September 2024
Volume 7
Part 10 – Response and recovery
Part 11 – Matters outstanding from Phase 1
Part 12 – The fire testing regime
Part 13 – International responses
Part 14 – Recommendations
Appendices
HC 19–VII
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 7 of 7)
E03165832 09/2024
The Grenfell Tower fire was one of the worst post-war civil disasters in the UK. As the emergency services fought the fire, hundreds of people were displaced from their homes in the tower and surrounding properties. Many of those affected felt that in the hours and days that followed the fire they were abandoned by the authorities at the time of their greatest need.
This Part of the report is concerned with the response of the local authority and the government in the days immediately following the fire.[1] We have examined the legal and organisational framework for responding to emergencies with a view to finding out what plans were in place for responding to a major emergency of that kind, what the response was, in particular by way of emergency relief, when the emergency struck and whether that response was adequate.
We have examined those matters through the lens of the Civil Contingencies Act 2004 (“the Act”) and its associated regulations and guidance which establish the duties and responsibilities of the government and local authorities to prepare for and respond to emergencies of all kinds. That includes consideration of the statutory duties to assess risk, develop and maintain emergency plans and ensure that those who have the task of responding to emergencies are adequately trained, practise putting their plans into action and have sufficient staff to meet their responsibilities. Some of the bodies identified in the List of Issues, including the government and the TMO, were not subject to duties under the Act, but in view of their importance we have included them in our investigation. As far as the Act itself is concerned, the overriding question is whether the Royal Borough of Kensington and Chelsea (“RBKC”) complied with its duties and (if it did) whether it was sufficiently prepared for, and responded adequately to, the fire.
That is the context in which we have examined the provision of emergency relief in the days immediately following the fire. There is no statutory definition of “emergency relief” and we have therefore drawn on the guidance published by the government to accompany the Act entitled Emergency Response and Recovery, which defines “humanitarian assistance” as the provision of proper care for those involved in and affected by a major incident. We have concentrated on the following aspects of emergency relief:
The most important question we have had to consider is whether those affected by the fire received adequate emergency relief and assistance from the authorities. We examine that through the evidence of those most directly affected, which is considered in relation to the various categories of emergency relief set out above.
In examining the adequacy of the response to the fire, we have concentrated on the actions of the government, the council and the TMO in the seven days following the fire. That is long enough to allow us to consider the key decisions made in those early hours and days that had significant consequences for the response and recovery effort. Those seven days cover both the initial period during which RBKC was in control of the response and the period that began in the afternoon of 16 June 2017 when London Local Authority Gold (“London Gold”) took control as part of the London-wide resilience arrangements. However, although our investigations have concentrated on that relatively short period, we recognise that the appalling after-effects of the fire continue to this day.
An important and striking feature of the response to the Grenfell Tower fire was the substantial involvement of community, voluntary and faith groups in providing sanctuary and support to those most seriously affected. We describe the circumstances in which that took place and the extent to which it filled a vacuum left by the authorities.
The framework for emergency planning and response arrangements in the United Kingdom is governed by the Civil Contingencies Act 2004 (“the Act”)[2] and the Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005 (“the Regulations”).[3]
Part I of the Act[4] deals with local arrangements for civil protection, defining an “emergency” and establishing a statutory framework of roles and responsibilities for responders. The Grenfell Tower fire was an emergency within the meaning of the Act.[5]
The Act divides responders into Category 1 responders (which include the fire and rescue, police, and ambulance services and local authorities)[6] and Category 2 responders (which include utility companies and transport providers).[7] Category 1 responders are subject to legal duties relating to civil protection, which include assessing the risk of emergencies occurring, putting in place emergency plans, making arrangements to provide information to the public about civil protection matters, maintaining arrangements to warn, inform, and advise the public in the event of an emergency, sharing information with other local responders to enhance co-ordination, and co-operating with other local responders to enhance co-ordination and efficiency.[8] Category 2 responders are required to co-operate with Category 1 responders in connection with the performance of their duties.[9]
Government departments are not responders for the purposes of the Act. Bodies such as the TMO are also not subject to duties under the Act.
In London, Category 1 responders discharge their statutory obligations collectively through the London Resilience Forum (“the Forum”) and work together within the Forum to assess the risk of an emergency of any particular kind occurring in London.[10] They are required to maintain plans for emergencies collectively within the Forum[11] and to maintain arrangements to warn the public and provide it with information and advice if an emergency is likely to, or has, occurred.[12]
Under Part 1 of the Act ministers have the power to make legally enforceable orders to reduce, control, or mitigate the effects of a local emergency, or take other action in connection with it, subject to an affirmative resolution of both houses of Parliament.[13] In cases of urgency, ministers can issue temporary written directions to responders, without any further formality, that remain binding for 21 days.[14] Neither of those powers was used in connection with the Grenfell Tower fire. The Act also contains provision for making emergency regulations,[15] but those powers were not used either.
Part I of the Act and the Regulations are supplemented by statutory guidance entitled Emergency Preparedness, revised by the Cabinet Office in 2011. It deals with matters that must be considered before an emergency occurs (the so-called “pre-emergency phase”) and describes the requirements of the Act and the Regulations.[16] The Act is further supplemented by non-statutory guidance entitled Emergency Response and Recovery, which gives guidance on how to respond to emergencies and what the recovery phase should entail.[17]
The UK’s approach to civil contingencies is based on the principle that decisions should be taken at the lowest appropriate level with co-ordination at the highest necessary level.[18] In all cases, local agencies are considered to be the building blocks of response and recovery operations.[19] The role of the government is to support and supplement the efforts of local responders through the provision of resources and co-ordination. The central and sub-national tiers of government only become involved in emergency response and recovery efforts where it is necessary or helpful to do so.[20]
Emergency Response and Recovery states that humanitarian assistance is about ensuring that those involved in and affected by a major incident are properly cared for.[21] That is likely to include the provision of basic shelter, information about what has happened, medical assistance and treatment, financial and legal support, psychosocial support, advice and direction on how to get further help and assistance, communication facilities to enable people to contact and meet each other, providing a link to a police investigation, where relevant, and providing a point of contact for longer-term support and advice.
Emergency Response and Recovery also indicated that in this case RBKC (as the relevant local authority) should work with partners to provide immediate shelter and welfare for survivors who did not require medical support, their families and friends, through rest centres, humanitarian and other centres, in order to meet their immediate or short-term needs), to provide for the medium- to longer-term welfare of survivors (for example, by means of support from social services and financial assistance and also by providing helplines to answer questions from the public in one place), to facilitate the remediation and re-occupation of sites or areas affected by the emergency, to co-ordinate the activities of any voluntary sector agencies and spontaneous volunteers and to lead the recovery effort.[22]
In addition to the two core guidance documents, Emergency Preparedness and Emergency Response and Recovery, there are a large number of further guidance and policy documents which deal with various aspects of the civil protection regime and emergency response arrangements.[23] They include Evacuation and shelter guidance,[24] Human Aspects in Emergency Management[25] and National Recovery Guidance.[26]
Katharine Hammond, then Director of the Civil Contingencies Secretariat (part of the Cabinet Office), told us that guidance and policy documents were made available to local responders through an online platform,[27] but that many local responders also had hard copies.[28] Although Ms Hammond could not recall any concern or complaint being raised about the complexity or quantity of guidance and policy documents or the general complexity of the civil contingencies framework,[29] the guidance and policy documents are lengthy, numerous, and do not always define important concepts in the same way.
Emergency Preparedness states that emergency plans should have particular regard to the vulnerable (those with mobility difficulties, those with mental health difficulties or who are dependent on others, such as children) and to survivors and others affected (those directly affected by the emergency or the anxiety of not knowing what has happened).[30] Emergency Response and Recovery recognises that special consideration must be given to the needs of various of groups for care and support, with particular reference to four groups which can make challenging demands on responding agencies, namely, (i) children and young people, (ii) faith, religious, cultural and minority ethnic communities, (iii) elderly people and (iv) people with disabilities.[31]
In addition, the Home Office issued guidance entitled The Needs of Faith Communities in Major Emergencies: Some Guidelines[32] and the Cabinet Office issued guidance documents which specifically addressed the needs of vulnerable people,[33] including Identifying people who are vulnerable in a crisis,[34] Expectations and Indicators of Good Practice Set for Category 1 and 2 Responders[35] and Preparation and planning for emergencies: responsibilities of responder agencies and others.[36] We have not found it necessary to examine that further guidance in detail.
At the time of the Grenfell Tower fire, most of the Cabinet Office guidance did not refer to the Equality Act 2010 or to how responders should discharge their duties under it, including the public sector equality duty, when planning for emergencies.[37] We observe that although the National Resilience Standards introduced in July 2018 now include one discrete reference to the Equality Act 2010,[38] the Act is not mentioned in either Emergency Preparedness or Emergency Response and Recovery. Nor is it listed in Chapter 19 of Emergency Preparedness, which addresses what is called “the fit with other legislation” but has not been revised since its publication in February 2011.[39]
Since 2005 the Civil Contingencies Secretariat has produced a National Risk Assessment. Originally it was produced annually but since 2014 it has been produced biennially.[40] The assessment, which since 2019 has been incorporated into the National Security Risk Assessment, is a classified document which identifies what the government considers to be the most serious types of risks facing the United Kingdom over the coming five years. In order for a risk to be included, it must constitute a civil emergency within the meaning of the Civil Contingencies Act, be an event that could plausibly occur within the next five years and have an effect which exceeds a certain minimum level. There are usually between 70 and 100 risks identified in the NRA.[41]
The designated “owner” of each risk, normally a government department, is responsible for collecting evidence to inform the assessment and is required to work with experts from within and outside the organisation to gain a clear understanding of the risk and its consequences. The owner of the risk is required to use the information obtained in that way to identify a serious but plausible manifestation of the risk (known as “a reasonable worst-case scenario”),[42] the likelihood of its occurring and the potential effect if it were to do so.[43] The most recent edition of the National Risk Assessment before the Grenfell Tower fire had been completed in 2016 and released in February 2017.[44] At that time, the Home Office was the owner of the risk in relation to fire.[45]
The National Risk Assessment released in 2017 included in its risks a significant wildfire.[46] It did not envisage a major fire in a high-rise building [47] and no consideration appears to have been given to an event of that kind.[48] Luke Edwards, director of fire and resilience within the Crime, Policing and Fire Group at the Home Office,[49] was not aware that it had been considered[50] and Ms Hammond was unable to say whether a tower block fire had been considered and discounted or had not been considered at all.[51]
The National Risk Assessment was based in part on certain assumptions (the National Resilience Planning Assumptions), which establish the maximum expected scale, duration, and severity of the common consequences of the reasonable worst-case scenario described in the risk summaries.[52] Examples include the number of casualties and the extent of disruption to certain essential services.[53]
The National Risk Assessment and the National Resilience Planning Assumptions together form the basis of the National Risk Register, which is a public document[54] used by local responders and local resilience forums to inform their own risk assessments and planning assumptions. The National Risk Register current at the time of the Grenfell Tower fire, published in March 2015,[55] identified the risk of severe wildfires but did not identify the risk of a major fire in a high-rise building.[56]
Ms Hammond said that although the National Risk Assessment issued in 2016 did not identify a significant urban fire (including a fire in a tower block), a number of reasonable worst-case scenarios indicated the need to plan for outcomes very similar to those seen at Grenfell Tower. That in turn should have meant that the omission of an urban fire did not prejudice the ability of Category 1 and Category 2 responders to make a fully informed local risk assessment.[57]
Ms Hammond accepted, however, that the inclusion of an urban or tower block fire in the 2016 version of the National Risk Assessment would have provided a focus for responders[58] and we consider that it would have significantly increased the likelihood of its inclusion in documents such as the London Risk Register, to which we come later. We note that the version of the Local Risk Management Guidance produced by the Civil Contingencies Secretariat in 2016, which was intended to help Category 1 and 2 responders fulfil their local risk assessment duties and provide advice on how best to use information from the 2016 National Risk Assessment in a local context,[59] directed responders to consider which of the risks identified in the National Risk Assessment were relevant to their own areas.[60]
The Civil Contingencies Secretariat is also responsible for the management of the online database which acts as a single repository of information obtained from a variety of sources which is thought to provide lessons for the future.[61] Known as the Joint Organisational Learning system, it is specifically intended to meet the need to capture, promulgate and implement lessons learnt from major incidents.[62] However, at the time of the Grenfell Tower fire the database did not include any lessons learnt from earlier incidents involving fires in high-rise buildings, such as the Lakanal House fire in July 2009, the Shirley Towers fire in Southampton in 2010 or the Adair Tower fire in October 2015.[63] Ms Hammond, who was not in post at the time of those incidents, did not know why lessons learnt from them had not been included.[64] It is not clear whether an urban or tower block fire would have merited inclusion as a separate risk in the 2016 version of the National Risk Assessment, but we are concerned that the omission from the database of lessons gained from any urban fires may have limited the material available to inform the assessment of risks.
Following the Grenfell Tower fire, the National Risk Register issued in September 2017 was revised to include the risk of fire in a residential building, with specific mention of the Grenfell Tower fire.[65] A Home Office witness explained that the decision to include it was made in the light of the widespread use of combustible cladding and the new understanding that other buildings might be at risk. It was thought that using the publicly available National Risk Register was a sensible way of communicating those matters more widely.[66] The National Security Risk Assessment completed in 2019, the most recent version of the National Risk Assessment, includes the example of a fire in a high-rise residential building as the reasonable worst case scenario for a fire risk, with the risk of wildfire remaining as an alternative.[67] The inclusion of an urban fire has also resulted in some small changes to the National Resilience Planning Assumptions, for example, a major fire is now a risk to consider in the planning assumption for rubble, debris, and trapped people.[68] Ms Hammond told us that the Civil Contingencies Secretariat had a better understanding of the fire risk which had been improved by revised Home Office modelling following the Grenfell Tower fire. As a result, it was now recognised that the consequences of a major tower block fire were more significant than had previously been assessed.[69]
Local resilience forums are responsible for risk assessments in their areas. The London Resilience Forum discharges the statutory duties in relation to Greater London to assess risks across London and maintain plans for responding to them.[70]
The London Risk Register is developed in a way that is consistent with the National Risk Register[71] and provides an overview of the principal risks which may affect London as a whole.[72] The register completed in February 2017 and therefore current at the time of the Grenfell Tower fire did not refer to the risk of a major fire in a residential tower block, although it did refer to the risk of a severe wildfire.[73] That was because a residential tower block fire had not been included in the register since it had not been included in the National Risk Register and had not been identified by the London Risk Assessment Group as a risk that required a London-wide approach.[74]
When it revised the London Risk Register in February 2017, the London Risk Assessment Group did not consider whether the fires at Lakanal House in July 2009 and Adair Tower in 2015 had altered the level of risk presented by a tower block fire in London, it seems because it had not been alerted to the fact that it might need to take account of those fires.[75] The responsibility to feed that risk into the process for compiling the London Risk Register rested with the relevant Category 1 responders, the London Borough of Southwark in the case of the Lakanal House fire and RBKC in the case of the Adair Tower fire.[76] In addition, the LFB, which had primary responsibility for identifying risks relating to fire in London, had not alerted those responsible for the London Risk Register to the risk of a major tower block fire.[77] As of May 2022, the London Resilience Group had still not given any consideration to those omissions.[78]
When he gave evidence, John Hetherington, then deputy head of the London Resilience Group,[79] accepted that the risk of a high-rise or urban tower block fire should have been included as a separate entry on the London Risk Register before June 2017 and that its absence was a serious failing.[80] We agree. The fires at Lakanal House and Adair Tower, not to mention the fires that had occurred in high-rise buildings abroad, ought to have prompted consideration of that risk which should have been taken into account by those responsible for the London Risk Register as part of their assessment and incorporated into it.
As a local authority, RBKC is a Category 1 responder. Its legal duties include assessing the risk of an emergency occurring.[81] RBKC is required to hold a Borough Risk Register compiled by the Borough Resilience Forum.[82] The purpose of the register is to identify risks to the borough, to quantify the likelihood of those risks occurring and the likely effect if they do, and to note measures that may mitigate those risks. RBKC’s Borough Risk Register was dated December 2016.[83] It did not include urban or tower block fires.
The Borough Risk Register issued in December 2016 described itself as a “living document” that was to be revised and updated as and when required.[84] There appears to have been little or no consideration of the inclusion of the risk of fire in a high-rise building, despite the history of fires in buildings of that kind in London, including the Adair Tower fire in October 2015 (which happened within RBKC’s resilience jurisdiction) and the Lakanal House fire in 2009.[85] Although the regulatory framework requires Category 1 responders to consider risks specific to their locality, it is apparent from the evidence of David Kerry[86] that significant reliance was placed on the London Risk Register instead of the Borough Risk Register.[87]
In our view, tower block fires should have been included in both the London and Borough risk assessments. Government tools (such as the Joint Organisational Learning online database) were defective and Ms Hammond’s expectation that the planning assumptions would act as a “safety net”, catching any gaps in the reasonable worst-case scenarios, did not reflect the reality of local risk assessment. If there had been a reference to a tower block fire in the National Risk Register, as there now is, it is likely that local risk assessors would have been prompted to consider the risks in detail.
It is appropriate that we begin our description of the response to the Grenfell Tower fire by recounting in their own words the personal experiences of those who were most directly affected. RBKC, as a Category 1 responder, had a responsibility to ensure that the needs of those affected by the fire were properly met. For that reason, the quality and effectiveness of the response must be judged in a large part by their experience. We recognise that, although many people were affected in similar ways, the experience of each person was unique and that recollections may be affected in many different ways. Although we do not doubt the sincerity and honesty of those who gave evidence, it has not been possible for us to obtain specific responses from those who were seeking to provide help and who might wish to put forward a different perspective. This chapter should therefore be read with that in mind. It should be understood as an account of the experiences of people who had suddenly lost their homes and all their possessions and were entirely dependent on others to satisfy their basic needs.
We received 220 witness statements dealing with the response to the fire. We also heard oral evidence from Karim Mussilhy, Hisam Choucair, Mahmoud Al-Karad, Mohammed Rasoul, Mouna El Ogbani, Fatima Boujettif, Hanan Cherbika, Nabil Choucair and Hanan Wahabi. An extensive thematic summary of the evidence of all those who had provided statements was read during the hearings.[88] That substantial body of evidence has enabled us to examine in detail the steps taken by RBKC, London Gold, the TMO and the government to provide humanitarian relief.
Although our investigations have concentrated on the seven days following the fire, we acknowledge that it continues to have a searing effect every day on many of those affected. We are extremely grateful to those who have shared their experiences with us and thank them for their courage and dignity in recounting them.
Taken as a whole, the evidence portrays a community whose lives have been changed forever by the fire. We learnt much of the immediate effects of the fire and of the long-lasting trauma that so many have experienced and still do. Those affected include, but are not limited to, survivors who escaped from the tower, residents of the tower who lost their homes, those who lost loved ones and those who were evacuated from nearby properties, some of whom also lost their homes. Such is the closeness of the local community that many survivors and residents are also bereaved, having lost loved ones, friends and neighbours. It is clear to us that they were, and, most importantly, felt themselves to have been, comprehensively failed by those to whom they looked for protection in the wake of a major disaster. Safety and security are as much to do with the perceptions of those affected as they are with the actions of those responsible for providing protection.
While the emergency services were fighting the fire, survivors, residents of the tower and those evacuated from surrounding properties[89] were abandoned without information about where to go or what to do.[90] There was “absolute chaos and confusion everywhere”.[91] The scene was described as a “horror film”[92] and a “war zone”.[93] Mr Mussilhy told us that the area was “engulfed”[94] with people and, given the chaos on the street, he expected to see people in authority with high-visibility jackets and clipboards, but there was nobody.[95] Such was the confusion about what to do or where to go that some survivors[96] and residents of the walkways slept in their cars.[97] Other residents waited for hours for buses that they had been told would be coming to take them to a rest centre,[98] but instead they had to walk in the early hours to rest centres that had opened spontaneously nearby.[99]
In the absence of timely support from the authorities, members of the community took it upon themselves to open informal rest centres. They organised themselves quickly in an effort to meet a diverse range of needs.[100] Community centres were filled with people with nowhere to go trying to find shelter. Although community rest centres did their best to support those affected, some were forced through overcrowding to refuse entry to those who were not survivors. [101] Some survivors had to sleep in rest centres,[102] while some of those who lived in the walkways were left wandering the estate, displaced and unable to return home.[103]
In the absence of anyone apparently in authority[104] or any information, survivors and residents were left to fend for themselves, having experienced the shock of the fire and in many cases searching frantically for loved ones. So far as they could see, the council and the TMO had “vanished” in the immediate aftermath of the fire[105] and were conspicuous by their absence.[106] Although RBKC began to assemble a presence in and around the tower from about 2.30am[107] and the TMO from 3.30am,[108] they were not clearly visible to those who might need them.
Many of those who had lost their homes experienced a number of problems with emergency accommodation. They included uncertainty about how long they might have to stay in hotels, unsuitable rooms, problems with the provision of suitable food, the distance of hotels from the community and failures to provide for particular needs.
The initial allocation of accommodation was confused and inconsistent. Some of those affected were allocated emergency accommodation in community rest centres, as RBKC sent representatives to the Rugby Portobello Trust and the Clement James Centre. Ms Wahabi told us about her experience of being allocated hotel accommodation at the Rugby Portobello Trust on 14 June 2017. She said that there had been no clear system for the allocation of emergency accommodation. She described feeling like “cattle just coming through”.[109] The interviews lacked privacy, empathy and humanity and were described by some as being undertaken in a robotic and formulaic way.[110] The lack of any system meant that individual needs could not be catered for.
RBKC housing teams were sent only to the Rugby Portobello Trust and the Clement James Centre.[111] Although TMO staff were sent to more community rest centres, they did not visit some important places, such as the Al Manaar Muslim Cultural Heritage Centre or St Francis of Assisi church.[112] That contributed to a lack of awareness amongst those affected of what support with accommodation was available and where.
Some survivors had to wait for days before being allocated accommodation.[113] Others were not contacted about their emergency accommodation until two weeks after the fire and in the meantime had to make their own arrangements.[114]
A particular concern was the lack of information about accommodation for those who had been taken to hospital. Some survivors were discharged with no information about where to go.[115] One family attended the Town Hall to try and get some information but were told to come back the following day as there was nobody available.[116]
For those who were allocated emergency accommodation there was often a lack of support in getting there. Some survivors were given oyster cards;[117] others were just told by telephone that a room had been made available to them but were given no information about how to get there. Many had no money and only the clothes they stood up in.[118] Some people arrived at the designated hotel only to find that it did not have a booking for them[119] and that they had to go and stay with friends.[120] Due to booking errors, one former resident of the tower went to three different hotels before arriving at the right one.[121]
The emergency accommodation arranged by RBKC was in many cases wholly inadequate. Many were distressed to find that they had been placed in rooms on high floors.[122] Those affected described how the rooms allocated to them were small and unsuitable.[123] Families of four[124] and five[125] were given one room[126] with a double bed. One couple was given a single room with a single bed and had to wait for a double room a month later.[127] Insufficient space in rooms meant that on one occasion a member of a family had to sleep on the sofa in the hotel reception.[128]
The council did not tell people who had been placed in hotels how long they would be able to stay there,[129] which added significantly to the anxiety that people were experiencing at that difficult time.[130] One family with three children were placed in a hotel on 17 June 2017, but were told the next day that they had to find alternative accommodation for themselves.[131] Many were told that they were booked in for only one night and had the uncertainty of not knowing whether the booking was going to be extended.[132] Some received notes under their doors saying they were booked in for another week[133] but others had a note left on the door giving them just a few hours to leave.[134] Ms El-Ogbani put it particularly vividly. She told us that the uncertainty was “really stressful and made us really angry, because you don’t know how you’re going to live the next day … our future was blank”.[135]
Although hotel placements were intended to be emergency accommodation, for many their stay was not temporary or short-term. Some people lived in inadequate and unsuitable conditions for months,[136] and in some cases longer,[137] while trying to rebuild their lives.
Some survivors and residents of the area surrounding the tower were accommodated in places far from their former homes. That created a sense of loneliness and isolation.[138] Some survivors were allocated accommodation as far away as Wandsworth and described an “acute sense of being completely isolated”.[139] They felt they were being ignored and “moved further and further away”.[140] No account appeared to have been taken of the need for people to be close to hospitals in order to visit their relatives[141] some of whom were in a critical condition.[142] Some described having to use two or three taxis each day for hospital visits, which was expensive and inconvenient.[143] As a result, many people struggled to visit rest centres and hospitals as well as taking their children to school.[144] Those affected described how stressful it was having to return to the area in order to visit the rest centres to obtain support.[145]
When arranging emergency accommodation RBKC failed to give sufficient consideration to the needs of particular groups. In some cases cots were not available for those with babies or young children[146] nor any means of sterilising babies’ bottles[147] or making up bottles of milk.[148] No consideration appeared to have been given to the needs of children or to the importance of space for homework and play.[149] Some pregnant women were not given sufficient consideration; one was forced to sleep on a sofa or the floor because the only bed in the room was too high for her to get into it.[150] Some of those who had restricted mobility struggled with their accommodation because it was not adapted to their needs, for example, by having a walk-in shower[151] or a bed lever.[152] At the time of the fire, many of those who lived in and around the tower were observing Ramadan, but halal food was not available at all hotels[153] and it was not possible to observe the requirement to eat at set times.[154] People relied on the provision of food and support from the community.[155]
An illustration of these difficulties was provided by Mr Rasoul. He told us in graphic terms how the needs of his elderly father with disabilities and of his children were not adequately assessed by RBKC in the immediate aftermath of the fire and that the support they needed had not been provided, despite their “lives being turned upside down” and the fact that they were grieving.[156]
There was significant confusion about whether food was available for survivors and residents at hotels and if so of what kind. One survivor, who lost her son in the fire, told us that she did not know what she was entitled to and so restricted herself to just one meal a day.[157] Some heard that the council would only pay for drinks, so they only ordered drinks.[158] Others spent their own money on food[159] because they did not become aware until a month after the fire that food would be paid for.[160] Mr Rasoul told us that he had not been aware for several weeks that food was available.[161] The arrangements for obtaining food at some hotels made some people feel like refugees.[162]
Other basic facilities, such as the means of laundering clothes, were not available.[163] Families had to pack their laundry into black bags and suitcases and take it to the laundrette in a taxi, which they felt was demeaning and humiliating. The picture we saw was that of a vulnerable group of people facing not only the shock, grief and trauma of the fire itself but also, as an immediate priority, the need to satisfy the most basic of their daily needs. Survivors described it as living in limbo, with no space to heal.[164]
Adjoining Grenfell Tower were a number of low-rise residential buildings known locally as ‘The Walkways’. The Walkways consisted of Hurstway Walk, Barandon Walk, Testerton Walk and Grenfell Walk. Treadgold House was not one of the Walkways but its residents were also evacuated and displaced.[165] While the council grappled with its response to the needs of those displaced from the tower, residents from the surrounding properties said they felt forgotten.[166]
In the days after the fire, responsibility for the residents evacuated from the surrounding properties appears to have been informally delegated by the council to the TMO. However, the numbers were huge: about 845 people had been displaced and were in need.[167] The TMO was singularly ill-equipped to deal with so many people. Residents described how in the provision of emergency accommodation their needs took second place.[168] Although they had been displaced from their homes, their needs were considered to be less important.[169] They were left in an invidious position, unable to return to their homes while the cordon remained in place but with insufficient hotel rooms available to accommodate them all. Many sought help from family and friends. Not all were so fortunate and some displaced residents were left sleeping on the grass by the Walkways close to the tower.[170]
Residents of the Walkways voiced their resentment at the way in which the council determined eligibility for the provision of support, including emergency accommodation, noting that “trauma does not work along strict geographical lines”.[171] However, allocation of emergency accommodation to this group of residents was haphazard. Exceptionally, some residents were allocated accommodation at the Westway Centre as early as 14 June 2017.[172] Those who were allocated hotel accommodation were placed much later on.[173] One resident of the Walkways was advised to stay at the Westway Centre despite being pregnant and having three children, aged one, six and twelve.[174] She was not placed in a hotel for two weeks.[175] Residents had to take the initiative to approach the council to try to secure a place in a hotel. For some that took a few weeks[176] but others were not placed in emergency accommodation until (in some cases) as late as October 2017.[177]
Others were actively denied emergency accommodation. One resident was told she should sleep on a friend’s sofa;[178] another family who lived in Testerton Walk were refused emergency accommodation by a representative of the council at the Westway Centre, because they lived “too far” from the tower, even though their neighbours were offered a place in a hotel immediately.[179]
Some Walkway residents tried to ask for accommodation through the council’s housing line, with unsatisfactory results.[180] One resident called the phone line three times because the council had failed to respond to her enquiries. She was told not to call again as she was not a priority and that she was taking up the line.[181] Others had similarly miserable experiences and were told a hotel would be organised for them, only for no one to follow up or call them back.[182] One resident was able to secure emergency accommodation only when he mentioned his partner’s chronic health condition, and even then the hotel to which they were sent was available for only one night.[183] The residents of the Walkways understood very well that many people needed help but they too were in shock and despair and needed somewhere to stay.[184] Several of them did not know that emergency accommodation was available[185] and did not ask for it.[186] At least one booked his own hotel accommodation as the only alternative was to stay at a rest centre, which he thought would have an adverse effect on his mental health.[187] One walkway resident who used a wheelchair was never made aware of the availability of emergency accommodation. He stayed at his sister’s home for three to four days and then returned home to Barandon Walk where there was no hot water or proper wheelchair access.[188]
Among the residents of the Walkways there was a general state of confusion and uncertainty about whether it was safe to return to their homes.[189] On the day after the fire, TMO staff told some residents that they could return at their own risk, but did not explain what the risks were or suggest any alternatives.[190] Some residents received a text message later in the week saying they could return home, but when they tried to do so were denied access by the police.[191]
Having nowhere else to go, some residents returned to their flats to find that there was no hot water or heating,[192] which was particularly difficult for those with small children.[193] They were left to use the showers at Virgin Active[194] and the Westway Centre.[195] Other residents returned home on 15 June 2017 and were allowed in, only to be told later in the afternoon that they had to leave again.[196]
The residents of Grenfell Walk were in a different position from that of other residents evacuated from nearby properties, in that, like the residents of Grenfell Tower, they needed to be resettled in new accommodation.[197] The council does not appear to have fully understood that fact when it came to the provision of humanitarian assistance.[198] Ms Cherbika told us that “we needed help desperately, and every door we kept going to was closed because we wasn’t bereaved or wasn’t a survivor … we was in between. We didn’t come out of the tower, but we couldn’t also go back to our properties, so we were homeless, but nobody was helping…”.[199] Some residents said that the difference in treatment between residents of the tower and residents of the Walkways created “hierarchy and a division” within the community which, before the fire, had been one.[200]
The Westway Centre initially opened spontaneously as a rest centre.[201] Staff responsible for its management said that no official support had been offered in the initial hours of the first day. [202] Representatives from RBKC and the TMO attended later on 14 June 2017[203] when it became the official rest centre in an attempt to concentrate support in one place. However, there were serious shortcomings in the way the centre was set up and managed, which meant that those who needed it encountered significant difficulties in obtaining immediate humanitarian support. We examine those shortcomings in Chapter 104. They included displaced residents being denied entry, a lack of clarity about the services available, a need for people to provide the same information on several occasions to obtain support of different kinds and an absence of staff representing those in authority, such as RBKC and the TMO.
Those working in the Westway Centre did not know that residents had been evacuated from nearby properties and that some had lost their homes. Many of those who went to the centre were therefore initially refused help.[204] Some were denied entry altogether.[205]
A number of residents and survivors had difficulty gaining entry to the Westway Centre after a registration system was introduced on 14 June 2017.[206] Many displaced people were asked to provide evidence of identity in order to enter the centre, despite the fact that they had lost everything in the fire. Sometimes those running help desks insisted on the production of identification documents before they would provide help.[207] Gaining access to the centre was considered so difficult that some residents had to “sneak in” after they had been refused official entry.[208]
Community leaders who visited the Westway Centre, described a multiple-choice system where people were asked “Are you a survivor, are you bereaved, or are you a visitor?”[209] The process was described as astonishingly perfunctory and without compassion.[210]
As part of the verification process, the Red Cross gave people wristbands on entry.[211] Some residents were concerned that that made them easily identifiable in the street, including by journalists, and did not like being “marked” and given a new wristband every day.[212]
The experiences of those who came to receive support at the Westway Centre were not happy. The physical layout of the space was confused and the centre lacked basic systems for processing the influx of donations and signs to direct people to services of different kinds.[213] Some survivors who had lost loved ones arrived at the Westway Centre after being discharged from hospital but did not see anyone from the council and were not given any help.[214] Although the council had a desk there, its staff appeared to be “powerless” as they could not offer any support to those affected other than emergency accommodation.[215] The centre was described as lacking “warmth”[216] and its atmosphere as being “formal and bureaucratic”.[217] For example, one individual who was trying to find five loved ones was told to send an email.[218] For some, “it felt like a shelter for government representatives and the council staff rather than a refuge and support centre…”.[219] Consequently, residents and survivors preferred the rest centres run by the community, as they were more “community orientated”.[220]
A particular problem with the way in which the Westway Centre was organised was that those in need of assistance had to go there and say what they needed in order to receive support. However, that meant that some of those who were injured, traumatised or isolated felt that they could not obtain what they needed when they should have been the priority.[221] We were told that “it felt as though rather than coming to us for support, we had to go to them.”[222] Some were thankful that they had been able to obtain some of the services available at the Westway Centre, such as replacement documents. Others, however, said that they felt very exposed. They complained of a lack of privacy and said that, because everything was happening in one place, it was overwhelming.[223]
Some survivors slept at the Westway Centre in the first few days following the fire. It was described by one person as being like a “refugee camp”,[224] with people sleeping on mats and donated mattresses on the tennis hall floor.[225] One member of staff was concerned that no consideration had been given to the trauma people had experienced.[226] It was described as a “very sad place to be” and “somewhere for people that did not have anywhere better to go.”[227] The Jafari family remained at the Westway Centre for 10 days[228] and describe staying there as “horrific” due to the lack of privacy.[229]
Given their role in supporting those affected by the fire, many community leaders had the opportunity to observe the services being provided at the Westway Centre close at hand. Some were of the view that centralising support at that location failed to consider existing relationships that those affected had with organisations in the area,[230] and that the centre was “intimidating”.[231]
Some staff from community rest centres refused to go to the Westway Centre and withdrew because they felt that the system in operation there was inhumane and cruel.[232] Instead of making traumatised survivors and the displaced constantly justify the need for support[233] there should have been a system, according to one volunteer, where people had to explain their situation once and receive the information and support needed in an environment where they felt safe and knew the staff. [234]
There were significant problems in providing financial assistance to those affected by the fire. The council did not have a policy in place for arranging and distributing financial assistance or communicating how it could be obtained. As a result, many of those who had been displaced or who had lost their belongings in the fire[235] had no access to funds at a time of unprecedented need and were trying to support themselves and their children.[236] Some people did not receive any financial assistance at all and were entirely dependent upon support from charities.[237] Others were actively denied assistance by the council. One survivor was told that she was not entitled to any financial assistance because she and her partner were in employment.[238] Other survivors were refused assistance,[239] or offered a significantly lower amount,[240] because they were not formally tenants of flats in the tower. Some residents who had been evacuated were refused financial assistance because they were leaseholders.[241] Although they did not feel ready to do so, some felt they had to go back to work soon after the fire simply because they could not afford to do otherwise.[242] Some residents were refused payments because, as they understood it, the money allocated to them had been wrongly given to someone else.[243] For those who did receive financial assistance, the payments were often significantly delayed;[244] some told us that they had had to wait for over four months for any financial assistance from the council.[245]
The general experience was of inconsistency of approach. As an illustration, one resident received £500 to be shared with her brother,[246] but others received as little as £100 in the first week and nothing thereafter.[247] Payments made were often insufficient given the variety of needs, such as travel, food and clothing.[248] People understandably felt demeaned and humiliated[249] when having to go back to ask for more financial assistance.[250] A great many of them were proudly independent and self-reliant and the experience of having to ask the authorities for a handout was a humiliating one.
The process of obtaining assistance was an uphill battle[251] and for many, embarrassing and intrusive.[252] One survivor was told by the council to write down everything she needed money for, despite the fact she had lost everything in the fire.[253] Mr Al-Karad told us that the difficulties in obtaining financial support added greatly to the stress he was under and it was not easy to get help. He said that in the first few months he had had to fight for what he needed and sometimes ask for it “20 times”.[254]
The source of the problem was that the council did not take active steps to tell people what they were entitled to and how they could obtain it.[255] Instead, it waited for them to ask.[256] During the week following the fire, and in some cases even later, people became aware by word of mouth that they were entitled to financial assistance.[257] By the time some people found out about the various kinds of assistance to which they were entitled, the council told them it was too late to claim.[258]
Adequate and timely financial assistance in the immediate aftermath of a major incident is an essential aspect of an effective humanitarian response. Those who did receive such assistance described how it made a huge difference to them to be able to choose what they needed for themselves.[259] In the absence of such support, others described the humiliation of having to search through donations to find suitable clothes, in some cases without success.[260]
In the immediate aftermath of the fire there was limited psychological support available and a lack of information about the kind of support that people could obtain. Survivors described how they struggled with their mental health, desperately needing help but not knowing where to get it at a time when they were at their most vulnerable.[261]
Many survivors and residents did not hear about the availability of counselling support until a considerable time after the fire.[262] Several survivors said that they had not received offers of counselling until two years later.[263] In the absence of support from other sources, people had to arrange their own.[264] Although counselling services were available at the Westway Centre, some chose not to make use of them as they did not consider it to be sufficiently private.[265]
Psychological support was available from 16 June 2017 in some of the hotels in which displaced people had been accommodated and some of them understood that counselling services were available if needed.[266] Other hotels did not provide such support, however, which meant that survivors had to go elsewhere if they wanted to find it.[267] Some residents were unable to obtain counselling services due to language barriers;[268] others found it too difficult to undertake counselling sessions through an interpreter and so stopped attending.[269] There were particular concerns about the lack of emotional support and counselling for children, all of whom had witnessed a grave tragedy and some of whom had lost family and friends in the fire.[270]
Psychosocial provision for the bereaved was particularly lacking. Those who lost several members of their families in the fire[271] received no offer of support at all from the council.[272]Other families who had lost relatives were identified for support only after the Inquiry’s hearings had begun, almost a year after the fire.[273]
The use of key workers was an important means of ensuring that those affected received the support they needed, but the system did not operate efficiently in many cases for a variety of reasons, including uneven and late allocation of key workers, inconsistent quality of service and a high turnover of staff.
Survivors were assigned key workers at different times, some within 24 hours of the fire,[274] others only after waiting three or four months.[275] Some were not allocated key workers until a year later because they had not been residents of the tower, and only then after asking for one.[276] Others were not assigned a key worker at all.[277] Some residents of the Walkways were told that key workers were available only to former residents of Grenfell Tower and Grenfell Walk.[278]
There was a similarly inconsistent approach to the allocation of key workers to the bereaved. Some people were contacted about a month after the fire,[279] while others were assigned a key worker some months later and then only after asking their family liaison officers to approach the council. [280]
There were mixed experiences of the quality of key workers, some of whom appeared to be more engaged than others. We were told of key workers who were not properly prepared for the task and not fully informed, and thus unable to provide support and information.[281] Residents often picked up important information before their key workers.[282] That led to increased stress and uncertainty for many.[283] Some key workers failed to respond to residents’ questions,[284] which caused further difficulty if support had to be arranged through a key worker.[285] A number of witnesses spoke of contradictory information about the support available being given by different key workers.[286] Some regarded their key workers as merely a “support placebo” because they lacked the authority to make decisions.[287]
On the other hand, some had more positive experiences of their key workers[288] and found them to be a useful single point of contact.[289] They provided regular information about the support available.[290] The benefits of the system were thus available but were unevenly distributed.
A number of those affected experienced a high turnover of key workers.[291] In some cases, key workers had to step down because they had been assigned too many people to look after.[292] Others could not continue in the role because they had been traumatised by their work.[293] Mr Rasoul told us that he had been allocated six different key workers in one month, with one lasting for just a weekend.[294] Some developed positive and supportive relationships with their key workers,[295] but in many cases there was a lack of continuity, with some leaving after a number of months.[296] For some, that was very unsettling. Ms Cherbika described her own experience thus: “They kept changing all the time. I probably went through eight or nine key workers, support workers, whatever workers … I felt like when I clicked with somebody … the council would take that person away”.[297] Some survivors were left for a time with no key workers.
A particular problem which some faced as a result of having a frequent change of key worker was that they had to describe their experiences from the beginning over and over again.[298] Some people found that traumatising.[299]
One common experience in the immediate aftermath of the fire was an absence of information from official sources about the assistance available. In the week following the fire those who had been displaced did not receive any communication from the council telling them what services were available or where to go for help.[300] There were no calls or text messages from either the council or the TMO.[301] The council did not use its website to provide information for those evacuated from the area within the cordon[302] who were waiting to find out when they could return to their homes. [303]
Despite what they had been through, survivors and residents were thus forced to seek information for themselves, which caused additional stress.[304] Ms El-Ogbani told us that there was: “No one from government, no one from the authority. We didn’t know where to go, we didn’t know how to seek help, we didn’t know what will happen next. It was just question mark, question mark, question mark…”[305] We heard the same experience voiced by many witnesses.
Mark Simms from the Rugby Portobello Trust told us that although RBKC had been gathering information, there was not much of it.[306] RBKC councillors offered help, but they were not there in an organisational role. They too, were struggling to get hold of information.[307] There was an “absolute sense that everyone was overwhelmed”.[308]
The lack of information had a direct effect on the distribution of support. Those who obtained information about the support available were the first to receive assistance, while those who did not were left behind.[309] That particularly affected vulnerable people, such as those with mobility problems and those who could not speak English.[310]
When official communications were eventually released, they were in English.[311] That included communications sent to those who had been placed in hotels. People described feeling at a disadvantage because they could not read English well and had significant difficulty in gaining access to services, which they felt created unfairness.[312] They had to rely on family and friends in order to help them understand the information provided and said that an interpreter would have provided greater support.[313] Some people did not want to rely on friends and neighbours to interpret confidential and personal information.[314] In some cases interpreters were provided, but not always in the right language.[315] Despite complaints to the council and, later, London Gold about the need for materials to be provided in different languages, it took some time for that to be done.
Those that were looking for their loved ones immediately after the fire encountered numerous obstacles to their searches.[316] Some families desperately went from hospital to hospital, rest centre to rest centre, in their search for information, but to no avail.[317] The overwhelming thrust of their evidence was that they had experienced feelings of utter helplessness and despair as they navigated an environment in which there was a complete absence of information.[318]
Family members visited the numerous rest centres that had been set up in the community, repeatedly asking for information about their loved ones.[319] It rapidly became apparent to them that neither the representatives of the council nor the TMO[320] were able to provide even the most basic information. The council staff at the Rugby Portobello Trust did not have a list of those who had lived in the tower and were asking people who they were and which flat they lived in.[321] Mr Rasoul told us that after he had escaped from the tower he had visited the Latymer Community Church (known at the time of the fire as the Latymer Christian Centre)[322] in his search for missing friends. There he found a representative from the TMO with a list of flat numbers and names, but the list incorrectly included people who no longer lived there.[323] As a result of the lack of information, the community felt compelled to compile its own list of those who were missing[324] and piece together its own picture of what had happened.[325] Mr Mussilhy told us that that was the only way for people to know who was still missing and who had survived.[326]
By the evening of 14 June 2017, the Westway Centre had been designated as the official rest centre. As we have already described, the site was hard to access without documentary identification or a wristband, but there was no clear information about how or where to obtain a wristband.[327] Even those who managed to get into the Westway Centre felt that they did not receive adequate information or assistance. Although there were information desks there, they did not have information about those who were missing in order to assist those looking for loved ones.[328]
In the absence of any official assistance, family members visited hospitals across London desperately looking for their loved ones.[329] It was difficult obtaining information from hospitals,[330] which were concerned about releasing personal information.[331] Hisam and Nabil Choucair told us about their painstaking visits to about 12 hospitals[332] in the search for members of their family. For them that merely compounded the trauma.[333]
Nabil Choucair told us about the call he made to the emergency services on 14 June 2017 seeking information about his family. He told us that he had searched rest centres, hospitals and had called the casualty bureau.[334] He said, “We were left to fend for ourselves, left to try and find help. … There was chaos. … Nobody knew what they were doing …”.[335] Those looking for their loved ones felt “lost with no direction of what to do or where to go next”.[336]
In the days that followed families continued their searches, desperately trying to find information.[337] A particular challenge arose when news of a different rest centre or possible hospital emerged, as they felt compelled to flock there in a (usually futile) attempt to obtain information.[338] Some families were not able to carry out extensive searches themselves and had to rely on help from relatives, without which they felt “completely forgotten or overlooked”.[339] Some people who had lost loved ones lived abroad and did not receive any information about their family members, which was itself distressing.[340]
One survivor who escaped the tower but became separated from his wife, who perished in the fire, was placed in emergency accommodation without any information about her or how he might find her.[341] Mr Mussilhy shared his experiences of his search for his uncle and his realisation as the days passed that “We were completely alone … and abandoned in the worst way possible while we were looking for our relatives.”[342]
A casualty bureau was opened by the Metropolitan Police at 08.00 on 14 June 2017.[343] Its existence was publicised as a point of contact at 08.02[344] but it was designed to receive information about those who were missing and not to release information to callers.[345] In the hours after the fire, many who called the number found it to be engaged[346] or were greeted with a recorded message stating that there were no people to answer calls and that they were waiting for call-handlers.[347] Others told us that, when they eventually got through, they were told that someone would come round or would call, but they did not hear back. Others called on many occasions but were told to call back another time for more information.[348] When callers were able to have a conversation with the operator, they found it to be entirely one-way, the operator simply asking for information about the caller and those who were missing.[349] The casualty bureau, at least to those who encountered it, was a means of gathering information, not providing information to relatives.[350]
The failure to contact bereaved families soon after the fire left many feeling that they did not matter.[351] Some of those affected felt that information was released by police in a haphazard way and that there was no co-ordinated effort to relay information to families.[352] Due to the scale of events, it took a number of days for family liaison officers to be appointed.
Families had mixed experiences of family liaison officers. Some people were assigned an officer about a week after the fire and found that support reassuring.[353] Others, however, found the officer allocated to them formal and difficult to talk to.[354] Some family members felt marginalised and unimportant[355] because they were not allocated their own officer[356] when an officer had been allocated to another family member in accordance with Metropolitan Police guidance.[357]
The absence of a clear and centralised system for providing information about those who were safe and those who were missing led to the growth of false information. Some people were told that their loved ones had been seen alive when they had in fact died.[358] It was difficult for family members to verify rumours that were circulating in the community as there was no single source of reliable information.[359] Those desperate for information were left in the dark and felt alone.[360] The dreadful results of the failure to establish a method of communicating with the former residents of the tower are best exemplified by the experience of one family who learned of their son’s death by hearing about it on the television news.[361]
In later chapters we shall refer extensively to the part played by Mr John Barradell under the arrangements made by the London boroughs for responding to emergencies affecting the capital. John Barradell, chief executive of the City of London, led what was called the Grenfell Fire Response Team. In order to provide the context for that part of the report in this chapter we give a brief description of the way in which local government in London fulfils its obligations under the Civil Contingencies Act through the operation of London Resilience.
London Resilience is an overarching term used to denote a structure that encompasses three different bodies: the London Resilience Forum, the London Resilience Group and the London Resilience Partnership.[362]
The London Resilience Forum is the term used to describe the group of organisations that meets periodically to co-ordinate arrangements for responding to major emergencies. It is currently chaired by the Deputy Mayor for Fire and Resilience, Baroness Twycross. At the time of the Grenfell Tower fire the role of Deputy Mayor for Fire and Resilience had not been established and Dr Twycross chaired the forum in her capacity as the chair of the London Fire and Emergency Planning Authority (LFEPA).[363] The deputy chair of the forum was the town clerk and chief executive of the City of London Corporation, John Barradell.[364]
The London Resilience Group is a body which provides business and administrative support for the London Resilience Forum.[365] Its staff are provided and hosted by the London Fire Brigade (LFB).[366] At the time of the Grenfell Tower fire, the head of London Resilience was Steve Hamm; his deputies were John Hetherington, Toby Gould and Hamish Cameron.[367]
The London Resilience Partnership is the term used to describe the persons and organisations in Greater London that are designated under the Civil Contingencies Act as Category 1 and Category 2 responders,[368] together with organisations which are not formally designated as responders but have important roles to play in resilience, such as faith and voluntary organisations, and the government in the form of the Ministry of Housing, Communities and Local Government (formerly the Department for Communities and Local Government (DCLG)).[369] The partnership consists of about 170 organisations.
The City of London and each of the London boroughs is an independent local authority. To co-ordinate their activities in relation to resilience they have established the Local Authorities’ Panel which represents the interests of all London local authorities on the Forum.[370] At the time of the fire the Local Authorities’ Panel was chaired by John Barradell.[371] In June 2014 the 33 local authorities were grouped into 6 sub-regional groups known as sub-regional resilience forums,[372] which acted as links between the borough resilience forums and the London Resilience Forum.[373]
By 2011 each of the London boroughs and the City of London had confirmed a resolution, originally passed in 2004 and known as the Gold Resolution,[374] to provide each other with mutual aid and assistance in the event of an emergency requiring a co-ordinated response. Under that resolution each authority delegated to whichever borough had agreed to undertake the role in response to a particular incident its power under section 138 of the Local Government Act 1972 to incur expenditure to avert or alleviate the effects of an emergency calling for a co-ordinated response. The boroughs and the City of London also entered into a memorandum of understanding setting out the procedure for implementing those arrangements.[375] We shall refer to those arrangements as “the Gold arrangements” and the chief executive of the borough to which power has been delegated under those arrangements as “London Gold”. The agreement for mutual aid and assistance is supported by the London Local Authority Co-ordination Centre, which co-ordinates requests for mutual aid between boroughs and across London as a whole.[376]
The Local Authorities’ Panel has oversight of, and is responsible for, the London Gold arrangements[377] and the Local Authorities’ Panel Implementation Group, which supports the panel on planning and preparation.[378] The London Resilience Partnership has no operational role if the Gold arrangements are invoked.[379] The panel included David Kerry, the contingency planning manager of RBKC, who acted as a practitioner advisor to Mr Barradell, the chair of the panel.[380]
The Grenfell Tower fire was only the third occasion on which the Gold arrangements had been implemented, the last occasion having been in 2014.[381] The evidence indicated that there was some uncertainty about how they could be invoked, in what circumstances and by whom,[382] whether they were based on any power[383] and the degree to which the chief executive of the affected borough could delegate responsibility for decision-making in the aftermath of an emergency to London Gold, apart from the powers contained in section 138.[384] We explore the extent to which that confusion affected the response to the fire further in Chapter 102.
Category 1 responders have a legal duty to have regard to voluntary organisations in their area that are relevant to an emergency.[385] The Voluntary Sector Panel and the Faith Sector Panel are two of the panels that make up the forum.[386] A representative of each of those panels therefore attends meetings of the forum.[387] Guidance on involving the voluntary sector was developed and agreed by the London Resilience Forum in a document entitled Voluntary Sector Capabilities Document.[388]
As an independent local authority each borough is required under the Civil Contingencies Act to maintain in conjunction with other Category 1 responders a borough resilience forum.[389] Each forum comprises representatives of Category 1 responder agencies within that borough and local Category 2 responders. It is required to meet at least every 6 months.[390] Mr Hetherington told us that engagement with the voluntary, faith and other sectors at that level is also encouraged.[391] Mr Kerry chaired RBKC’s borough resilience forum between 2013 and 2016.[392]
We consider that having the same person (in the case of RBKC, Mr Kerry) sitting on many related bodies created a danger of over-reliance on one person’s knowledge and experience. It also reduced the field of those within a borough able to acquire and share knowledge and experience of the London resilience arrangements in action. It appears that such a concentration of knowledge and experience was not unusual across London.[393]
The Greater London Authority (GLA) is a body corporate established under section 1(1) of the Greater London Authority Act 1999. It was made a Category 1 responder in 2011. It discharged its responsibilities principally through LFEPA by virtue of a protocol dated 28 January 2015.[394] In April 2018, LFEPA was abolished and replaced for present purposes by the London Fire Commissioner.[395] Regulation 7 allows for protocols to be entered into between responders.[396] In addition, regulation 55 specifically addresses London and the role of the London Fire Commissioner by empowering him or her to maintain plans in relation to London-wide emergencies,[397] to test those plans and train staff.[398] The commissioner carries out that function through the London Resilience network and in particular the sector panels within the forum. The GLA together with the commissioner and the boroughs funds the London Resilience Group.
Notwithstanding the GLA’s role in maintaining strategic oversight of resilience[399] and the fact that it has the power to appoint the chair of the London Resilience Forum, at the time of the Grenfell Tower fire there was no mechanism by which the Mayor of London or the GLA could scrutinise the work of the forum,[400] thus preventing either of them from exercising any effective supervisory or monitoring role.
The guidance in Emergency Preparedness states that the Mayor of London “plays a full part in supporting the effective implementation of the Act and improving the preparedness of the capital”.[401] Paragraph 9.23 of the guidance lists the ways in which the Mayor and the GLA should achieve that outcome. In summary, the Mayor and the GLA should be closely engaged in high-level discussions and decisions relating to the management of emergencies in London. The Mayor should inform Londoners about the content of emergency plans, warn and inform the public during an emergency and chair or appoint the chair of the forum.
The Mayor of London is not a Category 1 responder under the Civil Contingencies Act. However, because the Mayor forms part of the GLA,[402] we understand that he regards himself by extension as a Category 1 responder.[403] Consistent with that view, the statutory guidance, Emergency Preparedness, explicitly refers to the role of the Mayor of London in the preparedness[404] of the capital.[405]
The responsibilities of the Mayor of London in the response phase are set out in the Strategic Co-ordination Protocol,[406] namely, that he will support the operational response to an emergency in London by providing a unified statement so as to act as the “voice of London” and will collaborate closely with the Strategic Co-ordinating Group and central government where appropriate.[407] The term “voice of London” does not appear in the statutory guidance,[408] but David Bellamy, the Mayor’s current chief of staff, told us that his understanding of the expression was that in an emergency the Mayor will speak on behalf of London to Londoners to explain what is happening, to give them the information they need to understand what has happened and to tell them what effect it is expected to have on them.[409] However, the Mayor of London has no responsibility for the operational response to a civil emergency.[410] His is essentially a political and communications role.
RBKC, as a local authority, is a Category 1 responder within the meaning of the Civil Contingencies Act 2004. To assist in fulfilling its legal duty[411] RBKC had a Contingency Planning Unit, managed by Mr David Kerry. By 2017 Mr Kerry had enjoyed a long career in local authority emergency planning and was the chair of the Borough Resilience Forum. He also had an influential role in the London Resilience structures as the practitioner advisor to the Local Authorities’ Panel. With such a background, one might reasonably have expected that the council’s contingency plans, training and ability to deal with an emergency would be exemplary, or at least reasonably complete and robust. However, as we shall explain in Chapter 104, in June 2017 that was far from the case.
Category 1 responders have a statutory duty to maintain and modify emergency plans as necessary.[412] In addition, they have a statutory obligation to consider whether it would be appropriate to perform their duty by collaborating with another Category 1 responder in maintaining a multi-agency plan.[413]
The aim of emergency plans is to increase multi-agency and community resilience by ensuring that all those charged with tackling an emergency on behalf of the community know their roles, are competent to carry out the tasks assigned to them, have access to available resources and facilities and have confidence that their partners in response are similarly prepared.[414]
There are three groups of plans covering London as a whole:
Each of the frameworks is managed by a lead agency with a senior responsible “owner”, a member of the forum who has responsibility for developing the framework and in doing so for considering all risk assessments, planning assumptions and lessons learnt from previous incidents and exercises.[417] At the time of the fire there were no fewer than 25 plans in place, ten of which were formally activated or described arrangements that were deployed in response to the Grenfell Tower fire.[418] Two highly pertinent frameworks relevant to the response to the Grenfell Tower fire call for particular examination.
The Humanitarian Assistance framework[419] dated April 2017 was a draft framework due for approval by the London Resilience Forum on 28 June 2017.[420] Its aim was to ensure that humanitarian care was delivered in an effective manner that met the needs of those affected by a major emergency.[421]
The lead responder for humanitarian assistance is the local authority.[422] The Humanitarian Assistance framework provided that in the first few hours following an incident in which a significant number of people had been displaced the local authority would take the lead in providing rest centres with secondary responsibility being given to voluntary agencies.[423]
The purpose of a rest centre, as described in paragraph 8.13 of the Humanitarian Assistance framework, is to provide immediate shelter for people who have been evacuated from an area or are otherwise in need of emergency accommodation following an incident, to provide initial light refreshment for evacuees, to enable details of evacuees to be maintained in the centre for reference, to provide for the well-being of the evacuees, to offer support and information on a wide range of welfare-related subjects and to provide evacuees and survivors with current information about the incident and its potential effects on them.[424] We discuss the Humanitarian Assistance framework further in Chapter 104.
The guidance entitled Identification of the Vulnerable, drafted by the London Resilience Partnership, was published in January 2015 for local implementation.[425] The guidance adopts the Cabinet Office’s definition of vulnerability[426] and is directed at emergencies contained within a single borough. Its aim is said to be to inform, complement and align the capability planning of the Borough Resilience Forum to encourage a proactive and coherent approach towards the identification of vulnerable persons.[427]
It is the responsibility of the Borough Resilience Forum to identify vulnerable people and undertake the six core steps set out in the guidance.[428] They include compiling a “list of lists” for contacts of organisations that hold data on vulnerable people to enable them to obtain the information quickly in the event of an emergency. The guidance recognises that it would be impossible to maintain an accurate central list of vulnerable people.[429] Boroughs were supposed to have a systematic process in place for making the relevant information available quickly and to have run training exercises so that they were confident not only that their systems worked but that their staff knew how to operate them, not least because it would be difficult to obtain all the relevant information quickly at the time of an incident.[430] Mr Kerry’s view, however, was that apart from compiling a list of lists, the guidance was too difficult to achieve in practice.[431]
Mr Hetherington told us that that approach failed to meet the standards envisaged by the framework and provided examples from other boroughs of how it could have been done. He would have expected someone in Mr Kerry’s position to have done better.[432] He did not accept Mr Kerry’s view that the Cabinet Office guidance on the identification of the vulnerable was unachievable[433] and told us that although identifying vulnerable people was difficult, because the lists are subject to constant change, it was certainly achievable.[434] We think that the Cabinet Office guidance was indeed achievable and that Mr Kerry’s attitude to the identification of the vulnerable was defeatist and inappropriate.
In 2016 Mark Sawyer, then Deputy Head of Emergency Planning in the LFB Emergency Planning Team,[435] was instructed by the Local Authorities’ Panel to undertake a review of local authority emergency planning in London.[436] He was asked to undertake the task because the panel recognised the heightened pressure on councils and the increase in external and internal risks. Those risks included a “loss of corporate knowledge and capacity”.[437]
Mr Sawyer was supported in his review by Mr Kerry and their report, known as “EP2020”, was issued on 3 October 2016.[438] Their overall assessment was that there was a developing trend towards a reduction in capacity and capability across London and that the ability of local authorities to provide leadership on resilience to the level communities would expect and deserve was under strain.[439]
The report provided a clear and prescient warning. It identified the problems for civil contingency planning that reduced staffing levels had created. It is worth quoting the following passage:
“Emergency planning staffing levels are at the lowest point since 2009, with a downward trend established since the 2012 Olympics … This reduction combined with continuing demand for efficiencies across authorities has the potential to significantly affect our ability to satisfy the expectations of our communities and assure them that we possess the appropriate means to prepare and respond, where necessary, to the myriad of resilience challenges that need to be addressed”.[440]
The report also reviewed the Minimum Standards for London, introduced in 2007, which contained 16 standards designed to ensure that all local authorities had the appropriate policies and procedures in place to support the London Gold arrangements.[441] Those standards were set by the Local Authorities’ Panel with the aim of ensuring a basic standard of resilience planning by London’s local authorities that met statutory requirements and the government’s expectations and was commensurate with London’s risk profile.[442] At the time, compliance with the minimum standards was based on self-assessment in odd years (e.g. 2015) and a peer-review in even years (e.g. 2016).
The author identified a significant downward trend in meeting standards relating to plans and capabilities, which he regarded as a matter of concern.[443] The peer review results in 2016 illustrated that trend:[444] ten capabilities had been identified, in relation to which a quarter or more of boroughs within London reported an amber or red rating.[445] Those capabilities included training, humanitarian assistance and the identification of vulnerable persons. The report added that the Local Authorities’ Panel implementation group would continue to monitor those trends and identify ways in which to improve those capabilities. We consider the assessment for RBKC before the Grenfell Tower fire below.
Issue 9 of RBKC’s Contingency Management Plan[446] dated 30 April 2015 had been drafted by Mr Kerry.[447] It was the council’s core plan for major emergencies. Part 1 was an overarching generic contingency management plan, which was accompanied by a suite of annexes numbered 1 to 42 which set out plans covering particular situations.
There were substantial shortcomings in the RBKC Contingency Management Plan. As Mr Kerry accepted, a number of the annexes had been left empty,[448] or were wrongly labelled,[449] or were still in draft form, or contained outdated plans.[450] Significantly, they included Annex 16, a Humanitarian Assistance Centre plan dated 15 April 2008.[451] Mr Kerry acknowledged that it was outdated, was no longer viable and should have been removed.[452] A document entitled Framework for Identifying and Contacting Vulnerable Persons in an Emergency in Annex 21 was in draft form dated April 2012. Mr Kerry conceded that in hindsight more could have been done to produce a finished version,[453] but the real question is why there was insufficient foresight, given that the whole point of contingency planning is to look to the future.
There were different versions of Issue 9 of the Contingency Management Plan.[454] One version referred to a “Contingency Management Plan Part 2 - Tactics and Contacts” that was designed to provide information to assist those with designated roles in the response. Contingency Management Plan Part 2 (draft v2) was dated 21 June 2016.[455] It included action cards for Council Silver and for specific emergency responses.[456] Mr Kerry said that they were both draft documents,[457] but he conceded that there had been a need in 2017 for a proper guide to tactics.[458] In our view, there had been enough time to complete and incorporate Part 2 into the Contingency Management Plan in the year that followed. The action guides were likely to complement the plan and in an emergency direct the reader to the relevant plans contained in the Annexes and the London Resilience Partnership plans. That opportunity was not taken, as it should have been.
The Contingency Management Plan did not include a communications plan and Mr Kerry was not aware of any document that described how different parts of the council would co-ordinate their communications in an emergency.[459] There was a difference between Mr Kerry and the head of the Media Communications Team, Martin Fitzpatrick, about why that was.[460] However, it is not necessary for us to decide which of them was correct, given that the council has admitted that there was no up to date communications plan.[461] It is clear that there was a draft communications plan dated 2010 but that it had not been completed or added as an annex to the Contingency Management Plan before the Grenfell Tower fire. The consequences of the absence of a communication plan, the lack of any co-ordination with the Media Communications Team and the failure to integrate that team into the planning process were seen in the hours and days that followed the fire.
In its opening statement for Module 4 of the Inquiry RBKC accepted that it had failed adequately to practise an emergency communication plan. It also recognised that its failure had adversely affected the council’s response to the fire.[462]
Regulation 25 of the Civil Contingencies Regulations provides that the plans maintained by Category 1 responders must include provision for the training of an appropriate number of staff and the carrying out of exercises for the purpose of ensuring that plans are effective.[463]
At the time of the Grenfell Tower fire, LFEPA was responsible for providing training for London boroughs on plans affecting London as a whole.[464] In order to test those arrangements, LFEPA was obliged to design and deliver an annual programme of exercises.[465]
The London Resilience Group delivered training to those involved in the London Resilience Partnership, and the London Gold arrangements, as well as those involved in its own emergency response arrangements.[466]
The London Resilience Partnership’s programme of training and exercises[467] was designed by a group chaired by Mr Gould and Mr Hetherington, then joint deputy heads of the London Resilience Group.[468] It expected individual partners to make best use of the activities delivered through the programme but to retain full responsibility for their own preparedness, including training personnel, and the effectiveness of their response and recovery capabilities.[469] We were told that the London Resilience Partnership provided an overall addition to local training in the form of insight, information and an awareness of the role of the London Gold arrangements.[470]
The training to support the London Gold arrangements was delivered three times in 2016 to a number of local authorities but not to RBKC.[471] That was the last London Gold support team training delivered, after which it was decided there was no longer a requirement for local authorities to have a support team in place.[472]
The London Resilience Group provided training on its own emergency response arrangements which involved a series of internal sessions delivered to staff. Its staff also participated in events held under the training and exercise programme and local authority training events provided by London Resilience Partnership, which are examined further in this chapter.[473]
There was no mechanism by which the London Resilience Group or the Local Authorities’ Panel could assess the quality of training being given by an individual local authority, or its level of preparedness,[474] otherwise than through the Minimum Standards for London, which we have touched on above and which we examine further below.[475] The attendance of representatives from individual local authorities at training events provided by the London Resilience Partnership was voluntary.[476]
We consider the position in relation to training to have been unsatisfactory. It was piecemeal, unco-ordinated, not subject to any external assessment or validation and voluntary. Those shortcomings helped to create a situation in which individual local authorities lacked capability in some respects and the quality of preparedness could become inconsistent between different local authorities.
The Minimum Standards for London published by the Local Authorities’ Panel comprised a set of standards designed to ensure that all local authorities had appropriate procedures and policies in place to support the London Gold arrangements. It described the plans and capabilities that each borough should have in place to support arrangements for planning and response across London.[477] At the time of the fire, the 2016 draft of the standards applied, having been approved by the implementation group in September 2016.[478] It referred to publication of an annual programme of exercises to support the London Gold arrangements,[479] including an annual exercise involving all 33 boroughs, the Co-ordination Centre and London Gold.[480]
The exercise Unified Response in 2016 was the first substantial London-wide exercise held since exercise Safer City in 2013[481] that involved London Gold and the London Local Authorities Co-ordination Centre.[482] It was also the first opportunity in three years to test London-wide local authority co-ordination arrangements.[483] In November 2015, RBKC also participated in exercise Babel, organised by the London Borough of Hammersmith and Fulham, to explore and test the interoperability of the two boroughs’ response arrangements.[484]
Exercise Unified Response took place over four days between 29 February and 3 March 2016 and involved the simulation of a major building collapse at Waterloo station involving 70 fatalities.[485] One of its objectives was to test London’s multi-agency strategic co-ordination arrangements, including the Strategic Co-ordination Centre and plans, policies and procedures.[486] The evaluation report prepared by Dany Cotton, then London Fire Commissioner, and published in April 2017 identified a number of vulnerabilities and lessons to be learnt.[487] Vulnerabilities included inadequate situational awareness and decision-making, difficulty in tracking the number and locations of casualties, delay in setting up a survivor reception centre and concentrating too much on process and not enough on the care of survivors, a failure to manage faith and disability concerns consistently and to make sufficient resources available to prioritise support to children and young people correctly. Among lessons learnt were that situational awareness and decision-making could be improved by having a single source of information at the scene of an incident reporting to strategic-level command. Those deficiencies, revealed by a major London practical exercise only 17 months before the Grenfell Tower fire, were in many respects repeated in the response to it.
The exercise also identified communicating with the public as an area in which improvement was needed. That applied particularly to groups which had been disrupted by the incident and those who knew or were related to people who might have been affected by it.[488] That foreshadowed what we heard from a number of witnesses about their experiences following the Grenfell Tower fire. We also heard that arrangements for communicating with the public were not regularly practised before the fire.[489] Given that that problem had been identified in exercise Unified Response, more regular practice might have drawn attention to the importance of communicating effectively with the general public.
We understand that the evaluation report on exercise Unified Response[490] was shared quite widely across the Local Authorities’ Panel and that there was a mechanism[491] through the learning and implementation group to record the lessons and review the relevant frameworks.[492] We note that, for some reason, the evaluation report was not produced until April 2017 and therefore left little opportunity before the fire for the lessons to have been learnt effectively or produce any tangible change.[493]
We were told that it had been difficult to ensure that the right people attended the exercises and that there had been a tendency for the same people to attend regularly and others not at all. We agree with Mr Hetherington that responsibility for resilience must lie with the whole of an organisation, not just the contingency planning unit. Everyone in an organisation needs to be involved in resilience and consider it part of their personal responsibility. As far as possible, the arrangements underpinning it should be part of everyday processes to avoid putting new arrangements in place under pressure.[494]
In recognition of its obligation under the regulations[495] RBKC’s Contingency Management Plan provided for training to be offered to staff with designated emergency response roles annually; it also provided for an exercise to be held at least once a year to test the plan’s effectiveness.[496] However, training for those with designated roles in any response was not provided as often as the plan required. The Council Gold group (the chief executive and the executive directors) was responsible for setting the strategy for responding to an incident.[497] Before June 2017, the most recent Council Gold group training had been held on 14 September 2015. That took the form of a two-hour seminar attended by (among others) Nicholas Holgate, Tony Redpath, Stuart Priestley and Laura Johnson.[498] Mr Kerry had asked to have four hours available but was only allowed two. He conceded that the training was “insufficient”.[499] The failure to undertake Gold training regularly was of long standing. Before September 2015, the previous sessions had been on 29 March 2010 and 15 September 2008.[500]
There was no formal training programme in place for Council Silver, who held the crucial role of leading the operational response to an emergency.[501] Such a programme was implemented only after the Grenfell Tower fire.
An overarching feature of RBKC training was the absence of records.[502] Without such records, it was unable to demonstrate (or to keep any internal track of) how frequently training took place or who received it. Training of those responsible for staffing the Borough Emergency Control Centre (BECC)[503] and Local Authority Liaison Officers (LALOs) was infrequent, irregular and basic in nature.[504] The preparation of a new training plan for BECC officers was deferred to await a London-wide standardisation programme following exercise Unified Response in March 2016. Rebecca Blackburn, who worked with and reported to Mr Kerry as a Contingency Planning Officer at RBKC, told us that she thought that the decision left a significant gap in training.[505] We agree.
Exercises to practise the operation of the Contingency Management Plan were held infrequently and were of a limited nature. That was another long-standing problem about which concern had been expressed within the Contingency Planning Unit since 2013. At that time Ms Blackburn had expressed her concern about the lack of large-scale exercises to senior management.[506] In late 2016, on her return from a secondment, she found that the situation had deteriorated,[507] and that exercises were limited to London-wide exercises conducted by the London Resilience Group.[508] She considered that other members of staff were not aware of the Contingency Planning Unit or its work in general.[509] We accept what she said about that also.
RBKC’s participation in London-wide exercises was on occasion hampered by a lack of available staff. Four months before the Grenfell Tower fire, it was unable to participate in exercise Safer City because not enough people had volunteered to take part.[510] Ms Blackburn described the approach of RBKC to London Resilience Group exercises as being to do the least it could.[511] That was due to a combination of capacity, attitude and lack of commitment.[512]
The exercises that were carried out disclosed a number of problems.[513] They included insufficient staff at the BECC in the early stages, problems with information technology when setting up the BECC, senior staff covering more than one role and difficulties in obtaining information about vulnerable people. Improvements identified in the subsequent reports included the need for greater understanding of the incident, better channels of communication to provide current information, structured handovers in the BECC and more training and more frequent borough exercises. However, those lessons were not implemented and the problems appeared again during the response to the Grenfell Tower fire.
Mr Kerry recognised at the time that the training and exercises undertaken by RBKC were insufficient and did not accord with the Contingency Management Plan.[514] He admitted that the shortcomings had been caused by a lack of available staff.[515] Despite his pivotal role as the head of the Contingency Planning Unit, he did not consider that he was senior enough to press the chief executive, Mr Holgate, or senior management at RBKC over those matters.[516] Although he considered that Mr Holgate was supportive of training, Mr Kerry found RBKC’s senior management in general to be somewhat resistant to attending training.[517]
The lack of support from senior management at RBKC may explain the sense of inertia that prevailed in the Contingency Planning Unit and throughout RBKC towards planning for an emergency and its capacity to mount an effective response.
Within RBKC there was a systemic shortage of staff trained to deal with emergencies and ensure that it complied with its duties as a Category 1 responder. In 2014 Mr Kerry raised concerns with the council’s management board about what he saw as a significant lack of trained emergency staff.[518] He warned that the council did not have enough trained volunteers to carry out emergency management roles in the BECC in relation to a major incident.[519] There were only three qualified “Council Silvers”, far fewer than the ten he considered to be the minimum. In addition, there were only ten Incident Response Officers, half the number he considered necessary.[520]
There was no improvement when the position was reviewed in early 2016. Mr Kerry candidly summarised the position at that time as “rock bottom” and did not believe it had substantially improved by the time of the fire.[521]
As a local authority, RBKC was under a duty to set up and manage an emergency rest centre, should the need for one arise.[522] However, it had only one qualified rest centre manager and was heavily reliant on the Red Cross and aid from neighbouring boroughs.[523] Mr Kerry accepted that by June 2017 RBKC did not have enough trained personnel to undertake the roles required by the BECC.[524] However, without enough rest centre managers and BECC staff, it was never in a position to meet its responsibilities to open and manage an emergency rest centre.
The long-standing shortage in the number of trained emergency staff was partly the result of RBKC’s practice of seeking volunteers among its existing staff to undertake those roles rather than paying staff to be on standby.[525] The London Borough of Hammersmith and Fulham, which was a party to a tri-borough agreement with RBKC and Westminster City Council, did pay its staff to undertake emergency roles. Despite the concerns raised by Mr Kerry, RBKC had chosen not to change its policy by the time of the Grenfell Tower fire. In our view RBKC’s policy of relying on volunteers undermined its ability to practise its emergency plans in accordance with its statutory duty.
RBKC was systemically ill-equipped to deal with a serious emergency. Over a number of years, the capability of its staff to respond to a major emergency had been allowed to decline. There were clear warnings to senior management that it did not have enough trained staff and that contingency plans were not practised enough. As a result, RBKC was wholly unprepared to provide an adequate response to the Grenfell Tower fire.
Under the Minimum Standards for London each borough was required to report to the London Resilience Group each year the state of its preparedness for responding to an emergency, rating plans and capabilities as green (operational), amber (operational but requiring development) or red (not operational). The 2016 report was the most recent to have been completed at the time of the Grenfell Tower fire.[526] It was produced by Mr Kerry,[527] who rated various aspects as amber.[528] Training and borough level exercises fell into that category. RBKC recognised in the report that BECC exercises needed to be improved and that there was insufficient refresher training. The report also referred to a need to revise an analysis of training needs, but that was no more than an aspiration. The analysis had not been revised by the time of the Grenfell Tower fire.[529]
Significantly, the borough’s capability for humanitarian assistance was also rated amber.[530] That reflected the fact that its humanitarian assistance plan dating from April 2008 was out of date. Efforts to develop the plan stagnated because it was found too difficult.[531]
The report indicated that RBKC had no Humanitarian Assistance Lead Officer (HALO).[532] When a significant emergency has occurred, the HALO has an important part to play in bringing together various partners, including health agencies, the police, and voluntary and faith sectors to oversee the humanitarian assistance effort. The continued lack of a trained HALO created a significant gap in RBKC’s ability to respond effectively to a serious emergency.[533]
Minimum Standards for London required local authorities to have documented procedures in place allowing access at any time to information required to identify vulnerable persons known to them and to make that information available in a form in which it could be used by different responders.[534] That was another respect in which the report showed that RBKC required improvement. However, in reality the position fell far short of that, because in substance all that existed was a draft plan dated April 2012.[535]
The report showed that there had been no exercise to test the plan for identifying vulnerable persons and did not show that any lessons had been learnt from training or exercises. Despite requests to hold a multi-agency exercise in the wake of exercise Babel in November 2015 none had been carried out by June 2017, even though it had been intended to hold one by April 2016.[536] Mr Kerry accepted that the system in place at RBKC for identifying vulnerable people was materially inferior to those operated by its tri-borough partners.[537] Indeed, in March 2017, he had told Tony Andrews, Emergency Planning Manager (Humanitarian Assistance) at Westminster City Council that it remained a considerable concern within RBKC.[538]
Although the information in the report was received by the London Resilience Group, there was no oversight of the process, which relied entirely on self-assessment. Mr Hetherington told us that if a quarter or more of the boroughs were not fully operational (i.e. were either amber or red) in relation to any particular function, the London Resilience Group would inform the Local Authorities’ Panel to enable it to consider how it could improve them.[539] In relation to the identification of vulnerable persons, the reports for 2016 showed that nine of the 33 boroughs were amber.[540] For 2017, ten of the 33 boroughs were amber and one red.[541]
As part of its report RBKC also indicated that it did not have in place a documented strategy for community resilience which described a programme of multi-agency collaborative work with emergency responders, members of the public and voluntary and faith sectors.[542] Notwithstanding some limited efforts, there was generally a failure to engage with local voluntary agencies and faith groups. In that respect RBKC failed to discharge its statutory duty as a Category 1 responder to maintain plans involving the voluntary sector.[543] The fact is that RBKC did not have a strategy which actively considered and engaged the voluntary sector during the planning process or in training or exercises.[544] It was not treated as a priority by David Kerry and the Contingencies Planning Unit, although with hindsight he accepted that it should have been, a sentiment with which we agree.[545]
In our view, the report together with the wider evidence reveals a culture of neglect at RBKC over a number of years towards planning for humanitarian assistance. The existence of an effective plan for providing such assistance would probably have made a material difference to its response to the Grenfell Tower fire.[546]
None of those matters were reported to the chief executive or senior executive board of RBKC.[547] The council had no system in place to inform senior management that it was not meeting the standards expected by Minimum Standards for London. As a result, there was a lack of oversight in relation to those important matters. Ultimately, the defects identified in the report were the very areas in which its response to the fire failed.
In this chapter we examine the response of the London Resilience Group, the London Resilience Partnership, London Gold, the Mayor of London and the Greater London Authority, concentrating in particular on their reactions to the fire and the arrangements available to support RBKC in leading the humanitarian response.
The duty manager of the London Resilience Group is the person to be notified of an emergency and the person responsible for putting any strategic co-ordination arrangements into action.[548] On 14 June 2017 the duty manager was Matthew Hogan,[549] overseen by Toby Gould, a deputy head of London Resilience, who acted as the strategic advisor.[550] John Hetherington, also a deputy head of London Resilience, took over at 08.30.[551]
Although a major incident[552] had been declared by the Metropolitan Police at 01.26,[553] Mr Hogan first became aware of the Grenfell Tower fire from a BBC news flash on his mobile phone at 02.30.[554] The first official notification he received of the fire was in an email from Transport for London at 03.12.[555] That was not how the London Resilience Group would normally expect to be notified.[556] Mr Hogan should have been notified by the police themselves that they had declared a major incident.[557] At 03.18 Mr Hogan received a WhatsApp notification from Glenn Sebright, head of communications at the LFB, followed by an email at 03.20 stating that the LFB had also declared the fire a major incident.[558]
The London Resilience Partnership Strategic Co-ordination Protocol,[559] which sets out the arrangements for London’s response to a major incident,[560] does not say when the London Resilience Group ought to be notified; Mr Hetherington said that he would expect it to be notified as soon as reasonably practicable.[561] It is clear that there was a delay on the part of the police and the LFB in informing it of the fire.[562] As the Phase 1 report concluded, the declaration of a major incident is all but useless if it is not communicated to other Category 1 or 2 responders as soon as possible and that applies equally to communication to the London Resilience Group.[563]
In February 2017 the London Resilience Partnership published version 7.3 of its Strategic Co-ordination Protocol containing the procedures to be followed by its members in response to a major incident. The first step is to establish a strategic coordinating group,[564] the purpose of which is to enable the agencies responding to the incident to formulate a joint strategy, to agree on joint actions and share information[565] in order to provide direction in the response.[566] A full strategic co-ordinating group consists of both Category 1 and 2 responders, as well as others, such as the voluntary and faith sectors.[567] Local authority attendance at the strategic co-ordinating group is at Gold Group level, which means that either the chief executive of the affected borough or its Gold Commander is expected to attend.[568] That may also include the duty London Gold, whether or not he or she is involved in the response at that stage.[569] Mr Hetherington told us that if the duty Gold is available, he or she should attend meetings of the strategic co-ordinating group.[570]
The duty Gold had two functions when attending a strategic co-ordinating group meeting following the Grenfell Tower fire. The first was to ensure that RBKC had everything it needed; the second was to assess whether there were implications for other London boroughs.[571] John Barradell told us that before the Gold Resolution had been formally activated the role of the duty London Gold was to attend the strategic co-ordinating group meetings to keep a watching brief.[572] It was therefore a departure from the standard procedure that both the duty London Golds on the night of the fire, Andrew Blake-Herbert followed by Christopher Naylor, were absent from the initial strategic co-ordinating group meetings on the morning of 14 June 2017.[573]
Mr Sawyer, Chief Executive Liaison Officer (Resilience) for the City of London Corporation, said that it was not mandatory for London Gold to attend strategic coordinating group meetings,[574] particularly in relation to an incident confined to a single borough. That had changed, however, when it became clear that RBKC was unable to discharge its responsibilities.[575] Mr Barradell disagreed and admitted that he had been surprised that neither of the duty London Golds had attended a meeting of the strategic co-ordinating group.[576] It is therefore unclear why, after Mr Sawyer’s attendance at the first meeting that took place at 05.00, the duty London Gold did not attend any of the subsequent four meetings on 14 June 2017[577] or the meeting on 15 June 2017.[578] The first strategic co-ordinating group meeting attended by the duty London Gold was at 11.00 on 16 June 2017.[579] In our view, the prompt convening of a strategic co-ordinating group attended by people, including the duty London Gold, with the level of knowledge, expertise and authority to identify and commit the resources of their respective agencies, is essential to its proper functioning. Until the Gold resolution had been invoked, London Gold had no active part to play, but the presence of a duty London Gold could have provided a senior figure to assess and, if appropriate, challenge the information provided by RBKC.
The first meeting of the strategic co-ordinating group was held at 05.00 on 14 June 2017.[580] The LFB had asked for the meeting to be convened at 04.30, but the request was not made until 04.09 and Mr Gould and Mr Hogan did not think that there was enough time to organise a meeting by 04.30.[581] The meeting therefore took place at 05.00.[582] The lapse of time between the declaration of a major incident at 01.26 and the convening of a strategic co-ordinating group at 05.00 was caused in large part by a delay of almost two hours in telling the London Resilience Group of its occurrence. That in turn meant that the identification of potential difficulties and full coordination between the Category 1 and 2 responders did not formally begin until three and a half hours later.[583]
One of the responsibilities of the London Resilience Group duty manager is to ensure that London Gold is aware of the declaration of a major incident.[584] Mr Hogan contacted the duty London Gold, Andrew Blake-Herbert, at 04.55.[585] There is no guidance on how soon after being informed of a major incident the duty manager should notify London Gold, although as a matter of common sense it should be as soon as possible.[586] In this case, there was a delay of an hour and 43 minutes,[587] which on any view was far longer than was reasonable. Mark Sawyer, who was copied into the notification, told us that he thought that there had been insufficient time to notify the duty London Gold of the first strategic co-ordinating group meeting, so he attended himself.[588] Whether that affected the response of London Gold is difficult to tell, as, although Mr Sawyer did not take on the role of London Gold during the meeting, he was a representative of London Gold and had previous experience in dealing with major incidents.[589] Even so, if the duty London Gold had been present, he might have provided a wider perspective as chief executive of a London borough. That is all the more so given that RBKC’s own chief executive did not attend until the group’s third meeting at 08.30[590] and the first London Gold did not attend a meeting until 11.00 on 16 June 2017.[591]
The London Local Authority Gold Operating Procedure, produced by the LFB Emergency Planning department to guide London Gold and the support team,[592] describes the circumstances in which the Gold arrangements may be activated, when the duty Gold should be contacted in relation to an emergency and when circumstances with regional implications that require the support of Gold exist or are predicted.[593] No express guidance is given to the duty Gold about when the Gold arrangements may be activated, but Mr Hetherington’s view was that, given their experience and knowledge of running a local authority, chief executives are well-placed to judge whether there is a need for support.[594]
At about 04.55 on 14 June 2017, Mr Hogan and Mr Blake-Herbert spoke to each other on the telephone.[595] At that stage Mr Blake-Herbert was happy for RBKC to continue to take the lead.[596] Mr Hetherington and Mr Gould discussed the activation of the Gold arrangements in a telephone call at 05.42.[597] Mr Gould told Mr Hetherington that RBKC was dealing with the incident and that it did not require the arrangements to be activated.[598] In an email sent to Mr Hetherington at 05.58 Mr Hogan referred to his earlier telephone call to Mr Blake-Herbert and confirmed that he had been happy for RBKC to lead the response.[599]
The London Resilience Group contacted RBKC to ensure that it had enough support. At 07.44 Mr Gould asked Nicholas Holgate to indicate whether the position of RBKC had changed and whether it required London Gold’s assistance on any matters affecting London as a whole. Mr Gould said that he was not aware of any such matters, given that the incident was entirely within the borough. At 07.50 Mr Holgate told Mr Gould that, apart from a need for housing that might spill over borough boundaries, he did not think London Gold needed to prepare for action.[600] That did not surprise Mr Hetherington.[601]
It is clear to us that the London Resilience Group was working on the assumption that, as the incident was contained within one borough, the assistance of London Gold was unlikely to be required and that RBKC would take control unless other boroughs were affected.[602] Christopher Naylor, who became the duty Gold at 09.00 on 14 June 2017, said that the usual practice was that if the effect of an incident were confined to a single borough, that borough would retain control unless it invited outside support.[603] The Gold Resolution[604] did not provide for the duty Gold to intervene otherwise than in response to a request for assistance from the chief executive of the borough affected.[605] Likewise, once the Gold Resolution had been activated it was the task of London Gold to support the chief executive of the affected borough, not to take control of the response.[606]
We were told that the primary purpose of the Gold Resolution was to provide a single command in response to an emergency affecting the whole or a wide area of London, such as “rising tide” incidents,[607] or a roaming terrorist attack.[608] Before the Grenfell Tower fire, the London Resilience Group had expected that in the case of an incident confined to one location the relevant borough would take control of the response[609] and that London Gold would not be involved. If a disaster occurred of such a scale and complexity that no one local authority could be reasonably expected to respond to it on its own, it was expected that London Gold might become involved, but only if the borough asked for assistance.[610] That was based on the assumption that a borough knew its residents, resources and capacity best and could be expected to have an interest in leading the response to its residents.[611]
At the time of the fire, London Gold could not intervene unilaterally in a borough’s response if it had not been asked for assistance.[612] It was easier to invoke the Gold Resolution if an incident had occurred affecting a wide area than if the effect of an incident were confined to a single borough.[613] Mr Barradell confirmed that he had no power to invoke the Gold Resolution and that Mr Holgate had to do that.[614] The government also acknowledged that there was no readily available means for London Gold to take control or to require a borough to act in a particular way.[615]
Chief executives received little training to prepare them for taking on the role of London Gold. When Mr Naylor took over as London Gold at 09.00 on 14 June 2017 it was the first time he had acted in that capacity.[616] We were told that the only training a chief executive would receive from the London Resilience Group before being added to the London Gold rota was an hour-long briefing from someone at the London Resilience Group or Mr Sawyer and a tour of the special operations room at Lambeth.[617]
Local authorities took part in various training events delivered by the London Resilience Partnership,[618] but no training events specifically for chief executives who might be called upon to act as London Gold were held between March 2016 and November 2017.[619] At the time of the fire the most recent training for members of the London Gold support team had taken place in Islington, Waltham Forest and Camden in early 2016.[620] Its purpose was to provide an opportunity to acquire the individual and team skills needed to support London Gold and was not made available to local authority chief executives. RBKC did not receive any support team training in 2016 or in 2017 before the fire.[621]
The Gold Resolution was not considered to be a matter of concern in 2016 and as such was not within the scope of the review of local authority emergency planning which in 2016 gave rise to the “EP2020” report.[622] Mr Hetherington told us that it had been recognised before the Grenfell Tower fire that the training for chief executives needed to be improved. The process had begun before the fire, but the fire had caused the new training to be postponed.[623] Mr Sawyer also said that there had been a need to improve training for chief executives.[624] The second edition of the “EP2020” report published in 2019 recommended that all chief executives and their deputies attend training events and exercise programmes to prepare them to undertake the duties of London Gold.[625]
Jon-Paul Graham was duty officer at the GLA on the night of the fire.[626] He was first made aware of it at 03.09 on 14 June 2017 by the Commissioner of the LFB, Dany Cotton.[627] The Mayor of London, Sadiq Khan, was subsequently notified between 03.20 and 03.30 by the head of his private office, Ali Picton.[628]
Mr Graham attended the first three strategic co-ordinating group meetings on 14 June 2017. Emma Strain, Assistant Director of External Relations at the GLA, attended all the other meetings of the group between 14 and 20 June 2017, except the meeting on 18 June 2017, which was attended by David Bellamy, the Mayor of London’s chief of staff.[629] The Mayor’s Gold Cell group is called together when a major incident has been declared. Its purpose is to ensure that the Mayor is kept well informed in order to enable him to carry out his role as spokesman for the capital and provide civic leadership and reassurance.[630] It was convened by Mr Graham following the first strategic co-ordination group meeting at 05.00 on 14 June 2017.[631] Its first meeting was held at 08.00.[632]
In his written evidence, Mr Graham said that, at the meeting of the strategic co-ordinating group at 06.30, he had been shocked to hear that RBKC had not yet held its own Gold Group meeting and was not intending to do so until 11.00, four and a half hours later.[633] He was concerned even at that early stage that RBKC might not be coping with the demands of the incident.[634] However, Mr Graham did not report his concerns to Mr Bellamy and Mr Bellamy did not recall their being raised at the first meeting of the Mayor’s Gold Cell group.[635] An opportunity for the GLA and the Mayor to raise concerns about RBKC’s handling of the response may therefore have been missed, although, as we have said, there was no machinery by which either of them could take control of events.
