A rail firm has been fined £1 million following the death of a Penarth woman who leaned out of a train window.
Bethan Roper (28) suffered a fatal head injury on a high-speed Great Western Railway (GWR) train near Twerton, Bath in December 2018 - she had been struck by a tree branch after placing her head outside a droplight window.
The Office of Rail and Road (ORR) said Ms Roper's death was a ''preventable tragedy''.
GWR pleaded guilty to breaching health and safety laws after an investigation found they had not carried out steps to implement the findings of a risk assessment.
Droplight windows, which are found on trains with slam doors, can be lowered to open.
In May 2017, the Rail Accident Investigation Branch (RAIB) introduced new safety recommendations after a passenger died in a similar inicident near Balham, South London, the year before.
The ORR said GWR was aware of previous incidents, but they had not produced a specific written risk assessment until September 2017.
They identified droplight windows as one of the most significant risks to passenger safety - but the ORR said the assessment was "neither suitable nor sufficient" and GWR did not revise it despite the regulator's concerns.
The actions identified to reduce the risk had not been implemented before the fatal accident.
Ms Roper, a charity campaigner and political activist, had been on a Christmas shopping trip in Bath on 1 December 2018.
Three years later, an inquest heard she had been intoxicated when boarding the GWR train.
The window had a yellow warning label above stating "Caution - do not lean out of window when train is moving", but that was described by investigators as an insufficient deterrent.
A jury returned a narrative verdict into Ms Roper's death, which led to further safety reccommendations preventing passengers from leaning out of droplight windows.
As a result, all rolling stock operated by train companies that had droplight windows have since been withdrawn from service or fitted with engineering controls to prevent them from being opened while on the move.
GWR was also told to pay more than £78,000 in costs.
Richard Hines, ORR's chief inspector of railways, said: "Our thoughts remain with the family and friends of Bethan Roper."
"Her death was a preventable tragedy that highlights the need for train operators to proactively manage risks and act swiftly when safety recommendations are made to keep their passengers safe."
"Our investigation found that GWR fell short in its responsibilities, and this prosecution reflects the serious consequences of that failure. We welcome the actions taken since by GWR and the wider industry to reduce the risks."
"Safety must always remain the first priority across Britain’s railways."
A spokesperson for GWR told Bro Radio News: "Bethan Roper's death was a tragic incident, and our thoughts remain with her family and friends."
"We accept the judge's decision and remain committed to continuously improving passenger and colleague safety across our network."
"In sentencing, the judge recognised our strong safety record both before and after this incident, and the safety of our passengers and colleagues remains our highest priority."
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