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Grenfell Report: Key findings from the inquiry

Grenfell Inquiry’s final report sets out how a chain of failures across government and the private sector led to Grenfell Tower becoming a death trap.

The fire killed 72 people in 2017, with the cladding already found to be the “principal” reason for the blaze’s rapid spread.

On Wednesday, the final 1,700-page report of the six-year public inquiry into the fire was published.

Here are the key points from that report.

Government was warned 25 years before the disaster struck

The report by Sir Martin Moore-Bick, a retired High Court judge, says experts sounded an alarm about cladding fires in 1992 after the 11-storey Knowsley Heights tower caught alight in Huyton, Merseyside.

Seven years later there was another fire at Garnock Court in Irvine, North Ayrshire, and a committee of MPs repeated the concerns.

But the flammable cladding wasn’t banned because it had already been classed as meeting a British safety standard.

Fire tests proved how dangerous the cladding was

Safety tests in 2001 revealed the type of cladding of concern “burned violently”. The results were kept confidential and the government did not tighten any rules.

“We do not understand the failure to act in relation to a matter of such importance,” the inquiry panel said.

Eight years later in 2009, six people died in a fire at Lakanal House, a high rise in South London. The coroner at their inquests asked for a review of building regulations but, the inquiry found, this was “not treated with any sense of urgency.”

The 2010 coalition government ignored risks

In 2010 the coalition government headed by David Cameron was on a mission to cut regulations - which it had dubbed as “red tape” holding back British enterprise.

The inquiry found this policy so “dominated” thinking in government that “even matters affecting the safety of life were ignored, delayed or disregarded.”

The inquiry found that the then housing department was “poorly run” and fire safety had been left in the hands of a relatively junior official.

Privatisation of a key body added to problems

The Building Research Establishment (BRE) is a key body in the UK that was set up 100 years ago to help deliver quality science-led standards for the construction industry. It is the government’s expert adviser.

The BRE was privatised in 1997 - but the inquiry said it then became exposed to “unscrupulous product manufacturers.”

Dangers were 'deliberately concealed'

The inquiry found there had been “systematic dishonesty” from those who made and sold the cladding.

Arconic, a manufacturer, “deliberately concealed” the true extent of the danger of the cladding used to wrap Grenfell Tower. Fire tests it commissioned showed the cladding performed poorly but this information was not given to the BBA, a British private certification company tasked with keeping the construction industry up to date.

This “caused BBA to make statements that Arconic knew were ‘false and misleading’”, the report said.

Two firms made the insulation inside the cladding panels - Celotex and Kingspan.

Celotex made “false and misleading claims” about its product being suitable for Grenfell, said the inquiry. Kingspan, the inquiry said, misled the market by not revealing the limitations of its product.

Council body showed 'indifference'

The inquiry said Grenfell’s refit was poorly managed by contractors and the Royal Borough of Kensington and Chelsea’s company that ran social housing, known as a Tenant Management Organisation (TMO).

The inquiry said there had been a breakdown in trust and relations between the TMO and residents, which led to a “serious failure to observe responsibilities”.

It showed a “persistent indifference” to fire safety and the needs of vulnerable residents.

When the TMO had to replace self-shutting fire doors in the block - a key safety measure to prevent spread of smoke and flames - it did not order the correct specification that would improve the chances of residents being rescued.

'Merry go round of buck-passing'

The inquiry said that during the refit of the building there was a failure to establish who was responsible for safety standards - resulting in an "unedifying 'merry go round of buck-passing'".

Studio E, the architect, Rydon, the principal contractor, and Harley Facades, the cladding sub-contractor, “all took a casual approach to contractual relations,” said the report.

“They did not properly understand the nature and scope of the obligations they had undertaken, or, if they did, paid scant attention to them.”

The inquiry said Studio E “bears a very significant degree of responsibility for the disaster” before it had failed to recognise the cladding was combustible.

Harley Facades “bears significant responsibility” because it had not concerned itself with fire safety at any stage.”

Rydon failed to make clear which contractor was responsible for what - and it failed “to take an active interest in fire safety.”

