Coroner Mary Hassell was not getting the answer she was looking for. The Police expert witness, Simon Gladstone explained that killer Zanah Mohamed was fully aware that more than hundred people were on the pavement at 4:00, many attempting to cross the six lanes of Old Street after a night of clubbing. Driving at 50kmh with the road dog-legging left wasn’t something the Police officer would have done.
The Coroner insisted “Is it therefore “careless” to drive at that speed, when one is aware of the hazards?” The Policeman muffled and cowardly refused to give a resounding “Yes” (i.e. the correct answer). And so Hassell was denied the opportunity to send this case of miscarriage of justice back to the Crown Prosecution Service, who had shamefully refused to progress it.
It was a typical case of not rocking the boat, even more shameful because Gladstone had just retired, so had very little to lose in spelling out the obvious.
The Police covered themselves in more excrement when they even failed to charge the driver for failing to stop, because they missed a procedural deadline. See full report here.
And to complete this abject portrait of institutional failure, the killer was let off from being charged for Contempt of Court (for lying under oath), because the Coroner had forgotten to warn him that he could refuse to answer if he felt he could incriminate himself.
The Inquest was taking place at the fortress of the Old Bailey, where earlier in the week, another attempt to rectify a miscarriage of justice also failed. The private prosecutor was unable to convince twelve jurors that hitting someone perfectly visible is an act of carelessness.
So why is the system broken and why is it important to fix it?
The root cause is the way careless and dangerous driving are defined in the legislation.
According to section 2A of the RTA 1988, a person is to be regarded as driving dangerously if (and only if)—
(a)the way he drives falls far below what would be expected of a competent and careful driver, and
(b)it would be obvious to a competent and careful driver that driving in that way would be dangerous.
Careless is the same as (a) above with “far below” substituted with “below”.
The key point that is not addressed by the justice system is Who should judge the standard? Who is a competent and careful driver?
It would seem obvious that the judge should be someone who is officially recognised to be a competent and careful driver, according to objective standards. This means that the Police expert witness should be asked to make a statement on objective grounds whether the driving was dangerous or careless. That should be taken as a statement of facts, rather than an opinion.
The starting axiom should be that a careful driver does not kill or injure, unless the victim purposefully put herself in harm’s way (i.e. to commit suicide). It should be an extremely difficult hurdle to show that a careful driver would have killed someone.
In practice the judgment is made by a jury that statistically is composed by regular drivers who see themselves as competent and careful according to their own standards. Innumerable studies have shown that people over-rate their abilities in all domains and that driving is particularly rife for over-confidence of own skills. This is compounded by the very British “us-and-them” attitude of cataloging people according to accent, transport mode, schooling, etc.
So in effect we have incompetent, biased people making judgments.
The second order consequence of this absurdity is that Prosecutors and Police are extremely shy of charging and prosecuting killers, because of over-sensitivity to failing to obtain convictions.
We have a paradoxical situation where the legal system, rather than raising the standards of people’s behaviour to ensure everyone’s personal safety, is held hostage by the lowest denominator who resist to improving their behaviour.
It is rule by the mob.
In other words the system is broken. And a broken Justice System has deeply troubling social consequences; if people convince themselves that some people are above the law and the State does nothing to rectify the injustices, people will start using personal violence to rectify miscarriages and stop behaving as compliant citizens.
Duncan Dollimore, of the Cycling Defense Fund, said after the failure to convict Purcell, the killer of Michael Mason:
“If failing to see an illuminated cyclist on a well-lit road is not careless driving, and no explanation for that failure is required, that reinforces the arguments Cycling UK has made through our Road Justice Campaign for many years: namely the definition and identification of bad driving offences needs urgent review.”
In the graph below we see the consequences of this broken system. Please note that the headline is written by an innumerate journalist: Less than 20% of the sample received a prison sentence.
In other words, if you want to kill someone who rides a bike, use a car: you have an 80% chance of getting away with it.
UPDATE: Duncan Dollimore has written an excellent report of the Old Bailey hearing of the Mason case. It highlights the typical behaviour by Police that we have pointed to several times when they decide not to charge killers: they go in extensive and absurd victim blaming. Duncan adds three recommendations:
1. The current guidance regarding referral of fatal road collision cases to CPS for charging decisions needs to become a requirement, a rule which police forces can’t simply ignore as they did in this case;
2. Collision investigation standards are urgently needed, with accreditation and increased transparency as called for by RoadPeace through their collision investigation campaign.
