Prevention of Future Deaths reports · 2022

Connor Marron

Regulation 28 report to prevent future deaths, reference 2022-0190, written 22 Jun 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report22 Jun 2022
Reference2022-0190
DeceasedConnor Marron
CoronerAndrew Walker
Coroner areaInner North London
CategoryRailway related deaths
Sourcejudiciary.uk record · original PDF
Responses published3

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

North London Coroners Court,

Her Majesty’s Coroner for the 29 Wood Street,
Northern District of Greater London —Bamet ENS 4BE

(Harrow, Brent, Barnet, Haringey and Enfield) | |

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

1. Thames Water,
Clearwater Court,
Vastern Road,
Reading RG1 8DB

2. Alexandra Palace,
Alexandra Palace Way,
London N22 7AY

3. Network Rail,
One Eversholt Street,
London,
NW1 2DN

1 | CORONER

1am Mr Andrew Walker, H M Coroner and senior coroner, for the coroner area of
Northern District of Greater London

2 | CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

3 | INVESTIGATION and INQUEST

On the 4" January 2022 | opened an investigation touching the death of Connor Peter
Marron, aged 19 years old. | opened and inquest on the 315 January 2022. The inquest
concluded on the 7" June 2021, having been adjourned part-heard from the 21* April
2022. The conclusion of the inquest was “Open”, the medical case of death was 1a
Multiple compound injuries, 1b Train collision.

4 | CIRCUMSTANCES OF THE DEATH

On the Second of January 2022 at about 42 minutes past midnight Connor Peter Marron was struck and
fatally injured by a train 300 meters north of Hornsey Railway Station.

Mr Marron left the Victoria Stakes Public House to return to Alexander Palace, where he had earlier
attended an event, with the intention of recovering his phone.

Towards the edge of the grounds a stream runs alongside a railway line. There is a path then a fence
before the railway track itself.

It was not possible, from the evidence heard at the inquest, to be clear about what happened in the journey
Mr Marron took until the point at which Mr Marron is seen on CCTV train footage just before being struck by
a train. Mr Marron was soaked from his waist down and not wearing shoes at the time of the collision and
was seen on the train’s camera moving across the path of the train appearing to be unaware that the train
was approaching him.

5 | CORONER’S CONCERNS _

The MATTERS OF CONCERN are as follows. —

1. There was no lighting beside the stream or the railway fence, nor any signs
identifying the stream, its depth and any warning of danger.

2. There were no signs in that area to assist with locating a way out from that part
of the venue’s grounds.

3. The fence separating the venue grounds from the railway track was not
adequate to prevent ingress to the railway track.

6 | ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you
[AND/OR your organisation] have the power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by Wednesday the 17" August 2022 |, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons;-

The Family.

22"4 June 2022

Keadowe Welton

Responses

3 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Alexandra Palace (PDF)
Mr Andrew Walker 
HM Coroner 
North London Coroners Court 
29 Wood Street 
Barnet 
EN5 4BE 

Dear Mr Walker, 

Dear Mr Walker, 

4th August 2022 

Re: Regulation 28 Report - Inquest into the death of Connor Marron.  

We  acknowledge  receipt  of  your  report  under  Regulation  28  and  29  of  the  Coroners 
(Investigations)  Regulations  2013  further  to  the  inquest  into  the  death  of  Connor Peter 
Marron that was jointly sent to Alexandra Park and Palace Charitable Trust, (herein APPCT) 
Thames Water and Network Rail.  

We note your Matters of Concern raised in this report namely: 

1.  There  was  no  lighting  beside  the  stream  or  the  railway  fence,  nor  any  signs 

identifying the stream, it’s depth and any warning of danger 

2.  There were no signs in that area to assist with locating a way out from that part of 

the venue’s grounds 

3.  The fence separating the venue grounds from the railway track was not adequate 

to prevent ingress to the railway track.  

Before responding to the specific detail, please let me take this opportunity to share more 
information  regarding  APPCT  and  the  scope  of  its  land  ownership  and  operational 
responsibilities.  

