Grenfell Tower Inquiry: Phase 2 Report · 2024
Chapter 105: The response of the Tenant Management Organisation
Chapter 105: The response of the Tenant Management Organisation
Introduction
¶105.1 The principal purpose of the Tenant Management Organisation was to manage and maintain RBKC's housing stock. Unlike RBKC, it was not a responder for the purposes of the Civil Contingencies Act 2004. Nonetheless, from the first hours it was directly involved in several aspects of the humanitarian response to the disaster, including through attendance at rest centres, RBKC Gold group meetings, creating and managing a list of safe and missing residents and facilitating the return of residents evacuated from properties within the police cordon.
¶105.2 We heard evidence from Robert Black, the chief executive, and Teresa Brown, the Director of Housing, about the steps taken by the TMO in response to the situation created by the fire. We also received 47 witness statements from members of the TMO's staff.
Emergency planning
¶105.3 The TMO had its own emergency plan which identified various responsibilities in the event of a major emergency.1687 TMO Emergency Plan {RBK00057991}. It was created in August 2004 and had subsequently been revised in 2009 and 2016. For present purposes we are concerned with the 2016 version, which was in effect at the date of the fire.
¶105.4 Part 1 of the plan described the TMO's role in emergency planning and response. In their evidence, Mr Black and Ms Brown initially suggested that the plan had been designed for localised incidents1688 Brown {Day274/6:16-22}; Black {TMO10048970/2} page 2, paragraph 11. and had never been intended to apply to a major incident,1689 Black {TMO10048970/2} page 2, paragraph 11; Brown {TMO00869990/2} page 2, paragraphs 6-7. as the TMO did not have sufficient resources to deal with an emergency on that scale.1690 Black {TMO10048970/3} page 3, paragraph 12. In such an event, the RBKC Contingency Management Plan would come into operation rather than the TMO's emergency plan.1691 Black {TMO10048970/1} page 1, paragraph 4; Brown {TMO00869990/2-3} pages 2-3, paragraph 9. In those circumstances the TMO would have no formal role other than to provide resources and support RBKC when requested.1692 Black {TMO10048970/3} page 3, paragraph 15. However, the introduction to the emergency plan suggests that it did envisage a role for the TMO in response to a major incident that exceeded its own capabilities and resources.1693 TMO Emergency Plan {RBK00057991/13}. In such a situation, the TMO would be expected to work with the council. Both Mr Black1694 Black {Day275/8:6-22}; {Day275/14:11-25}. and Ms Brown1695 Brown {Day274/8:20}-{Day274/9:1}. accepted that the plan could, in theory, have applied to the Grenfell Tower fire, reflecting a degree of uncertainty about the part that the TMO was expected to play in response to a major emergency.
144Relationship with the council
¶105.5 There was no effective arrangement or shared understanding between the TMO and RBKC about the part that the TMO would play in the event of a major emergency affecting one or more of its properties1696 Black {Day275/15:1-6}. and RBKC's Contingency Management Plan did not refer to the TMO.1697 RBKC Contingency Management Plan {RBK00004396}; Brown {TMO10048970/3} page 3, paragraph 14. Following the fire at Adair Tower in October 2015, there was a discussion at the TMO executive team meeting on 11 November 2015 in which those present recognised the need for the TMO to be more involved with RBKC in emergency planning in order to ensure that all were aware of their responsibilities.1698 {TMO00840414/2} item 3. It was agreed that in response to an incident involving more than a few dwellings the TMO would provide details of residents' known vulnerabilities.1699 Summary of meeting on 11 April 2016 with Contingency Planning, Housing and TMO to follow-up on the Adair Tower fire {RBK00057975/3}. However, Mr Black did not seek to clarify with RBKC the formal role of the TMO in the event of an emergency;1700 Black {Day275/15:7-10}. he expected that Laura Johnson and her team would tell the TMO how it fitted into RBKC's plan.1701 Black {Day275/15:11-14}. At the time of the Grenfell Tower fire, therefore, the TMO did not have a formal and clearly defined role in RBKC's contingency planning arrangements.1702 Black {Day275/17:21}-{Day275/18:1}. Given that the need for such a role had been identified as a result of the Adair Tower fire, that gap should have been filled.
Training
¶105.6 The emergency plan required staff to undertake a number of tasks in the event of an emergency, including ensuring that the primary needs of residents were met, opening and managing rest centres to care for those affected and identifying residents' special needs or vulnerabilities.1703 TMO Emergency Plan {RBK00057991/28}. However, TMO staff were not properly trained to carry out those tasks. Notably, neither Mr Black nor Ms Brown undertook any training in responding to emergencies during the course of their employment by the TMO,1704 Brown {TMO00894124/1} page 1, paragraph 3; Black {Day275/10:23}-{Day275/11:2}. despite their senior roles and the fact that Ms Brown was identified in the emergency plan as a contact and key decision-maker.1705 TMO Emergency Plan {RBK00057991/17}; Brown {Day274/15:8-12}. Mr Black told us that, although no training had been provided to staff about their own responsibilities, staff on call and out-of-hours contractors did receive training on their responsibilities when on duty.1706 Black {Day275/17:14-20}. Although some staff received more general briefings from the TMO's Health and Safety team,1707 Chamchoun {TMO10048972/2} page 2, paragraph 5; Singh {TMO00840373/2} page 2, paragraph 5; Hutchison {TMO10048971/3} page 3, paragraph 17. several people who were identified in the emergency plan as key contacts had not received training on the plan itself,1708 Singh {TMO00840373/2} page 2, paragraph 5; Chamchoun {TMO10048972/2} page 2, paragraph 5. let alone in any detail.1709 Sharples {TMO10048975/2} page 2, paragraph 17. Mr Black could not recall whether any specific training on the emergency plan had been given to the executive team so that they could help staff understand their roles and responsibilities in co-operation with RBKC.1710 Black {Day275/17:6-12}. TMO staff had not received training in managing rest centres or collating information in an emergency situation.1711 Brown {Day274/60:16}-{Day274/61:14}; {Day274/63:21-25}. Mr Black accepted that TMO staff should have received more training in how to respond to an emergency.1712 Black {Day275/14:5-7}.
145The night of the fire
¶105.7 The TMO's emergency plan was not activated in response to the fire. Mr Black accepted that it could have been but that, in reality, the incident was overwhelming for the TMO. In any event, RBKC's Contingency Management Plan was in operation by the time he arrived at the scene.1713 Black {Day275/8:6-24}. RBKC did not actively ask for the TMO's assistance but welcomed the support it offered.1714 Black {TMO00887150/1-2} pages 1-2, paragraph 4. The TMO's involvement was essentially voluntary1715 Black {Day275/19:3}-{Day275/20:20}. and it co-operated with RBKC to respond to the situation as it evolved.1716 Black {Day275/19:3}-{Day275/20:20}. TMO staff brought particular insights into the tower, the local area and the residents that others did not share.1717 Black {Day275/30:3-7}. Ms Brown's understanding was that the council had been in charge of the response to the emergency and that the TMO had had a supporting role, providing assistance when RBKC asked it to do so.1718 Brown {Day274/11:2-16}. She told us that TMO staff had wanted to do what they could to help and so had stepped in.1719 Brown {Day274/11:2-16}.
¶105.8 Although RBKC asked the TMO for information on certain housing matters, it did not ask for its assistance in responding to the effects of the fire. However, despite the absence of any existing arrangements or any request to help in providing humanitarian assistance, TMO employees voluntarily made themselves an integral part of the response, both on the night of the fire and in the week that followed. Although Ms Brown had some practical experience in providing such assistance as a result of her involvement in the Adair Tower fire and dealing with smaller emergencies,1720 Brown {Day274/16:7}-{Day274/17:25}. that was not sufficient to prepare her or her team to respond to a major emergency of the kind then facing them.
Rest centres
¶105.9 The TMO was not involved in setting up any of the rest centres1721 Brown {Day274/26:13-16}. and RBKC did not initially tell Ms Brown what she and her staff were expected to do when they went there.1722 Brown {TMO00894124/4} page 4, paragraph 13; Brown {Day274/26:25}-{Day274/27:1-2}. Ms Brown told us that they had been left to decide for themselves what to do1723 Brown {Day274/26:25}-{Day274/27:1-2}. and that they thought that the most useful thing would be to go to rest centres and start supporting residents and collecting information for the LFB about who was safe and who was missing.1724 Brown {Day274/27:3}-{Day274/28:5}.
