“Chain of failures” and “systematic dishonesty” realised Grenfell tragedy

At 11.00 am this morning, retired High Court Judge and Public Inquiry Panel chair Sir Martin Moore-Bick delivered a 45-minute speech in which he criticised central Government, construction companies and regulators alike, in addition to putting forward a number of recommendations, including the perceived requirement for an independent construction body, a licensing scheme for contractors working on higher-risk buildings and a detailed inspection of the London Fire Brigade alongside the formation of a College of Fire and Rescue and necessary changes to be made to the way in which materials are tested for fire safety prior to installation.

According to the Grenfell Tower Inquiry Panel, the coalition and Conservative Governments “ignored, delayed or disregarded” concerns about the safety of industry practices, which were first brought to light back in the early 1990s and specifically so through the Knowsley Heights fire in Huyton on Merseyside, where the exterior cladding was found to have played a role in fire spread at the 11-storey building.

Also, and again according to the Inquiry Panel, the local council (ie the Royal Borough of Kensington and Chelsea) and the Tenant Management Organisation exhibited a “persistent indifference to fire safety, particularly so the safety of vulnerable people”.

Speaking in the wake of the report’s publication, Sir Martin Moore-Bick stressed that not all of the named organisations and companies “bear the same degree of responsibility for the disaster”, but he observed the report shows that they all “contributed in one way or another” to the tragedy, attributing most of the failings to “incompetence” and others to “dishonesty and greed”.

Returning to 14 June 2017

Victims of the Grenfell Tower tragedy included men, women and children ranging in age from an unborn baby through to an 84-year-old woman. Initially, the blaze broke out in a fourth floor flat in the early hours of the morning on 14 June 2017. A distress call was made to the London Fire Brigade just prior to 1.00 am. Around 30 minutes later, horrific scenes witnessed the flames reaching right up to the top floor of the 24-storey tower block.

Sir Martin Moore-Bick said: “The simple truth is that the deaths that occurred were all avoidable. Those who lived in the tower were badly failed over a number of years, and in a number of different ways, by those who were responsible for the safety of the building and its occupants.”

The Phase 2 report states the Inquiry Panel’s firm belief that successive Governments failed to take heed of several warnings about cladding from 2001 right through until 2017. In fact, the Government marked the materials used in the cladding for the Grenfell refurbishment as being ‘safe’ based on the ‘Class 0’ rating, despite the knowledge that this wasn’t an appropriate standard for judging given materials’ fire safety.

Aluminium Composite Material cladding

The Phase 1 report delivered by the Inquiry Panel was issued in 2019. One of its key findings was that the Aluminium Composite Material cladding used at Grenfell was not in compliance with the Building Regulations and served as the main reason as to why the flames spread so rapidly along the building’s façade.

During the refurbishment of the building, which took place in 2015-2016, it’s of the Inquiry Panel’s opinion that there was a failure to establish who was responsible for safety standards, duly resulting in an “unedifying ‘merry go round’ of buck-passing”.

The Phase 2 report suggests that the (then) Department for Communities and Local Government was “poorly run”, “complacent” and sometimes “defensive” when talk turned towards fire safety issues.

The coalition Government headed up by (then) Prime Minister David Cameron sought to cut regulation (dubbed by the Conservative administration as ‘red tape’) as it was seen to ‘restrain’ British enterprise. According to the Inquiry Panel, this approach “dominated” political policy thinking inside central Government to such an extent that “even matters affecting the safety of life were ignored, delayed or disregarded.”

Now, the Inquiry Panel has called for the formation of a dedicated Government body that would be ultimately responsible for fire safety and testing, as well as the regulation of construction products. The Inquiry Panel’s extensive report finds that prior arrangements for regulation in the construction industry were “too fragmented” in nature.

Response to the fire

According to the Phase 2 report, the London Fire Brigade should have been aware of the shortcomings of the Aluminium Composite Material cladding, particularly so with regard to high-rise fires in the wake of the Lakanal House blaze in 2009, during which six people lost their lives.

