72 avoidable deaths resulting from incompetence, dishonesty, greed and “a culmination of decades of failure by central government and other bodies in positions of responsible in the construction industry” – damning final report published in the Grenfell Tower Inquiry

Posted onSeptember 9, 2024
Isabel Gregory

This week marked the long-awaited publication of the final “phase 2” report of the Grenfell Tower Inquiry led by Sir Martin Moore-Bick alongside panel members Thouria Istephan and Ali Akbor OBE. A private event was held for bereaved family members, survivors and former residents of the tower and the buildings immediately adjacent to it on Tuesday before the public announcement and publication event on Wednesday. For those directly impacted by the fire the end of the inquiry represents a significant milestone in the search for answers, accountability and justice.

The Inquiry

The Grenfell Tower Inquiry has been conducted in two phases. The report for the first phase, which focused on events on the night of the fire, was published on 30 October 2019. Phase 2 of the Inquiry, which has taken the form of a wider examination of the underlying factors and events that led up to and culminated in the fire having such a devastating outcome, was opened on 27 January 2020 but suffered delay due to the Covid-19 pandemic.

The core question at the heart of Phase 2 of the Inquiry has been: How was it possible in 21^st century London for a reinforced concrete building, itself structurally impervious to fire, to be turned into a death trap that would enable fire to sweep through it in an uncontrollable way in a matter of a few hours despite what were thought to be effective regulations designed to prevent just such an event?

The Saunders Law team led by Cyrilia Davies Knight, alongside senior solicitors Isabel Gregory and Ben Curtis, and counsel Professor Leslie Thomas KC and Thalia Maragh, represent a number of Core Participants in the Inquiry, all of whom are bereaved family members, survivors and/or residents of the walkways adjacent to Grenfell Tower.

Key findings

The Inquiry’s final report can be found by clicking here. In it, the panel highlight the “systematic dishonesty” on the part of manufacturers who engaged in “deliberate and sustained strategies to manipulate the testing processes, misrepresent test data and mislead the market”; the failure of the certification bodies to apply proper standards of monitoring, scrutiny and supervision; the ineffective fire testing regime; and statutory guidance which they describe in parts as “fundamentally defective” and “wholly inappropriate”. The joint failures of RBKC and the TMO are laid bare in not only failing to ensure buildings and homes within their remit met fire standards and had adequate emergency plans in place but specifically in regard to the refurbishment project at Grenfell Tower and the response to the fire. The panel conclude that the choice of combustible materials for the cladding of the tower “resulted from a series of errors caused by the incompetence of the organisations and individuals involved in the refurbishment” and assumptions by all involved that others were responsible for fire safety. So too, elements of the response and recovery are criticised as “muddled, slow, indecisive and piecemeal” and certain aspects are said to have “demonstrated a marked lack of respect for human decency and dignity”. The panel make clear that the shortcomings in this respect were not due to any lack of financial resources. In contrast to the criticisms of the RBKC, TMO and London Resilience Network, the panel praise the local community for how they came together and took action, providing vital support to fill the gaps in the official response.

Whilst racial or social discrimination was ruled to be outside the formal terms of reference for the investigation, the panel acknowledge the repeated requests and urges from Core Participants throughout the inquiry to investigate such allegations and admit they have seen evidence of racial discrimination in the aftermath of the fire. The report also recognises the “undeniable fact that a significantly disproportionate number of those who died in the fire and of those who survived the fire but whose homes were destroyed were from ethnic minorities or socially disadvantaged” but many do not feel it goes far enough in addressing the disproportionate impact the disaster had and see this as a missed opportunity.

The findings attribute significant criticism to government and a range of organisations and public bodies. In particular:

