Source · Prevention of Future Deaths

Clarice Berry

Ref: 2026-0358 Date: 22 Jun 2026 Coroner: Bronia Hartley Area: Manchester West 3 responses identified · 2 indexed addressees View PDF

AI-generated concerns summaryThe coroner notes the absence of clear systems at S&G Properties (No 2) Limited and KMPM for identifying, categorising, escalating, and timeously addressing serious property hazards. Additionally, neither company has conducted post-incident evaluations of other properties for outstanding hazards.

Date 22 Jun 2026
56-day deadline 12 Nov 2026 est. estimated from the Judiciary.uk publication date
Responses identified 3 of 2

Coroner's concerns

AI summary
The coroner notes the absence of clear systems at S&G Properties (No 2) Limited and KMPM for identifying, categorising, escalating, and timeously addressing serious property hazards. Additionally, neither company has conducted post-incident evaluations of other properties for outstanding hazards.
View full coroner's concerns
am concerned that:
a.  neither S&G Properties (No 2) Limited nor KMPM are following the Department for Communities and Local Government guidance for landlords and property related professionals in respect of the Housing Health and Safety Rating System designed to avoid, or at the very least minimise, potential hazards, in particular by ensuring that conditions are reviewed regularly to try to see where and how its properties or the properties it is managing can be improved and made safer; b.  there are no clear systems in place at either company and at the intersection of the two companies to prevent the recurrence of circumstances such as those leading to the deceased’s death, namely the development of a serious hazard during a tenancy which, as in the deceased’s case, is reported but is not appropriately or timeously responded to, or which is not identified by the tenant, including in relation to:
i.         the categorisation of defects (e.g., urgent, structural, routine);
ii.        how structural concerns are escalated (including by way of the instruction of a structural engineer);
iii.       ensuring the timeous completion of works (and the implementation of interim measures, such as fencing off, where delay is envisaged); c.  neither S&G Properties (No 2) Limited nor KMPM have carried out a post-incident evaluation of whether the properties owned and management by them respectively are free from serious hazards which remain outstanding and have not come to the attention of the Local Authority and that these circumstances create a risk that other deaths will occur.

Responses

3 respondents

SG Properties no.2 limited

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AI-classified response stance Action Taken
AI-generated response summary

• S&G Properties (No. 2) Limited has instructed an independent professional property inspection company to carry out an inspection of every residential property it owns. • KMPM has substantially reviewed and strengthened its inspection procedures. • KMPM has developed structured inspection reports, formal hazard escalation procedures, and a documented workflow for managing potentially dangerous defects.

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[Page 1] RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 Please do not include any living persons’ names in this document, in accordance with the Chief Coroner’s PFD Publication Policy (2026). THIS RESPONSE IS BEING SENT TO: The Senior Coroner for the Coroner Area Manchester West in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following an inquest into the death of Clarice BERRY that concluded on 18 July 2026.
1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, S&G Properties (No 2) Limited provides this response within 56 days of the date of the Report to Prevent Future Deaths.
2. DATE OF RESPONSE 17 August 2026
3. CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN identified in the Report are as follows: a) neither S&G Properties (No 2) Limited nor KMPM is following the Department for Communities and Local Government guidance for landlords and property related professionals in respect of the Housing Health and Safety Rating System designed to avoid, or at the very least minimise, potential hazards, in particular by ensuring that conditions are reviewed regularly to try to see where and how their properties or the properties they are managing can be improved and made safer; b) there are no clear systems in place at either company and at the intersection of the two companies to prevent the recurrence of circumstances such as those leading to the deceased’s death, namely the development of a serious hazard during a tenancy which, as in the deceased’s case, is reported but is not appropriately or timeously responded to, or which is not identified by the tenant, including in relation to:
i. the categorisation of defects (e.g., urgent, structural, routine);
ii. how structural concerns are escalated (including by way of the instruction of a structural engineer);
iii. ensuring the timeous completion of works (and the implementation of interim measures, such as fencing off, where delay is envisaged); 9

