Chapter 37: Development of fire safety strategies and policies

¶37.1 Before 2008 the TMO's health and safety team comprising Adrian Bowman and Janice Wray carried out fire risk assessments itself in order to save money, rather than using external fire risk assessors.³⁹⁰³⁹⁰ Wray {Day140/85:17-19}; Briefing Note on Fire Safety dated 27 July 2009 by Janice Wray {TMO10037317/1} item 3; Email from Janice Wray to Robert Black and Liam Good copying in various others on 17 June 2009 about the LFB's intention to issue an enforcement notice {RBK00052535/4}. In May 2008, however, Collette O'Hara, a fire safety inspecting officer in the LFB's Kensington & Chelsea fire safety team (the LFB fire safety team), identified certain deficiencies in the TMO's fire risk assessments.³⁹¹³⁹¹ LFEPA (LFB) Report Form on the TMO by Collette O'Hara dated 16 November 2009 {LFB00031977/22}.

¶37.2 In January 2009, the LFB fire safety team was not satisfied that the TMO's fire risk assessments had improved. It therefore sent a series of letters to the TMO, each in relation to a property in respect of which it did not consider the fire risk assessment to be suitable and sufficient as required by article 9(1) of the Fire Safety Order. That precipitated a number of meetings and discussions between Angus Sangster, the team leader, Collette O'Hara and Janice Wray about the standard expected of fire risk assessments.³⁹²³⁹² LFEPA (LFB) Report Form on the TMO by Collette O'Hara dated 16 November 2009 {LFB00031977/22}; Wray {Day140/85:10}-{Day140/86:8}.

¶37.3 Following a site visit to one of the TMO's properties with Janice Wray on 17 June 2009, Mr Sangster and Ms O'Hara concluded that the TMO was not competent to carry out fire risk assessments itself. Accordingly, Mr Sangster advised Janice Wray that the LFB would issue an enforcement notice against RBKC and the TMO requiring fire risk assessments to be carried out by a competent person.³⁹³³⁹³ LFEPA (LFB) Report Form on the TMO by Collette O'Hara dated 16 November 2009 {LFB00031977/22}.

¶37.4 Later that day, Janice Wray told Laura Johnson and Jean Daintith, RBKC Executive Director of Housing, what the LFB intended to do.³⁹⁴³⁹⁴ Email from Janice Wray to Jean Daintith and Laura Johnson copying in others on 17 June 2009 about the LFB's intention to issue an enforcement notice {RBK00052535/3}. Jean Daintith immediately sought advice from RBKC's building control department, which said that the TMO's fire risk assessments were not sufficiently robust and that a specialist should be engaged to carry them out.³⁹⁵³⁹⁵ Email from Jean Daintith to Derek Myers cc David Prout on 17 June 2009 about the LFB's intention to issue an enforcement notice {RBK00052535/3}; Email from Jean Daintith to Derek Myers and Robert Black cc others on 18 June 2009 about the TMO's fire risk assessments {RBK00052528/1}.

¶37.5 As a result, on 18 June 2009, Alexis Correa, RBKC's health and safety advisor for the Housing, Health and Adult Social Care department, contacted Angus Sangster to explain that RBKC would provide funds to allow the TMO to appoint an external fire risk assessor and to carry out all necessary works. He sought an assurance that in those circumstances the LFB would not issue an enforcement notice. Mr Sangster agreed not to do so, subject to receiving from RBKC and the TMO a schedule for the completion of fire risk assessments.³⁹⁶³⁹⁶ LFEPA (LFB) Report Form on the TMO by Collette O'Hara dated 16 November 2009 {LFB00031977/23}.

