September 2024
Volume 6
Part 9 - The deceased
HC 19–VI
Presented to Parliament pursuant to section 26 of the Inquiries Act 2005
Ordered by the House of Commons to be printed 4 September 2024
This report contains content which some may find distressing.
© Crown copyright 2024
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ISBN 978-1-5286-5080-9
(Volume 6 of 7)
E03165832 09/2024
In the preceding chapters we have examined the circumstances in which the fire at Grenfell Tower came about. Most of the facts we have found and the conclusions we have drawn are relevant to all the deaths that occurred that night. The only exceptions are our findings about the treatment of those who for one reason or another were vulnerable and in respect of whom we have identified particular shortcomings. In this Part of the report, we set out our findings about the circumstances in which each person who died came to lose his or her life, a matter which it is the coroner’s duty to investigate. We begin by explaining our purpose in doing so.
Grenfell Tower is in an area of London which falls within the jurisdiction of Professor Fiona Wilcox, His Majesty’s Senior Coroner for London (Inner West). Between 20 June and 22 November 2017, Professor Wilcox opened 70 separate inquests into the deaths of those who died in the fire. She subsequently suspended those investigations pending the conclusion of this Inquiry and, if necessary, the police investigation. An inquest was not opened for Logan Gomes, the son of Marcio Gomes and Andreia Perestrelo, who was delivered stillborn following his mother’s escape from the tower. Professor Wilcox concluded that Logan did not have a life independent of his mother and so was outside her jurisdiction. We have, however, included in this Part of our report findings relevant to Logan. Maria del Pilar (Pily) Burton survived the fire but died in January 2018. The cause of her death was not found to be related to the fire. Pily Burton died within the jurisdiction of a different coroner and no inquest has been opened into her death. Nonetheless, in recognition of the regard in which she was held by the community at Grenfell Tower, we have included in this Part of our report the facts concerning her experience on 14 June 2017.
An inquest, whether conducted by a coroner alone or with a jury, is required to answer the four questions set out in section 5 of the Coroners and Justice Act 2009: who the deceased was and how, when and where the deceased came by his or her death. When the inquest is one in which article 2 of the European Convention on Human Rights (the Convention) is engaged, the question “how” is to be interpreted as including the circumstances in which the deceased came by his or her death.
At an early stage of the Inquiry, the chairman decided that, in discharging its Terms of Reference and insofar as it was properly permissible to do, the Inquiry would investigate the deaths caused by the fire to the same extent as would be required of the coroner. The chairman’s hope was to minimise the need for Professor Wilcox to conduct further detailed investigations, so sparing the relatives of those who died the stress of prolonged proceedings.[1]
Subsequently, the chairman issued a direction in which he said that, on the material then available, he saw no significant difficulty in making findings sufficient to meet the requirements of article 2 of the Convention. He proposed that while the Phase 1 report was being written the Inquiry would hold an oral hearing in which those representing the bereaved families could present the evidence relating to those who had died in order to enable him to make the appropriate findings in that report. In the end, however, it did not prove necessary to hold such a hearing. As is evident from the Phase 1 report, the Inquiry obtained a considerable amount of material, in particular the written and oral evidence of the firefighters, the bereaved and those who had survived the fire, that was analysed and presented in that report. Further, there were some aspects of the circumstances in which people had died, principally the physiological causes of death, that called for more detailed examination than was possible at that stage. Accordingly, further consideration of the circumstances of the deaths was deferred to Phase 2. The chairman made it clear that it remained his intention in Phase 2 to make the findings necessary to assist the coroner.[2]
Following further submissions and correspondence in 2019 and 2020, we concluded that the facts that we should investigate and record in relation to each deceased were:
We began hearing evidence about those matters on 4 July 2022. The hearings took a slightly different form in that, although Counsel to the Inquiry retained responsibility for adducing evidence, the greater part of them were taken up by a series of presentations of the essential circumstances surrounding the individual deaths by those representing the bereaved.
Those presentations were very helpful, not only in assisting us to identify the essential facts to be found in each case but also in reminding all those present and those watching the proceedings remotely of the personalities of the deceased and the lives they had led until the night of the fire. Our findings are based in part on evidence that had not been considered in any detail at the time the presentations were delivered, as well as on findings made in the Phase 1 report, none of which were disputed.
We have borne in mind throughout that we are not conducting an inquest; that remains the responsibility of the coroner. For that reason we have refrained from expressing any view about the conclusions a coroner might record. However, we continue to hope that our findings about the circumstances in which each of the deceased died will assist her in fulfilling her statutory obligations. It will be for her to decide what to make of our findings.
The Inquiry opened in May 2018 with a public commemoration of the deceased through the voices of their relatives and friends. Those reflections and memories are recorded in Chapter 32 of the Phase 1 report. As the Inquiry began, so it ended, by remembering those who lost their lives that night. It is of the utmost importance that our description of the circumstances in which people died are placed in the larger context of their lives and the pictures of them painted at the memorial hearings. Only in that way can they be remembered as the people they really were.
Many of those who died on 14 June 2017 were found in their own homes; others had sought shelter elsewhere in the tower or were overcome while trying to leave the building and were found in the lobbies or on the stairs. Three fell from the tower. Our findings are set out floor by floor and deal in turn with each of those who died on, or fell from, the particular floor. For those who died on the stairs we have described the circumstances relating to the floor on which their flat was located. None of the occupants of floors 12 or 13 died in the fire.
In making our findings we have relied on the following:
Almost all of that evidence was heard in Phase 1 and was the subject of findings made in chapters 9 to 20 of the Phase 1 report.
In some cases the deceased could be identified only by scientific means but in each case the coroner was satisfied that identification had been correctly established and was therefore able to issue an interim certificate of the fact of death. In those cases we have not thought it necessary to describe in detail the way in which the identity of the deceased was established.
In making our findings on the circumstances surrounding the deaths of those who lost their lives in the Grenfell Tower fire we have drawn heavily on the evidence of a number of eminent experts in a variety of fields. Their evidence may be conveniently described under the following headings:
In respect of each deceased person the coroner, Professor Wilcox, issued an interim certificate of the fact of death pursuant to regulation 9 of the Coroners (Investigations) Regulations 2013. She was able to do so because she was satisfied in each case that the remains in question were those of the particular deceased. That resolves conclusively the doubts that at one time were aired about how many people died in the fire and who they were. However, we think it appropriate to describe in general terms the careful and painstaking process by which the remains of those who died were recovered and their identities confirmed. The procedure adopted followed the guidance contained in the Disaster Victim Identification (DVI) Guide published by Interpol in 2014, which set the standards for the identification of victims of disasters and was used in conjunction with protocols developed by the archaeologists and anthropologists working with police officers trained in identifying victims of disasters.[3]
The task of recovering the human remains was led by Dr Karl Harrison MSc PhD DSc, the lead forensic archaeologist. Dr Harrison had 20 years’ experience as an expert forensic archaeologist, including working on police investigations.[4] Together with Dr Deborah Ryder PhD, he co-ordinated a team of 36 forensic archaeologists with expertise in the identification of human remains.[5] Archaeologists were attached to teams instructed to search individual flats, each of which was treated as a closed fire scene to prevent the mixing of debris and to maximise the opportunity to identify any human remains.[6] Those search teams included DVI officers and licensed search officers (LSOs). It was the responsibility of the DVI officers to maintain the continuity of the evidential chain in order to minimise the possibility of a fragment of human remains being missed or wrongly attributed. The LSOs had a more general search function.[7]
Forensic archaeologists arrived at the tower on Friday 16 June 2017 and carried out their work over the next five months.[8] They worked in different places at different times in response to the requirements of the police.[9] Dr Harrison divided the work of his team between June and December 2017 into three phases,[10] the first two of which concentrated on those flats which were thought likely to contain human remains.[11]
The first phase, which began on 16 June 2017 at a time when the team of archaeologists was smaller and the number of deceased was still unknown, had four elements. The first involved a visual assessment of the flats that were suspected to contain human remains. The search teams noted the significant volume of debris in those flats and assessed the challenges to the recovery and recording of human remains. The fragility of the remains that were visible led to a decision to search the debris in each flat in situ rather than remove it to another site. That avoided the risk of damaging the remains or mixing them up in circumstances where more than one person had died in a relatively small space.[12]
The second element was the early development of search strategies. Given the extensive fire damage to the flats, with internal walls almost entirely destroyed, each flat to be searched was divided into sectors. It was decided at the outset that all spaces within the tower that had been destroyed by fire would be searched to the same extent.[13]
The third element took place on 15 and 16 June 2017 and before archaeologists had become involved in searching the tower’s interior. Archaeologists assisted officers using victim recovery dogs to search the base of the tower and the area around it for human remains, since it was known at that stage that at least one person had fallen from the building.[14] At that time the area remained under the control of the LFB and debris was still falling.
The fourth and final element of the initial phase also began on 16 June 2017. That was the recovery of visible remains from flats and bodies from the communal areas and the stairwell. That operation was undertaken at a time when the authorities were still responding to an emergency and the debris in the flats remained hot enough to present a risk of re-ignition. The structural integrity of the tower was also being assessed at that time, which required additional safety measures, including a limit on the number of people entering a flat at any one time. In the circumstances, emphasis was placed on the speed of recovery.[15]
The initial phase allowed areas of particular interest to be identified. They included flats where fragments of human remains might be found because people had been reported as missing or witnesses believed they had seen people at the windows, even if there was no obvious sign of remains.[16] Acrow props were installed in flats to maintain structural stability. That made it necessary to move debris, which, wherever possible, was retained in the sector in which it had been found. If it was necessary to move debris out of a sector, it was not moved beyond the flat or lobby in which it had originated.[17]
The second phase involved the careful excavation of debris to preserve any remains, which could then be lifted out. The debris was then left in situ. A record was made of the location of remains as well as of the position of any fixtures and fittings. Personal effects such as jewellery were recovered.[18]
The third phase began in August and continued until November 2017. It involved the comprehensive searching and sieving of the debris in all areas which had been subjected to burning to recover any other human remains, to identify and retain any material that might assist in understanding the spread of the fire and fire protection within flats and in identifying individuals, and to locate valuable or sentimental items, which could then be returned to the family.[19]
The stairwell, part of the flats from floor 4 to floor 9 and all flats and lobbies from floor 10 to floor 23 were searched sector by sector. All debris in those areas of the tower was searched by hand by teams of DVI officers and LSOs led by a team leader and under the supervision of an archaeologist. Sieved material was bagged. The DVI officers and LSOs were given training in advance in recognising burnt bone, but the supervising archaeologist made a second check of any material that might be fragments of bone or tissue. In that way, any human remains as well as other items of potential significance, such as personal effects, medical implants or identification documents, were located and retained.[20]
A quality assurance process was adopted through the introduction in search areas of a foreign control object. There were no occasions on which a DVI or LSO team failed to find that object.[21] A system was put in place to ensure that all the debris had been searched and sieved and then retained in labelled bags. Each searched area went through two inspection stages. The second stage required an inspection panel comprising Dr Harrison or Dr Ryder as the lead archaeologist, the DVI co-ordinator, and the Scene Evidence and Recovery Manager to certify that all required steps had been taken.[22]
Once a certificate had been issued, the bagged debris was removed from the tower so that no extraneous material was left in the flat.[23]
In accordance with DVI protocols, when human remains were located, they were given a Unique Reference Number (URN) and placed in a sealed bag before being taken under secure conditions from the site of recovery to a holding area and then to the Westminster mortuary. The steps involved in this process were documented. A parallel system was followed in relation to items recovered from the building, such as identification documents and valuables, all of which were handed over to an exhibits officer.[24]
Following arrival at the mortuary, each bag was scanned and a preliminary assessment of the remains carried out.[25] Forensic pathologists conducted an initial post mortem examination, which was attended by forensic anthropologists when necessary.[26]
Dr Gaille MacKinnon, BA MSc MCIfA FRAI (ChFA) was a director of Alecto Forensic Services Ltd with over 24 years’ experience, including working on major terrorist incidents.[27] She led the team of forensic anthropologists instructed to identify the human remains recovered from the tower.[28]
Working with DVI-trained police officers, forensic pathologists and experts in DNA analysis, forensic odontology (a branch of forensic science that assists with identification of remains through the examination of dental records and dental remains) and fingerprints,[29] the role of Dr MacKinnon’s team was to construct a biological profile for each victim.[30] Following the initial post mortem examinations, they conducted a detailed anthropological examination of each of the 17 separate locations in the tower from which remains had been recovered, working on each flat or communal space separately.[31]
The remains were carefully documented, mapped and reconstructed, if possible.[32] An individual biological profile was constructed according to internationally recognised standards accepted in the wider scientific community.[33] It included looking at age at death, sex, ancestry and any features or variations that differ from one person to another.[34]
The purpose of the anthropological examinations was to ensure that all human remains were attributed to the individual deceased to whom they belonged.[35] A particular challenge was the commingling of remains where a number of victims had died in the same location. That challenge was met by using standard operating procedures and by undertaking examinations of each flat or communal space individually.[36] Dr MacKinnon’s team worked alongside experts in DNA analysis (which could be used to confirm identification)[37] and odontology.[38]
On completion of the forensic anthropology and odontology examinations for each deceased recovered from a particular flat or communal space, the human remains and documentation were reviewed in a procedure called “Anthropology Grand Rounds” involving Professor Wilcox, Detective Chief Inspector Andrew Chalmers (Deputy Senior Investigating Officer and Scene Senior Identification Manager), the Post Mortem Coordinator, Andrew Langley (Operational Forensic Manager (OFM), Metropolitan Police Service), and the lead anthropologists and odontologists.[39]
Dr MacKinnon confirmed that, based on her examination and having regard to the rigour with which the recoveries and clearance of the flats had been undertaken, she was very confident that the remains of all the victims had been recovered and correctly identified.[40]
The information reviewed during the Anthropology Grand Rounds procedure informed the deliberations of the Identification Commission, conducted under the direction of Professor Wilcox.[41] The identification of an individual deceased also drew upon other sources including comparative DNA and odontology.[42] At the Identification Commission, Professor Wilcox reached a final decision on the identity of the deceased whose remains had been recovered from the tower.
We have already referred to the involvement of forensic pathologists. Dr Ashley Fegan-Earl BSc (Hons) MB BS DMJ(Path) FRCPath FFFLM RCPathME led a team of 12 Home Office registered forensic pathologists who conducted post mortems on those who died in the fire and provided an opinion on the medical cause of death.[43]
Dr Fegan-Earl explained that although the work of experts in other disciplines could assist in determining the cause of death, it was for the pathologist, as the registered medical practitioner, to certify the medical cause of death.[44] The certification system uses a form which has two parts. The first gives the primary cause of death, which can be subdivided into two, Ia and Ib. For example, a doctor might record cardio-respiratory arrest as cause Ia and carbon monoxide poisoning as cause Ib, thereby indicating that cardio-respiratory arrest was due to carbon monoxide poisoning. Part II is used to record conditions that may have contributed to death, for example, heart disease.[45]
The destructive nature of the fire meant that a full post mortem was not possible in every case. Where a full post mortem could be conducted, a toxicology examination to ascertain whether there was carbon monoxide in the blood and an histology examination to ascertain whether there was soot in the airways was also undertaken, where possible. However, if a deceased’s body had been subject to extensive heat damage, a full post mortem was not possible.[46]
The results of the post mortems were reviewed by other members of the team.[47] The medical cause of death for many of those who died as a result of the fire was recorded as “Inhalation of fire fumes”, “Inhalation of the products of combustion” or “Consistent with the effects of fire”. Dr Fegan-Earl explained that the first two were essentially the same and had been used where there was pathological evidence to show that the deceased had inhaled fire fumes.[48] The third formulation had been adopted where it had not been possible to conduct a full post mortem.[49]
Dr Fegan-Earl agreed with Professor Purser’s opinion that those who died in the tower had very probably been rendered unconscious by inhalation of poisonous gases, including carbon monoxide and hydrogen cyanide. One possible description of the cause of death, therefore, was inhalation of asphyxiant gases. In his opinion it was overwhelmingly likely that the deaths were the result of the inhalation of fire fumes rather than burning.[50] Nonetheless, while not disputing Professor Purser’s opinion, Dr Fegan-Earl maintained that it was appropriate to use the expression “Consistent with the effects of fire” as the medical cause of death if it was not possible to confirm with certainty that the death was caused by inhalation of asphyxiant gases, although that conclusion might be strongly supported by scientific evidence and pathological experience.[51]
We have given careful consideration to the evidence of Dr Fegan-Earl and understand why he and his colleagues felt the need to show caution when ascertaining the medical cause of death. We keep in mind that it will be for the coroner to decide what to find as the cause of death in each case. However, as Dr Fegan-Earl acknowledged, we have the benefit of the evidence of a range of witnesses, including the expert evidence of Professor Purser. It is because of that additional evidence, and in particular the work done by Professor Purser, that we have reached the conclusion that, save for those who fell from the tower, we can safely find that death was due in each case to the inhalation of asphyxiant gases.
Professor David Purser CBE BSc PhD DipRCPath was instructed to give expert evidence on toxicology. In broad terms, he considered the causes of the incapacitation and death of those who died in the tower,[52] building on the preliminary conclusions he had reached in the report he provided for Phase 1.[53]
We found Professor Purser’s evidence helpful and it has informed our findings about the individual deceased in the following chapters. Having considered his evidence, we regard him as a reliable expert on whose evidence we can rely in drawing conclusions about the circumstances of the individual deaths.
Professor Purser’s expertise includes the physiological effects on the human body of the inhalation of toxic smoke and gases.[54] At the time he gave evidence, he was a visiting professor in the Centre for Fire and Hazards Science at the University of Central Lancashire.[55] His extensive experience is described in his report. He has wide practical experience of investigating the effects of major fires in this country and abroad, including taking part in an investigation by the French authorities into a fire inside the Mont Blanc tunnel.[56]
In order to reach a conclusion on the cause of the incapacitation and death of each deceased,[57] Professor Purser examined the changing conditions in the flats, lobbies and stairs throughout the night of the fire, relying on medical records of survivors, transcripts of emergency calls, photographs of the exterior of the tower, the evidence of other experts and the chairman’s findings in the Phase 1 report.[58]
To estimate the exposure of an individual to irritant smoke and its effect Professor Purser estimated the fuel load and range of materials involved in the fire to calculate the average composition of the asphyxiant gases entering the tower. For that purpose he relied upon a study published by BRE in March 2003 entitled The potential for including fire chemistry and toxicity in fire safety engineering[59] which contained the results of two experiments measuring yield and concentrations of various gases produced when certain products were burned.[60] He also relied on tests carried out by Professor Anna Stec[61] to determine the composition of smoke particulates and the yield of toxic gases obtained from burning samples taken from Grenfell Tower itself.[62] Professor Purser used descriptions given by witnesses of conditions in the tower and medical records of survivors to estimate the extent of smoke obscuration and irritancy.[63]
The mechanism of death from exposure to asphyxiant gases is twofold: first, the carbon monoxide bonds with haemoglobin to form carboxyhaemoglobin.[64] That prevents the haemoglobin from carrying oxygen[65] which deprives the brain and heart of oxygen.[66] Second, the carboxyhaemoglobin impairs the ability of the rest of the haemoglobin to deliver oxygen to tissues.[67] Ultimately that causes a lack of oxygen to the heart and brain.[68] Cyanide also prevents the tissues from metabolising.[69] Both can cause hypoxia.[70] He agreed that in describing the cause of death, the effect of carbon monoxide in combination with hydrogen cyanide would appropriately be termed, “asphyxia from asphyxiant gases”.[71]
Professor Purser’s study of conditions in the tower and information obtained from survivors added to the conclusions he drew from the toxicology and pathology reports on the deceased. The forensic data derived from those reports that record the concentration of carboxyhaemoglobin in the blood are important for measuring the toxicological effects of asphyxiant gases.[72]
Professor Purser’s study enabled him to reach with some confidence a conclusion on the production of toxic gases in the tower, how those who died were overcome and the causes of their deaths. In most cases he was also able to provide an opinion about the time when death occurred.[73] His conclusions were necessarily approximate due to the number of factors involved,[74] but we think that in each case they offer the most reliable estimate available.
Professor Purser reached a number of conclusions that are applicable to all the deceased and have informed the findings made in the following chapters. However, he accepted that they were subject to a number of qualifications. First, it was not possible to measure exact concentrations of smoke and toxic gases during the fire, so his conclusions were estimates based on the available evidence.[75] Second, the concentration of carboxyhaemoglobin sufficient to cause incapacitation and ultimately death depends on the particular characteristics of the individual concerned.[76] Third, if the amount of carboxyhaemoglobin in the blood of the deceased could not be measured, an estimate had to be made and it was not always possible to be confident about the level persisting at the time of death.[77] Fourth, Professor Purser drew information from a wide range of sources, as mentioned above. Fifth, in some cases there was very sparse information available about the person in question, which limited the confidence that could be placed in his conclusion.[78]
Moreover, the rate at which asphyxiant gases are absorbed depends on an individual’s personal characteristics.[79] Infants and children absorb gases at about twice the rate of adults, which hastens the time to collapse and death.[80] If infants and young children were sheltering with their parents, it is likely that they lost consciousness and died before their parents.[81] Respiratory conditions, such as asthma, also affect any response because they make people more susceptible to irritant particles in smoke[82] and those with the condition are generally more sensitive to their effect.[83] If people were unable to leave their flats or descend the stairs, their prospects of escape were reduced.[84]
Professor Purser identified three groups of material that contributed to the smoke within the tower: the external cladding and insulation and the window infill panels, the window surrounds and the contents of the flats.[85] During the early stages of the fire it is likely that the cladding, the window infill panels and the window surrounds were the main contributors to the smoke.[86] The smoke from the fire on the outside of the building entered the tower[87] and the contents of the flats became involved in the fire at different times as it progressed.[88] The contribution made by the different materials to the smoke varied.[89] We are satisfied that the cladding, insulation, window surrounds and window infill panels made a significant contribution[90] but we are unable to say how much of a contribution each of them made at different times and in different places.
From the descriptions of dense, irritant smoke in the lobbies, the very limited visibility described by the witnesses and the general fire conditions, Professor Purser estimated that the concentration of carbon monoxide and hydrogen cyanide was likely to have been high and in the lobbies sufficient to cause a person to collapse within about three-to-five minutes of exposure.[91]
He estimated that moderate concentrations persisted in the stairs,[92] which would have led to collapse (assuming no prior exposure) in approximately 15 to 30 minutes, if one were walking, or between 30 minutes and one hour, if static.[93]
Having studied data collected from 21 survivors, Professor Purser concluded that their exposure to asphyxiant gases had occurred mainly during their descent of the stairs, rather than while they were sheltering in their flats.[94] When considering the density of smoke in the stairs, and therefore the risk of inhaling a large enough dose to cause collapse while on the way down, Professor Purser drew a distinction between conditions up to about 01.49 and those thereafter.[95] He considered that until about 01.49 it was still possible to descend the stairs without danger of collapse.[96] After that it was still possible to escape by the stairs, but was more hazardous due to the dense smoke and absence of visibility in both the lobbies and the stairs.[97]
Most of those who left the tower after 01.49 used cloths or towels to avoid inhaling smoke. The greatest danger was of collapse due to the inhalation of asphyxiant gases, which causes breathlessness, dizziness, light-headedness and weakness, followed by collapse and loss of consciousness.[98] Continued inhalation of those gases causes death from asphyxia.[99]
Based on Professor Purser’s evidence we find that:[100]
In the light of Professor 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 time it took them to do that was therefore a significant factor.[104] If people left their flats before they were overcome, they had a good chance of being able to escape from the tower successfully.[105] 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.[106] Those who remained in their flats until the fire arrived but were then able to escape successfully had probably not been exposed to a large amount of asphyxiant gases.[107]
People were inhaling an increasing quantity of asphyxiant gases while they remained in their flats[108] and the longer they did so, the greater the danger of their accumulating enough to cause collapse and death.[109] However, in most cases they had inhaled a dose of asphyxiant gases sufficient to impede escape by the time the fire on the outside of the building reached the flats in which they were sheltering.[110] 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.[111] In some individual cases, personal characteristics affected both their ability to escape and their vulnerability to asphyxiant gases.[112]
When the fire reached the outside of the rooms in which people were sheltering, conditions deteriorated very rapidly and they were exposed to a large amount of asphyxiant gases.[113] When they then tried to evacuate, they had already accumulated a significant dose and collapsed quickly when exposed to further gases in the lobby or stairs.[114] Those who remained in their flats and did not leave were rapidly overcome.[115]
Almost all those who died in the tower had concentrations of carboxyhaemoglobin in their blood consistent with death from asphyxia rather than from heat or burns.[116] The two bodies with concentrations of less than 50% carboxyhaemoglobin that were recovered from the flats had heart disease which explained the lower result.[117] For eight of those who died in the lobbies or stairs, all except one had very high carboxyhaemoglobin concentrations and did not have significant burns.[118]
From those findings we conclude that all the deceased were comatose, and in most cases dead, before they were exposed to significant heat.[119] The severe burning of bodies was likely to have occurred in all cases sometime after death when the fire entered the flats and consumed all the combustible contents.[120]
Professor Purser was unable to say whether any of those who died had inhaled enough hydrogen cyanide to make a significant contribution to incapacitation and death.[121] He was of the opinion, which we accept, that it had made some contribution but that the dominant toxic gas causing incapacitation and death had been carbon monoxide.[122]
By 01.21 on 14 June 2017, the fire had spread up the east face of Grenfell Tower to reach the outside of Flat 76 on floor 10.[123] All the flats on floor 10 were still occupied at that time, but none of the occupants had contact with those who died on that floor.
Hoang Khanh Quang, who lived in Flat 76, and her former husband, Van Quang Ho, who was there that night, were the first to leave floor 10. Having been woken by a smoke alarm, Hoang Khanh Quang saw flames at the kitchen window. Both she and Van Quang Ho then became aware of black smoke filling the hallway. Leaving at speed and in obviously difficult circumstances, neither of them closed the front door of the flat, which did not have an effective self-closing device. They left the tower together at 01.26.[124]
Flat 76 rapidly filled with smoke, which then entered the floor 10 lobby. Within five minutes the lobby became so full of smoke that when the north lift unexpectedly stopped at that floor it was already dark and full of smoke. Some of the smoke penetrated the closed lift doors. More came in when the doors opened. The volume and density of the smoke that entered the lift made Nadia Jafari, who was in the lift, think that the lights had gone out. In the ensuing panic, three of the five people in the lift, Ali Yawar Jafari, Mohamednur Tuccu and Khadija Khalloufi, stumbled out and became trapped in the lobby of floor 10.[125]
The lift then continued its descent, reaching the ground floor at 01.26. Only Nadia Jafari and Rhea Rojo emerged. The extent of the smoke billowing from the lift as they left it, seen on CCTV, gives an indication of the amount of smoke on floor 10.[126] Nadia Jafari said that the smoke had been much thicker when the lift was at floor 10. At 01.28, in a call to the emergency services, the occupants of Flat 73, located in the south-west corner of the tower, reported smoke coming through their front door.[127]
Nagawa (Prossy) Nalukwago, who was staying in Flat 71, next to Flat 76, left the tower at 01.35. On leaving Flat 71, she had been confronted by thick black smoke which felt hot. Despite the conditions, she was able to make her way to the stairwell. While doing so, she stumbled over what she thought were three bodies.[128] They were the bodies of Ali Yawar Jafari, Mohamednur Tuccu and Khadija Khalloufi, all of whom had by then been overcome by the conditions in the lobby. That none of them had been able to reach the stairs shows how disorientating conditions on floor 10 were.
Clarita Ghavimi was woken at around 01.30 by a smoke alarm. She saw flames from her bedroom window. When she opened her front door, she found the lobby dark and smoky. She made her way to the stairwell door by touch because the lobby was too thick with smoke for her to see her way.[129] She was then rescued by another resident, Branislav Lukic, and carried down. They left the tower at 01.49.[130]
Between 01.40 and 01.42 a group of five firefighters led by CM Guy Tillotson began searching the tower to rescue anyone they could find. They went to floor 10 but found it so full of thick, black smoke that CM Tillotson decided that the firefighters could not enter the lobby without water.[131]
Date of birth: 1 January 1936 (81 years).
Place of birth: Kandahar, Afghanistan.
Gender: Male.
Occupation: Retired jeweller.
Usual address: Flat 86, floor 11, Grenfell Tower, London.
Place of death: Lobby of floor 10, Grenfell Tower, London.
Time of death: By about 01.37 on 14 June 2017.
Cause of death: la. Inhalation of asphyxiant gases. II. Coronary and hypertensive heart disease.
Born on 1 January 1936 in Kandahar, Afghanistan, Ali Yawar Jafari was an 81-year-old retired jewellery maker. He lived in Flat 86 on floor 11 of Grenfell Tower with his wife, Fatima Jafari, and their two adult daughters, Maria and Nadia Jafari. The family had lived there since 2003.[132]
Ali Yawar Jafari suffered from diabetes and heart disease.[133] Rydon’s survey of residents, prepared in November 2014 and provided to the TMO, recorded that he suffered from diabetes.[134] On the night of the fire, David Noble, a policy and diversity advisor with the TMO,[135] produced a spreadsheet listing the residents of the tower which was designed to record any known vulnerability or disability.[136] That spreadsheet was compiled from information held on the TMO’s Capita Insight system.[137] It did not identify Ali Yawar Jafari as a vulnerable resident.
Ali Yawar Jafari was last seen entering the tower at 19.40 on 13 June 2017.[138] He remained in his home preparing to break the Ramadan fast with his family.[139]
By 01.22 the fire had reached the top of floor 11 outside the kitchen of Flat 86.[140] By then the Jafari family were already aware of it and Fatima and Maria Jafari had started to make their way out of the building. Before doing so, Fatima asked Nadia to wake her father and help him outside. Nadia and her father were still in the flat when she saw flames push through the extractor fan of the kitchen window, the glass in that window shatter and the frame fall out. She shut the kitchen door and together with her father left the flat.[141]
In the lobby, Nadia Jafari and her father knocked on the doors of neighbours. She spoke to Natasha Elcock in Flat 82 and even tried to go back into Flat 86. She was not able to lock the door of the flat, which was left partly open. The smoke emerging from Flat 86 did not immediately fill the lobby of floor 11 and the lights were still visible. Nadia suggested to her father that they use the lift to leave the tower.[142] By that time, Ali Yawar Jafari had been exposed to only a limited amount of smoke.
Mohamednur Tuccu and Rhea Rojo were already in the north lift when it stopped at floor 11. Khadija Khalloufi, who had made her way down from her own flat on floor 17, entered the lobby of floor 11 and got into the lift at the same time as the Jafaris.[143] There appears to have been no smoke in the lift when it reached floor 11.
The lift started to descend but suddenly stopped at floor 10. Smoke began to seep in through the closed doors. When they opened, the inward rush of smoke filled the lift obscuring the lights. The occupants were left coughing and shouting. In the panic Ali Yawar Jafari, Mohamednur Tuccu and Khadija Khalloufi went into the lobby, which by then was filled with dense black smoke.[144] Unable to find a way out, Ali Yawar Jafari became trapped in the lobby on floor 10.
The lift probably stopped on floor 10 shortly before 01.26 (the time when Nadia Jafari and Rhea Rojo are seen leaving the lift on the ground floor).[145] Initially, Nadia Jafari thought her father had left the lift on the ground floor ahead of her.[146]
When they had left the tower and realised that their father had not escaped the building, Nadia and Maria Jafari tried to re-enter it but were stopped by a police officer, possibly PC Kiran Sangha, who recalled being told by a family he had prevented from entering the tower that their grandfather was stuck in the lift. The officer told a fireman outside the tower that there were people stuck in a lift but was told that the fire brigade had control of the lifts in the tower.[147] There is no evidence of what, if any, further steps were taken in response to what the officer had said.
CM Martin Hoare and FF Matthew Tanner tallied out at 02.55.[148] Having originally been sent to search Flat 74 on floor 10, they were reassigned with other firefighters to search for a missing firefighter on floor 12. Once that emergency had been resolved, they returned to their original task. When they reached floor 10 and opened the door to the lobby, they were confronted by intense heat with smoke extending down to a foot above the floor. Crawling into the lobby, they found Ali Yawar Jafari’s body near the lift and brought him out into the stairwell. CM Hoare accepted that he had originally wrongly identified the casualty as Mohamednur Tuccu.[149]
As he and FF Tanner were carrying Ali Yawar Jafari down the stairs, CM Hoare realised that he was running out of air.[150] Concluding that Ali Yawar Jafari had already died, the firefighters laid his body on the stairs.[151] Returning to the bridgehead, they reported where they had left him. FFs Charlie Rawlings, Andrew Brooks and James Morcos were sent to recover his body.[152] It was carried out of the tower at 03.34.[153] At 03.35, paramedic Mark Hodson confirmed that he was dead.[154]
The coroner, Professor Wilcox, was satisfied that the casualty recovered by CM Hoare and FF Tanner was Ali Yawar Jafari and therefore issued an interim certificate of the fact of death.[155]
The post-mortem on Ali Yawar Jafari found that his body was intact. There were soot deposits around his nose and mouth and some superficial burns and heat damage to the skin. The post-mortem also confirmed that he had suffered from severe heart disease which affected the blood supply to his heart and made him more vulnerable to the conditions produced during a fire, so contributing to his death.[156]
The level of carboxyhaemoglobin in a blood sample taken from Ali Yawar Jafari was found to be 47%.[157] That is within the toxic range for someone whose pre-existing heart disease made him more vulnerable to conditions in the lobby.[158] No cyanide was detected in the sample when it was later tested. As cyanide was found in samples taken from Mohamednur Tuccu and Khadija Khalloufi, its absence in the case of Ali Yawar Jafari was probably due to degradation of the sample over time.[159] It is likely therefore that Ali Yawar Jafari inhaled hydrogen cyanide, although we cannot say how much.
The medical cause of death was recorded as:
Ia. Inhalation of fire fumes.
II. Coronary and hypertensive heart disease.
In the light of Professor Purser’s evidence we find that a more accurate description of the primary cause of death is “inhalation of asphyxiant gases”.
Given his poor health, the manner in which he came to leave the lift on floor 10, the conditions in the lobby on that floor and the fact that his body was recovered near the lift, we find that Ali Yawar Jafari probably collapsed due to the inhalation of asphyxiant gases within a minute or so of stepping out of the lift. While unconscious, he continued to inhale those gases until his respiration and circulation ceased some minutes later and he died at about 01.37,[160] mainly from the effects of carbon monoxide poisoning.[161] He would have had to be rescued before about 01.35 to have had a reasonable prospect of survival.[162]
Date of birth: 24 May 1973 (44 years).
Place of birth: Eritrea.
Gender: Male.
Occupation: Security Officer.
Usual address: Arne House, Tyers Street, London
Place of death: Lobby of floor 10, Grenfell Tower, London
Time of death: By 01.46 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Born in Eritrea, Mohamednur Tuccu had lived in the United Kingdom since 1991. Aged 44 years (born 24 May 1973), he was working as a security guard at the time of the fire. Mohamednur Tuccu is not listed as a resident in the spreadsheet[163] produced on the night of the fire by David Noble.[164] His wife, Amal Ahmedin, and daughter, Amaya Tuccu-Ahmedin, lived in Flat 166 on floor 19. On the evening of 13 June 2017, Amna Idris, Amal Ahmedin’s cousin, was visiting the family.[165]
Mohamednur Tuccu was seen on CCTV entering Grenfell Tower at 00.36.[166] His movements thereafter are unknown, but it is very likely that he visited his family. By 01.25, the fire had reached the top of floor 19 and was outside Flat 166.[167] Shortly after 01.25, Meron Mekonnen, who lived in Flat 163, left her home having been alerted to the fire. She saw Amal Ahmedin and Amna Idris in the lobby of floor 19. They told each other that there was a fire in the building.[168] Meron Mekonnen left the tower at 01.32. Amal Ahmedin, with her daughter, and Amna Idris subsequently made their way up to shelter in Flat 201 on floor 23. It is likely that they reached it by about 01.30.[169] They died on floor 23 and we deal with the circumstances of their deaths in Chapter 97.
There is no evidence that Mohamednur Tuccu was in Flat 166 when Meron Mekonnen saw Amal Ahmedin or that he was among those who made their way up the tower. He was, however, in the north lift when Rhea Rojo entered it on floor 12.[170] It is not known where Mohamednur Tuccu entered the lift, but it would have been somewhere above floor 12. Since the lift stopped at floors 11 and 10 and reached the ground floor at 01.26,[171] it is reasonable to conclude that he left Flat 166 before the fire had reached floor 19.
When the lift stopped at floor 11, Khadija Khalloufi, who had made her way down the stairs from her home on floor 17 and had entered the lobby on floor 11, got into the lift together with Nadia Jafari and her father, Ali Yawar Jafari.[172]
The lift probably stopped on floor 10 shortly before 01.26, when Nadia Jafari and Rhea Rojo can be seen leaving the lift on the ground floor.[173]
It is unlikely that Mohamednur Tuccu had been exposed to any smoke before the lift reached floor 10. When the doors opened, the inward rush of smoke filled the lift obscuring the lights. Those in the lift were left coughing and shouting. In the panic Mohamednur Tuccu, together with Ali Yawar Jafari and Khadija Khalloufi, entered the lobby on floor 10, by then filled with dense black smoke.[174] Unable to find a way out, he was trapped there.
At 02.04,[175] FFs Oliver Desforges and Robert Mitchell were deployed with other firefighters to rescue Mariko Toyoshima-Lewis and her family from Flat 9 on floor 3. They were then deployed to floor 24. Climbing the stairs, the two firefighters realised that they did not have enough air to get there. They decided to search a floor they could reach,[176] which turned out to be floor 10.
FF Desforges said that the heat they encountered on opening the door from the stairwell into the lobby was the most intense he had ever experienced. The lobby was filled with hot black smoke and it was impossible to see anything. Keeping low to the ground, the two firefighters found and were able to recover two casualties, Mohamednur Tuccu and Khadija Khalloufi.[177]
With the assistance of other firefighters, Mohamednur Tuccu was carried down the stairs and out of the tower at 02:28.[178] At 02.37, paramedic Stuart Matthews formally confirmed that he was dead.[179]
The coroner, Professor Wilcox, was satisfied that the casualty recovered by FFs Desforges and Mitchell was Mohamednur Tuccu and therefore issued an interim certificate of the fact of death.[180]
The post-mortem on Mohamednur Tuccu recorded that his body was intact without any burns and that there were significant soot deposits on his face, in his nostrils and in his respiratory system.[181] There was bruising on the back of the head consistent with minor blows sustained during an attempt to escape.[182]
The level of carboxyhaemoglobin in a blood sample taken from him was found to be 73%,[183] which indicates that he had inhaled a considerable amount of carbon monoxide before he died. Later analysis of the blood sample measured a cyanide concentration of 0.18 milligrams/litre.[184] That is not in the toxic range but is elevated by comparison with the level naturally occurring in the blood.[185] It is likely that it was affected by degradation of the sample and did not reflect the level of cyanide in the blood at the time of death.[186] Its presence shows that Mohamednur Tuccu had inhaled some hydrogen cyanide at the time of his death but it is not possible to say how much.
The post-mortem recorded the medical cause of death as “inhalation of fire fumes” but in the light of more recent evidence we find that a more accurate description is “inhalation of asphyxiant gases”.
Given the circumstances in which Mohamednur Tuccu left the lift on floor 10, the conditions in the lobby on that floor and the level of carboxyhaemoglobin subsequently found in his blood, we are satisfied that he probably collapsed due to the inhalation of asphyxiant gases within a few minutes of stepping out of the lift. While unconscious, he continued to inhale those gases until his respiration and circulation ceased some minutes later and he died. The level of carboxyhaemoglobin in his blood indicates that the exposure to carbon monoxide alone would have been fatal, although he also inhaled some hydrogen cyanide.[187] He would have had to be rescued before about 01.35 at the latest to have had a reasonable prospect of survival.[188]
Having considered the evidence, we find that Mohamednur Tuccu had died by 01.46 before being exposed to the direct effect of the flames.
Date of birth: 6 September 1964 (52 years).
Place of birth: Mohammedia, Morocco.
Gender: Female.
Occupation: Homemaker.
Usual address: Flat 143, floor 17, Grenfell Tower, London.
Place of death: Lobby of floor 10, Grenfell Tower, London.
Time of death: By 01.44 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Born in Mohammedia, Morocco on 6 September 1964 as the eldest of seven siblings, Khadija Khalloufi was 52 years old at the time of her death. A graduate, she had managed a pharmacy in Morocco before moving to Holland to live and work and ultimately settling in London. At the time of the fire, Khadija Khalloufi lived in Flat 143 on floor 17 with her husband Sabah Abdullah. They had married in 1990.[189]
Khadija Khalloufi returned to Grenfell Tower on 13 June 2017 at 16.02[190] and remained in her home. Mesrob Kassemdjian, who lived in Flat 146 with his aunt, Rita Tankarian, alerted Khadija Khalloufi to the fire before leaving floor 17. She then turned back into her flat to speak to her husband, Sabah Abdullah. Mesrob Kassemdjian left the tower at 01.25 just ahead of Rita Tankarian. She recalled Sabah Abdullah telling her outside the tower that he had lost his wife on the stairs at some point between floors 14 and 17.[191]
Khadija Khalloufi was next seen by Nadia Jafari. She entered the lobby of floor 11, called the lift and waited for it with Nadia Jafari and her father, Ali Yawar Jafari.[192] We do not know why Khadija Khalloufi chose to enter floor 11. It is unlikely that at that stage she had been exposed to any smoke.
Mohamednur Tuccu and Rhea Rojo were already in the lift when it reached floor 11 and Khadija Khalloufi, Nadia Jafari and her father all entered it. When the lift suddenly stopped at floor 10, smoke began to seep in through the closed doors. When they opened, the inward rush of smoke filled the lift obscuring the lights. Those in the lift were left coughing and shouting. In the panic Khadija Khalloufi, together with Ali Yawar Jafari and Mohamednur Tuccu, came out into the lobby of floor 10, by then filled with thick black smoke.[193] Unable to find her way out, Khadija Khalloufi became trapped.
At 02.04,[194] FFs Oliver Desforges and Robert Mitchell were deployed with other firefighters to rescue Mariko Toyoshima-Lewis and her family from Flat 9 on floor 3. They were then deployed to floor 23. Climbing the stairs, the two firefighters realised that they did not have enough air to reach that floor. They decided to search a floor that they could reach.[195] That turned out to be floor 10.
FF Desforges described the heat they encountered on opening the door from the stairwell into the lobby was the most intense he had ever experienced. The lobby was filled with hot black smoke and it was impossible to see anything. Keeping low to the ground, he and FF Mitchell found and were able to recover two casualties, Mohamednur Tuccu and Khadija Khalloufi.[196]
Khadija Khalloufi was carried out of the tower at 02.28.[197] At 02.41, paramedic Stuart Matthews formally confirmed that she was dead.[198]
The coroner, Professor Wilcox, was satisfied that the casualty recovered by FFs Desforges and Mitchell was Khadija Khalloufi and therefore issued an interim certificate of the fact of death.[199]
The post-mortem on Khadija Khalloufi recorded that her body was intact without any burns and that there was dense soot staining around the nostrils and ears and extensive soot contamination in the respiratory system. There were some minor abrasions and bruising which she probably sustained during attempts to find her way out of the lobby on floor 10.[200]
The carboxyhaemoglobin level in a sample of blood taken from Khadija Khalloufi was 66%,[201] which indicated the inhalation of a significant amount of carbon monoxide. Later analysis of the sample showed a cyanide concentration of 0.59 milligrams/litre.[202] That is significantly higher than the background level of cyanide found naturally in the blood.[203] That it was detected shows that Khadija Khalloufi had inhaled hydrogen cyanide, but since the sample is likely to have degraded over time,[204] we do not know how much cyanide was in her blood at the time of her death.
The post-mortem recorded the medical cause of death as “inhalation of fire fumes” but in the light of more recent evidence we find that a more accurate description is “inhalation of asphyxiant gases”.
Given the circumstances in which Khadija Khalloufi left the lift when it reached floor 10, the conditions in the lobby and the level of carboxyhaemoglobin in her blood, we find that she probably collapsed due to the inhalation of asphyxiant gases within a few minutes of exiting the lift. While unconscious, she continued to inhale those gases until her respiration and circulation ceased some minutes later and she died. The level of carboxyhaemoglobin subsequently found in her blood indicates that the degree of exposure to carbon monoxide alone would have been fatal, but she must have also inhaled some hydrogen cyanide.[205]
Having considered the evidence, we are satisfied that Khadija Khalloufi had died by 01.44. She would have had to be rescued no later than 01.35 to have had a reasonable prospect of survival. We are satisfied that she died before being exposed to the direct effect of the flames.
By 01.22 on 14 June 2017 the fire on the outside of the building had reached the top of floor 11 outside Flat 86.[206] All six flats on floor 11 were still occupied. Except for Ali Yawar Jafari, whose body was recovered from the lobby of floor 10, and Abdeslam Sebbar, who remained in Flat 81, all the occupants of floor 11 survived the fire.
The Jafari family, in Flat 86, were the first to leave. Of that family, Nadia Jafari and her father, Ali Yawar Jafari, left last. By that time, flames and smoke had begun to penetrate Flat 86.[207]
The front door of Flat 86 did not have an effective self-closing device and when she left Nadia Jafari left the door partly open.[208] She did not see or smell smoke while she was in the lobby. She and her father then entered the lift when it stopped on that floor.[209] Since Nadia Jafari left the lift at 01.26 when it reached the ground floor,[210] it is likely that they entered the lift shortly before that time. As we have explained, Ali Yawar Jafari died after leaving the lift on floor 10.[211]
The occupants of Flat 85 (Youssef Khalloud, Mouna El-Ogbani and their three children) were the next to leave floor 11, followed by the occupants of Flat 84 (Miran Lovsin and Branislav Lukic). They all left the building between 01.27 and 01.49.[212] That left Abdeslam Sebbar in Flat 81, Natasha Elcock and her family in Flat 82 and Elpidio Bonifacio in Flat 83.
Between 01.28 and 04.41, those on floor 11 or their relatives outside the tower made 22 calls to the emergency services. Abdeslam Sebbar and his grandson made four calls between them.[213] Elpidio Bonifacio’s daughter-in-law made four calls about him between 02.58 and 05.31.[214] Natasha Elcock made 14 calls between 01.28 and 04.33.[215] The first two calls from Natasha Elcock showed how quickly conditions worsened in the lobby of floor 11. She described a rapid change in the density of the smoke between her first call at 01.28 (when there was only a small amount of smoke) and her second call at 01.33 (at which time she described the lobby as pitch black).[216] When at some time before 01.40, Miran Lovsin and Branislav Lukic made an unsuccessful attempt to leave Flat 84, they found the lobby full of thick black smoke.[217]
No firefighters were deployed to floor 11 before 04.00. Between then and 04.50, firefighters were sent to search Flats 81 to 84. They had difficulty searching floor 11 because of the intense heat in the lobby.[218] Another team that had been sent to floor 9 miscalculated and arrived on floor 11, where they helped Natasha Elcock, her partner and child, to leave.[219] The family left the tower at 04.47.[220]
Elpidio Bonifacio was the last surviving resident of the tower to be rescued, reaching the base of the tower at 08.07.[221]
No resident of floor 11 had contact with Abdeslam Sebbar on the night of the fire and there is no evidence to suggest that he ventured from Flat 81.
Date of birth: 11 September 1939 (77 years old).
Place of birth: Larache, Morocco.
Gender: Male.
Occupation: Retired.
Usual address: Flat 81, floor 11, Grenfell Tower, London.
Place of death: Flat 81, floor 11, Grenfell Tower, London.
Time of death: Between 3.50 and 04.05 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Born on 11 September 1939 in Larache, Morocco, Abdeslam Sebbar was a 77-year-old retired coffee shop owner and chef. He lived alone in Flat 81, a one-bedroom flat on the east side of floor 11 of Grenfell Tower.[222] He had been the tenant of Flat 81 since 1978 and very involved in his local community.[223]
In a letter to RBKC dated 9 November 2016 the TMO stated that Abdeslam Sebbar was diabetic and frail, had difficulty using stairs and needed accommodation at ground level or with a lift.[224] He appeared in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system,[225] but it contained no information about his physical limitations.[226]
Abdeslam Sebbar returned home at approximately 00.23 on 14 June 2017 and did not leave again.[227] He called the emergency services at 01.25, shortly after the fire reached the top of floor 11 at about 01.22.[228] In that call, he reported a fire but did not say where he was.[229]
Abdeslam Sebbar also called his son, Mohamed Sebbar, who, having learned of the fire, was driving to the tower with his own son, Youness Sebbar.[230] Mohamed Sebbar tried to reassure his father and told him to leave, although he believed his father would need help to do so. They were still speaking to each other when Mohamed Sebbar reached the tower at around 01.30.[231]
At 01.33, Abdeslam Sebbar made a second call to the emergency services which was the last direct contact he had with them. Before disconnecting the call, he reported that he was on floor 11 and that the fire was in his flat. He did not give the number of his flat.[232] By that time the fire had not penetrated Flat 81, but was established in the adjacent flat, Flat 86. As Natasha Elcock reported in the emergency call she made at the same time, smoke had by then reached the lobby of floor 11.[233]
Having reached the tower, Mohamed Sebbar spoke to his father twice more, the first time between 01.45 and 02.30.[234] At 02.46, Youness Sebbar made a call to the emergency services which was connected to Merseyside Fire and Rescue Service. He said that his grandfather was stuck in Flat 81 and had stopped talking and that help was needed urgently. That information was passed on to the LFB in a call timed at 02.47.[235] The Phase 1 report concluded that Abdeslam Sebbar stopped responding to his family shortly before 02.46.[236] However, in a statement dated 20 May 2022, Mohammed Sebbar recalled that his last call with his father had taken place after Youness Sebbar had made an emergency call at about 02.46. In that last call, Abdeslam Sebbar was sheltering in the lavatory of Flat 81 and was struggling to breathe. The call continued until approximately 03.30 when Abdeslam Sebbar stopped responding.[237]
Youness Sebbar made a second emergency call at 04.39 that was taken by CRO Pamela Jones, in which he asked if there was any information about his grandfather. Youness Sebbar gave the number of his grandfather’s flat and asked if it could be checked. He also asked where casualties were being taken. CRO Jones was not able to provide any information.[238]
Two of the emergency calls made by or about Abdeslam Sebbar (his own call at 01.33 and that of his grandson at 02.46) included information about his location and the fact that he was still in his flat. However, information about Abdeslam Sebbar did not reach the incident ground until 03.00:
From about 03.00, CU7 moved to recording information on a whiteboard using a grid system.[245] Photographs of that whiteboard,[246] taken much later, show that the following had been entered on the grid: “81 1 1 P” with the first “1” in green indicating an adult, the second “1” in black indicating a child, and the “P” in red and circled, indicating a priority.[247] A red tick was used on the grid to indicate that a crew had been deployed. No red tick appeared in the entry. The mention of a child is an error but, in any event, we do not know when the entry was made or how the information reached CU7. It was probably sent after Youness Sebbar made his call at 02.46.
Once the bridgehead had been moved to the ground floor, information was recorded on a green wall at the bottom of the stairs.[248] The inscription “BABY 81 82 83 84 – 11” appears in photographs of that wall taken by SM (now GM) Michael Mulholland at about 04.45.[249] It is not clear when that information was put there. It may have been after 04.05 as one of the manuscripts notes delivered to WM Brien O’Keeffe by runners refers to “81 11” together with what appears to be a time stamp of “04.05”.[250]
The remains of Abdeslam Sebbar were recovered from the bathroom of Flat 81.[251] The coroner, Professor Wilcox, was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.[252]
The post-mortem on Abdeslam Sebbar found soot in his airways and no clear evidence of burns or trauma before death.[253] The level of carboxyhaemoglobin in his blood was 90%,[254] indicating that he must have inhaled a considerable amount of carbon monoxide before he died. Later analysis of the same blood sample detected cyanide at a level of 0.17 milligrams/litre.[255] That is only slightly elevated compared to naturally occurring levels, probably as a consequence of degradation of the sample over time.[256] While the level of cyanide in his blood at the time of death is therefore unknown, its presence shows that he had been exposed to hydrogen cyanide before he died.
The post-mortem recorded the medical cause of death as “inhalation of fire fumes” but in the light of Professor Purser’s evidence we find that a more accurate description is “inhalation of asphyxiant gases”.
By 02.46, Abdeslam Sebbar had been sheltering in the bathroom for some time. Its location meant that it was one of the last parts of the flat to be affected by internal fires. While that afforded Abdeslam Sebbar some protection, he was still exposed to asphyxiant gases entering the flat from the lobby and the outside. By 02.53 the fire had reached the outside of Flat 81.[257] Flames could be seen inside the windows of Flat 81 from about 03.45.[258]
Mohamed Sebbar’s evidence about the last time he spoke to his father was not available when Professor Purser was preparing his report. However, the evidence did not affect his conclusion that Abdeslam Sebbar died from the inhalation of asphyxiant gases. Professor Purser estimated that Abdeslam Sebbar died within 20 to 30 minutes of losing consciousness.[259]
In the light of Mohamed Sebbar’s evidence, Professor Purser’s evidence of the effect of asphyxiant gases and the post-mortem evidence, we find that Abdeslam Sebbar lost consciousness at about 03.30 due to the inhalation of asphyxiant gases. He continued to inhale those gases until his respiration and circulation ceased some minutes later and he died before any flames reached his body. Although he must have inhaled hydrogen cyanide, the level of carboxyhaemoglobin in his blood was such that his exposure to carbon monoxide alone would have been fatal. Abdeslam Sebbar died between 03.50 and 04.05.
When the fire began, all the flats on floor 14 were occupied apart from Flat 114. Nina Mangoba and her family in Flat 116 were the first residents to leave. As the fire progressed the remaining residents were gathered in Flat 113, the home of Oluwaseun Talabi and Rosemary Oyewole. They were Denis Murphy from Flat 111, brothers Omar Alhaj Ali and Mohammad Alhajali from Flat 112 and Zainab Deen and her son, Jeremiah Deen, from Flat 115. Firefighters subsequently rescued Oluwaseun Talabi, Rosemary Oyewole and their daughter as well as Omar Alhaj Ali. Following that rescue, Mohammad Alhajali, Denis Murphy, Zainab and Jeremiah Deen remained in Flat 113. They died during the fire.
In Phase 1, the chairman made findings about the events on floor 14 and in Flat 113 in particular.[260] He said that the circumstances under which four people, one a child, had been left behind in Flat 113 required a more detailed examination than could conveniently be carried out in the context of the narrative description of the events of 14 June 2017 and proposed to undertake that examination at a later date after further submissions and possibly additional evidence had been received.[261]
In the end it was not necessary to hear any further evidence. We have, however, been assisted by representations made on behalf of the family of Mohammad Alhajali, the family of Denis Murphy and the LFB, as well as by a further statement from FF Peter Herrera, one of the firefighters involved in the partial evacuation of Flat 113.[262]
Since they are of particular importance to understanding the circumstances of the individual deaths on floor 14, we set out first not only our general findings about the events that took place on that floor but also our findings on how four people came to be left behind in Flat 113.
By 01.23, the fire had spread up the eastern face of the tower and had reached the top of floor 15.[263] Flat 116 was the first flat on floor 14 to be affected by the fire. When Nida Mangoba and her family left it, there was thick black smoke in the hallway but only light smoke in the lobby.[264] In Phase 1, the chairman was unable to decide whether Nida Mangoba’s recollection that she had left the front door open was faulty or whether the door had closed sometime after she left; FFs Desmond Murphy and Charles Cornelius later found the front door closed.[265] In any event, the front door did not impede the rapid ingress of smoke into the lobby.
According to Denis Murphy, who made an emergency call at 01.25 to report a fire in the tower, by then there was already significant smoke in the lobby.[266] Oluwaseun Talabi and Rosemary Oyewole found the lobby filled with smoke when they tried to leave shortly before their first call to the emergency services at 01.37.[267] The conditions in the lobby were such that those who remained on floor 14 after 01.30 felt unable to cross the lobby and reach the stairs.[268]
By 01.45, Denis Murphy,[269] Zainab Deen,[270] and Rosemary Oyewole,[271] had made six emergency calls of which four were to the LFB control room.[272] At that stage Omar Alhaj Ali and Mohammad Alhajali in Flat 112 had not made any calls to the emergency services but had communicated to firefighters on the ground by shouting from the windows.[273]
As a result of emergency calls being made from floor 14, the incident ground was informed that there were occupants trapped on that floor, which probably prompted the following actions:
FFs Desmond Murphy and Charles Cornelius were sent to Flat 111 on floor 14 to rescue a man. They tallied out at 01.51.[278] At about the same time, FFs Harvey Sanders and Nicke Merrion were also sent to floor 14. FF Sanders recalled that they had been sent specifically to Flat 111, but FF Merrion could not recall whether they had been sent to Flat 111 or Flat 112. FF Merrion recalled that he had been instructed to tell the occupants to remain in their flat.[279]
FFs Murphy and Cornelius arrived on floor 14 first. They found Denis Murphy in Flat 111 which was quite heavily smoke-logged.[280] FFs Sanders and Merrion arrived on floor 14 soon afterwards. FF Merrion went to Flat 112, where he spoke to Omar Alhaj Ali and his brother, while FF Sanders went to Flat 113, where he met Rosemary Oyewole and Oluwaseun Talabi with their daughter. Those two flats were relatively clear of smoke.[281]
Denis Murphy was moved initially to Flat 112.[282] The four firefighters met in the lobby and agreed to move all the occupants remaining on floor 14 to Flat 113, which was furthest from the fire.[283] Rosemary Oyewole and Oluwaseun Talabi agreed to their request to bring their neighbours into their flat.[284]
Flat 113 was a two-bedroom flat in the southwest corner of the tower.[285] FF Murphy was one of the firefighters who went into the flat. Before leaving it, he counted six adults and two children. He told them that the crew were low on air and were going to change their cylinders. Although the residents wanted to leave, FF Murphy told them to stay in the flat with the door shut and that another crew would come up to them.[286]
The firefighters’ decision to move all the occupants into one flat arose from their belief that conditions in the stairwell made it impossible for eight people to leave safely,[287] their view that Flat 113 was the safest place for them to be[288] and their concerns about how much air was left to them.[289] Although it was in the stairs that people escaping from floor 14 were most exposed to asphyxiant gases, those who had absorbed only a minimal amount of carbon monoxide in their flats and the lobbies before entering them could at all times survive the descent.[290] Since people were inhaling an increasing amount of asphyxiant gases while in their flats, the longer they remained in them, the greater the danger of their accumulating an amount sufficient to cause collapse and death.[291] We note that some of the occupants of Flat 113 were later able safely to evacuate floor 14 without the assistance of any specialist equipment at a time when conditions were described by Rosemary Oyewole as significantly worse.[292] Although we accept that it might have been possible for the occupants of floor 14 to have escaped safely at that time, we do not consider that the decision made by FFs Merrion, Sanders, Murphy and Cornelius can be criticised, given the circumstances confronting them.
Some time after the firefighters left floor 14, another crew of firefighters visited Flat 113 by chance. They were FFs Luke Cook and Brian Flanagan, who went to Flat 113 between 02.03 and 02.37, probably at around 02.20. They noted that the flat contained eight people, including two children. They left the residents in the flat and returned to the bridgehead. There is no evidence that they reported the location those still on floor 14 to the bridgehead.[293]
On returning from floor 14, FFs Merrion, Sanders, Murphy and Cornelius told the bridgehead that residents remained on that floor.
The LFB control room continued to pass information about floor 14 to the incident ground even after the first deployment of firefighters:
WM Glynn Williams began recording information on a ground floor wall of the tower at 02.15. He explained that he had written “FSG @2.15” on the wall and had then begun listing information immediately below that heading. (A second list was subsequently created on the wall to the left of the first.) The order in which he listed information initially matched that on the Sadler envelope and included Flats 111 and 115.[300] That WM Williams was also receiving fresh information, however, is suggested by his having written “1xA 1xK” (for 1 adult and 1 kid) next to Flat 115.[301]
In any event, the information that had been received from returning fire fighters and from the control room prompted the deployment of two more crews to floor 14 within minutes of FFs Murphy and Cornelius reaching the bridgehead.
FFs Herrera and Teresa Orchard tallied out at 02.26 and 02.27 respectively with instructions from WM Louisa de Silvo to go to Flat 113. A sketch of what looks like a football in which is written “113, FL 14th” and “Lambeth PL” (for pump ladder) was made on the wall on floor 3. Although WM De Silvo said that it was not in her handwriting, it may have related to the deployment of FFs Herrera and Orchard, given that the former was based at Lambeth Fire Station.[302]
FF Herrera recalled having been told that a man, woman and child needed to be rescued. On the other hand, FF Orchard recalled that they had been instructed to rescue six people in Flat 113. Although in the Phase 1 report the chairman noted that it was unlikely that WM De Silvo had given two members of the same crew inconsistent instructions relating to the same flat, he was not able to find which account was correct.[303]
FF Herrera’s recollection of the briefing reflects the emergency call made by Rosemary Oyewole at 01.37. However, although she mentioned that she had a baby, she did not confirm how many people were in the flat.[304] No other emergency calls were made from Flat 113 until after FFs Herrera and Orchard had set off. Although FF Orchard did not refer to six people in her contemporaneous note, we think that her recollection was more reliable on this point. It is closer in time to the earlier, but still recent, reports to the bridgehead provided by FF Merrion, Sanders, Murphy and Cornelius, even though the information about two children was lost. We find that it was those reports, and in particular the explicit reference of FFs Murphy and Cornelius to the need for crews to return to floor 14, that prompted the deployment of FFs Herrera and Orchard. It is possible, however, that some reference was made during the briefing to a family of three which, amid all the noise and activity at the bridgehead, FF Herrera mistook as his instructions.
CM Benjamin McAlonen and FF Elliot Juggins tallied out at 02.31 shortly after FFs Herrera and Orchard. They had been instructed by WM Paul Watson to find a woman and child in Flat 111 on floor 14.[305] That is, we think, confirmed by the inscription on the wall of floor 3 which referred to Flat 111 and floor 14, together with the word “Lambeth”. Since both CM McAlonen and FF Juggins were based at Lambeth Fire Station, the note probably refers to their deployment.[306] In our view, this briefing resulted from the information received from the calls to the emergency services made at 01.48. It was wrong in that Zainab and Jeremiah Deen had been in Flat 115 and, more importantly, were by then in Flat 113 together with others.
The two crews were not aware that they were both being deployed to floor 14.[307] The effect of the separate briefings was that only one crew (FFs Herrera and Orchard) was deployed to Flat 113 and without the spare BA sets that FF Cornelius had said were necessary. Neither member of that crew was aware that their task was to rescue eight people from Flat 113.[308]
CM McAlonen and FF Juggins reached floor 14 first. They searched Flat 111 before then searching Flat 112.[309] CM McAlonen tried to make radio contact with the bridgehead to gain more information but could not get through. FF Orchard and FF Herrera had reached floor 14 by then and went to Flat 113.[310] The two crews described the stairwell as being full of black smoke from the bridgehead up to floor 14 and the lobby on that floor to be smoke-logged.[311] Rosemary Oyewole and Oluwaseun Talabi said that when they left Flat 113, the lobby was full of acrid black smoke which made it difficult to breathe. The stairs were full of the same smoke but felt much hotter than the lobby. They ran down the stairwell and did not see any light until about floor 3.[312] Omar Alhaj Ali recalled the lobby and stairwell being filled with hot smoke and without any visibility. He did not see any light in the stairwell until he reached floor 2 or 3.[313]
There was a conflict of evidence relating to much of what happened when the firefighters reached Flat 113, but the following is not disputed. First, the evidence from both firefighters and occupants shows that Rosemary Oyewole and Oluwaseun Talabi (with their daughter tied to his back) left Flat 113 first, followed by Omar Alhaj Ali.[314] Second, FF Herrera was the only firefighter to enter Flat 113.[315] Third, as the chairman found in the Phase 1 report, FF Herrera did not conduct a search or secondary sweep of Flat 113.[316] Fourth, as we have already observed, four people did not leave Flat 113.
That four people were left behind is, on the face of it, an extraordinary state of affairs and makes it necessary to consider how it could have come about. We answer that question by reference to the evidence given by the firefighters and those who were present in Flat 113 at the time and survived the ordeal. In doing so we have considered the representations that we have already mentioned.
Unfortunately, the evidence bearing on the question is rather confusing. Rosemary Oyewole, Oluwaseun Talabi and Omar Alhaj Ali all gave evidence, as did FF Herrera and Orchard, but their accounts were difficult to reconcile with each other and in some cases were internally inconsistent.
