Chapter 46: Vulnerable residents

The Fire Safety Order

¶46.1 Articles 14 and 15 of the Fire Safety Order set out the duties of the responsible person to ensure that there are effective emergency exits and to establish and give effect to procedures to be followed in the event of serious and imminent danger. We need not set them out in detail here. However, we make two general observations at the outset. First, the expression "relevant persons" includes anyone who is lawfully on the premises.¹⁶⁸³¹⁶⁸³ DCLG regulatory reform (fire safety) order 2005 {CLG00000094/12}, Article 2 That clearly includes all occupants of the building and any visitors, regardless of their physical or mental capabilities, who are in those parts of the building to which the Fire Safety Order applies. The Order extends to the common parts but not to individual flats. Secondly, whatever the origins of the Fire Safety Order, it cannot be read as applying only to premises where there are employees of the responsible person present at all times to provide assistance with evacuation.

¶46.2 Between 2005 and 2017 there was much guidance available to assist those who had responsibility under the Fire Safety Order for managing fire safety to understand their duties to those with disabilities.

DCLG Guidance Note No. 1: Enforcement

¶46.3 DCLG Guidance Note No.1 published in October 2007 gave general guidance to enforcing authorities on the need to ensure that the means of escape were suitable and sufficient to allow safe escape from the premises. In relation to the duties under article 14, paragraph 77 of the guidance advised that all emergency routes and exits should lead as directly as possible to a place of safety and be adequate for everyone to escape quickly and safely. It also advised that the risk assessment should identify any person for whom special evacuation arrangements might need to be made because of their age, state of health, physical or mental abilities or, in some circumstances, their location on the premises.¹⁶⁸⁴¹⁶⁸⁴ DCLG regulatory reform (fire safety) order 2005 {CLG00000094/20}. However, no specific guidance was available in relation to different types of premises, such as high-rise residential buildings, and no distinction was made between residential and commercial premises.

The Sleeping Guide (2007)

¶46.4 The guidance entitled Fire Safety Risk Assessments: Sleeping Accommodation, commonly known as the "Sleeping Guide", published by the government in 2007, was intended to assist in carrying out fire risk assessments in relation to the common parts of buildings containing flats and maisonettes, as well as premises of other kinds.¹⁶⁸⁵¹⁶⁸⁵ HM Government Fire Risk Assessment (Sleeping Accommodations) Guidance 2015 {RBK00036722/6}. 12 bullet points which state that the guide will address the common areas of flats and maisonettes. It was not intended to apply to domestic premises occupied as a single private dwelling, including private flats or rooms. It recommended that when carrying out a fire risk assessment steps should be taken to identify people who may be particularly at risk, such as children and people with disabilities or with a sensory impairment.¹⁶⁸⁶¹⁶⁸⁶ HM Government Fire Risk Assessment (Sleeping Accommodations) Guidance 2015 {RBK00036722/16-17}. In particular, it advised that the means of escape should be assessed to make sure that they are suitable for the evacuation of everyone from the premises, including vulnerable residents. It suggested that, in evaluating the risk to people with disabilities, the responsible person might need to discuss their individual needs with them.

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¶46.5 The Sleeping Guide drew attention to the Disability Discrimination Act 1995 and advised that if a disabled person could realistically be expected to use the premises, the responsible person must make any reasonable adjustments that will make it easier for that person to use and, if necessary, escape from the premises.¹⁶⁸⁷¹⁶⁸⁷ HM Government Fire Risk Assessment (Sleeping Accommodations) Guidance 2015 {RBK00036722/54}, paragraph 1.15. In particular, it advised that the concept of "reasonable adjustments" applied equally to fire safety, although its precise application would depend on the circumstances of each case.¹⁶⁸⁸¹⁶⁸⁸ HM Government Fire Risk Assessment (Sleeping Accommodations) Guidance 2015 {RBK00036722/54}. As in other aspects, the Sleeping Guide also advised that if people with special needs used the premises, their needs should so far as practicable be discussed with them.¹⁶⁸⁹¹⁶⁸⁹ HM Government Fire Risk Assessment (Sleeping Accommodations) Guidance 2015 {RBK00036722/54}. It recommended that effective management arrangements be put in place for those who need help to escape.¹⁶⁹⁰¹⁶⁹⁰ HM Government Fire Risk Assessment (Sleeping Accommodations) Guidance 2015{RBK00036722/69}.

