Grenfell Tower Inquiry: Phase 2 Report · 2024
Chapter 42: Fire safety information
Chapter 42: Fire safety information
¶42.1 Under the Fire Safety Order the TMO had a duty to take such general fire precautions as would ensure, so far as was reasonably practicable, that Grenfell Tower was safe for those who lived there, their visitors and its own employees.1199 Article 8. General fire precautions include measures in relation to the means of escape and the arrangements for action to be taken if a fire occurs.1200 Article 4(1). It also had a duty to establish procedures to be followed in the event of serious and imminent danger to persons present in the parts of the tower to which the Fire Safety Order related.1201 Article 15(1). As part of our investigation into the fire that occurred on 14 June 2017, therefore, we have considered it appropriate to examine the steps taken by the TMO to comply with those duties. In earlier chapters we have examined the steps taken by the TMO to carry out fire risk assessments as required by the Fire Safety Order and we have described the problems that affected the smoke ventilation system. In this chapter we consider the information given to residents relating to fire safety.
¶42.2 Before the refurbishment Grenfell Tower had been constructed entirely of concrete, apart from some internal structures and the usual internal fittings. The structure was therefore not combustible. The front door of each flat was a fire door and had originally been fitted with a self-closing device. Although a fire could spread from one flat to another up the outside of the building or through the lift lobby, that was likely to happen relatively slowly, giving time for the occupants to escape and the fire brigade to gain control before many people were affected. That was the design principle behind the "stay put" strategy for responding to fires in individual flats which had proved effective in the past.
¶42.3 The existence of a "stay put" strategy was reflected in the advice the TMO gave residents about how to respond to a fire in the building. It also affected the way in which it approached the question of evacuation.
¶42.4 The TMO provided fire safety advice to residents in letters to new tenants, in magazines distributed to residents (Link magazine and Homeowner newsletter), through fire action notices and in roadshows held by the TMO Resident Engagement team.1202 Wray {TMO00000890/53-55} pages 53-54, paragraphs 245-250. Written materials were produced in the seven major languages identified as being most likely to meet the needs of the residents.
¶42.5 Before moving into a property, new residents were given a handbook that included some fire safety advice, including instructions not to store items in communal areas or obstruct the means of escape. The TMO did not display fire safety action notices in residential buildings because it considered that it had provided the relevant information in other ways.1203 Letter from Carl Stokes to Janice Wray dated 27 September 2010 {CST00001979}; Stokes {Day136/217: 2}-{Day136/219:8}; Stokes {Day136/220:15-22}.
136The resident's handbook
¶42.6 Historically, the resident's handbook had contained some fire safety advice,1204 Tenant's Handbook {IWS00001762} and Rasoul {IWS00001768/3} page 3, paragraph 13. such as how to prevent a fire and how to make sure that a smoke detector was installed, but no advice on how to respond to a fire.1205 Tenant's Handbook {IWS00001762} and Rasoul {IWS00001768/3} page 3, paragraph 13. The original stock of handbooks ran out in 2008 or 2009. There were no plans to publish any more at that time, but later on a decision was made to produce a new version.1206 Jones {TMO00900052/3} page 3, paragraph 9; "Tenant's Handbook" was used interchangeably with "Resident's Handbook". The TMO also produced a "Homeowner's Handbook" which was intended for leaseholders and contained information which was different from that provided to tenants. By January 2010 a first draft was said to be ready for consideration,1207 {TMO10000641/2}. but in the event it had not been published by the time the coroner made her recommendations following the Lakanal House inquests in March 2013, four years later. They included a recommendation that information and guidance should be provided to residents about fire procedures.
¶42.7 In June 2013, Janice Wray told the Health and Safety Committee that residents received fire safety information on the TMO's website, in the resident's handbook, through articles in Link and in letters and LFB leaflets to new tenants. She asked the committee to consider what other opportunities there were to promote fire safety and fire procedures to residents. No one appears to have pointed out that the new resident's handbook had not been finished and so could not be distributed to residents. It is not clear why Janice Wray told the committee that information was given in the handbook. Although she may not have had direct knowledge of the matter, she told us that she had thought that by March 2013 it had been finalised.1208 Wray {Day142/185:17-23}. However, that seems unlikely.