London Fire Brigade bosses didn’t prepare their teams

The LFB had known since the 2009 Lakanal fire that it faced challenges in fighting blazes in high-rise blocks. The firefighters who went into Grenfell had not been prepared for what they had to battle through to try to save lives.

The inquiry said senior officers had been complacent and lacked the skills to recognise the problems and correct them. There was a failure to share knowledge about cladding fires, a failure to plan for a large number of 999 calls, or train staff in what to tell trapped residents.

And so the disaster was the product of 'decades of failure'

The inquiry pulls no punches in concluding that the path to disaster began many years ago.

It says that the way building safety is managed in England and Wales is “seriously defective”. It recommends a single regulator, answerable to a government minister, so that officials and the industry can be held to account.

Sir Martin Moore-Bick:

Today the Panel in the Grenfell Tower Inquiry is publishing its final report dealing with

the root causes of the fire.

In Phase 1 of the investigations I examined the events of 14 June 2017: how the fire

started, how it escaped from the flat where it had begun and how it spread over the

whole building with tragic consequences. My report on that series of events was

published on 30 October 2019. In the second phase of the Inquiry the Panel has been

investigating the underlying causes of the fire with a view to identifying where mistakes

were made and ensuring that a similar disaster cannot occur again.

This second part of the investigations has taken longer than we had hoped, partly

because of the broad scope of our Terms of Reference and partly because, as our

investigations progressed, we uncovered many more matters of concern than we had

originally expected.

As we discovered, it is not possible properly to understand the causes of the fire

without understanding the way in which knowledge of the materials and methods of

construction employed in the refurbishment developed over the course of time, what

the government and others learnt about them and how the regulations and guidance

relating to their use developed during the same period. The information obtained in

that part of our investigations provided the background to our examination of the

refurbishment itself and the various decisions taken in the course of it, particularly in

relation to the selection of materials.

In addition, it has been necessary for us to examine the way in which fire safety at

Grenfell Tower was managed, including the arrangements for fire risk assessments

and the response to them, as well as the relationship between the Tenant

Management Organisation and the residents of the tower.

The firefighting operations of the London Fire Brigade were considered in detail in my

first report, but a number of questions relating to organisation and training could not

be answered at that stage and were deferred for consideration in Phase 2.

Also deferred to Phase 2 were certain questions relating to the development of the

fire, including the relative contributions of the different materials used in the cladding.

Another important aspect of our Terms of Reference was to investigate the response

of the authorities to the emergency.

Finally, but most importantly, it was necessary for us to investigate in as much detail

as the evidence would allow the circumstances surrounding the deaths of those who

perished in the fire.

The report we are publishing today contains our findings on all these and other

matters. However, the simple truth is that the deaths that occurred were all avoidable

and that 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 ensuring the safety of

the building and its occupants. They include the government, the Tenant Management

Organisation, the Royal Borough of Kensington and Chelsea, those who manufactured

and supplied the materials used in the refurbishment, those who certified their

suitability for use on high-rise residential buildings, the architect, Studio E, the principal

contractor, Rydon Maintenance Ltd, and some of its sub-contractors, in particular,

Harley Curtain Wall Ltd and its successor Harley Facades Ltd, some of the

consultants, in particular the fire engineer, Exova Warringtonfire Ltd, the local

authority’s building control department and the London Fire Brigade. Not all of them

bear the same degree of responsibility for the eventual disaster, but, as our reports

show, all contributed to it in one way or another, in most cases through incompetence

but in some cases through dishonesty and greed.

The failings can be traced back over many years and our efforts to get to the bottom

of what went wrong and why, account for the length of our report and the time it has

taken us to produce it. However, if an inquiry of this kind is to produce anything of

value, it is necessary for those who can influence the future direction of the

construction industry, the fire and rescue services, the management of fire safety in

buildings and resilience planning to understand exactly where mistakes were made

and how they can be avoided in the future.

The report is divided into 14 parts, broadly by reference to related subjects. Some

Parts contain several chapters; some only one. As with the Phase 1 report, it begins

with an Introduction followed by an Executive Summary. Although the Executive

Summary runs to 24 pages, the length of the report means that it can touch on only

the most significant elements of our conclusions. However, it should assist readers in

finding their way around the report.

