Chapter 38: Fire risk assessments

Introduction

¶38.1 Fire risk assessments lie at the heart of the arrangements by which the responsible person discharges its obligations under the Fire Safety Order. In this chapter, starting with the engagement of Salvus by the TMO in 2009, we consider how the TMO carried out fire risk assessments of the high-rise residential buildings within its housing stock, principally in relation to Grenfell Tower. In particular, we concentrate on the appointment of Carl Stokes as the TMO's preferred fire risk assessor, his qualifications and competence, the adequacy of his fire risk assessments and concerns that emerged about the quality of his work.

Fire risk assessments – background

¶38.2 Between 24 September 2009 and March 2010, Salvus carried out fire risk assessments of high-risk TMO properties for the TMO and RBKC.⁴⁷⁵⁴⁷⁵ Minutes of Fire Risk Assessments in high rise blocks meeting dated 7 September 2009 {SAL00000040/3}. The programme was a joint initiative between the RBKC and the TMO for which they had joint responsibility.⁴⁷⁶⁴⁷⁶ Wray {Day140/101:16-19}; Amanda Johnson {Day130/6:2-14}. Janice Wray took responsibility for identifying which blocks should take priority, the procurement, commissioning the fire risk assessments and ensuring that progress met the LFB's requirements.⁴⁷⁷⁴⁷⁷ Minutes of Fire Risk Assessments in high rise blocks meeting dated 7 September 2009 {SAL00000040/1}; Amanda Johnson {Day130/6:2-14}. Valerie Sharples, and for a brief period Abigail Acosta, were the TMO's project managers.⁴⁷⁸⁴⁷⁸ Minutes of Fire Risk Assessments in high rise blocks, introductory meeting between Consultant and Fire Brigade dated 16 September 2009 {TMO00842368/1}. Ann Muchmore, RBKC's performance and contracts monitoring officer, had responsibility for overseeing the contract.⁴⁷⁹⁴⁷⁹ Wray {Day140/101:20}-{Day140/102:9}.

¶38.3 At the start of the contract, Angus Sangster and Steve Reade of the LFB's Fire Safety team met Janice Wray, Adrian Bowman and Abigail Acosta and Andrew Furness and Steve Wain of Salvus.⁴⁸⁰⁴⁸⁰ Minutes of Fire Risk Assessments in high rise blocks, introductory meeting between Consultant and Fire Brigade dated 16 September 2009 {TMO00842368/1}. Angus Sangster repeated the LFB's requirements for the fire risk assessment programme, namely to have the entire property portfolio assessed within three years and to have the remedial work required for properties to be fully compliant with the Fire Safety Order completed within five years.⁴⁸¹⁴⁸¹ Minutes of Fire Risk Assessments in high rise blocks, introductory meeting between Consultant and Fire Brigade dated 16 September 2009 {TMO00842368/1}.

¶38.4 Salvus employed four fire risk assessors, including Carl Stokes.⁴⁸²⁴⁸² Minutes of Fire Risk Assessments in high rise blocks meeting dated 7 September 2009 {SAL00000040/1}. Carl Stokes started working for Salvus on 24 September 2009 on a six-month contract as a sub-contractor.⁴⁸³⁴⁸³ Stokes {Day136/6:5-8}; {Day136/7:19-21}; {Day136/58:6-18}.

Carl Stokes

¶38.5 Before he started working for Salvus, Carl Stokes had been an operational firefighter.⁴⁸⁴⁴⁸⁴ Stokes {CST00003063/4} page 4, paragraph 7. In 1986, he joined the Royal Berkshire Fire and Rescue Service.⁴⁸⁵⁴⁸⁵ Stokes {CST00003063/4} page 4, paragraph 7. During that time, he was seconded to the Fire Safety department and carried out familiarisation visits to high-rise buildings.⁴⁸⁶⁴⁸⁶ Stokes {CST00003063/5} page 5, paragraph 8; Stokes {Day136/4:22}-{Day136/5:5}. In 1994, Mr Stokes transferred to the Oxfordshire Fire and Rescue Service where he spent most of his time in the Fire Safety department.⁴⁸⁷⁴⁸⁷ Stokes {CST00003063/5} page 5, paragraph 9. Following the introduction of the Fire Safety Order, he received training on it and spent a significant amount of time auditing the findings made by fire risk assessors on behalf of responsible persons pursuant to the Fire Safety Order.⁴⁸⁸⁴⁸⁸ Stokes {CST00003063/5} page 5, paragraph 10; Stokes {Day136/10:14-17}. However, none of these included residential blocks of flats over 18 metres in height.⁴⁸⁹⁴⁸⁹ Stokes {Day136/15:24}-{Day136/16:9}.

¶38.6 On 12 December 2007, Mr Stokes was awarded a Fire Risk Assessment Certificate by the Northern Ireland Fire Safety Panel, which enabled him to carry out fire risk assessments.⁴⁹⁰⁴⁹⁰ Stokes {CST00003063/5} page 5, paragraph 11; {TMO00880581/12}. He set up C S Stokes and Associates Ltd in February 2009 and retired from the Oxfordshire Fire and Rescue Service in September 2009.⁴⁹¹⁴⁹¹ Stokes {CST00003063/6} page 6, paragraph 13. Carl Stokes was the sole director of C S Stokes and Associates Ltd and employed no-one else. He was therefore always a "one man band".⁴⁹²⁴⁹² Stokes {CST00003063/1} page 1, paragraph 1; Stokes {Day136/5:20}-{Day136/6:3}. When he started working for Salvus, he had no experience of carrying out fire risk assessments on highrise residential blocks of flats.⁴⁹³⁴⁹³ Stokes {Day136/19:7-13}. He had less than two years' experience as a certified fire risk assessor.⁴⁹⁴⁴⁹⁴ Stokes {Day136/19:25}-{Day136/20:7}.

Salvus's fire risk assessment programme

¶38.7 Salvus operated a quality control process under which all fire risk assessments were reviewed and discussed by email, when required, before being approved by the managing director, Andrew Furness.⁴⁹⁵⁴⁹⁵ 'Background re Carl Stokes employment with Salvus Consulting Limited' dated August 2019 {SAL00000002}. Mr Furness attended sites periodically to ensure consistency of assessments.⁴⁹⁶⁴⁹⁶ Minutes of Fire Risk Assessments in high rise blocks meeting dated 7 September 2009 {SAL00000040/1}. Steve Wain oversaw the team of fire risk assessors.⁴⁹⁷⁴⁹⁷ Minutes of Fire Risk Assessments in high rise blocks meeting dated 7 September 2009 {SAL00000040/1}.

¶38.8 In the case of the TMO, Andrew Furness held regular monthly meetings with Valerie Sharples and Janice Wray.⁴⁹⁸⁴⁹⁸ Minutes of Fire Risk Assessments in high rise blocks meeting dated 7 September 2009 {SAL00000040/3}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 16 September 2009 {TMO00842368/1}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 19 October 2009 {SAL00000044}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 23 November 2009 {SAL00000043}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 26 January 2010 {RBK00052572}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 23 February 2010 {SAL00000042}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 1 April 2010 {SAL00000041}.Show full note Ann Muchmore of RBKC and officers of the LFB Fire Safety Team often attended those meetings.⁴⁹⁹⁴⁹⁹ Minutes of Fire Risk Assessments in high rise blocks meeting dated 19 October 2009 {SAL00000044/1}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 23 November 2009 {SAL00000043/1}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 26 January 2010 {RBK00052572/1}; Minutes of Fire Risk Assessments in high rise blocks meeting dated 1 April 2010 {SAL00000041/1}.

¶38.9 Over the course of the six months between September 2009 and March 2010 the team at Salvus carried out fire risk assessments in relation to about 110 high-risk properties managed by the TMO, including Grenfell Tower.⁵⁰⁰⁵⁰⁰ Minutes of Fire Risk Assessments in high rise blocks meeting dated 16 September 2009 {TMO00842368/1}; Wray {TMO00842341/2} page 2, paragraph 9; {TMO00842374}; Minutes of the meeting between LFB, RBKC and TMO dated 20 April 2010 {TMO00873670/1}. Carl Stokes believed he had carried out between 20 and 30 of those assessments.⁵⁰¹⁵⁰¹ Stokes {Day136/61:17-25}.

¶38.10 The fire risk assessment in relation to Grenfell Tower was completed on 30 September 2009 by Carl Stokes under the supervision of Andrew Furness.⁵⁰²⁵⁰² Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128}; Stokes {Day136/70:2-16}. It identified the chief executive of RBKC and the TMO⁵⁰³⁵⁰³ Under General Information the Chief Executive of the Royal Borough of Kensington and Chelsea is listed as a Responsible Person. The Tenant Management Organisation Warden is listed as a Responsible Person/contact on site: Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/5}. as the responsible persons for the purposes of the Fire Safety Order, which reflected Carl Stokes's view⁵⁰⁴⁵⁰⁴ Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/5}; Stokes {Day136/69:7-10}. and presumably also that of Salvus. Janice Wray was consulted during the assessment.⁵⁰⁵⁵⁰⁵ Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/5}. The fire risk assessment was subject to a quality control process and was reviewed by Andrew Furness on at least two occasions.⁵⁰⁶⁵⁰⁶ Stokes {Day136/70:2-16}. It rated the overall risk for the building as "normal", but identified 51 defects requiring remedial measures to reduce the risk.⁵⁰⁷⁵⁰⁷ Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/6}; Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/15-19}. Of those 51 defects, 19 were categorised as involving statutory breaches and were marked in red. Each defect was given a "priority rating" which identified the length of time within which it was recommended that action be taken to remedy it.⁵⁰⁸⁵⁰⁸ Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/15-19}. Some of the measures required to remedy red defects, such as reviewing the evacuation procedure and confirming the policy and procedures for the operation of the smoke ventilation system, required action to be taken within one week.⁵⁰⁹⁵⁰⁹ Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/16-19}. Other defects requiring remedial measures marked in red required the TMO to take action within three months or to agree a plan within six months.⁵¹⁰⁵¹⁰ Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/19}. They included recommending that the TMO introduce and implement a system of formal checks on flat front doors to ensure that compartmentation remained fit for purpose.⁵¹¹⁵¹¹ Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/16}. The assessment also recommended that the TMO engage competent engineers to test the smoke ventilation system and the lifts, if testing was not being carried out in accordance with current industry best practice.⁵¹²⁵¹² Fire Risk Assessment of Grenfell Tower dated 30 September 2009 {CST00003128/18-19}.