¶37.6 On 9 July 2009, Janice Wray sent Mr Sangster a schedule of work³⁹⁷³⁹⁷ LFEPA (LFB) Report Form on the TMO by Collette O'Hara dated 16 November 2009 {LFB00031977/23}. that had been agreed between RBKC and the TMO,³⁹⁸³⁹⁸ Email from Alexis Correa to Pam Sedgwick cc others on 7 July 2009 about providing a schedule of works for fire risk assessments {TMO00866049/2}; Email from Alexis Correa to Janice Wray and others on 8 July 2009 describing the outcome of a meeting that day with Janice Wray, Liam Good and Ann Muchmore about fire risk assessments {TMO00865069/1}. but he did not consider it acceptable and suggested a further meeting to discuss the way forward.³⁹⁹³⁹⁹ LFEPA (LFB) Report Form on the TMO by Collette O'Hara dated 16 November 2009 {LFB00031977/23}; Briefing Note on Fire Safety dated 27 July 2009 by Janice Wray {TMO10037317/3} item 5. The meeting took place on 6 August 2009⁴⁰⁰⁴⁰⁰ Minutes of meeting between RBKC, TMO and LFB on 6 August 2009 {RBK00018535/1}. and was attended by representatives of the LFB fire safety team, RBKC and the TMO. During the meeting Keith Holloway, the TMO's Director of Strategic, Planning, Performance and Compliance, confirmed that fire risk assessments would be carried out by an external consultant. He and Jean Daintith also agreed that RBKC and the TMO would complete fire risk assessments for all their properties within three years, starting with high-risk properties, and carry out any work identified in them within five years.⁴⁰¹⁴⁰¹ Minutes of meeting between RBKC, TMO and LFB on 6 August 2009 {RBK00018535/2} item 5.

¶37.7 Although RBKC and the TMO felt that, in requiring that approach to fire risk assessments, the LFB was treating them unduly harshly, they agreed to comply with its requirements.⁴⁰²⁴⁰² Minutes of TMO Executive Team meeting dated 29 July 2009 {TMO00903017/5} item 9; Minutes of TMO Executive Team meeting dated 3 August 2009 {TMO00903019/3} item 2.4; Emails between Laura Johnson and Janice Wray cc Keith Holloway dated 4-5 August 2009 about fire safety {TMO10037329}; Minutes of meeting between RBKC, TMO and LFB on 6 August 2009 {RBK00018535/1} item 1; Minutes of meeting between RBKC, TMO and LFB on 6 August 2009 {RBK00018535/4} item 10.Show full note

¶37.8 On 7 September 2009, a fire risk consultant, Salvus Consulting Ltd (Salvus), was appointed by the TMO to carry out the first phase of fire risk assessments. It covered 110 properties that were considered to pose a high risk, including Grenfell Tower. Work was due to start on 24 September 2009.⁴⁰³⁴⁰³ Wray {TMO00842341/2} page 2, paragraph 9; Agreement between TMO and Salvus to appoint Salvus to carry out fire risk assessments on high-risk properties dated 7 September 2009 {TMO10037438/42}; TMO spreadsheet of potentially high-risk properties dated 1 July 2009 {TMO00842374}. There were meetings between Salvus, the LFB fire safety team, the TMO and RBKC on 16 September 2009 and 23 November 2009 to discuss the scope of the fire risk assessment programme and the method to be adopted.⁴⁰⁴⁴⁰⁴ Minutes of the meeting between Salvus, LFB fire safety team and TMO on 16 September 2009 {SAL00000039}; Minutes of the meeting between Salvus, LFB fire safety team, TMO and RBKC on 23 November 2009 {SAL00000043}.

¶37.9 On 27 January 2010, Robert Black and Laura Johnson wrote to Angus Sangster confirming the joint commitment of RBKC and the TMO to achieving compliance with the Fire Safety Order. In their letter they described what had been agreed in their meetings with the LFB fire safety team in relation to the fire risk assessment programme, which by that time was already under way. The LFB was evidently satisfied with their proposal.⁴⁰⁵⁴⁰⁵ Minutes of meeting between RBKC, TMO and LFB on 6 August 2009 {RBK00018535}; Minutes of the meeting between Salvus, LFB and TMO on 16 September 2009 {SAL00000039}; Minutes of the meeting between Salvus, LFB, RBKC and TMO on 23 November 2009 {SAL00000043}.

