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AI-generated response summaryKMPM 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
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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
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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
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• 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
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• 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.