¶105.10 In the early hours of 14 June 2017, TMO staff attended the Rugby Portobello Trust, St Clement's Church, the Methodist Church, the Westway Centre, and the Latymer Community Church.1725 TMO Staff Presence at Rest Centres {TMO00869981}. Ms Brown did not allocate any staff to other community rest centres, such as the Al Manaar Cultural Heritage Centre, St Francis of Assisi Church or the Salvation Army, because she did not know about them.1726 Brown {Day274/31:10-14}; {Day274/36:20-22}. TMO staff did not, therefore, collect information about residents that attended those centres.1727 Brown {Day274/31:16-25}. However, when he attended the second RBKC Gold group meeting at 15.00 on 14 June 2017,1728 RBKC Gold Group Meeting {RBK00023239}.
146¶Mr Black incorrectly told the meeting that the TMO had staff in every rest centre.1729 RBKC Gold Group Meeting {RBK00023239/2}. His error was the result of his not having been given the latest information about rest centres.
¶That contributed to RBKC's lack of accurate information about the number of people who had been displaced by the fire.
¶105.11 Between them RBKC and the TMO failed to take effective measures to tell survivors and displaced residents about the support available at the rest centres. Ms Brown told us that she had expected the Local Authority Liaison Officer (LALO) to tell the emergency services, who in turn would direct residents to the rest centres as they were evacuated,1730 Brown {TMO00869990/4} page 4, paragraph 18. since she was not allowed within the cordon.1731 Brown {Day274/39:9-23}. However, TMO staff did not take any steps to communicate with the LALO to ensure that residents were told where they could go.1732 Brown {Day274/39:20}-{Day274/40:3}. Similarly, no consideration was given to deploying TMO staff in the streets outside the police cordon in order to direct residents to rest centres.1733 Brown {Day274/40:24}-{Day274/41:7}. A significant number of residents who had been displaced did not know where to go after they had left the tower or their homes nearby.
The Westway Centre
¶105.12 During the course of 14 June 2017, the TMO was advised by Amanda Johnson and Robert Shaw of RBKC that they should tell people to go to the Westway Centre as the designated rest centre and stay there overnight.1734 Brown {Day274/42:3-25}. There was difficulty in persuading people to leave the existing rest centres because some wanted to stay in rest centres run by the community.1735 Brown {TMO00869990/7} page 7, paragraph 36; Brown {Day274/43:10-13}.
¶105.13 Although the Westway Centre had become the centralised place of support during the course of the day on 14 June 2017,1736 Priestley {RBK00035672/8-9} pages 8-9, paragraph 39. Ms Brown did not visit it, either on 14 June 2017 or subsequently,1737 Brown {TMO00894124/13} page 13, paragraph 46. because she considered that there were capable staff in place.1738 Brown {Day274/51:23}-{Day274/52:4}. There was a TMO desk at the Westway Centre but there were no TMO staff there on Saturday 17 June or Sunday 18 June 2017 because of worries about their safety.1739 Brown {TMO00894124/13} page 13, paragraph 47. Given the TMO's position as the body with whom most residents had had regular contact before the fire, it is not surprising that they expected to see people from the TMO offering support in the days following it. Some residents complained that the TMO was not sufficiently active in its response to the fire and had failed to provide support for people at the Westway Centre,1740 Razza {IWS00001607/9} page 9, paragraph 42. but it was not responsible for setting up the Westway Centre as a rest centre or for running it. That was the responsibility of RBKC.
147¶105.14 Until 19 June 2017 no mechanism was introduced at the Westway Centre to deal with questions from residents of the tower and surrounding blocks.1741 Internal TMO email sent on 19 June 2017 at 11.52 {TMO00870375}. On 23 June 2017 a log was created to help staff in providing responses to questions.1742 Internal TMO email sent on 23 June 2017 at 10.22 {TMO10035572}. TMO staff working at the Westway Centre were provided with daily briefings to enable them to assist people,1743 Brown {Day274/52:6-20}. but no written briefings were provided until 26 June 2017.1744 Briefing - Staff Expectations for covering TMO Westway Helpdesk {TMO10036663}.
List of those safe and missing
¶105.15 Ms Brown initially collated information about those missing to assist the LFB with rescue efforts.1745 Brown {TMO00869990/5} page 5, paragraph 23. That evolved into creating and maintaining a spreadsheet containing lists of safe and missing people to provide to RBKC to assist with providing emergency accommodation.1746 Brown {Day274/27:20-24}; Brown {Day274/58:17}-{Day274/59:2}; Email from Kiran Singh (TMO) on 14 June 2017 at 12.21 {TMO00869930} attaching list of safe and missing residents {TMO00869931}. The spreadsheet was also circulated to a number of agencies, including the casualty bureau and the BECC.1747 Brown {TMO00894124/6} page 6, paragraph 20; Brown {Day274/58:9-21}.
¶105.16 Ms Brown had not been asked by RBKC to undertake that task;1748 Brown {Day274/57:1-20}. she had done so voluntarily because it was a practical way in which she could help and she knew it was important.1749 Brown {Day274/57:1-9}. She directed her initial efforts only to residents of Grenfell Tower and not to those who had been evacuated from the Walkways or Treadgold House.1750 Brown {Day274/123:8-10}.
¶105.17 There were two fundamental problems with the creation and maintenance of the safe and missing lists. First, the spreadsheet was based on the tenancy information held by the TMO in its electronic records,1751 Tenancy List {TMO00866006}. which was incomplete and inaccurate. Secondly, the method by which TMO staff were collecting information at rest centres was haphazard. A combination of these two problems led to errors in the list and to people being misinformed about the safety of their loved ones.
Inaccurate information
¶105.18 The TMO relied for the accuracy of its records primarily on information provided by its tenants.1752 Singh {TMO00894410/2} page 2, paragraph 3c. Although good practice required it to carry out an audit of each property every year, it did not do so because it had more pressing matters to attend to.1753 Williams {TMO00879804/9} page 9, paragraph 62.
¶105.19 Ms Brown told us that the tenancy list contained a mixture of tenants and other household members.1754 Brown {Day274/68:6-19}. In some cases only the tenant appeared; in others the tenant and other members of the household were included. In some cases residents did not appear in the list at all. The information held by the TMO about disabilities or particular needs, such as preferred language and mental and physical health, was incomplete. The list was amended by staff whenever they were provided with fresh information. Ms Brown accepted the shortcomings of the tenancy list as the basis for identifying who was in the tower on the night of the fire.1755 Brown {Day274/71:12-19}. Kiran Singh, who produced the list, was unable to say when it had last been revised.1756 Singh {TMO00894410/2} page 2, paragraph 3c.
148¶105.20 The inaccuracies in the tenancy information provided by the TMO in turn created problems for other agencies using the information. The police had difficulty establishing a clear picture of who had been in the tower and realised by the end of the first day that the TMO's list was not accurate.1757 Email from the Metropolitan Police Service to various agencies regarding updated briefing on the number of fatalities and/or missing people {RBK00018233/2}.
¶105.21 The inaccuracies also hampered residents' searches for their loved ones. Mohammed Rasoul told us that, when he attended the Latymer Community Church, somebody whom he believed to be from the TMO was present with a list of flat numbers and names. Virginia Duffy was listed as the occupier of Flat 153, even though she had died the previous year. In June 2017 it was the home of Isaac Paulos, aged 5, who died in the fire.1758 Rasoul {Day265/146:4-19}.
¶105.22 After the fire, RBKC was aware that the tenancy information was inaccurate. As late as 17 June 2017, Mr Robert Shaw of RBKC sent an email to TMO staff asking how many residents, not just lead tenants, lived in the tower. Mr Singh qualified his reply with a warning that the information was not likely to be completely accurate as households had changed over the years and the TMO had not always been told.1759 Email correspondence between Robert Shaw (RBKC Housing) and Kiran Singh (TMO) on 17 June 2017 {TMO10035581/4}. Ms Brown accepted that meant that there were people who were not accounted for and therefore not contacted.1760 Brown {Day274/72:4-9}.
¶105.23 On 14 June 2017, the safe and missing lists were initially revised on the basis of information collected at rest centres. TMO staff later called all known residents of the tower who had not made contact through the rest centres, although that effort was hampered by the fact that contact information was not always correct.1761 Brown {TMO00869990/5} page 5, paragraph 23. Ms Brown and another colleague continued calling residents of the tower until about 21.00 on 14 June 2017, but in many cases without success.1762 Brown {TMO00894124/8} page 8, paragraph 28.
