Chapter 41: Inspection and maintenance of entrance doors

¶41.1 On the night of the Grenfell Tower fire many of the self-closing devices on the front doors of flats in the block failed to work effectively and some were entirely missing. As a result, many doors remained open when the occupants left, allowing smoke to enter the lobbies, which quickly became smoke-logged. The absence of effective self-closing devices was therefore an important cause of the inability of many occupants to escape the tower at a time when the stairs were relatively free of smoke. It represents a serious defect in the management of the building in relation to fire safety.

Legislation and guidance

¶41.2 Under article 17(1) of the Fire Safety Order the responsible person must ensure that any equipment or devices provided in respect of the premises under the order are subject to a suitable system of maintenance and are maintained in efficient working order and good repair where necessary in order to protect the safety of relevant persons.

¶41.3 Among the equipment and devices that fall within article 17(1) are fire-resisting doors and self-closing devices. Part G of the LGA Guide, which is entitled "Managing fire risk – ongoing control", indicates that arrangements for managing fire safety in a block of flats should include putting in place programmes for routine inspection, testing, servicing and maintenance of fire safety systems, such as fire-resisting doors and monitoring the common parts, both through formal inspections and informally as part of day-to-day activities by staff.⁹⁶⁷⁹⁶⁷ {HOM00045964/112}. It also recognises that whatever safety equipment is provided, its effectiveness will depend on proper inspection and maintenance.⁹⁶⁸⁹⁶⁸ {HOM00045964/113}.

¶41.4 Section 82.3 of the LGA Guide advised that it was good practice to inspect timber fire‑resisting doorsets every six months with a view to identifying defects, such as missing or ineffective self-closing devices and doors which had been replaced with non-fire-resisting products.

¶41.5 The Guide also said that entrance doors to flats should be fitted with effective self-closing devices that should be replaced as a matter of urgency when found to be missing or damaged. It also warned of the dangers of residents' removing or disconnecting them.⁹⁶⁹⁹⁶⁹ {HOM00045964/99}; {HOM00045964/105}.

¶41.6 Before the LGA Guide was published, on 30 April 2011 Carl Stokes wrote to Janice Wray about a draft version dated 18 April 2011⁹⁷⁰⁹⁷⁰ {TMO00847318/1}; {CST00012483}. quoting certain paragraphs which he considered could affect the programme for the replacement of entrance doors.⁹⁷¹⁹⁷¹ {TMO00847318/1}. Paragraph 68.2 in the draft LGA Guide was materially the same as that in the published version. Janice Wray was therefore aware by 30 April 2011, if not before, that entrance doors needed to be fitted with self-closing devices and that residents might remove or disconnect them.⁹⁷²⁹⁷² Wray {Day143/68:7}-{Day143/69:5}.

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Problems with self-closing devices

¶41.7 Shortly after Manse Masterdor began installing new entrance doors in March 2011, two problems began to emerge with the concealed self-closing devices fitted to them. One was a mechanical fault in the self-closing device which prevented the door from closing or which caused it to become stuck in the closed position. That appears to have been caused by a defect in the fixings connecting the self-closing device to the door and the doorframe. The other was that the self-closing devices were too strong for some residents, particularly those who were elderly or frail, who had difficulty opening and closing their doors. The evidence suggests that both problems were inherent in the design or manufacture of the doorsets rather than the result of defective installation. However, whether the problem was one of design, manufacture or installation, doors were proving difficult to open easily and the solution adopted by many, including the TMO's repair staff, was to remove the self‑closing devices, even though they were an important fire safety measure.

¶41.8 Our conclusions about the extent to which one or other of those problems affected the self-closing devices at Grenfell Tower and the extent to which they were remedied before 14 June 2017 depend to a significant extent on evidence provided by residents about their entrance doors and the requests for repairs sent to Manse Masterdor and the TMO. That evidence has its limitations, however. For example, there are many references to doors' not opening or closing properly that do not identify any more clearly the nature of the problem. Moreover, the lapse of six years between the start of the door replacement programme and the fire means that other factors, such as wear and tear, may have contributed to the condition of some of the self-closing devices on 14 June 2017. We have made findings about the condition of self-closing devices on 14 June 2017 where the evidence gives us sufficient confidence to do so, but it is important to acknowledge at the outset the limited nature of the information available to us.

Early discovery of failings: 2011

¶41.9 On 17 May 2011, Andy Webster, a project manager for Manse Masterdor, sent an email to fellow employees Paul Birkett and Richard Moore about the entrance doors being installed for the TMO in which he referred to a defect in concealed self-closing devices that prevented doors from closing. He recognised that the doors should not have left the factory in that state.⁹⁷³⁹⁷³ {MAS00000187/82}.

¶41.10 It is unclear from Mr Webster's email what the precise nature of the fault was, except that it prevented the doors from shutting. It appears to have arisen during the design or manufacturing process, but it is unclear how. It is not clear what steps Manse Masterdor took to cure the problem, either in relation to doors that were yet to be installed or in relation to doors that had already been fitted. (At Grenfell Tower 17 entrance doors had been fitted by that date.)⁹⁷⁴⁹⁷⁴ {MAS00000003}. It is clear, however, that Manse Masterdor did not tell the TMO about the problem.⁹⁷⁵⁹⁷⁵ Acosta {Day166/86:3-5}. There is no record of the problem being raised and discussed in the progress meetings for the entrance door replacement programme.

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¶41.11 On 24 June 2011, Carl Stokes sent an email to Abigail Acosta about problems with two newly installed entrance doors that he had identified during an inspection of King Charles House.⁹⁷⁶⁹⁷⁶ {TMO00867377/2}. He had found that the self-closing device had come out of the door of Flat 13. Abigail Acosta told Natasha Brown, resident liaison officer at Manse Masterdor, about the problem and she arranged for a fitter to repair it.⁹⁷⁷⁹⁷⁷ {TMO00867377/1-2}.

¶41.12 On 21 July 2011, Carl Stokes sent another email to Abigail Acosta about the same problem affecting newly installed entrance doors at Grenfell Tower. He said that he had been told that three self-closing devices had been dislodged from the doors. He did not say which flats were affected but he suggested that the screws securing the closer inside the door were too short.⁹⁷⁸⁹⁷⁸ {TMO00867783/2-3}.

¶41.13 Abigail Acosta sent the message on to Andy Webster on 26 July 2011.⁹⁷⁹⁹⁷⁹ {TMO00867783/2}. He said that he was aware of the problem and explained that although the factory had used the screws recommended by the manufacturers, they had turned out not to be long enough. As a precautionary measure the size of the screws had been increased.⁹⁸⁰⁹⁸⁰ {TMO00867783/1-2}. Apparently Mr Webster told Ms Acosta which other properties had also been affected, but she could not remember which ones they were.⁹⁸¹⁹⁸¹ Acosta {Day166/87:14-18}.

¶41.14 It is clear that from the outset inadequate screws and fixings presented a systemic problem in relation to self-closing devices on the new entrance doors throughout the TMO stock, as the TMO knew. It is also clear that as a result there was a real possibility that self-closing devices would become dislodged from the doors unless the screws and fixings were changed. It is less clear whether the problem was the same as, or related to, the problem with doors not shutting that Mr Webster had referred to in his email of 17 May 2011.

¶41.15 In his response to Abigail Acosta of 26 July 2011 Mr Webster said that Manse Masterdor had started changing the fixings as necessary,⁹⁸²⁹⁸² {TMO00867783/1-2}. but it changed the screws and fixings only of the doors that were affected, not of all doors.⁹⁸³⁹⁸³ Acosta {Day166/88:1-6}.

¶41.16 At Grenfell Tower, the vast majority of the new entrance doors had been installed by the end of June 2011.⁹⁸⁴⁹⁸⁴ {MAS00000003}. Unless Manse Masterdor returned to change them, therefore, they retained the original fixings and did not have the larger screws and fixings that the factory apparently used from July 2011 onwards. There is in fact no evidence that Manse Masterdor replaced the fixings of the self-closing devices on any of the new entrance doors.

¶41.17 We have seen no evidence that Abigail Acosta ever received confirmation that any remedial work had been carried out by Manse Masterdor at either King Charles House or Grenfell Tower. Further, there is no evidence that she, as project manager, carried out any checks herself or that she had a system to record any remedial work that needed to be carried out. She appears to have assumed that Manse Masterdor carried out any necessary remedial work and that the problem had been resolved.⁹⁸⁵⁹⁸⁵ Acosta {Day166/87:14}-{Day166/89:5}.

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¶41.18 Carl Stokes also assumed that the problem had been cured.⁹⁸⁶⁹⁸⁶ Stokes {Day138/75:24}-{Day138/76:3}; {Day138/83:5-21}. He did not carry out any checks at the time or investigate whether the problem had been satisfactorily resolved when he carried out his next fire risk assessment at Grenfell Tower in November 2012.⁹⁸⁷⁹⁸⁷ {CST00003084}; Record of Significant Findings and Action Plan {CST00003083}.

¶41.19 Whatever steps Manse Masterdor took to cure the problem, it is reasonably clear that it persisted, at least at Grenfell Tower, which may explain why so many self-closing devices were defective or missing on 14 June 2017.⁹⁸⁸⁹⁸⁸ {MET00039807/76-80}.

