Recurring concern

Inadequate fall protection at mezzanine and balcony openings

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First reported 25 Jul 2019•Latest report 29 Oct 2021

Definition

What this concern includes

Includes only assertions that directly instantiate the manually reviewed condition ‘Inadequate fall protection at mezzanine and balcony openings’ and satisfy this evidence boundary: Three distinct reports directly support absent or inadequate railing, containment or safety-net protection against people falling from balcony or mezzanine openings. Excludes the separate assertion about objects falling onto people below, which is a falling-object rather than person-fall control.

Not included

Excludes general work-at-height, ladder, platform-edge or dangerous-drop concerns where mezzanine openings are not the material safety condition.
Excludes generic building maintenance, staffing, training or risk-assessment deficiencies unless they directly impair fall prevention at mezzanine openings.
Excludes falls or injuries where no continuing deficiency in a mezzanine-opening fall-prevention control is identified.
Excludes fire-escape, roof-access and other environmental hazards unless the assertion specifically concerns protection of a mezzanine opening.
Excludes manifestations outside the manually reviewed boundary: Three distinct reports directly support absent or inadequate railing, containment or safety-net protection against people falling from balcony or mezzanine openings. Excludes the separate assertion about objects falling onto people below, which is a falling-object rather than person-fall control.

Reports: 2
Individual concerns: 3
Date range: 2019–2021
Stated actions: 5

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Clarion Housing Group Limited1

Urbn UK Limited1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

29 Oct2021
Inner North London
Concerns raised1
1. Lack of balcony containment
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Deploy additional controls at flat roofs posing significant unauthorised-access risks.
  Stated by Clarion Housing Group LimitedStated in progress
Respondent positions 1
1. Position
  The flat roof was not intended for access, so railings were unnecessary for its intended use.
  Stated by Clarion Housing Group LimitedDisputes the concern
AI-generated summary

Lorraine KARAT · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Lorraine Karat, aged 68, died after falling from a second-floor balcony outside her flat, possibly while asleep, following heavy drinking. The balcony had a low parapet and no railing, and access from the flat was not restricted by bars or window restrictors. Concerns included the absence of a risk assessment, warnings about unauthorised balcony use, and measures to prevent access to the balcony.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of balcony containment
Wider context from the report
“3. The balcony was not contained by a railing or other structure to make it safe for use. ”
Source location
Lorraine KARAT · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Deploy additional controls at flat roofs posing significant unauthorised-access risks.

Verbatim wording from the response
“4. There was no sign near the window warning the occupant not to go out onto the balcony and, most importantly, there were no bars on the window or window restrictors to prevent access to the balcony. Response: As noted in the action plan additional controls are now being deployed where flat roofs have been identified as posing a significant risk of access from a tenanted property.”

Source location
2021-0364-Response-from-Clarion-Housing-Group
Page 2 · response
Published 4 November 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The flat roof was not intended for access, so railings were unnecessary for its intended use.

Verbatim wording from the response
“3. The balcony was not contained by a railing or other structure to make it safe to use. Response: CHG did not intend the flat roof to be accessed and used by anyone and were unaware that Ms Karat was accessing it. If it had been the intention of CHG that the tenant was allowed to access the flat roof, then appropriate measures would have been taken to provide railings in compliance with Building Regulations.”

Source location
2021-0364-Response-from-Clarion-Housing-Group
Page 2 · response
Published 4 November 2021
Open published response
25 Jul2019
Nottinghamshire
Concerns raised2
1. Failure to prevent access to the mezzanine openings
2. Lack of fall protection below the mezzanine openings
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Replace the broken gate lock.
  Stated by Urbn UK LimitedStated completed
2. Action
  Restrict access beyond the gate to authorised staff and extend the instruction to new staff.
  Stated by Urbn UK LimitedStated in progress
3. Action
  Replace the scaffolding with high railings throughout.
  Stated by Urbn UK LimitedStated completed
1. Action
  Infilling the voids with steel plates.
  Stated by Urbn UK LimitedStatus unclear
Respondent positions 1
1. Position
  The incident was almost certainly caused by deliberate risk-taking, and no member of the public had previously attempted to access the area.
  Stated by Urbn UK LimitedDisputes the concern
AI-generated summary

Stanislawa Kmiecik · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Stanislawa Kmiecik entered an inaccessible mezzanine area in a Nottingham store and fell approximately 18 feet through an open space to the basement floor, sustaining multiple injuries and dying at the scene. The concerns identified included public and staff access to the area, lack of warning signage and fall protection, uneven flooring, and the risk of objects falling through the openings onto people below.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to prevent access to the mezzanine openings
Wider context from the report
“(3) Whilst the area is cordoned off from the main shop floor by way of a locked mesh gate and some scaffolding type posts, it remains possible for staff and/or members of the public to access the area. ”
Source location
Stanislawa Kmiecik · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of fall protection below the mezzanine openings
Wider context from the report
“(5) If a member of staff or the public were to access the area, there remains a risk of falling from height as there is no safety netting or other safety structure below either of the two openings in the mezzanine floor. ”
Source location
Stanislawa Kmiecik · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Replace the broken gate lock.

Verbatim wording from the response
“• the broken lock was replaced on Monday 15 April 2019 ;”

Source location
2019-0258-Response-by-URBN-UK-Limited
Page 1 · response
Published 6 September 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Restrict access beyond the gate to authorised staff and extend the instruction to new staff.

Verbatim wording from the response
“• immediately after the incident all moveable items beyond the gate were removed and all members of staff were instructed not to access the area beyond the gate unless authorised to do so. That instruction not to access the area beyond the gate has been repeated and will cover new members of staff ;”

Source location
2019-0258-Response-by-URBN-UK-Limited
Page 1 · response
Published 6 September 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Replace the scaffolding with high railings throughout.

Verbatim wording from the response
“• removal of all of the scaffolding and replaced with high railings throughout ;”

Source location
2019-0258-Response-by-URBN-UK-Limited
Page 2 · response
Published 6 September 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Infilling the voids with steel plates.

Verbatim wording from the response
“• infilling the voids with steel plates ;”

Source location
2019-0258-Response-by-URBN-UK-Limited
Page 2 · response
Published 6 September 2019
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The incident was almost certainly caused by deliberate risk-taking, and no member of the public had previously attempted to access the area.

Verbatim wording from the response
“We do not wish to pre-judge the evidence that will be heard at the inquest. However, it does seem plain that the cause of the incident was almost certainly a deliberate attempt by the deceased to put herself in a position of danger and potentially take her own life. There can be no other credible explanation for the individual unsecuring the gate or climbing over the gate and then going beyond the scaffolding. No member of the public has ever attempted previously to access the area beyond the gate.”

Source location
2019-0258-Response-by-URBN-UK-Limited
Page 1 · response
Published 6 September 2019
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of balcony containment

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Failure to prevent access to the mezzanine openings

Lack of fall protection below the mezzanine openings

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 1

Respondent positions 1

Actions described in response 4

Respondent positions 1