The Salvus Management Report

¶37.10 On 22 September 2009, Steve Wain, a Salvus fire risk assessor, carried out a detailed assessment of the TMO's fire safety management systems at the request of Russell Thompson, the TMO's Head of Assets Strategy and Investment.⁴⁰⁶⁴⁰⁶ Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/2}. Steve Wain set out his findings in a report of the same date entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" (known as the Salvus Management Report).⁴⁰⁷⁴⁰⁷ Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/1}.

¶37.11 The Salvus Management Report was divided into two parts. Part 1 identified 25 deficiencies in the TMO's fire safety management arrangements that created hazards. It also identified where there were inadequate control measures in place in relation to those hazards and the level of risk the hazards presented.⁴⁰⁸⁴⁰⁸ Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/2}. It based risk on both the likelihood of harm occurring and the likely severity of harm. A high-risk event, for example, was defined as one that was very likely or almost certain to occur and cause major injury or death and a medium-risk event as one that could occur in time and was likely to cause injury and ill health.⁴⁰⁹⁴⁰⁹ Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/2}. All but two of the deficiencies were assessed as presenting a high or medium to high level of fire risk.⁴¹⁰⁴¹⁰ Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/5-12}. Hazards included the absence of an overall fire safety policy setting out the TMO's strategic fire safety objectives, which was assessed as a high risk, the lack of policy and supporting arrangements to explain how the TMO would meet its fire safety objectives (for example, in relation to fire risk assessments and the maintenance of fire safety measures), which was also assessed as high risk and the lack of senior managerial audit of the fire safety arrangements to ensure that they were being satisfactorily implemented, which was assessed as medium to high risk.⁴¹¹⁴¹¹ Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/5}.

¶37.12 Although Janice Wray did not agree with all of Salvus's conclusions, she did accept that the TMO had not adequately recorded its fire safety arrangements.⁴¹²⁴¹² Wray {Day140/108:18-21}. Indeed, the TMO's Health and Safety Policy dated May 2009 was the only policy relevant to fire safety in existence at the time of the Salvus Management Report.⁴¹³⁴¹³ TMO's Health and Safety Policy dated May 2009 {TMO00870519}. It was not, however, a fire safety policy. It referred only briefly to fire safety and emergency procedures and made no mention at all of the Fire Safety Order, which had come into force in October 2006 some two and half years earlier.⁴¹⁴⁴¹⁴ TMO's Health and Safety Policy dated May 2009 {TMO00870519/5}.

¶37.13 Part 2 of the Salvus Management Report was an action plan which set out 49 steps required to reduce the risks that had been identified.⁴¹⁵⁴¹⁵ Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/13-19}. Salvus considered that 19 of them were required to remedy statutory breaches.⁴¹⁶⁴¹⁶ Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/13-19}. The key to colour coding on page 19 shows that red signifies a statutory breach. The statute and statutory instruments Steve Wain probably had in mind are set out in the "Reference Material" on page 4. According to the priority ratings, Salvus required that the majority be completed within one or three months or, if a plan had been agreed, within six months.⁴¹⁷⁴¹⁷ Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/13-19}. The "key to priority rating" on page 19 shows that "3" means "Undertake action within 1 month" and "4" means "Action within 3 months or agree plan within 6 months". There was, therefore, some urgency attached to the recommendations.

¶37.14 Salvus strongly recommended that the TMO develop an overall fire safety policy within one month setting out its strategic fire safety objectives. It also strongly advised that the TMO introduce policy and supporting arrangements to show how it would meet its strategic fire safety objectives (for example, in relation to fire risk assessments and the maintenance of fire safety measures) within three months or, if a plan had been agreed, within six months.⁴¹⁸⁴¹⁸ Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/13}.

¶37.15 Although we do not know exactly who received the Salvus Management Report, Janice Wray believed that copies had been sent to all those in the TMO who regularly dealt with Salvus. She mentioned Russell Thompson, Janet Rhymes, the TMO's Consultancy Services Manager, and also Ann Muchmore, RBKC's Performance and Contracts Monitoring Officer.⁴¹⁹⁴¹⁹ Wray {Day140/105:7-11}.