¶38.11 The programme ended in March 2010.⁵¹³⁵¹³ Wray {TMO00842341/2} page 2, paragraph 10; Minutes of Fire Risk Assessments in high rise blocks meeting dated 1 April 2010 {SAL00000041/1}. In February 2010, Janice Wray and Ann Muchmore evaluated the performance of Salvus in accordance with a commitment they had made to the LFB.⁵¹⁴⁵¹⁴ Wray {TMO00000890/30} page 30, paragraph 135; Wray {Day140/172:7}-{Day140/173:14}. Although, as she explained to us, they were not unhappy with Salvus's work, on 11 February 2010 Janice Wray told Ann Muchmore that she had some concerns that Salvus were "very rule-bound" and that they had shown some reluctance to challenge the LFB on behalf of the TMO.⁵¹⁵⁵¹⁵ {RBK00053588/3}. She noted that Salvus was not as robust as she had hoped and that Carl Stokes, who had done most of the inspections as a sub-contractor, might be willing to tender for the work in future.⁵¹⁶⁵¹⁶ {RBK00053588/1}. Janice Wray felt that Salvus had not given her a clear indication on fire safety issues raised by the LFB and she wanted to know whether the course of action suggested by the LFB was required before she committed the budget.⁵¹⁷⁵¹⁷ Wray {Day140/175:24}-{Day140/177:5}. They decided to invite tenders for carrying out fire risk assessments in relation to the medium – and low-risk phases of the programme.⁵¹⁸⁵¹⁸ Wray {TMO00000890/30} page 30, paragraph 135; Wray {Day140/174:1-5}.

¶38.12 Janice Wray's message reveals that the TMO wanted a fire risk assessor that would take its side against the LFB when debating its fire safety requirements instead of taking them entirely at face value. Given that the LFB was the enforcing authority under the Fire Safety Order, that was a mistake. It also explains why Carl Stokes, who was ill-qualified to carry out fire risk assessments of buildings on this scale, let alone to hold the entire TMO portfolio, was selected by the TMO as the sole fire risk assessor and allowed to retain that role for the best part of seven years.

Appointment of fire risk assessor for medium- and low-risk properties

¶38.13 Once the fire risk assessment programme for high-risk buildings had been completed, on 18 October 2010 the TMO started a six-month fire risk assessment programme of its medium risk properties.⁵¹⁹⁵¹⁹ {TMO00842327}; {CST00030040}. The fire risk assessment programme for the low-risk properties started later, on 17 August 2011.⁵²⁰⁵²⁰ {CST00030041}. Carl Stokes was appointed as the sole fire risk assessor for both programmes.⁵²¹⁵²¹ {CST00030041}; {CST00030040}; Wray {TMO00842341/3-4} pages 3-4, paragraphs 12-14. He began the reviews of the fire risk assessments for the high-risk properties in about December 2010.⁵²²⁵²² Stokes {CST00003063/9-10} pages 9-10, paragraphs 25 and 26; Stokes {Day136/89:7-15}; Wray {Day140/216:14-20}; {CST00001926}. Once the medium- and low-risk programmes had been completed, Carl Stokes was retained as the TMO's sole fire risk assessor indefinitely until his contract was terminated in about November 2017.⁵²³⁵²³ Wray {TMO00842341/4} page 4, paragraph 15; Stokes {Day136/89:3-6}; {Day136/8:14-17}.

¶38.14 RBKC and TMO made a commitment to the LFB to evaluate the performance of the fire risk assessor at the end of the medium- and low-risk programmes, resources permitting, and to appoint a competent fire risk assessor to complete the assessments.⁵²⁴⁵²⁴ {LFB00031977/30-31}. The TMO, with the agreement of RBKC, conducted a procurement process for a fire risk assessor for the medium-risk properties in 2010.⁵²⁵⁵²⁵ {TMO00842327}; Stokes {Day136/88:10-18}. It did not carry out a further procurement exercise for the review of the assessments relating to the high-risk properties or for the programme relating to the low-risk properties.⁵²⁶⁵²⁶ Wray {Day144/220:12-15}; Stokes {CST00003063/9-10} pages 9-10, paragraphs 25 and 26; Stokes {Day136/89:7-15}; Wray {Day140/216:14-20}.

¶38.15 The procurement process that was carried out in 2010 and the decision to appoint Carl Stokes bears further examination.

The decision to appoint Carl Stokes

¶38.16 On 11 February 2010, Janice Wray sought funding and approval from Ann Muchmore to invite tenders for carrying out fire risk assessments in relation to the medium-risk properties.⁵²⁷⁵²⁷ {RBK00053588/3}. In May 2010, the TMO Operations Committee was told that it had been agreed between the TMO and RBKC that a new fire risk assessor should be appointed for the medium-risk programme by July 2010.⁵²⁸⁵²⁸ {TMO10037422/2}.

¶38.17 On or around 6 August 2010, C S Stokes and Associates Ltd, Salvus, and three other companies were invited to tender for the medium-risk programme.⁵²⁹⁵²⁹ Wray {TMO00842341/2-3} pages 2-3, paragraphs 10 and 11. The invitation included a consultants' brief, which set out the proposed terms of the contract.⁵³⁰⁵³⁰ Wray {TMO00842341/2-3} pages 2-3, paragraph 10; {TMO00842371}. It provided at paragraph 1.10 that the consultant's appointment would be for a one year period with an option for the TMO to extend for a further year, subject to the consultant's satisfactory performance.⁵³¹⁵³¹ {TMO00842371/3}.

¶38.18 There was evidence to suggest that, even before the tender process had begun, Carl Stokes was undertaking fire risk assessments for the TMO. Invoices show that he had been carrying out fire risk assessments of areas of the TMO's offices from as early as 22 June 2010 and 2 July 2010.⁵³²⁵³² {CST00030111}; {CST00030077}. There was no evidence to show that he had formally applied for that work or had taken part in any formal procurement process. Janice Wray could not explain why he had been conducting fire risk assessments for buildings in the TMO stock before the procurement process had started.⁵³³⁵³³ Wray {Day141/15:19}-{Day141/17:8}. She was adamant that she had not already decided to appoint him as the fire risk assessor⁵³⁴⁵³⁴ Wray {Day141/17:9-21}. and that it was to be a joint decision with RBKC.⁵³⁵⁵³⁵ Wray {Day141/17:9-21}. That may be so, but the episode does suggest that in some way Carl Stokes had an advantage in the procurement process.

¶38.19 On 22 June 2010, Carl Stokes met Janice Wray.⁵³⁶⁵³⁶ {CST00001887}. He sent her a letter the following day setting out the matters they had discussed, including employee fire training, personal emergency evacuation plans (PEEPs) and the lift maintenance policy for buildings over 18 metres in height.⁵³⁷⁵³⁷ {CST00001887}. When he gave evidence he said that they had discussed the nature of the information that he would include in his fire risk assessments and their discussions were reflected in the assessments he subsequently produced.⁵³⁸⁵³⁸ Stokes {Day136/118:3-17}; {Day136/122:7-11}; Fire Risk Assessment for Grenfell Tower dated 29 December 2010 {CST00003181}. Carl Stokes could not explain the reason for that meeting.⁵³⁹⁵³⁹ Stokes {Day136/119:12-15}. Janice Wray suggested that he had only been seeking more information about the organisation and its policies and procedures.⁵⁴⁰⁵⁴⁰ Wray {Day141/9:16}-{Day141/10:5}. She thought he had been trying to create a good impression.⁵⁴¹⁵⁴¹ Wray {Day141/9:16}-{Day141/10:5}. Ms Wray did not meet any of the other applicants, nor did she tell any of them that she had provided Carl Stokes with the information set out in the letter.⁵⁴²⁵⁴² Wray {Day141/10:6-18}.

¶38.20 On the face of it, it appears that Carl Stokes was the favoured applicant because he had already carried out work for the TMO under its contract with Salvus and had continued to carry out work for it.

¶38.21 Carl Stokes submitted his tender on 24 August 2010.⁵⁴³⁵⁴³ {CST00002368}. Thereafter, interviews were held with a panel of two officers of the TMO, Janice Wray and either Janet Rhymes or Valerie Sharples, and one officer of RBKC.⁵⁴⁴⁵⁴⁴ {TMO00842327/1}; Wray {Day140/189:5-22}; Carl Stokes's interview was held on 6 September 2010 {CST00003159}.

