Last week was unusual. It is very rare for coroners to hear two road deaths back to back, particularly with similar circumstances. It is also very rare for coroners to hold inquests after a criminal court conviction. And most importantly, too rarely do they take action by making Rule 43 reports to prevent repeat deaths.

The two deaths were of cyclists killed by lorries in London. Brian Dorling was killed in October 2011 by a driver running a red light at an unsafe junction. Philippine De Gerin-Ricard was hit and killed in July 2013 on a cycle superhighway.

Coroners do not have to hold an inquest in cases where there is a criminal court case.   As David Cox had pleaded guilty to causing the death of Brian Dorling by careless driving, there had been no public review of the evidence and the circumstances of the crash. Mary Hassell, the Poplar Coroner, deserves credit for holding this inquest and not letting concern stop at the driver’s conviction.

Coroners have a duty to prevent further loss of life. As highlighted in our briefing Tackling lorry danger , they make Rule 43 reports in less than 5% of road death inquests. In each six month summary of Coroner Rule 43 reports, which used to be published by the MOJ, those with “wider significance” are highlighted. But never has a road death related report been highlighted —they never saw how the lessons learned from blind spots and sideguards could be used  to prevent further deaths.  Many cyclist (and pedestrian) deaths attributable to deficiencies in vehicle design are simply being treated as unfortunate ‘accidents’, or as one-offs. But RoadPeace knows them to be as a result of systemic failure, a failure which allows the deadliest of our vehicles to operate on our streets with known blind spots.

Responsibility for monitoring Rule 43 reports has now been transferred to the Chief Coroner Peter Thornton. It would be great if cycle campaigners offered to take him out on the road. We need coroners and their managers to appreciate just how much more can be done to make the roads safer. Just as there is an independent panel on custody related deaths, perhaps it is time there is one on lorry related deaths.

The motto for the Chief Coroner in Toronto is “We speak for the dead to protect the living”.  By speaking up last week, the Poplar coroner has taken action to help make cyclist deaths rare, rather than the monthly tragedies they are at present. All other coroners need to take note.

Updated on: 21 October 2013