The coroner found the approved temporary traffic management plan for the site where Dawson was killed was “vehicle-centric”.
Despite a 1m sealed shoulder for cyclists being specified in the plan, it was not available that day because it was filled with road cones, and cyclists using the pedestrian pathway were in a complete blind spot for heavy vehicle/truck drivers.
There was no gate controller to stop vulnerable road users crossing when trucks were entering or exiting the work site gate. Road users were also not given clear information about where pedestrians or cyclists should be.
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Coroner Thomas said all of those factors contributed to Dawson’s death.
‘It has reopened a deep wound’
The findings come nearly six years after Dawson died, prompting her family to make their own call for change.
Her aunt Caryn Dawson said the findings had opened a “deep wound” 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.
“How can a family begin to heal while waiting, year after year, for answers?
“Now 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.
“The pain is raw, the memories remain vivid, it is a harrowing experience to relive.”
Dawson said a timelier process would allow for recommendations to be implemented sooner, potentially preventing similar deaths in future.
Caryn Dawson. Photo / Supplied Caryn Dawson‘Much needs to change’
Caryn Dawson said the coroner’s findings confirmed what the family had long believed.
“She was failed by the latent flaws in the vehicle-centric design of the temporary traffic management system.
“A safe and satisfactory route for cyclists was not provided, and as a result, Fyfa lost her life.
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“The 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.”
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.
“I 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.”
A Coroners Court spokesperson told NZME the court was very aware of the additional stress that a delay can place on grieving families.
Significant work has been done to reduce the historical backlog, including adding more coroners to the bench, which has resulted in more timely resolutions.
“It 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.
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“The 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.”
Fyfa Dawson. Photo / Supplied Caryn DawsonCoroner: Cyclists must be a key part of traffic management plans
The inquiry into Dawson’s death was a complex one that also went through a police decision-making process on whether criminal charges were needed, and a WorkSafe investigation.
Coroner Thomas said in her findings that a shift in approach to temporary traffic management had occurred across the industry since Dawson died.
That included a new focus on a risk-based approach to the design and implementation of plans.
“Cyclists 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.
“However, it must not be forgotten, Ms Dawson’s 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.”
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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.
WorkSafe New Zealand investigated Dawson’s death, which resulted in a voluntary agreement with the companies involved, Downer and McConnell Dowell.
One of the recommended interventions was a protocol of minimum vehicle standards, in line with Australian and British minimum mandatory standards for heavy vehicles.
Coroner Thomas said NZ Transport Agency Waka Kotahi and the Ministry of Transport had accepted her recommendations.
If those recommended changes were considered and implemented, it would involve a nationwide change for the industry to improve heavy vehicle safety standards.
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
An NZTA spokesperson said the agency had fully co-operated with the coroner and all relevant investigations.
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It has accepted three of the coroner’s four recommendations.
“We support further consideration of the fourth recommendation relating to heavy vehicle standards and will work with the Ministry of Transport on the next steps,” the spokesperson said.
“We are already moving on changes to enhance safety for both road users and road workers with the introduction of a risk-based approach to temporary traffic management.”
The coroner’s key recommendations
• Gate controllers should be used in situations where vehicles enter or exit in front of vulnerable road users travelling in a traffic management site.
• Advanced technologies should be used where possible. An example is sensors that could activate a warning as the road user approaches a hazard if a gate controller is not available.
• NZTA and the Ministry of Transport consider introducing new/different standards as a minimum mandatory requirement for heavy vehicles.
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• NZTA consider a scheme that would provide heavy vehicle users with a free Fresnel lens that gives drivers a wide-angle view of the passenger side area to help them see in their blind spot.
Al Williams is an Open Justice reporter for the New Zealand Herald, based in Christchurch. He has worked in daily and community titles in New Zealand and overseas for the past 16 years. Most recently he was editor of the Hauraki-Coromandel Post, based in Whangamatā. He was previously deputy editor of the Cook Islands News.