Chapter 31: Structure and governance

Background

¶31.1 In 1991 the government pledged to increase opportunities for tenants of social housing to assume greater powers of management of the properties in which they lived, independent of the local authorities which owned the buildings. That was done by amending the Housing Act 1985 to create a right to manage, so that local authorities would be obliged to transfer their housing management functions to a tenant management organisation, provided that a majority of tenants were in favour of such a transfer and certain other conditions were met. Following a study carried out by RBKC of the feasibility of transferring its housing management functions to a tenant management organisation, a ballot of RBKC tenants was held. The necessary majority voted in favour of the proposal and following preliminary government approval the Kensington and Chelsea Tenant Management Organisation (the TMO) was incorporated on 19 April 1995.

¶31.2 Following a further ballot in which the majority of tenants again voted in favour of the transfer, the first formal management agreement came into force on 28 February 1996,¹¹ {RBK00018516}. under which RBKC appointed the TMO as its agent to carry out some (but not all) of its housing management functions.²² The TMO's management functions under this first Management Agreement {RBK00018516} included repairs, maintenance and services provision (Chapter 2), the collection of rent and levying of service charges (Chapter 3), the granting and management of tenancies (Chapter 5). Those functions were formally delegated on 1 April 1996 when the TMO became operational³³ RBKC's note on the chronology and history of the TMO {RBK00058262/4} paragraph 14. and 250 officers employed in RBKC's Housing Services Department transferred to the TMO.

Constitution

¶31.3 The TMO was set up as a company limited by guarantee and was owned by its members, all of whom were tenants or leaseholders of premises owned by RBKC. In April 1996, members of the TMO elected the first tenant and leaseholder members of the board.

¶31.4 The TMO board had 15 members consisting of eight residents (tenants and leaseholders, in which the former were in the majority), up to four members appointed by the council and three members appointed by the board itself.⁴⁴ Amended Memorandum of Association of KCTMO Constitution {RBK00050806/16} Article 15, clause 15.1.

¶31.5 Throughout its life, the TMO's board comprised tenant, leaseholder, council-appointed and independent board members. Its articles of association were designed to ensure that residents' representatives made up the majority of the board's members.⁵⁵ Amended Memorandum of Association of KCTMO Constitution {RBK00050806/16} Article 15, clause 15.1. In particular, the chair and the two vice-chairs were required to be residents' representatives.⁶⁶ Amended Memorandum of Association of KCTMO Constitution {RBK00050806/21} Article 23, clause 23.2.

¶31.6 The TMO's board was responsible for ensuring that the TMO's objectives were carried out and for ensuring its proper day-to-day management.⁷⁷ Amended Memorandum of Association of KCTMO Constitution {RBK00050806/20} Article 22, clause 22.1. In particular, the board was responsible for the appointment and dismissal of the chief executive and other senior managers.⁸⁸ Amended Memorandum of Association of KCTMO Constitution {RBK00050806/20} Article 22, clause 22.4.

¶31.7 The TMO board operated independently of RBKC except on matters relating to the Housing Revenue Account.⁹⁹ Black {TMO00000888/4} page 4, paragraph 23.

¶31.8 The TMO's principal object was to manage and maintain RBKC's housing stock and ancillary properties on its behalf¹⁰¹⁰ Amended Memorandum of Association of KCTMO Constitution {RBK00050806/2} Article 4, clause 4.1. and on behalf of its 5,600 members, who were either residents or leaseholders of RBKC properties.¹¹¹¹ Black {TMO00000888/4} page 4, paragraph 21.

¶31.9 In 1996 a Management Agreement was entered into with RBKC, under which the TMO agreed to manage the residential properties owned by RBKC.

Arm's Length Management Organisations

¶31.10 Arm's Length Management Organisations (ALMOs) were introduced by the government in its 2000 Housing Green Paper Quality and Choice: A decent home for all.¹²¹² RBKC's note on the chronology and history of the TMO {RBK00058262/8} paragraph 36.