¶42.8 When the TMO's Fire Safety Strategy was completed in November 2013, it referred to the resident's handbook as one means by which information about fire safety was communicated to residents.1209 Fire safety policy dated November 2013 {TMO00830598}. Although the strategy was submitted to the Health and Safety Committee for its views in November 2013, no one mentioned that the resident's handbook had still not been finished.1210 The meeting was attended by, among others, Sacha Jevans, Janice Wray, Peter Maddison, and Alex Bosman. Minutes of TMO Operational Health & Safety Meeting dated 15 November 2013 {TMO10004726/6}. In 2017, when the Health and Safety Committee's views were sought on the revised fire safety strategy, yet again no one raised the fact that the handbook had not been produced,1211 The meeting was attended, among others, by Barbara Matthews, Janice Wray, Peter Maddison and Teresa Brown. Minutes of Health and Safety Committee Meeting dated 13 June 2017 {TMO10021549/4}. even though it was one of the ways of communicating with residents referred to in the fire safety strategy.1212 Fire safety strategy dated June 2017 {TMO00847324/3}.
¶42.9 The delay in the production of the resident's handbook illustrates many aspects of the TMO's attitude to its fire safety obligations. Having rightly identified the need for a revised handbook in 2010, nothing had been produced by June 2017. Although the handbook had been repeatedly relied upon as a way of communicating information to residents about how to respond to a fire, no one at the TMO had noticed that supplies of the old handbook had been exhausted in 2008 or 2009 and that the new edition had never been produced. The effectiveness of the TMO's Emergency Plan depended to a great extent on residents being aware of what to do in an emergency, but the TMO's failure over such a long period of time to make it available denied residents one useful means of receiving that information. No reasonable explanation was offered for that failure.
137Letters to new residents
¶42.10 We have seen three draft letters to new residents containing fire safety advice. The first appears to date from December 2010.1213 {TMO00870665}. It advised new residents, among other things, that: a. there was a "stay put" strategy in place; b. they should not prop open fire doors; c. they must not disconnect the self-closing device on the entrance door to the flat; d. they should fit a smoke alarm, if one was not already installed; e. they should not use a lift in the event of a fire; f. they should refer to the resident's handbook for additional fire safety information; and g. they would be provided with a personal emergency evacuation plan (PEEP) if they had difficulty hearing or responding to a smoke alarm or had special requirements. The letter we were shown was a draft and we do not know whether it was sent to any new residents.
¶42.11 The letter was substantially revised in May 2013.1214 {TMO00865707}. In its new form it advised residents: a. to ensure that an operational smoke alarm was installed in their flats; b. that if there was a fire elsewhere in the building, residents were safe to stay in
their flats unless they were affected by heat, flames, smoke or the LFB or the TMO instructed them to leave; and
¶c. that the front door should be self-closing and should not be propped open. Residents were encouraged to report defective doors to the TMO. Again, it is not clear whether that letter was ever used.
¶42.12 Some minor changes were made to the letter in September 2016, but the contents remained essentially the same.1215 {TMO00865991}. We do not know why the reference to PEEPs was removed from the 2013 and 2016 drafts.1216 Wray {Day142/187:13-25}. Janice Wray thought that the housing officers who met residents took them through the induction pack and, if there were any concerns about vulnerability, came back to her so that appropriate action could be taken.1217 Wray {Day142/187:17-25}.
¶42.13 The letter was provided to residents as part of an induction pack by Moira MacDonald, the TMO officer who arranged viewings for prospective tenants.1218 Wray {Day142/187:4-11}. They could ask for a translation, but there is no evidence that they were routinely told that a translation could be provided. There was no system to record whether residents received the letter during the induction process.1219 Wray {Day142/187:1}.
138¶42.14 Daniel Lewis, a TMO Neighbourhood Co-ordinator, said that fire safety advice for new residents had not been included in the documents that formed part of the "Welcome Pack" that he had compiled and that the Neighbourhood Officer provided to new residents.1220 Lewis {TMO00899762/3} page 3, paragraph 10. Janice Jones agreed that the fire safety letter had not been included in the pack, but said that Moira MacDonald took her own paperwork to viewings, including a fire safety letter signed by Janice Wray.1221 Jones {TMO00900052/6} page 6, paragraph 24.