Rosemary Oyewole said that when her neighbours from Flats 111, 112 and 115 had been brought into her flat they had dispersed around the various rooms, as might be expected. However, after having been advised by one of the firefighters who had returned to Flat 113 that they should all go into her bedroom (the larger bedroom opposite the front door) they had congregated in that room. The two children had been sitting on the bed, Denis Murphy on the side of the bed nearer the door and Zainab Deen on the floor near the door into the hall.[317]
Rosemary Oyewole said that at the time there had been some smoke in the flat, but not enough to reduce visibility to a significant extent.[318] She said that after they had all gone into the bedroom she had kept the door closed in order to prevent smoke from coming into the room from the hall. Earlier, Oluwaseun Talabi had threatened to leave the flat by the bedroom window using an improvised rope made of bedsheets but had been dissuaded from doing so. As they waited to be rescued, however, they had become more desperate and, with the assistance of Omar Alhaj Ali and Mohammad Alhajali, Oluwaseun Talabi had begun to make a serious attempt to escape from the window with his daughter tied tightly to his back.[319] At that stage, according to Rosemary Oyewole, the bedroom door flew open and she saw a firefighter (who must have been FF Herrera) standing by the front door.[320] She rushed out of the room into the hall and out into the lobby, closely followed by Oluwaseun Talabi, who was still carrying their daughter on his back. She did not appear to have a clear recollection of having passed Denis Murphy or Zainab Deen, although she said that she must have done so; nor did she remember having said anything to the others in the room at that time.[321]
Oluwaseun Talabi recalled that when their neighbours had been brought into Flat 113 they had moved around quite a lot but had eventually all congregated in the larger bedroom.[322] He said he remembered Mohammad Alhajali sitting on the side of the bed further from the door reading his Qur’an.[323] As he was preparing to make a second attempt to leave from the window he had heard a knock at the front door. As he remembered it, the bedroom door had been open and he could see through to the front door. There was smoke in the flat, but visibility was reasonable.[324] He was asked by counsel to confirm that everyone had been in the bedroom at that point. He was clear that Zainab and Jeremiah Deen had been there and also Denis Murphy, as well as himself and Rosemary Oyewole, but he was unsure whether Omar Alhaj Ali and Mohammad Alhajali had also been there or whether they had been elsewhere in the flat. He thought that if the bedroom door had been open it would have been possible to see Denis Murphy and Jeremiah Deen from the hallway.[325]
Oluwaseun Talabi thought that the firefighter who had come to the door had not come far into the flat; indeed, he thought that he had scarcely crossed the threshold. Everything happened very quickly. He and Rosemary Oyewole had left the flat hand in hand with their daughter still tied to his back. He did not remember whether any of his neighbours had been ahead of him, or indeed what they had done. Again, he was not sure whether Omar Alhaj Ali and Mohammad Alhajali had been in the bedroom at that critical point.[326]
Omar Alhaj Ali recalled that when they had been moved into Flat 113, they had all initially gathered in the lounge.[327] He remembered Oluwaseun Talabi’s first attempt to leave by way of the window, but was not sure whether that had been the window in the bedroom or the window in the lounge.[328] He remembered that they had all gathered in the bedroom, but that it had seemed quite small and that he and his brother had walked around at times.[329] He described smoke coming under the front door and getting thicker in the hallway. Visibility, as he recalled, had reduced significantly.[330] He was not sure whether he had been in the bedroom when the firefighters came to rescue them, because people had been moving around in the flat. He said that when the firefighter opened the front door he had seen Oluwaseun Talabi run towards it, so he had followed him. He initially said that he thought Mohammed might have been in the lounge at that time, but later said that he thought he had been with everyone else in the bedroom. When the door was opened, thick black smoke had come into the flat making it difficult to see. He was not very sure whether he himself had been in the bedroom or the living room when the firefighter had opened the door, but he had followed Oluwaseun Talabi; everyone else, including Mohammed, had been behind him. Just before that he had been talking to Mohammed, who had been standing close to him. He did not remember any firefighter going into the bedroom or the lounge and was adamant that he had not had any conversation with FF Herrera. He just remembered being bundled out of the flat and across the lobby. [331]
When he had left the building, Omar Alhaj Ali looked for his brother and, realising that he might still be inside the tower, telephoned him. He told firefighters that Mohammed was still in Flat 113 with two other adults and a child[332] but denied, as FF Herrera recalled, ever having used words to the effect that he had been mistaken.[333]
FF Herrera said that, when he had been briefed by WM De Silvo, he had not been told to search the flat; simply that there were three people there waiting to be rescued, so he had expected them to be ready to leave as soon as he arrived.[334] As explained above, we consider it more likely that WM De Silvo’s briefing had reflected the information most recently received at the bridgehead.
FF Herrera said that he had banged on the door of Flat 113 and had shouted to those inside that they were the fire brigade and had come to take them down. He recalled that the occupants had at first appeared reluctant to open the door, perhaps because inside they were in clean, safe air, but that once they had opened the door a little he had been able to push his way in.[335] Although he said that at first he had gone only into the hall, he said that he had then gone as far as the living room. That might suggest that he had gone into the main reception room (at no point did he suggest that he had gone into a bedroom), but when asked whether he had formed an impression of the number of people there he said that there had been four, two men, one woman and a child.[336]
In his first statement FF Herrera had said that he had seen the silhouette of a man standing in the living room. He said that he had asked him whether there was anyone else in the flat, to which the reply had been “No, I am the last one”. FF Herrera said he had then taken him out into the lobby and towards the stairs. He said that he had not thought it necessary to search the flat because the man had been clear that there was no one else left in it. [337]
FF Herrera recalled that having told WM De Silvo and WM Williams that Flat 113 was empty, he and the other firefighters left the tower and were approached by Omar Alhaj Ali who told him that his brother was still inside the building. As FF Herrera recalled it, Omar Alhaj Ali had said words to the effect that he had been mistaken, possibly implying that he had been wrong to say that there was no one else in the flat. As a result of that conversation FF Herrera returned to the ground floor lobby and told WM Williams that there was another person in Flat 113. He then went to the bridgehead where he also told WM De Silvo, but he did not know what she had done with the information.[338] Another witness, Ammar Alkabib, who described himself as a friend of Omar Alhaj Ali and Mohammad Alhajali, provided a statement to the police, in which he said that he had been at the tower when Omar was brought out. He described Omar as asking in desperation where Mohammad was and saying, “It’s my mistake, it’s my mistake.”[339] Omar Alhaj Ali denied, however, having said anything of the kind.[340]
It is difficult to know what to make of this rather confused body of evidence. We are entirely confident that the man with whom FF Herrera said that he had had a brief conversation inside Flat 113 must have been Omar Alhaj Ali, since he was the only person taken out in addition to Oluwaseun Talabi, Rosemary Oyewole and their daughter, but Omar Alhaj Ali firmly denied that words of any kind had passed between himself and FF Herrera. Although the witnesses gave different descriptions of the amount of smoke in the flat, we think that by the time FFs Herrera and Orchard arrived it had probably become dense enough to restrict visibility to a significant extent. The fact that FF Herrera said that he had seen the silhouette of a man, tends to suggest that that was the case.
Despite the clear evidence of Rosemary Oyewole that everyone in the flat was together in her bedroom when the firefighters arrived, we think that is unlikely to have been the case. The evidence of Rosemary Oyewole and Oluwaseun Talabi suggests that as soon as the front door had been opened and the bedroom door was at least ajar, they rushed out of the room to be met by FF Herrera. In doing so they may have inadvertently obstructed his view into the room. At that point FF Herrera, who had walked further into the flat than Oluwaseun Talabi remembered and had reached the hall, saw the silhouette of a man in the lounge which caught his attention. That is not something about which he could reasonably have been mistaken and we do not think he was making it up. The man he saw was Omar Alhaj Ali, who had moved out of the bedroom into the lounge. FF Herrera said that he had reached the point at which he could see into the lounge and Omar Alhaj Ali accepted that he and his brother had moved around the flat from time to time, although the evidence suggests that the others had not done so once they had been advised to stay in the bedroom. We think it likely that, after FF Herrera had entered the flat (allowing a cloud of dense smoke to enter the hallway), the door to Rosemary Oyewole’s bedroom remained partly closed, thereby obstructing his view of Denis Murphy and Jeremiah Deen, both of whom were sitting on the bed. It is difficult to know why he did not see Zainab Deen or Mohammad Alhajali; it may have been because she was sitting on the floor and he was sitting on the far side of the bed, or perhaps because of a combination of poor visibility and the speed at which events unfolded at that point. We say that because, if the door had been wide open and the room substantially free of smoke, it is difficult to see how FF Herrera could have failed to see them.
We do not think FF Herrera’s evidence that he had formed the impression that there were four people in the “sitting room” is reliable. His reference to two men, one woman and a child can in the circumstances only have been to Omar Alhaj Ali, Oluwaseun Talabi, Rosemary Oyewole and their daughter. He was plainly unaware, for whatever reason, of the presence of Mohammad Alhajali, Denis Murphy, Zainab Deen and Jeremiah Deen, but we think it is reasonably clear that they were all in the bedroom when he arrived. No one suggested that FF Herrera had gone into that room at any stage and, for the reasons we have given, we think it quite likely that his view of it was obstructed.
The sharpest conflict of evidence relates to the conversation which FF Herrera said he had had in Flat 113 with Omar Alhaj Ali. We think it very unlikely that Omar Alhaj Ali actually said that he was the last person in the flat, since, knowing that there were others, including his brother, in the bedroom, he had no reason at that stage to think that he was. On the other hand, we do not think that FF Herrera invented the conversation. One has to remember that things were happening very quickly in only moderate visibility and that FF Herrera had been expecting to find only three people. On finding a fourth, it would be natural to ask whether there was anyone else, but the question, spoken through the mask of a BA set, might have been misinterpreted as referring only to the lounge, in which there was indeed no one else.
Although the weight of the evidence suggests that when he had left the tower and realised that his brother had not escaped with him, Omar Alhaj Ali did say that it was his mistake, we do not think that much significance can be attached to that. When describing his escape from Flat 113 Omar Alhaj Ali said he had thought that his brother was behind him, but he did not remember what he had been doing. When saying that he had been mistaken, he may well have been referring to his assumption that Mohammed was following him out of the building and we think it likely that, having himself escaped, he felt responsible for the fact that Mohammad had not. We accept that FF Herrera was anxious to leave the flat as quickly as possible but, having discovered that it contained at least one more person than he had been led to expect, he should not have relied on what he understood to be an assurance that there was no one else there and should have looked in the other rooms.
We have reached these conclusions with varying degrees of confidence, but given the uncertainties inherent in the evidence, we think they provide the most likely explanation of what occurred.
Omar Alhaj Ali left the tower at 02.45 followed a minute later by Rosemary Oyewole, Oluwaseun Talabi and their daughter.[341] CM McAlonen and FF Juggins followed them down.[342] At the bridgehead on floor 3 CM McAlonen told WM De Silvo which flats he and FF Juggins had visited and reported that three people had been brought down but that they could not confirm that Flat 113 was clear. By then the following had been written on the wall on floor 3: “14, 111, 115, 112, 113”. WM Silvo put a tick through Flats 111, 112 (which CM McAlonen and FF Juggins had visited) and 113, against which she wrote “3 rescues”.[343] CM McAlonen only mentioned “3 rescues” because, as he explained, he had not seen Rosemary Oyewole and Oluwaseun Talabi’s daughter.[344]
FF Herrera told WM De Silvo that Flat 113 had been searched and was empty. He said the same to WM Williams who put a tick next to the flat number on the ground floor wall, indicating that it had been cleared.[345] That may explain why “113/14” (with 113 circled and ticked) appears next to “3 rescues” on the wall.[346] As recorded in the Phase 1 report, a circle indicated that further information had been received and a cross through the number of the flat indicated that it had been searched and a rescue carried out.[347] It may also explain why a tick and “BA” (to show a crew had been deployed to and reached a flat) appears next to “113 14th” towards the bottom of the first list that WM Williams had made.[348]
We have mentioned that, on reaching the ground floor of the tower, Omar Alhaj Ali spoke to firefighters. The first of those conversations occurred even before FF Herrera spoke to WM Williams. Omar Alhaj Ali explained, by reference to a set of CCTV stills timed at 02.44, that he had been telling firefighters that other people remained in Flat 113, including his brother.[349] One of those firefighters was WM Williams.[350] That occupants still remained in Flat 113 was reinforced by FF Herrera’s return at 02.57[351] following his conversation with Omar Alhaj Ali outside the tower.
The information now available at the bridgehead probably prompted the deployment of FFs Jon Wharnsby and Terence Lowe, a crew based at Shoreditch, who tallied out at 03.04 to go to Flat 113 on floor 14.[352] The word “Shoreditch” appears just above “14 113” on the wall on floor 3, where the bridgehead was located up to about 03.10, which supports the conclusion that the entry relates to the deployment of that crew. However, the two firefighters did not reach floor 14. They encountered people in the stairwell whom they assisted down. FF Wharnsby recalled that by the time he and his colleague returned to the bridgehead it had moved to the ground floor. He said that he had made sure that others were aware that they had not completed their original task.[353]
Zainab Deen made two further emergency calls at 03.06 and 03.17, both of which were answered in the LFB control room.[354] In the first, CRO Sarah Russell took care to confirm her location, which she gave as Flat 113 on floor 14. The call ended abruptly.[355] In the first call Zainab Deen did not say how many people were in Flat 113, but in the second she said that she was there with her baby. She did not mention anyone else.[356] That this information reached the incident ground is apparent from the following:
From about that time, friends of Zainab Deen and Mohammed Alhajali, who were in contact with them by telephone, approached police officers and firefighters with information as follows:
In the Phase 1 report the chairman found that CM Mayne and FF Lundquist, a crew wearing extended duration breathing apparatus, were deployed as a result of FF Herrera’s report to the bridgehead that he had apparently not rescued all the occupants of Flat 113.[366] However, having reviewed the evidence further, we now think it more likely that they were in fact deployed in response to the two emergency calls made by Zainab Deen after 03.00. They were instructed to go to Flat 113 on floor 14 and tallied out at 03.29.[367] FF Lundquist recalled that the briefing was to rescue a mother and baby or small child. That must have been Zainab Deen and Jeremiah. When the crew reached the front of the queue of BA wearers at the bridgehead, however, their instructions were changed and they were redeployed to floors 3 and 4.[368] As we have explained above, it is likely that the information FF Herrera gave to the bridgehead prompted the earlier deployment of FFs Wharnsby and Lowe at 03.04. The time of the deployment and the nature of the briefing approximate more closely to the contents of Zainab Deen’s calls than the information FF Herrera had given to the bridgehead.
Even without the additional information, the bridgehead was aware shortly after the partial evacuation of Flat 113 that people were still trapped there. The fire did not reach the exterior of the bedroom, where the occupants had sheltered, before 03.35.[369] Even though conditions in the flat began to deteriorate rapidly thereafter,[370] Zainab Deen and Mohammad Alhajali were still in contact with friends outside the tower. However, no more firefighter crews were able to reach Flat 113.
Date of birth: 10 October 1960 (56 years).
Place of birth: Hammersmith, London.
Gender: Male.
Occupation: Painter and Decorator.
Usual address: Flat 111, floor 14, Grenfell Tower, London, W11.
Place of death: Flat 113, floor 14, Grenfell Tower, London, W11.
Time of death: Between 04.05 and 04.35 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Born on 10 October 1960, Denis Murphy was 56 years old in June 2017. He was the eldest of four children in a close-knit family and had two brothers and a sister. Denis Murphy had first moved into Grenfell Tower in 1984 with his wife and was still living there when his son was born in 1989. He returned to the tower in 1997 after he and his wife separated amicably. Denis Murphy continued to live at Grenfell Tower for the next 20 years and lived alone in Flat 111. A painter and decorator by trade, he was not working at the time of the fire. His passion for sport was something he maintained throughout his life.[371]
Denis Murphy had emphysema.[372] The spreadsheet produced on the night of the fire by David Noble based on information held on the TMO’s Capita Insight system[373] identified Denis Murphy as a resident but not as having any particular vulnerability.
We have set out our general findings about the events on floor 14 above. We focus here on factual matters of specific relevance to the death of Denis Murphy.
Denis Murphy returned to Grenfell Tower during the afternoon of 13 June 2017.[374] He did not leave after that.
As we have already observed, Flat 116 was the first flat on floor 14 to be affected by the spread of the fire up the tower. Flat 111 was on the east side of Grenfell Tower located between Flats 116 and 112[375] and was close to the exterior fire once it reached Flat 116. When he made his first 999 call from floor 14 at 01.25, Denis Murphy told OM Norman that the fire was outside his window. There was no smoke in the flat although he could smell it. Later in the call Denis Murphy reported that smoke was entering the flat from the lobby. The amount of smoke in the lobby was sufficient to deter him from leaving.[376]
Denis Murphy then called his brother Timothy Murphy and left a message. Timothy returned the call at about 01.36. During the call he could hear a smoke alarm in the background. Denis Murphy was coughing and sounded distressed and in a state of panic. He opened the front door when his brother told him to leave but then told Timothy Murphy that it was pitch black in the lobby and that smoke was coming into the flat. Timothy told Denis that he would call the emergency services and to shelter in the bathroom.[377]
The conditions in Flat 111 deteriorated rapidly. When at 01.40, Denis Murphy spoke to CRO Howson in his second 999 call, he told her that his flat was full of smoke coming in from the windows and front door and that he was sheltering in the bathroom. CRO Howson advised him to block the bathroom door with towels and reassured him that firefighters were on their way.[378]
Having spoken to Surrey Police, Timothy Murphy rang Denis Murphy again and reassured him that help was on its way.[379] Surrey Police spoke to the LFB control room at 01.48. They gave Denis Murphy’s name and location and said that he was trapped in the bathroom and struggling to breathe.[380]
As we have explained earlier in this part of the report, these calls to the emergency services (together with calls from other occupants trapped on floor 14) led to the deployment of firefighter crews to that floor.
FFs Murphy and Cornelius were the first crew to arrive on floor 14. They found Flat 111 to be heavily smoke logged. Denis Murphy was conscious but bent over and coughing with soot on his face. The firefighters immediately brought him into the lobby where the air was clearer. They decided not to escort him down the stairs, given the smoke conditions that they had encountered in the stairwell.[381] Following the arrival of FFs Sanders and Merrion on floor 14, Denis Murphy was moved to Flat 112 where the air was clear. Omar Alhaj Ali recalled that he had been coughing and having difficulty breathing when he came into Flat 112.[382] Subsequently, Denis Murphy was moved into Flat 113.[383]
Rosemary Oyewole did not recognise Denis Murphy when he first came into Flat 113; his face was covered in thick, black soot.[384] While he was able to move without help, Denis Murphy was quiet and appeared to be in shock.[385] Rosemary Oyewole helped him to wash his face and removed some of the soot from his eyes.[386] She left him in the living room, but when another set of firefighters (FFs Cook and Flanagan) visited the flat and told them to stay in the bedroom, she and Oluwasean Talabi encouraged Denis Murphy to move there. When he did do so, Denis Murphy sat on the edge of the bed.[387]
Denis Murphy remained in contact with his family. Timothy Murphy and his partner, Angela, spoke to him several times during the fire, but he could not remember the precise times of those calls or what they had said. The last contact Denis Murphy had with his family was at about 02.30 when he spoke to his sister Anne Murphy and his son Peter Murphy. He told them that he was in a neighbour’s flat and that he was struggling with his breathing.[388] Anne Murphy continued to call Denis Murphy’s telephone until 06.00 but received no answer.[389]
Although all those in Flat 113 were initially sheltering in different parts of it, most of them began to congregate in the bedroom facing the front door.[390] We have set out above our analysis of their movements and how Denis Murphy came to be left behind during the partial evacuation which followed the deployment of CM McAlonen and FFs Juggins, Herrera and Orchard to floor 14. We conclude that the bridgehead was aware shortly after that partial evacuation that people remained trapped on floor 14. No other firefighters were able to reach that floor.
There was no direct contact with Denis Murphy after the partial evacuation. There is nothing in the 999 calls made by Zainab Deen at 03.06 and 03.17[391] or from the longer call that she had with CM Batcheldor[392] which offers any information about Denis Murphy. That call ended at 04.48.[393]
Mohammad Alhajali’s friends and family gathered outside the tower and were able to reach him by telephone. His last conversation was with his brothers Omar and Hashem, during which Mohammad said that others in the flat were no longer responding to him. The precise time at which the call ended is uncertain. Hashem Alhajali thought that it had ended between 04.00 and 05.00, but Omar Alhaj Ali was taken to hospital at 04.26.[394] A friend and flatmate, Mahmoud Al-Karad, was with Omar when he was speaking to Mohammad. Mahmoud Al-Karad was unable to reach Mohammad Alhajali after 04.26.[395] A cousin, Aesem Alhajali, said that there came a time between 04.00 and 05.00 when no one was able to reach Mohammad Alhajali. It was as if his phone had been switched off. [396] In a 999 call at 05.05, Ammar Al Kabir, a cousin, said that he had last spoken to Mohammad Alhajali an hour earlier (evidence which we think is more reliable than his later recollection that the call had taken place at 04.30). In the circumstances, we conclude that the last contact with Mohammad Alhajali probably occurred at about 04.05. Following that contact, Mohammad Alhajali fell to his death from the tower.
The fire first reached the outside of the bedroom where those in Flat 113 had sheltered at about 03.33.[397] If they had not already done so, it would have caused them to move into the living room, which, being the most south-westerly part of the flat, would have been furthest away from the approaching fire. The fire reached the south side of the living room at about 03.52 but the west side of the flat remained unaffected.[398] The fire did not begin to affect the west side of the flat until sometime between 04.23 and 04.28.[399] In calls with friends and family outside the tower, Mohammed Alhajali asked that firefighters continue directing water at the part of the tower where Flat 113 was located.[400] From 03.28 a ground monitor was used to apply a jet of water to the south side of the tower although its reach varied.[401]
Denis Murphy’s remains were recovered from the kitchen area of Flat 113.[402] The coroner was satisfied about the identification of those remains and so issued an interim certificate of the fact of death.
The post-mortem report on Denis Murphy recorded the medical cause of death as “consistent with the effects of fire”, but in the light of more recent evidence we find that a more accurate description is “inhalation of asphyxiant gases”. Toxicological testing was not possible.
We accept Professor Purser’s conclusion that Denis Murphy had suffered significant exposure to smoke by the time he was moved to Flat 113.[403] In the time that he sheltered in Flat 113 he continued to be exposed to asphyxiant gases in the smoke coming into the flat, particularly from the lobby. That exposure increased significantly with the arrival of the fire outside the bedroom where he was sheltering. Conditions in Flat 113 continued to worsen as the fire spread to the south side of the living room.
The location of Denis Murphy’s remains is consistent with his having moved from the bedroom once the fire had reached that point. Although we do not have a record of the level of carboxyhaemoglobin in his blood, we note that in a sample taken from Mohammad Alhajali it had reached the threshold lethal level of 50%.[404] That supports our conclusion that the level of asphyxiant gases in Flat 113 after 03.33 was sufficient to cause Denis Murphy to lose consciousness. He continued to inhale those gases until his respiration and circulation ceased and he died at some time between 04.05 and 04.35. We are satisfied that Denis Murphy died before suffering any direct effects of fire.
Date of birth: 25 May 1985 (32 years).
Place of birth: Freetown, Sierra Leone.
Gender: Female.
Occupation: Unemployed.
Usual address: Flat 115, floor 14, Grenfell Tower, London, W11.
Place of death: Flat 113, floor 14, Grenfell Tower, London, W11.
Time of death: 04.35 to 04.50 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 4 December 2014 (2 years).
Place of birth: London, UK.
Gender: Male.
Occupation: n/a.
Usual address: Flat 115, floor 14, Grenfell Tower, London, W11.
Place of death: Flat 113, floor 14, Grenfell Tower, London, W11.
Time of death: Between 03.30 and 04.00 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Zainab Deen lived in Flat 115 with her son Jeremiah Deen. She was born on 25 May 1985 in Freetown, Sierra Leone and was 32 years old. She had moved to the UK at the age of 16. Jeremiah was born on 4 December 2014 in London. He was two and a half years old at the time of the fire and attending a local nursery.[405]
Zainab and Jeremiah Deen moved into Flat 115 in February 2015. When signing her tenancy agreement with RBKC Zainab Deen confirmed that she did not have a disability.[406] The spreadsheet produced on the night of the fire by David Noble based on information held on the TMO’s Capita Insight system[407] identified Zainab and Jeremiah Deen as residents. Jeremiah was identified as being under 18.
We have set out our general findings about the events on floor 14 above. We focus here on factual matters of specific relevance to the deaths of Zainab and Jeremiah Deen.
On 13 June 2017, Zainab Deen had had a successful job interview.[408] She returned to the tower with Jeremiah and her friend, Francis Dean, between 21.30 and 22.00.[409] Zainab and Jeremiah Deen were seen on CCTV in the lift lobby at 23.20 having come down with Francis Dean when he left the tower.[410]
Zainab Deen made her first call to the emergency services a few minutes after the fire had reached floor 14.[411] Having been connected to the police control centre at 01.29, she reported that she was on floor 14 and had a baby with her. The call then disconnected.[412]
At 01.38, Zainab Deen spoke to CRO Yvonne Adams in the LFB control room. She sounded distressed. She was able to tell CRO Adams that smoke was coming into her flat through the door and windows. CRO Adams advised Zainab Deen to block up the doors and shut the windows, which she did. She was not able to confirm Zainab Deen’s location before the call ended abruptly.[413]
At 01.48, Zainab Deen spoke to CRO Christine Howson in the LFB control room and was able to say that she was in Flat 115 on floor 14 with her baby. There was now smoke throughout the flat. CRO Howson advised her that the flat was “the safest place” and to keep trying to stop smoke coming in. She told Zainab Deen that the fire was not on floor 14 and said that she would alert the firefighters who would come to her.[414]
As we have explained earlier in this part of the report, Zainab Deen’s calls to the emergency services (together with those from others trapped on floor 14) led to the deployment of firefighter crews to that floor, albeit none were sent specifically to Flat 115.
At 02.01 and before any firefighters had visited Flat 115 the police operator who had spoken to Zainab Deen at 01.29 called her back. Zainab Deen was very distressed. The operator advised her that the fire brigade was trying to evacuate everyone and asked whether she could go downstairs.[415] At 02.12 the operator told the LFB control room that Zainab Deen and her son were trapped in Flat 115.[416]
FF Murphy recalled that, when they found Zainab Deen in Flat 115, she was very frightened and asked the firefighters not to leave her and her son alone.[417] Others sheltering in Flat 113 describe her as panicking for much of the time she was there.[418] Rosemary Oyewole carried Jeremiah Deen to the bedroom opposite the front door and put him on the bed with her own daughter.[419] Once in Flat 113, Zainab Deen spent much of her time on the telephone.[420] After she had moved to the bedroom opposite the front door she got up three or four times to open the door believing she could hear that help had arrived. Zainab Deen was very frightened and so Rosemary Oyewole had to be forceful when shouting at her to close the door. At that time, there was already smoke in the hallway of Flat 113.[421] After that Zainab Deen remained sitting on the floor by the door to the bedroom.[422]
At 02.12, Zainab Deen made another 999 call. It could not be put through to the LFB control room and the operator was in the course of transferring it to North West Fire Control when it was abandoned.[423] When that fire service called Zainab Deen back at 02.21, she gave her address as Flat 115 on floor 14, although she had by now been moved to Flat 113.[424] Francis Dean also spoke to North West Fire Control at 02.17 and told them that a woman and her son (he described them as his sister and her son) were trapped in Flat 115 on floor 14.[425] It does not appear that North West Fire Control passed the information from those calls to the LFB, but by then Zainab and Jeremiah Deen had already been moved to Flat 113.
Francis Dean had returned to the tower when Zainab Deen called him at 01.38 to tell him of the fire. They remained in contact, speaking again at 02.00 and 02.03, when she said she was now in Flat 113.[426] As well as making calls to the emergency services, Francis Dean spoke to firefighters and police officers telling them that Zainab Deen and her son were still in the tower.[427]
While initially all those now sheltering in Flat 113 were in different parts of the flat, they began to congregate in the bedroom facing the front door.[428] We have set out above our analysis of their various movements and how Zainab and Jeremiah Deen came to be left behind during the partial evacuation of Flat 113 which followed the deployment of CM McAlonen and FFs Juggins, Herrera and Orchard to floor 14.
Following that partial evacuation, Zainab Deen made two further 999 calls, both of which reached the LFB control room. At 03.06, Zainab Deen spoke to CRO Sarah Russell who was able to confirm that she was in Flat 113 on floor 14. It appears that Zainab Deen was still in the bedroom (she is heard to tell someone not to open the door). She also said that they were covered with smoke and that her baby was unconscious. When CRO Russell asked if they could leave, Zainab Deen replied: “No, we can’t leave. Nobody is coming for us.”[429] At 03.17, Zainab Deen made her last 999 call. She told CRO Howson that she was in Flat 113. CRO Howson advised her to cover herself with a towel and make her way down the stairwell. She told Zainab Deen to expect smoke in the stairwell. Zainab Deen appeared to agree to leave with Jeremiah.[430]
Those 999 calls led to the deployment of CM Mayne and FF Lundquist. However, no firefighter was able to reach floor 14 after the partial evacuation of Flat 113.
Zainab Deen’s final call to Francis Dean was the last contact with her. The call began at 03.34 and ended at 04.48.[431] She told Francis Dean that Jeremiah had collapsed. Francis Dean tried to tell Zainab Deen to cover herself and her son in wet blankets and leave but she refused to do so because of the smoke.[432]
As the call continued, Francis Dean encountered CM Batcheldor and passed his telephone to him. CM Batcheldor remained on the call with Zainab Deen for what he estimated to be over an hour. Shortly after beginning to speak to her, CM Batcheldor gave her location to WM Furnell who confirmed he was already aware of a call from her. He did not know that firefighters had already been sent to Flat 113 but had then had their instructions changed before they set out.[433]
Zainab Deen told CM Batcheldor that she could not get out and that she had been told to stay in the flat, which he took to mean that the stay put policy was still in place. His view was that Zainab Deen was trapped in the flat. CM Batcheldor sought to reassure her and concentrated on keeping her safe by advising her to move to the least smoky room, to lie down on the floor and to cover Jeremiah’s face with a cloth. When their conversation began, Zainab Deen said there was smoke in the flat but made no mention of fire.[434]
When he first began speaking to Zainab Deen, CM Batcheldor was able to hear Jeremiah Deen in the background. About 35 minutes into the call, she told him that her son had died. At this point CM Batcheldor passed the phone to Francis Dean for a few seconds, asking him to encourage Zainab Deen not to give up.[435] He returned to WM Furnell to ask what the position was and was told that firefighters could not get past floor 12.[436]
CM Batcheldor remained on the line speaking to Zainab Deen for about another 35 minutes. She was coughing and spluttering but became increasingly quiet. He could not hear anyone else in the background. There was silence for about five or 10 minutes before CM Batcheldor then heard her screaming before becoming silent again. After about another 10 minutes he believed Zainab Deen had died. He waited a few more minutes before disconnecting the call.[437]
CM Batcheldor did not tell Francis Dean that the line had gone silent, just that the battery had died. Francis Dean tried to call Zainab Deen again, but she did not answer.[438]
The fire first reached the outside of the bedroom where those in Flat 113 had sheltered at about 03.33.[439] If they had not already done so, that would have caused them to move into the living room, which, being the most south-westerly part of Flat 113, was farthest from the approaching flames. The fire reached the south side of the living room at about 03.52 but the west side of the flat was not affected.[440] It did not begin to affect the west side of the flat until sometime between 04.23 and 04.28.[441] In calls with friends and family outside the tower, Mohammed Alhajali asked that firefighters continue to direct water at the part of the tower where Flat 113 was situated.[442] From 03.28 a ground monitor was used to apply a jet of water to the south side of the tower although its reach varied.[443]
The remains of Zainab and Jeremiah Deen were recovered from the living room of Flat 113.[444] The coroner was satisfied about the identification of those remains and so issued interim certificates of the fact of death for both Zainab Deen and her son.[445]
The post-mortem for Zainab Deen found evidence of soot inhalation. Analysis of a blood sample detected carboxyhaemoglobin but it was not possible to measure its concentration.[446] The post-mortem for Jeremiah Deen found soot stained mucus in the respiratory system. Carboxyhaemoglobin was detected in a blood sample at a high concentration albeit the level could not be measured.[447]
In both cases, the examining pathologist was able to give the medical cause of death as “inhalation of fire fumes”. In light of more recent evidence, we find that a more precise description is “inhalation of asphyxiant gases”.
The exposure of Zainab and Jeremiah Deen to asphyxiant gases increased once the fire reached the west side of Flat 113 with the consequent deterioration of conditions inside. They and the other occupants were able, at least initially, to move to those parts of the flat which the fire had yet to reach. However, conditions worsened once the fire reached the south side of the flat.
During the call with CM Batcheldor, Zainab Deen was increasingly affected by the significant levels of toxic smoke permeating Flat 113 and as a result she struggled to respond to him. At a relatively late stage of the call Zainab Deen screamed out. We think that is more likely to have been because she realised that the fire was very close (and may even have begun to penetrate the flat) rather than because she was being directly affected by the fire itself. A significant period of time then elapsed (we think it could have been as much as 10 to 15 minutes) before CM Batcheldor disconnected the call, during which Zainab Deen made no response at all. We think that she died during that period, probably between 04.35 and 04.50. We are satisfied that Zainab Deen died before suffering the direct effects of fire.
The rate at which a child absorbs asphyxiant gases is roughly twice that of an adult,[448] which supports our conclusion that Jeremiah died before his mother. He was already beginning to be unresponsive by 03.06 when she spoke to CRO Russell. In the light of CM Batcheldor’s evidence we conclude that Jeremiah Deen died at some time between 03.35 and 04.10. Like his mother he would have lost consciousness but continued to inhale asphyxiant gases until his respiration and circulation ceased and he died. Jeremiah Deen died before suffering the direct effects of fire.
Date of birth: 27 November 1993 (23 years).
Place of birth: Damascus, Syria.
Gender: Male.
Occupation: Student.
Usual address: Flat 112, floor 14, Grenfell Tower, London, W11.
Place of death: Grenfell Tower, Grenfell Road, London, W11.
Time of death: Between 04.30 and 04.56 on 14 June 2017.
Cause of death: Multiple injuries consistent with a fall from height.
Mohammad Alhajali was born on 27 November 1993 in Damascus, Syria. He grew up in Darra, a small city in the south of Syria, with his parents and four siblings. In 2014, he left Syria with his brother Omar and came to the United Kingdom. He remained in close contact with his family in Syria, speaking to them every day.[449]
In June 2017, Mohammad Alhajali was 23 years old. He was studying engineering at university and working part-time. He was engaged to be married and was looking forward to building a life for his family in the United Kingdom.[450]
Mohammad Alhajali lived in Flat 112 with his brother, Omar Alhaj Ali, and their childhood friend, Mahmoud Al-Karad.[451]
Mohammad Alhajali did not have any known vulnerabilities. He was not recorded in the spreadsheet produced on the night of the fire by David Noble based on information held on the TMO’s Capita Insight system[452] because he was a tenant of a private landlord.
We have set out our general findings about the events on floor 14 above. We concentrate here on factual matters of specific relevance to the death of Mohammad Alhajali.
On the evening of 13 June 2017, Omar Alhaj Ali and Mohammad Alhajali went to their cousins’ house to break the Ramadan fast together.[453] They returned to the tower at around midnight.[454] Mohammad Al-Karad was still at work.[455] He returned after the fire had started.
The two brothers were alerted to the fire when they heard shouting outside and smelt smoke. The sight of flames at the level of floors 4 and 5 prompted them to leave. When they approached the front door of Flat 112, they saw smoke coming into the flat under the door. Finding the lobby dark and full of smoke, they decided not to leave. That was at about 01.30. The brothers then began to call for help from a window until a firefighter shouted back telling them to stay where they were.[456] They continued calling for help and firefighters next to the main entrance told them to stop shouting and that they were coming up to help them.[457] Given the absence at that time of information indicating that the occupants of Flat 112 needed to be rescued, it appears that the brothers’ calls for help did not result in a message being sent to the bridgehead.
The brothers opened their front door again at around 02.00 to see if it was now easier to leave. There was still smoke in the lobby with limited visibility. Flat 112 was still clear of smoke and they remained in the flat.[458]
We have described how calls to the emergency services made by those trapped on floor 14 led to the deployment of FFs Merrion and Sanders and FFs Cornelius and Murphy to that floor. When FF Merrion entered Flat 112, the brothers pleaded with him to take them out but he told them to remain in the flat.[459] Subsequently, they agreed to a request from FF Murphy to be allowed to move Denis Murphy into Flat 112, which had clean air.[460] At that time the visibility in the lobby had improved to the point at which Omar Alhaj Ali was able to make out firefighters there.[461] The firefighters then returned and moved Omar Alhaj Ali, Mohammad Alhajali and Denis Murphy from Flat 112 and Zainab Deen and Jeremiah Deen from Flat 115 to Flat 113.[462] Omar Alhaj Ali recalled that at that time the smoke in the lobby was not as thick as before.[463] For the reasons we have already given we conclude that no criticism can be made of the decision not to evacuate those on floor 14 at that time.
Although all those sheltering in Flat 113 were initially in different parts of the flat, most of them eventually congregated in the bedroom facing the front door.[464] We have set out above our analysis of their various movements and how Mohammed Alhajali came to be left behind during the partial evacuation of Flat 113, following the deployment of CM McAlonen and FFs Juggins, Herrera and Orchard to floor 14. We have also concluded that the bridgehead was aware shortly after the partial evacuation that people remained trapped on floor 14. However, no other firefighters were able to reach that floor.
Gathered outside the tower, Mohammad Alhajali’s friends and relations were in contact with him by telephone. Mahmoud Al Karad’s last conversation with Mohammad Alhajali was at 03.19. He told Mahmoud Al-Karad that he could not leave because he was with a mother and child. (He did not mention Denis Murphy.)[465] His last conversation was with his brothers Omar and Hashem. In that call Mohammad said that the others in the flat were no longer responding to him. The evidence of the precise time at which the call ended is uncertain. Hashem Alhajali estimated that it ended between 04.00 and 05.00, but Omar Alhaj Ali was taken to hospital at 04.26.[466] Mahmoud Al-Karad was with Omar when he was speaking to Mohammad. He was unable to reach Mohammad Alhajali after 04.26.[467] A cousin, Aesem Alhajali, said that no one was able to reach Mohammad Alhajali after some time between 04.00 and 05.00.[468] In a call to the emergency services at 05.05, Ammar Al Kabir, a cousin, said that he had last spoken to Mohammad Alhajali an hour earlier (evidence which we think is more reliable than his later recollection that the call had taken place at 04.30). In the circumstances, we conclude that the last contact with Mohammad Alhajali probably occurred at about 04.05.
Following that contact, Mohammad Alhajali fell to his death from the tower. His body was found by WM Steven Collins[469] by the gate on the elevated walkway leading to Grenfell Tower from Grenfell Walk and at the base of a 13.5 metre ladder. The ladder was not in use at the time but was leaning against the south face of the tower. The body of Mohammad Alhajali was covered in debris suggesting that he had fallen some time before his body was found. Together with CM Jamal Stern and FF William Murphy, WM Collins moved the body to a protected area inside the lobby of one of the walkways. No sign of life was found, and WM Collins then assigned another firefighter to locate a paramedic.[470] That paramedic pronounced life extinct at 04.56.[471]
The coroner, Professor Wilcox, subsequently issued an interim certificate of the fact of death for Mohammad Alhajali.[472]
The post-mortem for Mohammad Alhajali recorded injuries consistent with a fall from a height. The injuries were such that there would have been a near-instantaneous collapse and loss of consciousness with no protracted suffering. There were no signs of burns to the skin or airways were recorded. Soot deposits were found in the respiratory system, consistent with the inhalation of fire fumes. The level of carboxyhaemoglobin in a blood sample was found to be 50%, which confirms that Mohammad Alhajali had inhaled sufficient carbon monoxide to bring him within the fatal range.[473] Later analysis in April 2019 did not detect the presence of cyanide but that may simply have been due to the degradation of the sample over time.[474]
The reporting pathologist concluded that the inhalation of a potentially lethal dose of carbon monoxide was not inconsistent with an attempt by a fit young man to jump from the building.[475] The medical cause of death was recorded as “Multiple injuries consistent with fall from height”. We accept that conclusion.
The absence of any burns to Mohammad Alhajali’s skin suggests that he jumped before the exterior fire had enveloped the south side of Flat 113 and before a fire had developed in the interior of the flat. The time it took for WM Collins and his colleagues to move the body of Mohammad Alhajali, check for signs of life and then find a paramedic means that some minutes elapsed between finding the body and pronouncing life extinct. Taking these factors into consideration, we are satisfied that Mohammad Alhajali fell from the tower at some time between 04.05 and 04.30.
All six flats on floor 15 were occupied at 00.54 when the fire started.[476] Between 01.21 and 01.36, the occupants of Flats 121, 123, 125 and 126 left the tower. Only Steve Power, his daughter Rebecca Ross (both in Flat 122) and Christos Fairbairn (in Flat 124) then remained. Steve Power did not survive the fire.
Aziza El-Ouahabi Raihani from Flat 126 had left the tower[477] by the time the fire reached the outside of her flat at 01.23.[478] A few minutes earlier, Rashida Ali, who lived in Flat 125, had ventured into the lobby on floor 15 to find that it was still clear of smoke.[479] She left the tower at 01.23.[480]
Conditions quickly changed as the fire on the outside of the building entered Flat 126. At 01.27, FF David Badillo entered the tower on his way to floor 20 in search of Jessica Urbano Ramirez.[481] When the lift stopped at floor 15 and the doors opened it filled with black smoke. Struggling to breathe and see, FF Badillo left the lift, found his way to the stairwell door and went down the stairs.[482] He had no contact with any of the residents on floor 15.[483] By 01.31, FF Badillo had left the tower.[484] Reem Dedrich (Flat 123) and Sid Ali Atmani (Flat 125) left the tower at 01.33 and 01.36 respectively. The lobby on floor 15 was full of thick dark smoke when each of them escaped.[485]
FF Steven Mills and Geoffrey Campbell tallied out at 01.51 to go to Flat 175 on floor 20. When they reached floor 15, they realised that they could not reach floor 20 without extended duration breathing apparatus.[486] FF Mills recalled that before descending the stairs he and FF Campbell had banged on the doors of all the flats on floors 15 and 14.[487] FF Campbell was less certain whether they had stopped on floor 14 or floor 15 before descending and thought that they may have searched floor 9.[488] Christos Fairbairn heard banging on his front door,[489] but he did not become aware of the fire until much later, probably not before 02.20.[490] Since the firefighters had logged off the system by 02.11,[491] it is unlikely that what Christos Fairbairn heard had anything to do with them.
Neither Rebecca Ross, her father nor any relatives or friends made an emergency call reporting that persons were in Flat 122, although the LFB received that information by other means. Christos Fairbairn made six emergency calls, the first at 03.00 and the last at 03.31, four of which were to the fire and rescue service.[492] He was advised to leave the building and when he did do so he encountered firefighters who helped him out. Christos Fairbairn left the tower at 03.54.[493] His calls did not result in the deployment of any firefighters to floor 15.
Date of birth: 18 August 1953 (63 years).
Place of birth: London, UK.
Gender: Male.
Occupation: Retired.
Usual address: Flat 122, floor 15, Grenfell Tower, London.
Place of death: Flat 122, floor 15, Grenfell Tower, London.
Time of death: Between 03.15 and 04.00 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases. Coronary artery atheroma.
Steven (Steve) Power lived in Flat 122 with his daughter Rebecca Ross, his son Bobby Ross and his three dogs Stevie, Diva and Jess. A retired driver, he was a keen fisherman and disc jockey who had lived in the tower since 1985.[494]
Steve Power suffered from emphysema, which made walking difficult.[495] He had also been diagnosed with bowel cancer.[496] Rydon’s resident survey of November 2014 notes that they had yet to speak to him.[497] He did not appear in the spreadsheet listing vulnerable residents produced on the night of the fire by David Noble of the TMO based on information from the TMO’s Capita Insight system.[498]
Both Steve Power and Rebecca Ross were home in Flat 122 on the evening of the fire. Steve Power woke his daughter at about 01.30 to tell her that there was a fire in the building. She wanted to leave, but he thought they should remain in the flat.[499]
Rebecca Ross was able to see something of the fire from the flat, but it was only on seeing an image on Twitter that she realised its extent. By that time friends and family members were calling and urging Steve and Rebecca to leave and she tried to persuade her father to do so. At about 02.00, she opened the front door to see a cloud of thick grey smoke in the lobby although the lighting was still visible.[500]
At about 02.22, while Rebecca Ross was on the telephone to her brother Wayne Power-Davis, black smoke began to fill the flat. She and her father agreed to leave. While he put on his shoes, she soaked towels for them both. As she was moving to the front door, Rebecca Ross noticed that flames appeared to be about to come through the kitchen window. She found the lobby so full of black smoke that it was impossible to see. Her father was still in the flat when she left. Leaving the front door open, she managed to find her way to the stairwell and began to make her way down the stairs.[501]
At 02.47, FF Robert Dwyer and Christopher Perez encountered Rebecca Ross on the stairs between floors 10 and 11. She was struggling to breathe, so they decided to carry her down the stairs.[502] Rebecca Ross was able to tell them that her father was trapped in Flat 122 on floor 15. As well as sending that information to the bridgehead, the firefighters briefed the bridgehead directly when they reached it.[503]
Rebecca Ross left the tower at 02.54.[504] She subsequently learned that a friend of her father had spoken to him on the telephone after she had left Flat 122.[505] There is no further evidence of when the call was made or what was said, but it appears to have been the last contact with Steve Power.
Between 02.10 and 02.22 CU7 was given the task of managing information about people who needed to be rescued from the tower.[506] The crew used a laminated sheet to record information obtained from pieces of paper created in CU8.[507] It included the following information: “122 15 2 Persons”.[508] The same information appears on the whiteboard used by CU7 after 03.00 to record information.[509] There the number “2” was written in green indicating two adults.[510]
FF Mandeep Singh acted as a runner taking messages from the command units to the bridgehead and to WM Glynn Williams in the ground floor lobby of the tower.[511] From 02.15 WM Williams began using the wall of the lobby to record information that was then passed to the bridgehead.[512] One note in FF Singh’s handwriting read: “Glen Williams” at the top and then “15th Floor 122 x 2 people x 2 dogs.”[513] WM Williams did not see FF Singh’s note and the information was not added to the wall.[514]
The information in FF Singh’s note must be linked to his recollection of having been approached by a man to say that his father was on floor 15 in Flat 122. The man had told him that there were two people and two dogs in the flat and that his father was refusing to leave. FF Singh said he had recorded the information in a note and had taken it to the bridgehead.[515]
In any event, at some point, information about Flat 122 was recorded on the lobby wall. Photographs of that wall show the following had been written on it:
At the time that FF Dwyer relayed the information from Rebecca Ross, the bridgehead was still on floor 3. WM Louisa De Silvo recorded information about people needing to be rescued on a wall on that floor. It included: “122 FIRE IN THE KITCHEN 122”. The first “122” was circled and marked with two ticks and the second underlined and circled.[519] A tick against a particular flat indicated that a crew had been deployed there and a circle indicated that WM de Silvo had received further information, either by runner or radio or from a returning crew. A cross through the flat indicated that it had been searched. She thought that “122” had probably been written and circled again, and underlined, for emphasis because she had received further information about it or because firefighters had been unable to reach it.[520] It is likely that some of the information came from FFs Dwyer and Perez, since it appears on a control information form together with the time 2.47.[521]
Although WM De Silvo could not recall having deployed a crew to Flat 122,[522] FF Leon Whitley and Ricky Nuttall tallied out at 02.44 and 02.45 respectively with instructions to go to Flat 122. They took a hose with them. On reaching floor 15, they charged the hose and located Flat 122 but then realised they were low on air. Being concerned that they would not be able to carry out an effective rescue, they decided to return to the bridgehead. FF Nuttall described the visibility on floor 15 as zero with thick black smoke. By the time they reached the bridgehead, it had been moved to the ground floor. FF Nuttall tried to tell WM Williams about Flat 122, but he was too busy to take the information in. Outside the tower, FF Nuttall gave the information to a watch manager who said he would deal with it.[523]
The reference to two adults makes it likely that the information recorded in CU7 and by FF Singh was received before Rebecca Ross had left Flat 122. One source was probably a friend of Rebecca Ross outside the tower.[524] The proximity in timing between FFs Dwyer and Perez finding Rebecca Ross and FFs Nuttall and Whitley being deployed suggests that it was the information from FFs Dwyer and Perez that prompted their deployment. WM De Silvo may have added the detail about a fire in the kitchen of Flat 122 after that deployment. Of the notes made on the ground floor lobby, the reference to “BA” and “smoke log” are likely to refer to that deployment.
The information received from FFs Dwyer, Perez, Nuttall and Whitley did not prompt a further deployment to Flat 122.
The remains of Steve Power were recovered from the bedroom of Flat 122.[525] The coroner, Professor Wilcox, was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.[526] Steve Power was found with his dogs, Stevie, Diva and Jess.[527]
The post-mortem and toxicological investigations on Steve Power found soot in, and mild heat damage to, the respiratory system. Carboxyhaemoglobin was present in the blood but it was not possible to quantify the concentration. There was significant evidence of coronary artery atheroma, which, although not a direct cause of death, rendered Steve Power more vulnerable to the effects of carbon monoxide. A lower concentration would therefore have resulted in drowsiness, unconsciousness, and death.[528]
In the post-mortem report on Steve Power the medical cause of death was recorded as:
Ia. Inhalation of products of combustion
II. Coronary artery atheroma.
In the light of Professor Purser’s evidence, we find that a more accurate description of the primary cause of death is “inhalation of asphyxiant gases”.
The fire on the outside of the building reached Flat 122 between 02.23 to 02.29. By 02.49, it had spread from the east face of the living room to the south face. Between about 03.02 and 03.12 it spread to and across the external walls of the bedrooms.[529]
Steve Power’s pre-existing health conditions made it difficult for him to leave the tower with his daughter. Having regard to the extent to which Rebecca Ross was exposed to asphyxiant gases, the time at which the fire spread to his flat and his underlying health condition, we are satisfied that Steve Power lost consciousness soon after his daughter left Flat 122. The mild heat damage to his respiratory system probably occurred after he had lost consciousness. Steve Power died between 03.15 and 04.00.[530]
All the flats on floor 16 were occupied on 14 June 2017. Two residents of this floor, Sheila in Flat 132 and Joseph Daniels in Flat 135, died in the fire.
The fire reached floor 16 outside Flat 136 by 01.24.[531] Thereafter, conditions on that floor deteriorated rapidly.
Hamid Wahbi, the sole occupant of Flat 136 on the night of the fire, left his home on seeing smoke and flames enter through the kitchen window. The smoke had already reached the living room and hallway by the time he left. When he did so, Hamid Wahbi found the lobby on floor 16 clear of smoke.[532] He left his front door open[533] and, since it did not have an effective self-closing device, smoke entered the lobby.[534]
In Flat 135, Samuel Daniels, who lived there with his father Joseph Daniels, became aware of a burning smell. That was before Hamid Wahbi had left his flat. Samuel Daniels went into the lobby on three occasions to investigate. Initially, it was clear of smoke. When he next entered the lobby, he saw smoke from the ceiling down to waist level. On the third occasion there was still smoke in the lobby, but it remained possible to breathe. On all three occasions, he found the stairwell clear of smoke.[535]
When, having failed to persuade his father to leave, Samuel Daniels finally left Flat 135, thick black smoke came into the flat when he opened the front door. The lobby was filled with smoke and visibility was limited. The stairs at that time remained free from smoke.[536]
The occupants of Flat 131, Richard Fletcher, his wife, Hime Gashaw and their daughter left their flat at about the same time. There was thick black smoke in the lobby when they opened their front door. The family crossed the lobby and left the tower at 01.31.[537]
Samuel Daniels met FF Justin O’Beirne on the stairs and told him about his father.[538] FF O’Beirne called for assistance for a bedbound man on floor 16.[539] CM Jamal Stern and FF Richard Hippel responded to that call and went to floor 16.[540] CM Stern found the lobby of floor 16 to be smoke-logged when he first opened the stairwell door.[541] FF Hippel recalled black smoke coming out from the open stairwell door.[542] On floor 16 they found a man by the lobby door (Hamid Wahbi) and another man in the lobby (Edward Daffarn).[543]
When Edward Daffarn left Flat 134, the smoke in the lobby was so thick it was difficult for him to see. He struggled to find his way out until he was found by CM Stern and FF Hippel. Edward Daffarn left the tower at 01.34.[544]
Having assisted Edward Daffarn, CM Stern and FF Hippel then entered the first flat they found on floor 16, which is likely to have been Flat 136. They found it empty, extremely hot and heavily smoke-logged.[545] As they were low on air, they left before searching any other flats.[546] CM Stern said that they had knocked on the doors of two other flats, which he thought had been Flats 134 and 135.[547] FF Hippel said that when searching floor 16, he and CM Stern had kicked the front door of each flat and shouted out.[548] He could not explain why the occupants of Flat 133 had not heard them but suggested that they might have been asleep.[549] Sener Macit, in Flat 133, said that he had not heard any knocking on his door or any noises coming from the lobby.[550]
CM Stern and FF Hippel returned to the bridgehead on floor 2 at about 01.38. CM Stern told WM O’Keeffe that they had rescued one person (Edward Daffarn) but had been unsuccessful in rescuing another (Joseph Daniels). CM Stern was not sure if he had mentioned that the person they had been unable to rescue had been bedbound.[551] FF O’Beirne said that when he had left the tower, he told SM Brett Loft that there was a bedbound man on floor 16 whom crews had not been able to reach. SM Loft did not recall that exchange.[552]
After leaving the tower, Hamid Wahbi spoke to two firefighters, SM Loft and WM Watson.[553] He told them that there was a man and a woman on floor 16. Although he did not give a flat number, he was referring to Joseph Daniels in Flat 135 and Sheila in Flat 132.[554] SM Loft did not recall that conversation.[555]
By 01.45, only Sheila in Flat 132, Joseph Daniels in Flat 135 and Sener and Hanife Macit in Flat 133 remained on floor 16. Sener Macit was the only one to call the emergency services. His first call was at 01.37 and was put through to the police. He told them that he was on floor 16 but was not asked for, and did not give, the number of his flat.[556] The police passed the information that people were trapped on floor 16 to the LFB in a call taken by CRO Heidi Fox at 01.43.[557] The information was passed to CU8 at 01.46.[558]
Sener Macit’s first emergency call led to a conference call at 01.46 between the police operator, Sener Macit and CRO Adams in the LFB control room. Sener Macit told CRO Adams that he was in Flat 133 and that smoke was coming under his front door. He could not escape as it was pitch black.[559] CRO Adams passed on the details of that call to the incident ground at 01.50.[560]
Between 02.10 and 03.33, Sener Macit made a further six emergency calls. At 02.10, he was connected to North West Fire Control to whom he spoke for almost half an hour. At a late stage in that call, he was told that firefighters were on their way to floor 16 but was advised to leave his flat.[561] Following a failed attempt to leave, Sener Macit spoke to the LFB again at 02.41,[562] 02.49,[563] 03.02,[564] and 03.12.[565] His daughter also called the LFB at 03.01[566] and 03.45.[567] Sener and Hanife Macit eventually managed to escape without assistance, leaving the tower at 03.47.[568]
After CM Stern and FF Hippel had left floor 16, there were two further deployments, both after 03.00. CM Aldo Diana and FF Dean Nelson tallied out at 03:24.[569] They were sent to Flat 133 but failed to reach floor 16 as they stopped to help other residents escape.[570] The last crew deployed to floor 16 were SM Gareth Cook and CM Ben Gallagher who tallied out at 04.04.[571] They were sent to investigate reports of ten people trapped in a flat on floor 16 and 11 people trapped on floor 18. However, SM Cook’s alarm sounded between floors 6 and 12 and CM Gallagher’s air was low, so they returned to the bridgehead without reaching floor 16.[572] It is unclear what prompted that deployment, given the absence of information to support the suggestion that so many people were trapped on floor 16.
Date of birth: 10 February 1948 (69 years).
Place of birth: Lucknow, India.
Gender: Male.
Occupation: Retired.
Usual address: Flat 135, floor 16, Grenfell Tower, London.
Place of death: Flat 135, floor 16, Grenfell Tower, London.
Time of death: Between 02.55 and 03.15 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Joseph Daniels was born on 10 February 1948 in Lucknow, India. He was 69 years old at the time of the fire.[573] He came to the United Kingdom from India in 1982 after marrying Lucy Smyth. They moved into Flat 135 in 1983 and had one son, Samuel Daniels. The couple subsequently divorced and Joseph Daniels continued to live in Flat 135. He also had a daughter, Stephanie Hillier, from another relationship.[574]
By June 2017, Joseph Daniels was retired and in poor health. He shared Flat 135 with his son, Samuel Daniels, who was registered as his father’s full-time carer.[575]
By June 2017, Joseph Daniels was suffering from dementia and diabetes and had limited mobility.[576] He was not, however, bedbound. He needed the lift to leave the tower.[577] Samuel Daniels said his father had not been able to walk up and down the stairs for about a year and a half before the fire and had not left the flat at all for the last two months of his life.[578]
Rydon’s resident survey of November 2014 did not identify Joseph Daniels as having any known physical or mental health vulnerabilities, although it was noted that he had some vulnerabilities associated with his self-care.[579]
The TMO was aware of Joseph Daniels’ vulnerability. In 2015, it had referred him to an occupational therapist as he was having difficulty getting in and out of the bath. The referral recorded that he had mobility problems but did not want to use a walking stick or glasses for his poor vision.[580] An assessment in May 2015 carried out by RBKC’s social services department noted that he suffered from dementia, brain damage, type 2 diabetes, breathlessness and tremors.[581]
The spreadsheet produced on the night of the fire by David Noble[582] based on information held on the TMO’s Capita Insight system[583] did not identify Joseph Daniels as having any vulnerability.
Joseph Daniels was at home with his son, Samuel Daniels, on the evening of 13 June 2017.[584]
Samuel Daniels first became aware of the fire when he noticed a faint burning smell. He checked the flat, lobby and stairs but could not find its source. Nonetheless, he was sufficiently concerned to decide that he and his father should leave. Between efforts to persuade his father to leave, Samuel Daniels went into the lobby twice more, noticing an increasing amount of smoke there on each occasion.[585] The smoke entering the lobby at that stage was coming from Flat 136, the door to which had not closed after Hamid Wahbi left.[586]
Samuel Daniels could not persuade his father to leave. He left on his own, leaving the door open for his father to follow. Samuel Daniels had told the TMO on 4 April 2017 that the front door of Flat 135 did not close itself. A recommendation for a complete overhaul was made on the following day but the job was later recorded as “fully abandoned”.[587] However, it is likely that Joseph Daniels shut the door after his son had left because CM Stern and FF Hippel found it closed when they searched floor 16.
Samuel Daniels met FF O’Beirne in the stairwell at around floor 11 at some time between 01.28 and 01.38.[588] He told FF O’Beirne that his father was trapped in his flat on floor 16. FF O’Beirne told the bridgehead by radio that a man was bedbound on floor 16 and asked for assistance.[589] CM Stern and FF Hippel responded to that request.
On arriving at floor 16, CM Stern and FF Hippel found the lobby full of thick smoke and visibility very limited.[590] Having first helped Edward Daffarn, they searched the first flat they came to, probably Flat 136.[591] They could not search other flats, because they were running low on air,[592] but they did knock on other doors. There was a difference in recollection between them about how many doors they knocked on, but there is no evidence that Joseph Daniels was aware of the presence of the firefighters on floor 16.[593]
Samuel Daniels was waiting on the stairs when he saw the firefighters return from floor 16. He tried to ask them about his father but was told to leave the tower. He did so at 01.38.[594]
CM Stern and FF Hippel returned to the bridgehead on floor 2 at around 01.38. CM Stern told WM O’Keeffe that he and FF Hippel had rescued one person (Edward Daffarn) but had not been able to rescue another (Joseph Daniels). He was not sure if he had said that that person was bedbound.[595] FF O’Beirne said that he told SM Brett Loft that there was a bedbound man on floor 16 who the crews had been unable to reach. SM Loft did not recall this exchange with FF O’Beirne.[596]
Shortly after 02.17, CM Charles Batterbee made a note of the information on a forward information board that had been used while the bridgehead was located on floor 2.[597] His note did not include any reference to floor 16, which may explain why the information provided by the firefighters on their return from floor 16 did not lead to a further deployment before the bridgehead moved from floor 2 at about 02.17.[598]
The bridgehead was located on floor 3 between 02.17 and 03.10.[599] During that time information about people needing to be rescued was recorded on a wall in the lobby of floor 3. The only information about floor 16 on the wall was a note relating to Flat 133.[600]
The bridgehead was moved to the ground floor lobby at about 03.10. Once it was there, a green wall by the stairs was used to record information about those needing to be rescued.[601] A photograph of that wall taken at about 04.45 shows the numbers “134” and “135” on the wall.[602] We do not know who put that information on the wall but its limited detail reflects that recorded on a control information form provided to the Inquiry. The forms were used at the incident ground to record messages about people needing to be rescued. The relevant form recorded just the following, “133+134+135 16”.[603] On the form, “133” is scrubbed out and marked “left”, indicating that those in Flat 133 had got out but that Flats 134 and 135 remained occupied. It is not possible to say with any confidence who wrote on the form. (WM Sadler used a pad of such forms[604] but they were also used, for example, by those in CU7.)[605]
We cannot say when the information was put on the green wall (save that it must have been after 03.10) or indeed when the control information form was completed. If the information on the wall is associated with the control information form, it may have been recorded after Sener and Hanife Macit left the tower at 03.47. The information recorded in the control information form and the green wall may have come from more than one source. It is unlikely that Hamid Wahbi was the source of the information relating to Flat 135, as he did not provide the firefighters he spoke to outside the tower with the numbers of any flats.[606] It is more likely that the source, at least in relation to Flat 135, was Samuel Daniels. Once outside the tower, and having found his mother, he told someone, who may have been either a firefighter or a police officer, that his father was still in Flat 135. That was at about 02.00.[607] His mother gave the officer the number of the floor and the flat.[608]
The information that someone might still be in Flat 135 did not prompt any further deployments. The two deployments which took place after 03.24 were not sent to Flat 135 and neither of them reached floor 16. CM Diana and FF Nelson tallied out at 03.24[609] to go to Flat 133 but stopped to help other occupants escape. They reported that to the bridgehead.[610] SM Gareth Cook and CM Ben Gallagher set off at 04.04 to investigate reports of 10 people trapped in a flat on floor 16, but a shortage of air prevented them from reaching that floor.[611]
There was no further contact from Joseph Daniels after his son left Flat 135.
The remains of Joseph Daniels were recovered from the living room of Flat 135.[612] The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.[613]
The post-mortem on Joseph Daniels found soot deposits in his respiratory system. Analysis of a sample of his blood confirmed the presence of carbon monoxide, but the condition of the sample meant that its concentration could not be measured.[614] The medical cause of death was recorded as “consistent with the effects of fire”, but in the light of more recent evidence we find that a more accurate description is “inhalation of asphyxiant gases”.
If, as we think likely, the front door of Flat 135 was closed after Samuel Daniels left, it would have slowed the passage of smoke from the lobby into the flat. Exposure to asphyxiant gases was limited until the fire reached the outside walls of the bedrooms at between 02.32 and 02.34. Conditions in the living room deteriorated rapidly when the fire on the outside of the building reached the north side of the living room between 02.49 and 02.55.[615]
It is likely that Joseph Daniels lost consciousness and died from the inhalation of asphyxiant gases at some time between 02.55 and 03.15.[616] Accordingly, the last chance to rescue him was some time before 03.00. That was well before the deployments of CM Diana and FF Nelson at 03.24 and of SM Cook and CM Gallagher at 04.04.
Date of birth: 17 September 1932 (84 years).
Place of birth: Market Harborough, Leicestershire.
Gender: Female.
Occupation: Retired.
Usual address: Flat 132, floor 16, Grenfell Tower, London.
Place of death: Flat 132, floor 16, Grenfell Tower, London.
Time of death: Between 03.09 and 03.30 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Sheila was born on 17 September 1932 and was 84 years old.[617] In life, she made the decision to use only her first name, a decision that we have respected during the Inquiry. Retired, Sheila was a mother and grandmother, living alone in Flat 132. She had lived there since 23 April 1984.[618] Sheila led an independent life with a longstanding interest in meditation, yoga and alternative therapies.[619]
Sheila was physically fairly mobile but her health had deteriorated before the fire.[620] Like some other residents, she struggled when the lifts in the tower were not working,[621] but she did not appear in the TMO’s records as being vulnerable. Rydon’s resident survey of November 2014 recorded that she was over 80, had slight deafness and a poor memory.[622]
The spreadsheet produced on the night of the fire by David Noble[623] based on information held on the TMO’s Capita Insight system[624] did not identify Sheila as having any vulnerability.
Sheila returned to the tower at 14.22 on 13 June 2017. She does not appear to have left her flat again.[625] She usually went to bed between 20.00 and 21.00 and wore an eye mask and ear plugs.[626]
It is possible that Sheila never became aware of the fire. CM Stern and FF Hippel reached floor 16 sometime before 01.38,[627] but there is no evidence that she was aware of their presence. Sheila is not known to have made any telephone calls to friends or family. Nor did she make any calls to the emergency services.
Despite the repeated emergency calls made by Sener Macit in Flat 133 and the information reaching the incident ground about a man (Joseph Daniels) and a woman (Sheila) still on floor 16, only two crews were deployed there after CM Stern and FF Hippel. CM Diana and FF Nelson tallied out at 03.24[628] but stopped before reaching floor 16 to assist other occupants to escape. They reported back to the bridgehead.[629] SM Gareth Cook and CM Ben Gallagher tallied out at 04.04. They were sent to investigate reports of 10 people trapped in a flat on floor 16, but a shortage of air prevented them from reaching it.[630]
Neither crew was briefed to find Sheila and neither crew reached floor 16. Even if they had done so and had been able to search it, it is likely that Sheila would already have been dead.
Sheila’s remains were recovered from the bedroom of Flat 132. She was lying on her back with her head towards the window and near the remains of the mattress, indicating that she had probably been in bed when she died.[631] The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.[632]
The post-mortem examination on Sheila found that it was not possible to obtain samples suitable for toxicology analysis.[633] Although the examination concluded that it was not possible to give a definite cause of death, the medical cause of death was recorded as “consistent with the effects of fire”, but in the light of Professor Purser’s evidence we find that a more accurate description is “inhalation of asphyxiant gases”.
Sheila was in her bedroom throughout the fire. By 02.22, the fire was outside the living room and by 02.29 it had spread across the outside wall of that room. Between 03.09 and 03.17 it had begun to spread across the outside of the bedroom.[634] From the time the fire reached floor 16, Sheila was exposed to an increasing level of asphyxiant gases infiltrating her home, initially from the lobby. That exposure and the rate of absorption of asphyxiant gases increased rapidly once the fire reached the outside of her bedroom.[635] Given her prolonged exposure to asphyxiant gases, Sheila may have been unconscious before the fire reached her bedroom. If not, she became unconscious shortly after. She then continued to inhale asphyxiant gases until she died sometime between 03.09 and 03.30.[636]
We are satisfied that Sheila died through the inhalation of asphyxiant gases before suffering any direct effects of flames entering her bedroom.
All six flats on floor 17 were occupied at the time of Behailu Kebede’s telephone call to the emergency services.[637] By 01.30, the occupants of Flats 141, 143, 145 and 146 had left the building safely,[638] apart from Khadija Khalloufi, who died on floor 10.[639] Those residents who remained on floor 17, Kamru Miah, his wife, Rabeya Begum, and their adult children Mohammed Hamid, Mohammed Hanif and Husna Begum, all of whom lived in Flat 142, and Vincent Chiejina, who lived in Flat 144, all died in the fire.
Rita Tankarian, her nephew, Mesrob Kassemdijan, and his girlfriend, Fung Hee-Cheung, were in Flat 141 and were the first to leave floor 17. Although Rita Tankarian and Mesrob Kassemdijan could smell smoke in the lobby on floor 17, none was visible.[640] They left the tower between 01.25 and 01.26.[641]
The fire reached the outside of Flat 146 at about 01.24.[642] Virgilio (Larry) Castro lived there with his friend, Genaro Batoan. His girlfriend was also staying that night. Shortly before he and his girlfriend followed Genaro Batoan out of the flat, Larry Castro saw flames coming through the extractor fan in the kitchen window. The door to Flat 146 needed to be pulled shut as the self-closing device did not work effectively. Larry Castro thought that he had not pulled it shut. The black smoke that then came into the lobby made him cough.[643]
On leaving Flat 145, Corinne Jones saw Larry Castro outside his front door. Thick black smoke was coming from the top of the door and moving along the ceiling. She briefly went back into her flat and on returning to the lobby found that the amount of smoke had increased significantly.[644] She and Larry Castro both left the tower at 01.30.[645]
At 01.29, Husna Begum made an emergency call which was connected to the police. She reported that there was smoke coming into the flat, that flames could be seen outside, and that the fire was “in the house right next to us”.[646] Like Flat 146, Flat 142 was on the east side of the tower.