¶105.24 The minutes of the second RBKC Gold group meeting at 15.30 on 14 June 2017 recorded that the TMO had made contact with 81 households from the tower but that they did not know where some residents were staying.1763 RBKC Gold Group Meeting {RBK00023236/1}.
¶105.25 It is not clear whether residents to whom the TMO was able to speak were asked about any vulnerabilities or specific needs or whether they were offered any particular support.1764 Luke Towner stated that his partner was contacted by the TMO on 14 June only to confirm that if they escaped, they were not offered any support or a call back at a later date, Towner {IWS00001705/8} page 8, paragraph 41. Ms Brown told us that the focus at that stage had been on finding out whether people were safe.1765 Brown {Day274/95:19-25}.
149¶105.26 By 16 June 2017, 129 Grenfell Tower residents on the TMO's list had been accounted for but 102 had not been found.1766 {TMO00869959}. There was no clear plan for contacting those residents who had not been reached. That is consistent with the evidence we heard from survivors1767 Moghaddam {IWS00000392/8} page 8, paragraph 42; Patel {IWS00001610/10} page 10, paragraph 49; Ho {IWS00001551/16} page 16, paragraph 62; Gomes {IWS00001734/28} page 28, paragraph 44; Ross {IWS00001826/14-15} pages 14-15, paragraph 69. and residents of the tower who said they had not been contacted by the TMO in the first few days following the fire. Ms Brown did not know whether RBKC was also trying to account for the residents of the tower.1768 Brown {Day274/97:7-15}. By 19 June 2017 RBKC and the TMO had still not established an accurate list of those who had been living in the tower.1769 RBKC Log {RBK00028712/1}.
Haphazard recording of information
¶105.27 Before sending her staff to the rest centres, Ms Brown told them to collect the names and addresses of those who were safe and those who were missing and information on particular needs, including in relation to accommodation.1770 Brown {Day274/29:17-23}. They were not asked to record that information in a particular way1771 Brown {TMO00894124/7} page 7, paragraph 24. and did not use the template in the emergency plan.1772 {RBK00057991/31}. Ms Brown did not receive any instructions from RBKC on the kind of information that should be collected or how to collate and organise it.1773 Brown {Day274/57:1-20}.
¶105.28 Ms Brown thought that her staff were clear about what they needed to do,1774 Brown {Day274/60:16}-{Day274/61:14}. but one member of the team who had been sent to the Harrow Club did not think that she was the right person to be running a rest centre, having received no training. However, she felt she had no choice but to carry on.1775 Warrier {TMO10048986/4} page 4, paragraph 18, Ms Warrier was a Neighbourhood Team Leader.
¶105.29 Clare Richards, the chief executive of the Clement James Centre, was concerned by the way in which TMO staff were recording information. She said that they had been recording information on scraps of paper, had not been making an accurate record of who was there and had not known who they were looking for.1776 Richards {CFV00000012/13} page 13, paragraph 89. She offered them the use of laptops to capture information on a spreadsheet, but the offer was declined.1777 Richards {CFV00000012/13} page 13, paragraph 89. Ms Brown told us that she had not wanted staff to record information on different laptops because it would have taken time to amalgamate the different lists. She wanted a single spreadsheet1778 Safe and Missing List circulated at 12.21pm {TMO00869931}. to minimise confusion1779 Brown {Day274/80:10-16}. and the risk of error.1780 Brown {Day274/79:1-7}.
¶105.30 The pieces of paper containing handwritten notes1781 Examples of handwritten notes taken by the TMO staff at rest centres {TMO10035210}; {TMO10035236}; {TMO10035242}; {TMO10035218}; Brown {Day274/75:3-10}. from the various rest centres were passed to Mr Singh,1782 Brown {Day274/81:23}-{Day274/82:6}. who brought a laptop to the Clement James Centre on the morning of 14 June 2017.1783 Brown {TMO00894124/6} page 6, paragraph 20. He amended the original spreadsheet1784 Safe and Missing List circulated at 12.21pm {TMO00869931}. using the information on the loose sheets of paper and recorded whether residents were safe. He also recorded any other relevant information, such as whether they were staying with friends and relatives or in a hotel.1785 Brown {Day274/81:23}-{Day274/82:6}; Singh {TMO00894410/1-2} pages 1-2, paragraph 3a. Ms Brown accepted that there was a degree of error in recording information at the rest centres in that way,1786 Brown {Day274/76:8-15}. but said the system was as efficient as it could be.1787 Brown {Day274/79:11-25}.
150¶Unfortunately, although her efforts to create a centralised system were intended to reduce error, their outcome was the opposite.
Errors in the lists
¶105.31 As a consequence of the errors and omissions in the tenancy records and the defects in the further information gathered at the rest centres, there were a number of significant errors in the safe and missing lists.
¶105.32 In the spreadsheet circulated on 14 June 2017 at 12.211788 Safe and Missing List circulated at 12.21pm {TMO00869930}. a number of people who had died in the fire were marked as safe, including Denis Murphy,1789 {TMO10017313} Row 11: Denis Murphy was marked safe as seen by the yellow highlight. Khadija Khalloufi,1790 {TMO10017313} Row 51: Khadija Khalloufi was marked safe as seen by the yellow highlight. Faouzia El-Wahabi, Yasin El-Wahabi, Abdulaziz El-Wahabi and Nur Huda El-Wahabi1791 {TMO10017313} Rows 104-107: Faouzia El-Wahabi, Yasin El-Wahabi, Abdulaziz El-Wahabi and Nur Huda El-Wahabi were marked safe as seen by the yellow highlight. and Saber Neda.1792 {TMO10017313} Row 136: Saber Neda was marked safe as seen by the yellow highlight. Some of those marked safe were also marked as missing, such as Denis Murphy and Khadija Khalloufi.1793 {TMO10017313} Rows 11 and 51: Denis Murphy and Khadjia Khalloufi were also marked under the 'missing' tab as seen by the pink highlights. The same inaccuracies remained throughout the day. Revised lists were circulated by Mr Singh at 13.08 and 13.44; recipients included RBKC for forwarding to teams on the ground.1794 Brown {TMO00869990/5} page 5, paragraph 26. However, those lists still recorded as safe some who had died.1795 {TMO10017359} Safe and Missing list sent from Kiran Singh to Rob Shaw at RBKC at 13.44 on 14 June 2017. The same inaccurate information is recorded in the 'SAFE' tab at Row 11: Denis Murphy, Row 51: Khadija Khalloufi, Row 102: Jessica Urbano Ramirez, Rows 104-107: Faouzia El-Wahabi, Yasin El-Wahabi, Abdulaziz El-Wahabi and Nur Huda El-Wahabi, Row 136: Saber Neda, as seen by the yellow highlights.
¶105.33 Another spreadsheet circulated at 17.27 contained revisions made after the neighbourhood team had telephoned every resident from whom they had not heard, but it still listed Denis Murphy and Khadija Khalloufi as safe. The El-Wahabi family were still listed as safe, save for a note stating that one member might be missing.1796 {TMO00869982} Kiran Singh circulated Resident List at 17.27 confirming that the Neighbourhood team had rang every resident they had not heard from. Row 11: Denis Murphy, Row 51: Khadija Khalloufi, Rows 104-107: Faouzia El-Wahabi, Yasin El-Wahabi, Abdulaziz El-Wahabi and Nur Huda El-Wahabi, Row 136: Saber Neda, Row 102; Jessica Urbano Ramirez were marked 'safe' on that list as seen by the yellow highlights {TMO10017480}; Brown {TMO00869990/6} page 6, paragraph 27; Brown {Day274/89:15}-{Day274/91:5}. Ms Brown could not explain why people had been listed as safe and missing on the same spreadsheet; she told us that they had tried to check the information as they went along.1797 Brown {Day274/84:3-14}. She accepted that the safe and missing tabs on the spreadsheet should have been cross-checked to make sure that those recorded as safe were not also recorded as missing and vice versa.1798 Brown {Day274/85:18-23}.
¶105.34 Errors were clearly made in the reporting and recording of information at the rest centres,1799 Brown {Day 274/83:12-18}. but there were also significant errors in transferring the information from the handwritten notes into the spreadsheet. That was demonstrated by the fact that one handwritten note recorded Jessica Urbano Ramirez as missing,1800 Handwritten note marking residents as safe or missing in the rest centre {TMO10035210}. whereas in the lists circulated at 13.44,1801 {TMO10017359} Row 102: Jessica Urbano Ramirez marked 'safe' as seen by the yellow highlight. 14.461802 {TMO00869935} Row 102: Jessica Urbano Ramirez marked 'safe' as seen by the yellow highlight. and 17.261803 {TMO10017480} Row 102: Jessica Urbano Ramirez marked 'safe' as seen by the yellow highlight. she was marked as safe. That is likely to have been due more to human error than the method used to record the information.