¶42.15 We have been left with the impression that it was largely a matter of chance whether new tenants, at whom the fire safety letter in its various versions was directed, saw it at their viewings. The point of the letter was to bring home to tenants in clear terms the fire safety arrangements in their buildings. That was important, but the TMO simply failed to ensure that the message always reached its intended recipients.
'Link' magazine
¶42.16 Link was a quarterly publication for TMO tenants. Originally it was produced only in English, but from 2012 it contained information about how it could be translated into other languages.1222 See, for example, Link Magazine dated Winter 2012 {TMO00873414}; Link magazines from 2009 did not include information about how to translate the newsletter; see, for example, Link Magazine dated Winter 2009 {TMO10048206}. TMO leaseholders received the Homeowner newsletter instead of Link.
¶42.17 Some issues of Link and Homeowner contained fire safety advice. In the Winter 2009 issue of Link the TMO announced that a fire safety consultant would carry out fire risk assessments in the communal areas and would require access to the front doors of some flats. Residents were reminded not to smoke in communal areas and to keep those areas free of items.1223 Link Magazine Winter 2009 {TMO10048206/5}.
¶42.18 Fire safety advice was also included in the June 2013, Summer 2014 and Autumn/Winter 2015 issues.1224 Link Magazine Autumn/Winter 2015 {TMO00873549}; Link Magazine Summer 2014 {TMO10031098}; Link Magazine June 2013 {TMO00873438}; Link Magazine Winter 2009 {TMO10048206}. Only the latter, published after the Adair Tower fire, gave advice about evacuation and what to do if there was a fire.1225 Link Magazine Autumn/Winter 2015 {TMO00873549/25}.
¶42.19 Some editions of Homeowner also contained information about fire safety, including advice about compliance with the requirements relating to flat entrance doors and smoke alarms.1226 Homeowner Newsletter December 2013 {TMO00873466}; Homeowner Newsletter June 2015 {TMO00873520}; Homeowner Newsletter Winter 2015 {TMO00873536}. However, only the Summer 2016 issue contained advice about what to do in the event of a fire.1227 Homeowner Newsletter Summer 2016 {TMO00873556/4}. It is clear that, as Janice Wray accepted, there had been no regular programme for the distribution of fire safety advice; it was included as and when it seemed appropriate.1228 Wray {Day142/189:2-23}. Contrary to the statements made in the fire safety strategies of November 2013 and June 2017, Link and Homeowner did not regularly contain fire safety information or information about the evacuation strategy in properties managed by the TMO.1229 Fire safety strategy dated September 2013 {TMO00830598/3}; fire safety strategy dated June 2017 {TMO00847324/3}. In any event, they were distributed to tenants in a wide range of buildings, so it was not possible to include in them advice which related to specific buildings.
139Fire safety advice leaflets
¶42.20 Carl Stokes delivered leaflets on fire safety produced by the LFB to residents of smaller TMO premises.1230 Stokes {Day139/ 99:2}-{Day139/100: 20}; Carl Stokes confirmed he distributed the leaflet {CST00017272}. He did not do that in the larger blocks, as he thought the caretakers would leave them with the concierge instead. Carl Stokes did not deliver any leaflets to the residents of Grenfell Tower because there was a caretaker or handyman who did that.1231 Stokes {Day139/ 101:9-14}.
Roadshows
¶42.21 The TMO organised regular "Roadshows" which were used informally to consult or communicate with residents. On one occasion, on 14 May 2016, Janice Wray invited the LFB to attend a roadshow in Lancaster West Green to speak to residents about fire safety.1232 Wray {TMO00000890/54} page 54, paragraph 250; Email from Janice Wray to LFB dated 13 April 2016 {LFB00001085}. However, that was no substitute for consistent, clear and regular communication of fire safety advice to residents.