It is likely that the lobby of floor 17 rapidly filled with smoke within a few minutes after the fire reached the outside of Flat 146 and then entered it. The contents of Flat 146 were alight between 02.19 and 02.25.[647]
The kitchen window of Flat 142 faced east; its living room windows faced south and east. The bedroom windows faced south.[648] By about 02.23, the fire was outside the kitchen of Flat 142. By about 02.31, having spread south, it covered the entire east side of the flat. By 02.48, the fire had reached the south-facing windows of the living room. By 03.20 the fire was well established on the south face of Flat 142, affecting both the living room and bedroom windows. By 03.33, it had almost ceased outside the east and south faces of the flat and had spread west to Flat 143.[649] The evidence does not suggest that the contents of Flat 142 were alight at 03.33.[650]
Flat 144 was a one-bedroomed flat situated on the west side of the tower.[651] By 03.39 the fire was approaching the bedroom of Flat 144 and by 03.44 it was established outside it. By 03.58, the fire was outside the kitchen and was beginning to affect the living room. Flames continued to burn outside the living room but by about 04.30 they had ceased.[652]
Following Husna Begum’s emergency call at 01.29, the occupants of Flat 142 made three more emergency calls in the period up to 03.18. Those were the only emergency calls made from floor 17. None resulted in the deployment of firefighters.
Date of birth: 12 August 1937 (79 years of age).
Place of birth: Sylhet, Bangladesh.
Gender: Male.
Occupation: Retired.
Usual address: Flat 142, floor 17, Grenfell Tower, London.
Place of death: Flat 142, floor 17, Grenfell Tower, London.
Time of death: Between 03.20 and 03.33 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases. Ischaemic heart disease.
Date of birth: 15 November 1952 (64 years of age).
Place of birth: Bangladesh.
Gender: Female.
Occupation: Homemaker.
Usual address: Flat 142, floor 17, Grenfell Tower, London
Place of death: Flat 142, floor 17, Grenfell Tower, London.
Time of death: Between 03.20 and 03.33 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 19 January 1989 (28 years of age).
Place of birth: London.
Gender: Male.
Occupation: Sales Assistant.
Usual address: Flat 142, floor 17, Grenfell Tower, London.
Place of death: Flat 142, floor 17, Grenfell Tower, London.
Time of death: Between 03.20 and 03.33 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 20 February 1991 (26 years of age).
Place of birth: London.
Gender: Male.
Occupation: Sales Assistant.
Usual address: Flat 142, floor 17, Grenfell Tower, London
Place of death: Flat 142, floor 17, Grenfell Tower, London.
Time of death: Between 03.20 and 03.33 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 4 February 1995 (22 years of age).
Place of birth: London.
Gender: Female.
Occupation: Sales Assistant.
Usual address: Flat 142, floor 17, Grenfell Tower, London.
Place of death: Floor 17, Grenfell Tower, London.
Time of death: Between 03.20 and 03.33 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Kamru Miah, his wife Rabeya Begum and three of their adult children, Mohammed Hamid, Mohammed Hanif and Husna Begum lived in Flat 142. The family had moved to Grenfell Tower in August 2016.[653] Their eldest son, Mohammed Hakim, lived nearby but his wife, Farhana, was staying with his family in Flat 142. She was not there on the night of the fire.[654]
Kamru Miah was born on 12 August 1937 and was 79 years old. Respected within his community, he had moved to the United Kingdom in 1963 and was a retired baker and tandoori chef.[655] Rabeya Begum was born on 15 November 1952 and was 64 years old. She came to London after marrying Kamru Miah. Committed to her family, she had devoted herself to raising the couple’s four children.
Mohammed Hamid was born on 19 January 1989 and was 28 years old. He spent much time caring for his father, who had suffered two strokes.[656] Mohammed Hanif was born on 20 February 1991 and was 26 years of age. He was particularly creative with a talent for drawing and animation.[657] Husna Begum was born on 4 February 1995 and was 22 years old. Like her mother she was an excellent cook and enjoyed creative writing.[658] She was the youngest member of the family and the only daughter and was due to marry on 29 July 2017.[659] All three siblings worked full-time in the retail sector.[660]
Kamru Miah had previously suffered a heart attack and two strokes. He used a walking stick and easily got out of breath when walking.[661] Before the family moved to Grenfell Tower, Rohema Khanom, the niece of Rabeya Begum, had helped her complete an assessment form on which they had recorded that Kamru Miah had suffered a heart attack and a stroke and could not manage stairs. Rohema Khanom had also attended a meeting in August 2016 with RBKC to interpret for her aunt and uncle. She recalled that her uncle’s health had been discussed at that meeting.[662]
The spreadsheet produced on the night of the fire by David Noble[663] based on information held on the TMO’s Capita Insight system[664] did not identify Kamru Miah as a vulnerable person.
The family were all at home on the night of the fire. Mohammed Hakim had visited them so they could break the Ramadan fast together. He left at about 22.00. On arriving at his home, he telephoned his mother at about 23.00.[665]
At 01.29, Husna Begum made an emergency call that was connected to the police. She reported that smoke was entering the flat, that the family could see flames from a window and that the fire was in a nearby flat. She asked for help. The police operator told her that the LFB had been informed and that someone would be coming to help them. The sound of a smoke alarm could be heard in the background.[666] The mention of the fire being in a nearby flat must be a reference to Flat 146 and it is clear that smoke had started to infiltrate Flat 142 from the lobby by the time of the call.
At 01.38, the police notified the LFB that a family of five were in Flat 142 on floor 17 and that smoke was coming into the flat. OM Alexandra Norman passed the information to CU8 at 01.43.[667]
How it then reached the bridgehead, then on floor 2, is unclear, but a note recording “17th Fl, 142 FSC” was written on a wall, probably on the second-floor mezzanine.[668] While the bridgehead was on floor 2 WM Louisa De Silvo used a forward information board to record information about those awaiting rescue.[669] Shortly before the bridgehead moved to floor 3 (at around 02.17), CM Charles Batterbee went to the bridgehead and copied the information on a forward information board into his own notebook.[670] There was no reference to floor 17 and no deployment was made to that floor before the bridgehead moved to floor 3. Following that move, no information relating to Flat 142 was recorded on the wall on floor 3 used to record information about people needing to be rescued.[671]
At 02.27, Husna Begum made a second emergency call, speaking to CRO Heidi Fox in the LFB control room. She told CRO Fox that the family had been waiting for help for an hour and included two elderly adults. Husna Begum told her that the fire was right next to their window and that they were afraid they were going to die. CRO Fox told her that they were not going to die and that she would pass the information to the command unit.[672] By that time the fire was outside the kitchen window of Flat 142.[673]
At 02.29, CRO Fox created a service request in relation to Flat 142 and CRO Sharon Darby then sent a radio message at 02.30 which referred to five adults, including two elderly persons, being trapped inside Flat 142.[674] Although Husna Begum’s call at 02.27 probably explains the reference to Flat 142 which appears on the white laminated sheet used in CU7,[675] there is no evidence about what happened to that information once it had been received by CU7,[676] apart from the fact that it was recorded on a control information form.[677]
Having spoken to Husna Begum, who told her that there was a fire in the tower, Rohema Khanom made her way there. On the way she telephoned Husna Begum between 02.20 and 02.50 and then spoke to Rabeya Begum, who told her that the fire was now in the flat. Her aunt said that the family were all in the bedroom used by Mohammed Hanif and Mohammed Hamid. She then returned the phone to Husna Begum, who said it was pitch black in the flat, before ending the call.[678] By that time the fire covered the entire east side of Flat 142.[679]
At about 03.00, Rohema Khanom spoke to Mohammed Hanif, who told her that the family were all together.[680]
Husna Begum called her brother Mohammed Hakim at 03.08. She told him about the fire and said that the family were trapped in the flat. She said she did not think she would survive. She then ended the call.[681] Mohammed Hakim then tried to call all five members of his family, but the calls all went to voicemail.[682]
At 03.09, CRO Adams answered an emergency call from Husna Begum and one of her brothers. That was the third such call from Flat 142. Husna Begum told CRO Adams that there were five people in the flat and that there was fire in the kitchen and the hallway. There is no record of the call being passed to CU7. CRO Adams advised them to leave but was told that it was not possible to do so as the smoke in the stairs was too thick.[683] That suggests that the family must have tried at some point to leave Flat 142.
Husna Begum also spoke to Rohema Khanom again, but we do not know when. She told Rohema Khanom that it was smoky and dark and that she could not see anything. She was having difficulty breathing and was coughing continuously.[684]
The fourth and last emergency call from Flat 142 was made at 03.18. Husna Begum spoke again to CRO Fox, who advised the family to leave. Husna Begum said that they were unable to do so because it was too hot outside the door, probably meaning in the lobby. She said that there were five adults in the flat, including two elderly people, and that they were near the front door. Husna Begum asked for someone to come to the flat. CRO Fox said that she would pass the information on by radio. However, there is no entry on the LFB Short Incident Log of any service request to that effect and no other record of any radio call.[685] After that, no one in Flat 142 contacted the emergency services or anybody else outside the tower.[686]
The second of the two whiteboards used by SM Jason Oliff to collate information in the LFB control room to pass to the command units contained a reference to Flat 142.[687] It is likely, in view of its low position on the second whiteboard, that that reflected one of the later calls made by Husna Begum at 03.09 and 03.18. Flat 142 also appeared on the whiteboard grid on CU7, showing five persons and a “P” for priority, which might have indicated the presence of elderly persons. The photograph of the whiteboard grid was taken between about 03.15 and 04.00. It is therefore at least possible that it recorded the information given in Husna Begum’s call at 03.18.[688]
By the time Husna Begum made her last call at 03.18 the bridgehead had been moved to the ground floor (at around 03.10). After that, a green wall by the stairs was used to record information about those needing to be rescued.[689] A photograph of that wall taken at about 04.45 shows the number “142”.[690] It is not clear when it was put there.
The last crew that would have been able to reach floor 17 or above consisted of FFs Michael Pole, Niki Mitchell and Chris Cheesman, who were deployed to floor 23 between 02.51 and 02.53. However, having stopped at floor 18 to help evacuate the occupants of Flat 153, they realised that they did not have enough air to reach floor 23.[691] The last opportunity of rescue for the family in Flat 142 lay in the timely communication to the bridgehead of the information provided in Husna Begum’s second call at 02.27 and its being acted upon swiftly. The information did eventually arrive, but there is no evidence that it was acted on.[692]
The body of Husna Begum was recovered from the lobby of floor 17. Those of the other members of the family were recovered from the bedroom nearest the front door of Flat 142, which was the last area to be affected by the westward spread of the fire.[693] The coroner, Professor Wilcox, was satisfied about the identification of the remains recovered, and therefore issued interim certificates of the fact of death for all five members of the family.[694]
Husna Begum probably tried to leave after making her call to the emergency services at 03.18. We do not know whether other members of the family also tried to leave at the same time but were forced to return to Flat 142 by the conditions they encountered.
It is possible that until the time of the last emergency call, the family in Flat 142 were able to reduce their exposure to asphyxiant gases by keeping a bedroom window open.[695] However, once the fire had reached the window of the bedroom where they were sheltering, conditions in the room deteriorated rapidly within a few minutes.[696] The fire had reached the bedrooms of Flat 142 by 03.20 and had passed them by 03.33.[697] In the circumstances, we are satisfied that Kamru Miah, Rabeya Begum, Mohammed Hamid and Mohammed Hanif all died at some time between 03.20 and 03.33.
Husna Begum’s last emergency call to CRO Fox lasted one minute and 20 seconds.[698] By then the fire was affecting both the living room and bedroom windows on the south side of Flat 142.[699] It is likely that from about 01.29 to 03.20, Husna Begum (and indeed the other members of her family) was increasingly exposed to asphyxiant gases. Husna Begum had therefore already been exposed to a significant level of asphyxiant gases while she remained in Flat 142. On leaving the bedroom where she had been sheltering with her family, she encountered a high concentration of smoke and gases in the hallway of Flat 142 and then in the lobby.[700]
We find that Husna Begum sought to leave Flat 142 shortly after she had made her last emergency call and while the fire was still outside the bedroom where the family was sheltering. We are satisfied that she also died between 03.20 and 03.33.
The remains of the members of the family found in Flat 142 were extensively charred.[701] Heavy soot deposits were found in Kamru Miah’s airways. There was evidence of mild heat-related damage to the lining of the trachea which would have occurred while he was alive.[702] Soot deposits were also found in the airways of Rabeya Begum[703] and Mohammed Hamid.[704]
The level of carboxyhaemoglobin in a blood sample taken from Kamru Miah was 47%;[705] that in a sample taken from Mohammed Hanif was 69%.[706] Both are within the range associated with death from carbon monoxide poisoning. Toxicological analysis confirmed that Mohammed Hamid’s blood contained carboxyhaemoglobin but the concentration could not be measured.[707] It was not possible to conduct a toxicological examination of Rabeya Begum.[708]
Given the high levels of carboxyhaemoglobin in Kamru Miah and Mohammed Hanif’s blood and the fact that the four members of the family were together in the bedroom, we find that they were all exposed to a level of asphyxiant gases which was so high that it caused loss of consciousness and death before their bodies suffered any serious effects of direct heat or fire.[709] In Kamru Miah’s case, significant heart disease made him more vulnerable to collapse and death from the effects of asphyxiant gases.[710]
The body of Husna Begum was recovered intact. There was no obvious soot staining to her airways. Carboxyhaemoglobin appeared to be present in the blood, but it was not possible to measure the concentration due to the condition of the sample. There was significant heat damage to the body that is unlikely to have occurred while Husna Begum was still in Flat 142.[711]
Although the examining pathologist could not completely exclude the possibility that some heat damage had occurred before death, we think it more likely that it occurred after Husna Begum had died. We think that the extent of her exposure to asphyxiant gases (carbon monoxide with some hydrogen cyanide) and the physical exertion involved in leaving Flat 142 caused her to collapse and lose consciousness soon after entering the lobby. She continued inhaling those gases while unconscious and died shortly after.[712]
The medical cause of death in the case of Kamru Miah was recorded as:
Ia. Inhalation of products of combustion.
II. Ischaemic heart disease.
In the light of Professor Purser’s evidence, we find that a more accurate description of the primary cause of death is “inhalation of asphyxiant gases”.
The post-mortems on Rabeya Begum, Mohammed Hamid, Mohammed Hanif and Husna Begum recorded the medical cause of death in each case as “consistent with effects of fire”. A more accurate description would be “inhalation of asphyxiant gases”.
Date of birth: 1 June 1957 (60 years old).
Place of birth: Nigeria.
Gender: Male.
Occupation: Retired.
Usual address: Flat 144, floor 17, Grenfell Tower, London
Place of death: Flat 144, floor 17, Grenfell Tower, London
Time of death: Between 04.00 and 04.15 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Vincent Chiejina was born on 1 June 1957 and was 60 years old at the time of the fire. He spent his early years in Nigeria before travelling to the United Kingdom with his mother, Magdalene, and his sister, Jindu Maria. The eldest of four siblings, Vincent Chiejina and his family had lived on the Lancaster West estate between 1974 and 1981. He studied Electrical and Electronic Engineering at Sheffield University.[713] Vincent Chiejina had lived alone in Flat 144 on floor 17 of Grenfell Tower since February 2001.[714] He was an active member of the Roman Catholic Church[715] and a men’s group.[716]
Vincent Chiejina had a history of mental health difficulties. He had been diagnosed with schizophrenia, for which he received medication.[717] Rydon’s survey of Grenfell Tower residents carried in November 2014 and provided to the TMO recorded that he suffered from learning disabilities and schizophrenia.[718]
The spreadsheet produced on the night of the fire by David Noble[719] based on information held on the TMO’s Capita Insight system identified Vincent Chiejina as a vulnerable person but contained no information about his mental health or learning difficulty.[720]
Vincent Chiejina remained in his home throughout the course of the fire. He did not contact the emergency services and there is no evidence of his having contact with anyone else, either inside or outside the tower.[721]
There is no direct evidence of what Vincent Chiejina did during the course of the fire but it is possible that he may have been awake for part of the time, since his remains were recovered from the living room rather than the bedroom. The living room was affected by the fire later than the bedroom and kitchen.[722]
The remains of Vincent Chiejina were recovered from the living room of Flat 144 close to the window.[723] The coroner, Professor Wilcox, was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.[724]
The post-mortem on Vincent Chiejina recorded that he had mild coronary heart atheroma (heart disease). His remains were extensively charred. Soot was found in his respiratory system, including the lungs. There was evidence of damage to the lungs which could have been caused by the inhalation of hot smoke.[725] Toxicological analysis of a sample of his blood showed a carboxyhaemoglobin level of about 39%, but that must be regarded as little more than an estimate because of the condition of the sample.[726]
Over the course of the fire, the quantity of smoke in Flat 144 increased, with smoke initially penetrating the flat from the lobby from about 01.30. The rate at which smoke entered the flat increased from about 03.44, when the fire became established outside the bedroom before spreading to the outside of the kitchen.[727]
Vincent Chiejina was therefore exposed to a rising level of asphyxiant gases that increased even more when the fire reached the outside of his living room at about 03.58, resulting in a rapid deterioration of conditions in that room. The level of carboxyhaemoglobin in his blood indicates that he inhaled a considerable amount of asphyxiant gases before his death, probably sufficient to cause a loss of consciousness within minutes. The exposure to asphyxiant gases could of itself have been sufficient to cause death. The inhalation of hot gases before death may have contributed by causing breathing difficulties, again leading to rapid collapse followed shortly thereafter by death due to asphyxia.[728] It is possible that Vincent Chiejina’s mild heart disease increased his susceptibility to carbon monoxide.[729]
The post-mortem report recorded the medical cause of death as “inhalation of products of combustion” but in the light of more recent evidence we consider that a more accurate description is “inhalation of asphyxiant gases”.
We are satisfied that Vincent Chiejina died between 04.00 and 04.15 before suffering the direct effects of heat or fire.[730]
All six flats on floor 18 were occupied when Behailu Kebede made an emergency call to report a fire in his flat.[731] By 01.26, the fire had reached the outside of Flat 156 on floor 18,[732] the home of Shah Ahmed and his wife, Sayeda Ahmed. Woken by smoke alarms, Shah Ahmed saw fire outside his kitchen window, which then appeared to explode inward. He called the emergency services at 01.27 and was connected to the police. He was not able to speak to the operator before leaving with his wife. Together they knocked on their neighbours’ doors. Shah Ahmed left the door of his home shut. He and his wife then left floor 18, leaving the tower by 01.31.[733]
Rabia Yahya, who was in Flat 152 with her children, heard a knocking at her door. When she opened it she saw Shah and Sayeda Ahmed by the door to the stairwell. Sayeda Ahmed warned her of the fire and told her to leave.[734] Shortly after Shah and Sayeda Ahmed had raised the alarm, Hamid Kani, who lived alone in Flat 154, Sakina Afrasehabi and her sister, Fatemeh Afrasiabi, who was staying with her in Flat 151, left their homes. Berkti and Biruk Haftom, who lived in Flat 155, may have decided to leave even before the Ahmeds alerted their neighbours.[735] They all died, having sought refuge on floor 23. We return to the circumstances of their deaths in Chapter 97.
At 01.33, Rabia Yahya made a call to the emergency services which was put through to the LFB. She told CRO Angela Gotts that she was pregnant and trapped on floor 18 with her three children. Rabia Yahya was not asked for the number of her flat. She reported that she had been unable to leave because of thick black smoke which, she later recalled, had been in the stairwell. Rabia Yahya was advised to stay in her flat.[736] At 01.36, CRO Gotts created a service request in response to that call, recording that the caller was on floor 18.[737] OM Alexandra Norman and CRO Sharon Darby then told WM Daniel Meyrick in CU8 and the crew in appliance G261 that there was a person trapped on floor 18.[738] At 01.43, during the course of a radio exchange with CU8, CRO Darby again passed on information about a caller on floor 18 with thick smoke outside her flat.[739] At 01.45, CRO Darby recorded the service request as complete.[740]
WM Mark Kentfield recorded the information reaching CU8 on pieces of paper, which were then passed to SM Brett Loft positioned outside the tower.[741] They included the A4 sheet of paper that later became known as the “Sadler envelope”. The last entry in that document reads “152 – 18th pregnant”.[742] How the information passed from SM Loft to the bridgehead is unclear.[743] A photograph taken by FF Justin O’Beirne shows that after the bridgehead had moved to floor 3 there was written on the wall “18 MOTHER +CHLD NO FLAT NUMBER” followed by the number 152 circled. The number 18 was ticked.[744]
In any event, as a result FFs Katie Foster and Gregory Lawson were deployed at 01.53 to floor 18 in general rather than to a specific flat or to find a pregnant resident.[745] The crew probably reached floor 18 at or shortly after 02.00. By then, just two flats, adjacent to each other on the south side of floor 18, remained occupied. Rabia Yahya and her children were still in Flat 152. Yehualashet Enyew, Berkti Haftom’s lodger, had moved from Flat 155 to Flat 153 to join Paulos Tekle, Genet Shawo and their two sons.[746]
When they arrived at floor 18, FFs Foster and Lawson found the visibility in the lobby to be restricted by thick black smoke. They conducted a sweep of the floor. The door of the first flat they reached (Flat 151) was locked. When they reached Flat 152, they spoke to Rabia Yahya inside her home, which was still clear of smoke. They told her that they would check on neighbouring flats and get everyone out together. She was advised to put damp blankets against her front door.[747] FFs Foster and Lawson then moved to Flat 153. When Yehualashet Enyew opened the front door, Paulos Tekle was sitting on the ledge of a sitting room window. He moved back into the flat to speak to the firefighters. Their advice was again to block up the front door. Those in Flat 153 then covered the letterbox and front door and sat down to wait.[748]
FFs Foster and Lawson then searched Flat 154 followed by Flat 155. They found the doors to both flats open and their interiors to be pitch black and full of smoke. The door of Flat 156 was closed and they decided not to force an entry, given the indication that there was now fire inside.[749] The crew concluded that conditions were too difficult to enable them to rescue the nine remaining occupants on floor 18 at that time. They both tried to contact the bridgehead by radio but without success. As they were running low on air, they made their way down the stairs without returning to Flat 152 or 153.[750]
The fire reached Flat 152 by about 02.22.[751] Rabia Yahya thought that the fire had broken into her kitchen at about 02.30. She immediately left with her children and went to Flat 153. She found conditions in the lobby worse than when she had answered the door to FFs Foster and Lawson. The lobby felt hot and visibility was so poor that she had to use the wall as a guide. There was no smoke in Flat 153 when she arrived there.[752]
By about 02.30, all those remaining on floor 18 were sheltering in Flat 153. The fire brigade was aware that there were people there, both from information provided by FF Lawson when he returned to the bridgehead and from calls to, and between, the emergency services. However, no more firefighters were sent to floor 18 until shortly after 03.00 and those then deployed had to abandon their task. At about the same time, those in Flat 153 left the building. During the descent from floor 18, Isaac Paulos became separated from the group and died shortly afterwards.
Date of birth: 22 September 2011 (5 years old).
Place of birth: London.
Gender: Male.
Occupation: N/A.
Usual address: Flat 153, floor 18, Grenfell Tower, London.
Place of death: Lobby of floor 13, Grenfell Tower, London
Time of death: Between 03.09 and 03.15 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Isaac Paulos lived in Flat 153 with his mother, Genet Shawo, and his younger brother. His father, Paulos Tekle, did not live in Grenfell Tower but visited almost every day.[753] Isaac loved Taekwondo, swimming, and football. His teachers described him as especially gifted at maths and reading.[754]
Apart from his age, Isaac Paulos was not known to have any vulnerabilities. He was recorded as a child in the spreadsheet produced on the night of the fire by David Noble.[755]
Isaac Paulos returned home from a Taekwondo session at about 18.30 on 13 June 2017.[756] The family spent the evening together.[757] At some time after the fire had started, his parents were woken by sounds from the lobby. Opening the front door, they saw Rabia Yahya, who told them about the fire.[758] That conversation must have occurred just after Rabia Yahya had spoken to Sayeda Ahmed and before 01.32 when Paulos Tekle telephoned his friend Abraham Abebe who lived in Flat 44.[759] At 01.43, Genet Shawo spoke to Hashim Kedir, who lived in Flat 192. He told her that he had been advised by the emergency services to remain in his flat. He advised her to do the same.[760]
After leaving floor 18, FFs Foster and Lawson returned to the bridgehead, which by that time was on floor 3.[761] Their end of wear time was 02.27.[762] FF Lawson gave a debrief, drawing a plan on a wall to indicate which flats on floor 18 the crew had visited and which they had found empty. He also explained why they had not brought anyone down and that it was necessary to send more crews to floor 18 immediately.[763] A photograph taken by SM Gareth Cook at 03.08[764] shows that the information recorded on a wall of floor 3 while the bridgehead was located there included the following: “18 MOTHER + CHILD, NO FLAT NO 152” with a tick next to the number 18 and with “152” circled.[765] A tick against a particular flat indicated that a crew had been sent there and a circle indicated that the bridgehead had received further information by runner or radio or from a returning crew.[766] That information related to the deployment of FFs Foster and Lawson.
Leaving the bridgehead, FF Lawson went out through the ground floor lobby. There he spoke to CM Charles Batterbee, drawing another plan of floor 18 and repeating the information that he had given at the bridgehead. He did not see what CM Batterbee did with the information.[767] CM Batterbee recalled that FF Lawson had given him the numbers of two flats. CM Batterbee’s recollection was that those flats were on floor 18. He wrote the information on a piece of paper and WM Glynn Williams then wrote it on the wall of the ground floor lobby. The information was then passed to WM Paul Watson who took it to the bridgehead.[768]
Three control information forms contain information that relates to floor 18. The first refers to about four people being in Flat 153. The second, timed at 03.01, refers to Flat 153 but also records “People in Flat C+B waiting by window. CAME FROM BA CREW.” (The form then names FF Lawson as the source of information. A note in a different hand referring to four adults and 5 children appears on the blue copy of the form). The third (a yellow copy) is timed at 03.02 and refers (wrongly) to a family waiting in Flat 154. Again, FF Lawson is given as the source of the information.[769] The references to Flats 153 and 154 may explain why those flats were recorded by CM Batterbee.[770]
WM Williams had begun putting information on the ground floor wall at about 02.15.[771] Photographs of that wall[772] taken at a later stage show that it included references to Flats 154, 153 and 152. The letters “BA” appear against each flat number with ticks next to 153 and 152. All three flats are linked by a bracket to Floor 18 (written as “18th”). A reference to four people is written by Flat 152 (i.e. Rabia Yahya and her three children). These details reflect information provided by FF Lawson.
FF Lawson’s debrief did not prompt any further deployment to floor 18.
Rabia Yayha and her children had reached Flat 153 by 02.32, when Paulos Tekle made an emergency call reporting that there were four adults and five children in his flat. He told CRO Yvonne Adams that the fire was coming nearer and that they could not leave. CRO Adams told him that everyone should move to the room with the least smoke, that the fire service would get to them as soon as possible and that he should ring back if conditions got worse. Paulos Tekle later recalled that there had been no smoke or fire in Flat 153 at the time but that he had been able to see flames outside coming from the direction of Flat 152.[773]
Paulos Tekle’s call to the emergency services overlapped with a similar call made by Rabia Yahya at 02.34. She told CRO Heidi Fox that she was in Flat 153 and that the fire had reached Flat 152. CRO Fox told her that they should all try to leave. Rabia Yahya said they could not do so because of the thick black smoke and added that the firefighters had said they would return but had not done so. When asked who was there, Rabia Yahya told CRO Fox that there were four adults and five children sheltering in Flat 153 and that she was pregnant. CRO Fox said that she would alert the command unit to go to them.[774]
Although no service request was created following Paulos Tekle’s call at 02.32,[775] CRO Fox did create one at 02.40 following the call from Rabia Yahya and repeated it a minute later. However, neither call led to a radio message being sent to the incident ground.[776] References to both calls appear on the whiteboards used from about 02.33 by SM Jason Oliff to collate information coming into the LFB control room. It is likely therefore that he passed information about Flat 153 to the incident ground by mobile telephone.[777]
Paulos Tekle made another call to the emergency services at 02.35 which was taken by CRO Peter Duddy. He did not respond to CRO Duddy’s requests for information and the line then dropped out.[778] Shortly after, at 02.42, a further call from someone in Flat 153 was connected to the control room. The caller was probably Yehualashet Enyew. He told CRO Gotts that there were about nine people in the flat, that smoke was coming in and that the fire had reached Flat 152. Her advice was to block out the smoke if they could not leave and that the fire service would be informed to come and find them.[779] The call did not result in a service request.
At 02.45, CRO Christine Howson took a call from the police passing on information that three children and a pregnant woman were still in Flat 152 on floor 18.[780] That information, which plainly referred to Rabia Yahya and her children, had come from calls to the police made from outside the tower.[781] Shortly afterwards, at 02.47, CRO Gotts took a call from a relative of Rabia Yahya who was concerned that her sister-in-law was trapped on floor 18. The caller did not give the number of the flat. CRO Gotts replied that the control room had just received a message about floor 18 and told the caller that, if she spoke to Rabia Yahya, she should tell her to leave.[782]
That information from these calls reached the incident ground is apparent from the white laminated sheet used in CU7 to collate information.[783] It contained the following notations:
“152 18 3 kids, 1 PREGNANT adult”. There is a red asterisk next to the entry.
And a little lower:
“151 18 3 kids, 1 adult”
And as the last entry: “153 18 4 adults 5 children can’t escape”.[784]
At 02.48, CRO Howson answered a call in which Rabia Yahya said that they were trapped in Flat 153 on floor 18. When told that the fire had reached Flat 152, CRO Howson told her that the fire service would not be able to reach the flat and that its occupants should leave.[785] They spoke over each other at the relevant point in the call, so Rabia Yahya can only be heard saying that there were four people in Flat 153.[786]
At about that time, radio messages were being exchanged between CRO Sharon Darby and CU7, during which she said that about four people were trapped in Flat 153.[787] The calls from Yehualashet Enyew at 02.42 and Rabia Yahya at 02.48 were probably the source of the information.
At 02.51, Essex Fire and Rescue Service received a call from Paulos Tekle, who reported that smoke was entering Flat 153. CRO Russ White told him to block out the smoke, to try to get some fresh air, or to leave if it was safe to do so.[788] Having been advised by the LFB control room that callers from the tower should be told to leave, CRO White telephoned Paulos Tekle at 02.54 and left a message telling him that he and his family should cover themselves with wet towels and try to leave. He repeated that advice when he spoke to Paulos Tekle at 02.56.[789] Those in Flat 153 began to collect wet towels.
At 03.02, as the occupants of Flat 153 were preparing to leave, CRO Duddy telephoned Paulos Tekle to tell him that everyone in the flat had to leave.[790] At the same time, FF Joe Worley set out[791] together with three other firefighters to rescue a family of four from Flat 153 on floor 18.[792] However, the crew had to be stood down shortly after as they did not have extended duration breathing apparatus.[793] That deployment was probably prompted by the radio message sent by CRO Darby at 02.48.
From about 03.00, the crew of CU7 began recording information on a whiteboard using a grid system.[794] At some point they became aware that there were nine people in Flat 153, which was marked as a priority.[795]
Yehualashet Enyew was the first to leave Flat 153 holding Isaac Paulos by the hand. Rabia Yahya and her children followed. Paulos Tekle, carrying his youngest son, and Genet Shawo were at the rear of the group as they all left.[796]
Coincidentally, a group of firefighters arrived on floor 18 at that time. FFs Michael Pole, Niki Mitchell and Chris Cheesman had tallied out at 02.53, to go to floor 23. As they went up the stairs, the crew realised that they would not have enough air to get to floor 23 and back. They therefore decided to rescue anyone they could from the floor they had reached (floor 18) rather than continue going up. When they entered the lobby of floor 18, the crew came across the people leaving Flat 153. The group then formed a chain descending the stairs.[797]
By that time conditions were hazardous and disorientating. The lobby of floor 18 was dark and full of smoke. Dense smoke in the stairwell made it hot and difficult to breathe. Both Paulos Tekle and Yehualashet Enyew felt themselves beginning to lose consciousness. Rabia Yahya’s asthmatic son collapsed on the stairs and was carried down by firefighters.[798]
At some point during the descent from Flat 153, Isaac Paulos became separated from Yehualashet Enyew.[799] In the Phase 1 report the chairman found that the body of Isaac Paulos had been recovered from floor 13.[800] Further evidence suggests that he collapsed and died in the stairwell at the level of floor 13 and that his body was later moved into the lobby on that floor.[801]
In the Phase 1 report the chairman found that it was not possible on the evidence to reach a clear conclusion about how and when Yehualashet Enyew lost his grip on Isaac Paulos’ hand.[802] We have not received any further evidence that allows us to reach a more positive conclusion.
Paulos Tekle, Genet Shawo and their youngest son, Rabia Yahya and her three children and Yehualashet Enyew all left the tower between 03.13 and 03.18.[803]
Isaac Paulos probably collapsed on the stairs. His body was recovered from the lobby of floor 13.[804] The coroner, Professor Wilcox, was satisfied about the identification of his remains and therefore issued an interim certificate of the fact of death for Isaac Paulos.[805]
The post-mortem report on Isaac Paulos noted soot deposits over much of his body. Soot was also present in his airways and lungs. The signs of heat damage to his body were consistent with its having occurred after death. There was no sign that he had sustained any recent injuries before he died.[806]
The level of carboxyhaemoglobin in a blood sample taken from Isaac Paulos was found to be 67%, which is within the toxic range. Cyanide was detected at a level of 0.060 milligrams/litre.[807] That is below what is normally considered to be a toxic level but, since the sample is likely to have degraded over time,[808] it is not a reliable indication of the level of cyanide in the blood at the time of death. However, the presence of cyanide shows that Isaac Paulos was exposed to hydrogen cyanide before he died.
The post-mortem recorded the medical cause of death as “inhalation of fire fumes” but in the light of more recent evidence we find that a more accurate description is “inhalation of asphyxiant gases”.
Professor Purser observed that, if those in Flat 153 had left by about 01.40, the concentration of asphyxiant gases in the stairwell would have been considerably lower. However, if they had waited until FFs Foster and Lawson reached floor 18, conditions in the stairwell might have been similar to those they encountered when leaving about an hour later.[809] The occupants had had minimal exposure to asphyxiant gases before they left the flat.[810]
If the occupants of Flat 153 began to leave at about 03.04, as Professor Purser estimated,[811] it must have taken them at most 15 minutes to leave the tower. He thought that the group had been exposed to a significant dose of asphyxiant gases as they crossed the lobby on floor 18 and descended the stairs, but not enough to incapacitate them.[812]
However, the rate of uptake of toxic gases is more rapid in children than in adults.[813] Taking into account his size and the physical activity involved in descending the stairs, we are satisfied that Isaac Paulos is likely to have absorbed asphyxiant gases at almost twice the rate of an adult,[814] leading to rapid incapacitation and collapse.[815] We are therefore satisfied that he collapsed and lost consciousness within a few minutes of entering the stairs. Having lost consciousness, he continued to inhale asphyxiant gases until his respiration and circulation ceased shortly afterwards and he died.[816] Death was rapid and occurred between 03.09 and 03.15.
All the flats on floor 19 were occupied on the night of the fire. By 01.25, the fire had reached the top of floor 19 and was outside Flat 166.[817] Within a short time, nearly everyone had left their flats. By 01.30, only Flat 165, the home of Nicholas and Pily Burton, was still occupied.
Meron Mekonnen in Flat 163 had been alerted to the fire at 01.25 and told to leave. Although there was light smoke in the lobby when she left with her children, it did not affect her visibility or have any physical effect on her or her children. Meron Mekonnen and her children left the tower at 01.32.[818]
Amal Ahmedin and her daughter Amaya Tuccu Ahmedin lived in Flat 166. On 14 June 2017, her cousin, Amna Idris, was visiting them. All three took shelter on floor 23, where they died. Marjorie and Ernie Vital from Flat 162 were also among those who moved to floor 23. By 01.34, they were already in Flat 202, where they also eventually died. We return to the circumstances of the deaths of these individuals in Chapter 97.
Fadumo Ahmed lived alone in Flat 164. At around 01.20, she received a call alerting her to the fire. When she left her flat, she found the lobby full of dark grey smoke;[819] it is likely that it had come from Flat 166.
Fadumo Ahmed saw her neighbour Deborah (Debbie) Lamprell, who lived in Flat 161, near the lifts. They both took shelter in Flat 201 on floor 23. Amal Ahmedin, her daughter and Amna Idris were already in Flat 201 when Fadumo Ahmed reached it.[820] Later, Fadumo Ahmed left Flat 201. She was rescued by firefighters and carried out of the tower at 02.25.[821] Debbie Lamprell died in the fire, as did a friend, Gary Maunders, who had been visiting her that night and who took shelter in Flat 203. We return to the circumstances of their deaths in Chapter 97.
Shortly after 01.30, Nicholas Burton was woken by the sound of banging on his front door. We do not know who banged on the door; it is possible that he was woken by the sounds of neighbours leaving. In any event, when he opened the front door, there was so much black smoke outside that he could see little.[822]
At 01.41, a BT operator informed North West Fire Control that a caller from the tower had hung up. CRO Aisha Jabin called the number back and spoke to Debbie Lamprell. She said that she was one of a group of 10 people sheltering in a flat on floor 23; she later gave her flat number as 161.[823] Flat 161 was Debbie Lamprell’s home on floor 19. The information that there were people trapped in Flat 161 on floor 23 was passed to the LFB’s control room at 01.46 and to the incident ground at 01.47.[824] As a result, FFs Adam Johnson and Terence Roots were sent to Flat 161. They found it empty but found Nicholas and Pily Burton still in Flat 165 and helped them leave the tower. [825]
Date of birth: 10 August 1946 (70 years of age).
Place of birth: Ferrol, Galicia, Spain.
Gender: Female.
Occupation: Retired.
Usual Address: Flat 165, floor 19, Grenfell Tower, London.
Date of death: 29 January 2018.
Maria del Pilar (Pily) Burton lived with her husband Nicholas Burton and their beagle, Lewis Hamilton II, in Flat 165 on floor 19.[826] Pily had moved to Grenfell Tower in the 1970s. She worked for the National Health Service as a contract manager until she had to leave work in 2015 due to ill-health.[827]
The spreadsheet produced on the night of the fire by David Noble[828] based on information held on the TMO’s Capita Insight system[829] identified Pily Burton as a vulnerable person but contained no information about her condition.[830]
Having opened the front door of Flat 165 to find black smoke in the lobby, Nicholas Burton decided that he and Pily should remained where they were. He was aware of the stay put advice displayed in the tower. He placed wet towels across the bottom of the front door, woke Pily and helped her dress. They waited in their living room. A friend called him urging him to leave, but he felt it was too dangerous to do so as Pily was so frail.[831]
At 01.56, Nicholas Burton made a call to the emergency services which was answered by CRO Christine Howson. He told her that he was in Flat 165 on floor 19 with his wife and dog and that there was a lot of smoke in the lobby, some of which had come into the hallway of his flat when he opened the front door. CRO Howson told him that firefighters would visit them and advised him to remain in his flat.[832]
Prompted by another call from his friend, Nicholas Burton decided that the bathroom would be the safest place in which to wait. He moved Pily there and closed all the internal doors. Seeing the glow of the fire, he made his second and final emergency call at 02.13. He told CRO Yvonne Adams that he was trapped on floor 19, that no one had come, and that the flames were getting very close to their windows. CRO Adams told him that firefighters were trying to get to people and said that he should call back if conditions in the flat deteriorated. At the time of the call, the only smoke in the flat was that which had entered from the lobby when he had opened the front door just after 01.30.[833]
The bathroom was near the front door. Waiting there, Nicholas Burton heard a noise at the front door. FFs Johnson and Roots who were outside the door told him to get wet towels and to be ready to come out.[834] Having confirmed the number of people present and that the flat was not on fire, FF Johnson told the occupants to cover their heads with wet towels. He and FF Roots then searched Flat 161 before returning to Flat 165 to rescue Nicholas and Pily Burton.[835]
By that time, the lobby of floor 19 was full of thick black smoke and visibility was limited. The firefighters helped the couple across the lobby, into the stairwell and down the stairs. The stairwell was also full of thick black smoke and felt very hot. Both firefighters were concerned that they were low on air and tried to descend as quickly as they could. Pily Burton fell more than once and FF Johnson had to carry her down.
At some point the two firefighters became separated. FF Roots and Nicholas Burton reached the ground floor first, but Nicholas Burton refused to leave the building until he knew where his wife was. At about floor 10, two other firefighters appeared and helped FF Johnson to carry Pily Burton. They reached the ground floor a few minutes after Nicholas Burton. He followed as Pily Burton was carried out of the tower.[836] The couple left the tower at 02.32.[837]
FFs Johnson and Roots returned to the bridgehead and told WM O’Keeffe that they had brought two casualties down from Flat 165. They gave the same information to a firefighter who was recording information about people needing to be rescued and saw him write something on a wall. [838]
No service requests were generated in response to either of Nicholas Burton’s 999 calls[839] and no firefighters were deployed to Flat 165.
Pily Burton’s condition deteriorated in the months that followed her escape from Grenfell Tower. She suffered a severe stroke in early January 2018 and died in hospital on 29 January 2018 with Nicholas Burton by her side.[840]
On 14 June 2017, all the flats on floor 20 were occupied. Victoria (Vicky) King and her daughter Alexandra Atala, who lived in Flat 172, Mary Mendy and her daughter Khadija Saye, who lived in Flat 173, and four of the five members of the Belkadi family, who lived in Flat 175, died in the fire. Jessica Urbano Ramirez, whose family home was Flat 176, was among those who died in Flat 201 on floor 23. We describe the circumstances of Jessica Urbano Ramirez’s death in Chapter 97.
Emma O’Connor and Luke Towner from Flat 171 were the first of those who lived on floor 20 to leave the tower, doing so shortly before 01.20. When they left, smoke was coming through the vents on floor 20, but the lobby was otherwise clear.[841]
By 01.26, the fire had reached the outside of Flat 176.[842] At that time, the only person there was Jessica Urbano Ramirez. She must have left by or before 01.26, since she spoke to CRO Sarah Russell from Flat 201 at 01.29.
The lobby on floor 20 became full of smoke within minutes after the fire reached the outside of Flat 176.[843] Farah Hamdan spoke to CRO Alexandra Norman at 01.30 and reported that there was smoke coming into the flat from the lobby.[844] Petra Doulova and her husband, who lived in Flat 174, left the tower at 01.41. She described the lobby on floor 20 as being pitch black and full of smoke, making it difficult to breathe. The couple had to feel their way across the lobby to the stairwell door.[845]
FF David Badillo was one of the first firefighters to arrive at the tower.[846] He met Melanie Urbano Ramirez, Jessica Urbano Ramirez’s sister, outside the tower and agreed to go to Flat 176 to find her.[847] After a failed attempt to reach floor 20 alone, FF Badillo returned with CM Christopher Secrett and FF Christopher Dorgu. They tallied out at 01.33[848] and were the first firefighters to reach that floor.
The lobby on floor 20 was so full of smoke that CM Secrett could not see equipment he had put on the floor.[849] The firefighters moved around the lobby using touch and torches.[850] When they found Flat 176, FF Badillo found the front door slightly ajar. The flat was full of smoke but the contents were not alight, although fire could be seen outside a window which was about to fail. CM Secrett’s warning whistle on his breathing apparatus began to sound shortly after they returned to the lobby having searched the flat and found it empty. The crew decided to make their way back to the stairwell and down. They did not knock on the doors of any other flats.[851]
Between 01.30 and 03.33 several emergency calls were made to the control room from inside and outside the tower reporting that Flats 173 and 175 were still occupied.[852]
Three crews were deployed to floor 20 between 01.50 and 02.00.
FFs Geoffrey Campbell and Steven Mills tallied out at 01.51 to go to Flat 175, the home of the Belkadi family, but were unable to reach floor 20.[853] On their descent they met a Paddington crew led by CM Philip Wigley that had been sent to the roof of the tower.[854] FFs Campbell and Mills told them that they had been unable to rescue a woman on floor 20. Having continued upward but realising that they would not be able to reach the roof, the Paddington crew made their way to floor 20 intending to rescue the woman they had been told about. FF Duane Harris opened the door to the lobby which was full of smoke. Members of the crew shouted but did not go into the lobby to knock on the doors to the flats. At about that time FF Roberts found Fadumo Ahmed on the stairs between floors 20 and 21. The crew assisted her down the stairs and out of the tower.[855]
CM Craig Eden and FF Tom Welch were instructed by WM O’Keeffe to go to floor 20 to assess the situation and report to the bridgehead. CM Eden said they had been told that there were persons trapped on floor 20. FF Welch said that they had not been told that there were people who needed rescuing and that he had assumed that the building had been evacuated.[856] The crew tallied out at 01.59. A minute later, FFs Vincent Williams and Agnel Fernandes tallied out with instructions to go to Flat 175 on floor 20.[857]
CM Eden and FF Welch reached floor 20. By that time, they were running low on air, so they decided to connect a fire hose to the dry riser.[858] Both firefighters described the lobby as so full of hot smoke that they could not see anything. CM Eden banged loudly on three doors but received no response. FF Welch said that, as they followed a wall left past two flat doors to find the dry riser, CM Eden had banged on those doors and announced that they were firefighters. Given the location of the dry riser, they are likely to have been the doors of Flats 172 and 173.[859]
FFs Williams and Fernandes reached floor 20 shortly after CM Eden and FF Welch and met them there. They too recalled thick smoke and no visibility. They tried to find their way to Flat 175, kicking and banging on doors and shouting through letterboxes as they went.[860]
There were no further deployments to floor 20 after 02.00. FFs Luke Cook and Brian Flanagan were sent to floor 20 at some time after about 02.03 but we think it likely that they went to a different floor.[861]
Date of birth: 12 June 1946 (71 years old).
Place of birth: Highgate, London, England.
Gender: Female.
Occupation: Retired.
Usual address: Flat 172, floor 20, Grenfell Tower, London.
Place of death: Flat 172, floor 20, Grenfell Tower, London.
Time of death: By 3.30 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 24 April 1977 (40 years old).
Place of birth: Reading, England.
Gender: Female.
Occupation: NA.
Usual address: Flat 172, floor 20, Grenfell Tower, London.
Place of death: Flat 172, floor 20, Grenfell Tower, London.
Time of death: By 3.30 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Born on 12 June 1946, Victoria (Vicky) King was 71 years old in 2017. She had been the registered tenant of Flat 172 since 26 January 1998[862] and lived there with her daughter, Alexandra Atala. Born on 4 April 1977, Alexandra Atala was 40 years old.[863] Vicky King and Alexandra Atala had a very close relationship and lived together throughout their lives.[864]
Both Vicky King and Alexandra Atala had mental health difficulties.[865] Alexandra Atala suffered from panic disorder associated with agoraphobia.[866] RBKC and the TMO were aware of their vulnerabilities.
On 9 July 2006, Janice Jones recorded that both Vicky King and Alexandra Atala had mental health difficulties.[867] In a survey of tower residents carried out by Rydon in 2014 during the refurbishment both women were recorded as having problems with their mental health.[868]
In the spreadsheet produced on the night of the fire by David Noble[869] based on information held on the TMO’s Capita Insight system[870] Vicky King was listed as a resident but there was no reference to any vulnerability. Alexandra Atala was recorded as being vulnerable on the grounds of mental health.
Both Vicky King and Alexandra Atala were in Flat 172 when the fire started. Vicky King had returned to the tower in the afternoon of 13 June 2017.[871] Alexandra Atala had not left her home for some time. Neither mother or daughter had any contact, whether by telephone or otherwise, with anyone either in or outside the tower during the fire.
Although firefighters did manage to reach floor 20, none were sent specifically to Flat 172. There is no evidence that Vicky King or Alexandra Atala ever became aware of the fire or that they heard other residents leaving floor 20 or firefighters arriving on that floor.
The fire reached the east side of the kitchen and living room of Flat 172 between about 02.02 and 02.08.[872] At some time after 02.55 it had spread to the south face of the living room and the two bedrooms of Flat 172.[873]
The remains of Vicky King and Alexandra Atala were recovered from the second bedroom in Flat 172 (the most southerly room in the flat and so farthest away from the fire).[874] The coroner, Professor Wilcox, was satisfied about the identification of the remains recovered and therefore issued interim certificates of the fact of death for Vicky King and Alexandra Atala.[875]
The post mortem examination on Vicky King noted that there was soot in the oesophagus. The carboxyhaemoglobin content of a blood sample taken from her was 58%, which is within the fatal range and indicated that she had inhaled carbon monoxide before her death. It was not possible to test the remains of Alexandra Atala.[876]
Drawing on the evidence of other occupants of floor 20, the evidence of the occupants of flats in a similar location on other floors and the evidence of Professor Purser, we are satisfied that from about 01.30 smoke probably began to enter Flat 172 from the lobby. When the fire reached the east side of Flat 172 shortly after 02.00, smoke began to enter the flat from outside. Until about 02.45 Vicky King and Alexandra Atala could probably have escaped from the building if they had been able to cross the lobby and descend the stairs.[877]
Conditions in the second bedroom began to deteriorate once the fire started to spread across the southern face of Flat 172.[878] Since their remains were found in a bedroom, it is possible that Vicky King and Alexandra Atala were asleep by the time the fire started and slept through it.[879]
Taking into account the presence of soot in Vicky King’s respiratory system, the level of carboxyhaemoglobin in her blood and that her remains and those of Alexandra Atala were recovered from a bedroom, we are satisfied that inhalation of asphyxiant gases caused both of them to lose consciousness and die before the contents of Flat 172 caught fire.
The post mortem reports on Vicky King and Alexandra Atala recorded the medical cause of death in each case as “consistent with the effects of fire”,[880] but in the light of more recent evidence we find that a more accurate description is “inhalation of asphyxiant gases”.
There is not enough evidence to allow us to determine the time of death with any precision but we think that Vicky King and Alexandra Atala had probably both died by about 03.30.
Date of birth: 11 June 1963 (54 years).
Place of birth: Banjul, The Gambia.
Gender: Female.
Occupation: Carer.
Usual address: Flat 173, floor 20, Grenfell Tower, London.
Place of death: Stairwell, Grenfell Tower, London.
Time of death: Between 03.50 and 04.10 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 30 July 1992 (24 years).
Place of birth: Hammersmith, London.
Gender: Female.
Occupation: Artist.
Usual address: Flat 173, floor 20, Grenfell Tower, London.
Place of death: Stairwell, Grenfell Tower, London.
Time of death: Between 03.50 and 04.10 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Mary Mendy had been the sole tenant of Flat 173 since 17 January 1994.[881] She lived there with her daughter, Khadija Saye.
Mary Mendy was born on 11 June 1963 in The Gambia and was 54 years old.[882] She had moved to the United Kingdom in the 1980s.[883] Khadija Saye was born on 30 July 1992 in London.[884] She was 24 years old. At the time of the fire Mary Mendy was working as a care assistant. Khadija Saye had attended Rugby School on a scholarship and studied photography at the University of the Creative Arts in London. In May 2017, her work was exhibited at the Venice Biennale.[885]
There is no evidence that Mary Mendy or her daughter suffered from any vulnerability that would have impeded their escape.
Khadija Saye and Mary Mendy returned home during the evening of 13 June 2017. Khadija was seen on CCTV entering the lift lobby on the ground floor of the tower at 21.08. Her mother was seen on CCTV in the lift lobby at 23.06.[886] They remained in Flat 173 thereafter.
We do not know when they first became aware of the fire but at 01.49 Khadija Saye posted a message on Facebook saying that there was a fire in the tower and that she and her mother could not leave their flat.[887] The contents of that post suggest that neither Khadija Saye nor her mother had become aware of the presence on floor 20 of FFs Badillo, Dorgu and CM Secrett, who searched Flat 176 for Jessica Urbano Ramirez at some time between 01.33 and 01.57.[888] That may be because Flat 176 was in the northeast corner of the tower and Flat 173 in its southwest corner. It appears that Khadija Saye became aware of the presence of one or both of the other crews which later reached floor 20, since she told a friend in a telephone call at 02.50 that she had heard firemen “arguing” outside her door and then nothing else.[889] As Khadija Saye was able to say that those outside were firefighters, she must have heard them announce themselves as such. However, there is no evidence that Khadija Saye or her mother tried to call out to them.
At 02.26, Khadija Saye made an emergency call, in the course of which she told CRO Sarah Russell that a lot of smoke was coming into the flat. She and her mother were in the living room and had shut all but one of the windows. CRO Russell said that they could stay or to try to leave but Khadija Saye told her that they were too high up to leave and that there was too much smoke outside the front door. CRO Russell then advised her to try to prevent the smoke coming in by blocking doors and shutting windows. CRO Russell said she would notify the firefighter crews and explained that they were trying to make their way up but that it would take them some time.[890]
That was the only emergency call Khadija Saye made. She communicated with friends on Facebook who then made emergency calls to the LFB on her behalf reporting that she and her mother were trapped in Flat 173 on floor 20. There were five such calls between 02.50 and 03.33. On each occasion, the caller was advised to tell Khadija Saye to leave her flat.[891] No service requests appear to have been generated in response to any of those calls or to Khadija Saye’s earlier call. However, an entry reading “173 20th – 2 adults” appears on the second of the two whiteboards which SM Jason Oliff was using in the LFB control room from 02.33 to collate information to pass to the command units.[892] The position of that entry suggests that it had been prompted by one of the later calls about Flat 173.
Information about Flat 173 did reach the incident ground. Although no mention of Flat 173 appears on the white laminated sheet used in CU7 to collate information,[893] a reference to it was made on a whiteboard used in CU7 from about 03.00.[894] That whiteboard used a grid system. The figure “2” appears against Flat 173 indicating two adults. Next to it is a “P” in red, circled, indicating a priority.[895] A red tick was used on the grid to indicate that a crew had been deployed. No red tick appears on the grid.
The bridgehead was located on floor 3 between 02.17 and 03.10.[896] No note about Flat 173 appears on the wall of floor 3 where WM Louisa De Silvo recorded information while the bridgehead was located there. That may be because information about Flat 173 did not reach CU7 before 03.00.
WM Glynn Williams began recording information on the wall of the ground floor lobby at about 02.15. Someone had written “173 20 2P”.[897] The note was probably made by SM Peter Wolfenden, who entered the ground floor after the bridgehead had been moved there and started recording information on the wall from about 03.21.[898] He said that a tick had been used to indicate that a crew had been sent to a particular flat.[899] No tick appears next to the entry for Flat 173.
We are satisfied, therefore, that no crews were deployed specifically to Flat 173 in response to the calls made from or about it.
The advice for people to remain in their flats was changed at 02.35[900] after Khadija Saye’s call to the LFB. After her first post on Facebook, Khadija Saye next posted at 02.41.[901] At 02.55 she learned that the LFB’s advice was now to leave the building when a friend, who had called the control room, sent her a message. The same friend, having spoken to the control room again, repeated the advice to leave at 02.57.[902]
Khadija Saye replied that she was afraid to leave. At 03.05, as the exchange continued, she said that there was a lot of smoke in the flat. Having been reassured that there was only smoke in the stairwell, Khadija Saye sent another message at 03.14 saying that she had tried to leave but that the smoke had been too strong. Asked if she had found the way to the stairs, Khadija Saye replied that it was too dark and that she had begun to choke after a few steps. At 03.27, she described another attempt to leave, adding that it was impossible and that she had felt as though she was going to faint. At 03.30, in what was her last message, she said “It’s in my rooms”. We do not know if that was a reference to the fire or smoke. Her friend continued to send her messages, but we do not know if Khadija Saye saw them.[903]
Between 03.20 and 03.29, the fire reached the outside of the two bedrooms of Flat 173 on the south side of the tower. Between 03.37 and 03.53, it had reached the south side of the living room and moved round to the west side of the living room and to the kitchen of the flat.[904]
The arrival of the fire outside Flat 173 did not immediately cause Mary Mendy and Khadija Saye to try for a third time to leave their home, but they did so shortly after 03.30. This time they were able to cross the lobby and enter the stairwell.
FFs Methusael Sonson and James Cuthbert tallied out at 03.46 with instructions to search floor 5. Their end of wear time was 04.12. After they had been deployed, they were instructed to go to Flat 84 on floor 11. Making their way up the stairs, they found the body of Khadija Saye in the stairwell near floor 10. FF Sonson confirmed that she had no pulse.[905] Given where these firefighters found Khadija Saye, that must have been shortly before 04.12.
Khadija Saye’s body was subsequently moved to the lobby on floor 9 from which it was later carried out of the tower.[906] The coroner, Professor Wilcox, was satisfied about the identification of the casualty found by FFs Sonson and Cuthbert and therefore issued an interim certificate of death for Khadija Saye.[907]
CM Timothy Cutbill and FF Steven Bolton tallied out at 05.28 as part of a crew of four sent to floor 11 to search for casualties and, if possible, to go further up the tower. Their end of wear time was 05.59. As they ascended the stairs, they came across the body of Mary Mendy between floors 12 and 13.[908] Her body was later moved into the lobby on floor 13 and then taken out of the tower. [909] The coroner, Professor Wilcox was satisfied about the identity of the casualty found by FFs Cutbill and Bolton and issued an interim certificate of the fact of death for Mary Mendy.[910]
The post-mortems on Mary Mendy and Khadija Saye noted that, although it was not possible to obtain a blood sample from either of them, the presence of soot in their upper airways together with the discolouration of soft tissues showed that they had both inhaled carbon monoxide and hydrogen cyanide.[911]
Professor Purser calculated that, if Mary Mendy and Khadija Saye had entered the stairs at 03.36, the latest time at which they could have safely left the building without collapsing was about 03.16.[912] We accept his conclusion that, taking account of the conditions on floor 20 and in Flat 173 and the experience of survivors from flats in similar locations, Mary Mendy and Khadija Saye died from the inhalation of asphyxiant gases, mainly carbon monoxide but some hydrogen cyanide. They were exposed to a substantial amount of such gases while still in Flat 173, though not enough to incapacitate them. Conditions in the flat deteriorated by 03.30, when the fire had reached the bedrooms on the south side of the flat. Once they had left their home, their exposure to asphyxiant gases increased as they ventured into the smoke-filled lobby and then, albeit to a lesser degree, the stairwell. That exposure, coupled with the physical exertion required to descend from floor 20, caused them to collapse in the stairwell.[913]
Mary Mendy probably collapsed and lost consciousness between floors 12 and 13. Khadija Saye was able to continue for a short distance before she lost consciousness near floor 10. Thereafter, they both continued inhaling asphyxiant gases for a short time until their respiration and circulation ceased some minutes later and they died.
The post-mortem report on Khadija Saye recorded the medical cause of death as “inhalation of fire fumes and burns”.
The post-mortem report on Mary Mendy recorded the medical cause of death as “consistent with the inhalation of fire fumes”.
In the light of Professor Purser’s evidence we find that in each case a more accurate description is “inhalation of asphyxiant gases”.
Although Professor Purser estimated that Mary Mendy and Khadija Saye died between 04.00 and 04.20,[914] having regard to the evidence as a whole, including the time at which Khadija Saye made her last post on Facebook, we find that Mary Mendy had collapsed before FFs Sonson and Cuthbert found Khadija Saye. We therefore conclude that Mary Mendy and Khadija Saye both died between 03.50 and 04.10.
Date of birth: 23 February 1986 (31 years).
Place of birth: London, UK.
Gender: Female.
Occupation: Nursery Assistant.
Usual address: Flat 175, floor 20, Grenfell Tower, London.
Place of death: Stairwell between floors 19 and 20, Grenfell Tower, London.
Time of death: Between 02.45 and 03.10 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 1 August 1984 (32 years).
Place of birth: Morocco.
Gender: Male.
Occupation: Courier.
Usual address: Flat 175, floor 20, Grenfell Tower, London.
Place of death: Stairwell between floors 19 and 20, Grenfell Tower, London.
Time of death: Between 02.45 and 03.10 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 26 September 2008 (8 years).
Place of birth: London.
Gender: Female.
Occupation: Student.
Usual address: Flat 175, floor 20, Grenfell Tower, London.
Place of death: St Mary’s Hospital, Paddington, London.
Time of death: 15:01 on 15 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 12 December 2016 (6 months).
Place of birth: London.
Gender: Female.
Occupation: N/A
Usual address: Flat 175, floor 20, Grenfell Tower, London.
Place of death: Stairwell between floors 19 and 20, Grenfell Tower, London.
Time of death: Between 02.45 and 03.10 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Farah Hamdan and Omar Belkadi had lived in Flat 175 on floor 20 since 18 November 2013.[915] They lived there with their three daughters, Malak Belkadi, Leena Belkadi and their middle daughter who survived the fire.
Farah Hamdan was born on 23 February 1986 in London.[916] She was 31 years old and a teacher. Omar Belkadi was born on 1 August 1984 in Morocco. He was 32 years old and was working for a restaurant in June 2017 while training to be a taxi driver.[917] Malak, their eldest daughter, was born on 25 September 2008 at St Mary’s Hospital, London. She was eight years old when she died. Leena was born on 14 December 2016 at St Mary’s Hospital, London. She was six months old when she died.[918]
Farah Hamdan and Omar Belkadi did not have any known impairments. Their three children were under 18 years of age. The two elder daughters were recorded as living in the tower in the spreadsheet produced on the night of the fire by David Noble[919] and were known to be under 18. Leena was not listed.
