Grenfell Tower fire was ‘culmination of decades of failure’, report into 2017 tragedy which killed 72 finds

Cause of death ruling

Inquiry chairman Sir Martin Moore-Bick made findings about the cause of death, in an effort to assist the coroner as well as “sparing the relatives of those who died the stress of prolonged proceedings”.

“In light of the expert evidence we are able to make findings about the cause of death, including findings that all those whose bodies were destroyed by the fire were dead or unconscious when the fire reached them,” the report stated.

Residents 'abandoned' and 'utterly helpless'

The response of government and RKBC in the first week was described by the inquiry as “muddled, slow, indecisive and piecemeal”.

It concluded the council should have done more and that some aspects of the response “demonstrated a marked lack of respect for human decency and dignity and left many of those immediately affected feeling abandoned by authority and utterly helpless”.

The local authority had no effective plan and had not trained staff adequately to deal with such an incident but, the report noted, “none of that was due to any lack of financial resources”.

It credited members of the local community for their help in the immediate aftermath, which “only emphasised the inadequacies of the official response”.

Fire Brigade failures

The fire service did not fail to understand the lessons of the Lakanal House fire.

In fact its response “showed that it understood its significance immediately”, the report said.

But its failure “lay in its inability to implement any effective response”.

This failure had “many causes”, including a “chronic lack of effective leadership”, combined with “undue emphasis on process and a culture of complacency”.

Senior managers at the LFB failed to take steps to ensure that its arrangements for handling fire survival calls reflected national guidance.

Senior officers were complacent about the operational efficiency of the brigade and lacked the management skills to recognise the problems or the will to correct them.

'Merry-go-round of buck-passing’

There was a “serious lack of competence” and in some cases “outright dishonesty” when it came to the tower’s 2015-2016 refurbishment.

The report said: “Regrettably, the Grenfell Tower refurbishment was marked by a serious lack of competence on the part of many of those engaged on it and, in the case of some manufacturers of construction products, outright dishonesty.”

The failure to establish clearly who was responsible for what, including for ensuring designs were compliant with statutory requirements, resulted in an “unedifying ‘merry-go-round of buck-passing’.

"The construction professionals all pointed the finger at each other as being the person whose responsibility it was to make one or other of the critical decisions."

Landlords saw fire safety as 'inconvenience'

There was a “persistent indifference to fire safety, particularly the safety of vulnerable people” between 2009 and the time of the fire.

The council – the Royal Borough of Kensington and Chelsea (RBKC) and the landlord organisation – the Tenant Management Organisation (TMO) were jointly responsible for the management of fire safety at the tower.

But the demands of doing so “were viewed by the TMO as an inconvenience rather than an essential aspect of its duty to manage its property carefully”.

In turn, RBKC’s oversight of the TMO’s performance was “weak and fire safety was not subject to any key performance indicator”.

'Defective' guidance on fire tests

Statutory guidance on complying with a requirement under the Building Regulations requiring the external walls of a building to “adequately resist the spread of fire over the walls and from one building to another” was concluded to be “fundamentally defective”.

The use of Class 0, meaning “limited combustibility”, as a standard of fire performance for products to be used on the outside walls of tall buildings was “wholly inappropriate”.

Neither of the main British Standard tests reflected the development of a fire on the outside of a building or gave the information needed to assess how an external wall incorporating the product would perform in a fire.

'Systematic dishonesty' of building firms

Grenfell Tower came to be wrapped in flammable material because of “systematic dishonesty” among those who made and sold cladding panels and insulation products.

These firms “engaged in deliberate and sustained strategies to manipulate the testing processes, misrepresent test data and mislead the market”.

A former government agency, the Building Research Establishment (BRE), which provided advice on building and fire safety was “complicit in that strategy” when it came to the main insulation product from Celotex.

The BRE was privatised in 1997, but years before that “much of the work it carried out in relation to testing the fire safety of external walls was marred by unprofessional conduct, inadequate practices, a lack of effective oversight, poor reporting and a lack of scientific rigour.”

