Chapter 104: The response of RBKC

Chapter 104: The response of RBKC

Introduction

¶104.1 As the fire in Grenfell Tower continued to rage, hundreds of residents from the tower and surrounding properties were evacuated from their homes. As a Category 1 responder, RBKC was responsible for the provision of humanitarian assistance to those displaced. Its response was guided by its own Contingency Management Plan and the wider civil contingencies framework described in Chapter 99.

¶104.2 In this chapter we examine the provision of humanitarian assistance, which encompasses the provision of emergency shelter, food and drink, financial assistance, information about those who are missing, public communication and the provision of psychological support to those affected by the incident. RBKC led the response until support from London as a whole was enlisted through the operation of the Gold Resolution on 16 June 2017.^13021302 See above at Chapter 101. From that point on, John Barradell, as London Gold, led the response. The circumstances in which he became involved are described in Chapter 102.

Activation of the RBKC Contingency Management Plan

¶104.3 The RBKC Contingency Management Plan provided that if an incident occurred out of hours, the out of hours contact centre should contact the duty Silver,^13031303 RBKC Contingency Management Plan {RBK00004396/33}. who was responsible for determining the level of the initial council response and initiating the call‑out procedures.^13041304 RBKC Contingency Management Plan {RBK00004396/30} page 30, paragraph 4.1. Levels of response were graded from 1 to 3, level 3 being the most serious and requiring the setting up of a Borough Emergency Control Centre (BECC) at Kensington Town Hall.^13051305 RBKC Contingency Management Plan {RBK00004396/31-37}.

¶104.4 At 02.03 on 14 June 2017, the police informed RBKC of the Grenfell Tower fire using the out of hours service.^13061306 Phase 1 Report, Volume II, paragraph 14.272. Nickolas Layton, the duty officer, alerted David Kerry at 02.21.^13071307 Emergency Event Log Sheet for Grenfell {RBK00013296/1}. He told Mr Kerry that many had been able to leave the tower but that some people remained trapped and that casualties were expected.^13081308 Emergency Event Log Sheet for Grenfell {RBK00013296/1}. As the council did not have anyone on call to act as duty Silver due to staff shortages, Mr Kerry took on the responsibility of determining the level of response required.^13091309 Kerry {Day268/187:4-17}.

¶104.5 Mr Kerry realised that the incident was serious but he did not formally categorise it by reference to the Contingency Management Plan.^13101310 Kerry {Day268/189:19-24}. He remained at home and assumed the role of Borough Emergency Controller, whose task was to co-ordinate the council's response. (At the time, the term "Borough Emergency Controller" was being replaced by the term "Council Silver", and the two were used interchangeably.^13111311 Kerry {Day268/190:15-20}. We shall use the term "Council Silver".)

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¶104.6 Mr Kerry proceeded on the basis that the response should be at level 2 rather than level 3, the highest level.^13121312 Kerry {Day268/190:15}-{Day268/192:5}; RBKC Contingency Management Plan {RBK00004396/33}: A level 2 response requires the Duty Silver to become the controller, working from home. The Department and Service management are called out to respond. A level 3 response requires the Duty Silver to remain at home acting as controller until the Borough Emergency Control Centre (BECC) is opened and staffed. Later in the morning the severity of the incident became clearer to him and the response moved up to level 3.^13131313 Kerry {Day268/192:6-25}. The effect of his initial assessment, however, was that he did not open the Borough Emergency Control Centre (BECC) at the outset.^13141314 The role of the Borough Emergency Control Centre (BECC) is to oversee and co-ordinate the council's incident response Kerry {RBK00033579/8} page 8, paragraph 29. He accepted in hindsight that he initially underestimated the scale of the response required.^13151315 Kerry {Day268/195:10-24}.

¶104.7 Mr Kerry's first step was to contact Laura Johnson, RBKC's Director of Housing, at 02.34.^13161316 Emergency log sheet for Grenfell {RBK00013296/1}. Ms Johnson contacted Robert Black, the chief executive of the TMO,^13171317 Laura Johnson {RBK00035592/5} page 5, paragraph 15. and sent an email to her housing team at 02.53 telling them of the fire and alerting them to the likely need for a considerable amount of emergency accommodation the following day.^13181318 {RBK00001606}. Although Mr Kerry did not look at the TMO emergency plan,^13191319 Kerry {Day268/136:12-17}. he said that he had been aware that the TMO would attend the scene to assist RBKC.^13201320 Kerry {Day268/132:2-18}.

¶104.8 At 02.50 Mr Kerry contacted his line manager, Stuart Priestley, RBKC's Chief Community Safety Officer. They agreed that the situation should be monitored from home until further information was available.^13211321 Priestley {RBK00035672/4} page 4, paragraph 14. Shortly after that call, Mr Priestley became aware of the scale of the incident, having seen an email with images of the fire sent at 02.25 by a former LFB borough commander which said "You have a massive fire, Grenfell Tower".^13221322 Priestley {RBK00035672/4} page 4, paragraph 15. Mr Priestly tried to contact Mr Kerry and managed to speak to him at 03.31, over an hour after Mr Kerry had been told of the fire. They decided that the full contingency management plan should be put into action, that staff should be called in to the Town Hall and that work should be transferred from the BECC (in effect, Mr Kerry) to the Town Hall.^13231323 Priestley {Day270/15:19-25}. The effect was to raise the level of the response and to proceed on the basis of a level 3 response.

¶104.9 Nevertheless, some time elapsed before Mr Kerry set about calling staff, in particular those in the Contingency Planning Unit, into the Town Hall. At 04.09 he rang Keith Robins, the contingency management officer, but received no answer.^13241324 Emergency event log sheet {RBK00013296/4}. At 04.13 he rang Elaine Chumnery, a BECC officer, who returned his call at 04.49 and agreed to go to the Town Hall to support Mr Priestley in opening the BECC.^13251325 Emergency event log sheet {RBK00013296/5}. He rang Rebecca Blackburn at 05.23 and asked her to go in to the Town Hall at 08.00 to take over from him.^13261326 Emergency event log sheet {RBK00013296/7}.

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¶She arrived at the Town Hall at about 07.20. It is unclear whether the delay was due to

¶Mr Kerry's failing to grasp the urgency of the situation or whether he was struggling to deal with the number of demands on him at the time. It is likely that it was a combination of both, as Mr Kerry was seeking to stagger the attendance of staff to ensure that some were available to work later in the day.^13271327 Kerry {Day268/208:2-9}. However, in failing to obtain support from other staff at an earlier stage, he placed himself in an impossible position in seeking to discharge all his duties as Council Silver.

¶104.10 The delay in calling in staff and activating the BECC were compounded by problems in obtaining access to the facilities within the Town Hall. Although Stuart Priestley arrived at the Town Hall at 04.38, he was unable to find the key to the cupboard containing the telephones and computer equipment.^13281328 Priestley {Day270/16:18-21}. He sent an email to Mr Kerry at 05.25 with the subject "Can you come PDQ. We cannot get into the cupboards."^13291329 Priestley {Day270/19:7-11}; {RBK00035661}. There was a further delay of about an hour and a quarter until Mr Kerry arrived with the key at about 06.00.^13301330 Priestley {Day270/17:23}-{Day270/19:6}. RBKC have since installed a key box to prevent something similar happening in the future.^13311331 Kerry {Day269/14:5-10}.

¶104.11 Mr Kerry did not follow the protocol for the activation of the Contingency Management Plan. In particular, he should have contacted staff earlier, because there was too much for one person to do in the time available. Although it is easy to criticise with the benefit of hindsight, we think that Mr Kerry should have realised that as soon as he was warned about the risk of fatalities, and even more so as information began to come in about residents being evacuated from surrounding properties. At all events, the BECC was not operational at the Town Hall until about 06.00 on 14 June 2017; it should have been opened between about 03.00 and 04.00.^13321332 Blackburn {Day270/127:22}-{Day270/128:18}. That was a substantial delay that had significant consequences for RBKC's response, not least in identifying the number and location of the rest centres that had by then opened spontaneously. As hundreds of displaced people poured onto the streets of North Kensington in need of support, RBKC was already many hours behind in assessing and meeting those needs. We are reinforced in that view by the evidence of members of the Contingency Planning Unit whose own assessment of the initial response was that by the time the BECC opened RBKC had already lost control of the incident.^13331333 Blackburn {Day270/140:9-15}.

The involvement of Nicholas Holgate

¶104.12 Nicholas Holgate, town clerk and chief executive of RBKC, visited North Kensington early on the morning of 14 June 2017. He found the scale and ferocity of the fire deeply shocking.^13341334 Holgate {RBK00035426/4} page 4, paragraph 19. He visited the rest centres at the Harrow Club and Rugby Portobello Trust sometime between 04.30 and 06.00 and thought they were functioning properly.^13351335 Holgate {RBK00035426/4} page 4, paragraph 19; Holgate {Day273/48:10-11}. Still at the scene, he did not dial into the first meeting of the strategic co-ordinating group at 05.00,^13361336 Mr Kerry and Mr Priestley attended as RBKC's representatives. Minutes of the Strategic Coordinating Group Meeting at 05.00 on 14 June 2017 {MOL00000026/3}. since, as he told us, he had not been told about it.^13371337 Holgate {Day273/55:14}-{Day273/56:9}; Kerry {Day269/51:12}-{Day269/52:7}. John Hetherington, deputy head of planning, London Resilience, told us that the absence of the chief executive was not desirable, but in his experience not altogether unusual.^13381338 Hetherington {Day277/189:8-14}.

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¶104.13 Mr Holgate arrived at the Town Hall at about 06.00 and had a meeting with Mr Kerry, Ms Johnson, Mr Priestley and Robert Black. It is unclear at what time that meeting was held. Mr Priestley said that it had taken place at 06.30,^13391339 Priestley {Day270/22: 9}-{Day 270/24:20}. although Mr Kerry thought that it had taken place at 10.00.^13401340 Kerry Emergency Event Log 10.00 {RBK00013296/10}; Kerry {Day269/99:15}-{Day269/100:3}. Notwithstanding that difference of recollection, it is clear that there was a meeting that morning at which Mr Kerry provided significant advice to Mr Holgate. Mr Kerry's log records that he advised him that the incident was bigger than any one local authority in London could manage and that consideration should be given to asking for mutual aid for the BECC. The log further records that there were people who could support Mr Holgate and RBKC Gold, including John Barradell, Eleanor Kelly, Andrew Meek (head of organisational resilience at the London Borough of Haringey and London's expert on humanitarian assistance) and Alistair Ayres from Hammersmith and Fulham.^13411341 Kerry Emergency Event Log 10.00 {RBK00013296/10}; Kerry {Day269/99:15}-{Day269/100:3}.

¶104.14 Mr Kerry's advice was based on his concern that there were insufficient RBKC staff to keep the BECC running for an extended period.^13421342 Kerry {Day269/100:4-9}. He believed at the time, and maintained his view when giving evidence, that none of London's local authorities could have coped with the incident on their own, given its scale.^13431343 Kerry {Day269/100:10-24}. He told us that it was clear to him that it was massive and that it was for such incidents that there were mutual aid arrangements in place that he believed were well understood and practised. He told us that it was for the RBKC Gold strategic meeting to consider what resources were required. Once that assessment had been made, they would have been able to activate the London Gold arrangements, if necessary.^13441344 Kerry {Day269/104:24}-{Day269/105:4}. We accept his evidence about that.

¶104.15 Mr Priestley recorded in his log that in response to David Kerry's advice Mr Holgate had said "That looks like we can't cope".^13451345 Priestley Log {RBK00013318/2}. Mr Holgate did not recall making that comment, but he did not dispute the accuracy of Mr Priestley's note.^13461346 Holgate {Day273/69:7-12}. Mr Holgate did not agree with the view that the incident was bigger than any one local authority could manage.^13471347 Holgate {Day273/66:14-19}. Despite the advice of Mr Kerry, he thought that RBKC would be able to respond effectively, if everyone worked together as a team.^13481348 Holgate {Day273/67:6-9}. He denied being influenced by a need to preserve the council's reputation.^13491349 Holgate {Day273/72:9-18}. We are satisfied that the comment recorded by Mr Priestley accurately reflected Mr Holgate's state of mind. In our view his attitude was defensive and his confidence in RBKC's ability to manage the response was misplaced. It became more pronounced as it persisted into the following day, 15 June 2017.^13501350 RBKC Gold group meeting at 11.00 on 14 June 2017 {RBK00013271/4}; and 10.00 on 15 June 2017. {RBK00013270/3}.