[Page 2] c) neither S&G Properties (No 2) Limited nor KMPM have carried out a post-incident evaluation of whether the properties owned and management by them respectively are free from serious hazards which remain outstanding and have not come to the attention of the Local Authority.
4. DETAILS OF ACTION TAKEN S&G Properties (No 2) Limited recognises the need for:  regular and appropriately recorded reviews of the condition of its residential properties;  clear arrangements for identifying and categorising significant defects;  prompt escalation of structural concerns to suitably qualified professionals;  interim safety measures where works cannot be completed immediately;  effective monitoring of recommendations and remedial works through to completion; and  a portfolio-wide review to identify any serious hazards which may not previously have been reported. Following the conclusion of the inquest, S & G Properties (No. 2) Limited reviewed the arrangements through which the condition of its residential properties is monitored. The Company has instructed an independent professional property inspection company to carry out an inspection of every residential property owned by it. The purpose of the independent inspection programme is to provide an objective assessment of each property’s condition and to identify any maintenance, structural or safety matters requiring further investigation or action. The inspection process will have regard to the principles of the Housing Health and Safety Rating System. On receipt of each report, the Company will:  review the findings and recommendations;  obtain suitably qualified professional advice where specialist knowledge is required;  authorise appropriate remedial works;  make appropriate funds available, subject where necessary to professional advice and suitable quotations;  consider interim precautions where works cannot be completed immediately; and  monitor the matter until the recommended action has been completed or an informed decision has been recorded. The inspection programme is currently underway, and the Company will retain a schedule recording the date of each inspection, the recommendations made 10

[Page 3] and the action taken in response. KMPM, as a professional managing agent, continue to undertake the day-to- day management of the portfolio of properties owned by S&G Properties (No
2) Limited, to include ensuring statutory compliance, co-ordination of maintenance and repairs and management of tenants. Following the Inquest, I have been made aware that KMPM has substantially reviewed and strengthened its own inspection procedures. In particular, it has developed structured inspection reports, formal hazard escalation procedures and a documented workflow for managing potentially dangerous defects from identification through to completion.
5. DETAILS OF FURTHER ACTION PROPOSED S & G Properties (No. 2) Limited proposes to:  complete the independent inspection of all residential properties within the Company’s portfolio by 30.09.2026;  maintain a central schedule of inspections, recommendations, actions and completion dates;  review each independent inspection report at director level;  obtain specialist structural or surveying advice where an inspection identifies possible structural movement, instability or another potentially serious hazard;  ensure that reasonable interim safety measures are considered and implemented where appropriate pending permanent works;  provide appropriate authority and funding for necessary investigations and remedial works;  work with the managing agent to monitor recommendations through to completion; and  maintain an ongoing programme of periodic independent inspection, with the frequency reviewed according to the age, condition and risk profile of each property. The Company will continue to review these arrangements and will introduce further improvements where professional advice, changes in guidance or practical experience indicate that this is appropriate.
6. SIGNATURE Signed: Name: Position: Director For and on behalf of: S & G Properties (No. 2) Limited Date: 17 August 2026 11

SG Properties no.2 limited

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AI-classified response stance Action Taken
AI-generated response summary

The landlord has instructed an independent property inspection company to carry out comprehensive inspections of all residential properties, with findings to be personally reviewed and remedial actions taken. They have also discussed matters with their managing agents, KMPM, who have reviewed and strengthened their own inspection procedures.

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[Page 1] S&GProperties(No.2)Limited 2ndFloorParkgates BuryNewRoad Prestwich Manchester,M250TL 17August2026 MsBHartley,HMCoroner’sOfficer HMCoroner’sOffice&Courts PaderbornHouse HowellCroftNorth Bolton. BL11QY DearMadam Re:RESPONSETOAREPORTTOPREVENTFUTUREDEATHS-Regulation28oftheCoroners (Investigations)Regulations2013 I write in response to the Report to Prevent Future Deaths served following the inquest into thetragicdeathofMrsClariceBerry. Firstly,IwishtorepeatmysincerecondolencestoMrsBerry'sfamily.Herdeathwasaterrible tragedy and one which has caused me considerable sadness. Although nothing can change what has happened, I have spent a great deal of time reflecting upon the events and considering what further steps I, as a landlord, can take to reduce the possibility of anything similaroccurringagain. I am not a property management professional and have, for many years, relied upon my appointed managing agents, latterly Kaye Mackenzie Property Management (‘KMPM’) to undertake the day-to-day management of my residential properties. Their responsibilities haveincludedcollectingrents,arrangingrepairs,liaisingwithtenantsandbringingsignificant mattersrequiringmyattentiontomesothatIcouldmakedecisionsregardingexpenditureand repairs. WhilstIremainsatisfiedthatemployingprofessionalmanagingagentsistheappropriateway to administer my property portfolio, I have concluded that, as a landlord, I should introduce anadditionallevelofindependentoversight. Accordingly, I have instructed an independent property inspection company to carry out a comprehensive inspection of every residential property owned by S & G Properties (No. 2) Limited. Those inspections are currently underway and expected to be complete by 30 September2026.IhaveattachedtothiscorrespondenceacopyoftheIndependentInspection Scope/BlankInspectionReport.Pleasenotethatanyexampleinformationcontainedwithin the accompanying documents is an illustration and does not identify any current tenant, landlord,propertyorcontractor. 12