¶37.16 Janice Wray did not receive the Salvus Management Report until 20 November 2009.⁴²⁰⁴²⁰ Minutes of the meeting between Salvus, LFB, RBKC and TMO on 23 November 2009 {SAL00000043/4}. At item 5.4 it is recorded that Janice Wray received the email "late Thursday" which would have been 20 November 2009. See also Wray {Day140/118:4-12}; Wray {Day140/119:7-25}. We do not know why there was a delay of two months in her receiving it; on the face of it, it should have reached her much sooner. The delay may explain why she did not mention the report in her fire risk assessment report to the TMO board on 8 October 2009,⁴²¹⁴²¹ Janice Wray's report to the TMO Board entitled "Further Update on Fire Risk Assessments" dated 8 October 2009 {RBK00053571/1}. but it does not explain why, according to her report, Salvus had said at its meeting with the TMO on 24 September 2009 that generally the TMO had good fire safety policies and procedures in place, although they had not been consistently documented.⁴²²⁴²² Janice Wray's report to the TMO Board entitled "Further Update on Fire Risk Assessments" dated 8 October 2009 {RBK00053571/2} item 3.4. That statement is difficult to reconcile with the deficiencies in fire safety policy and arrangements that Salvus had identified in the report it had made only two days before that meeting. Regrettably, we have not seen any minutes of that meeting.

¶37.17 When Janice Wray received the Salvus Management Report she should have communicated at least the substance of its findings to the executive team, which in turn should have communicated them to the board and to RBKC. We have seen no evidence that that was done and we conclude that she did not do so. That would at least have set the record straight and would have corrected the false impression that Ms Wray had given the board on 8 October 2009.

¶37.18 Janice Wray may have discussed the report with Lornette Pemberton, the TMO's Head of Human Resources and Organisational Development and her line manager at the time and if so, she probably assumed that Ms Pemberton would report the deficiencies to the executive team.⁴²³⁴²³ Wray {Day140/122:16}-{Day140/123:12}; Wray {Day140/127:12-17}. Robert Black said that he could not recall the report but was sure that he had seen it.⁴²⁴⁴²⁴ Black {Day149/63:9}-{Day149/67:11}; Wray {Day140/133:6-10}.

¶37.19 In her fire risk assessment report on 10 December 2009, Janice Wray told the board that the TMO had received a report from the consultant that set out the fire safety framework within which it and any contractors should be working.⁴²⁵⁴²⁵ Janice Wray's report to the TMO Board entitled "Further Update on Fire Risk Assessments" dated 10 December 2009 {TMO00873623/2} item 4.5. However, she did not mention any of the critical findings or urgent measures that needed to be taken by the TMO in relation to the management of fire safety. She could not explain that omission,⁴²⁶⁴²⁶ Wray {Day140/123:7-12}. nor could she remember having told the executive team or the board about them. We have seen no evidence that she or anyone else did so and are forced to the conclusion that they were not drawn to the attention of either the executive team or the board.⁴²⁷⁴²⁷ Wray {Day140/122:24}-{Day140/123:12}.

¶37.20 The report and its findings were, however, discussed by Salvus, the TMO and RBKC at a progress meeting on 26 January 2010. That meeting was attended by Janice Wray, Russell Thompson, Abigail Acosta (a TMO project manager) and Ann Muchmore.⁴²⁸⁴²⁸ Minutes of the meeting between Salvus, RBKC and TMO on 26 January 2010 {RBK00052572/3-4} item 4. It is clear from the minutes of the discussion of the report that Ann Muchmore was aware of its existence, even if she had not been provided with a copy. However, we have seen no evidence that she ever shared the report more widely within RBKC. Laura Johnson had no recollection of having seen it.⁴²⁹⁴²⁹ Johnson {Day129/100:25}.

Implementation of the recommendations

¶37.21 At the meeting on 26 January 2010, Janice Wray raised a number of questions about the Salvus Management Report.⁴³⁰⁴³⁰ Minutes of the meeting between Salvus, RBKC and TMO on 26 January 2010 {RBK00052572/3-4} item 4. It is clear from the minutes of that meeting that many of Salvus's recommendations had yet to be implemented and indeed Janice Wray accepted that some had not been. For example, she said she had not had an opportunity to put in place policy and supporting arrangements to explain how the TMO would meet its strategic fire safety objectives.⁴³¹⁴³¹ Wray {Day140/125:3-20}. That was despite a recommendation that it be done within three months.⁴³²⁴³² Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/13} item 1.2.