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¶104.16 Following the meeting of the RBKC Gold group at 10.00 on 15 June 2017, Ms Blackburn told Mr Holgate and Tony Redpath that they needed to seek assistance from other London boroughs and activate the London Gold arrangements.^13511351 Blackburn {Day270/179:22}-{Day270/180:17}. Her view was that RBKC was not coping and that there were not enough members of staff to support the response.^13521352 Blackburn {Day270/181:6-8}. Mr Holgate and Mr Redpath both told her that the council could manage.^13531353 Blackburn {Day270/181:5}. Ms Blackburn's impression was that senior management at RBKC was reluctant to seek help.^13541354 Blackburn {Day270/180:7-11}. In her view, either they could not see what those on the ground were seeing or they could not cope and chose not to see it.^13551355 Blackburn {Day270/181:6-8}. Ms Blackburn told us that, having been in the BECC for two days, she ought to have been able to provide a clear picture of what was happening on the ground, but could not. That internal view was consistent with the concerns that were beginning to emerge on 15 June 2017 in the media, the London resilience agencies and the government.

The Borough Emergency Control Centre (BECC)

¶104.17 The BECC was the key element in the council's organisation in the days immediately following the fire. Despite the best efforts of those who volunteered to staff the BECC on the morning of 14 June 2017, it was overwhelmed by the incident.^13561356 Blackburn {Day270/138:4-20}; RBKC Module 4 Closing Submissions {RBK00068546/11} page 11, paragraph 30. It struggled throughout the period in which RBKC led the humanitarian response before handing over leadership to John Barradell during the afternoon of 16 June 2017. The circumstances in which that occurred are described in Chapter 102.

¶104.18 The computer equipment used by the BECC was outdated and slow. It was due for replacement but that had not taken place by the time of the fire.^13571357 Kerry {Day269/23:22}-{Day269/26:6}. Problems which had arisen in previous training exercises recurred. At the outset, it was not possible to obtain access to the system for logging information and technical assistance was needed to solve the problem.^13581358 Blackburn {RBK00058170/14} page 14, paragraph 9.10. That affected the ability of the BECC to function efficiently, not least because staff could not open a log to enter tasks and chart progress. Although he could have done so remotely, Mr Kerry had not created an electronic log at the outset. If he had done so, it would have been available to others within the BECC later.^13591359 Kerry {Day269/22:7-18}. Ms Blackburn eventually opened one at 13.18 on 14 June 2017, almost eleven hours after RBKC had been informed of the fire.^13601360 Blackburn {RBK00058170/14} page 14, paragraph 9.8; Blackburn {Day270/155:4-19}. As a result, important decisions taken in the previous hours had not been electronically logged.

¶104.19 Between 07.00 and 07.30 on 14 June 2017 David Kerry, as the first Council Silver and thus the person responsible for co-ordinating RBKC's overall response,^13611361 {RBK00004396/31}. transferred his duties as Council Silver to Stuart Priestley.^13621362 Priestley {Day270/34:20}-{Day270/35:1}; {Day270/35:22}-{Day270/36:10}; Kerry {Day269/62:2-13}. Mr Kerry did not provide him with a copy of his handwritten log (the electronic log was not yet open) and the handover was limited in detail.^13631363 Kerry {Day269/22:20}-{Day269/23:4}. That was partly a reflection of Mr Kerry's failure to appreciate the scale of the incident and partly the result of his being by that stage mentally and physically overcome by the incident.^13641364 Sawyer {GOL00001349/14} page 14, paragraph 70; Kerry {Day269/170:5-14}. He was uncertain about the number and locations of the rest centres that had opened during the morning and did not know how many displaced people were at them. At that stage RBKC had not sent any staff to the rest centres.^13651365 Laura Johnson {Day272/46:6-13}.

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¶104.20 A constant feature throughout the period in which RBKC led the humanitarian response was the shortage of trained staff to operate the BECC. Untrained volunteers from elsewhere in RBKC were drafted in to assist.^13661366 Kerry {Day269/63:21}-{Day269/64:16}; Priestley {Day270/40:13}-{Day270/41:4}. Mr Kerry, an experienced contingency planning manager, worked nights and was not available during the day when his advice was most needed. The burden of leading the operational response during the day fell on Mr Priestley. Although he was a trained Council Silver and Mr Kerry's manager, he had never previously held that role in an emergency.^13671367 Priestley {RBK00035672/3} page 3, paragraph 11; Priestley {Day270/7:11-20}; {Day270/11:11-13}; {Day270/12:8-14}. A further consequence of the staff shortages was that Mr Priestley had to manage the BECC in addition to acting as Council Silver.

¶104.21 By the evening of 14 June 2017 Mr Priestley thought that RBKC needed more help at every level of the response.^13681368 Priestley {Day270/71:4-14}. When he returned to the BECC on the morning of 15 June 2017 it was just as he had left it the previous evening. Both he and Rebecca Blackburn had expected more to have been done overnight by Mr Kerry, who had taken over as Council Silver, such as completing a rota for the rest centre, tidying up the BECC log and creating a strategy for the coming day.^13691369 Priestley {Day270/72:4}-{Day270/73:16}; Blackburn {Day270/173:6-14}. Mr Kerry confirmed that Council Silver was responsible for developing the tactical plan for responding to an emergency.^13701370 Kerry {Day268/59:2-5}. In our view the absence of coherent strategic and tactical plans hindered the response.

¶104.22 By 15 June 2017, it had become apparent that RBKC was unable to provide effective assistance. Mark Sawyer visited the Town Hall on the morning of 15 June 2017 to provide support.^13711371 The circumstances in which he attended RBKC are examined in Chapter 102 when considering the London- wide response. His observations provided an important external insight into how RBKC was coping with the challenge facing it. Mr Sawyer considered that the BECC was failing; it did not have a clear picture of the situation in North Kensington and no situation report had been produced.^13721372 Email from Mr Sawyer to himself on 1 July 2017 {GOL00001301} paragraph 6. (A situation report is vital to enable information to be shared with the Gold group internally and with the strategic co-ordinating group or London Local Authority Co-ordination Centre externally when needed.) The first situation report was not produced until 07.00 on 16 June 2017.^13731373 RBKC BECC Situation Report No.1, 16 June 2017 {RBK00015017}. Mr Sawyer's observations echoed Ms Blackburn's description of the BECC as lacking any organisation.^13741374 {RBK00029019/2} page 2, paragraph 3; Blackburn {Day270/138:1}-{Day270/139:19}. We consider that the inability of RBKC throughout that period to obtain, maintain and record in full information about the situation was a significant failing and delayed support being directed to those who were in need.

¶104.23 Mr Sawyer spent most of 15 June 2017 with Nicholas Holgate and attended the RBKC Gold group meetings.^13751375 RBKC Gold Group meeting on 15 June 2017 at 10.00 {RBK00013270} and at 15.30 {RBK00013262}; Sawyer {GOL00001349/14-15} pages 14-15, paragraphs 69-76. His immediate concern was that RBKC had not been galvanised into a proper response.^13761376 {GOL00001301} paragraph 2. He also advised Mr Holgate, following the meeting of the RBKC Gold group at 10.00 on 15 June 2017, to limit membership of the Gold group to his senior management team and tactical lead officer (Silver) to ensure that discussions were more strategic, as he thought that the meetings had concentrated too much on operational matters.^13771377 Sawyer {GOL00001349/14-15} pages 14-15, paragraph 73. Mr Sawyer thought that Mr Kerry had been traumatised and had ceased to be in a position to influence the strategic direction of the response.^13781378 {GOL00001301} paragraph 3.

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Emergency shelter and accommodation

¶104.24 The aim of the Humanitarian Assistance framework is to ensure that care is delivered in an effective way that meets the needs of those affected by a major emergency.^13791379 London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/4} page 4, paragraph 1.1. It provides that a rest centre can be opened when a significant number of people have been displaced following an incident.^13801380 London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/20} page 20, table 3. A rest centre is a building opened by a local authority for the temporary accommodation of people who have been displaced. It is a place where immediate practical and emotional support may be offered. It is a place of refuge and support for those affected or displaced by an emergency and is often the first point of contact that affected persons have with the authorities. The local authority is responsible for opening and running designated rest centres in the wake of an emergency.^13811381 London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/24} page 24, paragraph 8.15: "The decision to set up a rest centre will be made by the Local Authority often at the request of the police or fire brigade."

¶104.25 RBKC failed to open suitable rest centres in the early morning of 14 June 2017 to meet the needs of the growing number of people displaced from Grenfell Tower and the surrounding properties. Mr Kerry did not refer to the Contingency Management Plan to identify an appropriate centre from the directory annexed to it.^13821382 Contingency Management Plan, Emergency Shelter and Rest Centre Directory, Annex 15 {RBK00048005}. Instead, he accepted an offer from a member of the public to use Belushi's Bar in Shepherd's Bush that could provide shelter for up to 100 people.^13831383 David Kerry's Emergency Log {RBK00028849/1}. However, he failed to assess its suitability. Belushi's Bar was not on RBKC's list of approved premises and was about a mile from the scene of the fire.^13841384 {CAB00003753}; {LFB00119615}. That alone made it an unusual choice for a rest centre in an urban area.^13851385 Spragg {Day280/23:10-18}.

¶104.26 At 03.16 David Kerry called the Red Cross into action at Belushi's Bar under the Memorandum of Understanding.^13861386 Memorandum of Understanding between the British Red Cross and RBKC, 27 November 2015 {BRC00000055}; It had lapsed at the time of the Grenfell Tower fire but the British Red Cross confirmed that that would have made no difference to their attendance, Spragg {Day280/13:24}-{Day280/14:2}. Its staff arrived at 03.45.^13871387 British Red Cross Emergency Log {BRC00000051/4}. By contrast, no RBKC staff were deployed to support them or to manage the rest centre. By 05.30, no one affected by the fire had gone to Belushi's Bar^13881388 British Red Cross Emergency Log {BRC00000051/4}. and Mr Kerry made the decision to close it as a rest centre.^13891389 Kerry {Day269/46:21}-{Day269/47:2}. It was unusual for a rest centre to be empty for almost two and a half hours after it had been opened and it is clear that it was the wrong place to choose.^13901390 Spragg {Day280/23:7-13}. That signalled a false start from which RBKC struggled to recover. Vital Red Cross resources were diverted from the immediate area and further time was lost in getting help to those most in need.

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¶104.27 Mr Kerry accepted that the Humanitarian Assistance framework set out the responsibilities of RBKC in relation to setting up rest centres, but he did not accept that its reliance on the Red Cross to do that was an abdication of its responsibility as a Category 1 responder.^13911391 Kerry {Day268/89:2-25}. We accept that local authorities are entitled to make use of others to discharge their functions and frequently do so, but, as Mr Kerry himself accepted,^13921392 Kerry {Day268/91:7-11}. RBKC should have had its own staff at the rest centres to monitor and supervise the Red Cross.

¶104.28 On the morning of 14 June 2017 information about the existence and location of rest centres spread by word of mouth alone. The result was that those affected by the fire had to endure the stressful experience of going to different rest centres to find information and support.^13931393 Wesley Ignacio {IWS00001820/15} page 15, paragraph 78. The Harrow Club spontaneously opened in the early hours of the morning and soon after that, at about 03.30, it was formally adopted by RBKC as the second rest centre.^13941394 Layton {RBK00029034/6} page 6, paragraph 17; Kerry {RBK00033579/15} page 15, paragraph 58. The Harrow Club was on RBKC's list of approved rest centres. It was a long-established youth club with a large sports hall, located approximately half a mile from Grenfell Tower. Additional Red Cross staff arrived at 04.55 and recorded that there were about 25 people there.^13951395 British Red Cross Emergency Log {BRC00000051/4}. TMO staff arrived at 05.30 but there was no one from RBKC there.^13961396 Warrier {TMO00887108/2} page 2, paragraph 6. From 05.30 the Red Cross asked RBKC several times over a period of some five hours for information about when its staff would come to the rest centres to provide support.^13971397 British Red Cross Emergency Log {BRC00000051/4-6}. See entries 05.30, 06.45, 07.40, 08.15, 09.15, 10.30. The absence of its staff from the various community rest centres in the hours that followed the fire was a prominent feature of the council's early response.

¶104.29 The Rugby Portobello Trust is a local charity group whose building is situated about 400 yards from Grenfell Tower.^13981398 Simms {CFV00000005/2} page 2, paragraphs 7 and 9. On 14 June 2017 it opened spontaneously as a rest centre. We heard how people who were shocked, bewildered and in distress started arriving in large numbers in the early hours of 14 June 2017.^13991399 Simms {CFV00000005/4-6} pages 4-6, paragraphs 19-20, 28; William Thompson {IWS00000158/10} page 10, paragraph 60; Toyoshima-Lewis {IWS00001725/46} page 46, paragraph 154. At 05.45 the Red Cross became aware of its existence as a rest centre and notified RBKC. As a result, Mr Kerry decided to move people from the Harrow Club to the Rugby Portobello Trust.^14001400 British Red Cross Emergency Log {BRC00000051/5}. However, RBKC did not send any senior managers or staff there and by 10.30 none of its staff had arrived at any of the other places of shelter which had opened during the morning to accommodate the growing number of evacuees.^14011401 British Red Cross Emergency Log {BRC00000051/6}; Spragg {Day280/31:22-24}; Stuart Priestley's Log 14 June 2017 {RBK00013318/3}. They included the Clement James Centre, the Latymer Community Church and St. Mark's Church.^14021402 The operation of spontaneous rest centres run by voluntary and community groups is examined in Chapter 106. Its absence was noted by many survivors and added to the sense that they had been abandoned by the council.^14031403 Benjamin {IWS00001764/10} page 10, paragraph 69; Senate Jones {IWS00001691/2} page 2, paragraphs 5-6; Wesley Ignacio {IWS00001820/14} page 14, paragraph 75.