Alexandra  Park  comprises  of  196  acres  of  parkland  within  the  urban  setting  within  the 
London Borough of Haringey.  The park is a public recreation space that remains held in 
Trust for the public forever by the Act of Parliament, which is our key governing document. 
The Trust was recognised as charitable in the 1960s and we are therefore subject to Charity 
Law and regulation. The Trust has a sole Corporate Trustee, Haringey Council, who inherited 
the Trusteeship in 1980. The Trust’s assets and activities are overseen by a Trustee Board 
appointed by the Corporate Trustee and our two stakeholder committees.  

Image 1 appended to this letter demonstrates the extent of the park and land ownership 
boundary as shown by the dotted line. On the south east corner of the park, the boundary 
runs parallel to Newland Road. Routes to Nightingale Lane, Boyton Road, Greenway and 
Newland Road are accessed from Newland Road.  

The boundary of Alexandra Palace to the east adjoins Hornsey Water Treatment Works 
operated by Thames Water.  Alexandra Palace owned land has no direct boundary with any 

ALEXANDRA PALACE, ALEXANDRA PALACE WAY, LONDON, N22 7AY • 020 8365 2121 • ALEXANDRAPALACE.COM 
ALEXANDRA PARK AND PALACE CHARITABLE TRUST IS A REGISTERED CHARITY • CHARITY REGISTRATION NUMBER: 281991 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 railway assets owned by Network Rail. To access the railway boundary fence, an individual 
must first leave the park onto public streets and cross the New River; two locations owned 
by third parties. 

Given this description,  APPCT does not own or operate assets which fall into the scope of 
Matters  of  Concern  1  and  3  and  therefore  cannot  reasonably  be  expected  to  have  any 
duties arising as a result that would require action.   

We  note that  during  the  inquiry  you  found  no  evidence  to  reason  why  Connor  Marron 
chose  to  pass  through  this  lower  area  of  the  park  which  is  one  of  the  reasons  in  your 
decision to record an Open Determination. We have no indication of whether Mr Marron 
passed through the park in a considered manner or was in a state of distress, or indeed 
being pursued by an unknown third party.  

Images 2, 3 and 4 appended to this letter are taken from Google Maps and show the nature 
of the park boundary in this location. These images move from west to east along Newland 
Road clearly showing the park boundary fence along with the clear breaks in this perimeter 
and Gate 3 of the park at the most easterly extent. Alexandra Park is different to many 
London Park in that given its nature, privately owned but publicly accessible road and varied 
boundaries, the park is not secured at night and remains open to the public 24 hours a day.  

With particular reference to Matter of Concern 2, we do not share your concern that it is 
challenging for a park user to locate an exit from this area of the park. This is an open area 
of the park and with multiple options through which to exit the park and choose a number 
of adjoining roads. We are also very conscious of the precedent that such a decision could 
create for all park operators across the UK.  

Therefore  while  we  acknowledge  outputs  from  your  inquiry, APPCT  confirms  that  after 
careful consideration as discussed above, we do not intend to erect exit signs in this area 
of  the  park.  We  trust  that  the  above  discussions  and  associated  rationale  appropriately 
explains why Matters of Concern 1 and 3 do not fall under APPCT responsibility and why 
no action is proposed with regards to Matter of Concern 2.  

Should you wish to discuss any aspect of this letter further, please do not hesitate to get in 
touch.  

Yours sincerely, 

Chief Executive Officer 
Alexandra Park and Palace Charitable Trust 

ALEXANDRA PALACE, ALEXANDRA PALACE WAY, LONDON, N22 7AY • 020 8365 2121 • ALEXANDRAPALACE.COM 
ALEXANDRA PARK AND PALACE CHARITABLE TRUST IS A REGISTERED CHARITY • CHARITY REGISTRATION NUMBER: 281991
Response from Network Rail (PDF)
OFFICIAL 

Mr Andrew Walker 
HM Coroner and Senior Coroner for the Northern District of 
Greater London 
North London Coroners Court 
29 Wood Street 
Barnet 
EN5 4BE 

05 December 2022 

Re: Regulation 28 Report – Connor Peter Marron 

Dear Sir,  

I refer to your report dated 22nd June 2022 made under Paragraph 7, Schedule 5, of the Coroners and 
Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.   

