UK Inquiry Tracker

Tahnie Martin

PFD Report Partially Responded

Date of Report 10 October 2017

Coroner Emma Whitting

Coroner Area Black Country

Response Deadline ✓ from report 5 December 2017

Accident at Work and Health and Safety related deaths

Judiciary.uk Report PDF

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

Tahnie martin

Response received (text not yet extracted)

Sent To

RICS
ROYAL INSTITUE of CHARTERED SURVEYORS (RICS)

Response Status

Linked responses 1 of 2

56-Day Deadline 5 Dec 2017

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

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.