Source · Prevention of Future Deaths

Marcus Allen

Ref: 2018-0144 Date: 11 May 2018 Coroner: Kevin McLoughlin Area: West Yorkshire (East) Responses identified: 1 / 1 View PDF

Large lounge windows lacking restrictor devices open excessively, creating a fall hazard when residents must lean out to close them.

Date 11 May 2018
56-day deadline 10 Jul 2018
Responses identified 1 of 1
Other related deaths

Coroner's concerns

AI summary
Large lounge windows lacking restrictor devices open excessively, creating a fall hazard when residents must lean out to close them.
View full coroner's concerns
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(1) The large window in the lounge of flat no restrictor device fitted. In consequence it can open to a position which necessitated a person leaning out of the window in order to close it: This was considered by witnesses to create a hazard involving a risk that a person may fall When attempting t0 close the window: It may be that other windows in the flat complex also have the same potential hazard:

Responses

1 respondent
Estates Management Limited
27 Jun 2018 PDF
Action Taken

Estates & Management has provided further training to its teams on handling correspondence. Restrictors will be installed where necessary and letters have been sent to every leaseholder to carry out a survey, and amendments made to Health and Safety Risk Assessments to undertake annual inspections of apartments to check the restrictors are functioning correctly. (AI summary)

View full response
Dear Mr McLoughlin Response to Report to Prevent Future Deaths Regulation 28 of Coroners (Investigations) Regulations 2013 Further to your letter of 6 June 2018 to of Radcliffe Investments Limited ("Radcliffe Investments") and Jiter 10 you 0f12 June 2018, am writing to you on behalf of Radcliffe Investments having carried out an investigation into this matter. We are sorry to hear of the tragic incident that took place at 34 Whingate Mill last year. We thank you for drawing this matter to our attention and do apologise that your initial letters were not passed to our legal department or a member of the senior management team as they should have been. Please be assured that further training has been provided to our teams in order to address this. Background Our client; Radcliffe Investments, acquired the freehold interest in Whingate Mill on August 2017 which comprises 39 residential apartments held by leaseholders on long leases and which was converted in around 2017 . The leases are made between 3 contractual parties including the landlord, leaseholder and management company, Mill 39 (Management) Limited ("Mill 39"). Pursuant to the terms of the long leases, Mill 39 is contractually responsible for the maintenance of the structure, exterior and common parts of the development; including the windows. should point out that our client was not made aware of the tragic incident at the time of acquisition and was unaware until your letter notified us_ Actions Taken Since receiving your communications, Radcliffe Investments, through US, its agent; has taken the following steps in order to ascertain further information about the development and facilitate remedial actions_ As far as we were aware, Estata Property Management ("Estata' had been appointed by Mill 39 as property managers to out its maintenance obligations at the development as set out in the leases Reglatered Office: Molteno House 302 Regents Park Road London N3 2JX Company Reglstered in England Registratlon Number: 3244100 ISO AI5 eGisteRFD ARM Bvz Noc very We camy

In order to immediatelvaddress_the_points_in_vour_report, we sought to in contact with the directors of Mill 39, We subsequently discovered from records at Companies House that, in fact, the company dissolved on 19 December 2017 . We now understand from Estata that the former directors have instructed solicitors, Milners, to reinstate Mill
39. Our head of our Propertv Manaqement Philip Butnick, made contact with Estata on 13 June and spoke at length with development manager to investigate further confirmed that he was unaware of the incident until he received a letter you: He told us that he was drafting a response to you and contacting various letting agents, who act for leaseholders who do not live in the apartments but sublet them, in order to gain access to inspect all windows as soon as possible confired that he would arrange for the installation or repair of restrictors where necessary Dhilin requested a copy of the most recent fire risk assessment and health and safety report from Estata which he reviewed that evening, on receipt, and observed that there were no references t0 the windows_ also spoke with the former director of Mill 391 that evening_ told that had been involved with the renovation conversion of the development having retalned 2 of the apartments himself. also confirmed that he had been aware of the tragic incident and that Jf Leeds City Council Building Control had been dealing with your inquiry:-| 36o explined that following the incident the developer had visited to inspect all of wincows t0 verify that where restrictors were required had been installed although we have not carried out our Own physical inspection in order to verify this_ subsequently spoke with Estata at length on 14 June, 18 June, 19 June, 21 June and 22 June 2018, and has continually impressed upon the urgency to ensure that Estata take all necessary steps and prioritise the facilitation of access to all apartments in order to check the presence and operation of window restrictors as a matter of urgency: Having carefully considered your report] requested that an urgent survey of all windows at the development be carried out by Estata t0 check for restrictors and for them to be fitted wherever they were either not present or found to be faulty: As at the time of writing this letter, Estata have confirmed that it has completed its survey of all of the windows at the development and in number of instances restrictors are missing or broken_ asked Estata not to delay the remedial works pending completion of all surveys and that it should immediately install any missing restrictors and replace those found to be broken or faulty_ has also requested that, once the works are complete, annual health & safety checks are made by Estata to verify the restrictors remain installed and functioning correctly to ensure such incidents do not occur in future and will continue to liaise with Estata on a regular basis until such time that he is satisfied that all apartments have been surveyed and restrictors which operate properly are fitted throughout: Ihas also asked that windows located in the common parts of the property be inspected by Estala on a 6 monthly basis_ Action Proposed to Be Taken By way of summary, the following further actions are now proposed in respect of the development: Following completion of the window surveys on 22 June by Estata new or replacement restrictors are to be fitted to all windows above ground floor level where restrictors are missing or defective. We have been told by Estata that this will be dealt with as a matter of urgency by a reputable contractor appointed to carry out the works. wwill follow this up and seek confirmation from Estata that the works have been completed and fresh health and safety report carried out. hhas pointed out to Estata that under the get from he ihe they

