Grenfell Tower Inquiry: Phase 2 Report · 2024
Chapter 101: Local government
Chapter 101: Local government
Introduction
¶101.1 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
¶101.2 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 Hetherington {LFB00061158/2} page 2, paragraph 6; Hetherington {Day277/10:8-20}.
¶101.3 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 Hetherington {LFB00061158/3} page 3, paragraph 9. The deputy chair of the forum was the town clerk and chief executive of the City of London Corporation, John Barradell.364 Hetherington {Day277/25:13-16}, Minutes of London Resilience Forum meeting dated 6 February 2017 {LFB00119171/2}.
¶101.4 The London Resilience Group is a body which provides business and administrative support for the London Resilience Forum.365 Hetherington {Day277/16:9-13}. Its staff are provided and hosted by the London Fire Brigade (LFB).366 Hetherington {Day277/12:10-25}. 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 Hetherington {LFB00061158/2} page 2, paragraph 5; Hetherington {Day277/7:1-10}.
¶101.5 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 Hetherington {Day277/16:14-24}. 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 Bellamy {MOL00000025/5} page 5, paragraph 18; McManus {Day283/19:15-21}. The partnership consists of about 170 organisations.
36¶101.6 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 Hetherington {Day277/34:21-25}. At the time of the fire the Local Authorities' Panel was chaired by John Barradell.371 Hetherington {Day277/31:23}. In June 2014 the 33 local authorities were grouped into 6 sub-regional groups known as sub-regional resilience forums,372 Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005, Schedule {CAB00007003/27}. which acted as links between the borough resilience forums and the London Resilience Forum.373 Hetherington {LFB00119130/3} page 3, paragraph 9.
London Local Authority Gold
¶101.7 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 Hetherington {LFB00061158/4} page 4, paragraph 12; the Gold Resolution {LFB00061166}. 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 London Local Authorities Mutual Aid {LFB00061169/3} paragraph 1.1.1-1.1.5. 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 Hetherington {LFB00061158/5} page 5, paragraph 13; LLAG Operating Procedure v.8.0 July 2016 {LFB00061185}.
¶101.9 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 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}. The evidence indicated that there was some uncertainty about how they could be invoked, in what circumstances and by whom,382 Barradell {Day279/14:16}-{Day279/15:5}; {Day279/58:15-16}; Farrar {Day284/10:3}-{Day284/13:7}; Hetherington {Day277/60:6-23}. whether they were based on any power383 Hetherington {Day277/59:6}-{Day277/60:5}; Barradell {Day279/12:10-25}. 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
37¶138.384 Barradell {Day279/116:9-19}; Farrar {Day284/138:7-14} and {Day284/139:7-9}; Hetherington {Day277/58:4-8}. We explore the extent to which that confusion affected the response to the fire further in Chapter 102.
Voluntary and faith sector panels
¶101.10 Category 1 responders have a legal duty to have regard to voluntary organisations in their area that are relevant to an emergency.385 Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005, reg. 23; Hetherington {Day277/68:18-21}. The Voluntary Sector Panel and the Faith Sector Panel are two of the panels that make up the forum.386 London Resilience, Terms of Reference, Appendix 01/C {LFB00061162/7}. A representative of each of those panels therefore attends meetings of the forum.387 Hetherington {LFB00119130/12} page 12, paragraph 36. Guidance on involving the voluntary sector was developed and agreed by the London Resilience Forum in a document entitled Voluntary Sector Capabilities Document.388 Voluntary Sector Capabilities Document v.6.0 April 2017 {GOL000000027}.
Borough resilience forums
¶101.12 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 Hetherington {Day277/80:19-23}-{Day277/81:3}.
The Greater London Authority
38¶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.
¶101.14 Notwithstanding the GLA's role in maintaining strategic oversight of resilience399 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. 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 Bellamy {Day282/12:23}-{Day282/13:11}; {Day282/13:23}. thus preventing either of them from exercising any effective supervisory or monitoring role.
The Mayor of London
¶101.15 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 Emergency Preparedness, {CAB00004545/11} paragraph 9.22. 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.
¶101.16 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 s.2(1)(a) of the Greater London Authority Act 1999. we understand that he regards himself by extension as a Category 1 responder.403 Bellamy {Day282/17:18-24}. Consistent with that view, the statutory guidance, Emergency Preparedness, explicitly refers to the role of the Mayor of London in the preparedness404 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}. of the capital.405 Emergency Preparedness, {CAB00004545/11} Chapter 9 London.