¶38.22 Clause 1.5 of the consultants' brief required the consultant to hold a current fire risk assessment qualification.⁵⁴⁵⁵⁴⁵ {TMO00842371/3} paragraph 1.5. Carl Stokes held a qualification from the Northern Ireland Fire Safety Panel, having gained a Fire Risk Assessment certificate on 12 December 2007.⁵⁴⁶⁵⁴⁶ Stokes {CST00003063/5} page 5, paragraph 11; {TMO00880581/12}. The consultants' brief also required applicants to submit documentary evidence of their competence to undertake the appointment, in particular, their experience in assessing residential blocks.⁵⁴⁷⁵⁴⁷ {TMO00842371/3} paragraph 1.4. Carl Stokes submitted a pack of certifications but he did not provide any other details of his qualifications and experience.⁵⁴⁸⁵⁴⁸ Stokes {Day 136/72:21}-{Day136/73:14}; {TMO00880581}. The only document that demonstrated his qualifications and experience was a statement in a pro forma fire risk assessment he submitted⁵⁴⁹⁵⁴⁹ Stokes {Day136/73:18}-{Day136/74:21}; Stokes {CST00003063/17} page 17, paragraph 50; {CST00003071}. that read as follows:

¶"Assessment completed by:

Mr C Stokes, ACIArb, FPA Dip FP (Europe), Fire Eng (FPA), NEBOSH, FIA BS 5839 System Designer, Competent Engineer BS 5266, IFE Assessor/Auditor (FSO). 19 years Fire Safety experience with local Fire Authority, in enforcement and auditing roles, 3 years as an independent fire risk assessor. Member of the construction industry CPD certification Service. Professional Indemnity insurance cover provided by Hiscox. Enhanced C R B checked."

¶38.23 Mr Stokes accepted in evidence that he had included that statement to lead the reader to think that he possessed the formal qualifications and professional body memberships set out in it.⁵⁵⁰⁵⁵⁰ Stokes {Day136/75:5-21}. The purpose of including it was to advance his application to become the TMO's fire risk assessor.⁵⁵¹⁵⁵¹ Stokes {Day136/74:17-21}.

¶38.24 The statement was false in a number of respects. All but one of the qualifications referred to either did not exist or were irrelevant or meaningless.⁵⁵²⁵⁵² Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/55-58} paragraphs 6.45 and 6.46. The only one that was valid and correctly stated was "ACIArb", indicating he was an associate of the Chartered Institute of Arbitrators, which had no bearing on fire safety.⁵⁵³⁵⁵³ Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/55-56} paragraph 6.46. Carl Stokes also claimed to hold an "FPA Dip FP (Europe)", which, although incorrect in abbreviation,⁵⁵⁴⁵⁵⁴ The correct abbreviation is "CFPA(EU) Dip". was intended to convey that he had completed the Diploma in Fire Prevention awarded by the Confederation of Fire Protection Association, as indeed he had.⁵⁵⁵⁵⁵⁵ Todd {Day167/66:24}-{Day167/67:7}; Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/51} paragraph 6.16; {CTA00000011/56} paragraph 6.46. Carl Stokes was neither registered nor certificated by any professional or certification body as competent to carry out fire risk assessments.⁵⁵⁶⁵⁵⁶ {CTA00000011/58} paragraph 6.47. He suggested that the post-nominals were meant to evidence qualifications, training and experience required by the Fire Safety Order,⁵⁵⁷⁵⁵⁷ Stokes {Day136/77:11-15}. but the fire safety training he had completed did not entitle him to invent qualifications and use them as he did in that statement.⁵⁵⁸⁵⁵⁸ Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/55-58} paragraph 6.46. Mr Stokes accepted that he had known at the time that the statement was thoroughly misleading.⁵⁵⁹⁵⁵⁹ Stokes {Day136/81:24}-{Day136/82:6}.

¶38.25 His claim that at the time he had carried out the fire risk assessment on 21 August 2010 he had been an independent fire risk assessor for three years was also false. In fact, he had begun work as an independent fire risk assessor only 11 months earlier on 24 September 2009.⁵⁶⁰⁵⁶⁰ Stokes {Day136/83:9}-{Day136/84:12}. He accepted that the statement about the extent of his experience had been misleading.⁵⁶¹⁵⁶¹ Stokes {Day136/84:13-15}.

¶38.26 Each of the fire risk assessments produced by Carl Stokes stated that he was "a member of the construction industry CPD certification service", which, he explained, meant that he had attended "formal CPD designated training 2 or 3 times a year", usually lasting for one day.⁵⁶²⁵⁶² Stokes {CST00030186/7} page 7, paragraph 25(iii). As Mr Stokes was not registered or accredited by any professional body, he was under no requirement to undergo continuing professional development, but both Dr Lane and Mr Todd considered that even an unregistered fire risk assessor would be expected to undergo a certain amount of regular training.⁵⁶³⁵⁶³ Lane {Day171/27:20}-{Day171/28:9}; Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/46} paragraph 5.37. Mr Todd considered it necessary in order to keep up with new developments and to ensure that competence was maintained.⁵⁶⁴⁵⁶⁴ {CTA00000011/46} paragraph 5.37. As Dr Lane observed, some regular training is necessary to ensure that a fire risk assessor has sufficient skill and knowledge to do his job.⁵⁶⁵⁵⁶⁵ Lane {Day171/27:20}-{Day171/28:9}.

¶38.27 There was evidence that Mr Stokes did undertake a mixture of formal and informal training which complemented his practice as a fire risk assessor, such as attending training days and lectures held by fire industry bodies, such as the Fire Industry Association.⁵⁶⁶⁵⁶⁶ Stokes {CST00030186/7-8} pages 7-8, paragraphs 25-27; Stokes {CST00030186/45-49} pages 45-49, Appendix 1. He did not keep a training log or any other written record of the training he had undertaken and was not required to do so.⁵⁶⁷⁵⁶⁷ Stokes {CST00030186/8} page 8, paragraph 26. We saw no evidence that Carl Stokes consistently undertook any formal training on an annual basis during the years he was employed as the TMO's fire risk assessor and we conclude that he did not.⁵⁶⁸⁵⁶⁸ Stokes {CST00030186/7-8} pages 7-8, paragraphs 25-27; Stokes {CST00030186/45-49} pages 45-49; {CST00030191}.

¶38.28 Janice Wray knew that Carl Stokes had elected not to join any professional bodies.⁵⁶⁹⁵⁶⁹ Wray {TMO00000890/31} page 31, paragraph 139; Wray {Day140/197:17-19}. When she raised it with him, he told her that he did not feel that he would gain anything from such memberships.⁵⁷⁰⁵⁷⁰ Wray {TMO00000890/31} page 31, paragraph 139. On 1 February 2013, the Fire Risk Assessment Competency Council published A Guide to Choosing a Competent Fire Risk Assessor (the FRACC Guide) which recommended using fire risk assessment companies, including sole traders, who were "third party certificated to appropriate schemes operated by Certification Bodies which have been UKAS accredited to certificate against such schemes."⁵⁷¹⁵⁷¹ {HOM00025548/4}. but it could not make registration or certification mandatory. The FRACC Guide listed the holders of registers, such as the British Standards Institution, the Institute of Fire Prevention Officers (IFPO), the Institute of Fire Safety Managers, the Institution of Fire Engineers and Warrington Certificated Ltd.⁵⁷²⁵⁷² {HOM00025548/5}. Carl Stokes was never registered with or certificated by any of those bodies. Janice Wray was aware of the FRACC Guide and was aware that Mr Stokes had chosen not to join any professional register,⁵⁷³⁵⁷³ Wray {TMO00000890/31} page 31, paragraph 139; Wray {Day140/197:17-19}. but she was not concerned.⁵⁷⁴⁵⁷⁴ Wray {Day140/199:7-14}. She thought that, as he had already demonstrated his competence in the work he had done for the TMO, the FRACC Guide did not demand that he be certificated.⁵⁷⁵⁵⁷⁵ Wray {Day140/200:2-15}. However, she thought it would apply to the appointment of any future fire risk assessor.⁵⁷⁶⁵⁷⁶ Wray {Day140/197:22}-{Day140/200:16}.

¶38.29 Ms Wray said that she did not think that the interviewing panel (of which she had been a member) had considered Carl Stokes's statements about his qualifications, but she thought they might have looked at a copy of his curriculum vitae,⁵⁷⁷⁵⁷⁷ Wray {Day140/190:17}-{Day140/193:22}; {CST00001895}. in which he had claimed to be a fire risk auditor and assessor accredited by the Institute of Fire Engineers, even though he had not been a member of the institute.⁵⁷⁸⁵⁷⁸ {CST00001895}; Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/57} paragraph 6.46. She knew at the time that Carl Stokes used post-nominals to describe his qualifications, even though they were not genuine, but she was surprised to be told that some of the qualifications which he claimed to hold did not exist.⁵⁷⁹⁵⁷⁹ Wray {Day140/196:3-9}. His deliberately misleading description of his experience and qualifications demonstrate a lack of integrity and reliability on Mr Stokes's part, but it is the failure of the TMO and RBKC to pay any serious attention to his supposed qualifications that represent the more serious failing, since it betrays a fundamental carelessness about fire safety matters in the housing stock for which they were responsible.

¶38.30 When the TMO evaluated the competing tenders Carl Stokes's was rated first for quality; he also submitted the lowest price for a six-month programme.⁵⁸⁰⁵⁸⁰ {TMO00842327/2}. Overall his tender was just over £2,000 cheaper than that of his nearest competitor.⁵⁸¹⁵⁸¹ {TMO00842327/3}. He was thought to have the knowledge, competence, experience and enthusiasm to be a good partner.⁵⁸²⁵⁸² Wray {TMO00000890/31} page 31, paragraph 137. The fact that he was already known to the TMO because of his work with Salvus also weighed in his favour.⁵⁸³⁵⁸³ Wray {TMO00000890/31} page 31, paragraph 137.