151¶105.35 Ms Brown told us that she had understood that other organisations, including the council, the casualty bureau and the BECC, would be relying on the information in the list as a base and using it in delivering their emergency response.1804 Brown {Day274/59:15-24}. In particular, both she and Mr Black1805 Black {Day275/105:24}-{Day275/106:5}. had known that it would be relied on by RBKC's housing department.1806 Brown {Day274/85:3-7}. Mr Black told us that at the time he had thought it was the TMO's responsibility to provide the information, but in hindsight he thought it had been the responsibility of RBKC as Category 1 responder.1807 Black {Day275/107:12-18}. He said that although people had done their best, it was not as good as it should have been and he apologised for the heartbreak that that must have caused people.1808 Black {Day275/119:13}-{Day275/120:10}.
¶105.36 Given the significance of the safe and missing lists and the fact that several organisations were known to be relying on the information they contained, TMO staff should not have been left to do the best they could.1809 Brown {Day274/61:4-7}. The problems stemmed from poor record-keeping before the fire, resulting in tenancy information that was unreliable. If reliable information had been readily available to the TMO, it would have allowed more residents to be accounted for more quickly and their particular needs to be identified. it would also have reduced the risk of inaccurate and inconsistent information being circulated.
¶105.37 As a Category 1 responder, RBKC should have had a plan in place to account for safe and missing residents in the event of an emergency affecting any of its properties. Instead, the burden of devising a means of achieving that objective fell on a handful of staff at the TMO. However, the TMO should have made it clear to RBKC that it needed support to put in place a robust and effective system. Difficulties in establishing an accurate list of those who had been living in the tower continued throughout the following week.1810 RBKC Log 9 dated 19 June 2017 {RBK00028712/1}. Unfortunately, the system implemented by the TMO led to systemic errors, with people being wrongly told that their loved ones were safe, when they were in fact missing.1811 Daniels {IWS00002065/11} page 11, paragraphs 73-74; Chiapetto {IWS00001780/1} page 1, paragraph 2; Murphy {IWS00001709/3} page 3, paragraph 12; Wahabi {Day267/102:8-25}-{Day267/103:1-17}. A resident was informed by the TMO that his missing wife was reported as safe at the St Clements Centre. His son received a conflicting report from another TMO officer {RBK00012043}.
152Residents evacuated from the surrounding area
¶105.38 About 8451812 {TMO00869977}; Brown {TMO00894124/17} page 17, paragraph 60. residents of Hurstway Walk, Barandon Walk, Testerton Walk, Grenfell Walk and Treadgold House were evacuated on the night of the fire1813 Brown {Day274/97:21}-{Day274/99:3} residents from Bramley house were also evacuated but not for an extended period and so did not require accommodation. and were prevented by the police cordon from returning to their homes.1814 Brown {TMO00894124/19} page 19, paragraph 66; Police Cordon Slideshow {MET00080826}. The residents of Grenfell Walk have never been able to return to their properties.1815 Cherbika {Day266/117:1-3}; {Day266/177:19-21}; Moses {IWS00001276/13} page 13, paragraphs 88, 91 and 92; Lopez {IWS00001680/8} page 8, paragraphs 43, 47-48; Procedure Note for Resettlement Packages {RBK00028643}. As a result, there were significant numbers of people requiring emergency accommodation and other support.
¶105.39 Ms Brown told us that although RBKC had been responsible for managing the response to the emergency, the TMO had some operational capability which it used to help displaced residents.1816 Brown {Day274/172:1-25}.
Prioritising the needs for emergency accommodation
¶105.40 It does not appear that RBKC was fully aware of the number of people displaced or their particular needs. In part, that seems to have been due to a widely held expectation that residents evacuated from surrounding buildings would be able to return home without much delay.1817 Brown {Day274/102:9-18}. As a result, on 14 June 2017, RBKC's strategy was to prioritise residents of the tower for emergency accommodation.1818 Brown {Day274/48:25}-{Day274/49:5}; Brown {TMO00869990/6} page 6, paragraph 28. However, residents evacuated from the Walkways were not allowed to return home immediately and in many cases were not able to return for days, weeks and in some cases for a number of months.1819 Pasztor {IWS00001682/4} page 4, paragraph 17 (7-8 months); El-Sawy {IWS00001829/8} page 8, paragraph 34 (9 months); Ollivierre {IWS00001758/6} page 6, paragraph 26 (9 months); Elbouti {IWS00001605/11} page 11, paragraph 50 (10 months); As reflected in the minutes of the Gold Group meeting on 16 June 2017, at which Laura Johnson of RBKC said that she would house the vulnerable or those with children and without hot water but that others would have to manage, RBKC treated the problem as one for the TMO.1820 Black {Day275/64:20}-{Day275/65:4}; RBKC Gold Group Meeting Minutes at 10.00 on 16 June 2017 {TMO10033491/2} paragraph 7. However, RBKC did attempt to consider the needs of residents evacuated from surrounding properties who were vulnerable, elderly or had families.1821 Brown {Day274/46:2-6}.
¶105.41 On 14 June 2017 at 17.05, Robert Shaw, Housing Options and Allocations Manager at RBKC, asked for information from the TMO about the number of tenants living in the cordoned area, and in particular the number of those who were vulnerable, elderly or had families with children, in order to determine how many people required emergency accommodation.1822 {TMO00869925}. David Noble gave him a total number of residents across the evacuated properties, which included 25 disabled people.1823 {TMO00869977}. That response was incomplete and did not provide information about other vulnerabilities, the elderly or families with children. Furthermore, the figure of 25 people was based on information received from residents;1824 Brown {Day274/104:14-19}. the true number is likely to have been higher.1825 Brown {Day274/104:24}-{Day274/105:3}.
153¶105.42 Ms Brown told us that RBKC had been identifying vulnerable residents and those with children through social services and family and children's services.1826 Brown {Day274/105:17-21}. However it is clear that RBKC was relying on information provided by the TMO to decide whom to place in emergency accommodation.1827 Brown {Day274/107:10}-Day274/108:2}. As a result, at 17.48 on 14 June 2017 Mr Shaw sent an email to various colleagues at RBKC attaching the list of residents from the cordoned area. He told them that there were 845 residents (tenants and families), including 25 recognised as disabled by the TMO.1828 {TMO10033708}.
¶105.43 Although he went on to say that families with children, vulnerable people and older people would be housed if they did not have an alternative place to stay, he did not draw attention to the fact that information relating to the latter categories had not been provided by the TMO and that numbers were therefore still unknown.1829 {TMO00869945}. It was clear that even by the time of the RBKC Gold group meeting at 10.00 on 16 June 2017 not all families and those with vulnerabilities had been given hotel accommodation.1830 Black {Day274/64:10-15}.
The Westway Centre
¶105.44 During the afternoon of 14 June 2017 RBKC told the TMO that, if the police cordon remained in place, the remaining residents evacuated from buildings within the cordon would have to be accommodated at the Westway Centre unless they were vulnerable, elderly, disabled or had children.1831 Brown {TMO00894124/11} page 11, paragraph 38; Brown {TMO00894124/9} page 9, paragraph 31. TMO staff relayed that advice to the rest centres,1832 Brown {TMO00894124/9} page 9, paragraph 31. although residents at rest centres where there was no one from the TMO present may not have received it1833 Brown {Day274/112:3-19}. and indeed Ms Brown accepted that some people had not received it.1834 Brown {Day274/112:13-25}-{Day274/113:1-16}.
¶105.45 That method of communicating with those who had been evacuated from properties surrounding the tower was defective, not least because some were not aware of the existence of the rest centres1835 Belfassi {IWS00001802/6} page 6, paragraph 35. and others had even been refused entry.1836 Moses {IWS00001276/14} page 14, paragraph 97; Cherbika {Day 266/87:12-25}. No attempts were made that day to communicate with evacuated residents by other means as TMO staff were concentrating on going through the tenancy list for Grenfell Tower and trying to establish contact with those who had lived there.1837 Brown {Day274/113:17}-{Day274/114:3}. Although the TMO had the ability to send a single text message to a large group of people at the same time, it was not used.1838 Brown {Day274/114:4-9} it was not used until 16 June 2017.
