Chapter 107: Conclusions

Chapter 107: Conclusions

The human factor

¶107.1 No response to an emergency can be considered effective if it leaves those whom it is supposed to serve feeling abandoned and bereft. Yet that was the experience of very many of the people who had lost their homes in the Grenfell Tower fire or whose loved ones had lost their lives in it. Their experiences, described in their own words in Chapter 100, attest vividly to the failure of the system, but within the community in North Kensington the official response to the fire also served to confirm a deep distrust of those in authority, the existence of which long predated the fire. The community's perception was that in the days that followed the fire there was an absence of leadership,^20602060 Ramirez {IWS00002061/7} page 7, paragraph 46. no central structure and nobody effectively in charge.^20612061 Murphy {IWS00001722/5} page 5, paragraph 25. Those who had been displaced suffered at first hand from the lack of co-ordination between the various organs of central and local government which should have been able to meet their needs but instead demonstrated an inability to deal adequately with a tragedy on the scale that confronted them.^20622062 Ali {IWS00001617/13} page 13, paragraph 165.

Subsidiarity

¶107.2 The Grenfell Tower disaster shows that the principle of subsidiarity, which lies at the heart of the arrangements for responding to civil emergencies, is both its strength and its weakness. In general, the local authority, in conjunction with the emergency services, is usually best placed as a result of existing structures, familiarity with local conditions and knowledge of the communities affected, to respond effectively to an emergency, particularly one that is confined to a relatively small area. Even in cases where a larger area is involved, such as widespread flooding, the local authority is likely to be best placed to organise both the immediate response and the subsequent recovery. However, its effectiveness depends on four things: (i) the existence of an emergency plan that has been well thought out, is well understood by those who have to implement it and has been practised with sufficient frequency and rigour to ensure that it can be put into operation without undue delay; (ii) sufficient human and financial resources to enable the plan to be implemented; (iii) a chief executive with the necessary skills and strength of character to take control of the situation with the support of senior officers who are capable of taking responsibility for different aspects of the plan's implementation; and (iv) an understanding within the organisation of the importance of resilience and a commitment to achieving it.

¶107.3 Unfortunately, in the present case all four of those requirements were lacking. RBKC did not have an effective emergency plan that was directed to the displacement of a large number of people from their homes and such plan as it had did not make effective use of the TMO. In our view that is a serious criticism of a local authority responsible for resilience in a densely populated urban area containing many large residential buildings, in some cases in close proximity to each other. Fire is only one of a number of hazards that might necessitate the evacuation of a large number of people who would then require temporary accommodation. RBKC's plans did not include a system for obtaining a large amount of emergency accommodation at short notice. Nor, significantly, did it make any provision for identifying those who had been evacuated or for communicating with them. Arrangements for obtaining reliable information and disseminating it was also lacking.

¶107.4 The absence of a good plan was compounded by the failure of RBKC to train its staff adequately. The necessary understanding of the importance of resilience and commitment to it were missing. Exercises were not held regularly and staff were not required to attend the training sessions run by the London Resilience group. Deficiencies which were well known to the senior management were not corrected. As a result, when disaster struck there was no semblance of a well-oiled machine that could move into action with the minimum of delay.

¶107.5 Financial resources do not appear to have been unduly constrained, but in this case RBKC lacked the personnel needed to administer the response effectively, both for the purposes of staffing the BECC and to deal with those who needed help.

¶107.6 Finally, RBKC did not have the benefit of a chief executive capable of taking control of the situation, understanding the magnitude of the task facing it and mobilising support of the right kind without delay. Mr Holgate was suddenly confronted with an enormously difficult situation without the benefit of a clear plan and with imperfect information at his disposal. However, the fact remains that he was not well-suited to dealing with the crisis that was unfolding in front of him. Nor did he have the benefit of a strong group of officers to whom he could delegate responsibilities for some aspects of the response. He was reluctant to take advice from those with greater experience and was unduly concerned for RBKC's reputation. His mishandling of the situation demonstrates a dangerous weakness in the arrangements for responding to civil emergencies generally.

¶107.7 Some of those weaknesses could and should have been avoided by better preparation, but in many cases the mettle of the chief executive will not have been tested before a crisis erupts. As this incident demonstrated, it is difficult to force the hand of a chief executive who does not recognise his own or his authority's limitations. Whatever may be the effect of the London Gold arrangements, everyone accepted that they could not be activated otherwise than at the request of the local authority concerned. That was obviously frustrating for many, including the government, but was the consequence of their being a voluntary arrangement.

¶107.8 The government has wide powers under the Civil Contingencies Act to give specific directions to a Category 1 responder to perform its functions for the purpose of reducing, controlling or mitigating the effects of an emergency and such orders may require that person to collaborate with another or to delegate functions to another (section 5); and in a case of urgency the minister can give similar directions in writing. Although the government does, therefore, have the power to override the principle of subsidiarity, the use of those powers does not appear to have been considered in this case, perhaps because once John Barradell had taken control it was thought that no more could usefully be done to manage the response.

