Prevention of Future Deaths reports · 2018

Lucia Ciccioli

Regulation 28 report to prevent future deaths, reference 2018-0148, written 16 May 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report16 May 2018
Reference2018-0148
DeceasedLucia Ciccioli
CoronerRussell Caller
Coroner areaLondon Inner (West)
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

Head of Legal Service, General Counsel
Transport for London

Petty France

55 Broadway

London
SW1H OBD

Head of Shared mT Services

Wandsworth, Merton, Richmond and Sutton
Gifford House

67c St Helier Avenue

Surrey

SM4 6HY

1 | CORONER

| am Russell A Caller, HM Assistant Coroner, for the coroner area of Inner West
London

2 | CORONER’S LEGAL POWERS

{ make this report under paragraph 7, Schedule-5, of the Coroners and Justice Act
2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

3 | INVESTIGATION and INQUEST

On Friday 26"" January 2018 Russell Caller, HM Assistant Coroner, conducted an
Inquest into the death of Lucia CICCIOLI which occurred on Monday 24"" October
2016.

Medical Cause of Death
1.(A). Multiple Traumatic injuries

How, when and where and in what circumstances the deceased came by her
death:

The view of the evidence based upon photographs and CCTV and the evidence of the
Collision investigator was that the collision took place on Monday 24'" October 2016
just to the west of the cross road on LAVENDER HILL, junction with ELSPETH
ROAD, leading westbound towards CLAPHAM JUNCTION Train station.

Lavender Hill runs EAST to WEST across the road. North of the cross road is
LATCHMERE ROAD and south is ELSPETH ROAD vehicles passing through this
junction are controlled by a system of automatic traffic lights (ATS). Pedestrians are
provided with crossing on each four mouths of the junction. It was clear and the road
surface was wet.

, The circumstances of the collision are that Miss Lucia Ciccioli was cycling westbound
on LAVENDER HILL, heading westbound through the ATS controlled cross road
junction with ELSPETH ROAD. Miss Lucia CICCIOLI approached the road from lane
one, which is a dedicated left turn lane into ELSPETH ROAD.. Approximately 20
metres west of the cross road junction the collision occurred.

was driving westbound on LAVENDER HILL in a white/blue MAN,
articulated lorry registration He continued straight ahead
from late two of LAVENDER HILL which is a dedicated lane for going straight ahead
only.

As Miss Lucia CICCIOLI has exited the junction intending to head west (and not

turning left into ELSPETH ROAD) she has been struck by the MAN lorry

approximately 20 metres past the junction.

Miss Lucia CICCIOLI received fatal injuries as a result of the collision and died at the
4'" October 2016 at 08.12hours life was pronounced extinct by

Attached to this report is a CCTV Reconstruction Plan ( The “Reconstruction Plan”) to

assist with the description of the collision given above.

Conclusion as to the death:

Accidental Death

CIRCUMSTANCES OF THE DEATH

The evidence was that Miss Lucia CICCIOLI moved from lane one ( dedicated to the
left turn into ELSPETH Road) into lane two as she crossed the junction (position 3 on
the Reconstruction Plan) cycling towards LAVENDER HILL where the road appeared
to narrow and Lucia CICCIOLI travelled over a dip in the road where it appeared as if
a pot hole had not been repaired which caused her to lose her balance and fall and

collide with the MAN lorry.

During the Inquest it was suggested that the cycle lane ( see area coloured pink on
the Reconstruction Plan) was possibly misplaced and cyclists had difficulty in using
the same due to its very close proximity to lane two particularly when large vehicles
(in particular lorries) were in lane two. Notwithstanding that cyclists wished to remain
in the centre of the road _ cyclists felt obliged to place themselves in lane one even
though that was a dedicated route to the left into ELSPETH ROAD.

Moreover, cyclists found it extremely difficult to keep to the middle of-the road as they
crossed the junction due to an apparent “narrowing of the road” and a yellow box
junction positioned in the middle of the junction (in which they could not legally
stop).Further cause for concern was that there was a pothole positioned between
position 4 and position 5 of the Reconstruction Plan which required urgent repair.

CORONER’S CONCERNS

During the course of the Inquest evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you |

The MATTERS OF CONCERN are as follows. —

1) There is an inadequate cycle lane leading up to the traffic lights leading up to the
traffic lights at the junction with LATCHMERE ROAD and ELSPETH ROAD (the
cycle lane is coloured pink on the Reconstruction Plan).

2) There is inadequate protection generally for cyclists riding towards the junction
with LATCHMERE ROAD and ELSPETH ROAD particularly for those cyclists that
wish to go straight over the said junction towards LAVENDER HILL or for those
cyclists that wish to turn right at that junction into LATCHMERE ROAD.

