(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.