¶41.20 There was evidence that during the period from 2011 to 2013 the self-closing devices on the entrance doors of a number of flats at Grenfell Tower had become dislodged or that the doors would either not close at all or else become stuck in the closed position. It is likely that those problems were caused by inadequate screws and fixings, but it is possible that in some cases there were other faults. It is also evident that various repairers, including employees of Manse Masterdor, Morrisons⁹⁸⁹⁹⁸⁹ Morrisons Facilities Services Ltd provided reactive repair services for the TMO until the termination of their contract in June 2012 when Willmott Dixon was appointed by the TMO to provide those services. and Repairs Direct,⁹⁹⁰⁹⁹⁰ Repairs Direct Ltd was a wholly owned subsidiary of the TMO which was established in 2013 to provide reactive repair services for the TMO in place of Willmott Dixon. as well as Seamus Dunlea (the Lancaster West Estate handyman) and residents themselves removed self-closing devices so that doors could be opened and closed freely. Self-closing devices were removed from the doors of Flat 11,⁹⁹¹⁹⁹¹ Alison Moses {IWS00001281/4-5} pages 4-5, paragraphs 21-25 Flat 12,⁹⁹²⁹⁹² Dainton {IWS00000806/6} page 6, paragraph 33; Dainton {IWS00001974/5} page 5, paragraph 25; {RBK00053524} row 3709. Flat 25,⁹⁹³⁹⁹³ Rasoul {IWS00001768/7-8} pages 7-8, paragraphs 34-35; {RBK00053524} rows 3555 and 3052. Flat 32,⁹⁹⁴⁹⁹⁴ {MET00045733} row 5303. The flat was identified in that document by cross-checking the factory reference with the document showing the doors installed at Grenfell Tower {MAS00000003} row 15. Flat 41,⁹⁹⁵⁹⁹⁵ Kasote {IWS00000768/5} page 5, paragraph 19; Kasote {IWS00001775/7} page 7, paragraph 23; Kasote {Day117/63:17-20}. Flat 54,⁹⁹⁶⁹⁹⁶ Rawda Said {IWS00001729/2-3} pages 2-3, paragraph 4(b); Salma Said {IWS00001727/4-5} pages 4-5, paragraph 4(b). Flat 66,⁹⁹⁷⁹⁹⁷ Hanan Wahabi {IWS00000074/5} page 5, paragraph 16; {TMO00899663}; {TMO00899664}. Flat 76,⁹⁹⁸⁹⁹⁸ Quang {IWS00000080/3} page 3, paragraph 11; Quang {IWS00001821/8-9} pages 8-9, paragraphs 40-42; {RBK00053524} row 2851. Flat 82,⁹⁹⁹⁹⁹⁹ {TMO00868337/1}; {RBK00053524} row 3745. Flat 115,¹⁰⁰⁰¹⁰⁰⁰ {MET00045733} row 5110. The flat was identified in that document by cross-checking the factory reference with the document showing the doors installed at Grenfell Tower {MAS00000003} row 62. Flat 133,¹⁰⁰¹¹⁰⁰¹ Hanife Macit {IWS00000904/5} page 5, paragraph 32; Sener Macit {IWS00000069/7} page 7, paragraphs 39 and 40. Flat 134,¹⁰⁰²¹⁰⁰² Daffarn {IWS00000169/15} page 15, paragraph 47. Flat 152¹⁰⁰³¹⁰⁰³ Yahya {IWS00000498/3} page 3, paragraph 10; El-Guenuni {IWS00002034/2-3} pages 2-3, paragraph 7. and Flat 205.¹⁰⁰⁴¹⁰⁰⁴ Neda {IWS00000886/22} page 22, paragraph 132.

¶41.21 A common feature of all the flats listed above is that the self-closing device on the entrance door was missing on 14 June 2017.¹⁰⁰⁵¹⁰⁰⁵ {MET00039807/76-80}. We have seen no evidence that Manse Masterdor, the TMO or anyone else replaced the self-closing devices on those doors before 14 June 2017, except for Flat 32. In the case of that flat there is evidence that Manse Masterdor replaced the self-closing device.

¶41.22 There is positive evidence that the self-closing devices on the entrance doors of some of the flats listed above had not been replaced by June 2014. On 14 June 2014 Leon Taylor, a fire risk assessor for PSC London Ltd, carried out a fire risk assessment of Grenfell Tower on instructions from Michael Lyons, a health and safety manager employed by Repairs Direct.¹⁰⁰⁶¹⁰⁰⁶ Emails between Michael Lyons and Amelia Sales on 26-31 March 2014 {TMO00856436/1-2}; Taylor {PSC00000002/1} page 1, paragraph 2; Leon Taylor's fire risk assessment of Grenfell Tower dated 14 June 2014 {TMO10001286}. Mr Taylor inspected some of the new doors and found that their self-closing mechanisms had been disconnected; he also found that some of the old fire doors did not have self‑closing devices.¹⁰⁰⁷¹⁰⁰⁷ Leon Taylor's fire risk assessment of Grenfell Tower dated 14 June 2014 {TMO10001286} "FRA" sheet, Reference L6, rows 231-233. He took photographs of missing self-closing devices on at least three entrance doors, including Flats 25 and 76.¹⁰⁰⁸¹⁰⁰⁸ Photographs taken by Leon Taylor on 15 June 2014 of missing self-closing device at Flat 76 {PSC00000072}; Flat 25 {PSC00000082}; another flat entrance door where the number is not visible {PSC00000087}. He recommended that the entrance doors to all flats should have fully functioning, positive-action, working, self-closing devices fitted.¹⁰⁰⁹¹⁰⁰⁹ Leon Taylor's fire risk assessment of Grenfell Tower dated 14 June 2014 {TMO10001286} "Action Plan" sheet, row 9. We have seen no evidence that Repairs Direct or the TMO took any action in response to that recommendation.

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¶41.23 On 17 December 2015, Janice Wray sent an email to Siobhan Rumble to report Carl Stokes's concern that some residents of Grenfell Tower had told him that Seamus Dunlea had disconnected the self-closers on their entrance doors. Janice Wray asked Ms Rumble to tell him to stop disconnecting or removing self-closing devices, which apparently she did.¹⁰¹⁰¹⁰¹⁰ {TMO00859693/1}. On the face of it, that is consistent with Seamus Dunlea's own evidence.¹⁰¹¹¹⁰¹¹ Dunlea {MET00019959/6} page 6. It is not clear when he disconnected self-closing devices or on which doors, but it does indicate that by December 2015 some of the self-closing devices he had removed had not been replaced. There is no evidence that they were replaced at that point or that any investigation was carried out to determine from which flats they had been removed.¹⁰¹²¹⁰¹² Janice Wray could not remember, but said she would have asked Siobhan Rumble to ask for repairs, Wray {Day143/189:5-15}-{Day143/190:6-12}. Siobhan Rumble said she took no action beyond asking Seamus Dunlea to stop disconnecting and removing the self-closing devices, Rumble {Day120/43:1-5}. Carl Stokes did not investigate whether the issue had been addressed in his subsequent fire risk assessment of Grenfell Tower in April 2016 {CST00003161}.Show full note Moreover, the TMO did not have a system for the regular inspection and maintenance of entrance doors that might have revealed that self-closing devices at Grenfell Tower were missing or defective and prompted their replacement before the fire.

¶41.24 In those circumstances, the only plausible explanation for the absence of self-closing devices from the entrance doors of the flats on the night of the fire (except Flats 32 and 53) is that they had been removed as a result of problems that had arisen shortly after the doors had been installed and not replaced before the fire. It is unclear how the self-closing devices on the doors of Flats 32 and 53 came to be missing at the time of the fire.¹⁰¹³¹⁰¹³ {MET00039807/76-80}.

Excessive strength of the self-closing device

¶41.25 During the summer of 2011 there were various reports that the strength of the self-closing devices on new doors caused difficulties for residents when opening and closing them. There is evidence that the self-closing devices to Flats 43,¹⁰¹⁴¹⁰¹⁴ Sobieszczak {IWS00001539/4} page 4, paragraphs 16 and 17. 72,¹⁰¹⁵¹⁰¹⁵ Roncolato {IWS00001774/2} page 2, paragraph 8. 183¹⁰¹⁶¹⁰¹⁶ Gomes {IWS00001078/12} page 12, paragraphs 59 and 60. and 122¹⁰¹⁷¹⁰¹⁷ Beadle {IWS00001872/7} page 7, paragraphs 30 and 31. were removed or disabled as a result. We have seen no evidence that they had been repaired or replaced before 14 June 2017, but they were all missing on 14 June 2017 except one (Flat 43), which was present but not working.¹⁰¹⁸¹⁰¹⁸ {MET00039807/76-80}. Again, it is likely that the reason for their absence is because they had been removed or disabled as a result of the problems that had arisen shortly after the doors were installed and were not subsequently repaired or replaced.

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Inspection and maintenance of entrance doors

¶41.26 The TMO was repeatedly advised, both before and after the LGA Guide was published in July 2011, that it needed to put in place a system of regular inspection and maintenance of fire-resisting doors, including the entrance doors to flats.

¶41.27 The Salvus Management Report, dated 22 September 2009,¹⁰¹⁹¹⁰¹⁹ See Chapter 37. identified the absence of adequate inspection and monitoring of premises and facilities as a hazard. It specifically identified that the monthly safety inspection did not include any formal checks on fire doors¹⁰²⁰¹⁰²⁰ {SAL00000013/7} item 4.1. and contained a strong recommendation that the inspection sheet be revised to include formal checks on fire doors. Salvus advised that that needed to be done within a month to remedy what it considered to be a breach of the TMO's statutory obligations.¹⁰²¹¹⁰²¹ {SAL00000013/15} item 4.1.

¶41.28 In his fire risk assessment of Grenfell Tower dated 30 September 2009 on behalf of Salvus Carl Stokes recommended that a system of formal checks on the entrance doors to flats and all other fire compartmentation doors be introduced by the TMO to ensure that fire compartments remained fit for their purpose. He made it clear that checks should be made on all fire doors within the building and recommended that a system of inspection be put in place within three months or that a plan for doing so be agreed within six months.¹⁰²²¹⁰²² {CST00003128/16}.

¶41.29 Salvus repeated that recommendation in, at least, 12 other fire risk assessments on TMO properties which it carried out between September 2009 and January 2010 under the high‑risk programme. In each case, it recommended that a system of inspection be put in place within three months or that a plan for doing so be agreed within six months.¹⁰²³¹⁰²³ 9 Colville Square dated 25 September 2008 {CST00003736/12}; 11 and 12 Colville Square dated 25 September 2008 {CST00003737/12}; Gillray House dated 14 October 2009 {TMO00873667/19}; Salvus fire risk assessments of Dixon House dated 16 November 2009 {CST00002006/21}; Clydesdale House dated 16 November 2009 {CST00003596/15}; Elm Park House dated 9 December 2009 {CST00003744/15}; Whitstable House dated 25 January 2010 {CST00002008/20}; Frinstead House dated 25 January 2010 {CST00003214/22}; Markland House dated 15 January 2010 {CST00003215/22}; Adair Tower dated 28 January 2010 {CST00002623/17}; Hazelwood Tower dated 28 January 2010 {CST00002626/15}.Show full note

¶41.30 On 4 November 2010, Carl Stokes advised Janice Wray that when carrying out the programme of replacing the entrance doors to flats, the TMO ought to consider introducing an inspection system to ensure that the residents did not disconnect or disable the self‑closing devices.¹⁰²⁴¹⁰²⁴ {CST00001156/1}; {CST00001155}.

