Source · Prevention of Future Deaths

Tahnie Martin

Date: 10 Oct 2017 Coroner: Emma Whitting Area: Black Country Responses identified: 1 / 2 View PDF

Past building inspections failed to identify unsafe roof structures or document access issues, leading to unmaintained hazards and a risk of future incidents.

Date 10 Oct 2017

56-day deadline 5 Dec 2017

Responses identified 1 of 2

Accident at Work and Health and Safety related deaths

Coroner's concerns

AI summary

Past building inspections failed to identify unsafe roof structures or document access issues, leading to unmaintained hazards and a risk of future incidents.

View full coroner's concerns

During the course of the inquest; the evidence revealed the following: (1) Although there had been several recent inspectionslsurveys carried out in respect of the Blackrock building from 2011-2015, none of these had identified the_presence of the two structures on the_plant room roof. As a result_although heavy heavy heavy long steps had been taken t0 repairireplace other rotten timber and corroded metal structureslfittings on the roof by 23 February 2017, nothing had been done either to remove or to maintain the two structures on the plant room roof for at least 19 years, making them inherently unsafe and hazardous; (2) Furthermore , although it seems that the plant room roof would have been difficult to access during these inspectionslsurveys, none of the Building Surveyors who carried these out these surveyslinspections had referenced this fact in their reports nor indicated the necessity or urgency of

Responses

1 respondent

Tahnie martin

20 Oct 2017 PDF

Action Planned

RICS Regulation is currently reviewing its 'Building Surveys and Technical Due Diligence of Commercial Property' Guidance Note, with revisions due for completion in February 2018, and will consider the coroner's recommendations as part of this process. They are also seeking further information about the specific surveys to inform their own regulatory review. (AI summary)

View full response

Dear Ms Witting

Re: Regulation 28 report following the inquest into the death of Ms Martin

Your Regulation 28 report addressed to has been passed to me. I am very sorry to hear of the death of Tahnie Lee Martin in these circumstances.

We are already in the process of reviewing the Guidance Note referred to in your report (Building Surveys and Technical Due Diligence of Commercial Property, 4th edition). The revision is due to be completed, following a public consultation, in February 2018. We will consider the recommendation you make as part of the review.

We are grateful to you for raising your concerns with us. In order to ensure that our response addresses the cause of your concerns, it would be helpful if we could obtain information about the surveys of the Blackrock building which were carried out between 2011 and 2015, in particular the scope of the services that the surveyors were instructed to provide. It would also help us if we could have details of the evidence from the building surveyor referred to in your report. Would it be possible to obtain a transcript of this evidence?

My department will be writing to you under separate cover about your concerns about individual surveys mentioned in your report. We are mindful of our role as the regulator of the profession and the need to conduct our own review to ensure that we are fulfilling that role.

Report sections

Investigation and inquest

On 2 March 2017 an investigation was commenced into the death of Ms Tahnie Lee Martin, aged 29. The investigation concluded at the end of a 5 day jury inquest held before me on 6 October 2017. The medical cause of death was found to be: 1a Basal Ganglia Disruption 1b Multiple Base of Skull Fractures The Conclusion of the jury was a Narrative Conclusion: "The large heavy panel which struck Tahnie Lee Martin at 11.38am on 23 February 2017 became detached from the_plant room roof of the Blackrock building due to strong winds caused by 'Storm Doris'. The large panel became detached due to the absence of maintenance which had resulted in wet rot; badly corroded and defective fixtures which had allowed the large panel to be lifted by the wind.

Circumstances of the death

The circumstances of the death, as found by the jury, were that Tahnie Lee Martin was struck by a large panel on 23 February 2017 whilst she was out shopping with a friend on Dudley St; Wolverhampton. The panel was one half of a large wooden panel which had been formed the cover of a water tank situated on the top of the plant room roof of the Blackrock building, which had fallen into disuse. The expert evidence which was undisputed at the inquest, concluded that it had been at least 19 years since any maintenance work had been carried out on this structure which had directly led to the severe deterioration of both the timber and the corrosion of the metal fixings This also applied to another structure (the housing of a disused ventilation shaft) which was also situated on this roof and was similarly damaged by the winds on 23 February 2017; although, fortunately (unlike the water tank cover), not causing any personal injuryldeath to passers-by:

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.

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Report details

Date of report: 10 October 2017
Coroner: Emma Whitting
Coroner area: Black Country

Responses identified

Responses identified 1 of 2

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 5 Dec 2017.

Sent to

RICS

ROYAL INSTITUE of CHARTERED SURVEYORS (RICS)

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.