¶38.31 The consultants' brief required applicants to demonstrate that they were able to satisfy the provisions of a quality management system in accordance with BS EN ISO 9001,⁵⁸⁴⁵⁸⁴ {TMO00842371/5} paragraph 3.2. but Carl Stokes was not required to satisfy that provision.⁵⁸⁵⁵⁸⁵ Stokes {Day136/86:2-21}. He ought to have been. He was to all intents and purposes a sole trader who had no quality management system or arrangements in place for peer reviewing his work.⁵⁸⁶⁵⁸⁶ Stokes {Day136/86:2-21}; {Day136/61:9-16}. Janice Wray was not concerned about that or about the fact that his work for the TMO would not be supervised.⁵⁸⁷⁵⁸⁷ Wray {Day140/201:10-13}. She said that the LFB had still been heavily involved in scrutinising the TMO's fire risk assessments and that she had expected it to raise any problems quickly.⁵⁸⁸⁵⁸⁸ Wray {Day140/203:11-23}. Moreover, she claimed to have challenged Mr Stokes's fire risk assessments when she did not agree with them,⁵⁸⁹⁵⁸⁹ Wray {Day140/203:11-23}. but that is of little significance, since she had no relevant expertise and was certainly not independent. In the end she was reassured by the fact that he had been recruited by Salvus and that he had been one of the principal assessors it had used to produce fire risk assessments on its high-risk buildings.⁵⁹⁰⁵⁹⁰ Wray {Day140/201:10-25}. She knew that he was familiar with many of the TMO's buildings. She said he appeared to be extremely knowledgeable and she understood that everything he had done appeared to meet the requirements of the LFB.⁵⁹¹⁵⁹¹ Wray {Day140/202:12-15}; {Day140/202:20-25}.

¶38.32 Ms Wray's approach was not in itself contrary to the Fire Safety Order, given that there is no requirement under article 9 for the responsible person to commission an independent fire risk assessment, nor for the person carrying out a fire risk assessment to be qualified or competent,⁵⁹²⁵⁹² See Chapter 12 for the examination of the role of government in regulating standards of competence in this area. but it did create a risk that the resulting fire risk assessment would not meet the statutory requirement of being suitable and sufficient. No good reason was given to justify the failure of the TMO and RBKC to require Mr Stokes to show that he could satisfy the provisions of an appropriate quality management system in accordance with the consultants' brief.

¶38.33 By the end of September 2010, Amanda Johnson had approved the appointment and confirmed the funding of the medium-risk programme.⁵⁹³⁵⁹³ {TMO00842327/2}. On 28 October 2010, Robert Black approved the appointment,⁵⁹⁴⁵⁹⁴ {TMO00842327/2}. although Carl Stokes had signed the contract seven days earlier.⁵⁹⁵⁵⁹⁵ {CST00030040}. Laura Johnson was aware that the TMO obtained fire risk assessments because it was required to do so,⁵⁹⁶⁵⁹⁶ Laura Johnson {Day129/79:16-19}. but neither she nor anyone else in the RBKC Housing department received copies of them.⁵⁹⁷⁵⁹⁷ Laura Johnson {Day129/70:16-22}. Indeed, no one in the Housing department had the experience needed to analyse them or to challenge the TMO on their contents.⁵⁹⁸⁵⁹⁸ Laura Johnson {Day129/71:4-15}.

¶38.34 On 25 November 2010, Janice Wray reported to the Operations Committee the completion of the high-risk programme and the appointment of Carl Stokes as fire risk assessor for the TMO's medium risk properties.⁵⁹⁹⁵⁹⁹ Minutes of TMO Operations Committee meeting dated 25 November 2010 {RBK00052563/8}. She explained that he was willing to challenge the LFB if he considered its requirements to go beyond what it could reasonably require.⁶⁰⁰⁶⁰⁰ Minutes of TMO Operations Committee meeting dated 25 November 2010 {RBK00052563/8}. Clearly, Mr Stokes's willingness to be an advocate for the TMO in disagreements with the LFB was a material factor in the decision to appoint him.

The expansion of Carl Stokes's retainer in December 2010

¶38.35 From December 2010 onwards, Carl Stokes carried out fire risk assessments for the TMO on its high-risk buildings.⁶⁰¹⁶⁰¹ Stokes {CST00003063/9-10} pages 9-10, paragraphs 25 and 26; Stokes {Day136/89:7-15}; Wray {Day140/216:14-20}; {CST00001926}. The TMO did not invite tenders for that work.⁶⁰²⁶⁰² Wray {Day140/216:14-16}. Janice Wray believed she had taken advice from colleagues dealing with procurement, her line manager (Lornette Pemberton) and possibly RBKC before appointing Carl Stokes to review the fire risk assessments carried out the year before on high-risk buildings, but we have seen no evidence to support that.⁶⁰³⁶⁰³ Wray {Day140/215:7-15}; {Day140/216:14-20}; {Day140/217:15}-{Day140/218:14}. It had not originally been intended to appoint Carl Stokes to carry out that work⁶⁰⁴⁶⁰⁴ Wray {Day140/218:15-20}. but the need to review the assessments of the high-risk properties and the pressure of time led to a decision not to invite fresh tenders.⁶⁰⁵⁶⁰⁵ Wray {Day140/216:21}-{Day140/217:15}. Neither the TMO nor RBKC had established a programme for the regular review of the fire risk assessments on high-risk buildings at the conclusion of the first programme in March 2010. As a result, the need for the reviews had been overlooked and there was no proper recruitment or selection process.⁶⁰⁶⁶⁰⁶ Wray {Day140/217:8-18}. No written contract was entered into with Carl Stokes, who took over the work on an informal basis.⁶⁰⁷⁶⁰⁷ Wray {Day140/219:7-10}; Stokes {CST00003063/10} page 10, paragraph 26. Janice Wray could not recall whether the appointment had been approved by the TMO executive team or RBKC or how the funding for it had been obtained.⁶⁰⁸⁶⁰⁸ Wray {Day140/218:21}-{Day140/219:5}. The TMO simply drifted unthinkingly into a broader retainer of Carl Stokes without any formalities.

¶38.36 When the programme of fire risk assessments on medium-risk buildings had been completed, the low-risk programme began. Carl Stokes was appointed to carry it out.⁶⁰⁹⁶⁰⁹ {TMO00842318}. Sacha Jevans approved his appointment⁶¹⁰⁶¹⁰ Wray {TMO00842341/3} page 3, paragraph 14; {TMO00842378}. and Mr Stokes signed the contract on 24 August 2011.⁶¹¹⁶¹¹ {CST00030041}. The programme was completed in May 2012, well before the LFB's deadline of July 2012.⁶¹²⁶¹² {TMO10031056/2} paragraph 3.2.

¶38.37 Once the programmes covering the medium and low-risk buildings had been completed, the TMO continued to retain Carl Stokes as its fire risk assessor but did not enter into any new contracts with him.⁶¹³⁶¹³ Stokes {CST00003063/10} page 10, paragraph 26. He became responsible for carrying out fire risk assessments on all 650 properties managed by the TMO.⁶¹⁴⁶¹⁴ Wray {Day140/207:20}-{Day140/208:8}. He did not work exclusively for the TMO but it was his biggest client, having more buildings under its management than any other.⁶¹⁵⁶¹⁵ Stokes {Day136/9:8-9}. Robert Black was aware that Carl Stokes had been retained but he did not know that his continued appointment had not been subject to a further procurement process.⁶¹⁶⁶¹⁶ Black {Day150/17:2-17}. He had assumed that a formal procurement process of some kind had taken place and accepted that the failure to keep him informed pointed to a defect in the reporting processes and governance of the TMO.⁶¹⁷⁶¹⁷ Black {Day150/18:3-16}.

¶38.38 Carl Stokes was allowed, therefore, to drift into his role as the sole fire risk assessor for 650 properties, many of which were high-rise buildings, without any regard to formal selection or contracting processes. That was not a proper or safe way for either the TMO or RBKC to seek to discharge their duties under the Fire Safety Order and it created a risk that the standard of the fire risk assessments produced as a result might not meet the statutory requirement.

Carl Stokes's work as the TMO's fire risk assessor

¶38.39 Part 2 of the consultants' brief set out the scope of the work in relation to fire risk assessments that Carl Stokes had undertaken to carry out. Paragraph 1.1 of Part 2 required fire risk assessments to be undertaken and reviewed as regularly as the degree of risk dictated. It also required fire risk assessments to include an examination of each communal fire door.⁶¹⁸⁶¹⁸ {TMO00842371/6} paragraph 1.1.

¶38.40 Paragraph 1.3 of Part 2 of the brief instructed the fire risk assessor to focus on a building's compartmentation (and any possible shortcomings), the operation and adequacy of fire doors, firefighting equipment and automatic detection and other systems, the means of escape, fire safety management systems and the overall fitness for purpose of the building in relation to fire safety.⁶¹⁹⁶¹⁹ {TMO00842371/6} paragraph 1.3.

¶38.41 Janice Wray and Carl Stokes operated on the understanding that his work was always governed by the terms of the original contract, including the consultant's brief, even after his formal contracts for the programmes of fire risk assessments in relation to medium and low-risk buildings had come to an end.⁶²⁰⁶²⁰ Stokes {CST00003063/10} page 10, paragraph 26; Stokes {Day136/89:25}-{Day136/90:8}; Wray {Day140/220:1-25}.

