This paper reviews a Coroner’s inquest into the deaths of two people. The deaths were caused when a driver had a seizure, and lost control of his car, which then plowed into a café. The Coroner reviews the roles and responsibilities of primary and tertiary caregivers, with special focus on the question of who has the responsibility to inform the Drivers’ Licensing Authority of a patient’s unfitness to drive – the patient or the practitioner? The Coroner recommends the establishment of a multi-agency committee to advance work in this area. The paper notes a separate but parallel development – a review of AUSTROADS Assessing Fitness to Drive Guidelines, which may achieve the outcomes sought by the Coroner.