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

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

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.

Dear Mr Walker, 4th August 2022 Dear Mr Walker,

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 Mr Andrew Walker HM Coroner North London Coroners Court 29 Wood Street Barnet EN5 4BE

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.

Dear Senior Coroner Walker,

I am , Engineering and Asset Director for Thames Water and I 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.

17 August 2022 Mr Andrew Walker Senior Coroner for North London HM Coroner & Senior Coroner North London Coroners Court 29 Wood Street Barnet EN5 4BE

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. 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. 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.