¶38.42 The LGA Guide described four kinds of fire risk assessment: Type 1 – Common parts only (non-destructive); Type 2 – Common parts only (destructive); Type 3 – Common parts and flats (non-destructive); and Type 4 – Common parts and flats (destructive).⁶²¹⁶²¹ {HOM00045964/44-46} paragraph 35.1. Mr Stokes told us that he had carried out 'Type 1' assessments with elements of 'Type 3'.⁶²²⁶²² Stokes {CST00003063/16} page 16, paragraph 47. (He had carried out that hybrid type of fire risk assessment before the LGA Guide was published in July 2011.)⁶²³⁶²³ Stokes {CST00003063/16} page 16, paragraph 47. The LGA Guide stated that unless there was reason to expect serious deficiencies in structural fire protection, such as inadequate compartmentation, or poor fire stopping, a Type 1 inspection would normally be sufficient for most purpose-built blocks of flats.⁶²⁴⁶²⁴ {HOM00045964/45} paragraph 35.1.

¶38.43 On one reading of the Fire Safety Order, Carl Stokes was required to consider only the common parts of the building when carrying out a fire risk assessment.⁶²⁵⁶²⁵ Stokes {CST00003063/13} page 13 paragraph 36; Wray {TMO00000890/31} page 31, paragraph 140. In the case of purpose-built blocks of flats, like Grenfell Tower, that meant inspecting the lift-lobby areas of each floor, the refuse chute rooms, the staircase enclosure and both sides of the entrance doors to the flats, but not the interiors of individual flats.⁶²⁶⁶²⁶ Stokes {CST00003063/15-16} pages 15-16, paragraphs 43 and 44; {HOM00045964/44} paragraph 34.1; Stokes {Day136/94:2-18}. It was his practice also to report any problems with access to properties.⁶²⁷⁶²⁷ Wray {Day140/236:20-25}. He was not expressly instructed to consider the external walls of the properties he inspected⁶²⁸⁶²⁸ Wray {Day141/1:18-22}. and there was nothing in the LGA Guide to suggest that he should do so, unless there was reason to think that they might affect the compartmentation of the building.

¶38.44 Carl Stokes's practice in relation to Grenfell Tower was to carry out a primarily visual inspection. He also carried out some additional inspection of the inside of front doors where he could gain access.⁶²⁹⁶²⁹ Stokes {CST00003063/16} page 16, paragraph 48. In those circumstances, he checked the self-closer and whether a domestic fire alarm system was fitted.⁶³⁰⁶³⁰ Stokes {CST00003063/16} page 16, paragraph 48. In 2015, he was also asked to check the heat interface units.⁶³¹⁶³¹ Stokes {CST00003063/16} page 16, paragraph 48.

¶38.45 Mr Stokes agreed that for the purposes of making a Type 1 fire risk assessment he had to gain access to some flats in order to inspect the entirety of the entrance door, including the strips and smoke seals and self-closing device, if fitted.⁶³²⁶³² Stokes {Day136/94:2-25}.

¶38.46 PAS 79:2012, published by the British Standards Institution, contained the standards for carrying out fire risk assessments as they existed at the time of the Grenfell Tower fire. Paragraph (i) of the commentary on clause 16 says that fire safety management should be regarded as of equal importance to fire protection measures.⁶³³⁶³³ {CTA00000003/50} clause 16, commentary, paragraph (i). Clause 16 of PAS 79 required that, among other matters, any shortcomings in evacuation procedures should be identified.⁶³⁴⁶³⁴ {CTA00000003/54} clause 16.3. Carl Stokes was familiar with those provisions.

¶38.47 Mr Stokes assessed the TMO's fire safety management systems as part of his fire risk assessments on a continuing basis and expected Janice Wray to tell him if the TMO had changed its policies or procedures.⁶³⁵⁶³⁵ Stokes {Day136/164:3-15}. He was aware of the need to consider the arrangements for maintaining all the fire prevention measures required under the Fire Safety Order.⁶³⁶⁶³⁶ {HOM00045964/44} paragraph 34.5; Stokes {Day136/101:25}-{Day136/102:10}.

¶38.48 Carl Stokes frequently gave the TMO advice about matters relating to fire safety. For example, he might be asked whether matters he had raised in his fire risk assessment and action plans had been remedied or to provide comments or advice on discrete issues.⁶³⁷⁶³⁷ Stokes {CST00003063/10} page 10, paragraph 28. He gave advice on matters such as the TMO's programme for the replacement of flat doors, potentially non-compliant entrance doors to leaseholder's flats and work on the gas supply and was asked to inspect and assess the front doors of particular flats.⁶³⁸⁶³⁸ Stokes {CST00003063/29-33} pages 29-33, paragraphs 87-94; Stokes {CST00003063/47-48} pages 47-48, paragraphs 137-141; Wray{Day140/223:5-6}; {CST00000932}. In December 2016 and July 2017 he provided training to the Estate Service Assistants.⁶³⁹⁶³⁹ Stokes {CST00030186/9} page 9, paragraphs 28-32.

¶38.49 Carl Stokes was never appointed to advise on the refurbishment of Grenfell Tower, although he occasionally provided advice to the TMO and Rydon about matters relating to the refurbishment.⁶⁴⁰⁶⁴⁰ Stokes {CST00003063/11} page 11, paragraph 30(iv); Minutes of Grenfell Tower Progress Meeting No.22 dated 19 April 2016 {TMO10045055/2} Item 2.6. When Janice Wray wanted his advice on a particular matter she usually asked him to produce a report, which she then provided to the Asset Management team.⁶⁴¹⁶⁴¹ Wray {TMO00000890/9} page 9, paragraph 44. Sometimes Claire Williams instructed him directly,⁶⁴²⁶⁴² Wray {Day141/2:24}-{Day141/3:6}. for example, if she wanted a second opinion on a matter or if the project team wanted him to produce a report.⁶⁴³⁶⁴³ Wray {Day141/2:12-20}. During the course of the refurbishment he provided advice in relation to the smoke vents and lifts, rights of way to Grenfell Tower, the heating interface units, floor numbering and premises information boxes.⁶⁴⁴⁶⁴⁴ Wray {TMO00000890/10-14} pages 10-14, paragraphs 45-64; {CST00000894}; Stokes {CST00030186/43-44} paragraphs 167-172; Stokes {Day136/140:5}-{Day136/162:14}; {CST00003088}; {CST00003173}; {CST00001258}; {TMO10043487}.

Frequency of fire risk assessments

¶38.50 Carl Stokes carried out fire risk assessments on the properties managed by the TMO as instructed by Janice Wray.⁶⁴⁵⁶⁴⁵ Stokes {Day136/129:5-9}. Initially, she sent him a list of the properties requiring inspection in November each year and he assessed the buildings during the course of the following year.⁶⁴⁶⁶⁴⁶ Stokes {CST00003063/17} page 17, paragraph 51.

¶38.51 The TMO's fire safety strategy acknowledged that fire risk assessments could not remain valid indefinitely.⁶⁴⁷⁶⁴⁷ {TMO00830598/9} paragraph 14.3.1. It required fire risk assessments to be reviewed periodically in various circumstances.⁶⁴⁸⁶⁴⁸ {TMO00830598/9} paragraph 14.3.1. In the case of high-risk buildings, reviews were required annually and a new assessment every three years.⁶⁴⁹⁶⁴⁹ {TMO00830598/10} paragraph 14.3.4. In the case of medium or low-risk buildings, the intention was to carry out reviews on a two-yearly basis with a new assessment every four years.⁶⁵⁰⁶⁵⁰ {TMO00830598/10} paragraph 14.3.5. In practice, new fire risk assessments of Grenfell Tower, which was a potentially high-risk block, were made at least every two years. Two were carried out in 2016.⁶⁵¹⁶⁵¹ Fire Risk Assessment of Grenfell Tower dated 29 December 2010 {CST00003181}; Fire Risk Assessment of Grenfell Tower dated 20 November 2012 {CST00003084}; Fire Risk Assessment of Grenfell Tower dated 26 April 2016 {CST00003161}; Fire Risk Assessment of Grenfell Tower dated 20 June 2016 {CST00003145}.

¶38.52 The reviews of the fire risk assessments were carried out by the TMO Health and Safety team, primarily by Adrian Bowman.⁶⁵²⁶⁵² {TMO00830598/10} paragraph 14.3.3; Wray {Day140/233:6-16}. Janice Wray's "colleague" in the TMO Health and Safety team was Adrian Bowman: Wray {Day140/212:24}-{Day140/213:2}. Their purpose was to monitor whether the measures recommended by Carl Stokes had been completed and to check for obvious changes to the building. That included anything that would cause an increased level of risk, such as anti-social behaviour or work being carried out on site, of which the TMO was unaware.⁶⁵³⁶⁵³ Wray {Day140/232:14-23}. Adrian Bowman used the Significant Findings and Action Plans that Carl Stokes had submitted with the fire risk assessments to record whether remedial measures had been completed.⁶⁵⁴⁶⁵⁴ Wray {Day140/212:18}-{Day140/213:2}; Wray {Day140/233:6-15}.

Meetings with Carl Stokes

¶38.53 Before he started work Carl Stokes met Janice Wray on two occasions to obtain information, once on 22 June 2010 and once on 24 September 2010.