Regrettably, a log was not kept of the action taken by the Mayor’s Gold Cell group, nor were any minutes kept of its meetings in the days following the fire.[636] That was contrary to the Mayor’s own protocol, which expressly provided that maintaining a record of key events, actions and decisions together with their reasons was of paramount importance.[637] Mr Bellamy explained that the absence of logs and minutes was due to the relatively recent introduction of the protocol in November 2016, which had meant that the training required to establish it had not taken place. In addition, the resources of the London Resilience Group were stretched, as they were dealing with a number of other serious incidents at the time.[638] Be that as it may, the absence of records has made it difficult for us to tell when concerns were first raised by the Mayor’s office about RBKC’s handling of the response to the fire and when they were first communicated to others.
Until the early afternoon of 14 June 2017, the London Resilience Group thought that RBKC was taking appropriate steps to ascertain the needs of those affected by the incident and provide accommodation and practical support. It is clear to us that by that stage the scale of the incident should have been clear to everyone, not least because it involved the mass displacement of residents.[639] However, because it had failed to appreciate the scale of the incident and had not activated fully its Contingency Management Plan, RBKC was unable to cope on its own with the demands imposed on it. Mr Holgate was determined to retain control of the response and the mistaken understanding of the London Resilience Group, Mr Barradell and the London Gold that RBKC was able to keep up with the demands made the problem worse by delaying the introduction of experience and resources from across London.[640]
During the afternoon of 14 June 2017, Mr Sawyer was asked to arrange a conference call between a group which included Nicholas Holgate, Christopher Naylor (then London Gold), John Barradell, John Hetherington, Eleanor Kelly (chief executive of Southwark Council) and John O’Brien, (chief executive of London Councils).[641] The purpose of the call was to understand the support that RBKC was likely to require and how it could best be provided by other boroughs. The intention was to provide strategic support to Mr Holgate.[642]
The call took place at 17.30 on 14 June 2017. Although RBKC insisted that it was keeping up with the demand for support from residents, it was agreed during the call that Mr Barradell and Ms Kelly would offer peer support to Mr Holgate the next day, 15 June 2017. In addition, it was agreed that two senior directors from Southwark Council would attend RBKC on 15 June 2017 to provide advice and assistance.[643]
In addition to the offer of peer support, it was decided that Mr Sawyer would go to RBKC the following day to provide initial support and the benefit of his experience of previous major incidents.[644] Mr Sawyer agreed that his aim should be to encourage and identify potential areas of improvement.[645] It was rare for him to be asked to assist a local authority so soon after an incident;[646] his involvement reflected the size and complexity of the emergency.
There was no discussion during the call about invoking the Gold Resolution.[647] Mr Holgate was aware of the possibility of doing so, but formed the view that none of those taking part thought that it was necessary for there to be a wider response by local government.[648] No one told him that the incident was too big for one local authority to deal with. He therefore did not consider activating the Gold Resolution and gained the impression that the others taking part in the call thought that RBKC was coping adequately. Nevertheless, we are surprised that the Gold Resolution was not mentioned, particularly in view of the concern that Mr Naylor felt about RBKC’s ability to respond to the needs of the wider community.[649]
One reason for Mr Barradell’s failure to intervene at that stage was that he assumed, based on what he was being told by RBKC, that RBKC had a capable group of officers who understood what to do in such circumstances.[650] Despite the fact that by the time of the call there was, as he put it, “rising concern” about RBKC’s ability to manage the response,[651] he admitted that he had not challenged Mr Holgate’s own view of the situation. By the time he gave evidence he had come to regret that he had accepted what he was being told at face value, although it was obviously wrong.[652]
Among the matters discussed during the call were significant changes to the situation and the structures in place for co-ordinating support across London.[653] That involved describing the groups that were being set up under the auspices of the strategic co-ordinating group, including those dealing with mass fatalities and humanitarian assistance, and generally giving those involved an understanding of the breadth of the structures being set up.[654] Mr Hetherington also told us that it was necessary to do that, even though the Gold Resolution had not been invoked, in order to give Mr Holgate an understanding of the wider response that could be made available if he wanted to make use of it.[655]
Apart from Mr Holgate’s initial reluctance to ask for assistance from London Gold, there was also a reluctance on the part of the London Resilience Group to be drawn into long-term support. In an email sent after the conference call late on 14 June 2017 John Hetherington expressed the hope and expectation that, once RBKC had support from the right people, it could be left to get on with it.[656] Mr Sawyer told us that there was a general concern among the London Resilience Group at the time, unrelated to the Grenfell Tower fire, that individual boroughs needed to take more direct responsibility for responding to emergencies.[657]
The reluctance of the London Resilience Group to become engaged in long-term support was due to its involvement at that time in the response to other incidents, in particular, the London Bridge attack in Southwark.[658] That suggests a shortage of available resources across London at the time of the fire, but it was not the reason why more was not done sooner to assist RBKC.[659] If RBKC had asked for assistance, we are confident that it would have been provided with alacrity.
In addition to the offer of peer support made during the conference call, RBKC was inundated throughout 14 June 2017 with general[660] and specific[661] offers of help from various local authorities. They were, in the main, refused by RBKC, which did not wish to appear incapable of managing the situation but did not have sufficient regard to an objective analysis of its needs.[662] In particular, it feared that invoking the Gold Resolution would be seen as a sign that its response had failed.[663]
In our view RBKC’s decision to refuse external help was misguided and reflected a misplaced belief on the part of Mr Holgate that it could manage on its own. Mr Barradell was surprised that offers of support should have been turned down by any borough following an incident of that kind and would have expected a formal request for support.[664] That view was shared by Mr Sawyer,[665] who thought that RBKC was overwhelmed and lacked strategic oversight.[666] When he gave evidence Mr Holgate accepted that his refusal to accept external assistance at an earlier stage of the response had been due to his misguided belief that the council was managing the response adequately.[667] However, we also think that he was blind to the obvious and regarded accepting assistance as an admission of defeat.
Mr Barradell said that at the meeting on 14 June 2017 he had not had concerns about the ability of RBKC to manage the response,[668] which suggests that he was relying on his previous positive view of RBKC.[669] As such, on 14 June 2017 he did not offer advice or express any concern to Mr Holgate about his leadership, despite perhaps having certain reservations.[670]
At 18.15 on 14 June 2017, the Mayor of London spoke to the Secretary of State for Housing, Communities and Local Government, the Rt Hon Sajid Javid MP.[671] A summary of the call records that the Mayor said that he had been impressed with the government’s response thus far and that they had discussed matters such as the re-housing of displaced persons and the provision of counselling for firefighters.[672] In his witness statement, however, the Mayor said that he had expressed a deep concern for the situation faced by the local community and that, having seen the chaos on the ground, he had expressed the need for a single point of contact and advice for the local community and for visible support from the local authority and the government.[673]
Mr Bellamy told us that, although the Mayor himself had noticed certain things on his visit to the tower on 14 June 2017, he had not thought that he knew enough about RBKC’s response to make a reliable assessment of it and could rely only on what he had been told after the strategic co-ordinating group meetings.[674] The difference between the note of the Mayor’s conversation with the Secretary of State and his subsequent recollection is not of importance and we agree with Mr Bellamy that it would have been helpful for those who were present at the strategic co-ordinating group meetings to have questioned Mr Holgate more closely about what he said was happening.[675]
By the morning of 15 June 2017, officials from the Department for Communities and Local Government (DCLG) were seeking information about how the response was going. Although the Resilience and Emergencies Division (“RED”) was not responsible for supporting local authorities in an emergency and had no power to control their responses,[676] it did have a responsibility to collect and share information about an incident.[677]
On the morning of 15 June 2017, Lynne Dowdican, RED resilience advisor, spoke to the deputy head of the London Resilience Group,[678] who confirmed that RBKC was reasonably confident that it had found accommodation for all those who needed it and could deal with any shortage that might emerge.[679] At 09.24 she sent an email to the London Resilience Group asking how many people had been accommodated in rest centres overnight, whether families with vulnerable people or children had been housed and if so, in what kind of accommodation. She also enquired about the support available to families, the telephone numbers of the rest centres, family support services, the casualty bureau and the family and friends centre.[680] It appears that she was not prepared to take the assurances she had been given at face value. At 09.31 the London Resilience Group confirmed that answers were being sought from RBKC and the police. It provided a link to RBKC’s newsroom which gave out information about support lines, facilities, and telephone numbers that had been revised the evening before.[681]
At 10.01 on 15 June 2017, Philip James, a government liaison officer with RED, told Mr Gould about concerns that had been raised by Nicholas Hurd, the Minister of State for Policing and the Fire Service, some of which related to the adequacy of the sleeping facilities at the Westway Centre. He asked for confirmation that the Red Cross and the Samaritans were involved and that the sleeping conditions would be better that evening.[682] That message was passed on by Mr Gould to Mr Sawyer and Mr Holgate with a request for a positive response to the questions it contained. Mr Gould also asked whether Mr Holgate would like to appoint someone at RBKC to act as a point of contact for DCLG,[683] but Mr Holgate did not choose to do so.[684]
Mr Hetherington told us that he had not been made aware of the concerns that Mr Hurd had expressed about the sleeping facilities at the Westway Centre.[685] They were important matters of which Mr Hetherington should have been made aware. The fact that a government minister felt it necessary to raise such matters should have sounded a warning to Mr Holgate and Mr Gould that there were problems with the response.
At 10.20 Jenny Shellens of RED sent Mr James an email asking him to clarify a number of matters when he attended a meeting of the strategic co-ordinating group later that morning. They included the number of those displaced and what arrangements had been made for temporary accommodation. At the end of her message she asked him whether they could be satisfied that RBKC had a grip on the emergency.[686] Her question went unanswered.
A further sign that by the morning of 15 June 2017 DCLG was beginning to be concerned about the adequacy of RBKC’s response was the suggestion that Mr James might be sent from the police special operations room to the RBKC Borough Emergency Control Centre.[687] Mr Gould advised against it.[688] Mr Hetherington told us that there was no precedent for a government liaison officer to be deployed in a local authority’s BECC.[689] We think that it was more efficient for an official to be a standing member of the strategic co-ordinating group, thereby giving access to the information from all the agencies involved, rather than being present at the BECC.
The Mayor of London visited Grenfell Tower for the second time at 14.00 on 15 June 2017.[690] He described how the full scale of the tragedy was starting to become clear. During that visit some members of the community had been very upset and angry and wanted answers from someone in authority, so his attendance at the scene drew a large crowd. Someone threw a bottle of water at him.[691] He was advised by his security team to leave the Notting Hill Methodist Church by the back door but he felt strongly that it was his duty as Mayor to listen to the community’s concerns, so he remained and spoke to those affected for another hour.[692]
The news of what had happened during the Mayor’s visit was relayed to Mr Hetherington by Commander Jerome, the police Gold, who told him that the Mayor had been mobbed during his visit. Consequently, and as a result of further concerns about civil unrest, Commander Jerome, as chairman of the strategic co-ordination group was no longer willing to move from the emergency response phase to the recovery phase on 16 June 2017,[693] since that would entail handing over management of the response to RBKC alone.[694]
Mr Bellamy attended the second cross-government ministerial meeting at 15.30 on 15 June 2017,[695] which he said was the first time he had become aware that there was unease about RBKC’s handling of the response.[696] Following the meeting, he returned to City Hall, where he heard reports from a number of colleagues that RBKC was failing in its response.[697] He was sufficiently concerned at its lack of progress to telephone Mr Barradell at 17.39 to discuss what action could be taken to improve it.[698] It appears that that call took place shortly after the telephone conference between Mr Barradell and Mr Holgate at 17.00.
It was clear from Mr Bellamy’s evidence that his intervention in contacting Mr Barradell on 15 June 2017 following the second ministerial meeting had been generated by his worries rather than a desire for the Gold arrangements to be set in motion. He said that at the time he had not known enough about those arrangements to consider that possibility.[699]
By the evening of 15 June 2017, the London Resilience Group, DCLG and City Hall had all expressed significant concern about the response.[700] The performance of RBKC and London Resilience as a whole was under increasing scrutiny from both the government and the Mayor’s office and the need for an improvement had become paramount. In that context it is difficult to understand why there was further delay between the decision to activate the Gold arrangements and the formal steps required to do so.
The first formal request by RBKC for assistance from other local authorities was not made until 17.03 on 15 June 2017.[701] It was prompted by an email sent by Gillian Maxwell on behalf of the London Local Authority Coordination Centre to RBKC at 16.34 asking it to give some serious thought to what assistance it was likely to need from other boroughs over the next 24 to 48 hours.[702] (Mr Hetherington confirmed that he considered that request for staff to have been the council’s first request for mutual aid.)[703] RBKC responded at 17.03 to say that it was likely to need liaison officers, rest centre managers, rest centre teams and emergency planning staff and asked the London Local Authority Coordination Centre to arrange that on its behalf.[704] The request for assistance was sent to other boroughs at 17.54 on 15 June 2017.[705] That was almost 36 hours after the last surviving occupant had left the tower. We think that RBKC should have asked for assistance far sooner. The London Local Authority Coordination Centre had been open and ready to help since 08.15 on 15 June 2017 in the expectation that the Gold arrangements would be activated or that assistance would be requested and there is no reasonable explanation why its services could not have been used a good deal earlier.[706]
Mr Barradell told us that communications with Mr Holgate on 14 and 15 June 2017 were designed gently to encourage him to operate the Gold Resolution, although he accepted that his approach had perhaps not been forceful enough.[707] We are satisfied that Mr Barradell did not expressly raise with Mr Holgate the desirability of invoking the Gold arrangements at any time before the meeting at 17.00 on 15 June 2017. In fact, he did the opposite. When on 14 June 2017 Christopher Naylor, the duty Gold, asked Mr Barradell if there was more he could be doing to support RBKC, Mr Barradell told him that the operation of the Gold Resolution was a matter for Mr Holgate and that unless RBKC’s position changed he should remain on standby.[708] John Barradell was right in his understanding that only Mr Holgate as chief executive of RBKC could operate the Gold Resolution, but that did not need to prevent senior figures in London Resilience from giving him clear and firm advice of the need to seek assistance from other boroughs. Mr Barradell accepted that he should have been more robust.[709] As it was, an opportunity to persuade Mr Holgate that RBKC needed help immediately was lost.
At 17.00 on 15 June 2017 a conference call was held between Mr Holgate, Mr Barradell and Mr Sawyer to discuss Mr Sawyer’s fear that Mr Holgate and his senior management team were not fully aware of the scale and complexity of the task facing RBKC.[710] Dissatisfaction with the response of RBKC was growing among senior members of London Resilience and was being expressed in the media.[711] It reflected the fact that the situation had not improved significantly during the day.[712]
The evidence about exactly when and how it was agreed that the Gold arrangements would be put into operation is unclear. No minutes of the meeting were kept. Mr Holgate recalled that he had made the decision during the conference call at 17.00.[713] Ms Kelly referred to a series of later calls, during which Mr Holgate had asked for Mr Barradell’s support from the following day.[714] Mr Barradell said that at no point during the call at 17.00 had Mr Holgate asked for the Gold arrangements to be put into operation and that he had had further conversations with Mr Holgate later on to encourage him to do so.[715]
Despite the differences of recollection, the documents show that very soon after the conference call at 17.00, Mr Holgate decided to operate the Gold Resolution. At 18.39 Mr Hetherington recorded in his log a call from Mr Sawyer in which the reasons for the decision were described as being the increasing complexity of the incident, the recent request from RBKC for mutual aid and a number of other factors.[716]
Although the decision to put the Gold arrangements into operation had been made in the early evening of 15 June 2017, the formal steps required for that purpose were not taken until the afternoon of 16 June 2017.[717] The delay has never been satisfactorily explained. Mr Hetherington told us that he was unsure what had caused it.
In an email sent at 22.04 on 15 June 2017, Mr Hetherington told his colleagues in the London Resilience Group that the Gold arrangements were not likely to be activated before 13.00 the next day and that Mr Barradell would go to RBKC to see what he was taking on before he activated the Gold arrangements.[718] Mr Hetherington suggested that that was necessary because it was possible that the situation had already moved beyond that which the Gold arrangements were designed for.[719] He and Mr Barradell both described the situation as a unique set of circumstances which were close to reaching the limits of what those arrangements could respond to.[720]
As the evidence progressed it became clear that there was (and may still be) some uncertainty in people’s minds about the effect of operating the Gold arrangements. We described the Gold Resolution and the accompanying memorandum of understanding in Chapter 101. It did not provide for London Gold to take control of the management of the response, which remained in the hands of the chief executive of the borough affected by the emergency. It was no doubt possible for the chief executive to delegate to London Gold authority to act on behalf of the borough in certain respects, but that is another matter.
Mr Barradell assumed the position of London Gold during the early afternoon of 16 June 2017. Both Mr Sawyer and Mr Hetherington maintained that he had not taken over the response; rather that he had supported Mr Holgate and RBKC in the provision of humanitarian assistance.[721] We agree with Mr Sawyer that the Gold resolution did not give London Gold the power to take over the response to an incident.[722] Mr Hetherington said that before the fire, phrases such as “intervention” and “taking over” had not been part of the vocabulary of those who managed the London Gold arrangements; they had come to be used only after the fire.[723] Mr Barradell’s evidence was to a similar effect. He told us that London Gold stood by the borough and not in its shoes,[724] and rejected the suggestion that he had taken over the response to the fire,[725] because he had no authority to do so.[726] He said that at that stage Mr Holgate had still been in charge.[727]
It is important, in our view, that the individual boroughs and London Resilience as a whole understands clearly the effect of the arrangements for co-operation in mounting an effective response to an emergency, particularly one that affects two or more boroughs concurrently. Whatever the terminology and niceties of the arrangements, however, it is clear that the activation of the Gold Resolution led to significant additional resources and greater experience being made available to RBKC, but not to a handover of control. In the event, the government in the form of Dr Jo Farrar, director general for local government and public services at DCLG, intervened during the afternoon of 16 June 2017 to bring about an agreement under which Mr Holgate ceded control of the response to Mr Barradell.[728] From that moment Mr Holgate ceased to play any effective part in managing the response; he resigned as chief executive of RBKC on 21 June 2017.[729] It is important to note, however, that the substitution of Mr Barradell as leader of the response did not reflect the working out of these complex arrangements. It represented nothing more or less than a pragmatic response to a terrible emergency which required the co-operation, or at least the acquiescence, of RBKC. It throws into sharp relief the absence of any mechanism for vesting in one person control over the response to a major disaster affecting more than one borough.
The London Gold arrangements for the provision of mutual aid finally came into effect at 14.00 on 16 June 2017,[730] some 19 hours after the decision to operate them had been made. Mr Hetherington did not think at the time that the delay had had any adverse effect on the provision of emergency relief[731] and had seen no benefit in involving another chief executive in the early stages of the incident, given that whoever had been appointed would not have been familiar with the resources or capability of the borough or with its residents.[732] However, we do not altogether agree with that assessment. Although it is impossible to say what precise effect on the response the earlier operation of the London Gold arrangements would have had, it seems likely that if RBKC had had the benefit of Mr Barradell’s experience sooner, the response would have benefited from improved strategic oversight. The response was faltering and a greater sense of urgency would have reinforced it. Instead, time was lost over the weekend of 17 and 18 June 2017 setting up the structures and identifying the needs of those affected by the fire.
Mr Sawyer thought that the London Gold arrangements should have been activated during the morning of 14 June 2017.[733] Mr Kerry thought that they should have been activated early in the morning of 14 June 2017.[734] Mr Kerry may have been speaking with the benefit of hindsight, but on any view the scale of the incident was very substantial, involving the displacement of hundreds of people. As the day wore on it should have been increasingly obvious to RBKC that it did not have the capacity, skills or training required to lead the response on its own and should therefore have considered putting the London Gold arrangements into operation that day.
By the time the Gold resolution was activated on the afternoon 16 June 2017, RBKC had still not worked out what support it required.[735] It had been unable to obtain accurate information about the number of those affected by the tragedy or to assess their individual needs. As a result, the Gold team spent a considerable amount of time assessing the situation in order to determine what humanitarian assistance was required and organise it appropriately.[736]
During the afternoon of 18 June 2017 Mr Barradell asked DCLG to send a community expert to assist the response.[737] Hilary Patel was asked to act in that capacity and a community engagement meeting was held on 20 June 2017.[738]
Later on 18 June 2017, a public statement was made by Ms Kelly, the deputy London Gold,[739] on behalf of the newly established Grenfell Fire response team[740] acknowledging that the initial response had simply not been good enough. Although many would regard that as self-evident, it was an important public recognition of the deficiencies in the response. The number of chief executives who by that time were assisting the response with the aim of bringing about positive change was an indication of the scale and complexity of the task. It also demonstrates why the Gold Resolution should have been activated at an earlier stage. Despite the considerable efforts across local government in London, it took a number of days for London Gold to steer the response in a more effective direction.
A description of the part played by the government in the response to the Grenfell Tower fire must begin with a brief summary of the relevant legal and administrative arrangements in place at the time.
The government is not a responder under the Civil Contingencies Act.[741] It is, however, responsible for establishing the policy framework under which those who have a duty to respond to emergencies in England and Wales operate.[742] The formulation of that policy is the responsibility of the Cabinet Office, which, together with DCLG,[743] plays a non-statutory oversight role.[744]
Within the Cabinet Office, the Civil Contingencies Secretariat leads the work on emergency response and resilience. It is primarily a body that co-ordinates the work of others in the planning, response and recovery phases. It does not have a direct operational role in responding to emergencies.[745]
The Civil Contingencies Secretariat is part of the National Security Secretariat. It reports to Cabinet Office ministers and provides advice directly to the Prime Minister on matters relating to civil contingencies.[746] At the time of the fire, Katharine Hammond was Director of the Civil Contingencies Secretariat.
If an emergency occurs the Cabinet Office is responsible for notifying relevant government departments and agencies, ensuring a department has been identified to lead the response, providing staff to run the Cabinet Office Briefing Rooms (“COBR”) and any associated crisis facilities as appropriate, initiating the supporting structures for a central response and devising solutions to problems when necessary.[747]
If COBR has been activated, the Civil Contingencies Secretariat, in consultation with the lead government department, decides which elements of the supporting arrangements should be activated and how they may best be used. It also provides secretariat support and ensures that business is managed effectively [748] The COBR arrangements and the role of the lead government department role are explained below.
In consultation with the Prime Minister’s office (“No.10”) and the lead government department, the Cabinet Office decides whether to set in motion the central response mechanism,[749] co-ordinating the activities of national, regional and local responders and deciding which departments need to be represented at COBR meetings and how often such meetings need to take place.[750]
Responsibility for fire policy was transferred to the Home Office from DCLG on 1 April 2016.[751] In the case of a sudden major incident,[752] such as the Grenfell Tower fire, the Office for Security and Counter Terrorism, which was part of the Home Office, provided support for the government in the first 24 to 48 hours in the form of managing communications, providing information, briefing ministers for COBR meetings, monitoring the situation and co-ordinating action across the Home Office.[753]
The Home Office did not have an operational role in responding to any major fire.[754] Its main function was to support the independent fire services through the provision of resources and to provide advice and information to ministers and civil servants.[755] However, it became the lead government department for the response in the period immediately following the Grenfell Tower fire because of the prominence of the emergency services and its responsibility for the fire and rescue services.[756]
The Department for Communities and Local Government (DCLG) changed its name after the fire to the Ministry of Housing, Communities and Local Government.[757] At the time of the fire, Dame Melanie Dawes DCB was the Permanent Secretary.
The Resilience and Emergencies Division of DCLG (RED) was established in 2011.[758] The director general for local government and public services at the time of the fire was Dr Jo Farrar OBE, whose directorate included RED.[759] Jillian Kay, director of local government policy, was the director of RED; Katherine Richardson was the deputy director.[760] There was a head of emergencies management,[761] five heads of resilience[762] and resilience advisors who had responsibility for particular geographic areas and particular types of risk.[763]
RED had two functions: one was to produce advice and plans in preparation for the occurrence of identified risks; the other was to ensure effective communication between Category 1 and Category 2 responders and the government if an emergency were to occur.[764] Part of its responsibility was to co-ordinate planning and ensure that Category 1 responders had the support they needed.[765] In addition, RED was a standing member of local resilience forums[766] and was required to have a comprehensive understanding of their work.[767] That was a national responsibility. RED had offices in London, Leeds, Birmingham and Bristol.[768]
As part of its planning and advisory function, RED participated in exercises in London arranged by the London Resilience Forum. There was a small resilience advisor team that worked with the London Resilience Forum, including a head of resilience.[769] The involvement of RED resilience advisors was intended to help the London Resilience Forum understand the role of central government in the emergency response and to assist it in revising and improving plans.
The London-wide plans, discussed earlier, were developed by working groups that included representatives of Category 1 responders, including the London boroughs. RED assisted the production of those plans primarily by sharing information.[770] It was not the function of RED resilience advisors to approve any particular plan.[771]
RED was not responsible for overseeing a local authority’s response to an emergency.[772] Its function during the response phase, as set out in Emergency Response and Recovery, was to take immediate steps to ensure that it could support the local response as necessary.[773] The guidance provided some indication of the form that that support should take, such as the collection and sharing of information,[774] provision of strategic information and, if necessary, telling the responders where they could get wider help and support.[775]
When an incident occurred RED duty officers were the initial point of contact between DCLG, other organisations and the government generally. During a duty period, the duty Head of Resilience and two officers were normally on call 24 hours a day.[776] They were expected to join strategic co-ordinating group meetings as government liaison officers (GLO), to represent the government[777] and obtain relevant information to enable them to provide briefings for ministers and senior officials.[778] Any member of RED who undertook the role of duty officer would be regarded as suitable to take on the role of GLO.[779]
In London, there were two heads of resilience. They worked with the London Resilience Forum and supported it with plans relating to London as a whole. They also took part in training events and themselves provided training to Category 1 responders.[780]
If an incident occurred, the head of resilience would decide what degree of involvement from RED might be required.[781] If the deputy director considered that the incident would place significant pressure on RED’s resources, or if COBR had been activated, an emergency notice would be sent out.[782] That would inform the department, as well as other departments and ministers across government, that an emergency response had been triggered and that their own arrangements might need to be put into operation[783]
The role of the lead government department was to organise other government departments, to take the lead on any governmental group and to be the first point of contact for government as a whole. It did not normally have any operational role.[784]
When the response reached the point at which the demands on the emergency services were reducing, a decision would be made locally to transfer responsibility for the incident from the strategic co-ordinating group to a recovery working group.[785]
The government’s guidance on responding to emergencies was contained in a document entitled Responding to Emergencies in the form of a concept of operations,[786] known colloquially as “ConOps”.[787] ConOps restated the principle of subsidiarity and confirmed that local responders were the basic building blocks of the response to an emergency in the UK.[788] It identified three broad types of emergency likely to require the direct involvement of the government: level 1 significant emergencies, level 2 serious emergencies and level 3 catastrophic emergencies.[789]
ConOps directed that a level 2 or level 3 emergency required the initiation of the government’s crisis management facilities (i.e. COBR)[790] in order to enable the rapid co-ordination of the government’s response and effective decision-making.[791]
The Cabinet Office was responsible for deciding whether the central response mechanism should be activated,[792] consulting colleagues, the lead government department and the Prime Minister’s Office as necessary.[793] Although ConOps identified different levels of emergency with the intention of helping users to determine the likely form of government engagement, the decision was not taken in that way.[794] The important question was whether to activate the government response mechanism.[795] The phrase “COBR meeting” appears to have been used in Whitehall at the time without distinguishing between meetings taking place in the Cabinet Office Briefing Rooms and meetings taking place elsewhere in accordance with the COBR procedure.
“COBR” was sometimes used as shorthand for a decision-making body of senior politicians, civil servants and others convened in accordance with the COBR procedure. Such a body was supported by a number of separate groups called “cells”[796] and was designed to be flexible.[797]
For all level 2 and level 3 emergencies, other than terrorist incidents, the senior decision-making body was the Civil Contingencies Committee.[798] A situation cell was established to ensure that there was a single, immediate, authoritative overview of the situation available to decision-makers.[799] The situation cell developed and maintained a common recognised information picture (“CRIP”) consisting of information relating both to the incident and its significant wider consequences and including the main developments and decisions.[800]
ConOps indicated that, if there were uncertainty over the direction of the government’s response to an emergency or the effectiveness of the local response in England and Wales, the Cabinet Office would convene a meeting (if appropriate in COBR)[801] to assess the situation and advise ministers as necessary.[802] It recommended that, in cases of doubt, it was generally better to activate the central response, even if it were subsequently stood down.[803] ConOps advised that in practice, the level of government engagement may change over time (both up and down) as the demands of the emergency changed.[804]
In the event of a catastrophic or serious emergency in England, the Prime Minister, the Home Secretary or other senior ministers nominated by the Prime Minister, would direct the central government response from COBR. In cases of doubt, the Home Secretary would at least initially, assume the chair in COBR.[805]
If an emergency occurred, the Cabinet Office was responsible for notifying relevant departments and agencies and ensuring that a lead government department was appointed.[806]
The lead government department normally took responsibility for assessing the situation, ensuring that its ministers and other relevant ministers were briefed, and providing support as necessary to local responders. Individual departments remained responsible for their particular policy areas.[807]
At the time of the Grenfell Tower fire the Cabinet Office maintained a list of departments’ responsibilities for planning, response, and recovery from emergencies dated March 2009 which was intended to make clear in advance which department would lead on main potential challenges.[808] The document included a reference to an emergency involving a fire. As the Home Office was responsible for fire and rescue services, it was the logical lead government department in the case of the Grenfell Tower fire.[809] DCLG was the department assigned for the recovery phase of an incident of that kind, which was likely to engage local authority responsibilities. DCLG was the lead government department for matters involving local authorities.[810] Dame Melanie Dawes did not think that the appointment of a lead government department occurred automatically and therefore put her department forward to undertake that role on the morning of 14 June 2017.[811] She did not recall the Home Office asking the DCLG to be the recovery partner.
In paragraphs 2.16 to 2.18, ConOps envisaged that different government departments might lead on the response and recovery phases, although it recognised that in such a case they would need to work together closely from the outset to ensure a smooth handover of responsibilities at the appropriate time and the integration of those two different activities.[812]
The response phase encompasses the decisions and actions taken to deal with the immediate effects of an emergency, to protect life, contain and mitigate the effects of the emergency and create the conditions for a return to normality. It comprises two separate but closely related and often overlapping challenges: crisis management and consequence management.[813] Typically this phase lasts for a matter of hours or days.[814] It usually precedes the recovery phase.
In paragraph 2.16, ConOps set out the role of the lead government department for the response phase, which it undertook in consultation with other government departments and with support from the Cabinet Office as necessary, if COBR had been activated. The responsibilities were extensive, including producing a handling plan as soon as possible, acting as a focal point for communication between the government and strategic co-ordinating groups in the affected area, ensuring that responders and affected communities had access to the resources they needed to manage the emergency and ensuring that recovery is borne in mind throughout and that arrangements were in place to ensure a smooth transition to the recovery phase.[815] The guidance was silent on whether the lead government department for response was expected to fulfil the same role where COBR had not been activated.
The recovery phase is defined as the process of rebuilding, restoring and rehabilitating the community following an emergency.[816] It formally starts once the situation has been stabilised. However, preparation for the recovery phase should be considered alongside crisis and consequence management in the early stages of a response.[817]
According to ConOps, in order to ensure that all departments and agencies were aware of the arrangements for handover from the response to recovery phase and its implications, leadership should formally be handed over from the lead government department for response to the lead government department for recovery.[818] The timing of the formal handover from response to recovery was to be agreed between the two departments in consultation with the Cabinet Office. In some circumstances (e.g. flooding across a wide area), it is possible (and sometimes vital) for response and recovery activity to be undertaken at the same time.[819]
The role of lead government department for the recovery phase included acting as the focal point for communications between the government and the recovery co-ordinating group at local level, together with many of the responsibilities of the lead government department for the response phase.[820]
ConOps suggested that it was the activation of COBR that triggered responsibilities, particularly for the Cabinet Office and the lead government department for response. However, Ms Hammond told us that the Civil Contingencies Secretariat’s responsibilities arose in relation to any ministerial meeting convened to deal with a civil emergency, whether or not it was treated as a COBR meeting, and that the formal activation of COBR did not make a difference in practice.[821] The difference between what the guidance says and how things work in practice is unsatisfactory, given that the Civil Contingencies Secretariat is the author of ConOps, operates COBR and provides introductory training for civil servants in relation to COBR.[822]
The Civil Contingencies Secretariat provided training and support to local responders for a fee[823] through the Emergency Planning College, which was operated by SERCO on behalf of the Cabinet Office. The courses[824] were not mandatory for government departments nor for Category 1 or 2 responders.[825]
The number of Emergency Planning College training courses undertaken by a responder is at best a crude measure of their level of training and expertise. Apart from anything else, it does not take into account the existing qualifications of staff or training that has been undertaken with another supplier.[826] However, in the three and a half years before the Grenfell Tower fire the difference in the number of courses purchased by Westminster City Council (88)[827] and RBKC (3) is stark. Unlike Westminster, RBKC had taken no courses in civil protection.[828]
There was no system within the Civil Contingencies Secretariat for monitoring training or notifying responders that were not undertaking a minimum level of training that they should be doing more.[829] As a result, central government was not aware of shortfalls in the training of local responders.
In the three and a half years before the Grenfell Tower fire, there were also significant differences between central government departments in the number of delegates attending Emergency Planning College training courses. Only four delegates from each of DCLG[830] and the Home Office attended,[831] as against 94 from the Cabinet Office.[832] The Civil Contingencies Secretariat had a relatively high turnover of staff,[833] all of whom attended the Emergency Planning College as part of the normal induction process,[834] but it was not part of its function to monitor training undertaken by other government departments and it did not know how many courses were expected to have been undertaken by the departments that would regularly be deputed to act as lead government department for response or recovery.[835]
The Civil Contingencies Secretariat itself also provided introductory training for civil servants whose roles were likely to require them to work with COBR.[836] Ms Hammond did not think that training was mandatory for those with a direct role in COBR, but it was expected that they would undertake it.[837] It is not clear whether there was an expectation that ministers would receive training or an equivalent briefing.
RED conducted its own training led by Gill McManus, its acting head of London Resilience[838] and Lynne Dowdican. It included induction training, revision exercises and discussions following RED responses to reflect on what had been learnt.[839] The department also held RED training days, ran a mentoring programme and held training sessions in team meetings.[840] Most RED team members took part in the Multi-Agency Gold Incident Command course led by the College of Policing.[841] However, no training was provided specifically for duty officers.[842] Ms McManus accepted that that was inadequate[843] and RED has now introduced a specific training programme for duty officers.[844]
RED reserves,[845] who can be called upon by the department in an emergency response, had access to some training, but it was not mandatory[846] and apparently it was not unusual for a reserve to have received no training.[847] Given the role the reserves may be called upon to play in response to an emergency, we consider that to be unsatisfactory.
Resilience advisors in RED took part in training exercises arranged by the London Resilience Forum that acted out various situations to check emergency preparedness, to help the London Resilience Forum partners to understand the role of the government in an emergency response and to assist them with revising and improving their plans.[848] They included the major exercise known as exercise Unified Response that took place from 29 February to 4 March 2016[849] and has been referred to earlier. The most recent resilience exercise involving local responders and the government before the Grenfell Tower fire had taken place on 17 May 2017.[850]
In October 2015, RED had issued a learning strategy[851] which drew attention to the lack of structured monitoring of the lessons learnt from exercises and emergencies it had been involved in and the failure to link those lessons to training requirements.[852] The strategy also identified a lack of focus on training in the rest of the department.[853] Ms McManus told us that since the Grenfell Tower fire DCLG has taken a much more professional and structured approach to training which is being developed further.[854]
From time to time the Civil Contingencies Secretariat organised a survey of the capability of local responders to respond to emergencies of various kinds. The results were collated in a national Resilience Capability Survey. Before the Grenfell Tower fire the Civil Contingencies Secretariat used the Resilience Capabilities Survey to help identify potential gaps in capability.[855] A fresh survey had been carried out in the spring of 2017 but the results had not been analysed by the time of the Grenfell Tower fire and therefore the version currently in use was the 2014 survey.[856] Participation in the 2014 survey had not been compulsory and 29% of Category 1 and 2 responders had not taken part.[857] Moreover, it had been based entirely on self-assessment by responders with no external verification of the results.[858] Responses to the survey were processed and aggregated by a third party; the Civil Contingencies Secretariat received only a high-level report based on aggregated data[859] and was therefore unable to examine the responses of individual Category 1 and Category 2 responders.[860] Before the Grenfell Tower fire the capability of RBKC to respond to an emergency had not caused concern, either as a result of the survey or as a result of any information reaching the government from other sources.[861] Central government thus had no means of effectively predicting the effectiveness of a local responder.
Over the course of the seven days following the Grenfell Tower fire the government itself was still in a state of flux following the general election held on 8 June 2017.[862] It was already having to respond to a number of significant emergencies, including terrorist attacks at Manchester Arena and London Bridge, and on 19 June 2017 a further terrorist attack took place outside the Finsbury Park mosque.[863]
The National Security Secretariat watchkeepers (a small team of officials within the Civil Contingencies Secretariat who continuously monitor events) became aware of the Grenfell Tower fire at about 01.30 on 14 June 2017. The duty officer then notified Katharine Hammond, the senior civil servant on duty, of the fire at just after 03.00.[864]
The Civil Contingencies Secretariat assumed that the fire was a major incident and that a meeting of a strategic co-ordinating group of local responders would be called.[865] The duty officer contacted DCLG RED so that it could provide a GLO to attend the meeting on behalf of the government.[866] Denise Welch, resilience advisor and RED duty officer that night,[867] received the call at about 03.30.[868] Ms Welch called Gill McManus,[869] who was acting for the first time that night as duty head of resilience,[870] and then called David Norris, Home Office fire duty officer,[871] at about 03.45.[872] Mr Norris became aware of the fire only at that point.[873] Ms Welch followed up her call with an email at 04.13[874] and at 04.29 Mr Norris sent the information to various members of the Home Office staff.[875] Given the Home Office’s role in fire and rescue services,[876] we are surprised that it was unaware of the Grenfell Tower fire until it had been notified by DCLG RED.[877] RED also contacted the London Resilience Group, which confirmed that a major incident had been declared and that a strategic co-ordinating group meeting would take place at about 05.00. Ms McManus told us that it was unusual for RED not to have heard about an incident of this magnitude directly from the London Resilience Group.[878] Meanwhile, at 03.49, Ms Hammond sent an email to Stuart Wainwright, head of the Readiness and Response team, to notify him that the duty team was taking action.[879]
At 04.44, on Ms Hammond’s instructions, the duty officer sent a situation report to No.10,[880] the National Security Adviser, Mark Sedwill, and the Deputy National Security Adviser, Paddy McGuinness.[881] At 06.17, Alastair Whitehead, private secretary at No.10 with responsibility for the Home Office, sent an email to the Prime Minister informing her of a major fire at Grenfell Tower. He described the entire block as ablaze, with some reports suggesting that residents were still trapped inside. The Prime Minister confirmed receipt of the email at 08.14.[882]
The Home Office assumed the role of lead government department for the response phase in view of its responsibility for the fire and rescue services.[883] As part of that role the Home Office prepared situation reports in the days following the fire until 19 June 2017.[884] Dame Melanie Dawes contacted Dr Jo Farrar on the morning of 14 June 2017, indicating that she thought that DCLG would be designated the lead government department for the recovery phase. However, she told us that it would not automatically be asked to do so in relation to an incident of that kind and that she had no recollection of the Home Office asking DCLG to take on that role or talking to DCLG as the recovery partner.[885]
In her capacity as GLO Ms Welch joined the first strategic co-ordinating group meeting, which took place at 05.00, by telephone.[886] The GLO was not expected to attend the scene of an emergency[887] but was expected to attend the strategic command centre or special operations room at which the strategic co-ordinating group was based.[888] However, Ms McManus thought that it would be more effective for Ms Welch to join the meeting remotely,[889] so she did not ask her to go to the strategic command centre[890] and she did not do so.[891] In fact, no GLO was sent to the strategic command centre on the morning of 14 June 2017.[892] The presence of a GLO at an early stage of the response would have helped RED understand what was going on and what was needed and would have reinforced its effectiveness as a link between the strategic co-ordinating group and the government.[893]
On the morning of 14 June 2017, RED was not providing timely reports about the prevailing situation from the strategic co-ordinating group meetings.[894] Ms Welch produced a summary of the meeting at 05.00,[895] which she sent to colleagues at RED and to the Civil Contingencies Secretariat Control email address at 06.16.[896] However, the Civil Contingencies Secretariat Control did not send it on to Mr Wainwright until 07.13,[897] by which time the second meeting held at 06.30 had already started.[898] At that stage, no decision had been made about the need for national support,[899] as Mr Wainwright considered that the Civil Contingencies Secretariat would be better able to make that decision after the meeting.[900]
Mr Wainwright did not receive a summary of the 06.30 meeting until 08.40.[901] A summary of the next strategic co-ordinating group meeting held at 08.30 was not sent to RED until 10.41[902] and was not sent on to the Civil Contingencies Secretariat until 11.10.[903] DCLG considered it unusual[904] that the Civil Contingencies Secretariat asked it to join the next meeting of the strategic co-ordinating group at 14.00,[905] but, in view of the repeated delays in sharing information that morning, we find it unsurprising. In our view the failure to share information from the strategic co-ordinating group promptly undermined at a critical stage the government’s understanding of what was going on.
The focus of the emails sent by DCLG in the early hours of 14 June 2017 was on the department’s responsibilities for building regulations and housing, not on the local authority’s ability to deal with an incident the size of the fire.[906] Ms McManus told us that the information coming through at that time indicated that RBKC was coping well and that other boroughs were providing assistance.[907] She told us that, in the absence of a request for support, RED would not normally contact a local authority in the middle of an emergency response.[908]
At 08.09 Mr Wainwright sent an email to Ms Hammond saying that the LFB was not seeking additional resources and that the NHS had reported that it had sufficient capacity.[909] RBKC’s capacity was not mentioned. Ms Hammond told us that the national resources available to local responders included anything that the fire and rescue service needed, because at that stage they were in the response phase.[910]
We heard that on 14 June 2017 the Civil Contingencies Secretariat had been consistently told that the responders did not need any resources or assistance from the government.[911] Ms Hammond said that she had regarded the absence of a request for help from RBKC as reassuring.[912]
The response phase of the reaction to an emergency comprises crisis and consequence management, which for many emergencies is the biggest and most complex area of work.[913] It includes managing community relationships and providing shelter to displaced persons.[914] That overlapping, but integral, part of the response phase appears to have been overlooked in the initial stages of setting in motion the government’s response.
An emergency notice putting the rest of the department on notice that matters might escalate and that RED reserves might need to be brought in should be issued[915] if the deputy director considers that an incident will place significant pressures on RED’s resources or if COBR has been activated.[916] Katherine Richardson, deputy director of RED, decided to issue an emergency notice at 09.18[917] after receiving an email at 09.16 from Robert Mason, head of DCLG’s Emergencies Management Team.[918] Ms McManus told us that the emergency notice had been sent then,[919] after three strategic co-ordinating group meetings had been held and some eight hours after the police had declared a major incident,[920] because by that time staff had been available to set up the operations centre.[921] However, it seems clear to us that the delay was an oversight that was corrected by Mr Mason’s intervention.
The emergency notice informed recipients that RED had set up an operations centre[922] at 08.00.[923] (An operations centre is the name for a collection of “cells” working together on behalf of the department to respond to a severe emergency or one affecting a wide area.) However, by 09.37, at least two of the three main cells (the situation cell and the briefing cell) had not been formally activated.[924] Although a full operations centre is used only for the most serious emergencies, it was clear from the outset to Mr Mason that RED and the government generally were likely to be heavily involved in the case of the Grenfell Tower fire.[925] The delay in formally setting up the situation and briefing cells may have affected RED’s understanding of what was happening at the incident, although we recognise that DCLG was not standing still until the emergency notice was issued.
Despite the fact that Mr Mason was not on duty on 14 June 2017,[926] he was still recorded as the response manager for the operations centre in the emergency notice.[927] Mr Mason explained that the roles of response director and response manager were “standing roles”, which Ms Richardson, as deputy director of RED, and he, as head of emergencies management, would automatically fill.[928]
By 10.04 on 14 June 2017, the Prime Minister had asked for[929] a cross-government meeting[930] to be arranged to understand better what was happening, to ensure that the different departments that might have a role were co-ordinating their operations and to establish whether any additional assistance could be provided.[931] It was to be held at 10 Victoria Street.
It was decided that the meeting should be held at minister of state level, rather than cabinet-level, because the Home Secretary was unavailable.[932] It was chaired by the Minister for Policing and Fire, Mr Nicholas Hurd MP,[933] who had been appointed to the post two days earlier.[934] He told us that at the time he had not been aware of the Civil Contingencies Act or the Regulations, the Emergency Preparedness guidance, the Emergency Response and Recovery guidance or the ConOps guidance[935] and had had no training in resilience.[936]
Ms Hammond told us that she had not assumed that the minister would not have mastered his brief simply because he had been so recently appointed.[937] In our view, however, that might have been a safer assumption to make. Indeed, when Mr Hurd was asked whether he was adequately briefed for the task, he frankly admitted that that was scarcely possible, given that it was only his second day in the post.[938] The Civil Contingencies Secretariat later concluded that the first cross-government meeting should have been chaired by a more senior minister. A similar recommendation had been made by the cabinet in the aftermath of the flooding in 2014 and 2015.[939] With the benefit of hindsight Dame Melanie Dawes expressed the view that, if the initial cross-government meeting had been chaired at cabinet level[940] or by the Prime Minister, more questions might have been asked about the local response.[941] It is not clear why earlier recommendations were not followed. In our view, the cross-government meetings would have benefited from being chaired by a more senior minister who had a better understanding of what was required to respond to an emergency.
The meeting was described as a cross-government co-ordination meeting[942] and in the email correspondence relating to it was specifically stated not to have been a COBR meeting.[943] Alastair Whitehead told us that on 14 June 2017 there had been no detailed discussion within No.10 about activating COBR because it had been understood that, although the incident was serious, it was one that was being handled by the local emergency services, who could rely on the assistance of other boroughs where necessary.[944] It is interesting to note that none of the witnesses told us that they had referred to ConOps during the period following the fire.[945]
A message from Ms Hammond to Camilla Marshall in the No.10 Press Office at 12.58 on 14 June 2017 shed more light on the Civil Contingencies Secretariat’s understanding of the level of the emergency at the time. In it she sought to explain the difference between a formal crisis management response (the COBR process, technically a cabinet sub-committee) and a less formal co-ordination meeting.[946] She said that what really determined the difference was whether the government had a leading role in the response, which in that case was clearly being managed extremely well by local responders. They were therefore checking on requirements for resources and looking ahead to what arrangements for support were going to be needed from across the system in the next few days.[947] Although not identified as a factor, it is clear that the absence of a request from RBKC for support and the belief that the response was being handled well by local responders influenced the level of government engagement on 14 June 2017. Ms Hammond told us that if it had been clear to the Civil Contingencies Secretariat at the time that RBKC was struggling, it is possible that a COBR meeting would have been called.[948]
In preparation for the cross-government meeting at 16.00 on 14 June 2017 the Civil Contingencies Secretariat provided the secretariat support and developed an information pack (CRIP), as it would have done for a COBR meeting.[949] It is likely that some of the people working in the situation cell preparing the CRIP would also then have been part of the secretariat for the meeting.[950] Ms Hammond said that in practical terms there was no significance in the fact that the meeting was not formally a COBR meeting and that the Civil Contingencies Secretariat had done all the same things.[951] The implications of failing to activate COBR formally are discussed further at paragraphs 103.172 to 103.177.
At 09.00 on 14 June 2017, Dr Farrar received a briefing from Ms Richardson which included information about the leadership and co-ordination of the local response. At that stage, it had not become clear who was leading the response in relation to humanitarian assistance.[952] At 09.07, Dame Melanie Dawes sent an email to Nicholas Holgate offering government support as and when it might be helpful.[953] He responded by thanking her but did not ask for assistance, saying that there was plenty of “blue light resource”.[954] Mr Holgate told us that he had not thought of going back to Dame Melanie at a later stage because it was not obvious to him what assistance the government could provide.[955]
At 09.27 Dr Farrar’s secretary attempted to get hold of Mr Holgate to tell him that Dr Farrar was his primary contact in the government and to arrange a time for them to speak.[956] Dr Farrar followed that up with a text message to Mr Holgate but did not receive any response and was unable to speak to him until the next day.[957] DCLG continued to make efforts to contact RBKC and offer government support throughout 14 June 2017,[958] but its offers were couched in general terms.
At 13.42 on 14 June 2017 Dr Farrar’s secretary contacted Alex Powell, deputy director for local government stewardship at DCLG, to ask for background information on RBKC.[959] Dr Farrar described it as standard procedure[960] and no concerns were raised about the general performance of RBKC.[961] Dame Melanie sent some general information about the leader of RBKC, Nicholas Paget-Brown, and the chief executive, Nicholas Holgate, to the Rt Hon Alok Sharma MP, then Minister of State for Housing and Planning. She described Mr Paget-Brown as “a safe pair of hands” and said that Mr Holgate had previously worked in the Treasury and that the department had a very good relationship with him.[962] Dr Farrar accepted that the information that had been gathered was quite basic and superficial.[963] Crucially, no information was provided to Dr Farrar which was relevant to RBKC’s ability to respond to an emergency. Dr Farrar told us that she did not believe that it had been RED’s responsibility to make such an assessment and that it did not have the resources to do so.[964] The fact that the leader and chief executive of RBKC were both known to those at DCLG and held in high regard by those who knew them appears to have contributed to a confidence in the ability of RBKC to respond to the fire that turned out to be misplaced.[965]
One of the first things Mr Hurd did was to visit Grenfell Tower at approximately 13.00 on 14 June 2017,[966] where he met Dany Cotton, LFB Commissioner, and others.[967] He was not accompanied by anyone from RBKC, having taken the initiative himself to go there,[968] and did not visit any of the surrounding areas, including the rest centres.[969] He told us that, in hindsight, he wished things had been done differently because he could then have gone into the cross-government meeting with some basic information which he fairly conceded the meeting did not have.[970]
After consulting No.10 and the Home Office[971] the Civil Contingencies Secretariat produced a number of documents in preparation for the meeting on 14 June 2017, including an agenda, brief for the chairman and a list of those invited to attend.[972] Matters for discussion included immediate shelter and medium-term rehousing and support for those affected by the fire.[973] The list of those invited to attend did not include a representative from RBKC.[974] Ms Hammond told us that she had expected information about the local authority to come from the Mayor of London, RED and the ministers to whom they had been reporting.[975] She could not remember anyone deciding that RBKC should or should not be represented, but she accepted that it would have been normal for Mr Holgate, as the chief executive of RBKC, to attend a meeting of that kind.[976]
At 13.55 on 14 June 2017, RED sent the Civil Contingencies Secretariat by email Mr Holgate’s name and telephone number as the local government representative[977] and at 16.30, 30 minutes after the meeting had begun, RED asked the Civil Contingencies Secretariat to arrange for him to join the meeting by telephone to provide a local contribution as soon as possible.[978] Until that point the Civil Contingencies Secretariat had not appreciated that Mr Holgate’s details had been sent to enable him to join the meeting.[979] As a result, no one from RBKC attended the meeting. Apparently, no one at the meeting remarked on the absence of RBKC.[980]
Ms Hammond did not accept that the omission of Mr Holgate from the list of those invited was a significant error.[981] The failure of the Civil Contingencies Secretariat to include someone from RBKC in the list or to mention RBKC in the chairman’s brief made it less likely that anyone would notice Mr Holgate’s absence.
Ms Hammond did not think that the absence of RBKC had adversely affected the meeting’s understanding of what was happening, given the other sources of information available to it.[982] However, those sources of information were inevitably one step removed from the local authority. It is self-evident that many of the questions raised in the chairman’s brief, such as those relating to arrangements for emergency shelter, the provision being made for those requiring alternative accommodation, for how long alternative housing might be required and how difficult that would be for the local authority to organise, would have been better answered by the chief executive of RBKC, particularly in the context of a fast-moving emergency.[983]
Following the meeting, Mr Hurd told the media that he had left it feeling reassured that the resources and the capacity needed to support people were in place.[984] It appears to us that the government had fundamentally misunderstood the position.[985]
The minutes of the meeting do not record any discussion of the need for financial assistance, information or humanitarian support for those affected by the fire.[986] Although it was agreed that trauma counselling should be offered to firefighters and ambulance workers,[987] we have seen nothing to suggest that there was any discussion about providing counselling of a similar nature to former residents of the tower.[988] Moreover, although the minutes refer to providing temporary accommodation for residents of the tower they do not mention the need to provide accommodation for residents evacuated from the surrounding area.[989] It appears that, with the exception of shelter,[990] none of the initial needs of survivors without serious injuries described in Emergency Response and Recovery were considered at that first meeting.[991]
Following the fire, Workstream 4 of the National Security Capability Review drafted by the Civil Contingencies Secretariat acknowledged that there can be a tendency for the strategic co-ordinating group to concentrate during the early stages of a crisis on the response of the emergency services to the detriment of those matters that fall to local government and other civilian-led support services.[992] In our view, reliance at the cross-government meeting on information derived from members of the strategic co-ordinating group, but not from RBKC directly, is likely to have exacerbated any tendency to focus on that aspect.
Ms Hammond said that support from the government was more likely to be needed in the recovery phase. Be that as it may, it did not obviate the need for the first cross-government co-ordination meeting to consider the immediate needs of the survivors.[993] Indeed, ConOps specifically contemplated that for most emergencies response and recovery would initially be undertaken in parallel.[994]
In our view, at the meeting on 14 June 2017 too few of the right questions were asked about the local authority’s responsibilities to those affected. The questions that were asked were asked of the wrong people and the minister chairing the meeting did not have the experience needed to perform that task.
The Civil Contingencies Secretariat took the minutes of the meeting. Ms Hammond told us that minutes of such meetings are kept for the purposes of providing records[995] but are not circulated to those present for approval or correction and that, if anyone wanted to refer to them, it would be necessary to ask the Civil Contingencies Secretariat for permission.[996] The only document circulated to those who had been present at the meeting was a list of “Actions”.[997]
A draft version of the minutes contained the following passage:
“The Minister for Local Government stated that the local Council were presently identifying temporary accommodation for those residents of Grenfell Tower. Longer term re-housing would also be the responsibility of the Council. The Mayor of London pressed for further reassurance and asked that contact was made with the local Council to ensure that affected individuals are not left without accommodation.”[998]
However, in the final version[999] the final sentence of that passage was deleted and replaced by a sentence reading simply:
“The Council were not currently asking for additional support”.[1000]
It is not clear how the draft came to be altered and Ms Hammond could not assist.[1001] In our view, it is indicative of the approach of the Civil Contingencies Secretariat, which involves equating the absence of a request for support with reassurance that support is not needed. The working assumption was that if people needed help, they asked for it.[1002]
We accept that local authorities may not be predisposed to ask for support and may need both encouragement and a clear process for doing so.[1003] Mr Hurd said that the government should have realised earlier that the scale and complexity of the disaster were such that no one local authority could be expected to cope with it and that it should have been quicker to put in place the means of understanding what was happening in the locality.[1004] We agree and endorse the recommendation of the Civil Contingencies Secretariat that in future the government probe further to establish whether the local tier is handling the response to an emergency adequately.[1005] In our view, the absence of a request for support is not a safe or sufficient basis for the government to assume that support is not required.
We have seen evidence to suggest that the strategic co-ordinating group was aware of the shortage of accommodation recorded in RED’s summary of the meeting held at 19.30 on 14 June 2017.[1006] Nonetheless, on the morning of 15 June 2017 Dr Farrar did not question the shortfall of accommodation.[1007] Instead, she passed the information she had received from RBKC by email to Dame Melanie’s private secretary, noting that there had been a quick response in providing temporary accommodation on the evening of 14 June 2017 and that the task for 15 and 16 June 2017 was to find more permanent homes.[1008] Dr Farrar told us that she had trusted RED to follow up concerns and report any problems and that her email to Dame Melanie was a note of what she had been told.[1009]
At 08.34 on 15 June 2017, Alastair Whitehead sent an email to Stuart Wainwright observing that shelter still seemed to be a concern based on the situation report he had seen.[1010] He then sent an email to Lorna Gratton, private secretary at No.10 with responsibility for DCLG, in which he described rehousing and co-ordination of support for the families affected as “a mess” and proposed the deployment of DCLG teams in the area.[1011] At the same time, the Prime Minister was speaking directly to the Secretary of State, the Rt. Hon Sajid Javid MP, making the same point and asking what central government could do to support RBKC.[1012] Sir Jeremy Heywood, head of the Civil Service, also sent an email to Dame Melanie Dawes expressing concern that the local authority did not have a grip on the aftermath of the fire and asking whether DCLG should send staff to help.[1013] Dame Melanie told us that she had been concerned about what was being communicated at strategic co-ordinating group meetings because direct communication with the council was revealing problems that were not being raised at those meetings.[1014]
At about midday on 15 June 2017 the Prime Minister visited Grenfell Tower. She was briefed by the emergency services but did not meet any residents.[1015]
During the course of 15 June 2017, the Civil Contingencies Secretariat became increasingly concerned in the light of discussions with DCLG about whether individuals affected by the fire were being properly looked after.[1016] At 14.26, it received confirmation that DCLG had raised the provision of temporary accommodation with the local authority, but a full picture had yet to emerge and DCLG had not provided current information on the number of people displaced from the tower.[1017] The Civil Contingencies Secretariat’s increasing concern was also reflected in detailed questions about those matters in the chairman’s brief produced for the cross-government meeting later that day.[1018]
On the morning of 15 June 2017, Dame Melanie’s office tried unsuccessfully to arrange a call with Mr Holgate.[1019] At 12.30, Dr Farrar finally spoke to him.[1020] She thought it unsatisfactory that that was the first time they had spoken, given that she was the person in DCLG designated as the point of contact with him.[1021] Their conversation added to her concerns. Although Mr Holgate sounded very confident and reassuring, the information he gave her did not match that which she had received from other sources.[1022] For example, he assured her that there was hotel accommodation for everybody who needed it, although in addition to those who had lived in the tower there were 845 people who did not have access to their homes.[1023] During the call Dr Farrar twice offered government support to Mr Holgate, which he declined.[1024] Dr Farrar specifically asked him about support from London Resilience, which he confirmed he had, notwithstanding that the Gold arrangements had not then been formally invoked.[1025] We heard from Dame Melanie that she and Dr Farrar could have checked whether the Gold arrangements were in operation but did not do so.[1026]
By 14.45 on 15 June 2017 DCLG had deployed an official to the police strategic command centre. It had also offered to make DCLG staff available to help out at RBKC offices, but that had been declined. RED reported to No.10 that the police and RBKC together were getting things under control.[1027]
At about 15.00 on 15 June 2017, Ms McManus contacted Mr Priestley, chief community safety officer at RBKC and Council Silver responsible for the operational response.[1028] She did not recall having asked him how the local authority was coping and told us that that was not the kind of information she would gather at that point. In our view, that was a missed opportunity for RED to improve its understanding of the situation and explain what assistance it could provide.[1029]
The second cross-government meeting took place at 15.30 on 15 June 2017. It was again chaired by Nicholas Hurd and was the first cross-government meeting attended by Mr Holgate.[1030]
The minutes recorded that 77 people from Grenfell Tower and 25 people from the surrounding area had been placed in hotels for immediate shelter and, with only 30 people at the Westway Centre the previous night, a large number of people were assumed to have gone to stay with friends and family.[1031] At that stage, it appears that the Civil Contingencies Secretariat was not aware that about 845 people who had been evacuated from nearby properties were also likely to require short-term accommodation.[1032] Dr Farrar had discussed that figure with Mr Holgate at 12.30, but the summary of their call was not circulated to those who attended the cross-government meeting until four hours later.[1033] We consider that was an unreasonable delay in a fast-moving situation, which meant the opportunity to challenge the figures was missed.
During the meeting the Civil Contingencies Secretariat’s concern about RBKC’s handling of the response became firmer when it became clear that RBKC did not know how many people had been displaced from the tower.[1034] Mr Holgate was defensive and tried to assure ministers that no additional help was required.[1035] However, he was unable to articulate a clear plan for housing those affected and was unable to say how many people would require accommodation, what services they needed, what resources RBKC had to deliver those services or what support it would need to do so.[1036] We heard from Mr Hurd that his overriding impression was of the complete collapse of Mr Holgate’s credibility under questioning.[1037]
By 17.30, No.10 had asked DCLG to look into further support for RBKC, suggesting that people could be sent to assist it.[1038] However, DCLG still failed to recognise the seriousness of the problems with RBKC.[1039] At 20.39, Ms Hammond contacted DCLG proposing it take stock of how RBKC was doing[1040] and, later, suggested that Dr Farrar might call Mr Holgate as someone with experience of senior leadership in local government.[1041] At 21.03 Ms Richardson responded, confirming that Dr Farrar had spoken to Mr Holgate, offering specific support on housing, and that DCLG’s housing minister also intended to speak to RBKC the following morning in order to obtain the missing details.[1042]
On the morning of 16 June 2017, there was growing concern within the Civil Contingencies Secretariat that the government did not have an accurate picture of the situation as it affected the survivors and other local residents.[1043] Following the conclusion of the cross-government meeting on 15 June 2017, Mr Hurd had received a series of unofficial calls from individuals working as volunteers in the community, including the vicar of St Clement’s church, impressing upon him the extent of the problems and the need for government support.[1044]
At 07.41 on 16 June 2017, Lorna Gratton told DCLG of her concern about the organisation of the response and suggested that more support from the DCLG, such as the secondment of a small team of people similar to the victim support unit, might be necessary.[1045] Following that intervention and the concerns raised at the same time by Mr Hurd,[1046] Helen MacNamara sent a message to a colleague in DCLG saying that the Prime Minister had expressed concern and wanted the government to get a grip on the situation.[1047]
During the morning of 16 June 2017 Lorna Gratton asked DCLG to suggest ways in which RBKC could be supported,[1048] offering further resources, if required, and seeking a date by which everyone displaced by the fire would be re-housed, ideally within two weeks. She also sought a commitment from DCLG to ensure that further support was accepted by RBKC. DCLG suggested that the victim support unit within the Home Office could be expanded to provide support to those affected by the Grenfell Tower fire.[1049] A little later, Mr Hurd’s private secretary expressed concern about the lack of co-ordination of the response and emphasised the need to use the coming cross-government meeting to find out what was really happening.[1050] By that time the co-ordination of the government’s response was being severely hampered by inadequate information.[1051]
Following her conversation with Mr Holgate at 12.30 on 15 June 2017, Dr Farrar decided to join the Secretary of State’s visit to the Westway Centre on the morning of 16 June 2017.[1052] That visit became pivotal to her understanding of RBKC’s ability to manage the situation.[1053] She formed the view that the relief effort was neither well-managed nor properly co-ordinated.[1054] Dr Farrar told us that, when she attended the Westway Centre on 16 June 2017, she had been surprised by a notable absence of senior RBKC officers and had not been reassured by her discussions with those officials from RBKC who were there.[1055] At about 09.40 on 16 June 2017, Dr Farrar was present at a meeting between the leader of the council, Mr Paget-Brown, and the Secretary of State.[1056] She told us that she had been worried that the offers of support had not been passed to Mr Paget-Brown, who did not seem to be aware of what was available.[1057] When he had agreed that additional support for RBKC’s rehousing effort would be helpful, Dr Farrar communicated that by text message to Katherine Richardson, who sent it on to Sally Randall to take forward without delay.[1058]
The minutes of the meeting of the strategic co-ordinating group held at 11.00 following the Secretary of State’s visit recorded the government’s misgivings for the first time,[1059] in particular the Secretary of State’s worries about access to cash, donations and information for the survivors.[1060]
Following the meeting with Mr Paget-Brown on the morning of 16 June 2017, Dr Farrar contacted Ms Richardson[1061] and Dame Melanie Dawes to discuss the appointment of a specialist emergency manager, proposing Mr Barradell[1062] as a potential candidate.[1063] Separately, by the evening of 15 June 2017 the decision had been taken to activate the London Gold arrangements and Mr Barradell had arranged to attend RBKC for a preliminary discussion.[1064] It appears that RED was unaware that the decision to activate the Gold arrangements had been made on the evening of 15 June 2017 and that their formal activation was expected to occur the next day.[1065] The documents we have seen suggest that RED and DCLG generally did not have a good understanding of what was happening.[1066]
When Dr Farrar went to see Mr Holgate he was in discussion with John Barradell, who said that he was there to support Mr Holgate and that there would be a chief executive rota as part of the London Resilience arrangements.[1067] She felt that an experienced person needed to be in the lead, rather than acting as support.[1068] She intervened, asking Mr Barradell privately if he would take over the London Gold role on a permanent basis.[1069] He agreed in principle and she then sent a text message to Dame Melanie telling her that she was speaking to London Councils to obtain their agreement.[1070] Dr Farrar then spoke to John O’Brien, chief executive of London Councils,[1071] who agreed to help in bringing that about.[1072] Mr Holgate also agreed to that course.[1073] Dr Farrar told Ms Richardson that Mr Barradell had taken over London Gold full time under the London Councils’ arrangement.[1074] Mr Barradell said that Dr Farrar may have had a different understanding of the effect of activating the London Gold arrangements.[1075] However, Mr Barradell told us that when taking on a role beyond that envisaged by the civil contingencies structure in London, he was not concerned about his authority as long as he had the support of the political leadership of RBKC and the support of the government.[1076]
At about the same time Ms Hammond learned from David Bellamy that John Barradell had been appointed to take over from RBKC as “Recovery Gold”.[1077] She thought that the decision had been taken by the Mayor’s office or Mr Bellamy and that there had been an existing arrangement under which that was possible.[1078] Ms Hammond did not suggest that she had looked into the legal basis for his appointment; she said that no legal concerns had been raised.[1079] The CRIP produced at 12.00 on 16 June 2017 stated that John Barradell had been appointed to co-ordinate logistical support to RBKC.[1080]
The question when to move from response to recovery was raised repeatedly in correspondence in the days immediately following the fire but was never clearly answered.[1081] Mr Hurd told us that he had not been aware of the particular moment at which the Home Office had relinquished the role of lead government department to DCLG; rather he sensed that during the course of 15 June 2017 there had been a growing recognition that DCLG was effectively evolving as the lead ministry for the recovery phase.[1082]
At 08.14 on 16 June 2017 Dr Farrar received an email from Mr Mason, head of emergencies management at RED, indicating that the police had been pressing the previous day to transfer control of the local relief effort to RBKC but that RBKC felt it was too early.[1083] Dr Farrar expressed her concern that RBKC might find it difficult to take overall leadership of the relief effort and asked Mr Mason to contact the Home Office to gauge its view.[1084]
At 09.22 on 16 June 2017, Ms Hammond said that she thought it likely that there would be a transition to the recovery phase on 17 or 18 June 2017.[1085] However, at 10.50, No.10 notified the Civil Contingencies Secretariat that the Prime Minister had decided to chair that afternoon’s cross-government meeting and that it would be renamed “The Grenfell Tower Recovery Taskforce”.[1086] The change of name had been proposed by Mr Whitehead[1087] to shift the focus from the initial emergency response to supporting the recovery phase. It had been decided upon without consulting the Civil Contingencies Secretariat.[1088] ConOps provided that, although, following most emergencies, response and recovery activity will initially be undertaken in parallel,[1089] the timing of the formal handover from the response to the recovery phase should be agreed between the two lead government departments, in consultation with the Civil Contingencies Secretariat[1090] and should start once the situation has been stabilised.[1091]
Ms Hammond described the creation of the Grenfell Tower Recovery Taskforce as marking a formal shift in emphasis which reflected the primary focus of the meeting, rather than the end of one thing and the start of another.[1092] However, we do not think that the recovery phase began on 16 June 2017[1093] or that the first meeting of the Grenfell Tower Recovery Taskforce was concerned with recovery.[1094]
The government’s formal transition to the recovery phase took place on 25 July 2017[1095] with the first meeting of the Grenfell Ministerial Recovery Group.[1096] In our view, the designation by No.10 of the cross-government meetings as meetings of a “Recovery Taskforce” was rightly seeking to shift their focus towards the immediate needs of the survivors, but it ignored the fact that they were an essential part of the response phase and risked creating confusion while the situation had yet to be stabilised.
Meetings of the Grenfell Tower Recovery Taskforce (“the Taskforce”) were held in the Cabinet Office Briefing Rooms at 70 Whitehall, the location from which COBR normally operated.[1097] Although Ms Hammond invited us not to attach any significance to that change of location, we think that in this case it indicated an increase in government engagement in line with, at least, a Level 2 serious emergency, as outlined in ConOps,[1098] and that a de facto COBR meeting had been initiated for the first time.[1099]
Ms Hammond told us that there had been no reason to activate COBR on 16 June 2017 because the things that could be discussed at a COBR meeting could as easily be discussed at a meeting of the Taskforce.[1100] It seems to us that the Civil Contingencies Secretariat should have formally activated a COBR response by that time,[1101] as envisaged by ConOps, taking forward elements of the recovery phase before formally handing over to a ministerial recovery group to take further action once the situation had been stabilised.[1102] Neither the Prime Minister nor the officials in her office had expertise in responding to an emergency of the kind facing them and would have had to rely on the expertise and advice of the Civil Contingencies Secretariat, the relevant government departments and other public bodies.[1103] The evidence suggests that No.10 received no advice about the possibility of activating COBR at that stage, or the benefits of doing so, or about the distinction between the response and recovery phases.[1104]
Following the Prime Minister’s decision to chair the meeting of the Taskforce on 16 June 2017, the secretariat role of the Cabinet Office was largely taken over by No.10, which drafted the agenda, produced the CRIP[1105] and decided who should attend.[1106] It declined the Civil Contingencies Secretariat’s offer of a “pre-brief”.[1107]
The first Taskforce meeting took place at 13.00 on 16 June 2017. It was chaired by the Prime Minister, the Rt Hon Theresa May MP, and was attended by, among others, the National Security Adviser, Mark Sedwill, Mr Barradell, described as “Local Authority Gold Commander”,[1108] and Mr Holgate.[1109]
At the beginning of the meeting the Prime Minister said that she wanted to ensure that the government was providing the best package of support for the victims and doing everything possible to assist those on the ground.[1110] It is clear from the minutes that there were still significant problems over the provision of immediate support to those affected. The Secretary of State for Communities and Local Government could not provide an absolute assurance that there was complete co-ordination between the government and the local authority but told those present that DCLG had already undertaken to deploy more people.[1111] A list of Grenfell Tower residents remained outstanding,[1112] together with the number of residents that needed re-housing.[1113]
The Prime Minister said that she wanted the government to support the affected families and in particular wanted to establish a single point of contact for families that could deal with all aspects of their recovery.[1114] It was agreed that DCLG would set up an integrated support service following the model of the Victims of Terrorism Unit to co-ordinate cross-government activity and provide those affected with a single point of access to government services,[1115] such as immigration, benefits, transport, the coronial process, education, health and financial assistance.[1116]
The gap in victim support had been raised by Isla Hurley Brunt, then head of community resilience and recovery at the Civil Contingencies Secretariat,[1117] on 14 June 2017 when she sent an email to Ian Whitehouse expressing doubts about the support that would be available when it was unclear whether those affected were victims of crime.[1118] However, it was not until 16 June 2017 that a central victim support unit was proposed, notably by Ms Gratton, a No.10 official without the Civil Contingencies Secretariat’s expertise in emergency response.[1119] That stands in marked contrast to the automatic support that would have been available in response to a terrorist attack.[1120] We agree with the Civil Contingencies Secretariat’s own assessment that there were inconsistencies between the response to the Grenfell Tower fire and the response to recent terrorist attacks that require attention.[1121]
Following the meeting of the Taskforce on 16 June 2017, Ms Hammond chaired a meeting of officials focusing on the establishment of a Grenfell Victims Unit.[1122] During the meeting, representatives from the Victims of Terrorism Unit explained how it worked. It was agreed that every government department involved[1123] would identify someone to work with the unit and that HM Revenue and Customs would provide 20 caseworkers to start work on the morning of 17 June 2017.[1124] Jillian Kay, director for local government policy at DCLG,[1125] and Suzanne Kochanowski, also of DCLG, were given the responsibility for setting up the Grenfell Victims Unit.[1126]
On 17 June 2017, the 20 members of the HM Revenue and Customs surge team and two people from the Department for Transport were deployed by DCLG to Portland House, the centre of London Gold operations, to support the Gold Command under Mr Barradell, and the Westway Centre.[1127] Over the weekend, Ms Kay’s priorities were to understand the nature of the support being put in place by the new Gold Command structure and to enable the Grenfell Victims Unit to work alongside the support being provided locally. There was a danger that, if it were a separate channel of support, it could cause confusion and further frustration among those affected by the fire.[1128] DCLG had been pursuing the idea of a direct public telephone line for the victims unit[1129] until Ms Kay learned that Gold Command was intending to use a key worker model with a social worker or other named contact point for each of the affected families and was talking to the Red Cross about establishing a telephone line.[1130] In the light of that, DCLG developed a single telephone line and email address for family liaison officers and key workers to use to secure support from across the government,[1131] repositioning the Grenfell Victims Unit as a second line of support.[1132] By 16.11 on 18 June 2017, the telephone number and email address of the Grenfell Victims Unit were in use. However, at that stage there were still families without a family liaison officer or support worker. Although DCLG was aware of that, the victims unit emphasised that the service was not an advice line for victims and that families should not call it directly.[1133]
On 19 June 2017 a pack was produced by DCLG setting out the purpose of the victims unit. It contained a telephone number and email address, made it clear that they were to be used by support and key workers and in addition provided the telephone number for the Red Cross for victims to contact.[1134]
At 22.56 on 19 June 2017, Ms Kochanowski sent an email to Ms Kay telling her that the Westway Centre had been a bit chaotic[1135] and that it was still unclear whether the key workers had been appointed. She said that the number of cases being handled by the victims unit was low (three in all) but that was because government staff were by then present at the Westway Centre. She also warned that the staff provided by HMRC would struggle to resolve the more difficult problems and navigate their way around government departments.[1136]
Dame Melanie Dawes told us that DCLG’s provision of support had been slowed down by confusion about what the Grenfell Victims Unit was, what ministers had asked for and what ultimately could be provided.[1137] It seems to us that by 19 June 2017 the victims unit had become something quite different from what had been envisaged at the meeting of the Taskforce on 16 June 2017. The Prime Minister’s intention had been to use the unit directly to support victims and fill any gaps in the support provided by others, whereas the model adopted by DCLG followed the approach of the Victims of Terrorism Unit. That depended on support already being in place for all who needed it, which, in the case of the Grenfell Tower fire, was lacking.[1138]
Following the first Taskforce meeting, Mr Sedwill sent an email to Ms Hammond offering to contact DCLG about London-wide and government support for RBKC. He thought that RBKC was clearly out of its depth and that the Civil Contingencies Secretariat probably should have prompted DCLG to intervene earlier.[1139] His offer was declined by Ms Hammond on the grounds that Mr Barradell and Dame Melanie had spoken to each other and everything was all right.[1140]
During the afternoon of 16 June 2017, the Prime Minister attended a round table meeting at the Clement James Centre with residents and volunteers from Grenfell Tower and the surrounding area[1141] and at 17.56 she sent an email to senior officials in No.10 expressing her frustration at what she described as the “utter uselessness” of RBKC.[1142]
At 18.25, Mr Whitehead sent an email to Ms Hammond informing her that there would be another Taskforce meeting chaired by the Prime Minister the following day and possibly a conference call on Sunday.[1143] That was contrary to Ms Hammond’s assumption that the next Taskforce meeting would not be held until Monday afternoon.[1144] At that stage, Ms Hammond was worried about the pressure being put on DCLG.[1145] Again, it appears that the Civil Contingencies Secretariat was being pressed to increase the level of intervention and oversight.
At 19.36, Ms Gratton sent an email to Dame Melanie and the Principal Private Secretary to the Secretary of State informing them that the Prime Minister was keen to make a further offer of assistance to RBKC and Gold Command, proposing that DCLG bring together whatever additional resources it could for the council and that it contact Gold Command to identify where the government could immediately and helpfully place people.[1146]
That evening the Prime Minister also spoke to Mr Paget-Brown. He assured her that everyone made homeless would be in housing by the end of the day and that someone from RBKC would be in touch that evening with every one of the support centres.[1147] In the event those assurances were not met.
At 11.00 on Saturday, 17 June 2017, the Prime Minister chaired a further meeting of the Taskforce, again focusing on the provision of support for victims.[1148] Those attending the meeting were told that residents were unsure how to obtain support and needed help to do so.[1149] It was agreed that a number of steps should be taken directed at community engagement, obtaining detailed figures for the numbers of those who had been living in the tower, of those from the immediate vicinity who could not return to their homes and of those who could, keeping the Westway Centre open and providing financial support.[1150] A Taskforce meeting for officials was arranged for the following day to monitor progress.[1151]
On 17 June 2014 the Home Secretary, the Rt Hon Amber Rudd MP, and Mr Hurd visited the Westway Centre for the first time.[1152] They discovered a number of problems,[1153] which in turn prompted the Home Office to write to Mr Barradell, among others, with observations about the current response. They included drawing attention to the distribution of money, the provision of emergency accommodation and poor communication.[1154]
On the evening of 17 June 2017, Peter Tallantire, head of the crisis management team in the Civil Contingencies Secretariat,[1155] confirmed that it was not fully aware of what DCLG was doing and was worried that DCLG was operating in a largely reactive manner with limited power to influence the direction of the response.[1156] Mr Tallantire suggested that the Civil Contingencies Secretariat try to do more to control the outcome by deploying a liaison officer to DCLG to work alongside its team, thereby enabling the Civil Contingencies Secretariat to know what DCLG was thinking, shape events and help co-ordinate government support.[1157]
Nearly four days after the fire, with Mr Barradell in post and the Prime Minister chairing the Taskforce meetings, the situation on the ground remained chaotic. That prompted Mr Sedwill to email Dame Melanie Dawes proposing the appointment of a “Gold for Whitehall on all the wider issues”, or alternatively a “Gold plus Gold Minister”, warning that it was necessary to drop everything else.[1158] There was an acknowledgement, both within and outside the Civil Contingencies Secretariat, that it needed to deploy additional resources to help co-ordinate government support.
On the morning of Sunday 18 June 2017, Ms Hammond supported Mr Sedwill’s suggestion and offered to provide someone from the Civil Contingencies Secretariat to provide a link with whoever was chosen for the task.[1159] Following that morning’s meeting of Taskforce officials, she advised the Rt Hon Damian Green MP, First Secretary of State and Minister for the Cabinet Office, on how DCLG could be supported as the response to the emergency moved into recovery. Among other things she suggested that Ian Whitehouse be seconded to DCLG, which took place the next day.[1160]
Apart from one reference to a need to consider the religious dimension of burials,[1161] neither the briefs nor the minutes of the cross-government or Taskforce meetings indicate an understanding of the particular needs of people from protected groups[1162] or any steps being taken to meet them. In our view, questions should have been asked and a greater effort should have been made about the different groups of people affected in order to understand better the effects of the fire on them and to find out whether steps were being taken to mitigate them.
On the afternoon of 16 June 2017, Fiona Darby, deputy director for homelessness at DCLG, had contacted Laura Johnson, head of RBKC’s housing department, to propose that Lizzie Clifford, a housing specialist at DCLG, join RBKC’s BECC that afternoon as the link with DCLG to assist with the rehousing efforts.[1163] Ms Johnson proposed in response that Ms Clifford join her three days later, on 19 June 2017.[1164] Following an intervention by Mr Barradell,[1165] Ms Clifford was subsequently deployed to Portland House, the seat of London Gold’s operations,[1166] from the morning of 17 June 2017. Ms McManus was also deployed to Portland House on 17 June 2017.[1167]
At the meeting of the Taskforce on 17 June 2017 it was suggested that a single centre should provide services and advice to those affected by the fire, which was to be appropriately and sufficiently staffed by government officials and others and kept open for as long as necessary.[1168] The Home Office made arrangements for officials to go to the designated centre on 18 June 2017 to assist with immigration enquiries. The officials were instructed that no immigration enforcement action should be taken and that they should wear plain clothes rather than uniform and not carry their Home Office badges.[1169] The officials met their counterparts from DCLG at 08.00 in Westminster, as DCLG had not yet confirmed the location of the support centre. They subsequently arrived at the Westway Centre at 11.00.[1170] The officials stayed at the centre until 16.30, by which time they had not received any enquiries for some two hours.[1171] That day the Home Office also began operating a 24-hour telephone line to assist with immigration and passport matters.[1172]
On 18 June 2017, RED wanted to ensure it was providing support as requested by Gold Command.[1173] It was concerned about using junior civil servants to carry out tasks that involved engaging with the local community, for which they had not been trained and with which staff from other London boroughs were much more familiar.[1174] At the Taskforce meeting held that morning,[1175] Mr Barradell asked the government[1176] for support in the form of staff experienced in community engagement. As a result, an official from the integration and faith team at DCLG[1177] was deployed to Gold Command that evening.[1178] Mr Barradell also asked for and received professional help from DCLG and the Home Office to improve the signs and labelling at the Westway Centre.[1179] He was very complimentary about the support provided by central government.[1180]
On the evening of 18 June 2017, DCLG directed staff from six government departments to attend the Westway Centre for the next seven days, starting at 9.00 on Monday 19 June, as a “PM priority”.[1181] Although HM Revenue and Customs operated a “surge” team of administrative officers who could be deployed to perform specific administrative functions, they were of limited use as they did not have experience in carrying out departmental roles.[1182] Ms Hammond told us that it was uncommon for staff from government departments to be deployed as part of a local response to an emergency[1183] and there do not appear to have been any procedures in place for such an eventuality. The fact that government staff were deployed at the Westway Centre is an indication of the degree of concern felt about the effectiveness of the centre as the focal point for support for those affected by the fire.
That same day, at the request of the Home Secretary, the Home Office produced leaflets in several languages containing government advice; they were delivered to the Westway Centre on 19 June 2017.[1184] Mr Hurd accepted in evidence that they could and should have been sent out sooner.[1185]
On 19 June 2017, Francesca Flessati from the Foreign and Commonwealth Office contacted DCLG and the Civil Contingencies Secretariat asking whether the latter would be offering advice on crisis management co-ordination and asking for any documents explaining how the centre was supposed to operate, its aims and objectives and its co-ordination and communication processes.[1186] After receiving a response from the Civil Contingencies Secretariat expressing complete faith in Mr Barradell but declining to provide any substantive advice, Ms Flessati complained that just gathering civil servants in a sports hall with no proper communications did not seem the best way of providing an effective service.[1187] Although by that stage the London Gold arrangements had been invoked and the Westway Centre was no longer being run by RBKC, there were still problems with the response on the ground.[1188]
On the morning of 20 June 2017, Sebastian Bassett-James at the Department for Business, Energy and Industrial Strategy (“BEIS”) sent an email to the Civil Contingencies Secretariat raising similar concerns. Mr Bassett-James identified a lack of leadership and command and control and suggested that government oversight was needed together with more co-ordination and more information about what services were already being provided.[1189] In light of Mr Bassett-James’s email, Ms McManus notified London Gold that RED had received reports that the Westway Centre did not seem structured.[1190] When Ms Kay visited it late on the morning of 20 June 2017, she observed that it was fairly makeshift, with handwritten signs at the government desks that were hard to read. However, she considered the situation to be calm and improving.[1191]
We have seen no evidence that the Civil Contingencies Secretariat provided any documentation or other support to government staff deployed to the Westway Centre. Indeed, Ms Hammond told us that it had not formally co-ordinated their deployment and that any training of staff was a matter for individual departments.[1192] Given its expertise in emergency response and recovery, we consider that the Civil Contingencies Secretariat should have given them some guidance on the objectives of the centre, and the role that they were expected to play.[1193] The description of the Westway Centre as “organised chaos”, with large numbers of officials, charities and community groups all trying to help,[1194] is endorsed by the Civil Contingencies Secretariat’s own report, which found that most departmental staff who answered the urgent request for help on 18 June 2017 felt that the arrangements there were disjointed and that there was a lack of clear leadership or concern for the welfare of staff.[1195]
The minutes of the Taskforce meeting on 16 June 2017 recorded, for the first time, that there had been 800 families living within the cordon in addition to those living in the tower.[1196] Until that point, there does not appear to have been any consideration at the cross-government meetings of the needs of residents who had been forced to evacuate, most of whom could not return home. The minutes recorded a commitment to ensure that residents, including those with nearby homes within the cordon,[1197] were accommodated locally as quickly as possible, but government decision-making and monitoring continued to be hampered by inadequate and unreliable information.[1198] Six days into the emergency response, the categorisation of residents was still changing, and the government remained unclear about the precise number of residents of Grenfell Tower and Grenfell Walk who were in emergency accommodation.