¶37.22 It appears that Janice Wray had started to implement that particular recommendation within the required time but had stopped work before it was complete. There is a document headed "TMO Fire Safety Policy", apparently signed by Robert Black and dated December 2009,⁴³³⁴³³ Draft TMO Fire Safety Policy dated December 2009 {TMO00870171}. which appears to be an early draft of the fire safety policy. Although she had little recollection of it, Janice Wray thought she had probably started drafting it in response to Salvus's recommendation and had put it aside because of other work.⁴³⁴⁴³⁴ Wray {Day140/131:5-25}; Wray {Day140/142:6-11}. As it was, the TMO did not produce a fire safety policy in response to that recommendation until November 2013.⁴³⁵⁴³⁵ TMO Fire Safety Strategy dated November 2013 {TMO00830598}.

¶37.23 On any view, the pace at which the recommendations were implemented was glacial. Given a high or medium to high assessment of the danger posed by a recommendation's remaining incomplete, the TMO failed to act with the degree of urgency that the subject demanded. It is not clear whether the problem flowed from Janice Wray's failure to prioritise the work or whether she did not have the capacity to undertake it and failed to ask for more resources. Whatever the cause, given their importance, the TMO should have made sure that the recommendations were promptly implemented and it failed to do so.

¶37.24 One of the other recommendations made by Salvus was that within three months (or six months if a plan had by then been produced) the TMO should introduce a senior managerial audit of fire safety arrangements. There was also a recommendation that it be reviewed as part of the TMO's Business Plan.⁴³⁶⁴³⁶ Salvus report entitled "Fire Risk Assessment for Fire Safety Policy and Procedures" dated 22 September 2009 {SAL00000013/14} item 1.4. We have seen no evidence that the TMO had introduced such an audit before the Grenfell Tower fire on 14 June 2017 and no explanation has been given for its failure to do so.

¶37.25 The TMO Performance Agreement for 2012/13 contained a draft audit programme for the following year that included a full review of fire risk assessments by Lornette Pemberton.⁴³⁷⁴³⁷ TMO Performance Agreement 2012/13 {TMO00883568/42} paragraph 3.4. It is evident, however, that the audit was intended to relate to fire risk assessments rather than the fire safety management system as a whole. It would not, therefore, have fully met Salvus's recommendation. In any event, we have seen no evidence that Lornette Pemberton, or anyone else, carried out an audit of that kind and we conclude that no one did. Robert Black could not explain why it had not been carried out.⁴³⁸⁴³⁸ Black {Day149/211:14-22}. An audit of fire risk assessments did not appear again in the TMO audit programme before 14 June 2017.⁴³⁹⁴³⁹ TMO Performance Agreement 2013/14 {TMO10002878/22} item 3.2; TMO Performance Agreement 2014/15 Mid-Year Review {TMO10042117/5-6} item 2; TMO Performance Agreement 2015/16 {TMO10043715/20-21} item 3.2; TMO Performance Agreement 2016/17 {RBK00000589/24-25} item 3.2.

¶37.26 In June 2013, PAS 7:2013, a publicly available specification concerning fire risk management systems, was published by the British Standards Institution.⁴⁴⁰⁴⁴⁰ BSI Standards Publication PAS 7:2013 "Fire Risk Management System - Specification" {LFB00116924/2}. Paragraph 7.4.3 stated that an organisation should audit the fire risk assessment programme after the delivery of the fire risk assessments and hold review meetings at planned intervals to discuss the results of the audits of fire risk assessments and the efforts made to respond to the findings.⁴⁴¹⁴⁴¹ BSI Standards Publication PAS 7:2013 "Fire Risk Management System" {LFB00116924/23} paragraph 7.4.3.

