Esther HartSilver · Prevention of Future Deaths report

On 03/06/2015 I commenced an investigation into the death of Esther HartSilver. The investigation concluded at the end of the inquest on 16.2.17. The conclusion of the inquest was that she died of multiple injuries in a road traffic collision.

Esther HartSilver died having been involved in a road traffic collision on her way to work on 28th May 2015. She was cycling to King’s College Hospital where she worked as a physiotherapist. She was cycling along Denmark Hill. When she got to the junction of Denmark Hill with Orpheus Street she was cycling in the left hand (bus) lane. I will call this Lane 1. There was one further lane in the same direction. This was Lane 2. Denmark Hill forms part of the A215.

An HGV lorry was being driven in Lane 2. This lorry was due to turn left at the junction, turning into Orpheus Street. Just before the junction there is a pedestrian crossing with no phased traffic lighting. It is pedestrian controlled.

Lane 2 traffic was busy with traffic. The bus lane was more free. At 07.58 hours, as the lorry began to turn left, it came into collision with Miss HartSilver’s bicycle. It is not known whether Miss HartSilver was using a route to work that day which involved her planning to turn left into Orpheus Street or cycling straight ahead along Denmark Hill.

The HGV lorry’s indicator was on before it began its turn. Tragically, Miss HartSilver’s bicycle was caught by the lorry when the lorry turned into her lane and she was very seriously injured in the collision. She was seen by paramedics and the HEMS team and taken to King’s College Hospital. Despite quite extraordinary efforts of her colleagues at King’s College Hospital, she could not be saved and died there approximately six hours after her arrival. She was pronounced dead at 15.00 hours.

This report concerns the design of the junction of Denmark Hill with Orpheus Street (“the junction”).

The junction predisposes itself to the very risk materialising that sadly caused Miss HartSilver’s death. Traffic wishing to turn left may, at the moment, turn left from Lane 2. This means that they cross a lane of traffic that may well be travelling straight ahead. Miss HartSilver was an experienced London cyclist and the HGV driver an experienced driver also. It is the junction that is unusual.

It may not be unusual for a lorry turning into a side road to have to cross a bus lane. The junction can be distinguished from this, however. This is a more major junction than it appears. It is a major because it feeds all the traffic that would have wanted to turn right as well as left, from a very busy road into what is effectively a side road. Further, it has a pedestrian crossing just before it. This means that although there is an early sign warning traffic of the banned right turn and to turn left instead, there are mandatory zig-zag lines on the road leading up to the junction and therefore there is no signage on the road surface warning any user of the potential for conflict.

The red coloured road surface that is present in the bus lane goes across this junction and will make vehicles think it is still a bus lane. Officially, the bus lane stops because the zig-zags take over as there is a pedestrian crossing present immediately before the turning on the left.

I accept that changing the layout of the junction requires experts to consider the safety of not just cyclists - of other road users and pedestrians too. The problems also must not be moved to another geographical location. The road, also, is 'what it is' - a relatively narrow road for the amount of traffic it serves. I fully appreciate the difficulties and challenges in catering for the huge amount of traffic whilst keeping safety as a high priority.

This is a complex matter and different risks must be weighed up very carefully. There are a large number of buses flowing at this junction. There are 80 buses in each direction every hour. It is under consideration moving the pedestrian crossing further north.

I am told if the bus lane were to end earlier there would still be a risk with larger vehicles needing to swing into lane 2, from lane 1, in turning the corner. It would not reduce the risk to zero. I understand all that. If I was cycling in that bus lane, even having seen the sign saying that there is a left turn for those wanting to turn right ahead, I would not be reminded of the risk of vehicles turning anything in the road layout. There is also a significant amount of traffic turning across a bus lane.

████████ says that she saw a number of near misses when she visited the scene soon after the incident. She explains a near miss would be where a cyclist, for instance, would have to stop or slow to avoid a collision with traffic turning.

I am concerned that ████████ says there have been 18 collisions (reportable collision involving personal injury) in 5 years ending June 2016. Involved were 7 motorcyclists, 7 pedestrians, 4 cyclists and one involving two cars.

This junction essentially comes under the shared care of both Transport for London (“TfL”) and the London Borough of Southwark. They both have different functions and duties but it would take both working together to agree a change to the design.

As this case tragically shows, cyclists are at high risk of severe injury and death if they come into collision with other road users. I write this report to ask that the experts in TfL and the London Borough of Southwark come together (with the assistance of the police) to explore what can be done to reduce the risk to all vulnerable road users at this junction.

Since 2011 there has been an application in place to improve Camberwell and in particular two large junctions, and within this proposal the Orpheus road junction is included. My understanding of that proposal is that there are still fairly major decisions to be made about, for instance, whether it would beneficial or not to allow traffic travelling in the direction Miss HartSilver was travelling to turn right or whether the current system of traffic turning left stays.

The family think that changes have been put into place in the junction, as a temporary measure. They have not. It has already been decided by the London Borough of Southwark not to put in temporary measures in the junction as it was judged that such measures would not minimise the risk to vulnerable road users such as cyclists.