I would like to take this opportunity to express my sincere condolences to the family of Mr Marron. Please 
be assured that we take all incidents of this nature on the railway incredibly seriously and have carefully 
considered the matters raised in your report. I would also like to apologise for the delay in submitting 
Network  Rail’s  response,  which,  unfortunately,  resulted  from  your  report  being  initially  received  by  a 
former (now retired) Network Rail employee. 

Addressing the matters set out in your report in turn, in relation to the first two matters listed we note 
that  it  states  that  there  was  “….no  lighting  beside  the  stream  or  the  railway  fence,  nor  any  signs 
identifying the stream, its depth and any warning of danger” and “….no signs in that area to assist with 
locating a way out from that part of the venue’s grounds”. The stream and venue referenced are not 
located on Network Rail land and therefore the provision of lighting and/or signage in those locations is 
a matter for the relevant landowners, whom Network Rail understands are Thames Water and Alexandra 
Palace. With regard to lighting beside the railway fence, it is not Network Rail policy to provide lighting 
along its fence line and, accordingly, lighting is not in place along this particular section of fencing.   

In  relation  to  the  third  matter  listed,  whilst  your  report  states  that  the  fence  separating  the  venue 
grounds from the railway track was “….not adequate to prevent ingress to the railway track” and Network 
Rail’s post-incident inspection of the fencing (on the morning of 2nd January 2022) in the wider area 
recorded that a small gap in the fencing had been discovered, as well as damage to the Downside access 
gate, resulting in minor repairs being carried out immediately, we note that the BTP’s Post Incident Site 
Report  (BTP  Control  Works  Reference  15-020122)  (“the  PISR”)  concluded  that,  having  reviewed  the 
possible routes to the incident scene following the incident, “…….access onto the railway is inconclusive”.  

The PISR suggests two mitigation measures which could help to prevent similar incidents: 

•  ensuring  that  fence  line  inspections  comply  with  the  National  Safety  Briefing  in  relation  to 
Boundary Fencing Inspection Standard NR/L2/OTK/5100 Module 01 (1st April 2019) tactile / 
non-tactile  inspections  (“the  Standard”).  Network  Rail  takes  a  pro-active  approach  to  asset 
maintenance and renewal, with inspections complying with the Standard and remediation works 
carried  out  following  such  inspections.  Where  upgrading  of  an  asset  is  identified  as  being 
required, a fencing proposal is prepared by the Off-Track team and ranked in terms of priority, 
with  those  with  the  highest  scores  (indicating  that  they  are  the  highest  priority)  given 
precedence. Each route within an area is allocated a fund of monies to be used for maintenance 
and  repair works,  with  monies  focused  on  delivering  the  highest  priority  works  identified  i.e., 
those with the highest scores. The relevant section of fencing in this matter is inspected on a 
quarterly basis by the Network Rail Off-Track Team in line with the process described above; and 

Network Rail Infrastructure Limited Registered Office: Network Rail, One Eversholt Street, London, NW1 2DN Registered in England and Wales No. 2904587 www.networkrail.co.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 OFFICIAL 

• 

replacing the relevant section of chain link fencing and continuing with palisade fencing. Whilst, 
as mentioned previously, the route to the incident scene has been deemed inconclusive, we note 
that the fencing in closest proximity to the incident scene is, in fact, palisade fencing, rather 
than chain link fencing (the fencing in this particular area, which separates the venue grounds 
from the railway track, is currently of a mixed palisade and chain link design). Class I boundary 
measures, which include palisade fencing, are installed to provide a security measure where the 
risk of unauthorised access is probable and these boundary measures are designed with anti-
tamper and anti-climb components within the installation. The chain link section of fencing is 
approximately  ¼  mile  down  the  track,  on  the  opposite  side  of  the  tracks  and  across 
approximately 6 lines of track. However, following a recent scheduled inspection, Network Rail 
has decided that the chain link section of the fencing will be replaced with palisade fencing and 
this work is now part of the Route’s work bank to be carried out (this work has not yet been 
scheduled).  