¶41.31 On 8 November 2012, representatives of the LFB, the TMO, RBKC and the London Borough of Hammersmith and Fulham met to discuss responsibility for enforcing the law against leaseholders whose entrance doors were not adequately fire-resisting.¹⁰²⁵¹⁰²⁵ Jack {MET00040001/6} page 6, last paragraph; {LFB00004623}. Andy Jack, the Head of Fire Safety Enforcement at the LFB, Nicolas Comery, team leader of the LFB fire safety team, and Matthew Ramsey, a LFB fire safety inspecting officer, attended on behalf of the LFB. Janice Wray attended on behalf of the TMO. Carl Stokes also attended.¹⁰²⁶¹⁰²⁶ Jack {MET00040001/6-7} pages 6-7; Comery {LFB00032144/15} page 15, paragraph 50; Ramsey {LFB00032092/13} page 13, paragraphs 47 and 48. No minutes were made of that meeting.

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¶41.32 A further conversation took place immediately after that meeting involving, at least, Andy Jack, Carl Stokes and Nicolas Comery about the monitoring and maintenance requirements for entrance doors to flats and self-closing devices.¹⁰²⁷¹⁰²⁷ Jack {MET00040001/15} page 15. Janice Wray did not stay for the discussion but Carl Stokes told her afterwards what had been said.¹⁰²⁸¹⁰²⁸ Wray {Day143/116:24}-{Day143/117:1-7}; Stokes {Day138/167:16-25}. Andy Jack made the point that there was a need to maintain doors and self-closing devices in good working order and to carry out sufficient checks of their effectiveness.¹⁰²⁹¹⁰²⁹ Jack {MET00040001/19} page 19; Jack {Day147/68:19}-{Day147/69:24}. He also drew attention to the possibility of carrying out checks on self-closing devices during gas safety inspections.¹⁰³⁰¹⁰³⁰ Jack {MET00040001/19} page 19. It appears, however, that no agreement was reached about what form the TMO maintenance system should take.¹⁰³¹¹⁰³¹ Jack {Day147/75:1-7}.

The TMO's policy on inspection and maintenance of flat entrance doors

¶41.33 From late 2012 to November 2013 Janice Wray drafted the TMO's fire safety strategy with help from Carl Stokes.¹⁰³²¹⁰³² {CST00001188}; {CST00001187}; {CST00001159}; {CST00002046}; {TMO00830598}. As it was the TMO's overarching policy in relation to fire safety, we should have expected it to contain the arrangements for complying with important aspects of the Fire Safety Order, including the inspection and maintenance of entrance doors to flats and self-closing devices. That is particularly so in view of the specific advice which had been given to the TMO between 2009 and 2012 on the need for a system of regular inspection and maintenance of entrance doors and the recommendations in the LGA Guide that had been published in July 2011. Despite that, however, the TMO's fire safety strategy, which was completed in November 2013, did not provide for such a system.

¶41.34 Section 5 of the fire safety strategy covered management arrangements for fire safety. Paragraph 5.1 provided for a programme of regular estate inspections, risk assessments and monitoring by neighbourhood and health and safety staff. It said that inspections ensured that fire doors were operating effectively. It also said that repairs to fire doors and self-closing devices were given priority.¹⁰³³¹⁰³³ {TMO00830598/2-3} paragraph 5.1, first bullet point. However, the inspection checklist covered only communal fire doors and chute room doors, not the entrance doors to flats.¹⁰³⁴¹⁰³⁴ {TMO00830598/18}.

¶41.35 The fire safety strategy also provided for the inspection, testing and maintenance of all fire safety systems and equipment in accordance with the requirements of the relevant British Standard,¹⁰³⁵¹⁰³⁵ {TMO00830598/3} paragraph 5.1, second bullet point. but did not include the entrance doors to flats or other fire doors.¹⁰³⁶¹⁰³⁶ {TMO00830598/4-7} paragraphs 5.1, 6.2, 9.1.3, 9.2, 9.4 and 10.

¶41.36 Section 17 specifically dealt with the entrance doors to flats, but although it clearly envisaged that the TMO's fire risk assessor would inspect some entrance doors as part of his fire risk assessments, it made no provision for a system of regular inspection and maintenance of entrance doors and self-closing devices.¹⁰³⁷¹⁰³⁷ {TMO00830598/11} paragraph 17.

¶41.37 We have seen no evidence that before the TMO completed its fire safety strategy it gave any consideration to Mr Jack's suggestion at the meeting on 8 November 2012 that regular inspections of self-closing devices might be combined with the annual gas safety check.

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Janice Wray's email to Matthew Ramsey, 18 December 2013

¶41.38 On 18 December 2013, Janice Wray sent an email to Matthew Ramsey about various fire safety matters affecting Elm Park House.¹⁰³⁸¹⁰³⁸ {LFB00003534}. In response to a concern he had raised about self-closing devices there, Janice Wray described the TMO's approach to entrance doors as follows: first, when replacement doors were fitted they were fire-rated and fitted with self-closing devices; secondly, when properties became vacant self-closing devices were reinstated or installed as necessary; thirdly, at other times when major work was to be undertaken in a dwelling the self-closing device would be reinstated if it had been removed or disconnected.

¶41.39 We have seen no evidence that Matthew Ramsey or anyone else in the LFB fire safety team replied to that email or otherwise commented on the approach it described. Mr Ramsey said that neither he nor Nicolas Comery had approved it.¹⁰³⁹¹⁰³⁹ Ramsey {Day147/15:12-17}. Andy Jack said that he had not approved it either.¹⁰⁴⁰¹⁰⁴⁰ Jack {Day147/78:1-8}. Janice Wray accepted that the LFB had not approved it in the past.¹⁰⁴¹¹⁰⁴¹ Wray {Day143/123:13-25}. None of that is surprising. The TMO's approach inevitably led to irregular and infrequent inspections of the entrance doors to flats and so was inconsistent with both the LGA Guide's recommendation for six-monthly inspections and the advice given by Andy Jack in November 2012, which Janice Wray had already accepted.¹⁰⁴²¹⁰⁴² Wray {Day143/123:24}-{Day143/124:4}.

¶41.40 The TMO's approach to inspecting self-closing devices, as described by Janice Wray to the LFB, did not appear in the fire safety strategy. It was also absent from the document used by the TMO and Repairs Direct that described the condition that vacant properties were required to attain in order to be ready for letting (known as the "relettable standard") and was not included in the forms for recording inspections of vacant properties.¹⁰⁴³¹⁰⁴³ {TMO00905397}; {TMO00905501}; {TMOH00000805/1}; {TMO00861934}. However, a requirement to carry out a fire risk assessment inspection was added to a new version of the "relettable standard" that was produced in November 2014.¹⁰⁴⁴¹⁰⁴⁴ {TMO00905400/2}; {TMO00905535/2}. In addition, there is some evidence that the TMO and Repairs Direct were, in practice, inspecting the entrance doors to flats and their self-closing devices when vacant properties were inspected.¹⁰⁴⁵¹⁰⁴⁵ Brunning {TMO00880533/7} page 7, paragraph 34.

¶41.41 Quite apart from that, however, the policy was inadequate because it did not ensure that entrance doors were inspected on a regular and systematic basis. It could be many years before a property changed hands and was inspected. Records of repairs show that work was carried out on only 17 of the 120 flats in Grenfell Tower between the end of 2013, when the policy apparently came into existence, and 14 June 2017.¹⁰⁴⁶¹⁰⁴⁶ {RBK00053524}; {RBK00053297}. That means that the vast majority of entrance doors in Grenfell Tower had not been inspected before the fire.

¶41.42 The policy of inspecting the entrance door to a flat when major work was carried out was similarly inadequate, because it did not ensure regular inspection. It was only by coincidence that the flats in Grenfell Tower all underwent major work relatively shortly before 14 June 2017 as result of the refurbishment. Janice Wray conceded that the refurbishment provided a suitable occasion on which to visit the flats and inspect the self‑closing devices on the entrance doors,¹⁰⁴⁷¹⁰⁴⁷ Wray {Day143/123:3-11}. but in the event, that did not happen.

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Other situations in which the TMO inspected entrance doors

¶41.43 According to Janice Wray there were three other ways in which the TMO monitored entrance doors to ensure that they remained in good condition once the new doors had been installed.¹⁰⁴⁸¹⁰⁴⁸ Wray {TMO00000890/7} page 7, paragraph 31; Wray {TMO00847305/16-17} pages 16-17, paragraphs 53 and 54. First, Carl Stokes inspected a proportion of doors as part of the fire risk assessment programme. Secondly, flat entrance doors were to an extent monitored by caretakers, known as Estate Services Assistants, during their weekly and monthly inspections of the communal areas. Thirdly, the TMO expected tenants to report any problems with doors to their flats. However, that did not amount to a reliable system of regular inspection. Carl Stokes's inspections during fire risk assessments did not constitute a systematic and regular inspection of all or even a majority of entrance doors. He was required to carry out fire risk assessments at properties deemed to be high-risk only every two or three years and even less frequently at lower-risk properties.¹⁰⁴⁹¹⁰⁴⁹ Wray {Day143/95:2-6}; {CST00030042}. Moreover, he was expected to look at only a sample of entrance doors as part of his fire risk assessments.¹⁰⁵⁰¹⁰⁵⁰ These matters are addressed in detail in Chapter 38. {HOM00045964/43-45} paragraphs 33.2, 34.1 and 35.1; The TMO Consultant's Brief dated July 2009 for fire risk assessments in high-risk blocks, which became the instructions to which Salvus worked, stated at Part 2, section 1.1 that the "FRA and FRA reviews will include an individual examination of each fire door including whether it operates correctly": {TMO00865175/6}; However, at the meeting on 7 September 2009 between Salvus and TMO, Janice Wray agreed that only a random sample of doors needed to be inspected {SAL00000040/1} item 2.1; Wray {TMO00873629/2} page 2, paragraph 9.Show full note Accordingly, in a building as large as Grenfell Tower, there were likely to be many doors he had not checked even after several cycles of fire risk assessments. Moreover, it is not part of a fire risk assessor's task to inspect the entrance doors to flats as part of the responsible person's system of inspection and maintenance. His job is to assess whether that person has an effective system of inspection and maintenance in place.¹⁰⁵¹¹⁰⁵¹ Todd {Day168/17:21}-{Day168/18:3}; Lane {Day171/197:14}-{Day171/198:6}.