¶31.11 In 2002, RBKC applied to the government to allow the TMO to become an ALMO. The application was granted, with the result that strategic control of RBKC's housing capital programme was delegated to the TMO.¹³¹³ RBKC's note on the chronology and history of the TMO {RBK00058262/8} paragraph 39.

¶31.12 In April 2002, an extraordinary general meeting of the TMO was held at which the members voted unanimously to amend its constitution to allow it to operate as an ALMO and in September 2002, the Secretary of State formally consented to the delegation of additional responsibilities to it.¹⁴¹⁴ RBKC's note on the chronology and history of the TMO {RBK00058262/8} paragraph 39.

¶31.13 To give effect to the TMO's change of status, the 1996 Management Agreement was varied by a deed executed by RBKC and the TMO which came into effect on 7 November 2002. The deed appointed the TMO as an ALMO and, in particular, made the TMO responsible for developing and undertaking all major work schemes as defined in the Management Agreement as well as for the management of the capital programme.

¶31.14 In 2006, the 1996 Management Agreement and the 2002 deed were replaced by a Modular Management Agreement with effect from 1 April 2006 (the 2006 Agreement), under which the TMO continued to manage residential properties for RBKC as its managing agent. The text of the 2006 Agreement was based on a template approved by the government for agreements between local authorities and tenant management organisations. It was based on a standardised form with a chapter on each of the relevant subject areas, such as repairs and payment of rent.

¶31.15 Over the next decade there were further minor changes to the 2006 Agreement before it was superseded by a new Modular Management Agreement in 2015 which reflected the structure and content of a revised template.¹⁵¹⁵ For example, the 2006 Modular Management Agreement was varied in July 2008 to provide for implementation of an improvement plan {RBK00050380} and again in April 2010 to transfer responsibility for allocation of housing from the TMO to RBKC; RBKC's Note on the Chronology and History of the TMO {RBK00058262/11} paragraph 45. Thus, in the period leading up to the fire, the contractual relationship between the TMO and RBKC was contained in the 2006 and 2015 Agreements.¹⁶¹⁶ Tenant Management Organisation Modular Management Agreement Volume 1, Chapter 1 {RBK00018796/13} clause 5.

¶31.16 The effect of the two Agreements was essentially the same. Neither agreement transferred any ownership or rights in RBKC's housing stock to the TMO, except the right to manage and maintain that stock, and neither agreement affected RBKC's legal relationship with its tenants or leaseholders. In particular, RBKC retained its statutory, contractual and common law obligations to its leaseholders and tenants. The TMO undertook to carry out management functions in accordance with RBKC's legal obligations.¹⁷¹⁷ Tenant Management Organisation Modular Management Agreement Volume 1, Chapter 1 {RBK00018796/13} clause 6.2. In particular, the TMO was responsible for maintenance and repairs¹⁸¹⁸ Tenant Management Organisation Modular Management Agreement Volume 1, Chapter 2 {RBK00018796/33} clause 1.1. and for proposing major works.¹⁹¹⁹ Tenant Management Organisation Modular Management Agreement Volume 1, Chapter 2, {RBK00018796/34-35} clause 4.1. If the TMO decided that major works were necessary, it was obliged to prepare and approve works within the level of financial resources made available to it by RBKC.²⁰²⁰ Tenant Management Organisation Modular Management Agreement Volume 1, Chapter 2 {RBK00018796/35} clause 4.3.

The board and its committees

¶31.17 There were three committees of the TMO board: the Operations Committee, the Finance, Audit and Risk Committee and the Appointments and Remuneration Committee. Only the first two are relevant for present purposes.