No concern was raised in the cross-government meetings about the effectiveness of the TMO until the Taskforce meeting on 19 June 2017.[1199] Ms Hammond told us that she had been aware of concern about its poor relationship with the tenants, the difficulties in getting precise information and a sense that it was not fulfilling its function.[1200]
The minutes of that meeting also recorded problems with the provision of hot water and gas to about 400 households within the wider cordon and noted that all households affected in that way were entitled to hotel accommodation and access to the discretionary fund.[1201] The list of things to be done following the meeting included directing DCLG and “Recovery Gold” (Mr Barradell) to consider urgently how best to respond to worries about the effectiveness of the TMO and reaching an immediate decision on what steps to take next.[1202] However, the list did not identify any specific action to be taken in response to the lack of hot water or gas in properties within the wider cordon.[1203] Further, although those concerns were recorded at government level, Robert Black, the chief executive of the TMO, was not made aware of them[1204] or of the decision to give affected residents access to hotel accommodation and financial assistance.[1205] The lack of hot water remained a problem and was raised again at the meeting of Taskforce officials on 20 June 2017, when Mr Barradell suggested that an engineering solution was required.[1206]
On 20 June 2017, it became apparent to Dame Melanie Dawes that there was concern about the leadership of the TMO[1207] and thereafter DCLG began to think how it could orchestrate a change of leadership.[1208] However, the government does not appear to have properly understood the role of, or the limitations placed upon, the TMO.
On 16 June 2017, the Prime Minister announced that those who had lost their homes as a result of the fire must be re-housed at the earliest possible opportunity and that the aim was to achieve that within three weeks at the latest.[1209] In recognition of the exceptional nature of the circumstances and of the fact that that commitment went further than a local authority’s obligations to other homeless households, the government agreed to meet the costs of providing temporary accommodation.[1210] From 16 June 2017 onwards DCLG inevitably played a major part in seeking to deliver what it later recognised was an unrealistic commitment.[1211]
On 18 June 2017, Helen MacNamara, director general of housing and planning at DCLG, sent an email to Barbara Brownlee, who had taken over responsibility for finding accommodation for those rendered homeless, to clarify the government’s commitment.[1212] She said that residents of Grenfell Tower or Grenfell Walk (so-called “Category A” households) would be re-housed within three weeks in the local area with the costs of temporary accommodation met by the government.[1213] Consideration was still being given to the situation of those who had lived in other buildings in the vicinity of the tower. The commitment was no doubt well meant but was always unrealistic and raised expectations in a way that was irresponsible. Some residents were still living in hotel accommodation two years after the fire.[1214]
Providing financial assistance to those affected by the fire was hampered by a lack of reliable information. Records of financial support provided during previous emergencies were not readily available and information about the amount of money being distributed was often inconsistent or absent altogether.
At a meeting on 14 June 2017 Ms Richardson, Dr Farrar, Ms Kay and the Secretary of State discussed the local response and the support that the government could offer, including funding under the Bellwin scheme of emergency financial assistance to local authorities.[1215] The next day, the Secretary of State announced the availability of funding under that scheme,[1216] but did not indicate, otherwise than in general terms, which costs would be met. The details were still being clarified on 19 June 2017.[1217]
On the morning of 16 June 2017, Lorna Gratton asked the Treasury what the government had done in the past in similar circumstances by way of giving residents immediate help with basic necessities.[1218] It does not appear that any such request had been made previously.[1219] We are surprised that the Civil Contingencies Secretariat had not already obtained that information. It appears that DCLG had not spoken to the Treasury about the creation of a discretionary fund to support the residents of Grenfell Tower[1220] by the time of a discussion between the Secretary of State and No.10 that morning.[1221]
It appears that the creation of a substantial discretionary fund was discussed for the first time at a cross-government meeting on 16 June 2017,[1222] at which the Prime Minister said that a £5 million discretionary fund would be established to help support those affected.[1223] The size of the fund and what it would cover in general terms was announced by the Prime Minister later that day.[1224] From that point onwards, there were considerable difficulties in getting a clear and consistent understanding of how many people had received money and how much money had been distributed.[1225] At a number of Taskforce meetings, different figures were quoted by DCLG and ministers from the Department of Work and Pensions (DWP), making it difficult to obtain a clear picture.[1226]
At the meeting of the Taskforce on 17 June 2017 it was pointed out that after the winter floods in 2015 all affected households had been given a payment of £5,000.[1227] The Mayor of London recalled that some of those present appeared to be reluctant to make lump sum payments of £5,000 rather than payments by way of instalments to those who needed support.[1228] It was agreed in principle that every family that had lived in the tower and those who had been forced out of their homes by the fire should be eligible to receive a sum of money to be paid out immediately through DWP staff on the ground.[1229] Following the meeting, DCLG was directed to produce a proposal for distributing the support fund.
It was subsequently ascertained that the government had provided each household affected by the floods in 2015 with an initial £500 in cash and a further £5,000 paid into bank accounts (i.e. £5,500 in total). Miss Gratton asked whether colleagues were happy to take the same approach to avoid unfavourable parallels being drawn with that emergency.[1230] That was two days after the Prime Minister had confirmed a £5 million discretionary fund and more than four days after the fire. We are surprised that the information about payments made to the victims of flooding was not already available to the Civil Contingencies Secretariat. In our view, the lack of easily accessible information about how victims of previous emergencies had been supported financially contributed to the delay in funds being provided.
In the event, it was agreed that every household that had lost its home as a result of the fire should receive £5,500, made up of £500 in cash payment from the council and £5,000 paid into a bank account by DWP.[1231] Everyone over the age of 16 who had been displaced as a result of the fire was also able to claim a £500 cash payment. RBKC could increase the amount of the cash payment in individual circumstances,[1232] drawing on the further funding from the government’s Grenfell Tower Residents Discretionary Fund.[1233]
The Discretionary Fund scheme went into operation on 19 June 2017.[1234] We heard that some of those who went to the Portobello Road Post Office[1235] to receive payments had not had any previous contact with the emergency relief effort.[1236] The lack of any previous contact five days after the fire reflects poorly on the wider emergency relief effort. Westminster City Council staff who became involved as part of a tri-borough agreement[1237] reported that some of the people coming in for help were vulnerable and required counselling before any practical steps could be taken to make payments to them.[1238]
Following the Taskforce meeting on 19 June 2017, Mr Barradell was asked to confirm by the end of the day how many people eligible to receive a £500 cash payment had not yet done so and to make those payments as soon as possible.[1239] It was not until the CRIP produced for the meeting on 21 June 2017 that reasonably reliable information was available about the number of those who were eligible to receive payments and the number of those who had done so. Even at that stage the figures were not consistent with those contained in other documents of the same date.[1240] We agree with the Civil Contingencies Secretariat’s own assessment that its understanding of the operational response was poor throughout that period and that inconsistent and missing data, particularly from DCLG, represented a constant challenge.[1241]
DCLG was under considerable pressure during the seven days following the fire. Although RED was experienced in leading liaison with local responses in relation to other kinds of emergencies (such as flooding, or terrorist incidents), in the months before the Grenfell Tower fire it had been required to respond to emergencies more often than usual.[1242] At the same time, it was short of staff[1243] and was in the process of being reduced in size.[1244]
Furthermore, the scale of the Grenfell Tower fire, involving a huge loss of life and mass displacement, was greater than anything it had previously encountered. The disaster generated immense public and political concern, made all the more intense by the fact that it fell within its own area of policy responsibility (local government and housing).[1245] Although the emergency was concentrated in a single location, it had national implications for the safety of tower blocks[1246] and it appears that for that reason a significant part of the department’s limited resources was taken up with reviewing its response to the earlier Lakanal House fire.[1247] DCLG was, in effect, trying to manage two crises at the same time.[1248]
Even after Mr Barradell’s appointment as Recovery Gold, there were difficulties in obtaining clear, accurate information about who was responsible for what and the number of people needing support.[1249] Nevertheless, we have seen no evidence to suggest that Ms Hammond raised concerns about DCLG with Mr McGuinness or Mr Sedwill.[1250]
An Internal Lessons report produced by the Civil Contingencies Secretariat in August 2017 concluded that it should have pressed for a liaison officer from DCLG to be present within the COBR situation cell regardless of the pressures on resources at DCLG.[1251] However, in the email he sent to Katharine Hammond on 17 June 2017 Peter Tallantire indicated that he felt it was too late to do that and that it was probably the wrong solution, as most of the worries related to DCLG, which was already considered to be struggling.[1252] Mr Tallantire suggested instead that the Civil Contingencies Secretariat’s ignorance of DCLG’s thinking should be resolved by deploying a liaison officer from the Civil Contingencies Secretariat to DCLG.[1253] Although Ian Whitehouse was transferred to DCLG on 19 June 2017, we think that the Civil Contingencies Secretariat should have taken action at least three days earlier,[1254] once it realised that DCLG was overstretched and under-resourced.[1255]
On the afternoon of 17 June 2017, the Prime Minister hosted a further meeting with Grenfell residents and community members in which wide-ranging complaints were made about the co-ordination of the response, the distribution of money to those who needed it and the limited information available on where people should go for help of different kinds. Those who attended the meeting asked, among many other things, that the TMO be removed from the management of the buildings affected, that central co-ordinators ensure they had links with local leaders and that liaison officers be provided for those affected.[1256] Feedback from that meeting was then filtered back by No.10 to DCLG.[1257]
Thereafter, No.10 staff continued to be in direct contact with the residents and volunteers who had spoken to the Prime Minister and became involved in dealing with difficulties facing individual residents, such as re-housing[1258] and the distribution of cash.[1259] The staff of No.10 were not usually involved in detailed matters of that kind during the response to an emergency but, given the lack of co-ordination between the government and the local authority, they clearly felt compelled to respond to the personal concerns of those affected.[1260]
On 19 June 2017, Lorna Gratton and Jamie Cowling both raised the complaints of Walkway residents with DCLG. At 10.16 on 19 June 2017, Ms Gratton sent an email to DCLG relaying residents’ complaints about the organisation and responsiveness of the TMO and asking for proposals for finding out whether they were justified.[1261] By 13.27, Mr Cowling had informed DCLG that the TMO had sent texts to residents of the Walkways telling them to return to their homes, despite the fact that front doors were broken and there was significant dirt and debris from the fire both inside and out. Mr Cowling asked DCLG to let him know by 17.00 that day when repairs to residents’ doors and cleaning would begin.[1262] Following receipt of that email, DCLG sought to investigate how widespread was the problem of residents being expected to return to properties that did not have functioning utilities.[1263] At 16.00 on 19 June 2017, questions about the effectiveness of the TMO were raised at a cross-government meeting for the first time.[1264]
Although the meetings between the Prime Minister and a select group of residents and volunteers were seen as constructive and as providing a mechanism by which to identify problems that had yet to be resolved,[1265] we consider that they demonstrate the lack of co-ordination between the government and local responders and the extent to which the concept of resilience based on the principle of subsidiarity failed in the case of the Grenfell Tower fire.[1266]
Mr Tallantire’s note headed “Key Points of Discussion with No.10”, produced in the course of preparing the Civil Contingencies Secretariat’s report entitled Grenfell Tower tragedy – Lessons for the Central Response,[1267] drew attention to a lack of consistent, reliable data both centrally and locally, difficulties contacting DCLG staff and an assurance by Dame Melanie Dawes that all was well at DCLG which had all the staff it needed.[1268] Although the note contained a positive view of the Civil Contingencies Secretariat, it identified problems in relation to its communication with No.10. The Prime Minister’s office had been working directly with DCLG on most policy matters as it sought to get the government’s response under control and often did so without informing the Civil Contingencies Secretariat of the requests and decisions it had made.[1269]
At 15.47 on 20 June 2017, No.10 asked for a detailed brief from DCLG containing a description of the situation on the ground, the latest victim figures and a short background note on the wider Lancaster West estate.[1270] In response, the private secretary to the Secretary of State suggested that No.10 talk to colleagues from the Civil Contingencies Secretariat about the latest numbers, given the pressures on DCLG. He later explained that that had been a plea to No.10 to use the latest version of the CRIP as a situation report for the Prime Minister.[1271] No.10’s requests for more information and briefings created additional reporting mechanisms in parallel with those undertaken by the Civil Contingencies Secretariat, which added to the pressure on an already struggling DCLG. It also suggests that No.10 was not getting what it wanted from the Civil Contingencies Secretariat.
Mr Tallantire’s “Key Points of Discussion with No.10” proposed that the Civil Contingencies Secretariat think more about how it could support without getting in the way.[1272] In our view, it could have given No.10 better information about the emergency response and recovery arrangements and the options available to the government. At the same time, No.10 should have taken further steps to ensure that the Civil Contingencies Secretariat was aware of the requests and decisions it had made and was not kept in the dark.[1273]
During the days following the fire many of the suggestions for support that were implemented came from No.10 rather than the Civil Contingencies Secretariat. In a detailed and reflective analysis at the end of her evidence, Dame Melanie Dawes recognised that it would have helped the government, and the speed of ministerial decision-making, to have been clearer about the kind of support that it could provide in different situations and to consider in greater detail the kinds of action that the government might be asked to undertake.[1274] We agree.
Dr Farrar told us that government intervention in a local authority could range from a light-touch approach, under which individuals are deployed to a local authority to work within a specific department or within the existing leadership team, to the government’s taking over the running of a local authority, putting in commissioners to run it directly. However, an intervention of the latter kind takes a number of weeks to implement. Consequently, although Dame Melanie and Dr Farrar did discuss sending in commissioners, it would have been hard to do that quickly,[1275] not least because it generally involves taking over all the functions of the local authority concerned.[1276]
During the period immediately after the fire, the government appears to have thought that there were no powers readily available to it to intervene directly[1277] and that it was therefore forced to rely on the power of persuasion[1278] and the subsequent appointment of Mr Barradell. Ms Hammond told us that she had no recollection of any consideration being given to the powers available to ministers to give directions to Category 1 and Category 2 responders under sections 5(1) and 7 of the Civil Contingencies Act [1279] and we have seen no evidence to suggest that consideration was given to using the powers to make emergency regulations under part 2 of the Act.[1280]
On the morning of Monday 19 June 2017, No.10 proposed developing a new strategy for national and local resilience in response to major disasters which could include a new “Civil Disaster Reaction Force”.[1281] That proposal was prompted by concerns, even at that stage, about the response to the fire, rather than by any considered programme of work. It indicates the extent of the reflection being undertaken at the highest level and No.10’s realisation that the government had limited practical ability to intervene to control events. Mr McGuinness pointed out that local authorities provide assistance to each other (although not always quickly enough) and that they have the skills to reinforce each other. He expressed the view that RED was meant to provide the means by which the government could reinforce and support their action, but that it was underpowered.[1282]
In response, Ms Hammond suggested that RED should be enhanced to enable the government to spot failing local authorities more quickly and ensure that support reached them and that better mutual aid arrangements should be put in place between local authorities with the addition of a national deployment mechanism.[1283] She envisaged something similar to the National Police Co-ordination Centre,[1284] with a centrally co-ordinated mechanism receiving a request from one authority for additional support, finding that support and deploying it.[1285] Although a mechanism of that kind might have accelerated the process of providing mutual aid, it would not have solved the main difficulty, namely, that RBKC did not realise that it was unable to respond adequately to the situation that had been created. Reflecting on the Grenfell Tower fire a month later, Mr Sedwill re-emphasised his view that the government needed a mechanism to take over control in a crisis before a local authority realised that it could not cope.[1286]
In September 2017 as part of a National Security Capability Review the Civil Contingencies Secretariat was asked in the light of events that had occurred in June 2017 to consider whether it was possible in law for the government to require a Category 1 responder to accept national support.[1287]
We heard from Ms Hammond that none of the meetings to which we have referred were held under the auspices of COBR[1288] When asked about the many contemporaneous references to COBR[1289] and whether they indicated a degree of confusion about whether the process had been activated or not, Ms Hammond told us that they were simply administrative errors.[1290] Ms Hammond also sought to explain references to COBR on the basis that, from 16 June 2017, the Taskforce meetings were held in the rooms in which COBR meetings are often held.[1291] When asked why emails from Dame Melanie Dawes and Mr Sedwill referred to a Taskforce meeting as a COBR meeting,[1292] she maintained that there had been no confusion and that it was just a shorthand for a meeting of that type.[1293]
A considerable part of Ms Hammond’s evidence was spent clarifying the meaning and relevance of the reference to COBR. She explained that a parallel version of COBR was not operating,[1294] and her firm position throughout was that exactly the same things were done as would have been done if COBR had been formally activated.[1295]
Formally activating COBR represents the government’s highest level of response. Mr Hurd told us that it would have been appropriate to call a meeting at a more senior level from the start.[1296] In this case, formally activating COBR would have emphasised the gravity of the incident and would have resulted in more senior ministers chairing the early cross-government meetings.[1297] However, whether that would have made any material difference is debatable. The scale and urgency of the government’s response increased significantly when the Prime Minister took over the meetings.
We heard from Dame Melanie that, if the initial cross-government co-ordination meeting had been chaired at cabinet-level[1298] or by the Prime Minister, it might have provided an additional layer of questioning and challenge about the local response to that being provided by the DCLG and the Home Office.[1299] In our view, that could have made a material difference to the way in which the meetings were approached and the actions arising from them.
For those outside central government, activating COBR would in itself have been an important indication to local responders of the likely form of central government engagement in the initial stages[1300] and would have given them a signal that central government oversight was not with junior ministers but with senior cabinet ministers.
On 16 June 2017, Dame Melanie told Sir Jeremy Heywood that the new Gold Command considered the situation to be more complex than that which had followed the London bombings in 2005. She thought that the Prime Minister should have chaired a COBR meeting on 14 June 2017.[1301] Her message indicates that a reference to COBR resonated inside as well as outside government. We do not doubt that, but the emphasis, as we see it, was on the importance of involving the Prime Minister at an early stage.
As the fire in Grenfell Tower continued to rage, hundreds of residents from the tower and surrounding properties were evacuated from their homes. As a Category 1 responder, RBKC was responsible for the provision of humanitarian assistance to those displaced. Its response was guided by its own Contingency Management Plan and the wider civil contingencies framework described in Chapter 99.
In this chapter we examine the provision of humanitarian assistance, which encompasses the provision of emergency shelter, food and drink, financial assistance, information about those who are missing, public communication and the provision of psychological support to those affected by the incident. RBKC led the response until support from London as a whole was enlisted through the operation of the Gold Resolution on 16 June 2017.[1302] From that point on, John Barradell, as London Gold, led the response. The circumstances in which he became involved are described in Chapter 102.
The RBKC Contingency Management Plan provided that if an incident occurred out of hours, the out of hours contact centre should contact the duty Silver,[1303] who was responsible for determining the level of the initial council response and initiating the call-out procedures.[1304] Levels of response were graded from 1 to 3, level 3 being the most serious and requiring the setting up of a Borough Emergency Control Centre (BECC) at Kensington Town Hall.[1305]
At 02.03 on 14 June 2017, the police informed RBKC of the Grenfell Tower fire using the out of hours service.[1306] Nickolas Layton, the duty officer, alerted David Kerry at 02.21.[1307] He told Mr Kerry that many had been able to leave the tower but that some people remained trapped and that casualties were expected.[1308] As the council did not have anyone on call to act as duty Silver due to staff shortages, Mr Kerry took on the responsibility of determining the level of response required.[1309]
Mr Kerry realised that the incident was serious but he did not formally categorise it by reference to the Contingency Management Plan.[1310] He remained at home and assumed the role of Borough Emergency Controller, whose task was to co-ordinate the council’s response. (At the time, the term “Borough Emergency Controller” was being replaced by the term “Council Silver”, and the two were used interchangeably.[1311] We shall use the term “Council Silver”.)
Mr Kerry proceeded on the basis that the response should be at level 2 rather than level 3, the highest level.[1312] Later in the morning the severity of the incident became clearer to him and the response moved up to level 3.[1313] The effect of his initial assessment, however, was that he did not open the Borough Emergency Control Centre (BECC) at the outset.[1314] He accepted in hindsight that he initially underestimated the scale of the response required.[1315]
Mr Kerry’s first step was to contact Laura Johnson, RBKC’s Director of Housing, at 02.34.[1316] Ms Johnson contacted Robert Black, the chief executive of the TMO,[1317] and sent an email to her housing team at 02.53 telling them of the fire and alerting them to the likely need for a considerable amount of emergency accommodation the following day.[1318] Although Mr Kerry did not look at the TMO emergency plan,[1319] he said that he had been aware that the TMO would attend the scene to assist RBKC.[1320]
At 02.50 Mr Kerry contacted his line manager, Stuart Priestley, RBKC’s Chief Community Safety Officer. They agreed that the situation should be monitored from home until further information was available.[1321] Shortly after that call, Mr Priestley became aware of the scale of the incident, having seen an email with images of the fire sent at 02.25 by a former LFB borough commander which said “You have a massive fire, Grenfell Tower”.[1322] Mr Priestly tried to contact Mr Kerry and managed to speak to him at 03.31, over an hour after Mr Kerry had been told of the fire. They decided that the full contingency management plan should be put into action, that staff should be called in to the Town Hall and that work should be transferred from the BECC (in effect, Mr Kerry) to the Town Hall.[1323] The effect was to raise the level of the response and to proceed on the basis of a level 3 response.
Nevertheless, some time elapsed before Mr Kerry set about calling staff, in particular those in the Contingency Planning Unit, into the Town Hall. At 04.09 he rang Keith Robins, the contingency management officer, but received no answer.[1324] At 04.13 he rang Elaine Chumnery, a BECC officer, who returned his call at 04.49 and agreed to go to the Town Hall to support Mr Priestley in opening the BECC.[1325] He rang Rebecca Blackburn at 05.23 and asked her to go in to the Town Hall at 08.00 to take over from him.[1326] She arrived at the Town Hall at about 07.20. It is unclear whether the delay was due to Mr Kerry’s failing to grasp the urgency of the situation or whether he was struggling to deal with the number of demands on him at the time. It is likely that it was a combination of both, as Mr Kerry was seeking to stagger the attendance of staff to ensure that some were available to work later in the day.[1327] However, in failing to obtain support from other staff at an earlier stage, he placed himself in an impossible position in seeking to discharge all his duties as Council Silver.
The delay in calling in staff and activating the BECC were compounded by problems in obtaining access to the facilities within the Town Hall. Although Stuart Priestley arrived at the Town Hall at 04.38, he was unable to find the key to the cupboard containing the telephones and computer equipment.[1328] He sent an email to Mr Kerry at 05.25 with the subject “Can you come PDQ. We cannot get into the cupboards.”[1329] There was a further delay of about an hour and a quarter until Mr Kerry arrived with the key at about 06.00.[1330] RBKC have since installed a key box to prevent something similar happening in the future.[1331]
Mr Kerry did not follow the protocol for the activation of the Contingency Management Plan. In particular, he should have contacted staff earlier, because there was too much for one person to do in the time available. Although it is easy to criticise with the benefit of hindsight, we think that Mr Kerry should have realised that as soon as he was warned about the risk of fatalities, and even more so as information began to come in about residents being evacuated from surrounding properties. At all events, the BECC was not operational at the Town Hall until about 06.00 on 14 June 2017; it should have been opened between about 03.00 and 04.00.[1332] That was a substantial delay that had significant consequences for RBKC’s response, not least in identifying the number and location of the rest centres that had by then opened spontaneously. As hundreds of displaced people poured onto the streets of North Kensington in need of support, RBKC was already many hours behind in assessing and meeting those needs. We are reinforced in that view by the evidence of members of the Contingency Planning Unit whose own assessment of the initial response was that by the time the BECC opened RBKC had already lost control of the incident.[1333]
Nicholas Holgate, town clerk and chief executive of RBKC, visited North Kensington early on the morning of 14 June 2017. He found the scale and ferocity of the fire deeply shocking.[1334] He visited the rest centres at the Harrow Club and Rugby Portobello Trust sometime between 04.30 and 06.00 and thought they were functioning properly.[1335] Still at the scene, he did not dial into the first meeting of the strategic co-ordinating group at 05.00,[1336] since, as he told us, he had not been told about it.[1337] John Hetherington, deputy head of planning, London Resilience, told us that the absence of the chief executive was not desirable, but in his experience not altogether unusual.[1338]
Mr Holgate arrived at the Town Hall at about 06.00 and had a meeting with Mr Kerry, Ms Johnson, Mr Priestley and Robert Black. It is unclear at what time that meeting was held. Mr Priestley said that it had taken place at 06.30,[1339] although Mr Kerry thought that it had taken place at 10.00.[1340] Notwithstanding that difference of recollection, it is clear that there was a meeting that morning at which Mr Kerry provided significant advice to Mr Holgate. Mr Kerry’s log records that he advised him that the incident was bigger than any one local authority in London could manage and that consideration should be given to asking for mutual aid for the BECC. The log further records that there were people who could support Mr Holgate and RBKC Gold, including John Barradell, Eleanor Kelly, Andrew Meek (head of organisational resilience at the London Borough of Haringey and London’s expert on humanitarian assistance) and Alistair Ayres from Hammersmith and Fulham.[1341]
Mr Kerry’s advice was based on his concern that there were insufficient RBKC staff to keep the BECC running for an extended period.[1342] He believed at the time, and maintained his view when giving evidence, that none of London’s local authorities could have coped with the incident on their own, given its scale.[1343] He told us that it was clear to him that it was massive and that it was for such incidents that there were mutual aid arrangements in place that he believed were well understood and practised. He told us that it was for the RBKC Gold strategic meeting to consider what resources were required. Once that assessment had been made, they would have been able to activate the London Gold arrangements, if necessary.[1344] We accept his evidence about that.
Mr Priestley recorded in his log that in response to David Kerry’s advice Mr Holgate had said “That looks like we can’t cope”.[1345] Mr Holgate did not recall making that comment, but he did not dispute the accuracy of Mr Priestley’s note.[1346] Mr Holgate did not agree with the view that the incident was bigger than any one local authority could manage.[1347] Despite the advice of Mr Kerry, he thought that RBKC would be able to respond effectively, if everyone worked together as a team.[1348] He denied being influenced by a need to preserve the council’s reputation.[1349] We are satisfied that the comment recorded by Mr Priestley accurately reflected Mr Holgate’s state of mind. In our view his attitude was defensive and his confidence in RBKC’s ability to manage the response was misplaced. It became more pronounced as it persisted into the following day, 15 June 2017.[1350]
Following the meeting of the RBKC Gold group at 10.00 on 15 June 2017, Ms Blackburn told Mr Holgate and Tony Redpath that they needed to seek assistance from other London boroughs and activate the London Gold arrangements.[1351] Her view was that RBKC was not coping and that there were not enough members of staff to support the response.[1352] Mr Holgate and Mr Redpath both told her that the council could manage.[1353] Ms Blackburn’s impression was that senior management at RBKC was reluctant to seek help.[1354] In her view, either they could not see what those on the ground were seeing or they could not cope and chose not to see it.[1355] Ms Blackburn told us that, having been in the BECC for two days, she ought to have been able to provide a clear picture of what was happening on the ground, but could not. That internal view was consistent with the concerns that were beginning to emerge on 15 June 2017 in the media, the London resilience agencies and the government.
The BECC was the key element in the council’s organisation in the days immediately following the fire. Despite the best efforts of those who volunteered to staff the BECC on the morning of 14 June 2017, it was overwhelmed by the incident.[1356] It struggled throughout the period in which RBKC led the humanitarian response before handing over leadership to John Barradell during the afternoon of 16 June 2017. The circumstances in which that occurred are described in Chapter 102.
The computer equipment used by the BECC was outdated and slow. It was due for replacement but that had not taken place by the time of the fire.[1357] Problems which had arisen in previous training exercises recurred. At the outset, it was not possible to obtain access to the system for logging information and technical assistance was needed to solve the problem.[1358] That affected the ability of the BECC to function efficiently, not least because staff could not open a log to enter tasks and chart progress. Although he could have done so remotely, Mr Kerry had not created an electronic log at the outset. If he had done so, it would have been available to others within the BECC later.[1359] Ms Blackburn eventually opened one at 13.18 on 14 June 2017, almost eleven hours after RBKC had been informed of the fire.[1360] As a result, important decisions taken in the previous hours had not been electronically logged.
Between 07.00 and 07.30 on 14 June 2017 David Kerry, as the first Council Silver and thus the person responsible for co-ordinating RBKC’s overall response,[1361] transferred his duties as Council Silver to Stuart Priestley.[1362] Mr Kerry did not provide him with a copy of his handwritten log (the electronic log was not yet open) and the handover was limited in detail.[1363] That was partly a reflection of Mr Kerry’s failure to appreciate the scale of the incident and partly the result of his being by that stage mentally and physically overcome by the incident.[1364] He was uncertain about the number and locations of the rest centres that had opened during the morning and did not know how many displaced people were at them. At that stage RBKC had not sent any staff to the rest centres.[1365]
A constant feature throughout the period in which RBKC led the humanitarian response was the shortage of trained staff to operate the BECC. Untrained volunteers from elsewhere in RBKC were drafted in to assist.[1366] Mr Kerry, an experienced contingency planning manager, worked nights and was not available during the day when his advice was most needed. The burden of leading the operational response during the day fell on Mr Priestley. Although he was a trained Council Silver and Mr Kerry’s manager, he had never previously held that role in an emergency.[1367] A further consequence of the staff shortages was that Mr Priestley had to manage the BECC in addition to acting as Council Silver.
By the evening of 14 June 2017 Mr Priestley thought that RBKC needed more help at every level of the response.[1368] When he returned to the BECC on the morning of 15 June 2017 it was just as he had left it the previous evening. Both he and Rebecca Blackburn had expected more to have been done overnight by Mr Kerry, who had taken over as Council Silver, such as completing a rota for the rest centre, tidying up the BECC log and creating a strategy for the coming day.[1369] Mr Kerry confirmed that Council Silver was responsible for developing the tactical plan for responding to an emergency.[1370] In our view the absence of coherent strategic and tactical plans hindered the response.
By 15 June 2017, it had become apparent that RBKC was unable to provide effective assistance. Mark Sawyer visited the Town Hall on the morning of 15 June 2017 to provide support.[1371] His observations provided an important external insight into how RBKC was coping with the challenge facing it. Mr Sawyer considered that the BECC was failing; it did not have a clear picture of the situation in North Kensington and no situation report had been produced.[1372] (A situation report is vital to enable information to be shared with the Gold group internally and with the strategic co-ordinating group or London Local Authority Co-ordination Centre externally when needed.) The first situation report was not produced until 07.00 on 16 June 2017.[1373] Mr Sawyer’s observations echoed Ms Blackburn’s description of the BECC as lacking any organisation.[1374] We consider that the inability of RBKC throughout that period to obtain, maintain and record in full information about the situation was a significant failing and delayed support being directed to those who were in need.
Mr Sawyer spent most of 15 June 2017 with Nicholas Holgate and attended the RBKC Gold group meetings.[1375] His immediate concern was that RBKC had not been galvanised into a proper response.[1376] He also advised Mr Holgate, following the meeting of the RBKC Gold group at 10.00 on 15 June 2017, to limit membership of the Gold group to his senior management team and tactical lead officer (Silver) to ensure that discussions were more strategic, as he thought that the meetings had concentrated too much on operational matters.[1377] Mr Sawyer thought that Mr Kerry had been traumatised and had ceased to be in a position to influence the strategic direction of the response.[1378]
The aim of the Humanitarian Assistance framework is to ensure that care is delivered in an effective way that meets the needs of those affected by a major emergency.[1379] It provides that a rest centre can be opened when a significant number of people have been displaced following an incident.[1380] A rest centre is a building opened by a local authority for the temporary accommodation of people who have been displaced. It is a place where immediate practical and emotional support may be offered. It is a place of refuge and support for those affected or displaced by an emergency and is often the first point of contact that affected persons have with the authorities. The local authority is responsible for opening and running designated rest centres in the wake of an emergency.[1381]
RBKC failed to open suitable rest centres in the early morning of 14 June 2017 to meet the needs of the growing number of people displaced from Grenfell Tower and the surrounding properties. Mr Kerry did not refer to the Contingency Management Plan to identify an appropriate centre from the directory annexed to it.[1382] Instead, he accepted an offer from a member of the public to use Belushi’s Bar in Shepherd’s Bush that could provide shelter for up to 100 people.[1383] However, he failed to assess its suitability. Belushi’s Bar was not on RBKC’s list of approved premises and was about a mile from the scene of the fire.[1384] That alone made it an unusual choice for a rest centre in an urban area.[1385]
At 03.16 David Kerry called the Red Cross into action at Belushi’s Bar under the Memorandum of Understanding.[1386] Its staff arrived at 03.45.[1387] By contrast, no RBKC staff were deployed to support them or to manage the rest centre. By 05.30, no one affected by the fire had gone to Belushi’s Bar[1388] and Mr Kerry made the decision to close it as a rest centre.[1389] It was unusual for a rest centre to be empty for almost two and a half hours after it had been opened and it is clear that it was the wrong place to choose.[1390] That signalled a false start from which RBKC struggled to recover. Vital Red Cross resources were diverted from the immediate area and further time was lost in getting help to those most in need.
Mr Kerry accepted that the Humanitarian Assistance framework set out the responsibilities of RBKC in relation to setting up rest centres, but he did not accept that its reliance on the Red Cross to do that was an abdication of its responsibility as a Category 1 responder.[1391] We accept that local authorities are entitled to make use of others to discharge their functions and frequently do so, but, as Mr Kerry himself accepted,[1392] RBKC should have had its own staff at the rest centres to monitor and supervise the Red Cross.
On the morning of 14 June 2017 information about the existence and location of rest centres spread by word of mouth alone. The result was that those affected by the fire had to endure the stressful experience of going to different rest centres to find information and support.[1393] The Harrow Club spontaneously opened in the early hours of the morning and soon after that, at about 03.30, it was formally adopted by RBKC as the second rest centre.[1394] The Harrow Club was on RBKC’s list of approved rest centres. It was a long-established youth club with a large sports hall, located approximately half a mile from Grenfell Tower. Additional Red Cross staff arrived at 04.55 and recorded that there were about 25 people there.[1395] TMO staff arrived at 05.30 but there was no one from RBKC there.[1396] From 05.30 the Red Cross asked RBKC several times over a period of some five hours for information about when its staff would come to the rest centres to provide support.[1397] The absence of its staff from the various community rest centres in the hours that followed the fire was a prominent feature of the council’s early response.
The Rugby Portobello Trust is a local charity group whose building is situated about 400 yards from Grenfell Tower.[1398] On 14 June 2017 it opened spontaneously as a rest centre. We heard how people who were shocked, bewildered and in distress started arriving in large numbers in the early hours of 14 June 2017.[1399] At 05.45 the Red Cross became aware of its existence as a rest centre and notified RBKC. As a result, Mr Kerry decided to move people from the Harrow Club to the Rugby Portobello Trust.[1400] However, RBKC did not send any senior managers or staff there and by 10.30 none of its staff had arrived at any of the other places of shelter which had opened during the morning to accommodate the growing number of evacuees.[1401] They included the Clement James Centre, the Latymer Community Church and St. Mark’s Church.[1402] Its absence was noted by many survivors and added to the sense that they had been abandoned by the council.[1403]
RBKC had a responsibility to register those who went to rest centres seeking support,[1404] but it failed to put in place an adequate registration process, which in turn made it difficult to identify, organise and deliver the support needed.[1405] The absence of RBKC staff at the rest centres in those crucial early stages directly affected the effectiveness of the registration process. It was left to the TMO,[1406] the Red Cross and various voluntary organisations to fill the gap and make whatever arrangements they could.
In the absence of effective leadership there was no organised and integrated record of where people were and what they needed. The Red Cross tried using paper registration forms. At 04.55, its team arrived at the Harrow Club and found that the staff there had started to make a list of who was present and had given representatives of the TMO forms to register residents.[1407] However, the number of rest centres that had sprung into existence, some with no Red Cross presence, made the process haphazard.[1408] There was no system for recording information electronically; instead, everyone relied on loose pieces of paper with handwritten notes that were circulated among responders and staff from the TMO.[1409] Even when the Westway Centre became the official rest centre later on the 14 June 2017,[1410] the process of recording and handling information about residents remained rudimentary. People were just asked by the Red Cross to provide a note of their names and the numbers of their flats.[1411]
Significantly, in the early days of the response the registration that did take place did not appear to be collated and recorded centrally by RBKC. The starkest illustration of that was recalled by Mr Colin Brown, a senior Red Cross official, who said that the details of those who had registered were recorded using triple carbon paper, one copy being retained and the other two copies being provided to RBKC.[1412] RBKC did not ask them to put the information onto any electronic system or collate it in any other way. He recalled that, in the first few days while RBKC was still notionally in charge of the response, a Red Cross volunteer had found a box containing copies of several registration forms intended for RBKC unattended at the Westway Centre. He did not think that RBKC had made any effort to collate the data and arranged for his concerns to be reported to it.
Registration continued to present problems until 22 June 2017, even after London Gold had taken over management of the response.[1413] Without a coherent registration process, it was difficult to identify who had been affected, what their needs were and how best to respond to them. It was also sometimes unclear where those who had been affected actually were.[1414]
As the hours passed on the morning of 14 June 2017, no RBKC staff were sent to the rest centres. At the Town Hall, RBKC housing staff were being made ready for deployment as the BECC struggled to find out how many rest centres there were and how many of those who were at them had been affected by the fire.[1415] It was thanks to the initiative of Ms Blackburn[1416] that at about 10.00 RBKC housing staff were sent to the Rugby Portobello Trust and the Clement James Centre.[1417]
Laura Johnson, Director of Housing at RBKC, said that the delay in sending people to North Kensington had been caused not only by a shortage of staff at the Town Hall but also by a lack of information about which rest centres were being used.[1418] A further hindrance to the deployment of staff was the fact that several of the rest centres had been opened spontaneously by the community.[1419] It was difficult to co-ordinate the emergency response in the absence of a single official rest centre whose existence and location could be widely communicated.[1420]
Ultimately, council staff did not reach any of the rest centres for some eight hours after RBKC had been notified of the fire. That was far too long. In our view, the strategic decisions taken at the outset by Mr Kerry as Council Silver failed to reflect the seriousness and scale of the emergency. There was a consequent lack of urgency, direction and, ultimately, co-ordination. Given that staff from the TMO were present at rest centres from an early stage, contact could and should have been made with them to find out how many displaced persons were there and how many staff were required. RBKC employees should have been called in to the Town Hall earlier to ensure there were sufficient staff available to be sent to the rest centres.[1421] Both Ms Blackburn[1422] and Mr Priestley[1423] considered that they should have been despatched four hours earlier, at about 06.30.[1424]
The delay in sending out RBKC staff left the Red Cross and members of the community who voluntarily opened their premises without support and without information about how the response was being led. That made it difficult for them to know who was in charge, what was needed or what was going to be brought to the rest centres to enable them to direct people to the right source of support.[1425]
The Westway Centre is a large sports and fitness centre that opened spontaneously as a rest centre in the early hours of 14 June 2017.[1426] It was not until later in the afternoon on 14 June 2017 that RBKC decided to consolidate the rest centres and designate the Westway Centre as the one official location.[1427] At a meeting of the RBKC Gold group at 15.00[1428] that day it was confirmed that it would remain open overnight. At that stage RBKC was trying to determine how many people needed to be accommodated. By then, 30 households had been identified in the Clement James Centre, but no information was available from the other rest centres, despite the presence of TMO staff.[1429]
The decision to concentrate the provision of humanitarian assistance in one place was standard practice and viewed in isolation was a reasonable decision.[1430] However, the failure of communications led to a situation in which many who needed support did not know they should go to Westway Centre or what support was available there.
Unfortunately, the Westway Centre was not very readily accessible to many of those who were in need of support.[1431] Some survivors told us that they had been asked to provide identification and of having to sneak into the building if they could not provide it.[1432] Wristbands were introduced as a method of verifying the identity of those who had been displaced.[1433] As we have said in Chapter 100, the Westway Centre was described, both by those who went there and by the professionals who were there to support them, as unwelcoming. There was a visible police cordon at the entrance which in the words of one witness made it look like a “crime scene”.[1434] Although the police needed to maintain a presence in the light of the significant media interest, its effect, albeit unintentional, was to deter people who needed support from attending it or visiting it as often as they needed to.
The interior of the Westway Centre was described as chaotic and confusing, with a lack of signs to assist visitors.[1435] Survivors described it as uncomfortable[1436] and impersonal[1437] and there were concerns about inadequate sleeping arrangements. Some of those who had been displaced were sleeping on mats or mattresses donated to the relief effort.[1438] Coupled with a lack of privacy,[1439] cleanliness and facilities for disposing of rubbish,[1440] that demonstrated an inability on the part of those responsible for its management to create an environment that was appropriate and welcoming.
The problems at the Westway Centre were due in a large part to the lack of leadership and organisation.[1441] RBKC had no visible presence and the absence of senior RBKC staff and qualified rest centre managers was a constant theme among those who gave evidence. RBKC was reliant on volunteers from within its own staff and on staff from neighbouring boroughs to act as rest centre managers. The point was raised at the RBKC Gold group meeting on 15 June 2017.[1442] The absence of leadership at the Westway Centre left the Red Cross and the many volunteers at the centre without the support they needed.
The perception that RBKC staff were not present at the Westway Centre endured. On 17 June 2017, volunteers were complaining that RBKC was not helping and that they were doing everything.[1443] The perception was not entirely justified, but it was exacerbated by the lack of identifying tabards for staff to wear.[1444] The result was that it was difficult to distinguish RBKC staff among the many volunteers and others who were there. We were told that senior managers of RBKC had told staff not to wear tabards or lanyards out of a concern for their safety.[1445]
Shortly after leadership of the humanitarian response had passed to London Gold,[1446] Rupinder Hardy, a local authority liaison officer (LALO) from the London Borough of Ealing, attended the Westway Centre which at that point was still being managed by RBKC. Although Ms Hardy recognised that there would inevitably be an element of chaos, given the number of people involved,[1447] she did not find the Westway Centre a welcoming space where responders and services could easily be identified.[1448] She described it as a “shambles” and not what she was used to seeing from a local authority.[1449] She told us that the help desks were a jumble and that it was difficult to know what was going on and what support was being offered. She raised her concerns with Mr Barradell and Ms Kelly,[1450] who by that time were leading the response. As a result, they decided to transfer the management of the Westway Centre to the London Borough of Ealing. That took effect on 17 June 2017, when Ms Hardy assumed the role of manager and brought in a team from her borough.[1451]
Ms Hardy sought to improve the process for providing support at the Westway Centre.[1452] The new process included placing the service stalls in a U-shape, allowing people to come in from one side and work their way round the services that were being offered in order to receive the support, advice and help they required.[1453] Community workers reported that families were not going to the Westway Centre because they found the process of obtaining support difficult due to long queues, much paperwork and an unwelcoming atmosphere.[1454] Clare Richards, chief executive officer of the Clement James Centre, told us that although she could understand why the space had been set up as it was (i.e. to allow people to go from table to table), the reality was that people in a state of distress had to keep explaining why they were there and why they needed support.[1455] She considered that to be inappropriate and very upsetting for those affected.[1456] Ms Hardy accepted that the process was harrowing. She told us that one thing she had learned was that a process in which personal information was collected at a single point and then distributed to those providing the emergency response would have been better.[1457]
Despite the efforts and generosity of those who ran the Westway Centre and the many volunteers who attended to assist, as the official rest centre it fell far short of the service that those affected were entitled to expect and should have received following a major emergency.
Despite RBKC’s decision on 15 June 2017 to designate the Westway Centre as the official rest centre, displaced people were still making use of four or five other rest centres,[1458] which led to confusion within the community about which one was the official rest centre.[1459] As RBKC began to concentrate its efforts on the Westway Centre from 15 June 2017 onwards, it decided that other rest centres run by the community, such as the Rugby Portobello Trust which remained open, would not receive council services,[1460] despite the fact that people were relying on them.[1461] The resulting confusion was made worse by a failure to tell the community and religious centres about the services available at the Westway Centre. Volunteers from some of the centres reported that they did not know what services were being offered there.[1462]
The Reverend Mark O’Donoghue of Christ Church, Kensington contacted RBKC councillors, pointing out areas that needed rapid improvement. He emphasised the need for a single point of contact at RBKC to assist with the needs of those at the rest centres (mentioning, in particular, the Clement James Centre, the Rugby Portobello Trust and Latymer Community Church). He found it difficult to believe that it was beyond the wit of RBKC to appoint one person to talk to people like him, who could then talk to their own networks to provide help.[1463]
Community leaders said that what was needed was the visible presence of RBKC staff wearing identifying insignia, such as high-visibility jackets, and in possession of up-to-date information.[1464] In the absence of such a presence, information or support, community organisations felt abandoned.[1465]
In addition to its obligation to open a rest centre, RBKC had an statutory obligation to provide displaced persons with emergency accommodation.[1466] The council’s Housing Contingency Plan, dating from 2012, had not been the subject of an annual exercise in accordance with its own guidance and was not referred to during the response to the fire.[1467] The aim of the plan was, among other things, to support and extend the Contingency Management Plan and to provide the information and describe the procedures and action to be taken to ensure an effective, flexible and timely response by the housing department to any emergency that might arise.[1468] Furthermore, the RBKC’s own Housing Risk Register[1469] dated November 2016 recognised that it did not have sufficient capacity to arrange temporary accommodation in an emergency.[1470] However, there were no processes in place to address that deficiency. Although there were arrangements to make use of local premises as rest centres, there were no standing arrangements with local hotels of a kind that would facilitate the provision of accommodation for displaced residents.[1471]
From about 07.30 on 14 June 2017, RBKC housing officers began telephoning hotels in central and west London to reserve rooms in anticipation of a need to house people that evening.[1472] Laura Johnson told us that at that early stage they were looking for hotels within the borough or in adjacent boroughs because people needed to be close to their support networks.[1473]
Ms Johnson also told us that they had received a huge number of offers of accommodation from different organisations and members of the public.[1474] The accommodation ranged from spare bedrooms offered by members of the public to unfurnished accommodation in existing social housing blocks.[1475] Ms Johnson explained that she did not consider those offers to be appropriate because, she felt, people needed the privacy of a self-contained room and their own bathroom,[1476] as well as being close to their neighbourhood.[1477] Her team’s view was that hotel accommodation was the most appropriate solution.[1478]
In the days that followed the fire RBKC struggled to keep up with the demand for accommodation to house a growing number of displaced people. Over 800 people had been forced to leave their homes and although most went to stay with families or friends, many depended on the council to find them somewhere to live.[1479]
At the outset RBKC drew a distinction between those who had been displaced from the tower itself and those who had been displaced from the surrounding blocks within the wider cordon (i.e. the Walkways).[1480] In the first instance, those living in the Walkways were advised to try to stay with families or friends and were provided with accommodation only if they had nowhere to go.[1481] However, the criteria applied to those living in the Walkways were changed during the course of 14 June. At 13.46, Ms Johnson told Emma Strugnell, a media and communications officer at RBKC, that the council was providing emergency hotel or bed and breakfast accommodation for people who had lived in the tower;[1482] those who had been evacuated from the Walkways were to go to the emergency rest centres and would be provided with accommodation only if they were old or vulnerable in some way.[1483] In the case of those who were not old or vulnerable, RBKC waited to find out whether they could return to their homes or whether emergency accommodation at a rest centre would be needed. Later that day families with children were included among those eligible for accommodation.[1484]
The more restrictive criteria applying to residents of the Walkways created confusion within the housing department. They were not adequately communicated to staff and were not widely communicated to the public.[1485] They resulted in some Walkway residents who qualified for emergency accommodation not being offered it.[1486] At 16.21 on 14 June 2017, Ryan Bird, one of RBKC’s housing officers, pointed out to the housing team that the instructions were that those who did not live in the tower were not to be accommodated.[1487] Mr Bird noted in a later email that there were “Many helpful but confused folk here. Lots of information but little of it entirely accurate”.[1488]
By the night of 14 June 2017 and into 15 June 2017, 77 households had been placed in 102 hotel rooms and it was expected that more people would approach the council for accommodation.[1489] Ms Johnson told us that anyone who asked for a place was offered one immediately and without question.[1490] However, she was of the view that it was not her department’s responsibility to speak to everyone and make sure they had somewhere to stay; it was for those who needed accommodation to approach the housing team. She may or may not have been entitled to take that view, but the result was that some residents were sleeping rough simply because they were unaware that they could ask for emergency accommodation.[1491] RBKC accepted that they did not receive the level of care to which they were entitled under the Housing Contingency Plan and acknowledged that a number of Grenfell Tower residents were not told about the availability of emergency accommodation.[1492]
Part of the reason for the housing department’s failure to accommodate all residents on the first day of the fire is that Ms Johnson and the emergency planning team failed to recognise the scale of the incident in the early hours and failed to grasp what it required of them.[1493]
Most of those accommodated by RBKC in hotels were residents of the tower.[1494] Residents of the Walkways continued to be a secondary priority,[1495] despite their obvious need for alternative accommodation as a result of their homes lacking gas or water and containing debris from the fire.[1496] RBKC thought that residents of the Walkways should return to their flats, despite being told by the TMO that they were not yet suitable for reoccupation. Teresa Brown, the TMO’s Director of Housing, recommended that residents should not be rushed into returning until the TMO could ensure proper provision of services.[1497] Her advice was not accepted by RBKC, which stuck to its decision that those who lived in the Walkways should return to their flats. Ms Johnson told a Gold group meeting on 16 June 2017 that she would house the vulnerable or those with children and without hot water but that others would have to manage.[1498]
The lack of any existing plans or agreements with local hotels (for example, in relation to methods of payment) led to significant disruption and distress to those seeking accommodation. In some cases transport was a problem. Ms Johnson told us that on the first day her team had attempted to hire taxis to take people from the Westway Centre to their hotels, but she accepted that in some cases people had not been provided with transport and had been forced to make their own way to the hotels in which they had been placed.[1499]
Residents placed in hotels often had to be moved to alternative accommodation, sometimes without much notice.[1500] Despite informing the RBKC Gold group at 11.00 on 14 June 2017 that block bookings of hotels had been made until Monday 19 June 2017 as a short term solution,[1501] the group was told the following morning that officers were in the process of rebooking hotel rooms for all those that needed them.[1502] It was noted that four households had to be moved to another hotel on 15 June 2017 and, because some bookings could not be carried over the weekend (17 and 18 June 2017), RBKC needed to find alternative accommodation for 24 households.[1503] The first time that some residents who had been accommodated in hotels learned they needed to check out was when the hotel told them.[1504]
In some cases delays in bookings were caused by the lack of sufficient credit on RBKC’s credit cards.[1505] The problem persisted for a number of days following the fire, resulting in some employees using their own cards to secure rooms.[1506] The problem with credit limits had led to some payments being declined and to some hotels informing residents that their bookings would end.[1507] As part of the tri-borough arrangements for providing humanitarian assistance RBKC had agreed that duty officers and some senior Housing and Adult Social Care managers should be given greater spending limits for use in emergencies, but it appears that it had either failed to implement that agreement or had set inadequate credit limits.[1508]
With no list of approved local hotels, RBKC was unable to ensure that the hotels booked provided for residents with particular needs, which were often not met.[1509] That included, but was not limited to, people with disabilities[1510] and families with babies and young children.[1511] In many cases survivors found being housed on upper floors of hotels traumatic following their recent experiences.[1512]
Ms Johnson told us that RBKC had tried to meet the specific needs of those affected but conceded that they had not got it right in all cases.[1513] We have seen little to suggest that the allocation process involved much more than simply matching the numbers of people seeking accommodation to the rooms available. We consider that specific plans and standing agreements with hotel providers, coupled with periodic training exercises, would have equipped the housing department to respond better to the challenges it faced in finding accommodation for a large number of displaced residents.[1514]
After it had found them accommodation the housing department did not communicate adequately with its residents.[1515] They lacked clear guidance about when their bookings would end,[1516] about the food and services that they were entitled to receive at their hotels[1517] and about whom to contact for information and assistance.[1518] As a result, in many cases they did not receive the full extent of the support available to them and lived in a constant state of uncertainty. We have set out in detail in Chapter 100 the difficulties felt by some of those who had been displaced by the fire.
As a Category 1 responder RBKC should have been ready to meet the immediate personal needs of those affected by the emergency.[1519] They included food and drink of a suitable kind, access to places of worship and other personal, cultural or religious needs, but it does not appear to have given any consideration to matters of that kind and had no plan to provide for them. Those who attended the Westway Centre relied on the generosity of volunteers who brought them culturally appropriate food to meet their needs.[1520]
The problems of obtaining access to the Westway Centre led to many of those affected seeking support through unofficial rest centres, such as the Clement James Centre and the Rugby Portobello Trust, which became the main source of food for many in the days immediately following the fire.[1521]
Difficulties in providing for basic needs, such as food and drink, continued in some cases even after people had been placed in hotels. In some cases they did not know what food or drink they were entitled to receive.[1522] With hotel rooms in short supply, RBKC took rooms in a number of hotels that provided only limited services, which in some cases did not include food or drink.[1523] That prompted those in the community, voluntary and faith sector to obtain, distribute and serve food to some of those at hotels.[1524]
In some cases, hotels did not provide food suitable for those with particular religious needs, such as halal food, particularly during Ramadan. Although Ms Johnson was aware of the cultural and religious diversity of the residents of Kensington and Chelsea, she did not recall having made any specific request to hotels to accommodate religious dietary requirements.[1525] That was reflected in the evidence of Brahim El Amine, Mouna El-Ogbani and Sawson Choucair, all of whom were placed in hotels that did not serve food at times that respected their observation of Ramadan.[1526] As a result, they and others in their position had to rely on food being provided by the community.[1527] Similarly, Nadia Jafari, who was on a diet following surgery, had to rely on food she received from the mosque and charities.[1528]
RBKC accepted that it should have done more in the days following the fire to cater for those from diverse backgrounds, in particular those many residents of the Muslim faith who were observing Ramadan at the time. Their experience contributed to the widespread feeling among them that the council had no regard for their cultural and religious needs.
We do not believe that those were isolated incidents limited to a few individuals and families. The evidence suggests that the experiences of those, particularly from Muslim and minority ethnic communities, whose basic needs were not met were symptomatic of a more general, systemic failure on the part of RBKC to think about and plan for those needs in advance.
The outcomes and experiences of those affected which bore on their faith and ethnicity lead us to conclude that RBKC failed to take any or any adequate steps to follow the guidance contained in those parts of Emergency Preparedness (2013) and Emergency Response and Recovery (2005) to which we referred in the introduction. In particular, we conclude that RBKC failed to give any, or any adequate, consideration to the needs of the members of the various faith, religious, cultural and minority ethnic communities who were affected by the fire. That lack of consideration was marked by the absence from RBKC’s preparations of any plan for catering for their particular needs and a lack of any training to ensure that they were met. Nor did RBKC put in place any arrangements for addressing them in the days immediately following the fire. Such efforts as were made were piecemeal and unevenly distributed.
The guidance to which we have referred seems to us to reflect in a large measure the legislative aim of section 149(1) of the Equality Act 2010 in the context of civil contingencies. Whether RBKC failed to have due regard to the matters identified in section 149(1) of the Act in making its civil contingency arrangements is a question we are not in a position to answer. What matters more is how people were treated in practice. It is enough to say that in our view many of those affected by the fire who had particular religious or cultural or social needs suffered a significant degree of discrimination in ways that could and would have been prevented if the guidance had been properly followed.
The Humanitarian Assistance framework indicated that local authorities might provide financial assistance for food, clothing, toiletries and other essential requirements as part of their responsibility for providing humanitarian assistance.[1529] On 14 June 2017, arrangements were made by RBKC to provide those affected by the fire with such assistance. At the start, the housing team attended the rest centres with sufficient cash to give people a small sum of money, about £50 a person.[1530] At 12.33, Francis Austin, RBKC’s interim group finance manager, provided Kevin Bartle, then director of finance, with a note saying that £10,000 had been drawn in cash to be used to pay for immediate expenses.[1531] That included everything from toothbrushes to hotel accommodation. That evening, Robert Shaw, a RBKC housing officer, sent a message to his colleagues telling them that three rest centres were to remain open throughout the night and that TMO staff would be present with enough money to hand out to residents.[1532]
How those affected should be supported financially had not been planned in advance, which caused delay in implementing a process for the distribution of funds. On 15 June 2017 RBKC agreed that households should be given cash to cover immediate living expenses and a further allocation of up to £1,000 a household, leaving over for later consideration what procedure should be adopted for managing it.[1533] A further £36,000 was made available for residents, together with a draft form intended to be completed for each payment.[1534] That was the first time any formal plan for the distribution of cash had been put in place. It appears that following a further meeting on 16 June 2017, the arrangements were changed. Instead of payments of up to £1,000 being made available, £500 in cash was to be distributed to each household and the remaining £500 held available.[1535] That was considered the easiest way to provide emergency funds for people who did not have a bank account or did not have any of their cards or other documents of the kind needed to obtain access to funds in the bank.[1536]
Following the activation of the Gold resolution, RBKC remained responsible for the provision of financial assistance.[1537] Despite efforts to establish a procedure for providing households with access to funds,[1538] the facility does not appear to have been fully used. On 17 June 2017, Ms Hardy told us that she was given money in an envelope and a list of names, possibly those who had been given money, written on the back of the envelope.[1539] She was given no other information or explanation of how to organise the distribution. Perhaps because of changes in the amount of payments being made or the lack of rigour in the process, different amounts varying from £200 to £1,000 were distributed to the residents of the tower.[1540] According to Michael Adamson of the Red Cross, cash was distributed in a haphazard way by a number of different officials, which made it impossible to track who had received what.[1541]
Financial assistance was initially provided only to those displaced from the tower and not to those displaced from the Walkways.[1542] Some members of RBKC’s staff resorted to their own personal funds to provide financial support to those in need.[1543]
The housing department did not take steps to inform those affected by the fire that they were entitled to financial assistance,[1544] which resulted in delays in their receiving the assistance to which they were entitled and in some cases to their not receiving it at all.[1545] It was reported that people were either unaware of the opportunity to obtain financial assistance at the Westway Centre or were reluctant to go there.[1546]
Financial support provided to families staying in hotels was inconsistent; some families were left to support themselves. The problem was compounded by residents being placed in hotels at some distance from the Town Hall and the Westway Centre. On 18 June 2017, the London Borough of Ealing, which at the time was managing the Westway Centre, did not have the resources to visit displaced residents to distribute funds.[1547] A stark illustration of how certain families lacked support was provided to Gerry Crowley, property and place manager of the London Borough of Hammersmith and Fulham, who visited three hotels on 19 June 2017. He reported inconsistent levels of service being provided by the hotels and found that RBKC had not been in contact with residents at the Premier Inn, Hammersmith since placing them there almost six days earlier. The families had each been given only £50 to help with immediate expenses.[1548] Many people said they had encountered significant difficulty in obtaining financial support and as a result had been forced to rely on the generosity of charities and voluntary groups.[1549]
One of the recurring themes of the evidence given by those who had been displaced was that of the profound feeling of helplessness and despair they experienced as they desperately went from hospital to hospital, rest centre to rest centre, trying to obtain information about missing relatives, but to no avail.[1550] We have therefore tried to find out what led to that lack of information.
The guidance in Emergency Recovery and Response provides that steps should be put in place to ensure that information provided to those making enquiries is accurate, consistent and not contradictory.[1551] The Humanitarian Assistance framework described the purpose of family and friends reception centres as being to help reunite family and friends with survivors, to provide a place for the police to record enquiries about missing persons and collect information which may aid their investigation and to provide access to practical and emotional support.[1552] It is the responsibility of the police in consultation with local authorities to decide whether there is a need to set up a family and friends reception centre as part of a wider process of identifying victims of a disaster. Such centres are likely to be set up within the first 24 hours of the incident[1553] and are usually staffed by police, local authorities and voluntary organisations.[1554]
On 14 June 2017, RBKC told the police that a family and friends reception centre would be set up at the Salvation Army building at 12.30. Mr Adrian Clee, who had been appointed the Salvation Army’s strategic lead for the Grenfell Tower emergency response that morning,[1555] confirmed that it had opened its building on Portobello Road as a family and friends reception centre to provide a safe haven for those directly affected by the fire and relatives of those who were awaiting news.[1556] A member of staff from RBKC was sent to the centre and several police liaison officers attended to speak to witnesses and take statements.[1557] The police reported that at 22.05 on 14 June 2017 the centre had been closed down because no staff from RBKC were available to manage it.[1558] Its functions were transferred to the Westway Centre on 15 June 2017.
Unfortunately, those who were running the Westway Centre were not told that the friends and family reception centre had been moved there and as a result some people looking for information about friends or relations were wrongly turned away[1559] and sent to the wrong place.[1560] How that happened we do not know. On 16 June 2017 at 18.19, Emma Spragg sent an email to senior figures in RBKC voicing her concern about the way in which the Westway Centre was being described to ensure that friends and family could also have access to support.[1561] She pointed out that they were not always being allowed into the Westway Centre as some people understood it to be a rest centre for displaced residents only and that family and friends were to go to the Salvation Army. She wanted communications to be better co-ordinated.[1562]
Many of those seeking information about family and friends did not know where the reception centre was or where they should go to obtain information.[1563]
The Metropolitan Police Service was responsible for setting up a casualty bureau,[1564] the primary purpose of which was to provide an initial point of contact for receiving and assessing information relating to persons who had been, or were thought to have been, involved in the incident.[1565] The guidance in Emergency Response and Recovery provided that part of its function was to provide accurate information to relatives and friends.[1566] It is clear, however, that there was widespread confusion about the function of a casualty bureau and about whether, and if so how, it was expected to provide information to the public.
Detective Inspector Gail Granville told us that the purpose of a casualty bureau is to gather information, not to provide detailed information about those believed to be missing or dead.[1567] She said that information of that kind is provided only after the identification process involving the coroner has been completed and must be conveyed in a sensitive and appropriate manner by a trained family liaison officer.[1568] D I Granville explained that limited information is given to call-handlers to prevent them from inadvertently providing information to callers.[1569] It was unfortunate, therefore, that the telephone number of the casualty bureau was given to those seeking information about family and friends. The result was that they were unable to obtain any help from the casualty bureau without understanding why, which caused considerable frustration and anger.
The police Gold Commander, Commander Jerome, asked for a casualty bureau to be established at 02.30 on 14 June 2017.[1570] At 07.34 on 14 June 2017 RBKC advertised its number as an emergency contact number for anyone concerned about their loved ones.[1571] The telephone number was provided by the police in a statement to the media at 08.02. It was also publicised on social media and the Metropolitan Police website.[1572] The delay in setting up the casualty bureau resulted from the need to ensure that there were enough operators available who were appropriately trained to take the calls.[1573] The first calls were answered at 08.04; 4,446 calls were received on 14 June 2017.[1574] The number fell as the days passed and the lines were closed on 24 June 2017.[1575]
Some of those who called the casualty bureau reported that they had been unable to speak to anyone directly and received only an automated message.[1576] Those who were able to speak to someone were not provided with information; after giving details of their family members, they waited for further news but did not receive a call back.[1577]
The problems surrounding the family and friends reception centre and the limitations of the casualty bureau were compounded by the circulation of inaccurate information about those who were safe and those who were missing. The lists of those who were safe and missing provided to various agencies on 14 June 2017 had included errors, with some who had died in the fire shown as safe.[1578] The difficulties of obtaining accurate information about the fate of friends and relations demonstrates the fundamental importance of accurate registration and record-keeping at rest centres, coupled with clear and accessible sources of information for those enquiring in person or by telephone.
As a Category 1 responder RBKC had a duty under the Civil Contingencies Act 2004 to communicate with the public and provide them with information and advice as necessary in an emergency.[1579] RBKC’s media and communications team was small and its main functions were similar to those of a press office, responding to media enquiries and issuing press releases.[1580] At the time of the Grenfell Tower fire the Contingency Management Plan did not include any provision for emergency communications,[1581] although a plan may have been available within the communications team.[1582] RBKC conceded that those who worked in the media and communications team had failed adequately to rehearse the emergency communication plan with practical exercises and were insufficiently familiar with the plans that existed.[1583] RBKC also conceded that the arrangements that were in place were not capable of providing the level of service needed by the public after the fire and were not as clear or as well understood within the organisation as they should have been.[1584]
Martin Fitzgerald, RBKC’s head of media and communications, described the pressure as great, with unprecedented demands from various directions.[1585] We can well understand that, but, for whatever reason, there was a delay in providing clear, accessible information to the survivors, including information about where to go for help,[1586] which made it more difficult for them to obtain the emotional and practical support they needed.[1587] The stark truth is that RBKC’s communications systems were quickly overwhelmed. As a result, it failed to provide the public with clear, consistent information in the days immediately following the fire.[1588]
No dedicated helpline was set up at the outset to enable displaced residents to obtain information or advice.[1589] At 07.24 on 14 June 2017 RBKC published the telephone number of the casualty bureau as an emergency number to be used by anyone concerned about friends or relatives.[1590] At 10.13 RBKC’s housing department put its telephone number on the council’s website for use by residents who had been displaced.[1591] By the early afternoon it had published the same number as the point of contact for those wishing to volunteer to help the support effort.[1592] As a result, the line was inundated with calls and quickly became overwhelmed.[1593]
RBKC did not accept offers of assistance that could have strengthened and expanded its communications resources. At the meeting of the strategic co-ordinating group at 08.30 on 14 June 2017, Ms Spragg recommended making use of the Red Cross telephone helpline that was already in place following the Manchester Arena attack as a helpline for those affected.[1594] Her offer was not immediately accepted. She repeated her suggestion at the meeting of the humanitarian assistance steering group at 14.00 on 15 June 2017.[1595]
Later on 15 June 2017, RBKC accepted the offer of the Red Cross helpline but the line did not become operational until the next day, 16 June 2017.[1596] Sue Redmond, the interim executive director for adult social care and public health who was appointed as humanitarian assistance lead officer (HALO) on 15 June 2017, told us that the delay was caused by an attempt to link the RBKC housing line with the Red Cross line.[1597] It had not been possible to co-ordinate the two helplines by the time London Gold took over the response on 16 June 2017.[1598]
The delay in setting up a dedicated helpline was compounded by difficulties in publicising its number. Despite efforts by the Red Cross,[1599] as late as the evening of 17 June 2017 it was apparent from complaints made by those at the Westway Centre[1600] that the helpline number needed to be published immediately.[1601] In addition, concerns were expressed about the quality of the information being provided to those using the helpline. On 20 June 2017 checks by RBKC revealed that the helpline staff, although warm and friendly, were vague in their responses and merely advised callers to go to the Westway Centre.[1602] Further checks on 22 June 2017 indicated that the problems persisted. The call-handlers were directing callers to the Westway Centre or advising them to contact Victim Support but were not able to say what help either of them could offer,[1603] despite the fact that they had been given a guidance pack the previous day containing full details of how to deal with questions.[1604]
Inadequate provision was made for those whose first language was not English. The guidance in Emergency Response and Recovery was that, if it could reasonably be expected that an emergency would be likely to involve members of cultural or ethnic minorities, suitable arrangements should be built into plans.[1605] The Lancaster West estate was such a community, but despite that clear guidance, it was not until 24 June 2017, some seven days after London Gold had taken over the response, that the helplines made provision for those who did not speak English fluently or for whom English was not their first language.[1606] It was difficult for the operators of the helpline to know in advance which languages needed to be spoken, as no proper assessment of the likely requirements had been made, but the result was that some of those who did not speak English were unable to use the helpline for a number of days.[1607]
The lack of translation services was not limited to the helpline. Official communications, such as letters from the council, were available only in English.[1608] As a result, those who did not speak or read English found it difficult to obtain information and assistance. Others relied on their children and friends to translate for them.[1609]
RBKC failed to produce other forms of communication, such as flyers or information leaflets, with sufficient urgency, despite recognising the need to do so. At 05.01 on 15 June 2017, Councillor Mary Weale told Tony Redpath that she had raised the matter with Mr Holgate the previous day.[1610] A leaflet was then produced by some of the councillors, which was shared with Mr Holgate and Mr Redpath at 18.46 on 15 June 2017 for distribution.[1611] However, it took until the evening of 16 June 2017 for a final version of the leaflet to be produced[1612] and it was not distributed until 17 June 2017.[1613] The leaflets were produced in English and were not translated into other languages until 24 June 2017.[1614] Mr Redpath recognised at the time that it was extraordinary for the council to have taken so long to carry out such a simple task.[1615] He said that it had been faced with an avalanche of demands and had been unable to attend to anything other than the most immediate and pressing tasks.[1616]
In our view insufficient consideration was given to those important matters. The guidance quite properly emphasised the need for rapid and effective communication but RBKC failed to give it the priority it deserved. As the Grenfell Tower fire revealed, it had failed to grasp that accurate and timely information from an authoritative source is one of the most valuable forms of support that can be given to those seeking help, in whatever form.
Although RBKC used social media and maintained a website, information was not published promptly or consistently across the different media platforms and some of those dealing with the response were concerned that not enough information was being given out.[1617] At 16.15 on 14 June 2017, Desmond Zephyr, a LALO, told Mr Priestley, Ms Blackburn and Mr Kerry that information was not being released and that although he had directed people to the website, it was inadequate. He suggested greater use of social media.[1618] That view was echoed by the Mayor of London’s office.[1619]
The problems affecting communication with the public do not appear to have been resolved by the activation of London Gold. On 18 June 2017, the new Grenfell Fire response team issued a press statement giving details of the Red Cross helpline.[1620] A leaflet was also produced and circulated that day for distribution through DCLG which contained information about the Red Cross helpline, the contact number of the casualty bureau, details of bereavement services and NHS mental health support.[1621] As late as 20 June 2017 there was still concern about the absence of a central point of contact and the lack of effective communication with those affected.[1622] RBKC’s media and communications team was required to obtain London Gold’s approval before it published anything on the council’s website or communicated with the media, which caused significant delay in the publication of information.[1623] One member of the team, Bernard Brady, said that a response would often not be received from London Gold for hours or even until the following day (and sometimes not at all).[1624]
A key feature of the Humanitarian Assistance framework is the appointment of a humanitarian assistance lead officer (HALO) to co-ordinate the humanitarian response.[1625] The HALO brings together various partners, including health, the police, and voluntary and faith sectors, to oversee that aspect of the response. At the time of the fire RBKC had no one suitably trained to undertake that task and no relevant plan in place.[1626] The lack of a trained HALO significantly affected its ability to deal with the consequences of the fire.[1627]
Sue Redmond was an experienced director of adult social care who had worked at a senior level for a number of local authorities. She had returned to Hammersmith and Fulham in April 2017 and held a tri-borough role which also covered Westminster City Council and RBKC. She had not received any training or guidance from Hammersmith and Fulham or RBKC on the Contingency Management Plan.[1628] In her previous positions she had received some training in responding to emergencies, but she did not think that it had prepared her adequately for the Grenfell Tower fire.[1629] Her training had not given her any grounding in the function of the BECC, the role of a HALO,[1630] or what running the humanitarian assistance steering group entailed.[1631] She was wholly unprepared for the role she was thrust into.
The Humanitarian Assistance framework provided that if a major incident occurred with substantial consequences for the welfare of a community, the local authority would appoint a HALO,[1632] whose identity would be confirmed by the strategic co-ordinating group.[1633] The HALO was to call and chair the first meeting of the humanitarian assistance steering group,[1634] whose purpose was to determine the direction of the humanitarian response and ensure co-ordination of the activities of the responders. Its officers were to be senior officials who were able to make decisions about resources while having an overview of the needs of the people affected and ensuring there was appropriate support.[1635]
Although the framework did not say when the group was to meet for the first time, it did indicate that the humanitarian assistance effort should begin very soon after the incident.[1636] That was recognised by members of the London Resilience Group early on 14 June 2017. As a result, Andrew Meek, head of organisational resilience at the London Borough of Haringey, sent an email to David Kerry at 10.23 recommending that he appoint a HALO and plan a first meeting of the humanitarian assistance support group that afternoon.[1637] However, Mr Kerry had finished his shift that morning and had gone off duty and the message does not appear to have been passed to Stuart Priestley, then Council Silver, or the BECC.[1638]
That was only one of a number of reasons for the delay in setting up the group. The Humanitarian Assistance framework was in the process of being revised at the time and although a draft of the new version existed, it had not been published.[1639] Tony Andrews, Emergency Planning Manager (Humanitarian Assistance) at Westminster City Council, sent a copy of the revised version to RBKC at 13.16.[1640] Ms Redmond then had to spend time familiarising herself with the material in the expectation that she might become the HALO.[1641] Formal confirmation of her appointment was not made until the morning of 15 June 2017 at the RBKC Gold meeting.[1642] It is unclear why that was. At all events, the first meeting of the group chaired by Ms Redmond was not held until 14.00 on 15 June 2017.[1643] We consider that, in light of the seriousness of the incident and the advice received on the morning of 14 June 2017, a meeting should have taken place that afternoon.[1644] The delay of 24 hours had an adverse effect on the identification and assessment of the needs of those affected.
By the afternoon of 15 June 2017, the humanitarian assistance support group had developed an agenda which Ms Redmond considered to be massive and overwhelming.[1645] The operation of the group was subsequently criticised by some of those who attended the meeting. In an email to a colleague Toby Gould described it as disorganised. Some representatives were not present and the telephone conference facilities did not work well. He was not convinced that the group was giving enough attention to urgent business.[1646] Although national voluntary organisations, such as Victim Support and the Red Cross, had been represented, he thought there was a lack of understanding at RBKC about other relevant local voluntary organisations.[1647] Many community organisations involved in the response to the fire were frustrated by the lack of information being shared by London Gold and its failure to gather information from organisations on the ground.[1648]
Due to the delays in setting up the humanitarian assistance support group, it was unclear to those affected by the disaster what psychological support was available at the official rest centre. That in turn led to differences in the level of support received. Some survivors discovered that counselling was available from the NHS at the Westway Centre,[1649] but some people did not think that there was sufficient privacy to enable them to take advantage of it.[1650] Maureen Mandirahwe, a member of the tri-borough social care team, drew attention to the inadequacy of the mental health support at the Westway Centre and the lack of privacy for those grieving.[1651]
Psychological support was provided by the NHS West London Clinical Commissioning Group. The NHS is a Category 1 (and for some purposes a Category 2) responder with an established response plan.[1652] Although its staff were in the rest centres on 14 and 15 June 2017,[1653] by 16 June 2017 they were advising those in need to call a 24-hour telephone number to obtain mental health support services and information instead of offering to meet them.[1654] On 18 June 2017 the Prime Minister had asked for additional NHS staff to attend the next day.[1655] Those concerns were not isolated. Later that day it became clear that doctors did not know where to refer people needing care, who was in charge or whom to contact in connection with a need for acute care. There was a sense that no one was in charge.[1656]
Survivors described how they struggled with their mental health after the fire, desperately needing help but not knowing where to get it at a time when they were at their most vulnerable.[1657] Most of those who had been affected indicated that psychological support had not been offered to them within the seven days following the fire.[1658]
Some of those in need of mental health support received prompt assistance from the Red Cross,[1659] which provided psychosocial support at the Westway Centre.[1660] The Red Cross also worked with the NHS teams to increase their capacity to reach people in hotels and other places, although there was some delay in finding out where they were.[1661] There were variations in how that support was delivered. The most common form of mental health support required was counselling. It was provided by “Time to Talk” at the St Charles Centre[1662] and later by the Grenfell Health and Wellbeing service.[1663] A few people mentioned other sources of help, but they had often become available some time after the fire. Others asked their doctors to refer them for psychological support,[1664] or received counselling by other routes, such as through their employers.[1665] Yet others paid privately for their own counselling.[1666] Some survivors reported a delay in receiving psychological support, in some cases for as much as six months.[1667]
When London Gold assumed control on 16 June 2017, there was insufficient understanding of the needs of those affected and the humanitarian response was disorganised. Mary Harpley, chief executive of the London Borough of Hounslow, took over as HALO from 16 June.[1668] She described RBKC as exhausted and not in a position to provide any meaningful handover.[1669] As a result, London Gold had to spend time assessing the situation, obtaining contact information for families and finding out who the community leaders were.[1670] Ms Harpley identified a number of things that were needed, such as a single, definitive list of the hotels into which people had been placed, regular communication with survivors, a clear understanding of residents with the greatest needs and a list of the community, faith and other leaders with whom RBKC should have engaged.[1671] She thought that RBKC had tried to cover all the important strands of humanitarian assistance, but had not managed to demonstrate enough progress on any of them to give survivors and observers confidence that the right work was being done.[1672] Based on the other evidence we have seen, we agree with her assessment.
The use of key workers played an increasingly important part in enabling people to obtain the support that was available. On the afternoon of 16 June 2017, as concern about the provision of humanitarian assistance mounted, the Prime Minister declared that everyone affected by the fire, including those from the area surrounding the tower, should be allocated a key worker and that all the key workers should be social workers. That meant finding over 200 social workers from the London boroughs and defining their responsibilities.[1673] The role of a key worker was to provide practical support,[1674] not to provide psychological support, and differed from that of family liaison officers, who were police officers trained to support the next of kin of those who had died or were missing.[1675] In the days following the announcement, social workers from other boroughs who were being deployed as key workers arrived at the rest centre without notice and without any idea of what was expected of them,[1676] reflecting an initial lack of co-ordination and a failure to explain what they were expected to do.
Meeting the commitment to provide all those affected with a key worker proved difficult in the short term. On 19 June 2017, Mr Gould told the BECC that 43 social workers from 11 boroughs were available.[1677] By 21 June 2017, some people were still waiting to be given a key worker. However, even when a key worker had been provided, there was no guarantee that residents would be visited. By 21 June 2017, only two-thirds of the 106 residents who had been given key workers had been contacted. The number of residents actually visited was still unknown.[1678]
That remained a problem one month after the fire. On 13 July 2017 it was reported that all residents of the tower and Grenfell Walk had key workers, but a number of families from the Walkways housed in temporary accommodation had not been allocated a key worker because there were not enough available.[1679] The report recognised that even at that stage the problem could not be resolved quickly and it was uncertain when the government’s objective for every household in temporary accommodation to have a key worker was likely to be achieved.[1680]
The level of support provided to residents by key workers varied. Some said that their social workers and key workers had been helpful[1681] and that key workers had provided advice on counselling.[1682] Others reported that the high turnover of key workers was unhelpful[1683] and one complained that they had no experience of dealing with people facing trauma.[1684]
It does not appear that there was any urgent attempt to establish a system for responding to the needs of those whose mental health had been affected. It is not clear whether that was due to a lack of organisation on the part of RBKC or to the guidance in the Humanitarian Assistance framework, which indicated that formal help, such as counselling, should not be offered in the first few weeks after an incident.[1685]
Before ending this chapter it is important that we recognise that many of RBKC’s staff, not least those whose roles involved contact with the public, worked extremely hard for long hours, day after day. They too were seriously affected by the tragedy and were expected to carry on under circumstances that placed them under great deal of scrutiny and often challenge. In common with the residents of North Kensington they were let down by the leadership of the council, the inadequacy of its standing systems and the provision it made for staff.[1686]
The principal purpose of the Tenant Management Organisation was to manage and maintain RBKC’s housing stock. Unlike RBKC, it was not a responder for the purposes of the Civil Contingencies Act 2004. Nonetheless, from the first hours it was directly involved in several aspects of the humanitarian response to the disaster, including through attendance at rest centres, RBKC Gold group meetings, creating and managing a list of safe and missing residents and facilitating the return of residents evacuated from properties within the police cordon.
We heard evidence from Robert Black, the chief executive, and Teresa Brown, the Director of Housing, about the steps taken by the TMO in response to the situation created by the fire. We also received 47 witness statements from members of the TMO’s staff.
The TMO had its own emergency plan which identified various responsibilities in the event of a major emergency.[1687] It was created in August 2004 and had subsequently been revised in 2009 and 2016. For present purposes we are concerned with the 2016 version, which was in effect at the date of the fire.
Part 1 of the plan described the TMO’s role in emergency planning and response. In their evidence, Mr Black and Ms Brown initially suggested that the plan had been designed for localised incidents[1688] and had never been intended to apply to a major incident,[1689] as the TMO did not have sufficient resources to deal with an emergency on that scale.[1690] In such an event, the RBKC Contingency Management Plan would come into operation rather than the TMO’s emergency plan.[1691] In those circumstances the TMO would have no formal role other than to provide resources and support RBKC when requested.[1692] However, the introduction to the emergency plan suggests that it did envisage a role for the TMO in response to a major incident that exceeded its own capabilities and resources.[1693] In such a situation, the TMO would be expected to work with the council. Both Mr Black[1694] and Ms Brown[1695] accepted that the plan could, in theory, have applied to the Grenfell Tower fire, reflecting a degree of uncertainty about the part that the TMO was expected to play in response to a major emergency.
There was no effective arrangement or shared understanding between the TMO and RBKC about the part that the TMO would play in the event of a major emergency affecting one or more of its properties[1696] and RBKC’s Contingency Management Plan did not refer to the TMO.[1697] Following the fire at Adair Tower in October 2015, there was a discussion at the TMO executive team meeting on 11 November 2015 in which those present recognised the need for the TMO to be more involved with RBKC in emergency planning in order to ensure that all were aware of their responsibilities.[1698] It was agreed that in response to an incident involving more than a few dwellings the TMO would provide details of residents’ known vulnerabilities.[1699] However, Mr Black did not seek to clarify with RBKC the formal role of the TMO in the event of an emergency;[1700] he expected that Laura Johnson and her team would tell the TMO how it fitted into RBKC’s plan.[1701] At the time of the Grenfell Tower fire, therefore, the TMO did not have a formal and clearly defined role in RBKC’s contingency planning arrangements.[1702] Given that the need for such a role had been identified as a result of the Adair Tower fire, that gap should have been filled.
The emergency plan required staff to undertake a number of tasks in the event of an emergency, including ensuring that the primary needs of residents were met, opening and managing rest centres to care for those affected and identifying residents’ special needs or vulnerabilities.[1703] However, TMO staff were not properly trained to carry out those tasks. Notably, neither Mr Black nor Ms Brown undertook any training in responding to emergencies during the course of their employment by the TMO,[1704] despite their senior roles and the fact that Ms Brown was identified in the emergency plan as a contact and key decision-maker.[1705] Mr Black told us that, although no training had been provided to staff about their own responsibilities, staff on call and out-of-hours contractors did receive training on their responsibilities when on duty.[1706] Although some staff received more general briefings from the TMO’s Health and Safety team,[1707] several people who were identified in the emergency plan as key contacts had not received training on the plan itself,[1708] let alone in any detail.[1709] Mr Black could not recall whether any specific training on the emergency plan had been given to the executive team so that they could help staff understand their roles and responsibilities in co-operation with RBKC.[1710] TMO staff had not received training in managing rest centres or collating information in an emergency situation.[1711] Mr Black accepted that TMO staff should have received more training in how to respond to an emergency.[1712]
The TMO’s emergency plan was not activated in response to the fire. Mr Black accepted that it could have been but that, in reality, the incident was overwhelming for the TMO. In any event, RBKC’s Contingency Management Plan was in operation by the time he arrived at the scene.[1713] RBKC did not actively ask for the TMO’s assistance but welcomed the support it offered.[1714] The TMO’s involvement was essentially voluntary[1715] and it co-operated with RBKC to respond to the situation as it evolved.[1716] TMO staff brought particular insights into the tower, the local area and the residents that others did not share.[1717] Ms Brown’s understanding was that the council had been in charge of the response to the emergency and that the TMO had had a supporting role, providing assistance when RBKC asked it to do so.[1718] She told us that TMO staff had wanted to do what they could to help and so had stepped in.[1719]
Although RBKC asked the TMO for information on certain housing matters, it did not ask for its assistance in responding to the effects of the fire. However, despite the absence of any existing arrangements or any request to help in providing humanitarian assistance, TMO employees voluntarily made themselves an integral part of the response, both on the night of the fire and in the week that followed. Although Ms Brown had some practical experience in providing such assistance as a result of her involvement in the Adair Tower fire and dealing with smaller emergencies,[1720] that was not sufficient to prepare her or her team to respond to a major emergency of the kind then facing them.
The TMO was not involved in setting up any of the rest centres[1721] and RBKC did not initially tell Ms Brown what she and her staff were expected to do when they went there.[1722] Ms Brown told us that they had been left to decide for themselves what to do[1723] and that they thought that the most useful thing would be to go to rest centres and start supporting residents and collecting information for the LFB about who was safe and who was missing.[1724]
In the early hours of 14 June 2017, TMO staff attended the Rugby Portobello Trust, St Clement’s Church, the Methodist Church, the Westway Centre, and the Latymer Community Church.[1725] Ms Brown did not allocate any staff to other community rest centres, such as the Al Manaar Cultural Heritage Centre, St Francis of Assisi Church or the Salvation Army, because she did not know about them.[1726] TMO staff did not, therefore, collect information about residents that attended those centres.[1727] However, when he attended the second RBKC Gold group meeting at 15.00 on 14 June 2017,[1728] Mr Black incorrectly told the meeting that the TMO had staff in every rest centre.[1729] His error was the result of his not having been given the latest information about rest centres. That contributed to RBKC’s lack of accurate information about the number of people who had been displaced by the fire.
Between them RBKC and the TMO failed to take effective measures to tell survivors and displaced residents about the support available at the rest centres. Ms Brown told us that she had expected the Local Authority Liaison Officer (LALO) to tell the emergency services, who in turn would direct residents to the rest centres as they were evacuated,[1730] since she was not allowed within the cordon.[1731] However, TMO staff did not take any steps to communicate with the LALO to ensure that residents were told where they could go.[1732] Similarly, no consideration was given to deploying TMO staff in the streets outside the police cordon in order to direct residents to rest centres.[1733] A significant number of residents who had been displaced did not know where to go after they had left the tower or their homes nearby.
During the course of 14 June 2017, the TMO was advised by Amanda Johnson and Robert Shaw of RBKC that they should tell people to go to the Westway Centre as the designated rest centre and stay there overnight.[1734] There was difficulty in persuading people to leave the existing rest centres because some wanted to stay in rest centres run by the community.[1735]
Although the Westway Centre had become the centralised place of support during the course of the day on 14 June 2017,[1736] Ms Brown did not visit it, either on 14 June 2017 or subsequently,[1737] because she considered that there were capable staff in place.[1738] There was a TMO desk at the Westway Centre but there were no TMO staff there on Saturday 17 June or Sunday 18 June 2017 because of worries about their safety.[1739] Given the TMO’s position as the body with whom most residents had had regular contact before the fire, it is not surprising that they expected to see people from the TMO offering support in the days following it. Some residents complained that the TMO was not sufficiently active in its response to the fire and had failed to provide support for people at the Westway Centre,[1740] but it was not responsible for setting up the Westway Centre as a rest centre or for running it. That was the responsibility of RBKC.
Until 19 June 2017 no mechanism was introduced at the Westway Centre to deal with questions from residents of the tower and surrounding blocks.[1741] On 23 June 2017 a log was created to help staff in providing responses to questions.[1742] TMO staff working at the Westway Centre were provided with daily briefings to enable them to assist people,[1743] but no written briefings were provided until 26 June 2017.[1744]
Ms Brown initially collated information about those missing to assist the LFB with rescue efforts.[1745] That evolved into creating and maintaining a spreadsheet containing lists of safe and missing people to provide to RBKC to assist with providing emergency accommodation.[1746] The spreadsheet was also circulated to a number of agencies, including the casualty bureau and the BECC.[1747]
Ms Brown had not been asked by RBKC to undertake that task;[1748] she had done so voluntarily because it was a practical way in which she could help and she knew it was important.[1749] She directed her initial efforts only to residents of Grenfell Tower and not to those who had been evacuated from the Walkways or Treadgold House.[1750]
There were two fundamental problems with the creation and maintenance of the safe and missing lists. First, the spreadsheet was based on the tenancy information held by the TMO in its electronic records,[1751] which was incomplete and inaccurate. Secondly, the method by which TMO staff were collecting information at rest centres was haphazard. A combination of these two problems led to errors in the list and to people being misinformed about the safety of their loved ones.
