The ACT government was warned about a bicycle path constantly filling up with "incredibly dangerous" debris four years before such material contributed to the death of a cyclist.
While the fatality has already led to the construction of a wall to stop gravel accumulating on the path, the chief coroner is now calling for regular safety audits of bicycle paths across the territory.
Coronial findings published on Tuesday say Teresa Erika Foce, 63, died at Canberra Hospital in April 2018 after suffering significant brain injuries in a crash 17 days earlier.
Dr Foce, a psychiatrist and keen cyclist, was riding with her partner Michael Kearney towards Tharwa when the crash happened in Conder.
An investigation established that Dr Foce had hit a trailer being towed by a utility, which was travelling through a roundabout at the intersection of Tharwa Drive and Mentone View.
Police cleared the utility driver of any wrongdoing, and officers who attended the scene photographed skid marks in gravel on the off-road bicycle path beside Tharwa Drive.
Chief Coroner Lorraine Walker said she had inferred that the marks were caused by Dr Foce trying unsuccessfully to brake on the path as she approached the road.
"It is apparent from those photographs that gravel had fallen onto the bicycle path, which impacted on Dr Foce's ability to brake as she tried to cross Mentone View," Ms Walker said in her findings.
She noted that Mr Kearney had told police that Dr Foce, who wore prescription glasses, may not have even seen the gravel until she was right on top of it.
Mr Kearney also said Dr Foce's bike would logically skid if the sort of tyres she used hit the gravel.
"I consider these factors, along with the state of the bicycle path, would have contributed to the collision," Ms Walker said in her findings.
Ms Walker also detailed a complaint that the ACT government had received "from an unknown source" in April 2014.
The complaint said: "The bicycle path at the corner of Tharwa Drive and Mentone View keeps filling up with dirt. This makes it incredibly dangerous on a bicycle, since you come down the hill at speed ... and suddenly hit this corner filled with dirt. Could the dirt please be removed and the issue looked into?"
Government records indicate that the path was cleaned less than two weeks after the complaint, but it was not until after the fatality that a solution was put in place to stop more debris piling up.
Ms Walker said that since the incident, the ACT government had had the bike path swept and repaired.
A retaining wall had also been built, "so as to ensure that gravel from the nearby reserve is unlikely to be swept onto the bicycle path again".
Ms Walker said these measures alleviated concerns arising from the death of Dr Foce about public safety at that specific location.
"However, given this location was previously known to have issues with debris on the path, I recommend that, if no such program presently exists, the ACT government institute a regular audit program for its off-road bicycle paths to ensure that they are appropriately maintained and there are no obstructions or risk of obstruction from the surrounding environment," the coroner said.
"If such a program exists, I recommend it be reviewed to ensure that inspections occur at sufficient frequency so as to minimise the risk that a path becomes and remains obstructed to a level that may be dangerous to persons using the path."