¶104.30 RBKC had a responsibility to register those who went to rest centres seeking support,^14041404 Spragg {Day280/16:11-15}. but it failed to put in place an adequate registration process, which in turn made it difficult to identify, organise and deliver the support needed.^14051405 Adamson {BRC00000075/27} page 27, paragraph 124. The absence of RBKC staff at the rest centres in those crucial early stages directly affected the effectiveness of the registration process. It was left to the TMO,^14061406 The work of the TMO in compiling lists of the 'missing' and 'survivors', including the significant errors that occurred, is examined in Chapter 105. the Red Cross and various voluntary organisations to fill the gap and make whatever arrangements they could.

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¶104.31 In the absence of effective leadership there was no organised and integrated record of where people were and what they needed. The Red Cross tried using paper registration forms. At 04.55, its team arrived at the Harrow Club and found that the staff there had started to make a list of who was present and had given representatives of the TMO forms to register residents.^14071407 British Red Cross Emergency log, 04.55{BRC00000051/4}. However, the number of rest centres that had sprung into existence, some with no Red Cross presence, made the process haphazard.^14081408 Richards {CFV00000012/13} page 13, paragraph 89. There was no system for recording information electronically; instead, everyone relied on loose pieces of paper with handwritten notes that were circulated among responders and staff from the TMO.^14091409 Rupinder Hardy's Personal Briefing Document {LBE00000056/2} 17-18 June 2017: "All documentation was paper based in terms of residents/staff/volunteers on site". Even when the Westway Centre became the official rest centre later on the 14 June 2017,^14101410 Kerry {Day269/189:1-6}. the process of recording and handling information about residents remained rudimentary. People were just asked by the Red Cross to provide a note of their names and the numbers of their flats.^14111411 Omar Ali {IWS00001533/12} page 12, paragraph 59.

¶104.32 Significantly, in the early days of the response the registration that did take place did not appear to be collated and recorded centrally by RBKC. The starkest illustration of that was recalled by Mr Colin Brown, a senior Red Cross official, who said that the details of those who had registered were recorded using triple carbon paper, one copy being retained and the other two copies being provided to RBKC.^14121412 Colin Brown {BRC00000005/25} page 25, paragraph 100. RBKC did not ask them to put the information onto any electronic system or collate it in any other way. He recalled that, in the first few days while RBKC was still notionally in charge of the response, a Red Cross volunteer had found a box containing copies of several registration forms intended for RBKC unattended at the Westway Centre. He did not think that RBKC had made any effort to collate the data and arranged for his concerns to be reported to it.

¶104.33 Registration continued to present problems until 22 June 2017, even after London Gold had taken over management of the response.^14131413 Adamson {BRC00000075/21} page 21, paragraph 99. Without a coherent registration process, it was difficult to identify who had been affected, what their needs were and how best to respond to them. It was also sometimes unclear where those who had been affected actually were.^14141414 Adamson {BRC00000075/21} page 21, paragraph 98.

¶104.34 As the hours passed on the morning of 14 June 2017, no RBKC staff were sent to the rest centres. At the Town Hall, RBKC housing staff were being made ready for deployment as the BECC struggled to find out how many rest centres there were and how many of those who were at them had been affected by the fire.^14151415 Blackburn {RBK00035364/4} page 4, paragraph 19; Blackburn {Day270/139:11-24}. It was thanks to the initiative of Ms Blackburn^14161416 Blackburn {RBK00035364/5} page 5, paragraph 22. that at about 10.00 RBKC housing staff were sent to the Rugby Portobello Trust and the Clement James Centre.^14171417 Laura Johnson {RBK00035592/8} page 8, paragraph 33.

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¶104.35 Laura Johnson, Director of Housing at RBKC, said that the delay in sending people to North Kensington had been caused not only by a shortage of staff at the Town Hall but also by a lack of information about which rest centres were being used.^14181418 Laura Johnson {Day272/46:24}-{Day272/47:19}. A further hindrance to the deployment of staff was the fact that several of the rest centres had been opened spontaneously by the community.^14191419 RBKC Incident Situation Report {RBK00033583/2}. It was difficult to co-ordinate the emergency response in the absence of a single official rest centre whose existence and location could be widely communicated.^14201420 Laura Johnson {Day272/48:1-11}.

¶104.36 Ultimately, council staff did not reach any of the rest centres for some eight hours after RBKC had been notified of the fire. That was far too long. In our view, the strategic decisions taken at the outset by Mr Kerry as Council Silver failed to reflect the seriousness and scale of the emergency. There was a consequent lack of urgency, direction and, ultimately, co-ordination. Given that staff from the TMO were present at rest centres from an early stage, contact could and should have been made with them to find out how many displaced persons were there and how many staff were required. RBKC employees should have been called in to the Town Hall earlier to ensure there were sufficient staff available to be sent to the rest centres.^14211421 Kerry {RBK00033579/17} page 17, paragraph 78; Blackburn {RBK00035364/11} page 11, paragraph 52. Both Ms Blackburn^14221422 Blackburn {RBK00035364/5} page 5, paragraph 22; Blackburn {Day270/153:3-10}. and Mr Priestley^14231423 Priestley {Day270/47:10-20}. considered that they should have been despatched four hours earlier, at about 06.30.^14241424 Minutes of the SCG meeting at 06.30 on 14 June 2017 {MOL00000015/2} page 2, paragraph 3.5.

¶104.37 The delay in sending out RBKC staff left the Red Cross and members of the community who voluntarily opened their premises without support and without information about how the response was being led. That made it difficult for them to know who was in charge, what was needed or what was going to be brought to the rest centres to enable them to direct people to the right source of support.^14251425 Spragg {Day280/32:5-13}.

The Westway Centre

¶104.38 The Westway Centre is a large sports and fitness centre that opened spontaneously as a rest centre in the early hours of 14 June 2017.^14261426 Alison Norman {CFV00000061/1-2} pages 1-2, paragraphs 2a-2b. It was not until later in the afternoon on 14 June 2017 that RBKC decided to consolidate the rest centres and designate the Westway Centre as the one official location.^14271427 Norman {CFV00000061/5} page 5, paragraphs 3a-3c; Priestley {RBK00035672/8-9} pages 8-9, paragraph 39. At a meeting of the RBKC Gold group at 15.00^14281428 RBKC Gold Meeting Minutes, 14 June 2017 at 15.00 {RBK00013272/2}. that day it was confirmed that it would remain open overnight. At that stage RBKC was trying to determine how many people needed to be accommodated. By then, 30 households had been identified in the Clement James Centre, but no information was available from the other rest centres, despite the presence of TMO staff.^14291429 RBKC Gold Meeting Minutes, 14 June 2017 at 15.00 {RBK00013272/2}.

¶104.39 The decision to concentrate the provision of humanitarian assistance in one place was standard practice and viewed in isolation was a reasonable decision.^14301430 Priestley {RBK00035672/9} page 9, paragraph 39: "It was a challenge to communicate with the many number [sic] of rest centres which had established themselves that residents who required Council support and overnight accommodation should be encouraged to attend the Sports Centre." Spragg {BRC00000050/14} page 14, paragraph 61; Spragg {Day280/81:8-17}. However, the failure of communications led to a situation in which many who needed support did not know they should go to Westway Centre or what support was available there.

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¶104.40 Unfortunately, the Westway Centre was not very readily accessible to many of those who were in need of support.^14311431 Daffarn {IWS00002109/124} page 124, paragraph 384. Some survivors told us that they had been asked to provide identification and of having to sneak into the building if they could not provide it.^14321432 Hirsi {IWS00001776/4} page 4, paragraph 11. Wristbands were introduced as a method of verifying the identity of those who had been displaced.^14331433 Blanchflower {CFV00000045/9} page 9, paragraph 36; Hardy {Day276/8:22-24}; Cesar Ranito {IWS00001249/7-8} pages 7-8, paragraph 37. As we have said in Chapter 100, the Westway Centre was described, both by those who went there and by the professionals who were there to support them, as unwelcoming. There was a visible police cordon at the entrance which in the words of one witness made it look like a "crime scene".^14341434 Girma {IWS00001732/12} page 12, paragraph 23; Eleanor Kelly {GOL00001730/8} page 8, paragraph 19; Hardy {LBE00000025/6} page 6, paragraph 35; {LBE00000025/9} page 9, paragraph 42: "The initial appearance of the Rest Centre was like that of a cordoned off crime scene rather than a welcoming place where bereaved, survivors and residents would want to come for help". Although the police needed to maintain a presence in the light of the significant media interest, its effect, albeit unintentional, was to deter people who needed support from attending it or visiting it as often as they needed to.

¶104.41 The interior of the Westway Centre was described as chaotic and confusing, with a lack of signs to assist visitors.^14351435 Al-Karad {IWS00001541/23} page 23, paragraph 113. Survivors described it as uncomfortable^14361436 Antonio Roncolato {IWS00001774/19} page 19, paragraph 109. and impersonal^14371437 Jenny Dainton {IWS00001804/24} page 24, paragraph 152. and there were concerns about inadequate sleeping arrangements. Some of those who had been displaced were sleeping on mats or mattresses donated to the relief effort.^14381438 Alison Norman {CFV00000061/7} page 7, paragraph 4g; Belfassi {IWS00001802/6} page 6, paragraph 36; Hoang Khanh Quang {IWS00001821/11} page 11, paragraph 51; Maria Jafari {IWS00001815/14} page 14, paragraph 64; Email from Maureen Mandirahwe (WCC) to RBKC BECC at 21.08 on 17 June 2017 {RBK00005386/1}. Coupled with a lack of privacy,^14391439 Spragg {BRC00000050/18} page 18, paragraph 78 (b). cleanliness and facilities for disposing of rubbish,^14401440 Hardy {LBE00000025/18} page 18, paragraph 96. that demonstrated an inability on the part of those responsible for its management to create an environment that was appropriate and welcoming.

¶104.42 The problems at the Westway Centre were due in a large part to the lack of leadership and organisation.^14411441 Mussilhy {IWS00001783/8} page 8, paragraph 31; Kuchar {RBK00035291/5} page 5, paragraph 19: "I remember being advised on the walk there to put our ID badges away.". RBKC had no visible presence and the absence of senior RBKC staff and qualified rest centre managers was a constant theme among those who gave evidence. RBKC was reliant on volunteers from within its own staff and on staff from neighbouring boroughs to act as rest centre managers. The point was raised at the RBKC Gold group meeting on 15 June 2017.^14421442 Nicholas Austin {RBK00035340/5} page 5, paragraphs 17-18: "I volunteered to go down there [Rugby Portobello Trust] as a senior manager… I arrived there around 6.30pm. I was there until it closed. I had received no formal training in setting up or managing rest centres." RBKC Gold Group meeting on 15 June 2017 at 15.30 {RBK00013262/3}: "NA said the WSC needs a Senior Manager and a Rest Centre Manager. BECC working on a rota for Rest Centre Manager. Senior officers thin on ground but will think about this".Show full note The absence of leadership at the Westway Centre left the Red Cross and the many volunteers at the centre without the support they needed.

¶104.43 The perception that RBKC staff were not present at the Westway Centre endured. On 17 June 2017, volunteers were complaining that RBKC was not helping and that they were doing everything.^14431443 {LBE00000014/1}. The perception was not entirely justified, but it was exacerbated by the lack of identifying tabards for staff to wear.^14441444 Kerry {RBK00033579/19} page 19, paragraph 84. Minutes of the SCG meeting at 19.30 on 14 June 2017 {LFB00119322/3}: "David Kerry confirmed that identification tabards were being delivered to Rest Centres for their staff". The result was that it was difficult to distinguish RBKC staff among the many volunteers and others who were there. We were told that senior managers of RBKC had told staff not to wear tabards or lanyards out of a concern for their safety.^14451445 Health Response Group Meeting, 18 June 2017 at 14.00, {RBK00035310/3}. Email from Ann Ramage, Head of Environmental Health for commercial services of RBKC and LBHF, updating on the Westway Centre on 17 June 2017 {RBK00005539}.