¶101.17 The responsibilities of the Mayor of London in the response phase are set out in the Strategic Co-ordination Protocol,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. 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 Strategic Coordination Protocol {LFB00061180/25} at paragraph 2.8.11. The term "voice of London" does not appear in the statutory guidance,408 Bellamy {Day282/21:8}. 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 Bellamy {Day282/21:10-20}. However, the Mayor of London has no responsibility for the operational response to a civil emergency.410 Khan {MOL00000189/16} page 16, paragraph 62. His is essentially a political and communications role.
39The Royal Borough of Kensington and Chelsea
¶101.19 Category 1 responders have a statutory duty to maintain and modify emergency plans as necessary.412 Section 2 (1)(c)-(e) Civil Contingencies Act 2004 {CAB00004616/3}. 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 Regulation 22(2) Civil Contingencies Act 2004 (Contingencies Planning) Regulations 2005 {CAB00007003/12}.
¶101.20 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 Chapter 5 (Emergency Planning) of Emergency Preparedness {CAB00004623/19} paragraph 5.51.
¶101.21 There are three groups of plans covering London as a whole:
i. Multi-agency plans produced by the London Resilience Partnership, which set out the partnership's emergency response arrangements. They are also known as "frameworks".415 Hetherington {LFB00061158/7} page 7, paragraph 21. ii. Plans relating to arrangements made by local authorities for a regional response (e.g. the London Gold arrangements).416 Hetherington {LFB00061158/9-10} pages 9-10, paragraphs 23-27. iii. Plans relating to the internal arrangements made by the London Resilience Group for responding to an emergency.
¶101.22 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 Hetherington {Day277/130:25}-{Day277/131:11}. 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 Hetherington {LFB00061158/8} page 8, paragraph 22. Two highly pertinent frameworks relevant to the response to the Grenfell Tower fire call for particular examination.
40The Humanitarian Assistance framework
¶101.23 The Humanitarian Assistance framework419 Humanitarian Assistance Framework, April 2017 {LFB00061172}. dated April 2017 was a draft framework due for approval by the London Resilience Forum on 28 June 2017.420 Hetherington {LFB00061158/8} page 8, paragraph 22. 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 Humanitarian Assistance Framework, April 2017 {LFB00061172/4} paragraph 1.1.
¶101.24 The lead responder for humanitarian assistance is the local authority.422 Hetherington {LFB00061158/6} page 6, paragraph 18. 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 Humanitarian Assistance Framework, April 2017 {LFB00061172/20} paragraphs 7.2 and 8.15.
¶101.25 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 Humanitarian Assistance Framework, April 2017 {LFB00061172/24} paragraph 8.13. We discuss the Humanitarian Assistance framework further in Chapter 104.
The Identification of the Vulnerable framework
¶101.26 The guidance entitled Identification of the Vulnerable, drafted by the London Resilience Partnership, was published in January 2015 for local implementation.425 The Identification of the Vulnerable v.1 {LFB00061174}. The guidance adopts the Cabinet Office's definition of vulnerability426 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. 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 The Identification of the Vulnerable v.1 {LFB00061174/4} paragraph 1.2.
¶101.27 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 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. 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 Identifying people who are vulnerable in a crisis {CAB00014864/3}; The Identification of the Vulnerable v.1 {LFB00061174/8} paragraph 2.3.
41¶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 Hetherington {Day277/151:7-24}. Mr Kerry's view, however, was that apart from compiling a list of lists, the guidance was too difficult to achieve in practice.431 Kerry {Day268/177:12–16}.
¶101.28 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 Hetherington {Day277/152:3-19}. He did not accept Mr Kerry's view that the Cabinet Office guidance on the identification of the vulnerable was unachievable433 Kerry {Day268/175:15-16}; Hetherington {Day277:152:21}–{Day277/153:6}. and told us that although identifying vulnerable people was difficult, because the lists are subject to constant change, it was certainly achievable.434 Hetherington {Day277/153:12-18} e.g. London Borough of Brent, Identifying the Vulnerable Framework {LFB00061174/15}. 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.
Review of local authority emergency planning in London
¶101.29 In 2016 Mark Sawyer, then Deputy Head of Emergency Planning in the LFB Emergency Planning Team,435 Sawyer {GOL00001349/1} page 1. was instructed by the Local Authorities' Panel to undertake a review of local authority emergency planning in London.436 Sawyer {GOL00001349/2} page 2, paragraph 9. 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 Sawyer {GOL00001349/2} page 2, paragraph 9.
