Another death involving a lorry, another inquest failing to prevent future deaths. We must do better.

This week the inquest into Filippo Corsini’s death was held at Westminster Coroner’s Court, over 14 months after the fatal crash. The only observers were from the press and RoadPeace.  Here we try and share key points from the inquest. But please note that it was not always easy to hear and we apologise for any misunderstandings.

Inquest purpose

The coroner, Dr. Fiona Wilcox, had begun the inquest by reminding all there that the purpose of an inquest was to answer four key questions as to how, where, when and who came to their death. No one was on trial.

Crash

Just after 1230 on 31^st October 2016, Filippo Corsini was run over and killed by a lorry at the junction of Brompton Road and Sloane Street.  CCTV and witness evidence showed he had had been cycling westward and had overtaken the lorry on the offside and turned across the front of the lorry.

The lorry, also travelling westward, had been stationary at lights but was moving forward in a straight line when the collision occurred. The lorry was seen to have “caught the back of the bike and shot Filippo onto the road”, before running over him.  The lorry driver felt a bump, and alerted by passer-bys, he stopped and reversed his lorry off Filippo.

Post crash medical response

An off duty fire officer was reported to have been on the scene almost immediately and performed CPR. Emergency services were on the scene within minutes and HEMS arrived by 1300, but Filippo had suffered massive pelvic injuries.  Life was pronounced extinct at 1315.

The victim

Filippo Corsini (21) was a very keen and experienced cyclist, who participated in cycling competitions around the country.  His family touchingly described him as a “lover of cycling”.

He was in his second year at Regent’s Business University and had spent previous time in London studying English.

The toxicology tests were “entirely negative”, i.e. no alcohol or drugs were in his system.

Cycle

It was a custom built bike, a fixed gear bike which did not have a front brake. There was discussion around the illegality of such bikes with the coroner expressing concern that this affected Filippo’s manoeuvring, including his ability to speed up or slow down. The police did clarify that fixed gear bikes were legal if they have front brakes.

Lorry

It was a 50 yard long Mann tractor trailer unit, with the police describing it “as long as you routinely get” in London.

It was part of a convoy delivering materials to Winter Wonderland.  Even more importantly, it was a German lorry and thus left hand drive.

In the driver’s translated written statement (received on the day of the inquest), he said the lorry did not have any sensors. He did not mention any cameras in his statement. Sideguards and frontguards were also not mentioned.

Lorry driver

Thomas Dose had been an HGV driver since 1995 when he was trained in the Army.  He had been driving that lorry since February 2016 but had previous experience driving similar vehicles.

It was his first day driving in Britain.  (Note—this might have meant his first day driving on that trip or his first day ever driving in Britain) He had arrived the night before and slept outside Harwich.  There were no signs of fatigue. His tachograph was checked and it was mentioned that this was not required as he was a “Showman, and apparently exempt from certain requirements.

There was no mention of the results of drink or drug testing but as he was not prosecuted for any offence, these are assumed to have been negative.  Nor was there any evidence of him using his mobile phone (it was not reported at the inquest how this was investigated). He said he was following his Sat Nav but he was not distracted.

He stated he had stopped behind other traffic and intended to continue down Knightsbridge. He said he had accelerated slowly and had only gone a short distance before he felt a bump.

In his written statement, Dose said his heart went out to the family and friends of Filippo.

Driver’s vision

Dr. Wilcox asked the Forensic Collision Investigator PC Keen about the drivers’ line of sight out of the cab. He responded that it was “largely good , could be better”. This led to a discussion of a few items that might have restricted the driver’s vision through the windscreen , including a Showman sign. But PC Keen said he did not think the removal of these signs would have improved the cyclists’ conspicuity.

Mirrors

Dose testified that he had checked his mirrors back in Germany before starting the trip. He said that he was very conscious that his vehicle was large and heavy and posed danger to vulnerable road users. He stated he had checked his mirrors before taking off. This was reported to be standard practice for him.

There was no mention of the height of the cab or the importance of direct vision.

The family had sent in questions and the key issue raised was if the photos provided by the police accurately reflected the vision the driver would have had at the time of the crash.  The police explained it was an approximation and were not able to say how accurate they were. They did not provide confirmation that the driver height, seat position or vehicle loading had been replicated.