I note that the conclusion of this inquest was an ‘open’ verdict. However, I thought you may be interested 
in some of the other work we do as we are committed to maintaining a safe railway and to reducing 
opportunity for members of the public to harm themselves on or near the railway. An example of this is 
the work being carried out on the Peterborough to Kings Cross line of route, where this section of track is 
located, which is one of three Focus Areas where Network Rail is working closely with the British Transport 
Police,  Samaritans  and  Rail  Industry  partners  to  prevent  suicide.  Network  Rail  has  also  invested 
significantly in preventing unauthorised access in this line- of-route through physical mitigations, such 
as platform end barriers and mid-platform fences at stations and lineside fencing outside.   

I hope that this response answers your concerns but if I can be of any further assistance, or if you would 
like further clarification, please do not hesitate to contact me. 

Yours sincerely,  

Route Director (East Coast)  
Network Rail Infrastructure Limited 

Network Rail Infrastructure Limited Registered Office: Network Rail, One Eversholt Street, London, NW1 2DN Registered in England and Wales No. 2904587 www.networkrail.co.uk
Response from Thames Water (PDF)
Mr Andrew Walker  
Senior Coroner for North London  
HM Coroner & Senior Coroner  
North London Coroners Court  
29 Wood Street  
Barnet  
EN5 4BE 

Clearwater Court, 
Vastern Road, 
Reading 
RG1 8DB 

17 August 2022 

Regulation 28 Report to Prevent Future Death – Death of 
Connor Peter Marron 

Dear Senior Coroner Walker, 

, Engineering and Asset Director for Thames Water and I 

I am 
have executive responsibility for our asset standards. We were of course, sorry to 
hear of the tragic death of Mr Marron and have treated the Regulation 28 report 
issued on 22 June 2022 as a matter of great importance. The safety of our 
employees, members of the public and all those affected by our operations is a 
priority. Consequently, further to the Regulation 28 report, our Health, Safety and 
Wellbeing Director and one of his team attended the New River on 29 July as part of 
our investigations so we could respond meaningfully to your report. We hope that our 
response as set out in this letter is helpful and addresses the points of concern you 
raise.  

Thames Water was not aware of or involved with the British Transport Police 
Investigation or the Inquest and therefore, we contacted your office to ask for some 
background information in relation to the location where it is believed that Mr Marron 
might have accessed the New River in order to put this response together. We 
received this from Roger Andrews of the British Transport Police who provided a 
copy of its incident report and associated photographs.  

Your report is addressed to three recipients; Thames Water Utilities Ltd, Alexandra 
Palace and Network Rail and notes the following matters of concern, namely:   

1. 

There was no lighting beside the stream or the railway fence, nor any 
signs identifying the stream, its depth, and any warnings of danger. 

Thames Water Utilities Limited, a company registered in England and Wales with company number 02366661. 
Registered office address: Clearwater Court, Vastern Road, Reading RG1 8DB. VAT registration number: GB 537-4569-15. 

CC001_01_24_03_22 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2. 

3. 

There were no signs in that area to assist with locating a way out from that 
part of the venue’s grounds. 
The fence separating the venue grounds from the railway track was not 
adequate to prevent ingress to the railway track. 

I will address point number 1, as the other issues appear to relate to the 
responsibilities of Alexandra Palace and Network Rail respectively. Point 2 relates to 
lighting on the venue grounds, which is for Alexandra Palace, and fencing separating 
the venue from the railway track would appear to be the responsibility of Network 
Rail. 

This response addresses the lighting and signage present at parts of the New River 
path and in addition makes some observations concerning the possible entry points 
into the New River based on our site visit. These are offered to be helpful but of 
course, should be disregarded if they are unhelpful or go against any of the evidence 
heard at the Inquest. In addition, these observations will aid in our review of wider 
operational and maintenance requirements associate with the New River as part of 
our usual process when considering wider learnings following any significant event. 

Before addressing the specific issues raised and our proposed action, I thought it 
would be helpful to provide some context of the New River, the ‘stream’ that is 
referenced in your report. 

The New River is a water supply aqueduct originally built in 1613 to bring fresh 
drinking water from Hertfordshire to North London. Since 1992, Thames Water has 
worked with local people and partners to create a 45 km (28 mile) footpath that 
follows the course of the New River, linking the inner city to the open countryside. 
Today the river includes new channels and pipework sections, is up to 6 meters wide 
and 2.4 metres deep, with flow being regulated by a series of sluice gates. Further 
background on the New River can be found in Appendix1 including the approach 
taken to Route Safety. 