¶101.30 Mr Sawyer was supported in his review by Mr Kerry and their report, known as "EP2020", was issued on 3 October 2016.438 Recommendations for Local Government Emergency Planning and Resilience for the 2020's {GOL00001515}. 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 Recommendations for Local Government Emergency Planning and Resilience for the 2020's {GOL00001515/3}.
¶101.31 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:
42"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 Recommendations for Local Government Emergency Planning and Resilience for the 2020's {GOL00001515/8} paragraph 3.1.1.
¶101.32 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 Recommendations for Local Government Emergency Planning and Resilience for the 2020's {GOL00001515/12}. 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 Minimum Standards for London {LFB00119219/4-7}. 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).
RBKC plans
¶101.34 Issue 9 of RBKC's Contingency Management Plan446 Contingency Management Plan {RBK00004396} Issue 9 (dated 30 April 2015) was the relevant version at the time of the fire. dated 30 April 2015 had been drafted by Mr Kerry.447 Kerry {Day268/25:19}. 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.
¶101.35 There were substantial shortcomings in the RBKC Contingency Management Plan. As Mr Kerry accepted, a number of the annexes had been left empty,448 Kerry {RBK00058091/2-5} pages 2-5, eleven of which were left empty: annexes 5-9, 18, 30, 34, 37-38, 40-41 or were wrongly labelled,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. or were still in draft form, or contained outdated plans.450 Kerry {Day268/29:9-13}. Significantly, they included Annex 16, a Humanitarian Assistance Centre plan dated 15 April 2008.451 Annex 16 of the RBKC Contingency Management Plan, Humanitarian Assistance Centre plan {RBK00051900}; {Day263/123:18-23}; RBKC Opening Submissions {RBK00068467/10} paragraph 37. Mr Kerry acknowledged that it was outdated, was no longer viable and should have been removed.452 Kerry {RBK00058091/3} page 3. A document entitled Framework for Identifying and Contacting Vulnerable Persons in an Emergency in Annex 21 was in draft form dated April
43¶2012. Mr Kerry conceded that in hindsight more could have been done to produce a finished version,453 Kerry {RBK00058091/4} page 4. but the real question is why there was insufficient foresight, given that the whole point of contingency planning is to look to the future.
¶101.36 There were different versions of Issue 9 of the Contingency Management Plan.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. 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 Contingency Management Plan {RBK00005194}. It included action cards for Council Silver and for specific emergency responses.456 Contingency Management Plan {RBK00005194/3}. Mr Kerry said that they were both draft documents,457 Kerry {Day268/47:11-18}-{Day268/52:10-11}. but he conceded that there had been a need in 2017 for a proper guide to tactics.458 Kerry {Day268/48:24}-{Day268/49:5}. 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.
¶101.37 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 Kerry {Day268/43:18-21}. There was a difference between Mr Kerry and the head of the Media Communications Team, Martin Fitzpatrick, about why that was.460 Kerry {Day268/44:20}-{Day268/44:20}-{Day268/45:16}. 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 Kerry {Day268/43:18-21}. 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.
¶101.38 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 RBKC {Day263/115:15-24}.
Training and practice
¶101.39 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 The Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005 {CAB00007003/13}.
44¶101.40 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 Service Level Agreement between LAP and LFEPA {LFB00061184/2}. In order to test those arrangements, LFEPA was obliged to design and deliver an annual programme of exercises.465 Emergency Preparedness paragraph 9.6 {LFB00061171/6} and {LFB00061184/3}.
¶101.41 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 Hetherington {LFB00061158/14-15} page 14-15, paragraph 42.
¶101.42 The London Resilience Partnership's programme of training and exercises467 London Resilience Partnership and Training Programme 2017-2020 {LFB00061201}. was designed by a group chaired by Mr Gould and Mr Hetherington, then joint deputy heads of the London Resilience Group.468 LRP Training and Exercising Group Terms of Reference v.1.0 {LFB00061201/12} paragraph 6. 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 LRP training and exercising programme, 2017 to 2020 {LFB00061201/1} paragraph 1.3. 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 Hetherington {Day277/166:16}; {LFB00061201/2-7} paragraphs 3.1-3.15.
¶101.43 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 Hetherington {Day277/204:18-25}. 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 Overview of Local Authority Training Delivered by LRG 2016/17 {LFB00061215/3}.
¶101.44 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 Hetherington {LFB00061158/16} page 16, paragraphs 49-50.
