Ms Tahnie Lee Martin · Prevention of Future Deaths report

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.”

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.

(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 out these or 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).

I 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 (4th 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.”