DCLG supplementary guide "Means of Escape for Disabled People"

¶46.6 In 2007, DCLG published a supplementary guide which considered accessibility and the means of escape for disabled people.¹⁶⁹¹¹⁶⁹¹ Fire Safety Risk Assessment Supplementary Guide, Means of escape for disabled people {INQ00014732}. It was intended to be read with its other guides on fire risk assessment. The supplementary guide contains a "Legal Overview" in paragraph 1.1, in which it states that there should be adequate means of escape for all people, including disabled people, which do not depend on the fire and rescue service. It also points out that if an employer or a service provider does not make provision for the safe evacuation of disabled people, that may be discriminatory and a breach of the Fire Safety Order.¹⁶⁹²¹⁶⁹² Fire Safety Risk Assessment Supplementary Guide, Means of escape for disabled people {INQ00014732/6}.

¶46.7 The guide draws attention to the disability equality duty which, since 2006, had required all public bodies to promote the equality of disabled people.¹⁶⁹³¹⁶⁹³ Fire Safety Risk Assessment Supplementary Guide, Means of escape for disabled people {INQ00014732/6}. It also sets out guidance on preparing emergency evacuation plans for disabled people who are likely to be in the building or visiting it.

The LGA Guide 2011

¶46.8 The LGA Guide was drafted following the Lakanal House fire in July 2009 specifically to provide guidance on fire safety in purpose-built blocks of flats.¹⁶⁹⁴¹⁶⁹⁴ LGA Guide, Fire safety in purpose-built blocks of flats {HOM00045964/11} paragraph 2.1. It recognises that there is likely to be a diverse range of physical and mental capabilities among the occupants of a general needs block. The needs of vulnerable occupants are addressed in paragraphs 16.11-16.13 which recognise that older people and people with certain disabilities may have particular needs in responding to a fire. The guide also recognises, however, that in many circumstances it will be impracticable in existing blocks of flats to make special provision for such occupants.¹⁶⁹⁵¹⁶⁹⁵ LGA Guide, Fire safety in purpose-built blocks of flats {HOM00045964/25}.

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¶46.9 Section 79 is concerned with "Preparing for Emergencies". Paragraph 79.9 provides that in "general needs" blocks of flats the physical and mental abilities of the residents are likely to vary but suggests that it is usually unrealistic to expect the responsible person to plan for that or to have in place special arrangements, such as personal emergency evacuation plans. We assume that is intended to reflect the fact that the responsible person's duty under the Fire Safety Order is circumscribed by what is reasonably practicable. In our view, those whose ability to evacuate the building without assistance should be provided with personal emergency evacuation plans (see the chairman's recommendations in paragraph 33.22 of the Phase 1 report), although the content of such a plan will depend in each case on what is practicable. It is difficult to see what additional measures the TMO could have taken to assist the evacuation of disabled residents once they had entered the common parts of Grenfell Tower.

¶46.10 Paragraph 79.11, on the other hand, states that the case of a "general needs" block it is not realistic to expect the responsible person to hold information relating to residents with mobility or other conditions affecting their ability to escape in a way that enables it to be made available to the fire and rescue services, for example, in a premises information box. The justification offered is the difficulty of keeping that information up to date and the risk that inaccurate information could be more harmful than no information. However, although we understand the risks involved, we do not think it is impracticable for the responsible person to make available to the fire and rescue services by digital or other means reliable information about those with chronic disabilities whose ability to evacuate the building without assistance in an emergency is known to be compromised. Again, that was the subject of a recommendation in the chairman's Phase 1 report. In our view, therefore, this paragraph of the Guide should be reconsidered.

PAS 79:2012

¶46.11 We have considered some of the provisions of PAS 79:2012 in Chapter 39. For present purposes we note that it contained very detailed guidance on how to go about ensuring that a fire risk assessment took due account of the specific needs of vulnerable persons in the relevant building. It stated in terms that it applied to blocks of flats,¹⁶⁹⁶¹⁶⁹⁶ {CTAR00000003/9}. and indeed Carl Stokes himself rightly considered that it applied to his work for the TMO generally and to Grenfell Tower in particular. Although Colin Todd, who played an important part in drafting PAS 79 in 2005, and its revisions in 2007 and 2012, said that its focus was on commercial premises, he was constrained to accept that it (or at least the 2012 edition) applied to purpose-built blocks of flats.¹⁶⁹⁷¹⁶⁹⁷ Todd {Day166/132:23}-{Day166/133:5}; {Day166/133:24}-{Day166/134:19}. He also told us that in his view a fire risk assessor would have sufficient training and experience to know that some parts of PAS 79:2012 were not intended to apply to high-rise blocks of flats and other parts were.¹⁶⁹⁸¹⁶⁹⁸ Todd {Day167/106:5-10}. We see no overt support in PAS 79 2012 itself for that view, but in any event it was not an approach actually adopted by Carl Stokes, who did, albeit idiosyncratically and unevenly, follow the guidance it contained.

