Connor Marron

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.