“Syncope” is a medical term that refers to a brief episode of fainting and loss of consciousness. The most common cause is a sudden fall in blood pressure as occurs in simple fainting. The loss of consciousness is brief, usually lasting seconds, and is followed by a rapid full recovery with return of awareness of what is happening around the person.

Syncopal episodes (of all causes) lead to around 80,000 attendances each year to the emergency departments of Australian hospitals. Data suggests that around 2.5% of these attendances are for cough syncope. As Chris Brook has calculated, this means around 2000 cases per year or 40 cases per week. While some patients do suffer injury, fortunately it is rare that fatal accidents result. The risk of serious injury is however reflected in the UK regulations pertaining to when it is safe to drive after a bout of cough syncope (see below).  

Strong coughing is a well-recognised mechanism for producing a syncopal episode. While well-recognised, it remains poorly understood as only a small minority of people who have a coughing bout will experience syncope. Why this is so and what the underlying mechanism is remain unknown. It is equally unknown why in any one sufferer, cough syncope does not follow every chest infection that leads to severe coughing. The duration of the loss of consciousness in cough syncope is held to be in the order of 15-30 seconds[2].

Cough syncope can occur at any age and in persons without underlying lung disease but it is more likely to be seen in middle-aged males who are overweight, are smokers, drink alcohol and have chronic bronchitis or emphysema. While the presence of some or all of these factors may increase the risk of cough syncope, they are not essential for establishing the diagnosis of cough syncope.

The diagnosis is based almost entirely upon what any patient is able to describe to their doctor. There are no diagnostic tests available. If there has been a witness to the collapse, that person’s description will assist in confirming the diagnosis.

Although Dr Naughton declared cough syncope to be ‘incredibly rare’, this was seemingly not based on a detailed search of the medical literature. Not only has cough syncope been widely reported, but as mentioned above, cough syncope is regarded in the United Kingdom as a reason to withdraw or suspend a driving licence from any person in whom cough syncope has been diagnosed.

In 2018 Dr Naughton was again asked by the public prosecutor to give expert evidence in a case that involved a Victorian truck driver whose truck drifted on to the wrong side of the road, resulting in the death of a driver of an oncoming car. Naughton’s evidence was preferred over the views of the respiratory physician called by the defence and the truck driver was sent to prison. On appeal, the three judges recognised that there was convincing evidence that the truck driver had suffered a bout of cough syncope. The driver was exonerated without being sent to a second trial. The convincing evidence came from the truck driver’s brother, Stephen, who had been speaking via mobile phone with his brother at the time of the collision. The records of the telephone company confirmed the call. In the reasons for decision of the Court of Appeal, the evidence was summarized as follows:

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“62 As a starting point, for considering that question, two points are clear from the

evidence. First, as already mentioned, after the accident, the applicant was diagnosed to be

suffering from bibasal bronchial pneumonia. The unchallenged evidence of Stephen

Ferguson was that, in the immediate period that preceded the accident, the applicant had a

sustained and prolonged bout of coughing, which ended with a sound like a wheeze.

 

63 Secondly, Stephen Ferguson gave evidence that immediately before the collision, the

applicant ceased responding to questions put to him by Stephen in their telephone

conversation. As a result, Stephen Ferguson became quite concerned, and asked him on more

than one occasion ‘Geoff are you all right?’, to which he received no response.”

 

The full reasons for decision document are accessible here https://www.austlii.edu.au/cgi-bin/viewdoc/au/cases/vic/VSCA/2020/166.html

The diagnosis of cough syncope is based primarily on the account of any event by the sufferer. The diagnosis can be made more confidently if the episode is witnessed by a bystander. In that context, the previous and later episodes of cough syncope experienced by Robert Farquharson are important to document. While some of his experiences depend solely on self-reporting, others were independently witnessed. Here is a tabulation of his experiences of cough syncope: some episodes took place before the accident, others before his conviction and more have been documented in prison[3].  

And here for the record are Robert Farquharson’s reported episodes of cough syncope.

• In late August 2005 Robert experienced a blackout after coughing. He reported this to a friend two days later.

• On 2 September 2005, he experienced a severe bout of coughing and felt very dizzy. This was witnessed by his employer who assisted him to sit down while he recovered.

• On 4 September 2005 (Father’s Day), he had a coughing fit, blacked out and drove into a deep dam.

• On 18 May 2009, he blacked out after coughing, fell to the floor and broke his fibula. This episode was witnessed by several people. He was said to remain unconscious for several seconds.

• In December 2011,  he blacked out, fell to the ground, hit his head and now has a visible scar on his forehead. This episode was also witnessed.

• On 7 July 2019 he had a coughing fit in his prison cell, blacked out, fell from his bed and injured his right hand. This episode was overheard by the prisoner in the next cell, who called for medical assistance.

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[1] For further information see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8753616/  and https://pubmed.ncbi.nlm.nih.gov/24238768/ and https://en.wikipedia.org/wiki/Syncope_(medicine)

[2] In twenty seconds, a car travelling at 80 kph will traverse 444 metres. 

[3] This summary includes information from the prison medical records.