The TMO relied for the accuracy of its records primarily on information provided by its tenants.[1752] Although good practice required it to carry out an audit of each property every year, it did not do so because it had more pressing matters to attend to.[1753]
Ms Brown told us that the tenancy list contained a mixture of tenants and other household members.[1754] In some cases only the tenant appeared; in others the tenant and other members of the household were included. In some cases residents did not appear in the list at all. The information held by the TMO about disabilities or particular needs, such as preferred language and mental and physical health, was incomplete. The list was amended by staff whenever they were provided with fresh information. Ms Brown accepted the shortcomings of the tenancy list as the basis for identifying who was in the tower on the night of the fire.[1755] Kiran Singh, who produced the list, was unable to say when it had last been revised.[1756]
The inaccuracies in the tenancy information provided by the TMO in turn created problems for other agencies using the information. The police had difficulty establishing a clear picture of who had been in the tower and realised by the end of the first day that the TMO’s list was not accurate.[1757]
The inaccuracies also hampered residents’ searches for their loved ones. Mohammed Rasoul told us that, when he attended the Latymer Community Church, somebody whom he believed to be from the TMO was present with a list of flat numbers and names. Virginia Duffy was listed as the occupier of Flat 153, even though she had died the previous year. In June 2017 it was the home of Isaac Paulos, aged 5, who died in the fire.[1758]
After the fire, RBKC was aware that the tenancy information was inaccurate. As late as 17 June 2017, Mr Robert Shaw of RBKC sent an email to TMO staff asking how many residents, not just lead tenants, lived in the tower. Mr Singh qualified his reply with a warning that the information was not likely to be completely accurate as households had changed over the years and the TMO had not always been told.[1759] Ms Brown accepted that meant that there were people who were not accounted for and therefore not contacted.[1760]
On 14 June 2017, the safe and missing lists were initially revised on the basis of information collected at rest centres. TMO staff later called all known residents of the tower who had not made contact through the rest centres, although that effort was hampered by the fact that contact information was not always correct.[1761] Ms Brown and another colleague continued calling residents of the tower until about 21.00 on 14 June 2017, but in many cases without success.[1762]
The minutes of the second RBKC Gold group meeting at 15.30 on 14 June 2017 recorded that the TMO had made contact with 81 households from the tower but that they did not know where some residents were staying.[1763]
It is not clear whether residents to whom the TMO was able to speak were asked about any vulnerabilities or specific needs or whether they were offered any particular support.[1764] Ms Brown told us that the focus at that stage had been on finding out whether people were safe.[1765]
By 16 June 2017, 129 Grenfell Tower residents on the TMO’s list had been accounted for but 102 had not been found.[1766] There was no clear plan for contacting those residents who had not been reached. That is consistent with the evidence we heard from survivors[1767] and residents of the tower who said they had not been contacted by the TMO in the first few days following the fire. Ms Brown did not know whether RBKC was also trying to account for the residents of the tower.[1768] By 19 June 2017 RBKC and the TMO had still not established an accurate list of those who had been living in the tower.[1769]
Before sending her staff to the rest centres, Ms Brown told them to collect the names and addresses of those who were safe and those who were missing and information on particular needs, including in relation to accommodation.[1770] They were not asked to record that information in a particular way[1771] and did not use the template in the emergency plan.[1772] Ms Brown did not receive any instructions from RBKC on the kind of information that should be collected or how to collate and organise it.[1773]
Ms Brown thought that her staff were clear about what they needed to do,[1774] but one member of the team who had been sent to the Harrow Club did not think that she was the right person to be running a rest centre, having received no training. However, she felt she had no choice but to carry on.[1775]
Clare Richards, the chief executive of the Clement James Centre, was concerned by the way in which TMO staff were recording information. She said that they had been recording information on scraps of paper, had not been making an accurate record of who was there and had not known who they were looking for.[1776] She offered them the use of laptops to capture information on a spreadsheet, but the offer was declined.[1777] Ms Brown told us that she had not wanted staff to record information on different laptops because it would have taken time to amalgamate the different lists. She wanted a single spreadsheet[1778] to minimise confusion[1779] and the risk of error.[1780]
The pieces of paper containing handwritten notes[1781] from the various rest centres were passed to Mr Singh,[1782] who brought a laptop to the Clement James Centre on the morning of 14 June 2017.[1783] He amended the original spreadsheet[1784] using the information on the loose sheets of paper and recorded whether residents were safe. He also recorded any other relevant information, such as whether they were staying with friends and relatives or in a hotel.[1785] Ms Brown accepted that there was a degree of error in recording information at the rest centres in that way,[1786] but said the system was as efficient as it could be.[1787] Unfortunately, although her efforts to create a centralised system were intended to reduce error, their outcome was the opposite.
As a consequence of the errors and omissions in the tenancy records and the defects in the further information gathered at the rest centres, there were a number of significant errors in the safe and missing lists.
In the spreadsheet circulated on 14 June 2017 at 12.21[1788] a number of people who had died in the fire were marked as safe, including Denis Murphy,[1789] Khadija Khalloufi,[1790] Faouzia El-Wahabi, Yasin El-Wahabi, Abdulaziz El-Wahabi and Nur Huda El-Wahabi[1791] and Saber Neda.[1792] Some of those marked safe were also marked as missing, such as Denis Murphy and Khadija Khalloufi.[1793] The same inaccuracies remained throughout the day. Revised lists were circulated by Mr Singh at 13.08 and 13.44; recipients included RBKC for forwarding to teams on the ground.[1794] However, those lists still recorded as safe some who had died.[1795]
Another spreadsheet circulated at 17.27 contained revisions made after the neighbourhood team had telephoned every resident from whom they had not heard, but it still listed Denis Murphy and Khadija Khalloufi as safe. The El-Wahabi family were still listed as safe, save for a note stating that one member might be missing.[1796] Ms Brown could not explain why people had been listed as safe and missing on the same spreadsheet; she told us that they had tried to check the information as they went along.[1797] She accepted that the safe and missing tabs on the spreadsheet should have been cross-checked to make sure that those recorded as safe were not also recorded as missing and vice versa.[1798]
Errors were clearly made in the reporting and recording of information at the rest centres,[1799] but there were also significant errors in transferring the information from the handwritten notes into the spreadsheet. That was demonstrated by the fact that one handwritten note recorded Jessica Urbano Ramirez as missing,[1800] whereas in the lists circulated at 13.44,[1801] 14.46[1802] and 17.26[1803] she was marked as safe. That is likely to have been due more to human error than the method used to record the information.
Ms Brown told us that she had understood that other organisations, including the council, the casualty bureau and the BECC, would be relying on the information in the list as a base and using it in delivering their emergency response.[1804] In particular, both she and Mr Black[1805] had known that it would be relied on by RBKC’s housing department.[1806] Mr Black told us that at the time he had thought it was the TMO’s responsibility to provide the information, but in hindsight he thought it had been the responsibility of RBKC as Category 1 responder.[1807] He said that although people had done their best, it was not as good as it should have been and he apologised for the heartbreak that that must have caused people.[1808]
Given the significance of the safe and missing lists and the fact that several organisations were known to be relying on the information they contained, TMO staff should not have been left to do the best they could.[1809] The problems stemmed from poor record-keeping before the fire, resulting in tenancy information that was unreliable. If reliable information had been readily available to the TMO, it would have allowed more residents to be accounted for more quickly and their particular needs to be identified. it would also have reduced the risk of inaccurate and inconsistent information being circulated.
As a Category 1 responder, RBKC should have had a plan in place to account for safe and missing residents in the event of an emergency affecting any of its properties. Instead, the burden of devising a means of achieving that objective fell on a handful of staff at the TMO. However, the TMO should have made it clear to RBKC that it needed support to put in place a robust and effective system. Difficulties in establishing an accurate list of those who had been living in the tower continued throughout the following week.[1810] Unfortunately, the system implemented by the TMO led to systemic errors, with people being wrongly told that their loved ones were safe, when they were in fact missing.[1811]
About 845[1812] residents of Hurstway Walk, Barandon Walk, Testerton Walk, Grenfell Walk and Treadgold House were evacuated on the night of the fire[1813] and were prevented by the police cordon from returning to their homes.[1814] The residents of Grenfell Walk have never been able to return to their properties.[1815] As a result, there were significant numbers of people requiring emergency accommodation and other support.
Ms Brown told us that although RBKC had been responsible for managing the response to the emergency, the TMO had some operational capability which it used to help displaced residents.[1816]
It does not appear that RBKC was fully aware of the number of people displaced or their particular needs. In part, that seems to have been due to a widely held expectation that residents evacuated from surrounding buildings would be able to return home without much delay.[1817] As a result, on 14 June 2017, RBKC’s strategy was to prioritise residents of the tower for emergency accommodation.[1818] However, residents evacuated from the Walkways were not allowed to return home immediately and in many cases were not able to return for days, weeks and in some cases for a number of months.[1819] As reflected in the minutes of the Gold Group meeting on 16 June 2017, at which Laura Johnson of RBKC said that she would house the vulnerable or those with children and without hot water but that others would have to manage, RBKC treated the problem as one for the TMO.[1820] However, RBKC did attempt to consider the needs of residents evacuated from surrounding properties who were vulnerable, elderly or had families.[1821]
On 14 June 2017 at 17.05, Robert Shaw, Housing Options and Allocations Manager at RBKC, asked for information from the TMO about the number of tenants living in the cordoned area, and in particular the number of those who were vulnerable, elderly or had families with children, in order to determine how many people required emergency accommodation.[1822] David Noble gave him a total number of residents across the evacuated properties, which included 25 disabled people.[1823] That response was incomplete and did not provide information about other vulnerabilities, the elderly or families with children. Furthermore, the figure of 25 people was based on information received from residents;[1824] the true number is likely to have been higher.[1825]
Ms Brown told us that RBKC had been identifying vulnerable residents and those with children through social services and family and children’s services.[1826] However it is clear that RBKC was relying on information provided by the TMO to decide whom to place in emergency accommodation.[1827] As a result, at 17.48 on 14 June 2017 Mr Shaw sent an email to various colleagues at RBKC attaching the list of residents from the cordoned area. He told them that there were 845 residents (tenants and families), including 25 recognised as disabled by the TMO.[1828]
Although he went on to say that families with children, vulnerable people and older people would be housed if they did not have an alternative place to stay, he did not draw attention to the fact that information relating to the latter categories had not been provided by the TMO and that numbers were therefore still unknown.[1829] It was clear that even by the time of the RBKC Gold group meeting at 10.00 on 16 June 2017 not all families and those with vulnerabilities had been given hotel accommodation.[1830]
During the afternoon of 14 June 2017 RBKC told the TMO that, if the police cordon remained in place, the remaining residents evacuated from buildings within the cordon would have to be accommodated at the Westway Centre unless they were vulnerable, elderly, disabled or had children.[1831] TMO staff relayed that advice to the rest centres,[1832] although residents at rest centres where there was no one from the TMO present may not have received it[1833] and indeed Ms Brown accepted that some people had not received it.[1834]
That method of communicating with those who had been evacuated from properties surrounding the tower was defective, not least because some were not aware of the existence of the rest centres[1835] and others had even been refused entry.[1836] No attempts were made that day to communicate with evacuated residents by other means as TMO staff were concentrating on going through the tenancy list for Grenfell Tower and trying to establish contact with those who had lived there.[1837] Although the TMO had the ability to send a single text message to a large group of people at the same time, it was not used.[1838]
Mr Black attended the RBKC Gold group meeting at 10.00 on 15 June 2017 at which it was reported that only a limited number of people were at the Westway Centre.[1839] Although questions were asked about the whereabouts of the rest of the residents, it was assumed that they were staying with family and friends.[1840] Mr Black could not recall any discussion about the possibility that residents had not received the message to go to the Westway Centre or that some residents might be missing.[1841]
Although TMO staff were taking the lead operationally in respect of residents evacuated from properties within the police cordon, Mr Black accepted that he could have had a better understanding of how information was being collected and shared with RBKC. He did not have a clear picture of what the TMO was doing.[1842] Although he tried to stay on top of matters, he found it difficult to do so.[1843]
The first time efforts were made by the TMO to contact residents evacuated from buildings within the cordon was on 15 June 2017, when the neighbourhood team called residents to confirm their whereabouts.[1844] However, the process suffered from the same limitations as that used to compile the safe and missing lists, in that it was based on information taken from the housing management system.[1845] There was incomplete information relating to vulnerabilities,[1846] information about leaseholders rather than occupiers was recorded[1847] and contact details were out of date.[1848] That was particularly serious given that on the evening of 14 June 2017 RBKC had asked the TMO to provide information about residents who had been evacuated and were elderly, disabled, vulnerable or had children in order to place them in emergency accommodation. By the evening of 15 June 2017, TMO staff could not account for the whereabouts of residents of 216 of the 367 properties in Hurstway Walk, Testerton Walk and Barandon Walk.[1849]
A script was prepared to assist TMO staff making calls to residents of the Walkways and Grenfell Tower[1850] but there were significant differences in the information provided. Residents of Grenfell Tower were told that they could go to the Westway Centre for support and were provided with contact details for the casualty bureau and the temporary accommodation team.[1851] Those evacuated from the Walkways were not given that information.[1852] Given that RBKC had specifically told the TMO to tell residents of the Walkways that they should seek accommodation at the Westway Centre, that was a significant omission.[1853]
Stuart Priestley, RBKC’s Council Silver,[1854] told Ms Brown early in the morning of 15 June 2017 that consideration was being given to allowing residents of buildings within the police cordon to return to their properties.[1855] Ms Brown explained her concerns about people returning to their homes with no gas and no hot water or cooking facilities. In addition, doors damaged when the police had forced entry needed to be repaired and the door entry system needed to be re-routed.[1856] She suggested that the return of residents should not be rushed and should wait until the provision of services could be ensured. The decision that people should return to their properties was taken by RBKC; the TMO was in effect left to work out how to enable them to do so.[1857]
Although Ms Brown thought that her objections were being passed to the BECC,[1858] she was contacted later that evening and asked to meet Inspector Bean to inspect the area to identify what needed to be boarded up before residents returned.[1859] During the inspection she was told that it was the intention of RBKC Gold group that residents should return as soon as possible.[1860] Ms Brown told us that she had continued to be unhappy about that. She called her manager, Sacha Jevans, to pass on her views and spoke in turn to RBKC’s Director of Housing, Laura Johnson.[1861] Ms Brown subsequently learned that Laura Johnson had told Ms Jevans that the Gold group decision[1862] had to be followed.[1863]
The RBKC Gold group decided at its meeting at 15.30 on 15 June 2017 that the Walkway properties would be reoccupied that night.[1864] However, although the decision to allow residents to go home had been made in principle that day, it was not formally implemented until 16 June 2017.[1865] At the RBKC Gold group meeting at 10.00 on 16 June 2017 the position in relation to displaced residents was still not clear. The action sheet from the meeting records that the police were not providing clear information about re-occupation and were turning people away from Treadgold House.[1866] The formal decision to allow residents to return to Treadgold House was taken at 12.30 on 16 June 2017.[1867] Shortly after, a decision was made that residents of Barandon Walk, Testerton Walk and Hurstway Walk (except Flats 501-562) could also return home.[1868] Ms Brown[1869] and Mr Black told us that there had been confusion between the police, the BECC and RBKC Gold group in communicating the decision on when residents could return home.[1870]
The decision by RBKC to send residents home so quickly was driven by the shortage of emergency accommodation for the significant number of displaced people.[1871] That is evident from the notes of the first humanitarian assistance steering group meeting at 14.00 on 15 June 2017 which recorded that “Those disbanded [sic] in the cordoned off areas are not priorities as there is [sic] not resources to support this” and “AG [RBKC] explained that there is a shortage of hotels locally and those from Grenfell are the priority”.[1872] Similarly, the action sheet from the RBKC Gold group meeting at 15.30 on 15 June 2017 stated, “If cordon is not lifted, then [we] have over 800 people to find places. Will need to seek help from Government.”[1873]
The concerns expressed at an operational level by Ms Brown do not appear to have been voiced at a strategic level by Mr Black. Despite knowing of them,[1874] he could not remember whether he had raised them at any of the RBKC Gold meetings.[1875] There is no suggestion in the action sheets from those meetings that he raised any specific objections to returning residents to their homes, even though that was something his staff would have to organise. He accepted that the TMO was being required to send people back to their homes, despite their condition, because there were too many displaced people for RBKC to provide all of them with emergency accommodation.[1876] He accepted that that created difficulties for the TMO, which had to make sure the properties were habitable and safe.[1877]
Once Ms Brown had received confirmation on 16 June 2017 that residents could return to buildings within the cordon, she arranged for 11 TMO officers to telephone them to tell them that they could go home, at the same time warning them about the lack of heating and hot water and telling them about the washing facilities at the Westway Centre.[1878] She also arranged for 15 members of the TMO’s staff to visit the Walkways and Treadgold House to check on residents, refer people to support services, see whether any repairs or cleaning were required and check the electricity supply.[1879] TMO staff kept notes of those visits with the intention of keeping a record of vulnerabilities and of any need for assistance that could be added to the central electronic list of residents.[1880] However, the records were often haphazard,[1881] inconsistent and incomplete.[1882]
The TMO used the “text burst” facility for the first time on 16 June 2017 to let residents from Barandon Walk, Treadgold House and Hurstway Walk know that they could go home and to warn them that they might not have hot water or gas.[1883] Residents were told that they could continue to stay with family or friends or in what was described as “the resource centre”.[1884] That was intended to be a reference to the Westway Centre, but it is not clear whether people realised that. The message did not provide any information about the Westway Centre, what support was available there or how to get there. Although it was unlikely to reach everyone, the “text burst” facility was a useful means of communication and should have been used earlier and more often to provide information to displaced residents.
On 19 June 2017, further attempts to call residents were made.[1885] TMO staff also visited homes again to find out whether more residents had returned, to give advice and to see whether repairs were needed.[1886] A number of residents had still not returned home.[1887] The TMO repeated the exercise the next day to conduct welfare checks and identify the need for any further support,[1888] although some residents had still not returned home seven days after the fire.[1889] Despite the TMO’s efforts to communicate with the residents, some still complained that no one had contacted them,[1890] indicating that not all residents were being reached.
On 20 June 2017, Ms Brown asked RBKC for a list of those who had been provided with emergency accommodation in order to identify any residents that had not been given accommodation and had not yet returned to their properties.[1891] However, Mr Shaw told her that RBKC was still in the process of reconciling the list.[1892]
Detailed written briefings for staff trying to contact residents of Barandon Walk, Hurstway Walk and Testerton Walk were not provided until 20 June 2017[1893] and were issued again on 22 June 2017[1894] and 23 June 2017.[1895] They included guidance on the message to be given to residents of surrounding blocks, information about the support available at the Westway Centre, tasks to be carried out, staff rotas and useful contact information. They were much more detailed than the aide memoire provided earlier to assist staff making telephone calls.[1896]
It is clear that even after the Gold resolution had been activated and John Barradell had taken over the response, there was no clear strategy for dealing with displaced residents. On 19 June 2017 RBKC and the TMO were looking for guidance to the Westminster City Council housing team, which had been brought in as part of the wider London response.[1897]
As a result, in the days and weeks following the fire there were conflicting messages about when residents could return home. Although some residents had returned early at the instigation of RBKC Gold group,[1898] others were turned away by the police when they tried to return[1899] or were told that they could return at their own risk.[1900] Some were not told whether it was safe to return[1901] and at least one other had been told by RBKC representatives at the Westway Centre that he could not return.[1902] On 20 June 2017, Ms Brown sent an email to the BECC to clarify which residents could return home and which could not, so that a clear position could then be communicated to the police.[1903]
Overall, the evidence shows that the various bodies involved failed to co-operate properly to ensure that the information they gave about returning residents to their homes was the same.[1904] That left people without clear information for longer than was necessary, causing further inconvenience and distress.[1905]
Once residents had returned, Ms Brown’s worries about the condition of the properties were borne out. They mainly related to the lack of gas and hot water, which left residents without washing or cooking facilities for a long time. Permanent repairs to locks and doors did not begin until 29 June 2017.[1906] The gas supply was restored to all properties except Grenfell Walk by 29 June 2017 and hot water was restored to most, though not all, properties on 4 July 2017.[1907]
The TMO newsletter dated 27 July 2017 acknowledged continuing problems. It confirmed that the gas supply for many homes had been restored but that the supply had been capped in some properties for safety reasons. There were also air locks in the hot water system.[1908] Problems clearly persisted for a significant period of time. A resident of Barandon Walk remained in hotel accommodation until 16 December 2017, when the heating and hot water was restored.[1909] One family from Barandon Walk did not receive confirmation from RBKC that the problems with water, gas and heating had finally been resolved until April 2018.[1910]
Although RBKC was aware of the steps being taken by the TMO to help the residents, it did not offer any tangible support or resources to meet their needs or assist their return home,[1911] leaving the TMO to manage the needs of significant numbers of residents. The burden weighed heavily on Ms Brown, despite her not being a member of the TMO’s executive team. Mr Black told us that in retrospect it would have been better for RBKC or London Gold to have organised the return of displaced residents after 16 June 2017.[1912]
In our view, accounting for the significant number of displaced people and enabling them to return to their homes, where that was possible, was too great a task for the TMO, despite Ms Brown’s best efforts. Although RBKC was the responder which should have assumed that responsibility, it concentrated its efforts on the needs of the survivors from the tower largely to the exclusion of those who had been evacuated from the surrounding buildings. It is understandable that it should have done so in the initial stages of the disaster, but it should not have taken it long to realise that those who had been hastily evacuated from neighbouring buildings had also been seriously affected and had many of the same needs. As a Category 1 responder, RBKC should in our view have provided more support to the TMO in its efforts to enable the residents of those buildings to return to their homes. The roles and responsibilities of RBKC and the TMO in relation to the residents of the surrounding buildings were never clearly defined. As a result, RBKC did not make additional resources available to the TMO to provide the help they needed, nor did the TMO ask for them.
When the London Gold arrangements were put into operation during the afternoon of 16 June 2017 John Barradell took charge of the humanitarian response. Mr Black did not have a working knowledge of the London resilience arrangements or of London Gold’s powers and capabilities.[1913] He did not suggest that a senior member of the TMO’s staff should be attached to the London Gold group to help with providing support to residents of the Lancaster West estate,[1914] nor did he have a personal meeting with Mr Barradell.[1915] It was his impression that Mr Barradell had taken over the situation and wanted to bring fresh people in.[1916] Although the TMO had a detailed knowledge of the Lancaster West estate, he thought that it had been regarded as more of a hindrance than a help.[1917]
Mr Barradell accepted that the care of the residents evacuated from properties surrounding the tower fell within the scope of his responsibility and recognised that considerable support was being provided by the TMO.[1918] Nevertheless, he did not want it to be part of the arrangements because he did not believe that it had the confidence of the local community. He thought that the necessary functions could be better performed and directed by other people.[1919] He told us that demonstrating that those providing help were independent of the TMO was as much about building confidence as making sure that help was actually delivered.[1920]
The strategic decision by London Gold to keep the TMO at a distance was reflected in the day-to-day contact between them. Ms Brown’s contact with London Gold was limited to arranging for one person to carry out an inspection of the fire exits on the Walkways.[1921] She told us that she did not have any contact with Ms Brownlee[1922] or anyone from Westminster Council.[1923] We would have expected far greater communication between Ms Brown and London Gold, given that her team was helping to arrange the return of large numbers of residents to the surrounding properties. Everyone was seeking to tackle the problems created by the numbers involved and the difficulties of communication. Ms Brown acknowledged that London Gold had provided assistance to the TMO when it was asked for, particularly in relation to matters such as rebuilding the fire exits at the Walkways,[1924] but otherwise its involvement was limited to identifying vacant properties which it reported to Graham Webb, the managing director of Repairs Direct.[1925]
Mr Black told us that his impression was that London Gold would not help the TMO,[1926] and although it understood local authorities, he was not confident that it understood how the TMO was structured and how it operated.[1927] Although Mr Black had initially regarded London Gold’s involvement as a positive development,[1928] he did not think that the TMO had been adequately supported by it. It could have offered more help but decided not to do so and largely left the TMO to get on with it.[1929]
Given the central role played by the TMO in supporting the return of residents to properties within the cordon, we think that London Gold should have done more to establish direct contact with it, co-operate with it and provide it with support.
On 19 June 2017, officials from several central government departments were deployed to the Westway Centre. Later that day, reservations about the effectiveness of the TMO were voiced for the first time at the ministerial meeting chaired by the Prime Minister.[1930]
From 19 June 2017, officials from BEIS were present at the Westway Centre, answering some questions posed by residents and community representatives and relaying others to the government’s utilities co-ordination cell.[1931] Sebastian Bassett-James, who had been seconded from BEIS to take charge of the team responsible for restoring utilities, found it difficult to contact both RBKC and the TMO, which he understood to be providing the primary response to the fire.[1932] He said that the TMO had not provided the help needed to restore the utilities, leaving the residents frustrated for longer than necessary.[1933]
Mr Bassett-James said that, although the TMO had had people at the Westway Centre, they had not had authority to make decisions, take action or respond to his team’s questions,[1934] but Ms Brown told us that her staff at the Westway Centre were able to contact her and Mr Webb to get any necessary authority.[1935] According to Mr Bassett-James, when members of the BEIS team at the Westway Centre attempted to telephone the TMO their calls went unanswered and voicemails were not returned.[1936] By 21 June, BEIS was working with the Department for the Environment, Food and Rural Affairs (DEFRA) and DCLG to identify a point of contact within the TMO. Eventually they were successful.[1937]
In the opinion of Mr Black, the government did not understand the nature or role of the TMO or its limitations.[1938] For example, emails sent within No.10 on 21 June 2017 commented adversely on the TMO’s handling of communications with the residents,[1939] but Mr Black told us that during the days immediately following the fire the TMO had not been allowed to communicate with them without the approval of RBKC, which itself had had to be channelled through the Gold group.[1940] It seems that No.10 laboured under the misapprehension that the TMO had an extensive formal role which made it necessary or desirable that DCLG intervene to remove it from the situation.[1941] That was not correct and failed to take proper account of the fact that the TMO was not itself a responder.
DCLG gained its understanding of the position and effectiveness of the TMO from second-hand reports. On 19 June 2017 Dame Melanie Dawes became aware that concerns were being expressed in some quarters about the performance of the TMO, particularly in relation to restoring heating and hot water to the Lancaster West estate, when they were raised by John Barradell at the Grenfell Recovery Taskforce meeting that day.[1942] However, although those concerns were recorded at governmental level, Mr Black was not made aware of them.[1943] Mr Barradell told us that he had not raised them with the TMO because they had to be raised at the Grenfell Recovery Taskforce meeting in order for them to be addressed.[1944]
At the same meeting a decision was taken that residents who were affected by the lack of hot water and gas should be given hotel accommodation and financial assistance.[1945] However, that decision was not communicated to the TMO, which was responsible for arranging the return of the residents and dealing with matters relating to properties in the blocks that had been evacuated.[1946]
On 20 June 2017, internal DCLG correspondence recounted Ms Brownlee’s impression from a “TMO meeting” that the TMO had no leadership, that staff were “drifting around”, traumatised and without reliable information on important matters, such as the state of the flats in the Walkways.[1947] Ms Brown acknowledged that TMO staff were very traumatised by what had happened but maintained that they were concentrating on getting on with the job and doing what they could to support people.[1948] She denied that they lacked leadership.[1949] Ms Brownlee’s impression, as expressed in the DCLG correspondence, had not been informed by any discussion with Mr Black or Ms Brown.[1950]
Although internal DCLG correspondence recorded that the TMO needed “a new strong Chief Exec, who can provide a single point of liaison, clear information, and strong leadership”, neither DCLG nor Ms Brownlee sought to contact Mr Black or the TMO board.[1951] Mr Black told us that those negative impressions of the TMO had been formed without speaking to it and that, in his view, it had suited the government to blame the TMO.[1952] The decision to remove the TMO had been taken without a clear understanding of its structure or mode of operation or of the legal framework under which it operated.[1953] His view seems to us to be borne out by the documents we have seen.
Ms Brown did not recall having received any support from central government in the week following the fire.[1954] Mr Black told us that, although the structure worked on paper, the scale of the emergency was such that more resources were needed from the government, rather than simply instructions on what should be achieved.[1955] In our view, there was a tendency for other organisations and departments involved in the response and recovery phases to talk about the TMO rather than to it, and in doing so they left the TMO isolated and unsupported.[1956] We think that in the days after the fire the TMO was to some extent seen by the government as a useful scapegoat, perhaps to deflect criticism from its own shortcomings in what had evolved into a full-blown humanitarian crisis in the heart of West London.
Ms Brown told us that she felt she had been adequately supported by the TMO’s executive team to enable her to fulfil the various roles that her team had undertaken in the immediate aftermath of the fire. She told us that her manager, Sacha Jevans, had been contactable by telephone to discuss any problems.[1957] She also said that, with the benefit of the additional staff arranged by Mr Black by 18 June,[1958] she did not feel that the TMO had been under-resourced.[1959]
However, we do not think that the senior leadership of the TMO provided sufficient oversight or support to staff who were dealing with the problems in the days immediately following the fire. Although Ms Brown may have felt at the time that she was adequately supported,[1960] she was not aware of the limits of her capacity. Although she could always contact her line manager for support if she felt she needed it, those in positions of greater seniority ought to have taken positive steps to ensure that she and her team had all the support and resources they needed, not least because she had assumed a role for which there was no standing guidance or training and was, in essence, improvising.
Mr Black told us that he had found the scale of the incident personally overwhelming.[1961] As a result, he could not effectively manage the TMO’s role in the response. He told us that he had not asked RBKC for more resources,[1962] because everyone was in a difficult position.[1963] Clearly, however, he should have done so, as he accepted.[1964] He should have also made it known to RBKC that the expectations and demands on the TMO were beyond its capacity.
We accept that one reason for the TMO’s failure to seek help for itself was that its senior executives were overwhelmed by the scale, uncertainty and ever-shifting nature of the incident. However, for reasons explored elsewhere in this report, Mr Black’s style of management was to rely on his trusted team rather than share problems with those charged with oversight of the TMO, such as its board and RBKC.
Although Mr Black and Ms Brown fell short of what was expected of them in the period following the fire, we recognise that they were seeking to discharge a role that the TMO had assumed voluntarily. The root of the problem was the absence of an emergency plan clearly setting out the relationship between RBKC and the TMO and their respective responsibilities in the event of a major incident.
Olivia Hutchison was the head of customer services at the TMO.[1965] She provided daily email briefings[1966] for the Customer Services Centre team and Pinnacle (the TMO’s out of hours contact centre) to assist them in dealing with incoming calls from residents affected by the fire.[1967]
Early in the afternoon of 14 June 2017, Amanda McDuff of Pinnacle asked for advice on dealing with calls in the evening. At 14.15 Ms Hutchison replied that the TMO’s main concern was dealing with displaced residents.[1968] She said that customers in need of re-housing should attend the “Westfield Community Sports Centre”.[1969] There is no Westfield Community Sports Centre, but the Westfield retail site was very close to Grenfell Tower. No specific advice was provided for the residents of the surrounding blocks.[1970]
At 17.09 on 14 June 2017, Ms Hutchison told the Pinnacle Team that anyone requiring assistance with temporary accommodation should contact the council’s switchboard or go to the rest centres at the Westway Centre, Rugby Portobello Trust or St Clements Church.[1971]
At 17.37 on 15 June 2017, Ms Hutchison told Pinnacle that most residents of the tower had been placed in temporary accommodation but that residents from the surrounding buildings had still not been able to return to their homes due to fears for their safety.[1972] She said that the police had started letting some residents return, but that Hurstway Walk, Barandon Walk, Grenfell Walk, Testerton Walk and Treadgold House were all without hot water and would be without gas for cooking.[1973] In messages sent on 16 and 17 June 2017 Ms Hutchison identified which flats in each block could be re-occupied.[1974]
On 19 June 2017, there were further briefings referring to the lack of hot water and cooking facilities. A briefing released at 10.22 on 19 June 2017 directed residents who required emotional support to the NHS’s Single Point Access for Mental Health.[1975] None of the briefings provided to Pinnacle referred to financial support.[1976] In our view, the TMO should have told Pinnacle about the financial support available far earlier.
In the first few days after the fire the TMO tried to contact residents by knocking on doors and telephoning them, but no written communication was circulated until 22 June 2017.[1977] That letter was sent without London Gold’s approval,[1978] even though formal communications with residents required his permission.[1979] A number of residents had asked for written communication and TMO staff drafted information briefings for approval,[1980] but nothing further in writing was sent out until 27 July 2017.[1981] The delay was caused by the need to obtain the approval of London Gold.[1982] Written communications were originally intended to describe what was planned, but eventually became a record of what had been done,[1983] which was of little practical assistance to residents.[1984]
The evidence provided by local community leaders and representatives of the British Red Cross gave us a valuable insight into the assistance that they provided in the immediate aftermath of the fire. It is apparent that that assistance was required in order to fill a space which should have been occupied by RBKC.
We received 24 witness statements from individuals representing a range of local community organisations, charities and places of worship. Clare Richards, chief executive of the Clement James Centre, and Mark Simms, chief executive of the P3 Charity Group (of which the Rugby Portobello Trust is a part) gave evidence in person. Other organisations involved in the humanitarian response included the Al Manaar Muslim Cultural Heritage Centre, the Latymer Community Church, St Francis of Assisi Catholic Church, Notting Hill Methodist Church and the Harrow Club.
The evidence of witnesses from the local community painted a picture that portrays the very best of humanity. People from different backgrounds, faiths and communities came together in the face of grievous tragedy. They offered compassion, dignity and hope to the bereaved, survivors and the wider community. Their spontaneous response is a testament to the strength and resilience that characterises the North Kensington community. We pay special tribute to it.
As a Category 1 responder RBKC was required to have regard to the voluntary sector organisations carrying out activities in the geographical area for which it was responsible.[1985] The Emergency Preparedness guidance provides that:
“Category 1 responders must consider and discuss with relevant organisations the capabilities that those organisations within their area have to offer, and whether those capabilities should be built into response and recovery plans. Agreements reached should be captured in plans and signed off by all affected parties.”[1986]
Although the British Red Cross is neither a Category 1 nor Category 2 responder,[1987] Michael Adamson, its chief executive, told us that it is recognised by the government as a voluntary society with a function auxiliary to that of the public authorities.[1988] That recognition establishes a relationship between the Red Cross and the government, such that, without being dependent on it, the Red Cross is required to have regard to the needs of the government when carrying out its primary responsibility to alleviate suffering in emergencies.[1989]
RBKC had an established arrangement with the Red Cross but it failed to involve important community organisations in its contingency planning arrangements.[1990] It had no plans for the participation of community organisations in North Kensington and had not identified a function for any of them if an emergency occurred.[1991] Although RBKC had some limited engagement with larger voluntary organisations, it had not asked community leaders to become involved in a community resilience strategy, despite the willingness of many of them to take part.[1992] This failure is particularly significant, given that local community organisations came to play a central part in the response to the fire.
RBKC also failed to engage with and make full use of those organisations after the fire had occurred.[1993] There was little or no consideration given to the value that local community organisations could provide in responding to the fire. They had an understanding of the history, character and diversity of the North Kensington community that larger voluntary organisations, such as the Red Cross, lacked.[1994] It was the existing relationships and trusted networks that enabled local community organisations to cater for the particular needs of those affected, and to do so in sensitive, informed and specific ways. Not only was RBKC unable to do that itself; it lacked the willingness and the skill to recruit the local community networks to help it.
As a result, the community response was entirely voluntary and self-generated.[1995] In the early hours of 14 June 2017, community organisations opened their doors to provide shelter and sanctuary for those affected by the fire,[1996] despite the absence of any request from RBKC or the police. Community organisations were not aware of any co-ordinated response by the council;[1997] nor were they asked to be part of one.[1998]
In the absence of any plan or official co-ordination, community organisations faced significant challenges in providing support to those affected. Community leaders were faced with hundreds of distressed people, not knowing whether emergency accommodation would be available for the coming night.[1999] Ms Richards from the Clement James Centre told us that she thought that, given the scale of the emergency, a team of people from the council would come to co-ordinate arrangements, but unfortunately that did not happen.[2000]
In the early hours of 14 June 2017 and throughout that day, community rest centres were packed with crowds of survivors, people searching for loved ones and shocked local residents evacuated from their homes.[2001] People could not obtain information about who had escaped from the tower, who was in hospital and who was still missing, which was particularly distressing.[2002] It was very difficult to know where to look for the missing or obtain reliable information to provide support to those in need.[2003] Information was available only by word of mouth, but the situation was constantly changing.[2004] Despite expecting to be told what to do and to be a part of a co-ordinated plan, community leaders were left to support people with whatever resources they could muster.[2005]
Community organisations struggled to obtain information from official sources about what services were available.[2006] Organisations like the Clement James Centre, the Harrow Club and the Al Manaar Muslim Cultural Heritage Centre were trying to find out what was going on, without success.[2007] Mark Simms of the P3 charity told us that there had been no plan and that he had had no idea what the next day would bring, given that there was no communication from any official body about what to do.[2008] He tried to contact the council BECC on 14 June 2017 but could not get hold of anyone by telephone or email.[2009] By the end of the day he still had not received any information from the council about the official response.[2010] Indeed, he said that even at the time he was giving evidence he was still waiting to find out what the longer term plan was.[2011]
Community leaders described the involvement of RBKC in the first few days as a “chaotic fog, in which little information was available”.[2012] The absence of any overall co-ordination of the relief effort was regarded as astonishing.[2013] They said that the lack of information had compounded the distress for people in rest centres, with community leaders unable to provide any information or reassurance. The consequence was that people already facing so much stress were left to feel that nobody cared for them.[2014] These are, of course, general impressions conveyed to us long after the event rather than recollections of particular circumstances, but they are consistent with other, more specific, evidence.
Community leaders told us that in the days following the fire local organisations providing a humanitarian response had received little support from RBKC, the government or the TMO. Three days after the fire, Abdurahman Sayed from the Al Manaar Muslim Cultural Heritage Centre told councillors that they were struggling to cope with the logistical demands of dispensing large volumes of donations, organising volunteers and providing support to those relying on their services. Despite a request for assistance, the Al Manaar Muslim Cultural Heritage Centre received no support from RBKC.[2015] Community leaders shared the frustration of those who felt that the council and the government were absent at a time where they were needed most. Any support that did come was often too little, too late.[2016]
The experience of the community, voluntary and faith groups was that the authorities kept their distance and were slow to respond to the immediate needs of those affected by the fire. There was a clear need for an overall plan but instead, people were left to fend for themselves and not surprisingly they turned to the voluntary and faith sector and other organisations they trusted to fill the gap.[2017]
The following provides an indication of the support provided by some of the leading community organisations in what has been aptly described as a spontaneous outpouring of compassion.[2018]
The Rugby Portobello Trust provides support for young people in North Kensington and is located 400 yards from Grenfell Tower.[2019] It suspended its normal services in order to assist survivors from June until October 2017. It supported about 210 people representing 165 households from Grenfell Tower and Grenfell Walk.[2020] It offered assistance of various kinds to survivors, including the provision of clothing, food, money, accommodation and medical assistance, as well as a pop-up pharmacy and temporary doctor’s surgery.[2021] It also provided help with obtaining identification documents, access to bank accounts and technology.[2022] Subsequently, the Rugby Portobello Trust organised a scheme providing survivors with smartphones, laptops, televisions, kettles and microwaves.[2023] During the first week, it obtained about £80,000 in cash which it distributed to those in need.[2024] Later, at the request of the Charity Commission, it distributed payments in partnership with the National Zakat Foundation, a Muslim charity involved in the humanitarian response.[2025] The Rugby Portobello Trust issued over 3,200 separate grants totalling more than £16.8 million from funds generated by public donations.[2026]
In its response to the disaster the Rugby Portobello Trust focused on the importance of dignity in providing humanitarian support.[2027] That entailed ensuring that survivors had access to money, rather than just donated goods, in order to give them the ability to regain an element of control over their own lives.[2028]
The Clement James Centre is a local charity situated adjacent to the Lancaster West estate that supports the community through education, employment and wellbeing programmes.[2029] In the immediate aftermath of the Grenfell Tower fire, it provided food, distributed donations, provided access to information, collected prescriptions, obtained offers of accommodation which it allocated to those in need and created a list of those who were safe and missing.[2030] On 14 June 2017 the Clement James Centre was also involved in arranging emergency accommodation for people who had been displaced from the tower or surrounding blocks and had still not been told that they would be provided with accommodation.[2031]
The Al Manaar Muslim Cultural Heritage Centre is a place of worship that also provides cultural education and outreach.[2032] Its response included the provision of food and water and the distribution of donations.[2033] As the fire occurred during Ramadan, the mosque was already catering for about 300 people every evening. That increased to about 600 people a day after the fire.[2034] It later helped to provide services such as counselling, art therapy and survivors’ groups.[2035]
A number of other local community, voluntary and faith organisations also provided direct and immediate support. They included the Notting Hill Methodist Church, which provided a base for emergency relief in the first few days following the fire. It was particularly involved in the provision of clothes and toiletries to those from the Walkways and Grenfell Walk.[2036] The church helped those looking for missing loved ones to make posters appealing for information. The St Francis of Assisi catholic church offered a variety of support to those affected, including food and drink, spiritual and emotional support, practical assistance, such as mobile phone chargers, and the distribution of financial and other donations.[2037] Local organisations sought to ensure that dignity, compassion[2038] and sensitivity to specific needs was at the centre of their response.
The Al Manaar Muslim Cultural Heritage Centre was well known and respected within the local Muslim community and provided support for those with specific needs in relation to prayer, clothes, food and observing Ramadan.[2039] That was particularly important, given that many of those affected were of the Muslim faith. Similarly, the Latymer Community Church provided a safe space, refreshments, and someone for people to talk to. A Muslim prayer room was set up within the church for those observing Ramadan. It started a memorial wall where people left messages and flowers and which became a focal point for the community.[2040] Their actions acknowledged the importance of a humanitarian response that was sensitive to faith and culture and put that into action.
In the days and weeks that followed the fire, community leaders were involved in meetings with officials at various levels of government. An examination of those official meetings provide an insight into how the government was engaging with the community and a strong indication of the fundamental and pervasive problems that persisted in the humanitarian response, at least in the days after the fire.
The then Prime Minister, the Rt Hon Theresa May MP, attended the Clement James Centre on 16 June 2017 for an impromptu meeting.[2041] The purpose of the meeting was unclear, and the staff at the centre were given only 15 minutes’ notice.[2042] The perception was that the Prime Minister was listening to what people had to say and gave everyone a chance to speak.[2043] However, not a great deal was achieved, not least because the meeting was cut short by the Prime Minister’s security team due to crowds forming outside the church.[2044]
A further meeting was arranged at 10 Downing Street on 17 June 2017 with the same people.[2045] Among the matters raised was the need for highly visible hubs[2046] to be set up in the local area providing housing, legal support, counselling, police family liaison officers, financial support,[2047] psychological support and translators to ensure accessibility of information.[2048]
A particular complaint was that the people making the decisions were not communicating with those who were affected.[2049] London Gold, who had by then taken over leading the response, had not reached out to the community rest centres.[2050] There was a view amongst residents that people’s experiences needed to be captured, which they suggested could be done through consulting a representative group of residents about their needs.[2051] However, nothing came of that suggestion.
A further meeting took place on 20 June 2017 with Hilary Patel from the London Gold team at which various people from the voluntary sector and council officers were present.[2052] There was widespread dissatisfaction about the absence of further information or a commitment to resolve any of the problems that those affected were facing.[2053] Mr Sayed of the Al Manaar Muslim Cultural Heritage Centre, who continued to be involved with official meetings in the days and weeks following the fire, felt that representatives were not properly prepared[2054] to address the wishes of residents. Those affected were left with the sense that the council and the government simply did not care.[2055]
Despite the fact that the community organisations were not designed to respond to an emergency, they played a central role in meeting the immediate needs of those affected by the fire.[2056] However, because of the failure of RBKC and the apparatus of London Resilience to act with the necessary speed, the Rugby Portobello Trust and other community organisations found themselves leading actors in the response to the fire.[2057]
Those directly affected spoke positively of the community’s response.[2058] Mohammed Rasoul said, “The public’s response in the tragedy was something I’ll never forget for the rest of my life. To me, that represented what humanity should strive for…there were no barriers…everyone was proud of their identity, of their diversity…it wasn’t a barrier…in that moment you had something that we could all strive for in this society [that] we should be proud of.”[2059]
No response to an emergency can be considered effective if it leaves those whom it is supposed to serve feeling abandoned and bereft. Yet that was the experience of very many of the people who had lost their homes in the Grenfell Tower fire or whose loved ones had lost their lives in it. Their experiences, described in their own words in Chapter 100, attest vividly to the failure of the system, but within the community in North Kensington the official response to the fire also served to confirm a deep distrust of those in authority, the existence of which long predated the fire. The community’s perception was that in the days that followed the fire there was an absence of leadership,[2060] no central structure and nobody effectively in charge.[2061] Those who had been displaced suffered at first hand from the lack of co-ordination between the various organs of central and local government which should have been able to meet their needs but instead demonstrated an inability to deal adequately with a tragedy on the scale that confronted them.[2062]
The Grenfell Tower disaster shows that the principle of subsidiarity, which lies at the heart of the arrangements for responding to civil emergencies, is both its strength and its weakness. In general, the local authority, in conjunction with the emergency services, is usually best placed as a result of existing structures, familiarity with local conditions and knowledge of the communities affected, to respond effectively to an emergency, particularly one that is confined to a relatively small area. Even in cases where a larger area is involved, such as widespread flooding, the local authority is likely to be best placed to organise both the immediate response and the subsequent recovery. However, its effectiveness depends on four things: (i) the existence of an emergency plan that has been well thought out, is well understood by those who have to implement it and has been practised with sufficient frequency and rigour to ensure that it can be put into operation without undue delay; (ii) sufficient human and financial resources to enable the plan to be implemented; (iii) a chief executive with the necessary skills and strength of character to take control of the situation with the support of senior officers who are capable of taking responsibility for different aspects of the plan’s implementation; and (iv) an understanding within the organisation of the importance of resilience and a commitment to achieving it.
Unfortunately, in the present case all four of those requirements were lacking. RBKC did not have an effective emergency plan that was directed to the displacement of a large number of people from their homes and such plan as it had did not make effective use of the TMO. In our view that is a serious criticism of a local authority responsible for resilience in a densely populated urban area containing many large residential buildings, in some cases in close proximity to each other. Fire is only one of a number of hazards that might necessitate the evacuation of a large number of people who would then require temporary accommodation. RBKC’s plans did not include a system for obtaining a large amount of emergency accommodation at short notice. Nor, significantly, did it make any provision for identifying those who had been evacuated or for communicating with them. Arrangements for obtaining reliable information and disseminating it was also lacking.
The absence of a good plan was compounded by the failure of RBKC to train its staff adequately. The necessary understanding of the importance of resilience and commitment to it were missing. Exercises were not held regularly and staff were not required to attend the training sessions run by the London Resilience group. Deficiencies which were well known to the senior management were not corrected. As a result, when disaster struck there was no semblance of a well-oiled machine that could move into action with the minimum of delay.
Financial resources do not appear to have been unduly constrained, but in this case RBKC lacked the personnel needed to administer the response effectively, both for the purposes of staffing the BECC and to deal with those who needed help.
Finally, RBKC did not have the benefit of a chief executive capable of taking control of the situation, understanding the magnitude of the task facing it and mobilising support of the right kind without delay. Mr Holgate was suddenly confronted with an enormously difficult situation without the benefit of a clear plan and with imperfect information at his disposal. However, the fact remains that he was not well-suited to dealing with the crisis that was unfolding in front of him. Nor did he have the benefit of a strong group of officers to whom he could delegate responsibilities for some aspects of the response. He was reluctant to take advice from those with greater experience and was unduly concerned for RBKC’s reputation. His mishandling of the situation demonstrates a dangerous weakness in the arrangements for responding to civil emergencies generally.
Some of those weaknesses could and should have been avoided by better preparation, but in many cases the mettle of the chief executive will not have been tested before a crisis erupts. As this incident demonstrated, it is difficult to force the hand of a chief executive who does not recognise his own or his authority’s limitations. Whatever may be the effect of the London Gold arrangements, everyone accepted that they could not be activated otherwise than at the request of the local authority concerned. That was obviously frustrating for many, including the government, but was the consequence of their being a voluntary arrangement.
The government has wide powers under the Civil Contingencies Act to give specific directions to a Category 1 responder to perform its functions for the purpose of reducing, controlling or mitigating the effects of an emergency and such orders may require that person to collaborate with another or to delegate functions to another (section 5); and in a case of urgency the minister can give similar directions in writing. Although the government does, therefore, have the power to override the principle of subsidiarity, the use of those powers does not appear to have been considered in this case, perhaps because once John Barradell had taken control it was thought that no more could usefully be done to manage the response.
The structures of London Resilience, through which individual London boroughs perform their duties as Category 1 responders, are complex and, at least to the outsider, difficult to understand, being bedevilled by jargon and acronyms. That of itself does not matter, of course, if they are understood by those who must use them and operate effectively. There is reason to think, however, that there is a misunderstanding, both among some in local authorities and in government, about the effect of the Gold resolution. On its face, the Gold resolution is limited to authorising expenditure under section 138 of the Local Government Act 1972. Mr Barradell, who has considerable experience in matters relating to London Gold, was well aware that invoking the Gold resolution did not give London Gold power to take control of the response, which remained in the hands of Mr Holgate while he chose to exercise it. Indeed, Mr Barradell was not the chief executive designated to act as London Gold on 16 June 2017 and was therefore not the person who would have taken charge under those arrangements in any event.
The introduction of Mr Barradell to take control of the response owed little to the machinery of London Resilience or the operations of the Gold arrangements and much to the personal intervention of Dr Farrar and the influence of Mr Barradell himself in persuading Mr Holgate to step aside in his favour. That was not something envisaged by the standing arrangements and could not have been imposed on RBKC otherwise than by ministerial order. It points to a defect in the arrangements governing resilience, not only in London but potentially more widely. There was, and as far as we know still is, no derogation from the principle of subsidiarity within London, and the same presumably applies in the case of other large conurbations. Whether that should remain the case is a matter for the boroughs and the government to consider.
One thing that the disaster emphasised above all others was the need following a major emergency for rapid and reliable communication between those responsible for the response and those needing assistance. That requires planning, but with the aid of modern methods of communication should be capable of being achieved without too much difficulty unless there has been significant disruption to the internet and mobile telephone system. One of the most common complaints we heard from those that had been displaced was that they felt cut off or abandoned. It is clear to us that more thought and preparation needs to be put into establishing and operating communication points accessible to those affected by the incident, enabling them to be kept informed of developments and those attempting to provide support to gather vital information. Given the enormous importance of effective communications, emergency plans need to take into account the range of languages spoken in the locality.
Although from the outset the government was keen to assist the response, its effectiveness was undermined by a shortage of reliable information and by its limited powers to intervene. The machinery as we have described it was in place to enable information to be obtained from those directly involved in the response but it did not work as well as intended. The government can, of course, provide a local authority dealing with an emergency with resources of all kinds, if it is minded to do so, but the statutory structure does not give it the power to play an active role in the response, short of invoking the powers under sections 5 and 7 of the Civil Contingencies Act. The powers are far-reaching, but cumbersome in operation and not well suited to taking control of the response when the local authority is failing or just not managing the response in what the government considers to be the best way. The government, particularly senior ministers, can bring a great deal of influence to bear but that is not the same as being able to take decisions.
The TMO was not formally a responder and had not been integrated into RBKC’s emergency plan. That represented a significant failing on the part of RBKC because it held, or should have held, a lot of important information about the occupants of the tower and the surrounding buildings. The fact that the information it held was not as complete or reliable as it could or should have been detracted from its ability to assist those seeking to provide support to displaced residents, but RBKC should have realised that the TMO’s close knowledge of the buildings and their occupants had an important part to play in any response to a disaster affecting any part of its housing stock.
Although it was not formally part of the response, either as a responder under the Act or under RBKC’s emergency plan, the TMO threw itself into the response and helped to provide support, insofar as it was equipped to do so. It attracted a great deal of criticism from various quarters for its actions and omissions in the days following the fire, not all of it fair. We can understand why the hostile attitude of the residents towards it led Mr Barradell to keep it at arm’s length, but we think that some of those within government who criticised it did not properly understand its position or the scope of its powers. There was a tendency to view it simply as a part of RBKC, which was seen quite quickly as a failing authority. Many of the difficulties encountered in returning residents to flats in the Walkways were not of its making. We think that to some extent it was convenient for London Gold and RBKC to leave solving the problems associated with restoring the Walkways to a habitable condition to the TMO. In our view Teresa Brown and her team, who went to some of the rest centres on 14 June 2017 to give what help they could, are to be commended for their willingness to become directly involved and the efforts they made at what was a very difficult time.
The people who emerge from the events with the greatest credit are the members of the local community, who, with the support of local voluntary organisations, provided support in the hours immediately following the fire when the authorities were conspicuous by their absence. Although their willingness and ability to organise themselves effectively at short notice may have been exceptional, and is deserving of the highest praise, we think it likely that many local communities would rise to the challenge if the opportunity presented itself. The ability to harness the energy, skills and goodwill of the community should not be overlooked when planning an emergency response.
In the Phase 1 report the Chairman concluded that, although there were many different factors, the main reason why the flames spread so rapidly up Grenfell Tower was the presence of ACM panels with polyethylene cores which melted and acted as a source of fuel for the growing fire. He also concluded that it was more likely than not that the presence of polyisocyanurate (PIR) and phenolic foam insulation contributed to the rate and extent of the vertical spread of flame, but that it was not possible at that stage to quantify their respective contributions.[2063] He indicated that further work would be done during Phase 2 to gain a better understanding of how the materials behaved in conjunction with each other when exposed to fire. Further work also needed to be done to understand the extent to which exposed edges of the ACM panels and insulation boards may have contributed to the spread of flame.[2064]
In order to reach a better understanding of those matters, at our request a series of experiments was devised by Professors Bisby and Torero which were carried out by Professor Bisby and his colleagues at Edinburgh University. They included testing each material or product in isolation in order to understand its particular burning characteristics, followed by the testing of a series of models designed to shed light on the behaviour in fire of a ventilated rainscreen external wall system containing materials of the kind used on Grenfell Tower. The experiments were designed to enable them to identify the properties of both the individual constituents and the system as a whole that were most relevant to the growth and spread of fire at Grenfell Tower.
The work carried out by Professors Bisby and Torero is described in detail in their reports.[2065] Professor Bisby also gave oral evidence about it.[2066] In the space available to us we cannot describe their work in detail, but we have sought to draw out the important conclusions that emerge from their experiments. We are extremely grateful to Professor Bisby and Professor Torero and to all the others who were involved in helping with the experiments. The work they have produced is immensely valuable and helps to explain what caused the rapid spread of flame over the external wall of Grenfell Tower. We hope that the information derived from their experiments will assist others who may be designing ventilated rainscreen walls in the future.
At the end of Phase 1 there remained a degree of uncertainty about the mechanism by which the fire escaped from the kitchen of Flat 16 into the external wall as a result of a reconstruction carried out by BRE. The chairman indicated that when the full information had become available he would ask Professor Bisby and Professor Torero to prepare supplementary reports. That they have since done, as described in Chapter 110.
In his Materials Testing Report[2067] Professor Bisby described the tests carried out under his supervision on a number of the important materials and products used in the external cladding system at Grenfell Tower. They included:
The purpose of the tests was to record fundamental physical information about the materials and products and to assess their key characteristics and properties in fire.[2069] In particular, the testing aimed to quantify the thermal responses of the materials and thereby to provide information that would be relevant to understanding the contribution of each material to ignition, fire growth and fire spread during the fire at Grenfell Tower.[2070] The tests were undertaken both at the University of Edinburgh by Professor Bisby and, to a more limited extent, by BRE.[2071]
Four methods of thermal analysis testing were used.[2072] Each of them subjected a material or product to heat in a controlled environment and measured the changes that took place in various properties of the material during the heating process.[2073] We explain briefly below the information provided by each of the four methods.
The tests disclosed no unexpected results, given the properties of the materials tested and the information available on similar materials.[2077] Nothing in Professor Bisby’s work was challenged and we accept the validity of his conclusions.
In his report Work Package 1 – Regimes of Burning[2078] Professor Bisby assessed how each of the four products used in Grenfell Tower’s external wall responded to fire when tested in isolation. Over 150 separate experiments were carried out as part of that exercise.[2079] They were directed to demonstrating and understanding the complexity of the products’ response to heating (both thermal and mechanical) under a range of heating and fixing conditions. The work was also intended to develop an understanding of the various thermal and mechanical factors that were relevant to the subsequent system experiments, to provide an understanding of how the different products burned under different conditions and to provide additional background information.[2080] The tests were designed to answer questions relevant to quantifying the contributions of different products to the spread of fire at Grenfell Tower.[2081]
The report contains a detailed description of the responses of the four products to heating that we do not repeat here. (Those who are interested can read Professor Bisby’s report on the Inquiry’s website.) Instead, we list the important conclusions to be drawn from that work, taking each of the four products in turn. Again, nothing in Professor Bisby’s work was challenged and we accept the validity of his conclusions.
Although Reynobond ACM PE was the most difficult of the products to ignite,[2082] once ignited it released energy more rapidly than any of the others and released more energy per unit area than any of the other products.[2083] It had the highest heat of combustion[2084] and was the largest potential contributor to energy release in the external wall system at Grenfell Tower.[2085] Of the four products, it had the greatest potential to contribute to fire growth and spread by a substantial margin, contributing up to 59% of the total energy available on any given floor of the tower, calculated by reference to the density of the different materials used, the energy they contained per square metre and their approximate area on each floor.[2086]
In most of the experiments the bulk of the core of the product melted during heating and dripped downwards, flaming as it did so, collecting in burning pools on any available horizontal surfaces.[2087]
The colour of the core did not affect the heat of combustion, with no material difference being observed between the products with clear and black cores.[2088] Although the method of fixing in the tests did not materially influence the time it took for the panels to ignite,[2089] it did significantly influence the rate of burning and the rate at which heat was released by the product.[2090] The method of fixing also had a substantial influence on the extent to which the core of the product burned in place within the panels or dripped and flowed downwards.[2091]
Overall, Professor Bisby’s tests confirmed that Reynobond ACM PE was the most influential product for promoting external fire spread across the system, in that the amount of energy released and the speed at which it was released were directly related to the rate and extent of external fire spread.[2092]
This product was tested both with and without foil facers and the presence of the facer made a major difference to the way in which the product burned.[2093] The foil facers provided protection to the core of the product,[2094] which was comparatively difficult to ignite when tested in that form. When tested without a foil facer, however, it displayed a very low time to ignition and was comparatively easy to ignite.[2095] The foam core of the product itself displayed a substantially lower heat of combustion than either Reynobond ACM PE or the Aluglaze infill panels.[2096]
Once ignited, RS5000 had a much lower heat release rate per unit area than Reynobond ACM PE,[2097] both with and without foil facers in place.[2098] That was due to the fact that thermosetting polymer foams, including polyisocyanurate foam, form a layer of char[2099] and do not drip or melt.[2100] When tested, RS5000 showed a gradual thermal decomposition in response to sustained heat, with a layer of char forming that cracked[2101] and a low heat release rate.[2102] The periods over which that occurred were longer than those of external fire spread.[2103] Nonetheless, of the four products tested, RS5000 was the second highest contributor (38%) to the available energy per floor at Grenfell Tower.[2104]
When K15 was tested without its foil facers, it was relatively easy to ignite. With the foil facers in place, the time to ignition was significantly extended[2105] but was still shorter than that of RS5000 with foil facers.[2106] That was due to the presence of tiny perforations in the foil facers of K15[2107] that were not present in the facers of RS5000 and increased its reaction to fire[2108] by allowing the release of flammable products.[2109]
The heat of combustion of the phenolic foam core of K15 was comparable to that of RS5000,[2110] and was substantially lower than that of both the Reynobond rainscreen panels and the Aluglaze infill panels.[2111] As in the case of RS5000, once ignited, K15 exhibited a far lower heat release rate than Reynobond, both with and without foil facers.[2112] It also exhibited a sustained, gradual thermal decomposition,[2113] with a layer of char forming[2114] at a rate slower than external fire spread.[2115] Unlike RS5000, K15 showed some glowing[2116] and spalling, the latter resulting in hot fragments of phenolic foam being ejected.[2117] If it had been installed on Grenfell Tower in place of RS5000, it would have been the second largest potential contributor to the available energy per floor (39%).[2118] It is worth bearing in mind that K15 accounted for only some 5% of the insulation used in the external wall of Grenfell Tower. It is not known exactly where on the tower it was placed.
Although the extruded polystyrene core of the Aluglaze panels was comparatively easy to ignite[2119] and had both a higher heat of combustion[2120] and a higher heat release rate[2121] than either RS5000 or Kingspan K15, the maximum potential energy contribution from the Aluglaze panels was very small (2-3%).[2122] For that reason, they were not used in the experiments[2123] to which we refer below.
The configuration of the equipment used for the system experiments was intended to represent, in broad terms, a ventilated cladding system such as that installed at Grenfell Tower.[2124] It is described in detail by Professor Bisby in his report entitled Work Package 2 – System Interactions.[2125] It consisted of an open-sided ventilated cavity created by placing a Reynobond ACM PE panel opposite various different materials, mostly insulation products. The overall size of the panel was 50cm wide by 100cm tall, being the maximum size which could be safely accommodated in the laboratory at Edinburgh.[2126] A propane line burner, (essentially a metal pipe with small holes in it which allowed the size of the initial flames to be controlled)[2127] was used to heat and ignite the polyethylene core of the panel before being removed. The fire was then allowed to grow or extinguish itself without further intervention and a range of data was collected from each experiment.[2128]
The following figure taken from Professor Bisby’s report shows the experimental equipment ready for testing.[2129]
The apparatus used in the experiments was designed to deliver consistent and repeatable results and to allow a systematic exploration of the relative contributions of the different products to the fire.[2130] The main point of interest was how a fire involving the Reynobond developed and the factors that influenced it. There were two particular physical processes that it was thought would be of importance:
Once the polyethylene begins to melt, flow and ignite a complex heat transfer process occurs within the system. Energy is conducted away from the localised source of heat due to the high thermal conductivity of the aluminium skins,[2132] leading to the melting and involvement of ever greater quantities of polyethylene that then becomes available to burn. The process continues to release more energy than is required to melt and mobilise the polyethylene, leading to the growth of the fire.[2133] However, energy is also lost from the system and it is possible that losses due to conduction, radiation and convection can mean that the temperature of the panels cannot rise rapidly or may decrease, leading to the extinction of the fire.[2134] Understanding the factors that affect the release of energy is fundamental to understanding whether an ACM product will burn in any given situation.[2135]
The release of energy is also affected by two other important factors: (1) the size and shape of the rainscreen cavity and (2) other materials and products (whether combustible or not) in the system, including the insulation.[2136] In the case of a rainscreen cavity, the reduction in the area available for the entrainment of air typically results in longer flames than would be observed in a similar fire in the open air, which leads to the heating of a larger area with the potential for additional heat release and fire growth.[2137] In addition, the particular properties of the material forming the internal face of the cavity opposite the rainscreen panel determines the amount of thermal energy transferred back to the panels, either by reflection (e.g. from a foil facer)[2138] or as a result of ignition and burning which contributes additional energy to the system.[2139]
The experiments were intended to answer a number of important questions, including:
It is important to emphasise that the purpose of the experiments was to study the physical processes that might be relevant to the spread of fire at the tower, not to reproduce the tower on a small scale or to rate the products.[2141] The experiments were directed to the spread of flames in a vertical direction only and no attempt was made to assess the spread of fire horizontally or downward.[2142] All the tests carried out by Professor Bisby were designed specifically for the purpose because none of the standard tests was capable of providing the information he needed.[2143]
The experiments focused on testing the following four products:
Mineral wool insulation was used both for comparative purposes and to establish the fundamental thermal and physical processes leading to the upward spread of fire over the external wall.[2144]
Experiments were also performed with a water-cooled steel plate replacing the insulation (referred to in the report as a “heat sink cavity”) and without any cavity at all.[2145] Experiments were also carried out with different fixing arrangements for the panels. They included one with edge-routing to simulate cassette fixing and one with edge-routing and face riveting to simulate riveted fixing. Rivets passing through the panel were expected to hold the aluminium skins in place in the early stages of a fire.[2146]
Professor Bisby did not include the Aluglaze window infill panels in his experiments because they were not part of any continuous ventilated cavity at Grenfell Tower and were not thought to have played an important role in the spread of fire.[2147]
Initial experiments carried out at Edinburgh demonstrated the importance of five important matters that affect the development of fires in cladding systems and that Professor Bisby and his team subsequently set out to control and vary in order to understand the behaviour of the system as a whole. They were:
The important factors influencing the growth and speed of fire within a cladding system were found to be (i) the amount of downwardly mobile polyethylene, (ii) the locations where it could pool and burn and (iii) the surface area of the resulting pool fire and hence its heat release rate.[2148] In addition, a number of important forms of mechanical behaviour were observed when the panels were heated, including warping of the aluminium skins and partial or full separation of the aluminium skins leading to exposure of the polyethylene core.[2149]
The extent to which the insulation provided thermal feedback to the panels was another important factor leading to the growth and spread of fire within the cladding system.[2150] When heated to above their pyrolysis temperatures both Celotex RS5000 and Kingspan K15 produced combustible products which would burn within the cladding cavity, increasing the overall heat release rate and also potentially contributing to surface flaming of the insulation. That, in turn, influenced the thermal feedback to the panels and the growth and spread of fire within the system. To understand that better, experiments were performed with insulation products both with and without their foil facers.[2151]
The extent to which heat was lost from the cavity by convection, radiation or conduction heat transfer mechanisms was likely to influence the growth and spread of the fire and therefore some experiments were performed without a cavity.[2152]
Over 50 separate experiments were conducted in total, producing a large volume of data.[2153] In his report Professor Bisby described one of the experiments (Experiment 21) in detail because it exemplified a number of important processes that had been observed in some of the experiments and were of critical importance for Grenfell Tower. He also summarised what the data showed, both generally and with reference to the thermal and physical behaviour associated with each product and constituent material and the interactions between them.[2154] We have adopted the same structure in this part of our report, although readers should refer to the detailed information set out in Professor Bisby’s report and in the accompanying videos for a full explanation of the results of the experiments.
Experiment 21 was performed on a cladding arrangement using an ACM PE panel with a routed (i.e. cassette-type) fixing and foil-faced Kingspan K15 insulation.[2155] A number of key observations were made during the experiments,[2156] of which the following were the most important:
When considering the data from all 50 experiments, it became apparent that not all of the tests had resulted in the full involvement of the panels. For example, the experiments carried out without a cavity, those carried out with a heat sink cavity and those in which the panel was riveted at its base did not progress to full involvement. In those cases, the peak heat release rate, the insulation mass loss and the total heat released were much lower than in all those cases in which full involvement of the panel had occurred.[2161]
In those cases in which the panel did become fully involved in the fire some differences were observed in the magnitude of the peak heat release rate, the times taken to reach peak heat release rate, the mass of insulation lost and the total heat released.[2162] Those differences are discussed further below.
In the absence of a cavity, the polyethylene core of the ACM panel melted, dripped and ignited locally while the line burner was in place. However, the resulting pool fire failed to release enough energy to ensure that the energy retained within the system was sufficient for the temperature of the panel to increase at a distance from its base. As a result, insufficient polyethylene was mobilised to sustain continued burning and the growth of the fire and the fire extinguished itself when the line burner was removed.[2163] That demonstrated that a source of energy additional to that provided by the ignition of the polyethylene was required before localised burning of the polyethylene would lead to the delamination of the panels and full involvement of the core.[2164]
The introduction of a cavity in which a heat sink formed the internal face of the system resulted in minor increases in the feedback of heat to the panel and only a slight increase in the melting and mobilisation of the polyethylene core. That was caused by a slight increase in the height of the flames when they were small due to changes in air movements as well as the reflection of radiant heat.[2165] However, in none of those experiments did the panel become fully involved in the fire. That showed that the presence of a cavity was not by itself sufficient to cause the fire to develop.[2166] Insulation also needed to be present, either to retain energy in the system or to burn and contribute additional energy.[2167]
The incorporation into the system of non-combustible insulation in the form of mineral wool resulted in the growth of the fire to full involvement of the panel because the insulation retained sufficient energy within the system to raise the temperature of the panel to the necessary level. Once the panel became fully involved there was a rapid increase in the heat release rate and in the total heat released. That demonstrated that it is not necessary for the insulation to burn in order for a fire to grow to the point at which the panels are fully involved.[2168] It also suggests that the critical factor in the development of a fire is the extent to which energy is retained in the system. Energy transmitted back to the panels supports continued heating, melting and the involvement of the polyethylene core and the deformation of the aluminium skins, which in turn increases the surface area of the burning polyethylene.
The experiments showed that, by comparison with mineral wool, combustible foam insulation, whether PIR or phenolic, did not significantly increase the heat release rate or peak heat release rate of the system or the total heat released. However, the time taken to reach full involvement of the panels was shorter in the case of foam insulation (between 5 and 7 minutes) than in the case of mineral wool (between 10 and 12 minutes),[2169] primarily due to the ignition and surface flaming of the foam insulation, which both released additional heat and caused more uniform heating of the panel. As a result, the inner skin of the panel failed earlier, exposing a larger surface of polyethylene to burning.[2170] The combustibility of PIR and phenolic foams can therefore be seen to play a role in influencing the growth and spread of fire, but its contribution is secondary both to the burning of the polyethylene and to the insulating properties of the insulation.[2171]
In the experiments carried out using Celotex RS5000 the behaviour of the system did not appear to be affected by the thickness of the material, which varied between 80mm and 100mm.[2172] The behaviour of systems incorporating Celotex RS5000 (a PIR foam) was broadly similar to that of systems incorporating Kingspan K15 (a phenolic foam), although there were subtle differences in the amounts of spalling observed and Kingspan K15 continued to smoulder after the ACM had burned itself out.[2173] That propensity to continue smouldering differentiated the phenolic foam from the PIR foam[2174] and both the total loss of mass and the total heat release of the system were higher when it incorporated phenolic insulation.[2175]
Adding a foil facer to the mineral wool insulation resulted in a significant reduction in the time required for the fire to grow to the full involvement of the panel, a slight reduction in the amount of mass lost by the insulation up to that point, an increase in the temperatures within the panel and a very slight reduction in the total heat released. The introduction of the foil facer increased the reflective properties of the insulation, resulting in more rapid heating of the panel at a distance from the burning polyethylene at its base. The introduction of the foil facer also changed the surface properties of the insulation, including by promoting heat transfer by convection into the cavity.[2176]
Adding foil facers to RS5000 and K15 resulted in a clear increase in the time required to reach full involvement of the ACM, a reduction in the peak heat release rate (but without a major reduction in the total heat released), a clear reduction in the rate at which the insulation lost mass and a reduction in the temperatures measured at the midpoint of the panel.[2177] Professor Bisby concluded that the addition of the foil facers prevented early surface flaming of the insulation, thus reducing the early heating of the panel at a distance from the polyethylene pool fire at its base. The absence of surface flaming also resulted in less uniform heating of the inside face of the panel, a less symmetrical fire plume within the cavity and a more gradual compromising of the panel’s inside face. That tended to prevent the sudden exposure of a large area of polyethylene and promoted a more gradual release of energy as it burned.[2178]
In the case of Celotex RS5000, the addition of a foil facer resulted in a small reduction in the total mass lost. However, contrary to what might have been expected, the foil facer on Kingspan K15 promoted smouldering after the panel had burnt out,[2179] which explains a slightly greater loss of mass than when no foil facer was present.[2180]
Those experiments again demonstrate the complexity of the process of heat transfer in a rainscreen cladding cavity. They also suggest that an intuitive view of the factors that govern the initiation, growth and spread of fire in such situations may lead to incorrect conclusions.[2181]
Professor Bisby’s experiments showed that the method of fixing ACM panels is capable of fundamentally altering their response to fire.
The inclusion of aluminium rivets passing through both faces over the lower third of the panel prevented the fire reaching the point at which the panel became fully involved. The rivets held the aluminium skins together and prevented the panel opening up. That reduced the area of polyethylene exposed to the fire and also discouraged its mobilisation into the drip tray, slowing and reducing the supply of fuel to the pool fire burning at the base of the panel.[2182] However, if the rivets were placed higher up the panel they did not prevent the separation of the panels lower down, which led to a very sudden loss of integrity, exposure of the polyethylene and a high peak heat release rate.[2183] All this indicates that riveting ACM panels would be likely to improve their performance in fire under most (but not all) circumstances,[2184] but that the number and location of the rivets are important in enabling them to slow or prevent the growth of fire.[2185] The behaviour of the panel in riveted form is to be contrasted with that of the panel in simulated cassette form as demonstrated in Experiment 21, described above.
In the case of the panels in simulated cassette form, the creation of additional routing lines on the inside faces resulted in a reduction in the time taken to reach full involvement in the fire and higher peak heat release rates. Professor Bisby attributed that to the fact that the increased amount of routing provided additional opportunities for the polyethylene to become involved in the fire and increased the propensity of the skins to separate, thereby exposing a larger area of polyethylene to the flames. That resulted in an increase in the rate of fire growth and made its development to the point of the full involvement of the panel more likely and more rapid.[2186] Accordingly, the routing of ACM panels for the purpose of cassette fixing made their fire performance worse.[2187]
The evidence obtained from Professor Bisby’s experiments provides further support for our understanding of why systems incorporating cassette-fixed ACM panels performed far worse when subjected to the European single burning item test (BS EN 13823) than those incorporating rivet-fixed panels.[2188] The differences in fire performance between the two fixing types again emphasises the complex way in which even simple systems respond to fire and the potential significance of what appear to be minor changes in methods of mounting and fixing.[2189]
The results of Professor Bisby’s experiments support the main conclusion reached by the chairman in the Phase 1 report, namely, that the principal reason why the flames spread so rapidly up Grenfell Tower was the presence of ACM panels with polyethylene cores which had a high calorific value, melted and acted as a source of fuel for the growing fire.[2190] It is clear from the experiments that the principal factor which led to rapid growth of fire was the presence of unmodified polyethylene in the cores of the ACM panels, with its propensity to melt, drip and act as the primary source of fuel for the fire.[2191] It was the burning of the polyethylene, rather than the burning of the insulation, which by a considerable margin determined how the external wall of the tower performed.[2192] In the words of Professor Bisby, ACM panels represent an extreme fire hazard, given their intense burning properties. We were struck by his evidence that every time he ran an experiment which led to the full involvement of the ACM he was surprised and alarmed.[2193]
The experiments also support the conclusion in the Phase 1 report[2194] that it was more likely than not that the presence of PIR and phenolic foam insulation contributed to the rate and extent to which the flames spread vertically.[2195] However, it is now possible to be more specific about the precise contribution made by the insulation. In particular, the results of the experiments suggest that, although the contribution made by the insulation (with foil facers) to the total heat released during the period before the full involvement of the ACM is comparatively minor, representing less than 15% of the total energy released,[2196] it is the ability of the insulation to retain energy within the system and promote more rapid heating of the ACM that is the decisive factor in promoting the growth of fire.[2197] PIR and phenolic foam products are exceptionally good insulators, a property that made matters much worse once fire had entered the rainscreen cladding.[2198] That is why the experiments involving mineral wool also led to the full involvement of the ACM, because it too retains heat within the system and promotes rapid and extensive heating of the panels. It is not necessary for the insulation to be combustible for it to be capable of promoting the rapid and extensive growth of fire.[2199]
It should be noted that when they did not have foil facers, the contribution of the insulation products to heat release rates was much higher and was comparable to that of the panels. It follows that, in the absence of foil facers, the contribution to a fire of the energy released through the burning of the insulation may be significant.[2200]
The answers to the questions posed by Professor Bisby, therefore, are that it was not the presence of the cavity that caused the panels to burn with such vigour[2201] nor the burning of the combustible insulation products,[2202] but the fact that the cavity was very well insulated.[2203]
The information obtained from the experiments support the following conclusions about the fire performance of rainscreen cladding systems incorporating ACM panels with unmodified polyethylene cores of the kind used on Grenfell Tower:
Nothing we have said in this chapter affects the chairman’s previous conclusions about how the fire escaped from Flat 16 or the particular materials or physical processes that may have enabled that to occur.[2210] Professors Bisby and Torero were not asked to investigate the nature, amount or toxicity of the smoke emitted by any of the materials they examined under any conditions of burning.[2211]
In Chapter 22 of the Phase 1 Report the Chairman considered the process by which the fire escaped from the kitchen of Flat 16 at Grenfell Tower and entered the external wall. Based on the evidence available at the time, he concluded that it had escaped in one or other of two ways: either by flames passing through the cavity around the column following the collapse of the uPVC window jambs, or by flames passing through the open window and impinging on the rainscreen panels directly above.[2212] Although the video evidence was more consistent with the former mechanism, the latter might also have played a significant role.[2213] Ultimately, however, that was of little significance, because in both cases it was the proximity of combustible materials to the interior of the compartment that allowed the fire to spread.[2214]
In June 2019 the Metropolitan Police Service provided the chairman with a copy of a report dated 24 May 2019 by BRE of a large-scale reconstruction of the fire in Flat 16 that it had carried out and the conclusions it had drawn from it.[2215] The reconstruction sought to reproduce as accurately as possible the configuration and contents of the flat immediately before the fire and two storeys of the external wall above. Based solely on the results of that reconstruction, BRE concluded that the fire had probably spread to the external wall through the extractor fan and the window infill panel in which it had been mounted, igniting the exposed edge of the polyethylene core of the panel above the window. The second most likely route was through the construction around the window.[2216]
The chairman indicated in the Phase 1 report that once full information had become available from the reconstruction he would ask Professor Torero and Professor Bisby to prepare short supplemental reports explaining whether it caused them to alter or refine the views they had expressed during Phase 1. He also indicated that he was willing to receive submissions from core participants on the relevance of the reconstruction during Phase 2. In those circumstances, the findings made in Chapter 22 of the Phase 1 report remained provisional and subject to revision in this report.[2217]
Professor Torero and Professor Bisby both considered the reconstruction report for the purposes of Phase 2[2218] and Professor Torero also dealt with it in the course of his oral evidence.[2219] He explained that even a large-scale test which attempted to reproduce the original construction and contents of Flat 16 as faithfully as possible could not accurately reproduce the evolution of the fire, since very minor changes in variable factors, including ventilation and fuel content, can result in very different outcomes.[2220] He also analysed the fire created in the test and compared it with what is known about the evolution of the fire at Grenfell Tower, including the significant stages of its development. He concluded that the fire in the reconstruction was completely different from the fire that occurred in Flat 16 and that it was not possible to establish why its behaviour was so different.[2221] In particular, the fire in the reconstruction had developed more quickly and had become hotter, with key events occurring at different times,[2222] and had eventually reached flashover.[2223] As a result the materials around the window affected by the fire behaved differently during the reconstruction. That included the uPVC window surrounds, which are likely to have charred rather than deformed due to the sudden increase in temperature seen during the reconstruction. In those circumstances, the reconstruction represented a fire of a very different kind and did not cause him to change the opinions he had expressed in his previous evidence.[2224]
Professor Bisby was of the same view. He also emphasised that large-scale reconstructions are extraordinarily complex and that their outcomes are influenced by a range of factors that are difficult, if not impossible, to control. They include small differences in the type, amount and distribution of fuel within the compartment, the initial ventilation conditions, the creation of additional ventilation as a consequence of the fire (for example, through windows breaking) and the effects of wind. All those, and other, factors could alter drastically the progress of a fire.[2225] As a result, a reconstruction could only demonstrate what could happen, not what did happen.[2226]
Professor Bisby agreed with Professor Torero that BRE’s large-scale reconstruction created a fire that was inconsistent with the available evidence of what had occurred in Flat 16.[2227] He also made it clear that only by conducting a detailed analysis of the sensitivity of the reconstruction to various different factors (which was not possible given the limited data available from the reconstruction) could any conclusions be drawn about the relevance of what had been observed in the reconstruction.[2228] In those circumstances he concluded that the reconstruction did not provide any information that contradicted the evidence he had given during Phase 1 or cause him to alter his views.[2229]
We accept the unchallenged evidence of Professor Torero and Professor Bisby that the fire created in the BRE reconstruction differed significantly from the fire that occurred in the kitchen of Flat 16. Since the reconstruction did not lead either of them to revise his original opinion, there is no reason for us to depart from the provisional conclusions reached by the chairman in Chapter 22 of the Phase 1 report. Accordingly, they now represent our final conclusions on the means by which the fire escaped from Flat 16.
For many years a variety of tests has existed for measuring the performance of materials in response to fire, ranging from small-scale laboratory tests up to full-scale tests of the kind described in the BS 8414 series. We have referred in earlier chapters of our report to some of those that are most widely used. No tests were carried out specifically on the combination of materials used in the refurbishment of Grenfell Tower or on the proposed external wall system, but those responsible for the choice of materials and the design of the external wall relied indirectly on results of some of the standard tests because they were referred to in the BBA certificate relating to Reynobond. They also relied on a widespread misunderstanding, not helped by poor guidance in Approved Document B, that any material with a Class 0 surface was suitable for use in the external wall of a high-rise building.
In those circumstances we think it is appropriate to consider whether the established tests, in particular BS 476 Parts 6 and 7, the results of which support the Class 0 classification, the European classification system or BS 8414 Parts 1 and 2, which contain the test methods for full-scale testing of external wall systems, are capable of providing the information that is required to enable designers to assess compliance with functional requirement B4(1). Any discussion of that question calls for an understanding of technical matters of a kind that is possessed only by those who are experts in the field. We have had the benefit of receiving reports and hearing evidence from three leading experts, Professor José Torero,[2230] Professor Luke Bisby,[2231] and Dr Barbara Lane,[2232] all of whose evidence is available on our website. None of their evidence in relation to testing was challenged and we therefore feel justified in accepting it in full. It is lengthy and complex, but we would urge the government and any others who have an interest in or responsibility for testing the performance in fire of materials and products used in the construction industry to read it in full. For the purpose of this report, however, we have attempted to summarise in our own words those parts that are of particular relevance to the refurbishment of Grenfell Tower.
Every new building of any complexity, and certainly every high-rise building, should have a fire safety strategy created at the time of its original construction or as soon as possible thereafter. It is important to recognise that testing of materials for their performance in fire has to be related to the fire safety strategy for the particular building. It is the responsibility of those who design the building, including the external wall, to ensure that the information obtained from that testing is correctly used in the development of the fire safety strategy.[2233] In England and Wales the contents of the fire safety strategy are ultimately dictated by the functional requirements in Schedule 1 to the Building Regulations, which must be reflected in performance requirements appropriate to the building in question.[2234] It follows that the performance of the materials intended to be used will need to be assessed with the particular fire safety strategy in mind. Thus, in a building with a “stay put” strategy for responding to fire, no significant spread of fire beyond the compartment of origin can be tolerated,[2235] whereas in a building with a controlled evacuation strategy some spread of fire can be tolerated, provided it is compatible with the ability of the occupants to escape.[2236]
The processes affecting the spread of flame vertically are complex and depend on a number of factors, including the properties of the materials exposed to the flame, the rate at which combustible gases are produced and their propensity to transfer sufficient heat to perpetuate the flame and ignite adjacent material.[2237] Two approaches to making such an assessment may be taken: one is to assess the likely velocity of flame spread; the other is to assess whether the flame is likely to be extinguished.
Fire engineers have tools at their disposal for assessing the speed at which flames are likely to spread over a building’s external wall system. Simple methods can be used for the assessment of very simple systems and can be applied in a very conservative manner, although they may be better suited to ranking materials rather than to obtaining an understanding of how a system is likely to perform.[2238] Complex computational models can also be used.[2239] In all cases some simplification is required and certain assumptions must be made and a high degree of skill and experience is required to use the tools effectively.[2240]
Although some external wall systems continue to support burning and the spread of flame after an external source of heat has been removed, others that exhibit only small differences do not, with the result that the fire goes out.[2241]
A good example is provided by small differences in the degree of exposure to flame of the polyethylene core of an ACM PE panel in an insulated rainscreen system. As demonstrated by the experiments conducted by Professor Bisby and his colleagues at Edinburgh University, the extent to which the core is exposed to flame, which in turn depends on the fixing arrangements, has a significant effect on whether the panels sustain continuous flaming or the flames die out.[2242]
A material that is non-combustible will not catch fire, regardless of the temperature to which the surface is raised.[2243] It will not support ignition and therefore there will be no flames. A fire within a compartment can impose a heat flux in the order of 100kW/m² on the external walls. If the materials do not support ignition when exposed to a heat flux of that magnitude, they can be regarded as non-combustible.[2244]
It is very difficult to judge whether a combustible material will continue to burn when the source of heat is removed because it is necessary to assess whether sufficient heat is likely to be transferred ahead of the flame to sustain burning.[2245] However, there are currently no models that will accurately predict that and therefore it is necessary to test individual samples. Precision is essential because small changes in materials or the system as a whole can have a significant effect on the outcome. That makes any assessment of whether, and if so when, extinction will occur much more difficult.[2246]
Innovative techniques in the construction industry have added to the difficulty of assessing the fire performance of an external wall. One such technique is “encapsulation” in which a combustible material is enclosed in a non-combustible outer skin in a way that is intended to ensure that ignition cannot occur. It may involve full encapsulation, in which the combustible material is protected on all sides or partial encapsulation, in which the combustible material is exposed at the edges.[2247] Certain materials used for encapsulation, such as aluminium, have very high thermal conductivity and therefore will dissipate heat from an external source. If the heat is dissipated quickly, the combustible material may not reach the point of ignition and the exposed edges may not give rise to flaming.[2248]
A number of factors influence whether encapsulation will prevent ignition and the consequent risk of flames spreading. They include:
Assessing the performance of an external wall incorporating materials of that kind is more complicated than just modelling the spread of flame because it must take into account all the factors affecting the spread of flame, as well as factors affecting the physical behaviour of the system. As a result, it is necessary to carry out detailed and comprehensive testing of the system to identify the different kinds of mechanical failure that may occur and the conditions which induce them.[2250]
Although tools and models exist that can enable an assessment to be made of the spread of flames vertically over a flat surface, less attention has been given to the spread of flames within cavities. The width of the cavity plays an important part in determining the rate at which flames spread through it and increased rates at which flames have spread can be explained by the presence of open vertical channels which create chimney effects leading to increased burning of combustible material.[2251]
If the width of the cavity exceeds a certain size, however, the transfer of heat from one side to the other and an increase in the rate at which heat is transferred upwards both disappear. Flames then spread at a rate similar to that at which they spread over a flat surface. Conversely, if the width of the cavity falls below a certain size, thermal expansion of the gases interrupts the general flow of air and the flames cease to spread internally.[2252]
As Professor Bisby’s experiments demonstrated,[2253] an external wall system incorporating ACM PE panels contains many features that add to the difficulty of assessing its fire performance. They include:
Modern cladding systems include many other complexities, including cavity barriers, complex geometries and intumescent sealants, and very careful analysis is necessary to establish their probable fire performance.[2255] It is misguided to think that the only way to assess their performance accurately is to conduct a large-scale test that is representative of the worst circumstances likely to be encountered in practice. Although there may be some value in tests of that kind, the results are extremely difficult to interpret and it is therefore important that those who are responsible for carrying them out have a detailed understanding of the processes involved and the means by which failure can occur before they are undertaken.