¶31.18 The Finance, Audit and Risk Committee was responsible for health and safety (including fire safety). Every March, a Health and Safety report was presented to the Finance, Audit and Risk Committee. The report was also presented to the board and to RBKC's Housing and Property Scrutiny Committee (the Scrutiny Committee) as one means by which the TMO and RBKC monitored compliance with fire safety policies.²¹²¹ Matthews {TMO00873380/6} page 6, paragraph 20. The Finance, Audit and Risk committee also monitored the scope and effectiveness of the systems used to identify and assess all material financial and non-financial risks to the TMO.²²²² TMO Annual Health and Safety Report 2015/16 {TMO00843882/1}.

The executive team

¶31.19 The TMO's day-to-day operations were carried on by an executive team that reported to the chief executive. From May 2009, that was Robert Black. There were three executive directors at the time of the fire, Sacha Jevans (Operations), Barbara Matthews (Finance and ICT) and Yvonne Birch (People, Performance and Governance).

¶31.20 Each executive director led a senior management team responsible for the TMO's management functions. In June 2017, the team that reported to Sacha Jevans consisted of Peter Maddison, Director of Assets and Regeneration, Teresa Brown, Director of Housing, Hash Chamchoun, Director of Housing Support Services and Graham Webb, managing director of Repairs Direct Ltd, a subsidiary of the TMO which was responsible for carrying out repairs. For present purposes, it is sufficient to note that Janice Wray, who had been the Health and Safety and Facilities Manager since 2011, reported to Barbara Matthews.²³²³ Wray {Day140/6:16-17}.

The management of health and safety

¶31.21 The Director of Finance and ICT was responsible for ensuring the health and safety of all TMO residents, employees and contractors.²⁴²⁴ Matthews {Day147/103:21-25}. That included responsibility for putting in place arrangements to manage the risk of fire.²⁵²⁵ Matthews {Day147/113:8}-{Day147/114:5}. An important element of her role was to monitor the TMO's health and safety performance at a strategic level.²⁶²⁶ Matthews {TMO10049987/2} page 2, paragraph 7. Anthony Parkes was the Director of Finance and ICT between August 2009 and June 2015²⁷²⁷ Parkes {TMO00873400/1} page 1, paragraph 3. when he was succeeded by Barbara Matthews.

¶31.22 Before joining the TMO, Barbara Matthews had not held responsibility at any organisation for health and safety or fire safety management. She had received no training in, or experience of, managing health and safety²⁸²⁸ Wray {Day147/99:19}-{Day147/100:14}. or fire safety management. She received no training on the requirements of the Fire Safety Order, either before or during her time with the TMO,²⁹²⁹ Wray {Day147/100:25}-{Day147/101:3}. and was not familiar with its details.³⁰³⁰ Matthews {Day147/107:23}-{Day147/108:3}. She was not aware of the concept of the responsible person under the Fire Safety Order or of the substance of that person's duties,³¹³¹ Matthews {Day147/108:23}-{Day147/109:1}. nor did she take any steps to satisfy herself of the adequacy of the TMO's arrangements to discharge its duty to take general fire precautions under Article 8 of the Fire Safety Order.³²³² Matthews {Day147/110:24}-{Day147/111:2}.

¶31.23 Anthony Parkes, Barbara Matthews and the wider executive team relied heavily on Janice Wray for all aspects of health and safety. Although she was not part of the TMO's senior management team, the degree of reliance placed on her by Barbara Matthews and the broad autonomy she was given within her area of operations, meant that Janice Wray was effectively acting at senior management level in relation to health and safety.³³³³ Matthews {Day147/104:15}-{Day147/105:1}.

¶31.24 The TMO's Health and Safety Committee, chaired by Barbara Matthews, was the TMO's primary forum for discussion of health and safety matters.³⁴³⁴ Matthews {TMO00873380/2} page 2, paragraph 8. It was the body which oversaw health and safety performance and challenged managers of services on their compliance with health and safety duties.³⁵³⁵ Matthews {TMO00873380/2} page 2, paragraph 8. The health and safety committee was a critical element in the management of fire safety.³⁶³⁶ TMO Health and Safety Committee Terms of Reference dated September 2015 {TMO00873368/1}.