[Page 2] The inspection process will have regard to the principles of the Housing Health and Safety RatingSystem.Whereaninspectionidentifiesapotentiallyserioushazard,theCompanywill ensure that appropriate interim safety measures are considered without delay, suitably qualified professional advice is obtained where required, and any necessary remedial works aremonitoredthroughtocompletion.TheCompanywillretainaschedulerecordingthedate ofeachinspection,therecommendationsmadeandtheactiontakeninresponse. The purpose of appointing an independent inspector is to obtain an objective assessment of the condition of every property and to identify any maintenance, structural or safety issues requiring further attention. On receipt of each inspection report I will personally review the findings and, where recommendations are made, I will consider what further action is appropriate. Where specialist knowledge is required, I will obtain advice from suitably qualifiedprofessionalsbeforedecidinguponthemostappropriatecourseofaction. Where works are recommended, I am committed to making appropriate funds available, subject to obtaining suitable professional advice and quotations where necessary, so that defectscanbeinvestigatedandremediedwithinareasonabletimescale. I have also discussed these matters in detail with KMPM, which continues to manage my portfolio. I understand that KMPM has substantially reviewed and strengthened its own inspectionproceduresfollowingthistragicincident.IaminformedthatKMPMhasdeveloped structured inspection reports, formal hazard escalation procedures and a documented workflow for managing potentially dangerous defects from identification through to completion.Iwelcometheseimprovementsandfullysupporttheirimplementationacrossmy properties. Going forward, I intend that the management of my properties will benefit from two complementary levels of oversight. Firstly, KMPM will continue to undertake the day-to-day managementoftheportfolio,ensurestatutorycompliance,coordinaterepairsandliaisewith tenants. Secondly, independent inspections will provide an additional review of the physical condition of each property, allowing recommendations to be considered objectively and, whereappropriate,actedupon. Ibelievethatthesecombinedmeasuresprovideastrongersystemthanpreviouslyexistedand will assist in ensuring that significant defects are identified, assessed and addressed appropriatelysuchthattherewillbenorecurrenceoftheeventsof18July2021. TheeventssurroundingMrsBerry'sdeathhavebeendeeplyupsettingandhavereinforcedthe importance of continually reviewing the way residential properties are managed. I sincerely hopethattheadditionalmeasuresIhavenowimplementeddemonstratemycommitmentto learningfromthistragedyandtofulfillingmyresponsibilitiesasalandlord. Yoursfaithfully, Director S&GProperties(No.2)Limited 13

KMPM

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AI-classified response stance Action Taken
AI-generated response summary

KMPM has implemented significant changes to its property management procedures, including adopting HHSRS principles for inspections, introducing structured hazard categorisation, and establishing formal escalation procedures for structural concerns via a new Dangerous Hazard Workflow. They have also developed a formal Project Management Report and commenced a programme of periodic property inspections, with all properties to be inspected within twelve months.

