A motorist aged 91 killed a chef in a car crash after driving non-stop for 16 hours, some of it on the wrong side of the road, while he was delirious with an infection.
Billy Warwick-Jones, 20, died after a Ford Focus ploughed into his motorbike at a combined head-on collision speed of 100mph on the A3 near New Malden, Surrey, shortly before 6am on August 29 last year, an inquest heard.
The apprentice senior chef was struck by the elderly motorist - who was named in court only as Mr Woods - who had been driving down the wrong way down the main road for up to 14 miles.
A police probe found that the motorist, from Barnet, north London, may have been suffering from confusion and delirium caused by a urinary tract infection.
While waiting to determine whether to charge him with causing death by dangerous driving, Mr Woods died of Covid-19 in January this year.
In the four months after the crash, he was not arrested nor banned from driving - although he did hand his licence in to the DVLA at some point during that period.
Area Coroner Lydia Brown said she had 'grave concerns' about why a man with a history of urinary tract infections, which can cause sudden confusion in elderly people, was allowed to continue to drive.
She said she will be writing to the DVLA, the Minister for Transport, the GMC, and the GP in question in her report to prevent future deaths in which a response will be required within 56 days.
Billy Warwick-Jones, 20, died after a Ford Focus ploughed into his motorbike in Surrey
The crash happened on A3 near New Malden, Surrey, shortly before 6am on August 29, 2020
Now Billy's devastated family are calling for a law change so that over 70s have to be retested every five years.
Friends of Billy's say they met up with him at around 2.30am in Hyde Park, central London, as he was often awake during the night. Two witnesses say they saw him drink a can of Stella Artois which was unfinished by the time he went home at around 4am.
A toxicology report found Billy was just over the legal limit of alcohol and cocaine, but witnesses say that he was not riding recklessly and police confirmed this was not a contributing factor to his death.
Witnesses say the incident happened at just around dawn at around 5.40am when Billy was driving southbound near the junction of Coombe Road in Kingston-upon-Thames.
Due to the slight bend in the road, officers say Billy is likely to not have been aware of the vehicle being on the wrong side of the road and had limited time to think when the incident occurred.
The investigator officer said the 'last thing you would expect or encounter is a vehicle travelling towards you on the same carriageway'.
The court heard an off-duty paramedic stopped her car on the way to work and stopped on the carriageway to help but it soon became apparent that Billy could not be saved.
Will Holland, a police officer driving northbound a marked vehicle in the area, attempted to coordinate a response before the crash occurred but a helicopter was not available, the inquest was told.
Inquest told the driver - known only as Mr Wood - may have been delirious when he hit Billy
He said he had also completed a dynamic risk assessment and found he could not drive ahead to warn other road users, was concerned the use of blue lights would have caused the driver to speed up and drive even more dangerously, and so followed the car.
Inspector Holland said: 'There was a vehicle slowing with their hazard lights on so I felt able to stop and begin the initial triage.
'As I approached, I could see his eyes were closed and I could not see his chest rising and falling.
'Ahead I saw a female in a green London Ambulance Service uniform stop her car and help. She commenced CPR.
'The driver in the Ford Focus attempted to then start the vehicle. The male appeared elderly, incoherent, and seemingly unaware of the tragic incident around us. I took possession of his car key.'
Detective Sergeant James Hathaway, from the Met Police collision investigation unit of south west London, gave live evidence at West London Coroner's Court and said they were able to determine Billy's movements quickly.
He said: 'More complex were the movements of Mr Woods prior to the collision.
'Mr Woods was a 91-year-old male at the time of the collision. He lived in Barnet and didn't seem to have any plausible reason why he would be in that area, in southwest London at that time in the morning.
'It became apparent he lived alone, and was due to visit family, his daughter on the Friday evening.
'He had never arrived. It was believed by the family he decided to not come and didn't look further as to why he didn't arrive.