The complexity of the processes involved in assessing the performance of an external wall was demonstrated by the simplified tests carried out by Professor Bisby and his team on aspects of the external wall system of Grenfell Tower.[2256] He was able to identify some of the features of the system that significantly affected its performance in fire, including the significant differences between the performance of riveted panels and that of cassette-fixed panels and between foil-faced and non-foil-faced insulation.[2257] We refer to the information obtained from those tests in a separate chapter,[2258] but for present purposes it is clear that it is possible for small- and medium-scale tests to yield useful results, provided their limits are properly understood.[2259]
Fire science and fire engineering are relatively new disciplines[2260] and the development of the science of fire testing has been somewhat sporadic. Tests have often been developed in response to external events or the advent of new technologies,[2261] rather than being driven by the desire for knowledge in its own right.[2262] For example, World War II led to the development of a test method to measure the effectiveness of certain products at resisting fires caused by incendiary bombs. That led to a series of full-scale tests in corridors lined with different types of wall-board which evolved to become the BS 476-7 method for testing the surface spread of flame.[2263]
At the time of the Grenfell Tower fire, Approved Document B recommended that the external surfaces of the walls of high-rise buildings should meet the provisions of Diagram 40. In the case of Grenfell Tower Diagram 40e provided that, above 18 metres from the ground, the external surfaces of the walls should satisfy national Class 0 or European Class B. The main tests supporting the national Class 0 classification are BS 476-6 (fire propagation) and BS 476-7 (surface spread of flame). Despite our investigations, no one was able to explain how tests designed to determine the fire performance of wall linings were adopted in Approved Document B (and the antecedent versions of that statutory guidance) to assess the performance of the external walls of high-rise buildings.
We have explained in Chapter 5 how those tests are carried out and what information and data is obtained from them. As is clear from those descriptions, neither test is apt to provide relevant information about the performance of a material or product in a fire in the external wall of a building.
Fire propagation testing to BS 476-6 was developed as a method of testing the reaction to fire of internal wall linings[2264] and is directed primarily to assessing the performance of the surface of the product being tested. The sample to be tested is board-shaped and mounted in the test apparatus so that the edges are not exposed. Consequently, if materials within the product are encapsulated in or simply covered by a flame-retardant coating, direct ignition of the underlying layer or core is prevented.[2265] Unless the outer surface or coating of the product burns through, so that the underlying layer is exposed, the test will not detect the presence of any combustible material in the core or lower layers.[2266]
The test was designed to represent the development of a fire within a room and its transition to flashover.[2267] It does not correspond to the development of a fire on the outside of a building[2268] and does not provide information about the heating length or the speed at which flames will spread.[2269] The derivation of the fire propagation index is convoluted and it is not possible to relate the values obtained from the test to practical experience.[2270] The test standard itself makes clear that the test has been designed to give comparative information on the performance of products in the early stages of a fire and that it should not be used for assessing the fire hazard under actual fire conditions.[2271] It is not possible to calculate the heat flux to which the sample is exposed during the test, so its performance cannot be related to any particular design conditions, e.g. where assumptions are being made about the level of exposure to heat that can be accommodated in the external wall.[2272] The small size of the sample also precludes any assessment of the thermo-mechanical behaviour of the product.[2273]
Testing in accordance with BS 476-7 for surface spread of flame was developed as a way of measuring the spread of fires within corridors, not the spread of fire over an external wall.[2274] It was first published in 1971 and was revised in 1987 and 1997,[2275] but its origins lie in World War II and the risks posed by incendiary bombs.[2276] The test measures the spread of flame horizontally rather than vertically. In a fire in the external wall of a building the spread of flame vertically is likely to be the primary mechanism of development and a material which may not easily support the spread of flame laterally could well be capable of enabling it to spread vertically, even in the absence of an external source of heat.[2277] That phenomenon was seen at Grenfell Tower. Fire spread rapidly up the east face of the building; the much slower spread of fire horizontally was driven primarily by a very particular feature of the building, namely the crown, which allowed molten polyethylene to drip down the walls.[2278]
Heat fluxes of up to 120 kW/m² can occur in fires involving the external walls of buildings, which is very much higher than that imposed by the test (5-32.5 kW/m²).[2279] The sample holder used for the test obscures the edges of the product, thereby ensuring that only the surface is exposed to the heat and that any materials below the surface are protected.[2280] In those circumstances, the results achieved in the test do not enable one to assess how an external wall incorporating the product would perform in response to a fire.[2281]
Accordingly, neither the BS 476-6 test method nor the BS 476-7 test method provides any of the information needed to make an assessment of the suitability of a product for use in the external wall of a high-rise building and it is therefore inappropriate to use them as a measure of the performance of an external wall in a fire.[2282] The tests are too simplistic for that purpose, particularly in relation to composite products, because they primarily assess the properties of the surface rather than what lies beneath it. For that reason they do not provide any information about the likely performance of ACM panels on external walls.[2283] As Dr Connolly of BRE concluded in 1994,[2284] the tests do not accurately reflect the fire hazards associated with cladding systems.[2285] It is unfortunate that the government did not take steps to remedy the situation in the years before the Grenfell Tower fire, in view of the fact that there were numerous opportunities to abandon reliance on national Class 0 as a standard by which the fire performance of materials proposed for use in external walls of high-rise buildings could be judged.[2286]
The tests supporting the European system for classifying the reaction to fire of construction products were intended to enable designers to identify construction products that prevented or slowed the development of a fire in a compartment so that flashover and a fully developed fire did not occur.[2287] The classification system was based on a test known as the “room corner test”, which involved lining a full-scale compartment with a product, igniting it and monitoring the development of the fire.[2288] A smaller and less costly version of that test, known as the “Single Burning Item” test,[2289] was subsequently developed and now underpins classifications A2 to D of the European classification system.
The single burning item test is a scenario test, that is, a test which seeks to reproduce a set of circumstances that are considered reasonably likely to be encountered in practice, in this case a fire in the corner of a compartment formed by the meeting of two walls.[2290] Unlike the national tests referred to above, the temperature and heat release measurements obtained during the test are potentially of some value to a fire engineer seeking information to assess the fire performance of the product when used on an external wall because they allow some assessment to be made of the way in which the speed of flame spread develops over time, together with the heat release rate.[2291]
An important difference, however, between a fire in a room and a fire in the external wall of a building is the magnitude of the heat flux. The burner which is used in the single burning item test delivers a maximum heat flux of less than 40kW/m², which is much less than could be expected in the case of a fire in an external wall of a building, which can generate a heat flux of up to 120 kW/m². Consequently, although poor performance of a product in the single burning item test can indicate poor performance in a fire in an external wall, the converse does not always hold true. A material which has performed well in the test may perform badly in an external wall fire.[2292]
Moreover, the way in which heat develops in the structure created for the purposes of the test will inevitably differ significantly from that in which it develops in an external fire. As the test progresses the speed at which the flames spread will accelerate due to the increase of the heat flux operating on the sample. In practice, that means that the flame on the sample will usually spread over its full height. The remaining flame spread, which may be influenced by the increased heat flux, is likely to occur in a horizontal direction where burning is still to occur. That again is different from what would occur in a fire in the external wall of a tall building, in which flames spreading vertically will normally provide the dominant mechanism by which the fire spreads.[2293]
For the purpose of the test the bottom and top edges of the product are clamped in place and therefore shielded from exposure to the heat. The junction between the panels is also held in place by a metal section. The only edges of the sample that are exposed are those which occur at any joints within the test specimen itself or at the sides (although they too may be shielded if that reflects the end-use application). Consequently, the test does not reproduce conditions encountered in practice[2294] and material enclosing a combustible core might survive the test but not a fire. In a real fire the product might burn vigorously, allowing a large amount of heat to be released instantaneously, thereby becoming a significant hazard.[2295] Moreover, the test is not intended to, and does not, produce any data that reflects the way in which the physical structure of the product responds to heat.[2296]
It follows that the European classifications which emerge from the single burning item test (i.e. classifications A2 to D) are of little assistance when assessing the performance of external wall systems.[2297]
We note that there was some disquiet within the fire community when the European classification system was introduced. Concern was expressed about whether the single burning item test could credibly classify some types of construction products. In particular, a steel-clad polystyrene sandwich panel was found to lead to flashover in the room corner test, but more than half the laboratories that carried out such tests reported a very low heat release rate in the single burning item test.[2298] That led to some adverse comments on the test[2299] and a warning that, when considering its use in the context of national regulatory systems, it was important that the link to the development of a fire in a compartment be maintained so that the test and the results obtained from it were used appropriately.[2300] However, in the years before the Grenfell Tower fire the construction industry and those with responsibility for the regulations lost sight of that link.
From 2000 onwards the statutory guidance in England and Wales on the construction of the external walls of high-rise buildings referred to large-scale testing as a way of demonstrating compliance with functional requirement B4(1) of the Building Regulations and readers were told that advice on the use of insulation in external walls could be found in BR 135. Later, in 2006, Approved Document B referred to BR 135 (second edition) and stated that external walls should either meet the guidance or comply with the performance criteria in BR 135 using full-scale test data from BS 8414.[2301] That guidance remained in place up to the Grenfell Tower fire.[2302]
The first edition of BR 135, published in 1988, described the development of a research programme incorporating large-scale testing. That programme is best understood as a series of large-scale experiments rather than the methodical development of a means of assessing the performance of external wall systems in fire.[2303] The objective was to “identify the design principles on which constructional recommendations might confidently be based”[2304] and the primary focus was on the use of combustible insulation in a cladding system.[2305] The problem addressed by the study was the risk of flames spreading over the surface of a wall and within cavities[2306] but that risk was wholly unquantified and was not related to any particular evacuation strategy. It was therefore necessary to assess the results of the test in each case and determine the extent to which the risk of flame spread was acceptable given the fire safety strategy for the building under consideration.[2307]
Three particular cladding systems were assessed for the purposes of the first edition of BR 135, a system containing insulation between an external layer of render and a masonry wall, a system incorporating expanded polystyrene insulation fixed to a masonry wall with an external facing of aluminium sheets, and a system of timber cladding of the kind traditionally used for low-rise buildings,[2308] and the recommendations reflected the structures and physical characteristics of those systems.[2309] Importantly, the exterior materials used in the first two systems were non-combustible (cementitious render and aluminium) and therefore no question of the spread of flame over the external surface of the wall arose.[2310]
The principal danger identified in the experiments was the elongation of flames within cavities and therefore many of the recommendations were directed to the provision of fire barriers within cavities.[2311] However, subsequent studies carried out by BRE showed that fire barriers were not completely effective.[2312] In this country attention appears to have been concentrated on cavity barriers, although little effort has been made to understand their effectiveness.[2313] Despite that, later editions of BR 135 continued to focus almost exclusively on the threat posed by the propagation of fire through cavities.[2314] The only direct reference to the risk of flames spreading over the external panels of external wall systems is to be found in one paragraph in the third edition of BR 135, published in 2013.[2315] It seems clear, therefore, that the concentration on cavity barriers as a means of limiting the spread of fire over external walls had its origin in BR 135 but was not based on a proper understanding of their benefits and limitations.
BR 135 sets out the criteria by which an external wall system is to be judged acceptable. However, it contains no explanation of those criteria nor any indication of what they are deemed to represent[2316] and it is a striking fact that none of the witnesses was able to explain their basis.[2317] Moreover, BR 135 itself does not attempt to relate the criteria to the requirements of the Building Regulations or the guidance contained in Approved Document B[2318] and the relevance of the criteria to practical experience has never been clearly articulated.[2319] As a result, it has been left up to those seeking to make use of the data derived from tests in accordance with BS 8414 to satisfy themselves that the system under consideration is suitable for the intended use.[2320] That is made clear in the third edition of BR 135, which states that the classification applies only to the system as tested and described in the classification report.[2321]
The BS 8414 test itself is unsatisfactory in other respects. Some materials, such as high-pressure laminate, do not reach their maximum temperatures until about 30 minutes after the start of the test; for such products the initial 15-minute assessment period is therefore too short to identify the risk they pose.[2322] A system incorporating panels of that kind might satisfy the performance criteria in BR 135 but still not comply with the functional requirements of the Building Regulations.
BR 135 also has its defects. For example, it contains no criteria relating to mechanical performance. Although it says that mechanical performance of the system should be taken into account as part of an overall assessment,[2323] it offers no guidance on how to evaluate it, although it is possible to formulate effective criteria.[2324]
Making use of BS 8414 and BR 135 to assess the performance of an external wall system involves the application of performance criteria based on the temperature reached at a level of two storeys above the fire compartment within 15 minutes of the start of the test. The main difficulty with that approach is that it is possible for a fire that has become established in the external wall of a building to spread in a way that poses a significant danger although the criteria are still met. A fire may therefore spread beyond the compartment of origin in a way that is incompatible with a “stay put” evacuation strategy even if the external wall system has satisfied the performance criteria in BR 135.[2325]
That difficulty does not appear to have been recognised by any of the lay witnesses, including those from DCLG or BRE.[2326] We obtained the clear impression that many in the industry thought that if, following a test in accordance with BS 8414, a system satisfied the criteria in BR 135, the building when completed would inevitably satisfy functional requirement B4(1) of the Building Regulations. Indeed, many failed to appreciate that the BS 8414 test applies only to the system as a whole and does not tell one anything about its individual components. It is a matter of concern that no one appears to have considered whether the extent of flame spread that could occur while still satisfying the performance criteria in BR 135 was consistent with the adoption of a stay put evacuation strategy.
Only a limited amount of information can be obtained from a BS 8414 test. In particular, it produces very little information that is relevant to important questions relating to external wall systems, such as the speed at which flames are likely to spread and whether they can be expected to die out naturally.[2327] In particular, the thermocouples forming part of the test equipment does not provide information about:
At best the BS 8414 test can indicate only whether it would be wholly inappropriate to make use of a particular system when constructing the external wall of a building.[2329] It was not designed to and does not provide technical information which, taken in isolation, can enable the designer to be confident that a particular system will adequately resist the spread of fire over the walls of the building. Put another way, failure to meet the performance criteria in BR 135 will demonstrate that a given system is unlikely to comply with functional requirement B4(1) of the Building Regulations, but the converse is not necessarily true: a given system might meet the performance criteria of BR 135 and yet fail to comply with the functional requirement.
We think it important to recognise that only a limited amount of information can be obtained from a BS 8414 test. It can never accurately reflect the conditions the building will encounter in use because there will inevitably be differences between the large-scale test and the building itself. [2330] A significant responsibility therefore rests on the shoulders of the person charged with assessing the significance of the results.[2331]
Until recently it has not been recognised as widely as should have been the case that the functional requirements of the Building Regulations alone determine the standards that have to be met. That may be due in part to the fact that the statutory guidance is framed in prescriptive terms and is therefore easier and more attractive to follow. One aspect of that was a widespread assumption that if a system met the criteria in BR 135, the building would comply with functional requirement B4(1) without any need to analyse the information obtained from the test itself or consider the conditions likely to be encountered in use. In our view the way in which the guidance in Approved Document B is expressed helped to perpetuate that assumption. However, there was and always has been an obligation on construction professionals to assess the results of BS 8414 tests and BR 135 classifications.
The deceptively simple terms of Approved Document B diverted attention from the fact that the information derived from large-scale tests needed to be analysed in conjunction with other relevant information in order to understand the likely behaviour of the external wall when exposed to flames and heat generated by a fully developed compartment fire. In our view an analysis of that kind calls for a level of skill greater than that possessed by many of the construction professionals who routinely relied on such tests.
It is possible to criticise the BS 8414 test as not representing conditions likely to be encountered in practice and as being liable to deliver differing results based on random variations in the systems tested.[2332] Moreover, it is essential to recognise that even if it can be made more realistic it will never provide all the information necessary to make a reliable assessment of the performance of an external wall. That will have to be derived from a range of tests, including small- and medium-scale tests, to determine the physical properties of the external wall that are likely to influence the spread of fire. The proper role of the BS 8414 test is to check the accuracy of assessments based on other methods.[2333] It should never be the only basis upon which the performance of an external wall system is assessed.
The reaction to fire of the external wall of Grenfell Tower amply illustrates the point. Any competent designer should have appreciated that the presence of polyethylene in the ACM panels presented a very significant danger, given the amount of energy that could be released if it became involved in fire. It should also have been clear that the aluminium sheeting enclosing that polyethylene was likely to deform and delaminate in response to heating and that the exposed polyethylene was likely to melt and drip. The experiments carried out at the University of Edinburgh demonstrated that it was possible to design small- and medium-scale tests capable of identifying the thermo-mechanical processes that led to the deformation of the panels and the involvement of the polyethylene in the fire.[2334] It follows that any assessment of the likely performance of an external wall system calls for a methodical analysis of a range of data and cannot be based on a single test that may not adequately reflect conditions liable to be encountered in practice.
Finally, it is important to recognise that if large-scale tests are to be of any value, it is important to ensure that those who carry them out make the data derived from them fully available to the manufacturer and designer. That degree of co-operation was lacking on the part of many of those who were involved in large-scale testing before the Grenfell Tower fire.[2335]
In relation to external wall systems, so-called “desktop assessments” or “desktop studies” involve the use of data derived from (usually) large-scale tests of one or more systems to establish by extrapolation how the system being assessed would respond if subjected to the same or a similar test. In practical terms, it is a method of demonstrating by reference to data derived from a BS 8414 test carried out on another system that the system under consideration would, if it were to be subjected to the same test, satisfy the criteria in BR 135.[2336] Although no desktop study was undertaken in relation to the external wall of Grenfell Tower, by the time of the fire they had become commonplace,[2337] particularly after they had been recognised by the Building Control Alliance in its Technical Guidance Note 18 as a means of demonstrating compliance with paragraph 12.7 of Approved Document B.[2338]
Although a desktop assessment can, in principle, constitute a valid means of providing some of the information needed to assess the behaviour of an external wall system in response to fire,[2339] its value depends to a very substantial extent on the quality of the data available for that purpose and the competence of the person carrying it out. To carry conviction such an assessment will need to be the subject of peer review or other competent oversight.[2340]
The value of any desktop assessment of that kind also depends on both the author’s and the reader’s understanding of the limitations of the BS 8414 test and the criteria in BR 135. Just as a BS 8414 test should be regarded as no more than one source of information, so a desktop assessment should be treated as only part of what is a complex exercise that requires information from various sources.[2341]
Moreover, whether a system has itself been subjected to a test or has only been the subject of a desktop study, it is still necessary to assess how it is likely to perform as part of a building.[2342] For the reasons we have given, meeting the criteria in BR 135 does not of itself demonstrate compliance with the functional requirements of the Building Regulations[2343] and was not intended to do so.
There was ample evidence that those matters were not properly understood by construction and building control professionals in the years preceding the Grenfell Tower fire. For example, desktop assessments were often accepted by NHBC as “proving compliance” not only with Approved Document B but with the requirements of the Building Regulations themselves.[2344]
The need for a methodical and scientifically rigorous approach to assessing how a system that has met the criteria in BR 135 will perform in practice[2345] is of greater importance when the data that provides the basis for the assessment has been derived from one or more tests carried out on different systems.[2346] That exercise necessarily introduces additional layers of complexity, because the person making the assessment must take into account the potentially complex variations between the different systems. Accordingly, the level of expertise and experience required to make the assessment are higher.[2347]
BS 9414,[2348] which was published in 2019, offers guidance on the interpretation of BS 8414 test data and provides procedures and rules for the way in which such data can be extended to systems other than those tested.[2349] It proceeds on the assumption that the BS 8414 test series is in itself a sufficient mechanism for establishing the fire performance of a system; the limitations of the information that can be derived from BS 8414 test data are not acknowledged. It does not explain how the effect of any differences between the system as tested and the system as built are to be assessed without a desktop assessment at each stage of the process identified as requiring an application evaluation. Instead, it attempts to simplify the process of assessment using a set of prescriptive rules instead of calling for an examination by a qualified fire engineer.[2350] It aims to standardise what is intended to be an individual assessment.[2351] In our view it should be used with great caution and with the considerations we have mentioned in mind.
It seems clear to us that the regime that existed before the Grenfell Tower for assessing the performance of external walls in fire was inadequate. It relied heavily on small-scale tests which did not provide the information needed to make a reliable assessment of how materials were likely to perform in a significantly different context. It also relied on a large-scale test which lacked coherent performance criteria and provided limited useful information. The assessment method in BR 135 was too simplistic, allowing for a simple pass or fail result, when the results of the test required a degree of interpretation that was beyond the competence of most in the industry. Moreover, guidance on how to carry out effective desktop assessments was lacking.
Although we recognise that some changes have been made to the regulatory system since that time, including a ban on the use of certain combustible materials on some tall buildings, we remain troubled by the fact that there is still no fire testing regime that delivers relevant information and by the failure to recognise the need for the application of competent professional judgement. We think that a comprehensive overhaul of the fire testing regime needs to be undertaken together with initiatives that will improve the number of fire engineers capable of carrying out complex assessments.
In the years before the Grenfell Tower fire there were a number of similar fires in other countries that in some cases led to the introduction of new measures designed to prevent any recurrence. We have not attempted to carry out a comprehensive investigation into the measures adopted elsewhere but we consider that the information we have been able to obtain provides a strong foundation for the recommendations made in Part 14.
We have had the benefit of a report from Professor José Torero, whose experience in this field is unrivalled. Professor Torero has spent considerable periods of his career working in other countries, including Queensland, Australia (2012–2017)[2352] and more recently at the University of Maryland in the United States (2017–2019).[2353] He included as an appendix to his report on the current testing regime[2354] a review of international responses to the Grenfell Tower fire, on which he also gave oral evidence.[2355] We draw particular attention to that part of his report, which, in the absence of any challenge to his evidence, we have generally accepted. We recommend that it be read carefully by all those responsible for ensuring safety from fire. His report, together with the other documents and reports to which we have referred, all of which are available on the Inquiry’s website, provides the basis of much of what follows.
We are grateful to a number of foreign governments and other overseas bodies that have taken the trouble to tell us about their regulatory regimes relating to fire safety and the measures they have taken in response to cladding fires both in their own countries and elsewhere. We acknowledge in particular the contributions received from the National Fire Protection Association (NFPA) in the United States[2356], the Dubai Civil Defence Office[2357], the government of New South Wales,[2358] the government of Queensland[2359] and the government of Victoria.[2360] Although construction work in each state is governed by its own legislative provisions, the approach to regulation adopted throughout Australia is broadly similar to that adopted in England, which renders the response of the authorities there of particular interest.
In some countries the use of combustible materials in external walls had already been prohibited by the time fires in high-rise buildings began to be encountered. In those cases it was not thought necessary to introduce new measures in response to the threat beyond strengthening the existing provisions.[2361] That was the case, for example, in France and Germany and in Hong Kong and China.[2362] A similar approach has been taken in this country since the Grenfell Tower fire by prohibiting the use on the external walls of buildings over 18 metres in height of materials with a European classification lower than A2-s1,d0,[2363] but it is potentially disadvantageous because the development of new materials and methods of construction is liable to require frequent legislative intervention.[2364]
Since 1984, the legislation governing building work in England and Wales has been based on functional requirements. In the United States, by contrast, there is a preference for a much more prescriptive approach. A commercial body, the National Fire Protection Association (NFPA),[2365] publishes building and safety codes that, although voluntary, are widely adopted by clients and contractors. As a result, although each state is a separate legal jurisdiction with its own laws, most buildings are constructed in accordance with the requirements of the NFPA codes which require the provision of an extensive range of fire safety systems, such as sprinklers,[2366] voice alarm communication systems[2367] and two staircases[2368] and allow little scope for independent design choices.[2369] The codes are constantly revised by NFPA committees which meet regularly to ensure that they keep pace with the introduction of new technologies.[2370] A wide range of interested persons and organisations are included in the process and the effectiveness of the work is judged by reference to fire safety statistics.[2371] The prescriptive approach embodied in the NFPA codes reflects a conservative approach to fire safety which is embedded in North American culture.[2372] Under the codes, large-scale testing using a test method broadly similar to BS 8414, known as NFPA 285,[2373] is mandatory.[2374]
The fundamental differences of approach between the United States and the United Kingdom to regulating building work means that it is not possible to transpose individual elements from one system to another. One marked point of difference, however, from which we might learn, is that in the United States those involved in the design, construction and inspection of buildings are typically required by law to hold some form of certification, licence or similar qualification to demonstrate that they have achieved a minimum level of competence in the area in which they practise.[2375] However, the prescriptive nature of the codes means that construction professionals do not have to understand and interpret functional requirements, as is the case in England and Wales and Australia[2376] and to that extent the demands imposed on them are less onerous.
The NFPA codes and standards rely on independent testing laboratories to confirm that materials and products used in construction comply with their requirements.[2377] The requirement for accreditation and certification of professionals also extends to those involved in the testing, certification, design and approval process.
The UAE has one of the highest concentrations of high-rise buildings in the world.[2378] It has also experienced a large number of cladding fires. Before 2013, cladding forming part of the external wall of a building in the UAE often incorporated ACM rainscreen panels with unmodified polyethylene cores.[2379] The UAE Fire and Life Safety Code of Practice 2011[2380] did not contain any provisions relating to the spread of fire over external walls or any requirements for the reaction to fire of the external walls of buildings more than three metres apart.[2381] Following a serious fire in a high-rise building in 2012, the legislation was amended to introduce minimum requirements for cladding systems and for fire-stopping.[2382] Subsequently, a unified document was prepared in the form of the 2018 edition of the UAE Fire and Life Safety Code.[2383]
The UAE Fire and Life Safety Code 2018 adopts many elements of a prescriptive approach to building regulation. It prohibits the use of cladding assemblies for mid-rise and high-rise buildings that are not fire-rated[2384] and requires the incorporation of a fire resistant spandrel in buildings over 15 metres in height.[2385] It also requires materials used in external walls (including the cores of panels) to be tested in accordance with prescribed tests similar to those used in the UK and the USA[2386] and the system as a whole to be tested using a large-scale test method similar to NFPA 285 and BS 8414.[2387] All facade contractors have to be licensed by the Civil Defence Office.[2388]
A novel step taken by the UAE was the creation in 2012 of a “House of Expertise”, a group of fire and life-safety consultants chosen for their expertise in designing external walls and supervising facade contractors,[2389] whose role is to advise the Civil Defence Authority on proposals for the construction of new buildings.[2390] In practice all the most complex buildings are reviewed by the group.[2391] The role played by the House of Expertise, therefore, is akin to that played in this country by building control. In practice, the regulation of building work in the UAE now relies heavily on the expertise of that group.[2392]
The Fire and Life Safety Code recognises that a “stay put” strategy in response to a fire needs to be carefully evaluated and provides in terms that partial evacuation would be a suitable strategy for a high-rise building.[2393] That reflects a change of approach from that previously adopted,[2394] but it is not clear to what extent it applies to existing buildings designed to operate a “stay put” strategy.
The inspection and enforcement regime relating to the construction of new buildings in the UAE has also been strengthened in recent years.[2395] The construction of external walls is inspected and approved by a consultant or a member of the House of Expertise.[2396] All commercial buildings must contain equipment that actively monitors the fire safety systems (including fire alarm, water and lift systems) and reports any fault or fire in the building to a control centre.[2397]
Like the United States, the Commonwealth of Australia is a federation of states and territories. The National Construction Code, which applies to the country as a whole, prescribes certain standards that must be met by all new buildings. It obtains the force of law by being incorporated into the law of the different states and territories, sometimes with minor amendments. Like the Building Act 1984, those requirements are couched in functional terms. For example, it provides that “a building must have elements which will, to the degree necessary, avoid the spread of fire between buildings.”[2398] The fact that regulations are expressed in terms of functional (or performance) requirements means that the basic approach taken in Australia is the same as that taken in the UK.
The fire that affected the external wall of the Lacrosse building in Melbourne, Victoria on 25 November 2014 was a significant national event. Together with other building failures,[2399] it led to a series of investigations into the state of the construction industry in Australia. As a result, three important reports were published, the Lambert report in 2015 commissioned by the government of New South Wales,[2400] the Shergold & Weir report in 2018 commissioned by the federal government,[2401] and the Warren Centre reports produced by the University of Sydney.[2402] Taken together, they represented a careful and detailed investigation of professional practices in the construction sector in Australia that is of global significance.[2403]
The first report of the Warren Centre (The Warren Centre Education Report, 2019) drew attention to the fact that in 2017 only two state governments, those of Queensland and Tasmania, operated licensing schemes for fire engineers.[2404] Some other states had formulated requirements for practitioners wishing to be registered, but they were not enforceable and there were no penalties for practising as a fire engineer without being registered.[2405] The licensing of fire engineering professionals was also emphasised as an important recommendation in the Shergold & Weir report.[2406] We think that similar considerations apply in this country.
The competence of building professionals and its importance in ensuring fire safety in the built environment received particular attention in the Warren Centre reports, in particular, in a report specifically devoted to that subject.[2407] It identified the skills that fire engineers need to possess and can be obtained through an accredited degree programme followed by a period of supervised practice, continuing professional development and effective monitoring, all supported by disciplinary procedures when standards are not met. The report identified a need to raise standards among those seeking to become fire engineers and a requirement for consistency of approach to their education, training, supervision and regulation.[2408] Engineers Australia, the body that governs admission to the status of Chartered Engineer in Australia, subsequently adopted the Warren Centre report for the purposes of assessing applicants for membership.[2409]
In its final report the Warren Centre made a wide range of recommendations relating to fire engineering, including recommendations for the professional education, training, development and accreditation of fire engineers.[2410] It also made a number of recommendations for changes to the national building code and guidance, and for the introduction of a scheme for registering professional engineers, including the establishment of “assessment bodies” and a monitoring framework with sanctions for sub-standard work.[2411]
The Warren Centre reports provide a good example of collaboration between government, industry and the academic world in the delivery of a programme for the improvement of professional standards. It offers an interesting example of the kind of thing that might be done in the UK.[2412]
Following the Lacrosse fire in November 2014, Australia introduced a large-scale system test method known as AS 5113 to complement AS 1530.1, its existing combustibility test for materials,[2413] and AS 1530.3, which tests the reaction of the surface of a material to heat. AS 5113 is virtually identical to BS 8414.[2414]
We received a very full and helpful submission from the Government of Victoria describing the steps it has taken in response to the problem posed by combustible cladding following the fire at the Lacrosse building in November 2014. The fire led to an audit of buildings constructed between 2005 and April 2015 which disclosed that the external walls of half of them had been constructed using non-compliant materials and required remedial work. To assist with the audit the government developed a risk assessment tool to assess the danger to life and property posed by combustible cladding. It contained two sections, one relating to the risk of ignition and the spread of fire and one relating to the ability of the occupants to escape.
It is not surprising that in the face of a serious problem of that kind the government resorted to legislation, giving the relevant minister the power to prohibit the use of products considered to pose a high risk. However, although the legislation came into effect in 2018, as far as we know, the power has not yet been exercised.[2415] In that respect the government here has already gone further by prohibiting the use of rainscreen panels that are not classed A2-s1,d0 or better.[2416]
In its submission the government of Victoria helpfully described a number of other measures it has taken to promote remedial work on buildings with dangerous cladding. However, they were tailored to the particular circumstances existing in that state and we do not think that similar measures would be suitable to the UK. One step that we think the UK government could usefully take note of, however, was to take legal action against building professionals involved in the installation of non-compliant cladding. Under Victoria’s Building Act it is an indictable offence knowingly to carry out building work that is not in accordance with the Act or the regulations made under it, with a maximum penalty of five years’ imprisonment.[2417] That appears to be much stronger than section 35 of the Building Act 1984. Moreover, regulation of construction professionals by the Victorian Building Authority enables it to take disciplinary action against them when appropriate and at the time of the submission (September 2020) two practitioners had been suspended and a further nine faced disciplinary proceedings relating to the installation of non-compliant cladding.[2418] Currently, certain engineers, including fire engineers, must be registered to provide professional engineering services in Victoria.[2419]
The government of New South Wales was generous in providing us with a copy of its submission to the Public Accountability Committee describing its response to the emerging problem of combustible cladding. In July 2017 in response to the Grenfell Tower fire it devised a ten-point plan and established the New South Wales Fire Safety and External Wall Cladding Taskforce to develop new policies and operational proposals. The Taskforce meets regularly to plan and co-ordinate the government’s response to the risks posed by combustible cladding.
New South Wales also resorted to legislation. In December 2017 parliament passed legislation in the form of the Building Products (Safety) Act 2017, designed to ensure the safety of building products. The Act gives the Commissioner of Fair Trading power to prohibit the use of products if he has reasonable grounds to consider their use unsafe and to identify buildings on which products have been used in a way that is prohibited (including buildings on which products were used before the prohibition took effect). In August 2018 the Fair Trade Commissioner prohibited the use of ACM panels with cores of more than 30% polyethylene on certain buildings.[2420]
Other measures of note are the passing of legislation to strengthen the independence of building certifiers (broadly the equivalent of our building control officers) and the introduction of a requirement that certain functions affecting the fire safety of buildings be performed only by accredited fire safety practitioners.[2421] In New South Wales certain engineers need to be registered, including any professional engineer working on certain buildings, including apartment buildings.[2422]
The government of Queensland also responded generously to an invitation from the chairman to make a submission to the Inquiry describing its response to the problem of combustible cladding. A number of important points emerge from that submission, all of which we found most helpful when considering how the matter could best be taken forward in this country.
Like the government of NSW, the government of Queensland established a task force consisting of a dedicated team of experts representing the government, the construction industry and fire service professionals working across government to guide construction industry, professionals and building owners in responding to the dangers of combustible cladding.[2423]
Long before the Grenfell Tower fire the University of Queensland had developed a strong relationship with the fire service that included the provision of training.[2424] That approach was reinforced after the Grenfell Tower fire and a number of important initiatives were then undertaken.[2425] They included an audit of all publicly and privately-owned buildings to assess the extent of the risk and the amount of remediation required.[2426]
In Queensland the government took steps to ensure that building products were safe for their intended use. The Queensland Building and Construction Commission Act 1991 was amended to impose obligations on those involved in specifying or supplying products (including designers, architects, engineers, manufacturers, importers, suppliers and installers) to ensure that they are safe and fit for their intended purpose.[2427] The amendments also increased the powers of the Commission to investigate the use of inappropriate building products and to take action in respect of them, including by issuing warnings and recalling products.[2428]
In Queensland “Fire Engineer” is a protected title awarded by the Board of Professional Engineers of Queensland that certifies the professional competence of all engineers. The functions and duties of engineers are set out in the Professional Engineers Act 2002.[2429]
In collaboration with various international institutions the government of Queensland established a five-day continuing professional development course for fire engineers to provide the specialist knowledge that would enable them to understand the implications of using certain products and produce effective fire safety strategies.[2430] However, in 2019 Queensland also decided to resort to legislation, prohibiting the use of ACM panels with polyethylene cores of more than 30% by mass.[2431]
Nonetheless, recognising that there was a need to improve the knowledge of building surveyors and the industry more generally, it introduced a series of courses designed to be taken by building surveyors,[2432] building inspectors and other industry professionals as part of continuing professional development to enable them to acquire the knowledge needed to carry out fire risk assessments of buildings with complex combustible cladding systems.[2433]
One of the most innovative responses to the threat posed by combustible cladding was the creation by the University of Queensland, with funding from the government, of a library of cladding materials to provide a catalogue and point of reference for materials that designers might be thinking of using in the future. The Cladding Materials Library is a substantial database containing information about a large range of products, including their performance in fire.[2434] The intention behind it was to provide a source of publicly available information to assist fire engineers in assessing the hazards posed by particular materials. A series of tests was carried out on each product, including small-scale flammability tests, with the aim of identifying its properties.[2435]
It was originally intended to develop the Cladding Materials Library to incorporate the results of intermediate and large-scale tests, including tests similar to those carried out by Professor Bisby on the cladding materials used at Grenfell Tower.[2436] However, the programme was discontinued when the government decided to prohibit the use of certain cladding materials.[2437] Nonetheless, the Library remains publicly available and its development could be revived.
Although Queensland actively supported the introduction of the large-scale test, AS 5113, it recognised that the time and cost associated with such testing could cause difficulties for some building owners.[2438] It therefore developed testing protocols based on first principles[2439] that enabled the reliable identification of cladding systems that needed to be replaced.[2440] They included a testing protocol that enables the fire performance of individual materials to be tested[2441] and is directed to quantifying the speed at which fire is likely to spread over an external wall.[2442] As such, it allows a quick and conservative assessment of the behaviour of individual cladding products to be made.[2443] That reflects the requirement throughout Australia for a phased evacuation rather than a stay put strategy in response to a fire in a high-rise building.
We think that the following conclusions may fairly be drawn from this review:
We are invited by our Terms of Reference to recommend measures to be taken in response to any deficiencies we found to exist in the matters under investigation. We have grouped our recommendations by reference to the subject matter to which they relate.
As appears from the findings in our report, we are satisfied that the system of regulating the construction and refurbishment of high-rise residential buildings that existed at the time of the Grenfell Tower fire was seriously defective in a number of respects. The statutory guidance in Approved Document B was poorly worded and liable to mislead designers into thinking that complying with its terms would inevitably ensure that the building would comply with the legal requirements of the Building Regulations. The government department responsible for the Building Regulations failed actively to monitor the performance of the system and failed to ensure that dangers of which it became aware were communicated to industry. It was not sensitive to the need to make urgent changes to the statutory guidance if conditions required it.
The remarks that follow are directed to the system for ensuring safety from fire, but we have no reason to think that other aspects of building safety are not subject to similar considerations. Safety of people in the built environment depends principally on a combination of three primary elements, good design, the choice of suitable materials and sound methods of construction, each of which depends in turn in a large measure on a fourth, the skill, knowledge and experience of those engaged in the construction industry. Unfortunately, as our investigations have shown, at the time of the Grenfell Tower fire there were serious deficiencies in all four of those areas.
We think that over the course of time the arrangements under which the construction industry was regulated had become too complex and fragmented. At the time of the fire the Department for Communities and Local Government (now the Ministry of Housing, Communities and Local Government) was responsible for the Building Regulations and the statutory guidance, the Department for Business, Energy and Industrial Strategy (now the Department for Business and Trade) was responsible for regulating products and the Home Office was responsible for the fire and rescue services. Building control was partly in the hands of local authorities and partly in the hands of approved inspectors operating as commercial organisations, enforcement of the law relating to the sale of construction products was carried out by Trading Standards and commercial organisations provided testing and certification services to manufacturers of products. UKAS accredited organisations operating as conformity assessment bodies. In our view, this degree of fragmentation was a recipe for inefficiency and an obstacle to effective regulation.
In our view all the functions to which we have referred, as well as some others to which we refer below, should be exercised by a single independent body headed by a person whom, for the sake of convenience, we shall call a construction regulator, reporting to a single Secretary of State. The establishment of such a regulator would bring a number of benefits, not least a focal point in driving a much-needed change in the culture of the construction industry. It would enable information to be shared effectively between those responsible for different aspects of the industry and promote the exchange of ideas. Information on developments in the industry, both in this country and abroad, could be shared more easily between all those interested in it. We envisage that such a construction regulator would have sufficient resources to take on the following functions, most of which are currently discharged by one or other of a variety of bodies:
We are aware that in the period since the Grenfell Tower fire Parliament has passed the Building Safety Act 2022 to regulate work on higher-risk buildings, to impose particular duties on those involved in the construction and refurbishment of such buildings and to establish a Building Safety Regulator responsible for building control and for overseeing standards of competence. However, responsibility for the range of functions identified above remains dispersed. We therefore recommend that the government draw together under a single regulator all the functions relating to the construction industry to which we have referred.
For the purpose of this and our other recommendations we have used the expression “higher-risk building” in the sense in which it is used in the Building Safety Act, that is, a building that is at least 18 metres in height (or has at least seven storeys) and contains at least two residential units.[2444] However, we do not think that to define a building as “higher-risk” by reference only to its height is satisfactory, being essentially arbitrary in nature. More relevant is the nature of its use and, in particular, the likely presence of vulnerable people, for whom evacuation in the event of a fire or other emergency would be likely to present difficulty. We therefore recommend that the definition of a higher-risk building for the purposes of the Building Safety Act be reviewed urgently.
The fragmentation of responsibility for regulating the construction industry is currently mirrored in the range of government departments responsible for matters affecting fire safety. If a single body were responsible for all aspects of regulating matters affecting fire safety in the construction industry, that body should report to a single Secretary of State answerable to Parliament for all aspects of fire safety. That should improve the quality of government by providing an administrative environment in which information can be shared more quickly and more effectively between teams responsible for different aspects of the work and facilitate communication between the regulator and the department. It should also ensure that greater emphasis is placed on ensuring the safety of the built environment and that policy is developed in an holistic and coherent way. We therefore recommend that the government bring responsibility for the functions relating to fire safety currently exercised by MHCLG, the Home Office and the Department for Business and Trade into one department under a single Secretary of State.
The minister will need to be able to turn for advice to someone who has a good working knowledge and practical experience of the construction industry. We therefore recommend that the Secretary of State appoint a Chief Construction Adviser with a sufficient budget and staff to provide advice on all matters affecting the construction industry, including:
Nothing we have discovered in the course of our investigations has led us to think that expressing the legal requirements of the Building Regulations in terms of functional requirements is in itself unsatisfactory, but we do think that the way in which the statutory guidance in Approved Document B was expressed was unsatisfactory in a number of respects. We have drawn attention in Chapter 6 to the retention of Class 0 as a standard governing the fire performance of external wall panels and in Chapter 48 to the consequences of expressing in an apparently prescriptive form what is in reality no more than guidance. Most importantly we do not think that Approved Document B provides the information needed to design buildings that are safe in fire.
Approved Document B needs to be reviewed as a matter of urgency, taking into account the expert evidence of Professor Bisby, Professor Torero and Dr Lane, all of which is publicly available and none of which was significantly challenged in the course of our proceedings. It must then be kept under continuous review, together with the other Approved Documents, and amended annually or promptly whenever developments in materials or building methods make that desirable. It should be drafted conservatively to ensure, as far as possible, that compliance with it will provide a high degree of confidence that on completion of the work the building will comply with the Building Regulations. We therefore recommend that the statutory guidance generally, and Approved Document B in particular, be reviewed accordingly and a revised version published as soon as possible.
Our investigations have shown that levels of competence in the construction industry are generally low and that by the time of the Grenfell Tower fire many contractors, designers and building control officers treated the statutory guidance as containing a definitive statement of the legal requirements. It is understandable that those who turn to the guidance for advice about how to comply with the Building Regulations should be tempted to treat it as if it were definitive, but that is a danger that the Secretary of State needs to recognise and guard against. We therefore recommend that a revised version of the guidance contain a clear warning in each section that the legal requirements are contained in the Building Regulations and that compliance with the guidance will not necessarily result in compliance with them.
We do not think it appropriate for us to recommend specific changes to Approved Document B, save in one respect. As we have pointed out in Chapter 48, the guidance proceeds on the assumption that effective compartmentation renders a stay put strategy an appropriate response to a fire in a flat in a high-rise residential building. New materials and methods of construction and the practice of overcladding existing buildings make the existence of effective compartmentation a questionable assumption and we recommend that it be reconsidered when Approved Document B is revised. One thing that has emerged clearly from our investigations is that in order to ensure the safety of occupants, including any with physical or mental impairments, those who design high-rise buildings need to be aware of the relationship between the rate at which fire is likely to spread through the external walls and the time required to evacuate the building or the relevant parts of it. A stay put strategy in response to a compartment fire will be acceptable only if there is negligible risk of fire escaping into and spreading through the external wall. Calculating the likely rate of fire spread and the time required for evacuation, including the evacuation of those with physical or mental impairments, are matters for a qualified fire engineer. We do not think that it would be helpful to attempt to include in Approved Document B an indication of what would be acceptable because each building is different, but we recommend that the guidance draw attention to the need to make a calculation of that kind. It is one that ought to form an essential part of any fire safety strategy.
We think that a fresh approach needs to be taken to reviewing and revising the Building Regulations and statutory guidance that is driven primarily by considerations of safety. Fresh minds are needed. We therefore recommend that, as far as possible, membership of bodies advising on changes to the statutory guidance should include representatives of the academic community as well as those with practical experience of the industry (including fire engineers) chosen for their experience and skill and should extend beyond those who have served on similar bodies in the past.
A fire safety strategy for a building should describe its structure and the various fire protection systems it contains and set out how they work together to ensure the safety of the occupants in the event of a fire. Those involved in the design and execution of the Grenfell Tower refurbishment failed to understand properly the need for a fire safety strategy and therefore failed to ensure that a final version of the Outline Fire Safety Strategy begun by Exova was completed. That allowed the building to be in a dangerous condition on completion. In order to avoid a repeat of that error, we consider that there is a compelling case for requiring a fire safety strategy to be produced as a condition of obtaining building control approval for the construction or refurbishment of any higher-risk building and for it to be reviewed and approved on completion. We therefore recommend that it be made a statutory requirement that a fire safety strategy produced by a registered fire engineer (see below) to be submitted with building control applications (at Gateway 2) for the construction or refurbishment of any higher-risk building and for it to be reviewed and re-submitted at the stage of completion (Gateway 3). Such a strategy must take into account the needs of vulnerable people, including the additional time they may require to leave the building or reach a place of safety within it and any additional facilities necessary to ensure their safety.
Assessing the fire performance of an external wall requires reliable information about the products and materials proposed for use in its construction, which in turn requires the availability of suitable methods for testing reaction to fire. As we have explained in Chapter 111, the small-scale test methods that have traditionally been relied on do not provide the information needed for that purpose and the large-scale test method (BS 8414) and classification in accordance with BR 135 lacks relevant performance criteria and provides a limited amount of useful information.
As is apparent from the experiments conducted by Professor Bisby and Professor Torero for Phase 2 of our investigations, the factors that affect the way in which fire spreads over ventilated rainscreen external wall systems are complex and understanding them is an evolving science. Intuitive judgements are often wrong because a small change in the system can have a significant effect on the outcome. It follows that assessing whether an external wall system can support a particular evacuation strategy is difficult because the necessary information is not always available. We therefore recommend that steps be taken in conjunction with the professional and academic community to develop new test methods that will provide the information needed for such assessments to be carried out reliably.
In the light of Professor Torero’s evidence we think that BS 9414 will encourage people who are not trained fire engineers to think that they can safely assess the performance of a proposed external wall system by extrapolation from information obtained from tests on one or more different systems. For the reasons given by Professor Torero we think that BS 9414 should be approached with caution and we recommend that the government make it clear that it should not be used as a substitute for an assessment by a suitably qualified fire engineer.
It is essential that those responsible for designing buildings have access to reliable information about the materials and products they wish to use. In their product literature manufacturers make many claims for their products, some of which are not of an overtly technical nature but are calculated to give the impression that a particular product has passed a particular test or has been shown to be suitable for a particular use. That was one of the marketing devices employed by those who manufactured and sold the rainscreen cladding panels and the insulation used in the refurbishment of Grenfell Tower.
Manufacturers were able to use misleading marketing material in part because the certification bodies that provided assurance to the market of the quality and characteristics of the products failed to ensure that the statements in the certificates they issued were accurate and based on appropriate and relevant test evidence. The United Kingdom Assessment Service (UKAS), the organisation charged with accrediting them, failed to apply proper standards of monitoring and supervision. The fact that three separate manufacturers were able to obtain misleading certificates relating to their products is evidence of a serious failure of the system and points to a need for a different approach to the certification of construction products.
We do not think that the appointment of a National Regulator of Construction Products will solve the problem because the system will still depend on the effectiveness of the conformity assessment bodies and the limited oversight of UKAS. Conformity assessment bodies provide a commercial service combined with an element of regulation, but the two functions do not sit easily together. Pressure to acquire and retain customers can all too easily lead such bodies to be less rigorous in their examination of products and materials and enforcing their terms of contracts than could reasonably be expected of bodies acting in the public interest.
We therefore recommend that the construction regulator should be responsible for assessing the conformity of construction products with the requirements of legislation, statutory guidance and industry standards and issuing certificates as appropriate. We should expect such certificates to become pre-eminent in the market.
In our view clarity is required to avoid those who rely on certificates of conformity being misled. We therefore recommend
Designing buildings that are safe in the event of a fire requires particular skill. It is a skill that can be acquired only by specialised education and experience worthy of formal recognition. Unfortunately, the term “fire engineer” does not at present denote any formal qualification and as a result it is possible for a person to practise as a fire engineer without any formal qualification. The evidence we have heard suggests that not all those who profess to be fire engineers are capable of performing that role competently and that the complexity of the subject matter is not well understood.
In those circumstances, and particularly given the importance of fire engineers in ensuring the safety of life, we think that the profession of fire engineer should be formally recognised and that both the title and the function should be protected by statute. Over time that would create a body of registered fire engineers who are capable of contributing to the design and delivery of safe buildings and of educating those construction professionals with whom they work in effective fire safety strategies. We therefore recommend that the profession of fire engineer be recognised and protected by law and that an independent body be established to regulate the profession, define the standards required for membership, maintain a register of members and regulate their conduct. In order to speed up the creation of a body of professional fire engineers we also recommend that the government take urgent steps to increase the number of places on high-quality masters level courses in fire engineering accredited by the professional regulator.
Other construction professionals and more senior members of the fire and rescue services need to have a basic understanding of the principles of fire engineering as they apply to the built environment. The circumstances surrounding the Grenfell Tower fire show that an effective contribution from a fire engineer could have prevented the disaster by alerting the client and the principal contractor to the dangers of using aluminium composite panels with unmodified polyethylene cores and combustible insulation in the external wall of the building. They also show that the failure of Rydon and the TMO to understand the nature and importance of the analysis and advice that Exova should have provided contributed to their failure to obtain it. An authoritative statement of the skills that a fire engineer can be expected to bring to bear might assist the regulatory body and would improve the competence of other construction professionals and the fire and rescue services by enabling them to understand better the contribution that fire engineers can make to the construction of a safe building. It would also promote effective communication between them. Such a statement would need to draw on and reflect the experience of both practising fire engineers and those in the academic world to ensure that it was objective and properly reflected the scientific and intellectual demands of the role.
The development and maintenance of a statement of professional skills should ultimately be the responsibility of the body that regulates the profession, but pending the establishment of such a body we recommend that the government convene a group of practitioner and academic fire engineers and such other professionals as it thinks fit to produce an authoritative statement of the knowledge and skills to be expected of a competent fire engineer. Such a statement would also enable others in the construction industry to understand better the nature and importance of a fire engineer’s work. We think it would be of benefit to those carrying out this work to have regard to the reports of the Warren Centre, to which we refer in Chapter 112.
We also recommend that the government, working in collaboration with industry and professional bodies, encourage the development of courses in the principles of fire engineering for construction professionals and members of the fire and rescue services as part of their continuing professional development.
Traditionally, the role of the architect has been fundamental to any construction project of significant size. Regrettably, the work of Studio E on the Grenfell Tower refurbishment fell significantly below the standard reasonably to be expected of it in a number of significant ways, in particular, in failing to exercise proper care in relation to the choice of insulation and rainscreen panels. The evidence, not least the fact that similar materials have since been found on hundreds of other high-rise buildings, suggests that there may be a widespread failure among the profession to investigate properly or understand the nature of the materials being chosen for that purpose.
We recognise that both the Architects Registration Board and the Royal Institute of British Architects have taken steps since the Grenfell Tower fire to improve the education and training of architects. We recommend that they should review the changes already made to ensure they are sufficient in the light of our findings.
We also recommend that it be made a statutory requirement that an application for building control approval in relation to the construction or refurbishment of a higher-risk building (Gateway 2) be supported by a statement from a senior manager of the principal designer under the Building Safety Act 2022 that all reasonable steps have been taken to ensure that on completion the building as designed will be as safe as is required by the Building Regulations.
The design and build form of contract, which is now very widely used, makes the principal contractor responsible for the whole range of activities relating to the work, even though it invariably engages sub-contractors to carry out different aspects of it. We have criticised Rydon for various failings in its organisation of the Grenfell Tower refurbishment. They include a failure to make it clear which contractor was responsible for particular aspects of the design and a failure to take an active interest in fire safety. We are not the first to conclude that the construction industry as a whole needs to become technically more competent and less willing to sacrifice quality to speed and cost.
We think that one way in which to eliminate shortcomings of the kind we have identified and to improve the efficiency of contractors would be to introduce a licensing system for those wishing to undertake work on higher-risk buildings. That would ensure that those working on the most sensitive buildings are qualified by experience and organisation to do so and such a system should lead to a general increase in competence among contractors. We also think that, in order to ensure that fire safety is given the importance it deserves, a senior member of the contractor’s organisation should be personally responsible for taking all reasonable steps to ensure that on completion of the work the building is as safe as it should be. We therefore recommend that a licensing scheme operated by the construction regulator be introduced for principal contractors wishing to undertake the construction or refurbishment of higher-risk buildings and that it be a legal requirement that any application for building control approval for the construction or refurbishment of a higher-risk building (Gateway 2) be supported by a personal undertaking from a director or senior manager of the principal contractor to take all reasonable care to ensure that on completion and handover the building is as safe as is required by the Building Regulations.
The events surrounding the refurbishment of Grenfell Tower suggest that at that time those who commissioned building work may not have been fully aware of their responsibility for compliance with the provisions of the Building Regulations, particularly if an application for building control approval was made by a consultant on their behalf. We therefore welcome the introduction by regulations made under the Building Safety Act 2022 of a requirement for a Building Regulations compliance statement, made or approved by the client, to be provided at the time of an application for building control approval (Gateway 2). In the light of that requirement we do not think that any further action in relation to clients is currently required.
The evidence shows that in the period leading up to the Grenfell Tower fire many of those involved in major construction projects, including clients, contractors and even architects, regarded building control primarily as a source of advice and assistance. It was even described as an extension of the design team. In many cases that was how building control itself saw its role. That was a serious misunderstanding, but it was fostered by building control bodies themselves, who preferred to co-operate with applicants to enable proposals to be approved rather than enforce the Building Regulations rigorously. In our view, that has to change.
The government has taken steps to improve the regulation of building control and the competence of those who consider applications for approval. We expect the construction regulator to continue these new arrangements, which are intended to introduce a wholly new climate in which both applicants for approval and building control officers understand that the function of building control is regulatory in nature.
One of the causes of the inappropriate relationship to which we have referred was the introduction into the system of commercial interests. Approved inspectors had a commercial interest in acquiring and retaining customers that conflicted with the performance of their role as guardians of the public interest. Competition for work between approved inspectors and local authority building control departments introduced a similar conflict of interest affecting them. As things stand that underlying conflict of interest will continue to exist and will continue to threaten the integrity of the system. We therefore recommend that the government appoint an independent panel to consider whether it is in the public interest for building control functions to be performed by those who have a commercial interest in the process.
The shortcomings we have identified in local authority building control suggest that in the interests of professionalism and consistency of service all building control functions, including those currently performed by local authorities, should be exercised nationally. Accordingly, we recommend that the same panel consider whether all building control functions should be performed by a national authority.
Those who design buildings, particularly higher-risk and complex buildings, would benefit from having access to a body of information, such as data from tests on products and materials, reports on serious fires and academic papers. In Chapter 112 we have referred to the Cladding Materials Library set up by the University of Queensland, which could form the basis of a valuable source of information for designers of buildings in general. We recommend that the construction regulator sponsor the development of a similar library, perhaps as part of a joint project with the University of Queensland, to provide a continuing resource for designers.
Our investigations have revealed that some important recommendations affecting fire safety were ignored by the government in the years leading up to the Grenfell Tower fire. Recommendations made by the Select Committee in 1999 were not implemented and the department’s response to the recommendations made by the Lakanal House coroner was inadequate. The department had no system for recording recommendations made by public bodies or keeping track of its response to them. That was obviously unsatisfactory. We recommend that it be made a legal requirement for the government to maintain a publicly accessible record of recommendations made by select committees, coroners and public inquiries together with a description of the steps taken in response. If the government decides not to accept a recommendation, it should record its reasons for doing so. Scrutiny of its actions should be a matter for Parliament, to which it should be required to report annually.
As we have pointed out in Chapter 12, concern has been expressed for many years about the competence of some of those offering their services as commercial fire risk assessors and the absence of any scheme of regulation to ensure that responsible persons under the Fire Safety Order can have confidence in the skill and experience of those whom they instruct to carry out fire risk assessments on their behalf. We therefore recommend that the government establish a system of mandatory accreditation to certify the competence of fire risk assessors by setting standards for qualification and continuing professional development and such other measures as may be considered necessary or desirable. We think it necessary for an accreditation system to be mandatory in order to ensure the competence of all those who offer their services as fire risk assessors.
All modern lifts are fitted with fire control switches designed to be operated by drop keys to enable the fire and rescue services to take control of them in the event of a fire. We were surprised to learn that at the time of the Grenfell Tower fire there was a significant variation in the dimensions of drop keys available from commercial suppliers, not all of which were compatible with all fire control switches. We were also surprised to learn that, although drop keys for the use of firefighters are provided by fire and rescue services, firefighters commonly obtain their own from a variety of sources. As a result, it appears to have been largely a matter of chance whether the key carried by the first firefighter who tried to take control of a lift was capable of operating the switch. That is clearly unacceptable and may result in unnecessary casualties, as it did at Grenfell Tower.
We understand that since the problem came to light the LFB has taken steps to ensure that only drop keys of an approved pattern are carried by its firefighters. The evidence does not enable us to assess with any confidence whether similar problems have been encountered by other fire and rescue services and, if so, what steps they have taken in response. Accordingly, we are not in a position to determine whether greater standardisation of fire control switches and keys is required. We therefore recommend that the government seeks urgent advice from the Building Safety Regulator and the National Fire Chiefs Council on the nature and scale of the problem and the appropriate response to it.
Pipeline isolation valves are a critical part of the gas distribution network because they are intended to enable the supply of gas to be shut off quickly in an emergency. At the time of the fire at Grenfell Tower the valves could not be operated because they had been covered over in the course of hard landscaping. There was evidence that it was a common problem in the industry for pipeline isolation valves to be lost in that way. In our view that poses an unacceptable risk to health and safety and could have significant consequences. We therefore recommend that every gas transporter be required by law to check the accessibility of each such valve on its system at least once every three years and to report the results of that inspection to the Health and Safety Executive as part of its gas safety case review.
One of our expert witnesses, Mr Rodney Hancox, drew our attention to the danger posed by the fact that the internal gas pipework in some older buildings is not sleeved where it passes through walls and floors, as is now required by the Gas Safety Regulations 1972. He considers that a more active approach to replacement should be taken to avoid a serious leak with potentially catastrophic consequences.[2445] Although we are not in a position to make a formal recommendation to that effect, we think that the Health and Safety Executive and other relevant bodies should give careful consideration to his evidence.
In Parts 4 and 5 of the report we have discussed the TMO, its relationship with its residents and its management of fire safety at Grenfell Tower. We make a number of criticisms of the way in which it carried out its responsibilities, including in relation to handling complaints, remedying defects identified in fire risk assessments, installing and maintaining fire protection systems and routine inspection and maintenance of fire doors. Others responsible for the management of social housing should give them careful consideration and take appropriate action accordingly.
In other circumstances shortcomings of those kinds would probably have led us to make a number of recommendations directed to ensuring that they were rectified and not repeated. However, since the fire Parliament has enacted the Social Housing (Regulation) Act 2023, which enables the Regulator of Social Housing to play a more active role in setting appropriate standards and ensuring that they are met. The regulator also has the power to set standards on the competence and conduct of those involved in the provision of services relating to the management of social housing and to require providers of social housing to make information available both to tenants and the regulator. The Act also makes safety a priority and imposes a duty on landlords to investigate and remedy within a specified time of being reported defects that may adversely affect health.
In those circumstances, we do not consider it necessary to make any additional recommendations in relation to the matters that we have uncovered.
Our criticisms of the London Fire Brigade have been directed mainly to its failure to integrate the control room into the organisation effectively, its failure to ensure that adequate training was provided to control room staff in handling fire survival guidance calls and its failure to implement lessons learnt from previous incidents. In one way or another those are all criticisms of the organisation and management of the brigade, which in our view needs to become more streamlined and less bureaucratic.
Although the LFB is the country’s largest fire and rescue service and is subject to a range of demands not imposed on similar services, it has tended to adopt an insular approach and to be reluctant to learn from others. No doubt some of the criticisms we have made of the LFB could be made of other fire and rescue services, but in any event we think that there is scope for all fire and rescue services to learn from each other’s experience and thereby to promote best practice across the board, whether in relation to recruitment, training, organisation or management.
Although the National Fire Chiefs Council provides a forum for discussions and the formulation of policy, there is currently no central body that is equipped to provide education and training across the board to nationally approved standards. We welcome the government’s ambition to create an independent College of Fire and Rescue expressed in the white paper Reforming our Fire and Rescue Service[2446] and we therefore recommend that the government establish such a college immediately with sufficient resources to provide the following services nationally:
The constitution of the College of Fire and Rescue is a matter for the government in consultation with the National Fire Chiefs Council and other interested bodies, but it could be established as a not-for-profit company, independent of the government, with a board of directors drawn from a range of backgrounds, a significant proportion of whom are currently serving Chief Fire Officers or senior officers with significant firefighting experience. The board would be responsible for the overall management and operations of the college.
Although it is for the government to decide how the college should be constituted, we recommend that it should have a permanent staff of sufficient size to manage its operations and develop its functions in response to the demands of fire and rescue services nationally and the requirements of the board. The college will need access to permanent facilities, including facilities for practical training and education. We envisage that much of the training and education will be delivered and led by firefighters of suitable experience drawn as the occasion requires from fire and rescue services around the country.
The control room should be at the heart of any fire and rescue service and should, therefore, be recognised as a key part of the organisation and fully integrated into it. Its staff must be trained to handle whatever demands are reasonably foreseeable.
The demands imposed on the LFB’s control room by the Grenfell Tower fire were very great, but even so, its performance did not meet reasonable expectations. That was principally the result of inadequate training and a failure to carry out regular exercises, itself the result of poor management. The establishment of a College of Fire and Rescue could be expected to create improvements in all those areas by setting standards for training, by training more senior ranks to perform management roles effectively and by sharing best practice. In the meantime, we recommend that His Majesty’s Inspectorate of Constabulary and Fire and Rescue Services (“the Inspectorate”) inspect the LFB as soon as reasonably possible to assess and report on:
In Chapter 72 we are critical of the LFB’s arrangements immediately before the Grenfell Tower fire for assessing the competence of those expected to act as incident commanders, particularly in the early stages of the response to a fire in a high-rise residential building. Steps have already been taken to respond to the criticisms made by the chairman in his Phase 1 report, but in order to reassure those who live in London we recommend that as soon as reasonably possible the Inspectorate inspect the LFB to examine and report on the arrangements it has in place for assessing the training of incident commanders at all levels and their continuing competence, whether by a process of revalidation or otherwise.
In the years before the Grenfell Tower fire the LFB consistently failed to implement an effective system for the collection, storage and distribution of operational risk information, in particular in relation to high-risk, high-rise residential buildings. We therefore recommend that as soon as reasonably practicable the Inspectorate inspect the LFB to examine and report on its arrangements for collecting, storing and distributing information in accordance with section 7(2)(d) of the Fire and Rescue Services Act 2004, and in particular its arrangements for identifying high-risk residential buildings and collecting, storing and distributing information relating to them.
The LFB took steps to examine incidents, collect relevant information, establish boards and committees to digest it and produce appropriate changes to working practices. In most cases, however, the process was excessively bureaucratic and undermined the purpose for which it had been established. As a result, too little of the available information was translated into practical outcomes. We therefore recommend that the LFB establish effective standing arrangements for collecting, considering and effectively implementing lessons learned from previous incidents, inquests and investigations. Those arrangements should be as simple as possible, flexible and of a kind that will ensure that any appropriate changes in practice or procedure are implemented speedily.
We have explained in Chapter 80 why communication by radio is inherently likely to be adversely affected in certain environments, including tall buildings constructed mainly of dense or reflective materials such as stone, concrete, brick and steel. It is apparent, however, that the use of low-power intrinsically safe radio equipment exacerbates the problem because of its more limited transmission range. In many firefighting situations the danger of a spark from a radio igniting flammable gases is very low. The fire at Grenfell Tower is one example. We understand that intrinsically safe radios capable of operating at higher power are now available. We therefore recommend that fire and rescue services that continue to use low power intrinsically safe radios as part of breathing apparatus consider reserving them only for situations in which there is a real risk of igniting flammable gases and generally using radios of higher power, particularly in high-rise buildings.
There is strong evidence that in general digital radios are more effective than analogue radios. We therefore recommend that all fire and rescue services give consideration to providing all firefighters with digital radios.
Since radio communications are inherently unreliable in certain environments, we recommend that firefighters be trained to respond appropriately to the loss of communications and to understand how to restore them.
On the night of the Grenfell Tower fire firefighters were unable to distinguish between different types of hydrant. That is a clear indication of a need for better training and we therefore recommend that basic training on the structure and operation of the water supply system, including the different types of hydrants in use and their functions, be given to all firefighters. Training should also be given on effective measures to increase water flow and pressure when necessary.
The Grenfell Tower fire made unusual demands on the supply of water, but other major fires may make similar demands in future. If it becomes necessary to seek the assistance of the statutory water undertaker to increase the volume or pressure of the supply, the fire and rescue service should be able to communicate with it quickly and clearly. We therefore recommend that all fire and rescue services establish and periodically review an agreed protocol with the statutory water undertakers in their areas to enable effective communication between them in relation to the supply of water for firefighting purposes.
In paragraph 81.23 of Chapter 81 we considered British Standard 750:2002 relating to the flow coefficient of fire hydrants and noted that the standard does not state whether the figure stated in paragraph 10.2 relates to a simple hydrant tested under factory conditions or to a hydrant installed in the pipework necessary to connect it to the water network. Any confusion could easily be dispelled by a small amendment to the standard. We therefore recommend that the British Standards Institution amend BS 750 to include a description of the circumstances under which the flow coefficient to which it refers in paragraph 10.2 is to be measured.
How to deploy the available firefighters must remain the responsibility of the incident commander, who alone can judge how best to make use of the available resources. We also recognise that firefighters must be allowed to exercise discretion in how best to carry out their instructions. However, anyone reading Part 9 of the report will be struck by the number of times crews despatched to the highest floors of the tower in response to calls for assistance failed to reach their destinations because they decided to help people they encountered on the stairs on their way up. We cannot tell whether in any of those cases they would have been able to rescue people higher up the building if they had not done so, but we recommend that National Fire Chiefs Council consider whether, and if so in what circumstances, firefighters should be discouraged from departing from their instructions on their own initiative and provide appropriate training in how to respond to a situation of that kind.
The Grenfell Tower fire created an emergency on an unprecedented scale as a result of the loss of life, the destruction of so many homes and the displacement of over 800 people who were rendered homeless and, in many cases, for all practical purposes destitute. The arrangements for responding to civil emergencies were severely tested and in many respects did not perform as well as expected. In December 2022 the government published a new Resilience Framework and put in place what is described as a new strategic approach to resilience. We welcome those steps. Nevertheless, there remain areas in which we think further improvements need to be made.
The government’s powers in sections 5 and 7 of the Act to intervene in response to an emergency are far-reaching but they do not enable it to intervene promptly or decisively when a Category 1 responder is failing to rise to the challenge. We therefore recommend that the Act be reviewed and consideration be given to granting a designated Secretary of State the power to carry out the functions of a Category 1 responder in its place for a limited period of time.
The response of local voluntary organisations to the disaster demonstrated their capacity to act as valuable partners in responding to an emergency. Regulation 23 of the Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005 requires a Category 1 responder to have regard when making its plans to the activities of relevant voluntary organisations. We therefore recommend that the regulation be amended to require Category 1 responders to establish and maintain partnerships with the voluntary, community and faith organisations in the areas in which they are responsible for preparing for and responding to emergencies.
The current guidance on preparing for emergencies is contained in several documents, all of which are unduly long and in some respects out of date. We recommend that the guidance be revised, reduced in length and consolidated in one document which lays greater emphasis on the need for those leading the response to consider the requirements for recovery, the need to identify vulnerable people, the importance of identifying and ensuring co-operation with voluntary, community and faith groups and is consistent with the Equality Act 2010. We also recommend that regard for humanitarian considerations be expressly recognised by making it the ninth principle of effective response and recovery.
Although each London borough is a separate Category 1 responder, there are arrangements for promoting resilience across the capital as a whole, in particular through the London Local Authority Gold arrangements. Events demonstrated, however, that there is a need for a clearer understanding of the nature of the London Gold arrangements, in particular in situations in which a single borough is affected. We therefore recommend that the guidance on the operation of those arrangements be revised and that existing and newly appointed chief executives be given regular training to ensure they are familiar with its principles.
Our investigations revealed the inability of the London Resilience Forum to monitor the quality of its members’ planning, training and preparation for responding to emergencies. Neither Minimum Standards for London, which applied at the time, nor its replacement, Resilience Standards for London, gave the local resilience forum any means of securing compliance with the standards they prescribed. We note that in the Resilience Framework the government has recognised the need to strengthen local resilience forums. We therefore recommend that local resilience forums adopt national standards to ensure effective training, preparation and planning for emergencies and adopt independent auditing schemes to identify deficiencies and secure compliance. We also recommend that a mechanism be introduced for independently verifying the frequency and quality of training provided by local authorities and other Category 1 responders.
The failure of The Royal Borough of Kensington and Chelsea (RBKC) to meet the basic needs of those displaced in the days immediately following the fire demonstrated the need for local authorities to have effective plans in place for providing humanitarian assistance. It also emphasised the need for those plans to be supported by a qualified humanitarian assistance liaison officer (HALO) and for there to be regular practice in putting them into effect. There is scope for all those required to respond to emergencies to learn from each other’s experience and promote best practice.
RBKC was not able to provide an effective response to the emergency because it had not made adequate arrangements for staffing the emergency communication centre, had not made adequate provision for humanitarian assistance, including the provision of accommodation and financial support, did not have the ability to keep accurate records of those who needed help and had no effective system for communicating with the public. All those shortcomings could and should be avoided in future by a combination of measures, but underpinning them all is a need for the staff of local authorities to treat resilience and preparedness for emergencies as an essential part of their responsibilities. We therefore recommend that local authorities train all their employees, including chief executives, to regard resilience as an integral part of their responsibilities.
RBKC had no effective means of collecting and recording information about those who had been displaced from the tower and surrounding buildings, including those who were missing. Compiling reliable information of that kind is difficult and the challenges likely to be faced by local authority Category 1 responders will vary according to the nature of the emergency. We recommend that all local authorities devise methods of obtaining and recording information of that kind, if possible in electronic form, and practise putting them into operation under a variety of different circumstances.
Any local authority is likely to have difficulty finding temporary accommodation for a very large number of displaced persons but the need to do so should be recognised and contingency plans drawn up. We recommend that all local authorities make such arrangements as are reasonably practicable for enabling them to place people in temporary accommodation at short notice and in ways that meet their personal, religious and cultural requirements. Such arrangements should, as far as possible, involve local providers of social housing.
Effective humanitarian assistance is vital in ensuring that those who are most affected by an emergency are treated with dignity and respect and do not suffer additional trauma as a result of an inability to take control of their situation. In the case of the response to the Grenfell Tower fire three matters caused particular resentment: the circumstances surrounding some of the temporary accommodation, the difficulty in obtaining financial support in the days immediately following the fire and breakdowns in the support provided by key workers. Problems arising from the provision of suitable temporary accommodation may be difficult to resolve but other complaints should be easier to avoid by careful planning. We recommend that all local authorities include in their contingency plans arrangements for providing immediate financial assistance to people affected by an emergency. We also recommend that as part of their planning for emergencies local authorities give detailed consideration to the availability of key workers and the role they are expected to play so that suitable contingency arrangements can be made to ensure, as far as possible, continuity of support.
One important aspect of humanitarian assistance that was absent following the Grenfell Tower fire was regular communication between those providing assistance and those in need of it. For example, too many people who had been found temporary accommodation felt that they had then been left on their own, not knowing for how long they were expected to remain or on what terms and without anyone to turn to to provide that information. That gave rise to a sense of isolation and powerlessness. We recommend that as part of their emergency planning local authorities make effective arrangements for continuing communication with those who need assistance using the most suitable technology and a range of languages appropriate to the area.
It is also important not to lose sight of those who, although not physically affected by an emergency, may be worried about the safety of friends or relations caught up in it. Again, effective communication is essential. We recommend that all local authorities include in their plans for responding to emergencies arrangements for providing information to the public by whatever combination of modern methods of communication are likely to be most effective for the areas for which they are responsible. In future, to avoid confusion, wasted effort and frustration we also recommend that what in the past has been called by the police a “casualty bureau” be described in a way that makes it clear that it does not provide information to the public about people affected by the emergency.
We conclude our recommendations by looking back to Phase 1. In the Phase 1 report the chairman recommended that the owner and manager of every high-rise residential building be required by law to prepare personal emergency evacuation plans (PEEPs) for all residents whose ability to evacuate the building without assistance may be compromised (such as persons with reduced mobility or impaired cognition)[2447] and to include current information about them and their associated PEEPs in a premises information box.[2448]
The considerations that led him to make those recommendations led us to investigate in Phase 2 why the LGA Guide advised landlords and responsible persons that it was usually unrealistic to plan for the evacuation and assistance in the event of a fire of disabled and vulnerable residents living in general needs blocks of flats, such as Grenfell Tower.[2449] That led in turn to our making a number of criticisms of the government and to recommend that the advice in the LGA Guide be reconsidered.[2450]
Moreover, the further evidence that we have received in the course of Phase 2 has confirmed us in the view that the responsible person for a general needs residential building should collect sufficient information about vulnerable occupants to enable appropriate measures to be taken to assist their escape in the event of a fire.[2451] Much of the evidence relating to the individual deaths set out in Part 9 emphasises the importance of being able to provide the fire and rescue service with reliable information about the vulnerability of those needing to be rescued.
We therefore recommend that further consideration be given to the recommendations made in the Phase 1 report in the light of our findings in this report.
We also recommend that the advice contained in paragraph 79.11 of the LGA Guide be reconsidered.
| Expression | Meaning |
|---|---|
| AC | Assistant Commissioner (London Fire Brigade). |
| ACM | Aluminium Composite Material. |
| ACM PE panels | Aluminium composite material rainscreen panels with polyethylene cores. |
| Acolaid | An electronic record-keeping system used by RBKC’s building control department. |
| Aerial appliance | A vehicle-mounted ladder with a reach of 32 metres. |
| AOM | Assistant Operations Manager (London Fire Brigade). |
| AOV | Automatic Opening Vent. |
| BA | Breathing Apparatus. |
| BARIE | Breathing Apparatus Radio Interface Equipment. |
| BBA | British Board of Agrément. |
| BCA | Building Control Alliance. |
| BECC | Borough Emergency Control Centre. |
| BEIS | Department for Business, Energy and Industrial Strategy (historic). |
| BIS | Department of Business, Innovation and Skills (historic). |
| BR 135 | Methods for large-scale fire testing of external wall systems are contained in BS 8414 Parts 1 and 2. The classification method and performance criteria are set out in BR 135. |
| BRAC | Building Regulations Advisory Committee. |
| BRE | Building Research Establishment. |
| BS 476-11 | BS 476-11 is a British Standard (national) test method used for assessing the heat emitted by burning materials. It is the national test for assessing whether a material is of “limited combustibility” as defined in Approved Document B. |
| BS 476-4 | BS 476-4 is the British Standard (national) test method used to determine non-combustibility. |
| BS 476-6 | BS 476-6 is the British Standard (national) test method for assessing the fire propagation properties of products. This test, together with BS 476-7, is used to determine national Class 0 as defined in Approved Document B. |
| BS 476-7 | BS 476-7 is the British Standard (national) test method designed to determine the ease with which flame will spread across the surface of a product. It is the other test used to determine national Class 0. |
| BS 8414 | A British Standard (national) large-scale test method for assessing the fire performance of external wall systems. |
| BS 9414:2019 | A British Standard providing guidance on the interpretation of data derived from BS 8414 tests and principles for the way in which such data can be used to assess the performance of systems similar to those tested. |
| BS EN 13165 | The relevant European and national harmonised standard applicable to rigid polyurethane foam building products. |
| BS EN 13501-1 | The European standard containing the system for classifying the reaction of materials to fire. |
| BS EN 13823 | BS EN 13823 is a European test method commonly referred to as the “single burning item test”. It is designed to determine the performance of materials under conditions representative of a fire within a compartment. |
| BS EN ISO 1182 | BS EN ISO 1182 is a European test method for determining whether materials are non-combustible. |
| BS EN ISO 11925-2 | BS EN ISO 11925-2 is a European test method known as the “‘single-flame source”’ test. The test is designed to simulate a small flame being applied directly to the surface or edge of a material. |
| BS EN ISO 1716 | BS EN ISO 1716 is a European test method for measuring the gross heat of combustion (calorific value) of a product or material. |
| BSI | British Standards Institution. |
| cc1924 | A series of tests carried out on various products by the Building Research Establishment between 2001 and 2002 for the Department for Communities and Local Government |
| CDM Regulations | Construction Design and Management Regulations (2007 and 2015). |
| CDM-C | CDM Co-ordinator. |
| Class 0 | A national product performance classification for lining materials defined in Approved Document B. |
| CM | Crew Manager (London Fire Brigade). |
| COBR | Cabinet Office Briefing Rooms. This was sometimes used as shorthand for a decision-making body of senior politicians, civil servants and others convened in accordance with the COBR procedure. |
| CPD | Continuing Professional Development. |
| CRM | Customer Relationship Management platform. |
| CRO | Control Room Officer (London Fire Brigade). |
| CSTB | Centre Scientifique et Technique du Bâtiment. |
| CU | Command Unit (London Fire Brigade). |
| CWCT | Centre for Windows and Cladding Technology. |
| DAC | Deputy Assistant Commissioner (London Fire Brigade). |
| DC | Deputy Commissioner (London Fire Brigade). |
| DCLG | Department for Communities and Local Government (historic). |
| DVI | Disaster Victim Identification. |
| EDBA | Extended Duration Breathing Apparatus. |
| Euroclass | The European Reaction to Fire classification is the EU common standard for assessing the reaction of building materials to fire. |
| FENSA | Fenestration Self-Assessment scheme. |
| FF | Firefighter. |
| Fire Safety Order | The Regulatory Reform (Fire Safety) Order 2005. |
| FLO | Family Liaison Officer. |
| FRS | Fire and Rescue Service. |
| FSC | Fire and Rescue Service Circular. |
| FSG | Fire Survival Guidance. |
| GLA | Greater London Authority. |
| GLO | Government Liaison Officer. |
| GM | Group Manager (London Fire Brigade). |
| GRA | Generic Risk Assessments published by the Chief Fire and Rescue Adviser in conjunction with the DCLG to provide operational guidance to fire and rescue services. |
| HALO | Humanitarian Assistance Lead Officer. |
| HMICFRS | His Majesty’s Inspectorate of Constabulary and Fire and Rescue Services. |
| HSE | Health and Safety Executive. |
| IMP/IMPD | Incident Monitoring Process/Incident Monitoring Process Database. |
| JESIP | Joint Emergency Services Interoperability Principles. |
| LABC | Local Authority Building Control. A membership organisation created in 2005 to support local authority building control departments in England and Wales. |
| LALO | Local Authority Liaison Officer. |
| Lambda value | Thermal conductivity expressed in watts per metre kelvin (W/mK). |
| LFB | London Fire Brigade. |
| LFEPA | London Fire and Emergency Planning Authority (historic). |
| LGA | Local Government Association. |
| LGA Guide | Fire safety in purpose-built blocks of flats, published by the Local Government Association. |
| Limited combustibility | A classification that was defined in Table A7 in Approved Document B 2013. It included materials that were either non-combustible or met certain criteria when tested to BS 476-11 or were European classification A2-s3, d2 or better in accordance with BS EN 13501-1:2007. |
| LSO | Licensed Search Officer. |
| MPS | Metropolitan Police Service. |
| NBS | National Building Specification. |
| NHBC | National House Building Council. |
| Non-combustible | A description defined in Table A6 in Approved Document B 2013. |
| OJEU | Official Journal of the European Union. |
| OM | Operations Manager (London Fire Brigade). |
| ORD | Operational Risk Database (London Fire Brigade). |
| PEEP | Personal Emergency Evacuation Plan. |
| PIR | Polyisocyanurate. |
| POM | Principal Operations Manager (London Fire Brigade). |
| PORIS | Provision of Operational Risk Information System. |
| PUR | Phenolic insulation. |
| RBKC | Royal Borough of Kensington and Chelsea. |
| Reaction to fire | Describes the behaviour of a material or product when exposed to heat. |
| RED | The Resilience and Emergencies Division of the Department for Communities and Local Government. |
| RIBA | Royal Institute of British Architects. |
| RICS | Royal Institution of Chartered Surveyors. |
| RIF | Reference Information Files. |
| Rule 43 letter | Letter written pursuant to rule 43 of the Coroners Rules 1984 intended to prevent future deaths (historic). |
| SCG | Strategic Coordinating Group. |
| SDBA | Standard Duration Breathing Apparatus. |
| Section 7(2)(d) | A provision in the Fire and Rescue Services Act 2004 which requires fire and rescue authorities to make arrangements for obtaining information needed for the purpose of extinguishing fires and for protecting life and property in the event of fires in their areas. |
| Sleeping Guide | The guidance entitled Fire Safety Risk Assessments: Sleeping Accommodation, published by the government in 2007. |
| SM | Station Manager (London Fire Brigade). |
| SOM | Senior Operations Manager (London Fire Brigade). |
| StARS | Staff Attendance Recording System (London Fire Brigade). |
| TCAP | Training Commissioning and Alterations Process (London Fire Brigade). |
| TGN 18 | Technical Guidance Note 18 entitled Use of Combustible Cladding Materials on Residential Buildings produced by the Building Control Alliance. |
| TMO | Tenant Management Organisation |
| U-value | The rate of heat transfer through a material or structure, measured in watts per square metre kelvin (W/m2K). |
| UHF | Ultra High Frequency. |
| UKAS | United Kingdom Accreditation Service. |
| VISION | A mobilisation system used by the London Fire Brigade. |
| WM | Watch Manager (London Fire Brigade). |
This table explains the referencing conventions used in this report. Source documents and transcripts of oral evidence can be found on the Inquiry’s website.
| Documents {Document reference number/page number or numbers} |
|
|---|---|
| Format and Examples | Meaning |
| {CEL00000012} | Document reference CEL00000012 |
| {RHX00000012/220} | Page 220 of document reference RHX00000012 |
| {MET00005404/4-7} | Pages 4 to 7 of document reference MET00005404 |
| {RHX00000012/220} paragraph 470 | Paragraph 470 on page 220 of document reference RHX00000012 |
| {ART00005742/47} clause 1.2.8 | Clause 1.2.8 on page 47 of document reference ART00005742 |
| Witness statements of fact Witness surname {Document reference number/page number or numbers} |
|
| Format and Examples | Meaning |
| Stimpson {LABC0020158/7-11} | Pages 7 to 11 of the witness statement of Lorna Stimpson, document reference LABC0020158 |
| Dolan {MET00012711/2} paragraphs 7-10 | Paragraphs 7 to 10 on page 2 of the witness statement of Matthew Dolan, document reference MET00012711 |
| Experts’ reports Expert’s name, report name {document reference/page number or numbers} |
|
| Format and Examples | Meaning |
| Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/23} | Page 23 of the Phase 2 report of Professor Jose Torero entitled “Adequacy of the Current Testing Regime”, document reference JTOR00000006 |
| Stoianov, Water Expert Report {ISTRP00000006/23} line 17 | Line 17 on page 23 of the Phase 2 expert report of Dr. Ivan Stoianov, document reference ISTRP00000006 |
| Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/34-37} paragraphs 6.1.3-6.1.23 | Paragraphs 6.1.3 to 6.1.23 on pages 34 to 37 of the Phase 2 report of Professor Jose Torero entitled “Adequacy of the Current Testing Regime”, document reference JTOR00000006 |
| Transcript references {Phase 2 hearing day No./transcript page number:line number or numbers} Witness surname {Phase 2 hearing day No./transcript page number:line number or numbers} |
|
| Format and Examples | Meaning |
| {Day1/20:2} | Line 2 on page 20 of the transcript for Phase 2 hearing Day No. 1 |
| {Day1/20:2}-{Day1/21:3} | Line 2 on page 20 of the transcript for Phase 2 hearing Day No.1 to line 3 on page 21 of the transcript for Phase 2 hearing Day No.1 |
| Harrison {Day159/16:4-14} | The oral witness evidence of James Harrison on Phase 2 hearing day No. 159, as set out in lines 4 to 14 on page 16 of the transcript for Phase 2 hearing day No. 159 |
| Evans {Day72/177:23}-{Day72/178:2} | The oral witness evidence of Paul Evans on Phase 2 hearing day No. 72, as set out from line 23 on page 177 of the transcript for Phase 2 hearing day No. 72 to line 2 on page 178 of the transcript for Phase 2 hearing day No. 72 |
The following table provides the calendar date for each day of the Phase 2 hearings on which witnesses gave oral evidence, cross-referenced against the “DayX” format used in this report’s footnotes.