¶41.44 The inspection of entrance doors to flats was not formally one of the duties of the Estate Services Assistants and was not included in their daily, weekly or monthly inspection checklists.¹⁰⁵²¹⁰⁵² Daily Estate Staff Inspection Checklist for daily routines appended to TMO Fire Safety Strategy dated November 2013 {TMO00830598/16-19}; Daily Inspections Routine Checklist contained in Estate Staff Quick Reference Handbook {TMO10028449/83-88}; Record of weekly health and safety checks carried out by Estate Service Assistants between 1 January 2016 and 14 June 2017 {CST00000068}; Record of monthly health and safety checks carried out by Estate Service Assistants between 1 January 2016 and 14 June 2017 {CST00000069}.Show full note To the extent, therefore, that they did carry out such inspections, they did so irregularly and there was no means for them formally to record any defects that they found. Their inspections were also limited to reporting visible damage on the outside of an entrance door.¹⁰⁵³¹⁰⁵³ Rumble {TMO10050001/2-3} pages 2-3, paragraph 9; Wray {TMO00000890/7} page 7, paragraph 32; Wray {Day143/98:14}-{Day143/106:12}.

¶41.45 Paul Steadman, the Estate Services Assistant who carried out the inspections of the communal areas at Grenfell Tower, did not inspect entrance doors to flats otherwise than by making a visual check when passing.¹⁰⁵⁴¹⁰⁵⁴ Steadman {TMO10049875/3} page 3, paragraph 13; Steadman {Day146/8:20}-{Day146/9:18}. His inspections, therefore, were not systematic nor did they include the internal aspects of the doors, including, critically, the self-closing devices. The TMO's records show that he did not identify the need for a single repair to an entrance door or any other fire door as a result of his inspections of Grenfell Tower between 1 January 2016, when the records for those inspections began, and 14 June 2017.¹⁰⁵⁵¹⁰⁵⁵ TMO spreadsheet entitled "ESA002D_Fault Report Repairs" which shows "results for all fault report (repairs) forms completed" by Estate Services Assistants between 1 January 2016 and 14 June 2017 {CST00000067} sheet 2, filter for Paul Steadman in column E and Grenfell Tower in column H.

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¶41.46 Relying on tenants to report problems with their entrance doors did not amount to a system of inspection at all,¹⁰⁵⁶¹⁰⁵⁶ Wray {Day143/107:1-18}. but in any case to be effective would depend heavily on the extent to which residents were aware of the importance of their entrance doors, particularly the self-closing device, to fire safety in the building and of the need to report any defects. Residents who had disconnected self-closing devices themselves could not be expected to report the fact. Although the residents received some information about the purpose of fire-resistant entrance doors, they were not specifically told about the purpose and importance of self-closing devices and the need to report defects in them.¹⁰⁵⁷¹⁰⁵⁷ Wray {Day143/107:20}-{Day143/110:23}. The number of self-closing devices found to have been defective or missing on 14 June 2017 (77 out of 120), for which no request for repair had been made, demonstrates the folly of relying on residents to identify and report defects.¹⁰⁵⁸¹⁰⁵⁸ {MET00039807/76-80}.

¶41.47 The TMO's arrangements for the inspection of entrance doors therefore fell far short of the six-monthly inspections recommended by the LGA Guide and the advice received from the LFB in November 2012. By any measure they fell far below acceptable standards.

The TMO's reasons for not implementing a programme of regular inspections

¶41.48 Janice Wray was familiar with the recommendation in the LGA Guide that entrance doors be inspected every six months as part of a programme of planned preventative maintenance.¹⁰⁵⁹¹⁰⁵⁹ Wray {Day143/91:20-23}. She put the failure to implement such a programme down to a lack of resources and difficulties in obtaining access to flats.¹⁰⁶⁰¹⁰⁶⁰ Wray {Day143/92:8-15}; {Day143/143:16-25}. However, she accepted that the TMO might have been able to fund the programme, but only at the expense of something else.¹⁰⁶¹¹⁰⁶¹ Wray {Day143/93:24}-{Day143/94:2}. She was confident that she had discussed resourcing a programme of regular inspections with her line managers, Anthony Parkes and (from June 2015) Barbara Matthews, but could not recall when.¹⁰⁶²¹⁰⁶² Wray {Day143/94:5-13}. We have seen no evidence of any such discussions until after the Adair Tower fire on 31 October 2015. We consider that her frequent references to budget restrictions as a reason for not taking necessary action across the TMO estate in relation to fire safety were based on an assumption that any request for further funds would be refused. Neither she nor anyone else appears to have made any serious effort to obtain additional resources.

Adair Tower and the LFB's stance on self-closing devices

¶41.49 Both before and after the fire at Adair Tower on 31 October 2015 the LFB fire safety team raised concerns with the TMO about its approach and that of Carl Stokes to ensuring that self-closing devices were fitted on entrance doors to flats.

¶41.50 In early September 2015, the LFB fire safety team identified during an inspection that the entrance door to Flat 41 at Adair Tower, which had not been replaced as part of the replacement programme, did not have a self-closing device.¹⁰⁶³¹⁰⁶³ {LFB00003385/1-2}; {LFB00001613}. They also discovered that in his fire risk assessment of Adair Tower dated 20 February 2014 Carl Stokes had advised that self-closing devices were "not applicable" and that, although entrance doors to flats were not fitted with self-closing devices, he had not identified their absence as a concern and had not assessed the consequent risk or recommended remedial action.¹⁰⁶⁴¹⁰⁶⁴ Burton {LFB00084098/5-6} pages 5 and 6, paragraph 10; {LFB00024281/19}; {LFB00084107/1}. On 12 October 2015, the LFB issued a deficiency notice to the TMO in respect of Adair Tower based on the absence of self-closing devices.¹⁰⁶⁵¹⁰⁶⁵ {LFB00001613/4}.

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¶41.51 On 14 September and 22 October 2015, Janice Wray sent emails to Julie-Anne Steppings, the LFB fire safety inspecting officer who had conducted the inspection, and Rebecca Burton, the LFB fire safety team leader, respectively. She told them that the TMO's approach to self-closing devices on existing entrance doors reflected advice from Carl Stokes who had himself received clarification of the position from Andy Jack at the meeting on 8 November 2012.¹⁰⁶⁶¹⁰⁶⁶ {LFB00003385/1-2}. The meeting with Andy Jack is incorrectly referred to in that email as having taken place in November 2015. Email from Janice Wray to Rebecca Burton on 22 October 2015 {LFB00003440/1}. The LGA Guide had introduced the concept of a "nominal" or "notional" fire door to describe an existing door that does not meet current standards for fire-resistance but satisfied the previous standard and therefore did not necessarily need to be replaced.¹⁰⁶⁷¹⁰⁶⁷ {HOM00045964/98} paragraph 62.17. For the TMO, the concept applied to the doors that had not been replaced under the replacement programme, such as those at Adair Tower.

¶41.52 Although she did not say so explicitly, Janice Wray suggested that she had understood from Carl Stokes that the LFB accepted that self-closing devices were not required on "nominal" doors, despite the fact that the LGA Guide said that all entrance doors to flats and any doors leading onto a protected escape route needed to have a self-closing device.¹⁰⁶⁸¹⁰⁶⁸ {HOM00045964/99} paragraph 62.19. Janice Wray suggested that the LFB had changed its position in that respect.¹⁰⁶⁹¹⁰⁶⁹ {LFB00003440/1}. On 22 October 2015 Rebecca Burton replied to Janice Wray, telling her that she was unaware of any guidance that allowed fire doors not to be self-closing, especially those leading to the means of escape.¹⁰⁷⁰¹⁰⁷⁰ {LFB00003440/1}. We do not think that the LFB had changed its position, not least because the LGA Guide is clear on the point.¹⁰⁷¹¹⁰⁷¹ Burton {Day145/90:4-7}; {HOM00045964/99} paragraph 62.19.

LFB advice and enforcement action

¶41.53 After the fire at Adair Tower, Rebecca Burton sent an email to Andy Jack, Nicholas Coombe and Nicolas Comery on 1 November 2015 asking what had been agreed at the meeting with the TMO on 8 November 2012.¹⁰⁷²¹⁰⁷² {LFB00003385/1}. Although none of them could recall the precise details of what had been discussed, each of them effectively denied that they had agreed that entrance doors did not need to be self-closing.¹⁰⁷³¹⁰⁷³ {LFB00001610}; {LFB00003463/1}. Andy Jack said in evidence that he had been shocked by the suggestion. He was also shocked that Carl Stokes, as a former fire safety officer, should have thought that entrance doors did not need to be self-closing.¹⁰⁷⁴¹⁰⁷⁴ Jack {Day147/80:7-21}. Nicolas Comery was similarly clear that there had been no such agreement.¹⁰⁷⁵¹⁰⁷⁵ Comery {Day145/181:6-10}. We accept their evidence about that.

¶41.54 On 13 November 2015, Rebecca Burton met Janice Wray to discuss the LFB's concerns about Adair Tower.¹⁰⁷⁶¹⁰⁷⁶ {TMO00869184/3-4}; {TMO00840415}; {LFB00003445}; Burton {Day145/96:13-25}; Burton {LFB00084098/9} page 9, paragraph 16. They included the suitability and sufficiency of fire risk assessments, especially in relation to self-closing devices, and the claim that the LFB had agreed that entrance doors to flats did not need to be self-closing.¹⁰⁷⁷¹⁰⁷⁷ {LFB00003445}. She told Janice Wray that Andy Jack, Nicholas Coombes and Nicolas Comery all denied that they had agreed to that and she told Janice Wray that self-closing devices were required on all entrance doors.¹⁰⁷⁸¹⁰⁷⁸ Burton {Day145/97:1-7}; {Day145/97:17}-{Day145/98:2}. Janice Wray accepted that they had discussed the need for self-closing devices to be checked regularly.¹⁰⁷⁹¹⁰⁷⁹ Wray {Day143/139:4-11}.