3. The current classification of careless and dangerous driving offences, how driving standards are assessed, and charging standards, are simply not fit for purpose. They must be changed, with the standard of driving required being more objectively determined. Currently, the law requires jurors to consider whether another driver’s standard of driving fell “below”, or “far below” the standard which they believe would be expected of “a careful and competent driver”, whatever that standard might be. One person might well think they’re a careful and competent driver as they overtake a cyclist whilst speeding, leaving a 30 cm gap. I would disagree, so our perspectives on what falls “below the competent and careful driver” test will be irreconcilable. We are asking jurors to apply a standard that few understand, and which is far too subjective.
Investigative work by Tom Kearney has revealed the selective use of statistics by Transport for London, and its planned campaign of burying uncomfortable data, in spite of boasting about its so-called “world-leading bus safety programme”.
Imperial College runs the International Bus Benchmarking Group which looks at various performance variables of the bus systems in 14 large world cities.
The figures expose the management priorities of TfL Bus Operation:
So even though buses are getting slower and crashing more than buses in 10 out of 15 ‘world leading’ cities, London’s buses are the most profitable and most punctual.The only way those data can live side-by-side is if you run a Bus System that is purposely designed to kill and injure so that buses can be on time….and, more importantly, you can purposely hide that information from the public.
The London Assembly Transport Committee is conducting an Investigation of Bus Safety in London. Unlike the 2013 London Assembly Bus Investigation led by Val Shawcross AM-now-Deputy-Mayor-for-Transport (which did not scrutinise TfL Bus Safety Performance at all), Bus Safety Performance is the precisely the focus of this current investigation. Since TfL has been a member of the IBBG since 2004 and, according to this helpful IBBG promotional video, it receives frequent reports for its members to help managers “defend their performance” (cf 5:49 in video), I think it is incumbent on TfL to release all the Reports it has received from the IBBG since 2004 to the Transport Committee so that the London Assembly can conduct a meaningful investigation.
- you are sitting 2 metres from someone who killed a good friend of yours;
- a miracle saved you from meeting the same end as your friend;
- the Crime Prosecution Service has decided not to prosecute the killer;
- the killer has spent the last half hour lying to his teeth, even denying that he was aware that he killed your friend and severely injured you;
- you see video footage of the killing, showing in stark clarity the lies of the killer.
What do you do?
Few people will blame Corneille Massengo who, at the moment he watched himself and his friend Osman fly up in the air after being hit by a car driven by Zanah Mohamed, jumped on him showering him with punches, soon followed by eight of his friends.
This is what happens when the Justice System fails; it is a failure at different levels.
The Inquest to the killing of Osman Ebrahim was adjourned after the punch-up, so we have not heard the details of the Police investigation. We do know however:
- Osman and Corneille were crossing Old Street at 4:20, after leaving the Aquarium Club. The killer had an unimpeded view of them, did not slow down before impact and fled after the two young men were thrown 2 metres up in the air.
- All independent witnesses have stated that in their view the car was being driven at an excessive speed. It is our understanding that it actually was driven at 50kph.
- The CPS decided not to prosecute the killer going against the recommendation of the Police.
- There is a general issue with speeding drivers in the early hours of the morning in the Old Street area, especially between 2:00-4:00 when people leave clubs. Bouncers have stated that some people use the area as a race track.
- The killer, after leaving the Aquarium, went to retrieve his car and then parked it in front of the club, with music blaring, to pick up his two drunk friends. He sat on the bonnet and was acting like a prat, and then proceeded to do one or more laps of the above mentioned race track; it was during one of these laps that he killed Osman.
- The killer was apprehended, together with the two passengers, the day after
We can only guess at the warped logic of the CPS for not prosecuting the killer. It is actually probably very basic: “The killer did not break the speed limit, so we cannot win in court”.
The Coroner, Mary Hassell was unhappy that this case was being heard in her court and not at a Criminal Court. Probably her desire to put a light on the odious behaviour of the three people in the car on the night and ever since, led her to forget to warn them that they had a right to refuse to answer her questions if they felt that a truthful answer would incriminate them.