¶101.45 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 Hetherington {Day277/167:6-14}. otherwise than through the Minimum Standards for London, which we have touched on above and which we examine further below.475 Hetherington {Day277/170:3}. The attendance of representatives from individual local authorities at training events provided by the London Resilience Partnership was voluntary.476 Hetherington {Day277/166:24}-{Day277/167:4}.
¶101.46 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.
45¶101.47 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 Minimum Standards for London, Draft 2016.1 {LFB00119219/4} paragraph 3.1. At the time of the fire, the 2016 draft of the standards applied, having been approved by the implementation group in September 2016.478 Hetherington {LFB00119130/19} page 19, paragraph 61. It referred to publication of an annual programme of exercises to support the London Gold arrangements,479 Minimum Standards for London, Draft 2016.1 {LFB00119219/13} 1.14a. including an annual exercise involving all 33 boroughs, the Co-ordination Centre and London Gold.480 Minimum Standards for London, Draft 2016.1 {LFB00119219/14} 1.15a.
¶101.48 The exercise Unified Response in 2016 was the first substantial London-wide exercise held since exercise Safer City in 2013481 Hetherington {Day277/173:13}–{Day277/174:1}; Exercise Safer City 2017, Post Exercise Report, February 2017 v.1 {LFB00061212/4}. that involved London Gold and the London Local Authorities Co-ordination Centre.482 Kerry {RBK00033579/11} page 11, paragraph 39. It was also the first opportunity in three years to test London-wide local authority co-ordination arrangements.483 Hetherington {Day277/173:13}-{Day277/174:1}; Exercise Safer City 2017, Post Exercise Report, February 2017 v.1 {LFB00061212/4}. 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 Babel Post Exercise Report {RBK00005188/1}.
¶101.49 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 Exercise Unified Response {LFB00061214/141} paragraph 3.6; Hetherington {LFB00061158/15} page 15, paragraph 46. 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 Exercise Unified Response {LFB00061214/141}. 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 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. 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.
¶101.50 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 Exercise Unified Response Evaluation Report April 2017 {GOL00001154/149} paragraph 3.6.18. 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 Hetherington {Day277/177:21-25}. 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.
46¶101.51 We understand that the evaluation report on exercise Unified Response490 Exercise Unified Response Evaluation Report April 2017 {GOL00001154}. was shared quite widely across the Local Authorities' Panel and that there was a mechanism491 Hetherington {Day277/177:9-20}. through the learning and implementation group to record the lessons and review the relevant frameworks.492 Hetherington {Day277/176:18}-{Day277/177:20}. 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 Exercise Unified Response Evaluation Report April 2017 {GOL00001154}.
¶101.52 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 Hetherington {Day277/178:1-22}.
RBKC training and practice
¶101.53 In recognition of its obligation under the regulations495 The Civil Contingencies Act 2004 (Contingency Planning) Regulations 2005{CAB00007003/13} regulation 25. 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 Contingency Management Plan, Section 1.8 {RBK00004396/11}. 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 Kerry {RBK00033579/8} page 8, paragraph 26. 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 Kerry {RBK00058091/6-7} pages 6-7, paragraph 2.5. Mr Kerry had asked to have four hours available but was only allowed two. He conceded that the training was "insufficient".499 Kerry {Day268/78:2-6}. 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 Kerry {RBK00058091/8} page 8, paragraph 2.6-2.7.
¶101.54 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 Priestley {Day270/6:16}-{Day270/7:20}. Such a programme was implemented only after the Grenfell Tower fire.
47¶101.55 An overarching feature of RBKC training was the absence of records.502 Kerry {RBK00058091/25} page 25, paragraphs 6.5 and 7.1. 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 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. and Local Authority Liaison Officers (LALOs) was infrequent, irregular and basic in nature.504 Kerry {Day268/85:12}-{Day268/86:5}; Kerry {RBK00058091/27} page 27, paragraph 11.1; Blackburn {Day270/122:2-14}; {RBK00068318}. 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 Blackburn {Day270/106:19}-{Day270/107:13}. We agree.
¶101.56 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 Blackburn {Day270/115:20}-{Day270/116:25}. In late 2016, on her return from a secondment, she found that the situation had deteriorated,507 Blackburn {Day270/119:3-10}. and that exercises were limited to London-wide exercises conducted by the London Resilience Group.508 Blackburn {Day270/106:24}-{Day270/107:3}. She considered that other members of staff were not aware of the Contingency Planning Unit or its work in general.509 Blackburn {Day270/113:24-114:9}. We accept what she said about that also.
