Limited learning from Lucia Ciccioli’s inquest

Direct Vision Standards (DVS) for lorries cannot come soon enough. The week the consultation on the introduction of DVS for lorries closed, we had yet another inquest into the death of a cyclist hit by a lorry, and more evidence for the need for DVS.

Here, again, we try to summarise the evidence presented and the lessons learned from an inquest. This inquest was held over 15 months after the fatal collision.

Inquest purpose

As standard procedure, Russell Caller, Assistant Coroner for Westminster, reminded everyone that the coroners’ court was not a court of blame. Its purpose is to establish who, when, where and how someone has died.


Lucia Ciccioli was 32 and on her way to work for a morning shift at a restaurant when she was killed on 24 October 2016. It was a route with which she was familiar.

The summary provided by her cousin in Italy explained that she had come to England looking for work after university and to learn English. Finding many friends and a partner here, she had stayed. She was exceedingly beautiful, sunny, kind, friendly, very caring, honest and generous. She was involved with her local parish.

She did not like to waste time and did much physical activity. She had bought a bike to save money and be more independent. In wintertime she did not use her bicycle. She ate healthy food and continued to eat Italian food.

Lucia was careful with money and saving for her future. She took interest in others and was ready to take a joke.

This is what her family wanted the court to hear about the person killed on our roads. Lucia deserves to be remembered not just for the manner of her death- premature, violent and preventable—but for the way she lived her life–caring and compassionate.


Just after sunrise (07:41), Lucia was cycling west on Lavender Hill. The weather was cloudy and the road wet. She was stopped by the lights and positioned herself in the nearside left turn lane, close to the front bumper of a lorry headed in the same direction. When the lights changed, both vehicles moved forward. A pedestrian area narrowed the road on the left requiring Lucia had to move over to the right, in front of the lorry.  A few seconds after moving forward, the lorry clipped her rear wheel and she went down. The lorry ran over Lucia. It was 07:54.

One of the first on the scene was a passing doctor who held her hand. Her injuries were catastrophic and life was pronounced extinct at 08:12.

The driver was unaware of the collision until a car driver drove after him and blocked him in the road. After learning he had hit someone (initial reports referred to a pedestrian as Lucia’s bicycle had gotten caught under the lorry), he parked his lorry (about 188 metres beyond the crash site) and returned on foot to the scene.


Shaun Tomlin had been driving lorries for 26 years. Based in Battle, Sussex, he was working as a “tramper”, meaning he was sent to different places every week and returned home on weekends.

He had started from Battle that morning at about 04:15 and had made already made a delivery. He was on his way to West London to pick up some materials when the collision occurred. He testified that it was only when a car swerved in front of him and forced him to stop that he learned of the collision. He had not felt any bump from the collision, or heard any noise.

He testified that he had been expecting the lights to change and that he had looked in his mirrors. He said he always looked from left to right in his mirrors.


He was tested for drink and drug driving and both were negative. He also passed the eyesight test.


He testified to being on his mobile phone when the collision occurred.  It was a hands free phone and he had both ear phones in. The call was seven minutes long. The police reported that the reflection in the cab windscreen shown in the dashcam video showed the driver with both hands on the wheel. The family’s barrister asked if the use of earphones would have affected the driver’s ability to hear the collision. The police thought this was “probably not” but couldn’t say for definite.

Cyclist awareness

Tomlin was a cyclist himself and said he had had much experience with driving in London with many cyclists. He mentioned an instance where he had 22 cyclists around him and some hanging on his trailer.

He said he had had to do cycle training. He added that cyclists should also have to have the experience of driving a lorry in London.

Collision investigation

The Forensic Collision Investigator who had investigated this fatal crash was not able to attend the inquest.


There was one eyewitness who gave a thorough description of the crash. He was within metres of the vehicles and had noticed how close the cyclist and the lorry were before the collision. Traffic had stacked up at the light. When the lights changed, the lorry was faster than the cyclist and collided with her back wheel. He saw the lorry’s front two wheels run over Lucia and called the emergency services immediately.

He described the lighting as good, visibility “perfectly fine”. He could not remember hearing any noise from the collision. He estimated the vehicles had moved for a few (4-5) seconds before the collision occurred and it was a few more seconds (4-5) before the lorry was clear of the scene.

The cycle had gotten caught underneath the lorry and some witnesses, including the one who alerted the lorry driver to the collision, thought a pedestrian had been hit.


Police had two key sources of video evidence, the dash cam of the lorry and cameras on the bus behind the lorry.  The bus camera was said to be taking frames at 10 per second whilst the lorry dash cam operated at half that speed.

Prior to the collision, the video showed the lorry overtaking Lucia. The lorry driver was not asked about this, at least not at the inquest.

Driver’s vision

The police reported doing a sight line survey to establish the driver’s point of view. This included a reconstruction where a police officer cycled near the lorry in the police pound. They also did a desktop reconstruction where they plotted what the driver could see. Lucia was said to be 1.25 metres left of the lorry and ½ metre in front when they were at the lights.