¶105.46 Mr Black attended the RBKC Gold group meeting at 10.00 on 15 June 2017 at which it was reported that only a limited number of people were at the Westway Centre.1839 RBKC Gold Group Meeting {RBK00023234/1}. Although questions were asked about the whereabouts of the rest of the residents, it was assumed that they were staying with family and friends.1840 Black {Day275/49:24}-{Day275/50:8}. Mr Black could not recall any discussion about the possibility that residents had not received the message to go to the Westway Centre or that some residents might be missing.1841 Black {Day275/50:10-16}.
154¶105.47 Although TMO staff were taking the lead operationally in respect of residents evacuated from properties within the police cordon, Mr Black accepted that he could have had a better understanding of how information was being collected and shared with RBKC. He did not have a clear picture of what the TMO was doing.1842 Black {Day275/42:15}-{Day275/43:23}. Although he tried to stay on top of matters, he found it difficult to do so.1843 Black {Day275/89:16-25}.
Initial contact with evacuated residents
¶105.48 The first time efforts were made by the TMO to contact residents evacuated from buildings within the cordon was on 15 June 2017, when the neighbourhood team called residents to confirm their whereabouts.1844 Brown {TMO00869990/9} page 9, paragraph 46; Brown {Day274/123:1-15}; {Day274/133:1-10}. However, the process suffered from the same limitations as that used to compile the safe and missing lists, in that it was based on information taken from the housing management system.1845 Brown {Day274/133:10-25}-{Day274/134:1-25}. There was incomplete information relating to vulnerabilities,1846 {TMO10017528} Kiran Singh provided information on vulnerable residents to the National Grid on 15 June 2017 and confirmed "this will definitely be an underreported figure". information about leaseholders rather than occupiers was recorded1847 Brown {Day274/68:18-19}. and contact details were out of date.1848 See column L and the rows highlighted in red {TMO00894411}; Brown {Day274/135:19}-{Day274/136:5}. That was particularly serious given that on the evening of 14 June 2017 RBKC had asked the TMO to provide information about residents who had been evacuated and were elderly, disabled, vulnerable or had children in order to place them in emergency accommodation. By the evening of 15 June 2017, TMO staff could not account for the whereabouts of residents of 216 of the 367 properties in Hurstway Walk, Testerton Walk and Barandon Walk.1849 Email 15 June 2017 at 18.26 {TMO10036651}; Brown {Day274/129:23}-{Day274/132:22}.
¶105.49 A script was prepared to assist TMO staff making calls to residents of the Walkways and Grenfell Tower1850 {TMO10036636}. but there were significant differences in the information provided. Residents of Grenfell Tower were told that they could go to the Westway Centre for support and were provided with contact details for the casualty bureau and the temporary accommodation team.1851 {TMO10036636/2-3}. Those evacuated from the Walkways were not given that information.1852 {TMO10036636/1-2} detailed written briefings for staff knocking on doors and making telephone calls to the residents of Barandon, Hurstway and Testerton Walks were provided only on 20 June 2017 {TMO00894205}; 22 June 2017 Neighbourhoods Team Briefing {TMO10033766} and 23 June 2017 Support Briefing Note {TMO10035544}. Given that RBKC had specifically told the TMO to tell residents of the Walkways that they should seek accommodation at the Westway Centre, that was a significant omission.1853 Brown {TMO00894124/9} page 9, paragraph 31.
Decision to return residents
¶105.50 Stuart Priestley, RBKC's Council Silver,1854 For Council Silver's role see Chapter 101 and {RBK00035662/1} paragraph 2.1. told Ms Brown early in the morning of 15 June 2017 that consideration was being given to allowing residents of buildings within the police cordon to return to their properties.1855 Brown {Day274/142:24}-{Day274/143:1}. Ms Brown explained her concerns about people returning to their homes with no gas and no hot water or cooking facilities. In addition, doors damaged when the police had forced entry needed to be repaired and the door entry system needed to be re-routed.1856 Brown {TMO00869990/9} page 9, paragraph 45; Brown {Day274/142:3-23}. She suggested that the return of residents should not be rushed and should wait until the provision of services could be ensured. The decision that people should return to their properties was taken by RBKC; the
155¶TMO was in effect left to work out how to enable them to do so.1857 Brown {Day274/141:5-9}.
¶105.51 Although Ms Brown thought that her objections were being passed to the BECC,1858 Brown {Day274/143:2-12}. she was contacted later that evening and asked to meet Inspector Bean to inspect the area to identify what needed to be boarded up before residents returned.1859 Brown {TMO00869990/9} page 9, paragraph 48; Brown {Day274/142:24}-{Day274/144:14}. During the inspection she was told that it was the intention of RBKC Gold group that residents should return as soon as possible.1860 Brown {TMO00869990/9} page 9, paragraph 48. Ms Brown told us that she had continued to be unhappy about that. She called her manager, Sacha Jevans, to pass on her views and spoke in turn to RBKC's Director of Housing, Laura Johnson.1861 Brown {Day274/146:2}-{Day274/147:2}. Ms Brown subsequently learned that Laura Johnson had told Ms Jevans that the Gold group decision1862 RBKC Gold Group Meeting {RBK00023236/3}. had to be followed.1863 Brown {TMO00869990/9-10} pages 9-10, paragraph 48.
¶105.52 The RBKC Gold group decided at its meeting at 15.30 on 15 June 2017 that the Walkway properties would be reoccupied that night.1864 RBKC Gold Group Meeting {RBK00023236/3}. However, although the decision to allow residents to go home had been made in principle that day, it was not formally implemented until 16 June 2017.1865 Brown {TMO00894124/17} page 17, paragraph 59. At the RBKC Gold group meeting at 10.00 on 16 June 2017 the position in relation to displaced residents was still not clear. The action sheet from the meeting records that the police were not providing clear information about re-occupation and were turning people away from Treadgold House.1866 RBKC Gold Group Meeting {RBK00023238/2}. The formal decision to allow residents to return to Treadgold House was taken at 12.30 on 16 June 2017.1867 Brown {TMO00869990/11} page 11, paragraph 54. Shortly after, a decision was made that residents of Barandon Walk, Testerton Walk and Hurstway Walk (except Flats 501-562) could also return home.1868 Brown {TMO00894124/19} page 19, paragraph 67; Brown {TMO00869990/11} page 11, paragraph 55; {TMO00894201/1-2}. Ms Brown1869 Brown {Day274/151:1-25}-{Day274/152:1-5}. and Mr Black told us that there had been confusion between the police, the BECC and RBKC Gold group in communicating the decision on when residents could return home.1870 Black {Day275/61:15-25}; {Day275/63:14-17}.
¶105.53 The decision by RBKC to send residents home so quickly was driven by the shortage of emergency accommodation for the significant number of displaced people.1871 Brown {Day274/147:12}-{Day274/148:19}. That is evident from the notes of the first humanitarian assistance steering group meeting at 14.00 on 15 June 2017 which recorded that "Those disbanded [sic] in the cordoned off areas are not priorities as there is [sic] not resources to support this" and "AG [RBKC] explained that there is a shortage of hotels locally and those from Grenfell are the priority".1872 Humanitarian Assistance Board Meeting Minutes {RBK00020410/2}. Similarly, the action sheet from the RBKC Gold group meeting at 15.30 on 15 June 2017 stated, "If cordon is not lifted, then [we] have over 800 people to find places. Will need to seek help from Government."1873 RBKC Gold Group Meeting {RBK00023236/1}; Black {Day275/57:23}-{Day275/58:9}.
156¶105.54 The concerns expressed at an operational level by Ms Brown do not appear to have been voiced at a strategic level by Mr Black. Despite knowing of them,1874 Black {Day275/55:19}-{Day275/56:1}. he could not remember whether he had raised them at any of the RBKC Gold meetings.1875 Black {Day275/56:2-7}. There is no suggestion in the action sheets from those meetings that he raised any specific objections to returning residents to their homes, even though that was something his staff would have to organise. He accepted that the TMO was being required to send people back to their homes, despite their condition, because there were too many displaced people for RBKC to provide all of them with emergency accommodation.1876 Black {Day275/57:3-8}. He accepted that that created difficulties for the TMO, which had to make sure the properties were habitable and safe.1877 Black {Day275/58:4-9}.
