Finding into death of Sarah Michele Kajoba
Deceased
Sarah Michele Kajoba
Demographics
37y, female
Date of death
2017-12-17
Finding date
2021-09-15
Cause of death
Multiple injuries
AI-generated summary
Sarah Michele Kajoba, aged 37, died from multiple traumatic injuries sustained when a timber balcony collapsed at a Christmas party on 16 December 2017. The balcony had been undersized from construction in 1987, with inadequate maintenance over 31 years contributing to structural failure. The bearer beam was weakened by weathering, had a large knot at a critical support point, and was notched at its support junction. Poor maintenance—particularly failure to replace deteriorated timber members when earlier repairs were attempted—compounded the structural deficiency. Expert evidence identified that the beam exceeded maximum allowable span by 550mm and the load at collapse exceeded design capacity. The coroner found the building inspection system at the time failed to detect non-compliance with design approval. Clinical management by emergency responders and hospital staff was appropriate and did not contribute to death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Balcony beam undersized from original construction in 1987
- Beam exceeded maximum allowable span by 550mm
- Inadequate maintenance of timber balcony over 31 years
- Weathering and deterioration of Oregon timber beam
- Large knot at critical support point of beam
- Notching of beam at support junction reducing structural integrity
- Failed earlier attempt to strengthen beam with treated pine
- Concentration of load when group gathered for photograph
- Construction deviations from approved plans not detected by building inspector
- Design non-compliance with applicable 1987 standards
Coroner's recommendations
- That the Victorian Building Authority promotes among registered builders and building surveyors a practice of ensuring that balconies associated with residential premises are subject to mandatory inspections at either the frame stage or at the final stage and that the inspection is specifically directed to the compliance of the balcony with currently applicable standards
- That the Victorian Building Authority continues its efforts to improve public awareness of the need for regular inspections and competent maintenance of balconies, particularly where they are of timber construction or have timber structural members
- That the Victorian Building Authority continues its efforts to develop a specific standard addressing the design and durability of exposed structures in response to the 2018 paper referred to it by the Chair of the Building Regulations Advisory Committee
- That the Victorian Building Authority considers developing a system for certification of newly constructed balconies as to their maximum distributed load capacity
- That the Victorian Building Authority requires an alert to all users of newly constructed balconies in the form of signage to be permanently affixed to the balcony with an appropriately worded alert to owners and occupiers not to exceed that capacity and to be mindful of the need for regular inspection and competent maintenance
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