Five months after a cyclist was run over and killed riding through the St. Denis St. underpass, the coroner's office says the death could easily have been avoided.

Mathilde Blais, 33, was heading south on St. Denis when she was run over by a crane truck.

The coroner was unable to determine if the truck hit Blais while she was riding, or if she fell and was subsequently run over.

Blais died instantly as her head was crushed by the tires.

Coroner Paul Dionne wrote that the deadly incident could easily have been avoided if the truck driver had shared the lane with Blais, either by slowing down while going through the underpass or by veering into the other lane as is permitted under the Highway Code.

“I think it was a preventable death, an avoidable death. Mrs. Blais didn't have to die,” said Dionne

Dionne also wrote that a skirt along the bottom edge of the truck would have prevented Blais from falling underneath.

The coroner's recommendations are for the SAAQ to rewrite the Highway Code to indicate a minimum safe passing distance, and to emphasize road-sharing protocols in its advertising campaigns.

Dionne also would like to see Quebec's largest cities (members of the Quebec Municipal Union UMQ) to pass bylaws giving clear priority to bicycles, especially on major thoroughfares.

Montreal police said they will continue to issue tickets until drivers’ habits change.

“The more bikes there will be out there, the more concern there will be for safety and the more we will have to work together because the roads are not getting any wider,” said Andre Durocher of the Montreal police.

In the weeks after Blais's death Transportation Minister Robert Poeti promised to update the Highway Safety Code, and the city of Montreal altered traffic rules to allow bicycles to ride on the elevated sidewalk on that underpass.

The city has already invested millions and said it will continue to invest millions more to create safe spaces for cyclists on urban roads. They have also begun to install security barriers on its fleet of trucks.

“$2.5 million of investment to put these safeguards on our trucks in the city,” said Aref Salem, on the executive committee of the City of Montreal.

Head injuries are among the most common for cyclists and the ones that can be the most difficult to deal with, said MUHC Injury Prevention Coordinator Tara Grenier of the Montreal General Hospital.

“Memory loss, fatigue, irritability, paralysis, living with these kinds of things, it’s a completely different lifestyle so it's best to avoid them in the first place,” she said.

Read the coroner's report

Coroner's report for death of Mathilde Blais