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[Page 1] RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 Please do not include any living persons’ names in this document, in accordance with the Chief Coroner’s PFD Publication Policy (2026). THIS RESPONSE IS BEING SENT TO: The Senior Coroner, [X] for the Coroner Area Manchester West in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following an investigation into the death of Clarice BERRY.
1. RESPONDENT In accordance with Regulation 29 of the Coroners (Investigations) Regulations 2013, Kaye Mackenzie Property Management ("KMPM"), a property management business. respectfully provides this response within the prescribed period following receipt of the Report to Prevent Future Deaths.
2. DATE OF RESPONSE 21 August 2026
3. CONFIRMATION OF CORONER’S MATTERS OF CONCERN KMPM confirms that it has carefully considered each of the matters of Concern identified within the Report to Prevent Future Deaths. Following detailed consideration, KMPM has undertaken a comprehensive review of its property management procedures and has introduced a number of significant changes to its inspection, hazard identification, escalation, compliance monitoring and project management procedures. The actions implemented are explained in detail within the accompanying document entitled: "Response to a Report to Prevent Future Deaths – KMPM" together with the supporting appendices referred to within that response. Those documents are intended to address each of the concerns identified within the Regulation 28 Report. 34

[Page 2]
4. DETAILS OF ACTION TAKEN, KMPM has undertaken a comprehensive review of its property management procedures following the matters identified within the Regulation 28 Report. The actions taken are set out in detail in the accompanying document: Attachment 1 – Detailed Response to the Report to Prevent Future Deaths (KMPM) The measures implemented include:
• adoption of the Housing Health and Safety Rating System (HHSRS) principles as the framework for inspections;
• introduction of a programme of periodic property inspections;
• implementation of structured hazard categorisation;
• formal escalation procedures for structural concerns;
• introduction of the Dangerous Hazard Workflow;
• enhanced tenant, landlord and contractor communication procedures;
• implementation of enhanced compliance monitoring through the PALM Property Management System; and
• a comprehensive review of the managed property portfolio. The detailed response should be read together with the supporting appendices, which demonstrate the procedures now implemented by KMPM.
5. DETAILS OF FURTHER ACTION PROPOSED KMPM recognises that property management procedures should continue to evolve and improve. Accordingly, KMPM is continuing to implement the following measures:
• completion of an initial programme of periodic inspections across every property under KMPM's management, with the intention that all managed properties will receive an initial inspection within the next twelve months;
• ongoing refinement and implementation of the PALM Property and Letting Management System;
• continued review of inspection procedures having regard to the Housing Health and Safety Rating System Operating Guidance;
• continued monitoring and review of the Dangerous Hazard Workflow and associated procedures;
• continued review of contractor performance, inspection records and compliance systems; and
• ongoing review of management procedures to ensure that lessons identified through practical experience continue to be incorporated into KMPM's operating practices. KMPM remains committed to continually improving its systems in the interests of tenant safety and the prevention of future harm. 35

[Page 3]
6. SIGNATURE Proprietor KMPM DOCUMENTS ACCOMPANYING THIS RESPONSE
7. The following documents accompany and form part of this Regulation 29 Response. The accompanying documents are examples of the procedures and standard documentation now implemented by KMPM. Any names, addresses, contractor details or other identifying information contained within the examples are entirely fictitious and have been included solely to demonstrate the operation of those procedures. They do not relate to any actual landlord, tenant, contractor or property. Attachment 1 Detailed Response to the Report to Prevent Future Deaths – KMPM Supporting Appendices Appendix A – Property Inspection Report Appendix B – Dangerous Hazard Workflow Appendix C – Monthly Contractor Compliance Report Appendix D – Tenant Compliance Notification 36

[Page 4] 20 Junction Road, Shaw Heath, Stockport, SK1 3UD. 21 August 2026 HM Coroner’s Officer HM Coroner’s Office & Courts Paderborn House Howell Croft North Bolton. BL1 1QY Re: RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS - Regulation 28 of the Coroners (Investigations) Regulations 2013 In response to the Report to Prevent Future Deaths following the investigation into the death of Mrs Clarice Berry.
1. RESPONDENT KMPM respectfully submits this response pursuant to Regulation 29 of the coroners (Investigations) Regulations 2013. The findings made by the Court and the concerns identified within the Regulation 28 Report have been considered in detail. The death of Mrs Berry was a tragic event. KMPM has reflected carefully upon the circumstances of her death and the matters identified through the inquest. Since July 2021 KMPM has undertaken a comprehensive review of every aspect of the way KMPM manages residential properties, identifies hazards, records inspections, monitors repairs and escalates structural concerns. The purpose of this response is to explain the systems that have now been introduced to address each concern identified by the Court and to demonstrate KMPM's commitment to continual improvement in property safety.
2. RESPONSE TO THE CORONER'S MATTERS OF CONCERN KMPM has carefully considered each of the concerns identified within the Regulation 28 Report. The matters of concern relate principally to:
• regular review of properties
• identification of hazards 37