The family were at home on the night of the fire. Farah Hamdan was seen on CCTV entering the lift lobby of the tower at 18.31 with her daughters.[920] Omar Belkadi returned home later and was seen on CCTV in the lift lobby at 00.12.[921] They became aware of the fire at an early stage, since Farah Hamdan called her sister, Samira Hamdan, at about 01.00 to tell her of a fire at the tower.[922]
At 01.30, OM Alexandra Norman answered an emergency call from Farah Hamdan, who told her that the family were in the living room, that smoke was coming into the flat and that the fire was in a neighbour’s flat. That must have been a reference to Flat 176; the smoke was probably coming from the lobby. OM Norman’s advice was to stay in the flat unless it was safe to leave. She added that she did not know what conditions were like in the stairs.[923]
At 01.31, CRO Peter Duddy created a service request telling the incident ground that there was a fire on floor 20 and that people were trapped there.[924] A little later, following a call from Natasha Elcock at 01.33, he created another service request containing the same information and including a reference to Flat 82.[925]
At 01.35, OM Norman spoke to WM Daniel Meyrick in CU8, which had just arrived at the incident ground. She told him that five people were in Flat 175 on floor 20 with a lot of smoke entering the premises.[926] WM Meyrick was passing the information he received to WM Mark Kentfield at the incident ground by radio. He was also recording the information on a piece of paper.[927] It is likely that WM Meyrick recorded the information he received from OM Norman on such a piece of paper, which was subsequently used to populate a white laminated sheet in CU7. That sheet included the following notation: “175 20 5 PERSON”.[928]
While OM Norman was speaking to WM Meyrick, CRO Sharon Darby contacted appliance G261 with the information that there were persons on floor 20 reporting that smoke was coming into their flat. CRO Darby was not able to give the numbers of the flats affected.[929] At 01.35, she noted that the service requests relating to floor 20 were being acted upon and at 01.41 she marked them as completed.[930]
The calls made by OM Norman and CRO Darby were the first messages to reach the incident ground. At around 01.40, SM Brett Loft, who was positioned at the front of the tower to handle incoming information, received a piece of A4 paper from WM Kentfield containing a list of flats from which people needed to be rescued. It included a reference to Flat 175 on floor 20. SM Loft passed the information he received to the bridgehead.[931]
At that time the bridgehead was on floor 2, where it remained until 02.17. While it was there, WM Louisa De Silvo recorded information on a forward information board.[932] At about 02.13, CM Charles Batterbee went to the bridgehead and copied the information on a forward information board into his own notebook. It included Flat 175 on floor 20, against which a tick appeared. CM Batterbee explained that this indicated a flat to which crews had been deployed, as reported by WM De Silvo.[933] We find that the tick related to the deployment of FFs Mills and Campbell who had been sent to Flat 175 but did not reach floor 20.[934]
At 01.43, Farah Hamdan’s second emergency call was connected to North West Fire Control. She gave the number of her flat and the floor and reported that the fire had reached the floor below. She said that the family had tried to leave but that black smoke in the lobby had prevented them from doing so. Farah Hamdan also said that there was now smoke inside her own flat. She was advised to block the smoke from coming in and was told that her location had been passed to the crews.[935]
At about the same time, OM Norman in the LFB control room took a call from Team Leader Paula Craig at North West Fire Control, who told her that five people were in Flat 175 on floor 20.[936] It is unclear how that information was passed to the incident ground. No service request was created and when CRO Yvonne Adams called CU8 by telephone at 01.50 and 02.00 she did not refer to Flat 175.[937] However, an entry at 02.01.43 in the LFB’s short incident log notes that CU8 was told at about 01.50 that five people were trapped in Flat 175 on floor 20.[938] It may be that SM Jason Oliff, who was in contact with CU8 throughout on his personal mobile, passed the information on.[939]
At around 02.00 CM Eden and FF Welch left the bridgehead to investigate the situation on floor 20 while FFs Williams and Fernandes were sent to Flat 175 on floor 20.[940] That may have been the result of the emergency call made by Farah Hamdan at 01.43 or of information received from FFs Campbell and Mills on their return to the bridgehead.[941]
At 02.11, CRO Heidi Fox answered a third emergency call from Farah Hamdan. She told CRO Fox that, despite having put sheets under the front door, there was now a lot of smoke in the flat. Farah Hamdan gave her the number of the flat and the floor on which it was situated and said that the five people sheltering there included three children. CRO Fox confirmed that she was passing the information on. She advised Farah Hamdan to keep trying to stop smoke coming in with damp towels and sheets and to call back if the situation worsened.[942]
The notation “175 20th Flr – 2 adults 2 children” appears on a whiteboard in the LFB control room used by SM Oliff to record information about people needing to be rescued. Despite the error about the number of children, that note was probably made in response to Farah Hamdan’s call at 02.11, since that was the last call in which she provided her location.[943]
The final emergency call from Flat 175 at 02.17 was incomplete. The BT operator heard the caller say, “No Malak, it’s not safe” and then ask for the fire brigade. The call was then put through to the LFB but there was no further response from the caller.[944] It was at about that time that CM Eden and Welch and, shortly after them, FFs Williams and Fernandes reached floor 20.[945] Although the visibility there was extremely limited the two crews were aware of each other.[946]
When FF Williams and Fernandes reached Flat 175, FF Williams went in and spoke to Omar Belkadi and Farah Hamdan. He told them they needed to leave but they made no move to do so. FF Williams called the bridgehead to ask for assistance but could not hear the response. He then took the couple’s second daughter by the hand to encourage the rest of the family to follow him.[947]
FF Fernandes had also tried to use his radio to report that they had located a casualty but discovered that it was not working. CM Eden and FF Welch were still on floor 20. Both FF Williams and Fernandes shouted out to them for assistance. CM Eden positioned himself at the stairwell door while FF Welch moved closer towards Flat 175. In conditions of near zero visibility, FF Fernandes made his way to the stairwell door to hold it open. There was a similar lack of visibility in the stairwell.[948]
CM Eden’s recollection was that, while on floor 20, he had become aware that there were five people needing to be rescued from Flat 175.[949] He heard a man (Omar Belkadi) shouting for help and a woman (Farah Hamdan) calling out for her baby. FF Fernandes heard something similar. He first saw the family when they arrived at the stairwell door but was not aware how many of them there were. When FF Williams reached the stairwell, they began their descent. FF Fernandes went down first backwards, so that he could guide FF Williams, who was carrying the Belkadis’ second daughter.[950] He could not recall any conversation with CM Eden and FF Welch about evacuating the family.[951]
CM Eden and FF Welch tried to help Omar Belkadi. In response to CM Eden, Omar Belkadi said that apart from himself, the group was made up of his wife, two children and a baby. Omar Belkadi was, understandably, panicking and finding it difficult to breathe. CM Eden and FF Welch helped him down the stairs. CM Eden described the stairwell as full of smoke and hot. FF Welch thought that without breathing apparatus one would struggle to breath there.[952]
Although we are satisfied that FF Fernandes and Williams, carrying the Belkadi’s second daughter, entered the stairwell first, the evidence does not enable us to make a finding about the order in which the Belkadi family, supported by the firefighters, left floor 20. They did so in conditions that were particularly difficult and the firefighters were conscious that they were low on air.[953] FF Welch recalled that Omar Belkadi had collapsed as soon as they began descending. On CM Eden’s account they had got no further than the half landing between floors 20 and 19. At about that time, the low-pressure warning on the firefighters’ breathing apparatus began to sound.[954]
CM Eden and FF Welch decided that CM Eden would return to the bridgehead to seek help while FF Welch stayed with Omar Belkadi. In the event, FF Welch was able to leave Omar Belkadi with another crew as he had to return to the bridgehead because his air was running low.[955]
FF Williams carried the second daughter of Farah Hamdan and Omar Belkadi out of the tower at 02.26.[956] FF Fernandes provided a debrief on reaching the bridgehead but could not remember what he had said.[957] The end of wear time for CM Eden and FF Welch was between 02.27 and 02.29.[958] Neither of them said that he had provided any kind of debrief to the bridgehead on his return.[959]
When the bridgehead moved to floor 3 after 02.17, WM De Silvo started recording information about people needing to be rescued on a wall. There was a list of floors from 3 to 23 against which the numbers of specific flats were written as information came in. WM De Silvo put a tick against a flat number to show that a BA crew had visited it, a circle to indicate when further information was received and a cross to show that it had been searched and a rescue carried out. There was a tick to show that that Flat 175 had been visited. Given that there were no deployments to that flat after 02.00, it is likely that the information recorded on floor 3 was brought across from floor 2.[960]
No firefighters were deployed to look for Omar Belkadi, Farah Hamdan or their two children after CM Eden and FF Welch returned. At 02.44, FFs Tom Reddington and Nikki Upton tallied out to go to floor 21. They had reached what they believed was floor 18, when they came upon Farah Hamdan. She was unresponsive and the firefighters were unable to move her body as her leg was trapped in the banister railings. FF Upton found Malak Belkadi near her mother. They were able to move her and made the difficult decision to take her down since they could not free her mother.[961]
It is likely that FFs Upton and Reddington found Farah Hamdan and her daughter on the stairs higher than floor 18. As they were descending with Malak Belkadi, they encountered a four-person crew who were ascending to go to floor 23. They told them that they had left a female casualty who needed assistance. One of that crew, FF Jessamine Bate, then assisted FFs Upton and Reddington to carry Malak Belkadi down the stairs. The remaining three firefighters, FFs Michael Pole, Niki Mitchell and Chris Cheesman, continued upwards. When they realised that they had insufficient air to reach floor 23, they stopped at floor 18 and helped evacuate occupants in Flat 153. None of these firefighters describe seeing a female casualty on the stairs.[962]
Malak Belkadi was carried out of the tower at 03.07.[963]
After the fire the bodies of Farah Hamdan, Omar Belkadi and their daughter, Leena, were found on the stairs between floors 20 and 19.[964] The coroner was satisfied about their identification and therefore issued an interim certificate of the fact of death for each of them.[965]
The post-mortem on Omar Belkadi noted significant soot staining of the body and minor heat damage, both of which had occurred after death. Similarly, there was heavy soot staining and minor heat damage to Farah Hamdan’s body. Leena Belkadi had soot staining to her face and again some minor heat damage. In all three cases, there was soot staining of the respiratory airways, indicating inhalation of smoke-filled air. Toxicological analysis of blood samples taken from Farah Hamdan, Omar Belkadi and Leena Belkadi found the levels of carboxyhaemoglobin in their blood to be 85%, 87%, and 84% respectively,[966] in each case significantly higher than the lethal threshold.
Malak Belkadi was unconscious and in cardiac arrest when carried from the tower. Resuscitation efforts began at the scene and continued at St Mary’s Hospital where, at 03.41, a return of circulation was recorded. With treatment, the concentration of carboxyhaemoglobin in her blood dropped from 45% on arrival at hospital to 26%. Toxicological analysis of a sample taken five hours after the start of the fire recorded the level of carboxyhaemoglobin in her blood to be approximately 10%. As the post-mortem report for Malak Belkadi observes, that followed treatment in an oxygen-enriched environment. The level of cyanide in her blood, when first measured some hours after she had been brought out of the tower, was 0.19 milligrams/litre. That reflected the elimination half-life of cyanide being one to two hours. A CT scan showed general cerebral oedema with possible superimposed hypoxic ischaemic brain injury. No brain activity could be found. At 15.01 on 15 June 2017, Malak Belkadi was declared dead.[967] The coroner, Professor Wilcox, also issued an interim certificate of the fact of death for Malak Belkadi.[968]
The reports of the post-mortems carried out on Omar Belkadi, Farah Hamdan, Malak Belkadi and Leena Belkadi gave the medical cause of death as “inhalation of fire fumes” but in the light of Professor Purser’s evidence we find that a more accurate description is “inhalation of asphyxiant gases”.
In the light of the evidence as a whole, including that given by Professor Purser, we are satisfied that the family entered the stairwell at about 02.19. They all collapsed soon after doing so because they had already had a significant exposure to asphyxiant gases entering from the lobby rather than from the outside. Their departure from Flat 175 was made in difficult circumstances into a lobby which was heavily smoke logged. As the family crossed the lobby, they inhaled hot smoke and asphyxiant gases and continued to do so on entering the stairwell. The result was that they quickly accumulated an incapacitating dose of asphyxiant gases. The inhalation of hot gases contributed by causing breathing difficulties. The family continued to inhale asphyxiant gases (mainly carbon dioxide but also hydrogen cyanide) until their breathing ceased and they died. In the case of Malak Belkadi, she continued to breathe until she suffered cardiac arrest and fatal brain damage.
A blood carboxyhaemoglobin level of 30–40% is enough to cause a person to lose consciousness.[969] The lethal threshold is around 50%.[970] In children, because of their smaller body size, the rate of absorption of asphyxiant gases is more rapid than in adults.[971] It is likely that the blood carboxyhaemoglobin level of the Belkadi family reached the lethal threshold by about 02.49; it is unlikely that anyone would have survived if rescued after that time.[972]
All the times mentioned above are to some degree conjectural. All we can say with any confidence is that Omar Belkadi, Farah Hamdan and Leena Belkadi died between 02.45 and 03.10, probably closer to 02.45, and that both Farah Hamdan and Leena Belkadi were already dead by the time FFs Upton and Reddington found them. By that time Malak Belkadi was close to the point of death. Having been carried from the tower and despite the treatment provided at hospital, she died at 15.01 on 15 June 2017.
Except for Flat 185, all remaining five flats on floor 21 were occupied when the fire started. Ligaya Moore, who lived in Flat 181, and all five members of the El Wahabi family who lived in Flat 182, died in the fire.
By 01.26 on 14 June 2017 the fire on the outside of the building had already spread to floor 21.[973] Mustapha Abdu in Flat 184 was the first occupant of the floor to leave. He left the tower at 01.28 and had no contact with anyone else on floor 21.[974]
Helen Gebremeskel lived in Flat 186 with her daughter. Woken by her kitchen smoke alarm, she went into her kitchen to see black smoke and flames coming through the window. She and her daughter quickly left the flat closing the front door behind them[975] because it did not have an effective self-closing device.[976]
At 01.26, when she was in the lobby, Helen Gebremeskel called the emergency services to report a fire in her flat. She and her daughter tried to leave together with the El Wahabi family, but they abandoned the attempt and by 01.30 had taken shelter in Flat 183, the home of Marcio Gomes and Andreia Perestrelo.[977] By that time there was a layer of black smoke close to the ceiling of the lobby.[978] The El Wahabi family returned to Flat 182.
From about 01.25 the lobby of floor 21 rapidly filled with smoke to an extent that it deterred those who remained on that floor from trying to leave.
Further emergency calls alerted the control room to the fact that occupants were trapped on floor 21. Those still on floor 21 spoke to the control room on no fewer than 11 occasions. In Flat 182, the El Wahabi family were in contact with the control room in a call which lasted from 01.38 to 02.37.[982] They spoke to the control room again at 02.43, 02.46, 02.51, 02.53 and 02.57.[983] A call made at 02.39 was connected to the London Ambulance Service.[984] Marcio Gomes in Flat 183 spoke to the LFB control room at 02.21, 02.46, 02.55, 03.09 and 03.25.[985]
Only one firefighter crew, FFs Nikki Upton and Tom Reddington, was sent to floor 21. They set out at 02.44 but failed to reach floor 21 because they stopped to assist casualties they found on the stairs.[986]
However, one firefighter did reach floor 21. FF Dean Roberts was part of a five-member crew sent to the roof of the tower[987] that set out between 01.56 and 01.57.[988] Somewhere between floors 20 and 21, they found Fadumo Ahmed collapsed in the stairwell. While his colleagues helped her, FF Roberts continued up to floor 21 and opened the door to the lobby. He found it to be pitch black with smoke from floor to ceiling. He shouted and kicked the stairwell door but he did not see or hear any reaction before he left that floor.[989] There is no evidence that the occupants on floor 21 heard FF Roberts shout into the lobby.
Date of birth: 28 October 1938 (78 years).
Place of birth: San Luis, Philippines.
Gender: Female.
Occupation: Retired.
Usual address: Flat 181, floor 21, Grenfell Tower, London.
Place of death: Flat 181, floor 21, Grenfell Tower, London.
Time of death: Between 01.40 and 02.45 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Ligaya Moore was retired and was 78 years old in June 2017. Born in the Philippines, she had moved to London in 1972 and worked as a nanny. She met her husband, James Moore, in London and they moved into Grenfell Tower in 1981. Ligaya Moore continued to live in Flat 181 after the death of her husband.[990]
In 2013 the TMO became aware that Ligaya Moore was prone to hoarding and advised her that it could affect her tenancy.[991] The situation did not improve. In October 2014, following their survey of residents, Rydon informed the TMO that the accumulation of items in Flat 181 made it impossible for it to carry out works.[992] Janice Jones, TMO neighbourhood officer, referred Ligaya Moore to RBKC’s social services department for assistance. They tried to carry out an assessment in May 2015, but she was not willing to co-operate. Hoarding was noted to be a possible fire safety risk, the consequences of which would be catastrophic. Ligaya Moore was recorded as being independently mobile and able to call out if in danger. She did agree to a referral to a de-cluttering service but would not consent to social services contacting her doctor or to being contacted by the LFB for a fire safety check.[993]
A care and support plan completed in September 2015 noted that Ligaya Moore had had three sessions with the de-cluttering service and had agreed to be referred to Age UK’s de-cluttering service but had refused further involvement with social services. The housing department were to continue to monitor the situation.[994] Nerita Bunggay, a friend of Ligaya Moore who saw her every day, described her as so embarrassed by the state of her home that she did not want others to see it. Hoarding was still a problem for her in June 2017.[995]
Ligaya Moore appeared in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system.[996] It recorded that she was over 65 years of age but did not mention any other vulnerability.
Ligaya Moore returned to Grenfell Tower shortly after 22.20 on 13 June 2017.[997] She did not leave her home after that.
It is likely that she never became aware of the fire. No other occupant of floor 21 had any communication with her during its course and there is no evidence to suggest that she became aware of the movements of the other occupants trapped on that floor or that she had contact with the emergency services, family or friends by telephone or otherwise.
All the combustible contents of Flat 181 were destroyed in the fire.[998] Ligaya Moore’s remains were recovered from the bedroom area. They were associated with the remains of a bed which suggests that she was in bed at the time of the fire. The coroner was satisfied about the identification of the remains recovered and therefore issued an interim certificate of the fact of death.[999]
The post-mortem report for Ligaya Moore recorded the medical cause of death as “consistent with the effects of fire”, but in the light of more recent evidence we find that a more accurate description is “inhalation of asphyxiant gases”.
Flat 181 was a one-bedroom flat situated on the east side of the tower between Flats 186 and 182.[1000] The fire had reached floor 21 before 01.30.[1001] It was outside the living room of Flat 181 by about 01.32 and from then on smoke began to leak into Flat 181 both from the outside and the lobby. By about 01.52 the fire was outside the bedroom window.[1002]
It is very difficult to make a finding with any confidence about the time at which Ligaya Moore died. However, in the light of all the evidence including that of Professor Purser[1003], we think it likely that she became incapacitated as a result of inhaling asphyxiant gases, including carbon monoxide and hydrogen cyanide, by about 01.40 and that she had died in her sleep by about 02.00, well before fire took hold in her bedroom.
Date of birth: 01 December 1964 (52 years old).
Place of birth: Larache, Morocco.
Gender: Male.
Occupation: Hospital Porter.
Usual address: Flat 182, floor 21, Grenfell Tower, London.
Place of death: Flat 182, floor 21, Grenfell Tower, London.
Time of death: Between 03.00 and 03.20 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 01 June 1975 (42 years old).
Place of birth: Larache, Morocco.
Gender: Female.
Occupation: Homemaker.
Usual address: Flat 182, floor 21, Grenfell Tower, London.
Place of death: Flat 182, floor 21, Grenfell Tower, London.
Time of death: Between 03.00 and 03.20 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 09 August 1996 (20 years old).
Place of birth: Paddington, London.
Gender: Male.
Occupation: Student.
Usual address: Flat 182, floor 21, Grenfell Tower, London.
Place of death: Flat 182, floor 21, Grenfell Tower, London.
Time of death: Between 03.00 and 03.20 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 27 June 2001 (15 years old).
Place of birth: Paddington, London.
Gender: Female.
Occupation: Student.
Usual address: Flat 182, floor 21, Grenfell Tower, London.
Place of death: Flat 182, floor 21, Grenfell Tower, London.
Time of death: Between 03.00 and 03.20 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 22 February 2009 (8 years).
Place of Birth: Chelsea, London.
Gender: Male.
Occupation: Student.
Usual address: Flat 182, floor 21, Grenfell Tower, London
Place of death: Flat 182, floor 21, Grenfell Tower, London.
Time of death: Between 03.00 and 03.20 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Abdulaziz El Wahabi and Faouzia El Wahabi lived in Flat 182 on floor 21 of Grenfell Tower with their three children, Yasin, Nur Huda and Mehdi. Abdulaziz El Wahabi was born on 1 December 1964 in Larache, in northern Morocco. He was 52 years old and had worked as a hospital porter at University College Hospital for 22 years.[1004] His wife Faouzia was born on 1 June 1975, also in Larache. She was 42 years old and was a homemaker.[1005]
The couple’s three children were all born in London. Yasin was 20 years old, having been born on 9 August 1996. A trained football referee, he was studying accountancy at Greenwich University. [1006] Nur Huda was 15 years old, having been born on 27 June 2001. She was studying for her GCSEs at Holland Park Secondary School.[1007] Mehdi was eight years old, having been born on 22 February 2009. He was a pupil at Oxford Gardens Primary School.[1008]
None of the family had a disability that affected their ability to respond to an emergency. Nur Huda and Mehdi El Wahabi were both under 18 years of age at the time of the fire. In the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system Nur Huda was recorded as being under 18 but Mehdi did not appear.[1009]
Nur Huda El Wahabi was the first member of the family to return home on the evening of 13 June 2017, coming into the tower at 18.16. Abdulaziz, Faouzia and Mehdi El Wahabi returned at 21.17. Yasin El Wahabi was the last of the family to return to the tower, at 00.47 on 14 June 2017.[1010]
Hanan Cherbika, a friend of the El Wahabi family, called Nur Huda El Wahabi soon after 01.10. She told her that there was a fire in the tower and that the family needed to leave. Nur Huda El Wahabi reassured her that the fire was downstairs. Hanan Cherbika encouraged her to wake her mother and to let her decide what to do.[1011] Yousra Cherbika, Hanan Cherbika’s daughter, also spoke to Nur Huda El Wahabi, who told her that she was going to come down.[1012]
Hanan Wahabi, Abdulaziz El Wahabi’s sister, who lived in Flat 66 on floor 9, left the tower at 01.21. She called her brother just after 01.25 to warn him of the fire. She advised the family to leave the tower.[1013] Shortly afterwards, Helen Gebremeskel saw the El Wahabi family in the lobby on floor 21 and warned them there was a fire in her flat, Flat 186. They told her the whole building was affected. Together with Helen Gebremeskel and her daughter, the El Wahabi family then tried to leave the tower. They reached the stairs but could not go down as a group of people were coming up. Those coming up told them that they should all go back to their flats.[1014] The El Wahabi family returned to Flat 182. Helen Gebremeskel and her daughter went to Flat 183, the home of Marcio Gomes, Andreia Perestrelo and their two daughters.[1015]
Hanan Wahabi spoke to her brother again at about 01.30. He said the family had tried to leave but there had been too much smoke and they had been unable to see or breathe.[1016]
Flat 182 was in the south-east corner of the tower. The windows of the living room faced east and south.[1017] The El Wahabi family had converted it into a three-bedroom flat, with the bedroom of Abdulaziz and Faouzia El Wahabi being opposite the front door with a window facing south.[1018]
The first emergency call from Flat 182 was made at 01.38 and lasted for just over 59 minutes. It was answered by CRO Pam Jones in the LFB control room. While various members of the family spoke to CRO Jones at different times, Abdulaziz El Wahabi spoke to her for most of the call.[1019] He told CRO Jones that he was with his wife and three children in Flat 182.[1020]
During the call, the family told CRO Jones that they had tried to go down the stairs but had been forced to return as it was too smoky.[1021] CRO Jones advised them to stay in the flat if it was too smoky to leave, to block up any places where smoke was coming in and to get fresh air from a window.[1022] She said that she would let the firefighters know which flat the family were in and that they would try to reach them as soon as possible.[1023] At 01.47, the family reported that, despite the use of blankets, smoke was still coming into the flat through the front door. At this time they were sheltering in the living room.[1024]
At about 01.55, Abdulaziz El Wahabi told CRO Jones that someone outside had told the family that the fire had reached the flat next door (i.e. Flat 181).[1025] Over the next few minutes the family were able to see the fire next door and smoke began to come into the living room. CRO Jones advised them to move to another room and they then moved to the bedroom of Abdulaziz and Faouzia. By then the fire had reached the kitchen of Flat 182.[1026]
Hanan Wahabi called her brother for the last time at 02.15. Faouzia El Wahabi answered the telephone and Hanan Wahabi urged her to leave. Faouzia said they were trying to do so. She said that the fire was in the kitchen of Flat 182 and that the family had been told to go to the bedroom.[1027] Meanwhile, the call with CRO Jones was continuing. She ascertained that the bedroom was smoke-free and advised the family to remain there with the door shut and a window open for air. She assured them that firefighters would come to them.[1028]
Throughout the call with CRO Jones, members of the El Wahabi family were in contact with friends and family outside the tower who were telling them to leave. The family responded that they had been advised to remain in their flat.[1029] However, at about 02.24 smoke began to enter the bedroom through the open window and CRO Jones advised them to close the window.[1030] At about 02.34, having been told by OM Alexandra Norman that those in the tower should now be advised to leave, CRO Jones told the El Wahabi family to cover themselves with wet clothes and towels and to leave the flat.[1031] She continued to encourage the family to leave until the call was disconnected at 02.37.[1032]
The LFB control room passed messages about Flat 182 to the incident ground while CRO Jones was speaking to the El Wahabi family.
At about 01.47, CRO Jones told them that a message had been passed to firefighters about Flat 182 but she did not create a service request.[1033] At about 01.50, CRO Jones told them that the control room was calling the firefighters again.[1034] At that time, CRO Yvonne Adams, who was sitting next to CRO Jones, spoke to command unit CU8 and passed on information about two flats, one of which was Flat 182. CRO Adams told CU8 that those in Flat 182 had not been able to stop smoke coming under the front door, were in the living room and sounded “panicked”.[1035]
WM Mark Kentfield recorded the information reaching CU8 on pieces of paper which were then passed to SM Brett Loft who at that time was positioned outside the tower. He had taken charge of managing information about people needing to be rescued and was passing it to the bridgehead, probably by radio.[1036] The information provided to SM Loft included an A4 sheet of paper at the top of which was written “BRETT LOFT IC”. The seventh entry down on that document read: “182 – 21st FLOOR”.[1037] Given that SM Loft recalled receiving information on paper from WM Kentfield at around 01.40,[1038] it is likely that the mention of Flat 182 was the result of CRO Adams’s call to CU8.
At 02.00, CRO Adams made a second call to CU8, during which she passed on information about several flats, including Flat 182. She reported that there were two adults and three children trapped in the flat, that the fire was next door to them and that smoke was pouring in. An officer in CU8 replied that they had the impression that floors 21 to 23 were the most severely affected.[1039]
Between 02.10 and 02.22 CU7 was designated as the command unit responsible for handling information about people needing to be rescued.[1040] Initially the crew used a laminated white sheet to record information previously recorded in CU8 on pieces of paper.[1041] The entries on that sheet included a reference to Flat 182 where two adults and three children were trapped (although the flat was incorrectly recorded as being on floor 18). The reference to the composition of the family makes it likely that the call made by CRO Adams to CU8 at 02.00 was the source of that information. Indeed, the information on the laminated sheet appeared on a control information form on which was also written “From CU list”.[1042]
Shortly after 02.17, CM Charles Batterbee made a note of the contents of a forward information board used while the bridgehead had been located on floor 2 of the tower to record information about people needing to be rescued. There was no reference to Flat 182 but there was a reference to Flat 204 on floor 21.[1043] That suggests either that the message about Flat 182 that had been passed to CU8 at 01.50 and then again at 02.00 did not reach the bridgehead on floor 2, or that the information was passed on incorrectly. In any event, there was no deployment of firefighters to floor 21 while the bridgehead was located on floor 2.
At about 02.33, SM Jason Oliff began recording information about people needing to be rescued on two whiteboards in the LFB control room. The first entry, and the first information he passed to the command unit, was recorded as “182 21st Flr – 3 children 2 adults. Leave.”[1044] That follows the change of advice communicated to the El Wahabi family by CRO Jones.
That information did reach the bridgehead on floor 3, as is confirmed by a reference to Flat 182 on the wall used by WM Louisa De Silvo at the bridgehead to record information about those needing to be rescued.[1045] Flat 182 was circled and ticked to indicate that a crew had been deployed. (A circle indicated that she had received further information, including information from a returning crew.)[1046] In this case, the tick referred to the deployment at 02.44 of FFs Nikki Upton and Tom Reddington wearing EDBA to floor 21.[1047] FF Upton recalled that she and her colleague had been briefed by WM de Silvo and WM O’Keeffe but she could not remember whether they were to go to Flats 182 and 183 or to Flats 183 and 184.[1048] We think it was probably the former, because her contemporaneous note[1049] records that the crew were deployed to Flats 182 and 183. Moreover, no call for help had been received from Flat 184, whose occupant, Mustapha Abdu, had already escaped.
The two firefighters did not reach floor 21 because as they were going up the stairs they found Farah Hamdan and Malak Belkadi and brought Malak Belkadi down. On returning to the bridgehead, FF Upton told a crew manager that she and her colleague had not been able to reach floor 21. She could not recall to whom she had spoken.[1050]
After the call with CRO Jones had been disconnected at 02.37, the El Wahabi family made a series of short emergency calls. At 02.39, they were put through to the control room of the London Ambulance Service,[1051] which at that time was not aware that the LFB had revoked the stay put advice.[1052] The caller said that five people were trapped in Flat 182 and was told that help was on the way. The call handler then put the call on hold to ask a manager what instructions to give the caller, but at that point the connection was lost. The call handler did not call back as the protocols of the London Ambulance Service required.[1053]
At 02.43, Nur Huda El Wahabi spoke to CRO Heidi Fox in the LFB control room. She reported that there were two adults and three children in Flat 182 and, when asked, said that they could not leave. CRO Fox was in the course of advising her to cover herself in wet blankets when the call was disconnected.[1054]
Nur Huda El Wahabi made another emergency call that was answered by CRO Adams at 02.46. She confirmed that there were five people in Flat 182 and said there was too much smoke for them to get out. CRO Adams said they should try to cover themselves in wet towels and leave, as the fire brigade could not reach them. Nur Huda replied: “… too much smoke, I can’t breathe.”[1055]
When the call was disconnected, the line remained open to the BT operator who reconnected the call to the LFB on three further occasions at 02.51, 02.53 and 02.57.[1056] The transcripts of those calls,[1057] including the family’s exchanges with the BT operator,[1058] show that they were coughing, having difficulty breathing and saying that they were feeling faint. We conclude from that that by that time there was a significant amount of smoke in the bedroom.
The first two calls were answered by CRO Adams and CRO Christine Howson respectively. Both advised the El Wahabi family that they had to leave. During the calls the CROs were told that the family could not breathe and that they had tried to leave but had been unable to see because of the smoke. In the second of those calls, the family said that they were again trying to leave.[1059]
At 02.57, the El Wahabi family was connected to the LFB control room for the third and last time. The call ended at 02.58, the line going silent before CRO Howson could speak to any member of the family.[1060] That was the last contact anyone had with the El Wahabi family.
The whiteboard used in CU7 from about 03.00 to record information about people needing to be rescued shows that those later emergency calls may have resulted in information reaching that command centre.[1061] Photographs taken later show that Flat 182 appeared on the grid with “5” in green and “2” in black next to it.[1062] There was no red tick, which would have indicated a deployment.[1063] We conclude that those later emergency calls did not prompt a deployment to Flat 182.
The remains of the five members of the El Wahabi family were recovered from the bedroom of Abdulaziz and Faouzia El Wahabi.[1064] The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death for all members of the family.[1065]
The post-mortem reports for all five members of the El Wahabi family recorded the medical cause of death as “consistent with the effects of fire”, but in the light of Professor Purser’s evidence we find that a more accurate description is “inhalation of asphyxiant gases”.
Toxicological analysis was not possible.
We are satisfied that the members of the El Wahabi family probably lost consciousness shortly after the last emergency call from Flat 182 ended at 02.58 and perhaps rather earlier in the case of the younger members of the family. Death due to inhalation of asphyxiant gases, particularly carbon monoxide and hydrogen cyanide, occurred a few minutes later and before any internal fires had become established in the bedroom. Death probably occurred within 20 minutes of loss of consciousness, that is, by 03.20, and before suffering the direct effects of fire.[1066]
Date of birth: 14 June 2017.
Place of birth: London, UK.
Gender: Male.
Andreia Perestrelo and Marcio Gomes lived in Flat 183 on floor 21 with their two daughters. At the time of the fire, Andreia Perestrelo was pregnant with the couple’s son Logan whose birth was expected on 21 August 2017.[1067] It had been a healthy pregnancy and Andreia was intending to begin her maternity leave on 14 August 2017.[1068] The whole family was eagerly awaiting the new arrival.[1069]
Logan Gomes was delivered stillborn on 14 June 2017 following his mother’s evacuation from the tower.
The family returned home on the evening of 13 June 2017 after dinner with friends.[1070] They became aware of the fire shortly before 01.30, when Helen Gebremeskel knocked on their door following her attempt to leave floor 21 with the El Wahabi family. Helen Gebremeskel and her daughter were invited to shelter in Flat 183.[1071]
Some 20 minutes later, Marcio Gomes began to use wet towels to block out smoke which was by then seeping around the sides of the front door to Flat 183.[1072] He was in contact with Miguel Alves, another resident of the tower, who had already left. Miguel Alves passed on the advice of a policeman that Marcio Gomes should stay in the flat.[1073]
The two families then in Flat 183 decided to try to leave but were deterred by the amount of smoke in the lobby.[1074] Marcio Gomes then made his first emergency call at 02.21 and spoke to CRO Heidi Fox in the LFB control room. She explained that firefighters were going to the flats and that she would tell them about Flat 183. At 02.24, CRO Fox created a service request recording that three adults, including one pregnant lady and three children, were trapped. CRO Sharon Darby passed the message by radio to CU7 at 02.24.[1075]
Between 02.10 and 02.22 CU7 began handling information relating to people needing to be rescued.[1076] Initially, a white laminated sheet was used to record information. The entries on that sheet included “183 21 6 adults, 1 pregnant” (the number 6 was written in red pen and appeared to replace an erased 3).[1077] At about the same time, WM Paul Sadler was instructed to collate information about people needing to be rescued for onward transmission to the bridgehead which, from 02.17, was located on the third floor of the tower. He communicated with the bridgehead either by radio or through paper control information forms.[1078]
No note relating to Flat 183 appears on the wall on floor 3 used to record information about people needed to be rescued during the period when the bridgehead was located on that floor.[1079] However the existence of a control information form which contains information consistent with the service request created by CRO Fox (in particular the reference to a “pregnant lady”) suggests that the message did reach the bridgehead.[1080] The consequence was the deployment at 02.44 of FFs Nikki Upton and Tom Reddington to Flats 182 and 183 on floor 21, which was prompted not only by information about those needing to be rescued from Flat 182, but also, we find, by similar information relating to Flat 183.
However, FFs Upton and Reddington did not reach floor 21. They found Farah Hamdan and Malak Belkadi in the stairwell and brought Malak Belkadi down. On returning to the bridgehead, FF Upton told a crew manager that she and her colleague had not been able to reach floor 21. She could not recall to whom she had spoken.[1081]
Marcio Gomes made a second emergency call from Flat 183 at 02.46. He reported that the fire had reached the flat next door and was coming through the windows. CRO Christine Howson advised him to leave if he no longer considered it safe to remain. When he replied that there was too much smoke to leave, she advised him to use wet clothes as protection against the smoke and to get to the stairwell. It was not clear whether CRO Howson had been told of the change in the “stay put” advice at that time, as she gave the impression during the call that firefighters were still on their way up the building.[1082]
The two families made a further attempt to leave Flat 183 but could not cross the lobby. Marcio Gomes then made a third emergency call at 02.55 and spoke to CRO Angela Gotts. He told her that they were unable to leave and that smoke was coming into the flat despite towels being used to block it out. During that call, Marcio Gomes said that there were “...three kids and three adults and one heavily pregnant wife” in the flat. CRO Gotts said she would let the firemen know to come up to them. She did not create a service request but passed a message to CRO Sharon Darby, who then sent it by radio to CU7 at 02.58. The message stated that there were six persons in the flat, one of whom was pregnant. The information was also entered on a whiteboard in the LFB control room by SM Jason Oliff.[1083]
At 03.09, Marcio Gomes made a fourth emergency call and spoke to CRO Howson again. He was advised to leave but said it was not possible to do so. He said that there were six people in the flat, including someone who was pregnant. CRO Howson said she would inform the crews and make reaching him a priority. She asked him again to try to leave.[1084] By that time conditions in Flat 183 had deteriorated, with more smoke entering the flat.[1085]
Although we cannot trace the passage of the information given in the three emergency calls made by Marcio Gomes between 02.46 and 03.09 individually to the bridgehead, the fact that information about Flat 183 was reaching it is indicated by the following:
In any event, there was no further deployment of firefighters to Flat 183 or even to floor 21.
At 03.25, Marcio Gomes spoke to CRO Fox in what was his fifth emergency call. It lasted for 33 minutes and 53 seconds.[1092] By the time the call began conditions in Flat 183 had worsened, with smoke continuing to come through the front door. Initially, Marcio Gomes told CRO Fox that it was not possible to leave and that they had tried three times to do so. CRO Fox told him that she would try to make them a priority. After the call had continued for about a minute and a half, Marcio Gomes told CRO Fox that the fire had entered the flat. The two families then covered themselves with wet towels and made their way to the stairwell.[1093]
They found the lobby and the stairwell to be hot and full of smoke; there was no visibility or breathable air. CRO Fox continued talking to Marcio Gomes and encouraged him to continue through the lobby and down the stairs. While doing so she spoke to a colleague in the control room, passing on information and telling her that he was struggling to breathe. CRO Fox told him that firefighters were aware of their location and making their way up to them.[1094] Although CRO Fox said that a message was being sent to the incident ground by radio, we have not been able to confirm that that was done or whether any information reached the incident ground either by radio or telephone.
As he went down the stairs Marcio Gomes lost contact with his wife and daughters. He tried to make his way back up but encountered firefighters who said they would find them. He also spoke to a firefighter who asked which flat and which floor his family had started from.[1095] That contact may explain how WM Louisa De Silvo came to write “183 – Daughter” (underlined), with “21 or 22” written underneath on the green wall used on the ground floor to record information about people needing to be rescued after the bridgehead had moved there.[1096] CM Aldo Diana and FF Dean Nelson were the firefighters who told Marcio Gomes that they would find his family. Originally sent to Flat 133 on floor 16, they found Andrea Perestrelo, her younger daughter and Helen Gebremeskel, who were all close to collapse. The two firefighters then went up again to find Helen Gebremeskel’s daughter and Andrea Perestrelo’s elder daughter, both of whom had collapsed on the stairs. They carried them down.[1097]
The group left the tower between 03.37 and 03.55.[1098] Andreia Perestrelo, her daughters and Marcio Gomes were taken by ambulance to King’s College Hospital.[1099] Andreia Perestrelo and her daughters were put into induced comas. An emergency caesarean section was performed on Andreia Perestrelo at 23.03 on 14 June 2017. Sadly, Logan Gomes was stillborn.[1100]
The post-mortem on Logan Gomes found features of terminal pathophysiological stress and nothing to suggest developmental abnormality, malformation or any other underlying pathology. There was less than 5% carboxyhaemoglobin in his blood.[1101]
When admitted to hospital, Andreia Perestrelo had significant carbon monoxide poisoning and possible hydrogen cyanide poisoning. The resulting severe acidosis is likely to have been the cause of Logan’s death at some time during the day on 14 June 2017.[1102]
It is likely that those who were sheltering in Flat 183 absorbed a relatively small amount of asphyxiant gases before they left the flat.[1103] However, their exposure to the conditions in the lobby and the stairs, coupled with the physical effort involved in making their way down, resulted in their accumulating a quantity of asphyxiant gases by the time they reached the ground floor that was nearly sufficient to incapacitate them.[1104]
On the night of 14 June 2017 all six flats on floor 22 were occupied. Only Chia-Yuan (Naomi) Li and her cousin, Chin-Hsuan (Lydia) Liao from Flat 195 survived. Those who died were Nura Jemal, her husband, Hashim Kedir, and their three children who lived in Flat 192, Nadia Choucair, her husband, Bassem Choukair, and their three children, who lived in Flat 193, Sirria Choucair, the mother of Nadia Choucair, who lived in Flat 191, and Anthony (Tony) Disson, who lived in Flat 194. Mariem and Eslah Elgwahry, who lived in Flat 196, died in Flat 205 where they had taken shelter. We deal with the circumstances of their deaths in Chapter 97.
Naomi Li was alerted to the fire at about 01.15 when she became aware of a smell like burning plastic. Having spoken to Lydia Liao, she checked the lobby. Although she could smell smoke, she saw very little sign of it in the lobby. Returning to her flat, she telephoned her husband, Lee Chapman, who was abroad. At 01.21 she made an emergency call and spoke to CRO Yvonne Adams in the LFB control room, who told her that the fire brigade was attending a fire on the fourth floor of the tower and that she should stay in her flat. During that call Naomi Li gave CRO Adams the number of her flat.[1105]
Naomi Li decided to tell her neighbours. In the lobby she met and spoke to Nura Jemal, who then returned to Flat 192. She then saw Mariem and Eslah Elgwahry leaving Flat 196. When she told them that there was a fire on floor 4, Mariem Elgwahry replied that the fire was in their kitchen. At that time the door to Flat 196 was closed and Naomi Li could not see any smoke coming from it.[1106] She saw Mariem and Eslah Elgwahry enter the stairwell. Naomi Li next spoke to Tony Disson, who then returned to his own flat.[1107]
Naomi Li and Lydia Liao tried to leave but could not go down the stairs because a group of people were coming up. Returning to the lobby, they met Nadia Choucair, who invited them into Flat 193.[1108] Sirria Choucair was probably already there.
By 01.26, the fire on the outside of the building had reached floor 23. It is likely that from that time Flat 196, like other ‘Flat 6s’ in the tower, rapidly filled with smoke. The front door of Flat 196, although closed, failed to prevent smoke coming from the flat into the lobby of floor 22. In separate calls made at 01.30, both Naomi Li and Tony Disson reported that there was a lot of smoke on floor 22.[1109]
In subsequent calls to the emergency services, those trapped on floor 22 referred to the presence of a significant amount of smoke in the lobby.[1110] That was a significant factor in preventing them from leaving the building, despite their efforts to do so. Nura Jemal, Hashim Kedir and their children were able to move from Flat 192 to Flat 193, arriving there shortly before 03.00.[1111] Tony Disson was able to reach the stairwell but collapsed and died on the stairs.[1112] Only Naomi Li and Lydia Liao managed to escape from the building.[1113]
There were numerous emergency calls to the LFB, to North West Fire Control and to Kent, Essex and Surrey Fire and Rescue Services by and about those trapped on floor 22 during the fire.
Despite the information provided in those calls, the only deployment of firefighters to floor 22 was made in response to the call made by Naomi Li at 01.21.
Although information about those in Flats 192, 193 and 194 did reach the incident ground, none of it reached the bridgehead, with the result that there were no deployments to those flats. We do not know why information about Flat 195 given in a call made at 01.21 reached the bridgehead only after it had been moved to floor 3 (i.e. after 02.17), but we are satisfied that when it was received it prompted the deployment of CM Codd and FF Joseph.
One firefighter did reach floor 22. FF Dean Roberts was one of the five-member Paddington crew from appliance A216, which included CM Philip Wigley and FFs Martin Gillam, Russell Gonzalez and Andrew Harris. The crew was sent to the roof of the tower to carry out firefighting operations.[1136] They tallied out between 01.56 and 01.57. The crew did not reach the roof because they found Fadumo Ahmed on the stairs between floors 20 and 21 and helped her down. FF Roberts appears to have been able to make his way up to floor 22. He opened the stairwell door and shouted but received no response and re-joined his crew.[1137]
Date of birth: 7 March 1973 (44 years).
Place of birth: Addis Ababa, Ethiopia.
Gender: Male.
Occupation: Black Cab Driver.
Usual address: Flat 192, floor 22, Grenfell Tower, London.
Place of death: Flat 193, floor 22, Grenfell Tower, London.
Time of death: Between 03.37 and 04.20 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 1 August 1981 (35 years).
Place of birth: Silte, Ethiopia.
Gender: Female.
Occupation: Homemaker.
Usual address: Flat 192, floor 22, Grenfell Tower, London.
Place of death: Flat 193, floor 22, Grenfell Tower, London.
Time of death: Between 03.37 and 04.20 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 5 August 2003 (13 years).
Place of birth: London, UK.
Gender: Male.
Occupation: Student.
Usual address: Flat 192, floor 22, Grenfell Tower, London.
Place of death: Flat 193, floor 22, Grenfell Tower, London.
Time of death: Between 03.37 and 04.20 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 13 January 2005 (12 years).
Place of birth: London, UK.
Gender: Female.
Occupation: Student.
Usual address: Flat 192, floor 22, Grenfell Tower, London.
Place of death: Flat 193, floor 22, Grenfell Tower, London.
Time of death: Between 03.37 and 04.20 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 18 May 2011 (6 years).
Place of birth: London, UK.
Gender: Male.
Occupation: Student.
Usual address: Flat 192, floor 22, Grenfell Tower, London.
Place of death: Flat 193, floor 22, Grenfell Tower, London.
Time of death: Between 03.37 and 04.20 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Hashim Kedir, Nura Jemal and their three children lived in Flat 192 on floor 22 of the tower.[1138]
Nura Jemal was born on 1 August 1981 in Silte, Ethiopia. She was 35 years old. Her husband, Hashim Kedir, was born on 7 March 1973 in Addis Ababa, Ethiopia. He was 44 years old. Their three children were all born in London. The eldest, Yahya Hashim was born on 5 August 2003 and was 13 years old. Firdaws Hashim was born on 13 January 2005 and was 12. Their youngest child, Yaqub Hashim, was born on 18 May 2011 and was 6 years old.[1139]
Hashim Kedir had moved to the UK in 2000. He took various jobs before successfully passing the test to become a black cab driver. He and Nura Jemal met in the UK where they married. Their children were thriving at local schools.[1140]
No member of Nura Jemal and Hashim Kedir’s family had a known vulnerability.
The family came home at various times on 13 June 2017, Hashim Kedir being the last to return at 23.21.[1141] They became aware of the fire at an early stage. Naomi Li spoke to Nura Jemal in the lobby of floor 22 between her two emergency calls at 01.21 and 01.30.[1142] At 01.34, Hashim Kedir made his first call to the emergency services. During it he told CRO Duddy that smoke on the stairs had prevented the family from leaving and was now coming into their flat from the lobby. CRO Duddy’s advice was to close all doors and windows and to block any smoke coming through the door. He concluded by explaining that firefighters were on their way.[1143] When he gave that reassurance, CRO Duddy did not have confirmation that firefighters would attend but assumed that they would do so if they were told that a flat needed to be checked.[1144]
CRO Duddy did not create a service request in response to that call but one had already been created following calls from other occupants of floor 22. It recorded “PERSONS ON THE 22ND FLOOR SMOKE COMING INTO FLAT.”[1145] CRO Darby passed the information to appliance G261 at 01.35, stating that she could not provide flat numbers.[1146] The service request was marked as completed at 01.41.[1147]
No information relating to floor 22, including that passed on by CRO Darby, reached the bridgehead while it was located on floor 2.[1148]
At 01.43, Hashim Kedir spoke to Genet Shawo, who lived in Flat 153 on floor 18. He told her that the emergency services had told him to remain in his flat and he advised her to do the same.[1149]
Hashim Kedir and Nura Jemal continued to make calls to the emergency services.
Although the calls set out above cannot be traced individually to the incident ground, in light of the following facts we have concluded that information about Flat 192 did get through.
Information relating to floor 22 did not reach the bridgehead while it was on floor 2. Between 02.17 and 03.10 it was located on floor 3.[1169] No note relating to Flat 192 appears on the wall used by WM De Silvo to record FSG information while the bridgehead was located on floor 3.[1170]
Having been unsuccessful in their efforts to leave their home, Hashim Kedir, Nura Jemal and their children were able to make their way to Flat 193, reaching it shortly before 03.00. Naomi Li recalled Nura Jemal and her daughter coming into Flat 193 shortly after the Choucair family had tried unsuccessfully to leave. At that time the amount of smoke in Flat 193 made it difficult to see anyone.[1171] At 03.02 a BT operator put an emergency call from Hashim Kedir through to Kent Fire and Rescue Service explaining that they could not get the caller’s attention but could hear coughing and commotion in the background. The call-handler at the Kent Fire and Rescue Service was also unable to obtain a response.[1172]
Naomi Li made an emergency call at 03.07 during which she told CRO Howson that there were 12 people in Flat 193. She said that the smoke was very bad and that they could not leave. CRO Howson’s advice was to make their way to the stairwell.[1173] At that time everyone was in the living room of Flat 193. Naomi Li told them they had to leave. She was unable to see any reaction because of the amount of smoke in the flat. She and Lydia Liao were able to reach the stairwell.[1174] Making their way down the stairs, they were found by WM Peter Clarke, WM Alexander Cardy and FF Enrico Beltrami who helped them and Karen Aboud and her two children from Flat 92 to leave the tower.[1175]
Naomi Li said that she had told the firefighters that there were more than ten people still in Flat 193 on floor 22, but that she did not know what the firefighters had done with that information.[1176] WM Cardy said that he had made a report to WM De Silvo at the bridgehead but it is not clear whether he gave her any information about Flat 193.[1177] By that time the bridgehead had been moved to the ground floor where information was being recorded on a green painted wall at the rear of the lobby.[1178] There was no reference to Flat 193 on that wall.
That the information may have been passed on is suggested by an entry on the ground floor wall where, from 02.15, WM Glynn Williams had begun recording information about people needing to be rescued. SM Peter Wolfenden started recording information on the same wall from about 03.21.[1179] He said that a tick had been used to indicate that a crew had been sent to a particular flat.[1180] SM Wolfenden may well have been responsible for an entry on that wall which recorded “192 22 10 3K”,[1181] meaning ten people, including 3 children. No tick appears next to the entry. Although it is possible that that information may have been the result of emergency calls from those in Flat 193, and although the flat number is wrong, the reference to ten people reflects Naomi Li’s explanation. In any event, however that information came to reach the ground floor, it did not lead to the deployment of a crew to floor 22.
At 03.08, CRO Angie Gotts answered a call during which she spoke to both Hashim Kedir and Nura Jemal. They said they were in Flat 193 on floor 22 and that they could see a helicopter; they asked if it could help them to escape. CRO Gotts advised them to try and get out using wet towels to cover their heads.[1182]
At 03.14 Nadia Choucair told a BT operator that her baby was unconscious. The BT operator said the advice was to get out of the tower. As the call was being put through to the LFB, Nadia Choucair could be heard telling everyone that they needed to get to the stairs. The call ended before a call-handler could speak to her.[1183] At 03.21, a police operator telephoned Nadia Choucair and told her that she needed to leave. She said that there was too much smoke, but as the call ended she could be heard telling those in Flat 193 that they needed to leave.[1184]
The last contact with those still in Flat 193 was a call made by Hashim Kedir at 03.24 that was answered by CRO Duddy. He told CRO Duddy that there were 12 adults and seven children in the flat (in fact there were five adults and six children) and that they were trapped. As the call continued, CRO Duddy repeatedly told him that the only chance of survival was to leave by the stairs; a rescue by helicopter was not possible. Hashim Kedir said that it was not possible to leave; they had tried but had been unable to do so because of the smoke. Towards the end of the call, he could be heard calling out “I love you”. He was speaking to his children.[1185]
The remains of the five members of the Kedir and Jemal family were recovered from the living room of Flat 193.[1186] The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death for Hashim Kedir, Nura Jemal and their children, Yahya, Firdaws and Yaqub.[1187]
The medical causes of death in the cases of Hashim Kedir, Nura Jemal, Yahya Hashim and Yaqub Hashim were recorded as “consistent with the effects of fire”. The medical cause of death in the case of Firdaws Hashim was recorded as “inhalation of products of combustion”. In light of Professor Purser’s evidence, we find that a more accurate description of the cause of death in the case of all five members of the family is “inhalation of asphyxiant gases”.
It was possible to detect carboxyhaemoglobin in tissue recovered from Yahya Hashim and Firdaws Hashim, although the concentration could not be measured.[1188] The fact that two of those sheltering in Flat 193 inhaled smoke containing carbon monoxide indicates that it is likely that all those in the flat also did so.[1189] They would all have been exposed to asphyxiant gases entering Flat 193, particularly from the lobby.
Given that Naomi Li and Lydia Liao were able to escape, it is likely that until about 03.11, despite increasing amounts of smoke, those in Flat 193 had accumulated a relatively limited dose of asphyxiant gases.[1190] From about 03.11, however, they accumulated increasing amounts of asphyxiant gases as the fire on the outside of the building reached Flat 193, in particular, when it reached the living room at about 03.37.[1191] From that time, conditions deteriorated rapidly, causing the occupants to lose consciousness by about 04.13 and within a few more minutes they had inhaled a lethal dose of asphyxiant gases. Since children take up asphyxiant gases at twice the rate of adults, they are likely to have lost consciousness soon after 03.50.[1192]
We are satisfied that Hashim Kedir, Nura Jemal and their children Yahya, Firdaws and Yaqub all lost consciousness and died from the inhalation of asphyxiant gases between 03.37 and 04.20, before the fire reached their bodies. It is likely that the three children died before their parents.
Date of birth: 25 October 1956 (60 years).
Place of birth: Nahle Village, Lebanon.
Gender: Female.
Occupation: Retired.
Usual address: Flat 193, floor 22, Grenfell Tower, London.
Place of death: Flat 193, floor 22, Grenfell Tower, London.
Time of death: Between 03.37 and 04.20 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 1 December 1976 (40 years).
Place of birth: Nahle Village, Lebanon.
Gender: Male.
Occupation: Supermarket Section Co-Ordinator.
Usual address: Flat 193, floor 22, Grenfell Tower, London.
Place of death: Flat 193, floor 22, Grenfell Tower, London.
Time of death: Between 03.37 and 04.20 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 14 January 1984 (33 years).
Place of birth: London, UK.
Gender: Female.
Occupation: Nursery School Teacher Assistant.
Usual address: Flat 193, floor 22, Grenfell Tower, London.
Place of death: Flat 193, floor 22, Grenfell Tower, London.
Time of death: Between 03.37 and 04.20 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 22 November 2003 (13 years).
Place of birth: London, UK.
Gender: Female.
Occupation: Student.
Usual address: Flat 193, floor 22, Grenfell Tower, London.
Place of death: Flat 193, floor 22, Grenfell Tower, London.
Time of death: Between 03.37 and 04.20 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 1 March 2006 (11 years).
Place of birth: London, UK.
Gender: Female.
Occupation: Student.
Usual address: Flat 193, floor 22, Grenfell Tower, London.
Place of death: Flat 193, floor 22, Grenfell Tower, London.
Time of death: Between 03.37 and 04.20 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 17 May 2014 (3 years).
Place of birth: London, UK.
Gender: Female.
Occupation: N/A.
Usual address: Flat 193, floor 22, Grenfell Tower, London.
Place of death: Flat 193, floor 22, Grenfell Tower, London.
Time of death: Between 03.37 and 04.20 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Sirria Choucair was born on 25 October 1956 in Lebanon. She was 60 years old. Her daughter, Nadia, was born on 14 January 1984 in London. She was 33 years old. Bassem Choukair, Nadia’s husband, was born on 1 December 1976 in Lebanon and was 40 years old. Their three daughters were born in London. Mierna Choucair, born on 22 November 2003, was 13 years old, Fatima Choucair, born on 1 March 2006, was 11 years old and Zainab Choucair, born on 17 May 2014, was three years old.
At the age of 17 Sirria Choucair moved to the UK, where she married and brought up her family. She worked at the Royal Marsden Hospital until her retirement.[1193] Bassem Choukair and Nadia Choucair met when Nadia was visiting members of her family in Lebanon. He moved to the UK following their marriage and was Section Co-ordinator in a supermarket. Nadia Choucair worked at Avondale Park Primary School as a nursery officer. Mierna and Fatima were at school; the couple’s youngest daughter, Zainab, attended nursery.[1194]
Nadia Choucair, Bassem Choukair and their three children lived in Flat 193. Sirria Choucair lived in Flat 191 on the same floor.
Sirria Choucair had severe arthritis and back pain that affected her mobility.[1195] The survey of residents prepared by Rydon in November 2014 recorded that she had high blood pressure, back pain and difficulty in walking.[1196] She was recorded as a resident of Flat 191 in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system,[1197] but not as having any vulnerabilities. Nadia Choucair, Bassem Choukair and their eldest daughter, Mierna, were recorded as residents of Flat 193. Their younger daughters did not appear in the spreadsheet.
On the evening of 13 June 2017, the Choucair family were at home. CCTV shows Bassem Choukair returning to the tower at 15.02, shortly before his three children came back with Sirria Choucair at about 15.38. Nadia Choucair returned to the tower at 16.13.[1198]
It is unclear when the family became aware of the fire. Shortly before 01.30 Nadia Choucair opened her front door and saw Naomi Li from Flat 195 in the lobby. Naomi Li told her that the fire brigade had said that there was a fire on floor 4 but their neighbour said it was in her kitchen. (Naomi Li was referring to Mariem Elgwahry from Flat 196.)[1199] Nadia Choucair invited Naomi Li and her cousin, Lydia Liao, into her home, which was still free of smoke.[1200]
Naomi Li made her second emergency call from Flat 193 at 01.30. She told CRO Gotts in the LFB control room that she was in a neighbour’s flat on floor 22.[1201]
Between 02.17 and 03.00, the LFB control room received further emergency calls relating to eight people trapped in Flat 193.
Nadia Choucair made her first emergency call at 01.40. After seven minutes trying to connect her to the LFB, the BT operator redirected the call to Essex Fire and Rescue Service at 01.48.[1202] Nadia Choucair spoke to CRO Sharon Lancaster and gave her address as Flat 193 Grenfell Tower. She said that she was on floor 22 and that it was smoky in the flat.[1203] CRO Lancaster told her that the fire service was at the scene and that she would report to London for her.[1204]
CRO Lancaster and her colleague CRO Katrina Marshall tried to contact the LFB to pass on the information from Nadia Choucair but were unable to get through until 02.18.[1205] CRO Marshall spoke to CRO Adams in the LFB control room and told her that they had received a call from a person on floor 22 who said that it was starting to get smoky. Although she said that they had not obtained a flat number from the caller, that was incorrect as Nadia Choucair had told CRO Lancaster that she was in Flat 193. It appears that the information had not been entered on the incident log.[1206] CRO Adams told CRO Marshall that they had given the correct advice when telling Nadia Choucair to stay put.[1207]
Nadia Choucair and Bassem Choukair made two separate emergency calls at 02.37 and 02.43. On each occasion they were connected to the LFB control room and each spoke to CRO Adams. In both calls, CRO Adams was told that there were eight people in the flat (i.e. the six members of the Choucair family and Naomi Li and Lydia Liao).[1208]
When she called at 02.37, Nadia Choucair was advised to block any smoke coming in to the flat and to close the windows.[1209] CRO Adams reassured her that the firefighters were on their way and would get to her.[1210] When Bassem Choukair called at 02.43, CRO Adams encouraged him to try to find the stairs and get out.[1211] He said that it was not possible to leave because of the smoke. CRO Adams said that he should make the decision whether to leave or not.[1212]
At about 02.35, DAC Adrian Fenton in the LFB control room decided to revoke the stay put advice and tell people to try to leave the building. He was aware that at the time crews could not get above floor 15.[1213] It took some time for the change in advice to be disseminated to, and implemented by, the CROs.[1214] That might explain why at 02.37 CRO Adams advised Nadia Choucair to stay put, but at 02.43 she told Bassem Choukair to try to leave.
The information from the calls was passed to the incident ground.
In any event, that information did not reach the bridgehead, which from 02.17 was on floor 3.
After Bassem Choukair had spoken to CRO Adams at 02.43 the family tried to leave the flat covering their heads with wet towels.[1217] They reached Flat 194 and spoke to Tony Disson but then returned to Flat 193.[1218]
Soon after they had returned, Hashim Kedir, Nura Jemal and their children came into Flat 193.[1219] There were now 13 people in the flat. Those sheltering there spoke to the LFB control room on a number of occasions. They were encouraged to try to get out.
Following her call at 03.07, Naomi Li told everyone in the flat that they had to leave. She was not able to see their reactions because there was too much smoke in the room. Naomi Li and Lydia Liao did then leave. On the stairs they encountered WM Peter Clarke, WM Alexander Cardy and FF Enrico Beltrami, who helped them, and also Karen Aboud and her two children from Flat 92 to leave the building.[1226]
Naomi Li said that she told the firefighters that there were more than ten people in Flat 193 on floor 22. She did not know what the firefighters did with that information.[1227] WM Cardy said that he had reported to WM De Silvo at the bridgehead but it is not clear if he passed on any information about Flat 193.[1228] From 03.10, the bridgehead was on the ground floor and a green painted wall at the rear of the lobby was being used to record information about those still trapped in flats.[1229] No reference to Flat 193 appeared on that wall.
Separately, from 02.15, WM Glynn Williams had begun recording information about those needing rescue on a different wall on the ground floor. SM Peter Wolfenden began recording information on the same wall from about 03.21.[1230] He may well have been responsible for an entry on that wall that recorded “192 22 10 3K”,[1231] meaning ten people including three children. SM Wolfenden explained that a tick had been used to show that a crew had been sent to a flat[1232] but no tick appears next to that entry. Although the entry refers to Flat 192, the reference to ten people indicates that the source may have been Naomi Li, but it is also possible that the information came from calls made by others on floor 22. In any event, however the information recorded on the wall came to reach the ground floor, it did not lead to a deployment to floor 22.
At 03.08, CRO Gotts answered a call during which she spoke to both Hashim Kedir and Nura Jemal. They said they were in Flat 193 on floor 22. They said they could see a helicopter and asked for it to help them escape. CRO Gotts told them to try to get out using wet towels to cover their heads.[1233]
At 03.14 Nadia Choucair told a BT operator that her baby was unconscious. She was speaking of her youngest daughter, Zainab. The operator said the advice was to get out of the tower. As the call was being put through to the LFB, Nadia Choucair could be heard telling everyone in the room that they needed to get to the stairs. The call ended before someone in the control room could speak to her.[1234] At 03.21, a police operator telephoned Nadia Choucair and told her that she needed to leave. She said that there was too much smoke, but as the call ended she could be heard telling those in Flat 193 that they needed to leave.[1235]
Hashim Kedir’s call at 03.24 was the last contact with those still in Flat 193. He told CRO Duddy that there were 12 adults and seven children trapped in Flat 193 (in fact there were five adults and six children). As the call continued, CRO Duddy repeatedly told him that the only chance of survival was to leave by the stairs and that it was not possible to rescue them by helicopter. Hashim Kedir told CRO Duddy that it was not possible for them to leave; they had tried but had been unable to do so because of the smoke.[1236]
Information received by the LFB control room after 03.00 was passed on to the incident ground but did not result in any deployments. It was recorded in the following places:
The remains of the six members of the Choucair / Choukair family were recovered from the living room of Flat 193.[1245] The coroner was satisfied about the identification of the remains and issued interim certificates of the fact of death for Sirria Choucair, Bassem Choukair, Nadia Choucair and their three daughters, Fatima, Mierna and Zainab.[1246]
The medical cause of death in the case of the members of the Choucair / Choukair family was recorded as consistent with the effects of fire. In light of Professor Purser’s evidence we find that a more accurate description of the cause of the deaths of all six members of the family is “inhalation of asphyxiant gases”.
Although there is no toxicological analysis available for any member of the family, the fact that carboxyhaemoglobin was found in tissue recovered from the remains of Yahya Hashim and Firdaws Hashim (who also died in Flat 193) makes it likely that all those in Flat 193 had inhaled carbon monoxide,[1247] particularly as a result of gases entering the flat from the lobby of floor 22.
The fact that Naomi Li and Lydia Liao were able to escape from the tower makes it likely that until about 03.11 those in Flat 193 had accumulated a relatively low dose of asphyxiant gases, despite the increasing amounts of smoke in the flat.[1248] Their accumulation of such gases increased as the fire on the outside of the building reached Flat 193 and particularly when it reached the living room at about 03.37.[1249] From that time onwards conditions deteriorated rapidly, with the result that the inhalation of asphyxiant gases caused them to become unconscious by about 04.13. Within a few more minutes they had acquired a lethal dose. Since children absorb asphyxiant gases at twice the rate of adults, they are likely to have lost consciousness sooner, at about 03.50 or shortly after.[1250]
We find that Sirria Choucair, Bassem Choukair and Nadia Choucair and their three children, Mierna, Fatima and Zainab had all lost consciousness and died from the inhalation of asphyxiant gases between 03.37 and 04.20 before the fire reached their bodies. It is likely that the three children died before their parents.
Date of birth: 27 November 1951 (65 years).
Place of birth: Hammersmith, London, UK.
Gender: Male.
Occupation: Retired.
Usual address: Flat 194, floor 22, Grenfell Tower, London.
Place of death: Stairwell, Grenfell Tower, London.
Time of death: By 04.30 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Anthony (Tony) Disson was born on 27 November 1951. In June 2017 he was 65 years old and had retired. He and his wife, Cordelia, had three sons, Harriboy, Alfie and Charlie.[1251] Tony Disson had lived in Flat 194 since June 2010.[1252] His son, Charlie, lived with him but was not at home on the night of the fire.[1253]
A priority needs assessment for RBKC completed in June 2009 in support of Tony Disson’s application for emergency housing recorded that he had problems with his legs, which were getting worse, and that he needed access to a lift or a ground floor flat.[1254] Tony Disson’s tenancy agreement for Flat 194 recorded that he did not suffer from any disability.[1255]
In April 2016, a doctor at his local surgery wrote to the TMO in support of Tony Disson’s request for repairs to be carried out in his flat. The letter indicated that the current condition of the flat was having a detrimental effect on his health and well-being but did not refer to his having any difficulties with mobility.[1256]
Tony Disson was not identified as having any vulnerabilities in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system.[1257]
Tony Disson returned to the tower shortly before the fire began on 14 June 2017,[1258] having spent the day with his son, Alfie, and his wife, Cordelia.[1259] He became aware of the fire at an early stage, having spoken briefly to Naomi Li in the lobby on floor 22 at about 01.25.[1260] Conditions on floor 22 had deteriorated by 01.30 when he made his first call to the emergency services. He described conditions in the lobby as terrible and told CRO Heidi Fox in the LFB control room that he could not see anything. Although he said that he was on floor 22, he did not give her the number of his flat. She told him to use towels to block any smoke coming into his flat and said that firefighters were on their way.[1261]
At 01.32 a service request was created which recorded “PERSONS ON THE 22ND FLOOR SMOKE COMING INTO FLAT.”[1262] That was probably the result not only of Tony Disson’s first call but also of a call at 01.30 from Naomi Li, in which she reported that she was trapped on floor 22.[1263] CRO Darby passed that information to appliance G261 at 01.35, confirming that she could not provide the number of the affected flats.[1264] The service request was marked as completed at 01.41.[1265] The information was not passed to the bridgehead, which at that time was on floor 2, where it remained until 02.17.[1266] The forward information board used on floor 2 to record information about people needing to be rescued contained no reference to floor 22.[1267]
Tony Disson next spoke to the LFB control room at 01.50. He told CRO Peter Duddy that smoke was coming into his flat. CRO Duddy told him to close all the windows and said that firefighters were making their way to floor 22.[1268] That call did not prompt a message to the incident ground.
At 02.00, Tony Disson made his third emergency call. He told CRO Howson that conditions were deteriorating in his flat. He gave the numbers of his floor and his flat and was reassured that firefighters were coming to him.[1269] CRO Adams, who was speaking to command unit CU8 at the time, passed on the information that a pensioner was trapped in Flat 194 on floor 22.[1270] However, that information did not reach the bridgehead.
Tony Disson made further calls to the emergency services.
It was probably after the last of those calls that Bassem Choukair knocked on Tony Disson’s door, having left Flat 193 with his family. At the time Tony Disson was on the telephone to his wife, Cordelia. She heard Bassem Choukair ask him for help and Tony Disson reply that he could not help himself. She described Tony Disson as becoming more desperate from that point.[1274] The Choucair / Choukair family were back in Flat 193 by 02.55 when Nadia Choucair made another emergency call.[1275]
Tony Disson was also in contact with his son, Alfie, and his partner, Chanade Prentice. She made two emergency calls at 02.28 and 02.45 which were connected to Surrey Fire and Rescue Service.[1276] Surrey in turn contacted the LFB control room saying that a man was trapped in Flat 194 on floor 22.[1277] At 02.54, Sharon Haley, a friend and resident of the tower who had already left the building, also spoke to the LFB control room and gave it the same information.[1278]
Surrey gave the LFB control room Tony Disson’s mobile number. CRO Gotts called him at 02.51 and told him to leave.[1279] When Tony Disson called the LFB control room again at 03.01, CRO Fox gave him the same advice. He told CRO Fox that it was too dark and hot for him to leave.[1280] In calls to his family, Tony Disson described the conditions in his flat as worsening and said that it was filling with smoke.[1281]
The bridgehead was located on floor 3 between 02.17 and 03.10, when it was moved to the ground floor.[1282] Notwithstanding the significant number of calls to the emergency services from and about Tony Disson, information about him did not reach the bridgehead while it was on floor 3.
It follows that the emergency calls concerning Flat 194 did not prompt the decision to send CM Raoul Codd and FF John Joseph to floor 22 shortly after 03.00.[1290]
At about 03.00, Tony Disson told his son Alfie that the firefighters were not coming for him and that he was going to try to leave.[1291] Chanade Prentice spoke to Surrey Fire and Rescue Service again at 03.05 telling CRO Caili Beckham that the fire had now reached Tony Disson’s flat and that he was struggling to breathe.[1292]
When Surrey Fire and Rescue Service passed the information on to the LFB control room, they were told that the occupants of the tower were now being advised to leave. At 03.09, CRO Beckham called Alfie Disson to tell him of the change of advice. He said that his father would not leave because he could not see well enough to reach the stairs. CRO Beckham said that she would let the LFB know, as Tony Disson should be treated as a priority. She spoke to CRO Jones in the LFB control room at 03.10. CRO Jones could not offer any more advice but did call Tony Disson at 03.15. The call was not answered.[1293]
By about 03.20, Flat 194 was being affected by the fire on the outside of the building.[1294] Cordelia Disson spoke to Kent Fire and Rescue Service at 03.22. She said that she had just spoken to Tony Disson, that the fire had reached his front door and that he was having difficulty breathing. CRO Zoe Martin said that she would call him.[1295]
CRO Martin’s call to Tony Disson was the last contact anyone had with him. By that time, he had left his flat and had reached the stairs. The call ended abruptly.[1296] In the Phase 1 report the call is said to have been made at 03.31 but evidence received since shows that it was in fact made at 03.27.
Tony Disson’s body was found in the stairwell at the level of floor 18.[1297] The coroner was satisfied about his identity and issued an interim certificate of the fact of death.[1298]
The medical cause of death was recorded as “inhalation of fire fumes” but in the light of more recent evidence we find that a more accurate description is “inhalation of asphyxiant gases”.