Part 2 describes significant events that provided the background to the fire. It begins

by explaining how the regulations and guidance in force at the time of the

refurbishment came into being and the way in which the reaction to fire of materials

used in the construction of modern high-rise buildings was tested. We then consider

the involvement of the government in the form of the Department for Communities and

Local Government, the way in which it sought to monitor the causes of fires when they

occurred and, most importantly, the warning signs that were emerging from as early

as 1991 that some kinds of materials, in particular aluminium composite material

panels with unmodified polyethylene cores, were dangerous. We find that there was a

failure on the part of the government and others to give proper consideration at an

early stage to the dangers of using combustible materials in the walls of high-rise

buildings. That included failing to amend in an appropriate way the statutory guidance

on the construction of external walls. That is where the seeds of the disaster were

sown.

In Part 3 we set out our findings about the testing and marketing of the main products

used in the refurbishment, the Reynobond panels, the Celotex RS5000 insulation and

the small amount of Kingspan K15 insulation. We discovered that there had been

systematic dishonesty on the part of manufacturers involving deliberate manipulation

of the testing processes and calculated attempts to mislead purchasers into thinking

that what were combustible materials complied with the provisions of the statutory

guidance that advised against their use. That dishonest approach to marketing was

compounded by the failure of two of the bodies that provided certificates of compliance

with the Building Regulations and statutory guidance, the British Board of Agrément

and Local Authority Building Control, to scrutinise the information provided to them

with sufficient care and exercise the degree of rigour and independence that was to

be expected of them.

The Tenant Management Organisation was at the heart of events leading up to the

fire. In Part 4 we make our findings about its relationship with the residents of Grenfell

Tower. We find that the organisation was badly run and failed to respond to criticisms

of its treatment of residents in independent reports produced in 2009. It is clear that

for some years before the fire relations between the TMO and residents were marked

by distrust, antagonism and increasingly bitter confrontation. We find that for the TMO

to have allowed the relationship to deteriorate to such an extent reflects a serious

failure on its part to observe its basic responsibilities.

Part 5 of the report is concerned with the management of fire safety at the tower.

Again, we find that residents were badly let down. The picture is one of a persistent

failure to give sufficient importance to the demands of fire safety, particularly the safety

of vulnerable people, and a failure on the part of the Council to scrutinise that aspect

of the Organisation’s activities adequately. Part of the reason for that was the failure

of the chief executive, Robert Black, to ensure that the board of the TMO and the

Council were kept properly informed of matters affecting fire safety. That was despite

periodic expressions of concern by the LFB about compliance with the Fire Safety

Order, all of which should have been drawn to their attention.

The TMO’s failure to attach sufficient importance to fire safety is illustrated by its

reliance on a single person, Carl Stokes, as fire risk assessor for its entire estate,

despite his lack of qualifications and experience, by its failure to carry out necessary

remedial work identified in fire risk assessments promptly, by its failure to provide

measures to mitigate the absence of an effective smoke ventilation system and by its

failure to introduce appropriate arrangements for inspecting and maintaining fire

prevention systems, in particular self-closing devices on the entrance doors to

individual flats. In addition, the TMO failed to maintain a reasonably accurate record

of those residents of the tower who were vulnerable for one reason or another and

likely to need help to escape if a fire occurred.

Part 6 contains our findings about the refurbishment itself and again, the picture is

disturbing. First, the regulatory context in which the work was carried out was in our

view unsatisfactory because the statutory guidance, which was treated by many in the

construction industry, including those engaged on the refurbishment, as containing a

sufficient statement of what was required, did not make it clear enough that it was

subject to the overriding requirements of the Building Regulations. That was a

particular problem in relation to the rainscreen panels, which, although they satisfied

the requirement in the guidance for a material with a Class 0 surface, contained a

highly combustible core.

But that is only the beginning. The Tenant Management Organisation, as the client,

manipulated the process of appointing an architect to design the refurbishment to

avoid the need to invite open tenders for the architectural services. It did so because

it wanted to appoint Studio E, the architect for the existing Academy and Leisure

Centre project, despite the fact that it had no experience of overcladding a high-rise

building. That turned out to have significant consequences, because Studio E failed to

recognise, as a reasonably competent architect should have done, that the insulation

and rainscreen chosen for the refurbishment were combustible and unsuitable for that

purpose. ACM panels were chosen as the rainscreen to keep down the cost. Neither

Rydon, the principal contractor, nor Harley, its cladding sub-contractor, was aware of

the properties of the materials specified for use in the refurbishment, although Harley,

as a specialist cladding sub-contractor, should have been and Rydon, as principal

contractor, had its own responsibility to ensure the materials were suitable.

