Part 1: Introduction

Chapter 1: Introduction

¶1.1 In his introduction to his Phase 1 Report published on 30 October 2019 the chairman described the circumstances which led to the setting up of the public inquiry into the fire at Grenfell Tower on 14 June 2017. He also described the way in which the Inquiry had been organised and how it had gone about carrying out its task. Anyone who is not already familiar with those matters should refer to paragraphs 1.1 – 1.25 of that report. This second phase of the Inquiry builds on the findings made by the chairman in Phase 1 and is a direct continuation of that work. In those circumstances we do not think that it is necessary to repeat what is said in the introduction to the Phase 1 Report, but there have been some developments since it was published to which we should draw attention before turning to the substance of our report.

¶1.2 In Phase 1 the chairman set out to examine in detail the course of events on the night of 14 June 2017 with a view to identifying with as much confidence as possible what had taken place during the period between the outbreak of fire in the kitchen of Flat 16 at 00.54 and the escape of the last survivor at 08.07 that morning. The purpose of doing so was twofold: to enable those who had been directly involved in the fire, both residents and fire fighters, to give their accounts of the events of that night at the earliest opportunity and to find out as far as possible exactly what had happened during the early hours of 14 June 2017 before seeking to establish exactly what had gone wrong and why.

¶1.3 In Phase 2 we have set out to answer the question that has been at the forefront of many people's minds: how was it possible in 21st 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? There is no simple answer to that question, but in this report we identify the many failings of a wide range of institutions, entities and individuals over many years that together brought about that situation.

¶1.4 Following the publication of the Phase 1 report, the Prime Minister appointed Ms Thouria Istephan and Ms Benita Mehra as additional members of the Inquiry panel. In October 2019 Ms Redfearn resigned as an assessor and in February 2021 Mr John Mothersole, a former chief executive of Sheffield City Council, was appointed an assessor in her place, joining Mr Joe Montgomery and Professor David Nethercot, both of whom have continued to assist us generously with their time and advice. Needless to say, however, we remain entirely responsible for the conclusions in this report.

¶1.5 In January 2020 Ms Mehra resigned from the Panel. Mr Ali Akbor OBE was appointed in her place in October 2020.

¶1.6 In June 2022 Mr Mark Fisher resigned as Secretary to the Inquiry on his appointment as Chief Executive of the NHS Greater Manchester Integrated Care Board and was replaced by Ms Nicole Kett later that month. Her death in August 2022 after a short illness caused profound shock and sadness. In October 2022 Mr Matt Lewsey was appointed as Secretary in her place.

¶1.7 The procedure adopted in this Phase of the Inquiry has been the same as that in Phase 1. In particular, we have continued to ensure that our investigations have been as detailed and thorough as the extensive material that we have been able to gather has allowed. The chairman decided at an early stage that this phase could conveniently be divided into a number of separate modules, each reflecting an aspect of the background to the fire. That enabled the evidence to be adduced in an orderly way and minimised the need to call witnesses more than once. In most cases it also allowed expert evidence to be heard immediately after the factual evidence to which it related.

¶1.8 The Inquiry sat to hear evidence and opening and closing statements for Phase 2 for a total of 312 days. The hearings for Phase 2 began on 27 January 2020 but were interrupted almost immediately for a period of about five weeks at the instigation of certain core participants while an undertaking was obtained from the Attorney General to protect witnesses from the risk of having their evidence used against them in criminal proceedings.¹¹ The Attorney-General's Undertaking is at https://www.gov.uk/government/news/attorney-general-provides- undertaking-for-grenfell-tower-inquiry. Hearings began again in earnest on 2 March 2020 but had to be suspended on 16 March 2020 as a result of the restrictions imposed in response to the Covid 19 pandemic. Hearings resumed on 6 July 2020 and continued until 9 December 2020. During that period access to the hearing room was limited to those whose presence was essential, but the proceedings continued to be streamed and could be viewed by anyone interested in doing so.

¶1.9 Between 9 December 2020 and 8 February 2021 the proceedings were interrupted again by restrictions imposed in response to the pandemic, but between 8 February 2021 and 25 March 2021 our increasing familiarity with remote conferencing facilities and the outstanding assistance of our technical support teams at RTS Communications and Opus 2 International made it possible for us to continue hearings while observing the requirements of lockdown. On 19 April 2021 we were able to resume hearings at 13 Bishop's Bridge Road, albeit still with restricted access. Unrestricted public access to the hearing room resumed in September 2021 and continued until November 2022.

¶1.10 As before, all witness statements and documents put in evidence during the course of the hearings have been published on the Inquiry's website and the proceedings have been streamed live on the internet. In addition, arrangements were made for the proceedings to be video-recorded and transcribed and for access to both the video-recording and the transcript to be available through the Inquiry's website.