Website
¶42.22 The TMO maintained a website, which included a page containing fire safety advice. A page headed "Fire and smoke alarms" provided advice on fire safety measures. It first appeared on the website on 13 February 2012.1233 {TMO00899658/18}. The website set out detailed advice on fire safety, including advice on the evacuation strategy for residential blocks with purpose-built self‑contained dwellings.1234 {TMO00899658}.
¶42.23 Apart from a minor change to its contents, the "Fire and smoke alarms" page remained available on the TMO's website until 14 June 2017.1235 {TMO00899658/17}. Again, it was not a comprehensive statement of the fire safety advice to all residents and its efficacy depended on residents' accessing, and being able to access, the website to find information for themselves. Engagement, therefore, depended on the curiosity or sensitivity to risk of the individual tenant. The disadvantages of the website as a means of communicating fire safety information are obvious.
Fire Safety Advice during the refurbishment
¶42.24 From September 2013 to May 2016, the TMO and Rydon distributed newsletters almost monthly to the residents of Grenfell Tower. Two newsletters published in July 20141236 {CST00001919/2}. and May 2016 respectively1237 {JRP00000028/4}. contained fire safety advice.
140Fire action notices
¶42.26 In September 2009, Salvus identified a number of deficiencies in the TMO's management of fire safety across its housing stock, one of which was that adequate information and instruction on fire safety was not provided to employees. It also said that fire action notices were not displayed in properties where there was no fire alarm system and that residents did not receive specific individual emergency plans based upon the layout of their buildings.1241 {SAL00000013/10} section 7.2. It recommended that fire action notices should be displayed in all properties managed by the TMO setting out the fire action procedure for the particular property.1242 {SAL00000013/17} section 7.2.
¶42.27 On 26 January 2010, fire action notices were considered at a progress meeting with Salvus on fire risk assessments in high-risk blocks.1243 {RBK00052572/1} paragraph 2.2. There was a long discussion about whether to install a notice in the main entrance of each block setting out the emergency procedure in relation to that block. It was agreed that fire action notices should be put up in each block and that letters should be sent to residents describing the evacuation procedure.1244 {RBK00052572/1} paragraph 2.4.
¶42.28 On 13 May 2010, the TMO's Operations Committee agreed to put fire action notices in each block,1245 {TMO10037437/89}; Wray {Day142/211:11-18}. but the matter was not raised again at any subsequent meetings and in September 2010 Janice Wray presented a report on fire risk assessments which said nothing about fire action notices.1246 {TMO00899839/4}; {TMO00888971/1}. Instead, she reported that the TMO would write to the residents in each block explaining the relevant evacuation procedure and summarising the fire risk assessment's findings. The decision to post fire action notices was seemingly forgotten.
¶42.29 On 27 September 2010, Carl Stokes wrote to Janice Wray, at her request, about fire safety signage in the TMO's residential buildings.1247 {CST00002701}. He told her that, as the TMO provided fire safety information to residents in other ways, fire action notices were not required. Janice Wray accepted that advice, but she did not tell the Operations Committee or the executive team that the decision to put up fire action notices would not be carried out, though she believed that she had told her line manager.1248 Wray {Day142/212:15}-{Day142/213:20}.
¶42.30 Janice Wray was of the view that the LGA Guide (which was published after Carl Stokes's advice of 27 September 2010) supported her understanding that fire action notices were not required in high-rise residential blocks.1249 Wray {Day142/212:22}-{Day142/213:4}; {Day142/214:11-25}. The LGA Guide suggested that there would rarely be a need for a more elaborate emergency plan than a simple fire action notice. It also said that it was not universally necessary to display a fire action notice and that it was common to convey the emergency plan to tenants in other ways, for example, through residents' handbooks {HOM00045964}. She told us that she had thought that the passage in which it is stated that it is not always necessary to display fire action notices in blocks of flats with simple layouts was consistent with Carl Stokes's previous advice.1250 {HOM00045964/118}. Nonetheless, neither she nor Carl Stokes assessed each block to decide whether a fire action notice was required. On the contrary, the same generic approach was taken by the TMO to all its high-rise residential buildings.1251 Wray {Day142/217:6}-{Day142/219:19}. However, the LGA Guide did not say that fire action notices are never required in a purpose-built block; on the contrary, paragraph 79.1 provided in terms that a fire action notice would usually be all that would be needed by way of emergency plan for most purpose-built blocks.1252 {HOM00045964/118}. If Janice Wray and Carl Stokes thought that it supported a blanket decision not to put up fire action notices in any of the buildings managed by the TMO, they were mistaken.