[Page 5]
• categorisation of defects
• escalation of structural concerns
• monitoring outstanding works
• implementation of interim safety measures
• portfolio review following a serious incident. The systems described below have been specifically developed to address each of those concerns.
3. PERSONAL STATEMENT The death of Mrs Berry was a tragic event. KMPM has reflected carefully upon the circumstances of her death and the matters identified through the inquest. As proprietor of KMPM, I have taken personal responsibility for reviewing the business's procedures and ensuring that the measures described in this response are implemented and maintained.
4. REVIEW AND ENHANCEMENT OF INSPECTION PROCEDURES At the time of the events giving rise to this inquest, KMPM's property management service did not include a programme of routine periodic property inspections unless specifically requested or instructed by the landlord. The services provided principally comprised rent collection, accounting to landlords, arranging statutory compliance, responding to repairs reported by tenants, coordinating maintenance and administering the day-to-day management of the properties under instruction. Throughout the course of the inquest I carefully reflected upon whether the services provided by KMPM could be further strengthened in order to provide an additional level of oversight for both landlords and tenants. As a direct consequence of the lessons learned from this tragic case, KMPM has expanded its management service to include a programme of periodic property inspections across the properties under its management. These inspections are undertaken using the structured Property Inspection Report appended to this response and include a documented assessment of the property's overall condition, statutory compliance, visible safety issues and any indicators of structural deterioration. Attention is given to matters such as structural movement, bulging or leaning walls, defective masonry, retaining walls, roof coverings, chimney stacks, means of escape, damp, ventilation and any other visible hazards capable of presenting a risk to occupants or members of the public. Where significant hazards are identified they are no longer treated as routine repairs but are immediately transferred into the KMPM Dangerous Hazard Workflow, ensuring that the matter is formally recorded, monitored and followed through until appropriately resolved. Implementation of this inspection programme has now commenced. It is my intention that every property currently managed by KMPM will receive an initial periodic inspection within the next twelve months. Thereafter inspections will be undertaken on a planned cyclical basis, with additional inspections carried out where concerns are identified, following significant repair works or whenever circumstances indicate that an earlier inspection is appropriate. In addition, one of the landlords for whom KMPM acts has independently decided to appoint an external professional property inspection company to inspect that landlord's residential portfolio. KMPM welcomes this additional level of independent oversight and will work collaboratively with 38

[Page 6] the inspecting company to ensure that any recommendations are considered promptly and, where appropriate, progressed without delay. These measures represent a significant enhancement to KMPM's management service and form part of a wider programme of improvements introduced following the lessons learned from this tragic case. KMPM acknowledges that a formal structured review of the managed portfolio specifically directed at identifying serious hazards of the kind that contributed to Mrs Berry's death has not yet been completed. KMPM commits to completing an initial structural review of every property under its management within the next twelve months of the date of this response, let it be noted that KMPM are unaware of any structural defects outstanding, nor have been notified of any from existing tenants to date, KMPM have undertaken inspections of all properties in the past but not on a formal basis as set out in our proposed future conduct. Any structural concern identified during that review will be immediately transferred into the KMPM Dangerous Hazard Workflow, notified in writing to the relevant landlord, and where appropriate referred to the relevant local authority housing standards team. The outcome of that review will be documented and retained as part of KMPM's permanent records
5. PROPERTY INSPECTIONS KMPM has developed a structured Property Inspection Report to ensure that inspections are undertaken consistently and recorded in a clear, auditable manner. The report forms part of the permanent property record and provides a systematic assessment of:
• external elevations
• roof coverings and chimney stacks
• brickwork and pointing
• retaining and boundary walls
• windows and means of escape
• gardens and external structures
• internal accommodation
• damp and ventilation
• statutory safety matters
• tenant observations
• photographic evidence. Where significant hazards are identified, the inspection immediately transfers into the KMPM Dangerous Hazard Workflow.
6. Housing Health and Safety Rating System (HHSRS) KMPM has adopted the principles contained within the Department for Communities and Local Government's Housing Health and Safety Rating System Operating Guidance as the framework underpinning its property inspection procedures. Whilst KMPM's inspections are management inspections rather than full HHSRS assessments, inspectors are trained to identify hazards consistent with that guidance, including structural instability, damp and mould, fire safety, falls, means of 39