One of the problems that afflicted the refurbishment was a failure on the part of all

concerned to understand where responsibility for any particular decision lay. That was

especially the case in relation to the choice of the rainscreen. The generally prevailing

view was that, since ACM panels had been used on other buildings without apparent

problems, they were suitable for use on the tower, but no one was prepared to accept

responsibility for having chosen them and when questioned everyone who was asked

said that someone else had been responsible for ensuring that they were suitable. We

find that Studio E, Rydon and Harley all took an unacceptably casual approach to

contractual relations. None of their employees engaged on the project understood the

relevant provisions of the Building Regulations, the statutory guidance or such

guidance from industry sources as was available.

That might not have mattered quite so much if proper advice had been taken from a

competent and experienced fire engineer or if building control had performed its task

properly. In fact, the Tenant Management Organisation did instruct Exova

Warringtonfire to produce a fire safety strategy for the refurbishment, which should

have included advice on the effect of the overcladding and the compliance of the

external walls with functional requirement B4(1) of the Building Regulations. Exova

produced three versions of a fire safety strategy, but each version was stated to be a

draft and was incomplete because it did not deal with that question, which it said would

be covered in a future issue of the report. It was clear, therefore, that the fire safety

strategy was incomplete, but no one asked Exova to finish its work, nor did anyone

provide it with details of the proposed cladding to enable it to do so. Exova itself failed

to ask for the missing information or to complete the work it had been instructed to

carry out. The failure to obtain a final report was probably critical, because, if Exova

had considered the proposed cladding, it should, and probably would, have identified

the fact that the insulation and rainscreen did not comply with the statutory guidance.

In Part 8 we set out our findings on the management and training of the London Fire

Brigade in the years leading up to the fire. That part of our investigations represented

a continuation of the work started in Phase 1, in which I described the response of the

LFB on the night. I was critical of certain aspects of that response, in particular, the

way in which the control room handled calls from people trapped in the building and

the actions of some of the incident commanders who had not been properly trained to

deal with a fire of that nature. That made it necessary for us to examine the LFB’s

management and training in the period leading up to the fire as well as the way in

which it made use of the information available to it.

In this report we find that there were deficiencies in the organisation and management

of the control room, the training of control room officers and in the commissioning and

delivery of training to operational crews, in particular in relation to incident command.

There were also deficiencies in the collection of information needed to enable crews

to prepare effectively to respond to fires in individual buildings. The primary cause of

those problems was a chronic lack of effective leadership, combined with an undue

emphasis on process and an attitude of complacency.

We have also returned to investigate some aspects of firefighting operations on the

night of the fire on which I was unable to make findings in Phase 1, in particular,

problems with communications and the supply of water.

I shall return to Part 9 in a moment but for now I move to Part 10, in which we examine

the authorities’ response to the fire. Once again, we have found that those who lost

their homes as a result of the fire were badly let down by the organisations that should

have provided the support they desperately needed. The primary responsibility for that

lay with the Council, which, as a Category 1 responder under the Civil Contingencies

Act, should have had plans in place to enable it to respond effectively to the

emergency. In the event, however, it had failed to put in place suitable plans or provide

the training to its staff that was required to enable it to respond effectively to the

situation it faced. In addition, its chief executive was ill-suited to taking control of what

was undoubtedly a very serious challenge. The Council did not have the capacity to

identify those who needed accommodation and other important forms of assistance;

nor did it have arrangements in place for communicating with those affected by the

disaster or the wider public. As a result, it was not capable of meeting the immediate

needs of those who had been displaced from their homes for food and shelter. In the

end it was local voluntary and community organisations that filled the gap by providing

rest centres and temporary shelter.

