A caution sign could have been clearer on a train which a woman leaned out of and died, a report has found.
Bethan Roper suffered fatal injuries while on her way back from a Christmas shopping trip in Bath last December.
Her head hit a branch and she was pronounced dead at Bristol Temple Meads.
A new report into Bethan Roper’s death was published by the Rail Accident Investigation Branch (RAIB) today (October 16).
The report noted Network Rail had not undertaken a tree inspection on the stretch of track where the accident happened since 2009 and also said a sign on the train could have been clearer.
The lack of tree inspection meant the branch was close enough for a passenger leaning out of a window to come into contact with it, the report said.
The 35-page document lists a series of recommendations and key points – including a previously unseen toxicology report.
It said: “The toxicology report concluded that the passenger’s blood contained 142 milligrams of ethanol per 100 millilitres.
“This is nearly twice the UK legal driving limit of 80 milligrams in 100 millilitres of blood.
“It is generally recognised that this would cause a level of intoxication in the average social drinker which may affect their co-ordination and judgement.
“However, the actual effect on the passenger involved is unknown.”
It is thought Bethan had been visiting the Christmas market in Bath with friends on December 1 before she boarded the train home at around 10pm.
The group then stayed near the doors as the carriage they were in was busy.
The report said: “The RAIB is satisfied that one of the group of friends opened the window and at least one other friend leant out of the window before the passenger who was injured did so.
(Image: RAIB/PA Wire)
Sign could have been clearer
“Witness evidence indicates that the passenger had her head out of the window for a few seconds before falling back into the vestibule having sustained a serious head injury.”
The RAIB recognised a sign warning passengers not to put their head out of the window could have been clearer.
It found the word ‘caution’ suggests leaning out of the train window is something that may be done safely if a degree of care or precautions are taken.
It added the use of a yellow background to the sign is a recognised characteristic of a warning sign as opposed to the more appropriate use of a red background to convey danger.
The report read: “Had GWR specifically identified the hazard of passengers leaning out of opening windows and included it in its risk management process prior to the fatal accident at Balham, it is possible that it would have implemented additional mitigation measures which might have prevented the passenger leaning out of the window on 1 December 2018.”
A spokesman for GWR said: “Bethan Roper’s death in December last year was tragic incident, and our thoughts remain with her family and friends.
“There are some clear lessons for the wider railway industry, including GWR, to learn.
“At the time of the incident we were in the process of phasing out trains using droplight windows from our fleets, replacing them with modern, safer Intercity Express Trains with sealed windows.
“We have since introduced a number of measures to minimise the risks while those High Speed Trains were phased out, including enhanced door signage, strengthening announcements about the dangers of leaning out of windows, and re-briefing staff to continue to challenge unsafe behaviour.
“From the end of December we will no longer operate this type of train and are working to introduce automatic locks on windows on our Sleeper Service.”
(Image: Adrian Roper)
‘She was beautiful in every way’
The report concluded the sign, fitted in 2007, may also have been too small.
Bethan’s father Adrian paid tribute to his daughter after her death.
He said: “All of us who knew Bethan have been very privileged. She was beautiful in every way.
“Her goodness and fullness of spirit will live on in our hearts and actions.”
For the latest news in and around Bristol, check back on Bristol Live’s homepage.