Management of the New River and New River Path requires the ongoing 
collaboration of a variety of stakeholders, London’s Waterway Partnership, 
Countryside Agency, New River Action Group, Friends of New River Walk, local 
authorities as well as schools and communities along the route.  As with any 
responsible organisation, Thames Water has an established and comprehensive 
Safety Management System in place to meet its moral and statutory obligations. For 
our assets accessible to the public, we adopt the principles and practices set out in 
two key guides published by the Visitor Safety Group and created in partnership with 
English Heritage, The Environment Agency, National Trust, owners and other 
stakeholders. 

•  Managing Visitor Safety in the Historic Built Environment 
•  Managing Visitor Safety in the Countryside 

These guides clearly articulate that ‘Visitor safety management is about balancing 
the risks and benefits in order to provide overall benefit to society and individuals. It’s 
not about creating a totally risk free society…’  

Thames Water Utilities Limited, a company registered in England and Wales with company number 02366661. 
Registered office address: Clearwater Court, Vastern Road, Reading RG1 8DB. VAT registration number: GB 537-4569-15. 

CC001_01_24_03_22 

 
 
 
 
 
 
 When considering lighting requirements, Thames Water gives consideration to: 

•  The activities undertaken (in the case of the New River Path, this would be 

limited to walking as cycling and activities relating to accessing the water are 
prohibited). 

•  The volume of visitors and typical times that the path is in use. 
•  The proximity of additional specific hazards and effectives of additional 

controls relating to these hazards (the fencing of pipes that cross the river, 
fast flowing channels or area with restricted egress options). 

•  The construction and maintenance of pathways. 
•  The availability of natural or borrowed light from other sources. 
•  The potential to impact the environment for wildlife and residents through 

glare and light pollution. 

•  The creation of additional operational risks associated with maintenance. 

In terms of signage, Thames Water would usually install safety notices at the entry 
and exit points to stretches of the New River Path with additional prohibition or 
warning signs close or adjacent to any specific or additional hazard. When 
considering signage, a balanced assessment is made considering a number of 
factors, which includes: 

•  The size, positioning and potential over use of signage. 
•  The need to communicate information in a clear and simple manner. 
•  The limits in effectiveness of some signage for children, foreign language 

speakers or the visually impaired. 

•  Visual intrusion, particularly in natural environments. 
•  Associated risks from wilful and accidental damage. 

Although the fence referred to in the Regulation 28 report is the responsibility of 
Network Rail, we do consider fencing requirements relative to water access. We 
balance the need to retain public access/amenity and the obvious hazards of access 
to water with the need for specific additional controls. Consequently, we fence areas 
where access or egress from the river may be impeded by steep banks or where 
specific or additional hazards may exist for example, locations where pipes span the 
river and a crossing may be attempted, fast flowing channels, sluices, weirs, 
pumps/intakes, or other underwater obstructions.  

With this context and background in mind, I will now deal specifically with the areas 
of concern noted in the Regulation 28 report.   

We understand that the Inquest did not conclude whether Mr Marron accessed the 
New River or at what location. Therefore, our investigations focussed on a specific 
stretch of the New River as detailed in the “British Transport Police – Post Incident 
Site Report” and highlighted in Picture 1 below. This response sets out what signage 
and lighting is currently in place in that area and where we anticipate we will 
undertake further assessment or make changes.   

Thames Water Utilities Limited, a company registered in England and Wales with company number 02366661. 
Registered office address: Clearwater Court, Vastern Road, Reading RG1 8DB. VAT registration number: GB 537-4569-15. 

CC001_01_24_03_22 

 Observations of the specific area of river shown in Picture 1, relate to 9 locations 
show in Picture 2 below. In the interest of brevity, I reference the location and 
observation. 

Picture 1 – BTP Post Incident Site Report 

Picture 2 – Observation points from inspection 

Below is a summary of the observations made by the Health & Safety team during 
their site visit.  It should be noted that locations 1 to 6 constitute Thames Water 
property, locations 7 to 9 are private property belonging to the developer of 
apartments along Chadwell Lane and New River Avenue. 