The post-mortem on Tony Disson noted that there were heavy soot deposits on his head, face and arms. Soot was also found in the airways consistent with the inhalation of smoke-filled air. There was some heat damage to the skin. Toxicological analysis found the level of carboxyhaemoglobin in Tony Disson’s blood to be 71%. The post-mortem noted that such a level would be associated with death in any individual, even without the pre-existing widespread coronary artery disease from which he suffered.[1299]
The carboxyhaemoglobin level in his blood shows that Tony Disson had inhaled a significant quantity of carbon monoxide before he died. Later analysis in April 2019 of the blood sample did not detect any cyanide.[1300] However, it is likely that the sample had degraded over time, so the finding does not necessarily reflect the level of cyanide in his blood at the time of death.[1301]
Tony Disson was still in Flat 194 when he spoke to Cordelia Disson shortly before 03.22 and had not got very far down the stairs when CRO Martin spoke to him at 03.27. That suggests that he did not spend long in the lobby after leaving his flat. We conclude that by the time he left his flat Tony Disson had inhaled close to an incapacitating dose of asphyxiant gases.[1302] He lost consciousness and collapsed shortly after the call with CRO Martin. Tony Disson had probably suffered a lethal exposure to asphyxiant gases by about 03.56 and died before 04.30.[1303] In our view, the heat damage to the skin noted at the time of the post-mortem very probably occurred after death.
On the night of the fire the six flats on floor 23 were occupied as follows:
Flat 201 by Raymond (Moses) Bernard.
Flat 202 by Gloria Trevisan and her partner, Marco Gottardi.
Flat 203 by Rania Ibrahim and her two daughters, Fethia Hassan and Hania Hassan.
Flat 204 by Hesham Rahman.
Flat 205 by Mohammed (Saber) Neda, his wife, Flora (Shakila) Neda, and their son, Shekeb (Farhad) Neda.
Flat 206 by Fathia Ahmed Elsanousi and her daughter, Isra Ibrahim. Fathia Ahmed Elsanousi’s son, Abufras Mohamed Ibrahim, was visiting.
The fire reached floor 23 by 01.26. The exterior of Flat 206, in the north-east corner of the tower, was enveloped by flames by 01.30.[1304]
Farhad Neda in Flat 205, which had two bedrooms in the north-west corner of the tower, saw smoke entering the lobby from the smoke extraction vents at some time before 01.30. The smoke gradually filled the lobby. The Neda family tried to walk down the stairs but were unable to do so due to a group of people coming up from lower floors who told them that there was a fire. Altogether, 16 people moved up from lower floors to floor 23, only one of whom survived the fire. In the Phase 1 report the chairman set out the possible reasons why that upward movement occurred.[1305] It has not proved possible for us to reach any more confident conclusion.
There is evidence that by 01.39 the lobby on floor 23 was dark, probably due to smoke.[1306]
Between 01.50 and 02.20, Fadumo Ahmed ran to the stairwell from Flat 201. At that time the lobby was full of black smoke with no visibility. There was dark smoke in the stairwell which made her cough and feel dizzy. She had difficulty breathing.
Farhad Neda and Shakila Neda encountered similarly difficult conditions when leaving Flat 205 at some time after 02.15. The temperature in the lobby was higher than in the flat and the smoke caused a burning sensation that made Shakila Neda vomit and choke. The stairs were thick with black smoke and the handrail was not visible. Farhad Neda and Shakila Neda were rescued by firefighters and left the tower by 02.43.[1307] They were the last occupants of floor 23 to escape the tower.
There were numerous emergency calls reporting people trapped on floor 23. Some identified specific occupants and flats; others were made by members of the public who could see people signalling and waving from the top floor of the building.[1308] The information received at the incident ground resulted in deployments of firefighters to floor 23 but no firefighters succeeded in reaching it.
One crew was briefed to go to the roof.[1309] Three other crews were sent to floor 23.[1310] A fourth deployment to floor 23 was changed to a search and rescue operation just before the firefighters set off.[1311] The deployment of FFs Terence Roots and Adam Johnson to Flat 161 on floor 19 at about 02.05 had been to rescue Debbie Lamprell, but by then she had already moved to floor 23.[1312]
Having arrived at the incident ground at about 01.35, the Paddington crew (CM Philip Wigley, FFs Martin Gillam, Russell Gonzalez, Andrew Harris and Dean Roberts) equipped with extended duration breathing apparatus were sent by WM Michael Dowden to the roof of the tower to run a jet of water down from the top of the building.[1313] They tallied out between 01.56 and 01.57. They met FFs Steven Mills and Geoffrey Campbell coming down, who told them that they had been sent to rescue a woman in Flat 175 or a woman on floor 20. At about floor 15 or 16, the Paddington crew realised that they could not reach the roof. They went to floor 20 instead to try to rescue the woman FFs Mills and Campbell had told them about. They found Fadumo Ahmed between floors 20 and 21 and helped her. Fadumo Ahmed had come from Flat 201, where others were also sheltering. FF Gillam told us that she had told him that there was no one left on her floor but that none of the crew had asked her from which floor she had come. The crew’s end of wear times were between 02.21 and 02.23.[1314]
FFs John Wright, Zade Alassad and Scott Bell were sent to two flats on floor 23, which are likely to have been Flats 201 and 205. It is not clear exactly which emergency call or calls had prompted their deployment, but the call by Jessica Urbano Ramirez from Flat 201 at 01.29 may have prompted it, as messages were passed to the incident ground relating to it. The crew tallied out between 02.08 and 02.10. They stopped at floor 10 and helped other firefighters to carry the bodies of Mohamednur Tuccu and Khadija Khalloufi out of the tower. FF Bell recalled telling someone they had not reached floor 23, but he could not remember to whom he had spoken or what that person had done with the information. Their end of wear times were between 02.28 and 02.29.[1315]
CM Richard Evans and FF Gemma Bloxham were sent to Flat 205 on floor 23. They tallied out at 02.24. Between floor 18 and floor 20, they came across two occupants, probably Farhad Neda and Shakila Neda, and helped them to escape. Shakila Neda had been on the telephone to members of her family on floor 23. On overhearing the conversation, CM Evans tried to make radio contact with the bridgehead but did not obtain a response. Farhad Neda told the firefighters that his father and four other people were trapped in Flat 205. One of the firefighters wrote that in his notebook. Once CM Evans had got back down, he told the officer in charge at the bridgehead that he and FF Bloxham had not reached Flat 205. The crew’s end of wear time was 02.42.[1316]
FFs Michael Pole, Niki Mitchell, Chris Cheesman and Jessamine Bate from Euston Fire Station were deployed to floor 23, probably to Flats 204 (a west-facing flat) and 205. The crew had tallied out by 02.53. On the stairs, they met FFs Upton and Reddington carrying Malak Belkadi. FF Bates helped them to carry her. FFs Mitchell, Pole and Cheesman continued upwards and reached floor 18. There they realised that they did not have enough air to reach floor 23 and get back down again. Instead they helped to rescue those who had sheltered in Flat 153. FF Mitchell recalled telling WM Louisa De Silvo that they had not reached floor 23. The crew’s end of wear times were 03.15 to 03.17.[1317]
FFs Matthew Harold, David Friend and Richard Peacock tallied out between 03.31 and 03.32. They had originally been sent to Flat 203 on floor 23 in the south-west corner of the tower but their instructions were changed just before they set off. Instead, they were told to carry out search and rescue operations from the ground floor upwards. They searched floors 4 and 5 and found no casualties.[1318]
Flat 201, the home of Raymond (Moses) Bernard, was a one-bedroom flat facing east.[1319] Those who took refuge there included Fadumo Ahmed (Flat 164, floor 19), Debbie Lamprell and Gary Maunders (Flat 161, floor 19), Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris (Flat 166, floor 19), Berkti Haftom and Biruk Haftom (Flat 155, floor 18), Hamid Kani (Flat 154, floor 18) and Jessica Urbano Ramirez (Flat 176, floor 20). Most of those who moved up to floor 23 probably reached it by around 01.30.[1320]
Amna Idris and Gary Maunders did not live in Grenfell Tower. Amna Idris was visiting her cousin, Amal Ahmedin, and her family. Gary Maunders was visiting Debbie Lamprell.[1321] He moved from Flat 201 to Flat 203 at around 01.39.[1322]
There were three children in the group sheltering in Flat 201: Jessica Urbano Ramirez (12 years old), Biruk Haftom (12 years old) and Amaya Tuccu Ahmedin (3 years old).[1323]
Of the 11 people who were in Flat 201 at some point, only Fadumo Ahmed survived. She left the tower at 02.25 with the assistance of firefighters.[1324]
The remains of Moses Bernard, Debbie Lamprell, Amna Idris, Berkti Haftom, Biruk Haftom, Hamid Kani and Jessica Urbano Ramirez were all recovered from Flat 201.
The remains of Gary Maunders were recovered from Flat 203. Those of Amal Ahmedin and her daughter, Amaya Tuccu Ahmedin, were recovered from the lobby of floor 23. We do not know when or under what circumstances Amal Ahmedin and Amaya Tuccu Ahmedin left Flat 201.[1325]
By 01.29 the fire had spread to the eastern and northern sides of floor 23, affecting first Flat 206 in the north-east corner.[1326] The fire moved across Flat 206 in a southerly direction along the east face and towards Flat 201, which was next door.[1327]
Smoke had been entering the lobby on floor 23 since before 01.30.[1328] From about 01.30, Flat 201 filled with smoke from the lobby and from the fire outside the living room windows.[1329]
By 01.34, the occupants of Flat 201 were struggling to breathe. There were about ten people sheltering in the hallway of the flat. Fadumo Ahmed and Amal Ahmedin tried unsuccessfully to put out a fire which was burning at the top of the living room window.[1330]
The fire entered the living room and set things alight. The conditions in the flat prompted the group to move from the hallway to the bedroom.[1331] While in the bedroom, both Debbie Lamprell and Jessica Urbano Ramirez had long telephone calls with the emergency services.
By the time Fadumo Ahmed decided to leave thick smoke was coming into the flat from the lobby. At some time between 01.50 and 02.20 she left the flat and ran straight to the stairwell. Both the lobby and the stairs were filled with thick, dark smoke. Due to the smoke, there was no visibility in the lobby and the stairs could not be seen.[1332]
By about 01.56, the fire on the outside of the building had spread across the exterior of the living room and kitchen. It then spread outside the bedroom window where the occupants were sheltering.[1333]
By 02.01 the windows of the bedroom of Flat 201 were cracking. By 02.06, flames were entering the bedroom window and the interior of the flat was on fire.[1334]
By 02.20, towards the end of their respective emergency calls, Jessica Urbano Ramirez and Debbie Lamprell had stopped responding; they both probably lost consciousness at about that time.[1335]
It is likely that all those in Flat 201 lost consciousness from about 02.15 and had been exposed to a lethal dose of asphyxiant gases by about 02.23.[1336]
The firefighting crews deployed to floor 23 all tallied out after 02.08. Conditions in the stairwell between 02.00 and 02.20 had deteriorated to the point at which they posed a risk to anyone who attempted to escape.[1337] It is therefore doubtful that firefighters would have been able to rescue the occupants of Flat 201, even if they had succeeded in reaching floor 23.
Jessica Urbano Ramirez and Debbie Lamprell each made a long emergency call while they were in Flat 201. Although the calls overlapped in time, there does not appear to have been any direct communication between the two callers. Biruk Haftom also made an emergency call from Flat 201.[1338]
Although messages from Flat 201 were passed to the incident ground and recorded in various places, there was only one deployment of firefighters specifically to Flat 201.[1339]
Jessica Urbano Ramirez used Berkti Haftom’s telephone to make an emergency call at 01.27, but it was disconnected before the BT operator could transfer it to the LFB control room.[1340] The BT operator contacted the LFB control room at 01.29 and spoke to CRO Sarah Russell, telling her that the caller was a child who had asked for the fire brigade. CRO Russell called back using Berkti Haftom’s number and was connected to Jessica Urbano Ramirez at 01.29. The call lasted until 02.24. Jessica stopped responding towards the end of the call. Early in the conversation she reported her location as floor 23 and said that there were about ten other people in the flat.[1341] She said that smoke was coming from the floor and that people were having difficulty breathing. She later said that fire had entered the living room and that the group had moved from the hallway to the bedroom. She said she was in Flat 201. She also described the group as containing about 11 people, including a two-year-old child, who must have been Amaya Tuccu Ahmedin.[1342]
At 01.45, CRO Russell created a service request which sought assistance for 11 people trapped in the bedroom of a flat on floor 23.[1343] That was the first service request created as a result of information received from Jessica Urbano Ramirez.[1344] CRO Sharon Darby contacted CU8 at 01.46 and passed on a message about 11 people in a bedroom of a flat on floor 23.[1345] The service request was then marked as completed at 01.47.[1346]
The call continued. A further service request referring to 11 persons and a baby in Flat 201 was created at 01.58 (once CRO Russell had become aware of the flat number and the presence of a baby) and messages were passed to CU8 about Flat 201.[1347] The service request relating to 11 persons and a baby in Flat 201 was marked as completed at 02.00.[1348] Also at 02.00, CRO Adams rang CU8 to pass on a number of messages to WM Meyrick. One of those messages related to Flat 201 on floor 23 containing 11 adults and one child.[1349]
While Jessica Urbano Ramirez’s call to CRO Russell was going on, there was an unrelated attempt to rescue her. Her sister, Melanie, thought that Jessica was still in Flat 176. At 01.26 she told FF David Badillo that her sister was in Flat 176 on floor 20 and gave him the keys. FF Badillo first tried to reach the flat alone, then recruited CM Christopher Secrett and FF Christopher Dorgu to go with him. They set out by 01.35. Having reached Flat 176 and found it empty, they returned to the ground floor. Their end of wear time was 01.57. No information about the emergency call from Jessica Urbano Ramirez reached the crew during their deployment.[1350]
The messages about Flat 201 sent by the control room to the incident ground at 01.46 and 02.00 were passed on to the bridgehead, which was located on floor 2 until 02.17.[1351] Shortly after 02.17, CM Charles Batterbee recorded in his notebook the information written on a forward information board that had been used while the bridgehead was located on floor 2.[1352] Flat 205 appears in that entry, but not Flat 201. A circled note written on the wall on floor 2 refers to Flats 201 and 205 and the names Alassad, Bell and Wright.[1353] That is likely to have related to the unsuccessful deployment of firefighters John Wright, Zade Alassad and Scott Bell to floor 23 before 02.10. There were no further deployments to Flat 201 after that.
From about 02.33 SM Jason Oliff recorded information coming into the LFB control room on two whiteboards. In a photograph taken at the end of the incident the first whiteboard can be seen to include the notation “Flat 201 23rd flr – 2 yr old 11 people – now unconscious”.[1354] That probably reflected the call from Jessica Urbano Ramirez.
Between about 02.00 and 03.00, a white laminate sheet was being used by firefighters in command unit CU7 at the incident ground to record information about people needing to be rescued. The laminate sheet recorded “Flat 201 Floor 23 1 person lost call”.[1355] That message must have related to Jessica Urbano Ramirez’s call, during which she had stopped responding towards the end. Firefighters at the incident ground were therefore informed that contact with her had been lost.[1356]
At 01.41, a BT operator connected to North West Fire Control said that a caller for the LFB had hung up after waiting for about five minutes.[1357] That caller was Debbie Lamprell. At 01.41 CRO Aisha Jabin’s call back to Debbie Lamprell was connected. The call lasted for over 40 minutes, until 02.21. The group in Flat 201 had by then moved from the hallway to the bedroom. During the call, Debbie Lamprell confirmed her location as Flat 161 on floor 23.[1358] Flat 161 was her home address and was not on floor 23.
At 01.46, Team Leader Paula Craig at North West Fire Control contacted the LFB control room and spoke to AOM Debbie Real. Based on inaccurate information from Debbie Lamprell’s continuing emergency call she reported a call from “Flat 161 on Floor 23” with ten people trapped in the bedroom. AOM Real did not record the information contemporaneously in the incident log, but she appears to have passed it on to OM Alexandra Norman. OM Norman passed the information to the incident ground at 01.47 and at 02.01 recorded having done so in the incident log.[1359]
However, at around 01.52 Debbie Lamprell explained to CRO Jabin that she was in fact in Flat 201 on floor 23. As a result, CRO Jabin made further entries in the incident log, first to record that she was unsure of the flat number and then at 01.53 to record “10 PEOPLE IN FLAT 201 23rd FLOOR”.[1360]
The correct location of Flat 201 was not communicated to the LFB control room, nor was it recorded in the incident log or in radio messages, even after CRO Jabin had become quite sure that it was on floor 23. The forward information board at the bridgehead included an entry for Flat 161 on floor 19, which probably reflected the message passed by North West Fire Control to the LFB following Debbie Lamprell’s call.[1361]
As a result of that message, at about 02.05 FFs Terence Roots and Adam Johnson were deployed to Flat 161 on floor 19, which was empty. Having swept Flat 161, FFs Roots and Johnson helped Nicholas and Pily Burton from Flat 165 to leave the building.[1362]
At 01.32 CRO Christine Howson answered an emergency call from Biruk Haftom, who was in Flat 201 at the time. He said, “My actual door number is 155 but I’m at someone else’s house”. Biruk Haftom reported that eight children and a lot of adults were in a flat on the top floor and that the window was already “burning up”. He said they could not get out. He also reported a lot of smoke in the flat and in the building. CRO Howson told him and an adult who also spoke to her to try to stop smoke coming into the flat.[1363]
No service request appears to have been created in response to Biruk Haftom’s call, but OM Norman rang CU8 at 01.35 and reported that there were eight children and a number of adults on the top floor and that smoke was entering their flat.[1364] At 01.36, CRO Darby contacted appliance G261 and passed on that information.[1365]
FF Mandeep Singh arrived at the tower at 01.35 and was instructed to pass information about people needing to be rescued from the command unit to the bridgehead. He recalled having been handed telephones and speaking to residents inside the tower. During one such call, FF Singh spoke to a woman who gave her location as “the 23rd floor, doors 205 and 201”. She said that she had brought all the occupants of floor 23 into her flat. FF Singh advised her to stay put.[1366] A page from his notebook contains the following entry “23rd FLOOR ALL OCCUPANTS 205/201 [illegible] WM BRIAN O’KEITH WM (Illegible)”.[1367] In his witness statement FF Singh said that he thought the woman he had spoken to was the person who can be heard in a video recording saying that she will let people in. That was probably Rania Ibrahim, who was in fact in Flat 203, not Flat 201 or Flat 205.[1368]
WM Glynn Williams started to record information on the wall of the lobby on the ground floor at 02.15. He said the information had come from CU7. A photograph of the wall taken much later on in the incident includes the notation “201 23 11”.[1369]
The bridgehead was moved from floor 2 to floor 3 at about 02.17, where it remained until 03.10.[1370] Messages were recorded on the wall of that floor. There is no reference to Flat 201 on the wall during that time.[1371] Accordingly, it is likely that no further messages about Flat 201 were passed from CU7 to the bridgehead after 02.17.
After 03.00, the laminated sheet in CU7 was replaced by a whiteboard with a grid. A photograph of the whiteboard taken much later in the morning shows Flat 201 annotated with “11 1” and a red mark, which is difficult to read. The “11” is in green indicating 11 people and the “1” is in black indicating a child.[1372] The red mark may signify a “P” for priority.
Date of birth: 22 May 1954 (63 years old).
Place of birth: Penal, Republic of Trinidad and Tobago.
Gender: Male.
Occupation: Retired electrical engineer.
Usual address: Flat 201, floor 23, Grenfell Tower, London.
Place of death: Flat 201, floor 23, Grenfell Tower, London.
Time of death: About 02.45 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Born in Trinidad on 22 May 1954, Raymond (Moses) Bernard was 63 years old at the time of the fire. He came to the UK in 1969 to join his parents and completed his schooling here. At the age of 16, he began an electrical engineering apprenticeship working, once qualified, at the House of Lords and Buckingham Palace. A father of four, Moses Bernard had lived in Flat 201 for over 30 years. He lived there with his dog, Marley.[1373]
Moses Bernard had been diagnosed with arthritis ten years before his death in the fire. As a result, his mobility had deteriorated and he walked with the assistance of a cane. He had difficulty climbing stairs.[1374]
Moses Bernard’s sister, Sheramin Bernard, wrote to RBKC several years before the fire informing them of her brother’s medical and mobility problems in an attempt to have him re-housed on medical grounds. Sheramin Bernard received no reply. No assessment or review was carried out in light of the information provided.[1375]
Rydon carried out surveys of residents during the refurbishment and compiled a list of their vulnerabilities in November 2014. They carried out a survey on Moses Bernard’s home on 14 October 2014 and recorded that he had no problems with his health and no pets.[1376]
Moses Bernard was not identified as a vulnerable resident in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system.[1377]
Moses Bernard returned to Grenfell Tower in the early evening of 13 June 2017.[1378] It is uncertain when he first became aware of the fire but by about 01.30 he had offered refuge in his home to ten people.[1379]
Moses Bernard did not make any calls to the emergency services himself, but during the course of Biruk Haftom’s call to the LFB control room at 01.32 he took over and spoke briefly to CRO Howson, when towards the end of the call she asked to speak to an adult. Moses Bernard told her that the fire was approaching and that smoke was coming through the window.[1380]
Jessica Urbano Ramirez was sheltering in the bedroom of Flat 201 during her extended call with CRO Russell. About 17 minutes into the call she referred to a man who may have been Moses Bernard. She said he could not talk to CRO Russell because he was struggling to breathe.[1381]
The remains of Moses Bernard were recovered from the bedroom of Flat 201[1382]. The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.[1383]
The post-mortem report on Moses Bernard recorded a cause of death as “consistent with the effects of fire.”[1384] In the light of Professor Purser’s evidence, we find that a more accurate description is inhalation of asphyxiant gases.
We are satisfied that Moses Bernard died at about 02.45 before suffering the direct effects of fire.[1385]
Date of birth: 1 January 1982 (35 years old).
Place of birth: Sudan.
Gender: Female.
Occupation: Retail assistant.
Usual address: Flat 166, floor 18, Grenfell Tower, London.
Place of death: Floor 23 lobby, Grenfell Tower, London.
Time of death: Between about 02.20 and 02.30 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 25 February 2014 (3 years old).
Place of birth: London, UK.
Gender: Female.
Occupation: N/A.
Usual address: Flat 166, floor 18, Grenfell Tower, London.
Place of death: Floor 23 lobby, Grenfell Tower, London.
Time of death: Between about 02.20 and 02.30 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 1 January 1990 (27 years old).
Place of birth: Eritrea
Gender: Female.
Occupation: Student.
Usual address: Grafton Road, London W3.
Place of death: Flat 201, floor 23 Grenfell Tower, London.
Time of death: About 02.45 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Amal Ahmedin was born in Sudan on 1 January 1982 and was 35 years old in 2017. She lived in Flat 166 on floor 19 of Grenfell Tower with her daughter, Amaya Tuccu Ahmedin, who had been born in London on 25 February 2014 and was 3 years old when she died.[1386] Mohamednur Tuccu, the husband of Amal Ahmedin and the father of Amaya Tuccu Ahmedin, was also in Grenfell Tower on the night of the fire, probably visiting his family. We have dealt with the circumstances of his death in Chapter 86.
On the evening of 13 June 2017, Amna Idris, Amal Ahmedin’s cousin, was also visiting the family. Amna Idris had been born in Eritrea on 1 January 1990 and was 27 years old. She had joined her husband Ibrahim in London in March 2016.[1387]
Amal Ahmedin had no known vulnerabilities. She and Amaya Tuccu Ahmedin both appeared in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system.[1388] Amaya Tuccu Ahmedin’s age (3 years) was recorded in the spreadsheet.[1389]
Amal Ahmedin, Amna Idris and Amaya Tuccu Ahmedin all entered the tower on 13 June 2017. Mohamednur Tuccu entered the tower at 00.36 on 14 June 2017.[1390]
Meron Mekonnen was a neighbour of Amal Ahmedin and Amaya Tuccu Ahmedin. She lived at Flat 163 on floor 19 and was alerted to the fire at 01.25 by telephone. When she left her flat, she saw Amal Ahmedin and Amna Idris in the lobby of floor 19. She did not see Mohamednur Tuccu. The door to Flat 166 (the home of Amal Ahmedin and Amaya Tuccu Ahmedin) was wide open. It had a door closer but it was not working. Amal Ahmedin and Meron Mekonnen told each other about the fire before Amal Ahmedin ran back into Flat 166.
That was the last time Meron Mekonnen saw Amal Ahmedin. Amna Idris followed Meron Mekonnen and her daughters into the stairwell, probably before 01.30. It is likely that Flat 166 was affected by the fire at an early stage and that Amal Ahmedin and Amaya Tuccu Ahmedin left soon after.[1391]
There is no evidence that Mohamednur Tuccu was in Flat 166 when Meron Mekonnen saw Amal Ahmedin or that he was among those who made their way up the tower. He was, however, in the north lift when Rhea Rojo entered it on floor 12.[1392]
Amna Idris initially went down the stairs with a group of people including Meron Mekonnen and her children. At around floor 15 or floor 16, she heard a man shouting at them to go back and the group (including Amna Idris) began to run back upstairs. When she reached floor 19, Meron Mekonnen stopped and decided to go back downstairs again. She could not recall what Amna Idris had done at that time, but she must have gone upstairs to floor 23, as she was later seen in Flat 201 by Fadumo Ahmed.[1393]
Fadumo Ahmed, who lived in Flat 164 on floor 19, was made aware of the fire at around 01.20. When she left her flat, the lobby was full of thick, dark grey, steamy smoke which was hard to see through. She went up to floor 23 where she found that the smoke in the lobby was worse than it had been on floor 19. She recalled that Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris had been part of the group sheltering in Flat 201 by 01.30.[1394]
In her call to CRO Russell that had started at 01.29, Jessica Urbano Ramirez said that the group in the bedroom of Flat 201 included a two-year-old child, whom she also referred to as a baby. Debbie Lamprell also referred to a baby in her call to CRO Jabin that had started at 01.41. It is likely that they were both referring to Amaya Tuccu Ahmedin.[1395]
Between 01.50 and 02.20, Fadumo Ahmed left Flat 201. The remains of Amal Ahmedin and Amaya Tuccu Ahmedin were later found in the lobby of floor 23. It is not possible to determine at exactly what time Fadumo Ahmed left Flat 201 or whether Amal Ahmedin and Amaya Tuccu Ahmedin followed her out at the same time or left Flat 201 later.[1396]
At around 02.00, Jessica Urbano Ramirez was still talking to CRO Russell, and was heard to ask someone in the room not to leave. CRO Russell asked if someone was leaving, and Jessica Urbano Ramirez replied to say she had been mistaken. It is possible though, that she had been referring to Amal Ahmedin and Amaya Tuccu Ahmedin. At about 02.06, Jessica Urbano Ramirez said that the fire was in the flat and later confirmed that flames were coming through the bedroom window. CRO Russell tried to persuade her to move to another room. She told CRO Russell that people had tried to leave but had been unable to do so because of the smoke.[1397]
Meanwhile, Debbie Lamprell had told CRO Jabin at 02.01 that the windows were cracking and at 02.06 that the flat was on fire. CRO Jabin spoke to her team leader and told Debbie Lamprell to leave. Debbie Lamprell said she was unable to leave because people on the other side of the room were trying to get out. She confirmed that she was still in the bedroom.[1398] We do not know whether Debbie Lamprell was referring to Amal Ahmedin.
At some point Amal Ahmedin left Flat 201 with Amaya Tuccu Ahmedin. She was unable to cross the lobby on floor 23 and collapsed there. Amna Idris remained in Flat 201.
The remains of Amal Ahmedin and Amaya Tuccu Ahmedin were recovered from the communal lobby on floor 23.[1399] The remains of Amna Idris were recovered from the bedroom of Flat 201.[1400] The coroner was satisfied about the identification of the remains recovered and therefore issued interim certificates of the fact of death in respect of Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris.[1401]
Conditions in Flat 201 were deteriorating quite seriously at and after the time that Fadumo Ahmed left. If Amal Ahmedin and Amaya Tuccu Ahmedin left Flat 201 at any time after about 02.00, they would already have accumulated a significant proportion of the amount of asphyxiating gases needed to incapacitate them. We think it likely that they left Flat 201 between about 02.00 and 02.10, when the fire reached the bedroom window and conditions further deteriorated. By that time even the effort involved in getting up and walking from the flat into the lobby could have been sufficient to result in immediate collapse. Their remains were recovered from the lobby just outside Flat 201.[1402]
The post-mortems on Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris recorded the cause of death in each case as “consistent with the effects of fire” but in the light of Professor Purser’s evidence we find that a more accurate description is “inhalation of asphyxiant gases”. Toxicological testing was only possible for Amna Idris. That showed a level of blood carboxyhaemoglobin in her blood of 68%.[1403]
We are satisfied that Amal Ahmedin and Amaya Tuccu Ahmedin died between about 02.20 and 02.30 and that Amna Idris died at about 02.45.[1404]
Date of birth: 2 November 1987 (29 years old).
Place of birth: Asmara, Eritrea.
Gender: Female.
Occupation: Cleaner / Catering.
Usual address: Flat 155, floor 18, Grenfell Tower, London.
Place of death: Flat 201, floor 23, Grenfell Tower, London.
Time of death: About 02.45 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 27 April 2005 (12 years old).
Place of birth: London, UK.
Gender: Male.
Occupation: Student.
Usual address: Flat 155, floor 18, Grenfell Tower, London.
Place of death: Flat 201, floor 23 Grenfell Tower, London.
Time of death: About 02.45 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Berkti Haftom was born on 2 November 1987 in Eritrea and was 29 years old. Her son Biruk was born on 27 April in London and was 12 years old. They had lived in Flat 155 on floor 18 of Grenfell Tower since 2007. At the time of the fire, they were living in Flat 155 with Berkti’s partner Michele Chiapetto and a lodger, Yehualashet Enyew. Berkti Haftom was pregnant at the time of the fire.[1405]
Both Berkti and her son appear on the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system.[1406] Biruk Haftom’s age (12 years) was recorded.[1407] Neither had any known vulnerabilities.
Berkti Haftom and Biruk Haftom both returned to Grenfell Tower during the evening of 13 June 2017.[1408]
Yehualashet Enyew was awoken at about 01.15 on 14 June 2017 by the smell of smoke. He alerted Berkti Haftom to the fire at about 01.20. As he prepared to leave, he heard Berkti Haftom calling him from the hallway and then heard the door slam. When he left Flat 155, probably at about 01.30 or soon after, Berkti and Biruk Haftom were not in the lobby. At that point he found the stairwell filled with thick, choking smoke.[1409]
At some point before 01.27, Berkti and Biruk Haftom met Jessica Urbano Ramirez. She used Berkti Haftom’s phone to make an emergency call at 01.27,[1410] but the call was disconnected before the operator could put it through to the LFB.[1411] When Jessica called her mother, Adriana Ramirez, shortly afterwards, she said that she was on floor 18. Adriana Ramirez could hear voices in the background, which were probably those of Berkti and Biruk Haftom.[1412]
Shah and Sayeda Ahmed, who lived in Flat 156 on floor 18, were woken by the smoke alarms in their flat. They left their flat at about 01.27 and knocked on their neighbours’ doors. There was no answer from Flat 155, so Berkti and Biruk Haftom had probably already left Flat 155 to go upstairs.[1413]
Berkti Haftom, Biruk Haftom and Jessica Urbano Ramirez probably all reached floor 23 before 01.30.[1414] CRO Russell’s call to Jessica Urbano Ramirez at 01.29 was made on Berkti Haftom’s telephone.[1415] By that time, Jessica Urbano Ramirez was in Flat 201. When Fadumo Ahmed reached Flat 201 she joined a group in the hallway that included Berkti and Biruk Haftom.[1416]
Biruk Haftom spoke to CRO Howson at 01.32 from Flat 201. He told her that he lived in Flat 155 but was calling from someone else’s flat. He told her that there were eight children and a lot of adults in a flat on the top floor and that the window was already burning up. He said that there was a lot of smoke in the flat and in the building and that they could not get out. CRO Howson told him and the adult to whom she also spoke briefly to try to stop smoke coming into the flat.[1417] There is no evidence that Berkti Haftom contacted the emergency services.
Michele Chiapetto (Berkti Haftom’s partner) and the family of Berkti and Biruk Haftom made several unsuccessful attempts to contact them by phone during the night. Berkti Haftom’s phone stopped ringing at about 07.00.[1418]
The remains of Berkti and Biruk Haftom were recovered from the bedroom of Flat 201.[1419]
The coroner was satisfied about their identification and therefore issued interim certificates of the fact of death for Berkti and Biruk Haftom.[1420]
We are satisfied that the occupants of Flat 201, including Berkti and Biruk Haftom, had died by about 02.45 as the result of the inhalation of asphyxiant gases before they suffered from the direct effect of the flames.[1421]
The post-mortem recorded causes of death for both Berkti and Biruk Haftom as “consistent with the effects of a fire”,[1422] but in the light of Professor Purser’s evidence we find that a more accurate description is “inhalation of asphyxiant gases”.
Date of birth: 24 January 1956 (61 years).
Place of birth: Shahr-e-Ray, Iran.
Gender: Male.
Occupation: Retired.
Usual address: Flat 154, floor 18, Grenfell Tower, London.
Place of death: Flat 201, floor 23, Grenfell Tower, London.
Time of death: About 02.45 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Hamid Kani had been the sole tenant of Flat 154 on floor 18 since 10 September 1990.[1423] He lived alone. Having been born in Iran on 24 January 1956, he had come to London in the 1970s to study. In the 1980s he had been an actor and comedian but later changed careers, working in restaurants as a chef.[1424]
Hamid Kani suffered from backache and hip pain, making it difficult for him to climb stairs.[1425] He included a reference to his disability in the tenancy information form he completed on 23 April 2015.[1426] He was not identified as vulnerable in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system.[1427]
Hamid Kani returned to Grenfell Tower for the last time in the early evening of 13 June 2017.[1428]
When Shah and Sayeda Ahmed left their flat and knocked on their neighbours’ doors at about 01.27, Hamid Kani opened his door in response. He had therefore been alerted to the fire by 01.27.[1429]
Hamid Kani went up to floor 23 to take shelter and was able to enter Flat 201. He probably got there by about 01.30 and did not leave.[1430]
There is no evidence that he spoke to the emergency services or to relatives or friends during the fire.
The remains of Hamid Kani were recovered from between the bedroom area and the entrance to the bathroom from the hall of Flat 201.[1431] The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.[1432]
Hamid Kani was in a protected location in the hallway and bathroom area of the flat and was therefore more shielded from exposure to the heat. We are satisfied that he died at about 02.45, before suffering the direct effects of fire.[1433]
The post-mortem report on Hamid Kani recorded the cause of death as “consistent with the effects of fire”[1434] but in the light of Professor Purser’s evidence we find that a more accurate description is “inhalation of asphyxiant gases”.
Date of birth: 3 August 1971 (45 years).
Place of birth: Walthamstow, London.
Gender: Female.
Occupation: Personal Assistant / Safety Officer.
Usual address: Flat 161, floor 19 Grenfell Tower, London.
Place of death: Flat 201, floor 23 Grenfell Tower, London.
Time of death: Between 02.20 and 02.45 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Debbie Lamprell grew up as an only child in Highams Park. She worked as a safety officer at the Holland Park Opera. She had lived in Flat 161 on floor 19 of Grenfell Tower since 2005.[1435]
Debbie Lamprell had no known vulnerabilities.
Debbie Lamprell returned from work at 22.57 on 13 June 2017. Her friend Gary Maunders was visiting her that night. He also died in the fire.[1436]
Fadumo Ahmed was Debbie Lamprell’s neighbour and lived in Flat 164 on floor 19. She first became aware of the fire at around 01.20. When she left her flat, the lobby was full of thick, dark grey, steamy smoke that was hard to see through. Fadumo Ahmed saw Debbie Lamprell, who said people were going upstairs. Fadumo Ahmed said that Debbie Lamprell was not panicking, but behaved as if she had received instructions to go upstairs. Fadumo Ahmed and Debbie Lamprell went upstairs together. There was only a little bit of smoke in the stairwell between floors 19 and 23. Fadumo Ahmed said that she saw nobody other than Debbie Lamprell on the stairs.[1437] However, Debbie Lamprell later told CRO Jabin that she and her friend had gone up together, which suggests that Gary Maunders may have also climbed the stairs with Fadumo Ahmed and Debbie Lamprell.[1438]
Fadumo Ahmed and Debbie Lamprell joined a group of people sheltering in the hallway of Flat 201 on floor 23. Debbie Lamprell probably reached Flat 201 at about 01.30 or soon after.[1439]
Gary Maunders moved to Flat 203 at around 01.39.[1440] At about that time, Debbie Lamprell made an emergency call which lasted for under a minute. She was heard to shout for Gary, which indicates that she had lost contact with Gary Maunders by that time.[1441]
At 01.41 a BT operator spoke to North West Fire Control and said that a caller asking to speak to the LFB had hung up after waiting for around five minutes.[1442] The number belonged to Debbie Lamprell. When CRO Aisha Jabin called the number back, Debbie Lamprell answered and they spoke for over 40 minutes. During that call there was a misunderstanding about Debbie Lamprell’s location. She first gave her location as Flat 161 on floor 23, but later corrected that to Flat 201 on floor 23. Unfortunately, the correct location was not passed from North West Fire Control to the LFB control room. As a result, just before 02.10 FFs Roots and Johnson were sent to Flat 161 on floor 19 but there was no one there.[1443]
At about 01.55, Debbie Lamprell told CRO Jabin that the smoke was making it difficult for everyone to breathe and that the fire was “burning through the windows”.[1444]
At 02.01 Debbie Lamprell told CRO Jabin that the windows were cracking and at about 02.05 she said that she had lost her friend; he had disappeared and she did not know where he was. They had come up together, but he had gone.[1445] She must have been referring to Gary Maunders, who by then had already moved to Flat 203.
At 02.06 Debbie Lamprell told CRO Jabin that she could feel the heat and that the flat was on fire. CRO Jabin spoke to her team leader and then advised Debbie Lamprell to leave. She tried to leave the bedroom and could be heard telling someone to move out of the way of the door. Debbie Lamprell said that people on the other side of the room were trying to get out and that was why she could not get out. She confirmed that she was still on the floor in the bedroom. She stopped responding at about 02.20, just before the end of the call. That was the last known contact anybody had with Debbie Lamprell.[1446]
The remains of Debbie Lamprell were recovered from the bedroom of Flat 201.[1447] The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death for Debbie Lamprell.[1448]
Toxicology analysis was not possible.[1449] The post-mortem on Debbie Lamprell recorded the medical cause of death as “consistent with the effects of fire,”[1450] but in the light of Professor Purser’s evidence we find that a more accurate description is “inhalation of asphyxiant gases”.
We find that Debbie Lamprell probably lost consciousness due to the effects of asphyxiant gases at about 02.20 when she stopped responding to CRO Jabin. We are satisfied that she died between 02.20 and 02.45[1451] before suffering the direct effects of fire.[1452]
Date of birth: 4 July 2004 (12 years old).
Place of birth: London, UK.
Gender: Female.
Occupation: Student.
Usual address: Flat 176, floor 20, Grenfell Tower, London.
Place of death: Flat 201, floor 23, Grenfell Tower, London.
Time of death: Between 02.17 and 02.45 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Jessica Urbano Ramirez lived in Flat 176 on floor 20 with her family. She moved into Grenfell Tower in September 2013 with her mother, Adriana Ramirez, her father Ramiro Urbano and her sister Melanie.[1453] At the time of the fire, she was looking forward to celebrating her 13th birthday with her friends.[1454]
Jessica Urbano Ramirez appeared in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system as a child and was known to be under 18. She had no other known vulnerabilities.
On 13 June 2017, Jessica Urbano Ramirez returned to Grenfell Tower at 18.20.[1455] Adriana Ramirez and Melanie Urbano Ramirez were at home at the time. Adriana Ramirez left at around 18.30 to go to work.[1456] Melanie Urbano Ramirez stayed at the flat until about 22.00 when she also went out.[1457] Adriana Ramirez returned home at about midnight and checked on Jessica, who was asleep. She left the flat again at about 00.40 to take some medicine to the home of a friend who lived nearby.[1458] Jessica remained alone in the flat.
At some time before 01.27, Jessica Urbano Ramirez met Berkti and Biruk Haftom. At 01.27 she used Berkti Haftom’s phone to make an emergency call[1459] before calling her mother.[1460] The call was disconnected before the BT operator could connect it to the LFB. The BT operator contacted the LFB control room at 01.29 and spoke to CRO Russell telling her that the caller was a child and had asked for the fire brigade. CRO Russell agreed to call the number back.[1461]
Jessica Urbano Ramirez then called her mother and told her that she was on the “landing” on floor 18.[1462] They agreed that she should come down the stairs.[1463] However, instead of continuing down to the ground floor, Jessica went up to floor 23 with Berkti and Biruk Haftom and a group of other residents. She probably reached floor 23 by 01.30.[1464]
At 01.29, CRO Russell called Berkti Haftom; the call was answered by Jessica Urbano Ramirez.[1465] The call probably interrupted Jessica’s call with her mother as she answered the call saying ‘Mum’ three times and CRO Russell’s call overlapped in time with Jessica’s call to Adriana Ramirez.
The call between CRO Russell and Jessica Urbano Ramirez lasted 55 minutes. During the first 10 minutes of the call (between 01.30 and 01.40), Jessica told CRO Russell that she was in the hallway of a flat on floor 23 with about 10 other people. She later identified it as Flat 201.[1466] She said that smoke was coming “from the floor” and that people were having difficulty breathing. Jessica and the group of people in Flat 201 moved from the hallway to the bedroom.
Adriana Ramirez said that she spoke to Jessica a second time about 10 minutes later.[1467] The call records for Berkti Haftom’s phone show that she called Jessica back and it is likely that they spoke while the call with CRO Russell was on hold for a short period of time.[1468]
While the call was in progress, FF David Badillo from North Kensington made an attempt to rescue Jessica, who was still believed to be in Flat 176. At 01.26, he met Melanie Urbano Ramirez, Jessica’s sister, outside the tower. She gave him the keys to Flat 176 on floor 20 and told him that her sister was still there. At 01.27 FF Badillo went into the tower to rescue Jessica Urbano Ramirez.[1469] He was not able to make it to floor 20 immediately. He tried to take the lift to floor 20 but it stopped on floor 15 and the lift filled with black smoke. He found his way to the lobby doors and went down the stairs and out of the tower to get BA equipment.[1470] He returned to the tower with BA equipment and recruited CM Christopher Secrett and FF Christopher Dorgu to go to Flat 176 with him.[1471] They tallied out between 01.33 to 01.35.
When the crew reached floor 20 they found that the communal lobby and Flat 176 were smoke logged. They searched Flat 176 after finding the front door slightly ajar.[1472] They did not find anyone in Flat 176 and returned to the ground floor. Their end of wear time was 01.57.[1473] No information about the emergency call from Jessica Urbano Ramirez reached the crew during their deployment.[1474]
At 02.01, Jessica Urbano Ramirez was still talking to CRO Russell.[1475] She repeatedly said that she was having difficulty breathing.[1476]
At 02.06, Jessica Urbano Ramirez and Debbie Lamprell each reported separately that the flat was on fire.[1477] Jessica said that people had tried to leave but could not do so because of the smoke.[1478] She stopped responding to CRO Russell at around 02.17 but could be heard breathing until 02.24.[1479]
The remains of Jessica Urbano Ramirez and others were recovered from the bedroom of Flat 201.[1480] The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.[1481]
The post-mortem on Jessica Urbano Ramirez noted that it was not possible to be definite on the cause of death due to the condition of the remains, but that their appearance was consistent with the effects of fire.[1482] It was not possible to carry out toxicological analysis or DNA testing.
The post-mortem report recorded the medical cause of death as being consistent with the effects of a fire. However, in the light of Professor Purser’s evidence we find that the cause of death is more accurately expressed as inhalation of asphyxiant gases.
Jessica probably lost consciousness due to the inhalation of asphyxiant gases at around 02.17 when she stopped responding to CRO Russell. She would have continued to inhale those gases while unconscious until she died.[1483]
Professor Purser estimated that the level of carboxyhaemoglobin in Jessica Urbano Ramirez’s blood had exceeded the lethal threshold of 50% by about 02.23 and that she had died by 02.45.[1484] While the time of death might be different for children, he observed that she had lost consciousness at about the same time as Debbie Lamprell and there may not have been much difference in the time of death.[1485]
In the light of Professor Purser’s evidence we are satisfied that Jessica Urbano Ramirez died between 02.17 and 02.45 before suffering the direct effects of fire.
Flat 202 on floor 23 had two bedrooms and was situated in the south-east corner of the tower. It was the home of Gimja Tekie, who was not present during the night of the fire. Gloria Trevisan and Marco Gottardi had been living in Flat 202 since April 2017.[1486]
By 02.10, Flat 202 had become affected by the spread of the fire on the outside of the building.[1487] It spread across the east face of the kitchen and living room of Flat 202 from about 02.10. It moved across the south face of the living room between about 02.33 and 02.51 and had spread across the bedrooms by 02.55.[1488]
On the night of the fire, Majorie and Ernie Vital took shelter with Gloria Trevisan and Marco Gottardi. They had moved upstairs from their own flat on floor 19.[1489]
By approximately 01.25 the fire had reached the top of floor 19, where Flat 162, Majorie Vital’s home, was situated.[1490] There is no evidence that Majorie or Ernie Vital made contact with the emergency services, members of their family or friends on the night of the fire. At about 01.30, they went upstairs to floor 23.[1491] Fadumo Ahmed identified Ernie Vital as one of the people she had seen gathered inside or outside one of the flats on floor 23.[1492]
Ernie and Majorie Vital had knocked at the door and sought shelter in Flat 202. When Gloria Trevisan and Marco Gottardi opened the door, they found the lobby filled with a thick, dense smoke.[1493]
Gloria Trevisan’s parents were in Italy. Gloria called her mother, Emanuela Disaró, at 01.34 from Flat 202; the call lasted for just under 31 minutes. She told her mother that there were firefighters downstairs. She said they had been told to stay inside. It is not clear where that information came from. She said that they could not leave because of the smoke or go to the roof because the gate to the roof was locked. They made signs to attract attention.[1494]
Rania Ibrahim lived in Flat 203, a neighbouring flat on floor 23. At 01.38, she started to live stream on Facebook. A little over one minute into the recording, she opened her front door and called out into the lobby “Hello” and “Come here”. When Emanuela Disaró watched the video she thought that she could hear Marco Gottardi responding to Rania Ibrahim’s shouts, saying “We are here, we are inside my apartment.”[1495] They remained in Flat 202.
Gloria Trevisan made a video call to her parents at 02.13. She said the fire was large and had reached floor 23. Black smoke was entering the flat through the living room windows. Emanuela Disaró could hear her daughter coughing. Gloria Trevisan was having difficulty breathing. Emanuela Disaró could hear Marco Gottardi speaking to Ernie Vital in the background. She heard Marco Gottardi ask whether there was anyone in another apartment and then say that he would go out to ask. Then Emanuela Disaró heard Marco Gottardi say in English “I tried but there’s too much smoke.”[1496]
At 02.45 Gloria Trevisan began her last call from Flat 202 to her parents. It lasted for almost 23 minutes, until 03.08. She told her mother that Majorie and Ernie Vital and Marco Gottardi were still with her. Marco was also speaking to his parents. Gloria said that smoke was coming from everywhere and that there was no way out. The flat was full of smoke. She could see the fire outside the window. They had shut the window because pieces of glass had been coming in. Gloria’s eyes and throat were burning and hurting. She was having difficulty breathing. She said that the fire had come through the window. That was the last contact she had with either of her parents.[1497]
Marco Gottardi spoke to his father, Giannino Gottardi, at some point after 02.45. He told his father that they had not left the building because there was too much smoke and they had been told to stay put. He said he had filled the bath with water. The last call between Marco Gottardi and his father started at 03.15 and was brief.[1498] That was the last known contact with anyone in Flat 202.
Emanuela Disaró asked Gloria Trevisan during their last conversation whether they had made others aware that they were in the flat. Gloria Trevisan said that she had, and she asked the others in the flat the same question. Emanuela Disaró could not hear their responses. There is no record of any calls to the emergency services from any of those trapped in Flat 202.[1499]
The LFB was aware of conditions on floor 23 in general. In response to information received from emergency calls about seven people unable to leave Flat 205 on floor 23 (among other flats on other floors), a message was sent by radio to command unit CU8 at 01.43. CU8 confirmed receipt of that message confirming “the 23rd floor” and “heavy smoke logging”.[1500]
Between 02.01 and 02.02, CROs Gotts and Howson received calls from members of the public saying that they could see people at the top of the tower waving and signalling for help. In one call people were said to be on top of the building. As a result, a service request was created at 02.05 saying “Reports of people on the roof of the building”. CRO Darby passed that message to the incident ground at 02.05.[1501] Further calls were received until 03.11 from members of the public reporting seeing people on the top floor.[1502]
Date of birth: 2 December 1990 (26 years old).
Place of birth: Camposampiero, Italy.
Gender: Female.
Occupation: Trainee Architect.
Usual address: Flat 202, floor 23, Grenfell Tower, London.
Place of death: Flat 202, floor 23, Grenfell Tower, London.
Time of death: Between 03.15 and 03.30 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 26 June 1989 (27 years old).
Place of birth: Motta di Livenza, Italy.
Gender: Male.
Occupation: Architect.
Usual address: Flat 202, floor 23, Grenfell Tower, London.
Place of death: Flat 202, floor 23, Grenfell Tower, London.
Time of death: Between 03.15 and 03.30 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases; single vessel coronary artery atheroma.
Gloria Trevisan was 26 years old, having been born on 2 December 1990 in Italy. Marco Gottardi was 27 years old, having been born on 26 June 1989 also in Italy. They met at university and graduated with degrees in architecture in 2016. Wanting to improve their English and develop their professional skills, they came together to London in March 2017. Both found work with architectural practices in London. They moved into Flat 202 in April 2017.[1503]
Gloria Trevisan and Marco Gottardi did not have known vulnerabilities.
Gloria Trevisan and Marco Gottardi returned to Grenfell Tower at around 19.47 on 13 June 2017.[1504] They remained in Flat 202 thereafter.
At around 01.30, Ernie and Majorie Vital knocked on their front door, alerting them to the fire and joining them in Flat 202.
There is no evidence that Gloria Trevisan or Marco Gottardi made contact with the emergency services on the night of the fire, however they did call their families, as described above.
The remains of Gloria Trevisan and Marco Gottardi were recovered from the hallway of Flat 202.[1505] The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death.[1506]
We are satisfied that Gloria Trevisan and Marco Gottardi both died between about 03.15 and 03.30 before suffering the direct effects of fire.[1507]
Gloria Trevisan was found to have a blood carboxyhaemoglobin saturation of 78%.[1508] The post-mortem recorded the cause of her death as “inhalation of products of combustion” but in the light of Professor Purser’s evidence we find that a more accurate description of the primary cause of death is inhalation of asphyxiant gases.
The post-mortem report on Marco Gottardi recorded the cause of death as “inhalation of products of combustion” and “single vessel coronary artery atheroma”.
Carboxyhaemoglobin was present in Marco Gottardi’s blood, but it was not possible to measure the levels.[1509] The single vessel coronary atheroma put Marco Gottardi at risk of collapse and death at a lower carboxyhaemoglobin concentration than would otherwise have been the case.[1510]
Although we acknowledge the contribution of single vessel coronary atheroma, we consider that the primary cause of death was inhalation of asphyxiant gases.
Date of birth: 14 November 1948 (68 years old).
Place of birth: Soufrière, Dominica.
Gender: Female.
Occupation: Retired.
Usual address: Flat 162, floor 19, Grenfell Tower, London.
Place of death: Flat 202, floor 23, Grenfell Tower, London.
Time of death: Between 03.15 and 03.30 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 11 January 1967 (50 years old).
Place of birth: London, UK.
Gender: Male.
Occupation: Unemployed.
Usual address: Amhurst Park, London N16.
Place of death: Flat 202, floor 23, Grenfell Tower, London.
Time of death: Between 03.15 and 03.30 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Majorie Vital was a retired seamstress and had lived in Flat 162 on floor 19 of Grenfell Tower for nearly 40 years. It was there that she brought up her two sons. Ernie Vital was staying with her on the night of the fire.[1511]
Majorie Vital’s mental health vulnerability was recorded by RBKC in 1987 and by the TMO in a memorandum on 14 July 2004.[1512] Rydon sent an email to the TMO on 31 October 2014 saying that she had Parkinson’s Disease and needed support.[1513] That information was also recorded in November 2014 during the survey of residents carried out by Rydon.[1514]
Majorie Vital had declared both a disability and mental health support needs in response to a TMO questionnaire on 17 March 2015.[1515] She appeared in the TMO list of Grenfell Tower residents created by David Noble on 14 June 2017 from information held on the TMO’s Capita Insight system which recorded that she was in the age group “65 plus” and had some mental health problems.[1516]
Majorie Vital returned to Grenfell Tower at around 15.14 on 13 June 2017. Ernie Vital entered the tower at around 19.07 on 13 June 2017.[1517]
Majorie and Ernie Vital had both moved from floor 19 up to floor 23 by around 01.30. They knocked on Flat 202 and sought shelter with the residents of that flat, Gloria Trevisan and Marco Gottardi. They remained in that flat thereafter.
There is no evidence that either Majorie or Ernie Vital contacted anybody outside the tower on the night of the fire.
The remains of Majorie and Ernie Vital were recovered from the bathroom of Flat 202.[1518] The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death.[1519]
The post-mortem reports recorded the cause of death in the case of both Majorie Vital and Ernie Vital as “consistent with the effects of fire”.[1520] In the light of more recent evidence we find that a more accurate description of the primary cause of death is inhalation of asphyxiant gases.
We are satisfied that Majorie Vital and Ernie Vital died between about 03.15 and 03.30 before suffering the direct effects of fire.[1521]
Flat 203 on floor 23 had two bedrooms and was situated in the south-west corner of the tower. It was the home of Rania Ibrahim, her husband, Hassan Awadh Hassan (who was abroad at the time of the fire), and their two daughters, Fethia Hassan and Hania Hassan.[1522] The south-west corner of the tower was farthest from where the fire had started.[1523]
Smoke began to enter Flat 203 by 02.05, although at that stage not through the windows.[1524] From about 02.40 smoke increasingly affected the south facing wall of the tower, spreading towards Flat 203.[1525]
Flat 203 was the last of those on floor 23 to be affected by the spread of fire on the outside of the building. By about 03.11 the fire had reached the area between Flats 202 and 203 and continued to move in a westerly direction across Flat 203. By 03.43 Flat 203 was fully affected by the fire.[1526]
The fire reached the south-west corner of the tower at the level of floor 23 by 03.58. From 04.07 onwards, there was a rapid deterioration of the conditions in the living room of Flat 203.[1527]
The adult occupants of Flat 203 are likely to have become comatose from the inhalation of asphyxiant gases by about 04.13, and to have inhaled a lethal dose of asphyxiant gases by about 04.17.[1528] For the children, these events are likely to have happened sooner.[1529]
Rania Ibrahim gave shelter in her home to people who had fled from elsewhere in the tower. Those who went to Flat 203 seeking refuge were Fathia Ahmed Elsanousi, Isra Ibrahim, Abufras Ibrahim and Gary Maunders.[1530]
Fathia Ahmed Elsanousi lived in Flat 206 on floor 23 with her daughter, Isra Ibrahim. Abufras Ibrahim, the son of Fathia Ahmed Elsanousi, had been visiting his mother and sister on 14 June 2017.[1531]
Gary Maunders did not live in Grenfell Tower. He had been visiting Debbie Lamprell from Flat 161 on floor 19. They went up to floor 23 and initially took shelter in Flat 201 at about 01.30. Gary Maunders then moved to Flat 203 at about 01.39.[1532]
All those who were in Flat 203 died. Rania Ibrahim, Fethia Hassan, Hania Hassan, Isra Ibrahim, Fathia Ahmed Elsanousi and Gary Maunders all died there. Abufras Ibrahim fell from the tower and his body was recovered from outside the south side.[1533]
By 01.30 the outside of Flat 206, in the north-east corner of the tower (home to Fathia Ahmed Elsanousi and Isra Ibrahim), had become enveloped by flames.[1534] Fathia Ahmed Elsanousi, Isra Ibrahim and Abufras Ibrahim must have left it at an early stage. The precise time of their arrival at Flat 203 is not known but they must have reached it before 01.38 when Rania Ibrahim began to live-stream a video to Facebook. The female voice heard on the video telling Rania Ibrahim not to open the door was probably that of Isra Ibrahim. Abufras Ibrahim also appears in the video and can be heard telling Rania Ibrahim to close the door as she was letting smoke in.[1535]
At about 01.39 Rania Ibrahim can be seen opening the front door. Gary Maunders can be seen entering the flat when invited to do so. The video shows that the lobby on floor 23 was dark with smoke at the time.[1536] Shortly afterwards, Rania Ibrahim went out into the lobby where she was able to breathe, speak and stand, at least for a short period. She shouted “Hello” and “Come here”. It was probably Marco Gottardi from Flat 202 who responded by saying “We are here. I am inside our apartment”.[1537]
At around 01.43, a voice can be heard coming from outside the building shouting, “This is the fire service. If you are able, exit the building”. That was probably FF Patrick Murray.[1538]
FF Mandeep Singh arrived at the tower at 01.35 and was instructed to pass FSG information from the command unit to the bridgehead. He recalled being handed telephones and speaking to residents inside the tower. During one such call, FF Singh spoke to a female occupant of the tower who gave a location of the “23rd floor, doors 205 and 201”. She said that she had brought all of the occupants of floor 23 into her flat. FF Singh advised her to stay put.[1539] A page from his notebook contains the following entry “23rd FLOOR ALL OCCUPANTS 205/201 [illegible] WM BRIAN O’KEITH WM (Illegible)”.[1540] In his witness statement FF Singh said that he thought the woman he had spoken to was the same person who can be heard in a video recording, saying that she will let people in. This was probably Rania Ibrahim, who was in fact in Flat 203, and not in Flat 201 or Flat 205.[1541]
At 01.57 CRO Heidi Fox answered an emergency call from a member of Rania Ibrahim’s family.[1542] That was the first call relating to Flat 203. As a result, she created a service request at 01.59 in relation to “a person with two children” trapped in Flat 203 on floor 23. CRO Darby passed the information to CU8 by radio a few seconds later.[1543] At 02.00, CRO Darby marked the service request as completed.[1544] That was the only service request created in relation to Flat 203.[1545]
The second emergency call about Flat 203 was made at 02.05 by Isra Ibrahim. She told CRO Howson that there were five adults and two children in Flat 203. They were in the living room and kitchen area. Smoke was coming into the flat, but they were keeping the doors closed. No smoke was coming through the windows. Isra Ibrahim had smoke around her nose. CRO Howson advised her to remain in the flat.[1546]
At 02.21, Isra Ibrahim spoke to CRO Gotts. She reported that the occupants of the flat were stuck and the flat next door (probably Flat 202) was on fire. She gave her location as Flat 203 on floor 23. CRO Gotts advised her to try to block the doors and to stay away from the side of the flat on fire. Isra Ibrahim asked for someone to come to the flat immediately and whether helicopters could assist. CRO Gotts explained that firefighters were on the lower floors but were on their way up to floor 23. She said that the helicopter was being sent up so that they could see the fire from the air. At the very end of the call, CRO Gotts said “22nd floor, Flat 192. All right?”. That was not the location Isra Ibrahim had given, but the call ended before she could respond.[1547]
CRO Gotts passed the information orally to CRO Darby who sent a message to command unit CU7 at 02.26 about persons in Flat 192 on floor 22 who had said that the fire was in the flat next door to them. No service request was created by CRO Gotts in relation to either Flat 203 or Flat 192.[1548]
At 02.35, the “stay put” advice was revoked in the control room, but it took some time for all the control room operators to be told and for them to begin giving fresh advice.[1549]
At 02.42, Isra Ibrahim spoke to CRO Howson from Flat 203 and reported five adults and two children in the flat. That was the fourth emergency call relating to Flat 203. She said that the amount of smoke in the flat was increasing and that the flat next door (again, probably Flat 202) was on fire. CRO Howson advised Isra Ibrahim to block out the smoke, told her that firefighters were making their way to her and said that, as long as there were no flames, the flat was the safest place to be “because you don’t know what’s going on outside”.[1550]
At 02.58, an unidentified male caller spoke to CRO Howson. That was the fifth and final call relating to Flat 203. He told her that the police would not let him into the tower and had told him to call the emergency services. The caller said that he had just spoken to someone in Flat 203 with two children. CRO Howson told him that they needed to try to get out of the building and that she would pass on the information that people were still in the flat. The caller must have been referring to Rania Ibrahim. It is not known if he was able to speak to her again to pass on CRO Howson’s advice.[1551] That was the first time those in Flat 203 were advised to leave the building.
Rania Ibrahim appears to have thought that the “stay put” policy was still in place at that time. Munira Mahmud, a close friend who had earlier left floor 5, called her at about 03.00. Rania Ibrahim was coughing a lot and Munira Mahmud could tell that she was finding it difficult to breathe. Munira Mahmud tried to persuade her to leave. Rania Ibrahim said she had called the emergency services and that whoever had answered the call had told her to stay inside and wait for help. She also said that the roof door was locked but that they were sending help, as she could see a helicopter. Munira Mahmud continued to tell Rania Ibrahim that she should try to leave. That was the last conversation she had with Rania Ibrahim; she was unable to reach her by telephone again.[1552]
Sayeda Ibrahim spoke to her sister Rania Ibrahim at 01.00, 02.50 and 03.00. The call at 03.00 was the last known contact with anyone in Flat 203.[1553] Attempts by a friend of Munira Mahmud to call Rania Ibrahim from about 03.15 were unsuccessful.
Information about those needing to be rescued from Flat 203 was recorded at various places at the incident ground.
The information from the first emergency call relating to Flat 203 at 01.57 was passed by radio to CU8 at 02.00.[1554]
We have seen no evidence of messages passed to the incident ground in response to the second call made by Isra Ibrahim at 02.05.[1555] However, from 02.06, SM Oliff in the LFB control room was passing information to WM Meyrick in CU8 using his personal mobile telephone. The calls were not recorded and there is no record of the information he passed on.[1556]
The bridgehead was maintained on floor 2 from the beginning of the incident until about 02.17.[1557] CM Charles Batterbee copied information from a forward information board at the bridgehead into his own notebook. There is no reference to Flat 203 in that notebook,[1558] so it appears that the radio message about Flat 203 sent at 02.00 went astray and did not reach the bridgehead.
From 02.17 until about 03.08 the bridgehead was located on floor 3.[1559] During that period the third, fourth and fifth emergency calls were made in relation to Flat 203.
At 02.21, when the third call made by Isra Ibrahim came to an end, CRO Gotts misunderstood the caller’s location as being in Flat 192 on floor 22 and the radio message sent to command unit CU7 at 02.26 referred to persons in Flat 192 on floor 22. No other messages appear to have been passed to the incident ground in relation to Flat 203 as a result of that call.[1560]
The fourth and fifth emergency calls relating to Flat 203 were made at 02.42 and 02.58.
SM Oliff recorded information in the control room on two whiteboards from around 02.33. In a photograph taken at the end of the incident the first whiteboard shows the notation “Flat 203 23rd fl – 5 adults 2 children – smoke logging”.[1561] It is possible that SM Oliff passed information about Flat 203 to WM Meyrick in CU8 using his mobile phone.
Messages about Flat 203 did reach command unit CU7. Between about 02.00 and 03.00, a white laminated sheet was being used in CU7 to record information about people needing to be rescued. The laminated sheet recorded “Flat 203 Floor 23 5 adults 2 children” as can be seen in a photograph taken at 02.59.[1562]
Messages about Flat 203 were also inscribed on a wall of the lobby on the ground floor. WM Glynn Williams started to record information on the wall of the lobby on the ground floor at 02.15. He said the information came from CU7. A photograph of the wall taken much later in the incident includes the notation “203 23 5A 2C”.[1563]
After 03.00, the laminated sheet in CU7 was replaced by a whiteboard bearing a grid. A photograph taken of the whiteboard much later in the morning shows Flat 203 and the annotation “5 2 P”. The “5” is in green indicating five adults, the “2” is in black indicating two children, and the “P” is in red and is circled, indicating a priority.[1564]
Given that no firefighters were sent to Flat 203 before 03.08, when the bridgehead was moved from floor 3 to the ground floor, it appears that messages relating to Flat 203 did not reach the bridgehead while it was on floor 3. However, after the bridgehead had moved to the ground floor firefighters were sent to Flat 203, which suggests that information from at least one of the emergency calls relating to Flat 203 was passed to the bridgehead after 03.08.
FFs Matthew Harold, David Friend and Richard Peacock were initially sent to Flat 203 but at the last minute their instructions were changed and they were sent to carry out search and rescue operations on floors 4 and 5. They tallied out between 03.31 and 03.32.[1565]
None of the other firefighting crews sent to floor 23 succeeded in reaching it.
Date of birth: 3 March 1986 (31 years old).
Place of birth: Aswan, Egypt.
Gender: Female.
Occupation: Carer for children.
Usual address: Flat 203, floor 23, Grenfell Tower, London.
Place of death: Flat 203, floor 23, Grenfell Tower, London.
Time of death: Between 03.55 and 04.05 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 5 October 2012 (4 years old).
Place of birth: Chelsea, London.
Gender: Female.
Occupation: N/A.
Usual address: Flat 203, floor 23, Grenfell Tower, London.
Place of death: Flat 203, floor 23, Grenfell Tower, London.
Time of death: Between 03.55 and 04.05 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 4 June 2014 (3 years old).
Place of birth: Chelsea, London.
Gender: Female.
Occupation: N/A.
Usual address: Flat 203, floor 23, Grenfell Tower, London.
Place of death: Flat 203, floor 23, Grenfell Tower, London.
Time of death: Between 03.55 and 04.05 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Rania Ibrahim lived in Flat 203 with her husband, Hassan Awadh Hassan, and their two daughters, Fethia and Hania. Hassan Awadh Hassan was away at the time of the fire. Rania Ibrahim and her family moved into Flat 203 in 2016.[1566]
Born in Aswan, Egypt on 3 March 1986, Rania Ibrahim was 31 years old when she died. She had a place to study law in Cairo but had come to London to help her sister, who was unwell. She had met Hassan in London in 2010 and they got married. Fethia was born on 5 October 2012 and Hania on 4 June 2014. They were four and three years old respectively when they died.[1567]
The family appeared in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system. The ages of Fethia and Hania were respectively recorded as “5” and “3”. No other vulnerabilities were noted.[1568]
Rania Ibrahim, Fethia Hassan and Hania Hassan had all returned to Grenfell Tower for the last time by 18.09 on 13 June 2017.[1569]
On the evening of 13 June 2017, Rania Ibrahim and her daughters spent time with a close friend, Munira Mahmud, who lived in Flat 25 on floor 5 of Grenfell Tower. Munira Mahmud’s children played with Fethia and Hania and ate dinner. After Rania Ibrahim and her daughters had returned to Flat 203, at about 21.30 Munia Mahmud brought Rania Ibrahim food for the iftar meal ending the Ramadan fast.[1570]
Rania Ibrahim did not make any emergency calls herself. However, she appears to have given her mobile telephone to Isra Ibrahim, who made a number of emergency calls as described above.[1571] Calls were also made on behalf of Rania Ibrahim and her daughters by people outside the tower.
