A woman was killed by an overhanging tree branch when she stuck her head out of the window of a moving high-speed train, an inquest jury has concluded.
Bethan Roper, 28, suffered fatal head injuries while a passenger on the Great Western Railway (GWR) train travelling at around 75mph.
Miss Roper was returning home to South Wales on December 1 2018 from a day out with friends Christmas shopping in Bath.
The GWR London Paddington to Exeter service was using carriages fitted with droplight windows to enable passengers to use the handle on the outside when they needed to leave the train at the platform.
Investigators told Avon Coroner’s Court that the warning label above the window – a yellow sticker with the words: “Caution do not lean out of window when train is moving” – was not a sufficient deterrent.
The inquest heard that after the death of a passenger leaning out a window on a train in south London in August 2016, GWR completed a risk assessment of its droplight windows.
This resulted in a plan to install enhanced warning signs with a red background by May 2018, but this had not happened by the time Miss Roper was killed seven months later.
She was fatally injured just a few minutes after the train left Bath when her head was struck by an ash tree branch growing on land adjacent to the line.
A post-mortem examination found Miss Roper had died from head injuries.
Toxicology tests found she had a blood alcohol level of 142mg in 100ml of blood – meaning she was nearly twice the drink-drive limit.
The inquest also heard the tree had undergone inspections in 2009 and 2012 as part of a five-year cycle by Network Rail, which was responsible for the management of trackside vegetation.
The tree had been growing on the embankment five metres from the track and was later colonised by two types of wood decay fungi, which led to the failure of some of its stems.
The branch which killed Miss Roper had by February 2017 fallen towards the railway line and was resting on a chain link fence at the top of the embankment.
Further specialist inspections may have prevented the tragedy, an expert told the hearing.
Following five days of evidence, an inquest jury returned a majority conclusion of a narrative conclusion.
They said: “Bethan died as a result of an incident onboard a train travelling from Bath to Bristol Temple Meads on December 1 2018.
“Bethan boarded the train under the influence of alcohol. Despite a warning sign she leant out of a droplight window while the train was moving.
“She was struck by a stem of a tree sustaining a fatal head injury.”
Maria Voisin, senior coroner for Avon, said she would not be making a preventing future deaths report after hearing that the Mk 3 coaches – first introduced in the 1970s – were being phased out across the network and are being replaced by doors that open and close with the use of an electronic button.
Miss Roper, from Penarth, South Wales, worked for the Welsh Refugee Council charity and was chairwoman of Young Socialists Cardiff.
Speaking after the inquest, a spokesman for GWR said: “Bethan’s death was tragic incident, and our thoughts remain with her family and friends as they once again recall the terrible loss suffered that evening.
“At the time of the incident we were in the process of phasing out High Speed Trains using droplight windows from our fleets, replacing them with modern, safer Intercity Express Trains with sealed windows.
“This work was completed last year.
“We, and the wider rail industry, are committed to learning the lessons outlined, particularly around speed of the design, review and implementation of mitigations.”
Chris Pearce, interim Western director for Network Rail, said: “Safety has and always will be our first priority. Our thoughts remain with Beth’s family and friends following the tragic incident in December 2018.
“We urge passengers and the public to take care around trains and railway tracks.
“We have worked with the Rail Accident Investigation Branch, the Office of Rail and Road and the coroner throughout this process and will continue to work with our industry partners to improve safety.”