¶31.25 Between them Barbara Matthews and Janice Wray identified the matters that they considered should be put forward for discussion at executive team meetings and included in the annual health and safety report.³⁷³⁷ Matthews {TMO10049987/2} page 2, paragraph 8. They typically arose out of meetings of the health and safety committee, discussions in the broader housing sector or publications brought to the TMO's attention.³⁸³⁸ Matthews {Day147/105:7-17}.

¶31.26 The TMO maintained a "corporate risk map" that identified the various risks to its operations, the harm that might arise if they occurred and the measures that could be employed to mitigate them.³⁹³⁹ Matthews {Day147/132:8-14}; Example of Corporate Risk Map {TMO00899699}. It had identified health and safety as a strategic risk and was aware that the consequences of a failure to manage health and safety duties properly could result in serious injury or death.⁴⁰⁴⁰ Matthews {Day147/135:13-25}; Corporate Risk Map dated 16 March 2016 {TMO00899699/1} Risk 5. Health and safety committee meetings, involving executive and senior management teams, were held at regular intervals. At those meetings fire risk assessments and any measures required by them were discussed and remedial work monitored and audited.⁴¹⁴¹ Matthews {Day147/136:5-25}.

Janice Wray

¶31.27 Janice Wray played a fundamental role in the TMO's performance of its health and safety obligations, including its obligations in relation to fire safety. Although she saw her role as essentially advisory,⁴²⁴² Wray {Day140/7:22-25}. it is plain from the various versions of the TMO's health and safety policy that it was broader, more substantive and covered a range of matters, including those of the Competent Person for the purposes of the Fire Safety Order that we have set out in Chapter 35.⁴³⁴³ At paragraph 18. See also TMO Health and Safety Policy 2012 {TMO10031076/3}. This list was reproduced in the 2016 version of the policy {TMO10024402/3}. The 2010 version of the policy {TMO10031078/3} does not include the references at (i) and (j) to the Fire Safety Order. The responsibilities she was given were probably too much for one person to discharge properly without substantial assistance and effective oversight and unfortunately she had neither. Senior managers either did not realise that there was simply too much for her to do, or, if they did, they were nonetheless willing for her just to get on and do her best.

Annual health and safety reports

¶31.28 The principal means by which the TMO executive committee reported to the board and to RBKC on health and safety matters was its annual health and safety report. The document was prepared by Janice Wray and reviewed by Barbara Matthews and the executive team before it was submitted to the board.⁴⁴⁴⁴ Matthews {TMO10049987/3} page 3, paragraph 15. The matters reported to the board were those set out in the annual health and safety report and any exceptional events, such as the Adair Tower fire.⁴⁵⁴⁵ Matthews {Day147/105:18-25}. The TMO itself reported to RBKC's scrutiny committee⁴⁶⁴⁶ Matthews {TMO00873380/6} page 6, paragraph 20. and to RBKC at quarterly joint management meetings, principally through Robert Black.⁴⁷⁴⁷ Matthews {TMO00873380/9} page 9, paragraph 31.

¶31.29 From time to time Janice Wray met members of RBKC's housing team, such as Amanda Johnson and Celia Caliskan, and in the course of those meetings reported informally on what the TMO was doing.

¶31.30 Robert Black told us that Barbara Matthews and Janice Wray raised health and safety matters with him which might then be included in the annual health and safety report.⁴⁸⁴⁸ Black {Day149/56:14-25}. Although other TMO employees contributed to the report, it was substantially the work of Barbara Matthews and Janice Wray.⁴⁹⁴⁹ Black {Day149/57:10-19}. As a result, Mr Black was entirely reliant on their judgement to determine whether a matter concerning fire safety or fire safety management should be drawn to the attention of the board.⁵⁰⁵⁰ Black {Day149/57:2-8}.