¶38.54 In a letter to Janice Wray following their meeting on 22 June 2010, Carl Stokes asked her to send him a copy of the fire safety report produced by Salvus⁶⁵⁵⁶⁵⁵ {CST00001887/2}. "to back up any fire related issues that may be raised in some of the reports".⁶⁵⁶⁶⁵⁶ {CST00001887/2}. On 28 September 2010 Ms Wray sent Mr Stokes a copy of the report and action plan.⁶⁵⁷⁶⁵⁷ {CST00004383}; {SAL00000013}. He told us that he assumed that he had read it, but could not remember having done so.⁶⁵⁸⁶⁵⁸ Stokes {Day136/176:1}-{Day136/178:18}. If he did read it, however, it appears to have made very little impression on him. He did not recall having become aware of the weaknesses in the TMO's fire safety management system or the 19 statutory breaches that had been identified in the Salvus report.⁶⁵⁹⁶⁵⁹ Stokes {Day136/176:1}-{Day136/178:18}. Janice Wray, for her part, expected him to read the report and to ask her about any outstanding items and when they would be completed. However, she could not recall any such conversation with him⁶⁶⁰⁶⁶⁰ Wray {Day140/127:18}-{Day140/129:5}. and there is no evidence one ever took place. Carl Stokes does not appear to have taken any steps to find out whether the TMO had resolved, or planned to resolve, the statutory breaches identified in the report. We find that very surprising, given the widespread and significant failings identified by Salvus and the effect they must have had on the risk to the TMO's properties.⁶⁶¹⁶⁶¹ Stokes {Day136/177:11}-{Day136/179:6}.

¶38.55 A number of matters were discussed between Carl Stokes and Janice Wray at their meeting on 24 September 2010, some of which had already been covered in the meeting on 22 June 2010.⁶⁶²⁶⁶² {CST00003061}; {CST00001887}. The information Mr Stokes obtained on that occasion did not relate to any particular building,⁶⁶³⁶⁶³ Stokes {Day136/220:21-25}. but he used it to fill out the fire risk assessments relating to various buildings.⁶⁶⁴⁶⁶⁴ Stokes {Day136/125:14-20}. Not once during the seven years that he subsequently acted as the TMO's only fire risk assessor did he seek or obtain current information about the matters covered in the letters of 23 and 27 September 2010.

Carl Stokes's methods

¶38.56 The method adopted by Carl Stokes for carrying out fire risk assessments reflected the Health and Safety Executive's five steps for managing risks and PAS 79⁶⁶⁵⁶⁶⁵ Stokes {CST00003063/13} page 13, paragraph 35; {CTA00000003}; {RBK00036722/13}; https://www.hse.gov.uk/simple-health-safety/risk/steps-needed-to-manage-risk.htm. He explained that in his fire risk assessments for 2009 and 2010 he had kept in mind the guidance in the government's publication Fire Safety Risk Assessment – Sleeping Accommodation and, following its publication in July 2011, LGA Guide.⁶⁶⁶⁶⁶⁶ Stokes {CST00003063/13} page 13, paragraph 35; {RBK00036722}; {HOM00045964}. He would apply the HM Government Guide for Offices and Shops to the office part of Grenfell Tower: Stokes {CST00003063/13} page 13, paragraph 35(iii).

¶38.57 When Carl Stokes undertook a fire risk assessment, he obtained information from Janice Wray about the nature of the common parts and the active and passive fire safety measures they contained.⁶⁶⁷⁶⁶⁷ Stokes {CST00003063/18} page 18, paragraph 55(i). He asked for any reports of the testing of dry risers or any other services in the building.⁶⁶⁸⁶⁶⁸ Stokes {Day136/129:12-20}. He obtained maintenance and servicing records from the TMO's management system, Keystone, or by asking the maintenance department for them.⁶⁶⁹⁶⁶⁹ Stokes {CST00003063/22} page 22, paragraph 67; {TMO00859318}; Stokes {Day136/131:15}-{Day136/133:19}; Parsons {TMO00870938/2} page 2, paragraph 10. If he could not obtain the information he needed, he drew attention to its absence in the action plan.⁶⁷⁰⁶⁷⁰ Stokes {Day136/133:21-24}.

¶38.58 If Mr Stokes had completed a fire risk assessment for a building previously, he usually reviewed the last Action Plan and checked whether the remedial measures had been completed.⁶⁷¹⁶⁷¹ Stokes {CST00003063/23} page 23, paragraph 68; Stokes {Day136/145:7}-{Day136/146:5}; For an example see: Record of Significant Findings and Action Plan for Grenfell Tower dated 26 April 2016 with handwritten notes {CST00000003}. The check did not go much beyond a tour of the building and a look at the TMO's records (including what he described as "tick sheets") which showed what had been done since his last assessment.⁶⁷²⁶⁷² Stokes {Day136/129:12-20}; {Day136/147:21}-{Day136/148:16}. Janice Wray did not recall his ever asking her for completed action plans or sending him the action plan sheets and she could not recall a tick sheet at all.⁶⁷³⁶⁷³ Wray {Day140/232:25}-{Day140/233:23}. We saw no health and safety tick sheets nor any evidence that he was sent completed action plan sheets. We have concluded that when drawing up the latest fire risk assessment he had little information before him about which of the remedial measures he had recommended in his previous fire risk assessment had been completed and which had not and why.

¶38.59 When he visited a building for a fire risk assessment, Mr Stokes inspected it and spoke to anyone he met, such as residents or contractors.⁶⁷⁴⁶⁷⁴ Stokes {CST00003063/18} page 18, paragraph 55(ii); Stokes {Day136/202:16-24}. In the assessment he set out the names of those he had consulted, which would often be Janice Wray, one of the Estate Service Assistants or Claire Williams.⁶⁷⁵⁶⁷⁵ For example, see Fire Risk Assessment of Grenfell Tower dated 29 December 2010 {CST00003181/3}; Fire Risk Assessment of Grenfell Tower dated 26 April 2016 {CST00003161/3}. He asked for certificates and records when the opportunity to do so arose.⁶⁷⁶⁶⁷⁶ Stokes {Day136/69:11-16}. If work had been carried out by third parties, he would rely on their records.⁶⁷⁷⁶⁷⁷ Stokes {CST00003063/22} page 22, paragraph 67(iii). He thought that the first fire risk assessment of a building took about four hours to complete and four hours to write up; it would take him less time to carry out a review of an existing assessment.⁶⁷⁸⁶⁷⁸ Stokes {Day136/66:19-20}; {Day136/185:7-15}; {Day136/186:7-10}. He then prepared his fire risk assessment and a document entitled "Significant Findings and Action Plan".⁶⁷⁹⁶⁷⁹ Stokes {CST00003063/19} page 19, paragraph 55(iv); Stokes {Day136/143:8-16}. After his inspection he could request additional information but often he would draw attention to any missing information in the Action Plan.⁶⁸⁰⁶⁸⁰ Stokes {CST00003063/18} page 18, paragraph 55(iii); Stokes {Day136/143:8-16}.

¶38.60 If he was concerned about a particular matter, Carl Stokes included it in his Action Plan, which identified the risk or hazard and the remedial action to be taken.⁶⁸¹⁶⁸¹ Stokes {CST00003063/23} page 23, paragraph 68. He categorised the item of the significant findings as of high, medium or low priority. The Action Plan was set up as a checklist for the use of the TMO.⁶⁸²⁶⁸² Stokes {CST00003063/23} page 23, paragraph 68. See for example, Record of Significant Findings and Action Plan for Grenfell Tower dated 17 October 2014 {CST00003177}.

¶38.61 Carl Stokes set out his findings in a fire risk assessment that followed a standard template approved by the TMO, RBKC and the LFB before the start of work on the medium-risk properties.⁶⁸³⁶⁸³ Stokes {CST00003063/16} page 16, paragraph 45; Stokes {CST00003063/9} page 9, paragraph 24(iii); Stokes {CST00003063/17} page 17, paragraph 50; {TMO00842371/6} section 1.4; {RBK00029052/2}. At the time he entered into the contract on 21 October 2010 to carry out fire risk assessments on the medium risk properties Mr Stokes understood that copies would be provided to the LFB.⁶⁸⁴⁶⁸⁴ Stokes {CST00003063/17} page 17, paragraph 50.

Carl Stokes's fire risk assessments for Grenfell Tower

¶38.62 Carl Stokes carried out fire risk assessments of Grenfell Tower on 29 December 2010,⁶⁸⁵⁶⁸⁵ Fire Risk Assessment of Grenfell Tower dated 29 December 2010 {CST00003181}; Significant Findings and Action Plan dated 29 December 2010 {CST00003165}. 20 November 2012,⁶⁸⁶⁶⁸⁶ Fire Risk Assessment of Grenfell Tower dated 20 November 2012 {CST00003084}; Significant Findings and Action Plan dated 20 November 2012 {CST00003083}. 17 October 2014,⁶⁸⁷⁶⁸⁷ Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157}; Significant Findings and Action Plan dated 17 October 2014 {CST00003177}. 26 April 2016⁶⁸⁸⁶⁸⁸ Fire Risk Assessment of Grenfell Tower dated 26 April 2016 {CST00003161}; Significant Findings and Action Plan dated 26 April 2016 {CST00003098}. and 20 June 2016.⁶⁸⁹⁶⁸⁹ Fire Risk Assessment of Grenfell Tower dated 20 June 2016 {CST00003145}; Significant Findings and Action Plan dated 20 June 2016 {CST00003069}. In each case he identified the chief executive of RBKC as the responsible person,⁶⁹⁰⁶⁹⁰ See for example, Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/3}. although he did not provide any of his assessments directly to RBKC.⁶⁹¹⁶⁹¹ Stokes {Day136/191:10}-{Day136/193:9}. In fact, he had no contact with anyone at RBKC.⁶⁹²⁶⁹² Stokes {Day136/193:10-13}.