London Resilience

¶107.9 The structures of London Resilience, through which individual London boroughs perform their duties as Category 1 responders, are complex and, at least to the outsider, difficult to understand, being bedevilled by jargon and acronyms. That of itself does not matter, of course, if they are understood by those who must use them and operate effectively. There is reason to think, however, that there is a misunderstanding, both among some in local authorities and in government, about the effect of the Gold resolution. On its face, the Gold resolution is limited to authorising expenditure under section 138 of the Local Government Act 1972. Mr Barradell, who has considerable experience in matters relating to London Gold, was well aware that invoking the Gold resolution did not give London Gold power to take control of the response, which remained in the hands of Mr Holgate while he chose to exercise it. Indeed, Mr Barradell was not the chief executive designated to act as London Gold on 16 June 2017 and was therefore not the person who would have taken charge under those arrangements in any event.

¶107.10 The introduction of Mr Barradell to take control of the response owed little to the machinery of London Resilience or the operations of the Gold arrangements and much to the personal intervention of Dr Farrar and the influence of Mr Barradell himself in persuading Mr Holgate to step aside in his favour. That was not something envisaged by the standing arrangements and could not have been imposed on RBKC otherwise than by ministerial order. It points to a defect in the arrangements governing resilience, not only in London but potentially more widely. There was, and as far as we know still is, no derogation from the principle of subsidiarity within London, and the same presumably applies in the case of other large conurbations. Whether that should remain the case is a matter for the boroughs and the government to consider.

Communications

¶107.11 One thing that the disaster emphasised above all others was the need following a major emergency for rapid and reliable communication between those responsible for the response and those needing assistance. That requires planning, but with the aid of modern methods of communication should be capable of being achieved without too much difficulty unless there has been significant disruption to the internet and mobile telephone system. One of the most common complaints we heard from those that had been displaced was that they felt cut off or abandoned. It is clear to us that more thought and preparation needs to be put into establishing and operating communication points accessible to those affected by the incident, enabling them to be kept informed of developments and those attempting to provide support to gather vital information. Given the enormous importance of effective communications, emergency plans need to take into account the range of languages spoken in the locality.

The role of government

¶107.12 Although from the outset the government was keen to assist the response, its effectiveness was undermined by a shortage of reliable information and by its limited powers to intervene. The machinery as we have described it was in place to enable information to be obtained from those directly involved in the response but it did not work as well as intended. The government can, of course, provide a local authority dealing with an emergency with resources of all kinds, if it is minded to do so, but the statutory structure does not give it the power to play an active role in the response, short of invoking the powers under sections 5 and 7 of the Civil Contingencies Act. The powers are far-reaching, but cumbersome in operation and not well suited to taking control of the response when the local authority is failing or just not managing the response in what the government considers to be the best way. The government, particularly senior ministers, can bring a great deal of influence to bear but that is not the same as being able to take decisions.

The TMO

¶107.13 The TMO was not formally a responder and had not been integrated into RBKC's emergency plan. That represented a significant failing on the part of RBKC because it held, or should have held, a lot of important information about the occupants of the tower and the surrounding buildings. The fact that the information it held was not as complete or reliable as it could or should have been detracted from its ability to assist those seeking to provide support to displaced residents, but RBKC should have realised that the TMO's close knowledge of the buildings and their occupants had an important part to play in any response to a disaster affecting any part of its housing stock.

¶107.14 Although it was not formally part of the response, either as a responder under the Act or under RBKC's emergency plan, the TMO threw itself into the response and helped to provide support, insofar as it was equipped to do so. It attracted a great deal of criticism from various quarters for its actions and omissions in the days following the fire, not all of it fair. We can understand why the hostile attitude of the residents towards it led Mr Barradell to keep it at arm's length, but we think that some of those within government who criticised it did not properly understand its position or the scope of its powers. There was a tendency to view it simply as a part of RBKC, which was seen quite quickly as a failing authority. Many of the difficulties encountered in returning residents to flats in the Walkways were not of its making. We think that to some extent it was convenient for London Gold and RBKC to leave solving the problems associated with restoring the Walkways to a habitable condition to the TMO. In our view Teresa Brown and her team, who went to some of the rest centres on 14 June 2017 to give what help they could, are to be commended for their willingness to become directly involved and the efforts they made at what was a very difficult time.

The local community

¶107.15 The people who emerge from the events with the greatest credit are the members of the local community, who, with the support of local voluntary organisations, provided support in the hours immediately following the fire when the authorities were conspicuous by their absence. Although their willingness and ability to organise themselves effectively at short notice may have been exceptional, and is deserving of the highest praise, we think it likely that many local communities would rise to the challenge if the opportunity presented itself. The ability to harness the energy, skills and goodwill of the community should not be overlooked when planning an emergency response.