¶1.11 In his introduction to the Phase 1 report the chairman explained the effect of rule 13 of the Inquiry Rules and the approach that he had decided to take to sending warning letters to those who might be subject to criticism.²² Phase 1 Report Volume I paragraph 1.24. In this phase we decided that we should take the same approach, but that inevitably presented us with a considerable challenge, given the number of people who were likely to face criticism of one kind or another. Between June 2023 and April 2024 the Inquiry's solicitors wrote to 247 individuals and organisations informing them of the criticisms that we were minded to make of them and providing them with the relevant chapters of the draft report identifying the evidence on which those potential criticisms were based.

¶1.12 Between July 2023 and May 2024 the Inquiry received responses from the vast majority of those to whom warning letters had been sent, but the process as a whole took much longer than had been expected because in some cases the amount of material that a recipient had to consider was substantial. All the responses were carefully considered and in some cases we modified our provisional conclusions in the light of them. As in Phase 1, however, for the reasons explained by the chairman in the Phase 1 Report we did not take into account fresh evidence or new arguments that could have been, but had not been, put forward during the hearings.³³ Phase 1 Report Volume I paragraph 1.25.

¶1.13 In pursuing our investigations we have had the benefit of receiving the expert advice and assistance of a number of leading practitioners in a wide range of disciplines, all of whom provided us with written reports and subsequently gave evidence to the Inquiry at public hearings. We are most grateful to all of them for the enormous amount of time they devoted to our work and the enthusiasm which they brought to it. In most cases their opinions were not seriously challenged, but to the extent that they were, we have set out the points made in opposition to their evidence in the body of our report and have given reasons for our conclusions. Except in those cases, however, we consider that the weight of their expertise and the absence of any real challenge to their evidence justifies us in accepting their opinions unless we have some good reason not to do so. Where we have relied on their evidence we have identified in footnotes the relevant passages in their reports or oral evidence without referring to them in the body of the text.

¶1.14 Section 2(1) of the Inquiries Act 2005 expressly prohibits us from ruling on questions of legal liability, civil or criminal. That is a matter for the courts. However, section 2(2) expressly provides that we are not to be inhibited in the discharge of our functions by any likelihood of liability being inferred from any facts we find or recommendations we make.

¶1.15 When dealing with an area of activity, such as the refurbishment of Grenfell Tower, which involved a large number of organisations bound together by a web of contracts and subject to legislation in the form of the Building Regulations, it is impossible to describe the relationships between them and their individual responsibilities without referring to those contracts and the relevant regulations. We have taken the view, therefore, that to refer to them merely for what they state does not amount to determining liability and we have not expressed a view about any disputes that may exist between the parties to the refurbishment or others about their respective obligations. The contracts and the regulations say what they say and establish certain relationships; we have simply treated them as part of the context in which our findings are to be read.

¶1.16 It is not possible to identify any single cause of the tragedy; many different acts and omissions combined to bring about the Grenfell Tower fire, although some were more significant than others. With some exceptions we have not attempted to apportion blame. We have in general asked ourselves whether a particular act or omission contributed in some way to the fire and, if so, to what extent.

¶1.17 In response to the evidence that emerged during the Inquiry, all of which was published contemporaneously in one form or another, the government has already taken steps to overhaul the regulation of various aspects of the construction industry. In particular, it has prohibited the use of metal composite materials with unmodified polyethylene cores on external walls of buildings of any height, it has prohibited the use of materials that are not classed A2 (s1, d0) or better in the external walls of buildings over 18 metres in height, it has introduced new requirements for obtaining building control approval in relation to the construction and refurbishment of higher-risk buildings and has reformed the arrangements for the exercise of building control functions generally. The creation of an Office for Product Safety and Standards and the appointment of a National Regulator for Construction Products has also been put in hand and measures have been taken to improve the competence of those engaged in the design and construction of buildings generally. To that extent, it has already taken steps to cure many of the more glaring defects in the system we have identified and the scope for making recommendations is correspondingly reduced. Nonetheless, we think there are some important areas in which improvements need to be made and others in which the action taken by the government does not go far enough. In those cases we have made recommendations for change that in our view would make a significant difference to ensuring that fires of the kind that destroyed Grenfell Tower and took the lives of many of its occupants never occur again.

¶1.18 From the earliest days of the Inquiry there have been those who have asserted that discrimination on the grounds of race or social background played a significant part in the tragedy that befell Grenfell Tower on 14 June 2017. Originally that was reflected in calls for the Inquiry to examine social housing policy generally as well as the way in which flats in Grenfell Tower had been allocated. Those calls reflected a widely held belief that people of minority ethnic and socially disadvantaged backgrounds were routinely the subject of active discrimination that took the form of making available to them low quality or unsafe housing. A large proportion of the residents of Grenfell Tower at the time of the fire were from ethnic minorities and many were socially disadvantaged. The implication was that they had been allocated flats in what was known to be an unsafe building as a result of racial and social discrimination.