¶38.63 Provided nothing had changed, Mr Stokes's practice was to copy text from one fire risk assessment of Grenfell Tower to the next.⁶⁹³⁶⁹³ Stokes {Day136/187:4-17}. He also copied text from fire risk assessments of other buildings. For example, in the fire risk assessment for Grenfell Tower dated 17 October 2014, he included some text referring to balconies taken from the assessment of another building, even though there were no balconies at Grenfell Tower.⁶⁹⁴⁶⁹⁴ Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/1}. The passage was then repeated in his fire risk assessment dated 26 April 2016.⁶⁹⁵⁶⁹⁵ Fire Risk Assessment of Grenfell Tower dated 26 April 2016 {CST00003161/1}. Similarly, in section 11 of his fire risk assessments, he always included a passage headed "Pest control". In the fire risk assessment for Grenfell Tower dated 17 October 2014 he reported on the condition of pigeon netting on the balconies,⁶⁹⁶⁶⁹⁶ Fire Risk Assessment of Grenfell Tower dated 17 October 2014 {CST00003157/18}. although there were no balconies on Grenfell Tower. That was simply lazy and careless and undermined the authority and quality of the fire risk assessment. Thoughtless drafting of that kind was bad enough, but it was aggravated by the fact that the same inapposite information was repeated in the fire risk assessments dated 26 April 2016 and 20 June 2016.⁶⁹⁷⁶⁹⁷ Fire Risk Assessment of Grenfell Tower dated 26 April 2016 {CST00003161/19}; Fire Risk Assessment of Grenfell Tower dated 20 June 2016 {CST00003145/20}. Carl Stokes explained that the information had been repeated in those assessments because he knew that nothing had changed in relation to pest control and had not read the section again.⁶⁹⁸⁶⁹⁸ Stokes {Day136/190:23}-{Day136/191:4}. He did not read through those fire risk assessments before sending them to the TMO,⁶⁹⁹⁶⁹⁹ Stokes {Day136/191:5-7}. which Mr Todd described as very bad practice.⁷⁰⁰⁷⁰⁰ Todd {Day167/78:21-24}. We agree.

¶38.64 What is worse, nobody at the TMO noticed those inapposite observations that had clearly been transposed from fire risk assessments on other buildings. That strongly suggests that Janice Wray did not read the fire risk assessments with any degree of care. If she had too many things on her desk to read and digest, she ought to have asked for help. In her own words, she was "spread very thinly", as she had responsibility for 650 buildings across the whole of the borough.⁷⁰¹⁷⁰¹ Wray {Day140/48:12-20}. Failing to read such important documents with due care reflected the TMO's casual approach to fire safety.

¶38.65 Carl Stokes included a section headed "Legal statement" in every fire risk assessment for Grenfell Tower. In it he told the recipient (in this case the TMO), among other things, that it did not have to give a copy to anybody, not even the fire authority, and that, if it did so, the document could be used against it at a later date.⁷⁰²⁷⁰² See for example, the Fire Risk Assessment of Grenfell Tower dated 20 June 2016 {CST00003145/2}.

¶38.66 Mr Stokes explained that he included that statement in his fire risk assessments because it was his understanding that the Fire Safety Order required the responsible person only to record the significant findings and make them available for inspection.⁷⁰³⁷⁰³ Stokes {Day136/199:5-10}; Stokes {CST00003063/24} page 24, paragraph 70. As there was no requirement to record the risk assessment itself, he considered that there was no obligation to produce it to the fire service.⁷⁰⁴⁷⁰⁴ Stokes {CST00003063/24} page 24, paragraph 70(ii). He considered that a fire risk assessment that was critical of the fire safety arrangements could be used against the responsible person at a later date.⁷⁰⁵⁷⁰⁵ Stokes {CST00003063/24} page 24, paragraph 70(iii). Colin Todd thought that the statement was unnecessary, confrontational and wrong in law, given that the local fire and rescue service as the enforcing authority has extensive powers under article 27 of the Fire Safety Order to obtain information and documents relating to compliance with the Order.⁷⁰⁶⁷⁰⁶ Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/76} paragraph 8.15. Again, we agree.

Quality management and auditing

¶38.67 Carl Stokes did not operate a quality management system or peer review process. A one‑man company can implement a quality management system and can also be certificated under BS EN ISO 9001.⁷⁰⁷⁷⁰⁷ Todd {Day167/72:2-10}; Lane {Day171/32:8}-{Day171/33:2}. The absence of a quality management system was a structural weakness in Carl Stokes's business and the absence of such a system in relation to a company that was the only fire risk assessor for the TMO's entire portfolio of 650 buildings was a structural weakness in the TMO's fire risk management system.⁷⁰⁸⁷⁰⁸ Todd {Day167/73:16}-{Day167/74:20}.

¶38.68 Janice Wray placed an undue amount of trust and confidence in Mr Stokes's ability to carry out sufficient and suitable fire risk assessments. Although she claimed to have read every fire risk assessment and action plan (which, for reasons explained above, we doubt she did with any care) and although she sometimes challenged Carl Stokes when she did not agree with him, she did not monitor the technical quality of his documents⁷⁰⁹⁷⁰⁹ Wray {Day140/47:10-15}; {Day140/203:11-23}; Lane, Fire Safety Investigation Module 3 Report {BLARP20000027/145} paragraph 8.4.5. and could not have done so, since she had neither the necessary technical expertise nor the time to do it. As we have already mentioned, she was overworked as it was.⁷¹⁰⁷¹⁰ Wray {Day140/48:12-20}. However, it was a significant failure on the part of the TMO not to monitor the quality of the work done by Mr Stokes as the sole provider of fire risk assessments for its portfolio of buildings.⁷¹¹⁷¹¹ Lane, Fire Safety Investigation Module 3 Report {BLARP20000027/145} paragraphs 8.4.5 and 8.4.6.

¶38.69 The Publicly Available Specification "PAS 7:2013 entitled Fire risk management system – Specification" (PAS 7), published by the British Standards Institution in June 2013, contained guidance on the requirements for establishing a fire risk management system by which an organisation can put in place the practical steps required to carry out its fire safety policy.⁷¹²⁷¹² {LFB00116924/1-7}. It suggested that an organisation should audit its fire risk assessment programme after fire risk assessments had been delivered and conduct review meetings at planned intervals to discuss the results of the audits.⁷¹³⁷¹³ {LFB00116924/23} paragraphs 7.4.3 and 7.4.4.

¶38.70 Janice Wray was familiar with the provisions of PAS 7 but she did not arrange for the fire risk assessment programme to be audited.⁷¹⁴⁷¹⁴ Wray {Day145/12:6-21}. Her excuse was that she could not find the time to do it and that she had received a degree of reassurance from the fact that the LFB had been asking questions about some of the fire risk assessments that had led her to understand that they were of a suitable and sufficient standard.⁷¹⁵⁷¹⁵ Wray {Day145/14:9}-{Day145/15:25}. She accepted, however, that she should have arranged an audit and that she could not rely on the enforcement authority to act as an auditor.⁷¹⁶⁷¹⁶ Wray {Day145/14:9}-{Day145/16:6}. Ms Wray could not recall ever having raised the question of auditing the fire risk assessment programme with Barbara Matthews, although she admitted that she should have done so.⁷¹⁷⁷¹⁷ Wray {Day145/13:15-20}. Again, we agree.

¶38.71 Robert Black never gave any thought to whether a sole trader could properly act as the fire risk assessor for 650 buildings.⁷¹⁸⁷¹⁸ Black {Day150/19:9-12}. Nor did he ever consider specifically whether Janice Wray had sufficient resources to carry out her fire safety responsibilities properly.⁷¹⁹⁷¹⁹ Black {Day150/19:13}-{Day150/21:12}. He simply never brought his mind to bear on how the TMO, as the responsible person with statutory obligations, was actually setting out to discharge them. That indicates a lack of interest in matters of fire safety and explains his failure to exercise sufficient control over such matters. It also goes a long way to explain the casual approach to fire safety of the TMO as an organisation.

External concerns

¶38.72 In her first witness statement Janice Wray said that, as far as she could remember, the LFB had never commented on fire risk assessments produced by Carl Stokes in such a way as to give the TMO any reason to doubt his competence or the quality of the assessments themselves.⁷²⁰⁷²⁰ Wray {TMO00000890/36} page 26, paragraph 158. In fact, however, that was not the case. There were many occasions when both Mr Stokes's competence and the quality of his fire risk assessments were called into question, not only by the LFB but also by others. In the end, Janice Wray was not only constrained to admit that her statement was incorrect, but was unable to provide any credible explanation of how she had come to make it.⁷²¹⁷²¹ Wray {Day144/200:3}-{Day144/201:2}. On this aspect of our investigations, therefore, we have been able to place little weight on her evidence.

Concerns expressed by the LFB

¶38.73 During the last quarter of 2015, two of the LFB's fire safety inspecting officers, Julie-Anne Steppings and Michelle McHugh, told Rebecca Burton, the leader of the LFB's Fire Safety Team for Hammersmith, Fulham, Kensington and Chelsea, of the concerns they had about the approach taken in fire risk assessments produced by Carl Stokes for the TMO.⁷²²⁷²² Burton {Day145/119:1-4}; Burton {LFB00084098/12-13} pages 12-13, paragraph 24. As a result, between November 2015 and September 2016, she raised the matter with the TMO on a number of occasions.

¶38.74 Among the concerns identified by Rebecca Burton were that Carl Stokes would rely on inspections by the LFB and undocumented discussions and agreements with LFB personnel as support for his assessments.⁷²³⁷²³ Burton {LFB00032331/4-5} pages 4-5, paragraph 11. She did not think that he was providing the TMO with suitable and sufficient fire risk assessments and considered that the matter needed to be addressed.⁷²⁴⁷²⁴ Burton {LFB00032331/5} page 5, paragraph 11. She also highlighted a tendency on his part when carrying out a fire risk assessment to select the most convenient parts of different documents rather than identify the most suitable guide and apply it in full to the premises in question.⁷²⁵⁷²⁵ Burton {LFB00084098/7-8} pages 7-8, paragraph 11; {LFB00003439/1}.