Funding health and safety management

¶31.31 The TMO was funded by RBKC. It maintained three separate accounts: a management account, which covered its costs under the agreement with RBKC, a "Repairs Direct" account, which related to the cost of maintenance and repairs, and a Housing Revenue account into which rents were paid,⁵¹⁵¹ Black {Day149/21:6-7}. which it maintained on behalf of RBKC.⁵²⁵² Matthews {TMO00873380/10} page 10, paragraph 33.

¶31.32 The TMO's annual management fee was paid by RBKC into the TMO's management account. Robert Black thought that the TMO board's decision-making was not independent of RBKC because it depended on RBKC for its income.⁵³⁵³ Black {Day149/23:23}-{Day149/24:2}.

¶31.33 The cost of employing and running the health and safety team, including that of the fire risk assessment programme, was borne by the health and safety team budget, which was one of the departmental budgets within the Financial Services and ICT directorate.⁵⁴⁵⁴ Matthews {TMO00873380/10} page 10, paragraph 35. That budget did not include the cost of carrying out works required as a result of a fire risk assessment, which was borne by whichever team was responsible for the work in question.

Reporting to the Board and RBKC

¶31.34 The board of the TMO was the body ultimately responsible for its affairs, including strategic decisions relating to matters affecting fire safety in the buildings it managed. It was therefore important that it be kept informed of developments as they occurred, but regrettably there were many instances in which important information was not drawn to its attention. RBKC was responsible for the oversight of the TMO which reported to its scrutiny committees. Reports to the scrutiny committees did not always contain the information that might reasonably have been expected.

¶31.35 From the start of Robert Black's tenure as chief executive in May 2009, fire safety and the adequacy of the TMO's fire safety measures were regular subjects of discussion, primarily because of the LFB's concern about the TMO's approach to fire risk assessments.⁵⁵⁵⁵ Black {Day149/217:3-8}. The substance of those matters is discussed in Part 5, Chapter 37. At the outset the LFB was concerned that the TMO was producing its own fire risk assessments and that they were inadequate.⁵⁶⁵⁶ {RBK00052528/3}. The LFB was so troubled that it indicated that it would serve an enforcement notice on both the TMO and RBKC.⁵⁷⁵⁷ {RBK00052528/3}. As a result, the TMO entered into a contract with Salvus Consulting Ltd to carry out fire risk assessments in respect of all its high‑risk properties.⁵⁸⁵⁸ Black {Day149/212:1-4}.

¶31.36 The first fire risk assessments produced by Salvus in 2009 identified a number of risks that Janice Wray wanted to discuss with Robert Black. One concerned flat entrance doors.⁵⁹⁵⁹ {TMO10037375}. Mr Black was aware from at least October 2009 that defects in flat entrance doors (in particular, a lack of effective self-closing devices, intumescent strips and cold smoke seals) resulting in ineffective compartmentation had been identified by the fire risk assessments as a problem that required attention across the TMO's estate.⁶⁰⁶⁰ Black {Day150/3:18-25}. Mr Black was also aware of the Fire Safety Management report dated 22 September 2009 produced by Salvus for the TMO,⁶¹⁶¹ Fire Risk Assessment for Fire Safety Policy and Procedures prepared by Salvus Consulting Ltd {SAL00000013}. which drew attention to 19 respects in which Salvus considered the TMO to be in breach of the Fire Safety Order.⁶²⁶² Black {Day150/4:15-19}.