¶101.57 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 Kerry {Day268/97:13}-{Day268/98:1}; {RBK00058054/1}. Ms Blackburn described the approach of RBKC to London Resilience Group exercises as being to do the least it could.511 Blackburn {Day270/112:4-21}. That was due to a combination of capacity, attitude and lack of commitment.512 Blackburn {Day270/112:25}-{Day270/113:20}.
¶101.58 The exercises that were carried out disclosed a number of problems.513 Exercise Responder, October 2015 {RBK00058067/2}; Exercise Babel, November 2015 {RBK00005188/4}. 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.
48¶101.59 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 Kerry {Day268/72:19}-{Day268/73:6}. He admitted that the shortcomings had been caused by a lack of available staff.515 Kerry {Day268/73:7-16}. 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 Kerry {Day268/78:14-15}. 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 Kerry {Day268/78:22}-{Day268/80:17}.
¶101.60 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.
¶101.61 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 Kerry {Day268/61:19-23}; Report to the Management Board, paragraph 1.2 {RBK00058038/1}. 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 Kerry {Day268/62:6-11}. 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 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.
¶101.62 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 Kerry {Day268/70:10-11}.
¶101.64 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 Kerry {Day268/66:2-9}. 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.
49¶In our view RBKC's policy of relying on volunteers undermined its ability to practise its emergency plans in accordance with its statutory duty.
¶101.65 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.
¶101.66 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 Minimum Standards for London Assessment Template RBKC 2016 {RBK00036770}. It was produced by Mr Kerry,527 Kerry {Day268/146:6-8}. who rated various aspects as amber.528 MSL Assessment Template 2017 {RBK00047524}. 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 Blackburn {Day270/124:4}-{Day270/125:10}; Kerry {Day268/147:2-15}.
¶101.67 Significantly, the borough's capability for humanitarian assistance was also rated amber.530 Kerry {Day268/153:7}-{Day268/154:11}. 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 Kerry {Day268/153:7}-{Day268/155:7}.
¶101.68 The report indicated that RBKC had no Humanitarian Assistance Lead Officer (HALO).532 Kerry {Day268/164:18}-{Day268/168:4}; Humanitarian Assistance Framework {RBK00011313/2}. 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 Kerry {Day268/168:18-22}.
¶101.69 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 Identifying the Vulnerable Framework paragraph 1.7.1 {LFB00061174/6}; Minimum Standard tab 2.6 {LFB00119219/20}; Kerry {Day268/168:24}-{Day268/175:1}. 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 Kerry {RBK00058091/3-4} pages 3-4. Annex 21: 'A framework for identifying and contacting vulnerable persons in an emergency.
¶101.70 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 Kerry {Day268/170:9}-{Day268/171:5}; {RBK00005188/4}. 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 Kerry {Day268/179:22}-{Day268/181:8}. Indeed, in March 2017, he had told Tony Andrews,
50¶Emergency Planning Manager (Humanitarian Assistance) at Westminster City Council that it remained a considerable concern within RBKC.538 {RBK00058010}; Kerry {Day268/156:4}-{Day268/157:18}; {Day269/2:24}-{Day269/5:11}.
¶101.71 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 Hetherington {Day277/155:15)–{Day277/156:1}. In relation to the identification of vulnerable persons, the reports for 2016 showed that nine of the 33 boroughs were amber.540 MSL Peer Review Results 2016 {LFB00119221}. For 2017, ten of the 33 boroughs were amber and one red.541 MSL Results for all Borough 2017 (final); MSL Self-Assessment Results 2017 {LFB00119222/10} excludes Hackney {LFB00119232}.
¶101.72 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 Kerry {Day268/156:4}-{Day268/159:12}. 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 Section 2(1)(c)-(d) Civil Contingencies Act 2004 {CAB00004616/3}; Regulation 23 Civil Contingencies Act (Contingency Planning) Regulations 2005 {CAB00007003/13}. 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 The Role of the Voluntary Sector {CAB00004597/2} paragraph 14.6; Kerry {Day268/163:3-7}. 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 Kerry {Day268/159:5-12}, {Day268/158:25}-{Day268/159:6}.
¶101.73 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 RBKC Closing Submissions {RBK00068546/24} paragraph 84.
¶101.74 None of those matters were reported to the chief executive or senior executive board of RBKC.547 Kerry {Day268/151:2}-{Day268/153:5}. 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.
51