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¶41.55 On 23 December 2015, the LFB fire safety team served an enforcement notice on the TMO in respect of Adair Tower and sent a copy to RBKC.¹⁰⁸⁰¹⁰⁸⁰ {LFB00003383}. It described a number of matters that the LFB fire safety team considered to involve breaches of the Fire Safety Order. They included a failure to carry out a suitable and sufficient fire risk assessment for the purposes of Article 9 because the assessment carried out by Carl Stokes did not give adequate consideration to existing and required standards for self-closing devices. They also included a failure to maintain the fire resistance of the protected route because none of the doors that opened onto it were fitted with positive-action self-closing devices.¹⁰⁸¹¹⁰⁸¹ {LFB00003383/4-5}. The LFB issued another enforcement notice on 18 January 2016 in respect of Hazlewood Tower (Adair Tower's sister block) which included essentially the same alleged breaches in relation to self-closing devices.¹⁰⁸²¹⁰⁸² {RBK00001020}.

¶41.56 Rebecca Burton and Janice Wray discussed the LFB's stance on self-closing devices at their regular meeting on 5 January 2016.¹⁰⁸³¹⁰⁸³ {LFB00032330}. The minutes recorded the LFB's view that landlords should ensure that self-closing devices were fitted and that effective procedures were introduced to ensure that the devices remained operational and were not disconnected or removed by residents.¹⁰⁸⁴¹⁰⁸⁴ {LFB00032330/3} item 7; {LFB00032331/4} page 4, paragraph 10. That was, we consider, a clear and unambiguous warning to the TMO.

¶41.57 Janice Wray's response was that it would be difficult to establish any other sort of maintenance regime due to problems of access and that she would need to speak to her line management to devise a programme.¹⁰⁸⁵¹⁰⁸⁵ Burton {Day145/101:23}-{Day145/102:3}. They discussed ways in which the TMO could maintain self-closing devices, including by using caretakers, Estate Services Assistants and incorporating a check of self-closing devices into the TMO's annual electricity and gas safety checks.¹⁰⁸⁶¹⁰⁸⁶ Burton {LFB00032331/4} page 4, paragraph 10; Burton {Day145/102:8-24}. Rebecca Burton in effect said that, rather than pressing for entrance doors to be inspected every six months the LFB thought that it was better that inspections actually be carried out at less frequent intervals than to be scheduled at more frequent intervals that could not be achieved.¹⁰⁸⁷¹⁰⁸⁷ Burton {Day145/103:5-19}.

The response of the TMO and RBKC

¶41.58 After her meeting with Rebecca Burton on 5 January 2016, Janice Wray told Robert Black and Barbara Matthews that Rebecca Burton had stressed that the entrance doors to all flats in the TMO's housing stock needed to be fitted with self-closing devices and that the policy of checking self-closing devices only in vacant properties was insufficient.¹⁰⁸⁸¹⁰⁸⁸ {TMO00840451}. She also reported the LFB's view that the TMO should have a procedure in place for carrying out and recording regular checking of the devices as well as her own opinion that that would be virtually impossible to achieve. In response, Barbara Matthews asked Janice Wray whether it was possible to find out what approach other housing providers, including the London Borough of Hammersmith and Fulham, were taking to self-closing devices.¹⁰⁸⁹¹⁰⁸⁹ {TMO00902946/1}.

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¶41.59 Accordingly, later the same day Janice Wray sent an email to a number of housing providers to ask whether they required all entrance doors to flats to be self-closing and, if so, how they achieved it, what procedures they adopted to ensure that self-closing devices were not removed or disconnected, and what approach the relevant fire and rescue service took to them.¹⁰⁹⁰¹⁰⁹⁰ {TMO00865995/2-3}. All those who replied said that it was their policy to ensure that entrance doors were fitted with self-closing devices. None of them said that they had a formal system of inspection of self-closing devices, but three of the five who replied had informal approaches to checking self-closing devices, although the methods varied.¹⁰⁹¹¹⁰⁹¹ {CST00007708/1-2}; {CST00006634/1}; {TMO00865995/1}; {CST00002902/1}; {CST00002302/1-2}. None of those who replied had encountered a challenge to their approach by the fire and rescue service, except one that had also received a number of deficiency notices and an enforcement notice.¹⁰⁹²¹⁰⁹² {CST00002902/1}.

¶41.60 On 8 April 2016, Janice Wray circulated papers for the TMO Health and Safety Committee meeting on 12 April 2016.¹⁰⁹³¹⁰⁹³ {TMO10012661}. They included a paper dated 4 April 2016 entitled "Review of the Fire Safety Strategy",¹⁰⁹⁴¹⁰⁹⁴ {TMO10024351}; {TMO10012811/5} item 6.3. in which she said that it was time to review the strategy to make sure that the TMO's policies complied with the relevant legislation and the LFB's advice, guidance and requirements.¹⁰⁹⁵¹⁰⁹⁵ {TMO10024351}. However, for reasons which are not apparent, she did not invite the committee to consider the matters she had discussed with Rebecca Burton on 5 January 2016, namely, the need to install self-closing devices on all entrance doors and to put in place a system for the regular inspection and maintenance of self-closing devices.

James Swindells' email to Janice Wray of 1 August 2016

¶41.61 On 27 July 2016, James Swindells, an LFB fire safety inspecting officer, reported to Janice Wray, copying in Rebecca Burton, on his inspection of Lonsdale House.¹⁰⁹⁶¹⁰⁹⁶ {CST00009704/2}. He had found that a number of self-closing devices had been broken or removed by residents. Janice Wray replied on 1 August 2016 saying that the doors had been replaced as part of the entrance door replacement programme in 2012-2013 and had operational self-closing devices at that time. She said that the TMO could not control the action of residents and pointed out that, even if the self-closing devices were repaired or replaced, they could soon be removed or disabled again.¹⁰⁹⁷¹⁰⁹⁷ {CST00009704/1-2}.

¶41.62 In response Mr Swindells emphasised the obligation imposed on the responsible person by Articles 11 and 17 of the Fire Safety Order to monitor and maintain fire safety systems and suggested that residents should be reminded that the device was there to protect both them and their neighbours.¹⁰⁹⁸¹⁰⁹⁸ {CST00009704/1}.

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Review of the TMO fire safety strategy: September 2016

¶41.63 On 9 September 2016, Janice Wray circulated papers for a meeting of the TMO Health and Safety Committee on 13 September 2016.¹⁰⁹⁹¹⁰⁹⁹ {TMO00840649}. She again included a paper entitled "Review of the Fire Safety Strategy", in which she invited the committee to comment on various fire safety matters.¹¹⁰⁰¹¹⁰⁰ {TMO00840660/1-2}. On that occasion they included for the first time the need to install and inspect self-closing devices on entrance doors to flats as had been discussed with Rebecca Burton on 5 January 2016. Janice Wray could not explain the delay other than by saying that complying with the enforcement notices for Adair Tower and Hazlewood Tower had been time-consuming work.¹¹⁰¹¹¹⁰¹ Wray {Day143/152:17}-{Day143/153:19}. Given the obvious importance of the matter, that is scarcely a sufficient explanation.

¶41.64 Janice Wray invited the committee to consider the requirement for self-closing devices, the LFB's interpretation of the Fire Safety Order and what the TMO could do to advance the installation of self-closers.¹¹⁰²¹¹⁰² {TMO00840660/2}. She suggested that one option was to create, and give priority to, a programme for installing self-closing devices, which would need approval and financial support from RBKC. She also asked the committee to consider how the TMO might implement a system of regular inspection and maintenance of self-closing devices, asking a number of questions relating to practical matters, such as the extent to which the TMO's caretakers could assist, when checks might best be carried out and whether the importance of self-closing devices could be emphasised in communications to residents.¹¹⁰³¹¹⁰³ {TMO00840660/2}.

¶41.65 At its meeting on 13 September 2016 the committee acknowledged the need to have a more active policy on the installation of self-closing devices in order to meet the LFB's requirements. Someone suggested that the work could be included in cyclical redecoration projects but it was decided that further work needed to be done to obtain approval and funding from RBKC.¹¹⁰⁴¹¹⁰⁴ {TMO00840753/5} item 6.1. We have seen no evidence that the ways in which self-closing devices might be inspected were discussed, either at the meeting or subsequently.¹¹⁰⁵¹¹⁰⁵ {TMO00905766}.

¶41.66 The possibility of inspecting self-closing devices when carrying out annual gas safety checks had been raised by Andy Jack in November 2012. Janice Wray said that she had instructed Alex Bosman to discuss that with the TMO's gas safety contractors, but that they had refused to do it.¹¹⁰⁶¹¹⁰⁶ Wray {Day143/85:20}-{Day143/86:5}; {Day143/120:2}-{Day143/121:16}. She was not able to say when that discussion had taken place, only that it had probably occurred before her meeting with Rebecca Burton on 5 January 2016.¹¹⁰⁷¹¹⁰⁷ Wray {Day143/120:2}-{Day143/121:16}; {Day143/141:22}-{Day143/142:7}. However, that is not easy to reconcile with the matter being raised for discussion for the first time in September 2016. We have seen no other evidence that discussions of that kind took place and on balance we do not think that they did.

The involvement of RBKC

¶41.67 The fitting of self-closing devices was discussed at a meeting of the TMO executive team on 5 October 2016 attended by Robert Black, Sacha Jevans, Barbara Matthews and Yvonne Birch. The meeting was told that the LFB was putting pressure on the TMO to fit self-closing devices to all entrance doors to flats but that that had been resisted by Laura Johnson.¹¹⁰⁸¹¹⁰⁸ {TMO00843861/2} item 3.2. It was also told that the fire strategy was being revised to contain a programme for the work be done over a period of five years, although it was thought likely that the LFB would expect it to be done within a shorter period. It was agreed that it would be necessary to discuss the matter with RBKC, which would need to provide the necessary funding.¹¹⁰⁹¹¹⁰⁹ Jevans {Day127/97:25}-{Day127/98:5}.

