An investigation into the death of 28 year-old Bethan Roper, from Penarth, has been released today.

Bethan Roper was hit in the head by a tree branch while on board a Great Western Railway (GWR) train near Twerton, Bath.

The Rail Accident Investigation Branch (RAIB) released their report on the accident today.

They summarised the inadequate signage warning passengers about the use of windows on moving trains.

The report explained: ''On the type of coach making up the train, opening windows are provided to allow passengers to reach through and operate the external door handles when the train is in a station.

''This is the only means by which passengers can open the train doors.

''However, 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 accident occurred because the passenger did this when branches from a lineside tree were in close proximity to the train.''

Signs have subsequently been updated, since the circumstances leading to Miss Roper's death.

The Rail Accident Investigation Branch (RAIB) also commented on the tree growth along the route, which had not been inspected since 2009.

The report said: "A competent inspection of the tree undertaken at any time since at least 2014 would have identified the decay and, from this time onwards, the fungal fruit bodies.

''The decay alone, confirms the tree to have been in hazardous

condition for several years, and prior to January 2018 at least three stems would have been clear threats to the railway.''

It later states, ''Network Rail had not undertaken a tree inspection in the area of the accident since 2009 and this is possibly causal to the accident.''

The investigation said Miss Roper was travelling to Penarth via Bristol Temple Meads from Bath Spa station where she joined the train with a group of friends.

Despite the efforts of other passengers, including some with medical training, she was pronounced dead at Bristol station, the report said.

Regarding external factors the report states: ''It was dark at the time of the accident.

''Although some strong winds were experienced in the area three days before, the RAIB found no evidence that the weather or other external influences contributed to the cause of the accident.''

GWR had completed a risk assessment of its droplight windows after an earlier passenger death,

It had planned to install enhanced warning signs by May 2018, but this had not happened by the time of Ms Roper's death, investigators found.

Prior to the accident, GWR had begun a programme of replacing some High Speed Trains (HSTs) with new trains which do not have droplight windows and modifying the other HSTs to have power operated doors without opening windows.

The report says, ''the intention is that by January 2020 GWR will have replaced or modified all of its High Speed Train sets.''

As a direct result of this accident, it has since implemented a series of measures intended to mitigate the associated risks in the interim period before they are eliminated.

This included enhanced signage on doors (shown in the pictures), train managers making announcements about the dangers of leaning out of open windows and briefing staff about challenging unsafe passenger behaviour and closing windows.

The RAIB has made four recommendations and identified two learning points as a result of this accident. They are listed below.

• One recommendation is addressed to operators of mainline passenger trains, including charter operators, and seeks to minimise the likelihood of passengers leaning out of droplight windows when a train is away from stations.

• A second recommendation, is addressed to operators of heritage railways and seeks to improve their management of the risks associated with passengers leaning out vehicles.

• The third recommendation is addressed to Great Western Railway and seeks to reduce the potential for hazards associated with its operations being overlooked.

• The fourth recommendation is addressed to RSSB and seeks to ensure that its advice on emergency and safety signs reflects the level of risk associated with the hazard being mitigated.

• The learning points reinforce the importance of undertaking regular tree inspections and the value of train operators having well briefed procedures for dealing with medical emergencies on board trains.

Bethan Roper had chaired the Cardiff Young Socialists group and was an activist throughout her life.

Bethan Roper's family have recently set up a trust in her honour. It states that they will be: ''Building a better world for refugees in memory of a wonderful human being.''

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