The London-wide resilience structures that were intended to enable the capital to

respond to an emergency affecting more than one borough did not operate effectively,

partly because they were not designed to provide central direction to the response and

partly because the Royal Borough of Kensington and Chelsea did not seek assistance

promptly. In the event, the government, in the form of a senior official in the

Department for Communities and Local Government, brokered an arrangement under

which the experienced Town Clerk of the City of London took control of the operation.

An important chapter of this Part records the evidence given by those who were

personally affected by the fire. We are aware that giving evidence, particularly giving

evidence in public, was a difficult and daunting experience. We should therefore like

to thank all of those who contributed to our investigations by giving evidence, both in

the form of witness statements and by being willing to talk about their experiences in

public. By doing so they ensured that we received the fullest possible account of the

events that unfolded in the days following the fire.

In Parts 11, 12 and 13 of the report we deal with a number of different matters,

including the experiments carried out by Professor Bisby and Professor Torero on the

materials used in the refurbishment. They confirm that the Reynobond ACM panels

were the primary reason for the fire’s devastating progress.

Part 14 contains our recommendations. Although some steps have already been

taken to respond to the many failures we have identified, we think that more can and

should be done to bring about a fundamental change in the attitudes and practices of

the construction industry. Only such a change can ensure that in future buildings in

general, and higher-risk buildings in particular, are safe for those who live and work in

them.

We think that in different ways implementation of our recommendations will improve

fire safety, particularly in high-rise buildings, and ensure that dangerous materials

cannot be used in construction in the future. They will also improve the efficiency of

fire and rescue services nationally. They include:

● the appointment of a construction regulator to oversee all aspects of the

construction industry;

● bringing responsibility for all aspects of fire safety under one government

department;

● the establishment of a body of professional fire engineers, properly regulated

and with protected status and the introduction of mandatory fire safety

strategies for higher-risk buildings;

● a licensing scheme for contractors wishing to undertake the construction or

refurbishment of higher-risk buildings;

● the regulation and mandatory accreditation of fire risk assessors;

● the establishment of a College of Fire and Rescue to provide practical,

educational and managerial training to fire and rescue services; and

● the introduction of a requirement for the government to maintain a publicly

accessible record of recommendations made by select committees, coroners

and public inquiries, describing the steps taken in response or its reasons for

declining to implement them.

I now return to Part 9 of the report which is the most personal Part and contains the

most difficult reading. It contains a detailed account of the circumstances surrounding

the deaths of those who perished in the fire. I did not refer to it earlier because it

seemed to me fitting to end these proceedings, as they began in May 2018, with a

reminder that the fire at Grenfell Tower was above all a human tragedy in which many

lives were lost, families were torn asunder, homes were destroyed, and a community

was shattered.

The detailed reconstruction we have provided will be for many one of the most

important parts of our report. Although it may make painful reading, those who lost

relatives and friends naturally feel a need to know as much as possible about their

loved ones’ last moments. I said on many occasions that I hoped we could find

sufficient facts to satisfy the coroner of the circumstances surrounding their deaths

and avoid the need for any further proceedings.

I am now able to say that we have been able to make detailed findings about the

circumstances in which people died, including calls made to the emergency services,

the transfer of information from the control room to the incident ground, the recording

of that information on its way to and at the bridgehead and the steps taken to rescue

those who were trapped. We are satisfied that all those who died in the building were

overcome by toxic gases produced by the fire and with expert assistance we have

been able to establish a reasonably accurate time of death in each case. We are

satisfied that all those whose bodies were damaged by the fire were already dead by

the time it reached them.

In a moment my fellow panel members, Ms Istephan and Mr Akbor, wish to add some

comments of their own. Before they do so, however, I should like to thank the Inquiry

team, without whom it would not have been possible to carry out an investigation of

this kind. It would be invidious to single out individual names for mention on this

occasion because everyone involved, whatever their particular task, has played an

essential part in enabling us to do our work. With their help we have followed up many

lines of inquiry, some of which led to surprising revelations, and have collected and

digested a huge number of documents and statements, not to mention hearing many

days of oral evidence. All those who have worked for the Inquiry over the years are

named in an appendix to the report.

I now invite Ms Istephan to say a few words.

Thouria Istephan:

Thank you, Sir Martin.