'We looked at automatic plate reading and these suggest Mr Woods had been driving around for approximately 16 hours with no obvious gap in the movement of his vehicle prior to the collision.
'It appears that the first reading we have is in the Barnet area at 1.17pm on 28 August the day before the collision. It then moves into Hertfordshire and the Hartford area, the A1 corridor northbound, and as the afternoon progresses, at 5.41pm around Euston, and in the coming hours, he travelled to King's Cross, Kennington, Hyde Park Corner.
'In the early hours of 1am and 2am, he's in Kennington High Street and then at 2.19am he's in Wimbledon and then out to Surrey towards Reigate and the Leatherhead bypass.'
He added: 'The doctor who briefly treated and saw Mr Woods at the scene described him as being in a confused state and he was found to be suffering from a urinary tract infection at the time of the collision.
'We tried to interview Mr Woods in the coming weeks and months following the collision but he was never medically well enough for us to interview him - his cognitive ability was not there.
'We visited him, myself and DC Joanne Collins at his home address. He was so confused he believed DC Collins was his daughter. That confirmed to us he was not medically or mentally well enough for us to interview him.
'We looked to work with the Crown Prosecution Service to seek some early investigative advice and it was clear someone driving the wrong way down a carriage was clearly within the bounds of dangerous driving and the dangerous driving had directly led to the death of Billy.
'We looked to instigate a prosecution without having interviewed him and we referred a file to the Crown Prosecution Service.
'One of the actions we were given by them to look into was the mental state of Mr Woods and whether he had the mental capacity to be responsible for his actions.
'While we were trying to appoint an expert, Mr Woods was admitted to hospital - Barnet General Hospital - where it was found he contracted Covid-19 and he passed away on 4 January this year.
'With his death, there was no longer any possibility of criminal proceedings against him in our investigation.'
The Coroner returned a conclusion that Billy died of a road traffic collision with multiple injuries and it is likely he died almost instantaneously 'without any pain'. He was pronounced extinct at 6.36am.
Mrs Brown said: 'There was a 91-year-old man driving around, for no reason, London, Surrey, for periods of up to 16 hours.
'When he was found, in irony, he didn't appear to have any physical injuries but he was in a confused state. He was diagnosed with a urinary tract infection and it is well recognised in the elderly and infirm population this does frequently cause confusion - the medical state of delirium.
'He was never medically well enough to even be interviewed. I have seen his medical records and I am content this was the appropriate decision.
'The CPs would have charged him with dangerous driving if he had the capacity to respond to such a charge and it is clear that his actions led to Billy's death.
'There was not any CCTV to help us to understand the precise mechanism of this accident. From Billy's point of view, he was driving in a competent appropriate manner and it was as the police said it is the last thing you would expect to see when you're driving properly down the road a vehicle coming the wrong side coming towards you at speed.
'There was probably no time for Billy to take evasive action.
'There is no and I repeat no criticism of Billy's driving that night.'
She added: 'I have grave concerns at the outcome of this tragedy that a 91-year-old man, it wasn't reported to the DVLA by Mr Woods or by his family or by his GP. I've looked very carefully at the GMC guidance for medics. I've looked carefully at the DVLA extensive guidance.
'I've looked carefully at many matters to try and consider how we have our elderly dementing population prone to infections such as these well recognised to cause very quick onset delirious behaviour.
'How it can be they still have access to vehicles that by their very nature kill other people?
'It is recognised that we have an ageing population. It is recognised that more and more people have a licence and are continuing to drive.
'I don't have to find a solution but I have to raise my concerns and I will do so with the DVLA, the GMC, the Minister for Transport and with the GP in question.'
Giving tribute, his mum Kelly said: 'Billy did not have a bad bone in him. He was so caring and thoughtful towards others.'
His sister, Amy, said: 'Billy was the biggest character and would light up any room. He could honestly have been a comedian.
'What happened is so unfair. He didn't deserve this.
'He never got half the things he would have achieved. I believe he will always live on through my children who he loved more than life itself.'