¶31.37 In December 2009, Janice Wray prepared a report for a meeting of the TMO board on 10 December 2009.⁶³⁶³ {TMO00873623}. It is likely that a copy was provided to Mr Black.⁶⁴⁶⁴ Cover Letter to Board Member dated 4 September 2009 {TMO00881999}; Enclosure 16 {TMO00888764}; Board Action Sheet {TMO00882005/20}. In relation to the Salvus Fire Safety Management report it simply said that a management report had been received from the consultant which set out the fire safety framework within which the TMO and its contractors should be working.⁶⁵⁶⁵ {TMO00873623/2} paragraph 4.5. It said nothing about the 19 breaches of the Fire Safety Order that had been identified and gave the board no information about the serious defects that Salvus had found in the TMO's management of fire safety across its estate. There is no evidence that Mr Black presented the report to the board and no recorded explanation or discussion of its contents. We can only conclude that he and the executive team failed to make even the most basic disclosure to the board of the widespread systemic failings in the TMO's management of fire safety that Salvus had found. Janice Wray was seriously at fault in not writing a candid report for the board; Mr Black was equally at fault in failing to inform the board about the deficiencies in fire safety management.

¶31.38 Following the board meeting, Mr Black, Laura Johnson and Jean Daintith produced a report for the meeting of RBKC's Housing, Environmental Health and Adult Social Care Scrutiny Committee on 15 March 2010, which included an item on the TMO's fire risk assessment programme.⁶⁶⁶⁶ {RBK00030060}. Paragraph 3 of the report said that the increasingly stringent requirements of the LFB had led the TMO and RBKC to agree a new approach to fire risk assessments and carrying out any remedial work required as a result. The report did not mention that the LFB had been so concerned about the adequacy of the fire risk assessments carried out by the TMO itself that it had considered issuing an enforcement notice.⁶⁷⁶⁷ Black {Day150/9:8-14}. Mr Black could not account for that omission,⁶⁸⁶⁸ Black {Day150/9:21-22}. nor could he recall whether the scrutiny committee had been told of Salvus's recommendations or the TMO's response to them.⁶⁹⁶⁹ Black {Day150/9:24}-{Day150/10:5}. Robert Black's failure to disclose those matters was part of an emerging pattern of withholding from those to whom he reported the fact that there were serious problems with the management of fire safety by the TMO.

A fire at Grenfell Tower: 30 April 2010

¶31.39 On 30 April 2010, a fire broke out in the lift lobby on floor 6 of Grenfell Tower. On 5 May 2010 Janice Wray sent an email to Collette O'Hara of the LFB (with a copy to Robert Black) giving her report on it.⁷⁰⁷⁰ {TMO10048221/4}. She said there had been a leakage of smoke from the extraction system into the lobbies of floors 7, 12, 13, 15, 17, 18, 19 and 20 that had led a number of residents to believe that their lobbies were smoke-logged and that they were trapped in their homes. They had therefore telephoned the LFB asking for help.

¶31.40 When Janice Wray reported the incident to the TMO board in her report of 17 June 2010,⁷¹⁷¹ {TMO10037437/96-97} paragraphs 8.2 and 8.3. she did not say that smoke had leaked into the lobbies on eight floors (as described in the email to Collette O'Hara) nor did she mention the residents' belief that they had been trapped in their flats and had called the LFB. The report gave the impression that the smoke ventilation system had operated substantially as intended, but with some relatively minor leakage.⁷²⁷² {TMO10037437/97} paragraph 8.3. It grossly understated the extent to which smoke had spread within the tower and was seriously misleading. Mr Black accepted that it did not give the board proper information about the operation of the smoke ventilation system or, importantly, the residents' fear that they were trapped. Again, Mr Black could not explain why the board had been given a materially incomplete account.⁷³⁷³ Black {Day150/31:11}-{Day150/32:4}. He had seen Janice Wray's original report to Collette O'Hara and should have corrected the false impression that Ms Wray's report gave.

¶31.41 In March 2014 the LFB issued a deficiency notice to the TMO because of its failure to maintain the smoke ventilation system at Grenfell Tower.⁷⁴⁷⁴ {LFB00032101}. The system was finally replaced in 2016 as part of the refurbishment, but between 2010 and 2016 there was no fully functioning smoke ventilation system.⁷⁵⁷⁵ Black {Day150/45:5-8}. We return to this episode later in Chapter 43 because it seems that, as Mr Black accepted, the absence of a functioning smoke ventilation system was the subject of repeated complaints by the Grenfell Tower Leaseholders' Association.