Crash site

It was a dry and clear day with no issues around visibility.  The crash occurred in the yellow box junction. There was a pedestrian refuge with a raised kerb on the approach used by Filippo and the lorry driver.

The MPS Road Safety Engineering Unit did a site inspection within three weeks of the fatal crash. They also reviewed the collision history at the site. There had been 22 injuries from collisions at the junction in the previous three years. All were slight injuries except for a pedestrian seriously injured in a collision with a cyclist and a cyclist seriously injured by a motorcyclist, but this had occurred on a different approach.

The analysis included the locations of the other collisions, e.g. which junction approach and which direction of travel.  No similarities with this fatal collision were found.

Collision investigation

CCTV evidence was obtained from several of the nearby hotels and there was also mention of footage obtained from mobile phones and a black cab dashboard camera.  But there was no single camera that showed the whole incident. No video evidence was shown at the inquest.

An extensive set of photographs was reported to have been produced.

No evidence of mechanical defects were found. (There was no mention of the Commercial Vehicle Examination Unit who usually do the inspection of lorries in fatal and serious injury collisions).

Witnesses

The only witness to give oral evidence at the inquest was Philip Morley, a cab driver with 54 years driving experience, who was also a former HGV driver.  He was waiting in his cab across the junction.  He noticed the German lorry approach and saw the cyclist overtake on the outside, saying the cyclist was “pedalling extra fast as some of them do”.

He said the cyclist had just got ahead of the lorry when he made a left turn across it which shook him. He stated “he did not think the lorry driver had a chance, not where he was sitting”.  It was not clear if he was referring to the lorry driver being on the left hand side or being so high up in the cab, or both.  Or he might even have meant from where he, the cab driver, was sitting.

The only other witness evidence provided was from medical professionals. There was no mention of how many witnesses were identified or interviewed or the evidence they provided.

Reconstruction

The FCI reported conducting a reconstruction but no details were provided on what this involved. It was not certain if this was conducted at the site, or in another location or if it was a virtual reconstruction.

PC Keen mentioned that Filippo was not wearing a helmet and with his dark hair, there would have been a lack of contrast with the road surface. He said the driver would not have been expecting a hazard to appear from that direction. He did not expect the driver to have to look after he started moving off. Mr. Corsini might have been seen at a different time.  He could have stopped behind the lorry or filtered on the inside lane, as several on Santander bikes had done.

He calculated the lorry was traveling slightly faster than the cyclist. He believed that Filippo had crossed very close to the lorry, within an arms’ reach, and that further away, he might have been more visible.

PC Keen agreed with the eyewitness that the lorry driver did not stand a chance. He explained that Mr. Dose did not fall below standard of a careful driver and there were no criminal charges laid against him.

 Coroner conclusions

The coroner’s summary of the death included reporting that Filippo was just 21 and single when he died on the road on 31^st October 2016.

The driver was highly experienced and there was nothing to suggest any impropriety. He was well rested, mirrors appropriately adjusted.  She said this was a “finding of fact”.

She said the cycle involved was a fixed gear bike which was against regulations. This was stated as another finding of fact. She said that it reduced his ability to negotiate traffic and may have contributed to this incident.

She added that the  incident was a” one-off in this area” and caused by the cyclist overtaking very close to Mr. Dose and it was unlikely that he would have been visible. That was another fact finding. Mr. Corsini had overtaken an HGV that was accelerating at a reasonable pace—“for reasons only known to himself”

The vehicle went straight on top of him and he suffered catastrophic injuries. Despite immediate CPS and expert resuscitation, life could not be sustained.

Problem was of visibility and the couple of signs were a small interference. She accepted the evidence that due to the crucial moment when he chose to overtake, that it was highly unlikely that Mr. Does could have seen him.

She stated how..

Just as Mr. Corsini overtook him, Mr. Does should have been looking ahead and not reasonable to expect him to approach from the side. It was absolutely tragic. An accident.

 The outcome should not have happened. There was no blame on the driver.  Goodness knows what was going on through his head. He was an experienced cyclist.

Corsini was traveling fast and a regular bike might have been easier to manoeuvre –start and stop. We don’t know.

