The death of a woman after a board advertising Weston-super-Mare’s Grand Pier fell on her has been ruled an accident by the coroner.
Margaret Carter of Lydney, Gloucestershire died on October 28 2021 after the heavy A-frame, which had been left out in “gale force” winds, was blown over, knocking down Mrs Carter, who had been walking along the promenade, and landing on top of her. The 94-year-old then faced a three-and-a-half hour wait for an ambulance while on the ground in terrible weather. She died after being taken to Southmead Hospital.
Coroner Peter Harrowing concluded the inquest on January 27 2025, stating: “My conclusion as to how Margaret Carter came by her death was that it was an accident, neither intended nor envisioned by the individuals who placed that sign on that day or by the company by which they were employed.”
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But a conclusion of an accident does not mean that nobody was held responsible. Grand Pier Ltd has already pleaded guilty to criminal health and safety failings over the death a year ago, when it was ordered to pay almost £200,000 and comply with health and safety law.
Mrs Carter has been described by her family as having been “independent” and “completely fit in both body and mind” and determined to live to 100. Her son, Michael Carter has said: “She was the most wonderful person, full of life and energy, even at the age of 94.” He attended the inquest at Avon Coroner’s Court with his sister Sue Firman.
The inquest heard that Mrs Carter had been visiting Weston-super-Mare, her favourite place to visit, with family on the October day in 2021. She had been walking along the promenade at about noon when a strong gust of wind then hit the flat face of the A-board, which was over two metres high and weighed about 100 kilograms, blowing it over and onto her.
An ambulance was called but did not arrive for three and a half hours. The South Western Ambulance Service said at the time handover delays were putting strain on the service, and she was initially not categorised as high priority. Mr Harrowing said: “Fortunately for her, there were, as members of the public, off duty paramedics and an off duty police officer who were able to support her and provide her with first aid.”
The family now wants to get in touch with these Good Samaritans. Michael Carter, Mrs Carter’s son, told the Local Democracy Reporting Service: “It seemed like they put so much effort in given they were on holiday on a day out. […] For them to have stopped and helped for three hours, we just as a family want to contact them and say thank you.”
In statements read out by the coroner, people who had helped Mrs Carter said she was initially in good spirits and did not seem in severe pain, even laughing and joking. But as time went on her condition began to worsen. Six calls were made to 999 before the ambulance finally arrived.
The weather also got worse. By the time the ambulance arrived, Mrs Carter was under coats brought out from the Grand Pier to keep her warm. Pier staff had also put a gazebo over the scene to keep her dry from the rain, while people held a tarpaulin to stop sand being blown onto her from the beach.
One member of staff from the Grand Pier who was with her said, in a statement read out by the coroner, the ambulance crew was “visibly shocked” at how long she had been lying there. The ambulance crew took over from the off duty paramedics and called another ambulance and the critical care team, who were brought by helicopter which landed on the beach.
The inquest heard that the impact of her injuries led to heart failure. Mrs Carter was taken to Southmead Hospital in Bristol where the team were told in advance to prepare for her arrival. She arrived at 5.55pm but died less than an hour later at 6.45pm. A statement read out from Dr Delaney, who examined her, said: “In my opinion, these significant injuries would have created a high risk of death in an elderly person, even with more rapid medical intervention.”
The A-frame board which struck Mrs Carter was on wheels and not tethered to anything, as the pier said tethering it went against council rules. Annabell Hall, environmental health officer at North Somerset Council which investigated the incident, told the inquest it appeared to be “quite a subjective decision” whether Grand Pier staff put the boards out or thought it was too windy. The inquest heard that on the day of the incident, wind speeds in the area were as high as 39mph, which as a rule of thumb could be called “gale force.”
The board and three others like it were seized after the incident and have now been destroyed by North Somerset Council, following the conclusion of the criminal prosecution the council brought. The co-owner and director of Grand Pier Ltd, Michelle Michael, said that the company had already decided it would not use them again.
Ms Michael took the stand in the coroner’s court and was questioned by Mr Harrowing and by Mr Carter. She said that Grand Pier Ltd had now engaged a health and safety practitioner to advise and perform spot checks on the company, and all senior management had taken a health and safety qualification.
As actions had been taken, Mr Harrowing said he would not be making a report to prevent future deaths. He told Mr Carter and Ms Firman: “My sincere condolences to you both and all of Margaret Carter’s family.”
Mr Carter told the Local Democracy Reporting Service: “We are just pleased as a family that the pier have put measures in place in an effort to prevent this happening again in the future, which is ultimately the best that we could hope for.”
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