¶31.42 The next TMO board meeting took place on 22 May 2014. Robert Black prepared a report for that meeting which was circulated in advance.⁷⁶⁷⁶ TMO Board document pack {RBK00051017}; Chief Executive's report {RBK00051017/27-28}. It made no mention of the deficiency notice. Although he accepted that it was essential information for the board to receive, Mr Black could not explain why it had not been placed before it.⁷⁷⁷⁷ Black {Day150/101:2-24}. The omission can only have been deliberate. Yet again, Mr Black's failure to provide the board with important information relating to fire safety in the TMO's housing stock deprived it of the ability to take corrective action.

Adair Tower Deficiency Notice

¶31.43 On 12 October 2015, the LFB issued a deficiency notice in respect of Adair Tower.⁷⁸⁷⁸ {TMO00842271}. Some of the contraventions of the Fire Safety Order identified by the LFB resulted from failures to carry out remedial works called for in fire risk assessments.⁷⁹⁷⁹ Black {Day150/138:6-14}. Janice Wray received the notice on 22 October 2015,⁸⁰⁸⁰ {LFB00001645}. but she did not bring it to Robert Black's attention until the morning of 31 October 2015, when a fire occurred at Adair Tower.⁸¹⁸¹ Black {Day150/139:25}-{Day150/140:5}. Mr Black accepted that that had been a serious failing on her part,⁸²⁸² Black {Day150/140:6-8}. but it was consistent with a culture of concealment that had started at the top and filtered down to lower layers of management.

¶31.44 In the evening of 31 October 2015, Robert Black sent an email to the members of the TMO board to tell them about the fire.⁸³⁸³ {TMO00866480/2}. Although he emphasised the LFB's success in tackling it, he made no mention of the deficiency notice. The issue of such a notice was an obviously important piece of information, given that a fire had broken out only two weeks later in that very building. Yet again, Mr Black was unable to explain why he had not told the board about it.⁸⁴⁸⁴ Black {Day150/143:3-7}. We can only conclude that his failure to do so was deliberate.

¶31.45 On 4 November 2015, Rebecca Burton of the LFB sent an email to Janice Wray containing a list of questions relating to the Adair Tower fire.⁸⁵⁸⁵ {TMO00869184/3}. The email chain had originated with Janice Wray on 22 October 2015 because she had been told that the LFB was about to issue five more deficiency notices relating to other properties managed by the TMO.⁸⁶⁸⁶ {LFB00003440}. Some of them were based on the absence of effective self-closing devices on doors in buildings that had been inspected.⁸⁷⁸⁷ {TMO00869184/6}.

¶31.46 Janice Wray forwarded the correspondence between herself and Rebecca Burton to Robert Black and others the same day. Mr Black could not remember whether he had read it or had been made aware that the LFB was about to issue more deficiency notices, but he accepted that it was likely that he had.⁸⁸⁸⁸ Black {Day150/147:10-17}.

¶31.47 On 5 November 2015, Mr Black attended a meeting of RBKC's Housing and Property Scrutiny Committee. The minutes of that meeting record that he provided a report on the fire at Adair Tower, in which he said that the fire doors had worked well.⁸⁹⁸⁹ {RBK00048049/6}. He did not mention the deficiency notice that had been issued 19 days before the fire. Mr Black could not recall why the committee had not been told about the deficiency notice,⁹⁰⁹⁰ Black {Day150/143:3-7}. but the omission cannot have been accidental.

¶31.48 The fact that a deficiency notice had been issued, not to mention its contents, was clearly a matter of some importance and should have been drawn to the attention of the scrutiny committee.⁹¹⁹¹ Marshall {Day133/137:5-15}. Robert Black's failure to report those matters to the committee was a serious dereliction of duty on his part, but entirely consistent with the pattern of concealment he had established in relation to fire safety matters.