She passed her sympathy to family and friends of Mr. Corsini. “This was an absolutely tragic death and hoped that at least the family will be able to understand the circumstances of his death”.

Inquest conclusion (verdict)

The family asked, through their solicitor, for a Road Traffic Collision conclusion. Dr. Wilcox responded that it was up to her to decide and went on to later pronounce it an Accident, thereby denying the family their simple request.

RoadPeace could not understand the reasoning behind this. Road traffic collision does not imply any culpability or intention. It is more accurate than the generic accident and also avoids any connotations that it was unavoidable.

Preventing future deaths

Note:  Coroners have a duty to prevent future deaths. This is done by them writing Preventing Future Death reports. These are not expected to pose solutions or remedial measures but to ask the relevant authority what can be done to prevent repeat occurrences.  Very few are done—only about 3% of road death inquests result in a PFD.

Dr. Wilcox asked about Regulation 28, i.e. Preventing of Future Death (PFD) reports and fixie bikes. But she then noted that they were already illegal (when missing a brake) and there was little that could be done (through a PFD).

There was no discussion of a PFD on any other subject, including the need for Direct Vision lorries, front underrun guards, safety technology (cameras and/or sensors), or foreign lorries and/or drivers.

RoadPeace is working with TfL’s funded  CLOCS (Construction Logistics and Community Safety) programme on a checklist for coroners to encourage more PFDs in lorry related inquests. This inquest confirmed the need for such a checklist, as well as more information being supplied coroners and FCIs on the efforts underway to tackle lorry danger at source.

Inquest vs investigation

These notes are based on the inquest hearing. They do not reflect the investigation by the police, or even the coroner. Much remains unknown . Key questions include:

1. Why was there no mention of CLOCS or the Mayor’s programme to introduce Direct Vision lorries, including the current consultation on Direct Vision Standards (DVS)?
2. How many fatal collisions involve fixies? How many involve foreign lorries? How many involve a foreign driver on his first day driving in Britain?
3. It seemed that the lorry was not the first vehicle at the stop line. If other vehicles were in front, how did this affect the witness’s vision of the cyclist movements?
4. Did reversing the lorry off Filippo affect his chances of survival?
5. Was there any medical treatment, such as TXA—a life saving drug which stops bleeding, which could have increased his chance of survival?
6. What DVS rating would this lorry have obtained? (These have yet to be finalised).
7. Despite the stated aim of an inquest to answer questions surrounding unnatural death – and despite the alarmingly regularity and pattern of lorry deaths in London – so many questions around Filippo’s death remain unasked or unanswered.

RoadPeace believes that victims and their families deserve better.

Once again the inquest process failed to ask the probing questions necessary to really understand the circumstances around another preventable London road death. It also failed in the opportunity to look at preventing future deaths.

Too much focus was put on the victim’s choice of bike or hair colour, rather than looking at the systemic failures that allow large vehicles with known blind spots to share London’s streets with cyclists and pedestrians.

And in the absence of any meaningful enquiry by the coroner, Transport for London and the MPS should review every fatal collision  to see what would have prevented it. Both organisations know that the risk posed by lorries is not restricted to cyclists, but causes some 2-3 times as many pedestrian deaths as cyclists deaths. Within two days of this inquest, another pedestrian had been killed by a lorry and a second pedestrian injured in a separate lorry collision, just in London. And both organisations know what prevention efforts are in place under the schemes such as CLOCS and the London Freight Enforcement Partnership etc.

RoadPeace is calling for a review of every fatal collision  to see what would have prevented it.  This is the Swedish approach and is being adopted by the Welsh police services.  RoadPeace called for this to be included in the Mayor’s Transport Strategy and in the upcoming Vision Zero programme.  If fatal lorry collisions are to be avoided, these reviews must be undertaken. This is not about blame, but prevention.

How you can help prevent further deaths from lorry collisions

Respond to TfL’s Direct Vision consultation which closes next week (24 Jan). https://consultations.tfl.gov.uk/roads/direct-vision-standards-phase-2/

You don’t have to answer all questions –just be sure to support the development of Direct Vision Standards.

Updated on: 19 January 2018