¶46.12 PAS 79:2012 recommended that a fire risk assessment should consider factors that have a major effect on the risk of fire.¹⁶⁹⁹¹⁶⁹⁹ {CTA00000003/19}. They included the approximate number of occupants of the premises, the maximum number of members of the public likely to be present (unless small in number), the nature of the occupants (e.g. young or old, disabled or able-bodied), the familiarity of the occupants with the premises (e.g. fully familiar, slightly familiar or totally unfamiliar) and the state (or likely state) of the occupants (e.g. awake or asleep, alert or under the influence of alcohol or drugs). It recommended a 9-step approach to fire risk assessments. Step 1 was to obtain relevant information about the premises and their occupants, including those particularly at risk in the event of fire.¹⁷⁰⁰¹⁷⁰⁰ {CTA00000003/34} paragraph i.1. Step 6 was to make an assessment of the likely consequences to the occupants of a fire. Step 8 was to formulate a plan, if necessary, to address shortcomings in the fire precautions.¹⁷⁰¹¹⁷⁰¹ {CTA00000003/34} paragraphs i.6 and i.8.

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¶46.13 The commentary on clauses 12 and 15 contains guidance about assessing the risks to vulnerable persons in order to ensure that the fire risk assessment is suitable and sufficient. We draw particular attention to paragraphs viii, ix, xi, xiv and xv of the commentary on clause 12, and to paragraphs xx and xxviii of the commentary on clause 15.¹⁷⁰²¹⁷⁰² {CTA00000003/36-44}. Tellingly, paragraph xxix of the commentary on clause 15 provides that "Disabled evacuation strategy should not rely on rescue of disabled people by the fire and rescue service",¹⁷⁰³¹⁷⁰³ {CTA00000003/44}. but then goes on to say that "assistance with their evacuation is provided by persons within the premises".

¶46.14 Standing back from the detail, PAS 79:2012 envisages that the fire risk assessment will first assess whether there are persons particularly at risk because of their personal characteristics and consider whether adequate provisions are or can be put in place to ensure their safety. That approach is necessary to ensure that as far as is reasonably practicable those who are vulnerable have a means of escape which is as good as that available to those who do not share their particular vulnerability.

BS 9991:2015 Fire Safety Code of Practice

¶46.15 The Code of Practice BS 9991:2015 considered the means of escape for disabled occupants at various points. It advised on the need to be aware of the types of people in the building (such as disabled people, elderly people, children, pregnant women, etc) and any special risks or needs they might have.¹⁷⁰⁴¹⁷⁰⁴ {BSI00000059/20} paragraph d. Paragraphs 4.6 and 54, and Annex E, in particular, advised that fire safety management of a residential building needed to take account of the needs of disabled persons with permanent or temporary impairment. High-rise residential premises and premises with a "stay put" strategy in place are not excluded.

The TMO's fire safety planning for vulnerable residents

¶46.16 The TMO had a duty in relation to each building in respect of which it was a responsible person to identify and record the presence of residents with disabilities and the nature of those disabilities. That was necessary both for the purposes of carrying out a suitable and sufficient fire risk assessment and to enable it to take all such steps as were reasonably practicable to ensure their safety in the event of a fire. The "stay put" strategy assumed that residents would leave their flats only if they were affected by fire, heat or smoke but that in those circumstances they would escape into the lobby from where they could reach the stairs, which were in a protected area. Any resident who needed help to negotiate the stairs could telephone for assistance but ultimately would have to rely on another resident or the fire and rescue service to escape from the building. The TMO was entitled to assume that if a total or partial evacuation of the building was required it would be carried out under the direction and control of the LFB.

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¶46.17 With that in mind we consider what steps the TMO took to discharge its duty to vulnerable residents.

Concern about vulnerable residents: June 2009

¶46.18 By June 2009 the LFB had become concerned about the failure of the TMO to make adequate provision for disabled people to escape from some of its buildings. On 17 June 2009, it told Janice Wray that it intended to serve an enforcement notice on the TMO and RBKC due to their failure to make suitable and sufficient fire risk assessments of the communal areas of some of their blocks.¹⁷⁰⁵¹⁷⁰⁵ {RBK00053539}. In particular, the LFB considered that the fire risk assessment for Gillray House was not suitable and sufficient because there were no procedures to enable occupants with reduced mobility to escape.

