Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, written 10 Oct 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Oct 2017 |
|---|---|
| Deceased | Tahnie Martin |
| Coroner | Emma Whitting |
| Coroner area | Black Country |
| Category | Accident at Work and Health and Safety related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT 70: EE PRESIDENT OF ROYAL INSTITUE of CHARTERED SURVEYORS (RICS) & SEAN TOMPKINS, CHIEF EXECUTIVE OFFICER OF RICS, PARLIAMENT SQUIARE, LONDON, SW1P 3AD. 1 | CORONER | am Emma Whitting, Assistant Coroner for the Black Country area 2 | CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www. legislation.gov.uk/uksi/2013/1629/part/7/made 3 | 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 heavy 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 heavy panel to be lifted by the wind.” 4 | 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 heavy 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 long 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 injury/death to passers-by. 5 | CORONER’S CONCERNS During the course of the inquest, the evidence revealed the following: (1) Although there had been several recent inspections/surveys 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 steps had been taken to repair/replace other rotten timber and corroded metal structures/fittings on the roof by 23 February 2017, nothing had been done either to remove or to safely 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 inspections/surveys, none of the Building Surveyors who carried these out these surveys/inspections had referenced this fact in their reports nor indicated the necessity or urgency of doing so (considering the condition of the main roof generally). Whilst there were clearly matters of concern relating to thé individual surveys/inspections carried out, there were also matters of a more general concern: The MATTERS OF CONCERN are as follows. — | was informed by one of the Building Surveyor witnesses at the inquest that it was not unusual for parts of a commercial building to remain unaccessed during a commercial building survey. Although he, personally, did not consider it acceptable for a Building Surveyor not to mention any areas of a building not accessed (and, indeed, to provide advice about the steps required and cost to achieve this) in the survey report, it appears that: Neither (1) is it a mandatory requirement in the current RICS Guidance Note Building Surveys and Technical Due Diligence of Commercial Property (4'" Edition) for a Surveyor to refer to areas of a building not accessed; Nor (2) is it a mandatory requirement for a Surveyor to advise a Client about the specific risks of not obtaining such access and/or subsequent inspection. In my opinion, there is a risk that future deaths could occur unless action is taken. In the circumstances, it is my statutory duty to report to you. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 5 December 2017. |, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to all the Interested Persons (Ms Martin’s family, Wolverhampton City Council, Cushman & Wakefield Debenham Tie Leung Limited and B.E. Wolverhampton BV Limited). | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 10 OCTOBER 2017 SIGNED BY ASSISTANT CORONER: Vee sth,
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