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State Coroner Graeme Johnstone has found the death of an elderly man struck down by a cyclist on Melbourne's notorious Hell Ride was "unnecessary and preventable".
The ride is an informal, weekly 75-kilometre high-speed ride through Melbourne's bayside suburbs.
James Gould, 77 died after he was struck by cyclist William Raisin-Shaw as he tried to cross a pedestrian crossing at Beach Road, Mentone, in August last year.
Mr Raisin-Shaw, 31, of St Kilda, was one of up to 200 cyclists taking part in the Hell Ride.
He has been charged with failing to stop at a red light, a charge that carries a maximum fine of $215, and is due to appear in the Melbourne Magistrates' Court next month.
Accident 'extremely rare'
President of CycleSport Victoria, Klaus Mueller, said it would be a "double tragedy" if Beach Road did not become the world's safest road for cyclists and pedestrians after Mr Gould's death.
"Behaviour even within the Hell Ride has improved dramatically over recent years and I think it has improved further with this tragic incident," he told reporters outside court.
But Mr Mueller said it was up to cyclists to take individual responsibility for their own and others' safety when riding in packs.
"Every rider out there must recognise that they have got to comply with the rules. They are individually responsible for making sure that they don't run red lights or disobey the rules. They can't abrogate that responsibility to the larger group," Mr Mueller said.
He said it was extremely rare for a cyclist to kill a pedestrian and hoped Mr Gould's death would remain an isolated incident.
"In statistical terms, it's an extremely rare event for a cyclist to kill or hurt another road user. It's the cyclists themselves who are far and away the most vulnerable when they break the road rules."
'Unnecessary and preventable'
Delivering his finding into Mr Gould's death, Mr Johnstone said the ride had become "a high risk event... that is not suitable for either suburban streets or on main roads where the public frequent."
"It is troubling that a safety message, delivered over a number of years by Victoria Police... does not appear to have been heeded," Mr Johnstone said.
"That failure by the group to select responsible individuals, show any real joint leadership and manage behaviour has cost Mr Gould his life. It was unnecessary and preventable."
Mr Johnstone said it would be easy to focus on Mr Raisin-Shaw's behaviour, but said he did not want to underestimate the pressures placed on individual cyclists by the dynamics of the group.
Mr Raisin-Shaw declined to give evidence at the inquest but his lawyer Michael Sharpley told the court in May that his client had found himself "between a rock and a hard place" with riders behind him yelling at him to continue through the crossing, despite the fact the light had already turned red.
"His view was that to brake heavily, in circumstances where those behind had clearly signalled their intentions, would inevitably cause an accident - potentially a serious one, involving a number of cyclists," Mr Sharpley said in his submission.
'Recipe for disaster'
The coroner called on cycling organisations to work with police to make the ride safer.
"There is little doubt that large groups or bunches of cyclists running pedestrian lights or red lights is a recipe for disaster.
"With the running of red lights it is only a matter of time before we see a catastrophe when a car proceeding through an intersection with a green light strikes a group of cyclists."
Mr Johnstone quoted statistics which showed there had been 220 deaths from cycling nationally since 2000, including 47 in Victoria.
"The numbers are troubling and demonstrate the need for increasing work by the relevant agencies on safety issues," he said.
with Julia Medew
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