141¶42.31 The question of fire safety advice for residents was considered by the TMO again after the coroner published her recommendations following the Lakanal House inquests. The inquests had identified the need to find ways to advise residents about the fire procedure other than by the website, leaflets, magazines and letters. However, no effective alternative had yet been identified and fire action notices do not appear to have been discussed. On 2 May 2013, Janice Wray wrote a report for the Operations Committee about the TMO's fire risk assessments which summarised the coroner's recommendations following both the Lakanal House and Shirley Towers inquests, particularly as they touched upon the "stay put" strategy.1253 {TMO10031056/5}. The Lakanal House coroner's recommendations were discussed at a meeting between the LFB Fire Safety team and the TMO Health & Safety team at a meeting on 15 May 2013.1254 {TMO00844568/2-3}.
¶42.32 A further briefing note was circulated to the Health and Safety Committee about the recommendations and the implications for the TMO1255 {TMO10039112}. which included a reference to the need to provide information and guidance to residents about fire procedures. The coroner's recommendations were discussed again at a meeting of the TMO's Health and Safety Committee on 20 June 2013.1256 {TMO00880630/4}. Janice Wray asked the committee to consider other opportunities for promoting fire safety and bringing fire procedures to the attention of residents.1257 {TMO00880630/4}. There was no mention of the coroner's recommendation to put up fire action notices, however, and the committee did not identify any new ways of providing fire safety information to residents. Nor was there any discussion at the meeting of the agreement that had been reached by the committee in May 2010 to install fire action notices in each block or why that had not been done. There was no discussion either about whether the coroner's recommendations should lead the committee to reconsider the assumption that it was not necessary to put up fire action notices in any of the buildings managed by the TMO.
¶42.33 On 23 December 2015, following the Adair Tower fire on 31 October 2015, the LFB issued enforcement notices against the TMO and RBKC.1258 {RBK00029298/4}. One breach of the Fire Safety Order they identified was that the TMO's procedures in the event of serious and imminent danger were inadequate. That was because no instructions about action to be taken in the event of a fire had been displayed in the common parts of the premises where they might be seen by visitors and other relevant persons.1259 {RBK00029298/6}.
142¶42.34 Janice Wray and Rebecca Burton discussed the enforcement notice at their next regular meeting on 5 January 2016.1260 {RBK00013997/1}. Rebecca Burton confirmed that the LFB required work to be completed within six months from the date the notice had been posted, i.e. by 23 June 2016. She told Janice Wray that, although the notice related to Adair Tower, the LFB expected that the standards required in one block would be applied in others.1261 {RBK00013997/2}. Janice Wray told her that the TMO had not put up fire action notices because the buildings were not complex and a "stay put" strategy was in place. Rebecca Burton indicated that notices were required, but that it was not a priority.1262 {RBK00013997/2}. In the light of that Janice Wray did not think the requirement was pressing.1263 Wray {Day142/222:10}-{Day142/223:20}.
¶42.35 Rebecca Burton told us that in her view fire action notices were of limited use.1264 Burton {Day145/134:3-11}. When shown the wording of the enforcement order which proposed an adequate fire action notice in the common parts, she said that the LFB would suggest action but that it was for the responsible person to decide how to comply with the notice.
¶42.36 If the TMO had provided its residents with fire safety information, we can see why fire action notices might not have been required, but it did not provide them with such information. The tenancy pack included no fire safety information and had not done so for many years, and the newsletters contained no advice about what to do in the event of a fire until the Autumn/Winter 2015 issue of Link which was published after the Adair Tower fire. There was no resident's handbook.1265 {TMO00873549/25}. Nothing said by Rebecca Burton could fairly have led Janice Wray to think that it was acceptable to have no fire action notices in buildings managed by the TMO, let alone that that would be consistent with the LGA Guide. Janice Wray can fairly be criticised for seeking to justify doing the minimum in the face of the enforcement notice.