¶37.27 At paragraph 8.3.1, it provided that senior management should review the organisation's fire risk management system at planned intervals to ensure its continuing suitability, adequacy and effectiveness.⁴⁴²⁴⁴² BSI Standards Publication PAS 7:2013 "Fire Risk Management System" {LFB00116924/25} paragraph 8.3.1. That specification bears a striking resemblance to the recommendation made by Salvus in September 2009 for a senior managerial audit of fire safety arrangements.

¶37.28 Janice Wray was aware of PAS 7:2013.⁴⁴³⁴⁴³ Wray {Day145/11:12}-{Day145/12:17}. Despite that, she made no provision in the TMO fire safety strategy that she prepared in November 2013 for an audit of the fire risk assessment programme or for a review of the fire risk management system.⁴⁴⁴⁴⁴⁴ TMO Fire Safety Strategy dated November 2013 {TMO00830598}.

¶37.29 We have seen no evidence that RBKC or the TMO incorporated a specific audit of the fire risk assessment programme or a review by senior management of the fire risk management system into its policy. Nor have we seen any evidence that the management of the TMO ever implemented such an audit or review in practice. No explanation has been given for those chronic failings.

RBKC audit of the TMO's health and safety arrangements

¶37.30 The TMO, in conjunction with RBKC, set annual audit plans, the results of which allowed senior management to assess the adequacy and effectiveness of the internal controls in any particular year.⁴⁴⁵⁴⁴⁵ Patel {RBK00029884/2} page 2, paragraph 5. Audits were carried out by RBKC's audit department, whose reports gave an overview of the area of service being audited. They also provided an assurance assessment rating, which ranged from "substantial" to "limited", based on the findings and the number of recommendations made in the report. If a "limited" assurance rating was given, there was usually a review within six to nine months to assess the implementation of any recommendations.⁴⁴⁶⁴⁴⁶ Patel {RBK00029884/2} page 2, paragraph 5.

¶37.31 For TMO health and safety audits, each recommendation was given a high, medium or low priority and the overall audit would be given a "limited", "satisfactory" or "substantial" assurance rating. "Limited" assurance meant that there were weaknesses that put the objectives of the system at risk of failure. "Satisfactory" assurance meant that there were some weaknesses or omissions that put the objectives of the system at risk of failure. "Substantial" assurance meant that there was a sound system of control designed to achieve its objectives with few errors of weaknesses found.⁴⁴⁷⁴⁴⁷ Patel {RBK00029884/4} page 4, paragraph 12. RBKC's audit team provided an independent audit service for the TMO.⁴⁴⁸⁴⁴⁸ Patel {RBK00029884/4} page 4, paragraph 14.

¶37.32 An audit of the TMO's Health and Safety department was carried out by RBKC in April 2013.⁴⁴⁹⁴⁴⁹ {RBK00000313}. The report was circulated, initially in draft, to Sacha Jevans, Janice Wray, Peter Maddison and Anthony Parkes. When completed, copies of the report were sent to Robert Black and Laura Johnson.⁴⁵⁰⁴⁵⁰ {RBK00000313/1}. The audit provided only limited assurance that the TMO had adequate controls and processes in place in relation to health and safety.⁴⁵¹⁴⁵¹ {RBK00000313/4}. The report made two relevant recommendations, first, that all high priority remedial work identified in the annual health and safety inspection should be reviewed by the Health and Safety Team to ensure that it was undertaken promptly; and secondly, that appropriate performance indicators relating to health and safety inspections should be developed by management.

¶37.33 The TMO accepted that some performance indicators would be useful, including indicators relating to fire risk assessments and reviews, the service of enforcement and deficiency notices and the number of fires.⁴⁵²⁴⁵² {RBK00000313/21}.

Matt Hodgson's review

¶37.34 Following the audit in April 2013 and the finding of "limited assurance",⁴⁵³⁴⁵³ Black {Day149/135:19}-{Day149/136:13}. the TMO instructed Matt Hodgson, a health and safety professional, to complete a safety management review.