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¶41.68 Robert Black's view was that RBKC (in particular, Laura Johnson) was in a position to decide whether or not the TMO took the steps required by the LFB because it controlled the budget.¹¹¹⁰¹¹¹⁰ Black {Day150/211:17-20}. Laura Johnson said that she had suggested that any programme for installing self-closing devices should be spread over five rather than three years for financial and practical reasons.¹¹¹¹¹¹¹¹ Johnson {Day129/200:2}-{Day129/202:7}; Jevans {Day127/96:15}-{Day127/97:5}; Matthews {Day148/108:7-10}. She said that she had understood that it would probably have to be carried out within a shorter period, but that she had not wanted to set the TMO up to fail.¹¹¹²¹¹¹² Johnson {Day129/200:2}-{Day129/202:7}; Jevans {Day127/96:15}-{Day127/97:5}.

¶41.69 It is clear that Laura Johnson was not persuaded of the need to install self-closing devices over a three-year period. The minutes make that clear. Although she was right to have in mind the need to balance the expense of the proposed programme against the risks involved, her decision failed to give sufficient weight to the advice of the LFB and the nature of the risk that self-closing devices were intended to mitigate.

The deficiency notice for Grenfell Tower: 17 November 2016

¶41.70 On 17 November 2016, the LFB issued a deficiency notice to the TMO in respect of Grenfell Tower¹¹¹³¹¹¹³ {TMO10017254}. on the grounds that the protected escape route (corridors, lobbies and stairs) was compromised by doors that did not have self-closing devices. It also identified the doors to Flats 44 and 153 as having failed to close themselves when inspected.¹¹¹⁴¹¹¹⁴ {TMO10017254/4-5}. It recommended that the deficiencies be remedied by 18 May 2017. The deficiency notice thus informed the TMO of its obligations in respect of the installation and maintenance of self-closing devices and the urgency with which they needed to be discharged.

RBKC's decision

¶41.71 On 28 February 2017, Barbara Matthews sent a report on self-closing devices to members of the RBKC and TMO Joint Management Committee in advance of its meeting on 1 March 2017.¹¹¹⁵¹¹¹⁵ {RBK00000987}. It had been drafted by Janice Wray.¹¹¹⁶¹¹¹⁶ {RBK00000988}. It set out the LFB fire safety team's requirements in relation to the installation and inspection of self-closing devices, which were based on its view of articles 11 and 17 of the Fire Safety Order. The report drew attention to the TMO's concern that even regular inspections and maintenance would not ensure that self-closing devices remained effective. It referred to the email sent by James Swindells on 1 August 2016 voicing that concern, in which he said that the TMO only needed to put in place a reasonable system of inspection to discharge its duty.¹¹¹⁷¹¹¹⁷ {TMO00869692}. The report included an estimate prepared by Graham Webb, the managing director of Repairs Direct, of the cost of carrying out a programme of installation and inspection and the assumptions underlying.¹¹¹⁸¹¹¹⁸ {RBK00000988/3}; {TMO00905766}. It did not, however, mention the recommendation in the LGA Guide that inspections be carried out every six months. Although it was estimated that 50% of the TMO's properties did not have self-closing devices fitted to the entrance doors and that 40% of those that were present needed to be repaired or replaced, the report did not touch on the effect that self-closing devices have on the safety of residents.¹¹¹⁹¹¹¹⁹ {RBK00000988/3}.

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¶41.72 At the meeting of the Joint Management Committee concern was expressed at the fact that no other housing provider had a programme for the regular inspection of self-closing devices.¹¹²⁰¹¹²⁰ {RBK00014072/2} item 5. There appears to have been no reference to the recommendation in the LGA Guide for six-monthly inspections, the available means of carrying out inspections or the risk to the safety of residents if a programme of installation or regular inspection was delayed or not implemented.

¶41.73 On 3 March 2017, Barbara Matthews sought to confirm with Laura Johnson and Robert Black what she understood had been agreed at that meeting, namely, that the installation of self-closing devices would be carried out over a period of between three and five years but that regular inspection would not be introduced until legal advice had been obtained about the TMO's right to obtain access if tenants or leaseholders refused it.¹¹²¹¹¹²¹ {RBK00014053/4}. Laura Johnson said that she wanted to spread the installation programme over five years because it would make funding more manageable. In respect of the proposed inspection programme, she took an uncompromisingly negative line, saying that it would impose a continuing burden on the Housing Revenue Account without any evidence that it would affect the safety of residents and that she did not think it was necessary.¹¹²²¹¹²² {RBK00014053/4}.

¶41.74 Laura Johnson accepted that her message amounted to, or at least was interpreted by the TMO as, a direction to extend the period over which the installation programme was to be carried out and to not establish an inspection regime.¹¹²³¹¹²³ Johnson {Day129/225:1-5}. The TMO did not resist.¹¹²⁴¹¹²⁴ {RBK00014053/3}; {TMO00842281/1} item 3; {TMO00847312/5} item 4.2. In effect, therefore, she alone decided that the installation programme should be extended.¹¹²⁵¹¹²⁵ Johnson {Day129/221:20-23}. She did so without having taken any advice about the consequences for the safety of residents.¹¹²⁶¹¹²⁶ Johnson {Day129/221:24}-{Day129/222:2}. She effectively accepted that financial considerations were the principal, if not sole, basis for her decision.¹¹²⁷¹¹²⁷ Johnson {Day129/224:4-17}.

¶41.75 Laura Johnson admitted that she had not taken any steps to understand the risk to safety of not inspecting and maintaining self-closing devices¹¹²⁸¹¹²⁸ Johnson {Day129/225:17-20}. and she accepted that her decision not to establish an inspection system had been wrong.¹¹²⁹¹¹²⁹ Johnson {Day129/225:6-16}. She could not recall what her views had been on the LFB's clear advice about the need to inspect and maintain self closing devices, except that she had wanted to understand whether there was a statutory requirement to do so.¹¹³⁰¹¹³⁰ Johnson {Day129/225:6-16}. She said that she had not been aware of the recommendation in the LGA Guide that landlords should establish a system of inspection and maintenance of self-closing devices.¹¹³¹¹¹³¹ Johnson {Day129/226:24}-{Day129/227:3}. It is evident from the email she sent to Barbara Matthews on 6 March 2017 that money again was the driving force behind her refusal to introduce a system of inspection and maintenance.¹¹³²¹¹³² {RBK00014053/4}.

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Revision of the fire safety strategy: June 2017

¶41.76 Janice Wray revised the TMO's fire safety strategy in June 2017.¹¹³³¹¹³³ {TMO10017036}. In paragraph 18.1.1 there was a reference to the agreement with RBKC to carry out a programme of fitting self-closing devices to the entrance doors of all flats over a period of five years.¹¹³⁴¹¹³⁴ {TMO10017036/12} section 18.1.1. In the same paragraph it said that the TMO had a variety of methods of ensuring that self-closing devices remained in place and operational. They included inspections when properties were vacant and sample inspections during fire risk assessments.¹¹³⁵¹¹³⁵ {TMO10017036/12} section 18.1.1. In short, little, if anything, in the TMO's approach had changed.

Oversight by RBKC Housing Property and Scrutiny Committee

¶41.77 The evidence indicates that neither RBKC nor the TMO fully informed the Housing Property and Scrutiny Committee ("the scrutiny committee") about the position in respect of the installation and inspection of self-closing devices after the Adair Tower fire and before the Grenfell Tower fire. The evidence also indicates that, to the extent that the scrutiny committee was made aware of the LFB's concerns about self-closing devices, it did not take adequate steps to investigate why those concerns had arisen or to ensure that RBKC and the TMO had adequately addressed them.

¶41.78 In her report for the scrutiny committee meeting on 6 January 2016, Laura Johnson warned that the LFB intended to serve enforcement notices in respect of Adair Tower and Hazlewood Tower, in part because of the lack of self-closing devices on entrance doors to flats.¹¹³⁶¹¹³⁶ {RBK00032439/5-6} paragraphs 4.6-4.7. Robert Black reported orally to the meeting that the LFB's requirement to install self-closing devices applied not only to Adair and Hazlewood Towers, but to all the council's properties.¹¹³⁷¹¹³⁷ {RBK00014534/11}. However, he did not mention that the LFB also required a system of regular inspection to be put in place. We have seen no evidence that the scrutiny committee took steps at that point to find out how the problems with self-closing devices had arisen, particularly in the light of the replacement of entrance doors only a few years earlier and the continuing programme of fire risk assessments. We find that lack of curiosity surprising.

¶41.79 In her report for the meeting of the scrutiny committee on 13 July 2016 Laura Johnson provided further information about the enforcement notices relating to Adair and Hazlewood Towers.¹¹³⁸¹¹³⁸ {RBK00032476/1-2} paragraphs 1.3 and 1.4. She said that the TMO and RBKC had agreed to ensure that all entrance doors to flats in both blocks were adequately fire-rated and fitted with self-closing devices.¹¹³⁹¹¹³⁹ {RBK00032476/1-2} paragraphs 1.3 and 1.4. At the meeting, Councillor Nicholls asked whether RBKC complied at other locations. Ms Johnson told him that self-closing devices were fitted at all properties,¹¹⁴⁰¹¹⁴⁰ {RBK00032473/5} paragraph A9. although at that time the TMO was still discussing internally how to remedy the lack of self-closing devices across its properties. There is no record of Robert Black, who was in attendance, correcting her. The scrutiny committee did not take any further action to satisfy itself that RBKC and TMO had fully addressed the LFB's concerns in that respect.