Meeting between Janice Wray and Rebecca Burton on 13 November 2015

¶38.75 On 13 November 2015, a meeting took place between Janice Wray and Rebecca Burton following the fire that had occurred at Adair Tower on 31 October 2015. Neither of them kept a contemporaneous note of their discussions, but at different times each of them described the substance of them in emails to their respective superiors.

¶38.76 On 13 November 2015, Janice Wray sent a long email to Robert Black, Barbara Matthews and Sacha Jevans, in which she described the review being carried out by the LFB for the purposes of deciding whether to issue an enforcement notice. She referred to a number of questions that had been raised by Ms Burton, none of which had been critical of the fire risk assessment. She did not mention agreeing to raise any concerns with Carl Stokes.⁷²⁶⁷²⁶ {TMO10011001}.

¶38.77 On 5 May 2016, Rebecca Burton reported what had transpired in an email to her superior, Spencer Sutcliff, when discussing the review. She said that various areas of concern about fire risk assessments had been discussed with Janice Wray, including the assessor's approach to self-closing devices on flat entrance doors generally, his claim that the LFB had agreed that self-closing devices were not required on flat entrance doors and the failure of his fire risk assessment to reflect an understanding of the strategy for the building and how occupants were to be kept safe in the event of fire.⁷²⁷⁷²⁷ {LFB00003445/1}. Although he is not mentioned by name, it is obvious that when she referred to the fire risk assessor she was referring to Carl Stokes. She went on to record that Janice Wray had agreed to consider each of those points and discuss with Mr Stokes what improvements could be made.⁷²⁸⁷²⁸ {LFB00003445/1}.

¶38.78 The difference between the two accounts no doubt reflects the authors' different interests but is striking, nonetheless. However, any difficulty we might otherwise have had in deciding whether Ms Burton did in fact voice criticisms of the fire risk assessment was resolved by Ms Wray's admission that during the meeting Ms Burton had indeed raised the matters to which she had referred in her email.⁷²⁹⁷²⁹ Wray {Day144/204:2-4}. Ms Wray said that she had raised them with Carl Stokes, but we cannot be confident that she did, since there is no record of any such discussion.⁷³⁰⁷³⁰ Wray {Day144/204:9-16}. That itself is a matter for criticism, since, if the LFB had serious concerns about Carl Stokes, she ought to have made a record of when and how she had raised those matters with him.

¶38.79 Barbara Matthews was also well aware of the LFB's views about Carl Stokes's fire risk assessments.⁷³¹⁷³¹ Wray {Day144/206:4-17}. On 30 November 2015, Barbara Matthews had a telephone conversation with Rebecca Burton, during which they discussed the proposed enforcement notices for Adair and Hazlewood Towers. According to her note of the call, Barbara Matthews was told by Rebecca Burton that the fire risk assessments for Adair and Hazelwood Towers were not suitable and sufficient, that Carl Stokes had not considered the question of smoke ventilation and that his risk assessments were not comprehensive.⁷³²⁷³² Barbara Matthews' notebook, entry date 30 November 2015 {TMO00880324/31}. Rebecca Burton confirmed the note as an accurate record of the discussion: Burton {Day145/126:10-14}. Barbara Matthews told us that she had thought that Rebecca Burton was criticising only the particular fire risk assessments under discussion and not his overall performance⁷³³⁷³³ Matthews {Day148/75:23}-{Day148/76:4}. but she had no reason to believe that the defects that the LFB had highlighted were limited to those assessments and certainly should not have assumed that that was the case without further investigation.

¶38.80 On 4 December 2015, Barbara Matthews wrote to the TMO board to provide a report on the Adair Tower fire.⁷³⁴⁷³⁴ {TMO00902920}. She said that the LFB had confirmed that it would serve enforcement notices in respect of Adair and Hazlewood Towers.⁷³⁵⁷³⁵ {TMO00902920/1}. She explained that the LFB had advised the TMO of what she called "key matters of concern", specifically smoke ventilation and the absence of self-closing devices on flat entrance doors, but she made no reference to the direct criticism of Carl Stokes's fire risk assessments that Rebecca Burton had made during their conversation on 30 November 2015, less than a week earlier.⁷³⁶⁷³⁶ {TMO00902920/1}; {TMO00880324/31}. Nor, strikingly, did she refer to the service of the deficiency notice in relation to Adair Tower on 12 October 2015, a point which is considered elsewhere in this report.

¶38.81 Barbara Matthews could not explain why she had failed to include in her report any reference to the criticism of Carl Stokes's fire risk assessments, but in hindsight she accepted that she should have drawn it to the board's attention.⁷³⁷⁷³⁷ Matthews {Day148/81:23}-{Day18/83:2}. Her failure to do so was consistent with the desire of Robert Black and the executive team as a whole to keep any bad news about fire safety away from the board.

¶38.82 Rebecca Burton again raised her concern about Carl Stokes with the TMO at their bi‑monthly meeting on 5 January 2016. The minutes record that she told the meeting that Carl Stokes was prone to making statements that were not justified or supported and that he needed to provide support for what he said. If he referred to discussions with the LFB he needed to identify with precision in each case when they had taken place, who had been parties to them and what had been the outcomes.⁷³⁸⁷³⁸ Minutes of bi-monthly meeting between LFB and TMO dated 5 January 2016 {LFB00032330/3} item 8. Janice Wray agreed to raise the issues identified by Rebecca Burton with Carl Stokes. Janice Wray told us that she did speak to him,⁷³⁹⁷³⁹ Wray {Day144/208:9-11}. but the outcome is not clear and there is certainly no evidence that Carl Stokes's approach improved or that he absorbed the LFB's criticisms.

¶38.83 On 31 March 2016 there was a meeting of the TMO board at which Barbara Matthews described the progress of the enforcement notices relating to Adair and Hazlewood Towers.⁷⁴⁰⁷⁴⁰ Minutes of meeting of the TMO Board dated 31 March 2016 {TMO10045103/4} item 9.1. At the meeting, Jeff Zitron, a board member nominated by the council, asked why enforcement notices had been issued, given that at the time of the fire the TMO had valid fire risk assessments.⁷⁴¹⁷⁴¹ Minutes of meeting of the TMO Board dated 31 March 2016 {TMO10045103/4-5} item 9.2. Sacha Jevans responded, telling the board that enforcement notices had been served despite the fact that Carl Stokes had not identified any problems when carrying out his fire risk assessment, and that the LFB had identified none either when it carried out its fire audit.⁷⁴²⁷⁴² Minutes of meeting of the TMO Board dated 31 March 2016 {TMO10045103/5} item 9.2. That was wrong and misleading. In fact, the LFB had served a deficiency notice relating to Adair Tower on 12 October 2015, about 2 weeks before the Adair Tower fire, which had identified contraventions of Articles 11, 17(1) and 8 of the Fire Safety Order.⁷⁴³⁷⁴³ {LFB00084110/3-4}. The contravention of Article 17(1) identified referred expressly to an absence of a self-closing device on a flat entrance door, in contradiction to the statement in the fire risk assessment that flat entrance doors were fitted with a self-closing device: {LFB00084110/4}.

¶38.84 We have already commented on this and other examples of the TMO's executive officers misleading the board or failing to disclose to it material matters relating to fire safety. The result in this particular case was that Mr Zitron did not get a straight answer to his question but it was a question that the TMO ought to have asked itself instead of resorting to deflection and concealment. By this point, however, it seems that the TMO had become so heavily reliant on Carl Stokes that any challenge to his work was disregarded, even in the wake of a serious fire.

The TMO Health & Safety Report 2015/2016

¶38.85 In June 2016, Janice Wray and Barbara Matthews produced the TMO's Health & Safety Report for the period 1 April 2015 to 31 March 2016.⁷⁴⁴⁷⁴⁴ {TMO10024405/1-22}. In the section relating to fire risk assessments, it said that suitable and sufficient fire risk assessments were in place which had been produced in accordance with best practice as set out in PAS 79.⁷⁴⁵⁷⁴⁵ {TMO10024405/7} paragraph 7.9. No mention was made of the concerns raised by Rebecca Burton in November 2015 and January 2016. Janice Wray was unable to explain that omission,⁷⁴⁶⁷⁴⁶ Wray {Day144/217:20-25}. but she accepted that unless she included those criticisms in the report, or the matter had been raised by Barbara Matthews, neither the TMO's executive team nor the board nor RBKC would have been aware of them.⁷⁴⁷⁷⁴⁷ Wray {Day144/219:4-12}. Yet again, the board of the TMO was kept in the dark about concerns expressed by the enforcing authority about the quality of the TMO's fire risk assessments. That was a particularly important matter for the board to know because it put the TMO, and indirectly the members of the board, at risk of incurring liability for breach of the Fire Safety Order, which carried serious sanctions.

¶38.86 The report referred to the TMO's intention to procure a new contract for fire consultancy and fire risk assessment services.⁷⁴⁸⁷⁴⁸ {TMO10024405/18} paragraph 15.2. Janice Wray and Barbara Matthews both denied that that had been prompted by criticisms of Carl Stokes's work.⁷⁴⁹⁷⁴⁹ Wray {Day144/220:17}-{Day144/221:11}; Matthews {Day148/79:23}-{Day148/80:2}. In the event, the procurement manager apparently did not think that a new contract was required at that time and no steps were taken to obtain one. The subject was not discussed further by the TMO's Health and Safety Committee, the executive team or the board.⁷⁵⁰⁷⁵⁰ {TMO10047034/19}.