Hassell was so disgusted by the evident contradictions in what the two passengers said under oath, that my feeling was that she intended to charge them for contempt.
Sitting at the audience benches one could feel the tension rising; the killer was then called to the witness box. Amongst the lies he said was that a taxi parked in front of the Aquarium, pulled out just in front of him, thus hiding the view of the two pedestrians. It was at this point that the Coroner decided to show the CCTV footage, which would discredit the testimony. The killer stepped out of the witness box, and sat on a bench, just below the Coroner. Corneille moved from the rear of the room to the same bench, to have a better view, for the first time, of the moment he nearly died.
It was a perfect set-up for a showdown. The 20 sec. video rolled and the audience gasped when the car hits the two young men. But Corneille missed it and asked it to be run again. On the second showing, the clip was stopped when the car came into view (the taxi always stationary). Corneille followed it and then, at the top of the screen, saw himself and Osman fly in the air…
We wish Corneille well. We hope that he takes the Community Service sentence he will probably receive as an opportunity to channel his anger to constructive ways to improve the system that has failed him and Osman’s family so badly.
We are certainly glad that at last someone was able to teach a lesson to the scumbag who killed Osman, but that is not the way a modern society should design its justice system.
UPDATE 09.03.17 In the Evening Standard the Metropolitan Police is quoted as saying:
“Three men aged 21, 18, and 19 were arrested on the morning of March 29 after they handed themselves in at a police station. All three have since been released with no further action.
“A full investigation was conducted into the circumstances of the collision, led by detectives from the homicide and major crime command working alongside colleagues from the roads and transport policing command.
“A report was prepared for the Inner North London (St Pancras) coroner.”
We will provide an update when the Inquest resumes.
UPDATE 13.04.17 The Inquest resumed at the Old Bailey. Here is our report.
In the morning of 13.09.16, Sheila Karsberg got off a bus on Pratt Street in Camden. She intended to go up Camden High Street, so she walked on the pavement past the bus and noticing that the traffic lights were red for motor traffic she started to cross the street on the bicycle box. After four seconds while she was halfway across the lights turned green.
She was now in front of a Cement mixer which had been stationary at the lights. The driver’s main focus was on his right hand mirror, because the street ahead is misaligned and he needs to first make a slight right turn.
He doesn’t see Sheila in front of his cab, drives off and kills her.
Let’s repeat this: Sheila Karsberg was right in front of the cement mixer, but the driver did not see her and killed her.
Police estimated that because of blind spots, Sheila would have been visible to the driver for one second, had he been looking the right way. They decided not to charge the driver.
As we mentioned many times before, once Police decides to exonerate the killer, they feel they need to blame the victim for getting killed. So emphasis was placed on the irrelevant fact that the pedestrian lights were already red when Sheila stepped off the pavement.
“She broke the law, so she deserved to die”
That is essentially what Police is saying. The Coroner pursued this victim blaming by spending considerable time on her medical record, painting a picture of a diabetic with frequent memory lapses, onset of Alzheimer and worst of all (in the Coroner’s eyes) a propensity not to take the medication that she was prescribed.
“She was old, her brain not working well, a rebel, so she deserved to die”
What is most disheartening about attending these inquests is that no-one says: “Hang on a minute, this woman may have made a mistake but that is not a reason to kill her.”
Blind spots on monstrously big lorries are forgivable but walking across the street when lights are red is worth the death penalty.
We don’t want to blame the driver. Vision Zero is not in the blame business. We are in the problem solving business. And we think that errors like Sheila should not be punished by death.
Some work to improve the visibility of HGV drivers has been made but it is clearly insufficient. These are some of the essential things that should be done but are not done:
- It is unreasonable to expect a driver to be able to look at multiple mirrors at opposite directions in the sometime short time that he is stationary at lights; since a driver’s error has probable catastrophic consequences, much more technology is required to reduce the probability of errors. For example; movement sensors should be installed; rather than alerting drivers (again, they would be overwhelmed by too many inputs) the sensors should act directly on the mechanics and prevent further movement of the vehicle towards the moving person.