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Change of leadership

¶104.44 Shortly after leadership of the humanitarian response had passed to London Gold,^14461446 Hardy {Day276/3:14}-{Day276/4:4}; Hardy {LBE00000025/7} page 7, paragraph 39; Email from Rupinder Hardy at 09.36 on 17 June 2017 {LBE00000004}. Rupinder Hardy, a local authority liaison officer (LALO) from the London Borough of Ealing, attended the Westway Centre which at that point was still being managed by RBKC. Although Ms Hardy recognised that there would inevitably be an element of chaos, given the number of people involved,^14471447 Hardy {Day276/114:22}-{Day276/115:5}. she did not find the Westway Centre a welcoming space where responders and services could easily be identified.^14481448 Hardy {Day276/14:2}-{Day276/16:15}. She described it as a "shambles" and not what she was used to seeing from a local authority.^14491449 Hardy {LBE00000025/11} page 11, paragraph 57. She told us that the help desks were a jumble and that it was difficult to know what was going on and what support was being offered. She raised her concerns with Mr Barradell and Ms Kelly,^14501450 Hardy {LBE00000025/10} page 10, paragraphs 45-46; Email from Eleanor Kelly {GOL00000372} attaching notes of the meeting between John Barradell, Eleanor Kelly and Rupinder Hardy on 17 June 2017 {LBE00000055}. who by that time were leading the response. As a result, they decided to transfer the management of the Westway Centre to the London Borough of Ealing. That took effect on 17 June 2017, when Ms Hardy assumed the role of manager and brought in a team from her borough.^14511451 Hardy {LBE00000025/10} page 10, paragraph 48; Paul Najsarek was the Chief Executive of the London Borough of Ealing. Hardy {Day276/53:12-21}: 40 members of staff deployed from Ealing. Hardy {LBE00000025/14} page 14, paragraph 73: "The number of staff deployed by Ealing, in the region of 197 officers from the 17-22 June 2017".

¶104.45 Ms Hardy sought to improve the process for providing support at the Westway Centre.^14521452 Hardy {LBE00000025/19} page 19, paragraph 98. The new process included placing the service stalls in a U-shape, allowing people to come in from one side and work their way round the services that were being offered in order to receive the support, advice and help they required.^14531453 Hardy {Day276/77:3}-{Day276/78:3}; Rupinder Hardy's photographs taken during her deployment as LALO at the Rest Centre {LBE00000051}. Community workers reported that families were not going to the Westway Centre because they found the process of obtaining support difficult due to long queues, much paperwork and an unwelcoming atmosphere.^14541454 Email at 15.19 on 20 June 2017 from Sarah Mail (WCC) to RBKC, {RBK00012356/1} page 1, paragraph 1; {CLG00021227}. Clare Richards, chief executive officer of the Clement James Centre, told us that although she could understand why the space had been set up as it was (i.e. to allow people to go from table to table), the reality was that people in a state of distress had to keep explaining why they were there and why they needed support.^14551455 Richards {Day275/151:9-21}. She considered that to be inappropriate and very upsetting for those affected.^14561456 Richards {Day275/151:2-8}. Ms Hardy accepted that the process was harrowing. She told us that one thing she had learned was that a process in which personal information was collected at a single point and then distributed to those providing the emergency response would have been better.^14571457 Hardy {Day276/83:19}-{Day276/84:15}.

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¶104.46 Despite the efforts and generosity of those who ran the Westway Centre and the many volunteers who attended to assist, as the official rest centre it fell far short of the service that those affected were entitled to expect and should have received following a major emergency.

Community rest centres

¶104.47 Despite RBKC's decision on 15 June 2017 to designate the Westway Centre as the official rest centre, displaced people were still making use of four or five other rest centres,^14581458 Community Impact Assessment {RBK00005288/14}. which led to confusion within the community about which one was the official rest centre.^14591459 Spragg {Day280/33:9-14}. As RBKC began to concentrate its efforts on the Westway Centre from 15 June 2017 onwards, it decided that other rest centres run by the community, such as the Rugby Portobello Trust which remained open, would not receive council services,^14601460 Minutes of the ​​HASG meeting at 14.00 on 15 June 2017 {RBK00020525/1} unnumbered paragraph 7: "The Council's efforts are at Westway as a council-run rest centre. Other informal rest centre's (sic) may continue but they will not be resourced with Council services". despite the fact that people were relying on them.^14611461 Email from Nicholas Holgate to RBKC colleagues at 11.01 on 16 June 2017 {RBK00009876}. The resulting confusion was made worse by a failure to tell the community and religious centres about the services available at the Westway Centre. Volunteers from some of the centres reported that they did not know what services were being offered there.^14621462 Email from Lady Borwick, former MP for Kensington, at 17.39 on 18 June 2017 {CLG00009154/2}.

¶104.48 The Reverend Mark O'Donoghue of Christ Church, Kensington contacted RBKC councillors, pointing out areas that needed rapid improvement. He emphasised the need for a single point of contact at RBKC to assist with the needs of those at the rest centres (mentioning, in particular, the Clement James Centre, the Rugby Portobello Trust and Latymer Community Church). He found it difficult to believe that it was beyond the wit of RBKC to appoint one person to talk to people like him, who could then talk to their own networks to provide help.^14631463 Email from Mark O'Donoghue to RBKC {RBK00003251}.

¶104.49 Community leaders said that what was needed was the visible presence of RBKC staff wearing identifying insignia, such as high-visibility jackets, and in possession of up-to-date information.^14641464 Long {CFV00000010/6-7} pages 6-7, paragraph 32. In the absence of such a presence, information or support, community organisations felt abandoned.^14651465 Long {CFV00000010/7} page 7, paragraph 32.

Emergency accommodation

¶104.50 In addition to its obligation to open a rest centre, RBKC had an statutory obligation to provide displaced persons with emergency accommodation.^14661466 Local authorities have an initial duty to provide accommodation for all persons who are homeless and eligible for assistance, (Housing Act 1996, sections 188 and 189(1) Part 7); RBKC Housing Contingency Plan, {RBK00035406/7-8} pages 7-8, paragraphs 2.1.2 and 2.2. {RBK00002747}. The council's Housing Contingency Plan, dating from 2012, had not been the subject of an annual exercise in accordance with its own guidance and was not referred to during the response to the fire.^14671467 Laura Johnson {Day272/7:6}-{Day272/9:25; {Day272/10:13}-{Day272/11:3}. The aim of the plan was, among other things, to support and extend the Contingency Management Plan and to provide the information and describe the procedures and action to be taken to ensure an effective, flexible and timely response by the housing department to any emergency that might arise.^14681468 {RBK00035406/5} paragraph 1.2. Furthermore, the

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¶RBKC's own Housing Risk Register^14691469 RBKC Housing Risk Register, November 2016 {RBK00036587}. dated November 2016 recognised that it did not have sufficient capacity to arrange temporary accommodation in an emergency.^14701470 Laura Johnson {Day272/18:21}-{Day272/19:17}.

¶However, there were no processes in place to address that deficiency. Although there were arrangements to make use of local premises as rest centres, there were no standing arrangements with local hotels of a kind that would facilitate the provision of accommodation for displaced residents.^14711471 Laura Johnson {Day272/21:25}- {Day272/22:4}; {Day272/60:6-23}.

¶104.51 From about 07.30 on 14 June 2017, RBKC housing officers began telephoning hotels in central and west London to reserve rooms in anticipation of a need to house people that evening.^14721472 Stuart Priestley, RBKC Chief Community Safety Officer, Log – Wednesday 14 June 2017 {RBK00013318}. Laura Johnson told us that at that early stage they were looking for hotels within the borough or in adjacent boroughs because people needed to be close to their support networks.^14731473 Laura Johnson {Day272/55:7-19}.

¶104.52 Ms Johnson also told us that they had received a huge number of offers of accommodation from different organisations and members of the public.^14741474 Laura Johnson {Day272/63:17-24}. The accommodation ranged from spare bedrooms offered by members of the public to unfurnished accommodation in existing social housing blocks.^14751475 Laura Johnson {Day272/113:3-25}. Ms Johnson explained that she did not consider those offers to be appropriate because, she felt, people needed the privacy of a self-contained room and their own bathroom,^14761476 Laura Johnson {Day272/113:6-9}. as well as being close to their neighbourhood.^14771477 Laura Johnson {Day272/113:22-25}. Her team's view was that hotel accommodation was the most appropriate solution.^14781478 Laura Johnson {Day272/112:11-21}.

¶104.53 In the days that followed the fire RBKC struggled to keep up with the demand for accommodation to house a growing number of displaced people. Over 800 people had been forced to leave their homes and although most went to stay with families or friends, many depended on the council to find them somewhere to live.^14791479 Project Athena Report {RBK00028618/74-82} pages 74-82, paragraphs 18.8 and 20.8.

Allocation of accommodation

¶104.54 At the outset RBKC drew a distinction between those who had been displaced from the tower itself and those who had been displaced from the surrounding blocks within the wider cordon (i.e. the Walkways).^14801480 This included approximately 845 residents from Hurstway Walk, Barandon Walk, Testerton Walk, Grenfell Walk and Treadgold House {TMO00869977}; Teresa Brown {TMO00894124/17} page 17, paragraph 60; Police Cordon Slideshow {MET00080826}. In the first instance, those living in the Walkways were advised to try to stay with families or friends and were provided with accommodation only if they had nowhere to go.^14811481 Laura Johnson {RBK00035592/13} page 13, paragraph 49 However, the criteria applied to those living in the Walkways were changed during the course of 14 June. At 13.46, Ms Johnson told Emma Strugnell, a media and communications officer at RBKC, that the council was providing emergency hotel or bed and breakfast accommodation for people who had lived in the tower;^14821482 {RBK00018898/1}. those who had been evacuated from the Walkways were to go to the emergency rest centres and would be provided with accommodation only if they were old or vulnerable in some way.^14831483 {RBK00018898/1}. In the case of those who were not old or vulnerable, RBKC waited to find out whether they could return to their homes or whether emergency accommodation at a rest centre would be needed. Later that day families with children were included among those eligible for accommodation.^14841484 {RBK00031298/2}.

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¶104.55 The more restrictive criteria applying to residents of the Walkways created confusion within the housing department. They were not adequately communicated to staff and were not widely communicated to the public.^14851485 Laura Johnson {Day272/76:8-16}; {Day272/82:6}-{Day272/83:15}; Shawo {IWS00001290/3} page 3, paragraph 20. They resulted in some Walkway residents who qualified for emergency accommodation not being offered it.^14861486 {RBK00012043/5}: George Edwards was evacuated from a nearby building and was suitable for temporary accommodation but was turned away by the housing officer and told that "if it was determined that nearby evacuees were to be considered for housing he could return". At 16.21 on 14 June 2017, Ryan Bird, one of RBKC's housing officers, pointed out to the housing team that the instructions were that those who did not live in the tower were not to be accommodated.^14871487 {RBK00031298/2}. Mr Bird noted in a later email that there were "Many helpful but confused folk here. Lots of information but little of it entirely accurate".^14881488 {RBK00031298/1}.

¶104.56 By the night of 14 June 2017 and into 15 June 2017, 77 households had been placed in 102 hotel rooms and it was expected that more people would approach the council for accommodation.^14891489 {RBK00027735}; Laura Johnson {RBK00035592/12} page 12, paragraph 47. Ms Johnson told us that anyone who asked for a place was offered one immediately and without question.^14901490 Laura Johnson {RBK00035592/12} page 12, paragraph 47. However, she was of the view that it was not her department's responsibility to speak to everyone and make sure they had somewhere to stay; it was for those who needed accommodation to approach the housing team. She may or may not have been entitled to take that view, but the result was that some residents were sleeping rough simply because they were unaware that they could ask for emergency accommodation.^14911491 {TMO10036665} Column J, row 114, row 123 and row 390; {RBK00029413}, row 228. RBKC accepted that they did not receive the level of care to which they were entitled under the Housing Contingency Plan and acknowledged that a number of Grenfell Tower residents were not told about the availability of emergency accommodation.^14921492 Laura Johnson {Day272/94:6-13}; RBKC Opening Statement, {Day263/120:5-13}.

¶104.57 Part of the reason for the housing department's failure to accommodate all residents on the first day of the fire is that Ms Johnson and the emergency planning team failed to recognise the scale of the incident in the early hours and failed to grasp what it required of them.^14931493 Laura Johnson {Day272/43:12-23}.

¶104.58 Most of those accommodated by RBKC in hotels were residents of the tower.^14941494 RBKC Opening Statement, {Day263/120:9}. Residents of the Walkways continued to be a secondary priority,^14951495 Laura Johnson {Day272/74:22}-{Day272/75:16}; {RBK00031298}. despite their obvious need for alternative accommodation as a result of their homes lacking gas or water and containing debris from the fire.^14961496 Email from Judith Blakeman to Laura Johnson on 18 June 2017 {RBK00027966}, paragraphs 1 and 3; Email from TMO to RBKC regarding 11 households in need of accommodation as "there's debris from the fire on elevations" at 16.27 on 16 June 2017 {RBK00049529}; Email from Councillor Lasharie at 00.42 on 15 June 2017 {RBK00003049}; Email from Councillor Lasharie at 16.15 on 15 June 2017 {RBK00003071}. RBKC thought that residents of the Walkways should return to their flats, despite being told by the TMO that they were not yet suitable for reoccupation.