They did not have the driver’s height and used the normal height of 1.7 m for their calculations.

The coroner asked questions about the lorry’s dash cam and it was clarified that this was not for the driver’s assistance as he could not see the footage.

The police also explained that they would not expect the lorry driver to be using his Class VI mirror which looks down in front of the lorry when the lorry was travelling at 18mph (the estimated travelling speed of the lorry at time of collision).

The police explained that it can take three to six seconds for a lorry driver to check all their mirrors. They said that It cannot be a prolonged observation as the view will have changed in the other mirrors with a new situation arising.

They also said how lorry drivers were trained to anticipate traffic light changes and with the pedestrian countdown visible, the lorry driver would have been expected to have already looked in his left side mirrors when Lucia was not yet visible or very difficult to have seen. She was 18-20 metres behind the lorry. She was wearing dark clothing, no high viz and did not have a front light on her bike. At that time of day, cycle lights were not required but all other vehicles seen in the footage were illuminated, including two other cyclists. They said it would have been hard to see her against the background of wet dark asphalt.

The police also noted that if he had seen her, as she was in the left turn lane, he could have been expected to assume she was turning left and not expected her to move in front of him.

The family’s barrister asked if anybody else had driven the lorry (and might have changed the seat or mirrors) but the police said it had been collected from the crash site with a front loader and had been secure in the police pound.

The police were also asked about the difference between the height of the lorry driver and the police driver in the reconstruction but the police responded that it was only a guide. The reconstruction did not appear to require exact height measurements from the lorry driver.

Crash site

On the approach used by Lucia and the lorry driver, there were three lanes. Lucia was in the nearside lane which was a left turning lane, the lorry driver in the middle lane and lane three was a right hand turn lane. Between the first two lanes, there was a cycle feeder lane leading to the advance cycle box at the front of the junction. Lucia was not in this feeder lane and the police stated that cyclists were not required to use it.

There was a yellow box junction at the junction. On the far side of the junction, the road narrowed and Lucia had to shift right to avoid cycling into the kerb.

There was a pothole at the junction with the road sunken around a manhole cover.  It was said that this could cause a cyclist to wobble and they would have to move to the right to avoid it.

There were no signs warning that the cycle lane did not continue on the other side of the junction or that vehicles would need to merge. Cyclists were reported to have been “effectively left to their own devices”.

Site collision history

In the three years up to 30 April 2016, there had been 11 personal injury collisions at the junction, all of which were slight injuries. Three involved cyclists but only one of these occurred on Lavender Hill with the other two on the side road approaches. The slight injury cyclist collision on Lavender Hill was on the eastbound side. There had been no collisions involving lorries or westbound cyclists.

TfL and Wandsworth Council did a site inspection on 4th November. It was explained that Wandsworth Council was responsible for the road maintenance whilst TfL was responsible for the traffic movements/signalling.

The police reported that they had been trying to find out if the sunken utility cover had been repaired but they had yet to hear back.


It was a 45 foot articulated lorry. The driver testified he had checked its mirrors that morning, including with a walk around. His checks took a minimum 15 minutes and more like 20-25 minutes. He said he used a very detailed defect check sheet.


The lorry was examined by an inspector from the Driver and Vehicle Standards Agency. No defect was found to have caused or contributed to the collision.


The lorry had proximity sensors on the front nearside. They did not work above 7 kph/hr. This was explained because they would be going off all the time and the driver’s sensitivity to them would be reduced. One of the sensors was not working at the time of the collision but the police investigator testified that this would not have made any difference. The barrister representing the family asked if additional sensors would reduce future deaths. The police responded that he didn’t know and was not really qualified to respond. He noted the need to be careful of what was expected of lorry drivers.

 Front guards

The police also said they did not have the experience or expertise to know if front guards would prevent similar deaths.

Police conclusion

If the lorry driver had checked his nearside and wide angle mirrors as he moved off (rather than before), he would have seen Lucia. But she would have been in the left turn lane and the lorry driver could have expected her to turn.

If the lorry driver had anticipated the lights change (there was a pedestrian countdown signal and the lorry driver testified that this is what he did do), then he would have checked the relevant mirrors too early and Lucia would not have been visible. The investigator said lorry drivers are trained to anticipate lights changing.

Coroner conclusion

The coroner reminded those there that his role was to answer who, when, where and how the death occurred. The first three were relatively straightforward whilst the how was more difficult. He mentioned he was not considering either a suicide or an unlawful killing verdict.

He allowed the solicitors to make submissions to him. These covered the verdict and preventing future deaths.  The family’s solicitor asked for a narrative verdict on the basis that this would help the family understand the circumstances. The coroner reminded the solicitor that the family could purchase a copy of the inquest transcripts and get more information.