- A database of all KSIs involving HGVs should be used to understand how deaths like Sheila can be prevented. Now, nobody does this investigative work. That is why we have repeatedly called for an Independent Road Collision Investigative Authority, like is the case for all other means of transport
- CLOCS needs to be enlarged to include pedestrians. In 2016, HGV drivers killed four cyclists and fourteen pedestrians. It is absurd not to study the much greater number of cases.
We hope that the new Walking and Cycling Commissioner will lobby hard for the above changes.
There are many Sheila Karsberg in London and they don’t deserve to be trumpled over like a big rubbish bag (as the driver described what he thought he had run over).
There are similarities in the tragic violent deaths of Lavna Chuttoo and Bailey Gwynne
- Both were teenagers either on their way to school or at school
- Both killers did not intend to kill their victims
- Both killers were in possession of weapons whose main use is not to inflict harm
- Both killings were investigated by multiple agencies
There are some striking difference however in what happened after the two killings:
- One killer was tried, convicted and sentenced to nine years in detention; the other was not even charged
- The hearing of one case lasted five days; the hearing of the other lasted less than one hour
- National media conducted their own investigations in the circumstances leading to one killing; national media totally ignored the other.
- The multi-agency investigation of one of the killings looked to establish whether there were “wider issues for the whole of Scotland”; the investigation of the other killing just looked at possible interventions at the site of the killing
- The investigation of one of the killing was headed by a top civil servant, “with a track record of involvement in high-profile investigations across the UK”; the other investigation was carried out by a Police Officer, obviously ignorant of International best practice.
- One investigation openly published a set of proposals; the other investigations refrained from suggesting any intervention, afraid of objections from local residents. The only way to read the latter is through a Freedom of Information request.
- A senior Government Minister promised “to look at the conclusions of the first review and report back in due course”. No Government Minister is even aware of the other killing, let alone of the investigation report.
The most striking difference is that the killing which was properly investigated was a one-off, admittedly with a troubling background of contributing factors; the killing which was not properly investigated is sadly replicated several times around the country.
The reason for this galling unfairness is the weapon used: Bailey was killed with a knife; Lavna was killed with a motor vehicle.
We have reported before of the perfunctory inquest following the death of Lavna Chattoo, who was blamed for running into a turning HGV. Following the inquest, we requested the Traffic Investigation report which was not disclosed at the Inquest.
Here is what the Investigative Officer decided:
I discussed with the officer for Neighbourhood Engineering at the Highways and Transport Department at Kingston Council the alternative of a HGV prohibition except for access; we agreed that, with the Council’s adoption of enforcement powers, would be very difficult to enforce and with the required exemption for access would make no practical difference. Furthermore it wasn’t believed that HGVs used these side roads as a short-cut because they were too narrow and busy to allow large vehicles a journey saving time over the alternative larger roads. He explained that the Council had proposed to make the road one-way a few years ago to help prevent rat-running, prevent conflict between opposing traffic and to create more space for turning movements at the junction but that the proposal had been rejected by local residents. We were unable to anticipate any alternative practicable engineering measures that would help prevent this type of collision from happening again.
The amateurism of the report is alarming. Here are a few points:
- Both officers seem to be ignorant of (or choose not to consider) the standard Danish continuous pavement treatment of side-roads. This gives visual priority to pedestrians crossing a side road and reduces the prevalent abuse of Rule 170 by British drivers
- Contrary to the report, Kingston Council is very keen of using cameras to enforce road rules, when they can make money from it.
- If Trevor Perkins wants to operate its timber yard on a road which has many school children walking to school, it should have safety staff (orange lollypop people) operating when children walk to and from school; just like all constructions sites are required to do by the HSE.
- Surely local residents are likely to reconsider their objection to making their street one-way, in light of the tragedy that struck the Chattoo family.
Sadly Lavna’s killing was not a one-off; in September this year for example Aaron Matharu, 11 was killed while walking back from school, crossing a road where another child was severely injured the year before.
We can only hope that, the new Cycling and Walking Commissioner, Will Norman will spend little time, money and effort on “promoting” active travel, and concentrate on making our roads safe for walking and cycling especially for the most vulnerable in our communities.
Last month, more than 20 people were injured after a bus crashed into a railway bridge in Tottenham. It was not an isolated incident. We welcome this guest post by Dave Halliday, independent transport safety investigator.