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¶Teresa Brown, the TMO's Director of Housing, recommended that residents should not be rushed into returning until the TMO could ensure proper provision of services.^14971497 Teresa Brown {TMO00869990/9} page 9, paragraph 45; TMO staff also notified RBKC's Allocation Team about the need to re-house those with balconies overlooking Grenfell Tower, to avoid further trauma. Teresa Brown {TMO00869990/11} page 11, paragraph 57.

¶Her advice was not accepted by RBKC, which stuck to its decision that those who lived in the Walkways should return to their flats. Ms Johnson told a Gold group meeting on

¶16 June 2017 that she would house the vulnerable or those with children and without hot water but that others would have to manage.^14981498 RBKC Gold Group Meeting Minutes at 10.00 on 16 June 2017 {RBK00001862/2}.

¶104.59 The lack of any existing plans or agreements with local hotels (for example, in relation to methods of payment) led to significant disruption and distress to those seeking accommodation. In some cases transport was a problem. Ms Johnson told us that on the first day her team had attempted to hire taxis to take people from the Westway Centre to their hotels, but she accepted that in some cases people had not been provided with transport and had been forced to make their own way to the hotels in which they had been placed.^14991499 Laura Johnson {Day272/120:19}-{Day272/121:24}; Abdulhamid {IWS00001919/3} page 3, paragraph 16; Alison Moses {IWS00001281/9} page 9, paragraph 47. This was a requirement identified in the RBKC Housing Contingency Plan at Annex 2 {RBK00035406/19}.

¶104.60 Residents placed in hotels often had to be moved to alternative accommodation, sometimes without much notice.^15001500 {RBK00002735/2}; Sadafi {IWS00001806/23} page 23, paragraph 73; Lukic {IWS00001760/6} page 6, paragraph 24. Despite informing the RBKC Gold group at 11.00 on 14 June 2017 that block bookings of hotels had been made until Monday 19 June 2017 as a short term solution,^15011501 {RBK00013271/2}. the group was told the following morning that officers were in the process of rebooking hotel rooms for all those that needed them.^15021502 Gold Group Meeting Minutes at 10.00 on 15 June 2017 {RBK00013270}. It was noted that four households had to be moved to another hotel on 15 June 2017 and, because some bookings could not be carried over the weekend (17 and 18 June 2017), RBKC needed to find alternative accommodation for 24 households.^15031503 'Grenfell Residents Action Plan 15 June 2017: Short Term' {RBK00027735}. The first time that some residents who had been accommodated in hotels learned they needed to check out was when the hotel told them.^15041504 Laura Johnson {Day272/68:2-8}; {Day272/69:25}-{Day272/70:4}; El-Guenuni {IWS00002034/9} page 9, paragraph 34; Sadafi {IWS00001806/23} page 23, paragraph 73. See Chapter 2.3.4 Length of Hotel Placements in Chapter 2.

¶104.61 In some cases delays in bookings were caused by the lack of sufficient credit on RBKC's credit cards.^15051505 Laura Johnson {RBK00035592/23} page 23, paragraph 84; Laura Johnson {Day272/56:5-11}. The problem persisted for a number of days following the fire, resulting in some employees using their own cards to secure rooms.^15061506 Laura Johnson {Day272/58:10-22}; Laura Johnson {RBK00035592/24} page 24, paragraph 87. The problem with credit limits had led to some payments being declined and to some hotels informing residents that their bookings would end.^15071507 Email from Chris Scott (RBKC Housing) at 08.19 on 21 June 2017 {RBK00012306}. As part of the tri-borough arrangements for providing humanitarian assistance RBKC had agreed that duty officers and some senior Housing and Adult Social Care managers should be given greater spending limits for use in emergencies, but it appears that it had either failed to implement that agreement or had set inadequate credit limits.^15081508 {RBK00036274/2}; The agreement had been reached in early 2016 in the wake of the Adair Tower fire the previous October.

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¶104.62 With no list of approved local hotels, RBKC was unable to ensure that the hotels booked provided for residents with particular needs, which were often not met.^15091509 Redmond {Day271/89:19}-{Day271/90:20}. That included, but was not limited to, people with disabilities^15101510 David Lewis {IWS00001629/5} page 5, paragraph 21-23; Rasoul {IWS00001768/22} page 22, paragraph 107; Oyewole {IWS00001730/10} page 10, paragraph 17-19; Alison Moses {IWS00001281/10} page 10, paragraph 54. and families with babies and young children.^15111511 Khoudair {IWS00001616/11-12} pages 11-12, paragraph 81-88; Jason Miller {IWS00001940/9} page 9, paragraph 37; Zakariya Chebiouni {IWS00001979/5} page 5, paragraph 24; Mensah {IWS00001944/9} page 9, paragraph 43; Ryan Ignacio {IWS00001820/14} page 14, paragraph 70. In many cases survivors found being housed on upper floors of hotels traumatic following their recent experiences.^15121512 RBKC email at 17.53 on 18 June 2017, "1 gentleman put on 14th floor of hotel – needs moving" {RBK00039300}; Email from Maureen Mandirahwe (WCC) to RBKC BECC at 21.08 on 17 June 2017, "Complaints of traumatised persons being housed in a second floor hotel/tower, when they had vocalised from the onset that they cannot cope with living in a tower. They were moved to other towers 3 times. He came to us very angry and traumatised." {RBK00005386/2}; Emma O'Connor {IWS00001699/6} page 6, paragraph 33.Show full note

¶104.63 Ms Johnson told us that RBKC had tried to meet the specific needs of those affected but conceded that they had not got it right in all cases.^15131513 Laura Johnson {Day272/118:25}-{Day272/119:15}; {Day272/132:5-20}. We have seen little to suggest that the allocation process involved much more than simply matching the numbers of people seeking accommodation to the rooms available. We consider that specific plans and standing agreements with hotel providers, coupled with periodic training exercises, would have equipped the housing department to respond better to the challenges it faced in finding accommodation for a large number of displaced residents.^15141514 Laura Johnson {Day272/22:14}-{Day272/23:1}.

¶104.64 After it had found them accommodation the housing department did not communicate adequately with its residents.^15151515 Laura Johnson {Day272/170:4-25}. They lacked clear guidance about when their bookings would end,^15161516 Sener Macit {IWS00001563/12} page 12, paragraph 52; Bernard Shaw {IWS00001752/8} page 8, paragraph 39; Karema El-Sawy {IWS00001829/7} page 7, paragraph 31. about the food and services that they were entitled to receive at their hotels^15171517 Shawo {IWS00001290/4} page 4, paragraph 25; David Lewis {IWS00001629/6} page 6, paragraph 25; Ahmed Al-Assad {IWS00001789/11} page 11, paragraph 67; Araya {IWS00001648/4} page 4, paragraph 20; Rasoul {Day265/159:13-23}. and about whom to contact for information and assistance.^15181518 Samuel Daniels {IWS00002065/15} page 15, paragraph 99. As a result, in many cases they did not receive the full extent of the support available to them and lived in a constant state of uncertainty. We have set out in detail in Chapter 100 the difficulties felt by some of those who had been displaced by the fire.

¶104.65 As a Category 1 responder RBKC should have been ready to meet the immediate personal needs of those affected by the emergency.^15191519 Emergency Response and Recovery non-statutory guidance, {CAB00004519/119} page 119, paragraph 7.3.2.; LRP. Humanitarian Assistance Plan v3, {GOL00001151/27} page 27, paragraph 7.12-7.14; RBKC Contingency Management Plan {RBK00004396/17}. They included food and drink of a suitable kind, access to places of worship and other personal, cultural or religious needs, but it does not appear to have given any consideration to matters of that kind and had no plan to provide for them. Those who attended the Westway Centre relied on the generosity of volunteers who brought them culturally appropriate food to meet their needs.^15201520 Belfassi {IWS00001802/7} page 7, paragraph 40. Moussaid {IWS00001282/14} page 14, paragraphs 68-69.

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¶104.66 The problems of obtaining access to the Westway Centre led to many of those affected seeking support through unofficial rest centres, such as the Clement James Centre and the Rugby Portobello Trust, which became the main source of food for many in the days immediately following the fire.^15211521 Richards {CFV00000012/2-6} pages 2-6, paragraphs 7, 11, 20, 22 and 41; Ahmed Chellat {IWS00001306/1} page 1, paragraph 6; Ghamhi {IWS00001706/4} page 4, paragraph 23; Simms {CFV00000005/17} page 17, paragraph 78; Hariri {IWS00001295/14} page 14, paragraph 106.

¶104.67 Difficulties in providing for basic needs, such as food and drink, continued in some cases even after people had been placed in hotels. In some cases they did not know what food or drink they were entitled to receive.^15221522 Richards {Day275/147:11-16}. With hotel rooms in short supply, RBKC took rooms in a number of hotels that provided only limited services, which in some cases did not include food or drink.^15231523 Laura Johnson {Day272/132:1-4}. That prompted those in the community, voluntary and faith sector to obtain, distribute and serve food to some of those at hotels.^15241524 Richards {CFV00000012/3} page 3, paragraph 14.

¶104.68 In some cases, hotels did not provide food suitable for those with particular religious needs, such as halal food, particularly during Ramadan. Although Ms Johnson was aware of the cultural and religious diversity of the residents of Kensington and Chelsea, she did not recall having made any specific request to hotels to accommodate religious dietary requirements.^15251525 Laura Johnson {Day272/132:5-15}. That was reflected in the evidence of Brahim El Amine, Mouna El-Ogbani and Sawson Choucair, all of whom were placed in hotels that did not serve food at times that respected their observation of Ramadan.^15261526 El Amine {IWS00001946/10-11} pages 10-11, paragraph 46; El-Ogbani {Day266/23:20}-{Day266/24:5}; Sawson Choucair {IWS00001799/15-16} pages 15-16, paragraph 20(c). As a result, they and others in their position had to rely on food being provided by the community.^15271527 Senate Jones {IWS00001691/5} page 5, paragraph 24. Similarly, Nadia Jafari, who was on a diet following surgery, had to rely on food she received from the mosque and charities.^15281528 Maria Jafari {IWS00001815/13} page 13, paragraph 56.

¶104.69 RBKC accepted that it should have done more in the days following the fire to cater for those from diverse backgrounds, in particular those many residents of the Muslim faith who were observing Ramadan at the time. Their experience contributed to the widespread feeling among them that the council had no regard for their cultural and religious needs.

¶104.70 We do not believe that those were isolated incidents limited to a few individuals and families. The evidence suggests that the experiences of those, particularly from Muslim and minority ethnic communities, whose basic needs were not met were symptomatic of a more general, systemic failure on the part of RBKC to think about and plan for those needs in advance.

¶104.71 The outcomes and experiences of those affected which bore on their faith and ethnicity lead us to conclude that RBKC failed to take any or any adequate steps to follow the guidance contained in those parts of Emergency Preparedness (2013) and Emergency Response and Recovery (2005) to which we referred in the introduction. In particular, we conclude that RBKC failed to give any, or any adequate, consideration to the needs of the members of the various faith, religious, cultural and minority ethnic communities who were affected by the fire. That lack of consideration was marked by the absence from RBKC's preparations of any plan for catering for their particular needs and a lack of any training to ensure that they were met. Nor did RBKC put in place any arrangements for addressing them in the days immediately following the fire. Such efforts as were made were piecemeal and unevenly distributed.

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¶104.72 The guidance to which we have referred seems to us to reflect in a large measure the legislative aim of section 149(1) of the Equality Act 2010 in the context of civil contingencies. Whether RBKC failed to have due regard to the matters identified in section 149(1) of the Act in making its civil contingency arrangements is a question we are not in a position to answer. What matters more is how people were treated in practice. It is enough to say that in our view many of those affected by the fire who had particular religious or 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.

Financial assistance

¶104.73 The Humanitarian Assistance framework indicated that local authorities might provide financial assistance for food, clothing, toiletries and other essential requirements as part of their responsibility for providing humanitarian assistance.^15291529 London Resilience Partnership Humanitarian Assistance Framework, {RBK00011313/42}. "Local Authorities: May provide financial assistance". On 14 June 2017, arrangements were made by RBKC to provide those affected by the fire with such assistance. At the start, the housing team attended the rest centres with sufficient cash to give people a small sum of money, about £50 a person.^15301530 Laura Johnson {Day272/143:16-19}. At 12.33, Francis Austin, RBKC's interim group finance manager, provided Kevin Bartle, then director of finance, with a note saying that £10,000 had been drawn in cash to be used to pay for immediate expenses.^15311531 {RBK00012261}. That included everything from toothbrushes to hotel accommodation. That evening, Robert Shaw, a RBKC housing officer, sent a message to his colleagues telling them that three rest centres were to remain open throughout the night and that TMO staff would be present with enough money to hand out to residents.^15321532 {RBK00006091}; {TMO10031177/3}.