During that period, the Government determinedly resisted calls from across the fire sector to regulate fire risk assessors and to amend the Regulatory Reform (Fire Safety) Order 2005 in order to make it clear that this document applied to the exterior walls of buildings containing more than one set of domestic premises.

A “chronic lack of effective leadership” and “issues with training fire Control Room staff” are also highlighted by the Inquiry Panel. At the time of the Lakanal tragedy, the presiding Coroner’s request for a review of the Building Regulations wasn’t treated with “any sense of urgency”.

Post-Lakanal House, the London Fire Brigade was aware that it faced significant challenges in terms of fighting fires in high-rise tower blocks. The firefighters who attended the scene at Grenfell Tower were simply not prepared for what awaited them in their diligent battle to save lives.

The Inquiry Panel has noted that senior officers had been complacent and lacked the skills to recognise the problems and correct them. There was seemingly a failure to share knowledge about cladding fires, a failure to plan for a large number of 999 calls and a failure to train members of staff in terms of what to tell residents trapped inside the building.

Several recommendations are outlined in respect of the London Fire Brigade, among them that His Majesty’s Inspectorate of Constabulary and Fire and Rescue Services should inspect the former’s Control Room.

Further, Sir Martin Moore-Bick and his colleagues on the Inquiry Panel (namely Ali Akbor OBE and Thouria Istephan) recommend that the National Fire Chiefs Council ought to look into whether firefighters should be discouraged from using their own initiative, as opposed to official instructions, in similar situations.

In a statement issued to Parliament during Prime Minister’s Questions, Sir Keir Starmer apologised on behalf of the British state, saying that those affected by the Grenfell tragedy had been “let down very badly before, during and in the aftermath of the tragedy”. The Labour leader also referenced that “this is a moment to reflect on social justice”.

Potential for prosecutions

For their part, the Metropolitan Police Service and prosecutors have said that investigators will need until the end of 2025 to complete their work, with final decisions on potential criminal charges forthcoming “by the end of 2026”.

Metropolitan Police Service Deputy Assistant Commissioner Stuart Cundy said: “The publication of today’s Phase 2 report is a significant milestone for those deeply affected by the tragedy. The thoughts of the Metropolitan Police Service are with the bereaved, survivors and residents as well as the wider Grenfell Tower community. We remember with much sadness all those who lost their lives.”

Cundy continued: “The report is direct, comprehensive and reaches clear conclusions. Our policing investigation is independent of the Public Inquiry. It operates under a different legal framework and so we cannot simply use the report’s findings as evidence to bring charges.”

On that note, Cundy added: “In order to secure justice for those who died and all those affected by the fire, we must examine the Phase 2 report, line by line, alongside the evidence from the criminal investigation. This process will take us a period of at least 12-to-18 months. This will then lead to the strongest possible evidence being presented to the Crown Prosecution Service such that it can make charging decisions.”

Importantly, Cundy noted: “I cannot pretend to imagine the impact of such a long police investigation on the bereaved and survivors, but we have only one chance to make sure that our investigation is right. We will be thorough and diligent in our investigation work, while moving forward as swiftly as possible. We owe that to those who died and all those affected by the tragedy.”

Scale of the investigation

Post-Grenfell, detectives have identified (and are actively investigating) 19 companies or organisations and 58 individuals as suspects. They’ve entered an “early investigative advice” phase and submitted eight of 20 advice files to the Crown Prosecution Service.

Further, detectives have interviewed (under caution) upwards of 50 suspects for a total of more than 300 hours. They’ve spent more than a year forensically examining Grenfell Tower, painstakingly removing its exterior piece by piece. They’ve collated more than 27,000 exhibits now held in a 635 m² warehouse. Those exhibits include pieces of cladding, insulation, doors, windows and other elements of the building.

What’s more, detectives have followed up more than 27,000 separate lines of enquiry, taken more than 12,000 witness statements, retrieved upwards of 152 million documents and files and evaluated circa 1,600 witness statements provided to the Grenfell Tower Public Inquiry, as well as looking at 300 days’ worth of evidence and over 320,000 documents disclosed by the Inquiry.

*Read the Grenfell Tower Inquiry Phase 2 report in full online