¶31.49 On 4 December 2015, Barbara Matthews sent an email to the members of the TMO board (including Mr Black) telling them that the LFB intended to serve enforcement notices in relation to Adair Tower and Hazelwood Tower.⁹²⁹² {TMO00902920}. Again, the email is instructive as much for what is not said as for what is. She did not mention the deficiency notice issued on 12 October 2015, nor did she mention the various enforcement measures available to the LFB, although in a draft message to the board composed only two days earlier Robert Black had identified them.⁹³⁹³ {TMO00902919}. Neither Barbara Matthews⁹⁴⁹⁴ Matthews {Day148/81:16}-{Day148/82:5}. nor Robert Black⁹⁵⁹⁵ Black {Day150/164:18}-{Day150/165:22}. could explain why the fact that a deficiency notice issued on 12 October 2015 had again not been mentioned. Again, the omission can only have been deliberate.

¶31.50 An enforcement notice dated 23 December 2015 was served by the LFB on the TMO in relation to breaches of the Fire Safety Order identified following the fire at Adair Tower.⁹⁶⁹⁶ {TMO00840703}. The enforcement notice required the TMO to take steps to remedy the failures specified in the schedule to the notice by 23 June 2016.⁹⁷⁹⁷ {TMO00840703/1-2}.

¶31.51 On 6 July 2016, Janice Wray spoke to Ben Dewis of the LFB. During that call he told her about the current status of the LFB's investigation into the Adair Tower fire and the possibility of enforcement action. Janice Wray sent a note of the call by email to Laura Johnson, Robert Black and Barbara Matthews.⁹⁸⁹⁸ {RBK00001865}. In it she said that she was concerned to hear that investigations were continuing.⁹⁹⁹⁹ {RBK00001863}. Mr Black accepted that he must have seen and read the note¹⁰⁰¹⁰⁰ Black {Day150/206:5-7}. which made it clear that the LFB were considering taking legal action against the TMO in respect of breaches of the Fire Safety Order, including possible criminal proceedings, although, as the note recorded, Mr Dewis felt that was unlikely.

¶31.52 Robert Black reported to the TMO board on 20 July 2016. His report, which was circulated to the members before the meeting,¹⁰¹¹⁰¹ {TMO10014037/68}. did not mention the possibility that criminal proceedings might be taken against the TMO. Once more, he was unable to explain why he had not told the board about a potential prosecution for failing to comply with the Fire Safety Order, which was obviously a serious matter.¹⁰²¹⁰² Black {Day150/209:19}-{Day150/210:18}. It was his responsibility, as he accepted, to keep the board informed about anything that might affect its legal position,¹⁰³¹⁰³ Black {Day150/142:24}-{Day150/143:2}. but although he denied that he had deliberately withheld the information from the board, we are unable to accept that it was the result of a mere oversight.¹⁰⁴¹⁰⁴ Black {Day150/201:2-18}.

¶31.53 On 17 November 2016, the LFB issued a deficiency notice to the TMO in respect of Grenfell Tower.¹⁰⁵¹⁰⁵ {TMO10017254}. It was based on the absence of self-closing devices on some doors in the building, which was a potential breach of the Fire Safety Order. The notice required remedial action to be taken by 18 May 2017.

¶31.54 The events we have described lead us to conclude that although there was a satisfactory system in place within the TMO for reporting through senior management to the board and the scrutiny committee, it failed to operate effectively because of an entrenched reluctance on the part of Robert Black to inform the board and RBKC's scrutiny committees of matters that affected fire safety. It was his decision whether to report to the board what he knew about problems with fire safety at the TMO and he consistently chose not to do so. Robert Black consistently failed to tell either the board or RBKC of the LFB's concerns about the TMO's compliance with the Fire Safety Order or the various steps taken by the LFB to enforce it. His persistent failure to provide them with important information denied both the board and RBKC of the ability to exercise effective oversight of the TMO's performance of its obligations under the Fire Safety Order.

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