¶42.37 Shortly afterwards, on 8 January 2016, Councillor Pat Mason sent an email to Councillor Marshall expressing concern about the advice given to residents on fire procedures. The email followed a meeting of the Cabinet and Corporate Services Scrutiny Committee, which had discussed the Adair Tower fire.1266 {RBK00053869/5}. On 9 January 2016, Councillor Marshall asked Robert Black to set out the advice that was normally given to residents of high-rise residential buildings.1267 {RBK00053869}. Robert Black responded on 15 January 2016,1268 {RBK00053869/3}. saying that "stay put" advice was given to residents of high-rise buildings and was available on the website, in regular fire safety articles in Link and in LFB leaflets distributed by the fire risk assessor to some dwellings.1269 {RBK00053869/3-4}. In relation to procedures to respond to a major fire breaking out at the weekend when offices were closed, he said that Pinnacle, the out-of-hours call handling service, would activate the emergency plan. Janice Wray and Hash Chamchoun were the principal contacts and other staff were available. Estate services staff would also be called out to visit and assess the situation.1270 {RBK00053869/4}.
143¶42.38 On 14 April 2016, Councillor Pat Mason wrote to Robert Black asking whether fire safety information was provided to residents otherwise than on the TMO's website. He was concerned that not all residents might have access to the internet.1271 {TMO00865782/3}. Janice Wray responded on 15 April 2016 saying that such information was provided to residents on the TMO website, in the letter to new tenants and by regular articles in Link and Homeowner.1272 {TMO00865782/1}. However, her response tended to gloss over the defects we described earlier in the quality of the information provided by the TMO and its delivery to residents.
¶42.39 It was not until 13 September 2016 that the Health and Safety Committee considered putting up fire action notices in all buildings managed by the TMO.1273 {TMO00840753/5}. The committee expected the LFB to require notices to be placed in all buildings, having seen the position it had taken in the Adair Tower enforcement notice. The TMO therefore decided to adopt a risk-based approach and to start placing fire action notices in high-risk buildings.1274 {TMO00840753/5}. That was a far cry from what Janice Wray had understood to be required as a result of her meeting in early January 2016 with Rebecca Burton, but it was the correct approach. On 13 October 2016, Barbara Matthews asked Janice Wray to develop a programme for putting up fire action notices in all the TMO's buildings and to provide costings.
¶42.40 A month later, on 17 November 2016, the LFB issued a deficiency notice in relation to Grenfell Tower because there were no fire action notices in the common parts (among other reasons).1275 {TMO10017254}. The deficiency notice was issued a year after the Adair Tower fire, 11 months after the enforcement notice relating to Adair Tower and two months after Janice Wray had told the Health and Safety Committee that fire action notices would be installed in all properties managed by the TMO. Janice Wray was not able to say why there had been a delay in putting up the fire action notices; she thought they had been on order by that time.1276 Wray {Day143/3:7-14}; {Day143/6:24}-{Day143/7:8}. However, the evidence we have seen suggests that a quotation for fire action notices for Grenfell Tower had been requested on 23 November 2016 after Edward Daffarn and Councillor Blakeman had complained about the lack of notices.1277 {TMO00861289/2}.
The Grenfell Action Group blog - "KCTMO - Playing with fire"
¶42.41 On 20 November 2016, Edward Daffarn posted an article on the Grenfell Action Group blog entitled "KCTMO – Playing with fire". In it he criticised the TMO for failing to take fire safety seriously. He said that the Grenfell Action Group firmly believed that only a catastrophic event would expose what he described as the "ineptitude and incompetence" of the TMO.1278 {TMO00845987}. The post contained links to previous blogs on fire safety and referred to the Adair Tower fire in October 2015, saying that the LFB had found that the TMO had not looked after the safety of residents properly and had issued an enforcement notice compelling it to improve fire safety. He said that the residents of Grenfell Tower had received no proper fire safety instructions from the TMO. Residents, he said, had been informed by a temporary notice in a lift and one announcement in a recent regeneration newsletter that they should remain in their flats in the event of fire.1279 {TMO00845987/2}.