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¶41.80 In her report for the scrutiny committee meeting on 16 November 2016, Laura Johnson said that the works required by the Adair Tower and Hazlewood Tower enforcement notices had been completed.¹¹⁴¹¹¹⁴¹ {RBK00032461/1} paragraphs 1.1-1.3. However, she did not refer to the need to install and inspect regularly self-closing devices across the whole of the housing stock, although by that point she had begun discussing that with the TMO.¹¹⁴²¹¹⁴² {TMO00843861/2} item 3.2. Nor were they mentioned in the TMO's Mid Year Review of Performance which had been prepared for that meeting.¹¹⁴³¹¹⁴³ {RBK00000731}; {RBK00032475/8} paragraph A16. Laura Johnson and Barbara Matthews attended the meeting. There is no record of any fire safety matters having been raised by either of them.¹¹⁴⁴¹¹⁴⁴ Minutes of the meeting of the scrutiny committee meeting on 16 November 2016 {RBK00032475}.

¶41.81 As we have already said,¹¹⁴⁵¹¹⁴⁵ See Chapter 31. we have also seen no evidence that the scrutiny committee were ever informed about the deficiency notice the LFB issued in respect of Grenfell Tower dated 17 November 2016 and the concerns it identified in relation to the maintenance of self-closing devices before the Grenfell Tower fire.

¶41.82 At the scrutiny committee meeting on 4 May 2017, following the fire at Trellick Tower on 19 April 2017, Councillor Mackover and Councillor Pascall expressed concern about the TMO's approach to the installation of fire doors on properties owned by leaseholders.¹¹⁴⁶¹¹⁴⁶ Mackover {RBK00029923/18} page 18, paragraph 67; {RBK00052464/7} paragraph A8; {RBK00002340/1-2}. The scrutiny committee had not been briefed about the decision only a month or so earlier to spread the installation of self-closing devices over a period of five rather than three years and not to introduce a system of regular inspection and Laura Johnson did not draw it to their attention.

¶41.83 The minutes of a TMO executive team meeting on 17 May 2017 recorded that at the meeting of the scrutiny committee on 4 May 2017 Councillor Mackover had criticised the TMO's approach to fire doors but that Laura Johnson had made it clear that RBKC did not want the TMO to inspect the front doors of flats.¹¹⁴⁷¹¹⁴⁷ Minutes of the TMO executive team meeting on 17 May 2017 {TMO00894337/1-2} item 2.6.

¶41.84 Laura Johnson sent an email to Robert Black the following day in response to a question he had asked about the nature of Councillor Mackover's concern and whether he should contact him.¹¹⁴⁸¹¹⁴⁸ Emails between Laura Johnson and Robert Black on 17-18 May 2017 {RBK00002340/1-2}. She said that it related to the entrance doors of leaseholders' flats and that there was nothing in it. She recommended not contacting him. She thought that a section in the annual report would be sufficient. Robert Black agreed.¹¹⁴⁹¹¹⁴⁹ Email from Robert Black to Laura Johnson on 18 May 2017 {RBK00002340/1}.

¶41.85 It is evident, therefore, that the scrutiny committee was not told about the decisions that had been made, principally by Laura Johnson, about the installation and inspection of self‑closing devices before the Grenfell Tower fire.

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The TMO's approach to the repair of entrance doors

¶41.86 Section 5.1 of the TMO's fire safety strategy dated November 2013 said that repairs to fire doors and self-closing devices were given priority.¹¹⁵⁰¹¹⁵⁰ TMO fire safety strategy dated November 2013 {TMO00830598/3}. Beyond that, the TMO had no policy or procedure for responding to requests for repairs to fire doors, including entrance doors to flats. For example, they were not included in the TMO's Fire Protections Systems Policy & Procedure drafted in 2017, which set out the procedure for repairing faults in a number of fire protection systems, including sprinklers, fire alarms, fire extinguishers, hose reels and automatic opening vents.¹¹⁵¹¹¹⁵¹ TMO Fire Protections Systems Policy & Procedure Version 8 dated 10 January 2017 {TMO00899324/2}.

¶41.87 Despite the terms of section 5.1, the TMO's repair records for Grenfell Tower reveal no discernible system for giving repairs to fire doors priority over other matters.¹¹⁵²¹¹⁵² {RBK00053524}; {RBK00053297}. Where a need to repair a fire door was identified by Carl Stokes in the course of a fire risk assessment, it was marked as "FRA", or something similar, but we saw nothing to suggest that it was given priority.¹¹⁵³¹¹⁵³ {RBK00053524}; {RBK00053297}. The repair records suggest that defects of that kind were dealt with in the same way as any other kind of repair. That is consistent with a finding of a "Health Check" audit carried out on Repairs Direct after the Grenfell Tower fire that there was no structured approach to categorising repairs, which made them difficult to manage effectively.¹¹⁵⁴¹¹⁵⁴ {TMO00862541/11}.

¶41.88 Those sent to carry out repairs to self-closing devices at Grenfell Tower between 2011-2013 often simply removed them, so that doors could be opened and closed freely, but did not replace them. In the period up to 14 June 2017 Repairs Direct staff continued on occasions to remove, or offer to remove, self-closing devices or failed to identify the need to replace them when carrying out repairs to entrance doors. That occurred at Flat 26,¹¹⁵⁵¹¹⁵⁵ Dagnachew {IWS00001742/4} page 4, paragraph 4b; {RBK00053297} row 467. Flat 45,¹¹⁵⁶¹¹⁵⁶ Email from Glen Duggan to Janice Jones on 22 July 2015 {CST00000989/2}; Carl Stokes's letter to Janice Wray on 28 July 2015 {CST00001448}; Capita repair spreadsheet {RBK00053524} rows 686 and 1227; West {IWS00000021/3} page 3, paragraph 14; Paramasivan {IWS00001003/3} page 3, paragraph 9. Flat 126,¹¹⁵⁷¹¹⁵⁷ Repair records {RBK00053524} rows 30 and 163. Flat 131¹¹⁵⁸¹¹⁵⁸ Gashaw {IWS00001738/2-3} pages 2-3, paragraph 4b; Fletcher {IWS00001797/3} page 3, paragraph 5b; Repair record {RBK00053524} row 847. and Flat 135.¹¹⁵⁹¹¹⁵⁹ Daniels {IWS00000608/6} page 6, paragraph 40; Daniels {IWS00002065/3} page 3, paragraphs 13-15; Open Contractor spreadsheet {RBK00053297} row 82; Repair records {RBK00053297} row 82.

¶41.89 At each of those flats the self-closing device was found to be missing on 14 June 2017, apart from Flat 26 where the resident had refused the Repair Direct workman's offer to remove it.¹¹⁶⁰¹¹⁶⁰ {MET00039807/76-80}. In our view that is indicative of a broader failure by the TMO to ensure that those carrying out repairs fully understood the importance of effective self-closing devices and ensured that repairs did not undermine the protection offered by the doors.

Fire risk assessment and flat entrance doors

¶41.90 Paragraph 33.2 of the LGA Guide drew attention to the importance of ensuring that the fire resistance between flats and the common parts was considered as part of a fire risk assessment by examining at least a sample of the entrance doors to flats to ensure that they were fire-resisting and self-closing.¹¹⁶¹¹¹⁶¹ The LGA Guide {HOM00045964/43} paragraph 33.2. In a similar vein, Annex D to PAS 79:2012 stated that a fire risk assessor must consider whether all fire-resisting doors are properly self-closing.¹¹⁶²¹¹⁶² PAS 79:2012 {CTA00000003/104}.

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The approach to flat entrance doors to be expected of a fire risk assessor

¶41.91 We have no doubt that a fire risk assessor considering any building containing a large number of flats should inspect a representative sample of entrance doors.¹¹⁶³¹¹⁶³ Lane {Day171/177:22}-{Day171/178:11}; Todd {Day168/6:5-11}. Although they expressed themselves in slightly different terms the experts agreed that the number of doors that should be expected will be a matter of judgment in each case and depend on the nature and size of the building and the assessor's familiarity with it.¹¹⁶⁴¹¹⁶⁴ Lane {Day171/178:20}-{Day171/179:11}; {Day171/186:19}-{Day171/187:20}. There appears to have been a general understanding at the time among fire risk assessors that 10% of the total number with a minimum of two doors was sufficient.¹¹⁶⁵¹¹⁶⁵ Todd {Day168/6:12-20}.

¶41.92 The experts also agreed that a fire risk assessor should inspect both sides of the door, check whether the self-closing device was working effectively,¹¹⁶⁶¹¹⁶⁶ Lane {Day171/178:6-11}; {Day171/184:3-9}; Todd {Day168/6:7-11}. keep a record of the doors inspected,¹¹⁶⁷¹¹⁶⁷ Lane {Day171/180:7}-{Day171/182:16}; Todd {Day168/9:9-23}; Todd {Day168/14:20}-{Day168/15:20}. record any defects in the fire risk assessment¹¹⁶⁸¹¹⁶⁸ Lane {Day171/175:19}-{Day171/176:23}; {Day171/188:13}-{Day171/189:11}; Todd {Day168/20:10}-{Day168/24:1}. and assess the adequacy of the arrangements for the inspection and maintenance of entrance doors.¹¹⁶⁹¹¹⁶⁹ Lane {Day171/197:3-12}; Todd {Day168/17:8-19}.

¶41.93 Salvus and the TMO had agreed in late 2009 at the start of programme of assessing high-risk buildings that its fire risk assessors would inspect a sample of the entrance doors to flats during each of their assessments, although they did not agree a specific number or percentage of doors to be inspected.¹¹⁷⁰¹¹⁷⁰ The TMO Consultant's Brief dated July 2009 for fire risk assessments in high-risk blocks, which was the brief for Salvus, states at Part 2 section 1.1 that the "FRA and FRA reviews will include an individual examination of each fire door including whether it operates correctly": {TMO00865175/6}; However, at a meeting on 7 September 2009 between Salvus and TMO, Janice Wray agreed that only a random sample of doors needed to be inspected {SAL00000040/1} item 2.1; Wray {TMO00873629/2} page 2, paragraph 9.Show full note When Carl Stokes was engaged by the TMO to assess medium-risk buildings in September 2010, it does not appear that he and Janice Wray discussed the need to inspect a sample of doors but they both clearly proceeded on understanding that he would.¹¹⁷¹¹¹⁷¹ Janice Wray said Carl Stokes continued to inspect flat entrance doors as part of his fire risk assessments, Wray {TMO00000890/7} page 7, paragraph 31; Stokes {Day138/84:5-7}; Stokes {Day138/149:11-15}; {CST00002861}. That expectation was ultimately recorded in the TMO's fire safety strategy dated June 2017.¹¹⁷²¹¹⁷² {TMO10017036/12} section 18.1.