Location 1 

Location 1 has a kissing gate entrance to the New River path, with palisade fencing 
on either side in good condition. There is a small notice on the gate concerning right 
of access and entry at one’s own risk. However, the Thames Water standard hazard 
warning sign stating, ‘danger deep water, no swimming, no boating, no fishing’, 
which should be displayed at each access point to the river is not in place in this 
location. Arrangements have been made for this to be installed so it will mirror the 
signage at location 6 (see further comments below).  

Thames Water Utilities Limited, a company registered in England and Wales with company number 02366661. 
Registered office address: Clearwater Court, Vastern Road, Reading RG1 8DB. VAT registration number: GB 537-4569-15. 

CC001_01_24_03_22 

 
 
 
 
 
 
 
 Location 2 

At location 2, the riverbank from Chadwell Lane is overgrown and the sheet piled 
vertical bank would make entry difficult and likely result in total immersion. Similarly, 
to gain access across the river, in situ pipework would need to be traversed, again 
making this difficult and almost certainly result in total immersion. 

The pathway at location 1 is a significant distance from the bank of the river, making 
accidental entry unlikely at this point. The river depth between location 1 and the 
sluice at location 8 is around 130cm to 140cm, with a further 30cm to 40cm of silt on 
the riverbed. So, access along this stretch from either bank could be inconsistent 
with being wet from the waist down given the total depth of 160cm to 180cm, 
possibly slightly higher during the winter flow. 

Location 3 

We understand that location 3 is the point at which Mr Marron is believed to have 
passed through the Network Rail fence onto the train track. At this location the path 
is a significant distance from the river and the location where the hole in the fence 
was found is obscured by trees. 

There is no lighting between location 1 & 4, however the development on Chadwell 
Lane provides ‘borrowed’ lighting from streetlights and the apartments themselves 
(also see comments below) 

Location 4 

Location 4 consists of a concrete viewing area covering a channelled section of river. 
This is accessed from the Chadwell Lane development and is fully fenced, although 
it appears possible to pass between the fence railing to use this viewing area to 
traverse the river. There is dense undergrowth on the Chadwell Lane bank and 
shear sides of the channel. At this point the area is lit from the Chadwell Lane side.   

Location 5 

The river path at location 5 is at its narrowest, being close to the river, separated by 
a narrow steep bank, which shows some damage. There are also tree branches 
extending over the path close to head height. The path has no lighting but has 
borrowed lighting from the streetlights on the Chadwell Lane development and the 
High Street. At location 5 the river is 60cm – 70cm deep with around 20 cm of silt. 
On the opposite bank a brick pumping house is visible, with significant graffiti and 
direct access to the river. 

Location 6 

Location 6 has a kissing gate entrance to the New River path accessed from the 
High Street.  Thames Water standard hazard warning sign (stating ‘danger deep 
water, no swimming, no boating, no fishing’) is in place.   

Thames Water Utilities Limited, a company registered in England and Wales with company number 02366661. 
Registered office address: Clearwater Court, Vastern Road, Reading RG1 8DB. VAT registration number: GB 537-4569-15. 

CC001_01_24_03_22 

 
 
 
 
 
 
 
 
 
 
 
 
 Location 7 

Location 7 is the entry point to the development on New River Avenue and Chadwell 
Lane and is private property. There are Danger Deep Water signs in place along the 
length of the development pathway along the bank of the New River. 

It was also noted that along the side of a brick pump house there appeared to be a 
well-used path, indicating frequent access. To the rear of the pump house is a water 
discharge point that gives direct access into the New River. 

At this location the river depth in 60cm to 70cm with very little or no silt on the 
riverbed. It is also noted that at location 7 the in situ pipe running in the river ceases, 
so this is the only location on the development side of the river where a crossing 
could be made, unobstructed. 

Location 8 

At location 8, there is a sluice and sluice building, traversing the river. The building is 
secure with fenced access along one side. The nearside bank (Chadwell Lane) is 
fenced as is the far side with Palisade fencing. To one side of the sluice is a pipe 
crossing, here the pipe is protected with anti-climb measures and again fencing exist 
on both sides. It is therefore unlikely that access could be gained to the river or 
crossing possible due to the palisade fencing. 

