot of doctors will refer obviously unfit people to us saying look you know can you talk to him I don't want to lose the doctor-patient relationship and we think that's completely fine to do that so I guess you know the end result is that even though all the various individual conditions that everybody here's talked about of all got low relative risks the prevalence is going to rise as the population ages medical issues are of increasing significance doctors and other health professionals are going to have to deal with these things and there will be concern about the legal liability of practitioners it's something for us all to bear in mind look an old recovered stroke in itself if the person's recovered totally that's not an ongoing chronic condition that can affect driving but there's also the consideration of why had the stroke and in some cases if it's known why a person has the stroke perhaps you know due to a cardiac condition or you know something else then that's got to be adequately treated and I guess the best test is is he on ongoing medication is he being treated for something if he is then the safest thing to do is to notify big roads the issue being that if you don't notify somebody can always raise that question about liability and culpability the safest thing to do is to notify big roads might say fine go ahead drive don't bother us but at least you've done the right thing what we have to think about is how that off road assessment is informing what we're seeing on road and the on road assessment the on road errors that occur in isolation don't give us an adequate picture of whether this person's safe to drive also doesn't give me a good idea about whether there is potential for remediation or realistic potential for remediation all of those issues around the recommendations are really coming from the combined information from the off and on road assessment so if I just did an on road assessment and I didn't do the off road I wouldn't know why that person ran a red light but often I can tell you the key features from their off road assessment that's giving me a good understanding of why it is that they ran that red light at that time in the context of what happened in the environment so it's not just the errors that are occurring on road so I can say yes they sped 10 times 5 kilometres over the limit but it's did they do that because they didn't monitor the signs did they do that because they've got poor foot control did they do that because they're losing attention did they do that because a whole host of reasons that could be causing that what the off road does is gives us the depth of information to really try and determine why it is that those errors happened and then what the most appropriate course of recommendation is I suppose and it's really comes down to really around the remediation so a straight out fail yes you could say from the on road assessment you would probably say look this person is not going to be able to drive because of ABCD and E but sometimes people just have a really bad day and I think the off road assessment gives us really rich data to join those two things together and then make a much more informed recommendation than we would without the value of the off road assessment. It's partly to prove that they have a license but VicRoads might be privy to other information that I don't have that says that this person shouldn't be driving or doesn't meet the medical guidelines to drive that perhaps their GP doesn't even know so VicRoads hold all of that information some of which is not distributable to other members of the public apart from between VicRoads and the driver because that's where their privacy confidentiality sits. So we need to ask VicRoads to make sure that they're not aware of anything that's going to prevent this person from driving and that they're happy that the medical report that they've received meets the medical guidelines or medical standards to drive so we can't take the person certainly not on road without that clearance form and we don't do an off road assessment without it either because we don't want to drag them through that if they ultimately can't drive anyway so we wait for clearance first and then do the off and on road assessments within a week. I'm not aware of any cases like that where people have gotten to trouble for not giving advice and it'd be hard to prove I would have thought but and and and I think that one day it'll possibly happen but at the moment no no but but you know I think you're quite right in pointing that out as a risk it's really important to keep comprehensive notes it's always important to remember that every every patient you see might end up getting into some sort of trouble whether it's on the road or doing something else and one day those notes will end up in a courtroom. Yeah well certainly the person has the right to seek future assessments sometimes that is what will come out of a Vic Roads review of that person's file if they appeal a decision is that Vic Roads will determine that potentially another assessment is required and then they would actually seek out another therapist to perform a reassessment of someone's driving as Maureen said this morning driving is something that can change over time we also have to remember that the on-road assessment as extensive as we can possibly make it in a practical sense is still only a very small snippet of time so you're looking at you know an hour of somebody's driving so it might be that in that second hour they drove brilliantly and didn't run into the kind of errors that they had it might be that something untoward happened in that first assessment and it threw the person and then they made mistakes it's very very difficult to put those two assessments together and say well yes clearly on one day they didn't do well clearly on the other day they did drive well it was I'm glad I don't have to decide which one of those reports stands higher in determining the licensing decision Vic Roads and Morris get to do that first yeah I think if Vic Roads gets two conflicting reports from two professionals within a short period of time whether they're OTs or doctors or whoever they take these very very seriously they almost always get sent to us and we spend a bit of time on the telephone to the various people discussing this I mean people have been known to lie and cheat and connive as far as giving histories to people we've had people forge doctors letters and all the rest of it it's a bit hard to know how they can fake an OT test but you know almost anything's possible so you know if Vic Roads who's the ultimate respondent of all of these reports if they see that there's been some some difference between different professionals opinion they'll generally take that as a red flag to go looking into it a bit further