3) There is a yellow box in the middle of the said junction (situated between position
3 and 4 on The Reconstruction Plan) which causes concerns to cyclists when
they are either proceeding straight on or turning right from the junction as they
are prevented from legally stopping in the said yellow box.

4) There is no cycle lane provision in LAVENDER HILL immediately past the said
junction.

5) The narrow aspect of LAVENDER HILL immediately past the said junction places
cyclists in avulnerable position when they arrive in LAVENDER HILL from the
said junction.

6) The dip in the road in LAVENDER HILL (between position 4’and position 5 on the
Reconstruction Plan) is dangerous and is in need of urgent repair.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you
AND/OR your organisation have the power to take such action in relation to the
concerns raised above. It is for each addressee to respond to the matters relevant to
them. ; :

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report.
|, the assistant coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting
out the timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons :

ADL Legal LLP .
131 — 133 Cannon Street
London

EC4N 5AX

Serious Collison Investigation Unit
Merton Traffic Garage

15 Deer Park Road

London

SW19 38YX

DAC Beachcroft (Claims Ltd)
Motor Prosecutions

Portwell Place

Portwell Lane

Bristol

BS1 9HS

| am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary .
form. He may send a copy of this report to any person who he believes may find it
useful or of interest. You may make representations to me, the coroner, at the time of
your response, about the release or the publication of your response by the Chief

Coroner.

16" May 2018

Pil bee

Mr Russell Caller

HM Assistant Coroner

Inner West London
Westminster Coroner’s Court
33 Tachbrook Street

London

SW1V 2JUR

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Transport for London (PDF)
Transport for London

Gareth Powell
Managing Director
Surface Transport

Mr Russell Caller Transport for London

HM Assistant Coroner Ith Floor, Zone R4
Inner West London Palestra
Westminster Coroner’s Court 197 Blackfriars Road
33 Tachbrook Street London SEI 8NJ
SW1V 2JR

garethpowell@tfl.gov.uk
25 July 2018

Dear Mr Caller
Report to prevent future deaths

We were sorry to hear of the tragic death of Ms Ciccioli, and pass our sincere
condolences to her family.

We have carefully considered your Prevention of Future Deaths report dated 16 May
2018, following the inquest which took place on 26 January 2018.

Responsibility for managing the road network in Greater London is shared between
Highways England Company Limited, Transport for London (TfL), and the 32 London
local authorities, plus the City of London.

Highways England Company Limited is the highway authority for and manages the
national motorway network on behalf of the Secretary of State, including those parts of
the M25 orbital motorway, the M1, M4 and M11 within Greater London. TfL is both the
highway and traffic authority for all GLA roads (see below). TfL is also the traffic
authority for the GLA side roads (see below). The London local authorities are the
local highway authorities and responsible for all the remaining public highways within
their boundaries, including strategic roads.

“GLA roads” were initially designated by the Secretary of State under section 14A of
the Highways Act 1980 (the 1980 Act) and are now updated by way of order by the
Greater London Authority (GLA) under section 14B of the 1980 Act. TfL is both the
highway and traffic authority for all GLA roads.

“GLA side roads” were also initially designated by the Secretary of State under section
124A of the Road Traffic Regulation Act 1984 (the 1984 Act) and has since been
updated by way of orders by the GLA under section 124B of the 1984 Act. There is a
separate GLA side roads order for each London Borough. Although the London local
authorities remain the highway authority, TfL is the traffic authority for the extent of the
GLA side roads.

(OE disability
MAYOR OF LONDON a jee Wit umnien RIE

Both the GLA roads and the GLA side roads are also known as red routes due to them
being marked with either single or double red lines.

The London Borough of Wandsworth (LBW) and TfL as traffic and highway authorities
for the roads at the junction of Lavender Hill and Elspeth / Latchmere Road will work
together to reduce road danger through this junction.

Both authorities are seeking to reduce collisions across London. In the Mayor's
Transport Strategy (March 2018), TfL has committed to a ‘Vision Zero’ policy, which
aims to eliminate all deaths and serious injuries from road collisions on London's
streets by 2041.

On receipt of your report, officers from LBW and TfL met at the junction of the A3036
(Lavender Hill) with the A3220 (Elspeth Road / Latchmere Road) to discuss the six
matters of concern that you raised. Of these six matters, point (3) relates to a road for
which TfL is both the highway authority and traffic authority, with the remaining points
relating to roads for which LBW is the highway authority. Both TfL and LBW have and
will continue to work collaboratively in relation to the concerns you have made.

