A young woman died after hitting her head on an overgrown tree when she stuck her head out a train window.
Bethan Roper, 28, suffered fatal injuries while on her way back from a shopping trip to the Bath Christmas Markets in December 2018.
A Rail Accident Investigation Branch (RAIB) report has now been published into Ms Roper's death probing the lead up to her head hitting a tree branch as she leaned out of the moving train.
She was hit by the branch about two-and-a-half minutes after the train departed from Bath Spa, when the train was travelling at around 75mph.
The charity worker, from Penarth, Wales, was pronounced dead after arriving at Bristol Temple Meads station following the accident.
Today the Rail Accident Investigation Branch (RAIB) published its findings into the devastating event, criticising GWR saying the rail company "had not provided adequate mitigation measures to protect against the risk" of passengers putting their heads out of windows on moving trains.
It said certain recommendations after a similar death in 2016 were not implemented at the time and that a lack of inspection of trees in the area were "possibly causal" to Ms Roper's death.
Ms Roper was travelling on a rail coach with a "droplight" window, which can be opened to allow passengers to reach through and open external door handles when the train stops at a station.
The RAIB report said: "Other than warning signs, there is nothing to prevent passengers from opening and leaning out of such windows when trains are away from stations and moving."
The report also said Ms Roper had been drinking.
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 that Ms Roper had been visiting the Christmas market in leafy 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.
"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."
In 2016 another passenger travelling on a GWR train died after hitting a a gantry while leaning out of a drop-window in south London.
The RAIB then issued recommendations to train operators including GWR.
The RAIB report into Ms Roper's death said: "GWR published that risk assessment in September 2017. However, it did not complete the actions relevant to its own operation of coaches with droplight windows (enhanced signage and staff briefings) before this accident.
"So, at the time of the accident, it was effectively operating on the basis of its pre-2017 understanding of the risks, which did not include the risk to people from leaning out of the windows of a moving train."
Between April 2014 and January 2019 GWR recorded 16 occurrences of passengers or staff injured leaning out of a droplight window.
In 11 of the cases foliage was attributed in the incident.
The RAIB said: "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."
The report said Network Rail had not carried out a tree inspection in the area since 2009.
It said: "Given that the tree had been visibly (to an expert) in poor health for around five years prior to the accident, it is possible that had a tree inspection been carried out and the incident tree considered for a specialist tree inspection in the five years prior to the accident it might have been identified as needing felling or pruning."
Investigators found the lack of inspection was "possibly causal" to the incident.
Before Ms Roper's death, GWR had started replacing some trains with newer versions.
Since Ms Roper's death, the report said GWR has improved signs near droplight windows, briefed staff, and train managers now make announcements about the danger of leaning out of open windows.
GWR said that from the end of December it will no longer operate the type of train Ms Roper was on.
A spokesman 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.”
Ms Roper's father Adrian has previously spoken about her passion for fighting injustice and how he and her family and friends plan to continue her legacy.
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