Location 9 

Location 9 is on the path by the New River at the development on Chadwell Lane. 
There is ample street lighting as well as a double chain link fence and ‘danger deep 
water’ signage.   

Having visited and reviewed these locations in detail, there is warning signage 
pertaining to water hazards in place both on Thames Water property and the 
Chadwell Lane development, however location 1 requires signage to be installed. 
Although not something in the control of Thames Water, the owner of the Chadwell 
Lane development may wish to review signage at location 7.  Signage relating to the 
railway along its fence line is for Network Rail to make comments/recommendation. 

There appears to be adequate lighting on the Chadwell Lane development. The 
absence of lighting on Thames Water property would make visibility at night on the 
New River Path low, but not completely dark due to the borrowed light from the 
opposite bank and surrounding urban area.  The river itself reflects light and would 
be distinguishable from the path even in overcast weather at night. This coupled with 
the general distance of the path from the river, presents a low risk for a majority of 
the area concerned. Where the path narrows at location 5 and there are overhanging 
trees, where we will undertake a further review and make any necessary changes.   

Fencing of the river to prevent access, is present on the Chadwell Lane 
development, except for location 7, where there is also evidence of regular use 
(trodden path, graffiti etc.) of the area behind the pump building allowing for access 
directly into the river. Our assessment found that fencing on the Thames Water bank 

Thames Water Utilities Limited, a company registered in England and Wales with company number 02366661. 
Registered office address: Clearwater Court, Vastern Road, Reading RG1 8DB. VAT registration number: GB 537-4569-15. 

CC001_01_24_03_22 

 
 
 
 
 
 
 
 
 
 
 is consistent with fencing scheme to balance accessibility and safety/security. Hence 
only areas where there is easy egress out of the river are unfenced. Pipe crossings, 
channels and steep sided banks are also protected. 

The ongoing operation of the New River is inspected twice weekly by the River 
Inspection Teams.  Currently these inspections focus on operational matters relating 
to water supply but do touch on some safety and security matters. A review of these 
inspection requirements will aid in spreading learnings from this incident more 
broadly with respect to how we manage the New River. 

I hope our observations are helpful and whilst Mr Marron’s potential entry of the New 
River, whether intentional or accidental, did not directly or indirectly cause his death, 
the opportunity to review and learn with respect to what we have in place around the 
management of the river has not been lost. In response to our site visit and 
investigation, I propose the following actions subject to any necessary consultation 
and consents required and that we will reflect on any other changes we can make. 

1.  Install New River Path warning signage adjacent to the kissing gate in location 

1 by the end of September 2022. 

2.  Remove overhanging branches at location 5 by the end of September 2022. 
3.  Investigate options to improve the path and bank at its narrowest point, 

including considering lighting levels at location 5 by the end of December 
2002. Implementing any recommendation as soon as possible subject to 
necessary consents. 

4.  Write to Property Owner of the Chadwell Lane development by the end of 

September to share the outcome of the assessment we have undertaken with 
respect to access controls and signage at location 7. 

5.  Share the findings from this response with the New River Inspection Teams 
so that they can be incorporated, as appropriate, into the routine inspections 
of the New River by the end of September 2022. Any further improvements 
identified will be managed through Thames Water’s existing Asset Risk 
Management process on an ongoing basis. 

In line with our internal processes, these actions will be entered into our Risk 
Management System so that they are appropriately monitored through to completion. 
These actions will also receive oversight from our Health & Safety Team and Board 
Health, Safety & Environmental Committee.  If you require any additional 
information, please do not hesitate to contact me. 

Yours sincerely  

Engineering and Asset Director 

Appendix 1 – New River Path Information Booklet (attached) 

Thames Water Utilities Limited, a company registered in England and Wales with company number 02366661. 
Registered office address: Clearwater Court, Vastern Road, Reading RG1 8DB. VAT registration number: GB 537-4569-15. 

CC001_01_24_03_22

Related reports

Other reports by Andrew Walker

See all →

More reports categorised “Railway related deaths”

See all →

Track Railway related deaths

See every Prevention of Future Deaths report matching Railway related deaths, and how often a new one appears.

What would an alert for this have sent me? Search the full text

Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.

These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.