[Page 7] escape, electrical hazards and other matters capable of presenting a Category 1 or Category 2 hazard. Where such matters are identified, the inspection immediately transfers into the Dangerous Hazard Workflow.
7. HAZARD CATEGORISATION All defects identified during inspections are categorised. Repairs are classified as: Emergency Immediate danger to life or property. Structural Any indication of structural movement, instability or deterioration requiring professional assessment. Urgent - Repairs requiring prompt attention but not presenting immediate danger. Routine - General maintenance. This categorisation determines the management procedure and timescale.
8. STRUCTURAL DEFECT ESCALATION Where any inspection identifies evidence of possible structural movement, including:
• bulging walls
• leaning walls
• significant cracking
• movement
• unstable retaining walls
• deteriorating masonry the matter is immediately escalated. The property is removed from routine maintenance procedures and managed as a safety project. Where appropriate:
• An appropriately qualified structural engineer or building surveyor is instructed.
• Interim safety measures implemented.
• Tenant advised.
• Landlord notified immediately.
• Follow-up inspections arranged.
• Local Authority consulted where appropriate.
9. PROJECT MANAGEMENT 40

[Page 8] KMPM has developed a formal Project Management Report specifically for managing potentially dangerous defects. The report records:
• discovery of defect
• photographs
• risk assessment
• contractors instructed
• quotations
• professional reports
• client instructions
• target dates
• interim safety measures
• follow-up inspections
• completion dates
• final verification. This ensures that any identified dangerous matter remains subject to active monitoring and escalation until appropriately resolved. Each matter remains active until formally closed. A project cannot be closed solely because the matter has been reported. Closure requires confirmation that appropriate action has been completed or that an informed management decision has been recorded explaining why no further action is presently possible.
10. PALM PROPERTY MANAGEMENT SYSTEM KMPM currently operates an established electronic property management database for the recording of landlord, tenant, property, repair and statutory compliance information. Building upon that existing system, KMPM is now implementing the PALM (Property and Letting Management) system, which has been specifically designed to provide enhanced inspection scheduling, hazard tracking, compliance monitoring, document management and a comprehensive electronic audit trail. The development of PALM forms part of KMPM's wider programme of continual improvement and reflects the lessons learned from this tragic case. The system is intended to strengthen existing management procedures through increased automation, improved reporting and enhanced oversight of property safety matters. PALM has been specifically developed to provide:
• electronic property inspection records;
• automated diary reminders;
• hazard tracking;
• contractor allocation;
• statutory compliance monitoring;
• inspection scheduling;
• document management; 41

[Page 9]
• comprehensive audit trails;
• automated escalation reminders; and
• management reporting. The system is intended to ensure that significant hazards remain subject to active monitoring until appropriate action has been completed or further management review has been undertaken in accordance with KMPM's Dangerous Hazard Workflow.
11. COMPLIANCE MANAGEMENT PALM automatically monitors statutory compliance including:
• Gas Safety
• Electrical Installation Condition Reports
• EPC
• Smoke Alarms
• Carbon Monoxide Alarms Automatic reminders are generated in advance of expiry. Contractor reports are generated automatically. Tenants are contacted directly. The system maintains a complete audit trail.
12. LANDLORD COMMUNICATION Where significant defects are identified the landlord receives written notification together with:
• description
• photographs
• urgency
• recommended action
• estimated costs where available
• recommendation for specialist advice. Instructions are retained electronically. Where a significant hazard remains unresolved, KMPM will continue to monitor the matter and will execute further escalation in accordance with the Dangerous Hazard Workflow.
13. TENANT COMMUNICATION AND REPAIR REPORTING Tenants are encouraged to report defects as soon as they become aware of them. Repairs may initially be reported by telephone where immediate contact is required; however, KMPM's standard procedure is that all repair requests are confirmed by email wherever reasonably practicable. Tenants are asked to provide their full name, property address, contact telephone number, a description of the defect and, wherever possible, supporting photographs or videos. This 42

