Memorandum from N and M Tweddell, S Blandy
and S Schmoller (RS 68)
REDUCING ROAD
DEATHS CAUSED
BY SLEEP
APNOEA
Executive summary
1. This memorandum provides evidence of
the prevalence and danger of undiagnosed sleep apnoea in drivers—particularly
of LGVs and PSVs, and recommends action for better identification
of sufferers.
Brief introduction
2. We are the family of Toby Tweddell who
was killed on the M62 motorway on the edge of Liverpool on 8 August
2006. The car he was driving was standing in a queue of traffic
and was run into from behind by an LGV. The LGV driver had fallen
asleep at the wheel, and was subsequently diagnosed to be suffering
from sleep apnoea. Wishing to reduce similar road deaths in the
future, we believe that the Transport Committee should consider
the following evidence, and that having done so it should press
for further and stronger preventive action by the Department for
Transport and other government departments and agencies.
Factual information
3. Sleep apnoea is the most common of a
wide range of medical conditions which can produce poor sleep
quality. Sufferers are starved of oxygen during the night. They
awake momentarily many times each night, without being aware of
this, and as a result they experience waking symptoms ranging
from general drowsiness and tiredness, difficulties in concentrating,
through to sudden falling asleep.
4. The Government's road safety campaign
launched in March 2008 states that:
— about one in five crashes on motorways
and similar roads is caused by falling asleep at the wheel,1 and
about one in 10 on all roads;
— an estimated 300 people a year are
killed where a driver has fallen asleep at the wheel;
— if you fall asleep at the wheel you
are 50% more likely to cause death or serious injury because a
sleeping driver does not react before a crash; and
— about 40% of sleep-related crashes
are work related involving commercial vehicles.
5. International research studies on sleep
apnoea have established:
— around 4% of middle-aged men—about
500,000 people in the UK—suffer from sleep apnoea;2
— partly as a result of the sedentary
nature of their jobs, there is a significant incidence of obesity
amongst professional drivers, and approximately 50% of sufferers
from sleep apnoea are obese (see endnote 2). As many as one in
six professional drivers are estimated to be suffering from undiagnosed
sleep apnoea3; and
— sufferers from sleep apnoea have
been shown to be six to 15 times more likely to have a road-traffic
accident than those without the condition;4 and in simulated driving
performance tests, sleep apnoea sufferers score worse in terms
of hazard awareness and reaction times than test subjects who
are drunk.5
6. In the four months from October 2007,
at least four cases came to court of LGV drivers accused of causing
death by dangerous driving (nine people in total killed); all
four LGV drivers were suffering from sleep apnoea which was only
diagnosed after their accidents.6
7. All applicants and re-applicants for
LGV and PSV licences must complete a Medical Examination Report
(DVLA Form D4) with their general practitioner. This form contains
the questions "does the applicant have sleep apnoea syndrome?"
and "is there any other medical condition causing excessive
daytime sleepiness?". These questions are obviously not adequately
identifying sleep apnoea sufferers.
8. At present, sufferers from sleep apnoea
tend to under-report difficulties when driving,7 perhaps understandably
as they have risked losing their licence and livelihood. Drivers
should now be less concerned about this risk because the National
Institute for Health and Clinical Excellence (NICE) recommended
on 26 March 2008 that treatment for sleep apnoea using continuous
positive airway pressure (CPAP) devices should be available throughout
the NHS.
9. A relatively cheap and now widely available
screening tool for sleep apnoea is the pulse oximeter, which can
be used overnight at the patient's home rather than in a sleep
laboratory. It is estimated that, with experienced interpretation,
this tool can identify significant sleep apnoea in 80-90% of cases.
10. In 1999 the Task Force of the European
Respiratory Society8 pointed out the prevalence of sleep apnoea
amongst professional drivers, and the consequent high risk (and
high actual rate) of accidents caused. Their report highlighted
the need for uniformly accepted regulations concerning driver
licensing, with a shared responsibility between the physician,
patient and licensing authority.
11. Whilst some major businesses in road
and passenger transport do take sleep apnoea seriously, we are
not aware of any example of a company routinely testing its drivers
for sleep apnoea, and the general attitude (in the road-haulage
industry at least) is one of complacency, with, for example, no
mention of sleep apnoea, at the time of writing, on the Road Haulage
Association's information-packed web site, and no reference to
sleep apnoea in the syllabus of the Certificate of Professional
Competence (CPC) in Road Haulage.9
Recommendations for action
12. The Department for Transport, which
regulates the issuing and renewal of PSV and LGV licences, needs
to tighten up the requirements for identifying potential sufferers
of sleep apnoea. In particular, PSV and LGV drivers should regularly
be screened for this, and related disorders, and this should be
part of their licence requirements. Furthermore, it should be
a requirement on road haulage and passenger transport operators
for them to have screening processes in place. The syllabus of
the CPC in Road Haulage should be improved so that issues associated
with sleep apnoea, its identification and treatment, and the rules
pertaining to driver licensing are covered.
13. The Department of Work and Pensions,
in dialogue with the Health and Safety Commission, needs to ensure
that the Health and Safety Executive—with its responsibilities
for minimising work-related death and injury, and with its powers
to insist on action by employers to prevent risks to non-employees
(that is, road users at risk from drivers suffering from sleep
apnoea)—plays a much more prominent role in relation to
work-related fatal road-traffic accidents and their prevention.
In particular, HSE should be working on the introduction of legislation,
if necessary on a European basis, on compulsory testing of professional
drivers for sleep apnoea.