Before I joined the inquiry panel I spent nearly 30 years working as an architect. In

that role I developed a particular interest in health and safety, fire and accessibility

matters. Returning home from a holiday in June 2017, I flew over west London and

saw the burning tower in the early hours from the air. As for so many others, this was

a profound shock: first of course as a human response, but also as a professional who

had spent their career working to make buildings safe. Throughout this inquiry, we

have been determined to find out how such a disaster was possible - and what needs

to be done to save lives in the future.

As Sir Martin has just summarised, we have found many failings across a wide range

of institutions, organisations and individuals that spanned many years - which together

led to the terrible fire at Grenfell Tower. They include many failures of the construction

industry - my own sector - which is where I will focus my comments on today.

Since the fire, the Government has passed the Building Safety Act. The Act is welcome

but we need to go further. Our report identifies what we think is needed to make sure

that the legacy of Grenfell is real and brings about lasting and progressive change.

Our recommendations place new burdens and responsibilities on people and

organisations. I make no apologies for that: put simply, if you work in the construction

industry and you do not feel the weight of the responsibility you have for keeping

people safe - you are in the wrong job.

The change we need to bring about is partly about structures and regulations. Sir

Martin has set out the key points of what we have proposed, and the report explains

our recommendations in detail. But the necessary change is also one of culture and

behaviour. Change on this scale needs to be owned and led by those of us working in

the sector. It is not enough to pass an Act of Parliament and to sit back and think the

work is done. Without changes in behaviour - and a recognition that the needs of the

people who use our buildings must be placed at the centre of our work, the lessons of

Grenfell will not truly be learned in full.

One of the core themes of our report is technical incompetence of many of those

involved in the refurbishment project. As hundreds of other buildings are now known

to have similar cladding systems, it is clear that the problem of incompetence is

widespread. It follows that part of the change that is needed to the culture of the

industry is an ongoing commitment to the development of professional skills. If we are

not professionally curious we will not become technically competent. Again, this

change needs everybody in the construction industry to play their part in the

implementation of the Inquiry’s recommendations.

We must also keep at the very forefront of our minds our responsibilities towards those

who are most vulnerable. At Grenfell, a significant number of those who died were

children, had disabilities, or were vulnerable in other ways. The risks posed by a

particular building - and the right response to those risks - are always as diverse as

the people who live or work in it. That is why we recommend that the Government

thinks again about defining ‘higher-risk’ buildings solely by reference to their height. It

is why fire safety strategies must provide for the safety of all occupants - and it is why

a ‘stay put’ strategy will never be appropriate where there is a risk of fire spreading

over a building’s external walls. It is why we recommend that Government guidance

should be reviewed, so that the safety and resilience of a building is prioritised. And it

is why we stand by the Inquiry’s Phase 1 recommendation about the need for PEEPS

- personal emergency evacuation plans - for residents with mobility issues or other

impairments.

As an inquiry panel we have acted throughout with fairness, independence and

impartiality. That is what the law requires. At the same time, the losses so many people

have suffered and my involvement in this process have left a mark on me as a person

and a professional which will last far beyond this Inquiry. And although the inquiry is

now ending, we know that for many people their journey continues. We wish them

strength for the future.

I will now hand over to my colleague Ali.

Ali Akbor:

Thank you, Thouria.

My role as a panel member has been to listen to the evidence, to consider what I have

heard, and to work with Sir Martin and Thouria to agree findings and

recommendations.

Firstly, I would like to express my own heartfelt sympathy to all those whose lives have

been affected by this tragic fire. We know that an inquiry can feel like a very slow

process. What I can say is that we have been painstakingly thorough and that we

present our report to you with confidence in its veracity. Secondly, I would like to say

that I grew up in council housing. I was involved in creating social housing

organisations. I was chief executive of a housing association for twenty years. What I

can say is that working on the inquiry has had a profound impact on me both personally

and as a social housing professional.

In social housing we often say that we put our tenants at the heart of what we do. But

it is not enough just to pay lip service to that ideal. In our report we look at the

relationship between the Kensington and Chelsea Tenant Management Organisation

and its residents before the fire. We find that it was one of distrust, dislike, personal

antagonism and anger. Residents deserved to be treated with understanding and

respect. The TMO failed to do that.