144¶42.42 The post has since gained a degree of notoriety for its apparent prescience, but it did not in fact predict the fire at Grenfell Tower, much less what turned out to be its cause. Nonetheless, based on his own experience as a resident of Grenfell Tower, Mr Daffarn was able to put his finger on something very wrong with the TMO's management of fire safety and used his forthright style to make his point. Shorn of the rhetoric, it was a message that the TMO could not afford to ignore.
¶42.43 On 23 November 2016, Councillor Blakeman saw the blog post and raised its contents with Robert Black. She agreed with Mr Daffarn's point that instructions were not permanently available on noticeboards or in letters to residents (or in appropriate languages, where required) and asked whether that could be rectified.1280 {TMO10015228/2}.
¶42.44 Robert Black asked Janice Wray to prepare a response.1281 {TMO10015214/1}. She told him that advice on fire procedures was included in newsletters, on the website, in regular articles in Link and provided to all new tenants. She said the Health and Safety Committee had been considering putting up fire action notices in all the buildings and that, although the LFB had issued a deficiency notice relating to the absence of fire action notices, its attitude to the need for them had been inconsistent. Janice Wray asked for permission to order notices for Grenfell Tower to address Mr Daffarn's concerns.1282 {TMO10015214/1}. She also said that although Mr Daffarn was challenging the "stay put" strategy, none of the professionals with whom she had discussed Grenfell Tower had suggested that there was a need to change it.
¶42.45 A quotation for the cost of obtaining fire action notices was provided on 23 November 2016, presumably in response to the issue of the deficiency notice, Mr Daffarn's blog post and Councillor Blakeman's concerns.1283 {TMO00829191}. On 14 December 2016, Janice Wray confirmed that 30 fire action notices had been put up in Grenfell Tower the previous day.1284 {TMO00861381}. They cost £328.32.1285 Quote for fire action notices for Grenfell Tower {TMO00829191}.
¶42.46 In the response that she prepared for Mr Black to send to Councillor Blakeman, Janice Wray failed to mention that on 17 November 2016 the TMO had received a deficiency notice in relation to Grenfell Tower and that one of the deficiencies identified had been the absence of fire action notices. There is no doubt that Councillor Blakeman should have been told about the notice and its substance. She was a member of the TMO board who had specifically asked about fire safety advice in response to a resident's concerns and she should have been given the full picture. Janice Wray's failure to mention the deficiency notice to Councillor Blakeman mirrored Robert Black's own failure to bring the notice to the attention of the TMO Board, a matter to which we have referred in Chapter 31.
¶42.47 On 2 December 2016, Peter Maddison asked if any of the allegations in the blog post could be considered libellous.1286 {TMO00865831/3}. Barbara Matthews responded indicating that she had spoken to Robert Black and that they agreed to take no action in response to it.1287 {TMO00865831/1}. Peter Maddison's reaction, to seek advice about whether Mr Daffarn had libelled the TMO rather than to get to the bottom of the complaint, was telling. By this point, the TMO's defensiveness and hostility towards the Grenfell community, at least as represented by Mr Daffarn, had sunk to a new low.
145¶42.48 The history of fire safety notices illustrates a reluctance on the part of the TMO to take active steps to promote fire safety. Although the need for fire action notices was first raised in 2009 by Salvus, they were not provided until the end of 2016 after the LFB had issued a deficiency notice and Councillor Blakeman had questioned the position having read Mr Daffarn's blog post. In the end, fire action notices proved a relatively inexpensive means of providing fire safety advice. Their timely installation following Salvus's advice in 2009, or even immediately after the Adair Tower fire in 2015, would have ensured that consistent advice was available to residents. That might have gone some way to reassuring them that fire safety was taken seriously by the TMO. The delay in installing fire action notices should also be understood in the context of enquiries and complaints from residents of Grenfell Tower about the evacuation strategy.