Government, is criticised for its missed opportunities in the many years between the Knowsley Heights fire of 1991 to identify risks, heed warnings and its failure to act on “what it knew”; for failing to update, amend and/or clarify regulations, standards and/or guidance known to be misunderstood, unclear and/or otherwise inappropriate; for its “poorly run” department, “complacent and at times defensive attitude to matters affecting fire safety”; and its deregulation agenda which “dominated the department’s thinking to such an extent that even matters affecting the safety of life were ignored, delayed or disregarded”.
The Royal Borough of Kensington & Chelsea (“RBKC”), who from 2009-2017 demonstrated a “persistent indifference to fire safety, particularly the safety of vulnerable people”, and whose oversight of the TMO was “weak”. RBKC’s building control department is said to have failed to properly scrutinise the design and choice of materials for the refurbishment and/or to satisfy itself on completion that the work complied with the Building Regulations requirements. The panel state that the building control department at RBKC failed to perform the statutory function of ensuring compliance with building regulations and the surveyor responsible was “overworked, inadequately trained and had a very limited understanding of the risks associated with the use of ACM panels”. The panel further criticise RBKC’s role in the response to the fire, in particular in relation to catering for the needs of those from diverse backgrounds: “many who had particular religious, 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.” There was no clear plan despite “clear warnings to senior management” that it lacked sufficient trained staff to respond. The Chief Executive, Nicholas Holgate, is said to have been incapable of taking effective control, and unsuited to dealing with the crisis. Perhaps worse still, he was “reluctant to take advice from those with greater experience and was unduly concerned for RBKC’s reputation.”
The Tenant Management Organisation (“TMO”), whose “serious failure” allowed relations with residents to deteriorate into “distrust, dislike, personal antagonism and anger…a toxic atmosphere fuelled by mistrust on both sides”, despite it being the public body exercising control over their homes. The Chief Executive of the TMO, Robert Black, is singled out and criticised for his consistent failure to disclose LFB concerns about fire safety to RBKC. The TMO is also heavily criticised for its overall attitude towards fire safety, the lack of an adequate system for addressing defects identified in fire risk assessments and the “huge backlog of remedial work” that amassed prior to the fire along with inspection and maintenance regimes that “did not reflect best practice and were consistently followed”. The panel state: “the demands of managing fire safety were viewed by the TMO as an inconvenience rather than an essential aspect of its duty to manage its property carefully.” This is reflected in the failure to update the emergency plan which was flagged as outdated and incomplete after a fire at Adair Tower in 2015; and in the failure to collect information on vulnerable residents, something the panel describe as “a basic neglect of its obligations in relation to fire safety”. The panel also highlight how the TMO “manipulated the procurement process” for the refurbishment of Grenfell Tower to avoid a public tender, disregarded advice from its lawyers in negotiating a lower price with Rydon outside of the procurement process, chose products “largely on the grounds of cost” and “as the client it failed to take sufficient care in its choice of architect and paid insufficient attention to matters affecting fire safety, including the work of the fire engineer.”
Carl Stokes, is criticised on an individual level as the “ill-qualified” fire risk assessor who TMO allowed to “drift into that role without any formal selection of procurement process” and who “misrepresented his experience and qualifications (some of which he had invented”. TMO is criticised for continuing to “rely uncritically on him”, despite concerns expressed by the LFB as to his competence.
The Building Research Establishment (“BRE”), is criticised for its “unprofessional conduct, inadequate practices, a lack of effective oversight, poor reporting and a lack of scientific rigour” which “exposed it to the risk of manipulation by unscrupulous product manufacturers” and “compromised its integrity and independence”. The panel conclude it: “sacrificed rigorous application of principle to its commercial interests.”
Arconic, for “deliberately” concealing the danger of using Reynobond 55 PE in cassette form from the market despite being aware from 2007 of “serious concern” in the industry about the safety of ACM panels and the dangerous performance of this product by summer 2011. The panel opine that despite this awareness, Arconic “was determined to exploit what it saw as weak regulatory regimes” to sell the product, deliberately continuing to market and sell it with information known to be false and misleading, and concealing this from certification bodies.
Celotex, who “embarked on a dishonest scheme to mislead its customers and the wider market” by conducting tests using (but not disclosing the use of) fire-resistant boards “with the complicity of BRE” in 2014 rendering results “materially incomplete and misleading”. It further presented its RS5000 product to Harley as suitable and safe to use on Grenfell Tower “although it knew this was not the case”.
Kingspan, who “knowingly created a false market in insultation for use on buildings over 18 meters”, relied deliberately and continually on outdated tests despite changing the composition of products and failed to withdraw K15 from the market despite being aware of concerns and having concerns raised internally about the product’s safety. The panel state that Kingspan “cynically exploited the industry’s lack of detailed knowledge” and that its claim K15 met requirements for Class 0 was “disingenuous”.
The British Board of Agrement (“BBA”), the certification board whose procedures are described as “neither wholly independent nor rigorous” and who facilitated misleading certificates to be produced for products due to “systemic shortcomings and inadequate levels of competence and technical expertise among its staff”, and “seriously deficient”
Local Authority Building Control (“LABC”), whose “complete failure…over a number of years to take basic steps to ensure that the certificates it issued [in respect of Celotex’s RS5000 and Kingspan’s K15] …were technically accurate” allowed misleading statements to be included. The failure of scrutiny the panel suggests indicates that it “was willing to accommodate the customer at the expense of those who relied on the certificates.”
The National House Building Council (“NHBC”), was similarly criticised for being “unwilling to upset its own customers and the wider construction industry by revealing the scale of the use of combustible insulation in the external walls of high-rise buildings.”
United Kingdom Accreditation Service (“UKAS”), who failed to follow its own policies, and whose assessment processes “were lacking in rigour and comprehensiveness” leaving too much to trust.
Studio E, the architects of the refurbishment project, are said to bear “a very significant degree of responsibility for the disaster” and in many aspects to have failed to meet the standards of a reasonably competent architect.
Exova, similarly are said to bear “considerable responsibility”, particularly in respect of the failure to produce a final fire safety strategy for the refurbished building, nor to raise it with the design team. The panel say this is “wholly inconsistent with the careful approach to matters affecting the safety of life to be expected of a reasonably competent fire engineer.”
Rydon, who “gave inadequate thought to fire safety”, “had an inexperienced team” without sufficient knowledge of the regulations and/or guidance, were “complacent about the need for fire engineering advice” and who also bear considerable responsibility for the fire.
Harley, “failed in many respects to meet the standards to be expected of a reasonably competent cladding contractor” and “bears a significant degree of responsibility for the fire”. In particular, it “failed to ask the kind of questions about the materials being considered that a reasonably competent cladding contractor would have asked.”
London Fire Brigade, who failed to act in response to the Lakanal House fire in 2009 and the shortcomings identified. The panel say the LFB’s failings “were attributable to a chronic lack of effective management and leadership combined with an undue emphasis on process”; that senior officers were “complacent” and “lacked the management skills to recognise the problems or the will to correct them” and that “there was a tendency to treat problems of which managers became aware as undeserving of change or too difficult to resolve, even when they concerned operational or public safety.” So too, there was an “entrenched but unfounded assumption” that the UK building regulations prohibited external wall fires of the kind seen in other countries. Training failures are also highlighted along with the policy on high-rise firefighting, which the panel say “did not reflect national guidance”, and the failure to update communication equipment to modernise and alleviate known issues. The control room failings are attributed to “weak management over the preceding years combined with sporadic and ineffectual oversight by senior officers.”

