Jenny Wong was cycling through a leafy residential part of Oxford on a quiet Sunday morning when tragedy struck. On her way to a tennis lesson, the 32-year-old rode along the inside of a lorry-mounted mobile crane that was waiting at traffic lights.
She intended to cycle ahead along Headington Road, but witnesses saw her "wobbling" and she was knocked off her bicycle. The crane, intending to turn left into Headley Way, ran over her, killing her instantly.
Police said they were unable to prove if or when Wong would have been visible to the driver, and whether his driving fell below the required standard.
Wong's family and friends drew a crumb of comfort from the tragedy on September 26 2021. At the inquest, the coroner issued a rare Prevention of Future Deaths (PFD) report, raising serious concerns about the incident - and hopes among Jenny's friends and family that new measures would ensure no one else suffered the same fate.
The PFD said the crane driver had "virtually no view of the nearside of his vehicle or immediately in front of it". Describing regulations around mirrors for this type of vehicle as "confusing", the coroner sent the PFD to the Department for Transport (DfT), commenting: "In my opinion, action should be taken to prevent future deaths, and I believe you have the power to take such action."
The coroner also wrote to Oxfordshire County Council (OCC). Describing "an element of confusion" for cyclists at the location because of signage and road layout, he noted that the council planned improvements to make it safer for cyclists following Wong's death.
Today, however - well over three years after the fatality - Peter Barnett, a cycling campaigner who officially represented Wong at the inquest, claims that the DfT's response has been "disappointing and worrying". He also claims that OCC should have done more to make the junction safer after the crash, more urgently.
Yet with five deaths on UK roads each day, fears that the PFD system is failing are far from uncommon, as a new report, Learning From Tragedy, by the Parliamentary Advisory Council for Transport Safety (Pacts), reveals.
Demanding an urgent overhaul of the way UK road traffic fatalities are investigated, the report says that only 3 per cent of road deaths result in PFDs, in effect wasting precious, critical information about the underlying causes of crashes and - crucially - potential remedies that could prevent similar deaths and injuries in the future.
The report reveals that even when a PFD report is issued, some recipients fail to respond. Worse, there is no formal follow-up procedure to check that life and injury-saving measures have been implemented. Local authorities face no sanctions for failing to act on PFD recommendations, often leaving critical safety issues unresolved, says Pacts.
This is in sharp contrast to elaborate systems in place for tackling death and injury in the air, rail and maritime sectors, where death tolls are eclipsed by the number of people perishing on UK roads.
Despite 11 aviation-related deaths in 2023, compared with 1,624 deaths on the roads that year, the Air Accidents Investigation Branch (AAIB) works closely with the DfT to launch far-reaching investigations into serious incidents.
These can result in multiple experts being dispatched to crash scenes to comb through wreckage for evidence, with finds minutely analysed in the AAIB's laboratories, triggering detailed reports and key safety recommendations. Organisations on the receiving end are monitored by the AAIB to check which measures are put in place.
Despite the road death toll having plateaued for years, there is no central body for analysing trends or pinpointing at-risk groups for highway crashes, according to Pacts. In fact, there is "poor collaboration" between stakeholders, delaying potential safety improvements across organisations.
Mostly it is left to overstretched police forces to investigate road collisions on a localised, piecemeal basis. While their findings might be presented to courts or coroners, they are not more widely disseminated for others to learn from - or to allow life-threatening trends to emerge.
Pacts' research reveals that for 16,986 road deaths from 2013-2023, there were only 388 PFDs; one report for every 44 deaths. Some coroner areas produced none. "The absence of a PFD may cause grieving families to feel that the circumstances that led to their personal tragedy may arise again, leading to further fatalities and suffering for victims' friends and relatives," says the report. "Failing to learn and act on any such tragedy creates an open wound for the families involved and puts others at risk of the same fate."
Jamie Hassall, the executive director of Pacts, adds: "Failure to address known issues is not acceptable in other forms of transport. Why is it tolerated on the roads? If a Safe System approach is taken, road deaths could be reduced to zero."
Claiming that all road fatalities should be preventable and that current legislation is toothless, Pacts is demanding five major changes which, it says, could result in road-user lives being saved almost immediately, while dramatically reducing the annual toll of 30,000 serious road crash injuries.
It is calling for:
Pacts wants coroners to be given a road deaths reduction target to dramatically drive up the number of PFDs issued, with powers to enforce and follow up PFDs. It says the percentage of PFDs should rise from about 3 per cent of road death inquests to nearer 100 per cent.
Following Pacts' report, experts say further deaths are inevitable unless the PFD system is totally overhauled. Ross Morlock, the chief executive director of road safety charity Brake, said: "We see first-hand every day the trauma and devastation caused by road crashes. We know the urgent need for a dedicated Road Safety Investigation Branch to thoroughly investigate crashes and identify systemic issues. That so few PFD reports are produced is deeply concerning. We risk missing critical lessons from the needless loss of life on our roads every day."
Michael Woodford, the executive chairman of the Safer Roads Foundation, says: "It is important to support coroners to take the lessons learnt from one inquest of a road fatality and share these widely to prevent future deaths."
If the system is overhauled, Pacts believes PFDs could result in systemic changes such as flawed road designs, signs or road markings, even entire road layouts, being redesigned.
It says PFD reports could even spark recalls or modifications to specific vehicle models, new safety features in cars or increased governmental pressure on car-makers to include specific safety features. More localised results could include improved road surfaces, improved road drainage where flooding has caused problems, or improved visibility on bends.
Better enforced PFDs could even trigger driver awareness campaigns and help steer police enforcement strategies.
Today, Jenny Wong's death shows how a PFD can bring about change - but also expose deep flaws to the current system, Barnett believes.
OCC says it implemented the "majority" of opportunities identified in its investigation of the junction, and that it is committed to completing further improvements, as well as at other junctions. It has yet to make a safety "feeder lane" more accessible to cyclists, citing the need for consultation and stakeholder involvement. Improvements are also subject to road-width and weather constraints.
Wong's death was also pivotal to OCC launching a £4 million Vision Zero road safety strategy, aiming to eliminate deaths and serious injuries on Oxfordshire's roads by 2050, with a 50 per cent reduction by 2030.
The DfT, meanwhile, says that while "its thoughts remain with the family and friends of Jenny Wong... as mobile cranes vary in design for specialised tasks, further regulatory requirements would be impractical to impose". It says it has written to the Construction Plant-Hire Association to raise awareness and encourage members to consider additional devices or technology to help improve crane driver vision.
Barnett, however, believes that had tougher PFD regulations been in place at the time of Wong's death, safety concerns would have been addressed far more urgently and rigorously. He also says that regulations should be changed, requiring additional mirrors or other safety systems to be fitted to vehicles, which could be done "easily". "As the DfT says the regulations for mirrors on certain vehicles are impractical, then those vehicles should not be allowed on the road.
"If we had a more rigorous PFD system in place, as Pacts demands, this junction would have been made safer immediately," says Barnett. "As it is, each morning I look nervously at the Oxford Mail to see if another cyclist has been caught out like Jenny."