The bulge in the gable wall was pointed out again in about February or March 2021 to a gas engineer who was at the property to install a new boiler, but no works were carried out, Hartley wrote.
She noted in her report: “There was no monitoring of, and no structural engineer or quantity surveyor was instructed to investigate, the defective brickwork.”
After Berry’s death, investigations revealed the bowing had been caused by “the complete failure” of a series of wall ties in the upper part of the cavity wall below the gable wall.
The inquest heard evidence that the wall’s eventual collapse was “inevitable” without the necessary repairs, and that it was unlikely to have lasted another winter had it not collapsed when it did, the report said.
Hartley wrote: “I found that any reasonably competent property management company and/or responsible landlord would, at the very least, have ensured that the wall was monitored for any signs of progression and, by no later than 2018, would have ensured that a structural survey was performed.”
She added that, had such investigations happened, the collapse which caused Berry’s death would have been prevented.
The coroner found neither the landlord not the property management company followed government guidance designed to minimise potential hazards.
Hartley said no clear systems were in place to prevent a similar incident from happening again, “namely the development of a serious hazard during a tenancy which, as in the deceased’s case, is reported but is not appropriately or timeously responded to, or which is not identified by the tenant”.
Neither company carried out a post-incident evaluation to assess whether their properties were free from serious, outstanding hazards which have not come to the attention of the local authority, she added.
In their response, a director of S&G Properties (No 2) Limited, whose name has been redacted, said Berry’s death was “a terrible tragedy and one which has caused me considerable sadness”.
Among the actions the company said it had taken were arrangements for independent inspections to be carried out for all its residential properties.
In its response, KMPM said: “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.”