Numerous recommendations have been made, which the panel say aim to “to bring about a fundamental change in the attitudes and practices of the construction industry” to “ensure that in future buildings in general, and higher-risk buildings in particular, are safe for those who live and work in them”. These include a recommendation to appoint a construction regulator to oversee the industry, with responsibility for fire safety to be rolled into one government department; the establishment of a body of fire engineers properly regulated with protected status; mandatory fire safety strategies for high risk buildings, regulation and accreditation of fire risk assessors and a licensing scheme for contractors to work on high risk buildings.

Next steps

The Prime Minister in a statement released on Wednesday committed to responding to the report’s recommendations in full within six months, and thereafter to update Parliament annually on progress made against every commitment made.

Whilst Public Inquiries in the UK do not have the power to make determinations of civil or criminal liability, they can and usually do make findings which play a vitally important role in paving the way for criminal and/or civil actions to be brought. For many of the bereaved, survivors, residents and local community there is hope that the final report findings being published now marks one significant step closer to criminal charge decisions (which were previously put on pause pending the conclusion and report of the Public Inquiry) holding those responsible to account, and one step closer to some sense of justice for all they have had to, and continue to, endure.

Saunders Law’s response to the report

The report’s conclusions and the litany of criticisms levelled at those individuals and organisations whose failures, whether by act or omission, led to such a tragic loss of life and unimaginable suffering are welcomed by us and by our clients. We hope that this serves as a true catalyst for systemic change, accountability and reform, and that urgent concrete action is taken to ensure that the memory of those lost, and the voices of Grenfell’s survivors and victims, are not forgotten and that a tragedy of this kind is never repeated. We call on government, and all relevant parties, to urgently implement all of the recommendations suggested.

As we conclude, it is only fitting to leave the final words to one of our clients, all of whose individual and collective bravery, resilience and relentless pursuit of truth and justice has defined and guided the past seven years and the powerful findings in the final report. Bernie Bernard, who lost her brother Moses in the fire, reflects:

“The last seven years has been an emotional trauma that I cannot put into words. I now welcome the Report from Sir Martin Moore-Bick and his team which has highlighted the dishonesty and greed with the construction industry. For my family, I would now like to see:

the recommendations enforced within the industry in order that a similar tragedy never happens again; and
that the decision makers who knowingly put this project together serve a sentence and take accountability for their actions”

Saunders Law represents a number of Bereaved, Survivors and former residents of Grenfell Tower in the Public Inquiry. We offer expert legal assistance and representation in all public inquiry cases, and we are well-known for our work and thorough approach to complex cases, please contact us on +44(0)207 632 4300, or fill in our online enquiry form if you would like our assistance and we would be happy to discuss your matter with you.