Cyclist Jane Bishop's death on Auckland's Tamaki Drive has been blamed by a coroner on several factors including her own actions and the road's layout.
That is despite Auckland Transport's denial at an inquest last year that an alleged pinch-point where the 27-year-old British nurse died contributed to her death.
Ms Bishop hit an open car door and was run over by a truck on her way home from work on November 17, 2010.
Coroner Gordon Matenga, in a report issued today, has listed the road layout as well as Ms Bishop's actions and those of a man whose car door she hit as being causal factors. But he said he was satisfied changes made by Auckland Transport to the road - some just days after the crash - had improved its safety and that no recommendations specific to the case were therefore required from him.
Mr Matenga found Ms Bishop died from multiple injuries consistent with being run over by a motor vehicle, and that her death was accidental.
His report followed an inquest in which the council's transport body argued that the layout of the road, just east of a tight bend outside Kelly Tarlton's Underwater World, was not the cause of Ms Bishop's death from hitting motorist Glenn Becker's car door and then being run over by a passing truck.
But Mr Matenga said although it was not a major factor, he believed the layout contributed to the crash.
"It was the combination of factors which created the difficulty," he said.
"The road layout did contribute to the cause of the crash by creating a pinch-point and problems with line-of-sight in heavy traffic."
So did Ms Bishop's actions in overtaking to the left of a line of slow-moving vehicles and riding fast in the corridor between the moving vehicles and parked cars.
Mr Becker was acquitted on a charge in Auckland District Court of careless use of a motor vehicle causing death, but the coroner said if he had not chosen to get out of his car when he did, the crash would not have happened.
"This should not be taken as a pronouncement of liability or negligence, but a finding of fact," Mr Matenga said.
He accepted a court finding of Judge Phil Gittos that Mr Becker looked properly before opening his door, and that Ms Bishop was not in his field of vision when he got out of his car to go fishing.
Auckland Transport chief executive David Warburton said in a statement that "this tragic accident" occurred just days after his organisation was established, and it moved quickly to remove car parks near the bend in the road.
"Since then a number of other safety improvements have been implemented, including improved cycle lanes."
Mr Matenga did not refer to evidence at the inquest from a former Cycle Action Auckland chairman, Bevan Woodward, that he had warned an Auckland City Council transport leader in 2006 about the pinch-point.
The coroner also issued findings into the deaths of two other cyclists, including that of Auckland man Antony David Chapman, which he found was accidental after the 48-year-old struck a rock on a sweeping downhill bend in the main road between his Beachlands home and Maraetai on April 12 last year.
The third death, of 22-year-old Benjamin Patrick Thomas Lawless of Wellington, resulted in the conviction last year of an Victoria University law professor on a charge of careless driving causing death.
Yvonne van Roy hit him in her car at night at an intersection in Karori in 2011. She was ordered to pay $37,000 in reparations to Mr Lawless' mother and sister, and was disqualified from driving for nine months.
Mr Matenga is also now recommending that Wellington City Council review the intersection's layout to make it safer for pedestrians, cyclists and motorists.