Attempts to communicate with residents
¶105.55 Once Ms Brown had received confirmation on 16 June 2017 that residents could return to buildings within the cordon, she arranged for 11 TMO officers to telephone them to tell them that they could go home, at the same time warning them about the lack of heating and hot water and telling them about the washing facilities at the Westway Centre.1878 Brown {TMO00869990/11} page 11, paragraph 56. She also arranged for 15 members of the TMO's staff to visit the Walkways and Treadgold House to check on residents, refer people to support services, see whether any repairs or cleaning were required and check the electricity supply.1879 Brown {Day274/156:10}-{Day274/157:6}. TMO staff kept notes of those visits with the intention of keeping a record of vulnerabilities and of any need for assistance that could be added to the central electronic list of residents.1880 Singh {TMO00894410/5} page 5, paragraph 4d. However, the records were often haphazard,1881 {TMO00894169}. inconsistent and incomplete.1882 {TMO10017543} spreadsheet on 15 June 2017 which features residents from Grenfell Walk with no pre-populated columns relating to vulnerabilities; {TMO10034288} spreadsheet on 19 June 2017 features residents from Walkway properties and Bramley House, but not Grenfell Walk which does include pre-populated columns relating to vulnerabilities; {TMO10036665} spreadsheet on 15 June 2017 relating to all Walkways with pre-populated columns relating to vulnerabilities, but not Bramley House or Grenfell Walk residents.
¶105.56 The TMO used the "text burst" facility for the first time on 16 June 2017 to let residents from Barandon Walk, Treadgold House and Hurstway Walk know that they could go home and to warn them that they might not have hot water or gas.1883 It is not clear whether that was also sent to residents of Testerton Walk, or what was sent, if anything, to Grenfell Walk residents. Residents were told that they could continue to stay with family or friends or in what was described as "the resource centre".1884 Brown {TMO00869990/12} page 12, paragraph 58; {TMO00869949}. That was intended to be a reference to the Westway Centre, but it is not clear whether people realised that. The message did not provide any information about the Westway Centre, what support was available there or how to get there. Although it was unlikely to reach everyone, the "text burst" facility was a useful means of communication and should have been used earlier and more often to provide information to displaced residents.
¶105.57 On 19 June 2017, further attempts to call residents were made.1885 Brown {TMO00894124/25} page 25, paragraph 93. TMO staff also visited homes again to find out whether more residents had returned, to give advice and to see whether repairs were needed.1886 Brown {Day274/176:25}-{Day274/177:11}; Brown {TMO00869990/13} page 13, paragraph 69. A number of residents had still not returned home.1887 Brown {Day274/177:4-20}.
157¶The TMO repeated the exercise the next day to conduct welfare checks and identify the need for any further support,1888 Brown {TMO00869990/15} page 15, paragraph 78. although some residents had still not returned home seven days after the fire.1889 Brown {Day274/179:22-25}. Despite the TMO's efforts to communicate with the residents, some still complained that no one had contacted them,1890 Internal TMO email regarding a log of queries arising at the Westway Centre {TMO10035599/55}. indicating that not all residents were being reached.
¶105.58 On 20 June 2017, Ms Brown asked RBKC for a list of those who had been provided with emergency accommodation in order to identify any residents that had not been given accommodation and had not yet returned to their properties.1891 Brown {Day274/184:19}-{Day274/185:1}. However, Mr Shaw told her that RBKC was still in the process of reconciling the list.1892 {TMO10035589/17}.
¶105.59 Detailed written briefings for staff trying to contact residents of Barandon Walk, Hurstway Walk and Testerton Walk were not provided until 20 June 20171893 {TMO00894205}. and were issued again on 22 June 20171894 Neighbourhoods Team Briefing {TMO10033766}. and 23 June 2017.1895 Support Briefing Note {TMO10035544}. They included guidance on the message to be given to residents of surrounding blocks, information about the support available at the Westway Centre, tasks to be carried out, staff rotas and useful contact information. They were much more detailed than the aide memoire provided earlier to assist staff making telephone calls.1896 Script for calls to residents {TMO10036636}.
Continuing confusion
¶105.60 It is clear that even after the Gold resolution had been activated and John Barradell had taken over the response, there was no clear strategy for dealing with displaced residents. On 19 June 2017 RBKC and the TMO were looking for guidance to the Westminster City Council housing team, which had been brought in as part of the wider London response.1897 RBKC Gold Group Meeting Action Sheet {RBK00005507/2} "people in finger blocks constantly approaching for housing. Need a steer from the WCC Team…what do we do with the 91 families not from Grenfell Tower and Walk".
¶105.61 As a result, in the days and weeks following the fire there were conflicting messages about when residents could return home. Although some residents had returned early at the instigation of RBKC Gold group,1898 Brown {TMO00894124/17} page 17, paragraphs 58-59. others were turned away by the police when they tried to return1899 Brown {Day274/117:17-19}; {Day274/152:11-17}; Internal TMO email 19 June 2017 {TMO10035566/1}; Dowlut {IWS00001787/10} page 10, paragraph 37; Boujettiff {Day266/67:7-14}; McMahon {IWS00001966/9} page 9, paragraph 41; Pasztor {IWS00001682/3} page 3, paragraph 15. or were told that they could return at their own risk.1900 {TMO00869927}; Serroukh {IWS00001747/5} page 5, paragraph 22; RBKC Gold Group Meeting 20 June 2017 Action Sheet {TMO10033447/3}; Khadija Yahya {IWS00001825/10} page 10, paragraph 50; Mohamed Yahya {IWS00001827/8} page 8, paragraph 33. Some were not told whether it was safe to return1901 Hartley {IWS00001257/11} page 11, paragraphs 41-42; Levi {IWS00001753/12-13} pages 12-13, paragraphs 52 and 53; El-Sawy {IWS00001829/5} page 5, paragraph 22; Yahya {IWS00001825/10} page 10, paragraph 50. and at least one other had been told by RBKC representatives at the Westway Centre that he could not return.1902 Levi {IWS00001753/12} page 12, paragraph 52. On 20 June 2017, Ms Brown sent an email to the BECC to clarify which residents could return home and which could not, so that a clear position could then be communicated to the police.1903 Brown {TMO00869990/15-16} pages 15-16, paragraph 79; {TMO00894213}.
158¶105.62 Overall, the evidence shows that the various bodies involved failed to co-operate properly to ensure that the information they gave about returning residents to their homes was the same.1904 Brown {Day274/182:18}-{Day274/183:22}. That left people without clear information for longer than was necessary, causing further inconvenience and distress.1905 Brown {Day274/182:18}-{Day274/183:22}.
Problems on return
¶105.63 Once residents had returned, Ms Brown's worries about the condition of the properties were borne out. They mainly related to the lack of gas and hot water, which left residents without washing or cooking facilities for a long time. Permanent repairs to locks and doors did not begin until 29 June 2017.1906 Exhibit TB/64 {TMO00894218/3} page 3. The gas supply was restored to all properties except Grenfell Walk by 29 June 2017 and hot water was restored to most, though not all, properties on 4 July 2017.1907 Brown {TMO00894124/26} page 26, paragraphs 95 and 96.
¶105.65 Although RBKC was aware of the steps being taken by the TMO to help the residents, it did not offer any tangible support or resources to meet their needs or assist their return home,1911 Brown {Day274/172:22}-{Day274/173:2}. leaving the TMO to manage the needs of significant numbers of residents. The burden weighed heavily on Ms Brown, despite her not being a member of the TMO's executive team. Mr Black told us that in retrospect it would have been better for RBKC or London Gold to have organised the return of displaced residents after 16 June 2017.1912 Black {Day275/108:4-11}.
¶105.66 In our view, accounting for the significant number of displaced people and enabling them to return to their homes, where that was possible, was too great a task for the TMO, despite Ms Brown's best efforts. Although RBKC was the responder which should have assumed that responsibility, it concentrated its efforts on the needs of the survivors from the tower largely to the exclusion of those who had been evacuated from the surrounding buildings. It is understandable that it should have done so in the initial stages of the disaster, but it should not have taken it long to realise that those who had been hastily evacuated from neighbouring buildings had also been seriously affected and had many of the same needs. As a Category 1 responder, RBKC should in our view have provided more support to the TMO in its efforts to enable the residents of those buildings to return to their homes. The roles and responsibilities of RBKC and the TMO in relation to the residents of the surrounding buildings were never clearly defined. As a result, RBKC did not make additional resources available to the TMO to provide the help they needed, nor did the TMO ask for them.