The remains of Rania Ibrahim, Fethia Hassan and Hania Hassan were all recovered from the bathroom of Flat 203.[1572] The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death.[1573]
Toxicology testing for Rania Ibrahim and her daughters was not possible.[1574] The post-mortem reports on Rania Ibrahim, Fethia Hassan and Hania Hassan recorded their cause of death as “consistent with the effects of fire”.[1575] In the light of Professor Purser’s evidence we find that a more accurate description is “inhalation of asphyxiant gases”.
Given the lack of response to calls made to Rania Ibrahim’s telephone after 03.00, we consider it likely that Rania Ibrahim, Fethia Hassan and Hania Hassan had lost consciousness by that time. We are satisfied that they all died between 03.55 and 04.05 before suffering the direct effects of fire.[1576]
Date of birth: 1 January 1940 (77 years old).
Place of birth: Al Nuhood, West Kordofan province, Sudan.
Gender: Female.
Occupation: Retired.
Usual address: Flat 206, floor 23, Grenfell Tower, London.
Place of death: Flat 203, floor 23, Grenfell Tower, London.
Time of death: Between 04.20 and 04.40 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 8 August 1983 (33 years old).
Place of birth: Khartoum, Sudan.
Gender: Female.
Occupation: Care worker and sales assistant.
Usual address: Flat 206, floor 23, Grenfell Tower, London.
Place of death: Flat 203, floor 23, Grenfell Tower, London.
Time of death: Between 04.20 and 04.40 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 8 January 1978 (39 years old) .
Place of birth: Khartoum, Sudan.
Gender: Male.
Occupation: Fishmonger and sales assistant.
Usual address: Queensgate, London SW7.
Place of death: Outside Grenfell Tower, London.
Time of death: Between 03.50 and 03.55 on 14 June 2017.
Cause of death: Multiple injuries (consistent with a fall from height).
Fathia Ahmed Elsanousi was born in 1940 in Al Nuhood, Sudan and was 77 years old in 2017. She had been a headteacher in Sudan and had moved to the UK to escape the civil war there.[1577] Her daughter, Isra Ibrahim, was born on 8 August 1983 and was 33 years old. She and her mother had been tenants of Flat 206 since 2008.[1578] Abufras Ibrahim was born on 8 January 1978 and was 39 years old. He did not live in Grenfell Tower but was visiting his mother and sister on 14 June 2017.[1579]
Fathia Ahmed Elsanousi suffered from serious health problems that had been recorded in her housing file since 2000. She had breathing problems which required her to use a portable oxygen machine. Her mobility was impaired as a result of a stroke in 2006. She had been unable to manage stairs easily since January 2007.[1580] Isra Ibrahim did not have any known vulnerabilities. Neither she nor her mother were identified as vulnerable in the spreadsheet of vulnerable tower residents created by David Noble on 14 June 2017.[1581]
Fathia Ahmed Elsanousi last entered Grenfell Tower on 9 June 2017. Isra Ibrahim and Abufras Ibrahim entered Grenfell Tower in the evening of 13 June 2017.[1582]
The Neda family lived in Flat 205. At about 01.25, Farhad Neda and his mother, Flora Neda, looked out into the lobby of floor 23. Flora Neda saw Isra Ibrahim from Flat 206 start running down the stairs. Fathia Ahmed Elsanousi was behind her, walking slowly. That was at about the time that the fire reached the outside of floor 23.[1583] By 01.30 the flames had enveloped all the “Flat 6s”, including Flat 206.[1584]
By about 01.30, several occupants had reached floor 23, having come upstairs from lower floors. At about the same time, Fathia Ahmed Elsanousi and Isra Ibrahim returned to floor 23. By 01.38 they and Abufras Ibrahim were already sheltering with Rania Ibrahim and her children in Flat 203 when Rania Ibrahim began her live-stream video to Facebook.[1585]
Isra Ibrahim made three emergency calls from Flat 203, at 02.05, 02.21 and 02.42 as described above.
At about 03.50 Abufras Ibrahim fell from the tower. He fell first onto the canopy over the door to the main entrance of the tower on the south side. His body then landed on the south side of the tower close to the walkway connecting it to Grenfell Walk. His body was subsequently moved to a sheltered area by firefighters.[1586] He was pronounced dead at 06.05 on 14 June 2017 outside the tower.[1587]
The remains of Fathia Ahmed Elsanousi and Isra Ibrahim were both recovered from the bathroom in Flat 203.[1588] Abufras Ibrahim’s body was recovered from outside the tower. The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death for each member of the family.[1589]
Toxicological testing for Abufras Ibrahim showed that the level of carboxyhaemoglobin in his blood was 20%, which is significant but not incapacitating. His body showed slight soot stains to the skin and nostrils but no burns. Despite a long period of slow smoke infiltration from the lobby and 40 minutes of serious smoke penetration of the bedrooms, he had been able to limit his exposure until the fire spread to the outside of the room in which he had taken refuge.[1590]
The post-mortem report for Abufras Ibrahim recorded the cause of death as “Multiple injuries (consistent with fall from height)”. We are satisfied that Abufras Ibrahim died between 03.50 and 03.55, either instantly when he landed outside the tower or very shortly afterwards.
The post-mortem reports on Fathia Ahmed Elsanousi and Isra Ibrahim recorded the cause of death as “consistent with the effects of a fire”[1591] but in the light of Professor Purser’s evidence we consider that a more accurate description is “inhalation of asphyxiant gases”.
We are satisfied that Fathia Ahmed Elsanousi, Isra Ibrahim and Abufras Ibrahim all died before suffering the direct effects of fire.
Fathia Ahmed Elsanousi and Isra Ibrahim died from inhalation of asphyxiant gases between 04.20 and 04.40.[1592]
Date of birth: 4 January 1960 (57 years).
Place of birth: Hammersmith, London.
Gender: Male.
Occupation: Painter and decorator.
Usual address: Lancaster Road, London W11.
Place of death: Flat 203, floor 23, Grenfell Tower, London.
Time of death: Approximately 04.20 – 04.40 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Gary Maunders was born in London on 4 January 1960; in 2017 he was 57 years old. He was the father of two children. A talented footballer in his youth, Gary worked as a painter and decorator.[1593] On the night of the fire he was visiting Debbie Lamprell at her home in Flat 161 on floor 19 of the tower.
Gary Maunders was one of those who went up to floor 23 to take shelter. He probably reached it by about 01.30.[1594] He initially went into Flat 201, the home of Raymond (Moses) Bernard.
Fadumo Ahmed, Debbie Lamprell’s neighbour, left her flat at 01.20 and saw Debbie Lamprell near the lifts. She gained the impression that she had been told to go upstairs. They both walked up the stairs to floor 23. There was only a little bit of smoke in the stairwell at that time. Fadumo Ahmed said she did not see anyone else in the stairwell, but Debbie Lamprell later told CRO Jabin that she and her friend had come up together, which suggests that Gary Maunders may have also climbed the stairs with them.[1595] Fadumo Ahmed saw people at the door to Flat 201 and joined a group in the hallway that included Gary Maunders and Debbie Lamprell.[1596]
The occupants of Flat 201 were soon having difficulty breathing. The fire was at the window and then entered the living room.[1597]
We do not know how Gary Maunders and Debbie Lamprell became separated. Nor do we know at what time he left Flat 201. He entered Flat 203 at about 01.39,[1598] which coincides with Debbie Lamprell’s emergency call from Flat 201, during which she was shouting for “Gary”. That suggests she may already have lost contact with him.[1599]
Gary Maunders made no calls to the emergency services on the night of the fire.
Gary Maunders’ remains were recovered from the bathroom of Flat 203. Toxicological testing was not possible.[1600] The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.[1601]
The post-mortem report on Gary Maunders recorded the cause of death as “consistent with the effects of a fire”[1602] but in the light of Professor Purser’s evidence we find that a more accurate description is “inhalation of asphyxiant gases”.
We are satisfied that Gary Maunders died between 04.20 and 04.40.[1603]
Date of birth: 30 January 1960 (57 years old).
Place of birth: Cairo, Egypt.
Gender: Male.
Occupation: Retired.
Usual address: Flat 204, floor 23, Grenfell Tower, London.
Place of death: Flat 204, floor 23, Grenfell Tower, London.
Time of death: Between 03.45 and 04.00 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Hesham Rahman was born on 30 January 1950 in Egypt and was 57 years old in 2017. He was a retired hairdresser.[1604] Flat 204 had been his home since August 2012. He lived there alone.[1605]
Hesham Rahman had diabetes and associated serious mobility problems which pre-dated his move to Grenfell Tower. His cousin said that his health had deteriorated after 2012. He had difficulty using stairs and relied on the lifts at Grenfell Tower. He had a disability blue badge for his car and a parking space at the tower for drivers with disabilities.[1606]
RBKC was aware of Hesham Rahman’s health conditions and mobility difficulties. RBKC’s assessments of 19 December 2006, August 2009 and 7 December 2010 all recorded his difficulty in managing stairs.[1607] The assessment dated 7 December 2010 noted the contents of a letter from a consultant confirming his diagnoses and their interference with his ability to walk. He recommended an upper or lower ground floor property with no more than six steps to obtain access to the premises or a property up to fourth floor level with lift access.[1608]
A housing officer visited Hesham Rahman on 9 October 2012 and 28 June 2013 and on both occasions recorded that he had problems with mobility. A question whether any signs of a need for support had not been picked up when he was signed up for a tenancy was not completed in relation to the first visit and answered “No” in relation to the second.[1609]
Hesham Rahman was not identified as vulnerable in the spreadsheet of tower residents created by David Noble on 14 June 2017.[1610]
Hesham Rahman returned to Grenfell Tower at 20.54 on 13 June 2017.[1611]
At about 01.20, Anna Krivsoun, the daughter of Hesham Rahman’s former partner, called to tell him that the tower was on fire and that he should leave. He agreed and said he would get dressed.[1612]
At some point before 01.30, Farhad Neda from Flat 205 saw smoke entering the lobby on floor 23 through the smoke extraction system vents. He also saw Hesham Rahman open and close the door to Flat 204.[1613] That was the last contact anyone in the tower had with Hesham Rahman; no one else took shelter in Flat 204.
Hesham Rahman spoke to the emergency services on five occasions during the fire. He made his first call at 01.39 and spoke to OM Norman. He reported that a little smoke was coming into his flat and that he could smell it. He said that he could not see outside at all.[1614]
When Hesham Rahman received a call from OM Norman at 01.46, he said the fire had not reached his flat but was next door. The flats immediately next door to his were Flats 203 and 205. OM Norman said the fire was on floor 4 and he replied, “I think it’s gone upstairs”. OM Norman advised him to stay put, saying firefighter crews would get to him.[1615]
Although no service requests were created in response to Hesham Rahman’s first two emergency calls, it appears that information about a person needing to be rescued from Flat 204 was passed by telephone to command vehicle CU8 by OM Norman at 01.47. OM Norman recorded the message in the incident log afterwards at 02.01.[1616] That is the first record of Hesham Rahman’s situation and location being passed to the incident ground.
CRO Russell took Hesham Rahman’s third emergency call at 02.36. He reported smoke coming into his flat and said that he was finding it difficult to breathe. CRO Russell advised him to try to make his way out of the building. He told her that he had a disability and needed assistance. No service request was created in response to his call, but a note of his disability was added to a whiteboard in the control room. By the time she took that call CRO Russell had received the instruction from SOM Smith to change the “stay put” advice. She recalled that the new advice had been for people to cover themselves, not to breathe in the smoke and to make their way down the stairs.[1617]
Hesham Rahman’s fourth call to the emergency services was taken by CRO Russell at 03.10. He was then in the living room of his flat. He had blocked the front door but a lot of smoke was still coming in. He was advised to leave but said that he could not do so because he could not walk properly due to his disability. He told CRO Russell that he was lying on the floor with a wet cloth over his nose and that his windows were shut. CRO Russell told him that the crews were coming up to him. No service request appears to have been created in response to that call.[1618]
At 03.16, a person who identified herself as Hesham Rahman’s daughter spoke to CRO Yvonne Adams. When told to call him back and tell him that he needed to leave, the caller explained that he could not leave because of his disabilities.[1619]
Hesham Rahman’s fifth and final emergency call at 03.20 was also taken by CRO Adams. It lasted 2 minutes and 38 seconds. By that time the flat was full of black smoke and he could not see anything. The fire was coming into his flat. No service request was created in response to the call.[1620]
Anna Krivsoun made emergency calls on Hesham Rahman’s behalf from outside the tower, probably including calls made at 03.38 and 04.01. It was reported to CRO Gotts during the call at 03.38 that he had not been able to leave his flat and was struggling to breathe. At 04.01 the caller told CRO Russell that he was no longer responding and that it had been clear that he was struggling to breathe.[1621]
Anna Krivsoun had last spoken to Hesham Rahman by telephone at 03.43. She could hear him coughing and struggling to breathe.[1622] That appears to be the last contact Hesham Rahman had with anyone outside the tower.
At the incident ground, there were references to Hesham Rahman and Flat 204 in various places. WM Meyrick in command unit CU8 was receiving information by radio from the control room which he was passing to WM Kentfield.[1623] At some point between 01.40 and 01.49 SM Loft received a piece of paper from WM Kentfield on which messages had been recorded. That piece of paper later became known as “Sadler’s Envelope”. One of the notes recorded on the paper was “FLAT 204 23 FLOOR”.[1624]
Between about 02.00 and 03.00, a white laminated sheet was being used on CU7 to record emergency calls.[1625] It contained the notation “FLAT 204 FLOOR 23 1 PERSON disabled light smoke”.[1626]
At about 02.17, CM Batterbee went to the bridgehead on floor 2. He made a note of the entries on a forward information board, which included the note “204 (tick) 21st”.[1627] (Flat 204 was in fact on floor 23.)
WM Glynn Williams started to record information on the wall of the lobby on the ground floor at 02.15. A photograph of the lobby wall taken much later on in the incident shows the notation “204 21” with “21” circled.[1628] That is another example of inaccurate recording of the location of Flat 204.
Between about 02.20 and 03.08, WM Louisa De Silvo recorded information about people needing to be rescued on the wall of the lobby of floor 3 when the bridgehead had been re-located on that floor. A photograph of that wall from later in the incident shows the notation “EUSTON – 23 205 204” with 204 circled and ticked. The writing also included the expression “21 (tick) 204”.[1629] A tick against a particular flat indicated that a crew had been sent there and a circle indicated that further information had been received, by runner, by radio or from returning crews.[1630] The floor on which Hesham Rahman’s flat was situated seems to appear both correctly and incorrectly on the wall.
WM Sadler described being given an “envelope” (“Sadler’s Envelope”), which was in fact an A4-size piece of paper. He immediately photographed it, at 02.19.[1631] As noted above, that piece of paper had written on it “FLAT 204 23 FLOOR”.
From about 02.33 SM Oliff recorded information in the control room on two whiteboards.[1632] Following Hesham Rahman’s call to CRO Russell at 02.36, to the first whiteboard he added the details “1 disabled male” to the entry “204 23 flr”.[1633]
After 03.00, the laminated sheet used on command unit CU7 was replaced by a whiteboard with a grid. Flat 204 was annotated with “1 disabled P” with “1 disabled” in green and “P” in red and circled.[1634]
FFs Pole, Mitchell, Cheesman and Bate from Euston Fire Station were sent to floor 23, probably to Flats 204 (where Hesham Rahman lived) and 205. A photograph of the wall on floor 3 where the bridgehead was by then positioned shows that the word “Euston” had been written against Flats 204 and 205 on floor 23. In the bottom right-hand corner of the photograph can be seen the words “23rd Euston 204 205”.[1635] We therefore conclude that the emergency calls by and on behalf of Hesham Rahman did lead to an attempt to reach his flat.
The crew tallied out by 02.53. They came across another crew at about floor 12 and FF Bate was handed a child casualty, whom he decided to take out of the tower. FFs Mitchell, Pole and Cheesman continued upwards and reached what they thought was floor 18. There they realised that they did not have enough air to reach floor 23 and get back down again; they therefore helped to rescue seven residents from that floor. FF Mitchell recalled telling WM De Silvo that they had not reached floor 23. The crew’s “end of wear times” were between 03.15 and 03.17.[1636]
Flat 204 on floor 23 faced west and had one bedroom.[1637] The exterior fire spread to the outside of the bedroom of Flat 204 by 03.20 and to the outside of the living room by 03.34. By 03.42 it was spreading to the column between Flats 204 and 203 and affecting Flat 203 next door.[1638]
The remains of Hesham Rahman were recovered from a partitioned area, which may have been a cupboard, in the living room of Flat 204.[1639] The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.[1640]
Hesham Rahman was exposed to a slow increase in smoke and asphyxiant gases from about 01.29, followed by a more rapid increase after about 03.20 as the fire spread past his bedroom. The increase was even more rapid after the fire reached his living room.[1641]
Hesham Rahman is likely to have lost consciousness at about 03.43, which was the time of the last reported communication with him. He died at some point between about 03.45 and 04.00[1642] from the inhalation of asphyxiant gases and before suffering the direct effects of fire.[1643]
The post-mortem report on Hesham Rahman recorded the cause of death as “consistent with the effects of fire,[1644] but in light of Professor Purser’s evidence we find a more accurate description to be “inhalation of asphyxiant gases”. The latest time at which he could have been rescued successfully was 03.15.
Date of birth: 3 May 1960 (57 years).
Place of birth: Afghanistan.
Gender: Male.
Occupation: Chauffeur.
Usual address: Flat 205, floor 23, Grenfell Tower, London.
Place of death: West Side of Grenfell Tower, London.
Time of death: 02.41 on 14 June 2017.
Cause of death: Multiple injuries (consistent with a fall from height).
Mohammed Amied (Saber) Neda lived in Flat 205 with his wife, Shakila (Flora) Neda, and his son, Shekeb (Farhad) Neda. His family and friends knew him as Saber.[1645]
Saber Neda was born on 3 May 1960 in Afghanistan. In 2017 he was 57 years old. One of 10 children, he grew up in Afghanistan where he met his wife, Flora, in 1989. They married in 1991 in Kabul. The family moved to the UK in 1998 with their young son, Farhad. The family moved into Flat 205 in 1999.[1646] Saber Neda established his own chauffeur business, which by 2017 he had operated for 10 years.[1647]
Saber Neda did not have any known vulnerabilities.
Saber Neda returned home with his wife and son at 00.52 on 14 June 2017. On reaching floor 23 they noticed that a noise was coming from the vents of the extractor fans located in the lobby. Farhad Neda called the TMO at 01.10 to report it and also reported that there was an electrical burning smell. The call responder told him that they had received a call about the fire alarms and that the fire brigade was on its way.[1648]
At the time the lobby was clear of smoke.[1649] About 15 minutes later the family decided to leave the tower. Saber Neda had looked out the window and thought there was a fire downstairs. A burning smell was still detectable in the lobby. Visibility in the lobby was still clear when the Neda family tried to leave but Farhad Neda saw black smoke coming into the lobby from the smoke extraction vents.[1650]
The family reached the stairwell but were prevented from going down the stairs by people coming up from the lower floors.[1651] Among those coming up were Mariem and Eslah Elgwahry from floor 22 and Sakina Afrasehabi and Fatemeh Afrasiabi from floor 18. The Neda family returned to their flat and took in the Elgwahrys and Sakina Afrasehabi and Fatemeh Afrasiabi shortly before 01.30.[1652]
The Neda family took them into the living room. Black smoke slowly began to enter the flat underneath the front door. Within 10 to 15 minutes there were black marks around people’s noses due to the smoke.[1653]
Saber Neda did not make any calls to the emergency services on 14 June 2017, but Mariem Elgwahry made a number of calls from Flat 205. Her first two calls were made at 01.30[1654] and 01.38.[1655] As a result, a message about persons trapped in Flat 205 on floor 23 was passed to the incident ground.[1656] SM Loft was in front of the tower passing information he had received from WM Kentfield on command unit CU7 to the bridgehead, probably by radio.[1657] He said that the first message he had received related to Flat 205. He passed it to the bridgehead at about 01.40.[1658] Flat 205 and floor 23 were recorded on the forward information board used to record information about people needing to be rescued while the bridgehead was located on floor 2.[1659]
Although information about Flat 205 reached the bridgehead soon after 01.40, firefighters were not sent to floor 23 until 02.08.[1660] FFs Zade Alassad, Scott Bell and John Wright tallied out between 02.08 and 02.10 to go to Flats 201 and 205 on floor 23.[1661] Their names were written next to a circled note on a wall of floor 2 which read “Wandswor 23rd flts 201 205.”[1662] However, the crew did not reach floor 23 because they stopped to help other firefighters take down casualties found on floor 10.[1663] FF Bell said that he had told someone that they had not reached floor 23 but he could not remember to whom he had spoken or what that person did with the information.[1664]
Farhad Neda was in contact with friends outside the tower who were able to speak to firefighters and pass advice back to him. He also spoke directly with a firefighter who gave him advice. The collective advice was for those in Flat 205 to cover their faces with wet towels, wet the carpets, put wet towels against the doors and remain in the flat until firefighters came.[1665] The Nedas filled buckets with water which they threw on the carpets and soaked towels to cover their mouths when they saw smoke coming into the flat.[1666]
Mariem Elgwahry made a third emergency call from Flat 205 at 01.54 and spoke to CRO Gotts.[1667] At 01.57 CRO Darby sent a message to the incident ground about a caller in Flat 205 on floor 23 who had reported the fire coming up to the flat.[1668]
When Saber Neda saw that the fire had reached the bedroom in Flat 205 he closed the door and told everyone not to enter it.[1669] At around 02.15 Farhad Neda decided that they needed to leave. He seized his mother and shouted for his father to follow.[1670] Saber Neda agreed and said he would be behind them. He handed out wet towels to Eslah and Mariem Elgwahry and sisters Sakina Afrasehabi and Fatemeh Afrasiabi in preparation for them all to leave.[1671] Farhad Neda and Flora Neda then left the flat thinking that the others would follow them.
However, Saber Neda did not follow his family out but remained in Flat 205 with Fatemeh Afrasiabi, Sakina Afrasehabi and Mariem and Eslah Elgwahry.[1672]
In a further emergency call at 02.25, Mariem Elgwahry described the conditions in the flat as having deteriorated significantly.[1673] She said that they were running out of air and the whole flat was black.[1674] The fire had reached the bedroom and the door to that room had been closed. Mariem Elgwahry said that they had tried to leave but it was totally black outside the front door.[1675]
CRO Adams called CU8 at 02.28 to pass on a message about that call. She was unaware of a request that all information about people needing to be rescued should now be sent to CU7. We do not know whether a message was sent to the bridgehead from CU7.[1676]
In any event, a message reached the bridgehead sometime after 02.17 when it had moved to floor 3, since Flat 205 was included in the information on the wall on that floor.[1677] As a result CM Richard Evans and FF Gemma Bloxham were sent to Flat 205 on floor 23 after 02.24.[1678]
CM Evans and FF Bloxham had reached floor 20 when they came across Farhad and Flora Neda, whom they then helped to leave the tower.[1679] Farhad Neda told the firefighters that his father and four others were trapped in Flat 205, which one of them recorded in a notebook. As they left the main entrance Farhad Neda told the firefighters again that there were still people in the flat. CCTV shows him and his mother leaving the tower between 02.42 and 02.43.[1680]
CM Evans returned to the bridgehead and told the officer in charge that they had not reached Flat 205 but that they had brought two people down.[1681] That report may have led to a further deployment of firefighters to the top floor. At 02.51, FFs Niki Mitchell, Jessamine Bate, Michael Pole and Chris Cheesman from Euston Fire Station were sent to floor 23.[1682] On the wall of the bridgehead, then on floor 3, was written the word “Euston” against Flats 204 and 205 on floor 23.[1683] The notation was repeated further down where the words “23rd Euston 204 205” can be seen. The firefighters did not reach floor 23 but helped casualties escape from Flat 153 on floor 18.[1684] FF Mitchell recalled telling WM Louisa De Silvo that they had not reached floor 23 but had got fairly high up the tower and had rescued a family of seven. The crew’s end of wear times were between 03.15 and 03.17.[1685] Although they did not reach floor 23, their deployment was too late for them to have had any prospect of rescuing Saber Neda.
No firefighter successfully reached floor 23 on 14 June 2017.[1686]
At 02.37, Saber Neda called his nephew Lotfrahman (Massi) Abdulrahman. He was still in Flat 205 at the time and asked why no one had come to help. Massi Abdulrahman could hear female voices in the background. After the call ended he tried to call his uncle back, but without success.
At 02.40, Saber Neda left a message for his brother-in-law, Habibirahman Abdulrahman. He said: “Goodbye. We are now leaving this world, goodbye. I hope I haven’t disappointed you. Goodbye to all.” There was no further contact with Saber Neda.
At 02.41, the body of Saber Neda was found in the children’s playground on the west side of the tower. He had fallen from the tower.[1687] A paramedic formally pronounced him dead at 02.50.[1688] The coroner was satisfied about the identification of his remains and therefore issued an interim certificate of the fact of death.[1689]
The post-mortem on Saber Neda recorded the cause of death as multiple traumatic injuries consistent with a fall from a significant height. The injuries were unsurvivable and death, which occurred at or just before 02.41, was instantaneous.[1690] The level of carboxyhaemoglobin in his blood was 20%, significantly lower than the level associated with death from carbon monoxide poisoning.[1691]
Date of birth: 1 December 1952 (64 years).
Place of birth: Alexandria, Egypt.
Gender: Female.
Occupation: Retired.
Usual address: Flat 196, floor 22, Grenfell Tower, London.
Place of death: Flat 205, floor 23, Grenfell Tower, London.
Time of death: Between 02.50 and 03.30 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 11 April 1990 (27 years).
Place of birth: London, United Kingdom.
Gender: Female.
Occupation: Marketing Manager.
Usual address: Flat 196, floor 22, Grenfell Tower, London.
Place of death: Flat 205, floor 23, Grenfell Tower, London.
Time of death: 02.50 to 03.30 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Eslah Elgwahry lived in Flat 196 on floor 22 with her daughter Mariem. She was born on 1 December 1952 in Alexandria, Egypt and was 64 years old. Her daughter, Mariem was born on 11 April 1990 in London. She was 27 years old.[1692]
Eslah Elgwahry had lived in Grenfell Tower for 34 years. She raised her two children, Mariem and her older brother, Ahmed, alone after their father died when they were young. She instilled in them a strong bond.[1693] Eslah Elgwahry had retired by the time of the fire. Mariem Elgwahry graduated from Roehampton University and had established a successful career as a marketing manager.[1694]
Eslah Elgwahry had a complex range of health problems which resulted in her having difficulty walking.[1695] She was not able to climb many stairs without assistance. Mariem Elgwahry had no known vulnerabilities. She was Eslah Elgwahry’s carer.[1696]
Rydon’s survey of residents, prepared in November 2014 and provided to the TMO, recorded that Eslah Elgwahry had mental health problems and high blood pressure.[1697] On 24 June 2015, she completed a TMO Tenancy Information Form as part of a tenancy audit on Flat 196, in which she reported that she considered herself to have a physical disability and to need the support of a carer.[1698]
Both Eslah and Mariem Elgwahry were recorded as residents in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system. Eslah Elgwahry was identified as being over 65 but there was no record of her vulnerabilities.[1699]
Eslah Elgwahry was alone in Flat 196 on 13 June 2017 until 22.14 when Mariem Elgwahry returned to the tower.[1700] It is not clear when they first became aware of the fire but its rapid spread up the “Flat 6s” prompted them to leave their home. (The fire on the outside of the building had passed Flat 196 by 01.26.)[1701]
Mariem Elgwahry and Eslah Elgwahry left Flat 196 at about 01.25.[1702] Naomi Li, who lived in Flat 195, met them in the lobby of floor 22. Mariem told Naomi that the fire was already in their kitchen. Naomi said that they had closed the door to Flat 196 and Mariem Elgwahry was locking it before they left through the stairwell door.[1703]
Mariem Elgwahry and Eslah Elgwahry were prevented from going down the stairs by a group of other people going up.[1704] They went up to floor 23 instead.[1705] Together with Sakina Afrasehabi and Fatemeh Afrasiabi, who had come up from Flat 151 on floor 18, Eslah and Mariem Elgwahry were able to shelter in Flat 205, the home of the Neda family.[1706]
At 01.30, Mariem Elgwahry made her first call to the emergency services. She spoke to CRO Peter Duddy in the LFB control room[1707] and told him that she was with others on floor 23. Mariem Elgwahry said that the fire had broken into her flat on floor 22 and that they had been forced to run to a neighbour’s flat. She said there was smoke everywhere. The call was cut off before CRO Duddy could give her any advice.[1708]
Mariem Elgwahry’s second emergency call followed shortly afterwards at 01.38, when she spoke to CRO Fox in the LFB control room.[1709] She said that there was no smoke coming into Flat 205 and that there were seven people in the flat. CRO Fox told her to “put things on the door” and to keep the windows closed if smoke started to come in.[1710]
CRO Fox then created a service request which read, “Seven people in flat 205 on 23rd floor; persons unable to leave property.”[1711] CRO Darby passed the information to WM Meyrick in CU8 at 01.43.[1712] She then marked the service request as completed.[1713]
WM Kentfield was passing messages received by WM Meyrick in command unit CU8 to SM Loft, who was in front of the tower passing information to the bridgehead, probably by radio.[1714] He said that the first message he had received related to Flat 205.[1715]
Flat 205 and floor 23 appeared on the forward information board used to record information about people needing to be rescued while the bridgehead was located on floor 2.[1716]
Although information about Flat 205 reached the bridgehead soon after 01.40, firefighters were not sent to floor 23 until 02.08.[1717]
At 01.54, Mariem Elgwahry made a third call to the emergency services and spoke to CRO Gotts. She reported that she was one of seven people in Flat 205. She said that the flat was full of smoke and that the fire was approaching; they could see the flames outside the window. CRO Gotts told her that the firefighters were trying to send people up and that she would make them aware of their location and the urgency of the situation.[1718]
After the call had ended, CRO Gotts went to check that the earlier message about Flat 205 had been sent to the incident ground. Although she did not create a service request, CRO Darby sent a radio message at 01.57 saying that the caller in Flat 205 on floor 23 had reported that the fire was coming right up to her flat.[1719] We cannot say whether that further message reached the bridgehead or, if it did, whether it added to the information about Flat 205 already held there.
FFs Zade Alassad, Scott Bell and John Wright were sent by WM Watson to two flats on floor 23.[1720] They tallied out at between 02.08 to 02.10. Their names were written next to a circled note on the wall of floor 2 which read “Wandswor 23rd flts 201 205.”[1721] It is likely that they were sent to Flats 201 and 205.[1722]
FFs Alassad, Bell and Wright did not reach floor 23. They stopped at floor 10 and helped to carry down casualties found on that floor.[1723] FF Bell said that he told someone they had not reached floor 23 but he could not remember to whom he had spoken or what that person did with that information.[1724]
Mariem Elgwahry spoke to her brother, Ahmed Elgwahry, at about 01.43. She told him that there was a fire in the kitchen and that she was with their mother. Ahmed Elgwahry told her to get out of the building. He then left his home and went to the tower.[1725]
Mariem Elgwahry called Ahmed Elgwahry again at 01.48 and then 01.49. She told him that they had tried to go down the stairs but could not do so as others had been coming up and telling her to go back. She explained that she was now in Flat 205 after a neighbour had let them into his flat.[1726]
Mariem Elgwahry spoke to her sister-in-law, Ferzana Elgwahry, at 01.56. She was distressed and crying and coughed a lot during the call. She confirmed that they had already covered their mouths with damp towels.[1727]
Mariem Elgwahry was also in contact with her close friend, Lucy Ho. At about 02.00, Lucy Ho called her and tried to persuade her to leave. She told Lucy Ho that the emergency services knew where they were and would come for them. Lucy Ho went to find a firefighter who told her to speak to a police officer. She told the police officer that her friend, her mother and four others were in Flat 205.[1728] It has not been possible to identify that police officer.
Ahmed Elgwahry arrived at the tower at about 02.13 and then called Mariem Elgwahry. A police officer took Ahmed Elgwahry to a command unit, where a firefighter told Mariem Elgwahry to lie low and breathe through the drain in the bathroom and block out smoke using wet towels. The firefighter then told her to call the emergency services. The firefighter has not been identified.[1729]
Saber Neda saw that the fire had reached the bedroom in Flat 205 and closed the door. He then told everyone not to enter it.[1730] Farhad Neda decided that they needed to leave at around 02.15 and grabbed his mother and shouted for his father to follow.[1731] Saber Neda agreed and said he would be behind them. Saber Neda handed out wet towels to Eslah and Mariem Elgwahry and sisters Sakina Afrasehabi and Fatemeh Afrasiabi in preparation to leave.[1732] Farhad and Flora Neda then left the flat at this time believing that the others would follow them.
Eslah Elgwahry and Mariem Elgwahry remained in the flat with Saber Neda, Sakina Afrasehabi and Fatemeh Afrasiabi.[1733]
Mariem Elgwahry’s last call to the LFB was connected to CRO Howson at 02.25.[1734] Mariem Elgwahry said she was one of seven adults who were sheltering in the kitchen. They were running out of air and the whole flat was black.[1735] She said that she was with her mother, who was diabetic and had asthma. The fire had reached the bedroom and the door to that room had been closed. CRO Howson advised her to leave, if necessary. Mariem Elgwahry told her that they had tried to leave but that it was totally black outside the front door.[1736] Ahmed Elgwahry tried to call her while she was still speaking to CRO Howson.[1737]
CRO Adams called CU8 at 02.28 to pass on the information she had received from Mariem Elgwahry. She was not aware that a message from CU7 recorded in the incident log a few minutes earlier had asked for all information about people needing to be rescued to be sent to CU7 instead of CU8.[1738]
Mariem Elgwahry called Ahmed Elgwahry again at 02.31. She told him that she was with six or seven people in the kitchen of the flat. She said they could not leave because the lobby was full of black smoke and it was impossible to see.[1739]
The next deployments to floor 23 were after 02.24. CM Richard Evans and FF Gemma Bloxham were sent to Flat 205 on floor 23. They had reached floor 20 when they came across Farhad and Flora Neda on their way down. CM Evans and FF Bloxham stopped to help them out of the tower, not knowing that they had left the flat that they had been sent to.[1740] Farhad Neda told the firefighters that his father and four others were trapped in Flat 205, which was recorded by one of the firefighters in a notebook. As they left the main entrance, Farhad Neda told the firefighters again that there were still people in the flat. They are recorded on CCTV leaving the tower between 02.42 and 02.43.[1741]
The crew’s end of wear time was 02.42, which must have been at about the time that CM Evans told the officer in charge at the bridgehead that they had not reached Flat 205.[1742]
CM Evan’s message to the bridgehead may have led to a further deployment of firefighters to the top floor. At 02.51, FFs Niki Mitchell, Jessamine Bate, Michael Pole and Chris Cheesman from Euston Fire Station were sent to floor 23.[1743] At the bridgehead, then on floor 3, the word “Euston” had been written on the wall against Flats 204 and 205 on floor 23.[1744] The message was repeated further down. That crew did not reach floor 23 but helped casualties evacuate from Flat 153 on floor 18.[1745] FF Mitchell recalled telling WM Louisa De Silvo that they had not reached floor 23 but had got fairly high up the tower and had rescued a family of seven. The crew’s end of wear times were between 03.15 and 03.17.[1746]
No firefighter reached floor 23 on 14 June 2017.[1747]
The last telephone call between Ahmed Elgwahry and Mariem Elgwahry began at 02.33 and ended at 04.27. Ahmed Elgwahry said that there had been no background noise in the flat. He could hear coughing and his sister’s coughing increased. He tried to encourage her to leave but she said she could not leave as the landing was filled with thick black smoke. Ahmed Elgwahry believed that his sister did not want to leave their mother behind.[1748]
Ahmed Elgwahry could see that the kitchen of Flat 205 was the last room to be affected by the fire on the outside of the building. He heard Mariem Elgwahry begin to panic. She started mumbling and making a deep humming sound. She was initially able to make banging sounds in response to requests from her brother but stopped responding soon after. Ahmed Elgwahry then heard his mother say in Arabic, “I can’t breathe.” He thought that that was at about 03.10. He did not hear from them again. Five to ten minutes later he could hear the sound of glass windows breaking and the fire entering the flat. He kept the line open until 04.27, long after he had ceased to hear from them.[1749]
The fire reached the west face of Flat 205 by around 03.14.[1750] By 03.33, there was evidence of a large fire throughout Flat 205.[1751]
The remains of Eslah and Mariem Elgwahry were recovered from the kitchen area of Flat 205.[1752] The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death for Eslah and Mariem Elgwahry.[1753]
The pathologist who carried out the post-mortems on Eslah and Mariem Elgwahry attributed their deaths to the effects of fire but could not be more precise.[1754] However, in the light of the evidence as a whole, including that of Professor Purser, we are satisfied that they died from the inhalation of asphyxiant gases.
It is likely that they had lost consciousness by 02.50 and that the concentration of asphyxiant gases in their blood had exceeded the lethal threshold a few minutes later.[1755]
We are satisfied that Eslah and Mariem Elgwahry died between 02.50 and 03.30 before suffering the direct effects of fire.
Date of birth: 4 April 1952.
Place of birth: Abadan, Iran.
Gender: Female.
Occupation: Homemaker.
Usual address: Flat 151, floor 18, Grenfell Tower, London.
Place of death: Flat 205, floor 23, Grenfell Tower, London.
Time of death: Between 02.50 and 03.30 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Date of birth: 15 November 1957.
Place of birth: Abadan, Iran.
Gender: Female.
Occupation: Homemaker.
Usual address: Martin Close, Edmonton, London, N9.
Place of death: Flat 205, floor 23, Grenfell Tower, London.
Time of death: Between 02.50 and 03.30 on 14 June 2017.
Cause of death: Inhalation of asphyxiant gases.
Sakina Afrasehabi was born on 4 April 1952 in Abadan, Iran. She was 65 years old in June 2017.[1756] She was the sole tenant of Flat 151 and had lived there since February 2016.[1757] Her younger sister Fatemeh Afrasiabi was born on 15 November 1957 in Abadan, Iran. She was 59 years old in June 2017. Fatemeh Afrasiabi was staying with her sister on the night of 13 June 2017.[1758]
Sakina Afrasehabi and Fatemeh Afrasiabi grew up in Iran with four other siblings. They had a happy childhood before living through the revolution and the Iran-Iraq war. They moved to the UK from Iran and were very close.
Sakina Afrasehabi suffered from diabetes, high blood pressure and arthritis. Due to an accident in Iran, she could walk only with the aid of a walker. It was difficult for her to walk a short distance without assistance.[1759]
Sakina Afrasehabi was recorded as a resident in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO’s Capita Insight system. She was identified as being over 65 and as vulnerable because of her mental and physical health.[1760]
Fatemeh Afrasiabi and Sakina Afrasehabi spent the evening of 13 June 2017 in Flat 151 with family. Their other relatives left before 22.00 but Fatemeh Afrasiabi stayed the night with her sister.[1761]
Sakina Afrasehabi was first alerted to the fire by her neighbours from Flat 156, Shahid and Sayeda Ahmed. They had evacuated their flat after the fire broke into their kitchen at around 01.27 and had then knocked on the doors of all the other flats on that floor, including Flat 151.[1762]
Sakina Afrasehabi and Fatemeh Afrasiabi left their flat and were told by others they met on the stairs to go up to floor 23.[1763] There the Neda family invited them to shelter in their home, Flat 205. Mariem and Eslah Elgwahry, who had also come up to floor 23, joined them in Flat 205. By 01.30 there were seven people in Flat 205.[1764]
Neither Sakina Afrasehabi nor Fatemeh Afrasiabi themselves called the emergency services on 14 June 2017, but nonetheless a message was passed by the LFB control room to the incident ground about persons trapped in Flat 205.[1765] That was in response to calls received from Mariem Elgwahry at 01.30[1766] and 01.38.[1767] The fact that there were people trapped in Flat 205 was communicated to the bridgehead on floor 2 and recorded there on a forward information board.[1768]
The first team of firefighters sent to floor 23 in response to those messages set out between 02.08 and 02.10. FFs Zade Alassad, Scott Bell and John Wright were sent to Flats 201 and 205 on floor 23.[1769] A photograph taken of the wall on floor 2 shows writing which reads “Wandswor 23rd flts 201 205.” Next to this are the names of Alassad, Bell and Wright.[1770] FFs Alassad, Bell and Wright did not reach floor 23. They stopped at floor 10 and helped to carry down casualties found on that floor.[1771] FF Bell said that he told someone they had not reached floor 23 but he could not remember to whom he had spoken or what that person did with the information.[1772]
Farhad Neda said that conditions in Flat 205 had changed rapidly.[1773] He saw black smoke beginning to enter the flat beneath the front door. Within 10 to 15 minutes of the sisters’ coming into the flat there were black marks around people’s noses from the smoke.[1774]
Solmaz Sattar, the niece of Fatemeh Afrasiabi, had several telephone conversations with her aunt during the night. In a call which occurred after Solmaz Sattar had reached the tower, Fatemeh Afrasiabi said they were in Flat 205. Solmaz Sattar passed the information to a police officer and a firefighter standing nearby. The firefighter advised that they should remain in the flat and that they should make everything wet, including themselves. The Nedas had filled buckets with water which they threw on the carpets and soaked towels to cover their mouths when they saw smoke coming into the flat.[1775] Later, Fatemeh Afrasiabi told her niece that the water had stopped.[1776]
Fatemeh Afrasiabi and Sakina Afrasehabi were also in contact with Sharokh Aghlani, Sakina Afrasehabi’s son. Fatemeh Afrasiabi first called him around 01.20 to tell him of the fire. He went to the tower and told police officers there that his mother and aunt were on floor 23.[1777] (It has not been possible to identify with any confidence which officer Sharokh Aghlani and Solmaz Sattar spoke to.) It is possible that his message was passed to the bridgehead. At the same time, Mariem Elgwahry in Flat 205 had made further calls to the LFB control room at 01.54[1778] and 02.25.[1779] The information from both calls was passed to the incident ground at 01.57[1780] and 02.28 respectively.[1781]
At least one of the messages about Flat 205 reached the bridgehead while it was still on floor 3 (between 02.17 and 03.10). That led to a further deployment of firefighters. At 02.24 CM Richard Evans and FF Gemma Bloxham set out to go to Flat 205.[1782]
Shortly before that, Saber Neda had seen that the fire had reached the bedroom of Flat 205. He closed the door and told everyone not to enter it.[1783] At about 02.15 Farhad Neda decided that it was time to leave. He seized his mother and shouted for his father to follow.[1784] Saber Neda agreed and said he would be behind them. He gave wet towels to Sakina Afrasehabi and Fatemeh Afrasiabi in preparation to leave.[1785] Farhad and Flora Neda then left the flat thinking that the others would follow them. Instead, Sakina Afrasehabi and Fatemeh Afrasiabi remained in the flat with Saber Neda and Mariem and Eslah Elgwahry.[1786]
CM Evans and FF Bloxham had reached floor 20 when they came across Farhad and Flora Neda. CM Evans and FF Bloxham stopped to help them out of the tower.[1787] Farhad Neda told the firefighters that his father and four others were trapped in Flat 205, which was recorded by one of the firefighters in a notebook. As they left the main entrance between 02.42 and 02.43, Farhad Neda told the firefighters again that people were still in the flat.[1788]
At about 02.42 CM Evans told the officer in charge at the bridgehead that they had not reached Flat 205 but that they had brought two people down.[1789] That may have led to a further deployment of firefighters to the top floor.
At 02.51, FFs Niki Mitchell, Jessamine Bate, Michael Pole and Chris Cheesman from Euston Fire Station were sent to floor 23.[1790] The wall of the bridgehead, then on floor 3, shows that the word “Euston” had been written against Flats 204 and 205 on floor 23.[1791] The message was repeated on the lower right hand corner of the photograph where the words “23rd Euston 204 205” can be seen. They did not reach floor 23 but helped casualties evacuate from Flat 153 on floor 18.[1792] FF Mitchell recalled telling WM De Silvo that they had not reached floor 23 but had got fairly high up the tower and they had rescued a family of seven. The crew’s end of wear times were between 03.15 and 03.17.[1793]
No firefighter successfully reached floor 23 on 14 June 2017.[1794]
Shahrokh Aghlani spoke to his mother, Sakina Afrasehabi, and his aunt, Fatemeh Afrasiabi, several times in the early hours of 14 June 2017. During his last call he could hear them wheezing. He heard his aunt say “forgive us” before the line was disconnected. About 50 seconds before that he heard the sound of an explosion. It is difficult to determine when that conversation took place.[1795]
Ahmed Elgwahry was on the telephone to Mariem Elgwahry from 02.33 until 04.27. He said that he had last heard Mariem and Eslah Elgwahry respond to him at between 03.10 and 03.15. He also heard the sound of windows breaking about 5 to 10 minutes later.
Sakina Afrasehabi and Fatemeh Afrasiabi are likely to have become unconscious from the effects of asphyxiant gases at about the same time as Eslah and Mariem Elgwahry, given their close proximity to each other in the kitchen of Flat 205.
The remains of Sakina Afrasehabi and Fatemeh Afrasiabi were recovered from the kitchen area of Flat 205.[1796] The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death for Sakina Afrasehabi and Fatemeh Afrasiabi.[1797]
The pathologist who carried out the post-mortems on Sakina Afrasehabi and Fatemeh Afrasiabi attributed their deaths to the effects of fire but could not be more precise.[1798] However, in the light of the evidence as a whole, including that of Professor Purser, we are satisfied that they died from the inhalation of asphyxiant gases.
It is likely that Sakina Afrasehabi and Fatemeh Afrasiabi lost consciousness at about 02.50 and died at some time between 02.50 and 03.30 before suffering the direct effects of fire.
1) Phase 1 Report Volume I paragraph 1.9; Fegan-Earl {Day298/4:9-17}.
2) Fegan-Earl {Day298/4:18-24}; Phase 1 Report Volume IV paragraph 34.2.
3) MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/13}; Harrison {Day302/18:5}-{Day302/19:3}; {KHA00000001/3} page 3, paragraphs 9-12; Harrison {Day302/12:18}; {Day302/19:4}; {Day302/19:21} -{Day302/20:7}.
4) Harrison {KHA00000001/1} page 1, paragraphs 1 - 4.
5) Harrison {KHA00000001/2} page 2, paragraphs 5, 6 and 8.
6) Harrison {Day302/11:4}.
7) Harrison {Day302/15:8} -{Day302/17:1}.
8) Harrison {KHA00000001/1} page 1, paragraph 5.
9) Harrison {Day302/9:23}.
10) Harrison {KHA00000001/3} page 3, paragraph 7 and Table 1; Harrison {Day302/21:3}.
11) Harrison {Day302/22:2} {Day302/23:10}.
12) Harrison {KHA00000001/4} page 4, paragraph 15; {KHA00000001/5} page 5, paragraph 17; Harrison {Day302/23:13}-{Day302/27:24}.
13) Harrison {KHA00000001/5} page 5, paragraph 18; {KHA00000001/6} page 6, paragraph 20; Harrison {Day302/21:1}-{Day302/34:23}.
14) Harrison {KHA00000001/6} page 6, paragraph 21; Harrison {Day302/34:25}-{Day302/37:9}.
15) Harrison {KHA00000001/8} page 8, paragraph 23; {KHA00000001/9} page 9, paragraph 25; Harrison {Day302/37:10}-{Day302/41:3}.
16) Harrison {KHA00000001/9} page 9, paragraph 27.
17) Harrison {KHA00000001/9} page 9, paragraph 28; Harrison {Day302/43:6} -{Day302/48:13}.
18) Harrison {KHA00000001/9} page 10, paragraph 29; {KHA00000001/12} page 12, paragraph 36; {Day302/50:21}-{Day302/53:25}.
19) Harrison {KHA00000001/12} page 12, paragraph 37; Harrison {Day302/62:3}.
20) Harrison {KHA00000001/12} page 12, paragraph 37; {KHA00000001/17} page 17, paragraph 45; Harrison {Day302/55:2}-{Day302/57:24}; {Day302/59:5}; {Day302/62:13}-{Day302/57:24}; {Day302/64:17}.
21) Harrison {KHA00000001/19} page 19, paragraphs 47-48; Harrison {Day302/72:1}-{Day302/73:23}.
22) Harrison {KHA00000001/19} page 19, paragraph 49; {KHA00000001/20} page 20, paragraph 51; Harrison {Day302/68:21}-{Day302/71:15}; {Day302/78:1}-{Day302/80:25}.
23) Harrison {KHA00000001/20} page 20, paragraph 52.
24) Harrison {KHA00000001/39} page 39, paragraphs 87-91.
25) MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/68}; {GMK00000001/15-16}.
26) MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/16}.
27) MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/85-87}.
28) MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/20}.
29) MacKinnon {Day298/65:22}-{Day298/66:22-1}; {Day298/71:10-23}; MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/15}.
30) MacKinnon {Day298/63:9-14}.
31) MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/16}.
32) MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/28}.
33) MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/34}.
34) MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {Day298/63:9-14}; MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/35}; {GMK00000001/37}.
35) MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/38}; {GMK00000001/41}.
36) MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/21}
37) MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {Day298/82:22-25}; MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/23-24}.
38) MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/21-22}.
39) MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/42}.
40) MacKinnon {Day298/90:5-14}; {Day298/77:7-6}; {Day298/78:5-6}; {Day298/124:16-25}; {Day 298/125:4-10}.
41) MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/18}.
42) MacKinnon, Summary of the Forensic Anthropology Examination and Reporting Process {GMK00000001/22}.
43) Fegan-Earl {AWF00000001/2} page 2; Fegan-Earl {Day298/19:17-21}-{Day298/27:16}.
44) Fegan-Earl {Day298/42:14}-{Day298/43:2}.
45) Fegan-Earl {Day298/43:3-23}.
46) Fegan-Earl {AWF00000001/2} page 2; {AWF00000001/3} page 3; Fegan-Earl {Day298/25:11}-{Day298/40:25}.
47) Fegan-Earl {Day298/28:8}.
48) Fegan-Earl {Day298/46:142}-{Day298/47:8}.
49) Fegan-Earl {AWF00000001/4-5} pages 4-5; Fegan-Earl {Day298/44:15}-{Day298/46:5}.
50) Fegan-Earl {AWF00000001/4} page 4; Fegan-Earl {Day 280/49:2}-{day298/51:3}.
51) Fegan-Earl {Day298/51:5}-{Day298/52:11}.
52) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005}; Purser, Phase 2 Report, Section 5 {DAPR0000011}; Purser, Phase 2 Report, Section 6 {DAPR0000006}; Purser, Phase 2 Report, Appendix A {DAPR0000007}; Purser, Phase 2 Report, Appendix B {DAPR0000008}; Purser, Phase 2 Report, Appendix C {DAPR0000009}; Purser, Phase 2 Report, Appendix D {DAPR0000010}.
53) Purser {Day296/4:13-17}; {Day296/5:12-15}.
54) Purser {Day296/11:25}-{Day296/12:4}.
55) Purser {Day296/12:11-15}.
56) Purser, Phase 2 Report, Appendix D {DAPR0000010/5]; Purser {Day296/15:2-13}.
57) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/64-103}; Purser, Phase 2 Report, Appendix A {DAPR0000007}.
58) Purser {Day296/40:18}-{Day296/41:5}.
59) {DAP00000002}.
60) Purser {Day296/47:3}-{Day296/49:7}.
61) Stec, Assessment of the toxicity and extent of penetration of smoke from combustible products on the Grenfell Tower Report {AASR0000010}.
62) Purser {Day296/49:15}-{Day296/50:8}.
63) Purser {Day296/50:11-16}.
64) Purser {Day296/168:22}-{Day296/169:5}.
65) Purser {Day296/167:15-21}.
66) Purser {Day296/168:5-21}.
67) Purser {Day296/169:6-14}.
68) Purser {Day296/168:22}-{Day296:169:5}.
69) Purser {Day296/169:10-15}.
70) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/107}.
71) Purser {Day296/171:15-18}.
72) Purser {Day296/164:17-20}.
73) For Professor Purser’s range of time in each individual case, see Purser, Phase 2 Report, Section 6 {DAPR0000006}.
74) Purser {Day296/33:6}-{Day296/39:5}.
75) Purser {Day296/32:16-20}.
76) Purser {Day296/34:19}-{Day296/35:18}; {Day296/164:10-20} and {Day296/39:13}-{Day296/40:9}.
77) Purser {Day296/39:8-12}.
78) Purser {Day296/41:10-15}.
79) Purser {Day296/107:3-10}.
80) Purser {Day296/107:11-15}.
81) Purser {Day296/109:2-9}.
82) Purser {Day296/112:5-11}.
83) Purser {Day296/113:10-14}.
84) Purser {Day296/120:19}-{Day296/122:23}.
85) Purser, Phase 2 Report, Section 5 {DAPR0000011/4}.
86) Purser {Day297/166:5}-{Day297/167:6}.
87) {DAPR0000015/2}; Phase 1 Report Volume IV paragraph 24.8.
88) Purser {Day297/168:24}-{Day297/170:17}.
89) {DAPR0000015/2}.
90) Purser, Phase 2 Report, Section 5 {DAPR0000011/5}; Purser {Day297/186:18-21}.
91) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/49}.
92) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/50}.
93) Purser {Day296/67:17}-{Day296/68:16}.
94) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/153}; Purser {Day296/214:17}-{Day296/215:4}.
95) Purser, Phase 2 Report {DAPR0000005/95} Sections 1-4; Purser {Day296/159:11-20}. Professor Purser relied on the accounts of Petra Doulova, floor 20, who exited the tower at 01:41:26 and Branislav Lukic, floor 11, who exited the tower at 01:49:09. Phase 1 Report Volume III Annex A.
96) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/96}.
97) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/96}.
98) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/97}.
99) Purser, Phase 2 Report, Sections 1-4 {DPAR0000005/97}.
100) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/109}.
101) Purser {Day296/165:22}-{Day296/166:3}.
102) Purser {Day296/166:4-9}.
103) Purser {Day296/166:10-15}.
104) Purser {Day296/214:17}-{Day296/215:4}.
105) Purser {Day296/27:4-9}.
106) Purser {Day296/217:23}-{Day296/218:1}.
107) Purser {Day296/25:19}-{Day296/26:2}.
108) Purser {Day296/218:2-5}.
109) Purser {Day297/7:18}-{Day296/8:2}.
110) Purser {Day296/218:6-10}.
111) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/153}.
112) Purser {Day296/218:19-23}.
113) Purser {Day296/28:4-12}.
114) Purser {Day296/28:15-22}.
115) Purser {Day296/28:23-25}.
116) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/124} figure 18.
117) Purser {Day296/182:15-18}.
118) Purser {Day296/182:20}-{Day296/183:2}.
119) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/138}; Purser {Day296/183:18}-{Day296/184:16}.
120) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/139}; Purser {Day296/229:1-8}.
121) Purser {Day296/197:22}-{Day296/198:17}.
122) Purser {Day297/51:14-17}; {Day297/52:4-17}.
123) Phase 1 Report Volume II paragraphs 10.115-10.116; Phase 1 Report Volume IV paragraph 24.18.
124) Phase 1 Report Volume II paragraphs 10.197-10.202; Phase 1 Report Volume IV paragraph 24.31.
125) Phase 1 Report Volume II paragraphs 10.215 and 10.221-10.225.
126) Phase 1 Report Volume II paragraphs 10.94 and 10.215-10.219; Phase 1 Report Volume IV paragraph 25.6.
127) Phase 1 Report Volume II paragraph 10.203.
128) Phase 1 Report Volume II paragraph 11.114.
129) Phase 1 Report Volume II paragraphs 11.115 and 12.40-12.43.
130) Phase 1 Report Volume II paragraphs 12.41-12.43.
131) Phase 1 Report Volume II paragraphs 12.3-12.5 and 12.29.
132) Phase 1 Report Volume II paragraph 10.204; Phase 1 Report Volume IV paragraph 32.293.
133) Phase 1 Report Volume II paragraph 10.204.
134) Rydon Residents Survey {RYD00024466/33}.
135) Noble {TMO00000884/1} page 1, paragraph 3.
136) Noble {Day119/75:19-22}.
137) Noble {Day119/77:17}-{Day119/82:5}.
138) O’Riordan {MET00013136/3} page 3.
139) Nadia Jafari {IWS00000683/3} page 3, paragraph 10.
140) Phase 1 Report Volume II paragraph 10.116; Phase 1 Report Volume IV paragraph 25.6.
141) Phase 1 Report Volume II paragraphs 10.204-10.206.
142) Phase 1 Report Volume II paragraphs 10.206-10.209.
143) Phase 1 Report Volume II paragraphs 10.208 and 10.221-225.
144) Phase 1 Report Volume II paragraph 10.225.
145) Phase 1 Report Volume II paragraph 10.216.
146) Phase 1 Report Volume II paragraph 10.217.
147) Sangha {MET00007837/3} page 3.
148) Phase 1 Report Volume II paragraph 10.225.
149) Hoare {MET00008027/15-25} pages 15-16 and 25; Phase 1 Report Volume II paragraphs 10.224-10.225; Phase 1 Report Volume III paragraphs 17.13 (e) and 20 (c).
150) Standard duration breathing apparatus provides a working time of about 30 minutes depending on a range of factors, including workload and environmental conditions: Phase 1 Report Volume I paragraph 7.63.
151) Phase 1 Report Volume III paragraph 17.20 (c).
152) Rawlings {MET00005588/2} page 2; Brooks {MET00005262}; Morcos {MET00005585/1} page 1.
153) Phase 1 Report Volume II paragraph 10.225.
154) Hodson {MET00017061/5} page 5.
155) Interim certificate of the fact of death for Ali Yawar Jafari {MET00065589}.
156) Jafari post-mortem report {COR00000088/11}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/122} Table 17.
157) Jafari toxicology report {COR00000092/1}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/124} paragraph 493.
158) Jafari post-mortem report {COR00000088/11}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/125} paragraph 493.
159) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447.
160) Purser, Phase 2 Report, Section 6 {DAPR0000006/167-170} paragraphs 925-935; Purser, Phase 2 Report, Section 6 {DAPR0000006/172} paragraph 943 and Figure 46.
161) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/136} paragraph 568; Purser, Phase 2 Report, Section 6 {DAPR0000006/171-172} paragraphs 942 and 946.
162) Purser, Phase 2 Report, Section 6 {DAPR0000006/172} paragraph 945.
163) Noble {Day119/75:19-22}.
164) Noble {TMO00000884/1} page 1, paragraph 3.
165) Phase 1 Report Volume IV paragraphs 32.154-32.163.
166) O’Riordan {MET00013136/4} page 4.
167) Phase 1 Report Volume II paragraph 10.118.
168) Phase 1 Report Volume II paragraphs 10.255-10.257.
169) Phase 1 Report Volume II paragraphs 10.260 and 10.287-10.289.
170) Phase 1 Report Volume II paragraphs 10.219 and 10.224-10.225.
171) Phase 1 Report Volume II paragraphs 10.216-10.217.
172) Phase 1 Report Volume II paragraphs 10.208 and 10.221-10.224.
173) Phase 1 Report Volume II paragraph 10.216.
174) Phase 1 Report Volume II paragraph 10.225.
175) BA Telemetry Data {LFB00023326/1} page 1.
176) Phase 1 Report Volume II paragraphs 14.225-14.227; Mitchell {MET000086063/4-5} pages 4-5; Desforges {MET00008013/4-5} pages 4-5.
177) Mitchell {MET000086063/5} page 5; Desforges {MET00008013/5-6} pages 5-6.
178) Phase 1 Report Volume II paragraph 10.224.
179) Matthews {MET00013948/4} page 4.
180) Interim certificate of the fact of death for Mohamednur Tuccu {MET00065634}.
181) Tuccu post-mortem report {COR00001106/10}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/136} paragraph 570.
182) Tuccu post-mortem report {COR00001106/10}.
183) Tuccu first toxicology report {COR00001119/1}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/137} paragraph 571.
184) Tuccu second toxicology report {INQ00011095/1}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/141} paragraph 604.
185) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447.
186) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447.
187) Purser, Phase 2 Report, Section 6 {DAPR0000006/173-174} paragraphs 948-949.
188) Purser, Phase 2 Report, Section 6 {DAPR0000006/172} paragraph 945.
189) Phase 1 Report Volume IV paragraphs 32.234-32.239; Presentation relating to Khadija Khalloufi {Day306/24:22}-{Day306/26:19}.
190) O’Riordan {MET00013136/3} page 3.
191) Phase 1 Report Volume II paragraph 10.222.
192) Phase 1 Report Volume II paragraph 10.208.
193) Phase 1 Report Volume II paragraph 10.215.
194) BA Telemetry Data {LFB00023326/1} page 1.
195) Phase 1 Report Volume II paragraphs 14.222-14.227; Mitchell {MET000086063/4-5} pages 4-5; Desforges {MET00008013/4-5} pages 4-5.
196) Mitchell {MET000086063/5} page 5; Desforges {MET00008013/5-6} pages 5-6.
197) Phase 1 Report Volume II paragraph 10.224.
198) Matthews {MET00013948/4} page 4.
199) Interim certificate of the fact of death for Khadija Khalloufi {MET00065597}.
200) Khalloufi post-mortem report {COR00000840/14}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/122} Table 17.
201) Khalloufi first toxicology report {COR00000842/1}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/136} paragraph 569.
202) Khalloufi second toxicology report {INQ00011089/1}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/141} paragraph 604.
203) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447.
204) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447.
205) Purser, Phase 2 Report, Section 6 {DAPR0000006/172} paragraph 947.
206) Phase 1 Report Volume II paragraph 10.116.
207) Phase 1 Report Volume II paragraphs 10.204-10.206.
208) Phase 1 Report Volume II paragraph 10.207.
209) Phase 1 Report Volume II paragraph 10.208.
210) Phase 1 Report Volume II paragraph 10.216.
211) See Chapter 86.
212) Phase 1 Report Volume III Annex A.
213) Phase 1 Report Volume II paragraphs 10.91 and 11.106; Phase 1 Report Volume III paragraphs 15.119 and 19.72.
214) Phase 1 Report Volume III paragraphs 16.73, 16.90, 18.73, 19.74 and 20.49.
215) Phase 1 Report Volume II paragraphs 10.209-10.210, 10.316, 11.103, 11.105, 11.146, 12.54-12.55, 14.207-14.209, 14.237, 14.257; Phase 1 Report Volume III paragraphs 15.113-15.116, 15.154, 15.182, 17.105-17.108, 17.123, 18.48-18.50, 18.68, 19.42-19.44 and 19.71.
216) Phase 1 Report Volume II paragraphs 10.209-10.210 and 11.103-105.
217) Phase 1 Report Volume II paragraphs 11.108-11.112.
218) Phase 1 Report Volume III paragraphs 19.18(b), 19.19(c), 19.19(d), 19.19(f), 19.22(b) and 19.29(b).
219) Phase 1 Report Volume III paragraphs 19.19(g) and 19.44; Barritt {MET000083284/5-6} pages 5-6.
220) Phase 1 Report Volume III paragraphs 19.42–19.44.
221) Phase 1 Report Volume III paragraph 20.37.
222) Phase 1 Report Volume IV paragraph 32.301; Presentation relating to Abdeslam Sebbar {Day301/1:23}-{Day301/2:6}.
223) Sebbar {IWS00002375/1} page 1, paragraph 3; Presentation relating to Abdeslam Sebbar {Day301/2:3-18}.
224) Letter from TMO to RBKC dated 9 November 2016 {BSR00000108}.
225) Noble {Day119/77:17}-{Day119/82:5}.
226) Noble spreadsheet {TMO00862588}.
227) O’Riordan {MET00013136/4} page 4.
228) Phase 1 Report Volume II paragraph 10.116.
229) Phase 1 Report Volume II paragraph 10.91; Phase 1 Report Volume III paragraph 15.117.
230) Phase 1 Report Volume II paragraph 11.107.
231) Phase 1 Report Volume II paragraph 11.107.
232) Phase 1 Report Volume III paragraph 15.117; 999 call transcript {LFB00000312}.
233) Phase 1 Report Volume II paragraphs 10.116, 10.204-10.206 and 11.102-11.105.
234) Sebbar {IWS00002375/2} page 2, paragraph 7.
235) Phase 1 Report Volume III paragraph 15.119; 999 call transcript {INQ00000532}.
236) Phase 1 Report Volume III paragraph 15.119.
237) Sebbar {IWS00002375/2} page 2, paragraph 8.
238) Phase 1 Report Volume III paragraph 19.72.
239) LFB Short Incident Log Report {MET00013830/18}.
240) Phase 1 Report Volume III paragraphs 15.139-15.141 and 20.54 and Figures 15.8 and 15.9.
241) Phase 1 Report Volume II paragraphs 12.8-12.9 and Figure 12.3.
242) Phase 1 Report, Volume II paragraphs 14.103-14.105 and Figure 14.5; Photographs of ground floor wall {MET00005774} and {MET00005776}.
243) Phase 1 Report Volume III paragraph 17.11; Phase 1 Report Volume IV paragraph 28.86.
244) Cook Exhibit GAC/2 - Grenfell Tower statement notes {MET00015779/16} page 16; Phase 1 Report Volume II Figure 15.7.
245) Phase 1 Report Volume III paragraphs 15.13 and 16.12.
246) Phase 1 Report Volume III Figure 16.5; Photograph of whiteboard {MET00015924}.
247) Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}.
248) Phase 1 Report Volume IV paragraph 28.87.
249) Mulholland Exhibit MBM/02 - Photograph of green wall {MET00018721}; Mulholland Exhibit MBM/02 -Photograph of green wall {MET00018731}.
250) O’Keeffe {MET00013967/15} page 15; O’Keeffe notes {LFB00001929/1} page 1.
251) Purser, Phase 2 Report, Section 6 {DAPR0000006/159} paragraph 877.
252) Interim certificate of the fact of death for Abdeslam Sebbar {MET00065630}.
253) Sebbar post-mortem report {COR00000009/10} page 10; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/119} Table 17.
254) Sebbar first toxicology report {COR00000020/1} page 1; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/116} Table 16.
