THE death of a 94-year-old Forest woman who was hit by a board advertising Weston-super-Mare’s Grand Pier has been ruled an accident by the coroner.

Margaret Carter died on October 28, 2021, after the heavy A-frame was blown over in “gale force” winds, knocking her over and trapping her underneath as she walked along the promenade.

The Lydney pensioner spent three-and-a-half hours on the ground in terrible weather before an ambulance finally arrived, and died within 50 minutes of reaching Southmead Hospital in Bristol.

Coroner Peter Harrowing concluded the inquest on Monday (January 27), 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.”

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 laws.

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, who attended the inquest at Avon Coroner’s Court with his sister Sue Firman, said: “She was the most wonderful person, full of life and energy, even at the age of 94.”

The inquest heard that Mrs Carter had been visiting Weston-super-Mare, her favourite place to visit, with family and had been walking along the promenade at about noon when a strong gust of wind hit the flat face of the 2m-high 100kg A-board, blowing it over onto her.

Off duty paramedics and an off duty police officer tried to support her and provide her with first aid after calling 999, but the ambulance did not arrive for hours.

The South Western Ambulance Service said at the time handover delays were putting strain on the service, and she was not initially categorised as high priority.

In statements read out by the coroner, the Good Samaritans who 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, with six calls made to 999 before an ambulance finally arrived.

The weather also got worse, and coats were brought out from the Grand Pier to try and 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 the ambulance crew were “visibly shocked” at how long she had been lying there.

The on-duty 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, and she died at 6.45pm, 50 minutes after arriving at Southmead Hospital.

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.”

He also added that the family wanted to personally thank those who stopped and helped their mother.

“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,” he said.