We set out below TfL’s responses to your concerns.

Matters of Concern 1 and 2 (LBW is highway authority & TfL is the traffic authority)

1) There is an inadequate cycle lane leading up to the traffic lights leading up to the traffic
lights at the junction with LATCHMERE ROAD and ELSPETH ROAD (the cycle lane is

coloured pink on the Reconstruction Plan}.

2) There is inadequate protection generally for cyclists riding towards the junction with
LATCHMERE ROAD and ELSPETH ROAD particularly for those cyclists that wish to
go straight over the said junction towards LAVENDER HILL or for those cyclists that
wish to turn right at that junction into LATCHMERE ROAD.

TfL recognises that dedicated left-turn lanes potentially increase road danger for
cyclists proceeding straight ahead. We also acknowledge that the existing cycle feeder
lane into the advance stop line is less than the minimum width recommended in the
current version of the London Cycling Design Standards. However, the cycle lane was
compliant with the relevant standards that were in place when it was first implemented.

Working with LBW, TfL will investigate, including traffic modelling, whether the
dedicated ‘left-turn’ lane can be removed at this location, reducing the number of traffic
lanes from three to two. This would enable the footway on the south side of the
eastern arm of Lavender Hill to be widened, and the remaining two traffic lanes to
operate as a near-side ‘ahead and left-turn’ lane, and an off-side dedicated ‘right-turn’
lane.

The provision of an improved cycle feeder lane will also be considered as part of the
revised design, with consideration of the constraints on the western arm (see also
response to points 4 and 5, below).

Matters of Concern 3 (TfL is both the highway authority and traffic authority)

3) There is a yellow box in the middle of the said junction (situated between position 3 and
4 on The Reconstruction Plan) which causes concerns to cyclists when they are either
proceeding straight on or turning right from the junction as they are prevented from
legally stopping in the said yellow box.

A yellow box has been provided at the junction to help prevent obstructions. All
vehicles, including pedal cycles, may only enter a yellow box when the exit is clear.
Our observations have indicated that the junction does potentially experience exit
blocking from adjacent junctions. Without the yellow box facility, vehicles would remain
in the centre of the junction at the end of each traffic light green stage. Vehicles
entering the junction during the next traffic light green stage would then need to
navigate around those vehicles already in the junction. This increases road danger, as
inter-visibility between vehicles is reduced. For this reason, we consider that the yellow
box should be retained.

Matters of Concern 4 and 5 (LBW is highway authority and TfL is the traffic authority)

4) There is no cycle lane provision in LAVENDER HILL immediately past the said
junction.

5) The narrow aspect of LAVENDER HILL immediately past the said junction places
cyclists in a vulnerable position when they arrive in LAVENDER HILL from the said
Junction.

There is no existing cycle lane on the exit side of the western arm of Lavender Hill,
because there is insufficient carriageway space given the need to accommodate
general traffic progressing from the two existing straight-ahead lanes on the eastern
arm of Lavender Hill.

Providing a cycle lane in this scenario could give cyclists a false sense of security as
wider vehicles would need to enter the cycle lane to avoid a collision with an adjacent
vehicle.

However, if the proposal to change the layout on the eastern arm is feasible (as set
out under our response to concerns 1 and 2 above), this would enable a cycle lane to
be provided on the western arm, parallel to a single general traffic lane.

We note that there is an existing loading bay adjacent to local businesses on the exit
side of the western arm of Lavender Hill which is dedicated to loading between the
hours of 10am and 4pm Monday to Saturday but can be occupied by any vehicle
outside the hours of 7am to 7pm, Monday to Saturday. Cyclists must navigate around
this box when it is occupied, bringing them into further potential conflict with adjacent
traffic. Unfortunately, because the footway is narrow adjacent to this loading bay
(excluding the private forecourt), it prevents the loading bay being relocated off the
carriageway. However, working with LBW, TfL will investigate whether the loading bay
can be relocated to nearby Lavender Gardens or reduce the operating hours so that
cyclists are less likely to encounter an occupied bay. Any changes to the loading bay
will require consultation with the local community.

Working with the LBW, TfL proposes to complete a revised design of the junction and
set out next steps by December 2019. Subject to public consultation, any necessary
approvals, and available funding, construction could begin in 2020.

Matters of Concern 6 (LBW is highway authority)

6) The dip in the road in LAVENDER HILL (between position 4 and position 5 on the
Reconstruction Plan) is dangerous and is in need of urgent repair.

We understand that the dip has now been repaired.

Yours sincerely

Managing Director — Surface Transport

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