255) Sebbar second toxicology report {INQ00011094/1} page 1; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/116} Table 16.
256) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447.
257) Phase 1 Report Volume III paragraph 16.3.
258) External Spread of Fire Report {MET00012593/78-79} Images 45-56 (applying a +58 minute correction to timestamps).
259) Purser {Day297/145:10}-{Day297/148:6}.
260) Phase 1 Report Volume II paragraphs 14.109-14.111; Phase 1 Report Volume II paragraphs 14.195-14.206; Phase 1 Report Volume III paragraphs 15.91-15.95.
261) Phase 1 Report Volume III paragraph 15.96.
262) Herrera {LFB00032237}.
263) Phase 1 Report Volume II paragraph 10.118.
264) Phase 1 Report Volume II paragraphs 10.233-10.235.
265) Phase 1 Report Volume II paragraph 14.206.
266) Phase 1 Report Volume II paragraph 10.236.
267) Phase 1 Report Volume II paragraphs 11.91-11.92.
268) Phase 1 Report Volume II paragraphs 11.90-11.96 and 14.195; Phase 1 Report Volume IV paragraphs 25.10 (b) and 25.11 (b).
269) Phase 1 Report Volume II paragraphs 10.236 and 11.89.
270) Phase 1 Report Volume II paragraphs 10.237, 11.93, 12.58 and 12.96.
271) Phase 1 Report Volume II paragraphs 11.90-11.92.
272) Phase 1 Report Volume II paragraph 14.195.
273) Alhaj Ali {IWS00000781/6} page 6, paragraph 17.
274) Phase 1 Report Volume II paragraph 11.149.
275) Phase 1 Report Volume II paragraph 12.73 (d).
276) Phase 1 Report Volume II paragraphs 11.5-11.6, 12.18-12.19 and Figure 12.4.
277) Phase 1 Report Volume IV paragraph 28.84 (b); Phase 1 Report Volume II paragraphs 13.52-13.53 and Figures 14.4 and 13.2.
278) Phase 1 Report Volume II paragraph 13.7.
279) Phase 1 Report Volume II paragraphs 13.11-13.12.
280) Phase 1 Report Volume II paragraph 13.8.
281) Phase 1 Report Volume II paragraphs 14.197 and 14.200.
282) Phase 1 Report Volume II paragraphs 13.9 and 14.198.
283) Phase 1 Report Volume II paragraphs 14.88-14.89 and 14.201-14.203.
284) Phase 1 Report Volume II paragraph 14.202.
285) External Spread of Fire Report {MET00012593/12}.
286) Phase 1 Report Volume II paragraphs 14.90 and 14.203.
287) Phase 1 Report Volume II paragraphs 13.9, 13.13, 13.64 and 14.90.
288) Merrion {MET000086060/8} page 8; Merrion {Day38/16:4-15}.
289) Desmond Murphy {Day38/46:2-7}.
290) Purser {Day296/217:19-22}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/7} paragraph 26.
291) Purser {Day297/7:18}-{Day296/8:2}.
292) Oyewole {Day58/75:5-13}.
293) Phase 1 Report Volume II paragraph 14.111.
294) Phase 1 Report Volume II paragraphs 13.53, 14.73, and 14.110, Figures 13.2 and 14.4.
295) Phase 1 Report Volume II paragraph 14.110; Photograph of wall on floor 3 {MET00016948}.
296) Phase 1 Report Volume II paragraph 12.95.
297) Phase 1 Report Volume II paragraphs 12.58 and 12.96-12.97.
298) Control Information Form {LFB00001968/40}.
299) Phase 1 Report Volume II paragraphs 10.237 and 14.249; 999 call transcripts {LFB00000341}; {INQ00000270}.
300) Phase 1 Report Volume II paragraphs 14.100-14.103 and Figure 14.5; Williams {Day31/100:8}-{Day31/101:10}.
301) Williams {Day31/113:3-5}; Phase 1 Report Volume II Figure 14.5.
302) Phase 1 Report Volume III paragraph 15.91; Photograph of wall on floor 3{MET00015819}; De Silvo {Day30/45:15-25}; Herrera {Day38/97:20-22}.
303) Phase 1 Report Volume III paragraph 15.91.
304) Phase 1 Report Volume II paragraph 11.92; 999 call transcript {LFB00000678}.
305) Phase 1 Report Volume III paragraph 15.92.
306) Photograph of wall on floor 3{MET00015819}; McAlonen {Day38/160:8-10}; Juggins {Day40/62:16-18}.
307) Herrera {Day38/105:22-23}; Orchard {Day39/50:18-20}; McAlonen {Day38/167:11-14}; Juggins {Day40/65:18-21}
308) Phase 1 Report Volume III paragraph 15.91.
309) Phase 1 Report Volume III paragraph 15.93.
310) Phase 1 Report Volume III paragraph 15.94.
311) Herrera {Day38/106:13-19}; McAlonen {Day38/168:1-8}; Orchard {Day39/51:13-19}; {Day39/52:6-22}; Juggins {Day40/68:20}-{Day40/69:23}.
312) Oyewole {Day58/76:3}-{Day58/79:13}; Talabi {IWS00000851/14-15} pages 14-15, paragraphs 57-62.
313) Alhaj Ali {Day59/83:18}-{Day59/85:12}.
314) McAlonen {Day38/171:10}-{Day38/173:25}; Juggins {Day40/78:7}-{Day40/81:11}; Orchard {Day39/58:1-16}; Oyewole {Day58/73:24}-{Day58/74:11}; Talabi {Day59/148:6-18}; Alhaj Ali {Day 59/71:9-19}.
315) Orchard {Day39/57:9-11}; Herrera {Day38/110:9-12}; McAlonen {Day38/170:20-22}; Juggins {Day40/81:18-23}.
316) Phase 1 Report Volume III paragraph 15.96.
317) Oyewole {IWS00000852/9-11} pages 9-11, paragraphs 31-43; Oyewole {Day58/45:12}-{Day58/52:7}; {Day58/69:23}-{Day58/70:20}.
318) Oyewole {Day58/48:4-8}; {Day58/59:4-22}.
319) Oyewole {Day58/55:15}-{Day58/56:11}; {Day58/57:13}-{Day58/58:23}; {Day58/60:9}-{Day58/65:1}.
320) Oyewole {Day58/67:3}-{Day58/69:22}; {Day58/85:23}-{Day58/86:20}.
321) Oyewole {Day58/72:7-21}; {Day58/73:22}-{Day58/75:23}; {Day58/88:3}-{Day58/89:9}.
322) Talabi {Day59/127:9}-{Day59/128:19}.
323) Talabi {Day59/132:8-11}.
324) Talabi {Day59/137:6}-{Day59/138:21}.
325) Talabi {Day59/139:2}-{Day59/140:23}.
326) Talabi {Day59/141:2}- {Day59/143:25}.
327) Alhaj Ali {Day59/42:8-14}.
328) Alhaj Ali {Day59/47:6}-{Day59/49:6}.
329) Alhaj Ali {Day59/60:18}-{Day59/62:19}.
330) Alhaj Ali {Day59/58:17}-{Day59/59:17}; {Day59/67:15}-{Day59/68:22}.
331) Alhaj Ali {Day59/69:18}-{Day59/80:17}; {Day59/81:2}-{Day59/83:10}.
332) Alhaj Ali {Day59/85:18}-{Day59/93:5}.
333) Alhaj Ali {Day59/93:21}-{Day59/95:17}.
334) Herrera {Day38/102:22}-{Day38/103:11}; {Day38/120:16-20}; {Day38/128:21}-{Day38/129:7}.
335) Herrera {Day38/108:25}-{Day38/110:12}.
336) Herrera {Day38/109:7}-{Day38/112:6}.
337) Herrera {MET00010876/5} page 5; Herrera {Day38/112:7}-{Day38/114:22}.
338) Herrera {Day38/116:6-20}; {Day38/118:4}-{Day38/120:25}; {Day38/122:23}-{Day38/124:9}.
339) Alkabib {MET00021446/2} page 2.
340) Alhaj Ali {Day59/94:14-24}.
341) Phase 1 Report Volume III Annex A.
342) McAlonen {Day38/171:10}-{Day38/172:23}; Juggins {Day40/78:7}-{Day40/79:11}.
343) McAlonen {Day38/166:8-11}; {Day38/174:2-12}; De Silvo Exhibit LDS/3 - Photograph of wall on floor 3 {MET00015819}.
344) McAlonen {Day38/173:9}.
345) Herrera {Day38/116:6-9}.
346) De Silvo Exhibit LDS/3 - Photograph of wall on floor 3 {MET00015819}.
347) Phase 1 Report Volume IV paragraph 28.86.
348) Williams {Day31/106:17}-{Day31/107:21}; Phase 1 Report Volume II Figure 14.5.
349) Alhaj Ali {Day59/85:24}-{Day59/90:17}.
350) CCTV Stills {INQ00000449}, {INQ00000450}, {INQ00000253}, Williams {Day31/140:18}. In each still, WM Williams is the firefighter without a helmet.
351) LFB Operational Response Report {LFB00119333/248}.
352) BA Telemetry data {LFB00023326}; Wharnsby {Day38/186:16}-{Day38/187:13}.
353) Wharnsby {Day38/188:19}-{Day38/189:3}; {Day38/191:18}-{Day38/197:4}.
354) Phase 1 Report Volume III paragraphs 17.93 and 17.94.
355) 999 call transcript {LFB00000405}.
356) 999 call transcript {LFB00000418}.
357) Phase 1 Report Volume III paragraphs 15.139-15.141 and Figures 15.8 and 15.9.
358) Control Information Form {LFB00001968/44}.
359) Phase 1 Report Volume II Figure 14.5; Williams {Day31/137:13}-{Day31/139:21}. WM Williams said that the note “BA” which appears next to”113” was not intended to be linked by an arrow to that flat but to Flat 123 which appears immediately next in the list.
360) Al-Karad {IWS00000821/8-9} pages 8-9, paragraph 35; Al-Karad Exhibit MAK2 – telephone log {IWS00000791}.
361) Metropolitan Police Memo {LFB00001968/26}.
362) Phase 1 Report Volume II Figure 14.5.
363) Zainab Deen call records. These records were not available to the Inquiry at the time of publication of the Phase 1 Report.
364) Phase 1 Report Volume III paragraphs 17.95-17.97; Furnell {Day40/5:8-14}; {Day40/6:7-20}; {Day40/8:20}.
365) Batcheldor {Day34/172:5}-{Day34/173:10}; Notebook entry {LFB00001968/17}.
366) Phase 1 Report Volume IV paragraph 28.114.
367) Phase 1 Report Volume III paragraph 17.20 (d).
368) Phase 1 Report Volume III paragraph 17.20 (d).
369) Purser, Phase 2 Report, Section 6 {DAPR0000006/143} paragraph 769; External Fire Spread Report {MET00012593/78} image 42 (applying a +58 minute correction to timestamp).
370) Purser, Phase 2 Report, Section 6 {DAPR0000006/146-147} paragraph 793.
371) Phase 1 Report Volume IV paragraphs 32.285-32.291.
372) Murphy {IWS00001049/2} page 2, paragraph 4.
373) Noble {Day119/77:17}-{Day119/82:5}.
374) O’Riordan {MET00013136/2} page 2.
375) External Fire Spread Report {MET00012593/7}.
376) Phase 1 Report Volume II paragraphs 10.236 and 10.312.
377) Murphy {IWS00001049/2} page 2, paragraph 4.
378) Phase 1 Report Volume II paragraphs 11.89 and 12.70.
379) Murphy {IWS00001049/2} page 2, paragraph 6.
380) Phase 1 Report Volume II paragraph 12.95.
381) Phase 1 Report Volume II paragraphs 13.8-13.9.
382) Phase 1 Report Volume II paragraphs 14.198-14.199.
383) Phase 1 Report Volume II paragraphs 14.90 and 14.202.
384) Oyewole {IWS00000852/9} page 9, paragraph 34.
385) Oyewole {Day58/47:8-13}.
386) Oyewole {IWS00000852/10} page 10, paragraph 37; Talabi {Day59/127:17}–{Day59/128:8}.
387) Oyewole {IWS00000852/11} page 11, paragraph 42; Alhaj Ali {Day59/62:2-5}.
388) Phase 1 Report Volume III paragraph 19.40.
389) Phase 1 Report Volume III paragraph 19.40.
390) Phase 1 Report Volume II paragraph 14.206.
391) 999 call transcript {LFB00000405}; 999 call transcript {LFB00000418}; Phase 1 Report Volume III paragraphs 17.93-17.94.
392) Phase 1 Report Volume III paragraphs 17.95-17.97.
393) Zainab Deen call records. These records were not available to the Inquiry at the time of completion of the Phase 1 Report.
394) Hashem Alhajali {MET00007745/4} page 4; Phase 1 Report Volume III paragraphs 19.32-19.33
395) Phase 1 Report Volume III paragraph 19.34.
396) Aesem Alhajali {MET00039851/6} page 6.
397) Purser, Phase 2 Report, Section 6 {DAPR0000006/146} paragraph 792; External Spread of Fire Report {MET00012593/78} Images 41-42 (applying a +58 minute correction to timestamps).
398) Purser, Phase 2 Report, Section 6 {DAPR0000006/146} paragraph 792; External Spread of Fire Report {MET00012593/78} page 78, Image 47 (applying a +58 minute correction to timestamps).
399) External Spread of Fire Report {MET00012593/85} Images 44-47 (applying a +58 minute correction to timestamps).
400) Phase 1 Report Volume III paragraphs 17.88 and 19.35.
401) Stoianov, Chapter 5 {ISTRP00000006/141}, {ISTRP00000006/142}; {ISTRP00000006/148-153}.
402) Purser, Phase 2 Report, Section 6 {DAPR0000006/151} paragraph 826.
403) Purser, Phase 2 Report, Section 6 {DAPR0000006/139} paragraph 748.
404) Purser, Phase 2 Report, Section 6 {DAPR0000006/154} paragraph 845.
405) Phase 1 Report Volume IV paragraphs 32.266-32.273.
406) Tenancy Agreement for Zainab Deen {TMOH00013271}.
407) Noble {Day119/77:17}-{Day119/82:5}.
408) Dean {IWS00001048/2} page 2, paragraph 10.
409) Dean {IWS00001048/3} page 3, paragraph 11.
410) O’Riordan {MET00013136/4} page 4; Dean {IWS00001048/3} page 3, paragraph 14.
411) Phase 1 Report Volume II paragraph 10.118.
412) Phase 1 Report Volume II paragraph 10.237; 999 call transcript {INQ00000270/3-4}.
413) 999 call transcript {LFB00000321/7}.
414) Phase 1 Report Volume II paragraphs 12.58 and 12.96.
415) 999 call transcript {INQ00000270/3-4}.
416) 999 call transcript {LFB00000341}.
417) Phase 1 Report Volume II paragraph 14.203.
418) Oyewole {Day58/46:16}; Omar Alhaj Ali {Day59/46:17-18}.
419) Oyewole {Day58/46:19-23}.
420) Oyewole {Day58/46:24}-{Day56/Day47:4}.
421) Oyewole {Day58/59:4-15}.
422) Oyewole {Day58/61:19-20}; {Day58/69:23}-{Day58/70:20}; {Day58/87:15}.
423) Phase 1 Report Volume II paragraph 14.255.
424) 999 call transcript {MET00017520}.
425) 999 call transcript {LFB00000694}.
426) Phase 1 Report Volume III paragraph 17.91.
427) Phase 1 Report Volume III paragraph 17.92.
428) Phase 1 Report Volume II paragraph 14.206.
429) Phase 1 Report Volume III paragraph 17.93.
430) Phase 1 Report Volume III paragraph 17.94.
431) Zainab Deen call records. These records were not available to the Inquiry at the time of completion of the Phase 1 Report.
432) Phase 1 Report Volume III paragraphs 17.94-17.95.
433) Phase 1 Report Volume III paragraphs 17.96-17.97.
434) Batcheldor {Day34/162:3}-{Day34/164:20}.
435) Batcheldor {Day34/164:23}-{Day34/168:24}.
436) Batcheldor {Day34/168:24}-{Day34/169:22}.
437) Batcheldor {Day34/170:3}-{Day34/171:9}; Batcheldor {MET00007511/7} page 7.
438) Phase 1 Report Volume III paragraph 17.99.
439) Purser, Phase 2 Report, Section 6 {DAPR0000006/146} paragraph 792; External Spread of Fire Report {MET00012593/78} page 78, Images 41-42 (applying a +58 minute correction to timestamps).
440) Purser, Phase 2 Report, Section 6 {DAPR0000006/146} paragraph 792; External Spread of Fire Report {MET00012593/78} Image 47 (applying a +58 minute correction to timestamps).
441) External Spread of Fire Report {MET00012593/85} Images 44-47 (applying a +58 minute correction to timestamps).
442) Phase 1 Report Volume III paragraphs 17.88 and 19.35.
443) Stoianov, Chapter 5 {ISTRP00000006/141}, {ISTRP00000006/142}; {ISTRP00000006/148-153}.
444) Purser, Phase 2 Report, Section 6 {DAPR0000006/152} paragraph 827.
445) Interim certificate of the fact of death for Zainab Deen {MET00065637}; Interim certificate of the fact of death for Jeremiah Deen {MET00065619};
446) Zainab Deen post-mortem report {COR00001553}; Zainab Deen toxicology report {MET00039590}; Purser Phase 2 Report, Section 6 {DAPR0000006/152} paragraph 827.
447) Jeremiah Deen post-mortem report {COR00000735}; Jeremiah Deen toxicology report {MET00039530}; Purser Phase 2 Report, Section 6 {DAPR0000006/152} paragraph 828.
448) Purser, Phase 2 Report, Section 6 {DAPR0000006/153} paragraph 834.
449) Phase 1 Report Volume IV paragraph 32.279.
450) Phase 1 Report Volume IV paragraph 32.281.
451) Phase 1 Report Volume IV paragraph 32.274.
452) Noble {Day119/77:17}-{Day119/82:5}.
453) Alhaj Ali {IWS00000781/4} page 4, paragraph 12.
454) Mohammad Alhajali appears on CCTV returning to the tower at 00.07. O’Riordan {MET00013136/4}.
455) Phase 1 Report Volume II paragraph 11.94.
456) Phase 1 Report Volume II paragraphs 11.94 - 11.96.
457) Alhaj Ali {IWS00000781/7} page 7, paragraph 20.
458) Phase 1 Report Volume II paragraphs 14.196 - 14.197.
459) Phase 1 Report Volume II paragraphs 13.12 and 14.197.
460) Phase 1 Report Volume II paragraphs 13.9-13.10 and 14.198.
461) Phase 1 Report Volume II paragraph 14.199.
462) Phase 1 Report Volume II paragraph 14.88.
463) Phase 1 Report Volume II paragraph 14.202.
464) Phase 1 Report Volume II paragraph 14.206.
465) Phase 1 Report Volume III paragraph 17.88.
466) Hashem Alhajali {MET00007745/4} page 4; Phase 1 Report Volume III paragraphs 19.32-19.33.
467) Phase 1 Report Volume III paragraph 19.34.
468) Aesem Alhajali {MET00039851/6} page 6.
469) Collins {MET00010086/5} page 5.
470) Collins {MET00010086/10-13} pages 10-13; Collins Exhibit SMC/5 - Photographs of Grenfell Tower {MET00015914/24}.
471) Sibthorpe {MET00015658/5} page 5.
472) Interim certificate of the fact of death for Mohammad Alhajali {MET00065645}.
473) Alhajali post-mortem report {COR00001135}; Purser, Phase 2 Report, Section 6 {DAPR0000006/152} paragraphs 829-831.
474) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447.
475) Alhajali post-mortem report {COR00001135}; Purser, Phase 2 Report, Section 6 {DAPR0000006/152} paragraphs 830.
476) Phase 1 Report Volume II paragraph 10.15.
477) Phase 1 Report Volume III Annex A.
478) Bisby, Supplemental Phase 1 Expert Report {LBYS0000001/159}.
479) Ali {Day67/47:8-17}.
480) Phase 1 Report Volume III Annex A.
481) Phase 1 Report Volume II paragraph 10.79 (b).
482) Phase 1 Report Volume II paragraph 10.101 (a).
483) Badillo {Day13/119:6}-{Day13/123:7}.
484) Phase 1 Report Volume II paragraph 11.10.
485) Phase 1 Report Volume II paragraphs 11.86 and 11.87.
486) Phase 1 Report Volume II paragraph 13.14.
487) Mills {MET000080584/6} page 6.
488) Campbell {MET00010788/8-10} pages 8-10.
489) Phase 1 Report Volume II paragraph 14.194.
490) Phase 1 Report Volume II paragraph 14.194.
491) BA Telemetry Data {LFB00023326/1} page 1.
492) Phase 1 Report Volume III paragraphs 17.85, 17.138, 18.43 and 18.44.
493) Phase 1 Report Volume III paragraphs 18.46 and 18.47.
494) Phase 1 Report Volume IV paragraphs 32.259-32.263.
495) Ross {IWS00001036/6} page 6, paragraph 15.
496) Bobby Ross Exhibit BR/4 – Letters from North Kensington Law Centre to KCTMO {IWS00002360}.
497) Rydon Residents Survey {RYD00024466/24}.
498) Noble {TMO00000884}.
499) Phase 1 Report Volume II paragraph 14.191.
500) Phase 1 Report Volume II paragraphs 14.192-14.193.
501) Phase 1 Report Volume III paragraphs 16.64-16.66; Ross {IWS00001036/15} page 15, paragraph 35.
502) Dwyer {MET00012781/5-6} pages 5-6; Perez {MET00017426/6} page 6; LFB Operational Response Report dated July 2020 {LFB00119333/231}.
503) Perez {MET00017426/6} page 6.
504) Phase 1 Report Volume III Annex A.
505) Ross {IWS00001036/21} page 21, paragraph 55.
506) Phase 1 Report Volume IV paragraph 28.84 (d).
507) Phase 1 Report Volume II paragraphs 12.8-12.9.
508) Phase 1 Report Volume II Figure 12.3.
509) Phase 1 Report Volume III paragraph 15.13; Phase 1 Report Volume III paragraph 16.12 and Figure 16.5; Photograph of whiteboard {MET00015924}.
510) Goodall {MET000083296/11} page 11.
511) Singh {MET000083327/12} page 12.
512) Phase 1 Report Volume II paragraphs 14.103-14.105 and Figure 14.5; Photographs of ground floor wall {MET00005774} and {MET00005776}.
513) Singh Exhibit MSI/1 – pages from notebook {MET00013089/1}.
514) Phase 1 Report Volume IV paragraph 28.85 (a).
515) Singh {MET000083327/16} page 16.
516) Williams {Day31/113:23}-{Day31/114:1}; {Day31/162:9-22}.
517) Williams {Day31/164:18-21}.
518) Williams {Day31/164:9-17}.
519) Phase 1 Report Volume II Figure 15.7; The photograph was taken at 03.08 when the bridgehead was about to be relocated to the ground floor: Cook Exhibit GAC/2 - Grenfell Tower statement notes {MET00015779/16} page 16.
520) De Silvo {Day30/24:16}-{Day30/25:6}; {Day30/31:6}-{Day30/32:17}.
521) Control information form {LFB00001955/1}. The forms were used at the incident ground to record information about people needing to be rescued.
522) De Silvo {Day30/32:8-17}.
523) Phase 1 Report Volume III paragraphs 15.59-15.60; Nuttall {MET00012561/11-14} pages 11 and 13-14.
524) Ross {IWS00001036/11} page 11, paragraph 29.
525) Purser, Phase 2 Report, Section 6 {DAPR0000006/134} paragraph 723.
526) Interim certificate of the fact of death for Steven Power {MET00065616}.
527) Presentation relating to Steven Power {Day307/92:10-15}.
528) Power post-mortem report {COR00001432}; Power toxicology report {COR00001444}; Purser, Phase 2 Report, Section 6 {DAPR0000006/134} paragraph 723.
529) Purser, Phase 2 Report, Section 6 {DAPR0000006/133} paragraph 715.
530) Purser {Day297/114:14-25}.
531) Bisby, Supplemental Phase 1 Expert Report {LBYR00000001/149} Figure 96.
532) Phase 1 Report Volume II paragraph 10.238.
533) Phase 1 Report Volume II paragraph 10.238.
534) Wahbi {IWS00001157/6-10} pages 6 and 10, paragraphs 26 and 55; Wahbi {Day62/36:18}-{Day62/37:1}.
535) Phase 1 Report Volume II paragraphs 11.68 and 11.70.
536) Phase 1 Report Volume II paragraphs 11.77 and 11.78.
537) Phase 1 Report Volume II paragraphs 1171-11.73.
538) Phase 1 Report Volume II paragraph 11.79.
539) Phase 1 Report Volume II paragraphs 11.79, 10.101 (b) and 10.101 (c).
540) Phase 1 Report Volume II paragraphs 10.101 (b) and (c).
541) Stern {MET00012483/10} page 10.
542) Hippel {Day26/63:7}-{Day26/68:21}.
543) Phase 1 Report Volume II paragraphs 10.101 (c), 11.81 and 11.82.
544) Phase 1 Report Volume II paragraphs 10.101 (c) and 11.81.
545) Phase 1 Report Volume II paragraph 10.101 (c); Hippel {Day26/93:7}-{Day26/94:14}.
546) Phase 1 Report Volume II paragraph 10.101 (c).
547) Stern {MET00012483/12-13} pages 12-13; Stern Exhibit JAS/3 – Floorplan of Floor 16 {MET00016893}.
548) Hippel {Day26/93:7}-{Day26/96:13}.
549) Hippel {Day26/95:19-25}.
550) Macit {Day65/130:14-19}.
551) Phase 1 Report Volume II paragraph 11.15; Stern {Day26/190:3}-{Day26/193:20}.
552) Phase 1 Report Volume II paragraph 11.15.
553) CCTV Stills {INQ00000478}; {INQ00000477}; {INQ00000479}.
554) Wahbi {Day62/62:12}-{Day62/64:20}.
555) Loft {Day29/37:17}-{Day28/39:9}.
556) 999 call transcript {INQ00000280}.
557) Phase 1 Report Volume II paragraph 12.79; 999 call transcript {LFB00000497}.
558) Phase 1 Report Volume II paragraph 12.88; Short Incident Log Report {MET00013830/19-20}; LFB Radio Messages {LFB00002952}.
559) Phase 1 Report Volume II paragraph 12.89.
560) Phase 1 Report Volume II paragraph 12.90.
561) Phase 1 Report Volume II paragraph 14.188; Phase 1 Report Volume III paragraphs 15.86-15.87.
562) Phase 1 Report Volume III paragraph 15.89.
563) Phase 1 Report Volume III paragraph 15.89.
564) Phase 1 Report Volume III paragraph 17.80.
565) Phase 1 Report Volume III paragraphs 17.80-17.82.
566) 999 call transcript {LFB00000560}.
567) 999 call transcript {LFB00000529}.
568) Phase 1 Report Volume III paragraphs 18.39-18.42.
569) BA Telemetry Data {LFB00023326/2} page 2.
570) Diana {MET00018800/8-12} pages 8-12; Nelson {MET00010926/4-9} pages 4-9; Phase 1 Report Volume III paragraph 18.20 (b).
571) BA Telemetry Data {LFB00023326/3} page 3.
572) Phase 1 Report Volume III paragraph 19.9; Cook {MET00007882/14-15} pages 14-15.
573) Phase 1 Report Volume IV paragraph 32.255.
574) Presentation relating to Joseph Daniels {Day307/46:19}-{Day307/47:22}; Tenancy Agreement {TMOH00024682}.
575) Presentation relating to Joseph Daniels {Day307/47:24}-{Day307/48:3}.
576) Phase 1 Report Volume II paragraph 11.67.
577) Daniels {IWS00000608/2} page 2, paragraph 8.
578) Daniels {Day56/5:8-22}; Phase 1 Report Volume II paragraph 11.67.
579) Rydon Residents Survey {RYD00024466/20}.
580) TMO Referral Form {TMOH00024715}; Daniels {IWS00002065/9} page 9, paragraph 55.
581) Daniels {IWS00002065/8} page 8, paragraph 52; Email from RBKC regarding adult social care {RBK00038674}; Care and Support Plan Review of Samuel Daniels {RBK00059536/4}.
582) Noble {TMO00000884/1} page 1, paragraph 3.
583) Noble {Day119/77:17}-{Day119/82:5}.
584) Daniels {IWS00000608/8} page 8, paragraph 47.
585) Phase 1 Report Volume II paragraphs 11.68 and 11.70.
586) Phase 1 Report Volume IV paragraph 24.31; Wahbi {IWS00001157/10-11} pages 10-11, paragraph 55.
587) Daniels {IWS00000608/6} page 6, paragraph 40; Daniels {Day56/18:18}-{Day56/20:4}; Daniels Exhibit SD/02 -TMO repairs log for Flat 135 regarding front door not closing {IWS00002067}; Daniels Exhibit SD/03 - TMO dashboard snapshot of front door repair at Flat 135 {IWS00002068}; Daniels Exhibit SD/04 - TMO dashboard snapshot of the repairs log for Fat 135 {IWS00002069}.
588) Phase 1 Report Volume II paragraph 11.79.
589) Phase 1 Report Volume II paragraph 10.101 (b).
590) Stern {MET00012483/10} page 10; Hippel {Day26/63:7}-{Day26/68:21}.
591) Phase 1 Report Volume II paragraphs 11.81 and 10.101 (c).
592) Phase 1 Report Volume II paragraph 10.101 (c).
593) Stern {MET00012483/12-13} pages 12-13; Stern Exhibit JAS/3 - Floorplan of Floor 16 {MET00016893}; Hippel {Day26/69:19}-{Day26/73:7}.
594) Phase 1 Report Volume II paragraph 11.82.
595) Phase 1 Report Volume II paragraph 11.15; Stern {Day26/190:3}-{Day26/193:20}.
596) Phase 1 Report Volume II paragraph 11.15.
597) Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraph 28.84 (c).
598) Phase 1 Report Volume IV paragraph 28.84 (b).
599) Phase 1 Report Volume IV paragraphs 28.86 and 28.87.
600) Phase 1 Report Volume II Figure 15.7; The photograph was taken at 03.08 when the bridgehead was about to be relocated to the ground floor: Cook Exhibit GAC/2 - Grenfell Tower statement notes {MET00015779/16} page 16.
601) Phase 1 Report Volume IV paragraph 28.87.
602) Mulholland Exhibit MBM/02 - Photograph of green wall {MET00018739}.
603) LFB Control Information Forms {LFB00001955/10} page 10.
604) Phase 1 Report Volume IV paragraph 28.84 (e).
605) Phase 1 Report Volume IV paragraph 28.84 (g).
606) Wahbi {Day62/63:5}-{Day62/65:18}; CCTV Stills {INQ00000476}; {INQ00000477}; {INQ00000478}; Loft {Day28/37:17}-{Day28/39:9}.
607) Daniels {IWS00000608/14} page 14, paragraph 85; Daniels {Day56/71:13-23}.
608) Daniels {Day56/71:20}-{Day56/72:3}.
609) BA Telemetry Data {LFB00023326/2} page 2.
610) Diana {MET00018800/8-12} pages 8-12; Nelson {MET00010926/4-9} pages 4-9; Phase 1 Report Volume III paragraph 18.20 (b).
611) Phase 1 Report Volume III paragraph 19.9; Cook {MET00007882/14-15} pages 14-15.
612) Purser, Phase 2 Report, Section 6 {DAPR0000006/126} paragraph 678; Presentation relating to Joseph Daniels {Day307/71:3-6}.
613) Interim certificate of the fact of death for Joseph Daniels {MET00065647}.
614) Daniels post-mortem report {COR00000793/10}; Daniels supplementary post-mortem report {COR00000791/2}; Daniels toxicology report {MET00039529}; Purser, Phase 2 Report, Section 6 {DAPR0000006/127} paragraph 688.
615) Purser, Phase 2 Report, Section 6 {DAPR0000006/127} paragraph 686.
616) Purser, Phase 2 Report, Section 6 {DAPR0000006/127} paragraph 686; Purser {Day297/111:4-5}.
617) Phase 1 Report Volume IV paragraph 32.257.
618) Tenancy Agreement {TMOH00018942}.
619) Presentation relating to Sheila {Day304/58:24}-{Day304/59:18}.
620) Smith {COR00001396/4} page 4.
621) Video footage of the meeting with residents on 17 July 2015 {MET00078076}.
622) Rydon Residents Survey {RYD00024466/21}.
623) Noble {TMO00000884/1} page 1, paragraph 3.
624) Noble {Day119/77:17}-{Day119/82:5}.
625) O’Riordan {MET00013136/2} page 2.
626) Smith {COR00001396/4} page 4.
627) Phase 1 Report Volume II paragraph 10.101 (c).
628) BA Telemetry Data {LFB00023326/2} page 2.
629) Diana {MET00018800/8-12} pages 8-12; Nelson {MET00010926/4-9} pages 4-9; Phase 1 Report Volume III paragraph 18.20 (b).
630) Phase 1 Report Volume III paragraph 19.9; Cook {MET00007882/14-15} pages 14-15.
631) Purser, Phase 2 Report, Section 6 {DAPR0000006/130} paragraph 702; Presentation relating to Sheila {Day304/68:14-19}.
632) Interim certificate of the fact of death for Shiela {MET00065609}.
633) Sheila post-mortem report {COR00001397}.
634) Purser, Phase 2 Report, Section 6 {DAPR0000006/129} paragraphs 696-698.
635) Purser, Phase 2 Report, Section 6 {DAPR0000006/129} paragraphs 699-701.
636) Purser, Phase 2 Report, Section 6 {DAPR0000006/130} paragraphs 704-705.
637) Phase 1 Report Volume II paragraph 10.15.
638) Phase 1 Report Volume III Annex A.
639) See Chapter 86.
640) Phase 1 Report Volume II paragraphs 10.239-10.240.
641) Phase 1 Report Volume III Annex A.
642) Phase 1 Report Volume II paragraph 10.118.
643) Phase 1 Report Volume II paragraphs 10.242-10.243; Phase 1 Report Volume VI paragraph 24.31 (e).
644) Phase 1 Report Volume II paragraphs 10.244-10.245.
645) Phase 1 Report Volume II paragraphs 10.239-10.240.
646) Phase 1 Report Volume II paragraph 10.247.
647) Lane, Supplemental Phase 1 Report, Section 12 {BLAS0000012/19} paragraph 12.3.17.
648) External Spread of Fire Report {MET00012593/12} page 12.
649) Purser, Phase 2 Report, Section 6 {DAPR0000006/117} paragraph 640.
650) Purser, Phase 2 Report, Section 6 {DAPR0000006/118-119} paragraphs 640 and 648.
651) External Spread of Fire Report {MET00012593/12} page 12.
652) Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraph 667.
653) Hakim {IWS00000019/2} page 2, paragraph 4.
654) Phase 1 Report Volume IV paragraph 32.240.
655) Phase 1 Report Volume IV paragraph 32.241.
656) Phase 1 Report Volume IV paragraphs 32.242 and 32.248-32.249.
657) Phase 1 Report Volume IV paragraphs 32.242 and 32.251.
658) Phase 1 Report Volume IV paragraphs 32.242 and 32.252-32.253.
659) Hakim {IWS00000019/7} page 7, paragraph 21.
660) Hakim {IWS00000019/1} page 1, paragraph 3.
661) Khanom {COR00001147/7-8} pages 7-8; Hakim {IWS00000019/2} page 2, paragraph 6.
662) Khanom {COR00001147/2} page 2.
663) Noble {TMO00000884/1} page 1, paragraph 3.
664) Noble {Day119/77:17}-{Day119/82:5}.
665) Hakim {IWS00000019/3} page 3, paragraphs 9-10.
666) 999 call transcript {INQ00000264}; Phase 1 Report Volume II paragraph 10.247; Phase 1 Report Volume IV paragraph 28.102 (a).
667) Phase 1 Report Volume IV paragraphs 28.102 (b) and 28.102 (c).
668) Photograph of notes made by LFB on walls inside Grenfell Tower {MET00005789}.
669) Phase 1 Report Volume II paragraphs 13.52-13.53.
670) Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraph 28.84 (c).
671) Phase 1 Report Volume IV paragraph 28.102 (c); Phase 1 Report Volume II Figure 15.7.
672) 999 call transcript {LFB00000354}; Phase 1 Report Volume III paragraph 15.85; Phase 1 Report Volume IV paragraph 28.102 (d).
673) Purser, Phase 2 Report, Section 6 {DAPR0000006/117} paragraph 640.
674) Phase 1 Report Volume III paragraph 15.149; LFB radio message {LFB00002784}.
675) Phase 1 Report Volume II paragraphs 12.8-12.9; Phase 1 Report Volume IV paragraphs 28.86 and 28.102 (f).
676) Phase 1 Report Volume IV paragraph 28.102 (e).
677) LFB Control Information Forms {LFB00001955/12} page 12. The forms were used at the incident ground to record messages about people needing to be rescued.
678) Phase 1 Report Volume III paragraph 15.84.
679) External Spread of Fire Report {MET00012593/77} Image 25 (applying a +58 minutes time correction); Lane, Supplemental Phase 1 Report, Section 12 {BLAS0000012/10} Figure 12.3; Purser, Phase 2 Report, Section 6 {DAPR0000006/117} paragraph 640.
680) Phase 1 Report Volume III paragraph 17.76.
681) Phase 1 Report Volume III paragraph 17.76.
682) Hakim {IWS00000019/1} page 5, paragraph 15.
683) Phase 1 Report Volume III paragraph 17.77; Phase 1 Report Volume IV paragraph 28.102 (h).
684) Phase 1 Report Volume III paragraph 17.76.
685) 999 call transcript {LFB00000419}; Phase 1 Report Volume IV paragraph 28.102 (i).
686) Phase 1 Report Volume III paragraph 17.79.
687) Phase 1 Report Volume III paragraphs 15.139-15.141 and Figures 15.8 and 15.9.
688) Phase 1 Report Volume IV paragraph 28.102 (j).
689) Phase 1 Report Volume IV paragraph 28.87.
690) Mulholland Exhibit MBM/02 - Photograph of green wall {MET00018739}; Phase 1 Report Volume IV paragraph 28.102.(l).
691) See Chapter 92.
692) Phase 1 Report Volume IV paragraph 28.103.
693) Purser, Phase 2 Report, Section 6 {DAPR0000006/117} paragraph 638.
694) Interim certificates of the fact of death for Kamru Miah, Rabeya Begum, Mohammed Hamid, Mohammed Hanif and Husna Begum {MET0006560}; {MET00065588}; {MET00065642}; {MET00065628}, {MET00065594}.
695) Purser, Phase 2 Report, Section 6 {DAPR0000006/118-119} paragraphs 645 and 646.
696) Purser, Phase 2 Report, Section 6 {DAPR0000006/119} paragraph 646.
697) Bisby, Phase 1 Expert Report {LBYR00000001/175} Figure 116; Lane, Supplemental Phase 1 Report, Section 12 {BLAS0000012/11} Figure 12.4; Purser, Phase 2 Report, Section 6 {DAPR0000006/118} paragraph 640.
698) LFB Operational Response Report dated July 2020 {LFB00119333/289} page 289.
699) Purser, Phase 2 Report, Section 6 {DAPR0000006/118} paragraph 640.
700) Purser, Phase 2 Report, Section 6 {DAPR0000006/119-122} paragraphs 647 and 662-663.
701) Miah post-mortem report {COR00000814/4}; Rabeya Begum post-mortem report {COR00001322/5-6}; Hamid post-mortem report {COR00001153/4}; Hanif post-mortem report {COR00000812/4}; Purser, Phase 2 Report, Section 6 {DAPR0000006/119-121} paragraphs 649-652 and 657.
702) Miah post-mortem report {COR00000814/6-8}; Purser, Phase 2 Report, Section 6 {DAPR0000006/119} paragraph 650.
703) Rabeya Begum post-mortem report {COR000001322/8-9}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 652.
704) Hamid post-mortem report {COR00001153/4-5}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 653.
705) Miah toxicology report {COR00000822/1}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 651.
706) Hanif toxicology report {MET00039589/1}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 651.
707) Hamid post-mortem report {COR00001153/8}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 653.
708) Rabeya Begum post-mortem report {COR00001322/9}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 652.
709) Phase 2 Report, Section 6 {DAPR0000006/119-121} paragraphs 650-653 and 658.
710) Miah post-mortem report {COR00000814/8}; Purser, Phase 2 Report, Section 6 {DAPR0000006/119} paragraph 650.
711) Husna Begum post-mortem report {COR00000636/4}; Husna Begum toxicology report {COR00000642}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120-122} paragraphs 654, 659 and 664.
712) Purser, Phase 2 Report, Section 6 {DAPR0000006/119-122} paragraphs 647 and 662-663.
713) Phase 1 Report Volume IV paragraphs 32.228-32.230; Chiejina {IWS00002348/2} page 2, paragraphs 6 and 10.
714) Tenancy Agreement for Vincent Chiejina {TMOH00025056}.
715) Presentation relating to Vincent Chiejina {Day307/27:17-18}.
716) Phase 1 Report Volume IV paragraph 32.232.
717) Chiejina {IWS00002348/2} page 2, paragraphs 11-13.
718) Rydon Residents Survey {RYD00024466/18}.
719) Noble {TMO00000884/1} page 1, paragraph 3.
720) Noble spreadsheet {TMO00862588}.
721) Phase 1 Report Volume II paragraph 11.64.
722) Purser, Phase 2 Report, Section 6 {DAPR0000006/122} paragraph 666.
723) Purser, Phase 2 Report, Section 6 {DAPR0000006/122} paragraph 665.
724) Interim certificate of the fact of death for Vincent Chiejina {MET00065620}.
725) Chiejina post-mortem report {COR00001473/10}; Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraphs 669-670.
726) Chiejina toxicology report {COR00001483/1}; Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraphs 669-670.
727) Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraph 672.
728) Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraphs 670 and 673-674; Purser {Day297/102:13}-{Day297/103:18}.
729) Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraph 670; Purser {Day297/103:19}-{Day297/104:11}.
730) Purser {Day297/99:3}-{Day297/103:18}.
731) Phase 1 Report Volume II paragraph 10.15.
732) Phase 1 Report Volume II paragraph 10.118.
733) Phase 1 Report Volume II paragraphs 10.249-10.250; Phase 1 Report Volume III Annex A.
734) Phase 1 Report Volume II paragraph 10.251.
735) Phase 1 Report Volume II paragraphs 10.254, 10.289 and 14.125.
736) Phase 1 Report Volume II paragraph 11.59; 999 call transcript {LFB00000662/1-2} pages 1-2.
737) Short Incident Log Report {MET00013830/19} page 19.
738) Phase 1 Report Volume II paragraphs 11.148-11.154.
739) Phase 1 Report Volume II paragraphs 12.72-12.73.
740) Short Incident Log Report {MET00013830/19} page 19.
741) Phase 1 Report Volume II paragraph 11.6; Phase 1 Report Volume IV paragraph 28.84 (a).
742) Phase 1 Report Volume II paragraphs 12.18-12.19 and 14.71 and Figure 12.4.
743) Phase 1 Report Volume IV paragraph 28.84 (b).
744) O’Bierne {MET000083321/19} page 19; Phase 1 Report Volume III Figure 16.6.
745) Phase 1 Report Volume II paragraph 13.47.
746) Phase 1 Report Volume II paragraphs 11.60-11.62 and 14.180-14.181.
747) Phase 1 Report Volume II paragraphs 13.51, 13.67, 14.181 and 14.182.
748) Phase 1 Report Volume II paragraphs 13.49 and 14.184-14.186.
749) Phase 1 Report Volume II paragraph 13.50.
750) Phase 1 Report Volume II paragraphs 13.51 and 14.182.
751) Phase 1 Report Volume III paragraph 15.3.
752) Phase 1 Report Volume III paragraphs 15.79-15.81.
753) Tekle {IWS00001051/1-2} pages 1-2, paragraph 5.
754) Phase 1 Report Volume IV paragraphs 32.214-32.217.
755) Noble {TMO00000884/1} page 1, paragraph 3; Noble {Day119/75:19-21}; Noble spreadsheet {TMO00862588}.
756) O’Riordan {MET00013136/3} page 3.
757) Tekle {IWS00001051/3-4} pages 3-4, paragraphs 11-14.
758) Phase 1 Report Volume II paragraph 10.252.
759) Phase 1 Report Volume II paragraph 10.252. The call was not answered.
760) Phase 1 Report Volume II paragraph 11.61.
761) Phase 1 Report Volume III paragraph 17.11; Phase 1 Report Volume IV paragraph 28.86.
762) Phase 1 Report Volume III paragraph 15.31.
763) Phase 1 Report Volume III paragraph 15.31.
764) Cook Exhibit GAC/2 - Grenfell Tower statement notes {MET00015779/16} page 16.
765) Phase 1 Report Volume III Figure 15.7.
766) De Silvo {Day30/31:13}-{Day30/32:17}.
767) Phase 1 Report Volume III paragraph 15.32.
768) Batterbee {Day12/156:4}-{Day 12/158:25}.
769) Control Information Forms {LFB00001955/21-26} pages 21-22 and 26. The forms were used at the incident ground to record messages about people needing rescue.
770) Phase 1 Report Volume II paragraph 14.73.
771) Phase 1 Report Volume II paragraph 14.103.
772) Wolfenden Exhibit PFW/2 - Photograph of ground floor wall {MET00017597}; De Silvo Exhibit LDS/5 - Photograph of ground floor wall {MET00015815}.
773) Phase 1 Report Volume III paragraph 15.82; 999 call transcript {LFB00000361/5-6} pages 5-6.
774) Phase 1 Report Volume III paragraph 15.81; 999 call transcript {LFB00000365}.
775) Phase 1 Report Volume III paragraph 15.152.
776) Phase 1 Report Volume III paragraphs 15.152 and 15.173; Short Incident Log Report {MET00013830/23} page 23.
777) Phase 1 Report Volume III paragraphs 15.139-15.141, 15.152 and 15.173 and Figure 15.8.
778) 999 call transcript {LFB00000362}.
779) 999 call transcript {LFB00000371}.
780) 999 call transcript {LFB00000541}.
781) 999 call transcripts {INQ00000265}; {INQ00000266}.
782) 999 call transcript {LFB00000542}.
783) Phase 1 Report Volume II paragraphs 12.8-12.9 and Figure 12.3.
784) It is not clear what that was intended to indicate, but it may have been priority.
785) Phase 1 Report Volume III paragraphs 15.83 and 15.192.
786) 999 call transcript {LFB00000384/3} page 3.
787) LFB Radio messages {LFB00002340}; {LFB00002128}; {LFB00002031}; LFB Operational Response Report dated July 2020 {LFB00119333/234-235} pages 234-235.
788) 999 call transcript {LFB00000691}; Phase 1 Report Volume III paragraph 16.79.
789) Phase 1 Report Volume III paragraphs 17.57-17.58; White {MET00012847/5} page 5.
790) Phase 1 Report Volume III paragraphs 17.58 and 17.122; LFB callback transcript {INQ00000193}. CRO Duddy’s call was prompted by a conversation with Essex FRS {LFB00000557}.
791) BA Telemetry data {LFB00023326/2} page 2.
792) Worley {MET00007891/5} page 5; LFB Operational Response Report dated July 2020 {LFB00119333/286} page 286.
793) Grant {MET00007883/4-5} pages 4-5.
794) Phase 1 Report Volume III paragraphs 15.13 and 16.12.
795) Phase 1 Report Volume III Figure 16.5; Photographs of whiteboard {MET00008663}; {MET00015924}.
796) Phase 1 Report Volume III paragraph 17.58.
797) Phase 1 Report Volume III paragraphs 16.15-16.20 and 17.66-17.69.
798) Phase 1 Report Volume III paragraphs 16.19 and 17.58-17.71.
799) Phase 1 Report Volume III paragraph 17.61.
800) Phase 1 Report Volume III paragraph 17.72.
801) Tyldesley {MET000083333/7} page 7; Stevenson {MET00012860/2} page 2; Gray {MET00010806/14} page 14; Hiscock {MET00010877/4} page 4; Simpson {MET00008040/10} page 10; Purser, Phase 2 Report, Section 6 {DAPR0000006/112} paragraph 616.
802) Phase 1 Report Volume III paragraphs 17.56-17.74.
803) Phase 1 Report Volume III paragraph 17.72.
804) Phase 1 Report Volume III paragraph 17.72.
805) Interim certificate of the fact of death for Isaac Paulos {MET00065641}.
806) Paulos post-mortem report {COR00000675/9} page 9; Purser, Phase 2 Report, section 6 {DAPR0000006/111} paragraphs 607 and 609.
807) Paulos toxicology report {MET00053154}; Purser, Phase 2 Report, Section 1-4 {DAPR0000005/121} Table 17.
808) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112-113} paragraph 447.
809) Purser, Phase 2 Report, Section 6 {DAPR0000006/108} paragraphs 601–602.
810) Purser, Phase 2 Report, Section 6 {DAPR0000006/108-109} paragraphs 588 and 593.
811) Purser, Phase 2 Report, Section 6 {DAPR0000006/109} paragraph 593.
812) Purser, Phase 2 Report, Section 6 {DAPR0000006/111-112} paragraphs 609 and 614-615.
813) Purser, Phase 2 Report, Section 6 {DAPR0000006/112} paragraph 611.
814) Purser, Phase 2 Report, Section 6 {DAPR0000006/112-113} paragraph 618-623.
815) Purser, Phase 2 Report, Section 6 {DAPR0000006/112} paragraph 611.
816 Purser, Phase 2 Report, Section 6 {DAPR0000006/111-112} paragraphs 607 and 617; Purser, Phase 2 Report, Section 6 {DAPR0000006/114} paragraphs 627-628.
817) Phase 1 Report Volume II paragraphs 10.118 and 10.122.
818) Phase 1 Report Volume III Annex A.
819) Phase 1 Report Volume II paragraph 10.259.
820) Phase 1 Report Volume II paragraphs 10.259-10.260.
821) Phase 1 Report Volume II paragraphs 14.128–14.131.
822) Phase 1 Report Volume II paragraphs 11.56-11.57.
823) Phase 1 Report Volume II paragraphs 12.64-12.67 and 12.86; 999 call transcripts {MET00014977}; {LFB00055500}.
824) Phase 1 Report Volume II paragraph 12.86.
825) Phase 1 Report Volume II paragraphs 12.86 and 14.116.
826) Burton {IWS00000064/2} page 2, paragraph 9.
827) Phase 1 Report Volume IV paragraph 32.174.
828) Noble {TMO00000884/1} page 1, paragraph 3.
829) Noble {Day119/75:19-21}.
830) Noble spreadsheet {TMO00862588}.
831) Phase 1 Report Volume II paragraph 11.57.
832) Phase 1 Report Volume II paragraphs 13.75-13.77; 999 call transcript {LFB00000334}.
833) Phase 1 Report Volume II paragraphs 14.173-14.175; 999 call transcript {LFB00000344}.
834) Phase 1 Report Volume II paragraph 14.176.
835) Johnson {MET00010082/7} page 7; Johnson {Day45/14:1}-{Day45/15:20}.
836) Johnson {MET00010082/9-10} pages 9-10; Roots {MET00012876/6-7} pages 6-7; Burton {IWS00000064/12-13} pages 12-13, paragraphs 54-56.
837) Phase 1 Report Volume II paragraph 14.179.
838) Johnson {MET00010082/10} page 10.
839) Short Incident Log Report {MET00013830/21-22}.
840) Phase 1 Report Volume IV paragraph 32.174.
841) Phase 1 Report Volume II paragraph 10.261.
842) Phase 1 Report Volume II paragraph 10.118.
843) Phase 1 Report Volume IV paragraph 25.10 (b).
844) Phase 1 Report Volume II paragraph 11.47.
845) Phase 1 Report Volume II paragraphs 11.48-11.51.
846) Phase 1 Report Volume II paragraph 10.19.
847) Phase 1 Report Volume II paragraph 10.79.
848) Phase 1 Report Volume II paragraphs 11.10-11.11 and 12.6.
849) Phase 1 Report Volume II paragraph 12.30.
850) Badillo {Day13/154:15}.
851) Phase 1 Report Volume II paragraphs 12.6, 12.31 and 13.6.
852) Phase 1 Report Volume II paragraphs 11.47, 12.60, 14.167, 16.59 and 16.60.
853) Phase 1 Report Volume II paragraphs 13.14-13.15 and 14.85.
854) Phase 1 Report Volume II paragraphs 11.12-11.13.
855) Phase 1 Report Volume II paragraphs 13.14-13.15, 14.85-14.87 and 14.131-132; Gillam {Day27/71:20}-{Day27/73:16}.
856) Eden {MET00008019/5} page 5; Welch {MET000080606/7} page 7.
857) Phase 1 Report Volume II paragraph 14.80.
858) Phase 1 Report Volume II paragraph 14.81.
859) Eden {MET00008019/10} page 10; Welch {MET000080606/7} page 7.
860) Williams {MET00010829/6-7} pages 6-7; Fernandes {Day39/176:19}-{Day39/177:4}.
861) Cook {MMET00012855/3} page 3; Flanagan {MET00012855/7} page 7.
862) Lancaster West EMB New Letting form {IWS00001930/2}.
863) Phase 1 Report Volume IV paragraph 32.150.
864) Phase 1 Report Volume IV paragraph 32.153.
865) Bennett {IWS00001882/2} page 2, paragraphs 7-8.
866) Letter from Dr Meena Nathan to Stella Fitzgerald dated 12 December 2017 {BSR00000141}.
867) Floating Support Service Referral Form {IWS00001908}.
868) Rydon Residents Survey {RYD00024466}.
869) Noble {TMO00000884/1} page 1, paragraph 3.
870) Noble {Day119/77:17}-{Day119/82:5}.
871) O’Riordan {MET00013136/2} page 2.
872) Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 478.
873) Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 478.
874) Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 482; Presentations relating to Victoria King and Alexandra Atala {Day305/15:10}.
875) Interim certificates of the fact of death for Victoria King and Alexandra Atala {MET00065648}; {MET00065622}.
876) King post-mortem report {COR00001454/5} page 5; Atala post-mortem report {COR00000066/6} page 6; Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 481.
877) Purser, Phase 2 Report, Section 6 {DAPR0000006/87-88} paragraphs 482 and 484.
878) Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 482.
879) Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 480.
880) Atala post-mortem report {COR00000066}; King post-mortem report {COR00001454}.
881) Tenancy Agreement {TMOH00011129}.
882) Phase 1 Report Volume IV paragraph 32.142.
883) Phase 1 Report Volume IV paragraph 32.144.
884) Phase 1 Report Volume IV paragraph 32.142.
885) Phase 1 Report Volume IV paragraphs 32.147-32.148.
886) O’Riordan {MET00013136/3} page 3.
887) Phase 1 Report Volume II paragraph 12.61.
888) Phase 1 Report Volume II paragraph 11.10 and 13.16.
889) Email from Adele Evelyn to Marion Tefler dated 19 June 2017 {BSR00000102}.
890) Phase 1 Report Volume IV paragraph 16.59; 999 call transcript {LFB00000355/2}.
891) Phase 1 Report Volume III paragraph 16.60.
892) Phase 1 Report Volume III paragraphs 15.139-15.140 and Figure 15.9.
893) Phase 1 Report Volume II paragraphs 12.8-12.9; Phase 1 Report Volume IV paragraph 28.86.
894) Phase 1 Report Volume III paragraphs 15.13 and 16.12; Phase 1 Report Volume III Figure 16.5; Photograph of whiteboard {MET00015924}.
895) Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}.
896) Phase 1 Report Volume IV paragraphs 28.86 and 28.87.
897) Phase 1 Report Volume II paragraphs 14.103-14.105 and Figure 14.5.
898) Wolfenden {Day40/168:3}-{Day40/172:16}; {Day40/182:14}-{Day40/186:9}.
899) Wolfenden {Day40/188:5}-{Day40/190:4}.
900) Phase 1 Report Volume II paragraph 15.161.
901) Telfer Exhibit MT/1 – Facebook timeline {IWS00001188/18}.
902) Phase 1 Report Volume III paragraph 17.51; Telfer Exhibit MT/1 – Facebook timeline {IWS00001188/18}.
903) Phase 1 Report Volume III paragraphs 17.51-17.55; Telfer Exhibit MT/1 – Facebook timeline {IWS00001188/18-20}.
904) Purser, Phase 2 Report, Section 6 {DAPR0000006/102} paragraph 557.
905) Sonson {MET00010824/8} page 8; Cuthbert {MET00012878/11-12} pages 11-12; BA Telemetry Data {LFB00023326/3}.
906) Phase 1 Report Volume III paragraph 17.55.
907) Interim certificate of the fact of death for Khadija Saye {MET00065605}.
908) Cutbill {MET00010872/5} page 5; Boulton {MET000080564/8} page 8.
909) Phase 1 Report Volume III paragraph 17.55.
910) Interim certificate of the fact of death for Mary Mendy {MET00065585}.
911) Mendy post-mortem report {COR00001031}; Saye post-mortem report {COR00000855}; Purser, Phase 2 Report, Section 6 {DAPR0000006/103} paragraphs 565 and 567.
912) Purser {Day297/91:22}–{Day297/94:1}.
913) Purser, Phase 2 Report, Section 6 {DAPR0000006/104} paragraphs 568-574.
914) Purser {Day297/91:22}–{Day297/94:1}.
915) Tenancy Agreement {TMOH00011495}.
916) Phase 1 Report Volume IV paragraph 32.134.
917) Phase 1 Report Volume IV paragraph 32.139; Presentation relating to the Belkadi family {Day305/44:12-13}.
918) Phase 1 Report Volume IV paragraph 32.134.
919) Noble {TMO00000884/1} page 1, paragraph 3.
920) O’Riordan {MET00013136/3} page 3.
921) O’Riordan {MET00013136/4} page 4.
922) Phase 1 Report Volume II paragraph 14.168.
923) Phase 1 Report Volume II paragraph 11.47.
924) Phase 1 Report Volume II paragraph 11.144.
925) Phase 1 Report Volume II paragraphs 11.145 and 11.146.
926) Phase 1 Report Volume II paragraph 11.149.
927) Phase 1 Report Volume II paragraph 11.5.
928) Phase 1 Report Volume II paragraphs 12.8-12.9 and Figure 12.3.
929) Phase 1 Report Volume II paragraphs 11.147-148 and 11.152.
930) Short Incident Log Report {MET00013830/19}.
931) Phase 1 Report Volume II paragraphs 11.6 and 12.8-12.9 and Figure 12.4.
932) Phase 1 Report Volume II paragraphs 13.52-13.53.
933) Phase 1 Report Volume II paragraphs 14.73-74 and Figure 14.4.
934) See Chapter 89.
935) Phase 1 Report Volume II paragraph 12.60.
936) Phase 1 Report Volume II paragraphs 12.75-12.76.
937) Phase 1 Report Volume II paragraphs 13.86 and 14.230.
938) Short Incident Log Report {MET00013830/21} page 21.
939) Phase 1 Report Volume II paragraph 14.243.
940) Phase 1 Report Volume II paragraphs 14.80-14.81.
941) Campbell {MET00010788/12} page 12; Mills {MET000080584/7} page 7.
942) Phase 1 Report Volume II paragraph 14.167; 999 call transcript {LFB00000342}.
943) Phase 1 Report Volume III paragraphs 15.138-15.140.
944) Phase 1 Report Volume II paragraph 14.169.
945) Phase 1 Report Volume II paragraph 14.170.
946) Williams {MET00010829/3-8} pages 3 and 8; Fernandes (Day39/171:14-22}; Eden {MET00008019/11} page 11.
947) Phase 1 Report Volume II paragraph 14.82; Williams {MET00010829/7-9} pages 7-9.
948) Fernandes {MET000083292/4-5} pages 4-5; Williams {MET00010829/10} page 10; Eden {MET00008019/11} page 11.
949) Eden {MET00008019/11} page 11; Welch {MET000080606/9} page 9.
950) Phase 1 Report Volume II paragraph 14.83; Fernandes {Day39/181:5-20}.
951) Fernandes {Day39/183:2-14}.
952) Eden {MET00008019/11} page 11; Welch {MET000080606/9} page 9.
953) Eden {MET00008019/11} page 11; Williams {MET00010829/7} page 7.
954) Phase 1 Report Volume II paragraph 14.83; Eden {MET00008019/11} page 11; Welch {MET000080606/9} page 9.
955) Phase 1 Report Volume II paragraph 14.83.
956) Phase 1 Report Volume III Annex A.
957) Fernandes {Day39/184:22-24}.
958) BA Telemetry Data {LFB00023326/1} page 1.
959) Phase 1 Report Volume II paragraph 14.83.
960) Phase 1 Report Volume IV paragraph 28.86; Phase 1 Report Volume II paragraphs 15.23 and 15.25, Figure 15.7.
961) Phase 1 Report Volume III paragraph 15.57.
962) Phase 1 Report Volume III paragraph 15.58; LFB Operational Response Report dated July 2020 {LFB00119333/263} page 263.
963) Phase 1 Report Volume II paragraph 14.172.
964) Phase 1 Report Volume II paragraph 14.172.
965) Interim certificates of the fact of death for Omar Belkadi, Farah Hamdan and Leena Belkadi {MET00065583}; {MET00065592}; {MET00065638}.
966) Omar Belkadi post-mortem report {COR00001303/11}; Hamdan post-mortem report {COR00000397/9}; Leena Belkadi post-mortem report {COR00000876/9}; Leena Belkadi toxicology report {COR00000885}; Purser, Phase 2 Report, Section 6 {DAPR0000006/94} paragraph 522-524.
967) Report of paediatric intensive care consultant concerning Malak Belkadi {COR00001720/3-9} pages 3-9; Malak Belkadi toxicology report {COR00000966/1}; Purser, Phase 2 Report, Section 6 {DAPR0000006/95} paragraphs 525-527.
968) Interim certificate of the fact of death for Malak Belkadi {COR00001713}.
969) Purser, Phase 2 Report, Section 6 {DAPR0000006/97} paragraph 535.
970) Purser, Phase 2 Report, Section 6 {DAPR0000006/99} paragraph 543.
971) Purser, Phase 2 Report, Section 6 {DAPR0000006/99} paragraph 543.
972) Purser, Phase 2 Report, Section 6 {DAPR0000006/98} paragraphs 541-543.
973) Phase 1 Report Volume II paragraph 10.118.
974) Phase 1 Report Volume II paragraph 10.271.
975) Phase 1 Report Volume II paragraph 10.265.
976) Gebremeskel {Day68/133:1-2}; {Day68/143:15}.
977) Phase 1 Report Volume II paragraphs 10.269.
978) Phase 1 Report Volume II paragraph 10.270.
979) Phase 1 Report Volume III paragraph 11.42.
980) 999 call transcript {LFB00055498/6}.
981) Phase 1 Report Volume II paragraphs 15.74-15.76.
982) Phase 1 Report Volume II paragraph 13.103.
983) Phase 1 Report Volume III paragraphs 15.180 and 15.186-15.187.
984) Phase 1 Report Volume III paragraph 16.53.
985) Phase 1 Report Volume III paragraphs 15.130, 16.56, 16.84, 17.48, 17.50, 17.132, 17.139 and 18.29.
986) Phase 1 Report Volume III paragraph 15.57.
987) Phase 1 Report Volume II paragraphs 11.12-11.13.
988) BA Telemetry Data {LFB00023326}.
989) Phase 1 Report Volume II paragraphs 14.85-14.87; Roberts {Day27/125:5}-{Day27/127:17}.
990) Phase 1 Report Volume IV paragraphs 32.119 -32.124.
991) RBKC Core Assessment for Ligaya Moore {RBK00059526/2}.
992) Report dated 31 October 2014 from Rydon RLO {RYD00022561}.
993) RBKC Core Assessment for Ligaya Moore {RBK00059526/9-13}.
994) RBKC Care and Support Plan Review for Ligaya Moore {RBK00059524/3}.
995) Bunggay {IWS00002374/2} page 2, paragraphs 7-13.
996) Phase 1 Report Volume III paragraphs 20.65-20.66; Noble Spreadsheet {TMO00862588}.
997) O’Riordan {MET00013136/4} page 4.
998) Purser, Phase 2 Report, Section 6 {DAPR0000006/65} paragraph 315.
999) Interim certificate of the fact of death for Ligaya Moore {MET00065603}; Purser, Phase 2 Report, Section 6 {DAPR0000006/65} paragraph 319.
1000) External Spread of Fire at Grenfell Tower {MET00012593/7}.
1001) Phase 1 Report Vol II paragraph 10.118.
1002) Purser, Phase 2 Report, Section 6 {DAPR0000006/64} paragraph 314.
1003) Purser, Phase 2 Report, Section 6 {DAPR0000006/65} paragraph 319 and {DAPR0000006/66} paragraphs 320-321.
1004) Phase 1 Report Volume IV paragraphs 32.106 and 32.109.
1005) Phase 1 Report Volume IV paragraphs 32.106 and 32.110.
1006) Phase 1 Report Volume IV paragraphs 32.106 and 32.113.
1007) Phase 1 Report Volume IV paragraphs 32.106 and 32.115.
1008) Phase 1 Report Volume IV paragraphs 32.106 and 32.118.
1009) Noble Spreadsheet {TMO00862588}.
1010) O’Riordan {MET00013136/3} page 3.
1011) Hanan Cherbika {IWS00000016/5} page 5, paragraph 18.
1012) Yousra Cherbika {IWS00001032/6} page 6, paragraph 21.
1013) Phase 1 Report Volume II paragraph 10.266.
1014) Phase 1 Report Volume II paragraphs 10.267 and 10.268.
1015) Phase 1 Report Volume II paragraph 10.270.
1016) Phase 1 Report Volume II paragraph 11.42.
1017) External Spread of Fire at Grenfell Tower {MET00012593/7}.
1018) Wahabi {IWS00000074/3} page 3, paragraph 9 and {IWS00000074/22} page 22, Appendix I.
1019) Phase 1 Report Volume II paragraphs 13.103 and 14.157; 999 call transcript {LFB00055498/7}; {LFB00055498/16}; Wahabi {IWS00001146/9} page 9, paragraph 29.
1020) 999 call transcript {LFB00055498/8}.
1021) 999 call transcript {LFB00055498/3}; {LFB00055498/9-10}.
1022) 999 call transcript {LFB00055498/4-6}; {LFB00055498/10}.
1023) 999 call transcript {LFB00055498/11-12}; {LFB00055498/14-15}.
1024) 999 call transcript {LFB00055498/16-17}; {LFB00055498/20}.
1025) 999 call transcript {LFB00055498/31-32}.
1026) 999 call transcript {LFB00055498/35-50}; Phase 1 Report Volume II paragraphs 14.159-14.160.
1027) Wahabi {IWS00000074/16} page 16, paragraph 55.
1028) 999 call transcript {LFB00055498/57-67}; {LFB00055498/73-76}.
