Coroner Thomas said all of those factors contributed to Dawson\u2019s death. <\/p>\n
\u2018It has reopened a deep wound\u2019<\/p>\n
The findings come nearly six years after Dawson died<\/a>, prompting her family to make their own call for change.<\/p>\n Her aunt Caryn Dawson said the findings had opened a \u201cdeep wound\u201d for the family, and she called for the Government to urgently review the state of the coronial processes, including the resourcing and workloads placed on coroners.<\/p>\n \u201cHow can a family begin to heal while waiting, year after year, for answers? <\/p>\n \u201cNow that the report has finally been released, it has reopened a deep wound; we are transported back to that devastating day as if it happened yesterday.<\/p>\n \u201cThe pain is raw, the memories remain vivid, it is a harrowing experience to relive.\u201d<\/p>\n Dawson said a timelier process would allow for recommendations to be implemented sooner, potentially preventing similar deaths in future.<\/p>\n Caryn Dawson said the coroner\u2019s findings confirmed what the family had long believed.<\/p>\n \u201cShe was failed by the latent flaws in the vehicle-centric design of the temporary traffic management system.<\/p>\n \u201cA safe and satisfactory route for cyclists was not provided, and as a result, Fyfa lost her life.<\/p>\n AdvertisementAdvertise with NZME.<\/a><\/p>\n \u201cThe impact of her loss is beyond words. First, she was let down by inadequate planning and then again, by a system too slow to respond. Much needs to change.\u201d<\/p>\n Dawson said one of the many challenges that comes with losing a loved one to a sudden and unexpected death is the involvement of the coroner and the prolonged process that follows.<\/p>\n \u201cI am not aware of any other profession or system in which it would be considered acceptable to take six years to provide answers following a fatal incident.\u201d<\/p>\n A Coroners Court spokesperson told NZME the court was very aware of the additional stress that a delay can place on grieving families.<\/p>\n Significant work has been done to reduce the historical backlog, including adding more coroners to the bench, which has resulted in more timely resolutions.<\/p>\n \u201cIt is important to note that every death reported to the coroner is different, and the circumstances of some deaths mean they may take longer to investigate.<\/p>\n AdvertisementAdvertise with NZME.<\/a><\/p>\n \u201cThe time it takes depends on the complexity of how the person died, the evidence the coroner needs to gather and whether the coroner is waiting for a prosecution or any other investigation to finish.\u201d<\/p>\n The inquiry into Dawson\u2019s death was a complex one that also went through a police decision-making process on whether criminal charges were needed, and a WorkSafe investigation.<\/p>\n Coroner Thomas said in her findings that a shift in approach to temporary traffic management had occurred across the industry since Dawson died.<\/p>\n That included a new focus on a risk-based approach to the design and implementation of plans. <\/p>\n \u201cCyclists must be a key part of the design and delivery of temporary traffic management plans during roadworks; I acknowledge industry changes have been made since 2019, and some lessons learned. <\/p>\n \u201cHowever, it must not be forgotten, Ms Dawson\u2019s death has illustrated system-level errors in the implementation of a vehicle-centric temporary traffic management plan which did not clearly communicate to road users where cyclists should ride and did not provide satisfactory options for cyclists.\u201d<\/p>\n AdvertisementAdvertise with NZME.<\/a><\/p>\n If a gate controller had been stationed at the gate or advanced technologies had been used, such as sensors that activate warnings, they may have reduced the risk of death. <\/p>\n WorkSafe New Zealand investigated Dawson\u2019s death, which resulted in a voluntary agreement with the companies involved, Downer and McConnell Dowell<\/a>.<\/p>\n One of the recommended interventions was a protocol of minimum vehicle standards, in line with Australian and British minimum mandatory standards for heavy vehicles.<\/p>\n Coroner Thomas said NZ Transport Agency Waka Kotahi and the Ministry of Transport had accepted her recommendations. <\/p>\n If those recommended changes were considered and implemented, it would involve a nationwide change for the industry to improve heavy vehicle safety standards.<\/p>\n An NZTA spokesperson said the agency had fully co-operated with the coroner and all relevant investigations.<\/p>\nCaryn Dawson. Photo \/ Supplied Caryn Dawson\u2018Much needs to change\u2019<\/p>\n
Fyfa Dawson. Photo \/ Supplied Caryn DawsonCoroner: Cyclists must be a key part of traffic management plans <\/p>\n
A memorial plaque for Fyfa Dawson is close to the accident site in Christchurch. The words on the plaque were written by Fyfa in an Instagram post.NZTA still has work to do <\/p>\n