Carl Stokes's inspection of entrance doors at Grenfell Tower

¶41.94 In section 12 of his fire risk assessment template referring to the means of escape Carl Stokes included the questions whether fire doors were fitted with self-closing devices and whether they functioned correctly.¹¹⁷³¹¹⁷³ For example, Carl Stokes's fire risk assessment of Grenfell Tower dated 26 April 2016 {CST00003084/18}. It was his own addition to the model template contained in PAS 79:2012.¹¹⁷⁴¹¹⁷⁴ PAS 79:2012, Annex B model proforma fire risk assessment template {LFB00034866/77}.

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¶41.95 Carl Stokes said that he did not make appointments to inspect doors but knocked on doors and asked residents whether he could inspect them and, in particular, whether self-closers were fitted.¹¹⁷⁵¹¹⁷⁵ Stokes {CST00003063/20} page 20, paragraphs 58 and 59. He said that tried to inspect at least a handful, or about 5%, of entrance doors¹¹⁷⁶¹¹⁷⁶ Stokes {Day136/96:3-12}. and that if the doors in a building were of the same kind, he aimed to inspect a sample. If they differed, he aimed to inspect at least one of each kind.¹¹⁷⁷¹¹⁷⁷ Stokes {Day136/95:21}-{Day136/96:2}. However, even when the doors in a building were all of the same kind, inspecting only 5% of them was barely enough.¹¹⁷⁸¹¹⁷⁸ Lane {Day171/179:14}-{Day171/180:6}; Todd {Day168/8:24}-{Day168/9:8}.

¶41.96 Notwithstanding what he said about his approach to sample inspections, the evidence suggests that at Grenfell Tower Carl Stokes did not carry out sample inspections of entrance doors which extended to both the external and internal faces of the doors, including self-closing devices. The evidence tends to support the conclusion that he looked only at the outside of doors and that he noted only such damage as he happened to see rather than visiting a number of flats as part of an organised plan. In the course of four fire risk assessments he carried out at Grenfell Tower between November 2012 and June 2016 Carl Stokes identified defects in only four entrance doors.¹¹⁷⁹¹¹⁷⁹ Carl Stokes identified holes in the flat entrance doors of flats 166 and 202 in his Record of Significant Findings and Action Plan for Grenfell Tower dated 20 November 2012 {CST00003083/3} item 12b. Carl Stokes identified that the flat entrance door of Flat 24 was damaged and that the door to Flat 112 was being replaced, was not marked as fire rated and did not have a self-closing device, Record of Significant Findings and Action Plan dated 20 June 2016 {CST00003069/4-5} items 12g and 12h.Show full note Only one of them was a defect that affected the inside face of the door: a self-closing device missing from the door to Flat 112. As it happened, the door to Flat 112 was being replaced in June 2016 and had been open at the time he was carrying out his fire risk assessment. His ability to inspect the inside of the door had therefore been fortuitous rather than planned.¹¹⁸⁰¹¹⁸⁰ Stokes {Day138/130:17}-{Day138/131:1}.

¶41.97 Carl Stokes's failure to identify defects on the inside of doors, particularly defective and missing self-closing devices, is in stark contrast with what others who carried out sample inspections of entrance doors at Grenfell Tower found. Leon Taylor, who carried out a sample inspection of entrance doors in the course of a fire risk assessment on 14 June 2014 found at least three self-closing devices missing,¹¹⁸¹¹¹⁸¹ {TMO10001286} 'FRA' sheet, ref L6, row 232; Taylor {PSC00000002/2} page 2, paragraph 2.d. whereas Carl Stokes, who carried out a fire risk assessment on 17 October 2014, did not find any self-closing devices missing. Michelle McHugh, of the LFB fire safety team, carried out an inspection of a sample of entrance doors during her audit of Grenfell Tower on 26 October 2016 and found that three self-closing devices were defective,¹¹⁸²¹¹⁸² {LFB00105489/6} penultimate paragraph under 'Observations'. but Carl Stokes did not find any devices missing during his fire risk assessments in April and June 2016 or during an inspection he carried out on 18 October 2016, only a week or so before Ms McHugh.¹¹⁸³¹¹⁸³ {CST00003098}; {CST00003069}; {CST00003137}.

¶41.98 Given the number of self-closing devices that were found to be missing or broken after the fire (some 77 out of 120), and in the light of Leon Taylor and Michelle McHugh's findings, we think it likely that, if Carl Stokes had inspected both the inside and outside of a representative sample of entrance doors during his fire risk assessments, he would have discovered a significant number of missing or defective self-closing devices.¹¹⁸⁴¹¹⁸⁴ {MET00039807/76-80}. Accordingly, we think it unlikely that he did routinely inspect the inside of doors.

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¶41.99 Carl Stokes kept no record of which flats he had visited or tried to visit as part of his fire risk assessments or of the results of any such inspections, except in relation to the four defects he identified in his action plans.¹¹⁸⁵¹¹⁸⁵ For example, {CST00003084/19}.

¶41.100 In each of his fire risk assessments Carl Stokes stated that the entrance doors to the flats had recently been replaced with new self-closing 30-minute fire doors but he did not say that he had inspected a sample of entrance doors.¹¹⁸⁶¹¹⁸⁶ {CST00003157/19}; {CST00003161/21}; {CST00003145/20}. Further, in his contemporaneous notes of the fire risk assessment he carried out on 20 June 2016, he recorded only the defects that he had identified on the outside of the door to Flat 24 and on the open door to Flat 112.¹¹⁸⁷¹¹⁸⁷ {CST00000003/10}. He did not include a note of any other flats he had sought to enter, nor what he had found. That has left us in some doubt whether he did, in fact, inspect a representative sample of entrance doors during any of his fire risk assessments.

¶41.101 Gaining access to flats clearly posed a problem for Carl Stokes from time to time. In his fire risk assessment of Grenfell Tower dated 30 September 2009 (when he was working for Salvus), he recorded that the entrance to each flat appeared to be a rated fire door to FR30 standard but that without being able to obtain access to all the flats he could not confirm that every door was fitted with an intumescent strip, cold smoke seals and a self-closing device.¹¹⁸⁸¹¹⁸⁸ Carl Stokes's fire risk assessment of Grenfell Tower dated 30 September 2009 {CST00003128/9} item 3.4. He confirmed when he gave evidence that he had not always been able to gain access to flats because, for example, the residents were out at work.¹¹⁸⁹¹¹⁸⁹ Stokes {CST00003063/20} page 20, paragraphs 58 and 59; Stokes {Day138/149:11-15}. However, he did not tell the TMO that he was having difficulty in inspecting the inside of entrance doors to flats because people were not at home to let him in,¹¹⁹⁰¹¹⁹⁰ Carl Stokes said that he considered the sample inspections he carried out to be sufficient and that he did not tell the TMO that he had been unable to obtain access to a sufficient number of doors because he was happy with the process that he had adopted. Stokes {Day138/150:11}-{Day138/151:11}. and except for the fire risk assessments he produced in 2009, he did not record that as a problem. If he could not gain access to enough flats to inspect a representative sample of doors, he ought to have told Janice Wray so that she could arrange access for him.¹¹⁹¹¹¹⁹¹ Lane {Day171/181:19-24}.

¶41.102 Carl Stokes also failed to record in his fire risk assessments for Grenfell Tower problems that he knew existed in relation to self-closing devices. For example, in the assessment he carried out in November 2012, he did not mention the recurring problem of people disconnecting self-closing devices that he had identified in July 2011.¹¹⁹²¹¹⁹² {TMO00867783}; {CST00003084/19}. Similarly, in the assessment he carried out in April 2016, he did not mention the missing self-closing device at Flat 45 that he had identified in July 2015, nor the fact that Seamus Dunlea had been removing self-closing devices on entrance doors, something he had discovered in December 2015.¹¹⁹³¹¹⁹³ {CST00001448}; {TMO00859693}; {CST00003161}. There is nothing to suggest that he had been told that those problems had been satisfactorily resolved and he ought, therefore, to have taken steps as part of his next fire risk assessment to find out. If they had not, or if he did not get a satisfactory response, he should have taken that into account in assessing the risk.

¶41.103 We have seen no evidence that Carl Stokes ever considered the TMO's arrangements for the inspection and maintenance of entrance doors to flats, whether as part of his fire risk assessments or otherwise, much less that he advised it that they were inadequate. When he was asked to comment on the draft strategy in early 2013, he did not tell Janice Wray that it needed to include arrangements for the inspection and maintenance of entrance doors, although the LGA Guide recommended inspections every six months and Andy Jack had referred to the need for regular inspection in the course of their conversation on 8 November 2012.¹¹⁹⁴¹¹⁹⁴ {CST00002046}.

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¶41.104 We have seen no evidence that Carl Stokes ever drew Janice Wray's attention to the recommendation in the LGA Guide, although she said she had been aware of it.¹¹⁹⁵¹¹⁹⁵ Wray {Day143/71:20}-{Day143/72:14}; {Day143/91:20-23}. Nor did he mention it in his letter of 30 April 2011 when he drew her attention to other provisions of the draft LGA Guide which could adversely affect the replacement of doors, including the risk of residents' removing self-closing devices.¹¹⁹⁶¹¹⁹⁶ Note the letter from Carl Stokes to Janice Wray is wrongly dated as 30 April 2010 {TMO00847318/1}. He also failed to draw it to her attention after the Adair Tower fire when there were discussions about the approach the TMO should take to self-closing devices, of which he appears to have been aware.¹¹⁹⁷¹¹⁹⁷ For example, {CST00007708/1-2}; {CST00006634/1}; {CST00002902/1}; {CST00002302/1-2}.

¶41.105 In the fire risk assessment of Grenfell Tower he produced in April 2016, Carl Stokes referred to the TMO's policy of inspecting self-closing devices in vacant properties¹¹⁹⁸¹¹⁹⁸ {CST00003161/21}. but he did not comment on its adequacy. It is not clear what prompted him to refer to the policy for the first time in April 2016.

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