¶104.74 How those affected should be supported financially had not been planned in advance, which caused delay in implementing a process for the distribution of funds. On 15 June 2017 RBKC agreed that households should be given cash to cover immediate living expenses and a further allocation of up to £1,000 a household, leaving over for later consideration what procedure should be adopted for managing it.^15331533 {RBK00027735}. A further £36,000 was made available for residents, together with a draft form intended to be completed for each payment.^15341534 {RBK00020131}. That was the first time any formal plan for the distribution of cash had been put in place. It appears that following a further meeting on 16 June 2017, the arrangements were changed. Instead of payments of up to £1,000 being made available, £500 in cash was to be distributed to each household and the remaining £500 held available.^15351535 Amanda Gill {RBK00044877/8} page 8, paragraph 46; {RBK00047576}; Laura Johnson {Day272/143:14}– {Day272/145:5}. That was considered the easiest way to provide emergency funds for people who did not have a bank account or did not have any of their cards or other documents of the kind needed to obtain access to funds in the bank.^15361536 Laura Johnson {Day272/143:22}-{Day272/144:1}

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¶104.75 Following the activation of the Gold resolution, RBKC remained responsible for the provision of financial assistance.^15371537 {CAB00014720}. Despite efforts to establish a procedure for providing households with access to funds,^15381538 {RBK00020131}. the facility does not appear to have been fully used. On 17 June 2017, Ms Hardy told us that she was given money in an envelope and a list of names, possibly those who had been given money, written on the back of the envelope.^15391539 Hardy {Day276/87:4}-{Day276/88:15}. She was given no other information or explanation of how to organise the distribution. Perhaps because of changes in the amount of payments being made or the lack of rigour in the process, different amounts varying from £200 to £1,000 were distributed to the residents of the tower.^15401540 {RBK00026735}. According to Michael Adamson of the Red Cross, cash was distributed in a haphazard way by a number of different officials, which made it impossible to track who had received what.^15411541 Adamson {BRC00000075/15} page 15, paragraph 68.

¶104.76 Financial assistance was initially provided only to those displaced from the tower and not to those displaced from the Walkways.^15421542 Augustine {RBK00035411/6} page 6, paragraph 29. Some members of RBKC's staff resorted to their own personal funds to provide financial support to those in need.^15431543 Augustine {RBK00035411/6} page 6, paragraph 30.

¶104.77 The housing department did not take steps to inform those affected by the fire that they were entitled to financial assistance,^15441544 Laura Johnson {Day272/149:2-9}. which resulted in delays in their receiving the assistance to which they were entitled and in some cases to their not receiving it at all.^15451545 Laura Johnson {Day272/150:2-12}; Hanan Cherbika {IWS00001286/11} page 11, paragraph 85; Jevon Moses {IWS00001276/16} page 16, paragraph 113; Toyoshima-Lewis {IWS00001725/66} page 66, paragraph 265. It was reported that people were either unaware of the opportunity to obtain financial assistance at the Westway Centre or were reluctant to go there.^15461546 {RBK00004144}.

¶104.78 Financial support provided to families staying in hotels was inconsistent; some families were left to support themselves. The problem was compounded by residents being placed in hotels at some distance from the Town Hall and the Westway Centre. On 18 June 2017, the London Borough of Ealing, which at the time was managing the Westway Centre, did not have the resources to visit displaced residents to distribute funds.^15471547 {RBK00004144}. A stark illustration of how certain families lacked support was provided to Gerry Crowley, property and place manager of the London Borough of Hammersmith and Fulham, who visited three hotels on 19 June 2017. He reported inconsistent levels of service being provided by the hotels and found that RBKC had not been in contact with residents at the Premier Inn, Hammersmith since placing them there almost six days earlier. The families had each been given only £50 to help with immediate expenses.^15481548 {RBK00021897/3}. Many people said they had encountered significant difficulty in obtaining financial support and as a result had been forced to rely on the generosity of charities and voluntary groups.^15491549 Talabi {IWS00001731/7} page 7, paragraph 22; Rosita Bonifacio {IWS00001887/7} page 7, paragraph 47; Aziza Raihani {IWS00001300/4} page 4, paragraph 25.

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Information about those who were missing

¶104.79 One of the recurring themes of the evidence given by those who had been displaced was that of the profound feeling of helplessness and despair they experienced as they desperately went from hospital to hospital, rest centre to rest centre, trying to obtain information about missing relatives, but to no avail.^15501550 Abu Baker Mohamed Ibrahim {IWS00001751/5} page 5, paragraphs 17 and 21. We have therefore tried to find out what led to that lack of information.

Family and friends reception centre

¶104.80 The guidance in Emergency Recovery and Response provides that steps should be put in place to ensure that information provided to those making enquiries is accurate, consistent and not contradictory.^15511551 Emergency Response and Recovery, non-statutory guidance accompanying the Civil Contingencies Act 2004 {CAB00004519/122} page 122, paragraph 7.4.2. The Humanitarian Assistance framework described the purpose of family and friends reception centres as being to help reunite family and friends with survivors, to provide a place for the police to record enquiries about missing persons and collect information which may aid their investigation and to provide access to practical and emotional support.^15521552 London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/24-25} pages 24-25, paragraph 8.17. It is the responsibility of the police in consultation with local authorities to decide whether there is a need to set up a family and friends reception centre as part of a wider process of identifying victims of a disaster. Such centres are likely to be set up within the first 24 hours of the incident^15531553 London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/25}, page 25, paragraphs 8.20-8.21. and are usually staffed by police, local authorities and voluntary organisations.^15541554 Emergency Response and Recovery, non-statutory guidance accompanying the Civil Contingencies Act 2004 {CAB00004519/122-123} pages 122-123, paragraph 7.4.4.

¶104.81 On 14 June 2017, RBKC told the police that a family and friends reception centre would be set up at the Salvation Army building at 12.30. Mr Adrian Clee, who had been appointed the Salvation Army's strategic lead for the Grenfell Tower emergency response that morning,^15551555 Clee {CFV00000059/1} page 1, paragraph 1. confirmed that it had opened its building on Portobello Road as a family and friends reception centre to provide a safe haven for those directly affected by the fire and relatives of those who were awaiting news.^15561556 Clee {CFV00000059/3-4} pages 3-4, paragraph 2. A member of staff from RBKC was sent to the centre and several police liaison officers attended to speak to witnesses and take statements.^15571557 Clee {CFV00000059/4} page 4, paragraph 2. The police reported that at 22.05 on 14 June 2017 the centre had been closed down because no staff from RBKC were available to manage it.^15581558 Stokoe {MET00079356/30} page 30, paragraph 4; Clee {CFV00000059/4} page 4, paragraph 2 believed it was closed on 15 June 2017. Its functions were transferred to the Westway Centre on 15 June 2017.

¶104.82 Unfortunately, those who were running the Westway Centre were not told that the friends and family reception centre had been moved there and as a result some people looking for information about friends or relations were wrongly turned away^15591559 Spragg {Day280/54:5-12}. and sent to the wrong place.^15601560 Spragg {Day280/55:16-22}. How that happened we do not know. On 16 June 2017 at 18.19, Emma Spragg sent an email to senior figures in RBKC voicing her concern about the way in which the Westway Centre was being described to ensure that friends and family could also have access to support.^15611561 Email from Emma Spragg at 18.19 {RBK00038595/1}: "Friends and family are not always being allowed in as people at Westway believe it to be a rest centre for displaced residents (CAC) and that F and F are to go to the Salvation Army." She pointed out that they were not always being allowed into the Westway Centre as some people understood it to be a rest centre for displaced residents only and that family and friends were to go to the Salvation Army. She wanted communications to be better co-ordinated.^15621562 {RBK00038595}.

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¶104.83 Many of those seeking information about family and friends did not know where the reception centre was or where they should go to obtain information.^15631563 Nabil Choucair {Day267/10:3-8}; Alison Moses {IWS00001281/11} page 11, paragraph 65; Gashaw {IWS00001738/24} page 24, paragraph 24.

The casualty bureau

¶104.84 The Metropolitan Police Service was responsible for setting up a casualty bureau,^15641564 Granville {MET00077845/1-2} pages 1-2, paragraph 4. the primary purpose of which was to provide an initial point of contact for receiving and assessing information relating to persons who had been, or were thought to have been, involved in the incident.^15651565 Emergency Response and Recovery: non-statutory guidance {CAB00004519/124} page 124, paragraph 7.5.6. The guidance in Emergency Response and Recovery provided that part of its function was to provide accurate information to relatives and friends.^15661566 Emergency Response and Recovery: non-statutory guidance {CAB00004519/124} page 124, paragraph 7.5.7. It is clear, however, that there was widespread confusion about the function of a casualty bureau and about whether, and if so how, it was expected to provide information to the public.

¶104.85 Detective Inspector Gail Granville told us that the purpose of a casualty bureau is to gather information, not to provide detailed information about those believed to be missing or dead.^15671567 Granville {MET00077845/8-9} pages 8-9, paragraph 29. She said that information of that kind is provided only after the identification process involving the coroner has been completed and must be conveyed in a sensitive and appropriate manner by a trained family liaison officer.^15681568 Granville {MET00077845/8} page 8, paragraph 29. D I Granville explained that limited information is given to call-handlers to prevent them from inadvertently providing information to callers.^15691569 Granville {MET00077845/9} page 9, paragraph 30. It was unfortunate, therefore, that the telephone number of the casualty bureau was given to those seeking information about family and friends. The result was that they were unable to obtain any help from the casualty bureau without understanding why, which caused considerable frustration and anger.

¶104.86 The police Gold Commander, Commander Jerome, asked for a casualty bureau to be established at 02.30 on 14 June 2017.^15701570 Chalmers {MET00077804/3} page 3, paragraph 11. At 07.34 on 14 June 2017 RBKC advertised its number as an emergency contact number for anyone concerned about their loved ones.^15711571 {RBK00060585}. The telephone number was provided by the police in a statement to the media at 08.02. It was also publicised on social media and the Metropolitan Police website.^15721572 Chalmers {MET00077804/11} page 11, paragraph 51. The delay in setting up the casualty bureau resulted from the need to ensure that there were enough operators available who were appropriately trained to take the calls.^15731573 Chalmers {MET00077804/6} page 6, paragraph 31. The first calls were answered at 08.04; 4,446 calls were received on 14 June 2017.^15741574 Chalmers {MET00077804/8-9} pages 8-9, paragraph 40. The number fell as the days passed and the lines were closed on 24 June 2017.^15751575 Chalmers {MET00077804/9-10} pages 9-10, paragraph 43.

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¶104.87 Some of those who called the casualty bureau reported that they had been unable to speak to anyone directly and received only an automated message.^15761576 Rajaa Chellat {IWS00001284/2} page 2, paragraph 11. Those who were able to speak to someone were not provided with information; after giving details of their family members, they waited for further news but did not receive a call back.^15771577 Nabil Choucair {Day267/14:11-25}.

¶104.88 The problems surrounding the family and friends reception centre and the limitations of the casualty bureau were compounded by the circulation of inaccurate information about those who were safe and those who were missing. The lists of those who were safe and missing provided to various agencies on 14 June 2017 had included errors, with some who had died in the fire shown as safe.^15781578 Spreadsheet: the resident list circulated at 12.21 on 14 June 2017 ​​{TMO00869931}. The difficulties of obtaining accurate information about the fate of friends and relations demonstrates the fundamental importance of accurate registration and record-keeping at rest centres, coupled with clear and accessible sources of information for those enquiring in person or by telephone.

RBKC's public communications

¶104.89 As a Category 1 responder RBKC had a duty under the Civil Contingencies Act 2004 to communicate with the public and provide them with information and advice as necessary in an emergency.^15791579 Section 2(1)(g) of the Civil Contingencies Act 2004 {CAB00004616/3}; Emergency Preparedness Guidance, Chapter 7 {CAB00004543/3} page 3, paragraph 7.1. RBKC's media and communications team was small and its main functions were similar to those of a press office, responding to media enquiries and issuing press releases.^15801580 RBKC Opening Statement {Day263/115:12-15}. At the time of the Grenfell Tower fire the Contingency Management Plan did not include any provision for emergency communications,^15811581 Kerry {Day268/43:7-21}. although a plan may have been available within the communications team.^15821582 Fitzgerald {RBK00059598/2} page 2, paragraph 8. RBKC conceded that those who worked in the media and communications team had failed adequately to rehearse the emergency communication plan with practical exercises and were insufficiently familiar with the plans that existed.^15831583 RBKC Module 4 Opening Statement {RBK00068467/25-26} paragraphs 99-100. RBKC also conceded that the arrangements that were in place were not capable of providing the level of service needed by the public after the fire and were not as clear or as well understood within the organisation as they should have been.^15841584 RBKC Opening Statement {Day263/115:4-6}.