[Page 10] information enables the reported issue to be accurately assessed, prioritised and allocated to the appropriate contractor. Upon receipt, each repair request is formally recorded within KMPM's management records and forms part of the property's permanent audit trail. The repair is assessed according to its nature and urgency, allocated where appropriate to an approved contractor, monitored throughout its progress and retained on file together with all subsequent communications, quotations, reports and completion records. Where a reported defect indicates a potentially significant hazard or possible structural concern, the matter is immediately removed from the routine repairs process and transferred into the KMPM Dangerous Hazard Workflow. The tenant is kept informed of the action being taken, any interim safety measures, expected timescales and contractor appointments until the matter has been satisfactorily resolved. This documented reporting procedure ensures that repair requests are not reliant upon informal conversations or individual recollection, but are supported by a clear contemporaneous record capable of review and audit.
14. CONTRACTOR MANAGEMENT Approved contractors are allocated by discipline. Examples include:
• Gas Engineers
• Electrical Contractors
• EPC Assessors
• Structural Engineers
• Roofing Contractors
• General Builders All works are tracked through completion.
15. FOLLOW-UP INSPECTIONS Dangerous defects cannot be closed following instruction alone. Follow-up inspections are undertaken until:
• works completed
• photographs received
• contractor confirms completion
• tenant satisfied
• final inspection completed. Only then is the project formally closed.
16. CONTINUAL IMPROVEMENT KMPM accepts that property management procedures should continually evolve. 43

[Page 11] The systems described within this response will continue to be reviewed and improved. Additional procedures will be implemented whenever opportunities for improvement are identified. Procedures will be reviewed at least annually and sooner where legislation, guidance or practical experience identifies opportunities for further improvement.
17. CONCLUSION The matters identified through the inquest have informed substantial enhancements to KMPM's procedures for identifying, escalating, monitoring and resolving property safety concerns.. Whilst no management system can entirely eliminate the risks inherent within older housing stock, KMPM believes that structured inspection, documented escalation, proactive monitoring and continual review materially reduce the likelihood of significant hazards remaining unidentified or unmanaged. It is respectfully submitted that these procedures directly address the concerns identified within the Regulation 28 Report by:
• introducing regular structured inspections;
• implementing formal hazard categorisation;
• establishing mandatory escalation of structural concerns;
• ensuring appropriate specialist involvement;
• providing continuous monitoring of outstanding works;
• introducing comprehensive electronic compliance management;
• strengthening communication with landlords, tenants and contractors; and
• embedding an auditable project management process for all potentially dangerous defects. KMPM remains fully committed to maintaining and further developing these procedures in the interests of tenant safety and the prevention of future harm. Appendices I append the following documents as evidence:
1. Property Inspection Report (latest version).
2. Dangerous Hazard Workflow.
3. Contractors Monthly Compliance Report
4. Tenants Monthly Compliance Email Should you require any further information please do not hesitate to contact the writer.

Report sections

Investigation and inquest
On 23 July 2021 I commenced an investigation into the death of Clarice BERRY aged 77. The investigation concluded at the end of the inquest on 18 June 2026. The conclusion of the inquest was that:

Clarice Berry died as a result of chest injuries sustained when the gable end wall and the upper part of the outer leaf of the end wall of her home collapsed onto her, in circumstances where the wall was affected by structural defects including wall tie failure of which there was clear evidence, and where no investigation or remedial works had been carried out, which, if undertaken, would have prevented the collapse.

The medical cause of death was: 1a. Chest Injuries.
Circumstances of the death
1.  On 18 July 2021 the deceased was doing something in the lean-to carport beneath the gable end of her home [REDACTED], when the entirety of the gable wall and the upper part of the outer leaf of the end wall (1.9m³ of brickwork with a mass of approximately 3,800kg) collapse, trapping her beneath the rubble.

2.  The deceased suffered a severe fracture of the sternum and fractures to all her ribs. These chest injuries were incompatible with life and her death was diagnosed at 16:10 hours at Royal Albert Edward Infirmary.

3.  The deceased lived at [REDACTED] with her husband [REDACTED] under a Rent Act protected tenancy which Mr Berry inherited from his father in 1964.