Residents' complaints about fire safety advice
¶42.49 Mr Daffarn's was not a lone voice. The blog post of 20 November 2016 was the culmination of a long history going back to 2010 of complaints about fire safety by residents of Grenfell Tower.
¶42.50 On 3 September 2010, the Leaseholders' Association wrote to Robert Black setting out 11 areas of concern that had arisen as a result of the fire on 30 April 2010.1288 {TMO10037439}. The letter said that no one in the block had been aware of the evacuation procedure and that they had not been given information about what to do in the event of a fire in the previous 36 years.1289 {TMO10037439/5}.
¶42.51 Anthony Parkes responded on Robert Black's behalf on 21 September 2010,1290 {TMO00846320}. saying that the fire alarm was functioning and the smoke ventilation system had been working at the time (although in fact it had not).1291 {TMO00846320/4}. He did not address the complaint that residents had not been informed of the evacuation procedure.
¶42.52 On 6 October 2010, the Leaseholders' Association sent another letter to the TMO making a number of complaints again.1292 {IWS00001310}. Anthony Parkes responded on 27 October 2010. Among other things, he said there was a "stay put" strategy in place, which he explained. He also said that information about fire safety was regularly published in Link and that the TMO planned to write to the residents of each block to advise on the action to be taken in response to a fire in that block.1293 {TMO00836390}. He also expressed the TMO's commitment to working with the Association and invited it to provide some dates when they could meet for a discussion.
¶42.53 In 2012, the Association made further complaints about the management of fire safety. On 14 November 2012, it sent an email to David Ward, the TMO's Home Ownership Manager, about the plan to replace the entrance doors to tenants' flats,1294 {TMO00833837}. asking why leaseholders had not been included in the programme if the replacement related to fire safety and complaining about their omission. They also complained about the lack of health and safety training or drills in case of an emergency.1295 {TMO00833837/1}. Paul Dunkerton responded on 20 November 2012 reminding the leaseholders that a "stay put" strategy was in place at Grenfell Tower, meaning that if a fire were to break out anywhere other than in their own flats they were safe to remain in their homes.1296 {TMOH00027332/2}. The existence of the "stay put" strategy was repeated in several subsequent letters responding to various points raised by the Leaseholders' Association.
146¶42.54 On 29 September 2016, the Association sent an email to Councillor Blakeman raising a number of complaints, including the failure of the TMO to organise any fire drill at Grenfell Tower since 2012. They referred to the recent fire at Shepherd's Bush and asked her to investigate their various concerns.1297 {TMO00846025/35}.
¶42.55 Robert Black circulated the email within the TMO and asked for responses.1298 {TMO00847231}. Janice Wray told him that fire drills were not required in blocks with a "stay put" fire strategy.1299 {TMO10033125}. The purpose of fire drills, she said, was to test the procedure to be followed in the event of a fire and if that was to stay put, a fire drill would conflict with the way residents were expected to respond.1300 {TMO10033125}. Peter Maddison prepared a draft response in which he explained that Grenfell Tower maintained a "stay put" fire strategy1301 {RBK00000142}. and that, if the LFB decided that an evacuation was necessary in response to a particular incident, it would organise it.1302 {RBK00000142}. It is not clear whether that response was sent to the Leaseholders' Association.
¶42.56 Grenfell Compact was formed in 2015 to voice residents' concerns during the refurbishment. Councillor Blakeman responded briefly to the Leaseholders' Association's email on 4 October 2016 attaching a list of complaints that had been prepared by Grenfell Compact in May 2016 together with the TMO's responses to them.1303 {TMO00846745}; {TMO00846746}. They did not include a complaint about the absence of fire action notices, but as mentioned earlier, fire action notices were put up in Grenfell Tower on 13 December 2016.
¶42.57 The repeated complaints by the Leaseholders' Association about fire safety advice and procedures over the years prompted responses from the TMO but not a review of the fire safety advice provided to residents. Instead, the TMO simply repeated the "stay put" advice in correspondence with the Association and took no further action. It is difficult to know, even with the benefit of hindsight, whether the earlier installation of fire action notices would have made any difference, but it might have addressed some of the concerns of the Association to have had the advice set out in accessible and publicly available notices.
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