¶104.90 Martin Fitzgerald, RBKC's head of media and communications, described the pressure as great, with unprecedented demands from various directions.^15851585 Fitzpatrick {RBK00059598/3} page 3, paragraph 16. Email from Mark Sawyer to himself on 1 July 2017 {GOL00001301} paragraph 6, "Comms team in denial and overwhelmed. Asked why missed 08.30 comms call - missed amongst two hundred emails". We can well understand that, but, for whatever reason, there was a delay in providing clear, accessible information to the survivors, including information about where to go for help,^15861586 Spragg {Day280/68:2-10}; Spragg {BRC00000050/18} page 18, paragraph 78(a). which made it more difficult for them to obtain the emotional and practical support they needed.^15871587 Spragg {Day280/68:12-17}; Spragg {BRC00000050/18} page 18, paragraph 78(a). The stark truth is that RBKC's communications systems were quickly overwhelmed. As a result, it failed to provide the public with clear, consistent information in the days immediately following the fire.^15881588 RBKC Opening Statement {Day263/115:17-24}.

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¶104.91 No dedicated helpline was set up at the outset to enable displaced residents to obtain information or advice.^15891589 Emergency Preparedness, Chapter 7, paragraph 7.58 provides that "immediately when an emergency occurs, and during the first hours, the public would want amongst other things a helpline number" {CAB00004543/28} page 28, paragraph 7.58. It also says that "responders should plan how to make best use of helplines and public inquiry points... in any emergency. ...Helplines may already be in place for other purposes. Plans can be developed to take them over and provide their staff with a relevant briefing or suitable recorded messages" ({CAB00004543/42} page 42, paragraph 7.90-7.91).Show full note At 07.24 on 14 June 2017 RBKC published the telephone number of the casualty bureau as an emergency number to be used by anyone concerned about friends or relatives.^15901590 {RBK00060585}. At 10.13 RBKC's housing department put its telephone number on the council's website for use by residents who had been displaced.^15911591 {RBK00060669}. By the early afternoon it had published the same number as the point of contact for those wishing to volunteer to help the support effort.^15921592 {RBK00060676}. As a result, the line was inundated with calls and quickly became overwhelmed.^15931593 Spragg {Day280/72:5-13}.

¶104.92 RBKC did not accept offers of assistance that could have strengthened and expanded its communications resources. At the meeting of the strategic co-ordinating group at 08.30 on 14 June 2017, Ms Spragg recommended making use of the Red Cross telephone helpline that was already in place following the Manchester Arena attack as a helpline for those affected.^15941594 Spragg {Day280/69:8-20}; SCG Meeting on 14 June 2017 at 08.30 {LFB00003366/4}. Her offer was not immediately accepted. She repeated her suggestion at the meeting of the humanitarian assistance steering group at 14.00 on 15 June 2017.^15951595 Spragg {Day280/69:21-25}; HASG Meeting Minutes from 15 June 2017 at 14.00 {RBK00001920/4}.

¶104.93 Later on 15 June 2017, RBKC accepted the offer of the Red Cross helpline but the line did not become operational until the next day, 16 June 2017.^15961596 Spragg {Day280/70:10}-{Day280/71:15}; British Red Cross Operational update 9 {BRC00000087/25}. Sue Redmond, the interim executive director for adult social care and public health who was appointed as humanitarian assistance lead officer (HALO) on 15 June 2017, told us that the delay was caused by an attempt to link the RBKC housing line with the Red Cross line.^15971597 Email from Sue Redmond on 15 June 2017 {RBK00011415}; Humanitarian Assistance Steering Group Actions and Decisions sheet, 16 June 2017 at 12.00 {RBK00002040/1}; Redmond {Day271/109:10-11}. It had not been possible to co-ordinate the two helplines by the time London Gold took over the response on 16 June 2017.^15981598 Redmond {Day271/111:15-25}; {Day271/112:9-16}; Spragg {Day280/70:10}-{Day280/71:15}.

¶104.94 The delay in setting up a dedicated helpline was compounded by difficulties in publicising its number. Despite efforts by the Red Cross,^15991599 Gemma Hamilton {BRC00000012/5} page 5, paragraph 20. Leaflets advertising the number were delivered to the Westway Centre. as late as the evening of 17 June 2017 it was apparent from complaints made by those at the Westway Centre^16001600 Email from Tony Andrews to Andrew Meek and RBKC BECC sent on 17 June 2017 at 17.44 {GOL00000982}. that the helpline number needed to be published immediately.^16011601 Email from Tony Andrews on 17 June 2017 at 17.28, circulating key points and actions from the Community Assistance Centre Group meeting {RBK00021073}. In addition, concerns were expressed about the quality of the information being provided to those using the helpline. On 20 June 2017 checks by RBKC revealed that the helpline staff, although warm and friendly, were vague in their responses and merely advised callers to go to the Westway Centre.^16021602 {RBK00041515/3}.

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¶Further checks on 22 June 2017 indicated that the problems persisted. The call-handlers were directing callers to the Westway Centre or advising them to contact Victim Support but were not able to say what help either of them could offer,^16031603 {RBK00041515/1}. despite the fact that they had been given a guidance pack the previous day containing full details of how to deal with questions.^16041604 {RBK00023810/1}.

Language barriers

¶104.95 Inadequate provision was made for those whose first language was not English. The guidance in Emergency Response and Recovery was that, if it could reasonably be expected that an emergency would be likely to involve members of cultural or ethnic minorities, suitable arrangements should be built into plans.^16051605 {CAB00004519/130} page 130, paragraph 7.7.6. The Lancaster West estate was such a community, but despite that clear guidance, it was not until 24 June 2017, some seven days after London Gold had taken over the response, that the helplines made provision for those who did not speak English fluently or for whom English was not their first language.^16061606 Spragg {Day280/74:2}-{Day280/75:19}. It was difficult for the operators of the helpline to know in advance which languages needed to be spoken, as no proper assessment of the likely requirements had been made, but the result was that some of those who did not speak English were unable to use the helpline for a number of days.^16071607 Spragg {Day280/75:20}-{Day280/76:8}.

¶104.96 The lack of translation services was not limited to the helpline. Official communications, such as letters from the council, were available only in English.^16081608 Zakaria El-Sawy {IWS00001822/10} page 10, paragraph 42; Khanh Quang {IWS00001821/15} page 15, paragraph 75-76. As a result, those who did not speak or read English found it difficult to obtain information and assistance. Others relied on their children and friends to translate for them.^16091609 Belfassi {IWS00001815/16} page 16, paragraph 71.

Leaflets

¶104.97 RBKC failed to produce other forms of communication, such as flyers or information leaflets, with sufficient urgency, despite recognising the need to do so. At 05.01 on 15 June 2017, Councillor Mary Weale told Tony Redpath that she had raised the matter with Mr Holgate the previous day.^16101610 {RBK00004117/1}. A leaflet was then produced by some of the councillors, which was shared with Mr Holgate and Mr Redpath at 18.46 on 15 June 2017 for distribution.^16111611 {RBK00038615}. However, it took until the evening of 16 June 2017 for a final version of the leaflet to be produced^16121612 {RBK00020873/1}. and it was not distributed until 17 June 2017.^16131613 {RBK00003124/2}. The leaflets were produced in English and were not translated into other languages until 24 June 2017.^16141614 Spragg {Day280/75:3-8}; {BRC00000087/39}. Mr Redpath recognised at the time that it was extraordinary for the council to have taken so long to carry out such a simple task.^16151615 {RBK00003124/2}. He said that it had been faced with an avalanche of demands and had been unable to attend to anything other than the most immediate and pressing tasks.^16161616 {RBK00003124/2}.

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¶104.98 In our view insufficient consideration was given to those important matters. The guidance quite properly emphasised the need for rapid and effective communication but RBKC failed to give it the priority it deserved. As the Grenfell Tower fire revealed, it had failed to grasp that accurate and timely information from an authoritative source is one of the most valuable forms of support that can be given to those seeking help, in whatever form.

Social media

¶104.99 Although RBKC used social media and maintained a website, information was not published promptly or consistently across the different media platforms and some of those dealing with the response were concerned that not enough information was being given out.^16171617 Email sent at 10.13 for a website update with details of the rest centre at Rugby Portobello Trust {RBK00060669}; Twitter update at 11.39 with details of rest centre at Rugby Portobello Trust {RBK00060621}; Twitter update at 11.40 with details of rest centre at St Clement Church {RBK00060622}; Twitter update at 11.41 with details of rest centre at the Westway Centre {RBK00060623}; {RBK00060669}. At 16.15 on 14 June 2017, Desmond Zephyr, a LALO, told Mr Priestley, Ms Blackburn and Mr Kerry that information was not being released and that although he had directed people to the website, it was inadequate. He suggested greater use of social media.^16181618 {RBK00008513}; Also see email from Ann Ramage to Martin Fitzpatrick on 17 June 2017 at 02.29 {RBK00010918/2} That view was echoed by the Mayor of London's office.^16191619 {GOL00000147}.

¶104.100 The problems affecting communication with the public do not appear to have been resolved by the activation of London Gold. On 18 June 2017, the new Grenfell Fire response team issued a press statement giving details of the Red Cross helpline.^16201620 {RBK00012573}. A leaflet was also produced and circulated that day for distribution through DCLG which contained information about the Red Cross helpline, the contact number of the casualty bureau, details of bereavement services and NHS mental health support.^16211621 {CLG00009134}. As late as 20 June 2017 there was still concern about the absence of a central point of contact and the lack of effective communication with those affected.^16221622 Email from Hilary Patel (the DCLG) to Doug Patterson (London Borough of Bromley) on 20 June 2017 {GOL00000289/1}. RBKC's media and communications team was required to obtain London Gold's approval before it published anything on the council's website or communicated with the media, which caused significant delay in the publication of information.^16231623 Brady {RBK00059591/2} page 2, paragraph 10. One member of the team, Bernard Brady, said that a response would often not be received from London Gold for hours or even until the following day (and sometimes not at all).^16241624 Brady {RBK00059591/2} page 2, paragraph 10.

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The humanitarian assistance steering group

¶104.101 A key feature of the Humanitarian Assistance framework is the appointment of a humanitarian assistance lead officer (HALO) to co-ordinate the humanitarian response.^16251625 London Resilience Partnership Humanitarian Assistance Framework, {RBK00011313/4} paragraph 1.1 and {RBK00019712/9}, paragraph 3.7: Local authorities will prepare to respond to the humanitarian need by: Identifying a senior officer to lead the Humanitarian Response (usually a director with responsibility for adult social care) – hereafter described as the Humanitarian Assistance Lead Officer (HALO).Show full note The HALO brings together various partners, including health, the police, and voluntary and faith sectors, to oversee that aspect of the response. At the time of the fire RBKC had no one suitably trained to undertake that task and no relevant plan in place.^16261626 Kerry {Day268/164:18}-{Day268/168:4}; London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/2}. The lack of a trained HALO significantly affected its ability to deal with the consequences of the fire.^16271627 Kerry {Day268/168:18-23}.

¶104.102 Sue Redmond was an experienced director of adult social care who had worked at a senior level for a number of local authorities. She had returned to Hammersmith and Fulham in April 2017 and held a tri-borough role which also covered Westminster City Council and RBKC. She had not received any training or guidance from Hammersmith and Fulham or RBKC on the Contingency Management Plan.^16281628 Redmond {RBK00058120/2} page 2, paragraphs 2.1-2.2. In her previous positions she had received some training in responding to emergencies, but she did not think that it had prepared her adequately for the Grenfell Tower fire.^16291629 Redmond {RBK00035676/3} page 3, paragraph 13; Project Athena interview, {RBK00029014/2}, unnumbered ninth paragraph. Her training had not given her any grounding in the function of the BECC, the role of a HALO,^16301630 Redmond {Day271/24:2}-{Day271/25:5}; {Day271/31:9-16}; Redmond {RBK00035676/8} page 8, paragraph 36. or what running the humanitarian assistance steering group entailed.^16311631 Redmond {RBK00058120/3} page 3, paragraph 3.3; Redmond {Day271/29:3-5}. She was wholly unprepared for the role she was thrust into.

¶104.103 The Humanitarian Assistance framework provided that if a major incident occurred with substantial consequences for the welfare of a community, the local authority would appoint a HALO,^16321632 London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/9} page 9, paragraph 3.9. whose identity would be confirmed by the strategic co-ordinating group.^16331633 London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/9} page 9, paragraph 3.10. The HALO was to call and chair the first meeting of the humanitarian assistance steering group,^16341634 London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/9} page 9, paragraphs 3.1, 3.7 and 3.11. whose purpose was to determine the direction of the humanitarian response and ensure co-ordination of the activities of the responders. Its officers were to be senior officials who were able to make decisions about resources while having an overview of the needs of the people affected and ensuring there was appropriate support.^16351635 London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/12} page 12, paragraph 4.14. {RBK00019712/48}.