With the following exceptions, “Day” references in Part 9 of the report refer to evidence heard in Phase 1 of the Inquiry. The exceptions are days numbered 296 and above, which comprised presentations given in respect of the deceased as well as relevant expert evidence. Appendix 2 of our Phase 1 report provides a complete list of witnesses heard during that phase of the Inquiry.
| Day | Calendar date | Witnesses |
|---|---|---|
| Day 6 | 2 March 2020 | Andrzej Kuszell / Bruce Sounes |
| Day 7 | 3 March 2020 | Bruce Sounes |
| Day 8 | 4 March 2020 | Bruce Sounes |
| Day 9 | 5 March 2020 | Neil Crawford |
| Day 10 | 9 March 2020 | Neil Crawford |
| Day 11 | 10 March 2020 | Neil Crawford |
| Day 12 | 11 March 2020 | Tomas Rek / Bruce Sounes |
| Day 14 | 16 March 2020 | Cate Cooney |
| Day 15 | 6 July 2020 | Dr Clare Barker |
| Day 16 | 7 July 2020 | Terence Ashton |
| Day 17 | 8 July 2020 | Terence Ashton |
| Day 18 | 9 July 2020 | Terence Ashton |
| Day 19 | 13 July 2020 | Tony Pearson |
| Day 20 | 14 July 2020 | Bruce Sounes |
| Day 21 | 15 July 2020 | Bruce Sounes |
| Day 22 | 16 July 2020 | Simon Lawrence |
| Day 23 | 20 July 2020 | Simon Lawrence |
| Day 24 | 21 July 2020 | Simon Lawrence |
| Day 25 | 22 July 2020 | Simon Lawrence |
| Day 26 | 23 July 2020 | Simon O’Connor |
| Day 27 | 27 July 2020 | David Hughes |
| Day 28 | 28 July 2020 | Stephen Blake |
| Day 29 | 29 July 2020 | Stephen Blake |
| Day 30 | 30 July 2020 | Gary Martin / Daniel Osgood |
| Day 31 | 7 September 2020 | Zak Maynard |
| Day 32 | 8 September 2020 | Ray Bailey |
| Day 33 | 9 September 2020 | Ray Bailey |
| Day 34 | 10 September 2020 | Mark Harris |
| Day 35 | 14 September 2020 | Mike Albiston / David Anketell-Jones |
| Day 36 | 15 September 2020 | David Anketell-Jones |
| Day 37 | 16 September 2020 | David Anketell-Jones / Kevin Lamb |
| Day 38 | 17 September 2020 | Kevin Lamb |
| Day 39 | 21 September 2020 | Ben Bailey |
| Day 40 | 22 September 2020 | Ben Bailey |
| Day 41 | 23 September 2020 | Geof Blades |
| Day 42 | 24 September 2020 | Andrew McQuatt / Jonathan White |
| Day 43 | 28 September 2020 | Gurpal Virdee / Mark Osborne |
| Day 44 | 29 September 2020 | Grahame Berry / Mark Dixon |
| Day 45 | 30 September 2020 | John Hoban |
| Day 46 | 1 October 2020 | John Hoban |
| Day 47 | 5 October 2020 | John Allen / Simon Cash |
| Day 48 | 6 October 2020 | Simon Cash |
| Day 49 | 7 October 2020 | Simon Cash / Philip Booth |
| Day 50 | 8 October 2020 | Philip Booth / Neil Reed |
| Day 51 | 12 October 2020 | Paul Dunkerton |
| Day 52 | 13 October 2020 | Mark Anderson |
| Day 53 | 14 October 2020 | David Gibson |
| Day 54 | 15 October 2020 | David Gibson / Claire Williams |
| Day 55 | 19 October 2020 | Claire Williams |
| Day 56 | 20 October 2020 | Claire Williams |
| Day 57 | 21 October 2020 | Peter Maddison |
| Day 58 | 22 October 2020 | Peter Maddison |
| Day 59 | 26 October 2020 | Peter Maddison |
| Day 60 | 27 October 2020 | Beryl Menzies |
| Day 61 | 28 October 2020 | Dr Barbara Lane |
| Day 62 | 29 October 2020 | Dr Barbara Lane |
| Day 63 | 2 November 2020 | Paul Hyett |
| Day 64 | 3 November 2020 | Paul Hyett |
| Day 65 | 4 November 2020 | Paul Hyett |
| Day 68 | 10 November 2020 | Dr Barbara Lane |
| Day 69 | 11 November 2020 | Jonathan Roome |
| Day 70 | 12 November 2020 | Jonathan Roome / Jonathan Roper |
| Day 71 | 16 November 2020 | Jonathan Roper |
| Day 72 | 17 November 2020 | Jonathan Roper / Paul Evans |
| Day 73 | 18 November 2020 | Paul Evans |
| Day 74 | 19 November 2020 | Jamie Hayes |
| Day 75 | 23 November 2020 | Ivor Meredith |
| Day 76 | 24 November 2020 | Ivor Meredith |
| Day 77 | 25 November 2020 | Gareth Mills |
| Day 78 | 26 November 2020 | Debbie Berger / Philip Heath |
| Day 79 | 30 November 2020 | Philip Heath |
| Day 80 | 1 December 2020 | Malcolm Rochefort |
| Day 81 | 2 December 2020 | Tony Millichap |
| Day 82 | 3 December 2020 | Tony Millichap |
| Day 83 | 7 December 2020 | Adrian Pargeter |
| Day 84 | 8 December 2020 | Adrian Pargeter |
| Day 85 | 9 December 2020 | Adrian Pargeter / Richard Burnley |
| Day 86 | 8 February 2021 | Andrew Pack |
| Day 87 | 9 February 2021 | Deborah French |
| Day 88 | 10 February 2021 | Deborah French |
| Day 89 | 11 February 2021 | Deborah French / Vince Meakins |
| Day 90 | 15 February 2021 | Vince Meakins / Claude Schmidt |
| Day 91 | 16 February 2021 | Claude Schmidt |
| Day 92 | 17 February 2021 | Claude Schmidt |
| Day 93 | 18 February 2021 | Claude Schmidt |
| Day 94 | 22 February 2021 | Claude Schmidt |
| Day 95 | 23 February 2021 | Philip Clark |
| Day 96 | 24 February 2021 | Philip Clark |
| Day 97 | 25 February 2021 | Philip Clark / Stephen Howard |
| Day 98 | 1 March 2021 | Stephen Howard |
| Day 99 | 2 March 2021 | Stephen Howard / Patrick Jones |
| Day 100 | 3 March 2021 | Tony Baker |
| Day 101 | 4 March 2021 | David Jones |
| Day 102 | 8 March 2021 | Christopher Mort |
| Day 103 | 9 March 2021 | Christopher Mort / Richard Kay |
| Day 104 | 10 March 2021 | Christopher Ibbotson |
| Day 105 | 11 March 2021 | Hamo Gregorian |
| Day 106 | 15 March 2021 | Valentina Amoroso |
| Day 107 | 16 March 2021 | Prayer Nkomo / Brian Moore |
| Day 108 | 17 March 2021 | Brian Moore / Chris Hunt |
| Day 109 | 18 March 2021 | Chris Hunt / John Albon |
| Day 110 | 22 March 2021 | John Albon |
| Day 111 | 23 March 2021 | John Albon / Adrian Pargeter |
| Day 112 | 24 March 2021 | Adrian Pargeter / Richard Burnley |
| Day 113 | 25 March 2021 | Richard Burnley |
| Day 116 | 19 April 2021 | Lee Chapman / David Collins |
| Day 117 | 20 April 2021 | Betty Kasote / Youssef Khalloud / Emma O’Connor / Corinne Jones |
| Day 118 | 21 April 2021 | Edward Daffarn |
| Day 119 | 22 April 2021 | David Noble / Mark Anderson |
| Day 120 | 26 April 2021 | Siobhan Rumble / Nicola Bartholomew |
| Day 121 | 27 April 2021 | Claire Williams |
| Day 122 | 28 April 2021 | Claire Williams / Peter Maddison |
| Day 123 | 29 April 2021 | Peter Maddison |
| Day 124 | 4 May 2021 | Peter Maddison |
| Day 125 | 5 May 2021 | Jonathan Sakula |
| Day 126 | 6 May 2021 | Teresa Brown |
| Day 127 | 10 May 2021 | Sacha Jevans |
| Day 128 | 11 May 2021 | Laura Johnson |
| Day 129 | 12 May 2021 | Laura Johnson |
| Day 130 | 13 May 2021 | Laura Johnson / Amanda Johnson |
| Day 131 | 17 May 2021 | Amanda Johnson / Rock Feilding-Mellen |
| Day 132 | 18 May 2021 | Rock Feilding - Mellen / Nicholas Paget-Brown |
| Day 133 | 19 May 2021 | Nicholas Paget-Brown / Quentin Marshall |
| Day 134 | 20 May 2021 | Sam Mackover / Judith Blakeman |
| Day 135 | 24 May 2021 | Judith Blakeman |
| Day 136 | 25 May 2021 | Carl Stokes |
| Day 137 | 26 May 2021 | Carl Stokes |
| Day 138 | 27 May 2021 | Carl Stokes |
| Day 139 | 1 June 2021 | Carl Stokes |
| Day 140 | 7 June 2021 | Janice Wray |
| Day 141 | 8 June 2021 | Janice Wray |
| Day 142 | 9 June 2021 | Janice Wray |
| Day 143 | 10 June 2021 | Janice Wray |
| Day 144 | 15 June 2021 | Janice Wray |
| Day 145 | 16 June 2021 | Janice Wray / Rebecca Burton / Nicolas Comery |
| Day 146 | 17 June 2021 | Paul Stedman / Robert Regan |
| Day 147 | 21 June 2021 | Matthew Ramsey / Andy Jack / Barbara Matthews |
| Day 148 | 22 June 2021 | Barbara Matthews |
| Day 149 | 23 June 2021 | Robert Black |
| Day 150 | 24 June 2021 | Robert Black |
| Day 151 | 28 June 2021 | Robert Black |
| Day 152 | 29 June 2021 | Graham Webb |
| Day 154 | 1 July 2021 | Paul Hanson |
| Day 155 | 5 July 2021 | Hugh Mahoney |
| Day 156 | 6 July 2021 | Granville Partlow |
| Day 157 | 7 July 2021 | Roy Jones / Matt Cross-Smith |
| Day 158 | 8 July 2021 | Alan Whyte |
| Day 159 | 12 July 2021 | James Harrison |
| Day 160 | 13 July 2021 | Matthew Dolan |
| Day 161 | 14 July 2021 | Rodney Hancox |
| Day 162 | 15 July 2021 | Stephen Ellis / Ian Moorhouse |
| Day 163 | 19 July 2021 | Gary Poynter / Roger Anthony / Mark Wallis |
| Day 164 | 20 July 2021 | Warren Jenchner / Robin Cahalarn |
| Day 165 | 21 July 2021 | Roger Howkins |
| Day 166 | 26 July 2021 | Abigail Acosta / Colin Todd |
| Day 167 | 27 July 2021 | Colin Todd |
| Day 168 | 28 July 2021 | Colin Todd / Beryl Menzies |
| Day 169 | 29 July 2021 | Beryl Menzies |
| Day 170 | 7 September 2021 | Dr Barbara Lane |
| Day 171 | 8 September 2021 | Dr Barbara Lane |
| Day 172 | 9 September 2021 | Dr Barbara Lane |
| Day 177 | 21 September 2021 | Peter Groves |
| Day 178 | 22 September 2021 | Peter Groves / Rita Dexter |
| Day 179 | 23 September 2021 | Rita Dexter |
| Day 180 | 27 September 2021 | Rita Dexter / Gary Reason |
| Day 181 | 28 September 2021 | Gary Reason |
| Day 182 | 29 September 2021 | Gary Reason |
| Day 183 | 30 September 2021 | Daniel Daly |
| Day 184 | 4 October 2021 | Daniel Daly / Dr Sabrina Cohen-Hatton |
| Day 185 | 5 October 2021 | Dr Sabrina Cohen-Hatton |
| Day 186 | 6 October 2021 | David Brown |
| Day 187 | 7 October 2021 | David Brown |
| Day 188 | 13 October 2021 | Dr Paul Grimwood |
| Day 189 | 18 October 2021 | Professor Chris Johnson |
| Day 190 | 19 October 2021 | Steve McGuirk |
| Day 191 | 21 October 2021 | Professor Jose Torero |
| Day 195 | 1 November 2021 | Peter Cowup |
| Day 196 | 2 November 2021 | Peter Cowup |
| Day 197 | 3 November 2021 | Peter Cowup |
| Day 198 | 4 November 2021 | Patrick Utting |
| Day 199 | 8 November 2021 | Scott Hayward |
| Day 200 | 9 November 2021 | Scott Hayward |
| Day 201 | 10 November 2021 | Scott Hayward |
| Day 202 | 11 November 2021 | Joanne Smith |
| Day 203 | 15 November 2021 | Joanne Smith |
| Day 204 | 16 November 2021 | Joanne Smith |
| Day 205 | 17 November 2021 | Philip Thomas George |
| Day 206 | 18 November 2021 | Philip Thomas George / David Brown |
| Day 207 | 22 November 2021 | David Brown |
| Day 208 | 23 November 2021 | Danielle Cotton |
| Day 209 | 24 November 2021 | Danielle Cotton |
| Day 210 | 25 November 2021 | Danielle Cotton / Ronald Dobson |
| Day 211 | 29 November 2021 | Ron Dobson |
| Day 212 | 30 November 2021 | Ron Dobson / Andrew Roe |
| Day 213 | 1 December 2021 | Andrew Roe |
| Day 216 | 8 December 2021 | Barry Turner |
| Day 217 | 9 December 2021 | Barry Turner / David Ewing |
| Day 218 | 13 December 2021 | David Ewing |
| Day 219 | 14 December 2021 | Steve Evans |
| Day 220 | 15 December 2021 | Steve Evans |
| Day 221 | 16 December 2021 | Steve Evans |
| Day 223 | 31 January 2022 | John Lewis |
| Day 224 | 1 February 2022 | John Lewis |
| Day 225 | 2 February 2022 | John Lewis / Diane Marshall |
| Day 226 | 3 February 2022 | Diane Marshall / Lorraine Turner |
| Day 227 | 7 February 2022 | Lorraine Turner |
| Day 228 | 8 February 2022 | David Metcalfe |
| Day 229 | 9 February 2022 | Dr David Crowder |
| Day 230 | 10 February 2022 | Dr David Crowder |
| Day 231 | 14 February 2022 | Dr Sarah Colwell |
| Day 232 | 15 February 2022 | Dr Sarah Colwell |
| Day 233 | 16 February 2022 | Dr Sarah Colwell |
| Day 234 | 17 February 2022 | Dr Sarah Colwell / Dr Debbie Smith |
| Day 235 | 21 February 2022 | Dr Debbie Smith |
| Day 236 | 22 February 2022 | Dr Debbie Smith |
| Day 237 | 23 February 2022 | Dr Debbie Smith |
| Day 238 | 24 February 2022 | Dr Debbie Smith / Anthony Burd |
| Day 239 | 28 February 2022 | Anthony Burd |
| Day 240 | 1 March 2022 | Anthony Burd |
| Day 241 | 2 March 2022 | Bob Ledsome |
| Day 242 | 3 March 2022 | Bob Ledsome |
| Day 243 | 7 March 2022 | Richard Harral |
| Day 244 | 8 March 2022 | Richard Harral |
| Day 245 | 9 March 2022 | Bob Ledsome / Sir Ken Knight |
| Day 246 | 10 March 2022 | Sir Ken Knight / Dennis Davis |
| Day 247 | 14 March 2022 | Louise Upton |
| Day 248 | 15 March 2022 | Louise Upton |
| Day 249 | 16 March 2022 | Dame Melanie Dawes |
| Day 250 | 17 March 2022 | Brian Martin |
| Day 251 | 21 March 2022 | Brian Martin |
| Day 252 | 22 March 2022 | Brian Martin |
| Day 253 | 23 March 2022 | Brian Martin |
| Day 254 | 24 March 2022 | Brian Martin |
| Day 255 | 28 March 2022 | Brian Martin |
| Day 256 | 29 March 2022 | Brian Martin |
| Day 257 | 30 March 2022 | Sir Brandon Lewis / Brian Martin |
| Day 258 | 31 March 2022 | Lord Wharton of Yarm |
| Day 259 | 4 April 2022 | Stephen Williams |
| Day 260 | 5 April 2022 | Lord Barwell |
| Day 261 | 6 April 2022 | Lord Pickles |
| Day 262 | 7 April 2022 | Lord Pickles |
| Day 264 | 12 April 2022 | Karim Mussilhy |
| Day 265 | 13 April 2022 | Hisam Choucair / Mahmoud Al-Karad / Mohammed Rasoul |
| Day 266 | 14 April 2022 | Mouna El-Ogbani / Fatima Boujettif / Hanan Cherbika |
| Day 267 | 25 April 2022 | Nabil Choucair / Hanan Wahabi |
| Day 268 | 26 April 2022 | David Kerry |
| Day 269 | 27 April 2022 | David Kerry |
| Day 270 | 28 April 2022 | Stuart Priestley / Rebecca Blackburn |
| Day 271 | 3 May 2022 | Sue Redmond |
| Day 272 | 4 May 2022 | Laura Johnson |
| Day 273 | 5 May 2022 | Nicholas Holgate |
| Day 274 | 9 May 2022 | Teresa Brown |
| Day 275 | 10 May 2022 | Robert Black / Clare Richards / Mark Simms |
| Day 276 | 11 May 2022 | Rupinder Hardy / Michael Adamson |
| Day 277 | 12 May 2022 | John Hetherington |
| Day 278 | 16 May 2022 | John Hetherington / Mark Sawyer |
| Day 279 | 17 May 2022 | John Barradell |
| Day 280 | 18 May 2022 | Emma Spragg / Katharine Hammond |
| Day 281 | 19 May 2022 | Katharine Hammond |
| Day 282 | 23 May 2022 | David Bellamy / Nick Hurd |
| Day 283 | 24 May 2022 | Gill McManus |
| Day 284 | 25 May 2022 | Dr Jo Farrar CB |
| Day 285 | 26 May 2022 | Dame Melanie Dawes |
| Day 286 | 6 June 2022 | Simon Lay |
| Day 287 | 7 June 2022 | Dr Barbara Lane |
| Day 288 | 8 June 2022 | Dr Ivan Stoianov |
| Day 289 | 9 June 2022 | Professor Jose Torero / Professor Luke Bisby |
| Day 290 | 13 June 2022 | Professor Luke Bisby |
| Day 291 | 15 June 2022 | Professor Luke Bisby / Professor Jose Torero |
| Day 292 | 16 June 2022 | Professor Jose Torero |
| Day 296 | 29 June 2022 | Professor David Purser |
| Day 297 | 30 June 2022 | Professor David Purser |
| Day 298 | 4 July 2022 | Dr Ashley Fegan-Earl / Gaille MacKinnon |
| Day 299 | 5 July 2022 | Presentations relating to those who lost their lives in the fire: Eslah Elgwahry, Mariem Elgwahry - Danny Friedman KC Sakina Afrasehabi, Fatemeh Afrasiabi - Danny Friedman KC Mohammed Neda - Imran Khan KC Rania Ibrahim, Fethia Hassan, Hania Hassan - Danny Friedman KC |
| Day 300 | 6 July 2022 | Presentations relating to those who lost their lives in the fire: Deborah Lamprell - Danny Friedman KC Jessica Urbano Ramirez - Allison Munroe KC Hamid Kani - Michael Mansfield KC Berkti Haftom , Biruk Haftom - Danny Friedman KCRaymond Bernard - Thalia Maragh |
| Day 301 | 7 July 2022 | Presentations relating to those who lost their lives in the fire: Abdeslam Sebbar - Danny Friedman KC Hesham Rahman - Danny Friedman KC Husna Begum, Kamru Miah, Mohammed Hamid, Mohammed Hanif, Rabeya Begum - Sam Stein KC |
| Day 302 | 11 July 2022 | Dr Karl Harrison |
| Day 303 | 12 July 2022 | Presentations relating to those who lost their lives in the fire: Sirria Choucair, Nadia Choucair, Bassem Choukair, Mierna Choucair, Fatima Choucair, Zainab Choucair - Danny Friedman KC Hashim Kedir, Nura Jemal, Yahya Hashim, Firdaws Hashim, Yaqub Hashim - Danny Friedman KC Gary Maunders - Allison Munroe KC |
| Day 304 | 13 July 2022 | Presentations relating to those who lost their lives in the fire: Tony Disson - Allison Munroe KC Ligaya Moore - Michael Mansfield KC Sheila - Danny Friedman KC |
| Day 305 | 14 July 2022 | Presentations relating to those who lost their lives in the fire: Victoria King, Alexandra Atala - Danny Friedman KC Khadija Saye, Mary Mendy - Allison Munroe KC Farah Hamdan, Omar Belkadi, Malak Belkadi, Leena Belkadi - Allison Munroe KC |
| Day 306 | 19 July 2022 | Presentations relating to those who lost their lives in the fire: Logan Gomes - Sam Stein KC Khadija Khalloufi, Ali Yawar Jafari - Danny Friedman KC Amal Ahmedin, Amaya Tuccu Ahmedin, Mohamednur Tuccu, Amna Mahmud Idris - Imran Khan KC |
| Day 307 | 20 July 2022 | Presentations relating to those who lost their lives in the fire: Isaac Paulos - Imran Khan KC Vincent Chiejina - Allison Munroe KC Joseph Daniels - Allison Munroe KC Steve Power - Danny Friedman KC Fathia Ahmed Elsanousi, Abufras Mohamed Ibrahim, Isra Ibrahim - Danny Friedman KC |
| Day 308 | 21 July 2022 | Presentations relating to those who lost their lives in the fire: Mohammad Alhajali - Danny Friedman KC Denis Murphy - Allison Munroe KC Zainab Deen, Jeremiah Deen - Allison Munroe KC Abdulaziz El-Wahabi, Faouzia El-Wahabi, Yasin El-Wahabi, Nur Huda El-Wahabi , Mehdi El-Wahabi - Allison Munroe KC |
It would not have been possible to conduct an inquiry of this kind without the support of a large and dedicated team of lawyers and administrators, most of whom have worked tirelessly behind the scenes to enable us to carry out our task. Their contribution has been immense and we owe them a great debt of gratitude. We should therefore like to thank the following persons who have been members of the team at various times since the Inquiry was set up in June 2017.
Richard MILLETT KC
Kate GRANGE KC
Andrew KINNIER KC
Bernard RICHMOND KC
Dermot KEATING KC
Bilal RAWAT
Caroline FEATHERSTONE
Mark FISHER CBE
Nicole KETT
Matt LEWSEY
Joe MONTGOMERY CB
John MOTHERSOLE
David NETHERCOT OBE
Joyce REDFEARN CBE
Timothy AKERS
Stuart ALLEN
Naima ASIF
Rajkiran BARHEY
Thomas BEAMONT
Georgina BLOWER
Samantha BONNER
Abigail BRIGHT
Aphra BRUCE -JONES
Samuel BURRETT
Joseph BYRNE
Alex CAMERON
Chloe CAMPBELL
Rhoderick CHALMERS
Kate CHIDGEY
Nargees CHOUDHURY
Tom COCKROFT
Clementine CORAM JAMES
Hannah CURTAIN
Beverley DA COSTA
David DAINTY
Alexandra DAVEY
Marie DE REDMAN
Helena DRAGE
Charles DURRANT
Tatyana EATWELL
George EYRE
Emma - Louise FENELON
Kate FORTESCUE
Adam GADD
Maria GHERMAN
Harriet GILCHRIST
James GRAY
Rose GROGAN
Emily HAMILTON
Rose HARVEY
Jamila HASSAN
Nicholas HIGGS
Matthew HODGETTS
Emma HYNES
Roxanne IQBAL - CLARE
Zeenat ISLAM
Abimbola JOHNSON
Samantha JONES
Molly JOYCE
Priya KHANNA
Araniya KOGULATHAS
Sushil KUMAR
Daniel LAKING
Brad LAWLOR
Kirsty LEA
Hilary LENNOX
Natasha LLOYD-OWEN
Jonathan LODWICK
Caroline LODY
Patricia LONDONO
Shanice MAHMUD
Priya MALHOTRA
George MALLET
Neil MATTHEWS
John McNAMARA
David MESSLING
Sharmistha MICHAELS
Scarlett MILLIGAN
Conor MULLEN
Daniel O’DONOGHUE
Celia OLDHAM
Ayesha OMAR
Rachel OWUSU-AGYEI
Rebecca PENFOLD
Lucy PLUMPTON
Ricky POWELL
Sarah READ
Sam ROAKE
Catherine ROSE
Kerrie Ann ROWAN
Timothy SALISBURY
Daniel SEARLE
Kat SHIELDS
Natasha SHOTUNDE
Vida SIMPEH
Shanthi SIVAKUMARAN
Michael SPENCER
Michael STANDING
Caroline STEWART
Kelly STRICKLIN - COUTINHO
Emma STUART-SMITH
Rachel SULLIVAN
Camilla TER HAAR
Rachel TROUP
Alex USTYCH
Thomas WHITE
George WILLS
Kieran WILSON
Melanie WINTER
Julia DICKINS
Ross HOWARTH
Cathy KENNEDY
Shafi NASSER
Hanae BENNANI
Erica BERKI
Luke JACOB
Victoria O’BRIEN
Erin PECK
Emily SCHWIKKARD
Rosalynn TRY-HANE
Anna VENTURINO
Holly WALDRON
Hollie WAUGH
Thomas WOOD
Alex AFOLABI
Xavier AJUWON
Christine AKOL
Una ANYANWU
Reka ARCIDIACONO
Osai Layla BASHARDUST
Precious BOATENG
Omobolanle BODE-GEORGE
Afsana CHOWDHURY
Amber DAVID
Jaimish DESAI
Esther FAKOYA
Zandagi FEDAIE
Elizabeth FOSTER-AILERU
Maureen GOH
Haroon HASSAN
Sahira HUSSAIN
Dhanisha JANI
Eleni KATSARI
Tinessa KAUR
Paramdeep KHERA
Natalie LARBI
Ling LI
Dionne LUKE-MACAULEY
Francesca MANCINELLI
Luke MCLEAN
Cosan MEHMET
Sarah OSONDU
Juliet OTU-AMPONSAH
Shalini PATEL
Demi PATTNI
Daryl PEAGRAM
Daniel QUIALA
Sintayehu ROMANO
Amos SAWYERS
Massah SHARKA
Annemarie SHEA
Manmeet SIRA
Olabisi SOWUNMI
Mark STOW
Emma THOMPSON
Kevin VADHER
Remi WETE
Mashal YONUSZADEH
Zelage YONUSZADEH
Nana ACQUAH
Epke ATTAH
George AUSTIN-WEBSTER
Shankar BALARAJAH
Tom BLACKBURN
Laura BROOKS
Jane BULTITUDE
Hannah BRYANT
Nav CHAUHAN
Kay CHAUHAN
Dileeni DANIEL - SELVARATNAM
Eavan DOWSE
Paul EDENS
Heather FAIRWEATHER
Julian FLETCHER
Sam HERROD
Joanna HEZELDEAN
Tofayel HOQUE
Kainat HUSSAIN
Linda ILEY
Amanda JEFFERY
Lucy JOHNSON
Bushra KHERALLAH
Kathy KNOX
Christine MAY
Ellie McDONALD
Curtis MOISE
Aisha - Asher MORGAN
Jim NAREY
Kana NATARAJAN
Melanie PEFFER
Brenda PINNOCK
Justine RAINBOW
Paul SOUNDARAJAH
Michael THOMAS
Kathleen TURNER
Geraldine WELTON
Mike WICKSTEED
Marta WILLIAMS
Charlotte WOODALL
We are also very grateful to those from RTS Communications, Epiq and Opus 2 International who with unfailing skill and dedication provided the technical and professional services that enabled us to conduct our hearings effectively and make them available on line to those who could not attend in person.
1) Paragraph 1(h) of the Terms of Reference.
2) Civil Contingencies Act 2004 {CAB00004616}.
3) Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005 {CAB00007003}.
4) Civil Contingencies Act 2004, Sections 1-18 {CAB00004616/1}.
5) Civil Contingencies Act 2004, Sections 1(1)(a) and 1(2) {CAB00004616/1}.
6) Civil Contingencies Act 2004, Schedule 1, Part 1, paragraph 1(c) and paragraph 1A {CAB00004616/31}.
7) Civil Contingencies Act 2004, Schedule 1, Part 3{CAB00004616/34}.
8) Civil Contingencies Act 2004, Section 2{CAB00004616/2}; Explanatory Memorandum to Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005, paragraph 7.2 {HOM00000492/4}.
9) Civil Contingencies Act 2004, Section 2(1) {CAB00004616/2}; Civil Contingencies Act 2004 (Contingency Planning) Regulations, Regulation 4(5) {CAB00007003/5}.
10) Civil Contingencies Act 2004, Section 2(1)(a) and (b) {CAB00004616/2}.
11) Civil Contingencies Act 2004, Section 2(1)(d) {CAB00004616/3}.
12) Civil Contingencies Act 2004, Section 2(1)(g) {CAB00004616/3}.
13) Civil Contingencies Act 2004, Section 5(1) and 5(3); Civil Contingencies Act 2004, Section 17(2) {CAB00004616/7} and {CAB00004616/18}. Orders can require collaboration with a specified person or body or confer a power on a minister or some third party that would normally be exercised by a responder (Civil Contingencies Act 2004, Section 5(4) {CAB00004616/7}). They can also require or permit the disclosure of information, which would otherwise not be available (Civil Contingencies Act 2004, Section 6 {CAB00004616/8}).
14) Civil Contingencies Act 2004, Section 7 {CAB00004616/9}.
15) Civil Contingencies Act 2004, Sections 19-31 {CAB00004616/20-28}. See also Responding to Emergencies: The UK Central Government Concept of Operations (“ConOps”) {CAB00000026/66-67}.
16) Emergency Preparedness: Chapter 1 {CAB00000079}; Chapter 2{CAB00007027}; Chapter 3 {CAB00004536}; Chapter 4 {CAB00004537}; Chapter 5 {CAB00004623}; Chapter 6 {CAB00007026}; Chapter 7 {CAB00004543}; Chapter 8 {CAB00004544}; Chapter 9 {CAB00004545}; Chapter 10 {CAB00004531}; Chapter 11 {CAB00004594}; Chapter 12 {CAB00004595}; Chapter 13 {CAB00004596}; Chapter 14 {CAB00004597}; Chapter 15 {CAB00004598}; Chapter 16 {CAB00004599}; Chapter 19 {CAB00004622}.
17) Emergency Response and Recovery {CAB00004519}.
18) Emergency Preparedness, Chapter 16 {CAB00004599/3} paragraph 16.1.
19) Emergency Response and Recovery {CAB00004519/18} paragraph 2.4.1.
20) Emergency Response and Recovery {CAB00004519/18} paragraph 2.4.2.
21) Emergency Response and Recovery {CAB00004519/116} paragraph 7.1.1.
22) Emergency Response and Recovery {CAB00004519/33-34} paragraph 3.2.34.
23) {CAB00000010} sets out policies, procedures, plans and strategy documents of which the Civil Contingencies Secretariat considered as of potential relevance to the Grenfell Tower fire response. Hammond {CAB00014764/2} page 2, paragraph 8.
24) {CAB00004627}.
25) {CAB00000036}.
26) {INQ00015207}.
27) Resilience Direct is the private web-based platform used by responders both in planning and in response and recovery. Hammond {CAB00014764/10} page 10, paragraph 33.
28) Hammond {Day280/139:18}-{Day280/140:4}.
29) Hammond {Day280/140:11-25}.
30) Emergency Preparedness, Chapter 5 {CAB00004623/39-40} paragraphs 5.97-5.103.
31) Emergency Response and Recovery {CAB00004519/129-131} section 7.7.
32) “Needs of Faith Communities in Major Emergencies” guidance {CAB00014865}.
33) MacFarlane {CAB00014862/3-4} pages 3-4, paragraph 11; Emergency Preparedness, Chapter 5 {CAB00004623/39} paragraphs 5.98.
34) “Identifying People Who Are Vulnerable in a Crisis: Guidance for Emergency Planners and Responders”, guidance, published in 2008, specifically refers to minority language speakers {CAB00014864/14} and the Disability Discrimination Act as “other legislation may interact with responsibilities under the Civil Contingencies Act” {CAB00014864/7} paragraph 11.
35) “Expectations and Indicators of Good Practice Set for Category 1 and 2 Responders” guidance, revised in October 2013, lists giving special consideration to vulnerable people when producing plans as a “mandatory requirement” {CAB00004629/26} and reminds responders of the need to consider vulnerable groups when communicating with the public {CAB00004629/28}.
36) “Preparation and planning for emergencies: responsibilities of responder agencies and others” guidance, published in February 2013 {CAB00014785}.
37) The Equality Act 2010 was identified in Annex C of Human Aspects in Emergency Management as a key piece of legislation that should be considered when planning for Humanitarian Assistance {CAB00000036/56}. In contrast and by way of example, at the London level the Act was referred to directly in the London Resilience Partnership’s 2015 document “Identification of the Vulnerable: A Guidance Note for Local Implementation” {LFB00061174/6} paragraph 1.6 and the Humanitarian Assistance Framework, v.5 dated April 2017 {LFB00061172}.
38) MacFarlane {CAB00014862/5} page 5, paragraph 14.
39) Emergency Preparedness, Chapter 19 {CAB00004622}.
40) McCloghrie {CAB00014798/2} page 2, paragraph 6.
41) McCloghrie {CAB00014798/3} page 3, paragraph 11.
42) A reasonable worst case scenario (RWCS) is defined as a challenging yet plausible manifestation of the risk. Hammond {CAB00014799/5-6} pages 5-6, paragraph 17.
43) McCloghrie {CAB00014798/4} page 4, paragraph 13.
44) Hammond {CAB00014799/3} page 3, paragraph 8.
45) Hammond {Day280/103ː1-17}; Hammond {CAB00014799/4} page 4, paragraph 10.
46) McCloghrie {CAB00014798/10-11} pages 10-11, paragraph 36.
47) Edwards {HOM00050071/7-8} pages 7-8, paragraph 28.
48) Hammond {CAB00014868/2} page 2, paragraphs 7-8; Edwards {HOM00050071/8} page 8, paragraph 30.
49) Edwards {HOM00050071/1} page 1, paragraph 3.
50) Edwards {HOM00050071/8} page 8, paragraph 30.
51) Hammond {Day280/107ː4-8}.
52) Hammond {CAB00014799/2} page 2, paragraph 4.3; Hammond {CAB00014799/10} page 10, paragraph 33.
53) Hammond {CAB00014799/16-17} pages 16-17, paragraph 55.
54) Hammond {CAB00014764/6} page 6, paragraph 22.
55) National Risk Register 2015 {CAB00007009}.
56) National Risk Register 2015 {CAB00007009/27-28}.
57) Hammond {Day280/114ː8-15}.
58) Hammond {Day280/133ː2-7}.
59) Hammond {CAB00014799/13-15} pages 13-15, paragraphs 45-49.
60) Hammond {CAB00014799/14} page 14, paragraph 48.1.
61) MacFarlane {CAB00014794/10} page 10, paragraph 35.
62) MacFarlane {CAB00014794/10} page 10, paragraph 35.
63) MacFarlane {CAB00014803/3} page 3, paragraph 7.
64) Hammond {Day280/120ː2-14}.
65) National Risk Register 2017, “Industrial and Urban Accidents” {CAB00000069/46-49}. See also the National Risk Register 2020 “Major Fires” {INQ00015149/83-86}. In that edition the “Major Fires” chapter is separate to the chapter on “Industrial Accidents”.
66) Edwards {HOM00050071/9} page 9, paragraph 32.
67) McCloghrie {CAB00014798/12} page 12, paragraph 40.
68) McCloghrie {CAB00014798/12} page 12, paragraph 40.
69) Hammond {CAB00014799/20} page 20, paragraph 65.
70) Civil Contingencies Act 2004, Section 2(1)(d) {CAB00004616/2-3}.
71) Hetherington {LFB00119130/14} page 14, paragraph 44.
72) Hetherington {Day277/109:11-23}.
73) London Risk Register v.5.4, 2017 {LFB00061165/13}.
74) Hetherington {Day277/110:14-24}.
75) Hetherington {Day277/111:1-11}.
76) Hetherington {Day277/116:17-25}.
77) Hetherington {Day277/128:5-25}.
78) Hetherington {Day277/117:1-3}.
79) Hetherington {LFB00061158/2} page 2, paragraph 5; Hetherington {Day277/7:1-10}.
80) Hetherington {Day277/121:12-19}.
81) Civil Contingencies Act 2004, Section 2{CAB00004616/2}.
82) Kerry {Day268/19:22}-{Day268/20:2}; Civil Contingencies Act 2004, Sections 2(1)(a)-(f) {CAB00004616/2-3}.
83) {RBK00036688/9} page 9, table 3.1.
84) {RBK00036688/8} section 2.3.
85) Kerry {Day268/23:11-17}.
86) Kerry {Day268/22:17}-{Day268/23:10}.
87) Also referred to as the Community Risk Register {RBK00036688/8} section 2.2.
88) {Day264/108:21}-{Day264/213:12}; {Day267/41:16}-{Day267/93:10}.
89) Residents were evacuated from Grenfell Walk, Treadgold House, Hurstway Walk, Barandon Walk and Testerton Walk. Residents were also evacuated from Bramley House but not for an extended period and did not require accommodation.
90) Levi {IWS00001753/8-9} pages 8-9, paragraphs 34 and 36; Dainton {IWS00000939/12} page 12, paragraph 80; John {IWS00001681/2-3} pages 2-3, paragraph 11; Adam {IWS00001301/10} page 10, paragraph 85; Khalloud {IWS00001754/5} page 5, paragraph 24.
91) Sadafi {IWS00001806/3} page 3, paragraph 8.
92) Mussilhy {Day264/17:7-8}.
93) Cherbika {Day266/89:5}.
94) Mussilhy {Day264/20:5}.
95) Mussilhy {Day264/22:2-21}.
96) Moghaddam {IWS00001266/4} page 4, paragraphs 14 and 15.
97) Ranito {IWS00001256/4-5} pages 4 - 5, paragraphs 22 and 23.
98) Ahmed {IWS00001335/129} page 129, paragraph 358.
99) Thompson {IWS00000158/10} page 10, paragraph 60.
100) The response of the community, voluntary and faith sectors is examined in Chapter 106.
101) Moses {IWS00001276/14} page 14, paragraph 97; Cherbika {Day266/87:21-24}.
102) Khoudair {IWS00001616/11} page 11, paragraph 33; Alfawaz {IWS00001274/7} page 7, paragraph 55; John {IWS00001685/8} page 8, paragraph 33.
103) Ranito {IWS00001256/4-5} pages 4 - 5, paragraphs 22 and 23.
104) Ramiro Urbano {IWS00000496/8} page 8, paragraph 45.
105) Chiapetto {IWS00001780/4} page 4, paragraph 15.
106) Abebe {IWS00000847/10} page 10, paragraph 31.
107) Nick Layton (LALO) Initial Log {RBK00014632/1}.
108) Summary of Actions taken by the TMO Document {TMO00899668/1}.
109) Wahabi {Day267/111:10}-{Day267/112:14}.
110) Wahabi {Day267/111:10}-{Day267/112:14}; Simms {Day275/193:15-17}.
111) Laura Johnson {RBK00035592/8} page 8, paragraph 33.
112) TMO Staff Cover on 14 June 2017 {TMO00869981}; Brown {Day274/31:10-25}.
113) Yousuf {IWS00001626/3} page 3, paragraph 14; Alves {IWS00001596/10} page 10, paragraph 53; El-Guenuni {IWS00002034/8} page 8, paragraphs 31.
114) Patel {IWS00001610/10} page 10, paragraph 49.
115) Alhaj Ali {IWS00001533/12-13} pages 12 - 13, paragraphs 62 and 63.
116) Abdulhamid {IWS00001919/3} page 3, paragraph 16.
117) Abdulhamid {IWS00001919/3} page 3, paragraph 16.
118) Moses {IWS00001281/9} page 9, paragraph 47.
119) Ali {IWS00001617/12} page 12, paragraph 144.
120) Alves {IWS00001587/18} page 18, paragraph 93.
121) Batoon {IWS00001687/11-12} pages 11 - 12, paragraph 47.
122) Thompson {IWS00002110/33} page 33, paragraph 120; Burton {IWS00001661/24} page 24, paragraph 129; Yahya {IWS00000498/8} page 8, paragraph 32; Hamide {IWS00001651/4} page 4, paragraphs 17 and 18.
123) Mohamed {IWS00001545/11} page 11, paragraph 47; Abdu {IWS00001956/10} page 10, paragraphs 52 and 53; Yousuf {IWS00001626/3} page 3, paragraph 14.
124) Alves {IWS00001587/18} page 18, paragraph 91; Chebiouni {IWS00001979/5} page 5, paragraph 24.
125) Yahya {IWS00000498/8} page 8, paragraph 32; Adam {IWS00001301/12} page 12, paragraph 100.
126) Rasoul {Day265/156:1-7}.
127) Kabouh {IWS00001613/6} page 6, paragraph 30.
128) Jamalvatan {IWS00001704/5} page 5, paragraph 21.
129) Macit {IWS00001563/12} page 12, paragraph 52; Shaw {IWS00001752/8} page 8, paragraph 39; El-Sawy {IWS00001829/7} page 7, paragraph 31.
130) Ho {IWS00001551/20} page 20, paragraph 82.
131) El-Guenuni {IWS00002034/9} page 9, paragraph 34.
132) Quang {IWS00001821/12} page 12, paragraphs 58.
133) Daniels {IWS00002065/15} page 15, paragraph 99.
134) Sadafi {IWS00001806/23} page 23, paragraph 73.
135) El-Ogbani {Day266/22:14-16}.
136) Pasztor {IWS00001682/4} page 4, paragraph 17 (7-8 months); El-Sawy {IWS00001829/8} page 8, paragraph 34 (9 months); Ollivierre {IWS00001758/6} page 6, paragraph 26 (9 months); Elbouti {IWS00001605/11} page 11, paragraph 50 (10 months).
137) Lopez {IWS00001680/8} page 8, paragraph 48 (14 months); Rasoul {Day265/154:14} (19 months); Cherbika {Day266/102:5} (just over a year); Hanan Wahabi {Day267/113:25}-{Day267/114:3} (18 months); Chebiouni {IWS00001979/6} page 6, paragraph 34 (18 months).
138) Al-Karad {Day265/111:17-19}; Chiapetto {IWS00001780/3} page 3, paragraph 10; Pahlavani {IWS00001244/14} page 14, paragraph 42.
139) Demissie {IWS00001540/6} page 6, paragraph 21.
140) Lukic {IWS00001760/6} page 6, paragraph 25.
141) El-Guenuni {IWS00002034/9} page 9, paragraph 35.
142) Gomes {IWS00001078/39} page 39, paragraph 203.
143) Neda {IWS00001302/3} page 3, paragraph 15.
144) Hassani {IWS00001636/17-18} pages 17 - 18, paragraph 72; Khalloud {IWS00001754/6} page 6, paragraph 31.
145) Ignacio {IWS00001820/15} page 15, paragraph 78.
146) Mensah {IWS00001944/9} page 9, paragraph 43.
147) Ignacio {IWS00001820/14} page 14, paragraph 70.
148) Cherbika {Day266/104:15}-{Day266/105:8}.
149) Cherbika {Day266/102:15}-{Day266/103:9}; Cherbika {Day266/119:9-20}; Chebiouni {IWS00002043/6} page 6, paragraph 35; Chebiouni {IWS00002043/8} page 8, paragraph 52.
150) Adam {IWS00001296/4} page 4, paragraph 23.
151) Moses {IWS00001281/10} page 10, paragraph 54; Rasoul {Day265/157:13-25}.
152) Lokko {IWS00001516/4-5} pages 4-5, paragraph 34.
153) Moses {IWS00001281/10} page 10, paragraph 58.
154) El Amine {IWS00001946/10-11} pages 10-11, paragraph 46; El-Ogbani {Day266/23:20}-{Day266/24:5}; Choucair {IWS00001799/15-16} pages 15-16, paragraph 20(c).
155) Chebiouni {IWS00002043/6} page 6, paragraph 39; Jones {IWS00001691/5} page 5, paragraph 24.
156) Rasoul {Day265/171:19-25}-{Day265/172:1-5}.
157) Shawo {IWS00001290/4} page 4, paragraph 25.
158) Lewis {IWS00001629/6} page 6, paragraph 25.
159) Al-Assad {IWS00001789/11} page 11, paragraph 67.
160) Araya {IWS00001648/4} page 4, paragraph 20.
161) Rasoul {Day265/159:13-23}.
162) Ortiz {IWS00001283/7} page 7, paragraphs 51 and 53.
163) El-Ogbani {Day266/25:1-5}; Khalloud {IWS00001754/6} page 6, paragraph 30.
164) Rasoul {Day265/160:10}-{Day265/161:5}.
165) Brown {TMO00869990/4} page 4, paragraph 18; Brown {TMO00894124/17-18} pages 17 - 18, paragraphs 60 and 61; Exhibit TB/59 {TMO00894203/2}.
166) Sang {IWS00001939/11} page 11, paragraph 55.
167) Exhibit TB/11 {TMO00869977/2}; Brown {TMO00894124/17} page 17, paragraph 60.
168) Boujettif {Day266/75:1-14}.
169) Archid {IWS00001618/15} page 15, paragraph 83.
170) Dowlut {IWS00001787/10-11} pages 10-11, paragraphs 37, 38 and 39; Wake {IWS00001642/5} page 5, paragraph 18.
171) Bedford {IWS00001652/8-9} pages 8 - 9, paragraph 32.
172) Novell {IWS00001288/10} page 10, paragraph 57.
173) Rullo {IWS00001655/9} page 9, paragraph 36.
174) Raihani {IWS00001263/2} page 2, paragraph 10.
175) Raihani {IWS00001263/5} page 5, paragraph 22.
176) Al-Assad {IWS00001789/9} page 9, paragraph 54.
177) Lara {IWS00001589/11} page 11, paragraph 41.
178) Richer {IWS00001253/11} page 11, paragraph 51.
179) Lasharie {IWS00001546/5-6} pages 5-6, paragraph 24.
180) Stergiopoulou {IWS00001586/11} page 11, paragraph 43.
181) Hessel {IWS00001645/8} page 8, paragraph 33.
182) Gil {IWS00001679/7} page 7, paragraph 56; McMahon {IWS00001966/10} page 10, paragraph 43.
183) Ranito {IWS00001249/8} page 8, paragraph 39.
184) Hessel {IWS00001645/8-9} pages 8 - 9, paragraph 33.
185) John {IWS00001681/3} page 3, paragraph 15.
186) Hartley {IWS00001257/11} page 11, paragraph 43.
187) Norbert {IWS00001252/8} page 8, paragraph 41.
188) John {IWS00001681/3-4} pages 3 - 4, paragraphs 17, 20 and 21.
189) Hartley {IWS00001257/11} page 11, paragraphs 41 and 42; Levi {IWS00001753/12-13} pages 12 - 13, paragraphs 52 and 53; El-Sawy {IWS00001829/5} page 5, paragraph 22; Yahya {IWS00001825/10} page 10, paragraph 50.
190) Serroukh {IWS00001747/5} page 5, paragraph 22.
191) Boujettif {Day266/67:7-14}.
192) John {IWS00001681/4} page 4, paragraphs 20-22.
193) Serroukh {IWS00001747/5-6} pages 5 - 6, paragraphs 23 and 24.
194) Serroukh {IWS00001747/6} page 6, paragraph 24.
195) Archid {IWS00001618/14} page 14, paragraph 79.
196) O’Connell {IWS00001574/5} page 5, paragraph 17.
197) Procedure Note for Resettlement Packages {RBK00028643}.
198) Cherbika {Day266/116:23}-{Day266/117:23}.
199) Cherbika {Day266/117:16-23}.
200) Moses {IWS00001276/13} page 13, paragraph 92.
201) Norman {CFV00000061/2} page 2, paragraphs 2a- 2d.
202) Norman {CFV00000061/4} page 4, paragraph 2l.
203) Norman {CFV00000061/4} page 4, paragraph 2m.
204) Gomez {IWS00001264/8} page 8, paragraphs 53 and 54.
205) Moussaid {IWS00001282/5} page 5, paragraph 25; Moses {IWS00001276/14} page 14, paragraph 99. Cherbika {Day266/89:16}-{Day266/91:4}.
206) Girma {IWS00001732/12} page 12, paragraph 23.
207) Thompson {IWS00002110/34} page 34, paragraph 123.
208) Hirsi {IWS00001776/4} page 4, paragraph 11.
209) Simms {Day275/211:15-20}.
210) Simms {Day275/211:22-25}.
211) Ranito {IWS00001249/7-8} pages 7 - 8, paragraph 37.
212) Vieiro {IWS00001798/12} page 12, paragraph 50; Dainton {IWS00001974/31} page 31, paragraph 177.
213) Alves {IWS00001587/16} page 16, paragraph 83.
214) Alhaj Ali {IWS00001533/12-13} page 12 - 13, paragraphs 62 and 63; Jolly {IWS00001621/6-7} page 6-7, paragraphs 30 and 31.
215) Miller {IWS00001940/12} page 12, paragraph 52.
216) Boujettif {Day266/71:12-14}.
217) Dainton {IWS00001804/24} page 24, paragraph 152; Wahabi {Day267/131:9-18}.
218) Patterson {CFV00000055/12} page 12, paragraph 44.
219) Girma {IWS00001732/12} page 12, paragraph 23.
220) Wahabi {Day267/131:9-18}; Girma {IWS00001732/12} page 12, paragraph 23.
221) Jolly {IWS00001621/6-7} page 6 - 7, paragraphs 30 and 31; Richards {Day275/150:24}-{Day275/151:4}.
222) Girma {IWS00001732/12} page 12, paragraph 23.
223) Wahabi {Day267/130:18}-{Day267/131:5}.
224) Ragab {IWS00001536/6-7} pages 6 - 7, paragraphs 29 and 30.
225) Norman {CFV00000061/7} page 7, paragraph 4(g).
226) Norman {CFV00000061/7} page 7, paragraph 4(g).
227) Lukic {IWS00001760/4-5} pages 4 - 5, paragraphs 18 and 19.
228) Jafari {IWS00001815/14} page 14, paragraph 64.
229) Jafari {IWS00001815/13} page 13, paragraph 55.
230) Richards {CFV00000012/24-25} pages 24 - 25, paragraph 155.
231) Richards {CFV00000012/6} page 6, paragraph 46; Richards {CFV00000012/16} page 16, paragraph 107.
232) Simms {Day275/203:17}-{Day275/204:4}.
233) Richards {Day275/152:16-17}.
234) Richards {Day275/152:2-15}.
235) Raihani {IWS00001300/4} page 4, paragraph 25; El-Ogbani {Day266/36:21}-{Day266/37:8}.
236) El-Ogbani {Day266/36:21}-{Day266/37:9}.
237) Bonifacio {IWS00001887/7} page 7, paragraph 47.
238) Jones {IWS00001548/12} page 12, paragraph 56.
239) Nalukwago {IWS00001568/1} page 1, paragraph 6.
240) Afeworki {IWS00001756/5} page 5, paragraph 26.
241) Rullo {IWS00001655/9} page 9, paragraph 38.
242) Al-Sadi {IWS00001247/7} page 7, paragraph 39.
243) Serroukh {IWS00001747/7} page 7, paragraph 30; Yahya {IWS00001827/8} page 8, paragraph 37; Ollivierre {IWS00001758/6} page 6, paragraph 25.
244) Ortiz {IWS00001283/8} page 8, paragraph 60.
245) Raihani (IWS00001300/4} page 4, paragraph 25; Richer {IWS00001253/12} page 12, paragraph 58; Talabi {IWS00001731/7} page 7, paragraph 22.
246) Ross {IWS00001826/12} page 12, paragraph 58.
247) Wahabi {Day267/117:20}-{Day267/118:7}; Hariri {IWS00001295/11} page 11, paragraph 86.
248) Al-Karad {Day265/124:2-6}.
249) El Amine {IWS00001946/10} page 10, paragraph 44; Cherbika {IWS00001305/12} page 12, paragraph 100; Gil {IWS00001679/11} page 11, paragraph 90.
250) El Amine {IWS00001946/10} page 10, paragraph 44.
251) Abdulhamid {IWS00001919/5} page 5, paragraph 22.
252) Rasoul {Day265/164:5-11}.
253) Dainton {IWS00001804/19} page 19, paragraph 124.
254) Al-Karad {Day265/121:22}-{Day122:4}.
255) Abdulhamid {IWS00001919/5} page 5, paragraph 22; Li {IWS00001622/9}, page 9, paragraphs 62 and 63.
256) Rasoul {Day265/164:11-18}.
257) Jones {IWS00001548/12} page 12, paragraph 56; Ahmed {IWS00001335/132} page 132, paragraph 364.
258) Abdulhamid {IWS00001919/5} page 5, paragraph 22; Toyoshima-Lewis {IWS00001725/66} page 66, paragraph 265.
259) Moses {IWS00001281/11} page 11, paragraph 61.
260) Al-Karad {Day265/106:22}-{Day265/107:21}.
261) Ross {IWS00002356/8} page 8, paragraphs 42 and 45; Diejomaoh {IWS00001303/5-6} pages 5 - 6, paragraphs 27 and 28; Cherbika {Day266/106:1-22}.
262) Pahlavani {IWS00001244/15} page 15, paragraph 46; Ramirez {IWS00002061/6} page 6, paragraph 35.
263) Sobieszczak {IWS00001555/8} page 8, paragraphs 29 and 30; Jamalvatan {IWS00001704/7} page 7, paragraph 30.
264) Miller {IWS00001940/19} page 19, paragraph 90; Ramirez {IWS00002061/6} page 6, paragraph 35; Kebede {IWS00001795/10} page 10, paragraph 38; Jones {IWS00001710/5} page 5, paragraphs 29 and 30.
265) Laci {IWS00001831/6} page 16, paragraph 40.
266) Vieiro {IWS00001798/10} page 10, paragraph 42.
267) Wahabi {Day267/125:16-25}.
268) Al Assad {IWS00001267/5} page 5, paragraph 25.
269) Kabouh {IWS00001942/7} page 7, paragraph 34.
270) Cherbika {Day266/118:23}-{Day266/119:8}.
271) Choucair {IWS00001080/2} page 2, paragraph 5.
272) Ghamhi {IWS00001706/4-5} pages 4 - 5, paragraphs 28 and 31; Choucair {Day265/78:7-8}.
273) Kelbeto {IWS00001577/4-5} pages 4 - 5, paragraphs 29 and 30.
274) Jones {IWS00001548/14} page 14, paragraph 64.
275) Jamalvatan {IWS00001724/7} page 7, paragraph 29; Ranito {IWS00001249/9} page 9, paragraph 44.
276) Benjamin {IWS00001764/12} page 12, paragraphs 83 and 84.
277) Young {IWS00001261/10} page 10, paragraph 47.
278) Murray {IWS00001639/8} page 8, paragraph 43.
279) Pumar {IWS00002346/5} page 5, paragraph 29.
280) Jniah {IWS00001600/16} page 16, paragraph 61.
281) Gashaw {IWS00001738/24} page 24, paragraph 24; Raihani {IWS00001300/5} page 5, paragraph 28.
282) Ramirez {IWS00002061/6} page 6, paragraph 36.
283) Kassemdjian {IWS00001784/15} page 15, paragraph 77.
284) Patel {IWS00001610/15} page 15, paragraph 70.
285) Patel {IWS00001610/15-16} pages 15 - 16, paragraph 72.
286) Dainton {IWS00001974/35} page 35, paragraphs 201, 202 and 207.
287) Haynes {IWS00001809/9} page 9, paragraph 30.
288) Ibrahim {IWS00001751/7-8} pages 7 - 8, paragraph 29.
289) Hessel {IWS00001645/13} page 13, paragraph 53; Benkhaoula {IWS00001269/7} page 7, paragraphs 60 and 61.
290) Laci {IWS00001831/8} page 8, paragraphs 51 and 52; Sobieszczak {IWS00001562/13} page 13, paragraph 58.
291) Kasote {IWS00001775/8} page 8, paragraph 28; Sobieszczak {IWS00001562/13} page 13, paragraph 58; Neda {IWS00001302/4} page 4, paragraph 19; Beadle {IWS00001872/15} page 15, paragraph 61.
292) Patel {IWS00001610/15} page 15, paragraphs 70 - 72.
293) Hessel {IWS00001645/13} page 13, paragraph 53.
294) Rasoul {Day265/167:18-21}.
295) Alfawaz {IWS00001274/11-12} pages 11-12, paragraphs 88-91.
296) Alhaj Ali {IWS00001533/26} page 26, paragraphs 131 and 132.
297) Cherbika {Day266/108:16-25}-{Day266/109:1-2}.
298) Alhaj Ali {IWS00001533/26} page 26, paragraphs 131 and 132; Neda {IWS00001302/4} page 4, paragraph 19; Rasoul {Day265/167:5-17}; Ollivierre {IWS00001758/5} page 5, paragraph 24.
299) Cherbika {Day266/109:7-19}; Al-Karad {Day265/126:19-24}; Rasoul {Day265/169:17}-{Day265/170:5}; Ali {IWS00001617/15} page 15, paragraphs 183 - 185.
300) Ho {IWS00001551/16} page 16, paragraph 62.
301) Ho {IWS00001551/16} page 16, paragraph 62.
302) Hartley {IWS00001257/13} page 13, paragraph 50.
303) Quang {IWS00001552/20} page 20, paragraph 83.
304) Le-Blanc {IWS00001271/26} page 26, paragraphs 239 and 240; Vieiro {IWS00001798/12} page 12, paragraph 49; Murray {IWS00001639/8} page 8, paragraphs 45 and 46; Gil {IWS00001679/13} page 13, paragraphs 102-104; Gashaw {IWS00001738/18} page 18, paragraph 20.
305) El-Ogbani {Day266/29:17-21}.
306) Simms {Day275/193:7-18}.
307) Simms {CFV00000005/10} page 10, paragraph 42.
308) Simms {CFV00000005/10} page 10, paragraph 42; Simms {Day275/195:17}-{Day275/196:21}.
309) Abdulhamid {IWS00001919/5-6} pages 5-6, paragraph 27.
310) Abdulhamid {IWS00001919/5-6} pages 5-6, paragraph 27; Vieiro {IWS00001798/12} page 12, paragraph 49.
311) El-Sawy {IWS00001822/10} page 10, paragraph 42.
312) Jamalvatan {IWS00001724/6-8} pages 6-8, paragraphs 27 and 33; Lopez {IWS00001680/11} page 11, paragraphs 68 and 69; Belfassi {IWS00001802/11} page 11, paragraphs 70 and 71; Elbouti {IWS00001605/13-14} pages 13-14, paragraph 64.
313) Quang {IWS00001821/15} page 15, paragraphs 75 and 76; Kebede {IWS00001795/11} page 11, paragraph 45; El-Sawy {IWS00001829/9} page 9, paragraph 41.
314) Belfassi {IWS00001802/11} page 11, paragraphs 70 and 71.
315) Jafari {IWS00001815/16} page 16, paragraph 71.
316) John {IWS00001685/8} page 8, paragraph 32.
317) Ibrahim {IWS00001751/5} page 5, paragraphs 17 and 21; Nabil Choucair {Day267/7:23}-{Day267/12:2}.
318) Nowak {IWS00001559/10} page 10, paragraph 50; Mussilhy {Day264/62:1-8}.
319) El-Baghdady {IWS00001535/8} page 8, paragraphs 36 and 38; Jniah {IWS00001600/9} page 9, paragraph 32; Chiejina {IWS00002348/5} page 5, paragraphs 30 and 32; Hisam Choucair {Day265/19:7-12}.
320) Rasoul {Day265/146:14-19}.
321) Dainton {IWS00001804/19} page 19, paragraph 122.
322) Blanchflower {CFV00000045/1} page 1, paragraph 2.
323) Rasoul {Day265/146:14-19}.
324) John {IWS00001685/8} page 8, paragraph 32.
325) Burton {IWS00001661/29} page 29, paragraph 153.
326) Mussilhy {Day264/68:15-24}.
327) Mussilhy {Day264/32:20-21}; Chellat {IWS00001284/1} page 1, paragraph 5.
328) Anderson {IWS00001561/4} page 4, paragraphs 11-12.
329) Hisam Choucair {Day265/39:25}-{Day265/40:3}; Nabil Choucair {Day267/10:25}-{Day267/11:4}; Al-Karad {Day265/97:11-25}; Anderson {IWS00001561/3} page 3, paragraph 10.
330) Ramiro Urbano {IWS00001984/7} page 7, paragraph 42; Chiejina {IWS00002348/4} page 4, paragraph 26.
331) Hisam Choucair {Day265/50:9-14}; Nabil Choucair {Day267/46:24}-{Day267/47:2}.
332) Nabil Choucair {Day267/23:2-12}.
333) Hisam Choucair {Day265/72:14-20}.
334) Nabil Choucair {Day267/17:9}-{Day267/26:6}.
335) Nabil Choucair {Day267/32:12-22}.
336) Anderson {IWS00001561/4} page 4, paragraphs 11 and 12.
337) Spence {IWS00001657/3} page 3, paragraph 11.
338) Hisam Choucair {Day265/34:1-4}.
339) Lamprell {IWS00001673/7} page 7, paragraph 45.
340) Ibrahim {IWS00001650/3} page 3, paragraph 12; Jebari {IWS00001550/4} page 4, paragraphs 15 and 18.
341) Abdullah {IWS00001279/5} page 5, paragraph 22.
342) Mussilhy {Day264/27:7-12}.
343) Chalmers {MET00077804/6}, page 6, paragraph 30.
344) Chalmers {MET00077804/11}, page 11, paragraph 51.
345) Mendy {IWS00002349/2} page 2, paragraph 6.
346) Bernard {IWS00002337/7} page 7, paragraph 53.
347) Murphy {IWS00001709/3} page 3, paragraph 9.
348) Lamprell {IWS00001673/3} page 3, paragraph 20; Lamprell {IWS00001673/8} page 8, paragraph 49.
349) Jones {IWS00001691/4} page 4, paragraph 15; Nabil Choucair {Day267/12:20-25}.
350) El-Gourja {IWS00001700/5} page 5, paragraph 24.
351) El-Wahabi {IWS00001697/5} page 5, paragraph 21.
352) Chellat {IWS00001306/2-3} pages 2-3, paragraph 14.
353) Anderson {IWS00001561/5} page 5, paragraph 16.
354) Alhaj Ali {IWS00001533/10} page 10, paragraphs 50 and 51.
355) Elsanosi {IWS00001837/4} page 4, paragraphs 12 and 14.
356) Jniah {IWS00001600/15} page 15, paragraph 55.
357) Kieran {MET00077793/5} page 5, paragraph 16; Exhibit KK/1 {MET00077792/37-38} Section 5.7.
358) Daniels {IWS00002065/11} page 11, paragraphs 73 and 74; Chiapetto {IWS00001780/1} page 1, paragraph 2; Murphy {IWS00001709/3} page 3, paragraph 12; Wahabi {Day267/102:8}-{Day267/103:17}.
359) Jniah {IWS00001600/4} page 4, paragraph 13.
360) Shawo {IWS00001290/5} page 5, paragraph 35.
361) Shawo {IWS00001290/5} page 5, paragraph 35.
362) Hetherington {LFB00061158/2} page 2, paragraph 6; Hetherington {Day277/10:8-20}.
363) Hetherington {LFB00061158/3} page 3, paragraph 9.
364) Hetherington {Day277/25:13-16}, Minutes of London Resilience Forum meeting dated 6 February 2017 {LFB00119171/2}.
365) Hetherington {Day277/16:9-13}.
366) Hetherington {Day277/12:10-25}.
367) Hetherington {LFB00061158/2} page 2, paragraph 5; Hetherington {Day277/7:1-10}.
368) Hetherington {Day277/16:14-24}.
369) Bellamy {MOL00000025/5} page 5, paragraph 18; McManus {Day283/19:15-21}.
370) Hetherington {Day277/34:21-25}.
371) Hetherington {Day277/31:23}.
372) Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005, Schedule {CAB00007003/27}.
373) Hetherington {LFB00119130/3} page 3, paragraph 9.
374) Hetherington {LFB00061158/4} page 4, paragraph 12; the Gold Resolution {LFB00061166}.
375) London Local Authorities Mutual Aid {LFB00061169/3} paragraph 1.1.1-1.1.5.
376) Hetherington {LFB00061158/5} page 5, paragraph 13; LLAG Operating Procedure v.8.0 July 2016 {LFB00061185}.
377) Hetherington {LFB00119130/3} page 3, paragraph 9; Local Authority Gold Resolution {LFB00061166}.
378) Hetherington {LFB00061158/9} page 9, paragraph 23.
379) Hetherington {Day277/67:12}-{Day277/68:2}.
380) Kerry {RBK00033579/2} page 2, paragraph 8; Hetherington {Day277/66:13-15}.
381) Hetherington {Day277/46:9-12}; There were instances when mutual aid was provided, for example, the Croydon flooding in 2014, but Croydon London Borough Council remained the lead responder {Day277/44:20-25}-{Day277/45:1-12}.
382) Barradell {Day279/14:16}-{Day279/15:5}; {Day279/58:15-16}; Farrar {Day284/10:3}-{Day284/13:7}; Hetherington {Day277/60:6-23}.
383) Hetherington {Day277/59:6}-{Day277/60:5}; Barradell {Day279/12:10-25}.
384) Barradell {Day279/116:9-19}; Farrar {Day284/138:7-14} and {Day284/139:7-9}; Hetherington {Day277/58:4-8}.
385) Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005, reg. 23; Hetherington {Day277/68:18-21}.
386) London Resilience, Terms of Reference, Appendix 01/C {LFB00061162/7}.
387) Hetherington {LFB00119130/12} page 12, paragraph 36.
388) Voluntary Sector Capabilities Document v.6.0 April 2017 {GOL000000027}.
389) Regulation 4(7)(b) Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005 {CAB00007003/6}; Hetherington {LFB00119130/2} page 2, paragraph 7.
390) Regulation 4 Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005 {CAB00007003/5}.
391) Hetherington {Day277/77:6-8}.
392) Kerry {Day268/17:25}-{Day268/18:4}; Kensington and Chelsea Borough Resilience Forum Minutes dated 11 April 2013 {LFB00056788}.
393) Hetherington {Day277/80:19-23}-{Day277/81:3}.
394) Protocol relating to the discharge of statutory resilience functions by London Fire and Emergency Planning Authority on behalf of the Greater London Authority {MOL00000042}.
395) Policing and Crime Act 2017, Chapter 3, section 9(1) and (2), see London Fire and Emergency Planning Authority Property Transfer Scheme 2018 {MOL00000170/1}.
396) The Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005 {CAB00007003}.
397) The Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005, Reg.55(1)(a) {CAB00007003/23}.
398) The Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005, Reg.55(1)(c) {CAB00007003/23}.
399) Protocol relating to the discharge of statutory resilience functions by London Fire and Emergency Planning Authority on behalf of the Greater London Authority {MOL00000042/29} Schedule 1.
400) Bellamy {Day282/12:23}-{Day282/13:11}; {Day282/13:23}.
401) Emergency Preparedness, {CAB00004545/11} paragraph 9.22.
402) s.2(1)(a) of the Greater London Authority Act 1999.
403) Bellamy {Day282/17:18-24}.
404) Process of preparing to deal with known risks and unforeseen events or situations that have the potential to result in an emergency. Emergency Preparedness, Glossary {CAB00000055/21}.
405) Emergency Preparedness, {CAB00004545/11} Chapter 9 London.
406) Strategic Coordination Protocol {LFB00061180/25} at paragraphs 2.8.9-2.8.11, 2017 v.7.1. This Protocol is explained in Phase 1, Report Volume IV, paragraph 30.24-30.28.
407) Strategic Coordination Protocol {LFB00061180/25} at paragraph 2.8.11.
408) Bellamy {Day282/21:8}.
409) Bellamy {Day282/21:10-20}.
410) Khan {MOL00000189/16} page 16, paragraph 62.
411) Section 2 Civil Contingencies Act 2004 {CAB00004616/2}.
412) Section 2 (1)(c)-(e) Civil Contingencies Act 2004 {CAB00004616/3}.
413) Regulation 22(2) Civil Contingencies Act 2004 (Contingencies Planning) Regulations 2005 {CAB00007003/12}.
414) Chapter 5 (Emergency Planning) of Emergency Preparedness {CAB00004623/19} paragraph 5.51.
415) Hetherington {LFB00061158/7} page 7, paragraph 21.
416) Hetherington {LFB00061158/9-10} pages 9-10, paragraphs 23-27.
417) Hetherington {Day277/130:25}-{Day277/131:11}.
418) Hetherington {LFB00061158/8} page 8, paragraph 22.
419) Humanitarian Assistance Framework, April 2017 {LFB00061172}.
420) Hetherington {LFB00061158/8} page 8, paragraph 22.
421) Humanitarian Assistance Framework, April 2017 {LFB00061172/4} paragraph 1.1.
422) Hetherington {LFB00061158/6} page 6, paragraph 18.
423) Humanitarian Assistance Framework, April 2017 {LFB00061172/20} paragraphs 7.2 and 8.15.
424) Humanitarian Assistance Framework, April 2017 {LFB00061172/24} paragraph 8.13.
425) The Identification of the Vulnerable v.1 {LFB00061174}.
426) The Identification of the Vulnerable v.1 - The guiding principle of the framework is that; “While all people caught up in an emergency could be (and in some circumstances will be) defined as vulnerable due to their proximity to the event, planning and response arrangements should focus on those who are assessed as not being self-reliant and may need external assistance to become safe”. {LFB00061174/5} paragraph 1.5.
427) The Identification of the Vulnerable v.1 {LFB00061174/4} paragraph 1.2.
428) The Identification of the Vulnerable v.1 (1) Assess, prioritise and accept risks; (2) Ascertain who holds what information: That included compiling a “list of lists” for contacts of organisations that hold data on vulnerable people; (3) Establish planning and procedural arrangements; (4) Document options for dynamic identification; (5) Understand information sharing principles; (6) Exercise and assure {LFB00061174/8} paragraph 2.1.
429) Identifying people who are vulnerable in a crisis {CAB00014864/3}; The Identification of the Vulnerable v.1 {LFB00061174/8} paragraph 2.3.
430) Hetherington {Day277/151:7-24}.
431) Kerry {Day268/177:12–16}.
432) Hetherington {Day277/152:3-19}.
433) Kerry {Day268/175:15-16}; Hetherington {Day277:152:21}–{Day277/153:6}.
434) Hetherington {Day277/153:12-18} e.g. London Borough of Brent, Identifying the Vulnerable Framework {LFB00061174/15}.
435) Sawyer {GOL00001349/1} page 1.
436) Sawyer {GOL00001349/2} page 2, paragraph 9.
437) Sawyer {GOL00001349/2} page 2, paragraph 9.
438) Recommendations for Local Government Emergency Planning and Resilience for the 2020’s {GOL00001515}.
439) Recommendations for Local Government Emergency Planning and Resilience for the 2020’s {GOL00001515/3}.
440) Recommendations for Local Government Emergency Planning and Resilience for the 2020’s {GOL00001515/8} paragraph 3.1.1.
441) Recommendations for Local Government Emergency Planning and Resilience for the 2020’s {GOL00001515/12}.
442) Minimum Standards for London {LFB00119219/4-7}.
443) Recommendations for Local Government Emergency Planning and Resilience for the 2020’s {GOL00001515/12-13} Fig 3.4.
444) Local Authorities’ Panel/London Resilience document {GOL00000136/2} paragraph 5.
445) Local Authorities’ Panel/London Resilience document Amber includes “requires development of training programme / some key personnel have not been trained in their role and there is no programme in place to do so”. Red means no operational capability {GOL00000136}.
446) Contingency Management Plan {RBK00004396} Issue 9 (dated 30 April 2015) was the relevant version at the time of the fire.
447) Kerry {Day268/25:19}.
448) Kerry {RBK00058091/2-5} pages 2-5, eleven of which were left empty: annexes 5-9, 18, 30, 34, 37-38, 40-41
449) Annex 14a (“Guidance for setting up a Community Assistance Centre”) was incorrectly numbered; and Annex 15 (“Emergency Shelter and Rest Centre Directory”) was the incorrect version of the document, with the correct version having been labelled as Annex 14a along with another document. Kerry {RBK00058091/3} page 3.
450) Kerry {Day268/29:9-13}.
451) Annex 16 of the RBKC Contingency Management Plan, Humanitarian Assistance Centre plan {RBK00051900}; {Day263/123:18-23}; RBKC Opening Submissions {RBK00068467/10} paragraph 37.
452) Kerry {RBK00058091/3} page 3.
453) Kerry {RBK00058091/4} page 4.
454) {RBK00028631/5} exhibited by Nicholas Holgate, Town Clerk, RBKC; {RBK00004396/5} exhibited by David Kerry does not refer to CMP Part 2 at page 5.
455) Contingency Management Plan {RBK00005194}.
456) Contingency Management Plan {RBK00005194/3}.
457) Kerry {Day268/47:11-18}-{Day268/52:10-11}.
458) Kerry {Day268/48:24}-{Day268/49:5}.
459) Kerry {Day268/43:18-21}.
460) Kerry {Day268/44:20}-{Day268/44:20}-{Day268/45:16}.
461) Kerry {Day268/43:18-21}.
462) RBKC {Day263/115:15-24}.
463) The Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005 {CAB00007003/13}.
464) Service Level Agreement between LAP and LFEPA {LFB00061184/2}.
465) Emergency Preparedness paragraph 9.6 {LFB00061171/6} and {LFB00061184/3}.
466) Hetherington {LFB00061158/14-15} page 14-15, paragraph 42.
467) London Resilience Partnership and Training Programme 2017-2020 {LFB00061201}.
468) LRP Training and Exercising Group Terms of Reference v.1.0 {LFB00061201/12} paragraph 6.
469) LRP training and exercising programme, 2017 to 2020 {LFB00061201/1} paragraph 1.3.
470) Hetherington {Day277/166:16}; {LFB00061201/2-7} paragraphs 3.1-3.15.
471) Hetherington {Day277/204:18-25}.
472) Overview of Local Authority Training Delivered by LRG 2016/17 {LFB00061215/3}.
473) Hetherington {LFB00061158/16} page 16, paragraphs 49-50.
474) Hetherington {Day277/167:6-14}.
475) Hetherington {Day277/170:3}.
476) Hetherington {Day277/166:24}-{Day277/167:4}.
477) Minimum Standards for London, Draft 2016.1 {LFB00119219/4} paragraph 3.1.
478) Hetherington {LFB00119130/19} page 19, paragraph 61.
479) Minimum Standards for London, Draft 2016.1 {LFB00119219/13} 1.14a.
480) Minimum Standards for London, Draft 2016.1 {LFB00119219/14} 1.15a.
481) Hetherington {Day277/173:13}–{Day277/174:1}; Exercise Safer City 2017, Post Exercise Report, February 2017 v.1 {LFB00061212/4}.
482) Kerry {RBK00033579/11} page 11, paragraph 39.
483) Hetherington {Day277/173:13}-{Day277/174:1}; Exercise Safer City 2017, Post Exercise Report, February 2017 v.1 {LFB00061212/4}.
484) Exercise Babel Post Exercise Report {RBK00005188/1}.
485) Exercise Unified Response {LFB00061214/141} paragraph 3.6; Hetherington {LFB00061158/15} page 15, paragraph 46.
486) Exercise Unified Response {LFB00061214/141}.
487) Exercise Unified Response {LFB00061214/144} paragraph 3.6.7; {LFB00061214/151} paragraph 3.6.25; {LFB00061214/153} paragraph 3.6.34; {LFB00061214/155} paragraphs 3.6.37-38; {LFB00061214/157} paragraph 3.6.41; {LFB00061214/157-158} paragraphs 3.6.43 and 44; {LFB00061214/159} paragraph 3.6.45; {LFB00061214/173-174} paragraph 3.7.8.
488) Exercise Unified Response Evaluation Report April 2017 {GOL00001154/149} paragraph 3.6.18.
489) Hetherington {Day277/177:21-25}.
490) Exercise Unified Response Evaluation Report April 2017 {GOL00001154}.
491) Hetherington {Day277/177:9-20}.
492) Hetherington {Day277/176:18}-{Day277/177:20}.
493) Exercise Unified Response Evaluation Report April 2017 {GOL00001154}.
494) Hetherington {Day277/178:1-22}.
495) The Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005{CAB00007003/13} regulation 25.
496) Contingency Management Plan, Section 1.8 {RBK00004396/11}.
497) Kerry {RBK00033579/8} page 8, paragraph 26.
498) Kerry {RBK00058091/6-7} pages 6-7, paragraph 2.5.
499) Kerry {Day268/78:2-6}.
500) Kerry {RBK00058091/8} page 8, paragraph 2.6-2.7.
501) Priestley {Day270/6:16}-{Day270/7:20}.
502) Kerry {RBK00058091/25} page 25, paragraphs 6.5 and 7.1.
503) The role of the Borough Emergency Control Centre (BECC) is to oversee and coordinate the Council’s incident response, being a single point of contact and source of information for Council Gold, Council Silver, external agencies and other council services; Kerry {RBK00033579/8} page 8, paragraph 29.
504) Kerry {Day268/85:12}-{Day268/86:5}; Kerry {RBK00058091/27} page 27, paragraph 11.1; Blackburn {Day270/122:2-14}; {RBK00068318}.
505) Blackburn {Day270/106:19}-{Day270/107:13}.
506) Blackburn {Day270/115:20}-{Day270/116:25}.
507) Blackburn {Day270/119:3-10}.
508) Blackburn {Day270/106:24}-{Day270/107:3}.
509) Blackburn {Day270/113:24-114:9}.
510) Kerry {Day268/97:13}-{Day268/98:1}; {RBK00058054/1}.
511) Blackburn {Day270/112:4-21}.
512) Blackburn {Day270/112:25}-{Day270/113:20}.
513) Exercise Responder, October 2015 {RBK00058067/2}; Exercise Babel, November 2015 {RBK00005188/4}.
514) Kerry {Day268/72:19}-{Day268/73:6}.
515) Kerry {Day268/73:7-16}.
516) Kerry {Day268/78:14-15}.
517) Kerry {Day268/78:22}-{Day268/80:17}.
518) Kerry {Day268/61:19-23}; Report to the Management Board, paragraph 1.2 {RBK00058038/1}.
519) Kerry {Day268/62:6-11}.
520) Report to the Management Board, paragraph 2.1 {RBK00058038/1-2} explains that Borough (Council) Silver manages the council’s tactical response to an incident and paragraph 3.1 gives the required number. Paragraph 2.2 sets out the role of Incident Response Officer and paragraph 3 gives the required number.
521) Kerry {Day268/70:10-11}.
522) Humanitarian Assistance Framework {RBK00019712/24}, paragraph 8.15.
523) Kerry {RBK00058091/50-51} pages 50-51, paragraphs 37.2, 38.1.
524) Kerry {Day268/61:10-13}.
525) Kerry {Day268/66:2-9}.
526) Minimum Standards for London Assessment Template RBKC 2016 {RBK00036770}.
527) Kerry {Day268/146:6-8}.
528) MSL Assessment Template 2017 {RBK00047524}.
529) Blackburn {Day270/124:4}-{Day270/125:10}; Kerry {Day268/147:2-15}.
530) Kerry {Day268/153:7}-{Day268/154:11}.
531) Kerry {Day268/153:7}-{Day268/155:7}.
532) Kerry {Day268/164:18}-{Day268/168:4}; Humanitarian Assistance Framework {RBK00011313/2}.
533) Kerry {Day268/168:18-22}.
534) Identifying the Vulnerable Framework paragraph 1.7.1 {LFB00061174/6}; Minimum Standard tab 2.6 {LFB00119219/20}; Kerry {Day268/168:24}-{Day268/175:1}.
535) Kerry {RBK00058091/3-4} pages 3-4. Annex 21: ‘A framework for identifying and contacting vulnerable persons in an emergency.
536) Kerry {Day268/170:9}-{Day268/171:5}; {RBK00005188/4}.
537) Kerry {Day268/179:22}-{Day268/181:8}.
538) {RBK00058010}; Kerry {Day268/156:4}-{Day268/157:18}; {Day269/2:24}-{Day269/5:11}.
539) Hetherington {Day277/155:15)–{Day277/156:1}.
540) MSL Peer Review Results 2016 {LFB00119221}.
541) MSL Results for all Borough 2017 (final); MSL Self-Assessment Results 2017 {LFB00119222/10} excludes Hackney {LFB00119232}.
542) Kerry {Day268/156:4}-{Day268/159:12}.
543) Section 2(1)(c)-(d) Civil Contingencies Act 2004 {CAB00004616/3}; Regulation 23 Civil Contingencies Act (Contingency Planning) Regulations 2005 {CAB00007003/13}.
544) The Role of the Voluntary Sector {CAB00004597/2} paragraph 14.6; Kerry {Day268/163:3-7}.
545) Kerry {Day268/159:5-12}, {Day268/158:25}-{Day268/159:6}.
546) RBKC Closing Submissions {RBK00068546/24} paragraph 84.
547) Kerry {Day268/151:2}-{Day268/153:5}.
548) London Resilience Group Duty Officers’ Handbook v.1.3.1., March 2017 {LFB00061187/6} Figure 2.2; Hogan {LFB00119334/6} page 6, paragraph 21.
549) Hogan {LFB00119334/1} page 1, paragraph 4; Hogan {LFB00119334/6} page 6, paragraph 20.
550) The London Resilience Strategic Advisor role is defined in the London Resilience Group Duty Officers’ Handbook v.1.3.1, March 2017 {LFB00061187/6} paragraph 2.2, see also {LFB00061187/15-16}.
551) Gould {LFB00061268/3} page 3, paragraph 8.
552) A major incident is defined as an event or situation with a range of serious consequences which requires special arrangements to be implemented by one or more emergency responder agency: ‘Joint Doctrine: The Interoperability Framework’, 2nd Edition, July 2016 {CAB00004642/8}.
553) Phase 1 Report Volume IV paragraph 30.38.
554) Hogan {LFB00119334/6} page 6, paragraph 22.
555) {LFB00119337}; Hogan {LFB00119334/7} page 7, paragraph 26.
556) Hetherington {Day277/182:2-15}.
557) Hetherington {Day277/182:2-15}. The London Resilience Partnership Strategic Co-ordination Protocol v.7.3, February 2017 (public facing) {GOL00001153/3} and Hogan {LFB00119334/7} page 7, paragraph 25 states, “any partner organisation experiencing or having knowledge of a potential disruptive, major incident or emergency should contact the LRG Duty Officer to jointly assess the situation to determine the level of strategic co-ordination required”.
558) Hogan {LFB00119334/8} page 8, paragraph 28; “40 pump fire, major incident, north Kensington”. Glenn Sebright then emailed LRT Alerts and other London Resilience Partners at 03.21 stating that LFB had declared the fire a ‘major incident’ {LFB00119338}.
559) The London Resilience Partnership Strategic Co-ordination Protocol v.7.3, February 2017 (public facing) {GOL00001153}, the protocol is introduced in the Phase 1 Report Volume IV paragraphs 30.24 - 30.28.
560) {CAB00004616/1}; {GOL00001153/10} paragraph 1.1.1.
561) Hetherington {Day277/182:17-25}.
562) MPS at 01.26 although CAD said “critical incident”, LFB at 02.06 and LAS at 02.26, Phase 1 Report Volume IV paragraph 30.38.
563) Phase 1 Report Volume IV paragraph 30.19.
564) {MET00023288}.
565) Emergency Response and Recovery {CAB00004519/20}, paragraph 2.6.1.
566) {MET00023288/15-16} paragraphs 2.2.2- 2.2.7; Hetherington {LFB00061158/5} page 5, paragraph 14.
567) {MET00023288/37} Appendix 2.
568) Hetherington {Day277/187:16-19}; {MET00023288/17} paragraph 2.2.12. states “Representatives at the Strategic Coordinating Group must have the level of knowledge, expertise and authority to identify and to commit the resources of their respective agency.”
569) {MET00023288/37} Appendix 2.
570) Hetherington {Day277/189:5-7}.
571) Hetherington {Day278/87:1-9}; Sawyer {Day278/89:23}-{Day278/90:1}.
572) Barradell {Day 279/17:19}-{Day 279/19:9}.
573) Barradell {Day279/29:15-25}; {MET00023288/33}.
574) Sawyer {Day278/86:10-17}.
575) Sawyer {Day278/92:5-10}.
576) Barradell {Day279/29:25}.
577) Strategic Coordinating Group meetings on 14 June 2017: 06.30 {LFB00028077}; 08.30 {LFB00003366}; 14.00 {LFB00003369}; 19.30 {LFB00119322}.
578) Strategic Coordinating Group meeting on 15 June 2017 at 11.00 {MOL00000047}.
579) Minutes of the Strategic Coordinating Group Meeting on 16 June 2017 at 11.00 {MOL00000036}. Sawyer {Day278/87:11-20}; The LLAG also attended on 17 June 2017 at 14.00 and 22 June 2017 at 13.00.
580) Minutes of the 05.00 Strategic Coordinating Group Meeting on 14 June 2017 {MOL00000026}; Hetherington {Day277/187:3-5}.
581) {LFB00119343}.
582) Hogan {LFB00119334/12} page 12, paragraph 43; Gould {LFB00061268/5} page 5, paragraph 12; {LFB00119343}.
583) “A key feature of leadership decision-making in crises and emergencies is the need for decisions to be made quickly…” {MET00023288/22} paragraph 2.7.5.
584) {MET00023288/14} paragraph 2.1.5; {LFB00061187/9}.
585) At 04.38 Mr Hogan sent an email to Mr Naylor, the chief executive of the London Borough of Barking and Dagenham, and Paul Martin, the chief executive of Richmond and Wandsworth Council, to give them the sign-in details for the 05.00 Strategic Coordinating Group meeting as he wrongly thought that Mr Naylor was the duty Gold and Mr Martin the secondary Gold. Mr Hogan then tried calling Mr Naylor at 04.38, 04.39 and 04.41. {LFB00119351/1}; Hogan {LFB00119334/13} page 13, paragraph 50; Hogan {LFB00119334/17} page 17, paragraph 74.
586) Hetherington {Day277/185:3}; {MET00023288/14} paragraph 2.1.5 states that the LRG manager will check that relevant organisations are aware including the duty LLAG.
587) The period between the LRG being notified of the fire at 03.12 and Mr Blake-Herbert, duty Gold being notified by Mr Hogan at 04.55.
588) Sawyer {Day278/87:13}-{Day278/88:4}.
589) Sawyer {GOL00001349/10} page 10, paragraph 49; Sawyer {Day278/87:11-20}.
590) {MOL00000014}.
591) {MOL00000036}.
592) London Local Authority Gold Operating Procedure v.8. (January 2016) {LFB00061185/5} paragraph 1.
593) London Local Authority Gold Operating Procedure v.8. (January 2016) {LFB00061185/5} paragraph 3.
594) Hetherington {Day277/196:4-15}.
595) Hogan {LFB00119334/14} page 14, paragraph 58.
596) {LFB00119359/1}; Gould {LFB00061268/7} page 7, paragraph 18.
597) Hetherington Incident Log Book {LFB00061216/6}.
598) Hetherington {LFB00061158/18} page 18, paragraph 54.
599) {LFB00119359/1}; Gould {LFB00061268/7} page 7, paragraph 18.
600) {LFB00061289/1}.
601) Hetherington {Day277/196:24} – {Day277/197:1}.
602) Mr Hetherington gave an example of ‘overspill’ in the case of a terror incident which, although confined to a single borough, may have ramifications as regards the monitoring of hate crime or preventing crime, in which case LLAG would oversee those aspects of the response, Hetherington {Day277/197:16}-{Day277/198:5}; Barradell {Day279/31:3-16}.
603) Naylor {GOL00001603/2} page 2, paragraph 4.
604) The Gold Resolution, July 2010 {GOL00001725}; Addendum to the Gold Resolution, July 2010 {GOL00001717}.
605) Naylor {GOL00001603/2} page 2, paragraph 4.
606) Barradell {Day279/19:22}-{Day279/20:15}.
607) For example, flood, pandemic or a civil disturbance which develops over time; Naylor {GOL00001603/2} page 2, paragraph 5.
608) Naylor {GOL00001603/2} page 2, paragraphs 4-5.
609) Hetherington {Day277/197:16}-{Day277/198:5}.
610) Hetherington {Day277/198:12}.
611) Hetherington {Day277/198:12-19}.
612) Barradell {Day279/14:6-21}.
613) Barradell {Day 279/14:16}-{Day 279/15:5}.
614) Barradell {Day279/58:15-16}.
615) Key points from the discussion between Peter Tallantire, a Deputy Director in the Civil Contingencies Secretariat, Cabinet Office, and No.10 {CAB00014827} paragraph 1; Tallantire {CAB00014830/9} page 9, paragraph 27.6.
616) Gould {LFB00061268/9} page 9, paragraph 26.
617) Hetherington {Day277/202:16}-{Day277/203:6}.
618) Hetherington {LFB00061158/16} page 16, paragraph 48; London Resilience Partnership’s training strategy and programme {LFB00061201} paragraphs 3.4, 3.13, 3.25, 3.26.
619) Details of local authority training events delivered by the London Resilience Group from March 2016 - June 2017 {LFB00061215/3}.
620) {LFB00061215/3}.
621) Hetherington {Day277/205:17}.
622) Sawyer {Day278/72:7-25}. Recommendations for Local Government Emergency Planning and Resilience for the 2020’s (“EP2020”), report by Mark Sawyer, 3 October 2016 {GOL00001515/3} paragraph 2, ‘The two elements excluded are; the London Local Authority Gold Resolution and the principle of all 33 chief executives participating in the London Local Authority Gold rota’.
623) Hetherington {Day277/204:5-16}.
624) Sawyer {Day278/187:1-3}.
625) EP2020 Enhancement Programme, July 2019 {INQ00015129/15} Recommendation 20.
626) Graham {GLA00000004/4} page 4, paragraph 18.
627) Graham {GLA00000004/4} page 4, paragraph 18.
628) Bellamy {MOL00000025/15} page 15, paragraph 68.