Its systems were concluded not to have been “robust enough to ensure complete independence”.

It was judged to have played “an important part in enabling Celotex and Kingspan to market their products” for use in the external walls of high-rise buildings.

The certification bodies, the British Board of Agrement (BBA) and the Local Authority Building Control (LABC), “failed to ensure that the statements in their product certificates were accurate and based on test evidence”.

The UKAS, which is responsible for oversight of certification bodies, “failed to apply proper standards of monitoring and supervision”.

Safety 'ignored and disregarded'

Following the Lakanal House fire, the government had a “deregulatory agenda, enthusiastically supported by some junior ministers and the secretary of state”.

The agenda “dominated the department’s thinking to such an extent that even matters affecting the safety of life were ignored, delayed or disregarded”.

All 72 deaths avoidable

All 72 deaths in the Grenfell Tower fire were avoidable and the people who lived there were “badly failed” by authorities and the construction industry through incompetence, dishonesty and greed, inquiry chairman Sir Martin Moore-Bick said.

Government ignored warnings

For almost three decades before the fire the government had “many opportunities” to identify the risks posed especially to high-rise budlings by flammable cladding and insulation, the report said.

By 2016, the year before the fire, it was “well aware of those risks, but failed to act on what it knew”.

After the Lakanal House fire in Camberwell, south London, in July 2009, in which six people died, the coroner’s recommendations were “not treated with any sense of urgency” and “legitimate concerns” were “repeatedly met with a defensive and dismissive attitude by officials and some ministers”.

Victims died before flames reached them

All of the victims of the Grenfell Tower disaster whose bodies were destroyed by fire were dead or unconscious by the time the flames reached them, an inquiry has found.

In the final report into the fire, chairman Sir Martin Moore-Bick made some findings on the 72 victims’ cause of death, in the hope that it would assist the coroner.

The report found that all of the victims burned by the fire were dead or unconscious due to “inhalation of asphyxiant gases”, primarily carbon monoxide.

The disaster also claimed five other victims, including three who jumped from the tower, stillborn baby Logan Gomes, and 74-year-old Maria del Pilar Burton, who died in January 2018.

Sir Martin said expert evidence suggested it was possible to descend the tower’s stairs “without danger of collapse” by 1.49am. After that it was still possible but “more hazardous due to the dense smoke and absence of visibility”.

“In light of Professor (David) Purser’s evidence, we think it likely that those who died in the tower after having left their flats inhaled most of the carbon monoxide that killed them while they were descending the stairs,” the report said.

“Those who did not survive the journey down the stairs had inhaled a significant amount of asphyxiant gases while in their flats and before entering the stairs.”

The report added that the “key distinction” between those who survived and those who died is that “those who survived left before the fire spread to the outside of their flats or the rooms in which they were sheltering”.

It concluded that “all the deceased were comatose, and in most cases dead, before they were exposed to significant heat”.

“The severe burning of bodies was likely to have occurred in all cases sometime after death when the fire entered the flats and consumed the combustible contents,” the report added.

'Culmination of failures'

The Grenfell Tower fire was “the culmination of decades of failure” by central government and the construction industry to properly consider the danger of combustible materials in high-rise residential buildings, the final report into the 2017 disaster has concluded.

Scotland Yard: one chance to get probe right

Metropolitan Police officers leading the criminal probe into the Grenfell Tower fire have “one chance to get our investigation right”, Deputy Assistant Commissioner Stuart Cundy said.

He warned it would take up to 18 months to go through the Inquiry report “line by line”.

'Justice not delivered'

The final Grenfell Inquiry report is a “significant chapter” but “justice has not been delivered”, Grenfell United said.

The group representing some of the bereaved and survivors of the 2017 blaze insisted police and prosecutors must now “ensure that those who are truly responsible are held to account and brought to justice”.