One key element of air and rail travel is that an incident, which has the potential of a far more serious outcome is investigated, and action taken BEFORE we have fatalities – or very serious injuries. Without any special effort I’ve noted 3 bus de-roofings in London – 2 in the past 20 days, 2 at the same bridge and 2 ‘party bus’ private charters. My memory runs back to West Street in Glasgow in 1994, when 3 died, after the driver of a chartered bus followed a car driver showing him the way through the city – that was 22 years ago and STILL we have buses running into bridges?
There are some key common factors in the recent London crashes. ALL are relatively small operators, and ALL were NOT operating on a registered service bus route, so TfL has no oversight of the routes being used, and the option of drivers making up the route as they go along increases the potential for taking the wrong turning. Almost unforgivable though was the rail replacement service not following a route that avoided hitting the bridge on the route where it was replacing trains. I know that road (I went to school in Isleworth) and it isn’t even on a direct route connecting the stations between Brentford and Hounslow!
The law requires Councils to investigate crashes and then take action to prevent future crashes (Section 39 RTA 1988) This detail should be readily available – published on-line – rather than something that has to be extracted by FoI reports, so that we can see learn from the mistakes made, and see that action is being taken to prevent the same crashes – twice (at least) in a year in just the 3 examples here.
With London’s substantial number of railway lines on viaducts and bridges there might even be an option (in the absence of an empowered National roads regulator) for TfL to require ALL double decker buses operating in London to have a proximity detection system fitted within a defined time limit, with the priority to equip vehicles not operated on registered bus routes. The detection system could incorporate an engine shut down and brake application (like the safety systems on trains) if a driver failed to acknowledge the warning and stop.
The planned system (promised – but with no timetable for delivery) for speed limiting on TfL’s contracted London Buses services can include the engine shut-down (and brake application) feature through a proven ‘beacon’ system, on the approaches to a low bridge. This sort of kit is already in use on buses and refuse trucks in Scotland (and elsewhere) – cutting the speeds on school grounds and waste processing sites.
22 years seems a long time over which no lessons have been learned – or action taken. How many close calls before the next fatal crash?
Earlier this week, Mark Treasure wrote insightfully how, at the core of many failures in building people-friendly road infrastructure is the propensity to ask the wrong questions.
This failure to ask the right questions, and come up with the right solutions, is epitomised not just by a focus on ‘education’ but also on what I would call ‘trinkets’ – things like helmets, lights, reflectives, clothing, and so on. In much the same way as with ‘education’, the process involves shifting responsibility onto the user, and ignoring basic environmental problems. Instead of examining why Road X is unsafe to walk along in dark clothing, we urge people to wear reflectives. Instead of examining why pedestrians wearing ordinary clothes can’t negotiate the streets in your urban area safely, we hand out lights to them.
At a Conference in January 2017, TfL’s Leon Daniels will stress what he thinks are the key Sources of Road Danger
The five main sources of road danger in London are:
• Travelling too fast
• Becoming distracted
• Undertaking risky manoeuvres
• Drink or drug use while driving
• Failing to comply with the law
The presentation will explain how, by focusing attention on these five sources of danger, TfL can prioritise the main causes of deaths and serious injuries and take further steps to eradicate the risk of collisions from occurring.
Knowing Daniels’s infamous pedigree in victim blaming, it is difficult not to think that the further steps he is alluding to will be centred on “behaviour change through education”.
This, of course flies in the face of Vision Zero principles, or Safe System thinking as TfL Head of Road Safety Simon Bradbury likes to call it:
So here are the right questions that Leon Daniels needs to ask:
What measures can TfL take when designing, building, operating and managing the roads to reduce the incidence of speeding, carelessness, distraction by operators of motor vehicles?
What measures can TfL take when designing, building, operating and managing the roads to reduce the severity of collisions when human beings make errors?
What can TfL learn when errors by road users cause the death or serious injury of human beings?
Of course users have a responsibility to behave in a civilised manner and enforcement has a role in leading people away from anti-social behaviour, but too many people have been killed because TfL builds road with the assumption of perfection in human behaviour.
As Simon Bradbury says, “a fundamental change in approach” is needed.
In June 2015, as TfL proudly announced that their target of reducing road deaths in the capital by 40% from the 2005-09 baseline by 2020 had been achieved six years early, discussions focused on a new target.