629) Strain {GLA00000009/1} page 1, paragraph 3; Bellamy {MOL00000025/13} page 13, paragraphs 60 and 63; Minutes 14/06/17 at 05.00 {MOL00000026/3}, 06.30 {MOL00000015/3}, 08.30 {MOL00000014/5}, 14.00 {LFB00003369/6}, 19.30 {LFB00119322/7}, 15/06/17 at 11.00 {MOL00000047/6}, 16/06/17 at 11.00 {MOL00000036}, 17/06/17 at 14.00 {LFB00119508}, 18/06/17 at 13.30 {MOL00000004}, 19/07/17 at 11.30 {MOL00000045}, 20/07/17 at 13.00 {MOL00000043}. The GLA is a standing member of the Strategic Coordinating Group, see {LFB00123769/7}.
630) Mayor of London’s Major Incident and Civil Contingencies Response Protocol - Gold Cell (November 2016) {MOL00000040/12} Section 4.
631) Graham {GLA00000004/6} page 6, paragraph 32.
632) Graham {GLA00000004/6} page 6, paragraph 32.
633) Graham {GLA00000004/7} page 7, paragraph 35.
634) Graham {GLA00000004/7} page 7, paragraph 36, Mr Graham’s kept a typed note which he used to brief colleagues in City Hall {GLA00000004/5} paragraph 26. That note {MOL00000039} did not refer to any concerns as set out in his statement.
635) Graham {GLA00000004/8} page 8, paragraph 39; Bellamy {Day282/30:23}-{Day282/31:5}.
636) Bellamy {Day282/32:13-19}.
637) {MOL00000040/15} paragraph 4.4.
638) Bellamy {Day282/33:7}-{Day282/35:13}.
639) {LFB00061223}.
640) Barradell {Day279/96:16-22}.
641) Holgate {Day273/112:7-12}; Sawyer {GOL00001349/7} page 7, paragraph 34; Sawyer {GOL00001349/8-9} pages 8-9, paragraph 41.
642) {GOL00000155}.
643) Kelly {GOL00000439/9} page 9, paragraph 31; Sawyer {GOL00001349/9-10} pages 9-10, paragraph 46; Email from Mr Hetherington to Mr Holgate, Mr Naylor, Mr Barradell, Mr O’Brien and Mr Sawyer at 18.58 on 14 June 2017 {LFB00061225}.
644) {LFB00061225}; Barradell {Day279/68:14}-{Day279/69:11}.
645) Sawyer {Day278/136:4-23}.
646) Sawyer {Day278/108:7-23}; Sawyer {Day278/109:21-24}.
647) Holgate {Day273/118:11-22}. Hetherington {LFB00119130/30} page 30, paragraph 95. “The activation of LLAG was not discussed during this call, which focused on what immediate support was required by RBKC from other boroughs”.
648) Holgate {RBK00035426/6} page 6, paragraph 32.
649) Naylor {GOL00001603/6} page 6, paragraph 13.
650) Barradell {Day279/50:4-6}; Barradell {Day279/51:14-23}.
651) Barradell {Day279/50:20-24}.
652) Barradell {Day279/49:7-15}.
653) {LFB00061224/2}.
654) {LFB00061224/2}; Hetherington {Day277/218:6-23}.
655) Hetherington {Day277/218:1-12}.
656) {LFB00061229}.
657) Sawyer {Day278/111:17}-{Day278/112:6}.
658) Hetherington {Day277/224:6-25}.
659) Hetherington {Day277/224:6-25}.
660) {RBK00002651}; {RBK00009882}.
661) {GOL00000326}; {RBK00060182}; {RBK00064677}.
662) Barradell {Day279/84:16-25}; Barradell {Day279/97:7-22}.
663) Barradell {Day279/85:11-17}.
664) Barradell {Day279/43:10-24}.
665) Sawyer {Day278/115:5-16}.
666) Sawyer {Day278/115:21}-{Day278/116:2}.
667) Holgate {Day273/130:17-23}.
668) Barradell {Day279/48:5-9}.
669) Barradell {Day279/50:4-6}; Barradell {Day279/96:16-22}.
670) Barradell {Day279/69:5-11}.
671) Khan {MOL00000189/8} page 8, paragraph 32.
672) {CLG00003011}.
673) Khan {MOL00000189/9} page 9, paragraph 33; {MOL00000182}.
674) Bellamy {Day282/53:1-10}.
675) Bellamy {Day282/53:16-25}.
676) Farrar {Day284/135:23-24}.
677) McManus {CLG10009725/23} page 23, paragraph 95; Farrar {Day284/8:2-4}.
678) Dowdican {CLG00030419/6} page 6, paragraph 27.
679) {LFB00119653} Email forwarded to Hamish Cameron with Laura Johnson’s (RBKC) response to the DCLG queries.
680) {LFB00061311/1}.
681) {LFB00061311/1}.
682) {LFB00061313/1}.
683) {LFB00061313/1}.
684) Hetherington {Day278/9:11}-{Day278/10:9}.
685) Hetherington {Day278/9:21}-{Day278/10:23}.
686) {CLG00003099/2}.
687) {CLG00018936/3} email at 09.52 and {CLG00018936/2} email at 10.09.
688) Email from Mr Gould to John Bentham 15 June 2017 at 10.09 {CLG00018936/2}.
689) Hetherington {Day278/7:19}-{Day278/8:8}.
690) Khan {MOL00000189/10} page 10, paragraph 41.
691) Khan {MOL00000189/11} page 11, paragraph 46.
692) Khan {MOL00000189/12} page 12, paragraph 48.
693) Emergency Response and Recovery {CAB00004519/83}.
694) {LFB00061233}.
695) Minutes of the Ministerial Meeting at 15.30 on 15 June 2017, {CAB00002720} and Actions, {CAB00001255}.
696) Bellamy {Day282/58:17}-{Day282/59:10}.
697) Bellamy {Day282/61:8}-{Day282/61:10}; {Day282/62:6}; {GLA00000854/26} “Is there a way we can get across that RBKC are totally out of their depth”.
698) Bellamy {MOL00000025/16} page 16, paragraph 79; Bellamy {Day282/59:24} - {Day282/60:1}.
699) Bellamy {Day 282/67:11-15}.
700) {LFB00061238}.
701) Emergency Response and Recovery, non-statutory guidance accompanying the Civil Contingencies Act 2004, {CAB00004624/225}: Mutual aid is “An agreement between Category 1 and 2 responders and other organisations not covered by the Act, within the same sector or across sectors and across boundaries, to provide assistance with additional resource during an emergency”. RBKC did receive assistance from Westminster City Council and the London Borough of Hammersmith and Fulham as part of the tri-borough agreement on 14 and 15 June 2017.
702) {LFB00061234/2}.
703) Hetherington {Day278/29:10-14}; {LFB00061234/2}.
704) {LFB00061234/1}.
705) Hetherington {LFB00061158/23} page 23, paragraph 73.
706) Hetherington {Day278/25:17}-{Day278/26:4}.
707) Barradell {Day279/58:6-11}.
708) Naylor {GOL00001603/5} page 5, paragraph 11.
709) Barradell {Day279/207:5-6}.
710) Sawyer {GOL00001349/11} page 11, paragraph 54.
711) Kelly {GOL00000439/9} page 9, paragraph 32.
712) Blackburn {Day270/181:6-8}.
713) Holgate {RBK00035426/7} page 7, paragraph 38; Holgate {Day273/170:24}-{Day273/171:25}.
714) Kelly {GOL00000439/9} page 9, paragraph 33.
715) Barradell {Day279/86:2-12}; Barradell {Day279/87:18}-{Day279/88:9}.
716) {LFB00061219/12}.
717) Hetherington {LFB00061158/26} page 26, paragraph 88; Hetherington {LFB00119130/32} page 32, paragraph 101.
718) {LFB00061240/1}.
719) Hetherington {Day278/36:7-15}.
720) Barradell {Day279/22:7-21}; Hetherington {Day278/38:9-23}.
721) Sawyer {Day278/149:20-24}; Hetherington {Day278/39:3-15}.
722) Sawyer {Day278/155:20}-{Day278/155:25}.
723) Hetherington {Day277/56:13-19}.
724) RBKC Module 4 Closing Submissions {RBK00068546/12} paragraph 34; Barradell {Day279/22:2-7}; Barradell {Day279/22:22}-{Day279/23:12}; Barradell {Day279/19:22}-{Day279/23:12}.
725) Barradell {Day279/83:3-17}.
726) Barradell {Day279/112:1-6}.
727) Barradell {Day279/112:12-15}.
728) Holgate {RBK00035426/10} page 10, paragraph 51.
729) Farrar {CLG00030414/16-17} pages 16-17, paragraphs 78-79; Barradell {Day279/113:13-25}; Barradell {Day279/121:21}-{Day279/123:4}.
730) Barradell {GOL00000244/10} page 10, paragraph 39.
731) Hetherington {Day278/40:5 -20}.
732) Hetherington {Day277/198:12-19}.
733) Sawyer {Day278/153:4-7}.
734) Kerry {Day273/222:19}-{Day273/223:1}.
735) Sawyer {Day278/151:12-17}.
736) Harpley {GOL00000441/4} page 4, paragraph 13.
737) LLAG log book (entry no.12) at 11.36 on 18 June 2017 {GOL00001675/3}.
738) Patel {CLG10009793/10} page 10, paragraphs 35-36; Gregory {HOM00046125/3} page 3, paragraph 7; Email from Rachael Wright-Turner on 21 June 2017 containing the notes of the Community Engagement meeting on 20 June 2017, {RBK00022888}. This is explored further at Chapter 106.
739) Email including the statement of Eleanor Kelly {CLG00005448}.
740) Eleanor Kelly was also the Deputy Chair of the Local Authorities’ Panel. Kelly {GOL00000439/3} page 3, paragraph 12.
741) Civil Contingencies Act 2004.
742) Hammond {CAB00014764/3} page 3, paragraph 9.
743) Now called the Ministry of Housing, Communities and Local Government.
744) Hammond {CAB00014764/6} page 6, paragraph 21.
745) Hammond {CAB00014764/9} page 9, paragraph 29.
746) Hammond {CAB00014764/10} page 10, paragraph 34.
747) ConOps {CAB00000026/19-20} para 2.26(e)-(j).
748) ConOps {CAB00000026/22} paragraph 3.4.
749) ConOps {CAB00000026/19} paragraph 2.26(d).
750) ConOps {CAB00000026/37} paragraph 3.53.
751) {HOM00050060/5}.
752) As opposed to a rising tide incident {HOM00050060/8}.
753) Edwards {HOM00050058/2} page 2, paragraph 6.1.
754) Lamberti {HOM00046095/4} page 4, paragraph 14.
755) Lamberti {HOM00046095/4} page 4, paragraph 14.
756) Edwards {HOM00050071/2-3} pages 2- 3, paragraph 9.
757) McManus {Day283/4:7-20}.
758) Dowdican {CLG00030419/1} page 1, paragraph 3.
759) Farrar {Day284/5:13-17}.
760) McManus {CLG10009725/4} page 4, paragraph 11.
761) Mason {CLG00030435/2} page 2, paragraph 5.
762) McManus {CLG10009725/4} page 4, paragraph 11.
763) Richardson {CLG00030412/6} page 6, paragraph 18.
764) Richardson {CLG00030412/2} paragraph 6.
765) Emergency Preparedness, Chapter 2 {CAB00007027/59} paragraph 2.153.
766) Emergency Preparedness, Chapter 2 {CAB00007027/59} paragraphs 2.153-2.154.
767) Emergency Preparedness, Chapter 2 {CAB00007027/59} paragraph 2.154.
768) Richardson {CLG00030412/6} page 6, paragraph 18.
769) Richardson {CLG00030412/4} page 4, paragraph 12.
770) McManus {Day283/25:20}-{Day283/26:9}.
771) McManus {Day283/26:13-22}.
772) Farrar {Day284/135:23-24}.
773) Emergency Response and Recovery {CAB00004624/154-55} paragraph 9.1.2.
774) Emergency Response and Recovery {CAB00004624/154-55} paragraph 9.1.2; McManus {CLG10009725/23} paragraph 95; Farrar {Day284/8:2-4} the DCLG RED was not responsible for supporting the local authority response.
775) Emergency Response and Recovery {CAB00004624/154-55} paragraph 9.1.2; McManus {CLG10009725/23} paragraph 95.
776) DCLG Emergency Response Plan, version 3.4, June 2017 {CLG00021013/6} paragraph 1.15.
777) McManus {CLG10009725/3} page 3, paragraph 7(b) and (c); McManus {CLG10009725/23} page 23, paragraph 95, except for incidents, such as terrorism, or the release of chemical, biological, radioactive or nuclear material, for which the Home Office would deploy a GLO and the DCLG RED would form part of the Government Liaison Team {CLG00021013/5} paragraph 1.13; {CAB00000026/39} paragraph 3.56; {CAB00000026/51} paragraph 6.2(ii); {CAB00004624/154} paragraph 9.1.2.
778) DCLG Emergency Response Plan, version 3.4, June 2017 {CLG00005657/44}.
779) McManus {Day283/53:17-20}.
780) Dowdican {CLG00030419/2-3} pages 2-3, paragraphs 9-10.
781) McManus {CLG10009725/23} page 23, paragraph 94.
782) DCLG Emergency Response Plan, version 3.4, June 2017 {CLG00005657/11} paragraph 2.16; McManus {CLG10009725/23} page 23, paragraph 94.
783) For instance, if they are a Lead Government Department, they may be required to release staff members to support the RED Operations, McManus {CLG10009725/23} page 23, paragraph 94; DCLG Emergency Response Plan, version 3.4, June 2017 {CLG00005657/11} paragraph 2.17.
784) Farrar {Day284/15:3-13}.
785) DCLG’s Emergency Response Plan {CLG00005657/41}.
786) {CAB00000026} First published by Civil Contingencies Secretariat in 2010 and revised in April 2013.
787) Tallantire {CAB00014769/3} page 3, paragraph 10.
788) ConOps {CAB00000026/7} paragraph 1.7.
789) ConOps {CAB00000026/8-9} paragraph 1.8 sets out examples of each level and the type of direct central government engagement typical for each {CAB00000026/68}.
790) ConOps {CAB00000026/11} paragraph 2.2.
791) ConOps {CAB00000026/11} paragraph 2.2.
792) The terminology of “central government response mechanism” and “COBR” are used throughout ConOps in some cases as equivalent terms: see ConOps {CAB00000026/8-9} paragraph 1.8; ConOps {CAB00000026/11} paragraph 2.2; ConOps {CAB00000026/19} paragraph 2.26(d); ConOps {CAB00000026/68}] and in others as distinct alternatives: ConOps {CAB00000026/36} paragraphs 3.50-3.51, ConOps {CAB00000026/45} paragraph 4.2 iii.
793) ConOps {CAB00000026/19-20} para 2.26.
794) Hammond {Day280/163:2-3}.
795) Hammond {Day280/164:1-9}. See also Hammond {Day280/155:8-10}.
796) It is not obvious that this referred to people rather than places, but it is the former. Para 2.26 of ConOps refers to the Cabinet Office’s role in initiating the supporting structures for the central response such as the situation cell, the secretariat, and policy support and provide staff for the activation of those support mechanisms.
797) ConOps {CAB00000026/21} paragraph 3.2.
798) A Cabinet Office construct bringing together ministers and officials from the key departments and agencies involved in the response and wider impact management along with other organisations as appropriate, see ConOps {CAB00000026/23} paragraph 3.7.
799) ConOps {CAB00000026/23-24} paragraph 3.9.
800) ConOps {CAB00000026/24} paragraph 3.10.
801) The ConOps guidance did not make it clear whether the use of “COBR” here referred to activation of central government’s crisis management facilities or a meeting held in the physical location of the Cabinet Office Briefing Rooms.
802) ConOps {CAB00000026/45} paragraph 4.2iii.
803) ConOps {CAB00000026/37} paragraph 3.52.
804) ConOps {CAB00000026/9} paragraph 1.10.
805) ConOps {CAB00000026/45} paragraph 4.2iv.
806) ConOps {CAB00000026/19-20} paragraph 2.26(e)-(j); Hammond {CAB00014764/12} page 12, paragraph 38.
807) ConOps {CAB00000026/13} paragraph 2.8; ConOps {CAB00000026/27} paragraph 3.24.
808) {HOM00013085}.
809) Hammond {Day280/166:11-12}; Dawes {Day285/32:5}-{Day285/33:4}.
810) Hammond {Day280/170:2-6}.
811) Dawes {Day285/20:5}-{Day285/21:2}.
812) ConOps {CAB00000026/16} paragraph 2.17.
813) ConOps {CAB00000026/6-7} paragraph 1.5 and ConOps {CAB00000026/27} paragraphs 3.22-3.23.
814) Emergency Response and Recovery {CAB00004519/10} paragraph 1.3.2.
815) ConOps {CAB00000026/15-16} paragraph 2.16.
816) ConOps {CAB00000026/7} paragraph 1.6.
817) ConOps {CAB00000026/7} paragraph 1.6.
818) ConOps {CAB00000026/43} paragraph 3.74.
819) ConOps {CAB00000026/43} paragraph 3.76; Hammond {Day281/86:19}-{Day281/87:1}.
820) ConOps {CAB00000026/16-17} paragraph 2.18.
821) Hammond {Day280/165:7-17}; {Day280/171:20}-{Day280/172:25}. Later in Ms Hammond’s evidence, she told us that there would never be a formal activation of the COBR procedure {Day280/174:24}-(Day280/175:12}.
822) MacFarlane {CAB00014794/7} page 7, paragraph 23, provided by Robert MacFarlane’s team within the CCS.
823) EPC 2017 Training Course Programme {CAB00014795}. For example, in 2017, the cost per attendee for a 2-day training on ‘Planning for Mass Fatalities’ was £835 plus VAT.
824) Titles included “Strategic emergency and crisis management”, “Emergency Control Centre Operations”, “Chief Executives: your role in civil protection”, and “Webinar: planning for needs of vulnerable adults in emergencies” {CAB00014792} Cat 1 Responders, column C, rows 40, 52, 130 and 185.
825) MacFarlane {CAB00014794/4-5} pages 4-5, paragraphs 14, 19.
826) {Day280/149:18}-{Day280/150:2}.
827) {CAB00014792} Cat 1 Responders, Row 51, columns F, G, H and I.
828) {CAB00014792} Cat 1 Responders, Row 317, columns F, G, H and I.
829) Hammond {Day280/150:3-10}.
830) {CAB00014793} Row 119, columns E, F, G and H.
831) {CAB00014793} Row 202, columns E, F, G and H.
832) {CAB00014793} Row 7, columns E, F, G and H.
833) Hammond {Day280/146:1-2}.
834) Hammond {Day280/147:8-9}.
835) Hammond {Day280/145:2-12}.
836) MacFarlane {CAB00014794/7} page 7, paragraph 23.
837) Hammond {Day280/151:5-7}.
838) Ms McManus had been temporarily promoted to head of resilience for the London area from within Robert Mason’s team. Mason {CLG00030435/6} page 6, paragraph 16. She confirmed that she had not received any specific training before her appointment as a head of resilience {Day283/42:16-20}.
839) McManus {Day283/35:11-15}; Dowdican {CLG00030419/2} page 2, paragraph 9.
840) Dowdican {CLG00030419/2} page 2, paragraph 9.
841) Richardson {CLG00030412/15} page 15, paragraph 48.
842) Welch {CLG00030737/3} page 3, paragraph 14; McManus {Day283/46:9-10} and {Day283/47:3-6}.
843) McManus {Day283/47:3-8}
844) McManus {Day283/46:19-21}.
845) There were 51 RED reserves at the time of the Grenfell Tower fire, Richardson {CLG00030412/7} page 7, paragraph 22.
846) Richardson {CLG00030827/5} page 5, paragraph 9b.
847) Doug Taylor, resilience advisor, had not received any RED reserve training. McManus {Day283/124:20}-{Day283/125:3}.
848) Welch {CLG00030737/4} page 4, paragraph 15.
849) McManus {CLG00030739/2} page 2, paragraph 8.
850) Dowdican {CLG00030419/2} page 2, paragraph 7.
851) Resilience and Emergencies Division Training, Exercising and Organisational Learning Strategy 2015 – 2018, version 0.3, 2015 {CLG00030780}.
852) Resilience and Emergencies Division Training, Exercising and Organisational Learning Strategy 2015 – 2018, version 0.3, 2015 {CLG00030780/4} paragraph 3.2.
853) Resilience and Emergencies Division Training, Exercising and Organisational Learning Strategy 2015 – 2018, version 0.3, 2015 {CLG00030780/4} paragraph 3.3.
854) McManus {Day283/38:3-7}.
855) Hammond {CAB00014764/6} page 6, paragraph 21.
856) Hargreaves {CAB00014871/4} page 4, paragraph 13; 2014 Resilience Capabilities Survey: Highlight Report {CAB00000094}.
857) 2014 Resilience Capabilities Survey: Highlight Report {CAB00000094/3}.
858) Workstream 3 of the National Security Capabilities Review {CAB00007083/4}.
859) Hargreaves {CAB00014871/5} page 5, paragraph 14.
860) Hargreaves {CAB00014871/5} page 5, paragraph 14.
861) Workstream 3 of the National Security Capabilities Review {CAB00007083/4}.
862) Held on Thursday 8 June 2017 {CAB00014768/1} paragraph 1.
863) That attack occurred in Finsbury Park, London, England, on 19 June 2017. Email at 10.46, 19.06.17 {CAB00005309} and Kay {CLG00030430/15} page 15, paragraph 62.
864) Hammond {CAB00014764/13} page 13, paragraph 42.
865) Hammond {Day280/176:19}-{Day280/177:14}.
866) Hammond {Day280/177:11-14}. We note that ConOps indicated that the GLO would normally be from the lead government department, ConOps {CAB00000026/39} paragraph 3.56.
867) Welch {CLG00030737/1} page 1, paragraph 1; Welch {CLG00030737/2-3} pages 2-3, paragraph 11.
868) Welch {CLG00030737/4} page 4, paragraph 16; McManus {CLG10009725/5} page 5, paragraph 15.
869) Welch {CLG00030737/4} page 4, paragraph 17.
870) McManus {CLG10009725/5} page 5, paragraph 15.
871) Welch {CLG00030737/4} page 4, paragraph 17.
872) McManus {CLG10009725/7} page 7, paragraph 23.
873) Welch {CLG00030737/4} page 4, paragraph 17.
874) Email at 04.13 on 14 June 2017 {CLG00008000/4}; Welch {CLG00030737/4} page 4, paragraph 17.
875) Email at 04.29 on 14 June 2017 {CLG00008000/3-4}.
876) Hurd {HOM00046080/1} page 1, paragraph 4.
877) McManus {CLG10009725/7} page 7, paragraph 23; McManus {Day283/49:14}-{Day283/50:3}.
878) McManus {Day283/51:10-18}.
879) Hammond {CAB00014764/13} page 13, paragraph 44.
880) Emails at 06.17 and 08.14, 14.06.17 {CAB00005650}.
881) Hammond {CAB00014764/13} page 13, paragraph 44; amongst those copied into the 04:44, 14.06.17 email were DCLG RED and OSCT Operational Support in the Home Office {CAB00000337/5-6}.
882) {CAB00005650}.
883) Hurd {Day282/115:14}-{Day282/116:2}; Hurd {HOM00046080/1} page 1, paragraph 4.
884) Known as Sit Reps and dated 14, 15, 16, 17 and 19 June 2017 {HOM00046089}; Hurd {HOM00046080/6} page 6, paragraph 21; ConOps {CAB00000026/15} paragraph 2.16(ii).
885) Dawes {Day285/20:16}-{Day285/21:2}.
886) Hammond {CAB00014764/14} page 14, paragraph 45.
887) McManus {CLG10009725/23} page 23, paragraph 95.
888) Emergency plan {CLG00005657/40-41}; McManus {Day283/55:8-17}; {Day283/56:14}-{Day283/58:7}.
889) McManus {Day283/55:21}-{Day 283/56:9}.
890) McManus {CLG10009725/7} page 7, paragraph 25; emails at 04.40 and 04.55 on 14 June 2017 {CLG00030443/1}.
891) McManus {Day283/61:24}-{Day283/62:18}.
892) McManus {Day283/89:1-11}.
893) Richardson {CLG00030412/28} page 28, paragraph 105; McManus {Day283/61:9-23}; McManus {Day283/58:7-12}; Module 4 Closing statement on behalf of the Department for Levelling Up, Housing and Communities {CLG00036423/2} paragraph 4b.
894) Readout of 05.00 SCG meeting {CAB00000157/2}; readout of 06.30 SCG meeting {CAB00010263/1-2}; readout of 08.30 SCG meeting {CAB00008475/2}.
895) {CAB00000157/2-3}.
896) Email at 06.16 on 14 June 2017 {CAB00000157/2}. The OSCT Operation Support within the Home Office circulated to the CCS Control and others a situation report at 05:56 on 14 June 2017, which included reference to, but not a summary of, the 05:00 SCG meeting {HOM00046089/1-3}.
897) Email at 07.13 on 14 June 2017 {CAB00000157/2}; Hammond {Day280/181:23}-{Day280/182:1}.
898) Both the DCLG RED and the Home Office joined the 06:30 SCG by telephone: email at 07:27 on 14 June 2017 {CAB00000157/1}.
899) Hammond {Day280/183:14-16}.
900) Email at 07.27 on 14 June 2017 {CAB00000157/1}.
901) Email at 08.35 on 14 June 2017 {CAB00014771/3-4}.
902) Email at 10.41 on 14 June 2017 {CAB00008475/2}.
903) Email at 11.10 on 14 June 2017 {CAB00008475/1}.
904) McManus {Day283/85:7-23}; email at 13.24 on 14 June 2017{CLG00008026/1}.
905) Email at 11.43 on 14 June 2017{CLG00008024/2}.
906) Emails at 04.08 and 04.33 {CLG00030443/1}; emails at 05.55 and 07.12 {CLG00002860}; email at 08.07 {CLG00030453}; email at 08.11 {CLG00002867/2}; email at 08.26 on 14 June 2017 {CLG00030455}; McManus {Day283/65:8-12}.
907) McManus {Day283/77:18}-{Day283/78:3}.
908) McManus {Day283/78:5-15}.
909) Email at 08.09 on 14 June 2017 {CAB00000159/1}; Hammond {CAB00014816/9} page 9, paragraph 20.
910) Hammond {Day280/184:11-19}.
911) {Day280/188:2-4}; Hammond {CAB00014764/14} page 14, paragraph 46.
912) {Day280/190:16-17}.
913) ConOps {CAB00000026/27} paragraphs 3.22-3.23.
914) ConOps {CAB00000026/6-7} paragraph 1.5; ConOps {CAB00000026/27} paragraph 3.22-3.23.
915) The DCLG RED Reserves are people who work in other parts of the Department who can be released to work on urgent RED projects: McManus {CLG10009725/11} page 11, paragraph 41.
916) DCLG’s Emergency Response Plan {CLG00005657/11} paragraph 2.16.
917) Email at 09.18 on 14 June 2017 {CLG00002875/2}; DCLG’s Emergency Response Plan {CLG00005657/11} paragraph 2.16.
918) Robert Mason {CLG00030435/2} page 2, paragraph 4. Page 7, paragraph 19; Email at 09.16 on 14 June 2017 {CLG00002874/1}.
919) Email at 09:37 on 14 June 2017 {CLG00002879/1-2}; email at 09.39 on 14 June 2017 {CLG00002876}; Emergency Notice {CLG00008012}.
920) Phase 1 Report II paragraph 10.332.
921) McManus {Day283/94:6-10}.
922) The three main cells are the situation cell, the policy cell and the briefing cell: DCLG’s Emergency Response Plan {CLG00005657/12-13} paragraphs 3.7-3.17.
923) DCLG RED Emergency Notice {CLG00008012}; McManus {CLG10009725/22} page 22, paragraph 93.
924) Email at 09.37 on 14 June 2017 from Lynne Dowdican to RED Control notifying them that she had appointed an Operations Centre Manager and was seeking a briefing cell and a situation cell {CLG00002879/1-2}. Ms Dowdican had taken over from Gill McManus minutes earlier, see email at 09.32 on 14 June 2017 {CLG00002875/1}; McManus {Day283/81:13}-{Day283/82:5}.
925) Robert Mason {CLG00030435/6-7} pages 6-7, paragraph 17.
926) Robert Mason {CLG00030435/7} page 7, paragraph 19; Robert Mason {CLG10009810/2-3} pages 2-3, paragraph 7.
927) {CLG00008012}.
928) Robert Mason {CLG00030435/7} page 7, paragraph 19; Robert Mason {CLG10009810/2-3} pages 2-3, paragraph 7.
929) Whitehead {CAB00014857/9} page 9, paragraph 27.
930) Email at 10.04 on 14 June 2017 {CAB00000337/1}.
931) Whitehead {CAB00014857/9} page 9, paragraph 27.
932) Email at 10.04 on 14 June 2017{CAB00000337/1-2}.
933) Email at 10.04 on 14 June 2017 {CAB00000337/1}.
934) Appointed on 12 June 2017; Hurd {HOM00046080/1} paragraph 1.
935) Hurd {Day282/114:15}-{Day282/115:4}.
936) Hurd {Day282/115:5-13}.
937) Hammond {Day281/154:14-16}.
938) Hurd {Day282/148:16-23}.
939) Grenfell Tower tragedy – Lessons for the Central Response {CAB00014768/4} paragraph 17.
940) By a Secretary of State.
941) Dawes {CLG00030653/36} page 36, paragraph 119.
942) Email at 10.09 on 14 June 2017 {CAB00000337/1}.
943) Email at 10.14 on 14 June 2017 {CAB00014775}.
944) Whitehead {CAB00014857/8} page 8, paragraph 26.
945) Hammond {Day280/159:18-22}.
946) Email at 12.58 on 14 June 2017 {CAB00013996/1}.
947) Email at 12.58 on 14 June 2017 {CAB00013996/1}.
948) Hammond {Day280/212:20-25}.
949) Hammond {CAB00014816/8} page 8, paragraph 17; ConOps {CAB00000026/24} paragraph 3.10.
950) Hammond {Day281/192:5}-{Day281/193:5}.
951) Hammond {Day280/200:15-22}; Hammond {Day280/213:1-8}.
952) Farrar {Day284/16:14-23}.
953) Email at 09.07 on 14 June 2017 {RBK00005766}.
954) Email at 09.09 on 14 June 2017 {RBK00005766}.
955) Holgate {Day273/98:3}-{Day273/99:3}.
956) Email at 09.27 on 14 June 2017 {CLG00030460}; Farrar {Day284/27:6}-{Day284/28:3}.
957) Farrar {Day284/28:4-11}; Holgate {Day273/98:19-23}; Farrar {CLG00030414/6} page 6, paragraph 27; Farrar {CLG00030414/10} page 10, paragraph 44.
958) Email at 11.22 on 14 June 2017 {RBK00048990}; email at 12.16 on 14 June 2017 {CLG00030466/1}; Randall {CLG00030427/13-14} pages 13-14, paragraph 54; email at 16.37 on 14 June 2017 {CLG00002995}.
959) Farrar {CLG00030414/6} page 6, paragraph 30.
960) Farrar {Day284/29:1-11}.
961) Farrar {Day284/29:14}-{Day284/30:3}; email at 14.05 on 14 June 2017 {CLG00002954}.
962) Email at 14.19 on 14 June 2017 {CLG00002952}.
963) Farrar{Day284/33:5}-{Day284/34:4}.
964) Farrar {Day284/34:10}-{Day284/35:4}.
965) {CLG00002952}; Farrar {Day284/35:1-4}.
966) Hurd {HOM00046080/2} page 2, paragraph 6; Hurd {Day282/145:23}-{Day282/146:1}.
967) Hurd {HOM00046080/2} page 2, paragraph 7.
968) Hurd {Day282/147:19}-{Day282/148:15}.
969) Hurd {Day282/146:2-12}.
970) Hurd {Day282/147:19}-{Day282/148:15}.
971) Emails at 10.44 {CAB00001126/2}, and 12.05 on 14 June 2017 {CAB00001126/1}; email at 13:51 on 14 June 2017 {CAB00002927}.
972) {CAB00001129}; {CAB00002715}; {CAB00002711}.
973) {CAB00001129}; {CAB00002715/2-3} items 3(b)-3(c).
974) {CAB00002711}.
975) Hammond {Day281/5:1-10}.
976) Hammond {Day281/7:23-24}.
977) Email at 13.55 on 14 June 2017 {CAB00000365/1}.
978) Email at 16.30 on 14 June 2017 {CAB00007461/2}.
979) Emails at 17.40, 17.49 and 17.59 on 14 June 2017 {CAB00007461/1-2}.
980) Hammond {CAB00014764/16} page 16, paragraph 51.
981) Hammond {Day281/6:2-13}.
982) Hammond {Day281/8:19-24}.
983) Chair’s Brief {CAB00002715/2} paragraph 8.
984) Fourth SIT REP – 18:20hrs on 14 June 2017 (Home Office, OSCT Operational Support) {HOM00046089/16}.
985) That is echoed in the CCS report ‘Grenfell Tower tragedy - Lessons for the Central Response’, which identified a “significant discrepancy between the situation as generally understood in Whitehall for the first 24-36 hours, and that facing the local community” but failed to identify Mr Holgate’s absence from the 14 June cross-government co-ordination meeting as a contributing factor. That is because the review erroneously recorded RBKC’s chief executive as having attended the meeting on 14 June 2017. That was a critical error in what was intended to be an exercise in identifying lessons learnt, {CAB00014768/1} paragraph 4 and {CAB00014768/2-3} paragraph 11.
986) Minutes 14 June 2017 {CAB00002714}.
987) Minutes 14 June 2017 {CAB00002714/1} paragraph (c).
988) Hammond {Day281/10:10}.
989) Minutes 14 June 2017 {CAB00002714/1} paragraph (b). See also Hurd {Day282/145:7-17}.
990) To which there is a brief, general mention: “The local Council were presently identifying temporary accommodation for those residents of Grenfell Tower.” {CAB00002714/1} paragraph (b).
991) The guidance indicates that the initial needs of survivors without serious injuries are likely to include shelter and warmth, information on and assistance with contacting family and friends, support in their distress, food and drink, treatment of injuries and medicinal and mobility needs, changing, washing and toilet facilities and perhaps spare clothing. It also warns that the immediate and longer-term psychological needs of survivors without serious injuries (who may also be bereaved) should not be overlooked {CAB00004519/119-120} paragraphs 7.3.2-7.3.4.
992) Workstream 4 of the National Security Capability Review, dated 28 September 2017 {CAB00007084/2} paragraph 6.
993) Hammond {Day280/210:23}-{Day280/211:8}.
994) ConOps {CAB00000026/43} paragraph 3.76.
995) Hammond {Day281/11:18-25}.
996) Hammond {Day281/23:17-19}; emails at 12.22 {CAB00009842/2} page 2 and 17.55 {CAB00009842/1}.
997) Actions 14 June 2017{CAB00001236}; Hammond {CAB00014868/8} page 8, paragraph 23(f).
998) Draft Minutes 14 June 2017 {CAB00013811/1}. That draft version was emailed internally within the CCS at 11.21 on 15 June 2017 {CAB00013810}.
999) Hammond {CAB00014868/7} page 7, paragraph 23(a).
1000) Minutes 14 June 2017 {CAB00002714/1} paragraph (b).
1001) Hammond {Day281/21:10-25}.
1002) Hurd {Day282/205:12-24}.
1003) Workstream 4 of the National Security Capability Review, dated 28 September 2017 {CAB00007084/3} paragraph 8.
1004) Hurd {Day282/207:25}–{Day282/208:15}.
1005) Workstream 3 of the National Security Capability Review, dated 28 September 2017 {CAB00007083/10}.
1006) Email at 21.28, 14.06.17 {CLG00008048/2}; Email at 20.49, 14.06.17 {CAB00007180/1-3}; Farrar {Day284/39:15}-{Day284/44:5}.
1007) Farrar {CLG00030414/8} paragraph 39; Farrar {Day284/53:14}-{Day284/54:4}.
1008) Email at 10.37 on 15 June 2017 {CLG00003102}.
1009) Farrar {Day284/52:1}-{Day284/54:4}.
1010) Email at 08.34 on 15 June 2017 {CAB00003270/1}.
1011) Email at 09.15 on 15 June 2017 {CAB00005941}.
1012) Email at 09.17 on 15 June 2017 {CAB00005941}.
1013) Email at 09.12 on 15 June 2017 {CLG10009750}.
1014) Dawes {Day285/99:8-20}.
1015) Emails from 09.09 to 13.55 on 15 June 2017 {CLG00008159/2-6}; Jones {IWS00001723/5} page 5, paragraph 30; El-Gourja {IWS00001700/8} page 8, paragraph 34; Dainton {IWS00001974/38} page 38, paragraph 221.
1016) Wainwright {CAB00014776/8} page 8, paragraph 29.
1017) Action Tracker {CAB00001253/1-2} Items 2-3, circulated by email at 14.27 on 15 June 2017 {CAB00003286}.
1018) Chair’s Brief on 15 June 2017 {CAB00002721/2} paragraphs 8-9.
1019) Email at 09.52 on 15 June 2017 {CLG00003084}; Dawes {CLG00030653/16} page 16, paragraph 50.
1020) Farrar {Day284/28:4-11}; Farrar {CLG00030414/10}, page 10, paragraph 44.
1021) Farrar {Day284/68:15}-{Day284/69:18}.
1022) Farrar {Day284/73:3-5}.
1023) Email at 16.26 on 15 June 2017 {CLG00008140}; Farrar {Day284/71:1}-{Day284/72:3}.
1024) Farrar {Day284/74:6-7}.
1025) {LFB00061240/1}; Farrar {Day284/84:15}-{Day284/85:25}; McManus {Day283/102:18}-{Day283/103:21}.
1026) Dawes {Day285/212:14-23}.
1027) The DCLG RED Note to No.10 at 14.45 on 15 June 2017 {CLG00003194}; Kay {CLG00030430/7} page 7, paragraph 29.
1028) Email at 15.10 on 15 June 2017 {CLG00020191}.
1029) McManus {Day283/99:10-25}.
1030) Minutes of 15 June 2017 {CAB00002720/1}. That appears to have been the first contact between Mr Hurd and Mr Holgate: Hurd {Day282/154:17-21}.
1031) Minutes 15 June 2017 {CAB00002720/3} paragraph 2(a).
1032) Hammond {Day281/47:14}-{Day281/48:5}.
1033) Email at 16.26 on 15 June 2017 {CLG00008140/1-2}.
1034) Hammond {Day281/44:25}-{Day281/45:3}.
1035) Richardson {CLG00030412/21} page 21, paragraph 77; Hurd {Day282/173:12-14}.
1036) Wainwright {CAB00014776/9} page 9, paragraph 30.
1037) Hurd {Day282/168:6-12}; See also email at 20.08 on 15 June 2017 {CAB00002899/1}.
1038) Email at 17.32 on 15 June 2017 {CAB00006264/1}.
1039) Email at 22.09 on 15 June 2017 in which Dame Melanie expressed her view about how well RBKC was “gripping this” {CLG10009757}.
1040) Email at 20.11 on 15 June 2017 {CAB00002896/2}.
1041) Email at 20.39 on 15 June 2017 {CAB00002896/1}.
1042) Email at 21.03 on 15 June 2017 {CAB00002896/1}.
1043) Hammond {Day281/68:20-21}.
1044) Hurd {Day282/174:13-22}.
1045) Email at 07.41 on 16 June 2017 {CLG00008227/2}.
1046) Email at 08.02 on 16 June 2017 {CLG00008227}.
1047) Email at 08.23 on 16 June 2017 {CLG00008227}.
1048) Table of the DCLG calls and meetings on 16 June 2017 {CLG00018819/3}.
1049) Email at 11.19 on 16 June 2017 {CAB00006453/1}.
1050) Email at 09.33 on 16 June 2017 {CAB00001152/1-2}.
1051) Hurd {Day282/181:20}-{Day282/182:10}.
1052) Farrar {CLG00030414/10} page 10, paragraph 46; email at 19.21 on 15 June 2017 {CLG00003210/1}.
1053) Farrar {Day284/121:11-13}.
1054) Farrar {CLG00030414/14} page 14, paragraph 62.
1055) Farrar {CLG00030414/14} page 14, paragraph 63; Farrar {Day284/113:18}-{Day284/115:9}.
1056) Farrar {CLG00030414/14} page 14, paragraph 63.
1057) Farrar {Day284/119:21-25}.
1058) Farrar {CLG00030414/14-15} pages 14-15, paragraph 67; text message at 10.13 on 16 June 2017 {CLG00030628}; See also email at 14.11 on 16 June 2017 {CLG00003383} summarising the meeting between the Secretary of State and Mr Paget-Brown.
1059) McManus {Day283/105:15}-{Day283/106:3}.
1060) Minutes of SCG meeting at 11.00 on 16 June 2017 under heading ‘DCLG’ {MOL00000036/3}.
1061) Text message {CLG00030627}.
1062) The Deputy Chair of the London Resilience Forum, Chair of the Local Authorities’ Panel and the Town Clerk and Chief Executive of the City of London Corporation.
1063) Farrar {CLG00030414/16} page 16, paragraph 75.
1064) {LFB00061240/1}; Sawyer {GOL00001349/11} page 11, paragraph 54.
1065) {LFB00061236}; McManus {Day283/102:18}-{Day283/103:21}; {LFB00061250}
1066) {CLG00030627}; Farrar {CLG00030414/16} page 16, paragraphs 76-77; {CLG00003297}; {CLG00030514}; Farrar {CLG00030414/16} page 16, paragraph 77.
1067) Farrar {CLG00030414/16} page 16, paragraph 78.
1068) Farrar {Day284/132:21-23}.
1069) Farrar {CLG00030414/17} page 17, paragraph 79.
1070) Farrar {CLG00030414/16} page 17, paragraph 79.
1071) Farrar {Day284/140:2-13}; Farrar {Day284/143:8}.
1072) Farrar {Day284/140:18-22}.
1073) Farrar {CLG00030414/16-17} pages 16-17, paragraph 78-79.
1074) {CLG00030626}.
1075) Barradell {Day279/113:1-25}.
1076) Barradell {Day279/116:9}-{Day279/117:3}.
1077) Hammond {CAB00014764/19} page 19, paragraph 68.
1078) Hammond {Day281/77:8-11}.
1079) Hammond {Day281/77:8-11}.
1080) CRIP 3 {CAB00000148/1-2}.
1081) Whitehouse {CAB00014782/8-9} pages 8-9, paragraphs 21-23; email at 13.05 on 14 June 2017 {CAB00004061}; email at 21.28 on 14 June 2017 containing notes from the 19.30 SCG meeting {CLG00008048/1-2}; Farrar {Day284/40:19}-{Day284/43:15}; email at 06.42 on 15 June 2017 {CAB00003269/1}; email at 08.32 on 15 June 2017 {CAB00003269/1}.
1082) Hurd {Day282/116:16-24}.
1083) Email at 08.14 on 16 June 2017 {CLG00003294/1}; Farrar {CLG00030414/12-13} pages 12-13, paragraph 57.
1084) Email at 09.02 on 16 June 2017 {CLG00003294/1}; Farrar {CLG00030414/12-13} pages 12-13, paragraph 57.
1085) Email at 09.22 on 16 June 2017 {CAB00001150/1}.
1086) Email at 10.50 on 16 June 2017 {CAB00000473/3}; Tallantire {CAB00014769/3} page 3, paragraph 12; Gratton {CAB00014853/22} page 22, paragraph 64.
1087) Whitehead {CAB00014857/20} page 20, paragraph 54.
1088) Hammond {CAB00014764/20} page 20, paragraph 69.
1089) ConOps {CAB00000026/43} paragraph 3.76.
1090) ConOps {CAB00000026/43} paragraph 3.74-3.76.
1091) ConOps {CAB00000026/7} paragraph 1.6.
1092) Hammond {Day281/88:25}-{Day281/89:11}.
1093) Hammond {Day280/210:23}-{Day280/211:8}.
1094) Hammond {Day281/91:6-10}.
1095) The local transition appears to have taken place at 23.59 on Friday 23 June 2017 {GOL000000062/3}.
1096) Summary Grenfell Fire Response (CCS Internal Lessons) {CAB00000105/1} paragraph 1; Whitehouse {CAB00014782/13-14} pages 13-14, paragraph 34.
1097) ConOps {CAB00000026/21} paragraph 3.1.
1098) Hammond {Day281/91:11-16}; ConOps {CAB00000026/8-9} paragraph 1.8.
1099) Hammond {Day281/202:16-22}.
1100) Hammond {Day281/93:23}-{Day281/94:6}.
1101) ConOps {CAB00000026/19} paragraph 2.26(d).
1102) ConOps {CAB00000026/27} paragraph 3.22; See also ConOps {CAB00000026/22} paragraph 3.2 diagram which includes a “Recovery Group” as one of the potential COBR supporting structures to be activated.
1103) Gratton {CAB00014853/22} page 22, paragraph 63.
1104) Gratton {CAB00014853/5} page 5, paragraph 15.
1105) Email at 11.39 on 16 June 2017 {CAB00001158/1}; email at 10.50 on 16 June 2017 {CAB00012900}; email at 13.19 on 18 June 2017 {CAB00003178/1}.
1106) Emails from 12.56 to 12.59 on 16 June 2017 {CAB00000462/1-2}; Attendees List for 16 June 2017 {CAB00002728}.
1107) Emails at 19.40 and 19.46 on 16 June 2017 {CAB00001286/2}.
1108) Minutes 16 June 2017 {CAB00002726/2}.
1109) Minutes 16 June 2017 {CAB00002726/2}.
1110) Minutes 16 June 2017 {CAB00002726/2} paragraph 1.
1111) Minutes 16 June 2017 {CAB00002726/3} paragraph 3.
1112) Minutes 16 June 2017 {CAB00002726/6} paragraph 15.
1113) Minutes 16 June 2017 {CAB00002726/5} paragraph 8.
1114) Draft Minutes 16.06.17 {CAB00012896/1}.
1115) Actions 16 June 2017 {CAB00002727/1} Action 4.
1116) Kay {CLG00030430/9} page 9, paragraph 38.
1117) Hurley Brunt {CAB00014787/1} page 1, paragraph 1: Isla Hurley Brunt reported to Ian Whitehouse.
1118) Email at 18:03 on 14 June 2017 {CAB00014358}; Isla Hurley Brunt {CAB00014801/4} page 4, paragraph 14.
1119) Email at 07.41 on 16 June 2017 {CAB00005546/1}.
1120) Email at 09.43 on 15 June 2017 {CLG00003087/2}; Grenfell Tower tragedy – Lessons for the Central Response {CAB00014768/3} paragraph 13.
1121) Grenfell Tower tragedy – Lessons for the Central Response {CAB00014768/3} paragraph 13.
1122) Hammond {CAB00014764/20} page 20, paragraph 72; email at 16.14 on 16 June 2017 {CLG00030523/2-3}.
1123) Jillian Kay’s 16 June 2017 Paper on Victims Unit: Grenfell Tower {CLG00030529}; Kay {CLG00030430/9} page 9, paragraph 39.
1124) Email at 18.28 on 16 June 2017 {CLG00030523/2-3}; Kay {CLG00030430/9} page 9, paragraph 38. Her Majesty’s Revenue and Customs’ surge team was made up of operational staff who were trained to deploy into administrative roles in different parts of central government.
1125) Kay {CLG00030430/2} page 2, paragraph 7.
1126) Hammond {CAB00014816/17} page 17, paragraph 45; Kay {CLG00030430/9} page 9, paragraph 37.
1127) Kay {CLG00030430/10} page 10, paragraph 41.
1128) Kay {CLG00030430/9} page 9, paragraph 38.
1129) Jillian Kay’s 16 June 2017 Paper on Victims Unit: Grenfell Tower {CLG00030529/1} paragraph 5.
1130) Kay {CLG00030430/10-11} pages 10-11, paragraph 44.
1131) Email at 18.10 on 17 June 2017 {CLG00030555}.
1132) Kay {CLG00030430/10-11} pages 10-11, paragraph 44.
1133) Email at 16.11 on 18 June 2017 {CLG00008945}.
1134) Pack for Key Workers {CLG00005692/1}; email at 20.06 on 19 June 2017 {CLG00005691/1}; Kochanowski {CLG00030416/14} page 14, paragraph 50.
1135) Email at 22.56 on 19 June 2017 {CLG00030588}. Ms Kay told us that that had prompted her to visit the Westway Centre on 20 June 2017, Kay {CLG00030430/15} page 15, paragraph 63.
1136) Email at 22.56 on 19 June 2017 {CLG00030588}.
1137) Dawes {Day285/214:15}-{Day285/215:8}.
1138) Not everyone had a key worker or social worker by that stage.
1139) Email at 15.50 on 16 June 2017 {CAB00002898/1}.
1140) Email at 15.58 on 16 June 2017 {CAB00002898/1}.
1141) List of attendees {CAB00005765/2} attached to email at 16.13 on 16 June 2017 {CAB00005764}; email at 17.26 on 18 June 2017 {CAB00006308/1-4}.
1142) Email at 17.56 on 16 June 2017 {CAB00005339}.
1143) Email at 18.25 on 16 June 2017 {CAB00011967/1}.
1144) Emails at 18.04 and 18.22, 16 June 2017 {CAB00011967/1-2}.
1145) Email at 09.22 on 16 June 2017 {CAB00001150/1}; Hammond {Day281/166:7-10}.
1146) Email at 19.37 on 16 June 2017 {CAB00005727}.
1147) Email at 19.54 on 16 June 2017 {CAB00006343}; However, Ms Gratton’s note of 17 June 2017 indicates that Nicholas Paget-Brown did not make contact with all mosques, churches and temples by end of day Friday {RBK00038856/1-3}.
1148) Minutes 17 June 2017 {CAB00002735}.
1149) Minutes 17 June 2017 {CAB00002735/3} paragraph 5.
1150) Actions, 17 June 2017 {CAB00001248/1-2} actions 2, 4, 5 and 11.
1151) Minutes 17 June 2017 {CAB00002735/7} paragraph 20.
1152) Email at 16.11 on 17 June 2017 {LFB00119799/1}; Hurd {HOM00046080/15-16} pages 15-16, paragraph 51.
1153) Hurd {Day282/189:16}-{Day282/190:3}.
1154) {HOM00046091}.
1155) Peter Tallantire had taken over from Stuart Wainwright as the Deputy Director leading on the response on the evening of 15 June 2017, following a short, informal handover meeting, Tallantire {CAB00014769/2} page 2, paragraph 7.
1156) Email at 23.19 on 17 June 2017 {CAB00003152/1}.
1157) Email at 23.19 on 17 June 2017 {CAB00003152/1}.
1158) Email at 23.47 on 17 June 2017 {CAB00002980/1-2}.
1159) Email at 07.11 on 18 June 2017 {CAB00002980/1}.
1160) Hammond {CAB00014764/22} page 22, paragraph 79.
1161) Minutes 16 June 2017 {CAB00002726/6} paragraph 15.
1162) The relevant protected characteristics under the Equality Act 2010 are set out at section 149. Emergency Response and Recovery identifies four groups which require special consideration, see {CAB00004519/129-131} section 7.7.
1163) Randall {CLG00030427/19} page 19, paragraph 74.
1164) Emails at 14.16 and 14.44 on 16 June 2017 {CLG00003398/1}.
1165) Emails at 16.14 and 16.24 on 16 June 2017 {CLG00003453/1-2}.
1166) McManus {CLG10009725/14} page 14, paragraphs 57-58; McManus {Day283/126:12}-{Day283/127:4}.
1167) McManus {CLG10009725/14} page 14, paragraphs 57-58; McManus {Day283/126:12}-{Day283/127:4}.
1168) Minutes 17 June 2017 {CAB00002735/4} paragraph 9(ii); Actions 17 June 2017 {CAB00001248/2} Action 5.
1169) Owen {HOM00046114/3} page 3, paragraph 11.
1170) Owen {HOM00046114/4} page 4, paragraph 13.
1171) Owen {HOM00046114/4} page 4, paragraph 16.
1172) Hepple {HOM00046110/6-7} pages 6-7, paragraph 19.
1173) Kay {CLG00030430/12} page 12, paragraph 51.
1174) McManus {Day283/119:10} -{Day283/120:8}.
1175) That was a meeting, chaired by Paddy McGuinness and attended only by officials, rather than ministers: Attendees List for 18 June 2017 {CAB00002785}; Hammond {CAB00014764/21} page 21, paragraph 76.
1176) Kay {CLG00030430/13} page 13, paragraph 54; Kay {CLG00030430/14} page 14, paragraph 59; email at 20.01 on 18 June 2017 {CLG00009076}.
1177) Suzanne Kochanowski was a senior team leader within the division and responsible for government policy and stakeholder engagement on race equality, racial and ethnic minorities, faith communities and community cohesion {CLG00030416/2} page 2, paragraph 5; See also Patel {CLG10009793/3} page 3, paragraph 6.
1178) Kay {CLG00030430/13} page 13, paragraph 56.
1179) Email at 18.04 on 18 June 2017 {CLG00008968/1}; Kay {CLG00030430/14} page 14, paragraph 59.
1180) Barradell {Day279/215:18}-{Day279/216:3}.
1181) Email at 18.36, 18 June 2017 {CLG00020672/2-3}.
1182) Hammond {Day281/144:16-25}: for example, issuing a driving licence.
1183) Hammond {CAB00014816/18} page 18, paragraph 47.
1184) Lamberti {HOM00046095/6} page 6, paragraph 20.
1185) Hurd {Day282/199:1-3}.
1186) Email at 14.54 on 19 June 2017 {CAB00009996/3}.
1187) Email at 15.49 on 19 June 2017 {CAB00012084/3}.
1188) London Local Authority Gold Incident Log Book {GOL00001690/7}; McManus {Day283/132:8}-{Day283/134:8}.
1189) Email at 11.46 on 20 June 2017 {CAB00009946/2}; Bassett-James {BEI00002844/3-5} pages 3-5, paragraphs 12-19.
1190) London Local Authority Gold Incident Log Book {GOL00001690/7} entry 73; McManus {Day283/132:8}-{Day283/134:8}.
1191) Kay {CLG00030430/15-16} pages 15-16, paragraphs 65-69.
1192) Hammond {CAB00014816/18} page 18, paragraph 47; By comparison, Sebastian Bassett-James at BEIS produced a Utilities Co-ordination Cell staff guide, specifically designed to support staff in the Utilities Coordination Cell who were physically present at the Westway Centre because they were not crisis professionals and therefore needed specific guidance {BEI00002843}; Bassett-James {BEI00002844/2-3} pages 2-3, paragraphs 10-11; Bassett-James {BEI00002844/7-8} pages 7-8, paragraphs 30-32.
1193) Email at 15.49 on 19 June 2017 {CAB00012084/3}.
1194) Gill {HOM00046118/2} page 2, paragraph 8.
1195) Grenfell Tower tragedy - Lessons for the Central Response {CAB00014768/3-4} paragraph 16.
1196) Minutes 16 June 2017 {CAB00002726/4} paragraph g.
1197) Minutes 16 June 2017 {CAB00002726/2} Item 2(1).
1198) Grenfell Tower tragedy - Lessons for the Central Response {CAB00014768/3} paragraph 12.
1199) Minutes 19 June 2017 {CAB00002741/3-4} paragraph 7.
1200) Hammond {Day281/138:13}-{Day281/139:10}.
1201) Minutes 19 June 2017 {CAB00002741/3-4} paragraph 7.
1202) Actions 19 June 2017 {CAB00002739/1} Action 1.
1203) Actions 19 June 2017 {CAB00002739}.
1204) Black {Day275/104:12-16}.
1205) Black {Day275/78:20}-{Day275/79:1}.
1206) Minutes 20 June 2017 {CAB00002792/3} paragraph 6.
1207) Dawes {Day285/184:11-22}; {CLG00005813/1}; Dawes {CLG00030653/32} page 32, paragraph 102.
1208) Dawes {Day285/185:18-22}.
1209) Randall {CLG00030427/8} page 8, paragraph 28.
1210) Randall {CLG00030427/8} page 8, paragraph 28.
1211) Randall {CLG00030427/8} page 8, paragraphs 28-29. See also email at 12.52 on 16 June 2017 {CLG00003260}.
1212) Email at 15.15 on 18 June 2017 {CLG00030574}.
1213) Email at 15.15 on 18 June 2017 {CLG00030574}.
1214) Al-Assad {IWS00001789/9} page 9, paragraph 56.
1215) Farrar {Day284/18:25}-{Day284/20:1}. Bellwin is the name given to the statutory scheme established under s.155 of the Local Government and Housing Act 1989 to provide emergency financial assistance to local authorities, Baldwin {CLG00030437/3} page 3, paragraph 8; Kay {CLG00030430/4} page 4, paragraph 14.
1216) Baldwin {CLG00030437/4} page 4, paragraph 13.
1217) Baldwin {CLG00030437/5} page 5, paragraph 14; email at 01.01 on 19 June 2017 {CLG00009221/1-5}.
1218) Email at 08.50 on 16 June 2017 {CAB00005938/6-7}.
1219) Emails at 09.17 and 11.53 on 16 June 2017 {CAB00005938/5-6}.
1220) Baldwin {CLG00030437/2} page 2, paragraphs 4-5; Baldwin {CLG00030437/5} page 5, paragraph 16.
1221) No.10 asked for a briefing on whether RBKC could set up a hardship fund, potentially funded by Bellwin, which would allow people to get SIM cards, mobile phones etc to reconnect, email at 11.37 on 16 June 2017 {CLG00008316/2}.
1222) Minutes 15 June 2017 meeting refer simply to DWP “working to provide access to emergency and hardship funds” {CAB00002720/3} paragraph 2(b).
1223) Minutes 16 June 2017 {CAB00002726/4} paragraph 7.
1224) Baldwin {CLG00030437/5} page 5, paragraph 16.
1225) Hammond {CAB00014816/28} page 28, paragraph 72.
1226) Summary Grenfell Fire Response (CCS Internal Lessons) {CAB00000105/1} paragraph 5.
1227) Minutes 17 June 2017 {CAB00002735/5} paragraph 12(c); Khan {MOL00000189/14-15} pages 14-15, paragraph 60.
1228) Khan {MOL00000189/14-15} pages 14-15, paragraph 60.
1229) Actions 17 June 2017 {CAB00001248/2} Actions 9 and 11.
1230) Email at 14.49 on 18 June 2017 {CAB00005286/1}. See also email at 14.29 on 18 June 2017 {CLG00005376/1}; email at 14.55 on 18 June 2017 {CAB00005286/1}; emails at 14.10, 14.33 and 17.50 on 18 June 2017 {CLG00005468/1-3}.
1231) Baldwin {CLG00030437/8-9} pages 8-9, paragraph 28.
1232) Baldwin {CLG00030437/8-9} pages 8-9, paragraph 28.
1233) Email at 01.01 on 19 June 2017 {CLG00009178/2}.
1234) Baldwin {CLG00030437/9} page 9, paragraph 29. By lunchtime on 19 June, £202,000 of discretionary support had been provided, Baldwin {CLG00030437/10} page 10, paragraph 31.
1235) Email at 01.01 on 19 June 2017 {CLG00009178/2}.
1236) Baldwin {CLG00030437/10} page 10, paragraph 32.
1237) See paragraph 91.64.
1238) Baldwin {CLG00030437/10} page 10, paragraph 32.
1239) Actions 19 June 2017 {CAB00002739/1} Action 4.
1240) CRIP 9 {CAB00002403/4} Minutes 20 June 2017 {CAB00002792/3} paragraph 9: “63 (out of approximately 125) payments of £5,000 had been paid to households”.
1241) Grenfell Tower tragedy - Lessons for the Central Response {CAB00014768/3} paragraph 12; Summary Grenfell Fire Response (CCS Internal Lessons) {CAB00000105/1} paragraph 5.
1242) These included the Westminster terrorist attack on 22 March 2017, the Manchester Arena bombing on 22 May 2017, the London Bridge terrorist attack on 3 June 2017, and the General Election on 8 June 2017 (including the run-up to it), Mason {CLG00030435/4} page 4, paragraph 11.
1243) Email at 20.26 on 20 June 2017 {CAB00012068/2}.
1244) Email at 08.48 on 19 June 2017 {CAB00002960/1}; On 14 June 2017, Dame Melanie had told Sir Jeremy Heywood that “at some point we may need to reflect on the impact of cuts to the civil service (DCLG will be less than 50% of its 2010 size by 2020)”, email at 20.00 on 15 June 2017 {CLG10009757/2}.
1245) Whitehouse {CAB00014782/14} page 14, paragraph 35.
1246) Minutes 14 June 2017 {CAB00002714}; Dawes {CLG00030653/36} page 36, paragraph 118.
1247) Dawes {Day285/98:13}-{Day285/100:9}.
1248) Dawes {Day285/98:13}-{Day285/100:9}.
1249) Tallantire {CAB00014769/5} page 5, paragraph 18.
1250) Hammond {Day281/73:18-22}.
1251) Summary Grenfell Fire Response (CCS Internal Lessons) {CAB00000105/1} paragraph 5; Hammond {Day281/201:1-18}.
1252) Email at 23.19 on 17 June 2017 {CAB00003152/1}.
1253) Email at 23.19 on 17 June 2017 {CAB00003152/1}.
1254) Email at 15.50 on 16 June 2017 {CAB00002898/1}.
1255) Email at 09.22 on 16.06.17 {CAB00001150/1}; Hammond {Day281/166:7-10}.
1256) Email at 18.03 on 17 June 2017 {RBK00038856/1-3}.
1257) Emails from 17.26 to 20.04 on 18 June 2017 {CAB00006308}.
1258) Emails from 16.11 to 19.24 on 17 June 2017 {CLG00005331}.
1259) Email at 17.24 on 18 June 2017 {CAB00005730}.
1260) Gratton {CAB00014853/29} page 29, paragraph 79. See also {CLG00005565/1-2}.
1261) Email at 10.16 on 19 June 2017 {CLG00009261}.
1262) Email at 13.27 on 19 June 2017 {CAB00005619}. See also email at 15.28 on 19 June 2017 {CAB00005564/1}; emails at 09.29 and 09.37 on 21 June 2017 {CAB00005909/1}.
1263) Emails from 14.02 to 14.15 on 19 June 2017 {CLG00005583/1-2}. See also email at 17.05 on 19 June 2017 {CLG00005667/2-3}.
1264) Minutes 19 June 2017 {CAB00002741/3-4} paragraph 7.
1265) Email at 18.06 on 19 June 2017 {CAB00006017/1}; email at 22.57 on 18 June 2017 {CAB00006311/1}.
1266) The principle of subsidiarity, by which decisions should be taken at the lowest appropriate level with co-ordination at the highest necessary level, is outlined in Chapter 99.
1267) {CAB00014768}; Tallantire {CAB00014830/9} page 9, paragraph 27.6.
1268) {CAB00014827}; Hammond {Day281/205:15-18}.
1269) {CAB00014827}.
1270) Email at 15.47 on 20 June 2017 {CAB00001178/2}.
1271) Email at 19.31 on 20 June 2017 {CAB00001178/1}.
1272) {CAB00014827}.
1273) {CAB00014827}.
1274) Dawes {Day285/214:15}-{Day285/215:8}.
1275) Farrar {Day284/100:7}-{Day284/102:20}.
1276) Farrar {Day284/107:21}-{Day284/109:17}.
1277) Key points from the discussion between Peter Tallantire and No.10 {CAB00014827}.
1278) Farrar {Day284/107:21}-{Day284/109:17}.
1279) Hammond {Day280/94:2-18}. Dr Farrar accepted that an order under section 5 has to be made by a statutory instrument, subject to the affirmative resolution procedure and, as such, would have taken considerable time to implement, Farrar {Day284/146:7}-{Day284/148:12}. Sections 5(1) and 7 of the Act {CAB00004616/7-10}. Ministerial Intervention under Part 1 of the Act is outlined in Chapter 99.
1280) Sections 19-31 of the Act {CAB00004616/20-28}. Emergency Powers are outlined in Chapter 99.
1281) Email at 08.25 on 19 June 2017 {CAB00002960/2-3}.
1282) Email at 08.40 on 19 June 2017 {CAB00002960/1-2}.
1283) Email at 08.47 on 19 June 2017 {CAB00002960/1}.
1284) Email at 18.42 on 19 June 2017 {CAB00002897/1}.
1285) Hammond {Day281/168:7-22}.
1286) Email at 07.37 on 17 July 2017 {CAB00002910/1}.
1287) Workstream 4 of the National Security Capability Review dated 28 September 2017 {CAB00007084/10} paragraph 32.
1288) Hammond {CAB00014816/8} page 8, paragraph 17.
1289) On 16 June 2017 Action 11 on the Actions List starts “COBR agreed…” {CAB00002727/2}; at 07.08 on 20 June 2017 Lorna Gratton refers to “COBR” in an internal No.10 email {CAB00005733/1}. Further, the Civil Contingencies Secretariat’s Summary “Grenfell Fire Response (Civil Contingencies Secretariat Internal Lessons) asserted that COBR was activated on 14 June 2017 and ran until 25 July, when the Ministerial Recovery Group met for the first time, {CAB00000105/1}.
1290) Hammond {Day281/105:9-11}.
1291) Hammond {Day281/105:17-23}.
1292) Email at 20.26 on 16 June 2017 {CAB00002932/1}; email at 23.47 on 17 June 2017 {CAB00002980/1-2}.
1293) Hammond {Day281/115:23}-{Day281/116:8}; Hammond {Day281/125:12-13}.
1294) Hammond {Day281/202:16-22}.
1295) Hammond {Day280/207:17-19}.
1296) Hurd {Day282/126:4-10}.
1297) ConOps {CAB00000026/45} paragraph 4.2(iv).
1298) By a Secretary of State.
1299) Dawes {CLG00030653/36} page 36, paragraph 119.
1300) Whitehead {CAB00014857/4} page 4, paragraph 15.
1301) Email at 19.49 on 16 June 2017 {CLG00008533}.
1302) See above at Chapter 101.
1303) RBKC Contingency Management Plan {RBK00004396/33}.
1304) RBKC Contingency Management Plan {RBK00004396/30} page 30, paragraph 4.1.
1305) RBKC Contingency Management Plan {RBK00004396/31-37}.
1306) Phase 1 Report, Volume II, paragraph 14.272.
1307) Emergency Event Log Sheet for Grenfell {RBK00013296/1}.
1308) Emergency Event Log Sheet for Grenfell {RBK00013296/1}.
1309) Kerry {Day268/187:4-17}.
1310) Kerry {Day268/189:19-24}.
1311) Kerry {Day268/190:15-20}.
1312) Kerry {Day268/190:15}-{Day268/192:5}; RBKC Contingency Management Plan {RBK00004396/33}: A level 2 response requires the Duty Silver to become the controller, working from home. The Department and Service management are called out to respond. A level 3 response requires the Duty Silver to remain at home acting as controller until the Borough Emergency Control Centre (BECC) is opened and staffed.
1313) Kerry {Day268/192:6-25}.
1314) The role of the Borough Emergency Control Centre (BECC) is to oversee and co-ordinate the council’s incident response Kerry {RBK00033579/8} page 8, paragraph 29.
1315) Kerry {Day268/195:10-24}.
1316) Emergency log sheet for Grenfell {RBK00013296/1}.
1317) Laura Johnson {RBK00035592/5} page 5, paragraph 15.
1318) {RBK00001606}.
1319) Kerry {Day268/136:12-17}.
1320) Kerry {Day268/132:2-18}.
1321) Priestley {RBK00035672/4} page 4, paragraph 14.
1322) Priestley {RBK00035672/4} page 4, paragraph 15.
1323) Priestley {Day270/15:19-25}.
1324) Emergency event log sheet {RBK00013296/4}.
1325) Emergency event log sheet {RBK00013296/5}.
1326) Emergency event log sheet {RBK00013296/7}.
1327) Kerry {Day268/208:2-9}.
1328) Priestley {Day270/16:18-21}.
1329) Priestley {Day270/19:7-11}; {RBK00035661}.
1330) Priestley {Day270/17:23}-{Day270/19:6}.
1331) Kerry {Day269/14:5-10}.
1332) Blackburn {Day270/127:22}-{Day270/128:18}.
1333) Blackburn {Day270/140:9-15}.
1334) Holgate {RBK00035426/4} page 4, paragraph 19.
1335) Holgate {RBK00035426/4} page 4, paragraph 19; Holgate {Day273/48:10-11}.
1336) Mr Kerry and Mr Priestley attended as RBKC’s representatives. Minutes of the Strategic Coordinating Group Meeting at 05.00 on 14 June 2017 {MOL00000026/3}.
1337) Holgate {Day273/55:14}-{Day273/56:9}; Kerry {Day269/51:12}-{Day269/52:7}.
1338) Hetherington {Day277/189:8-14}.
1339) Priestley {Day270/22: 9}-{Day 270/24:20}.
1340) Kerry Emergency Event Log 10.00 {RBK00013296/10}; Kerry {Day269/99:15}-{Day269/100:3}.
1341) Kerry Emergency Event Log 10.00 {RBK00013296/10}; Kerry {Day269/99:15}-{Day269/100:3}.
1342) Kerry {Day269/100:4-9}.
1343) Kerry {Day269/100:10-24}.
1344) Kerry {Day269/104:24}-{Day269/105:4}.
1345) Priestley Log {RBK00013318/2}.
1346) Holgate {Day273/69:7-12}.
1347) Holgate {Day273/66:14-19}.
1348) Holgate {Day273/67:6-9}.
1349) Holgate {Day273/72:9-18}.
1350) RBKC Gold group meeting at 11.00 on 14 June 2017 {RBK00013271/4}; and 10.00 on 15 June 2017. {RBK00013270/3}.
1351) Blackburn {Day270/179:22}-{Day270/180:17}.
1352) Blackburn {Day270/181:6-8}.
1353) Blackburn {Day270/181:5}.
1354) Blackburn {Day270/180:7-11}.
1355) Blackburn {Day270/181:6-8}.
1356) Blackburn {Day270/138:4-20}; RBKC Module 4 Closing Submissions {RBK00068546/11} page 11, paragraph 30.
1357) Kerry {Day269/23:22}-{Day269/26:6}.
1358) Blackburn {RBK00058170/14} page 14, paragraph 9.10.
1359) Kerry {Day269/22:7-18}.
1360) Blackburn {RBK00058170/14} page 14, paragraph 9.8; Blackburn {Day270/155:4-19}.
1361) {RBK00004396/31}.
1362) Priestley {Day270/34:20}-{Day270/35:1}; {Day270/35:22}-{Day270/36:10}; Kerry {Day269/62:2-13}.
1363) Kerry {Day269/22:20}-{Day269/23:4}.
1364) Sawyer {GOL00001349/14} page 14, paragraph 70; Kerry {Day269/170:5-14}.
1365) Laura Johnson {Day272/46:6-13}.
1366) Kerry {Day269/63:21}-{Day269/64:16}; Priestley {Day270/40:13}-{Day270/41:4}.
1367) Priestley {RBK00035672/3} page 3, paragraph 11; Priestley {Day270/7:11-20}; {Day270/11:11-13}; {Day270/12:8-14}.
1368) Priestley {Day270/71:4-14}.
1369) Priestley {Day270/72:4}-{Day270/73:16}; Blackburn {Day270/173:6-14}.
1370) Kerry {Day268/59:2-5}.
1371) The circumstances in which he attended RBKC are examined in Chapter 102 when considering the London-wide response.
1372) Email from Mr Sawyer to himself on 1 July 2017 {GOL00001301} paragraph 6.
1373) RBKC BECC Situation Report No.1, 16 June 2017 {RBK00015017}.
1374) {RBK00029019/2} page 2, paragraph 3; Blackburn {Day270/138:1}-{Day270/139:19}.
1375) RBKC Gold Group meeting on 15 June 2017 at 10.00 {RBK00013270} and at 15.30 {RBK00013262}; Sawyer {GOL00001349/14-15} pages 14-15, paragraphs 69-76.
1376) {GOL00001301} paragraph 2.
1377) Sawyer {GOL00001349/14-15} pages 14-15, paragraph 73.
1378) {GOL00001301} paragraph 3.
1379) London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/4} page 4, paragraph 1.1.
1380) London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/20} page 20, table 3.
1381) London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/24} page 24, paragraph 8.15: “The decision to set up a rest centre will be made by the Local Authority often at the request of the police or fire brigade.”
1382) Contingency Management Plan, Emergency Shelter and Rest Centre Directory, Annex 15 {RBK00048005}.
1383) David Kerry’s Emergency Log {RBK00028849/1}.
1384) {CAB00003753}; {LFB00119615}.
1385) Spragg {Day280/23:10-18}.
1386) Memorandum of Understanding between the British Red Cross and RBKC, 27 November 2015 {BRC00000055}; It had lapsed at the time of the Grenfell Tower fire but the British Red Cross confirmed that that would have made no difference to their attendance, Spragg {Day280/13:24}-{Day280/14:2}.
1387) British Red Cross Emergency Log {BRC00000051/4}.
1388) British Red Cross Emergency Log {BRC00000051/4}.
1389) Kerry {Day269/46:21}-{Day269/47:2}.
1390) Spragg {Day280/23:7-13}.
1391) Kerry {Day268/89:2-25}.
1392) Kerry {Day268/91:7-11}.
1393) Wesley Ignacio {IWS00001820/15} page 15, paragraph 78.
1394) Layton {RBK00029034/6} page 6, paragraph 17; Kerry {RBK00033579/15} page 15, paragraph 58.
1395) British Red Cross Emergency Log {BRC00000051/4}.
1396) Warrier {TMO00887108/2} page 2, paragraph 6.
1397) British Red Cross Emergency Log {BRC00000051/4-6}. See entries 05.30, 06.45, 07.40, 08.15, 09.15, 10.30.
1398) Simms {CFV00000005/2} page 2, paragraphs 7 and 9.
1399) Simms {CFV00000005/4-6} pages 4-6, paragraphs 19-20, 28; William Thompson {IWS00000158/10} page 10, paragraph 60; Toyoshima-Lewis {IWS00001725/46} page 46, paragraph 154.
1400) British Red Cross Emergency Log {BRC00000051/5}.
1401) British Red Cross Emergency Log {BRC00000051/6}; Spragg {Day280/31:22-24}; Stuart Priestley’s Log 14 June 2017 {RBK00013318/3}.
1402) The operation of spontaneous rest centres run by voluntary and community groups is examined in Chapter 106.
1403) Benjamin {IWS00001764/10} page 10, paragraph 69; Senate Jones {IWS00001691/2} page 2, paragraphs 5-6; Wesley Ignacio {IWS00001820/14} page 14, paragraph 75.
1404) Spragg {Day280/16:11-15}.
1405) Adamson {BRC00000075/27} page 27, paragraph 124.
1406) The work of the TMO in compiling lists of the ‘missing’ and ‘survivors’, including the significant errors that occurred, is examined in Chapter 105.
1407) British Red Cross Emergency log, 04.55{BRC00000051/4}.
1408) Richards {CFV00000012/13} page 13, paragraph 89.
1409) Rupinder Hardy’s Personal Briefing Document {LBE00000056/2} 17-18 June 2017: “All documentation was paper based in terms of residents/staff/volunteers on site”.
1410) Kerry {Day269/189:1-6}.
1411) Omar Ali {IWS00001533/12} page 12, paragraph 59.
1412) Colin Brown {BRC00000005/25} page 25, paragraph 100.
1413) Adamson {BRC00000075/21} page 21, paragraph 99.
1414) Adamson {BRC00000075/21} page 21, paragraph 98.
1415) Blackburn {RBK00035364/4} page 4, paragraph 19; Blackburn {Day270/139:11-24}.
1416) Blackburn {RBK00035364/5} page 5, paragraph 22.
1417) Laura Johnson {RBK00035592/8} page 8, paragraph 33.
1418) Laura Johnson {Day272/46:24}-{Day272/47:19}.
1419) RBKC Incident Situation Report {RBK00033583/2}.
1420) Laura Johnson {Day272/48:1-11}.
1421) Kerry {RBK00033579/17} page 17, paragraph 78; Blackburn {RBK00035364/11} page 11, paragraph 52.
1422) Blackburn {RBK00035364/5} page 5, paragraph 22; Blackburn {Day270/153:3-10}.
1423) Priestley {Day270/47:10-20}.
1424) Minutes of the SCG meeting at 06.30 on 14 June 2017 {MOL00000015/2} page 2, paragraph 3.5.
1425) Spragg {Day280/32:5-13}.
1426) Alison Norman {CFV00000061/1-2} pages 1-2, paragraphs 2a-2b.
1427) Norman {CFV00000061/5} page 5, paragraphs 3a-3c; Priestley {RBK00035672/8-9} pages 8-9, paragraph 39.
1428) RBKC Gold Meeting Minutes, 14 June 2017 at 15.00 {RBK00013272/2}.
1429) RBKC Gold Meeting Minutes, 14 June 2017 at 15.00 {RBK00013272/2}.
1430) Priestley {RBK00035672/9} page 9, paragraph 39: “It was a challenge to communicate with the many number [sic] of rest centres which had established themselves that residents who required Council support and overnight accommodation should be encouraged to attend the Sports Centre.” Spragg {BRC00000050/14} page 14, paragraph 61; Spragg {Day280/81:8-17}.
1431) Daffarn {IWS00002109/124} page 124, paragraph 384.
1432) Hirsi {IWS00001776/4} page 4, paragraph 11.
1433) Blanchflower {CFV00000045/9} page 9, paragraph 36; Hardy {Day276/8:22-24}; Cesar Ranito {IWS00001249/7-8} pages 7-8, paragraph 37.
1434) Girma {IWS00001732/12} page 12, paragraph 23; Eleanor Kelly {GOL00001730/8} page 8, paragraph 19; Hardy {LBE00000025/6} page 6, paragraph 35; {LBE00000025/9} page 9, paragraph 42: “The initial appearance of the Rest Centre was like that of a cordoned off crime scene rather than a welcoming place where bereaved, survivors and residents would want to come for help”.
1435) Al-Karad {IWS00001541/23} page 23, paragraph 113.
1436) Antonio Roncolato {IWS00001774/19} page 19, paragraph 109.
1437) Jenny Dainton {IWS00001804/24} page 24, paragraph 152.
1438) Alison Norman {CFV00000061/7} page 7, paragraph 4g; Belfassi {IWS00001802/6} page 6, paragraph 36; Hoang Khanh Quang {IWS00001821/11} page 11, paragraph 51; Maria Jafari {IWS00001815/14} page 14, paragraph 64; Email from Maureen Mandirahwe (WCC) to RBKC BECC at 21.08 on 17 June 2017 {RBK00005386/1}.
1439) Spragg {BRC00000050/18} page 18, paragraph 78 (b).
1440) Hardy {LBE00000025/18} page 18, paragraph 96.
1441) Mussilhy {IWS00001783/8} page 8, paragraph 31; Kuchar {RBK00035291/5} page 5, paragraph 19: “I remember being advised on the walk there to put our ID badges away.”.
1442) Nicholas Austin {RBK00035340/5} page 5, paragraphs 17-18: “I volunteered to go down there [Rugby Portobello Trust] as a senior manager… I arrived there around 6.30pm. I was there until it closed. I had received no formal training in setting up or managing rest centres.” RBKC Gold Group meeting on 15 June 2017 at 15.30 {RBK00013262/3}: “NA said the WSC needs a Senior Manager and a Rest Centre Manager. BECC working on a rota for Rest Centre Manager. Senior officers thin on ground but will think about this”.
1443) {LBE00000014/1}.
1444) Kerry {RBK00033579/19} page 19, paragraph 84. Minutes of the SCG meeting at 19.30 on 14 June 2017 {LFB00119322/3}: “David Kerry confirmed that identification tabards were being delivered to Rest Centres for their staff”.
1445) Health Response Group Meeting, 18 June 2017 at 14.00, {RBK00035310/3}. Email from Ann Ramage, Head of Environmental Health for commercial services of RBKC and LBHF, updating on the Westway Centre on 17 June 2017 {RBK00005539}.
1446) Hardy {Day276/3:14}-{Day276/4:4}; Hardy {LBE00000025/7} page 7, paragraph 39; Email from Rupinder Hardy at 09.36 on 17 June 2017 {LBE00000004}.
1447) Hardy {Day276/114:22}-{Day276/115:5}.
1448) Hardy {Day276/14:2}-{Day276/16:15}.
1449) Hardy {LBE00000025/11} page 11, paragraph 57.
1450) Hardy {LBE00000025/10} page 10, paragraphs 45-46; Email from Eleanor Kelly {GOL00000372} attaching notes of the meeting between John Barradell, Eleanor Kelly and Rupinder Hardy on 17 June 2017 {LBE00000055}.
1451) Hardy {LBE00000025/10} page 10, paragraph 48; Paul Najsarek was the Chief Executive of the London Borough of Ealing. Hardy {Day276/53:12-21}: 40 members of staff deployed from Ealing. Hardy {LBE00000025/14} page 14, paragraph 73: “The number of staff deployed by Ealing, in the region of 197 officers from the 17-22 June 2017”.
1452) Hardy {LBE00000025/19} page 19, paragraph 98.
1453) Hardy {Day276/77:3}-{Day276/78:3}; Rupinder Hardy’s photographs taken during her deployment as LALO at the Rest Centre {LBE00000051}.
1454) Email at 15.19 on 20 June 2017 from Sarah Mail (WCC) to RBKC, {RBK00012356/1} page 1, paragraph 1; {CLG00021227}.
1455) Richards {Day275/151:9-21}.
1456) Richards {Day275/151:2-8}.
1457) Hardy {Day276/83:19}-{Day276/84:15}.
1458) Community Impact Assessment {RBK00005288/14}.
1459) Spragg {Day280/33:9-14}.
1460) Minutes of the HASG meeting at 14.00 on 15 June 2017 {RBK00020525/1} unnumbered paragraph 7: “The Council’s efforts are at Westway as a council-run rest centre. Other informal rest centre’s (sic) may continue but they will not be resourced with Council services”.
1461) Email from Nicholas Holgate to RBKC colleagues at 11.01 on 16 June 2017 {RBK00009876}.
1462) Email from Lady Borwick, former MP for Kensington, at 17.39 on 18 June 2017 {CLG00009154/2}.
1463) Email from Mark O’Donoghue to RBKC {RBK00003251}.
1464) Long {CFV00000010/6-7} pages 6-7, paragraph 32.
1465) Long {CFV00000010/7} page 7, paragraph 32.
1466) Local authorities have an initial duty to provide accommodation for all persons who are homeless and eligible for assistance, (Housing Act 1996, sections 188 and 189(1) Part 7); RBKC Housing Contingency Plan, {RBK00035406/7-8} pages 7-8, paragraphs 2.1.2 and 2.2. {RBK00002747}.
1467) Laura Johnson {Day272/7:6}-{Day272/9:25; {Day272/10:13}-{Day272/11:3}.
1468) {RBK00035406/5} paragraph 1.2.
1469) RBKC Housing Risk Register, November 2016 {RBK00036587}.
1470) Laura Johnson {Day272/18:21}-{Day272/19:17}.
1471) Laura Johnson {Day272/21:25}- {Day272/22:4}; {Day272/60:6-23}.
1472) Stuart Priestley, RBKC Chief Community Safety Officer, Log – Wednesday 14 June 2017 {RBK00013318}.
1473) Laura Johnson {Day272/55:7-19}.
1474) Laura Johnson {Day272/63:17-24}.
1475) Laura Johnson {Day272/113:3-25}.
1476) Laura Johnson {Day272/113:6-9}.
1477) Laura Johnson {Day272/113:22-25}.
1478) Laura Johnson {Day272/112:11-21}.
1479) Project Athena Report {RBK00028618/74-82} pages 74-82, paragraphs 18.8 and 20.8.
1480) This included approximately 845 residents from Hurstway Walk, Barandon Walk, Testerton Walk, Grenfell Walk and Treadgold House {TMO00869977}; Teresa Brown {TMO00894124/17} page 17, paragraph 60; Police Cordon Slideshow {MET00080826}.
1481) Laura Johnson {RBK00035592/13} page 13, paragraph 49
1482) {RBK00018898/1}.
1483) {RBK00018898/1}.
1484) {RBK00031298/2}.
1485) Laura Johnson {Day272/76:8-16}; {Day272/82:6}-{Day272/83:15}; Shawo {IWS00001290/3} page 3, paragraph 20.
1486) {RBK00012043/5}: George Edwards was evacuated from a nearby building and was suitable for temporary accommodation but was turned away by the housing officer and told that “if it was determined that nearby evacuees were to be considered for housing he could return”.
1487) {RBK00031298/2}.
1488) {RBK00031298/1}.
1489) {RBK00027735}; Laura Johnson {RBK00035592/12} page 12, paragraph 47.
1490) Laura Johnson {RBK00035592/12} page 12, paragraph 47.
1491) {TMO10036665} Column J, row 114, row 123 and row 390; {RBK00029413}, row 228.
1492) Laura Johnson {Day272/94:6-13}; RBKC Opening Statement, {Day263/120:5-13}.
1493) Laura Johnson {Day272/43:12-23}.
1494) RBKC Opening Statement, {Day263/120:9}.
1495) Laura Johnson {Day272/74:22}-{Day272/75:16}; {RBK00031298}.
1496) Email from Judith Blakeman to Laura Johnson on 18 June 2017 {RBK00027966}, paragraphs 1 and 3; Email from TMO to RBKC regarding 11 households in need of accommodation as “there’s debris from the fire on elevations” at 16.27 on 16 June 2017 {RBK00049529}; Email from Councillor Lasharie at 00.42 on 15 June 2017 {RBK00003049}; Email from Councillor Lasharie at 16.15 on 15 June 2017 {RBK00003071}.
1497) Teresa Brown {TMO00869990/9} page 9, paragraph 45; TMO staff also notified RBKC’s Allocation Team about the need to re-house those with balconies overlooking Grenfell Tower, to avoid further trauma. Teresa Brown {TMO00869990/11} page 11, paragraph 57.
1498) RBKC Gold Group Meeting Minutes at 10.00 on 16 June 2017 {RBK00001862/2}.
1499) Laura Johnson {Day272/120:19}-{Day272/121:24}; Abdulhamid {IWS00001919/3} page 3, paragraph 16; Alison Moses {IWS00001281/9} page 9, paragraph 47. This was a requirement identified in the RBKC Housing Contingency Plan at Annex 2 {RBK00035406/19}.
1500) {RBK00002735/2}; Sadafi {IWS00001806/23} page 23, paragraph 73; Lukic {IWS00001760/6} page 6, paragraph 24.
1501) {RBK00013271/2}.
1502) Gold Group Meeting Minutes at 10.00 on 15 June 2017 {RBK00013270}.
1503) ‘Grenfell Residents Action Plan 15 June 2017: Short Term’ {RBK00027735}.
1504) Laura Johnson {Day272/68:2-8}; {Day272/69:25}-{Day272/70:4}; El-Guenuni {IWS00002034/9} page 9, paragraph 34; Sadafi {IWS00001806/23} page 23, paragraph 73. See Chapter 2.3.4 Length of Hotel Placements in Chapter 2.
1505) Laura Johnson {RBK00035592/23} page 23, paragraph 84; Laura Johnson {Day272/56:5-11}.
1506) Laura Johnson {Day272/58:10-22}; Laura Johnson {RBK00035592/24} page 24, paragraph 87.
1507) Email from Chris Scott (RBKC Housing) at 08.19 on 21 June 2017 {RBK00012306}.
1508) {RBK00036274/2}; The agreement had been reached in early 2016 in the wake of the Adair Tower fire the previous October.
1509) Redmond {Day271/89:19}-{Day271/90:20}.
1510) David Lewis {IWS00001629/5} page 5, paragraph 21-23; Rasoul {IWS00001768/22} page 22, paragraph 107; Oyewole {IWS00001730/10} page 10, paragraph 17-19; Alison Moses {IWS00001281/10} page 10, paragraph 54.
