An 83-year-old man, who hit and killed a cyclist in the Adelaide Hills, had failed two driving tests after suffering a stroke and should not have been behind the wheel, a coroner has found.
Edmund Smordowski, 63, was hit from behind by Kevin Rice who told police he didn't see the cyclist before the crash in June 2012.
Mr Rice has since died, but had to sit a driving test three times after suffering a stroke in 2011 before he was finally passed.
South Australian deputy coroner Anthony Schapel said Mr Smordowski's death could have been avoided if Mr Rice had been a driver of even basic competence.
"The conclusion that at the time of this accident Mr Rice should not have been permitted to drive is one that unfortunately is difficult to resist," Mr Schapel said in his finding on Monday.
The coroner said even the man's son had urged him to give up driving, something he stubbornly refused to do.
The inquest heard that after being diagnosed with heart disease and suffering a stroke, Mr Rice had been forced to have an annual test to keep his licence.
He failed the first two, but passed at the third attempt.
But Mr Schapel noted that all three tests were conducted over the same route and and all were conducted by different instructors.
He said it was clear that had Mr Rice's tests been conducted by the same examiner, his good fortune to pass at the third, and final attempt, would have been put into better context.
Among his recommendations, the coroner has called for changes to the law to ensure such tests are conducted by the same assessor and that tests be conducted over different routes.