We saw a similar failure to treat residents as people - and as individuals - in the

aftermath of the fire. Including in the way that those with religious, cultural or social

needs suffered discrimination as a result of RBKC’s failure to prepare properly for

emergencies. It was obvious to me from watching and listening to evidence being

given at the hearings that there were two different groups of people, those who lived

at Grenfell and those who worked for the TMO, RBKC and their agents.

In our report we set out how the Government’s focus on deregulation dominated the

department’s thinking such that even matters affecting the safety of life were ignored,

delayed or disregarded. The deregulation agenda had a parallel impact on the social

housing sector - particularly in terms of consumer standards and protection for tenants.

The effects of that can be seen in the many failings of the TMO which we set out in

our report - and which were not prevented or addressed by the regulatory system then

in place.

Parliament has now passed the Social Housing (Regulation) Act, which will enhance

the powers of the regulator in support of stronger consumer standards, and which

stresses the need for involvement and empowerment of tenants, and the

reintroduction of inspections of landlords. In my view, this was not a moment too soon.

Our report underlines why its full implementation is so important and so urgent.

I have focused so far on the TMO’s role as a social housing provider. The TMO also

played an important part in the refurbishment of Grenfell Tower in its role as the

project’s client. We have found that the TMO paid insufficient care in its choice of

architect and failed to pay enough attention to fire safety. I hope that our report acts

as a reminder to the clients of future building projects - including social housing

providers - that they have a responsibility to the users of their buildings to ensure that

safety is not sacrificed to the demands of speed and cost. Regulations should not be

treated as boxes to be ticked, but as a way of giving residents confidence that their

homes are safe.

Finally, I would like to echo something that Thouria has said. We cannot in a few words

here today do full justice to the totality of our report. What is needed is for those with

responsibility for building safety - in my sector as in Thouria’s - to read the report, to

reflect on it, and to treat Grenfell as a touchstone in all that they do in the future. That

is to act with professionalism, with competence, and to put people first.

I will now pass you back to Sir Martin. Thank you.

Sir Martin Moore-Bick:

We should remember that the Grenfell Tower fire was and remains an intensely

personal tragedy for all those who lived in and around the tower and above all for those

who died, their families and friends.

We invite you, therefore, to join us in remembering them while I read out their names:

Fathia Ahmed Elsanousi

Abufras Mohamed Ibrahim

Isra Ibrahim

Mohammed Amied (Saber) Neda

Hesham Rahman

Rania Ibrahim

Fethia Hassan

Hania Hassan

Marco Gottardi

Gloria Trevisan

Raymond Herbert (Moses) Bernard

Eslah Elgwahry

Mariem Elgwahry

Anthony Keith Disson

Bassem Choukair

Nadia Choucair

Mierna Choucair

Fatima Choucair

Zainab Choucair

Sirria Choucair

Hashim Kedir

Nura Jemal

Yahya Hashim

Firdaws Hashim

Yaqub Hashim

Abdulaziz El Wahabi

Faouzia El Wahabi

Yasin El Wahabi

Nur Huda El Wahabi

Mehdi El Wahabi

Ligaya Moore

Jessica Urbano Ramirez

Omar Belkadi

Farah Hamdan

Malak Belkadi

Leena Belkadi

Mary Mendy

Khadija Saye

Victoria King

Alexandra Atala

Mohamednur Tuccu

Amal Ahmedin

Amaya Tuccu -Ahmedin

Amna Mahmud Idris

Majorie Vital

Ernie Vital

Debbie Lamprell

Gary Maunders

Berkti Haftom

Biruk Haftom

Hamid Kani

Isaac Paulos

Sakina Afrasehabi

Fatemeh Afrasiabi

Vincent Chiejina

Khadija Khalloufi

Kamru Miah

Rabeya Begum

Mohammed Hamid

Mohammed Hanif

Husna Begum

Joseph Daniels

Sheila

Steven (Steve) Power

Zainab Deen

Jeremiah Deen

Mohammad Alhajali

Denis Anthony Peter Murphy

Ali Yawar Jafari

Abdeslam Sebbar

Logan Gomes

Pily Burton

Thank you all very much.

Posted on: 4 September 2024

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Executive Summary