14. The Department of Health, which funds
and shapes the work of medical practitioners, needs to ensure
that those involved in the diagnosis of sleep apnoea are well
briefed about the problem, its symptoms, its serious implications
(particularly when the sufferer drives for a living), and on the
importance of getting sufferers tested and off the road until
their condition has been treated, with consideration given to
making it a responsibility of GPs to report on their diagnosis
to the Department of Transport rather than this being solely the
responsibility of the driver.
Background References
1. Horne, J A and Reyner, L A, "Sleep-related
vehicle accidents", British Medical Journal, 1995:310,
pp 565-7. http://www.bmj.com/cgi/content/abstract/310/6979/565
last accessed 5/4/2008
2. Young, T, Palta, M, Dempsey, J, Skatrud, J,
Weber, S and Badr, S, "The occurrence of sleep-disordered
breathing among middle-aged adults", New England Journal
of Medicine, 1993:328, pp 1230-35. https://content.nejm.org/cgi/content/abstract/328/17/1230
last accessed 5/4/2008
3. Howard, Mark E, Desai, Anup V, Grunstein,
Ronald R, Hukins, Craig, Armstrong, John G, Joffe, David, Swann,
Philip, Campbell, Donald A and Pierce, Robert J, "Sleepiness,
Sleep-disordered Breathing, and Accident Risk Factors in Commercial
Vehicle Drivers", American Journal of Respiratory and Critical
Care Medicine, 2004:170, pp 1014-21. http://171.66.122.149/cgi/content/abstract/170/9/1014
last accessed 5/4/2008
4a. Findley, L J, Unverzagt, M E, Suratt, P M,
et al, "Automobile Accidents Involving Patients with Obstructive
Sleep Apnoea", American Review of Respiratory Disease,
1988:138, pp 337-40. http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&uid=3195832&cmd=showdetailview&indexed
=google last accessed 5/4/2008
4b. Teran-Santos, J, Jimenez-Gomez, A and Cordero-Guevara,
J, "The association between sleep apnoea and the risk of
traffic accidents", New England Journal of Medicine,
1999:340, pp 847-51. https://content.nejm.org/cgi/content/abstract/340/11/847
last accessed 5/4/2008
4c. Horstmann, S, Hess. C W, Bassetti, C, Gugger,
M and Mathis, J, "Sleepiness-Related Accidents in Sleep Apnoea
Patients", Sleep, 2000:23, pp 1-7. http://sleepsolutions.com/clinical—library/230306.pdf
last accessed 5/4/2008
5. George, C F, Boudreau, A C and Smiley, A,
"Simulated driving performance in patients with obstructive
sleep apnoea", American Journal of Respiratory and Critical
Care Medicine, 1996:154(1), pp 175-81. http://ajrccm.atsjournals.org/cgi/content/abstract/154/1/175
last accessed 5/4/2008
6. Cases coming to court in the four months from
October 2007:
On 1 August 2005 Alice-Anne Fuge, Nestor Siles and
Jessie McCann were killed on the A82 near Alexandria, Scotland,
by an LGV driven by Colin Kane. On 21 July 2006 Malcolm, Janice,
Richard and George Dowling were killed on the A34, near Bicester,
by an LGV driven by Ian King. On 8 August 2006 Toby Tweddell was
killed while waiting in a traffic queue at the M62 Rocket Interchange,
Merseyside, by an LGV driven by Colin Wrighton. On 14 April 2007
Leonard Nicholls was killed on the A48, Eastern Avenue, Cardiff,
by an LGV driven by Hayden Bailey. In every case the driver of
the LGV—each of whom suffered unknowingly from sleep apnoea—had
fallen asleep at the wheel. Kane, King, Wrighton and Bailey were
all prosecuted for causing death by dangerous driving. The outcomes
of the four cases differed. On 1 October 2007, the Crown Prosecution
Service decided to offer no evidence against Wrighton, who was
acquitted. On 12 October 2007 a Scottish jury found the case against
Kane unproven. In contrast, on 7 December 2007, King was convicted
by the jury at Oxford Crown Court and jailed for 3 years and 9
months on 11 January 2008. On 23 February 2008, Bailey pleaded
guilty and was sentenced to 10 months in jail with a 3-year driving
ban.
7. Engleman, H M, Hirst, W S and Douglas, N J,
"Under reporting of sleepiness and driving impairment in
patients with sleep apnoea/hypnopnoea syndrome", Journal
of Sleep Research, 1997:6, pp 272-5. http://www.blackwell-synergy.com/doi/abs/10.1111/j.1365-2869.1997.00272.x
last accessed 5/4/2008
8. McNicholas, W T and Krieger, J, on behalf
of the Task Force members, "Public health and medicolegal
implications of sleep apnoea", European Respiratory Journal,
2002:20, pp 1594-1609. http://www.ersj.org.uk/cgi/reprint/20/6/1594
last accessed 5/4/2008
9. 16 companies (out of 30 approached) replied
to an enquiry made in December 2007 by Nic and Monica Tweddell
concerning the company's approach to the problem of sleep apnoea.
Industry practice varies widely and in no case was compulsory
testing and/or treatment of drivers for sleep apnoea the norm;
nor is there yet any significant use of technical systems to detect
driver sleepiness. The Traffic Commissioners (the issuing authority
for operator licences) require professional competence to be demonstrated
by at least one member of the management team of a road-haulage
business that operates vehicles with a gross plated weight of
more than 3.5 tonnes or vehicles which are not plated and which
have an unladen weight of more than 1525 kg. One way of demonstrating
this competence is by the designated member of the management
team achieving the Certificate of Professional Competence in Road
Haulage.
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