4.  The property is an end-terrace. The end wall is a cavity wall but the gable wall above is solid. From 2013 onwards, the property had a number of recognised features of cavity wall tie corrosion:
a.        Cracking on the exposed south facing elevation (the gable end); b.         A crack on the inside of the gable wall;
c.        Increased likelihood of cracking due to the presence of accelerating factors; and
d.        An outward bulge; together with the following accelerating factors:
i.         Acidic black ash mortar;
ii.        General exposure; and
iii.        Location in a (former) industrial area (where rain is more acidic).

5.  From at least 2013, Mr Berry was concerned about bowing of the gable end wall and began pointing out the bowing of the wall to anyone attending the property who he believed to be associated in some way with the tenancy.

6.  His report to the previous managing agent – Healy Simpson Limited – fell by the wayside because shortly following it, the property changed hands following the death of its previous owner and a new managing agent was instructed (Kaye Mackenzie). The new owner was S&G Properties (No 2) Limited. S&G Properties (No 2) Limited had a longstanding relationship with Kaye Mackenzie, which had managed other properties owned by the company for decades.

7.  On 6 August 2013 (nearly 8 years prior to the deceased’s death), a property manager from Kaye Mackenzie visited the property and spoke with Mr Berry. Amongst other minor items requiring repair, Mr Berry pointed out the bowing or “bellying” end wall. The property manager recorded the following within the handwritten notes he made in respect of the visit: ‘Gable wall big bulge in wall – needs urgent repointing/+rebuild’

8.  On 29 March 2016, same property manager visited the property again and made the following handwritten note: ‘Gable needs repointing’

9.  Subsequent to this, others observed the bowing of the wall, such as a rent officer from the Valuation Office Agency and neighbours on the street.

10.  Google Streetview images of the property in 2016, 2017 and 2018 show the gable wall. The images all show widened brickwork joints and bowing is clearly visible in the image from 2018.

11.  Kaye Mackenzie was a partnership and in January 2020 the partnership was wound up. The abovementioned property manager retired but one of the former Kaye Mackenzie partners continued the property management side of the business as KMPM.  KMPM continued to manage the same properties which had been managed by Kaye Mackenzie, including 9 Old Lane.

12.  In around February or March 2021, a gas engineer visited the property to install a new boiler after the old one was condemned. The job took three or four days, during which time Mr Berry once again pointed out the bulge in the gable wall.

13.  No works were done on the gable wall prior to deceased’s death (not even repointing).  Save as above, there was no monitoring of and no structural engineer or quantity surveyor was instructed to investigate the defective brickwork.

14.  On 18 July 2021 the entire gable wall and upper part of the outer leaf of the end wall below collapsed as set out in paragraph 1 above.

15.  The investigations carried out by HSE Specialist Inspectors following deceased’s death revealed the complete failure of a series of wall ties in the upper part of the cavity wall below the gable wall. This is what accounted for the bowing which Mr Berry had been reporting since 2013.

16.  The inquest heard evidence from a HSE Specialist Inspector that:
a.       the underlying structural problem was the failure of the wall ties; b.          repointing might have slowed the progressive outward movement of the now unrestrained outer leaf of the wall, but without reinstatement of the connection between the inner and outer leaves, the eventual collapse of the wall was inevitable;
c.       if the wall hadn’t collapsed when it did, it probably wouldn’t have lasted another winter;
d.       any competent surveyor or structural engineer would have been able to identify wall tie failure and advise on remedial steps (which may not have even required a partial rebuild depending on the extent to which the outer leaf had peeled away).

17.  I found that any reasonably competent property management company and/or responsible landlord would, at the very least, have ensured that the wall was monitored for any signs of progression and, by no later than 2018, would have ensured that a structural survey was performed.

18.  I found that had such investigations been effected, on the balance of probabilities remedial action would have been taken and the collapse which caused the deceased’s death would have been prevented.

19.  The inquest explored with witnesses from S&G Properties (No 2) Limited and KMPM the systems in place now to ensure the identification and remediation of hazards which arise during tenancies.
Action should be taken
In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action.

Similar PFD reports

Shared signals

Report details

Reference
2026-0358
Date of report
22 June 2026
Coroner
Bronia Hartley
Coroner area
Manchester West

Responses identified

Responses identified 3 of 2
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 12 Nov 2026 (estimated from the Judiciary.uk publication date).

Sent to

KMPM
S&G Properties (no.2) limited

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