¶104.104 Although the framework did not say when the group was to meet for the first time, it did indicate that the humanitarian assistance effort should begin very soon after the incident.^16361636 London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/11} paragraph 4.2. That was recognised by members of the London Resilience Group early on 14 June 2017. As a result, Andrew Meek, head of organisational resilience at the London Borough of Haringey, sent an email to David Kerry at 10.23 recommending that he appoint a HALO and plan a first meeting of the humanitarian assistance support group that afternoon.^16371637 {GOL00001052}. However, Mr Kerry had finished his shift that morning and had gone off duty and the message does not appear to have been passed to Stuart Priestley, then

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¶Council Silver, or the BECC.^16381638 Andrew Meek {GOL00001166/2} page 2, paragraph 6 at 10.23; Kerry {Day269/120:5}-{Day269/121:16}.

¶104.105 That was only one of a number of reasons for the delay in setting up the group. The Humanitarian Assistance framework was in the process of being revised at the time and although a draft of the new version existed, it had not been published.^16391639 Meek {GOL00001166/5} page 5, paragraph 6 and {GOL00001166/9} page 9, paragraph 12; {GOL00001166/5} page 5, paragraph 6, entry 'evening': Andrew Meek drafted a revised Humanitarian Assistance Centre (HAC) Plan during the evening of 17 June 2017 as the Humanitarian Assistance Framework did not contain an HAC plan {RBK00021646}. Tony Andrews, Emergency Planning Manager (Humanitarian Assistance) at Westminster City Council, sent a copy of the revised version to RBKC at 13.16.^16401640 {RBK00011312}. Ms Redmond then had to spend time familiarising herself with the material in the expectation that she might become the HALO.^16411641 Redmond {RBK00058120/5} page 5, paragraphs 7.2-7.3. Formal confirmation of her appointment was not made until the morning of 15 June 2017 at the RBKC Gold meeting.^16421642 Redmond {RBK00058120/2-3} pages 2-3, paragraphs 3.1-3.4. It is unclear why that was. At all events, the first meeting of the group chaired by Ms Redmond was not held until 14.00 on 15 June 2017.^16431643 Redmond {Day271/70:22}-{Day271/71:9}; Gold Group Meeting Minutes at 10.00 on 15 June 2017 {RBK00013270/3}; Humanitarian Assistance Steering Group Minutes {RBK00001920}. We consider that, in light of the seriousness of the incident and the advice received on the morning of 14 June 2017, a meeting should have taken place that afternoon.^16441644 Redmond {Day271/52:23}-{Day271/53:4}. The delay of 24 hours had an adverse effect on the identification and assessment of the needs of those affected.

¶104.106 By the afternoon of 15 June 2017, the humanitarian assistance support group had developed an agenda which Ms Redmond considered to be massive and overwhelming.^16451645 Redmond {Day271/73:19-25}; {Day271/76:7-8}. The operation of the group was subsequently criticised by some of those who attended the meeting. In an email to a colleague Toby Gould described it as disorganised. Some representatives were not present and the telephone conference facilities did not work well. He was not convinced that the group was giving enough attention to urgent business.^16461646 {LFB00061320/1} page 1, paragraph 4. Although national voluntary organisations, such as Victim Support and the Red Cross, had been represented, he thought there was a lack of understanding at RBKC about other relevant local voluntary organisations.^16471647 {RBK00019929/3}. Many community organisations involved in the response to the fire were frustrated by the lack of information being shared by London Gold and its failure to gather information from organisations on the ground.^16481648 Richards {Day275/166:2-6}.

Psychological support

¶104.107 Due to the delays in setting up the humanitarian assistance support group, it was unclear to those affected by the disaster what psychological support was available at the official rest centre. That in turn led to differences in the level of support received. Some survivors discovered that counselling was available from the NHS at the Westway Centre,^16491649 Dedrich {IWS00001275/7} page 7, paragraph 49; Sener Macit {IWS00001563/14} page 14, paragraph 65; Gashaw {IWS00001738/18} page 18, paragraph 20; Wesley Ignacio {IWS00001820/16} page 16, paragraph 85; but some people did not think that there was sufficient privacy to enable them to take advantage of it.^16501650 Laci {IWS00001831/6} page 6, paragraph 40. Maureen Mandirahwe, a member of the tri-borough social care team, drew attention to the inadequacy of the mental health support at the Westway Centre and the lack of privacy for those grieving.^16511651 {RBK00011468}; Log of issues, {RBK00014781}.

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¶104.108 Psychological support was provided by the NHS West London Clinical Commissioning Group. The NHS is a Category 1 (and for some purposes a Category 2) responder with an established response plan.^16521652 Proctor {NHS00000002/4} page 4, paragraph 13. Although its staff were in the rest centres on 14 and 15 June 2017,^16531653 Minutes of the Health Response Group teleconference on 15 June 2017 at 17.00 {RBK00026985/2} page 2, paragraph 2.1. by 16 June 2017 they were advising those in need to call a 24-hour telephone number to obtain mental health support services and information instead of offering to meet them.^16541654 {RBK00038406}. On 18 June 2017 the Prime Minister had asked for additional NHS staff to attend the next day.^16551655 {RBK00011424}. Those concerns were not isolated. Later that day it became clear that doctors did not know where to refer people needing care, who was in charge or whom to contact in connection with a need for acute care. There was a sense that no one was in charge.^16561656 {RBK00011798}.

¶104.109 Survivors described how they struggled with their mental health after the fire, desperately needing help but not knowing where to get it at a time when they were at their most vulnerable.^16571657 Bobby Ross {IWS00002356/8} page 8, paragraphs 42 and 45; Diejomaoh {IWS00001303/5-6} pages 5-6, paragraphs 27-28; Hanan Cherbika {Day266/106:1-22}. Most of those who had been affected indicated that psychological support had not been offered to them within the seven days following the fire.^16581658 Towner {IWS00001705/8} page 8, paragraph 42; Shawo {IWS00001290/4} page 4, paragraph 29.

¶104.110 Some of those in need of mental health support received prompt assistance from the Red Cross,^16591659 Deen {IWS00002301/5} page 5, paragraph 35. which provided psychosocial support at the Westway Centre.^16601660 Spragg {Day280/47:8-23}; Spragg {BRC00000050/16} page 16, paragraph 71. The Red Cross also worked with the NHS teams to increase their capacity to reach people in hotels and other places, although there was some delay in finding out where they were.^16611661 Spragg {Day280/48:1-12}. There were variations in how that support was delivered. The most common form of mental health support required was counselling. It was provided by "Time to Talk" at the St Charles Centre^16621662 Pahlavani {IWS00001244/15} page 15, paragraph 46. and later by the Grenfell Health and Wellbeing service.^16631663 Rullo {IWS00001655/10} page 10, paragraph 43. A few people mentioned other sources of help, but they had often become available some time after the fire. Others asked their doctors to refer them for psychological support,^16641664 Alfawaz {IWS00001274/11} page 11, paragraph 85. or received counselling by other routes, such as through their employers.^16651665 Christopher Roncolato {IWS00001786/13} page 13, paragraph 78; Hamza Jones {IWS00001710/5} page 5, paragraph 30. Yet others paid privately for their own counselling.^16661666 Norbert {IWS00001252/10} page 10, paragraph 55. Some survivors reported a delay in receiving psychological support, in some cases for as much as six months.^16671667 Alison Moses {IWS00001281/11} page 11, paragraph 64; Farhad Neda {IWS00001302/4} page 4, paragraph 20; Wahabi {IWS00001714/15} page 15, paragraph 68.

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Identification of specific needs

¶104.111 When London Gold assumed control on 16 June 2017, there was insufficient understanding of the needs of those affected and the humanitarian response was disorganised. Mary Harpley, chief executive of the London Borough of Hounslow, took over as HALO from 16 June.^16681668 Harpley {GOL00000441/1} page 1, paragraph 4. She described RBKC as exhausted and not in a position to provide any meaningful handover.^16691669 Harpley {GOL00000441/4} page 4, paragraph 13. As a result, London Gold had to spend time assessing the situation, obtaining contact information for families and finding out who the community leaders were.^16701670 See Chapter 102. Adamson {BRC00000075/17} page 17, paragraph 77. Ms Harpley identified a number of things that were needed, such as a single, definitive list of the hotels into which people had been placed, regular communication with survivors, a clear understanding of residents with the greatest needs and a list of the community, faith and other leaders with whom RBKC should have engaged.^16711671 Harpley {GOL00001114/2} page 2, paragraph 3. She thought that RBKC had tried to cover all the important strands of humanitarian assistance, but had not managed to demonstrate enough progress on any of them to give survivors and observers confidence that the right work was being done.^16721672 Harpley {GOL00001114/2} page 2, paragraph 3. Based on the other evidence we have seen, we agree with her assessment.

Key workers

¶104.112 The use of key workers played an increasingly important part in enabling people to obtain the support that was available. On the afternoon of 16 June 2017, as concern about the provision of humanitarian assistance mounted, the Prime Minister declared that everyone affected by the fire, including those from the area surrounding the tower, should be allocated a key worker and that all the key workers should be social workers. That meant finding over 200 social workers from the London boroughs and defining their responsibilities.^16731673 Redmond {RBK00035676/13} page 13, paragraph 64. The role of a key worker was to provide practical support,^16741674 Chamberlain {RBK00035302/14-15} pages 14-15, paragraph 57. not to provide psychological support, and differed from that of family liaison officers, who were police officers trained to support the next of kin of those who had died or were missing.^16751675 Humanitarian Assistance Guidance Pack {BRC00000008/2}. In the days following the announcement, social workers from other boroughs who were being deployed as key workers arrived at the rest centre without notice and without any idea of what was expected of them,^16761676 {RBK00012323}. reflecting an initial lack of co-ordination and a failure to explain what they were expected to do.

¶104.113 Meeting the commitment to provide all those affected with a key worker proved difficult in the short term. On 19 June 2017, Mr Gould told the BECC that 43 social workers from 11 boroughs were available.^16771677 {RBK00009467}. By 21 June 2017, some people were still waiting to be given a key worker. However, even when a key worker had been provided, there was no guarantee that residents would be visited. By 21 June 2017, only two-thirds of the 106 residents who had been given key workers had been contacted. The number of residents actually visited was still unknown.^16781678 {RBK00022845}.

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¶104.114 That remained a problem one month after the fire. On 13 July 2017 it was reported that all residents of the tower and Grenfell Walk had key workers, but a number of families from the Walkways housed in temporary accommodation had not been allocated a key worker because there were not enough available.^16791679 {RBK00044499} email from Martin Hinckley WCC to RBKC 13 July 2017 attaching residents without key workers and addressed to Natasha Bishop at the Key Workers Hub {RBK00044500/1}. The report recognised that even at that stage the problem could not be resolved quickly and it was uncertain when the government's objective for every household in temporary accommodation to have a key worker was likely to be achieved.^16801680 {RBK00044500/1}.

¶104.115 The level of support provided to residents by key workers varied. Some said that their social workers and key workers had been helpful^16811681 Novell {IWS00001288/11} page 11, paragraph 67. and that key workers had provided advice on counselling.^16821682 Alan Ali {IWS00001745/8-9} pages 8-9, paragraph 38. Others reported that the high turnover of key workers was unhelpful^16831683 Le-Blanc {IWS00001271/30} page 30, paragraph 284; Khoudair {IWS00001616/14} page 14, paragraph 111; Yousuf {IWS00001626/4} page 4, paragraph 21. and one complained that they had no experience of dealing with people facing trauma.^16841684 Rashida Ali {IWS00001617/15} page 15, paragraph 185.

¶104.116 It does not appear that there was any urgent attempt to establish a system for responding to the needs of those whose mental health had been affected. It is not clear whether that was due to a lack of organisation on the part of RBKC or to the guidance in the Humanitarian Assistance framework, which indicated that formal help, such as counselling, should not be offered in the first few weeks after an incident.^16851685 London Resilience Partnership Humanitarian Assistance Framework {RBK00011313/6-7} pages 6-7, paragraphs 2.7-2.8.

¶104.117 Before ending this chapter it is important that we recognise that many of RBKC's staff, not least those whose roles involved contact with the public, worked extremely hard for long hours, day after day. They too were seriously affected by the tragedy and were expected to carry on under circumstances that placed them under great deal of scrutiny and often challenge. In common with the residents of North Kensington they were let down by the leadership of the council, the inadequacy of its standing systems and the provision it made for staff.^16861686 In an email sent on 17 June 2017 at 16.00 to Ray Brown (RBKC), Rebecca Hennessy (also RBKC) said that she was angry at the lack of leadership and how the situation had been handled by [RBKC]. She felt let down by the council. Those in authority refused to listen to those on the ground and there were no clear communications {RBK00049712}.

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