Some people, including members of Transport for London’s board, argued that a Vison Zero target should be set, recognising that no preventable death was acceptable.
TfL is reluctant to set a target of Zero because it mistakenly thinks that any deaths will be blamed on them. That is not correct: every death is a failure, and it is imperative to learn from failures; to really do that one must detach the learning from the blaming. [A cynic may say that managers’ bonuses cannot be linked to an “unachievable” target]
So a compromise was reached and this headline was paraded on TfL’s website:
Anyone reading the headline would assume that the new target would be 50% of the 127 people killed on London roads in 2014. That would still mean that TfL expects 63 people to be killed in 2020, more than one/week. At present ratios, 38 people would be killed while walking or cycling.
It now transpires that TfL does not think that such a reduction of preventable deaths is achievable. They have kept the old baseline of 2005-09, so the so-called halving is actually a reduction from a 40% reduction target to a 50% reduction target, i.e. only 10 percentage points.
This is a trick that TfL has employed before, namely when they set the 40% target in the first place.
The 40% target was announced in June 2013, in the Safe Streets for London report. The Executive Summary on page 10 states:
TfL will reduce KSIs by a further 40 per cent by 2020
When they say “a further 40%” one would expect they mean from the 2012 figures. Wrong, it was from the 2005-09 average. Now the 2012 figures already showed a 17% reduction from the 2005-09 baseline. Therefore TfL’s target was only a FURTHER 23% reduction from the baseline.
That 23% reduction was reached in 2 years rather than 8 years as planned. Great.
Why then not try to achieve the same rate of reduction in the next six years?
This chart shows how timid the new target actually is:
You can see that a real halving of KSIs by 2020 using 2014 as a baseline (orange line) is consistent with the trend of the previous seven years (green line) (it actually is less demanding).
The new TfL target, which they call “challenging”, effectively expects 900 more KSI in 2020 than could be achieved if present trends continued.
When I challenged TfL about their lack of ambition, I received this reply:
The annual Casualties in Greater London report is published each spring and currently these figures are compared against the 2005-09 baseline. At this time, within the context of the ambition set by the ‘Safe Streets for London: Road Safety Action Plan for London 2020’, we feel it is appropriate to retain the same baseline period.
With regards to using 2014 as the new baseline; we set our casualty baseline over a number of years instead of just one. This is in line with the Department for Transport’s position. This controls the effects of short-term, statistically insignificant variations in data and gives a robust comparison period for the target.
We remain confident stretching the target from a 40 per cent to 50 per cent reduction over the life of the Safe Streets for London Plan is challenging but achievable, representing significant additional KSI reductions to the period to 2020.
I then asked Simon Bradbury, Head of Road Safety at TfL, whether he found it acceptable that in 2020 more than 100 people would be killed on London roads. Again he defended these scandalous targets.
We asked Valerie Shawcross, Deputy Mayor of London for Transport, Caroline Pidgeon, Chair of the London Assembly Transport Committee and TfL Board member Michael Liebreich to comment on the misleading headline and the cowardly target. They all refused to respond, showing lack of manners and decency.
This is not about numbers; it is about the lives unnecessarily destroyed by traffic violence; the area between the red and the orange line represents 2544 people who will be either killed or seriously injured by 2020 because of the cowardice of Transport for London and those who should oversee it.
Is there anything more devastating than losing one’s teenage daughter, killed in a violent act, a totally avoidable death if people had been more observant, if people had responded to safety concerns, if people understood that the sanctity of life (especially that of young people) comes before the convenience of business?
Lavna Chuttoo was walking to school on Coombe Road, New Malden, with friends in the morning of 17.11.15.
They were walking from left to right in the picture. A lorry driver had overtaken them 45 metres before and was therefore aware of their presence; however he turned left into Lime Grove, without looking and killed Lavna.
Police investigators however blamed Lavna for running across the junction. British Police is deeply ignorant of rule 170 (as is most of the brainwashed British public) and believe that a vehicle turning left into a side street has priority over a pedestrian going straight across, which obviously is not the case.
Moreover, the junction has raised concerns in the past. Here are two quotes:
David Hoddinott, 63, of Ely Close, said: “The Lime Grove junction with Coombe Road is particularly bad as you have to be aware of traffic entering and leaving Lime Grove and Cambridge Avenue.