1029) Phase 1 Report Volume II paragraph 14.162.
1030) 999 call transcript {LFB00055498/80}.
1031) Phase 1 Report Volume III paragraph 15.156; Jones {LFB00032090/6} page 6, paragraph 30.
1032) 999 call transcript {LFB00055498/95-101}.
1033) 999 call transcript {LFB00055498/15}; LFB Short Incident Log {MET00013830}.
1034) 999 call transcript {LFB00055498/23}.
1035) Phase 1 Report Volume II paragraphs 13.85-13.86; Transcript of call between LFB control room and CU8 {INQ00000203}.
1036) Phase 1 Report Volume II paragraph 11.6 and Phase 1 Report Volume IV paragraphs 28.84 (a) and 28.84(b).
1037) Phase 1 Report Volume II paragraphs 12.18-12.19 and figure 12.4.
1038) Phase 1 Report Volume II paragraphs 11.7 and 12.19.
1039) Phase 1 Report Volume II paragraphs 14.230 and 14.231; Transcript of call between LFB control room and CU8 {INQ00000195}.
1040) Phase 1 Report Volume IV paragraph 28.84d.
1041) Phase 1 Report Volume II paragraphs 12.8-12.9.
1042) Control Information Form {LFB00001922/6}.
1043) Phase 1 Report Volume II paragraph 14.73 and Figure 14.4; Phase 1 Report Volume IV paragraphs 28.84(b) and 28.84(c).
1044) Phase 1 Report Volume III paragraphs 15.139-15.141 and Figure 15.8.
1045) O’Beirne {MET000083321/19} page 19; Phase 1 Report Volume III Figure 16.6.
1046) Phase 1 Report Volume IV paragraph 15.25.
1047) Phase 1 Report Volume III paragraph 15.57.
1048) Upton {MET00007524/5} page 5; Upton {Day38/144:22}-{Day38/147:21}.
1049) Upton {MET00005625/1} page 1.
1050) Upton {Day38/150:24}- {Day38/151:11}.
1051) Phase 1 Report Volume III paragraph 16.53.
1052) Phase 1 Report Volume III paragraph 15.172.
1053) 999 call transcript {INQ00000383}; Woodrow {LAS00000009/12} page 12; Woodrow {Day72/129:10}-{Day72/131:22}.
1054) Phase 1 Report Volume III paragraph 16.53; 999 call transcript {LFB00000374}.
1055) Phase 1 Report Volume III paragraphs 15.186 and 16.54; 999 call transcript {COR00000376/6}.
1056) Phase 1 Report Volume III paragraph 16.54.
1057) 999 call transcript {COR00000376/8} and {COR00000376/10}.
1058) 999 call transcript {COR00000376/1-5}.
1059) 999 call transcript {COR00000376/8} and {COR00000376/10}.
1060) Phase 1 Report Volume III paragraph 16.54 (c).
1061) Phase 1 Report Volume III paragraphs 15.13 and 16.12.
1062) Phase 1 Report, Volume III Figure 16.5; Photograph of whiteboard {MET00015924}.
1063) Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}.
1064) Purser, Phase 2 Report, Section 6 {DAPR0000006/68} paragraph 369.
1065) Interim certificate of the fact of death for Abdulaziz El Wahabi, Faouzia El Wahabi, Yasin El Wahabi, Nur Huda El Wahabi and Mehdi El Wahabi {MET00065595}; {MET00065626}; {MET00065631}; {MET00065627}; {MET00065652}.
1066) Purser, Phase 2 Report, Section 6 {DAPR0000006/69} paragraphs 371 and 373 and {DAPR0000006/70} paragraph 378; Purser {Day297/69:11}-{Day297/72:6}.
1067) Phase 1 report Volume IV paragraphs 32.101-32.102.
1068) Perestrelo {IWS00000349/1} page 1, paragraph 5.
1069) Phase 1 report Volume IV paragraphs 32.102-32.103.
1070) Perestrelo {IWS00000349/8} page 8, paragraph 46.
1071) Phase 1 Report Volume II paragraphs 10.267-10.269.
1072) Phase 1 Report Volume II paragraph 14.163.
1073) Phase 1 Report Volume II paragraph 14.164.
1074) Phase 1 Report Volume II paragraph 14.165.
1075) Phase 1 Report Volume II paragraph 14.165; Phase 1 Report Volume II paragraph 15.130; LFB Short Incident Log {MET00013830/22}.
1076) Phase 1 Report Volume IV paragraph 28.84d.
1077) Phase 1 Report Volume II Figure 12.3 and paragraphs 12.8-12.9; Phase 1 Report Volume III Figure 15.6 and paragraphs 15.11-15.13.
1078) Phase 1 Report Volume I1 paragraph 14.65-14.72; Phase 1 Report Volume IV paragraph 28.84e.
1079) Phase 1 Report Volume II Figure 15.7.
1080) Control Information Form {LFB00001922/10}.
1081) Upton {Day38/150:24}-{Day38/151:11}.
1082) Phase 1 Report Volume III paragraphs 15.78, 15.189 and 15.191.
1083) Phase 1 Report Volume III paragraphs 15.139-15.141, 16.56 -16.57, 16.84, Figures 15.8 and 15.9; 999 call transcript {LFB00000392}; Radio transcript {LFB00002017}.
1084) Phase 1 Report Volume III paragraph 17.48; 999 call transcript {LFB00000412}.
1085) Phase 1 Report Volume III paragraphs 17.50 and 17.132.
1086) Phase 1 Report Volume III paragraphs 15.13 and 16.12 and Figure 16.5; Photograph of whiteboard {MET00015924}.
1087) Control Information Forms {LFB00001922/12-15}.
1088) Control information form {LFB00001922/14}.
1089) Sadler {Day29/95:5}-{Day29/100:20}.
1090) Phase 1 Report Volume II paragraphs 14.103-14.105 and Figure 14.5; Photographs of ground floor wall {MET00005774} and {MET00005776}.
1091) Williams {Day31/137:13}-{Day31/139:21}.
1092) Phase 1 Report Volume III paragraph 17.50; 999 call transcript {LFB00055501}.
1093) Phase 1 Report Volume III paragraphs 18.29-18.31.
1094) Phase 1 Report Volume III paragraphs 18.30-18.34; 999 call transcript {LFB00055501/17}; {LFB00055501/6-21}.
1095) Phase 1 Report Volume III paragraph 18.35; 999 call transcript {LFB00055501/30}.
1096) De Silvo {Day30/63:1}; De Silvo Exhibit LDS/7 - photo of green wall {MET00015820}.
1097) Phase 1 Report Volume III paragraph 18.20; Nelson {MET00010926/6} page 6; Diana {MET00018800/10} page 10.
1098) Phase 1 Report Volume III paragraph 18.37.
1099) Perestrelo {IWS00000349/14} page 14, paragraph 83.
1100) Perestrelo {IWS00000349/14} page 14, paragraphs 84-87.
1101) Purser, Phase 2 Report, Section 6 {DAPR0000006/80} paragraph 433.
1102) Letter from Dr Leonie Penna to Andreia Perestrelo dated 28 July 2017 {BSR00000140}; Purser, Phase 2 Report, Section 6 {DAPR0000006/84} paragraph 462. An extract from Dr Penna’s letter was read out during the presentation concerning Logan Gomes {Day306/19:8}.
1103) Purser, Phase 2 Report, Section 6 {DAPR0000006/77-84} paragraph 416 and 460.
1104) Purser, Phase 2 Report, Section 6 {DAPR0000006/76-79} paragraphs 426-431.
1105) Phase 1 Report Volume II paragraphs 10.272, 10.276 and 10.308.
1106) Phase 1 Report Volume II paragraph 10.277.
1107) Phase 1 Report Volume II paragraph 10.277.
1108) Phase 1 Report Volume II paragraph 10.279.
1109) Phase 1 Report Volume II paragraphs 11.37-11.40.
1110) Phase 1 Report Volume II paragraph 12.62; Phase 1 Report Volume III paragraphs 16.33-16.39.
1111) Phase 1 Report Volume III paragraph 16.42.
1112) Phase 1 Report Volume III paragraphs 18.27-18.28.
1113) Phase 1 Report Volume III paragraphs 17.35-17.36 and 17.104.
1114) Phase 1 Report Volume II paragraph 10.280; Phase 1 Report Volume III paragraphs 16.39 and 17.32-17.37.
1115) Phase 1 Report Volume II paragraphs 12.62, 14.155 and 14.269; Phase 1 Report Volume III paragraphs 16.34-16.35, 16.41, 17.38-39 and 17.126; 999 call transcript {LFB00000396}.
1116) Phase 1 Report Volume III paragraph 17.38.
1117) Phase 1 Report Volume III paragraph 17.39.
1118) Phase 1 Report Volume II paragraph 11.41.
1119) Phase 1 Report Volume II paragraph 14.153.
1120) Phase 1 Report Volume II paragraphs 14.153-14.154; Phase 1 Report Volume III paragraphs 16.47-16.50.
1121) 999 call transcript {LFB00000658}.
1122) Phase 1 Report Volume III paragraphs 16.51 and 17.130.
1123) Phase 1 Report Volume III paragraph 18.23.
1124) Phase 1 Report Volume II paragraphs 11.37, 12.63 and 14.152; Phase 1 Report Volume III paragraphs 16.43-16.46, 16.45-16.46 and 17.41.
1125) Phase 1 Report Volume III paragraphs 15.148, 15.183, 15.195, 17.44-17.46, 17.127 and 17.131; 999 call transcript {LFB00000549}.
1126) 999 call transcript {LFB00000469}; Phase 1 Report Volume III paragraph 18.27.
1127) Phase 1 Report Volume II paragraphs 11.152-11.153.
1128) Phase 1 Report Volume II paragraph 11.6; Phase 1 Report Volume IV paragraph 28.84 (a).
1129) Phase 1 Report Volume II paragraph 12.18.
1130) Phase 1 Report Volume II paragraphs 12.18-12.19, 14.71 and Figure 12.4.
1131) Phase 1 Report Volume IV paragraph 28.84 (b).
1132) Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraph 28.84 (c).
1133) Phase 1 Report Volume IV paragraphs 28.86-28.87.
1134) O’Beirne {MET000083321/19} page 19; Phase 1 Report Volume III Figure 16.6.
1135) Phase 1 Report Volume III paragraph 17.13 (g); LFB Telemetry data {LFB00023326}; Codd {MET00012539}.
1136) Phase 1 Report Volume II paragraphs 11.13 and 13.5.
1137) Phase 1 Report Volume II paragraphs 14.85-14.87; Roberts {MET00007890/6} page 6.
1138) Phase 1 Report Volume IV paragraph 32.89.
1139) Phase 1 Report Volume IV paragraph 32.90.
1140) Phase 1 Report Volume IV paragraphs 32.93-32.98.
1141) O’Riordan {MET00013136/3-4} pages 3-4.
1142) Phase 1 Report Volume II paragraph 10.277.
1143) Phase 1 Report Volume II paragraph 11.41; 999 call transcript {LFB00000315/3}.
1144) Duddy {Day42/215:7}-{Day42/216:5}; Phase 1 Report Volume II paragraph 11.157.
1145) LFB Short Incident Log {MET00013830}.
1146) Phase 1 Report Volume II paragraph 11.152.
1147) LFB Short Incident Log {MET00013830}.
1148) Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraphs 28.84b and 28.84c
1149) Phase 1 Report Volume II paragraph 11.61.
1150) Phase 1 Report Volume II paragraph 14.153; 999 call transcript {LFB00000339}.
1151) Phase 1 Report Volume II paragraph 14.3.
1152) Phase 1 Report Volume II paragraphs 14.153 and 14.251; 999 call transcript {LFB00000345}.
1153) Phase 1 Report Volume II paragraphs 14.154 and 14.266; 999 call transcript {LFB00000351}.
1154) 999 call transcript {LFB00000671}.
1155) 999 call transcript {INQ00000289}.
1156) Phase 1 Report Volume III paragraph 16.48.
1157) 999 call transcript {INQ00000276/3} page 3.
1158) Phase 1 Report Volume III paragraph 16.49; 999 call transcript {INQ00000378}.
1159) Phase 1 Report Volume II paragraph 16.50.
1160) Phase 1 Report Volume II paragraphs 14.247-14.248.
1161) Phase 1 Report Volume IV paragraph 28.84 (d).
1162) Phase 1 Report Volume II paragraphs 12.8-12.9.
1163) LFB Control Information Forms {LFB00001955/10} page 10.
1164) Phase 1 Report Volume II paragraphs 14.243 and 14.261.
1165) Phase 1 Report Volume III paragraph 15.140 and Figure 15.8.
1166) Phase 1 Report Volume III paragraphs 15.13 and 16.12.
1167) Phase 1 Report Volume III Figure 16.5; Photograph of whiteboard {MET00015924}.
1168) Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}.
1169) Phase 1 Report Volume IV paragraphs 28.86 and 28.87.
1170) Phase 1 Report Volume III Figure 15.7.
1171) Phase 1 Report Volume III paragraphs 16.41-42 and 16.50-51.
1172) 999 call transcript {LFB00000658}.
1173) Phase 1 Report Volume III paragraphs 16.51 and 17.33; 999 call transcript {LFB00000404}.
1174) Phase 1 Report Volume III paragraphs 17.34-36.
1175) Phase 1 Report Volume III paragraph 17.20 (a).
1176) Phase 1 Report Volume III paragraph 17.104.
1177) Cardy {MET00010085/10} page 10.
1178) Phase 1 Report Volume IV paragraph 28.87.
1179) Wolfenden {Day40/168:3}-{Day40/172:16}; {Day40/182:14}-{Day40/186:9}.
1180) Wolfenden {Day40/188:5}-{Day40/190:4}.
1181) De Silvo Exhibit LDS/5 - Photograph of ground floor wall {MET00015815}.
1182) Phase 1 Report Volume III paragraph 17.130; 999 call transcript {LFB00000406}.
1183) Phase 1 Report Volume III paragraphs 17.37-17.38; 999 call transcript {COR00001081}; 999 call transcript {LFB00000414}.
1184) 999 call transcript {LFB00000337} page 3.
1185) Phase 1 Report Volume III paragraphs 18.24-18.26.
1186) Purser, Phase 2 Report, Section 6 {DAPR0000006/46} paragraph 219.
1187) Interim certificates of the fact of death for Hashim Kedir, Nura Jemal, Yahya Hashim, Firdaws Hashim and Yaqub Hashim {MET00065640}; {MET00065629}; {MET00065633}; {MET00065587}; {MET00065644}.
1188) Purser, Phase 2 Report, Section 6 {DAPR0000006/47} paragraph 220.
1189) Purser, Phase 2 Report, Section 6 {DAPR0000006/55} paragraph 263.
1190) Purser, Phase 2 Report, Section 6 {DAPR0000006/47-51} paragraphs 224 and 240.
1191) Purser, Phase 2 Report, Section 6 {DAPR0000006/51-54} paragraphs 238 and 251.
1192) Purser, Phase 2 Report, Section 6 {DAPR0000006/54} paragraph 253.
1193) Phase 1 Report Volume IV paragraphs 32.76–32.81.
1194) Phase 1 Report Volume IV paragraphs 32.82-32.84.
1195) Sawson Choucair {IWS00001799/9} page 9, paragraph 9; Hisam Choucair {IWS00001851/2} page 2, paragraph 8; Nabil Choucair {IWS00002365/2} page 2, paragraph 8.
1196) Rydon Residents Survey {RYD00024466/17}.
1197) Phase 1 Report Volume III paragraphs 20.65-20.66; Noble Spreadsheet {TMO00862588}.
1198) O’Riordan {MET00013136/2-3} pages 2-3.
1199) Phase 1 Report Volume II paragraphs 10.279-10.281.
1200) Phase 1 Report Volume II paragraph 10.279.
1201) Phase 1 Report Volume II paragraph 10.281.
1202) 999 call transcript {MET00015407}.
1203) 999 call transcript {LFB00000325}.
1204) Phase 1 Report Volume II paragraph 12.62.
1205) Phase 1 Report Volume II paragraph 12.94.
1206) Phase 1 Report Volume II paragraph 14.269.
1207) Phase 1 Report Volume II paragraph 12.94; 999 call transcript {LFB00000347}.
1208) Phase 1 Report Volume III paragraph 16.36.
1209) Phase 1 Report Volume III paragraph 16.34.
1210) Phase 1 Report Volume III paragraph 16.34.
1211) Phase 1 Report Volume III paragraph 16.35.
1212) Phase 1 Report Volume III paragraph 16.35.
1213) Phase 1 Report Volume III paragraphs 15.161–15.163.
1214) Phase 1 Report Volume III paragraph 15.168.
1215) Phase 1 Report Volume II paragraphs 15.140-15.141 and Figure 15.8.
1216) Phase 1 Report Volume II Figure 12.3.
1217) Phase 1 Report Volume III paragraphs 16.36-16.37.
1218) Phase 1 Report Volume III paragraph 16.45.
1219) Phase 1 Report Volume III paragraph 16.42.
1220) Phase 1 Report Volume III paragraph 16.41; Liao second witness statement {IWS00001191/2} page 2, paragraphs 7, 8 and 9.
1221) 999 call transcript {LFB00000396}.
1222) Phase 1 Report Volume III paragraph 17.126.
1223) Phase 1 Report Volume III paragraph 17.128.
1224) Phase 1 Report Volume III paragraph 17.33.
1225) Phase 1 Report Volume III paragraph 17.37.
1226) Phase 1 Report Volume III paragraph 17.20 (a).
1227) Phase 1 Report Volume III paragraph 17.104.
1228) Cardy {MET00010085/10} page 10.
1229) Phase 1 Report Volume IV paragraph 28.87.
1230) Wolfenden {Day40/168:3}-{Day40/172:16}; {Day40/182:14}-{Day40/186:9}.
1231) De Silvo Exhibit LDS/5 - Photograph of ground floor wall {MET00015815}.
1232) Wolfenden {Day40/188:5}-{Day40/190:4}.
1233) Phase 1 Report Volume III paragraph 17.130; 999 call transcript {LFB00000406}.
1234) Phase 1 Report Volume III paragraphs 17.37-17.38; 999 call transcript {COR00001081}; 999 call transcript {LFB00000414}.
1235) 999 call transcript {LFB00000337/3} page 3.
1236) Phase 1 Report Volume III paragraphs 18.24-18.26.
1237) Phase 1 Report Volume III Figure 15.9.
1238) Phase 1 Report Volume III Figure 16.5.
1239) De Silvo Exhibit LDS/5 - Photograph of ground floor wall {MET00015815}; Williams {Day31/155:18}-{Day31/157:8}; Control information form {LFB00001922/20}.
1240) Williams {Day31/99:13-16}; Wolfenden {Day40/183:24}-{Day40/184:25}.
1241) Phase 1 Report Volume II Figure 14.5.
1242) Furnell Exhibit TGF/2 - original notes {MET00017035}; Furnell {Day40/37:2-25}.
1243) Furnell {Day40/24:15-24}.
1244) Furnell {Day40/38:9-19}.
1245) Purser, Phase 2 Report, Section 6 {DAPR0000006/46} paragraph 219.
1246) Interim certificates of the fact of death for Sirria Choucair, Bassem Choukair, Nadia Choucair, Mierna Choucair, Fatima Choucair and Zainab Choucair {MET00065600}; {MET00065610}; {MET00065613}; {MET00065651}; {MET00065599}; {MET00065618}.
1247) Purser, Phase 2 Report, Section 6 {DAPR0000006/55} paragraph 263.
1248) Purser, Phase 2 Report, Section 6 {DAPR0000006/47-50} paragraphs 224 and 235.
1249) Purser, Phase 2 Report, Section 6 {DAPR0000006/51-54} paragraphs 238 and 251.
1250) Purser, Phase 2 Report, Section 6 {DAPR0000006/54} paragraph 253.
1251) Phase 1 Report Volume IV paragraphs 32.68- 32.69.
1252) Tenancy Agreement {TMOH00000779}.
1253) Charles Disson {IWS00000239/1} page 1, paragraph 2.
1254) Priority Needs Assessment {TMOH00000849}.
1255) Tenancy Agreement {TMOH00000779}.
1256) GP Liaison letter to KCTMO dated 26 April 2016 {TMOH00000861}.
1257) Noble Spreadsheet {TMO00862588}.
1258) O’ Riordan {MET00013136/4} page 4.
1259) Alfie Disson {IWS00000241/4} page 4, paragraph 60; Cordelia Disson {IWS00000242/9} page 9, paragraphs 113-114.
1260) Phase 1 Report Volume II paragraph 10.277.
1261) Phase 1 Report Volume II paragraphs 11.37-11.39; 999 call transcript {LFB00000459}.
1262) LFB Short Incident Log {MET00013830}.
1263) 999 call transcript {INQ00000472}.
1264) Phase 1 Report Volume IV paragraph 28.84 (b).
1265) LFB Short Incident Log {MET00013830}.
1266) Phase 1 Report Volume IV paragraph 28.84 (b).
1267) Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraph 28.84 (c).
1268) Phase 1 Report Volume II paragraph 12.63.
1269) Phase 1 Report Volume II paragraph 14.152; 999 call transcript {LFB00000337/3}.
1270) Phase 1 Report Volume II paragraphs 14.230-14.231; 999 call transcript {INQ00000195/5}.
1271) 999 call transcript {LFB00000352}.
1272) 999 call transcript {LFB00000695}.
1273) Phase 1 Report Volume III paragraphs 16.43 and 17.41.
1274) Phase 1 Report Volume III paragraphs 16.44-16.45.
1275) Phase 1 Report Volume III paragraph 16.41.
1276) Phase 1 Report Volume II paragraph 17.44.
1277) 999 call transcript {LFB00000357}; 999 call transcript {LFB00000544}.
1278) 999 call transcript {LFB00000549}; Haley {IWS00001219/11} page 11, paragraph 123.
1279) 999 call transcript {LFB00000469}.
1280) 999 call transcript {LFB00000395}; Phase 1 Report Volume II paragraph 17.41.
1281) Phase 1 Report Volume II paragraph 17.43
1282) Phase 1 Report Volume IV paragraphs 28.86-28.87.
1283) Phase 1 Report Volume III paragraphs 15.139-15.141 and Figures 15.8 and 15.9.
1284) Phase 1 Report Volume II paragraphs 12.8-12.11 and Figure 12.3.
1285) Phase 1 Report Volume III paragraphs 15.13 and 16.12.
1286) Phase 1 Report, Volume III Figure 16.5; Photograph of whiteboard {MET00015924}.
1287) Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}.
1288) Phase 1 Report, Volume II paragraphs 14.103-14.105 and Figure 14.5; Photographs of ground floor wall {MET00005774} and {MET00005776}.
1289) Phase 1 Report Volume III paragraphs 15.23-15.24; Phase 1 Report Volume II Figure 15.7.
1290) Phase 1 Report Volume III paragraph 17.13 (g).
1291) Phase 1 Report Volume III paragraph 17.43.
1292) Phase 1 Report Volume III paragraph 17.44.
1293) Phase 1 Report Volume III paragraphs 17.45 and 17.131.
1294) Phase 1 Report Volume III paragraph 17.7.
1295) Phase 1 Report Volume III paragraph 17.46.
1296) Phase 1 Report Volume III paragraph 18.27; 999 call transcript {LFB00000660}.
1297) Phase 1 Report Volume III paragraph 18.28.
1298) Interim certificate of the fact of death for Anthony Disson {MET00065649}.
1299) Disson post-mortem report {COR00000181/12}; Purser, Phase 2 Report, Section 6 {DAPR0000006/57} paragraphs 278-279.
1300) Disson toxicology report {INQ00011096/1} page 1; Purser, Phase 2 Report, Section 6 {DAPR0000006/61} paragraph 296.
1301) Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447.
1302) Purser, Phase 2 Report, Section 6 {DAPR0000006/61} paragraphs 296-304.
1303) Purser, Phase 2 Report, Section 6 {DAPR0000006/60} paragraph 295; Purser {Day297/43:3-7}.
1304) Phase 1 Report Volume II paragraphs 10.118 and 10.122; External Fire Spread Report {MET00012593/14}.
1305) Phase 1 Report Volume II paragraphs 10.284-10.286 and 10.290-10.292.
1306) Phase 1 Report Volume II paragraphs 11.29-11.34; External Fire Spread Report {MET00012593/14}.
1307) Phase 1 Report Volume III paragraphs 15.64-15.67 and Annex A.
1308) Phase 1 Report Volume II paragraph 14.235.
1309) Phase 1 Report Volume II paragraphs 11.12-11.13, 13.5, 13.15 and 14.85-14.87; Phase 1 Report Volume III paragraph 15.30.
1310) Phase 1 Report Volume II paragraph 14.117; BA Telemetry Schedule {LFB00023326}; Phase 1 Report Volume III paragraphs 15.54-15.56 and 15.66; Phase 1 Report Volume III paragraphs 16.15-16.20 and Figure 16.6.
1311) Phase 1 Report Volume III paragraph 18.15 (b).
1312) Phase 1 Report Volume II paragraph 12.86.
1313) Phase 1 Report Volume II paragraphs 11.12-11.13, 13.5, 13.15 and 14.85-14.87; Phase 1 Report Volume III paragraph 15.30.
1314) Phase 1 Report Volume II paragraphs 11.12-11.13, 13.5, 13.15 and 14.85-14.87; Phase 1 Report Volume III paragraph 15.30.
1315) Phase 1 Report Volume II paragraph 14.117; BA Telemetry Data {LFB00023326}.
1316) Phase 1 Report Volume III paragraphs 15.54-15.56 and 15.66.
1317) External Fire Spread Report {MET00012593/14}; Phase 1 Report Volume III paragraphs 16.15-16.20 and Figure 16.6.
1318) Phase 1 Report Volume III paragraph 18.15(b); External Fire Spread Report {MET00012593/14}.
1319) Phase 1 Report Volume IV paragraph 32.55; External Fire Spread Report {MET00012593/14}.
1320) Phase 1 Report Volume II paragraphs 10.257, 10.258, 10.260, 10.289 and 14.125.
1321) Phase 1 Report Volume II paragraphs 10.223 and 14.136.
1322) Phase 1 Report Volume II paragraphs 11.30-11.31.
1323) Phase 1 Report Volume IV paragraphs 32.126, 32.154 and 32.198.
1324) Phase 1 Report Volume II paragraph 14.131; Phase 1 Report Volume III Annex A.
1325) Phase 1 Report Volume II paragraph 14.132.
1326) Phase 1 Report Volume II paragraph 10.107.
1327) Lane, Phase 1 Supplemental Report, Section 12 {BLAS0000012/8-9}; External Fire Spread Report {MET00012593/18-19}.
1328) Phase 1 Report Volume II paragraphs 10.285-10.286.
1329) Purser, Phase 2 Report, Section 6 {DAPR0000006/9} paragraph 18.
1330) Phase 1 Report Volume II paragraphs 11.25-11.26; 999 call transcript {LFB00055504/5-10}.
1331) Phase 1 Report Volume II paragraph 11.25.
1332) Phase 1 Report Volume II paragraphs 14.128-14.130.
1333) Purser, Phase 2 Report, Section 6 {DAPR0000006/9} paragraph 19.
1334) Phase 1 Report Volume II paragraphs 14.134 and 14.138.
1335) Phase 1 Report Volume II paragraphs 14.135 and 14.140; 999 call transcript {LFB00055500/42-43}; 999 call transcript {LFB00055504/78-82}; Purser, Phase 2 Report, Section 6 {DAPR0000006/12} paragraph 36.
1336) Purser, Phase 2 Note on Toxicity Endpoints {DAPR0000013}.
1337) Phase 1 Report Volume IV paragraph 25.28.
1338) Phase 1 Report Volume II paragraphs 10.289 (d) and 14.127.
1339) Phase 1 Report Volume II paragraph 14.117.
1340) 999 call transcript {MET00015554}.
1341) Phase 1 Report Volume II paragraph 10.317.
1342) Phase 1 Report Volume II paragraphs 11.25, 12.66 (b) and 12.67.
1343) Phase 1 Report Volume II paragraph 12.84.
1344) Phase 1 Report Volume II paragraph 12.84.
1345) Phase 1 Report Volume II paragraph 12.88.
1346) LFB Short Incident Log {MET00013830/20}.
1347) Phase 1 Report Volume II paragraph 13.104.
1348) LFB Short Incident Log {MET00013830/21}.
1349) Phase 1 Report Volume II paragraphs 14.230-14.232; LFB Short Incident Log {MET00013830/19-21}.
1350) Phase 1 Report Volume II paragraphs 10.79 (b), 10.101 (a), 11.10 and 13.17.
1351) Phase 1 Report Volume IV paragraphs 28.11, 28.84 (b) and 28.86.
1352) Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraph 28.84 (c).
1353) Phase 1 Report Volume II Figure 13.2 and paragraph 13.53.
1354) Phase 1 Report Volume III paragraphs 15.139-15.140 and Figure 15.8.
1355) Phase 1 Report Volume II paragraphs 12.8-12.9 and Figure 12.3; Phase 1 Report Volume IV paragraph 28.85 (d).
1356) As there had been no further update passed on from NWFC to the LFB control room in relation to Debbie Lamprell’s call (see below), this must have related to Jessica Urbano Ramirez’s call.
1357) 999 call transcript {MET00014977}.
1358) Phase 1 Report Volume II paragraph 12.86.
1359) Phase 1 Report Volume II paragraph 12.85.
1360) Phase 1 Report Volume II paragraph 12.86.
1361) Phase 1 Report Volume II paragraphs 12.86 and 14.73.
1362) Phase 1 Report Volume II paragraphs 12.85-12.86 and 14.116.
1363) Phase 1 Report Volume II paragraphs 10.289 (d) and 11.28.
1364) LFB Short Incident Log {MET00013830}; Phase 1 Report Volume II paragraphs 11.148-11.149.
1365) Phase 1 Report Volume II paragraph 11.155.
1366) Phase 1 Report Volume III paragraph 15.16; Singh {MET000083327/16-17} pages 16-17;
1367) Singh Exhibit MS/1 - pages from notebook {MET00013089/2}.
1368) Phase 1 Report Volume III paragraph 15.16; Singh {MET000083327/16-17} pages 16-17.
1369) Phase 1 Report Volume II paragraphs 14.103-14.104 and Figure 14.5.
1370) Phase 1 Report Volume IV paragraphs 28.86-28.87.
1371) Phase 1 Report Volume III Figure 15.7.
1372) Phase 1 Report Volume III Figure 16.5; Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}.
1373) Tenancy Agreement {TMOH00001235}; Phase 1 Report Volume IV paragraphs 32.55 -32.58.
1374) Bernard {IWS00002337/3} page 3, paragraphs 21-23.
1375) Bernard {IWS00002337/3-4} pages 3-4, paragraphs 21-24.
1376) Rydon Residents Survey {RYD00024466/5}.
1377) Phase 1 Report Volume III paragraphs 20.65-20.66; David Noble Spreadsheet {TMO00862588}.
1378) O’Riordan {MET00013136/3} page 3.
1379) Phase 1 Report Volume II paragraphs 10.257, 10.258, 10.260, 10.289 and 14.125.
1380) Phase 1 Report Volume II paragraph 11.28; Presentation relating to Raymond (Moses) Bernard {Day300/77:17}-{Day300/78:14}.
1381) 999 call transcript {LFB00055504/32-33}.
1382) Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 14.
1383) Interim certificate of the fact of death for Raymond Bernard {MET00065646}.
1384) Bernard post-mortem report {COR00000150/5}.
1385) Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20.
1386) Phase 1 Report Volume IV paragraph 32.154.
1387) Phase 1 Report Volume IV paragraphs 32.163-32.165.
1388) Noble {TMO00000884/1} page 1, paragraph 3.
1389) David Noble’s list {TMO00862588}.
1390) O’Riordan {MET00013136/2-4} pages 2-4.
1391) Phase 1 Report Volume II paragraphs 10.223, 10.255-10.257 and 10.289(e); Mekonnen {Day55/23:25}-{Day55/24:6}; BRE Investigation Report {MET00039807/77}.
1392) Phase 1 Report Volume II paragraphs 10.219 and 10.224-10.225.
1393) Phase 1 Report Volume II paragraph 10.258; Mekonnen {IWS00000912/3-4} pages 3-4, paragraphs 17-20; Phase 1 Report Volume III Annex A.
1394) Phase 1 Report Volume II paragraphs 10.259-10.260 and 10.289; Phase 1 Report Volume III Annex A; External Fire Spread Report {MET00012593/12}.
1395) Phase 1 Report Volume II paragraphs 12.66-12.67, 12.86, 14.127 and 14.132; 999 call transcript {LFB00055504/36-37}.
1396) Phase 1 Report Volume II paragraphs 14.128 and 14.132.
1397) Phase 1 Report Volume II paragraphs 14.132-14.134.
1398) Phase 1 Report Volume II paragraphs 12.86, 14.127 and 14.138-14.140.
1399) Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 16.
1400) Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 14.
1401) Interim certificates of the fact of death for Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris {MET00065590}; {MET00065639} and {MET00065591}.
1402) Purser, Phase 2 Report, Section 6 {DAPR0000006/10} paragraphs 21 and 24; {DAPR0000006/11} paragraphs 26-28.
1403) Amal Ahmedin post-mortem report {COR00000111/5-7}; Amal Ahmedin post-mortem report {COR00000111/5-7}; Amna Idris post-mortem report {COR00000155/3-8}.
1404) Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20; Purser {Day296/28:15}-{Day296/29:8}.
1405) Phase 1 Report Volume IV paragraphs 32.197-32.198 and 32.203; Tenancy Agreement {TMOH00026234}.
1406) Noble {Day119/77:17}-{Day119/82:5}.
1407) Noble spreadsheet {TMO00866002}.
1408) O’Riordan {MET00013136/3} page 3.
1409) Phase 1 Report Volume II paragraphs 10.253 and 11.58-11.60.
1410) 999 call transcript {MET00015554}.
1411) 999 call transcript {LFB00000481}.
1412) Phase 1 Report Volume II paragraph 10.289 (f); Ramirez {IWS00001116/4-5} pages 4-5, paragraphs 21 and 22.
1413) Phase 1 Report Volume II paragraphs 10.249-10.250, 10.254 and 10.289 (b).
1414) Phase 1 Report Volume II paragraph 10.289.
1415) Phase 1 Report Volume II paragraph 10.289 (f).
1416) Phase 1 Report Volume II paragraphs 10.259-10.260.
1417) Phase 1 Report Volume II paragraphs 10.289 (d) and 11.28.
1418) Chiapetto {IWS00000679/2-4} pages 2-4, paragraphs 10-17; Semre {IWS00000954/4} page 4, paragraphs 24-25.
1419) Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 14.
1420) Interim certificates of the fact of death for Berkti and Biruk Haftom {MET00065608}; {MET00065623}.
1421) Purser, Phase 2 Report, Section 6 {DAPR0000006/13} paragraph 38; Purser {Day296/28:15}-{Day296/29:8}.
1422) Berkti Haftom post-mortem report {COR00000216/5}; Biruk Haftom post-mortem report {COR00000240/3}.
1423) Tenancy agreement {TMOH00026143}.
1424) Phase 1 Report Volume IV paragraphs 32.204-23.209.
1425) GP Letter dated 23 July 1990 {TMOH00026128}.
1426) KCTMO Tenancy Information form {TMOH00026145/10}.
1427) Phase 1 Report Volume III paragraphs 20.65–20.66; David Noble Spreadsheet {TMO00866002}.
1428) O’Riordan {MET00013136/3} page 3.
1429) This timing is derived from the fact that at 01.27 the MPS operator asked the BT operator for a playback of Shah Ahmed’s 999 call, in which Shah Ahmed had not spoken to the BT operator. Phase 1 Report Volume II paragraphs 10.249-10.250 and 10.289 (b).
1430) Phase 1 Report Volume II paragraphs 14.125 and 10.287-10.289.
1431) Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 14.
1432) Interim certificate of the fact of death for Hamid Kani {MET00065623}.
1433) Purser, Phase 2 Report, Section 6 {DAPR0000006/13} paragraph 38; Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20.
1434) Kani post-mortem report {COR00000566/7}.
1435) External Fire Spread Report {MET00012593/12}; Phase 1 Report Volume IV paragraphs 32.186-32.189; Presentation relating to Debbie Lamprell {Day300/1:21}-{Day300/2:20}.
1436) O’Riordan {MET00013136/4} page 4; Presentation relating to Debbie Lamprell {Day300/2:21-25}; Phase 1 Report Volume II paragraph 14.136; Phase 1 Report Volume III Annex A.
1437) Phase 1 Report Volume II paragraphs 10.259-10.260.
1438) 999 call transcript {LFB00055500/29}.
1439) Phase 1 Report Volume II paragraphs 10.259-10.260 and 10.289.
1440) Phase 1 Report Volume II paragraphs 11.30-11.31.
1441) 999 call transcript {COR00000269}.
1442) Phase 1 Report Volume II paragraphs 12.66-12.67; 999 call transcript {MET00014977}.
1443) Phase 1 Report Volume II paragraphs 12.85-12.86 and 14.116.
1444) Phase 1 Report Volume II paragraph 12.64.
1445) Phase 1 Report Volume II paragraphs 14.127 and 14.138; 999 call transcript {LFB00055500/26-29}.
1446) Phase 1 Report Volume II paragraphs 14.138-14.140; 999 call transcript {LFB00055500/42-43}.
1447) Archaeology Report Volume 2 {COR00001585/190}.
1448) Interim certificate of the fact of death for Debbie Lamprell {MET00065596}.
1449) Coroner’s report for Lamprell {COR00000254/7}.
1450) Lamprell post-mortem report {COR00000263/6-7}.
1451) Purser {Day297/12:14-25}.
1452) Purser, Phase 2 Report, Section 6 {DAPR0000006/13} paragraph 38; Purser {Day296/28:15}-{Day296/29:8}.
1453) Tenancy Agreement {IWS00002062/7}.
1454) Phase 1 Report Volume IV paragraph 32.132.
1455) O’Riordan {MET00013136/3} page 3.
1456) Ramirez {IWS00001116/4} page 4, paragraph 18; Ramirez {MET00007773/3} page 3.
1457) Ramirez {IWS00001116/4} page 4, paragraph 20; {MET00007773/3} page 3.
1458) Ramirez {IWS00001116/4} page 4, paragraph 19; {MET00007773/4} page 4.
1459) 999 call transcript {MET00015554}.
1460) 999 call transcript {COR00000774}.
1461) 999 call transcript {LFB00000481}.
1462) Ramirez {IWS00001116/4-5} page 4-5, paragraph 21.
1463) Ramirez {IWS00001116/4-5} page 4-5, paragraph 21; Phase 1 Report Volume II paragraph 10.289(f).
1464) Phase 1 Report Volume II paragraph 10.289.
1465) Phase 1 Report Volume II paragraph 10.289(f).
1466) Phase 1 Report Volume II paragraphs 10.317 and 11.25.
1467) Ramirez {IWS00001116/5} page 5, paragraph 22.
1468) 999 call transcript {LFB00055504/19}.
1469) Phase 1 Report Volume II paragraph 10.79 (b).
1470) Phase 1 Report Volume II paragraph 10.101 (a).
1471) Phase 1 Report Volume II paragraph 11.10.
1472) Phase 1 Report Volume II paragraphs 12.6, 12.30 and 13.16.
1473) Phase 1 Report Volume II paragraph 13.16.
1474) Phase 1 Report Volume II paragraph 13.17.
1475) Phase 1 Report Volume II paragraph 14.133.
1476) Phase 1 Report Volume II paragraph 14.133.
1477) Phase 1 Report Volume II paragraphs 14.134 and 14.138.
1478) Phase 1 Report Volume II paragraph 14.134.
1479) 999 call transcript {LFB00055504/76-82}.
1480) Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 14.
1481) Interim certificate of the fact of death for Jessica Urbano Ramirez {MET00065625}.
1482) Ramirez post-mortem report {COR00000770/3}.
1483) Purser, Phase 2 Report, Section 6 {DAPR0000006/13-17} paragraphs 36–58.
1484) Purser, Phase 2 Report, Section 6 {DAPR0000006/14} paragraph 48; Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20; Purser, Phase 2 Report, Section 6 {DAPR0000006/15} Figure 28; Purser {Day297/12:14-25}.
1485) Purser {Day297/13:4-18}.
1486) External Fire Spread Report {MET00012593/12}; Phase 1 Report Volume IV paragraph 32.50; Disaró {IWS00000543/3} page 3, paragraphs 8-9; External Fire Spread Report {MET00012593/12}; Tekie {IWS00000953/3} page 3, paragraph 16.
1487) Phase 1 Report Volume II paragraph 14.3.
1488) Purser, Phase 2 Report, Section 6 {DAPR0000006/18} paragraph 63.
1489) Phase 1 Report Volume II paragraphs 10.287 and 10.289 (g).
1490) Phase 1 Report Volume II paragraph 10.118.
1491) Phase 1 Report Volume II paragraphs 14.125 and 10.287-10.289; External Fire Spread Report {MET00012593/12}.
1492) Ahmed post-mortem report {MWP00000034/3}; Ahmed {COR00000103/1} page 1; Foley {COR00000304/1} page 1.
1493) Phase 1 Report Volume II paragraph 11.35.
1494) Phase 1 Report Volume II paragraphs 10.287-10.289, 11.35, 14.125 and 14.141; Disaró {IWS00000543/6} page 6, paragraphs 20-21.
1495) Phase 1 Report Volume II paragraphs 11.29-11.35; External Fire Spread Report {MET00012593/12}.
1496) Phase 1 Report Volume II paragraphs 14.142-14.143.
1497) Phase 1 Report Volume III paragraphs 16.21 and 16.23.
1498) Phase 1 Report Volume III paragraphs 16.25 and 17.30.
1499) Phase 1 Report Volume III paragraph 16.22. Calls to the emergency services were made by and on behalf of people trapped in Flats 201, 203, 204 and 205 on floor 23. Information about people trapped in all of these flats was recorded at the incident ground: Phase 1 Report Volume II Figure 12.3.
1500) LFB Control Room Report {LFB00004790/43-46}.
1501) Phase 1 Report Volume II paragraphs 14.235-14.236.
1502) LFB Control Room Report {LFB00004790/63-124}.
1503) Phase 1 Report Volume IV paragraphs 32.545-32.54.
1504) O’Riordan {MET00013136/3}.
1505) Purser, Phase 2 Report, Section 6 {DAPR0000006/19} paragraph 71.
1506) Interim certificates of the fact of death for Gloria Trevisan and Marco Gottardi {MET00065586}; {MET00065617}.
1507) Purser, Phase 2 Report, Section 6 {DAPR0000006} Table 20; Purser {Day296/28:15}-{Day296/29;8}.
1508) Trevisan post-mortem report {COR00000546/9}.
1509) Gottardi post-mortem report {COR00000974/8}; Gottardi toxicology report {MET00007684/1}.
1510) Purser {Day297/33:4-20}.
1511) Tenancy Information Questionnaire for Flat 162 {TMOH00025319/3}; Phase 1 Report Volume IV paragraphs 32.176-32.182.
1512) RBKC letter dated 24 August 1987 {TMOH00025230}; TMO Memorandum {TMO00865242}.
1513) Email from Rydon dated 31 October 2014 {TMOH00025320}.
1514) Rydon Residents Survey {RYD00024466/14}.
1515) Tenancy Information Questionnaire for Flat 162 {TMOH00025319/9}.
1516) David Noble’s list {TMO00862588}.
1517) O’Riordan {MET00013136/2-3} pages 2-3.
1518) Purser, Phase 2 Report, Section 6 {DAPR0000006/19} paragraph 71.
1519) Interim certificate of the fact of death for Majorie and Ernie Vital {MET00065611}; {MET00065635};
1520) Majorie Vital post-mortem report {COR00000934/6}; Ernie Vital post-mortem Report {COR00000309/4}.
1521) Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20; Purser {Day296/28:15}-{Day296/29;8}.
1522) External Fire Spread Report {MET00012593/12}; Phase 1 Report Volume IV paragraph 32.34.
1523) Phase 1 Report Volume II paragraph 14.145.
1524) Phase 1 Report Volume II paragraph 14.146.
1525) Purser, Phase 2 Report, Section 6 {DAPR0000006/35} paragraph 159.
1526) Lane, Phase 1 Supplemental Report, Section 12 {BLAS0000012/11}; Phase 1 Report Volume III paragraph 18.5; Purser, Phase 2 Report, Section 6 {DAPR0000006/35} paragraph 162.
1527) Phase 1 Report Volume III paragraph 18.4; Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 165.
1528) Purser, Phase 2 Report, Section 6 {DAPR0000006/38} Figure 34.
1529) Purser, Phase 2 Report, Section 6 {DAPR0000006/54} paragraph 253; Purser {Day297/65:3-8}.
1530) Phase 1 Report Volume II paragraph 14.125.
1531) Phase 1 Report Volume IV paragraph 32.7.
1532) Phase 1 Report Volume II paragraphs 10.259-10.260, 10.287-10.289 and 11.30-11.31.
1533) Phase 1 Report Volume III paragraph 18.22; Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraphs 166-167.
1534) Phase 1 Report Volume II paragraphs 10.118 and 10.122; External Fire Spread Report {MET00012593/12}.
1535) Phase 1 Report Volume II paragraphs 11.30-11.31.
1536) Phase 1 Report Volume II paragraph 11.32 and Figure 11.9.
1537) Phase 1 Report Volume II paragraphs 11.33 and 11.35.
1538) Phase 1 Report Volume II paragraph 11.34.
1539) Phase 1 Report Volume III paragraph 15.16; Singh {MET000083327/16-17} pages 16-17;
1540) Singh Exhibit MS/1 - pages from notebook {MET00013089/2}.
1541) Phase 1 Report Volume III paragraph 15.16; Singh {MET000083327/16-17} pages 16-17.
1542) LFB Control Room Report {LFB00004790/57}.
1543) Phase 1 Report Volume II paragraph 13.105.
1544) LFB Short Incident Log {MET00013830/21}.
1545) LFB Short Incident Log {MET00013830}.
1546) Phase 1 Report Volume II paragraph 14.146.
1547) Phase 1 Report Volume II paragraph 14.147; 999 call transcript {LFB00000663/1-5}. The first image of the fire taken by the National Police Air Support (“NPAS”) helicopter was taken at 01.43, therefore it had reached the tower sometime before or around this time: Phase 1 Report Volume II paragraph 12.104 and Figure 12.8.
1548) Phase 1 Report Volume III paragraph 15.144.
1549) Phase 1 Report Volume III paragraph 15.168.
1550) Phase 1 Report Volume III paragraph 15.73.
1551) Phase 1 Report Volume III paragraphs 16.27-16.28.
1552) Phase 1 Report Volume III paragraph 16.29.
1553) Phase 1 Report Volume III paragraphs 16.30-16.31; Mahmud {MET00080727/18-19} pages 18-19.
1554) LFB Control Room Report {LFB00004790/58}.
1555) LFB Control Room Report {LFB00004790}.
1556) Phase 1 Report Volume II paragraph 14.243.
1557) Phase 1 Report Volume IV paragraphs 28.84(b) and 28.86.
1558) Phase 1 Report Volume II paragraph 14.73 and Figure 14.4.
1559) Phase 1 Report Volume III paragraph 17.11; Phase 1 Report Volume IV paragraph 28.86.
1560) LFB Control Room Report {LFB00004790/81}.
1561) Phase 1 Report Volume III paragraphs 15.139-15.140 and Figure 15.8.
1562) Phase 1 Report Volume II paragraphs 12.8-12.9 and Figure 12.3.
1563) Phase 1 Report Volume II paragraphs 14.103-14.104 and Figure 14.5.
1564) Phase 1 Report Volume III paragraph 16.12 and Figure 16.5; Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}
1565) Phase 1 Report Volume III paragraph 18.15(b).
1566) Tenancy Agreement for Hassan Awadh Hassan {TMOH00010399}; Presentations relating to Rania Ibrahim, Fethia Hassan and Hania Hassan {Day299/52:1-22}.
1567) Phase 1 Report Volume IV paragraphs 32.34-32.43.
1568) David Noble’s list {TMO00862588}.
1569) O’Riordan {MET00013136/3} page 3.
1570) Mahmud {IWS00000776/1-4} pages 1-4, paragraphs 3, 15, 16; Presentations relating to Rania Ibrahim, Fethia Hassan and Hania Hassan {Day299/54:10-15}.
1571) Presentations relating to Rania Ibrahim, Fethia Hassan and Hania Hassan {Day299/58:15-19}.
1572) Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 167.
1573) Interim certificate of the fact of death for Rania Ibrahim, Fethia Hassan and Hania Hassan {MET00065635}; {MET00065604}; {MET00065636}.
1574) Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 167.
1575) Rania Ibrahim post-mortem report {COR00000444/3}; Fethia Hassan post-mortem report {COR00001724/3}; Hania Hassan post-mortem report {COR00001723/3}.
1576) Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20; Purser {Day296/28:15}-{Day296/29:8}.
1577) Phase 1 Report Volume IV paragraphs 32.8-32.12.
1578) Presentations relating to Fathia Ahmed Elsanousi, Isra Ibrahim and Abufras Ibrahim {Day307/96:7-10}.
1579) Phase 1 Report Volume IV paragraph 32.7.
1580) Presentations relating to Fathia Ahmed Elsanousi, Isra Ibrahim and Abufras Ibrahim {Day307/99:5-13}; Health Assessment Form {BSR00000110}.
1581) David Noble’s list {TMO00862588}.
1582) O’Riordan {MET00013136/2-4} pages 2-4.
1583) Phase 1 Report Volume II paragraphs 10.283 and 10.118; Farhad Neda {Day61/37:1-25}; Neda {IWS00000887/7} page 7, paragraph 33; Flora Neda {Day61/130:12-18}.
1584) Phase 1 Report Volume II paragraph 10.122.
1585) Phase 1 Report Volume II paragraphs 10.289 and 11.29-11.30.
1586) Phase 1 Report Volume III paragraph 18.22; Moore {MET00010819/10} page 10; Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 166.
1587) Abufras Ibrahim post-mortem report {COR00000049/3}.
1588) Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 167.
1589) Interim certificate of the fact of death for Fathia Ahmed Elsanousi; Isra Ibrahim and Abufras Ibrahim {MET00065632}; {MET00065593}; {MET00065614}.
1590) Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 166.
1591) Elsanousi post-mortem report {COR00000443/3}; Isra Ibrahim post-mortem report {COR00000448/5-6}.
1592) Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20.
1593) Phase 1 Report Volume IV paragraphs 32.191-32.196.
1594) Phase 1 Report Volume II paragraphs 14.125 and 10.287-10.289; External Fire Spread Report {MET00012593/12}.
1595) 999 call transcript {LFB00055500/29}.
1596) Phase 1 Report Volume II paragraphs 10.259-10.260.
1597) Phase 1 Report Volume II paragraphs 10.289 (d), 11.25 and 11.28.
1598) Phase 1 Report Volume II paragraphs 11.29-11.30.
1599) 999 call transcript {COR00000269}. Debbie Lamprell remained in Flat 201 and at 02.05 during a 999 call she referred to having lost her friend, saying they had come up together, but he had gone: 999 call transcript {LFB00055500/26-29}.
1600) Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 167.
1601) Interim certificate of the fact of death for Gary Maunders {MET00065624}.
1602) Maunders post-mortem report {COR00000521/3}.
1603) Purser, Phase 2 Report, Section 6 {DAPR0000006/1} Table 20.
1604) Phase 1 Report Volume IV paragraphs 32.29-32.32.
1605) Tenancy Agreement {TMOH00013384/6-7}.
1606) El-Baghdady {IWS00001535/2-4} pages 2-4, paragraphs 7-14.
1607) {BSR00000133/3-5}; {BSR00000130/3-5}; {BSR00000131/3-4}.
1608) {BSR00000131/2-3}.
1609) {TMOH00013422/1}; {TMOH00013423/1-2}.
1610) David Noble’s list {TMO00862588}.
1611) O’Riordan {MET00013136/3} page 3.
1612) Krivsoun {MET00039926/1} page 1.
1613) Phase 1 Report Volume II paragraphs 10.149 and 10.283-10.286.
1614) Phase 1 Report Volume II paragraph 11.36.
1615) Phase 1 Report Volume II paragraph 12.68; External Fire Spread Report {MET00012593/12}. Of the two neighbouring flats, the exterior fire affected Flat 205 first, by 02.09-02.10: Lane, Phase 1 Supplemental Report, Section 12 {BLAS0000012/9-11}.
1616) Phase 1 Report Volume II paragraph 12.76; LFB Short Incident Log {MET00013830/21}; LFB Control Room Report {LFB00004790/50}.
1617) Phase 1 Report Volume III paragraph 15.169; LFB Short Incident Log Report {MET00013830}.
1618) Phase 1 Report Volume III paragraph 17.26; LFB Short Incident Log Report {MET00013830}.
1619) Phase 1 Report Volume III paragraph 17.28.
1620) Phase 1 Report Volume III paragraphs 17.27 and 18.21; LFB Short Incident Log Report {MET00013830}.
1621) Phase 1 Report Volume III paragraph 18.21.
1622) Phase 1 Report Volume III paragraph 18.21.
1623) Phase 1 Report Volume II paragraph 11.5.
1624) Phase 1 Report Volume II paragraphs 12.18-12.19 and Figure 12.4.
1625) Phase 1 Report Volume IV paragraph 28.85(d).
1626) Phase 1 Report Volume IV paragraph 28.102(f); {MET00015930}.
1627) Phase 1 Report Volume II paragraph 14.73 and Figure 14.4.
1628) Phase 1 Report Volume II paragraphs 14.103-14.104 and Figure 14.5.
1629) Phase 1 Report Volume II paragraph 14.108; Phase 1 Report Volume III paragraph 15.23 and Figure 15.7
1630) De Silvo {Day30/14:18}-{Day30/15:15}.
1631) Phase 1 Report Volume II paragraph 14.71.
1632) Phase 1 Report Volume III paragraph 15.139.
1633) Phase 1 Report Volume III paragraph 15.169.
1634) Phase 1 Report Volume IV paragraph 28.85 (d); {MET00015924}.
1635) Phase 1 Report Volume III paragraph 16.15 and Figure 16.6.
1636) Phase 1 Report Volume III paragraphs 16.15-16.20.
1637) External Fire Spread Report {MET00012593/12}.
1638) Purser, Phase 2 Report, Section 6 {DAPR0000006/24} paragraph 93 and {DAPR0000006/32} paragraph 139.
1639) Purser, Phase 2 Report, Section 6 {DAPR0000006/33} paragraph 143.
1640) Interim certificate of the fact of death for Hesham Rehman {MET00065606}.
1641) Purser, Phase 2 Report, Section 6 {DAPR0000006/33} paragraph 145.
1642) Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20.
1643) Purser, Phase 2 Report, Section 6 {DAPR0000006/33-34} paragraphs 146-147 and 153.
1644) Rahman post-mortem report {COR00001718/4}.
1645) Phase 1 Report Volume IV paragraph 32.22.
1646) Phase 1 Report Volume IV paragraphs 32.22–32.27.
1647) Phase 1 Report Volume IV paragraphs 32.22–32.27.
1648) Phase 1 Report Volume II paragraph 10.148.
1649) Phase 1 Report Volume II paragraph 10.150.
1650) Phase 1 Report Volume II paragraph 10.283.
1651) Phase 1 Report Volume II paragraph 10.284.
1652) Phase 1 Report Volume II paragraph 10.284.
1653) Phase 1 Report Volume II paragraph 13.79.
1654) Phase 1 Report Volume II paragraph 10.289 (a).
1655) Phase 1 Report Volume II paragraphs 11.27 and 11.163.
1656) LFB Short Incident Log Report {MET00013830/19}; Phase 1 Report Volume II paragraphs 12.72 and 12.73 (b).
1657) Phase 1 Report Volume II paragraph 12.18.
1658) Phase 1 Report Volume II paragraph 12.19.
1659) Phase 1 Report Volume II paragraph 14.73 and Figure 14.4.
1660) Phase 1 Report Volume IV paragraph 28.101.
1661) Phase 1 Report Volume II paragraph 14.117.
1662) Phase 1 Report Volume II Figure 13.2 and paragraph 14.117; Phase 1 Report Volume IV paragraph 28.101.
1663) Phase 1 Report Volume II paragraph 14.117.
1664) Phase 1 Report Volume II paragraph 14.117.
1665) Phase 1 Report Volume II paragraph 13.81.
1666) Phase 1 Report Volume II paragraph 13.80.
1667) Phase 1 Report Volume II paragraphs 13.78 and 13.98.
1668) Phase 1 Report Volume II paragraph 13.98.
1669) Phase 1 Report Volume III paragraph 15.64.
1670) Phase 1 Report Volume III paragraph 15.64.
1671) Phase 1 Report Volume III paragraph 15.64.
1672) Phase 1 Report Volume III paragraph 15.65.
1673) Phase 1 Report Volume III paragraph 15.143
1674) Phase 1 Report Volume III paragraph 15.61.
1675) Phase 1 Report Volume III paragraph 15.61.
1676) Phase 1 Report Volume III paragraph 15.147.
1677) Phase 1 Report Volume III Figure 15.7.
1678) Phase 1 Report Volume III paragraph 15.54.
1679) Phase 1 Report Volume III paragraphs 15.54-15.56; Phase 1 Report Volume IV paragraph 28.101.
1680) Phase 1 Report Volume III paragraphs 15.66-15.67.
1681) Phase 1 Report Volume III paragraph 15.56.
1682) Phase 1 Report Volume IV paragraph 28.101.
1683) Phase 1 Report Volume III paragraph 16.15 and Figure 16.6.
1684) Phase 1 Report Volume III paragraphs 16.17-16.20; Phase 1 Report Volume IV paragraph 28.101.
1685) Phase 1 Report Volume III paragraphs 16.17-16.20.
1686) Phase 1 Report Volume IV paragraph 28.101.
1687) Phase 1 Report Volume III paragraph 15.70.
1688) Matthews {COR00001112/5} page 5.
1689) Interim certificate of the fact of death for Saber Neda {MET00065621}.
1690) Neda post-mortem report {COR00001210/15}.
1691) Neda post-mortem report {COR00001210/14}.
1692) Phase 1 Report Volume IV paragraphs 32.61-32.63.
1693) Phase 1 Report Volume IV paragraphs 32.61-32.63.
1694) Phase 1 Report Volume IV paragraphs 32.64-32.65.
1695) Elgwahry {IWS00001757/7} page 7, paragraph 19.
1696) Elgwahry {IWS00001757/7} page 7, paragraph 19.
1697) Rydon Residents Survey {RYD00024466/6}.
1698) Tenancy Audit Form for Flat 196 {IWS00001778}.
1699) Noble spreadsheet {TMO00866002}.
1700) O’Riordan {MET00013136/3} page 3. Eslah Elgwahry was seen on CCTV in the lift lobby of the tower at 15.21. O’Riordan {MET00013136/2} page 2.
1701) Phase 1 Report Volume II paragraph 10.118.
1702) Phase 1 Report Volume II paragraph 10.277.
1703) Phase 1 Report Volume II paragraphs 10.277 and 10.281.
1704) Phase 1 Report Volume II paragraph 10.282.
1705) Phase 1 Report Volume II paragraph 10.284.
1706) Phase 1 Report Volume II paragraphs 10.284 and 10.288-10.289.
1707) Phase 1 Report Volume II paragraph 10.289 (a).
1708) Phase 1 Report Volume II paragraph 11.141.
1709) Phase 1 Report Volume II paragraphs 11.27 and 11.163.
1710) Phase 1 Report Volume II paragraphs 11.163-11.164.
1711) LFB Short Incident Log {MET00013830/19}.
1712) Phase 1 Report Volume II paragraphs 12.72 and 12.73 (b).
1713) LFB Short Incident Log {MET00013830/19}.
1714) Phase 1 Report Volume II paragraph 12.18.
1715) Phase 1 Report Volume II paragraph 12.19.
1716) Phase 1 Report Volume II paragraph 14.73 and Figure 14.4.
1717) Phase 1 Report Volume IV paragraph 28.101.
1718) Phase 1 Report Volume II paragraphs 13.78 and 13.98.
1719) Phase 1 Report Volume II paragraph 13.98.
1720) Phase 1 Report Volume II paragraph 14.117.
1721) Phase 1 Report Volume II Figure 13.2 and paragraph 14.117; Phase 1 Report Volume IV paragraph 28.101.
1722) Phase 1 Report Volume II Figure 13.2 and paragraph 14.117, Phase 1 Report Volume IV paragraph 28.101.
1723) Phase 1 Report Volume II paragraph 14.117.
1724) Phase 1 Report Volume II paragraph 14.117.
1725) Ahmed Elgwahry {IWS00000988/2} page 2, paragraphs 5 and 6.
1726) Ahmed Elgwahry {IWS00000988/3} page 3, paragraph 9.
1727) Ferzana Elgwahry {IWS00000995/3} page 2, paragraph 10.
1728) Phase 1 Report Volume II paragraph 14.149.
1729) Phase 1 Report Volume II paragraph 14.150.
1730) Phase 1 Report Volume III paragraph 15.64.
1731) Phase 1 Report Volume III paragraph 15.64.
1732) Phase 1 Report Volume III paragraph 15.64.
1733) Phase 1 Report Volume III paragraph 15.65.
1734) Phase 1 Report Volume III paragraph 15.143
1735) Phase 1 Report Volume III paragraph 15.61.
1736) Phase 1 Report Volume III paragraph 15.61.
1737) Phase 1 Report Volume III paragraph 15.62.
1738) Phase 1 Report Volume III paragraph 15.147.
1739) Phase 1 Report Volume III paragraph 15.62.
1740) Phase 1 Report Volume III paragraphs 15.54-15.56; Phase 1 Report Volume IV paragraph 28.101.
1741) Phase 1 Report Volume III paragraphs 15.66-15.67.
1742) Phase 1 Report Volume III paragraph 15.56.
1743) Phase 1 Report Volume IV paragraph 28.101.
1744) Phase 1 Report Volume III paragraph 16.15 and Figure 16.6.
1745) Phase 1 Report Volume III paragraphs 16.17-16.20; Phase 1 Report Volume IV paragraph 28.101.
1746) Phase 1 Report Volume III paragraphs 16.17-16.20.
1747) Phase 1 Report Volume IV paragraph 28.101.
1748) Phase 1 Report Volume III paragraph 17.21.
1749) Phase 1 Report Volume III paragraphs 17.23-17.24.
1750) Bisby, Supplemental Phase 1 Expert Report {LBYS0000001/221} paragraph 1043; Purser, Phase 2 Report, Section 6 {DAPR0000006/29} paragraph 119.
1751) Phase 1 Report Volume III paragraph 17.4 and Figures 17.3 and 17.4; Purser, Phase 2 Report, Section 6 {DAPR0000006/29} paragraph 120.
1752) Purser, Phase 2 Report, Section 6 {DAPR0000006/24} paragraph 100
1753) Interim certificate of the fact of death for Eslah and Mariem Elgwahry {MET00065607}; {MET00065615}.
1754) Eslah Elgwahry post-mortem {COR00001002/4}; Mariem Elgwahry post-mortem {COR00000337/3}.
1755) Purser, Phase 2 Report, Section 6 {DAPR0000006/28} paragraph 117; Purser Summary table of toxicity endpoints in each 23rd floor flat {DAPR0000013}.
1756) Phase 1 Report Volume IV paragraphs 32.218–32.227.
1757) Aghlani {IWS00000774/1} page 1, paragraph 3.
1758) Phase 1 Report Volume IV paragraphs 32.218–32.227.
1759) Aghlani {IWS00000774/1-2} pages 1-2, paragraphs 5-6.
1760) Spreadsheet of residents {TMO00866002}.
1761) Sattar {IWS00000769/2} page 2, paragraph 7; Afrasehabi {IWS00000767/2} page 2, paragraph 7.
1762) Phase 1 Report Volume II paragraphs 10.249-10.250.
1763) Phase 1 Report Volume II paragraph 10.289 (c).
1764) Phase 1 Report Volume II paragraphs 10.284 and 10.288-10.289.
1765) Phase 1 Report Volume II paragraphs 12.18-12.19, 12.72 and 12.73 (b); LFB Short Incident Log Report {MET00013830/19}. Phase 1 Report Volume II paragraphs 12.72 and 12.73 (b). Phase 1 Report Volume II paragraphs 12.18-12.19.
1766) Phase 1 Report Volume II paragraph 10.289 (a) .
1767) Phase 1 Report Volume II paragraphs 11.27 and 11.163.
1768) Phase 1 Report Volume II paragraph 14.73 and Figure 14.4.
1769) Phase 1 Report Volume II paragraph 14.117; Phase 1 Report Volume II Figure 13.2 and paragraph 14.117; Phase 1 Report Volume IV paragraph 28.101.
1770) Phase 1 Report Volume II Figure 13.2.
1771) Phase 1 Report Volume II paragraph 14.117.
1772) Phase 1 Report Volume II paragraph 14.117.
1773) Phase 1 Report Volume IV paragraph 25.17. By 01.54, Mariem Elgwahry described Flat 205 as full of smoke in a 999 call.
1774) Phase 1 Report Volume II paragraph 13.79.
1775) Phase 1 Report Volume II paragraph 13.80.
1776) Phase 1 Report Volume II paragraph 13.82.
1777) Phase 1 Report Volume III paragraph 17.25.
1778) Phase 1 Report Volume II paragraphs 13.78 and 13.98.
1779) Phase 1 Report Volume III paragraph 15.143
1780) Phase 1 Report Volume II paragraph 13.98.
1781) Phase 1 Report Volume III paragraph 15.147.
1782) Phase 1 Report Volume III paragraph 15.54.
1783) Phase 1 Report Volume III paragraph 15.64.
1784) Phase 1 Report Volume III paragraph 15.64.
1785) Phase 1 Report Volume III paragraph 15.64.
1786) Phase 1 Report Volume III paragraph 15.65.
1787) Phase 1 Report Volume III paragraphs 15.54-15.56; Phase 1 Report Volume IV paragraph 28.101.
1788) Phase 1 Report Volume III paragraphs 15.66-15.67.
1789) Phase 1 Report Volume III paragraph 15.56.
1790) Phase 1 Report Volume IV paragraph 28.101.
1791) Phase 1 Report Volume III paragraph 16.15 and Figure 16.6.
1792) Phase 1 Report Volume III paragraph 16.17-16.20; Phase 1 Report Volume IV paragraph 28.101.
1793) Phase 1 Report Volume III paragraphs 16.17-16.20.
1794) Phase 1 Report Volume IV paragraph 28.101.
1795) Phase 1 Report Volume III paragraph 17.25.
1796) Purser, Phase 2 Report, Section 6 {DAPR0000006/24} paragraph 94.
1797) Interim certificate of the fact of death for Sakina Afrasehabi and Fatemeh Afrasiabi {MET00065598}; {MET00065612}.
1798) Afrasehabi post-mortem report {COR00000425/5}; Afrasiabi post-mortem report {COR00001380/5}.