159The TMO and London Gold
¶105.67 When the London Gold arrangements were put into operation during the afternoon of 16 June 2017 John Barradell took charge of the humanitarian response. Mr Black did not have a working knowledge of the London resilience arrangements or of London Gold's powers and capabilities.1913 Black {Day275/75:4-15}. He did not suggest that a senior member of the TMO's staff should be attached to the London Gold group to help with providing support to residents of the Lancaster West estate,1914 Black {Day275/86:6-12}. nor did he have a personal meeting with Mr Barradell.1915 Black {Day275/79:4-6}. It was his impression that Mr Barradell had taken over the situation and wanted to bring fresh people in.1916 Black {Day275/86:15-20}. Although the TMO had a detailed knowledge of the Lancaster West estate, he thought that it had been regarded as more of a hindrance than a help.1917 Black {Day275/86:21}-{Day275/87:3}.
¶105.68 Mr Barradell accepted that the care of the residents evacuated from properties surrounding the tower fell within the scope of his responsibility and recognised that considerable support was being provided by the TMO.1918 Barradell {Day279/175:12}-{Day279/176:6}. Nevertheless, he did not want it to be part of the arrangements because he did not believe that it had the confidence of the local community. He thought that the necessary functions could be better performed and directed by other people.1919 Barradell {Day279/181:1-9}. He told us that demonstrating that those providing help were independent of the TMO was as much about building confidence as making sure that help was actually delivered.1920 Barradell {Day279/183:8-16}.
¶105.69 The strategic decision by London Gold to keep the TMO at a distance was reflected in the day-to-day contact between them. Ms Brown's contact with London Gold was limited to arranging for one person to carry out an inspection of the fire exits on the Walkways.1921 Brown {Day274/215:19}-{Day274/216:12}. She told us that she did not have any contact with Ms Brownlee1922 At the relevant time, Ms Brownlee was the Director of Housing and Regeneration for Westminster City Council {GOL00000859/2} page 2, paragraph 6; and was leading on the housing response for London Gold; Brownlee {GOL00000859/4} page 4, paragraph 17. or anyone from Westminster Council.1923 Brown {Day274/215:19-22}. We would have expected far greater communication between Ms Brown and London Gold, given that her team was helping to arrange the return of large numbers of residents to the surrounding properties. Everyone was seeking to tackle the problems created by the numbers involved and the difficulties of communication. Ms Brown acknowledged that London Gold had provided assistance to the TMO when it was asked for, particularly in relation to matters such as rebuilding the fire exits at the Walkways,1924 Brown {Day274/202:19}-{Day274/203:4}. but otherwise its involvement was limited to identifying vacant properties which it reported to Graham Webb, the managing director of Repairs Direct.1925 Brown {Day274/174:3-21}.
¶105.70 Mr Black told us that his impression was that London Gold would not help the TMO,1926 Black {Day275/74:14-19}. and although it understood local authorities, he was not confident that it understood how the TMO was structured and how it operated.1927 Black {Day275/74:20-25}. Although Mr Black had initially regarded London Gold's involvement as a positive development,1928 Black {TMO00887150/12} page 12, paragraph 44. he did not think that the TMO had been adequately supported by it. It could have offered more help but decided not to do so and largely left the TMO to get on with it.1929 Black {Day275/110:3-16}; {Day275/112:6-23}.
160¶105.71 Given the central role played by the TMO in supporting the return of residents to properties within the cordon, we think that London Gold should have done more to establish direct contact with it, co-operate with it and provide it with support.
The TMO and the government
¶105.72 On 19 June 2017, officials from several central government departments were deployed to the Westway Centre. Later that day, reservations about the effectiveness of the TMO were voiced for the first time at the ministerial meeting chaired by the Prime Minister.1930 Grenfell Tower Recovery Taskforce Ministerial Meeting Minutes {CAB00002741/3-4} pages 3-4, paragraph 7; Email from Jamie Cowling to Katherine Richardson on 19 June 2017 at 13.27 {CLG00005618/3} page 3.
¶105.73 From 19 June 2017, officials from BEIS were present at the Westway Centre, answering some questions posed by residents and community representatives and relaying others to the government's utilities co-ordination cell.1931 Bassett-James {BEI00002844/3} page 3, paragraph 11. Sebastian Bassett-James, who had been seconded from BEIS to take charge of the team responsible for restoring utilities, found it difficult to contact both RBKC and the TMO, which he understood to be providing the primary response to the fire.1932 Bassett-James {BEI00002844/12} page 12, paragraph 49. He said that the TMO had not provided the help needed to restore the utilities, leaving the residents frustrated for longer than necessary.1933 Bassett-James {BEI00002849/6} page 6, paragraph 21.
¶105.74 Mr Bassett-James said that, although the TMO had had people at the Westway Centre, they had not had authority to make decisions, take action or respond to his team's questions,1934 Bassett-James {BEI00002849/4} page 4, paragraph 15. but Ms Brown told us that her staff at the Westway Centre were able to contact her and Mr Webb to get any necessary authority.1935 Brown {Day274/205:17}-{Day274/206:15}. According to Mr Bassett-James, when members of the BEIS team at the Westway Centre attempted to telephone the TMO their calls went unanswered and voicemails were not returned.1936 Bassett-James {BEI00002849/4} page 4, paragraph 16. By 21 June, BEIS was working with the Department for the Environment, Food and Rural Affairs (DEFRA) and DCLG to identify a point of contact within the TMO. Eventually they were successful.1937 Bassett-James {BEI00002849/6} page 6, paragraph 20.
¶105.75 In the opinion of Mr Black, the government did not understand the nature or role of the TMO or its limitations.1938 Black {Day275/97:4}. For example, emails sent within No.10 on 21 June 2017 commented adversely on the TMO's handling of communications with the residents,1939 Email from Jamie Cowling from No.10 on 21 June 2017 at 09.29 {CAB00005909/1}. but Mr Black told us that during the days immediately following the fire the TMO had not been allowed to communicate with them without the approval of RBKC, which itself had had to be channelled through the Gold group.1940 Black {TMO10048970/2} page 2, paragraph 8; Black {TMO00887150/2} page 2, paragraph 7; Black {Day275/96:19-21}. It seems that No.10 laboured under the misapprehension that the TMO had an extensive formal role which made it necessary or desirable that DCLG intervene to remove it from the situation.1941 Email from Chris Gray on 21 June 2017 at 09.38 {CAB00005909/1}. That was not correct and failed to take proper account of the fact that the TMO was not itself a responder.
161¶105.76 DCLG gained its understanding of the position and effectiveness of the TMO from second-hand reports. On 19 June 2017 Dame Melanie Dawes became aware that concerns were being expressed in some quarters about the performance of the TMO, particularly in relation to restoring heating and hot water to the Lancaster West estate, when they were raised by John Barradell at the Grenfell Recovery Taskforce meeting that day.1942 Dawes {CLG00030653/32} page 32, paragraph 102. However, although those concerns were recorded at governmental level, Mr Black was not made aware of them.1943 Black {Day275/104:12-16}. Mr Barradell told us that he had not raised them with the TMO because they had to be raised at the Grenfell Recovery Taskforce meeting in order for them to be addressed.1944 Barradell {Day279/181:22}-{Day279/182:25}.
¶105.77 At the same meeting a decision was taken that residents who were affected by the lack of hot water and gas should be given hotel accommodation and financial assistance.1945 Ministerial Meeting Minutes on Grenfell Tower fire {CAB00002741/3-4} paragraph 7. However, that decision was not communicated to the TMO, which was responsible for arranging the return of the residents and dealing with matters relating to properties in the blocks that had been evacuated.1946 Black {Day275/78:20}-{Day275/79:1}.
¶105.78 On 20 June 2017, internal DCLG correspondence recounted Ms Brownlee's impression from a "TMO meeting" that the TMO had no leadership, that staff were "drifting around", traumatised and without reliable information on important matters, such as the state of the flats in the Walkways.1947 Email from Sally Randall at 10.50 {CLG00021055/3}. Ms Brown acknowledged that TMO staff were very traumatised by what had happened but maintained that they were concentrating on getting on with the job and doing what they could to support people.1948 Brown {Day274/214:20-24}. She denied that they lacked leadership.1949 Brown {Day274/215:13-18}. Ms Brownlee's impression, as expressed in the DCLG correspondence, had not been informed by any discussion with Mr Black or Ms Brown.1950 {CLG00005723} Teresa Brown did not speak to Ms Brownlee or anyone at Westminster, Brown {Day274/215:1-22}; {Day274/216:9-10}.
