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A coroner says the brakes on the bike of a Hampshire teenager, killed when he was hit by a car, suffered a 'catastrophic failure'.
A coroner is to write to an accident prevention charity about bicycle safety after recording a narrative verdict at the inquest into the death of Kadian Harding in a road crash when his front brake failed.
David Ridley, coroner for Wiltshire and Swindon, spoke of the tragic loss of the 14-year-old, from the village of Steep near Petersfield, as he said he would use his powers under Rule 43 and write to the Royal Society for the Prevention of Accidents.
Mr Ridley said he would be preparing a report for RoSPA detailing the "lessons learned" and whether anything could be done to raise the awareness of getting a bike checked before it is ridden for the first time. He said:
"The front brake suffered a complete catastrophic failure due to the pinch bolt, more likely than not, on the front yoke not being sufficiently tight, allowing the forces generated by pulling the front brake lever to pull the cable through the pinch bolt, causing the cantilever not to function at all.
"The rear brake had some function, but it is unclear as to the extent of its function, but the forces applied to the pads were not sufficient when pulling the levers to generate a locking of the wheel when fully applied as to generate a skid at any point over the remainder of the path or into the road.''
Mr Ridley continued:
"As I made clear at the outset of the inquest, Rule 42 prohibits me in relation to my findings, of finding any civil and criminal liability of any named person.
"An inquest is not a court of blame. It is not a trial.
"This case is a sad and tragic case. A lot of my work involves sad cases but this - in respect of a vibrant 14-year-old boy - is even more touching.''
The teenager suffered fatal injuries when he was in a crash with a Mercedes van on the evening of July 25 last year on the A4 at Clatford, near Marlborough, Wiltshire.
The inquest in Salisbury was told that the teenager was so worried about the bike's brakes that just a few hours before he died he had taken it to a repair shop in Marlborough.
Kadian then went on a bike ride with his family when tragedy struck at 5.50pm.
It was only a twist of fate that the group ended up on the track leading to the A4 because they had taken a wrong turn.
Kadian was riding down a steep path with five other people, including his father and aunt, when he was unable to stop as he approached the busy road.
Eyewitnesses described hearing Kadian screaming as he went down the path at a speed of between 25mph and 30mph desperately trying to slow the bike down before hitting the van.
The schoolboy suffered catastrophic head injuries and died at the scene.
Experts agreed that the front brake of the bike had failed but were unable to say whether the rear brake was working correctly at the time of the collision.
During two days of evidence, the inquest heard that Kadian had taken the Surly long haul trucker bicycle to a bike shop close to his home in Hampshire on at least two occasions in the weeks before he died.
On the day he died the teenager had taken the bicycle to the Acceler8 shop in Marlborough, having been told to get the brakes checked by his father.
Mr Thomas Harding, an experienced cyclist, told the hearing:
"I specifically said: 'We are really concerned about the brakes. You must get the front and back brakes looked at.'
"He said they looked over all the brakes and replaced a cable. I didn't have a go (on the bike) but I did try both front and back brakes.
"I noticed they were much firmer now. I noticed the pads were now about 1mm apart."
Witness Richard Knowles, who lives close to the crash scene, said he heard Kadian screaming as he cycled down the path.
"From the moment he came out of the tree line to the moment he passed me was only a few seconds,'' he said.
"He was pumping the brakes and that made me realise he was in trouble.
"He was standing up on the pedals. He was applying so much force to his brakes that he was trying to keep the bike stable.
"I think I said to him words to the effect of 'come off'. He made no attempt to steer off the path. He made no attempt to come off the pedals and put his feet on the floor."
Philip Birkett, owner of Acceler8, said Kadian had come into the shop and asked him to look at the gears and the rear brakes. He said:
"I stand by my work and everything I did was correct. When that bike left the shop it was in a perfectly safe condition."
Mr Birkett denied the suggestion from the barrister representing the Harding family that he had adjusted both the front and rear brakes.
He added that he did not hold any qualifications for repairing bicycles.
Experts agreed that Kadian's front cantilever brake had failed because the pinch bolt was not tightened sufficiently and the brake cable had slipped.
But Chris Juden and David Price were unable to say - due to the damage sustained in the crash - what condition the rear brakes were in at the time of the boy's death.
In a statement issued after the hearing, Kadian's parents, Thomas and Debora, said:
"It has not yet been a year since our beautiful 14-year-old son, Kadian, died.
"During this time we have relived every moment of the events leading up to his death.
"The coroner today issued a narrative verdict. As we heard, and the coroner found, the brakes did not work on Kadian's bike."
Sally Moore, from law firm Leigh Day, said the Harding family would be taking legal action.
"The coroner agreed that there had been catastrophic failure of the front brake and that the back brake was not working sufficiently so as to stop the bicycle in an emergency."