terms of the leases the windows fomm part of the common parts and need to be inspected as part of any health and safety report carried out 2 Mill 39 is to be reinstated by its former directors has been advised by Estata that Milners solicitors have provided the necessary paperwork to the directors of Mill 39 to enable the company to be reinstated Philip will be seeking regular updates on the progress of the reinstatement application:
3. As part of our investigations we have found that the majority of the apartments at the development are sublet via letting agencies. Estata have notified us that they will ask the letting agencies to inspect the properties at regular intervals and notify them of any issues with the windows (or indeed any other safety issues) Radcliffe Investments will also be writing to all leaseholders at the development to remind them that they should notify the landlord of any subletting arrangements and register details of their subtenant with uS so that there is record of occupancy assisting Estata with the day to day management of the development and to ensure that leaseholders' tenants understand they should notify Estata immediately regarding all defects or issues_ Please do not hesitate to contact me directly should you require our client to take any further action or require any further assistance_ Yours sincerely For and on behalf of Estates & Management Ltd Contact: errhot 3

(kn^ kare i9 i9/1-stlres @ I}.5.19 estata Acehvak Ha Kevin McLoughlin Coroner' s Office and Court 71 Northgate Wakefield WFI 3BS RE: KM/KLA/1919/17 Monday, 25 June 2018 RE: Whingate Mills, Leeds Dear Kevin; Further to your letter; 7th June 2018. can confirm receipt of the Regulation 28 Report. The following actions have been undertaken: Initial survey of flats. This identified that restrictors are installed on some windows and are functioning correctly: Flats have been identified where restrictors are missing: We will install restrictors where necessary utilising service charge monies held. Letters sent to every leaseholder of apartments at Whingate Mills notifying them of the report and request for a full survey to be carried out: Where restrictors are not present; these will be installed using service charge monies; Contact made with all letting agents active at Whingate Mills notifying them of the report and request that they remind the residents of the importance of the restrictor,to report any faults which may develop and also ensure the restrictors are checked during change of tenancies_ Contact with the developer of Whingate Mills, Structured Homes Limited to notify them of the report: Amendments made to our Health and Safety Risk Assessments to undertake annual inspections of apartments to check the restrictors are functioning correctly:

Report sections

Investigation and inquest
On 2m June 2017 commenced an investigation into the death of Marcus Anthony Allen; aged 32. The investigation concluded at end of the Inquest on 8th May 2018. The conclusion of the Inquest was a Narrative Conclusion that he sustained fatal head injuries when he fell a window at his home at 34 Whingate Mills Flats, Armley, Leeds on 1st June 2017 ,
Circumstances of the death
On 1# June 2017 at approximately 2215 hours neighbours heard a noise and on looking outof their wndows saw the motionless body of a man lying beneath the open window of TThe Emergency Services attended and pronounced _e mlan; Ialer Idenilied as Marcus Anthony Allen, dead at 2255 hours on 15t June 2017 at the car park of Whingate Mills Flats, Armley; Leeds. Mr Allen was known to use the drug, Ketamine. Toxicology analysis revealed he had consumed Ketamine at a level known to cause confusion; ioss of coordination; psychological disassociation and hallucinations. A Police investigation concluded that Mr Allen had fallen from the lounge window of his flat on the second floor. No devices restricting opening of the large window were fitted. The circumstances in which he came t0 fall are unclear as is his intention at that time.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action.

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Report details

Reference
2018-0144
Date of report
11 May 2018
Coroner
Kevin McLoughlin
Coroner area
West Yorkshire (East)

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 10 Jul 2018.

Sent to

Radcliffe Investment Properties

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