Tony Scott is boss of the New Malden branch of builders’ merchant Travis Perkins, which sees heavy goods vehicles drive into its site, near the junction at Lime Grove, where Lavna was hit.
He said: “It was not speed that caused that. I don’t know what they can do about it to be honest. It’s not safe, people just turn into it [Lime Grove] not necessarily looking.
“It’s very busy along here at that time of morning. There’s schools around here so there’s a lot of schoolchildren about.”
Having determined that the lorry driver had no case to answer, the Police then always feels compelled to build a story of blame around the victim (who conveniently cannot dispute it). They are quite clever: taking advantage of the frail psychological state of the traumatised family, they offer compassion and understanding, at the same time painting a picture of a tragic error by the victim.
The tactics are invariably successful: the family of the victim are won over by the narrative and start to recite typical comments such as “Oh, if only he/she had just waited …” or “Oh, if only I had been louder in telling him/her to wear a hi-viz vest”, in other words blaming the victim or themselves
As an outsider, one feels disgust on how the Police misuse their authority to manipulate minds at such frail moments.
In the case of Lavna, the psychological pressure of the Police was even able to convince the father that only a Documentary Inquest was required; in other words, rather than the Police report heard and cross-examined in Court, it was briefly summarised by the Coroner, no questions asked.
Indeed many questions needed to be asked, such as
- Why was the driver entering a residential street which has a sign saying “Unsuitable for HGVs”?
- Was the driver not aware of the presence of the children on the pavement, which he had passed only few moments before?
- What are the recommendations of the Traffic Management Officer?
- What has Kingston Council done to make the roads to the two schools in the area (one, a primary school, on Lime Grove itself) safer, in view of its obligations according to S39 of the RTA88 and the petition signed by hundreds of residents?
But the West London Coroner seems as lacking in curiosity and awareness of his duties as the Southwark Coroner.
Chettan Chuttoo, Lavna’s father, knows the answer to Question 4: a resounding NOTHING.
That should have been the headline of the newspapers after the Inquest: “Why is the Council not making the road safe for the hundreds of school children?” This is what Mr Chuttoo was asking at the end of the Inquest, but the journalists chose not to hear. And the media, the third column of this Orwellian conspiracy to keep the British public docile and dumb in the face of unremitting traffic violence, without exception ran with the victim blaming story under the cloak of the “compassion” headline:
This again is a dishonest attempt to confuse compassion with acceptance of violence by the powerful. Jesus Christ actually said:
I say unto you, That ye resist not evil: but whosoever shall smite thee on thy right cheek, turn to him the other also.
“Ye resist not evil”. Mr Chuttoo is indeed compassionate, but he is also wise: he understands that the unbearable tragedy that visited his family has a cause and it is this evil, the evil of acceptance and passive promotion of traffic violence, that needs to be resisted and stamped out.
We wish him the best in forcing Kingston Council to make urgent changes so that the children of New Malden can go to school in safety, without having the need of second-guessing the intentions of people in charge of killing machines. For a start they need to put a zebra crossing at the entrance of Lime Grove.
(a)a senior coroner has been conducting an investigation under this Part into a person’s death,
(b)anything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, and
(c)in the coroner’s opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances,
the coroner must report the matter to a person who the coroner believes may have power to take such action.
(2)A person to whom a senior coroner makes a report under this paragraph must give the senior coroner a written response to it.
(3)A copy of a report under this paragraph, and of the response to it, must be sent to the Chief Coroner.
The standards of Coroners varies considerably and we are concerned that the Southwark Coroner is in breach of the Act.
We have witnessed two occasions where he conducted inquests following the death of people riding bicycles. In both occasions the Police reports clearly indicated concerns that “circumstances creating a risk of other deaths will occur, or will continue to exist, in the future” and the Coroner did not make these concerns public and did not take the action which is required to take by Law.
After a fatal collision, two branches of the Police investigate the circumstances of the collision:
- Collision Investigators examine the mechanics of the crash
- A Traffic Management Officer examines the road layout and other environmental issues
In both occasions, detailed below, the Coroner chose not to make public the report of the Traffic Management Officer highlighting his concerns.
