(Update)It’s been nearly five years since a Hamilton high school teacher went into diabetic shock behind the wheel causing a crash that killed three innocent people. But Wednesday, Ontario’s ombudsman released a report aimed at ensuring a tragedy like it never happens again.A bureaucratic farce. Those are the words that Ombudsman Andre Marin used to describe the series of circumstances that allowed Allan Maki to drive while suceptible to episodes of hypoglycemia.It was completely preventable. And to according Ombudsman Andre Marin, it was the system that failed: “This is where the tragic tale turned to beaurocratic farce.”It was June 26th 2009. High school teacher Allan Maki goes into diabetic shock while driving. His car hits a cyclist named Tong Vi Duong, and then a car carrying newlyweds Jeffery Roche and Hanna Gordon Roche. All three were killed. As criminal proceedings went forward, the victims’ family members noted that Maki’s license was not even suspended until 18 months after the crash.Marin said: “If the system didn’t kick to suspend Mr. Maki’s license for one and a half years, later, how can we be confident that it is working to monitor at risk drivers.”Maki is a type 1 diabetic, and when he renewed his license two years before the crash, it was on an outdated form. 19 recommendations to the Ministry of Transportation, include that the ministry update it’s medical history form and that the medical review section clearly reviews forms more carefully. Also that they work more closely with the medical community to proactively monitor at risk patients.Rupert Gordon is the victims brother: “It actually feels positive, my sister and my brother in law were very positive people.”Rupert Gordon had been in contact with the ombudsman’s office through the entire process and he says today brings something positive from a tragic incident, and corrects systematic failure: “To know that the kinds of things that were present in the system are the kinds of things that we can actually affect change with, in order to make sure that other don’t go through this experience, that’s a good thing, that means a lot to me and a think there are ways in which it honors the people that we love.”The Ministry of Transportation has agreed to adopt all of the suggested changes, in the hopes of preventing future tragedies.