¶1.19 It may well be that the Grenfell Tower fire has raised questions about social housing policy, whether in RBKC or more generally, that deserve examination, though whether a public inquiry conducted under the Inquiries Act 2005 is the most suitable method of doing so may be open to debate. To have acceded to the calls for us to undertake that task, however, would have extended the scope of the Inquiry (and the time taken to produce a report) very significantly, since, even if limited to the allocation of social housing by RBKC, it would have required an examination of the council's housing records over a period of some years. Any examination of social housing policy more widely would have extended that task enormously. As a result, the Prime Minister decided not to include those matters in the Inquiry's Terms of Reference.

¶1.20 Nonetheless, at various stages during the Inquiry we have been urged to investigate what is alleged to have been a culture of racial and social discrimination in the institutions involved in one way or another in the refurbishment, particularly RBKC and the TMO. The desire to investigate and expose discrimination of that kind flowed from 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.

¶1.21 For the reasons we have explained, the existence of racial or social discrimination in the allocation of social housing falls outside our terms of reference, but any factors that affected the decisions that led to the creation of an unsafe building are within our scope and we have done our best to investigate them thoroughly. Our response to those who wanted us to investigate racial and social discrimination has always been that we would look out for it and that if we came across any evidence that racial or social prejudice might have affected any of the decisions that led, directly or indirectly, to the disaster, we would examine it thoroughly and publish our findings, as befits an inquiry seeking to uncover the truth.

¶1.22 We should say at once that we have seen some evidence of racial discrimination in the way in which some of those who survived the fire were treated in the days immediately following it at a time when they were at their most vulnerable and we have described what happened in Part 10 of this report. We have also seen evidence that the TMO failed over the course of years to treat residents of the tower and the Lancaster West Estate more generally with the courtesy and respect due to them. That is described in Parts 4 and 5. However, we have seen no evidence that any of the decisions that resulted in the creation of a dangerous building or the calamitous spread of fire were affected by racial or social prejudice and none of those representing the bereaved, survivors or residents has drawn any such evidence to our attention, although they have had access to all the material before us.

¶1.23 How Grenfell Tower came to be home to a disproportionately large number of socially disadvantaged people, many from ethnic minority backgrounds, is a question that lies outside our terms of reference. It must be remembered, however, that almost without exception they had been living there, in some cases for many years, before the refurbishment was ever contemplated. Many residents told us how much they liked living there. The tower was a concrete structure and before the refurbishment was largely impervious to fire. At the time most residents were allocated their flats it was perfectly safe and we have seen nothing to suggest that following the refurbishment anyone in the RBKC housing department thought it had ceased to be so. There was no question, therefore, of allocating homes to those of non-white ethnicity in a building known to be dangerous.

¶1.24 In the course of the Inquiry we have examined a very large number of documents relating to the refurbishment and many hours of testimony from those involved in designing, planning, executing and approving the work. In this report we have described in some detail the course of events that led to the disaster. We have identified many errors, due in the most part to incompetence, carelessness and a failure to take responsibility for important aspects of the work that affected fire safety. In a few cases, principally involving the manufacturers of building products, we have identified dishonesty. However, we have seen no evidence that any decisions directly affecting the design or execution of the refurbishment were affected by racial or social prejudice. Although the TMO was anxious to keep the cost of the refurbishment down, and although some of the decisions taken to achieve that end were ultimately responsible for the tragedy, we saw no evidence that any of those responsible for them was aware of their potential consequences.

¶1.25 Given the repeated urging by some of those representing the bereaved, survivors and residents to consider whether the race or social background of those who lived in the tower played a part in bringing about the disaster and the implicit assertion that it did, we think it right to make it clear that our investigations have not brought to light any evidence to support that conclusion.

¶1.26 We are only too well aware that our investigations into the fire and the production of our report have taken longer than many would have wished. However, as our work has gone on it has become increasingly apparent that the disaster was the result of shortcomings in the construction industry that were far more extensive than had previously been envisaged. As the scale of the problems became ever clearer it seemed to us that those most directly affected by the fire deserved to be given a detailed and thorough description of the circumstances that led to the fire so that they could understand how it had come about and where responsibility for it lay. We hope that they and others who read our report will be satisfied that our investigations have been as detailed and thorough as they would have wished.

¶1.27 An inquiry of this magnitude involves an enormous amount of work and could not be conducted without a large and well-organised team of lawyers, administrators and technical professionals. We are fortunate to have had the support throughout the duration of the Inquiry of some of the most skilled, loyal and dedicated people one could hope to find, many of whom have been working for the Inquiry since it was set up in June 2017. Some have played a very public role, while others have remained entirely in the background, but they have all played an essential part in enabling us to discharge our terms of reference. A list of those who have worked with us on our investigations can be found in Appendix C. We cannot speak too highly of their professionalism and dedication.