¶105.79 Although internal DCLG correspondence recorded that the TMO needed "a new strong Chief Exec, who can provide a single point of liaison, clear information, and strong leadership", neither DCLG nor Ms Brownlee sought to contact Mr Black or the TMO board.1951 {CLG00005723}; Black {Day275/100:15-23}. Mr Black told us that those negative impressions of the TMO had been formed without speaking to it and that, in his view, it had suited the government to blame the TMO.1952 Black {Day275/104:23}-{Day275/105:8}. The decision to remove the TMO had been taken without a clear understanding of its structure or mode of operation or of the legal framework under which it operated.1953 Black {Day275/101:1-17}. His view seems to us to be borne out by the documents we have seen.
¶105.80 Ms Brown did not recall having received any support from central government in the week following the fire.1954 Brown {Day274/203:7-10}. Mr Black told us that, although the structure worked on paper, the scale of the emergency was such that more resources were needed from the government, rather than simply instructions on what should be achieved.1955 Black {Day275/80:8-16}. In our view, there was a tendency for other organisations and departments involved in the response and recovery phases to talk about the TMO rather than to it, and in doing so they left the TMO isolated and unsupported.1956 Black {Day275/112:6-20}. We think that in the days after the fire the TMO was to some extent seen by the government as a useful scapegoat, perhaps to deflect criticism from its own shortcomings in what had evolved into a full-blown humanitarian crisis in the heart of West London.
162Resources and support
¶105.81 Ms Brown told us that she felt she had been adequately supported by the TMO's executive team to enable her to fulfil the various roles that her team had undertaken in the immediate aftermath of the fire. She told us that her manager, Sacha Jevans, had been contactable by telephone to discuss any problems.1957 Brown {Day274/173:3-25}. She also said that, with the benefit of the additional staff arranged by Mr Black by 18 June,1958 Brown {Day274/196:2-23}; {Day274/202:16-18}; Brown {TMO00894124/24} page 24, paragraph 87. she did not feel that the TMO had been under-resourced.1959 Brown {Day274/202:3-12}.
¶105.82 However, we do not think that the senior leadership of the TMO provided sufficient oversight or support to staff who were dealing with the problems in the days immediately following the fire. Although Ms Brown may have felt at the time that she was adequately supported,1960 Brown {Day274/196:21-25}-{Day274/197:1}. she was not aware of the limits of her capacity. Although she could always contact her line manager for support if she felt she needed it, those in positions of greater seniority ought to have taken positive steps to ensure that she and her team had all the support and resources they needed, not least because she had assumed a role for which there was no standing guidance or training and was, in essence, improvising.
¶105.83 Mr Black told us that he had found the scale of the incident personally overwhelming.1961 Black {Day275/27:25}-{Day275/28:7}. As a result, he could not effectively manage the TMO's role in the response. He told us that he had not asked RBKC for more resources,1962 Black {Day275/47:6-13}. because everyone was in a difficult position.1963 Black {Day275/46:22}-{Day275/47:5}. Clearly, however, he should have done so, as he accepted.1964 Black {Day275/45:15}-{Day275/46:4}. He should have also made it known to RBKC that the expectations and demands on the TMO were beyond its capacity.
¶105.84 We accept that one reason for the TMO's failure to seek help for itself was that its senior executives were overwhelmed by the scale, uncertainty and ever-shifting nature of the incident. However, for reasons explored elsewhere in this report, Mr Black's style of management was to rely on his trusted team rather than share problems with those charged with oversight of the TMO, such as its board and RBKC.
¶105.85 Although Mr Black and Ms Brown fell short of what was expected of them in the period following the fire, we recognise that they were seeking to discharge a role that the TMO had assumed voluntarily. The root of the problem was the absence of an emergency plan clearly setting out the relationship between RBKC and the TMO and their respective responsibilities in the event of a major incident.
163Communications with the public
¶105.86 Olivia Hutchison was the head of customer services at the TMO.1965 Hutchison {TMO10048971/1} page 1, paragraph 3. She provided daily email briefings1966 On 14 June 2017 {TMO00869621/2-10}; 16 June 2017 {TMO00869621/16-19}; 20 June 2017 {TMO00869621/30-33} briefings were sent more than once a day; A briefing for the weekend of 17 and 18 June 2017 was sent in advance, on 16 June 2017 {TMO00869621/18-19}. The briefings contained a staff briefing, information about respite centres, contact numbers to redirect residents in need, information on hot water and gas, information on helplines, such as the casualty bureau and housing team, and information regarding donations and volunteering. for the Customer Services Centre team and Pinnacle (the TMO's out of hours contact centre) to assist them in dealing with incoming calls from residents affected by the fire.1967 TMO's out of hours provider {TMO00869621}; Brown {TMO00894124/20} page 20, paragraph 71.
¶105.87 Early in the afternoon of 14 June 2017, Amanda McDuff of Pinnacle asked for advice on dealing with calls in the evening. At 14.15 Ms Hutchison replied that the TMO's main concern was dealing with displaced residents.1968 Email from Olivia Hutchison to Amanda McDuff {TMO00869621/6-7}. She said that customers in need of re-housing should attend the "Westfield Community Sports Centre".1969 Email from Olivia Hutchison to Amanda McDuff on 14 June 2017 at 14.15 {TMO00869621/6}. There is no Westfield Community Sports Centre, but the Westfield retail site was very close to Grenfell Tower. No specific advice was provided for the residents of the surrounding blocks.1970 Email from Olivia Hutchison to Amanda McDuff {TMO00869621/6-7}.
¶105.88 At 17.09 on 14 June 2017, Ms Hutchison told the Pinnacle Team that anyone requiring assistance with temporary accommodation should contact the council's switchboard or go to the rest centres at the Westway Centre, Rugby Portobello Trust or St Clements Church.1971 Email from Olivia Hutchison to Pinnacle team {TMO00869621/8}.
¶105.89 At 17.37 on 15 June 2017, Ms Hutchison told Pinnacle that most residents of the tower had been placed in temporary accommodation but that residents from the surrounding buildings had still not been able to return to their homes due to fears for their safety.1972 Email from Olivia Hutchison to Pinnacle team {TMO00869621/11-12}. She said that the police had started letting some residents return, but that Hurstway Walk, Barandon Walk, Grenfell Walk, Testerton Walk and Treadgold House were all without hot water and would be without gas for cooking.1973 Email from Olivia Hutchison to Pinnacle team {TMO00869621/11-12}. In messages sent on 16 and 17 June 2017 Ms Hutchison identified which flats in each block could be re-occupied.1974 Emails from Olivia Hutchison to Pinnacle team, TMO staff and other London Boroughs {TMO00869621/18-24}.
¶105.90 On 19 June 2017, there were further briefings referring to the lack of hot water and cooking facilities. A briefing released at 10.22 on 19 June 2017 directed residents who required emotional support to the NHS's Single Point Access for Mental Health.1975 Email from Olivia Hutchison to the Customer Services Centre team and TMO staff {TMO00869621/26-27}. None of the briefings provided to Pinnacle referred to financial support.1976 Various emails from Olivia Hutchison providing updates to Customer Services Centre team, Pinnacle team, TMO staff and London Boroughs {TMO00869621/2-34}. In our view, the TMO should have told Pinnacle about the financial support available far earlier.
¶105.91 In the first few days after the fire the TMO tried to contact residents by knocking on doors and telephoning them, but no written communication was circulated until 22 June 2017.1977 Brown {TMO00894124/28} page 28, paragraph 103; {TMO00869984}. That letter was sent without London Gold's approval,1978 Brown {TMO00894124/28-29} pages 28-29, paragraph 105. even though formal communications with residents required his permission.1979 Brown {Day274/190:12-17}. A number of residents had asked for written communication and TMO staff drafted information briefings for approval,1980 Email thread {TMO10035589/58-59} email from Kiran Singh on 21 June 2017 at 10.45 entitled 'Comms to residents.' but nothing further in writing was sent out until 27 July 2017.1981 {TMO00869985} it should also be noted that the TMO sent their second briefing to London Gold for approval on 12 July, 20 days after the first briefing {TMO00894179/1-2}. The delay was caused by the need to obtain the approval of London Gold.1982 Brown {Day274/190:17-23}. Written communications were originally intended to describe what was planned, but eventually became a record of what had been done,1983 Brown {TMO00869990/18} page 18, paragraph 93. which was of little practical assistance to residents.1984 Brown {TMO00869990/18} page 18, paragraph 93.
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