Carmaker BMW’s delay in recalling U.K. cars with an electrical fault contributed to a driver’s death, a U.K. inquest has found.

The coroner found that BMW only recalled the faulty cars following the fatality, but also blamed the U.K.’s vehicle safety regulator for its failure to push the carmaker to act more quickly.

Despite the delayed recall, however, the coroner found that there was insufficient evidence to conclude the death was corporate manslaughter.

Narayan Gurung died when his Ford Fiesta crashed into a tree after he swerved to avoid a broken-down BMW early morning on Christmas Day 2016. The car had suffered “a total electrical failure,” which meant the BMW driver was unable to put on the hazard lights to warn other drivers that he had stalled.

The BMW driver, Resham Gurung (no relation to the victim), confirmed there were two incidents previously when he could not unlock his car with the key fob.

BMW had known about electrical faults with this particular model of car for five years before the fatal incident, and had issued repair kits (costing £12.79, or U.S. $17) to dealerships to fix it. But because the regulator, the U.K.’s Driver and Vehicle Standards Agency (DVSA), did not consider that the fault could lead to “total electrical failure,” it did not prioritise it as a major concern.

“In the past, DVSA’s processes may not been as robust or as efficient as they needed to be. We have been addressing this as a matter of urgency and have already made a number of significant changes, ensuring that all reported safety defects are assessed quickly and thoroughly.”

Gareth Llewellyn, Chief Executive, DVSA

Surrey Assistant Coroner Anna Loxton heard that the DVSA needed “overwhelming evidence” of a fault before a recall could be requested.

She added that while the DVSA had been aware of a fault since October 2014 when it started to receive an “unusually high” volume of complaints from drivers, it did not make a “fundamental shift” until after Mr. Gurung’s death. She also criticised the DVSA for the lack of clarity in its Code of Practice as to what should constitute a “prior warning” of a fault and whether these should refer to safety-related issues only.

The coroner said: “Despite recognising this risk, the DVSA failed to call for, and BMW AG and BMW UK failed to initiate, a recall until after Mr. Gurung's death.”

She also raised concerns that there is no set form of written notice given by the DVSA when it decides a recall is required under the Code and that, as a result, no such notice was sent to BMW.

Gareth Llewellyn, DVSA chief executive, accepted the coroner’s findings. In a statement, he said: “In the past, DVSA’s processes may not been as robust or as efficient as they needed to be. We have been addressing this as a matter of urgency and have already made a number of significant changes, ensuring that all reported safety defects are assessed quickly and thoroughly.”

BMW initially recalled 36,410 petrol cars last year after Mr. Gurung’s death, but in May the company was forced to recall nearly ten times as many U.K. cars as it originally planned after a BBC consumer rights programme found that more vehicle types were at risk of stalling while being driven. BMW had initially recalled just 36,000 cars, but the BBC programme then prompted it to extend the recall to a further 312,000 vehicles.

In a statement, BMW described Mr. Gurung’s death as “a tragic accident,” and “considers that it has followed all the processes required by the relevant regulations,” though it added that “we recognise the need for the automotive industry to review relevant processes and procedures.”

Both the DVSA and BMW have, however, been critical of each other’s approach to the recall.

Llewellyn suggested that BMW’s failure to report faults may have skewed its own approach to oversight. “The coroner has accepted that BMW did not make DVSA aware of 19 cases of electrical failure in this model between 2011 and 2014 as it is required to do under the General Product Safety Regulations. Had it done so, DVSA’s response, in 2014, might have been different.”

In response, BMW said that it “would welcome the opportunity to work with the DVSA in relation to its review of the Code of Practice.”