Milan Dokic · Prevention of Future Deaths report

On the 17th February 2017 Dr. Fiona Wilcox, HM Senior Coroner, for the Coroner Area Inner London West submitted a report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 which was sent subsequent to preliminary evidence taken by the Senior Coroner at a Pre-inquest Review touching the death of Milan Dokic on 14th February 2017

Subsequent to the aforementioned Pre Inquest Review the Inquest took place on 11th July 2017

Medical Cause of Death

1 (a) Multiple Traumatic Injuries

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

The view of the evidence based upon CCTV recordings and the view of the collision investigator was that Mr Dokic was travelling east on a motorcycle and overtaking a van from the inside on Battersea Park Road on the 1st March 2016 in wet conditions, when he lost control of his vehicle when he drove onto the blue cycle lane just past the pedestrian crossing opposite the junction with Forfar Road. The CCTV clearly shows the motorcycle losing grip and sliding along the road. Sadly, Mr Dokic came off, and hit a bollard sustaining injuries that led to his death at the scene.

At the Inquest I stated in my summing up, that the death was caused by a combination of factors including the manoeuvre Mr.Dokic made from the main highway into Cycle Super Highway 8 (“CSH8”) and the speed he was travelling at the time and the lack of grip on the blue area on the CSH8 set at 56.5 being below the recommended level of 60 set for the blue area on CSH8

Conclusion as to the death:

Accidental death contributed by Neglect

The evidence was that the blue cycle lane of the CSH8 at the point where he came off when later tested by the collision investigator offers a much lower grip than the conventional road surface with a skid resistance value of 56.5 compared to the road surface of 77.05 and the CSH8 before the pedestrian crossing an even higher skid resistance value of 89.85.

I understand that some cyclists have raised concerns that the CSH8 appears in places to have lower grip than other areas of road surface.

The Collision Investigator was also concerned that Battersea Park Road at the junction with Forfar Road is an area in which turning maneuvers are frequent and so it may be an area of particular danger to vulnerable road users prone to slip such as motorcyclists and cyclists.

1. There is an inadequate system of determining grip levels on CSH8 and on other Cycle Super Highways and on other roads in London.

2. There has been a failure to monitor grip values on Cycle Super Highways in London.

3. Urgent research needs to carried out on having a clear scientific way of determining grip values which can be applied to roadways in London.

4. Urgent research should be carried out into the adverse effects of having adjacent areas of road with very different grip values and , subject to such research, remedial response is needed once that research has been carried out.