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Coroner criticised for claiming there was 'nothing practical' he could do to prevent a repeat of fatal collision

The coroner claimed there was nothing he could suggest to prevent a repeat of the 'terribly sad case'. ...

A coroner has been criticised for suggesting that there was 'nothing practical' he could do to prevent a repeat of a fatal collision involving the driver of a bin lorry and a cyclist. 

Samantha Blackborow was killed in the crash after the lorry driver failed to see her, an inquest heard. 

The 35-year-old was riding in a cycle lane in Horspath Driftway, Oxford, on 3 November 2020. 

Oxford Coroner's Court heard she appeared in the lorry's mirrors for 'only a short space of time'.

Senior Coroner for Oxfordshire, Darren Salter, expressed his condolences to Ms Blackborow's family but said there was 'nothing practical' he could recommend to prevent a repeat of the 'terribly sad case', the BBC reports.

Following the hearing however many people argued the coroner could have proposed new safer, segregated cycling infrastructure.

People also argued he could have commented on the importance of motorists being certain it is safe to turn before doing so and their responsibility to ensure the safety of vulnerable road users. 

Earlier this year police concluded there was 'insufficient evidence' that the lorry driver's driving had fallen 'below the required standard'. 

Ms Blackborow, a specialist nurse from the city, had cycled along the Eastern Bypass and then joined Horspath Driftway's cycle lane seconds before the accident. 

Robin Dowsett, who was driving the Veolia waste lorry, said he was stuck in heavy traffic and indicated to pull into a side road for the Horspath Driftway Retail Park, without seeing Ms Blackborow. 

"I wasn't aware of anything," Mr Dowsett said, adding: "I'm sorry but I wasn't." 

Mr Salter concluded: "[Ms Blackborow] did appear in the mirrors but there were several mirrors and several things that Mr Dowsett had to look at and it was only a short space of time that she was in the mirror for. 

"On the evidence it is far from clear that an indicator or audible warning signal [from the lorry] could've been seen or heard by her." 

He added there was 'nothing practical' he could suggest to prevent a repeat of the 'terribly sad case'. 

He recorded a conclusion of road traffic collision.

A Veolia spokesperson said: "Our thoughts and sincere condolences remain with Samantha Blackborow's family and friends at this difficult time."

Following the inquest people took to social media to point out that a segregated cycle lane could help prevent any future collisions at the junction. 

Others said that whatever the circumstance, the responsibility for making sure it is safe to turn should always be on the vehicle doing the turning. 

People also expressed anger and confusion at the fact the lorry driver admitted he wasn't aware of the cyclist but his driving was still deemed to be acceptable. 

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15 comments

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joe9090 | 2 years ago
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Why do they not make it a law that you have to always give way to cyclists coming up on your left? It works well in the Nwetherlands, all drivers are trained for this extra check before making a turn.

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AlsoSomniloquism | 2 years ago
1 like

I was just checking this place out on Streetview and although there is a big gap in the years, it is suspiciously noticeable how faded the bike lane was on that specific turning over several years and then how fresh it was in the pic on the tweet with the ghost bike attached to the railings. I wonder if the new paint job happened before or after the accident? I'm not giving the driver an excuse still, however there might have been less of a looking for bikes if the lane was as faded as it looked a few years earlier. 

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EK Spinner | 2 years ago
1 like

we see this time and time again, very poor driving standards, on very poor infrastructure, maybe its about time some responsibility was directed towards the person who signed of on the design and approved a bike lane that creates asituation where left turning traffic is not in the left most lane

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Ian Carey | 2 years ago
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Any death is tragic, especially if preventable, which I suspect this may have been. I was not at the inquest, nor have I read the transcript, so clearly I cannot comment on the proceedings. However, from my one experience involving the death of a relative (not cycling related), I have concluded that the bereaved family should seriously consider employing a lawyer in such cases. Although an inquest is not supposed to be 'adversial', they often can be. I feel that families should be seeking legal advice soon after the death and then preparing for the inquest, which can often be a year or more later. A lawyer should be asking lots of questions, which can then be answered formally at the inquest. Sadly this seldom happens until the actual inquest, by which time memories have faded, evidence has not been collected and expertly reviewed. Detailed preparation can result in a better inquest outcome. However, this, as one would expect, comes at considerable cost, often beyond the reach of many families who have lost loved one to 'accidents'. 

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GMBasix | 2 years ago
3 likes
Quote:

Mr Salter concluded: "[Ms Blackborow] did appear in the mirrors but there were several mirrors and several things that Mr Dowsett had to look at and it was only a short space of time that she was in the mirror for.

Assuming the picture I found is representative of Veolia's vehicles in Oxford, they have around 7 mirrors to monitor.  But not all of them all the time.  Only 1-2 of them are relevant in the approach to turning and during the turn itself. And since the HGV was crossing another vehicle [cycle] lane in order to complete the maoeuvre, the onus was very much on him to make sure the maoeuvre was safe: "I wasn't aware of anything," is not an acceptable level of safety; you need to be certain the lane is clear.

In looking for an image of the HGV, I stumbled into the Mirror's report, with the usual waste-of-skin comments:

  • "I'm afraid it sounds as if she went up the inside of a lorry stationary in queueing traffic and indicating to turn left? There are usually stickers on the back of lorries reminding cyclists how incredibly dangerous it is to do that, because of the blind spot. It causes so many of these types of deaths."
  • "It sounds like the lorry driver was blameless, and sadly the lady took a risk by cycling up inside of his vehicle as he was indicating to turn. Perhaps her mind was elsewhere, nurses have been so busy lately. I feel so sorry for her family knowing she died like that."