¶37.35 Mr Hodgson prepared two reports, dated 19 July 2013⁴⁵⁴⁴⁵⁴ Safety management review, July 2013 {TMO10003124}. and September 2013 respectively,⁴⁵⁵⁴⁵⁵ Safety management review, September 2013{TMO00873398} paragraph 2. both of which were marked for the attention of Robert Black. The reports set out to provide an independent assessment of the implementation of the TMO's health and safety policy and its supporting arrangements.⁴⁵⁶⁴⁵⁶ Safety management review, September 2013 {TMO00873398/4}.

¶37.36 In his first report Mr Hodgson identified 39 matters that required attention across the broad range of the TMO's health and safety responsibilities.⁴⁵⁷⁴⁵⁷ Safety management review, July 2013 {TMO10003124/9}. For example, he recommended a review of the section of the corporate policy dealing with roles and responsibilities to make sure that the management of health and safety was appropriate to the TMO. He also concluded that the designation of RBKC's chief executive as the responsible person for the purposes of the Fire Safety Order was not appropriate. He advised that someone within the TMO should be designated as the responsible person and should receive the training and resources necessary to allow the role to be performed effectively.⁴⁵⁸⁴⁵⁸ Safety management review, July 2013 {TMO10003124/34} paragraph 1.

¶37.37 More fundamentally, Mr Hodgson found that the health and safety policy did not identify the risks to which the TMO was exposed and failed to explain in sufficient detail what arrangements were necessary to satisfy, among other matters, its obligations in relation to fire safety.⁴⁵⁹⁴⁵⁹ Safety management review {TMO00873398/19} paragraph 5. He observed that many of the fire safety arrangements had been grouped together in a way that lacked the detail required to produce an effective planned preventative maintenance process.

¶37.38 Matt Hodgson's analysis echoed the criticism made by Salvus in 2009. The maintenance process remained reactive, which defeated the object of effective policy arrangements, namely, the clear definition of planned preventative maintenance arrangements that ensured compliance with the TMO's health and safety obligations.⁴⁶⁰⁴⁶⁰ Safety management review {TMO00873398/19}. Mr Hodgson therefore recommended a full review of the policy arrangements to ensure that there was a section for each property risk in order to achieve compliance.⁴⁶¹⁴⁶¹ Safety management review {TMO00873398/20} item 4. Robert Black was asked whether any new policies had been introduced or any existing policies revised following that recommendation. He could not remember.⁴⁶²⁴⁶² Black {Day149/141:13-16}.

¶37.39 Matt Hodgson also considered the position in relation to fire risk assessments.⁴⁶³⁴⁶³ Safety management review July 2013 {TMO10003124/33}. He found that the TMO's records of fire risk assessments were not up-to-date and that it was therefore not possible to see whether and, if so, to what extent the TMO had complied with its duties. It was clear, however, that there were between 900 and 1,000 outstanding matters arising from previous fire risk assessments.

¶37.40 Following receipt of the report, Robert Black prepared a report for the meeting of the TMO's board on 5 September 2013. In it he referred to Mr Hodgson's initial report and said that an action plan was being prepared for incorporation into the final report, but he did not mention any of the shortcomings identified by Mr Hodgson, not least the fact that the TMO itself and the members of the board could be exposed to liability if some of the deficiencies that had been identified were not remedied. Nor did he mention the lack of a co-ordinated approach to risk management or a lack of leadership from the executive team. In evidence, Mr Black agreed that they were all important matters for the TMO board to know.⁴⁶⁴⁴⁶⁴ Black {Day150/87:13-23}. He suggested that the reason he had not revealed those findings to the board was that at that stage the report was still in draft.⁴⁶⁵⁴⁶⁵ Black {Day150/88:24}. The fact is that the Hodgson report contained a powerful criticism of the TMO's health and safety arrangements and was all the more serious for the fact that four years had passed since the Salvus report and not all of the recommendations had been carried out. If Mr Black had disclosed those matters to the board he would no doubt have been asked some very difficult questions. We can only infer that he chose not to face up to them and hoped instead to keep Mr Hodgson's conclusions away from the board and thereby avoid embarrassment.