1511) Khoudair {IWS00001616/11-12} pages 11-12, paragraph 81-88; Jason Miller {IWS00001940/9} page 9, paragraph 37; Zakariya Chebiouni {IWS00001979/5} page 5, paragraph 24; Mensah {IWS00001944/9} page 9, paragraph 43; Ryan Ignacio {IWS00001820/14} page 14, paragraph 70.
1512) RBKC email at 17.53 on 18 June 2017, “1 gentleman put on 14th floor of hotel – needs moving” {RBK00039300}; Email from Maureen Mandirahwe (WCC) to RBKC BECC at 21.08 on 17 June 2017, “Complaints of traumatised persons being housed in a second floor hotel/tower, when they had vocalised from the onset that they cannot cope with living in a tower. They were moved to other towers 3 times. He came to us very angry and traumatised.” {RBK00005386/2}; Emma O’Connor {IWS00001699/6} page 6, paragraph 33.
1513) Laura Johnson {Day272/118:25}-{Day272/119:15}; {Day272/132:5-20}.
1514) Laura Johnson {Day272/22:14}-{Day272/23:1}.
1515) Laura Johnson {Day272/170:4-25}.
1516) Sener Macit {IWS00001563/12} page 12, paragraph 52; Bernard Shaw {IWS00001752/8} page 8, paragraph 39; Karema El-Sawy {IWS00001829/7} page 7, paragraph 31.
1517) Shawo {IWS00001290/4} page 4, paragraph 25; David Lewis {IWS00001629/6} page 6, paragraph 25; Ahmed Al-Assad {IWS00001789/11} page 11, paragraph 67; Araya {IWS00001648/4} page 4, paragraph 20; Rasoul {Day265/159:13-23}.
1518) Samuel Daniels {IWS00002065/15} page 15, paragraph 99.
1519) Emergency Response and Recovery non-statutory guidance, {CAB00004519/119} page 119, paragraph 7.3.2.; LRP. Humanitarian Assistance Plan v3, {GOL00001151/27} page 27, paragraph 7.12-7.14; RBKC Contingency Management Plan {RBK00004396/17}.
1520) Belfassi {IWS00001802/7} page 7, paragraph 40. Moussaid {IWS00001282/14} page 14, paragraphs 68-69.
1521) Richards {CFV00000012/2-6} pages 2-6, paragraphs 7, 11, 20, 22 and 41; Ahmed Chellat {IWS00001306/1} page 1, paragraph 6; Ghamhi {IWS00001706/4} page 4, paragraph 23; Simms {CFV00000005/17} page 17, paragraph 78; Hariri {IWS00001295/14} page 14, paragraph 106.
1522) Richards {Day275/147:11-16}.
1523) Laura Johnson {Day272/132:1-4}.
1524) Richards {CFV00000012/3} page 3, paragraph 14.
1525) Laura Johnson {Day272/132:5-15}.
1526) El Amine {IWS00001946/10-11} pages 10-11, paragraph 46; El-Ogbani {Day266/23:20}-{Day266/24:5}; Sawson Choucair {IWS00001799/15-16} pages 15-16, paragraph 20(c).
1527) Senate Jones {IWS00001691/5} page 5, paragraph 24.
1528) Maria Jafari {IWS00001815/13} page 13, paragraph 56.
1529) London Resilience Partnership Humanitarian Assistance Framework, {RBK00011313/42}. “Local Authorities: May provide financial assistance”.
1530) Laura Johnson {Day272/143:16-19}.
1531) {RBK00012261}.
1532) {RBK00006091}; {TMO10031177/3}.
1533) {RBK00027735}.
1534) {RBK00020131}.
1535) Amanda Gill {RBK00044877/8} page 8, paragraph 46; {RBK00047576}; Laura Johnson {Day272/143:14}–{Day272/145:5}.
1536) Laura Johnson {Day272/143:22}-{Day272/144:1}
1537) {CAB00014720}.
1538) {RBK00020131}.
1539) Hardy {Day276/87:4}-{Day276/88:15}.
1540) {RBK00026735}.
1541) Adamson {BRC00000075/15} page 15, paragraph 68.
1542) Augustine {RBK00035411/6} page 6, paragraph 29.
1543) Augustine {RBK00035411/6} page 6, paragraph 30.
1544) Laura Johnson {Day272/149:2-9}.
1545) Laura Johnson {Day272/150:2-12}; Hanan Cherbika {IWS00001286/11} page 11, paragraph 85; Jevon Moses {IWS00001276/16} page 16, paragraph 113; Toyoshima-Lewis {IWS00001725/66} page 66, paragraph 265.
1546) {RBK00004144}.
1547) {RBK00004144}.
1548) {RBK00021897/3}.
1549) Talabi {IWS00001731/7} page 7, paragraph 22; Rosita Bonifacio {IWS00001887/7} page 7, paragraph 47; Aziza Raihani {IWS00001300/4} page 4, paragraph 25.
1550) Abu Baker Mohamed Ibrahim {IWS00001751/5} page 5, paragraphs 17 and 21.
1551) Emergency Response and Recovery, non-statutory guidance accompanying the Civil Contingencies Act 2004 {CAB00004519/122} page 122, paragraph 7.4.2.
1552) London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/24-25} pages 24-25, paragraph 8.17.
1553) London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/25}, page 25, paragraphs 8.20-8.21.
1554) Emergency Response and Recovery, non-statutory guidance accompanying the Civil Contingencies Act 2004 {CAB00004519/122-123} pages 122-123, paragraph 7.4.4.
1555) Clee {CFV00000059/1} page 1, paragraph 1.
1556) Clee {CFV00000059/3-4} pages 3-4, paragraph 2.
1557) Clee {CFV00000059/4} page 4, paragraph 2.
1558) Stokoe {MET00079356/30} page 30, paragraph 4; Clee {CFV00000059/4} page 4, paragraph 2 believed it was closed on 15 June 2017.
1559) Spragg {Day280/54:5-12}.
1560) Spragg {Day280/55:16-22}.
1561) Email from Emma Spragg at 18.19 {RBK00038595/1}: “Friends and family are not always being allowed in as people at Westway believe it to be a rest centre for displaced residents (CAC) and that F and F are to go to the Salvation Army.”
1562) {RBK00038595}.
1563) Nabil Choucair {Day267/10:3-8}; Alison Moses {IWS00001281/11} page 11, paragraph 65; Gashaw {IWS00001738/24} page 24, paragraph 24.
1564) Granville {MET00077845/1-2} pages 1-2, paragraph 4.
1565) Emergency Response and Recovery: non-statutory guidance {CAB00004519/124} page 124, paragraph 7.5.6.
1566) Emergency Response and Recovery: non-statutory guidance {CAB00004519/124} page 124, paragraph 7.5.7.
1567) Granville {MET00077845/8-9} pages 8-9, paragraph 29.
1568) Granville {MET00077845/8} page 8, paragraph 29.
1569) Granville {MET00077845/9} page 9, paragraph 30.
1570) Chalmers {MET00077804/3} page 3, paragraph 11.
1571) {RBK00060585}.
1572) Chalmers {MET00077804/11} page 11, paragraph 51.
1573) Chalmers {MET00077804/6} page 6, paragraph 31.
1574) Chalmers {MET00077804/8-9} pages 8-9, paragraph 40.
1575) Chalmers {MET00077804/9-10} pages 9-10, paragraph 43.
1576) Rajaa Chellat {IWS00001284/2} page 2, paragraph 11.
1577) Nabil Choucair {Day267/14:11-25}.
1578) Spreadsheet: the resident list circulated at 12.21 on 14 June 2017 {TMO00869931}.
1579) Section 2(1)(g) of the Civil Contingencies Act 2004 {CAB00004616/3}; Emergency Preparedness Guidance, Chapter 7 {CAB00004543/3} page 3, paragraph 7.1.
1580) RBKC Opening Statement {Day263/115:12-15}.
1581) Kerry {Day268/43:7-21}.
1582) Fitzgerald {RBK00059598/2} page 2, paragraph 8.
1583) RBKC Module 4 Opening Statement {RBK00068467/25-26} paragraphs 99-100.
1584) RBKC Opening Statement {Day263/115:4-6}.
1585) Fitzpatrick {RBK00059598/3} page 3, paragraph 16. Email from Mark Sawyer to himself on 1 July 2017 {GOL00001301} paragraph 6, “Comms team in denial and overwhelmed. Asked why missed 08.30 comms call - missed amongst two hundred emails”.
1586) Spragg {Day280/68:2-10}; Spragg {BRC00000050/18} page 18, paragraph 78(a).
1587) Spragg {Day280/68:12-17}; Spragg {BRC00000050/18} page 18, paragraph 78(a).
1588) RBKC Opening Statement {Day263/115:17-24}.
1589) Emergency Preparedness, Chapter 7, paragraph 7.58 provides that “immediately when an emergency occurs, and during the first hours, the public would want amongst other things a helpline number” {CAB00004543/28} page 28, paragraph 7.58. It also says that “responders should plan how to make best use of helplines and public inquiry points... in any emergency. ...Helplines may already be in place for other purposes. Plans can be developed to take them over and provide their staff with a relevant briefing or suitable recorded messages” ({CAB00004543/42} page 42, paragraph 7.90-7.91).
1590) {RBK00060585}.
1591) {RBK00060669}.
1592) {RBK00060676}.
1593) Spragg {Day280/72:5-13}.
1594) Spragg {Day280/69:8-20}; SCG Meeting on 14 June 2017 at 08.30 {LFB00003366/4}.
1595) Spragg {Day280/69:21-25}; HASG Meeting Minutes from 15 June 2017 at 14.00 {RBK00001920/4}.
1596) Spragg {Day280/70:10}-{Day280/71:15}; British Red Cross Operational update 9 {BRC00000087/25}.
1597) Email from Sue Redmond on 15 June 2017 {RBK00011415}; Humanitarian Assistance Steering Group Actions and Decisions sheet, 16 June 2017 at 12.00 {RBK00002040/1}; Redmond {Day271/109:10-11}.
1598) Redmond {Day271/111:15-25}; {Day271/112:9-16}; Spragg {Day280/70:10}-{Day280/71:15}.
1599) Gemma Hamilton {BRC00000012/5} page 5, paragraph 20. Leaflets advertising the number were delivered to the Westway Centre.
1600) Email from Tony Andrews to Andrew Meek and RBKC BECC sent on 17 June 2017 at 17.44 {GOL00000982}.
1601) Email from Tony Andrews on 17 June 2017 at 17.28, circulating key points and actions from the Community Assistance Centre Group meeting {RBK00021073}.
1602) {RBK00041515/3}.
1603) {RBK00041515/1}.
1604) {RBK00023810/1}.
1605) {CAB00004519/130} page 130, paragraph 7.7.6.
1606) Spragg {Day280/74:2}-{Day280/75:19}.
1607) Spragg {Day280/75:20}-{Day280/76:8}.
1608) Zakaria El-Sawy {IWS00001822/10} page 10, paragraph 42; Khanh Quang {IWS00001821/15} page 15, paragraph 75-76.
1609) Belfassi {IWS00001815/16} page 16, paragraph 71.
1610) {RBK00004117/1}.
1611) {RBK00038615}.
1612) {RBK00020873/1}.
1613) {RBK00003124/2}.
1614) Spragg {Day280/75:3-8}; {BRC00000087/39}.
1615) {RBK00003124/2}.
1616) {RBK00003124/2}.
1617) Email sent at 10.13 for a website update with details of the rest centre at Rugby Portobello Trust {RBK00060669}; Twitter update at 11.39 with details of rest centre at Rugby Portobello Trust {RBK00060621}; Twitter update at 11.40 with details of rest centre at St Clement Church {RBK00060622}; Twitter update at 11.41 with details of rest centre at the Westway Centre {RBK00060623}; {RBK00060669}.
1618) {RBK00008513}; Also see email from Ann Ramage to Martin Fitzpatrick on 17 June 2017 at 02.29 {RBK00010918/2}
1619) {GOL00000147}.
1620) {RBK00012573}.
1621) {CLG00009134}.
1622) Email from Hilary Patel (the DCLG) to Doug Patterson (London Borough of Bromley) on 20 June 2017 {GOL00000289/1}.
1623) Brady {RBK00059591/2} page 2, paragraph 10.
1624) Brady {RBK00059591/2} page 2, paragraph 10.
1625) London Resilience Partnership Humanitarian Assistance Framework, {RBK00011313/4} paragraph 1.1 and {RBK00019712/9}, paragraph 3.7: Local authorities will prepare to respond to the humanitarian need by: Identifying a senior officer to lead the Humanitarian Response (usually a director with responsibility for adult social care) – hereafter described as the Humanitarian Assistance Lead Officer (HALO).
1626) Kerry {Day268/164:18}-{Day268/168:4}; London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/2}.
1627) Kerry {Day268/168:18-23}.
1628) Redmond {RBK00058120/2} page 2, paragraphs 2.1-2.2.
1629) Redmond {RBK00035676/3} page 3, paragraph 13; Project Athena interview, {RBK00029014/2}, unnumbered ninth paragraph.
1630) Redmond {Day271/24:2}-{Day271/25:5}; {Day271/31:9-16}; Redmond {RBK00035676/8} page 8, paragraph 36.
1631) Redmond {RBK00058120/3} page 3, paragraph 3.3; Redmond {Day271/29:3-5}.
1632) London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/9} page 9, paragraph 3.9.
1633) London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/9} page 9, paragraph 3.10.
1634) London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/9} page 9, paragraphs 3.1, 3.7 and 3.11.
1635) London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/12} page 12, paragraph 4.14. {RBK00019712/48}.
1636) London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/11} paragraph 4.2.
1637) {GOL00001052}.
1638) Andrew Meek {GOL00001166/2} page 2, paragraph 6 at 10.23; Kerry {Day269/120:5}-{Day269/121:16}.
1639) Meek {GOL00001166/5} page 5, paragraph 6 and {GOL00001166/9} page 9, paragraph 12; {GOL00001166/5} page 5, paragraph 6, entry ‘evening’: Andrew Meek drafted a revised Humanitarian Assistance Centre (HAC) Plan during the evening of 17 June 2017 as the Humanitarian Assistance Framework did not contain an HAC plan {RBK00021646}.
1640) {RBK00011312}.
1641) Redmond {RBK00058120/5} page 5, paragraphs 7.2-7.3.
1642) Redmond {RBK00058120/2-3} pages 2-3, paragraphs 3.1-3.4.
1643) Redmond {Day271/70:22}-{Day271/71:9}; Gold Group Meeting Minutes at 10.00 on 15 June 2017 {RBK00013270/3}; Humanitarian Assistance Steering Group Minutes {RBK00001920}.
1644) Redmond {Day271/52:23}-{Day271/53:4}.
1645) Redmond {Day271/73:19-25}; {Day271/76:7-8}.
1646) {LFB00061320/1} page 1, paragraph 4.
1647) {RBK00019929/3}.
1648) Richards {Day275/166:2-6}.
1649) Dedrich {IWS00001275/7} page 7, paragraph 49; Sener Macit {IWS00001563/14} page 14, paragraph 65; Gashaw {IWS00001738/18} page 18, paragraph 20; Wesley Ignacio {IWS00001820/16} page 16, paragraph 85;
1650) Laci {IWS00001831/6} page 6, paragraph 40.
1651) {RBK00011468}; Log of issues, {RBK00014781}.
1652) Proctor {NHS00000002/4} page 4, paragraph 13.
1653) Minutes of the Health Response Group teleconference on 15 June 2017 at 17.00 {RBK00026985/2} page 2, paragraph 2.1.
1654) {RBK00038406}.
1655) {RBK00011424}.
1656) {RBK00011798}.
1657) Bobby Ross {IWS00002356/8} page 8, paragraphs 42 and 45; Diejomaoh {IWS00001303/5-6} pages 5-6, paragraphs 27-28; Hanan Cherbika {Day266/106:1-22}.
1658) Towner {IWS00001705/8} page 8, paragraph 42; Shawo {IWS00001290/4} page 4, paragraph 29.
1659) Deen {IWS00002301/5} page 5, paragraph 35.
1660) Spragg {Day280/47:8-23}; Spragg {BRC00000050/16} page 16, paragraph 71.
1661) Spragg {Day280/48:1-12}.
1662) Pahlavani {IWS00001244/15} page 15, paragraph 46.
1663) Rullo {IWS00001655/10} page 10, paragraph 43.
1664) Alfawaz {IWS00001274/11} page 11, paragraph 85.
1665) Christopher Roncolato {IWS00001786/13} page 13, paragraph 78; Hamza Jones {IWS00001710/5} page 5, paragraph 30.
1666) Norbert {IWS00001252/10} page 10, paragraph 55.
1667) Alison Moses {IWS00001281/11} page 11, paragraph 64; Farhad Neda {IWS00001302/4} page 4, paragraph 20; Wahabi {IWS00001714/15} page 15, paragraph 68.
1668) Harpley {GOL00000441/1} page 1, paragraph 4.
1669) Harpley {GOL00000441/4} page 4, paragraph 13.
1670) See Chapter 102. Adamson {BRC00000075/17} page 17, paragraph 77.
1671) Harpley {GOL00001114/2} page 2, paragraph 3.
1672) Harpley {GOL00001114/2} page 2, paragraph 3.
1673) Redmond {RBK00035676/13} page 13, paragraph 64.
1674) Chamberlain {RBK00035302/14-15} pages 14-15, paragraph 57.
1675) Humanitarian Assistance Guidance Pack {BRC00000008/2}.
1676) {RBK00012323}.
1677) {RBK00009467}.
1678) {RBK00022845}.
1679) {RBK00044499} email from Martin Hinckley WCC to RBKC 13 July 2017 attaching residents without key workers and addressed to Natasha Bishop at the Key Workers Hub {RBK00044500/1}.
1680) {RBK00044500/1}.
1681) Novell {IWS00001288/11} page 11, paragraph 67.
1682) Alan Ali {IWS00001745/8-9} pages 8-9, paragraph 38.
1683) Le-Blanc {IWS00001271/30} page 30, paragraph 284; Khoudair {IWS00001616/14} page 14, paragraph 111; Yousuf {IWS00001626/4} page 4, paragraph 21.
1684) Rashida Ali {IWS00001617/15} page 15, paragraph 185.
1685) London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/6-7} pages 6-7, paragraphs 2.7-2.8.
1686) In an email sent on 17 June 2017 at 16.00 to Ray Brown (RBKC), Rebecca Hennessy (also RBKC) said that she was angry at the lack of leadership and how the situation had been handled by [RBKC]. She felt let down by the council. Those in authority refused to listen to those on the ground and there were no clear communications {RBK00049712}.
1687) TMO Emergency Plan {RBK00057991}.
1688) Brown {Day274/6:16-22}; Black {TMO10048970/2} page 2, paragraph 11.
1689) Black {TMO10048970/2} page 2, paragraph 11; Brown {TMO00869990/2} page 2, paragraphs 6-7.
1690) Black {TMO10048970/3} page 3, paragraph 12.
1691) Black {TMO10048970/1} page 1, paragraph 4; Brown {TMO00869990/2-3} pages 2-3, paragraph 9.
1692) Black {TMO10048970/3} page 3, paragraph 15.
1693) TMO Emergency Plan {RBK00057991/13}.
1694) Black {Day275/8:6-22}; {Day275/14:11-25}.
1695) Brown {Day274/8:20}-{Day274/9:1}.
1696) Black {Day275/15:1-6}.
1697) RBKC Contingency Management Plan {RBK00004396}; Brown {TMO10048970/3} page 3, paragraph 14.
1698) {TMO00840414/2} item 3.
1699) Summary of meeting on 11 April 2016 with Contingency Planning, Housing and TMO to follow-up on the Adair Tower fire {RBK00057975/3}.
1700) Black {Day275/15:7-10}.
1701) Black {Day275/15:11-14}.
1702) Black {Day275/17:21}-{Day275/18:1}.
1703) TMO Emergency Plan {RBK00057991/28}.
1704) Brown {TMO00894124/1} page 1, paragraph 3; Black {Day275/10:23}-{Day275/11:2}.
1705) TMO Emergency Plan {RBK00057991/17}; Brown {Day274/15:8-12}.
1706) Black {Day275/17:14-20}.
1707) Chamchoun {TMO10048972/2} page 2, paragraph 5; Singh {TMO00840373/2} page 2, paragraph 5; Hutchison {TMO10048971/3} page 3, paragraph 17.
1708) Singh {TMO00840373/2} page 2, paragraph 5; Chamchoun {TMO10048972/2} page 2, paragraph 5.
1709) Sharples {TMO10048975/2} page 2, paragraph 17.
1710) Black {Day275/17:6-12}.
1711) Brown {Day274/60:16}-{Day274/61:14}; {Day274/63:21-25}.
1712) Black {Day275/14:5-7}.
1713) Black {Day275/8:6-24}.
1714) Black {TMO00887150/1-2} pages 1-2, paragraph 4.
1715) Black {Day275/19:3}-{Day275/20:20}.
1716) Black {Day275/19:3}-{Day275/20:20}.
1717) Black {Day275/30:3-7}.
1718) Brown {Day274/11:2-16}.
1719) Brown {Day274/11:2-16}.
1720) Brown {Day274/16:7}-{Day274/17:25}.
1721) Brown {Day274/26:13-16}.
1722) Brown {TMO00894124/4} page 4, paragraph 13; Brown {Day274/26:25}-{Day274/27:1-2}.
1723) Brown {Day274/26:25}-{Day274/27:1-2}.
1724) Brown {Day274/27:3}-{Day274/28:5}.
1725) TMO Staff Presence at Rest Centres {TMO00869981}.
1726) Brown {Day274/31:10-14}; {Day274/36:20-22}.
1727) Brown {Day274/31:16-25}.
1728) RBKC Gold Group Meeting {RBK00023239}.
1729) RBKC Gold Group Meeting {RBK00023239/2}.
1730) Brown {TMO00869990/4} page 4, paragraph 18.
1731) Brown {Day274/39:9-23}.
1732) Brown {Day274/39:20}-{Day274/40:3}.
1733) Brown {Day274/40:24}-{Day274/41:7}.
1734) Brown {Day274/42:3-25}.
1735) Brown {TMO00869990/7} page 7, paragraph 36; Brown {Day274/43:10-13}.
1736) Priestley {RBK00035672/8-9} pages 8-9, paragraph 39.
1737) Brown {TMO00894124/13} page 13, paragraph 46.
1738) Brown {Day274/51:23}-{Day274/52:4}.
1739) Brown {TMO00894124/13} page 13, paragraph 47.
1740) Razza {IWS00001607/9} page 9, paragraph 42.
1741) Internal TMO email sent on 19 June 2017 at 11.52 {TMO00870375}.
1742) Internal TMO email sent on 23 June 2017 at 10.22 {TMO10035572}.
1743) Brown {Day274/52:6-20}.
1744) Briefing - Staff Expectations for covering TMO Westway Helpdesk {TMO10036663}.
1745) Brown {TMO00869990/5} page 5, paragraph 23.
1746) Brown {Day274/27:20-24}; Brown {Day274/58:17}-{Day274/59:2}; Email from Kiran Singh (TMO) on 14 June 2017 at 12.21 {TMO00869930} attaching list of safe and missing residents {TMO00869931}.
1747) Brown {TMO00894124/6} page 6, paragraph 20; Brown {Day274/58:9-21}.
1748) Brown {Day274/57:1-20}.
1749) Brown {Day274/57:1-9}.
1750) Brown {Day274/123:8-10}.
1751) Tenancy List {TMO00866006}.
1752) Singh {TMO00894410/2} page 2, paragraph 3c.
1753) Williams {TMO00879804/9} page 9, paragraph 62.
1754) Brown {Day274/68:6-19}.
1755) Brown {Day274/71:12-19}.
1756) Singh {TMO00894410/2} page 2, paragraph 3c.
1757) Email from the Metropolitan Police Service to various agencies regarding updated briefing on the number of fatalities and/or missing people {RBK00018233/2}.
1758) Rasoul {Day265/146:4-19}.
1759) Email correspondence between Robert Shaw (RBKC Housing) and Kiran Singh (TMO) on 17 June 2017 {TMO10035581/4}.
1760) Brown {Day274/72:4-9}.
1761) Brown {TMO00869990/5} page 5, paragraph 23.
1762) Brown {TMO00894124/8} page 8, paragraph 28.
1763) RBKC Gold Group Meeting {RBK00023236/1}.
1764) Luke Towner stated that his partner was contacted by the TMO on 14 June only to confirm that if they escaped, they were not offered any support or a call back at a later date, Towner {IWS00001705/8} page 8, paragraph 41.
1765) Brown {Day274/95:19-25}.
1766) {TMO00869959}.
1767) Moghaddam {IWS00000392/8} page 8, paragraph 42; Patel {IWS00001610/10} page 10, paragraph 49; Ho {IWS00001551/16} page 16, paragraph 62; Gomes {IWS00001734/28} page 28, paragraph 44; Ross {IWS00001826/14-15} pages 14-15, paragraph 69.
1768) Brown {Day274/97:7-15}.
1769) RBKC Log {RBK00028712/1}.
1770) Brown {Day274/29:17-23}.
1771) Brown {TMO00894124/7} page 7, paragraph 24.
1772) {RBK00057991/31}.
1773) Brown {Day274/57:1-20}.
1774) Brown {Day274/60:16}-{Day274/61:14}.
1775) Warrier {TMO10048986/4} page 4, paragraph 18, Ms Warrier was a Neighbourhood Team Leader.
1776) Richards {CFV00000012/13} page 13, paragraph 89.
1777) Richards {CFV00000012/13} page 13, paragraph 89.
1778) Safe and Missing List circulated at 12.21pm {TMO00869931}.
1779) Brown {Day274/80:10-16}.
1780) Brown {Day274/79:1-7}.
1781) Examples of handwritten notes taken by the TMO staff at rest centres {TMO10035210}; {TMO10035236}; {TMO10035242}; {TMO10035218}; Brown {Day274/75:3-10}.
1782) Brown {Day274/81:23}-{Day274/82:6}.
1783) Brown {TMO00894124/6} page 6, paragraph 20.
1784) Safe and Missing List circulated at 12.21pm {TMO00869931}.
1785) Brown {Day274/81:23}-{Day274/82:6}; Singh {TMO00894410/1-2} pages 1-2, paragraph 3a.
1786) Brown {Day274/76:8-15}.
1787) Brown {Day274/79:11-25}.
1788) Safe and Missing List circulated at 12.21pm {TMO00869930}.
1789) {TMO10017313} Row 11: Denis Murphy was marked safe as seen by the yellow highlight.
1790) {TMO10017313} Row 51: Khadija Khalloufi was marked safe as seen by the yellow highlight.
1791) {TMO10017313} Rows 104-107: Faouzia El-Wahabi, Yasin El-Wahabi, Abdulaziz El-Wahabi and Nur Huda El-Wahabi were marked safe as seen by the yellow highlight.
1792) {TMO10017313} Row 136: Saber Neda was marked safe as seen by the yellow highlight.
1793) {TMO10017313} Rows 11 and 51: Denis Murphy and Khadjia Khalloufi were also marked under the ‘missing’ tab as seen by the pink highlights.
1794) Brown {TMO00869990/5} page 5, paragraph 26.
1795) {TMO10017359} Safe and Missing list sent from Kiran Singh to Rob Shaw at RBKC at 13.44 on 14 June 2017. The same inaccurate information is recorded in the ‘SAFE’ tab at Row 11: Denis Murphy, Row 51: Khadija Khalloufi, Row 102: Jessica Urbano Ramirez, Rows 104-107: Faouzia El-Wahabi, Yasin El-Wahabi, Abdulaziz El-Wahabi and Nur Huda El-Wahabi, Row 136: Saber Neda, as seen by the yellow highlights.
1796) {TMO00869982} Kiran Singh circulated Resident List at 17.27 confirming that the Neighbourhood team had rang every resident they had not heard from. Row 11: Denis Murphy, Row 51: Khadija Khalloufi, Rows 104-107: Faouzia El-Wahabi, Yasin El-Wahabi, Abdulaziz El-Wahabi and Nur Huda El-Wahabi, Row 136: Saber Neda, Row 102; Jessica Urbano Ramirez were marked ‘safe’ on that list as seen by the yellow highlights {TMO10017480}; Brown {TMO00869990/6} page 6, paragraph 27; Brown {Day274/89:15}-{Day274/91:5}.
1797) Brown {Day274/84:3-14}.
1798) Brown {Day274/85:18-23}.
1799) Brown {Day 274/83:12-18}.
1800) Handwritten note marking residents as safe or missing in the rest centre {TMO10035210}.
1801) {TMO10017359} Row 102: Jessica Urbano Ramirez marked ‘safe’ as seen by the yellow highlight.
1802) {TMO00869935} Row 102: Jessica Urbano Ramirez marked ‘safe’ as seen by the yellow highlight.
1803) {TMO10017480} Row 102: Jessica Urbano Ramirez marked ‘safe’ as seen by the yellow highlight.
1804) Brown {Day274/59:15-24}.
1805) Black {Day275/105:24}-{Day275/106:5}.
1806) Brown {Day274/85:3-7}.
1807) Black {Day275/107:12-18}.
1808) Black {Day275/119:13}-{Day275/120:10}.
1809) Brown {Day274/61:4-7}.
1810) RBKC Log 9 dated 19 June 2017 {RBK00028712/1}.
1811) Daniels {IWS00002065/11} page 11, paragraphs 73-74; Chiapetto {IWS00001780/1} page 1, paragraph 2; Murphy {IWS00001709/3} page 3, paragraph 12; Wahabi {Day267/102:8-25}-{Day267/103:1-17}. A resident was informed by the TMO that his missing wife was reported as safe at the St Clements Centre. His son received a conflicting report from another TMO officer {RBK00012043}.
1812) {TMO00869977}; Brown {TMO00894124/17} page 17, paragraph 60.
1813) Brown {Day274/97:21}-{Day274/99:3} residents from Bramley house were also evacuated but not for an extended period and so did not require accommodation.
1814) Brown {TMO00894124/19} page 19, paragraph 66; Police Cordon Slideshow {MET00080826}.
1815) Cherbika {Day266/117:1-3}; {Day266/177:19-21}; Moses {IWS00001276/13} page 13, paragraphs 88, 91 and 92; Lopez {IWS00001680/8} page 8, paragraphs 43, 47-48; Procedure Note for Resettlement Packages {RBK00028643}.
1816) Brown {Day274/172:1-25}.
1817) Brown {Day274/102:9-18}.
1818) Brown {Day274/48:25}-{Day274/49:5}; Brown {TMO00869990/6} page 6, paragraph 28.
1819) Pasztor {IWS00001682/4} page 4, paragraph 17 (7-8 months); El-Sawy {IWS00001829/8} page 8, paragraph 34 (9 months); Ollivierre {IWS00001758/6} page 6, paragraph 26 (9 months); Elbouti {IWS00001605/11} page 11, paragraph 50 (10 months);
1820) Black {Day275/64:20}-{Day275/65:4}; RBKC Gold Group Meeting Minutes at 10.00 on 16 June 2017 {TMO10033491/2} paragraph 7.
1821) Brown {Day274/46:2-6}.
1822) {TMO00869925}.
1823) {TMO00869977}.
1824) Brown {Day274/104:14-19}.
1825) Brown {Day274/104:24}-{Day274/105:3}.
1826) Brown {Day274/105:17-21}.
1827) Brown {Day274/107:10}-Day274/108:2}.
1828) {TMO10033708}.
1829) {TMO00869945}.
1830) Black {Day274/64:10-15}.
1831) Brown {TMO00894124/11} page 11, paragraph 38; Brown {TMO00894124/9} page 9, paragraph 31.
1832) Brown {TMO00894124/9} page 9, paragraph 31.
1833) Brown {Day274/112:3-19}.
1834) Brown {Day274/112:13-25}-{Day274/113:1-16}.
1835) Belfassi {IWS00001802/6} page 6, paragraph 35.
1836) Moses {IWS00001276/14} page 14, paragraph 97; Cherbika {Day 266/87:12-25}.
1837) Brown {Day274/113:17}-{Day274/114:3}.
1838) Brown {Day274/114:4-9} it was not used until 16 June 2017.
1839) RBKC Gold Group Meeting {RBK00023234/1}.
1840) Black {Day275/49:24}-{Day275/50:8}.
1841) Black {Day275/50:10-16}.
1842) Black {Day275/42:15}-{Day275/43:23}.
1843) Black {Day275/89:16-25}.
1844) Brown {TMO00869990/9} page 9, paragraph 46; Brown {Day274/123:1-15}; {Day274/133:1-10}.
1845) Brown {Day274/133:10-25}-{Day274/134:1-25}.
1846) {TMO10017528} Kiran Singh provided information on vulnerable residents to the National Grid on 15 June 2017 and confirmed “this will definitely be an underreported figure”.
1847) Brown {Day274/68:18-19}.
1848) See column L and the rows highlighted in red {TMO00894411}; Brown {Day274/135:19}-{Day274/136:5}.
1849) Email 15 June 2017 at 18.26 {TMO10036651}; Brown {Day274/129:23}-{Day274/132:22}.
1850) {TMO10036636}.
1851) {TMO10036636/2-3}.
1852) {TMO10036636/1-2} detailed written briefings for staff knocking on doors and making telephone calls to the residents of Barandon, Hurstway and Testerton Walks were provided only on 20 June 2017 {TMO00894205}; 22 June 2017 Neighbourhoods Team Briefing {TMO10033766} and 23 June 2017 Support Briefing Note {TMO10035544}.
1853) Brown {TMO00894124/9} page 9, paragraph 31.
1854) For Council Silver’s role see Chapter 101 and {RBK00035662/1} paragraph 2.1.
1855) Brown {Day274/142:24}-{Day274/143:1}.
1856) Brown {TMO00869990/9} page 9, paragraph 45; Brown {Day274/142:3-23}.
1857) Brown {Day274/141:5-9}.
1858) Brown {Day274/143:2-12}.
1859) Brown {TMO00869990/9} page 9, paragraph 48; Brown {Day274/142:24}-{Day274/144:14}.
1860) Brown {TMO00869990/9} page 9, paragraph 48.
1861) Brown {Day274/146:2}-{Day274/147:2}.
1862) RBKC Gold Group Meeting {RBK00023236/3}.
1863) Brown {TMO00869990/9-10} pages 9-10, paragraph 48.
1864) RBKC Gold Group Meeting {RBK00023236/3}.
1865) Brown {TMO00894124/17} page 17, paragraph 59.
1866) RBKC Gold Group Meeting {RBK00023238/2}.
1867) Brown {TMO00869990/11} page 11, paragraph 54.
1868) Brown {TMO00894124/19} page 19, paragraph 67; Brown {TMO00869990/11} page 11, paragraph 55; {TMO00894201/1-2}.
1869) Brown {Day274/151:1-25}-{Day274/152:1-5}.
1870) Black {Day275/61:15-25}; {Day275/63:14-17}.
1871) Brown {Day274/147:12}-{Day274/148:19}.
1872) Humanitarian Assistance Board Meeting Minutes {RBK00020410/2}.
1873) RBKC Gold Group Meeting {RBK00023236/1}; Black {Day275/57:23}-{Day275/58:9}.
1874) Black {Day275/55:19}-{Day275/56:1}.
1875) Black {Day275/56:2-7}.
1876) Black {Day275/57:3-8}.
1877) Black {Day275/58:4-9}.
1878) Brown {TMO00869990/11} page 11, paragraph 56.
1879) Brown {Day274/156:10}-{Day274/157:6}.
1880) Singh {TMO00894410/5} page 5, paragraph 4d.
1881) {TMO00894169}.
1882) {TMO10017543} spreadsheet on 15 June 2017 which features residents from Grenfell Walk with no pre-populated columns relating to vulnerabilities; {TMO10034288} spreadsheet on 19 June 2017 features residents from Walkway properties and Bramley House, but not Grenfell Walk which does include pre-populated columns relating to vulnerabilities; {TMO10036665} spreadsheet on 15 June 2017 relating to all Walkways with pre-populated columns relating to vulnerabilities, but not Bramley House or Grenfell Walk residents.
1883) It is not clear whether that was also sent to residents of Testerton Walk, or what was sent, if anything, to Grenfell Walk residents.
1884) Brown {TMO00869990/12} page 12, paragraph 58; {TMO00869949}.
1885) Brown {TMO00894124/25} page 25, paragraph 93.
1886) Brown {Day274/176:25}-{Day274/177:11}; Brown {TMO00869990/13} page 13, paragraph 69.
1887) Brown {Day274/177:4-20}.
1888) Brown {TMO00869990/15} page 15, paragraph 78.
1889) Brown {Day274/179:22-25}.
1890) Internal TMO email regarding a log of queries arising at the Westway Centre {TMO10035599/55}.
1891) Brown {Day274/184:19}-{Day274/185:1}.
1892) {TMO10035589/17}.
1893) {TMO00894205}.
1894) Neighbourhoods Team Briefing {TMO10033766}.
1895) Support Briefing Note {TMO10035544}.
1896) Script for calls to residents {TMO10036636}.
1897) RBKC Gold Group Meeting Action Sheet {RBK00005507/2} “people in finger blocks constantly approaching for housing. Need a steer from the WCC Team…what do we do with the 91 families not from Grenfell Tower and Walk”.
1898) Brown {TMO00894124/17} page 17, paragraphs 58-59.
1899) Brown {Day274/117:17-19}; {Day274/152:11-17}; Internal TMO email 19 June 2017 {TMO10035566/1}; Dowlut {IWS00001787/10} page 10, paragraph 37; Boujettiff {Day266/67:7-14}; McMahon {IWS00001966/9} page 9, paragraph 41; Pasztor {IWS00001682/3} page 3, paragraph 15.
1900) {TMO00869927}; Serroukh {IWS00001747/5} page 5, paragraph 22; RBKC Gold Group Meeting 20 June 2017 Action Sheet {TMO10033447/3}; Khadija Yahya {IWS00001825/10} page 10, paragraph 50; Mohamed Yahya {IWS00001827/8} page 8, paragraph 33.
1901) Hartley {IWS00001257/11} page 11, paragraphs 41-42; Levi {IWS00001753/12-13} pages 12-13, paragraphs 52 and 53; El-Sawy {IWS00001829/5} page 5, paragraph 22; Yahya {IWS00001825/10} page 10, paragraph 50.
1902) Levi {IWS00001753/12} page 12, paragraph 52.
1903) Brown {TMO00869990/15-16} pages 15-16, paragraph 79; {TMO00894213}.
1904) Brown {Day274/182:18}-{Day274/183:22}.
1905) Brown {Day274/182:18}-{Day274/183:22}.
1906) Exhibit TB/64 {TMO00894218/3} page 3.
1907) Brown {TMO00894124/26} page 26, paragraphs 95 and 96.
1908) {TMO00869985/4}.
1909) Lara {IWS00001589/12} page 12, paragraph 44.
1910) El-Sawy {IWS00001829/8} page 8, paragraph 34.
1911) Brown {Day274/172:22}-{Day274/173:2}.
1912) Black {Day275/108:4-11}.
1913) Black {Day275/75:4-15}.
1914) Black {Day275/86:6-12}.
1915) Black {Day275/79:4-6}.
1916) Black {Day275/86:15-20}.
1917) Black {Day275/86:21}-{Day275/87:3}.
1918) Barradell {Day279/175:12}-{Day279/176:6}.
1919) Barradell {Day279/181:1-9}.
1920) Barradell {Day279/183:8-16}.
1921) Brown {Day274/215:19}-{Day274/216:12}.
1922) At the relevant time, Ms Brownlee was the Director of Housing and Regeneration for Westminster City Council {GOL00000859/2} page 2, paragraph 6; and was leading on the housing response for London Gold; Brownlee {GOL00000859/4} page 4, paragraph 17.
1923) Brown {Day274/215:19-22}.
1924) Brown {Day274/202:19}-{Day274/203:4}.
1925) Brown {Day274/174:3-21}.
1926) Black {Day275/74:14-19}.
1927) Black {Day275/74:20-25}.
1928) Black {TMO00887150/12} page 12, paragraph 44.
1929) Black {Day275/110:3-16}; {Day275/112:6-23}.
1930) Grenfell Tower Recovery Taskforce Ministerial Meeting Minutes {CAB00002741/3-4} pages 3-4, paragraph 7; Email from Jamie Cowling to Katherine Richardson on 19 June 2017 at 13.27 {CLG00005618/3} page 3.
1931) Bassett-James {BEI00002844/3} page 3, paragraph 11.
1932) Bassett-James {BEI00002844/12} page 12, paragraph 49.
1933) Bassett-James {BEI00002849/6} page 6, paragraph 21.
1934) Bassett-James {BEI00002849/4} page 4, paragraph 15.
1935) Brown {Day274/205:17}-{Day274/206:15}.
1936) Bassett-James {BEI00002849/4} page 4, paragraph 16.
1937) Bassett-James {BEI00002849/6} page 6, paragraph 20.
1938) Black {Day275/97:4}.
1939) Email from Jamie Cowling from No.10 on 21 June 2017 at 09.29 {CAB00005909/1}.
1940) Black {TMO10048970/2} page 2, paragraph 8; Black {TMO00887150/2} page 2, paragraph 7; Black {Day275/96:19-21}.
1941) Email from Chris Gray on 21 June 2017 at 09.38 {CAB00005909/1}.
1942) Dawes {CLG00030653/32} page 32, paragraph 102.
1943) Black {Day275/104:12-16}.
1944) Barradell {Day279/181:22}-{Day279/182:25}.
1945) Ministerial Meeting Minutes on Grenfell Tower fire {CAB00002741/3-4} paragraph 7.
1946) Black {Day275/78:20}-{Day275/79:1}.
1947) Email from Sally Randall at 10.50 {CLG00021055/3}.
1948) Brown {Day274/214:20-24}.
1949) Brown {Day274/215:13-18}.
1950) {CLG00005723} Teresa Brown did not speak to Ms Brownlee or anyone at Westminster, Brown {Day274/215:1-22}; {Day274/216:9-10}.
1951) {CLG00005723}; Black {Day275/100:15-23}.
1952) Black {Day275/104:23}-{Day275/105:8}.
1953) Black {Day275/101:1-17}.
1954) Brown {Day274/203:7-10}.
1955) Black {Day275/80:8-16}.
1956) Black {Day275/112:6-20}.
1957) Brown {Day274/173:3-25}.
1958) Brown {Day274/196:2-23}; {Day274/202:16-18}; Brown {TMO00894124/24} page 24, paragraph 87.
1959) Brown {Day274/202:3-12}.
1960) Brown {Day274/196:21-25}-{Day274/197:1}.
1961) Black {Day275/27:25}-{Day275/28:7}.
1962) Black {Day275/47:6-13}.
1963) Black {Day275/46:22}-{Day275/47:5}.
1964) Black {Day275/45:15}-{Day275/46:4}.
1965) Hutchison {TMO10048971/1} page 1, paragraph 3.
1966) On 14 June 2017 {TMO00869621/2-10}; 16 June 2017 {TMO00869621/16-19}; 20 June 2017 {TMO00869621/30-33} briefings were sent more than once a day; A briefing for the weekend of 17 and 18 June 2017 was sent in advance, on 16 June 2017 {TMO00869621/18-19}. The briefings contained a staff briefing, information about respite centres, contact numbers to redirect residents in need, information on hot water and gas, information on helplines, such as the casualty bureau and housing team, and information regarding donations and volunteering.
1967) TMO’s out of hours provider {TMO00869621}; Brown {TMO00894124/20} page 20, paragraph 71.
1968) Email from Olivia Hutchison to Amanda McDuff {TMO00869621/6-7}.
1969) Email from Olivia Hutchison to Amanda McDuff on 14 June 2017 at 14.15 {TMO00869621/6}.
1970) Email from Olivia Hutchison to Amanda McDuff {TMO00869621/6-7}.
1971) Email from Olivia Hutchison to Pinnacle team {TMO00869621/8}.
1972) Email from Olivia Hutchison to Pinnacle team {TMO00869621/11-12}.
1973) Email from Olivia Hutchison to Pinnacle team {TMO00869621/11-12}.
1974) Emails from Olivia Hutchison to Pinnacle team, TMO staff and other London Boroughs {TMO00869621/18-24}.
1975) Email from Olivia Hutchison to the Customer Services Centre team and TMO staff {TMO00869621/26-27}.
1976) Various emails from Olivia Hutchison providing updates to Customer Services Centre team, Pinnacle team, TMO staff and London Boroughs {TMO00869621/2-34}.
1977) Brown {TMO00894124/28} page 28, paragraph 103; {TMO00869984}.
1978) Brown {TMO00894124/28-29} pages 28-29, paragraph 105.
1979) Brown {Day274/190:12-17}.
1980) Email thread {TMO10035589/58-59} email from Kiran Singh on 21 June 2017 at 10.45 entitled ‘Comms to residents.’
1981) {TMO00869985} it should also be noted that the TMO sent their second briefing to London Gold for approval on 12 July, 20 days after the first briefing {TMO00894179/1-2}.
1982) Brown {Day274/190:17-23}.
1983) Brown {TMO00869990/18} page 18, paragraph 93.
1984) Brown {TMO00869990/18} page 18, paragraph 93.
1985) The Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005 {CAB00007003/13} Regulation 23; See also Emergency Preparedness, Chapter 14 – The Role of the Voluntary Sector {CAB00004534/3-5} paragraphs 14.3 - 14.17.
1986) Emergency Preparedness, Chapter 14 – The Role of the Voluntary Sector {CAB00004534/4} paragraph 14.6.
1987) Adamson {BRC00000075/28-29} pages 28 - 29, paragraph 129.
1988) Adamson {BRC00000075/5} page 5, paragraph 24.
1989) Adamson {BRC00000075/5} page 5, paragraph 24.
1990) Simms {Day275/182:4-19}.
1991) The Clement James Centre was on a list of centres in RBKC’s Contingency Management Plan that would be opened in the event of an emergency to offer space but RBKC did not ask for it to be opened in response to the Grenfell Tower fire: Richards {CFV00000012/2} page 2, paragraph 5.
1992) Simms {Day275/182:10-14}; Richards {Day275/125:10-21}.
1993) Simms {Day275/182:20-23}.
1994) Richards {Day275/169:1-8}.
1995) Simms {Day275/182:20}-{Day275/183:2}; Richards {Day275/127:25}-{Day275/128:2}.
1996) Sayed {CFV00000043/2} page 2, paragraph 7.
1997) Richards {CFV00000012/15} page 15, paragraph 104.
1998) Richards {Day275/165:8-11}.
1999) Richards {Day275/141:16-23}.
2000) Richards {Day275/127:18-24}.
2001) Blanchflower {CFV00000045/3} page 3, paragraph 12.
2002) Blanchflower {CFV00000045/3} page 3, paragraph 12.
2003) Hisam Choucair {Day265/45:22}-{Day265/52:8}; Nabil Choucair {Day267/10:15}-{Day267/26:12}.
2004) Blanchflower {CFV00000045/3} page 3, paragraph 13.
2005) Blanchflower {CFV00000045/7-8} pages 7 - 8, paragraph 28.
2006) Skinner {CFV00000002/7} page 7, paragraph 21.
2007) Simms {Day275/210:2-6}.
2008) Simms {CFV00000005/11} page 11, paragraph 48.
2009) Simms {Day275/185:18-20}.
2010) Simms {Day275/198:9-12}.
2011) Simms {Day275/198:25}-{Day275/199:1}. Day 275 was 10 May 2022.
2012) Long {CFV00000010/6} page 6, paragraph 31.
2013) Long {CFV00000010/6} page 6, paragraph 31.
2014) Richards {Day275/141:22-23}; Richards {Day275/164:4-14}.
2015) Sayed {CFV00000043/4} page 4, paragraph 17.
2016) Sayed {CFV00000043/8} page 8, paragraph 35; Sayed {CFV00000043/5} page 5, paragraph 22.
2017) Blanchflower {CFV00000045/10} page 10, paragraph 41; Blanchflower {CFV00000045/3} page 3, paragraph 13.
2018) Skinner {CFV00000002/1} page 1, paragraph 2.
2019) Simms {CFV00000005/1-2} pages 1 - 2, paragraphs 5 and 6.
2020) Simms {Day275/200:6-10}; {Day275/204:6-11}.
2021) Simms {Day275/199:7-16}.
2022) Simms {Day275/185:21}-{Day275/186:6}; Simms {CFV00000005/18} page 18, paragraph 84.
2023) Simms {Day275/199:21}-{Day275/200:4}.
2024) Simms {Day275/186:11-16}.
2025) Simms {CFV00000005/14} page 14, paragraph 64.
2026) Simms {Day275/200:24}-{Day275/201:3}.
2027) Simms {Day275/188:1-16}.
2028) Simms {CFV00000005/8} page 8, paragraph 36; Simms {Day275/187:15}-{Day275/188:16}.
2029) Richards {CFV00000012/1} page 1, paragraph 3.
2030) Richards {Day275/129:3-15}; Richards {CFV00000012/2} page 2, paragraph 7.
2031) Richards {Day275/145:1-9}.
2032) Sayed {CFV00000043/1} page 1, paragraph 2.
2033) Sayed {CFV00000043/4} page 4, paragraph 13.
2034) Sayed {CFV00000043/4} page 4, paragraph 12.
2035) Sayed {CFV00000043/6} page 6, paragraph 27.
2036) Long {CFV00000010/7} page 7, paragraph 34.
2037) Skinner {CFV00000002/2-3} pages 2 - 3, paragraph 5.
2038) Richards {Day275/128:9-23}.
2039) Sayed {CFV00000043/3} page 3, paragraph 9.
2040) Blanchflower {CFV00000045/4-5} pages 4 - 5, paragraph 17.
2041) Richards {Day275/152:21-25}.
2042) Richards {Day275/153:4-5}.
2043) Richards {Day275/154:10-11}.
2044) Richards {Day275/154:10-17}.
2045) Richards {Day275/154:17-24}.
2046) Notes from the meeting with Theresa May on 17 June 2017 {CFV00000041}.
2047) Richards {Day275/155:6-14}.
2048) Richards {Day275/159:10}-{Day275/160:7}.
2049) Richards {Day275/157:6-9}.
2050) Richards {Day275/157:12-14}.
2051) Richards {Day275/156:25}-{Day275/157:2}; Notes from the meeting with Theresa May on 17 June 2017 {CFV00000041}.
2052) Richards {CFV00000012/23} page 23, paragraph 153.
2053) Richards {Day275/163:7-9}; Simms {Day275/202:16}-{Day275/203:3}; Simms {CFV00000005/13} page 13, paragraph 60.
2054) Sayed {CFV00000043/5-6} pages 5 - 6, paragraph 23.
2055) Sayed {CFV00000043/6} page 6, paragraphs 24 and 25.
2056) Sayed {CFV00000043/8} page 8, paragraph 34.
2057) Simms {Day275/214:4-8}.
2058) Yousuf {IWS00001626/4} page 4, paragraph 25; Razza {IWS00001607/8-9} pages 8 - 9, paragraph 41; Sobieszczak {IWS00001562/12} page 12, paragraph 54.
2059) Rasoul {Day265/165:3-22}.
2060) Ramirez {IWS00002061/7} page 7, paragraph 46.
2061) Murphy {IWS00001722/5} page 5, paragraph 25.
2062) Ali {IWS00001617/13} page 13, paragraph 165.
2063) Phase 1 Report, Volume IV, paragraph 23.52.
2064) Phase 1 Report, Volume IV, paragraphs 23.52 and 32.62.
2065) Bisby, Phase 2 Materials Testing Report {LBYMT00000002}; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002}; Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001}; Torero, Phase 2 Report {JTOR00000006/66-78} paragraphs 9.0.1- 9.3.16.
2066) Bisby {Day289/105:10}-{Day289/186:20}; {290/9:11}-{Day290/84:2}.
2067) Bisby, Phase 2 Materials Testing Report {LBYMT00000002}.
2068) Bisby, Phase 2 Materials Testing Report {LBYMT00000002/2} paragraph 4; Bisby, Phase 2 Materials Testing Report {LBYMT00000002/14} paragraph 79 and Table 1.
2069) Bisby, Phase 2 Materials Testing Report {LBYMT00000002/2} paragraphs 6-8.
2070) Bisby, Phase 2 Materials Testing Report {LBYMT00000002/30} paragraph 135.
2071) Bisby, Phase 2 Materials Testing Report {LBYMT00000002/2} paragraph 2; Bisby, Phase 2 Materials Testing Report {LBYMT00000002/7} paragraph 29; Bisby, Phase 2 Materials Testing Report {LBYMT00000002/30} paragraphs 138-142.
2072) Bisby, Phase 2 Materials Testing Report {LBYMT00000002/30} paragraphs 138-142.
2073) Bisby, Phase 2 Materials Testing Report {LBYMT00000002/30} paragraph 137.
2074) Bisby, Phase 2 Materials Testing Report {LBYMT00000002/31} paragraphs 152-156.
2075) Bisby, Phase 2 Materials Testing Report {LBYMT00000002/35} paragraphs 176-179.
2076) Bisby, Phase 2 Materials Testing Report {LBYMT00000002/35-36} paragraphs 182-185.
2077) Bisby, Phase 2 Materials Testing Report {LBYMT00000002/38} paragraph 191; Bisby, Phase 2 Materials Testing Report {LBYMT00000002/57} paragraph 276; Bisby, Phase 2 Materials Testing Report {LBYMT00000002/61} paragraph 288; Bisby, Phase 2 Materials Testing Report {LBYMT00000002/67} paragraphs 320-321; Bisby, Phase 2 Materials Testing Report {LBYMT00000002/68} paragraphs 326-331.
2078) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002}.
2079) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/4} paragraph 16.
2080) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/2-3} paragraphs 8-12; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/12} paragraphs 72-74.
2081) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/12} paragraph 75.
2082) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/72-76} Tables 7, 8 and 9, Figures 28-29 and paragraph 391.
2083) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/66-67} paragraphs 361-362, Table 4 and Figure 26.
2084) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/4} paragraph 18; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/63} Table 3, Figure 24 and paragraph 357.
2085) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/4} paragraph 19; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/67} Figure 26.
2086) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/4} paragraph 19; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/65} Table 4.
2087) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/5} paragraph 26; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/58} paragraphs 331-332; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/50} paragraph 278.
2088) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/63} Table 3 and Figure 24.
2089) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/73} Table 8; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/107} paragraph 627.
2090) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/108-109} Figure 36 and paragraphs 630-633 and 637; Bisby {Day289/144:20}-{Day289/145:4}.
2091) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/109} paragraphs 634-639; Bisby {Day289/145:4-9}.
2092) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/80} paragraph 453.
2093) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/93} paragraph 496; Bisby {Day289/146:20-24}; {Day289/148:16-21}.
2094) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/100} paragraph 569; Bisby {Day289/133:18}-{Day289/134:3}.
2095) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/6} paragraphs 44-45; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/72-76}, Tables 7, 8 and 9, Figures 28 and 29 and paragraph 393.
2096) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/6} paragraph 41; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/63-64} Table 3 and Figure 24 and paragraph 357.
2097) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/7} paragraph 47; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/89} paragraph 453; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/79} Figure 30; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/84}, Figure 33; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/86}, Figure 35.
2098) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/82} paragraph 427; Bisby, Phase 2 Experiments Work Package 1 Regimes of Burning {LBYWP100000002/88}, paragraph 445.
2099) Phase 2, Experiments Work Package 1, Regimes of Burning {LBYWP100000002/88} paragraph 448; Bisby {Day289/146:12-19}; {Day289/148:4-15}.
2100) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/58} paragraph 330; Bisby, Phase 2 Experiments Work Package 2, Systems Interactions {LBYWP200000001/22} paragraph 143; Bisby {Day289/149:9-11}.
2101) Bisby {Day289/148:6-15}; {Day289/149:23}-{Day289/150:5}.
2102) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/89} paragraph 454; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/94}, paragraph 497; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/100} paragraph 564.
2103) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/7} paragraph 46; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/89} paragraph 454.
2104) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/65-67} Table 4, Figures 25 and 26; Bisby {Day289/153:3-9}; Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/22} paragraph 141.
2105) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/8} paragraphs 58-59; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/72-76} Tables 7, 8 and 9, Figures 28 and 29 and paragraphs 394-395; Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/80} paragraph 460.
2106) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/75} paragraph 394.
2107) Bisby {Day289/120:1-7}; {Day289/134:13-18}; {Day289/153:10-16}; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/75} paragraph 394; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/102}, paragraphs 588-589.
2108) Bisby {Day289/134:19-23}.
2109) Bisby {Day289/169:23}-{Day/170:3}.
2110) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/7} paragraph 54.
2111) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/63-64} Table 3, Figure 24 and paragraph 357.
2112) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/89} paragraph 455; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/79} Figure 30; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/84} Figure 33; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/86}, Figure 35.
2113) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/80} paragraph 458; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/95} paragraphs 515-516; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/102} paragraph 584.
2114) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/89} paragraph 456; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/119} paragraph 713; Bisby {Day289/151:2-9}.
2115) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/80}, paragraph 453.
2116) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/89} paragraph 456; Bisby {Day289/151:10-13}; {Day289/152:5-10}.
2117) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/23} paragraph 150.
2118) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/119} paragraph 709; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/65-67} Table 4, Figures 25 and 26.
2119) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/75} paragraph 392.
2120) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/63-64} Table 3, Figure 24 and paragraph 357.
2121) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/79-80} Figures 30 and 31; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/82} paragraph 426; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/84-85} Figures 33 and 34; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/89} paragraph 452.
2122) Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/64-67} paragraphs 360 and 362, Table 4 and Figures 25 and 26; Bisby, Phase 2 Experiments Work Package 1, Regimes of Burning {LBYWP100000002/116-117} paragraphs 686, 689 and 693.
2123) Bisby, Phase 2 Experiments Work Package 2, Regimes of Burning {LBYWP200000001/21} paragraph 138.
2124) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/3} paragraph 11.
2125) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/38-57} paragraphs 244-345; Bisby {Day289/159:3}-{Day289/163:22}.
2126) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/42} paragraph 261.
2127) Bisby {Day289/159:14-20}.
2128) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/2} paragraph 4.
2129) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/39} Figure 5.
2130) Bisby {Day289/158:15-21}.
2131) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/24} paragraphs 162-164.
2132) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/24-25} paragraph 167.
2133) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/25} paragraph 168.
2134) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/25} paragraphs 168-169.
2135) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/25} paragraph 171.
2136) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/25} paragraph 171.
2137) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/25-26} paragraphs 173-174.
2138) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/26} paragraph 182.
2139) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/26-27} paragraph 183.
2140) Bisby {Day289/158:1-11}.
2141) Bisby {Day289/158:22}-{Day289/159:2}.
2142) Bisby {Day290/62:4-5}.
2143) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/28} paragraph 196; Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/77} paragraph 9.3.7.
2144) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/28} paragraphs 197-201.
2145) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/28} paragraphs 202-204.
2146) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/28-29} paragraphs 205-209; Bisby {Day289/162:20}-{Day289/163:17}.
2147) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/21} paragraphs 137-138.
2148) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/29} paragraph 212.
2149) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/30} paragraphs 213-214.
2150) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/30} paragraphs 215-216.
2151) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/30} paragraphs 217-218.
2152) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/30} paragraphs 219-220.
2153) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/58} paragraph 346. Each test was run twice to check the repeatability of the results – Bisby {Day289/181:9-11}.
2154) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/58} paragraphs 348-350.
2155) Bisby {Day289/164:3-7}.
2156) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/59-65} paragraphs 356-381; Bisby {Day289/164:3}-{Day289/172:13}. For a more detailed examination of the physical processes examined during the tests see Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/68-76} paragraphs 9.1.1-9.2.21.
2157) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/64} Figure 20.
2158) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/67} paragraph 394.
2159) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/65} Figure 23.
2160) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/62} paragraph 381; Bisby {Day290/65:10}-{Day290/66:8}; {Day290/66:19}-{Day290/67:9}.
2161) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/79} paragraph 449.
2162) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/79} paragraph 450.
2163) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/124-125} paragraph 665; {LBYWP200000001/81-85} paragraphs 467-479.
2164) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/83} paragraphs 471-472.
2165) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/125} paragraph 666; {LBYWP200000001/85-88} paragraphs 480-486.
2166) Bisby {Day289/175:14-16}.
2167) Bisby {Day289/175:21-24}.
2168) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/125} paragraph 667; {LBYWP200000001/88-91} paragraphs 487-494.
2169) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/78} Figure 32; {LBYWP200000001/92} paragraph 506.
2170) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/125} paragraph 668; {LBYWP200000001/91-103} paragraphs 495-547.
2171) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/96} paragraph 517; {LBYWP200000001/100} paragraph 535; Bisby {Day289/178:2-17}.
2172) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/125} paragraph 669.
2173) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/125} paragraph 670.
2174) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/97} paragraph 528.
2175) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/100} paragraph 534.
2176) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/126} paragraph 671; {LBYWP200000001/108} paragraphs 559-567.
2177) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/126} paragraph 673.
2178) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/126} paragraph 674; {LBYWP200000001/109} paragraphs 569-573.
2179) Local burnout means that the polyethylene is not burning any more whether inside the panel or the drip tray – Bisby {Day290/62:24}-{Day290/63:7}.
2180) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/126} paragraph 675; {LBYWP200000001/109} paragraph 574; Bisby {Day290/66:19}-{Day290/67:19}.
2181) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/109} paragraph 575.
2182) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/127} paragraph 679.
2183) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/112} paragraph 585.
2184) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/127} paragraph 680; {LBYWP200000001/112} paragraphs 583-585.
2185) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/127} paragraph 680.
2186) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/126-127} paragraph 677.
2187) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/127} paragraph 678; {LBYWP200000001/111-112} paragraphs 581-582.
2188) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/112-113} paragraph 586. As discussed in Chapter 20.
2189) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/113} paragraph 587.
2190) Phase 1 Report, Volume IV, paragraph 23.52.
2191) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/114-117} paragraphs 597-604 and 620; Bisby {Day289/184:7-10}.
2192) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/128-129} paragraph 695.
2193) Bisby {Day289/185:15-22}.
2194) Phase 1 Report, Volume IV, paragraph 23.52.
2195) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/115-117} paragraphs 605-620.
2196) Even if all of the mass lost from the burning of the insulation products is assumed to be converted into energy, the Celotex RS5000 insulation is unlikely to have contributed more than 20% of the total energy released, the mineral wool about 0.1% of the total energy released and the Kingspan K15 about 53% of the total energy released. The figure for K15 reflects its propensity to smoulder after the ACM has substantively burned out – Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/128-129} paragraphs 692-695.
2197) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/127-128} paragraphs 682-686.
2198) Bisby {Day289/184:14-17}.
2199) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/128} paragraph 690; Bisby {Day289/184:21-24}.
2200) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/128} paragraphs 688-689.
2201) Bisby {Day289/178:21-25}.
2202) Bisby {Day289:179:5}-{Day289/182:20}.
2203) Bisby {Day289/179:1-4}.
2204) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/129} paragraph 696.
2205) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/129} paragraph 698; {LBYWP200000001/24} paragraphs 158-159; {LBYWP200000001/4} paragraph 17; Bisby {Day289/157:7-16}; {Day289/183:23}-{Day289/184:6}.
2206) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/129} paragraphs 701-703; {LBYWP200000001/4} paragraph 17; Bisby {Day290/73:11}-{Day290/74:14}.
2207) Torero, Phase 2 Report, Adequacy of the Current Testing Regime {JTOR00000006/67} paragraph 9.0.11; {JTOR00000006/76} paragraph 9.3.3.
2208) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/130} paragraph 704.
2209) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/129} paragraph 699.
2210) Phase 1 Report Volume IV paragraphs 22.36-22.40.
2211) Bisby, Phase 2 Experiments Work Package 2, System Interactions {LBYWP200000001/5} paragraph 34.
2212) Phase 1 Report Volume IV paragraphs 22.36-22.39.
2213) It should be noted that the reference to Professor Bisby’s Hypothesis B2 in paragraph 22.39 of the Phase 1 Report Volume IV on page 538 is a typographical error which should actually refer to Professor Bisby’s Hypothesis B1.
2214) Phase 1 Report Volume IV paragraph 22.39.
2215) BRE Global Grenfell Tower Fire Investigation Reconstruction {MET00040237}.
2216) BRE Global Grenfell Tower Fire Investigation Reconstruction {MET00040237/4} penultimate paragraph.
2217) Phase 1 Report Volume IV paragraph 22.42.
2218) Torero, Phase 2 Report {JTOR00000006/163-169} paragraphs 13.1.10-13.1.43; Bisby, Phase 2 BRE Reconstruction Report {LBYP20000003}.
2219) Torero {Day292/107:18}-{Day292/108:16}.
2220) Torero, Phase 2 Report {JTOR00000006/164} paragraph 13.1.16.
2221) Torero, Phase 2 Report {JTOR00000006/166} paragraph 13.1.31.
2222) Torero, Phase 2 Report {JTOR00000006/167} paragraphs 13.1.33-13.1.34; Torero {Day292/107:18}-{Day292/108:16}.
2223) “Flashover” is a term used to describe the near simultaneous ignition of all combustible material within an enclosed area.
2224) Torero, Phase 2 Report {JTOR00000006/167-169} paragraphs 13.1.35-13.1.43.
2225) Bisby, Phase 2 BRE Reconstruction Report {LBYP20000003/10} paragraph 58.
2226) Bisby, Phase 2 BRE Reconstruction Report {LBYP20000003/11} paragraph 60.
2227) Bisby, Phase 2 BRE Reconstruction Report {LBYP20000003/11} paragraphs 62-64.
2228) Bisby, Phase 2 BRE Reconstruction Report {LBYP20000003/11} paragraph 65.
2229) Bisby, Phase 2 BRE Reconstruction Report {LBYP20000003/12} paragraph 75.
2230) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006}.
2231) Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001}; Bisby, Phase 2 Report: BR 135 Desktop Assessment Report {LBYP20000004}.
2232) Lane, Phase 2 Module 2 presentation: An explanation of the relevant Reaction to Fire tests and Classification methods to restrict the combustibility of external walls of high buildings {BLARP20000022}.
2233) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/29} paragraph 4.2.7.
2234) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/33} paragraph 6.0.1.
2235) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/38-39} paragraphs 6.2.7-6.2.8 and 6.2.11-6.2.16.
2236) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/34-37} paragraphs 6.1.3-6.1.23.
2237) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/49} paragraph 7.2.23.
2238) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/54} paragraph 7.3.27.
2239) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/54-55} paragraphs 7.3.30-7.3.33.
2240) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/55} paragraph 7.3.35.
2241) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/56} paragraph 7.4.1.
2242) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/56} paragraph 7.4.2; Bisby, Phase 2 Experiments Work Package 2: System Interactions {LBYWP200000001/79} paragraph 449; Bisby {Day291/9:18}-{Day291/12:19}.
2243) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/56} paragraph 7.4.7.
2244) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/57} paragraph 7.4.10.
2245) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/56} paragraphs 7.4.3-7.4.4.
2246) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/59} paragraph 7.5.6.
2247) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/60-61} paragraphs 8.1.3-8.1.4 and Figure 6.
2248) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/61} paragraph 8.1.5 and Figure 6.
2249) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/61-62} paragraph 8.1.8.
2250) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/62} paragraph 8.1.11.
2251) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/63} paragraph 8.2.2 and 8.2.4.
2252) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/63} paragraph 8.2.3.
2253) See Chapter 109.
2254) The surface temperature of a material with a low thermal inertia will increase rapidly when heated and it will ingite more quickly – see Bisby Phase 1 Report {LBYS0000001/19} paragraph 121; Grenfell Tower Inquiry Phase 1 Report, Volume IV, page 522 paragraph 22.13.
2255) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/64-65} paragraphs 8.2.6-8.2.9.
2256) Bisby Phase 2 Experiments Work Package 2: System Interactions {LBYWP200000001/4} page 4, paragraph 17.
2257) Chapter 109.
2258) Chapter 109.
2259) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/65} paragraphs 8.2.12; {JTOR00000006/66-78} paragraphs 9.01-9.3.16; Torero {Day289/77:16}-{Day289/78:1}.
2260) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/81-83} paragraphs 10.1.10-10.1.20.
2261) Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/75} paragraph 356.
2262) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/83-84} paragraphs 10.1.20-10.1.27.
2263) Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/58} paragraphs 259-261.
2264) Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/32-33} paragraph 156.
2265) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/127} paragraphs 12.3.54-12.3.55.
2266) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/129} paragraphs 12.3.64.
2267) Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/35} paragraph 162; Bisby {Day290/100:19}-{Day290/101:10}.
2268) Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/35} paragraph 163; Bisby {Day290/109:24}-{Day290/110:8}; {Day290/118:3-23}.
2269) Torero {Day289/91:6-16}.
2270) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/127} paragraph 12.3.57.
2271) See Chapter 5; {CTAR00000016/11} paragraph 11(i); Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/129} paragraphs 12.3.58-12.3.60.
2272) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/129} paragraph 12.3.62; Torero {Day292/28:7-16}.
2273) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/129} paragraph 12.3.65.
2274) Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/30} paragraph 145; Bisby {Day290/109:24}-{Day290/110:8}.
2275) Lane {BLARP20000022/61}. There was also a change to the foreword in 2014.
2276) Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/58} paragraphs 259-261.
2277) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/133} paragraph 12.3.80.
2278) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/133} paragraph 12.3.81; Grenfell Tower Inquiry Phase 1 Report, Chapter 23, page 558, paragraph 23.55.
2279) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/133} paragraph 12.3.82; Torero {Day292/33:11-23}.
2280) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/133} paragraph 12.3.84.
2281) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/133} paragraph 12.3.83. Professor Torero also explains in his report how Professor Drysdale and others have concluded that the results of the test are strongly dependent on the particular apparatus used and therefore the test ought not to be used to assess the material properties of the product in a real-world situation, see Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/132-133} paragraphs 12.3.77-12.3.79 and see also Torero {Day292/30:20}-{Day292/32:11}.
2282) Torero {Day 292/32:12}-{Day292/33:9}, see also Bisby {Day290/114:3-5}.
2283) Torero {Day292/34:16-20}.
2284) See Chapter 7.
2285) {RCO00000001/46} 4th paragraph.
2286) See Chapter 7.
2287) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/136-137} paragraphs 12.4.17-12.4.19.
2288) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/137} paragraph 12.4.20; Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/35} paragraph 165.
2289) Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/35} paragraphs 165-166 and {LBYP20000001/114} paragraphs 595-596.
2290) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/150} paragraph 12.4.68.
2291) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/151-152} paragraphs 12.4.79 and 12.4.85.
2292) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/152} paragraph 12.4.81.
2293) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/152} paragraphs 12.4.82-12.4.84.
2294) Torero Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/153} paragraphs 12.4.91-12.4.93; Torero {Day292/44:4}-{Day292/45:11}.
2295) Torero {Day292/44:25}-{Day292/45:11}.
2296) Torero Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/153} paragraph 12.4.93.
2297) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/153} paragraph 12.4.90; Torero {Day292/41:2}-{Day292/42:17}; Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/116} paragraph 604.
2298) B Messerschmidt, The Capabilities and Limitations of the Single Burning Item (SBI) Test, Fire & Building Safety in the Single European Market, FireSeat, 2008 {INQ00014960} and see Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/153-154} paragraphs 12.4.94-12.4.96 and Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/37-38} paragraphs 175-177.
2299) “FireSeat 08 - Presentation by Birgitte Messerschmidt. Part 3 of 4” (https://www.youtube.com/watch?v=wsQHKDUomSA) 00:03:02 – 00:03:14; Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/116} paragraph 608. Also Lane {Day68/61:22-62:}.
2300) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/148} paragraph 12.4.67, with reference to B Messerschmidt, The Capabilities and Limitations of the Single Burning Item (SBI) Test, Fire & Building Safety in the Single European Market, FireSeat, 2008 {INQ00014960}.
2301) {CLG10000007/95} section 12.5.
2302) A further version of BR 135 was published in 2013 {CLG00000224}.
2303) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/103} paragraphs 12.2.26 and 12.2.28 and see the evidence of Dr Connolly summarised in Chapter 7.
2304) {BRE00001077/4}.
2305) See the title to the document at {BRE00001077} and see e.g. pages 3, 5, 7.
2306) {BRE00001077/4-5} under the heading “Regulatory Aspects”.
2307) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/103} paragraph 12.2.29-12.2.30.
2308) {BRE00001077/4-6} see in particular pages 5-6 under the heading “Experimental Fires”.
2309) {BRE00001077/9}; Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/104} paragraph 12.2.33-12.2.34.
2310) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/105} paragraph 12.2.39.
2311) {BRE00001077/9}.
2312) Connolly’s 10 Large-Scale Tests in 1994 {RCO00000001/46} section 4.2.3 second paragraph and see Chapter 7.
2313) Bisby {Day290/162:4-14}; Torero {Day292/68:5}-{Day292/69:20}.
2314) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/105-106} paragraph 12.2.43; BR 135 2nd Edition {BRE00005554}; BR 135 3rd edition {BRE00005555}.
2315) {CEL00000584/22} section 6.4.1 which states: “Combustible panels are typically based on vinyl or glass-reinforced plastic, although various new products are being developed in this area, some of which also contain insulation materials. These products generally have good surface spread of flame characteristics to prevent rapid fire spread across the surface of the system, but once the panels become involved in the fire, they have the potential to generate falling debris, add to the overall fire load, and provide a route for fire to propagate up the outside of the building.”
2316) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/106} paragraph 12.2.48.
2317) See for example the examination of Dr Colwell (who was involved in Fire Note 3 and Fire Note 9 and co-authored both the second and third editions of BR 135) at {Day231/167:23}-{Day231/176:25}; Debbie Smith {Day236/107:20}-{Day236/113:18}; Martin {Day251/119:4}-{Day251/120:24}. See also Chapter 7.
2318) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/108} paragraph 12.2.58.
2319) Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/42} paragraph 207.
2320) Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/42} paragraph 209.
2321) {CEL00000584/27} left column.
2322) Lane, Phase 2 Module 2 presentation: An explanation of the relevant Reaction to Fire tests and Classification methods to restrict the combustibility of external walls of high buildings {BLARP20000022/257} where Dr Lane highlighted temperature readings taken in BS 8414 tests conducted by MHCLG of HPL panels over A1 insulation. See also Lane {Day68/115:15}-{Day68/117:21}.
2323) {BRE00005555/29} section A2.4 and {BRE00005555/33} section B2.4.
2324) See e.g. the Loss Prevention Standard 1582 approved by the Loss Prevention Council which has performance criteria for mechanical performance - {INQ00013964/12} paragraph 4.1.5.
2325) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/109} paragraphs 12.2.63-12.2.64.
2326) Colwell {Day231/175:11-24}; Smith {Day236/114:4}-{Day236/115:4}; Martin {Day251/96:19}-{Day251/98:19}; Burd {Day238/214:10}-{Day238/215:6}.
2327) Torero {Day289/67:8-18}.
2328) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/109} paragraphs 12.2.65-66.
2329) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/110} paragraph 12.2.68; Torero {Day292/77:8-17}; Bisby {Day290/143:1-8}; Torero {Day292/76:25}-{Day292/77:6}.
2330) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/110} paragraphs 12.2.69-12.2.73; Bisby, Phase 2 Report: Regulatory Testing and the Path to Grenfell {LBYP20000001/42-43} paragraphs 210-211; Bisby {Day290/138:22}-{Day290/141:13}.
2331) Bisby {Day290/140:3}-{Day290/141:13}.
2332) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/111} paragraph 12.2.78 and see for example the paper by Schultz J, Kent, Crimi, Glocking, Hull, “A Critical Appraisal of the UK’s Regulatory Regime for Combustible Facades,” Fire Technology, 57, 261-290, 2021 {INQ00014943}.
2333) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/111-112} paragraph 12.2.79; Torero {Day292/84:12}-{Day292/86:25}.
2334) Chapter 109.
2335) See in particular Chapter 22 and Chapter 24.
2336) Bisby, Phase 2 Report: BR 135 Desktop Assessment Report {LBYP20000004/8} paragraph 41.
2337) See for example Lewis {NHB00003433/38} page 28, paragraph 148; Lewis {NHB00003433/53} page 53, paragraph 194; Evans {NHB00003020/70} page 70, paragraph 190(d); Evans {NHB00003020/77} page 77, paragraph 200(a).
2338) {NHB00000760}.
2339) Bisby, Phase 2 Report: BR 135 Desktop Assessment Report {LBYP20000004/8} paragraphs 41 and 44; Torero Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/114} paragraph 12.2.93; Torero {Day292/91:17}-{Day292/92:3}.
2340) Bisby, Phase 2 Report: BR 135 Desktop Assessment Report {LBYP20000004/2} paragraph 7; {LBYP20000004/39} paragraphs 288 and 289; Bisby {Day291/66:6-13}; {Day291/89:4-11}.
2341) Torero, Phase 2 Report: Adequacy of the Current Testing Regime {JTOR00000006/115} paragraphs 12.2.96 and 12.2.97; Bisby {Day290/92:8}-{Day290/93:3}; {Day291/66:22}-{Day291/67:10}; {Day291/74:19}-{Day291/75:10}.
2342) Bisby, Phase 2 Report: BR 135 Desktop Assessment Report {LBYP20000004/8} paragraphs 45 and 46; {LBYP20000004/24} paragraph 170; {LBYP20000004/42} paragraph 305; Bisby {Day290/123:10}-{Day290/124:7}; {Day290/140:17}-{Day290/141:9}; {Day291/73:4-24}.
2343) Bisby {Day291/69:2-6}.
2344) Evans {NHB00003020/10} page 10, paragraph 28(a); Evans {NHB00003020/15} page 15, paragraph 42, second sentence; Evans {NHB00003020/22} page 22, paragraph 68; Evans {NHB00003020/24} page 24, paragraph 74(b); Evans {NHB00003020/38} page 38, paragraph 107, final sentence; Evans {NHB00003020/63} page 63, paragraph 173, final sentence; Evans {NHB00003020/66}, page 66 paragraph 183; Evans {Day220/15:11-18}; {Day220/64:20-23}; {Day221/163:15-21}; {Day221/170:7-13}; {BLM00000211/3} second paragraph in blue text; Lewis {Day224/45:19-24}; {Day224/74:3-14}; {Day224/128:15}-{Day224/129:11}. See also {NHB00001408/4} paragraph 1.1.1.
2345) Bisby, Phase 2 Report: BR 135 Desktop Assessment Report {LBYP20000004/24} paragraph 170.
2346) Bisby {Day291/68:6-14}.
2347) Torero {JTOR00000006/114}, Phase 2 Report: Adequacy of the Current Testing Regime paragraph 12.2.95.1 and {JTOR00000006/115} paragraphs 12.2.97 and 12.2.98. See also Bisby {Day291/67:16}-{Day291/68:5}.
2348) {BSI00001934}.
2349) {BSI00001934/9} first paragraph.
2350) Torero {Day292/95:19-21}; {Day292/99:20}-{Day292/100:19}; {Day292/103:25}-{Day292/104:13}.
2351) Torero {Day292/100:9-19}.
2352) Torero, Phase 2 Report {JTOR00000006/4} paragraph 1.2.1. Between 2012 and 2017 Professor Torero was Professor of Civil Engineering and Head of the School of Civil Engineering at the University of Queensland, Australia.
2353) Torero, Phase 2 Report {JTOR00000006/4} paragraph 1.2.1. Between 2017 and 2019 Professor Torero held the John L. Bryan Chair at the Department of Fire Protection Engineering and was the Director of the Center for Disaster Resilience at the Department of Civil Engineering at the University of Maryland, USA.
2354) Torero, Phase 2 Report {JTOR00000006}.
2355) Torero {Day291/106:10}-{Day291/193:18}; {Day292/1:20}-{Day292/3:18}.
2356) {USA0000001}.
2357) Johnson {DCD00000001/1} page 1, paragraphs 3-3.1.2.
2358) {NSW0000001}.
2359) {QLD00000002}.
2360) {VIC00000001}.
2361) Torero, Phase 2 Report {JTOR00000006/210} paragraph A3.1.
2362) Torero, Phase 2 Report {JTOR00000006/210} paragraph A3.1.
2363) The Building etc. (Amendment) (England) Regulations 2022, regulation 2(4)(b).
2364) Torero {Day292/129:1-10}.
2365) {USA0000001/4} fifth paragraph; Torero, Phase 2 Report {JTOR00000006/211} paragraph A3.9; Torero {Day291/109:19}-{Day291/110:9}; {Day291/121:23}-{Day291/122:2}.
2366) {USA0000001/5} third paragraph.
2367) {USA0000001/5} fourth paragraph.
2368) Torero {Day291/120:7-8}.
2369) Torero {Day291/113:13}-{Day291/114:2}; {Day291/120:2-19}; {Day291/115:20}-{Day291/116:7}.
2370) Torero {Day291/120:25}-{Day291/121:9}.
2371) Torero {Day291/121:10}-{Day291/122:24}.
2372) Torero {Day291/122:25}-{Day291/123:24}. Professor Torero contrasted this approach with that which has prevailed in Europe where the existing building stock and the need for post-war regeneration meant that less prescriptive, conservative solutions had to be adopted. Torero {Day291/123:25}-{Day291/124:23}.
2373) NFPA test standard 285: Standard Fire Test Method for Evaluation of Fire Propagation Characteristics of Exterior Non-Load-Bearing Wall Assemblies Containing Combustible Components {USA0000001/6} first paragraph.
2374) {USA0000001/6} section 3, first paragraph.
2375) {USA0000001/6} section 3, third paragraph.
2376) Torero {Day291/128:12-19}.
2377) {USA0000001/7-9} section 4.
2378) Johnson {DCD00000001/2} page 2, paragraph 4.
2379) Johnson {DCD00000001/2} page 2, paragraph 4.1.1.
2380) {INQ00014966}.
2381) Torero, Phase 2 Report {JTOR00000006/211} paragraph A3.10.
2382) Johnson {DCD00000001/2} page 2, paragraphs 4.1.2 and 6.2.
2383) Johnson {DCD00000001/3} page 3, paragraphs 6.5-6.5.1; https://www.dcd.gov.ae/portal/eng/UAEFIRECODE_ENG_SEPTEMBER_2018.pdf.
2384) Torero, Phase 2 Report {JTOR00000006/211-212} paragraph A3.10; see the 2018 UAE Fire and Life Safety Code, Chapter 1 {INQ00014966} section 2.6.
2385) Torero, Phase 2 Report {JTOR00000006/212} paragraph A3.10; Johnson {DCD00000001/4} page 4, paragraph 6.6.1; see the 2018 UAE Fire and Life Safety Code, Chapter 1 {INQ00014966} section 2.8.10.
2386) Torero, Phase 2 Report {JTOR00000006/212} paragraph A3.11; see the 2018 UAE Fire and Life Safety Code, Chapter 1, at e.g. 1.1.35 to 1.1.40 and section 2.6.
2387) Torero {Day291/145:8-13}.
2388) Johnson {DCD00000001/5} page 5, paragraph 6.9.
2389) Johnson {DCD00000001/5} page 5, paragraph 6.9.
2390) Johnson {DCD00000001/3} page 3, paragraph 6.3.
2391) Torero {Day291/135:4-17}.
2392) Torero {Day291/136:10-14}.
2393) Table 19.1 of the Code on page 1236 at https://www.dcd.gov.ae/portal/eng/UAEFIRECODE_ENG_SEPTEMBER_2018.pdf.
2394) Torero {Day291/138:5}-{Day291/139:24}.
2395) Torero, Phase 2 Report {JTOR00000006/213} paragraph A3.12; Johnson {DCD00000001/6-7} pages 6-7, paragraphs 8-8.5.
2396) Johnson {DCD00000001/5} page 5, paragraph 6.9.
2397) Johnson {DCD00000001/2} page 5, paragraph 5.1.
2398) National Construction Code, CIP2(1)(c).
2399) Including structural failures and moisture ingress failures. Torero {Day291/150:25}-{Day291/151:3}.
2400) Lambert M. Independent Review of the Building Professionals Act 2005 – Final Report, October 2015 {INQ00014958}.
2401) Shergold, P. and Weir, B., Building Confidence – Improving the effectiveness of compliance and enforcement systems for the building and construction industry across Australia, February 2018 {INQ00014963}.
2402) The Warren Centre Project – professionalising fire safety engineering, The Warren Centre, University of Sydney, https://www.sydney.edu.au/engineering/industry-and-community/the-warren-centre/fire-safety-engineering.html, study launched in July 2018 and final report dated 2020.
2403) Torero, Phase 2 Report {JTOR00000006/213} paragraph A3.15.
2404) https://www.sydney.edu.au/content/dam/corporate/documents/faculty-of-engineering-and-information-technologies/industry-and-government/the-warren-centre/the-education-report-fire-safety-engineering-the-warren-centre.pdf
2405) Lane, Phase 2, Recommendations Report {BLAR200000001/127} paragraph 5.10.4.
2406) Lane, Phase 2, Recommendations Report {BLAR200000001/127} paragraphs 5.10.5-5.10.6.
2407) This was report 5 of the series {INQ00014933}.
2408) {INQ00014933/29-30}.
2409) Lane, Phase 2, Recommendations Report {BLAR200000001/129} paragraph 5.10.15.
2410) {INQ00014933/21-23}.
2411) {INQ00014933/24-25}.
2412) Torero, Phase 2 Report {JTOR00000006/193} paragraph A2.29.
2413) This test is very similar to the BS 476-4 test. Torero {Day292/5:23}-{Day292/6:1}.
2414) Torero {Day292/5:15-25}.
2415) {VIC00000001/8} section 3.3.
2416) The Building etc. (Amendment) (England) Regulations 2022, regulation 2(4)(b).
2417) {VIC00000001/8} section 3.6.
2418) {VIC00000001/8} section 3.6.
2419) https://www.engineersaustralia.org.au/credentials/registration/state-registration#accordion-1506.
2420) {NSW0000001/42}.
2421) {NSW0000001/46}.
2422) https://www.engineersaustralia.org.au/credentials/registration/state-registration#accordion-1506
2423) {QLD00000002/4}; {QLD00000002/21}.
2424) Torero {Day291/181:2-11}.
2425) Torero {Day291/182:4-19}.
2426) {QLD00000002/8}.
2427) {QLD00000002/16}.
2428) {QLD00000002/8}.
2429) {QLD00000002/20} first paragraph.
2430) {QLD00000002/28}.
2431) {QLD00000002/24}.
2432) Building surveyors in Queensland must be licensed as building certifiers and are decision-makers for building approval compliance {QLD00000002/19}.
2433) {QLD00000002/29}.
2434) https://claddingmaterialslibrary.com.
2435) Torero {Day292/12:1-9}.
2436) Torero {Day292/14:10-19}.
2437) Torero {Day292/14:22}-{Day292/15:10}.
2438) {QLD00000002/17}.
2439) {QLD00000002/30}; Torero {Day292/4:7-19}. Small-scale tests were conducted which extracted the key information which is relevant to the spread of fire, including thermal inertia, ignition temperatures and mechanisms for mechanical failure.
2440) Torero {Day292/3:14}-{Day292/4:19}.
2441) {QLD00000002/30}.
2442) Torero {Day292/4:20}-{Day292/5:4}; {Day292/20:2-16}.
2443) {QLD00000002/30}.
2444) Building Safety Act 2022, sections 31 and 65.
2445) See his reports at {RHX00000012/220} paragraphs 468-469, {RHX00000020/2-17} paragraphs 1-45 and his oral evidence at Hancox {Day161/181-204}.
2446) CP 670
2447) Phase 1 report Volume IV paragraph 33.22(e).
2448) Phase 1 report Volume IV paragraph 33.22(f).
2449) See Part 2, Chapter 14, paragraph 14.2.
2450) See Part 2, Chapter 14, and especially paragraph 14.17.
2451) Part 5, Chapter 46, paragraph 46.90.