Stickers! I've seen them on Fiesta vans.  Fiesta vans!  Stupid fault-shifting stickers.  Of course, the stationary lorry was indicating, so they had right of way to cross another lane(!)  Because of the blind spot. It's not a "blind" spot, it's a "didn't wobble my head to look" spot. In any case, the coroner says she was visible in the mirror. In slow-moving traffic, he should have anticipated a cyclist in the cycle lane.

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chrisonabike | 2 years ago
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Again this won't bring anyone back nor address any feelings about whether the driver should have taken some responsibility, but it is alway possible for coroners to submit a Report to Prevent Future Deaths. Indeed it is their duty "where the coroner believes that action should be taken to prevent future deaths". Only a couple of snags:

  • It sounds like it's left to the coroner to judge if this would help. In this case it sounds like the coroner thought "just one of those things". I don't know what criteria / standards they have to follow here. Given that they have to rule on a huge variety of circumstances the chances that they will be well appraised of e.g. possible modern road safety interventions may be slim.
  • Those issued a report have to respond. However that appears to be it. Reading the reports reveals that a common response in many cases is something like "this was regrettable but we think we're doing a good job so ... we'll keep doing it the same way, thank you".
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GMBasix replied to chrisonabike | 2 years ago
2 likes

I have no idea what guidance is given to coroners, but it doesn't sound as though they are encouraged to seek specialist advice on road safety from, for example, cycle infrastructure specialists.

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chrisonabike replied to GMBasix | 2 years ago
1 like
GMBasix wrote:

I have no idea what guidance is given to coroners, but it doesn't sound as though they are encouraged to seek specialist advice on road safety from, for example, cycle infrastructure specialists.

Indeed. Ideally we'd have something like the rail, air or marine accident investigation board for the roads to gather lessons from this. Probably not likely in England soon as it's against the political tenor ("More quangos? More regulation? 'Elf and safety gone mad!"). And they'd have to be able to require changes...

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GMBasix replied to chrisonabike | 2 years ago
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chrisonatrike wrote:

...Probably not likely in England soon as it's... 

  a bureaucratic attack in the war on the [stifled snigger] infallible, skilled elite [/stifled snigger] that is the hard-pressed British motorist.

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eburtthebike | 2 years ago
3 likes

"Earlier this year police concluded there was 'insufficient evidence' that the lorry driver's driving had fallen 'below the required standard'."

Apart from the tiny matter of the death of Samantha Blackborow, but maybe they didn't notice that.  If they need more evidence than that, they're in the wrong job, and so is the coroner.

This case demonstrates the staggering inherent bias in the system, in our society, when someone is killed but no-one is responsible, and both the police and coroner wash their hands of the case.

Andy Cox got it absolutely right.

HC "170
Take extra care at junctions. You should

watch out for cyclists,...."  Unless you're driving a bin lorry.

"182
Use your mirrors and give a left-turn signal well before you turn left. Do not overtake just before you turn left and watch out for traffic coming up on your left before you make the turn, especially if driving a large vehicle. Cyclists, motorcyclists and other road users in particular may be hidden from your view.

183
When turning keep as close to the left as is safe and practicable
give way to any vehicles using a bus lane, cycle lane or tramway from either direction."

That driver should be thanking his lucky stars that the police are either incompetent or his brother works for them.

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hawkinspeter | 2 years ago
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Sounds to me like it's totally on the lorry driver. If you're going to make a maneouvre, then the onus is you to ensure that it is safe to do so. Not seeing someone in your mirror is different to being certain that a left turn across a cycle lane is safe. Either the lorry or the driver (or both) were not fit to be on the roads.

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Velo-drone | 2 years ago
3 likes

Did the lorry driver approach the cyclist from behind?

If so the "didn't see" argument is simply an admission of (at minimum) careless driving and should be treated as such

And even a sensibly placed bollard on cycle lane at the turn off to ensure wide turn into the side road would have prevented this

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AlsoSomniloquism replied to Velo-drone | 2 years ago
3 likes

Lorry was stuck in heavy traffic so cyclist probably did approach from behind. However I did wonder if the indication was a last second thing. Why does the coroner give the lorry driver a way out. Oh no, several mirrors..... poor driver. 

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Velo-drone replied to AlsoSomniloquism | 2 years ago
3 likes

Doesn't exactly help though, does it? 

If the lorry is stuck in heavy traffic alongside a cycle lane then those are exactly the circumstances in which a competent lorry driver would be taking great pains to check and ensure that they are taking the turn safely and that nothing is proceeding in the empty lane next to their stationary one.  That's surely HGV Driving 101??

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wycombewheeler replied to AlsoSomniloquism | 2 years ago
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AlsoSomniloquism wrote:

Lorry was stuck in heavy traffic so cyclist probably did approach from behind. However I did wonder if the indication was a last second thing. Why does the coroner give the lorry driver a way out. Oh no, several mirrors..... poor driver. 

well after all we are told indicating should not be automatic, nor should indicators be left on while stationary in traffic apparently, lest it irritate the following driver.

Doesn't seem clear from reports whether indicators were not on when cyclist approached. whether they were on but obscured in some way, or whether they were clearly visible all the time.

"Robin Dowsett, who was driving the Veolia waste lorry, said he was stuck in heavy traffic and indicated to pull into a side road for the Horspath Driftway Retail Park, without seeing Ms Blackborow. "

Doesn't say he was stuck in traffic indicating, but then also doesn't say he was stuck in traffic then indicated. so it's vague as to whether the indicators were flicked on only when the opportunity to move occured.

Bend radius on the junction is large, so bin lorry could have been occupying a position close to the kerb, blocking the cycle lane and preventing this. Either seal the corrner so this can't happen, or having decided to leave the cycle lane clear to allow cyclists to pass instead of blocking it, then he must monitor the cycle lane to ensure it stays empty before turning. 

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