As with Filippo Corsini’s inquest, the coroner ignored the family’s verdict request, and gave an Accidental death verdict.

Preventing Future Deaths

The family’s barrister raised several concerns, including the presence of the pothole, absence of cycle lane through junction, use of mobile phone (legislation requiring earphones be limited to one ear) , need for additional proximity sensors (and working at higher speeds), as well as improved junction markings.

The lorry driver’s solicitor urged careful consideration to the coroner as some of the above suggestions required legislation and there was no evidence as to effectiveness. There was no evidence that mobile phone or lack of sensors had contributed to the collision.

 The lorry driver’s solicitor was very critical of the junction, including the road layout and its maintenance. He queried if cyclists had to obey yellow box junction markings (this was clarified that they do). He asked the police to agree that junctions should be designed with those unfamiliar with the road layout in mind.  He argued the design and yellow box junction meant cyclists were dependent on motor vehicles allowing them to merge or they were left stranded. He asked if the yellow box junction could stop before the edge of the road and allow space for cyclists to continue through junction.

He also asked if it would help if there were two lanes clearly marked on the other side of the junction. The police replied this would require removal of a loading bay, as six metres would be needed for the two lanes. They said it was an option that could be explored.

The Coroner reported that he would be sending a Rule 28 letter (Preventing Future Death report) to Wandsworth Council and TfL, urging them to reconsider the junction and what could be done to make it safer.

He did not mention taking any action around discouraging the use of lorries with restricted vision or hands free mobile phone use. But then to be fair to the coroner, no evidence on the increased risk associated with both of these was presented.  The only search for a pattern was with the collision site. The only person testifying at the inquest trained in prevention was from the MPS’s Road Safety Management unit which reviews road environments, not driver behaviour or vehicle design.

RoadPeace conclusion

It is good the coroner is acting to reduce the risk of repeat occurrences. But it was worrying to see the lack of awareness of the evidence on the dangers of using a hands free phone or lorries with restricted vision—combined, they can be even more lethal.

Hands free is not risk free

Evidence dates back over 15 years as to the risks associated with hands free phones. The Times’ Cities fit for Cycling Campaign, was inspired by the lorry driver distracted by a hands free call which left Mary Bowers requiring lifelong care. And drivers have been convicted of causing death by dangerous driving due to the distraction caused by a hands free call. Samantha Ayres was jailed for three years for causing the death of David Kirk by dangerous driving.

Tackling lorry danger at source –through DVS

It is also alarming that there was no awareness of the efforts being made to introduce safer lorries into London, especially through the DVS initiative. Those being asked for recommendations as to how to prevent future deaths should be kept updated on what TfL’s research shows to reduce risk.

TfL’s commitment to DVS

Why we need the DVS

Safety is the Mayor’s priority and he has committed to a ‘vision zero’ approach to road danger reduction. This means tackling road danger at its source to ensure London has the safest streets, people and vehicles.

Over the past 3 years, HGVs were involved in 20% of pedestrian fatalities and over 70% of cyclist fatalities, despite HGVs only making up 4% of road miles in London.

HGV blind spots are a major contributory factor in fatal collisions involving cyclists and pedestrians. The DVS is intended to help address this.

We do not pretend to have the answers.  But we are concerned that the right questions are not being asked. These should include:

  1. If all the sensors had been working, would the lorry driver have been alerted to Lucia’s presence at the junction? Would additional sensors have made a difference? Would any of the new systems being introduced have made a difference?
  2. Would Lucia have been visible if the lorry had a full length passenger door window?
  3. Could Lucia’s death have been prevented by a front under-run guard?
  4. Would the improved response time from a direct vision lorry have been enough to prevent the fatal collision?
  5. Did the lorry have an automatic braking system? Would this have made a difference?
  6. Were there other phone calls made by the driver which could have meant a prolonged period of distraction? The lorry driver had overtaken Lucia once and so should have been aware that he was sharing the road with cyclists.
  7. How much difference did the driver’s height make? As he was shorter than the average height used by police, we assume he had even greater restricted vision. But perhaps “blind spots” are so large that drivers’ height do not make a difference. After all, there is no height restriction on lorry drivers.
  8. Should all junctions of similar design be reviewed?
  9. Should all yellow box junctions be reduced to allow a through cycle lane across junctions?

As with the inquest into Filippo Corsini, we owe it to the victims and their families – and every other vulnerable road user sharing roads with lorries – to do better.

This includes with thorough investigations through to evidence based countermeasures.  Blind spots should not be accepted but measured carefully and properly considered as a risk factor. Lorry drivers need to be trained in why avoidable distractions should be avoided.

And safer vehicles will be key. We need safer lorry design with full length passenger door windows and underrun guards, and higher quality safety technology, including front and side sensor systems, and automatic braking systems.  Until direct vision lorries are the only lorries allowed, such primary safety measures as cameras and alarms, and secondary safety measures such as under-run guards are essential.