In spite of the Police concerns, the Coroner chose not to issue Prevention of Future Death reports. This can only be explained if the Coroner followed 7.1.c, i.e. in his opinion no action “should be taken to prevent the occurrence or continuation of such circumstances”. But surely if that is the case, he must explain why he reached such conclusion. The fact that he chose not to disclose the Police concerns clearly point to a cover-up.
Here are the details:
Inquest of the death of Tafsir Butt at Vauxhall Gyratory
Ross Lydall has written an excellent account of the Inquest .
These are the recommendations found in the Traffic Management Officer’s report, suppressed by the Coroner:
Following the site visit I have the following recommendations /observations .
1) South bound South Lambeth Road on approach to Parry Street be made a three lane carriageway for mixed traffic, each lane to be slightly wider than the present ones to accommodate large goods vehicles having to straddle existing lanes when turning into Parry Street . This then allows room for a dedicated cycle lane along the near-side of Parry Street .
2) North bound South Lambeth Road on approach to Parry Street to have a near-side cycle lane leading to the recommended cycle lane in Parry Street .
3) To have a lighting review under the railway bridge in Parry Street .
4) South Lambeth Place north west bound to have the cycle lane joining point with the main carriageway greater highlighted with either or both markings and/or lighting .
Essentially there are two areas of concern and in both cases the Coroner chose to disregard them:
- Deficiency of cycle lanes on the gyratory. Following the death of Butt, and a few months prior to the inquest, a new segregated cycle infrastructure was opened; it allows cyclists heading to Vauxhall Bridge and to Albert Embankment (and this would have included Butt) to avoid the treacherous gyratory. But what about cyclists heading to Nine Elms: are they catered by the new cycle tracks or are they still led on the same death trap that killed Butt? This is is a question that the Coroner needed to ask but chose not to.
- Lighting under the bridge. Both TMO and crash investigators stated that the tunnel under the railway bridge is insufficiently lit. However rather than following the TMO’s recommendation and ask TfL to review the lighting, the Coroner chose to blame Butt for wearing dark clothing.
Inquest of the death of Abdelkhalak Lahyani at Elephant & Castle
We described the Inquest here. Again the Coroner chose not to make public the Traffic Management Officer’s Report and in spite of its recommendations chose not to issue a Prevention of Future Deaths report, without stating his reasons.
Lahyani was killed when a lorry turned left from a lane that had “Only Right Turn” arrows.
Here are the conclusions of the Police report (my bold):
During the site visit it was noticed that all buses both passing through and waiting at the junction straddled the cycle feeder lane. Lane two did not appear wide enough for buses to wait without straddling the feeder lane.
The positioning of the cycle feeder lane between lanes one and two where lane one is a lane for vehicles intending to turn left, is within the Traffic Signs Regulations and General Directions guidelines and is a previously used design . At this location, in order for this design to be safe for cyclists, drivers in lanes two and three must adhere to the advisory right turn arrows on the carriageway . Lane two does not appear wide enough for larger vehicles to use without impeding the cycle feeder lane . Lanes two and three are clearly marked with arrows that they should be used by traffic intending to turn right ahead. These arrows however are not mandatory. According to the road layout, a cyclist using the feeder lane could reasonably expect vehicles in lane two to be turning right.
Transport for London have looked at the option of using mandatory directional arrows as part of the signal phasing but have discounted this .
We will not dwell on the point that the Traffic Signs Regulations and General Directions guidelines is a discredited document and that even TfL acknowledges that many of its guidelines compromise the safety of people cycling.
The report makes clear that
- the design is too cramped for the safety of cyclists
- the right hand turn from the lanes to the right of the cycle lane must be made mandatory
And yet the Coroner chose to disregard the report, did not ask why “Transport for London have looked at the option of using mandatory directional arrows as part of the signal phasing but have discounted this ” and did not issue a Prevention of Future Death report.
We have often decried that the present system, without an Independent Investigative Road Collision Authority, is not fit for purpose. Many avoidable killings are poorly investigated and lessons are not learned.
In this post we are highlighting that some of the actions of the people appointed to prevent avoidable deaths breaches the Law and we encourage the Chief Coroner to issue clear guidelines and to be more vigilant of illegal behaviour by Coroners.