¶37.41 Yet again, Mr Black's decision not to inform the board about those important matters prevented it from exercising effective supervision and control over the development of adequate fire safety management policies and arrangements. That was a very serious failing on his part.

¶37.42 The result was that by the end of 2013, the TMO's executive team had received two independent reports, four years apart, on its fire safety management arrangements, each of which had made far-reaching criticisms and recommendations. Those reports went to the chief executive but not to the board. They were not acted on in any material way by the TMO, not least because Mr Black's failure to bring them to the attention of the board meant that there was no pressure on him to take action. His own failure to take responsibility for implementing the recommendations and put in place a strategy for solving the myriad of deficiencies in the management system was a further serious failing on his part. It was also a serious failing on the part of Janice Wray, who knew as much as he did and on whom he relied. Clearly neither of them regarded fire safety as a high priority, even though the TMO had gone to the trouble and expense of commissioning the reports.

Further audits

¶37.43 In December 2013, RBKC carried out a further audit of the TMO's Health and Safety department.⁴⁶⁶⁴⁶⁶ Exhibit AP/3 - RBKC, TMO Health and Safety Follow up Audit Report {RBK00000320}. The report was circulated in draft to Peter Maddison, Alex Bosman and Janice Wray before the final version was sent to Sacha Jevans and Anthony Parkes. Robert Black also received it.⁴⁶⁷⁴⁶⁷ Black {Day150/64:20}-{Day150/65:1}. The level of assurance had risen from "limited" to "satisfactory" because of the steps that the TMO said had been taken.⁴⁶⁸⁴⁶⁸ Exhibit AP/3 - RBKC, TMO Health and Safety Follow up Audit Report {RBK00000320/2}.

¶37.44 The action said to have been taken on key performance indicators is set out on page 9 of the report.⁴⁶⁹⁴⁶⁹ Exhibit AP/3 - RBKC, TMO Health and Safety Follow up Audit Report {RBK00000320/9}. Notwithstanding the clear terms of the TMO's response to the report produced in April 2013, no indicators had been prepared for fire risk assessments or reviews, the service of enforcement or deficiency notices or the number of fires. The TMO did not set up a system to monitor each indicator until January 2016.⁴⁷⁰⁴⁷⁰ Black {Day150/63:3-6}. No explanation was given for that delay.⁴⁷¹⁴⁷¹ Black {Day150/63:18}-{Day150/64:11}. The TMO did not inform RBKC of the contents of the two Hodgson reports, much less provide it with copies.

¶37.45 Another audit of the TMO's health and safety arrangements was undertaken as part of the 2015/16 audit plan. The final report, dated March 2016, was a "high level audit review". It did not identify any shortcomings in the TMO's management of fire safety. It found that appropriate procedure and guidance documents existed covering fire safety policy and had recently been revised.⁴⁷²⁴⁷² Exhibit AP/4 - RBKC, TMO Final Internal Audit Report {RBK00000531/6}. It said that fire risk assessments were carried out by a specialist consultant and were reviewed by the TMO Assistant Safety Advisor during routine inspections to ensure that any significant findings and recommendations were pursued in a timely manner and in accordance with their stated priority. Checks on the electronic database relating to ten estates had confirmed that they were up to date and that all fire equipment had been inspected within the past twelve months.⁴⁷³⁴⁷³ Exhibit AP/4 - RBKC, TMO Final Internal Audit Report {RBK00000531/6-7}.

¶37.46 That finding failed to take account of the serious backlog of remedial work required by previous fire risk assessments that existed in the months before the final audit report.⁴⁷⁴⁴⁷⁴ See for example minutes from the 11 November 2015 TMO Executive Committee meeting, item 3 "Adair Tower - Responses" {TMO00843593/2}. The TMO failed to correct the auditor's mistake in thinking that all remedial work had been carried out in a timely manner and in accordance with their stated priority. None of the witnesses from the TMO could explain that failure. As a consequence, the audit report gave the misleading impression that there were no deficiencies in the TMO's management of fire safety. Nor, once again, did the TMO take the opportunity to tell RBKC about the contents of Matt Hodgson's reports or the systemic failings in its fire safety management he had identified.