¶46.19 Janice Wray sent an email to Robert Black advising him of the LFB's intention and at his request she sent it to Jean Daintith and Laura Johnson at RBKC.¹⁷⁰⁶¹⁷⁰⁶ {TMO00901459}. It eventually reached Alexis Correa, Health and Safety Advisor in RBKC's Housing, Health and Adult Social Care Services department, and Claire Wise (then a member of the Housing Policy Team).

¶46.20 On 18 June 2009 Claire Wise sent an email to Janice Wray in which she said that there was little information on the application of the Fire Safety Order to dwellings, but that there might be duties under the Disability Discrimination Act 1995 not to treat disabled people less favourably than people without a disability. She advised Ms Wray that if an evacuation plan was in place that was unsuitable for a person with a disability, alternative provision for disabled people should be provided.¹⁷⁰⁷¹⁷⁰⁷ {RBK00052528/1-2}. She went on to say that she thought that provision for disabled people in domestic premises and communal areas had slipped through the net in legislation and guidance.¹⁷⁰⁸¹⁷⁰⁸ {RBK00052528/2}. She asked Janice Wray for a meeting to discuss progress and an action plan. She also suggested it would be an opportunity for collaborative working with the fire brigade to develop a model to be applied across the remaining TMO buildings.

¶46.21 Jean Daintith forwarded that exchange to Robert Black later that day. She told him that Alexis Correa had confirmed that the fire risk assessments were not robust enough and that a specialist would need to be engaged.¹⁷⁰⁹¹⁷⁰⁹ {RBK00052528/1}.

¶46.22 Janice Wray accepted that the LFB had recommended there should be a procedure in place to enable residents with reduced mobility to escape,¹⁷¹⁰¹⁷¹⁰ Wray {Day142/82:6-9}. but admitted that she had not sought advice about the TMO's duties under the Fire Safety Order or the Disability Discrimination Act 1995.¹⁷¹¹¹⁷¹¹ Wray {Day142/84:15}-{Day 142/85:24}.

¶46.23 Two points emerge from this exchange. First, that the TMO at the highest level was aware from as early as 2009 of the need to consider the arrangements for the safe evacuation of disabled people and, secondly, that RBKC was itself fully aware of the fact.

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Salvus's Advice: September 2009

¶46.24 In its report entitled "Fire Risk Assessment for Fire Safety policy and procedures" dated 22 September 2009, Salvus identified a need for the TMO to establish procedures to ensure the safety of disabled or vulnerable persons in the event of a fire.¹⁷¹²¹⁷¹² {SAL00000013}. The absence of such procedures was described as constituting a breach of the statutory requirements. In the enclosed action plan, it recommended that as a high priority the TMO consider developing formal procedures to deal effectively with fire safety concerns associated with disabled or vulnerable tenants and leaseholders and also any employees.¹⁷¹³¹⁷¹³ {SAL00000013/18}. It marked the item as needing to be completed within three months or a plan to be agreed within six months.

¶46.25 Following receipt of the report, a progress meeting was held on 19 October 2009 attended by Salvus, the TMO and RBKC.¹⁷¹⁴¹⁷¹⁴ Minutes of Progress Meeting dated 19 October 2009 {RBK00047771/1}. Paragraph 4.3 of the minutes records that Salvus had been unable to confirm whether any residents had sensory impairments at the time of the fire risk assessment and the TMO was advised to tell tenants to contact it if they had a disability affecting their ability to react to an alarm.¹⁷¹⁵¹⁷¹⁵ Minutes of Progress Meeting dated 19 October 2009 {RBK00047771/2}. The minutes also record that the TMO had attempted to identify and record vulnerable residents. Andrew Furness of Salvus said that if the fire risk assessor had been informed about the location of vulnerable residents and the nature of their vulnerabilities in advance, the assessment would have been more comprehensive. It was agreed that an attempt would be made to obtain that information in relation to one of the TMO properties, the World's End Estate.¹⁷¹⁶¹⁷¹⁶ Minutes of Progress Meeting dated 19 October 2009 {RBK00047771/2-3}.

¶46.26 It seems that the effort was to some extent successful. On 19 October 2009 (the same day as the meeting), two spreadsheets were produced containing data about vulnerable persons.¹⁷¹⁷¹⁷¹⁷ {TMO00866618}. That is the only documentary evidence we have seen of TMO officials' attempting to gather information about vulnerable residents for the purposes of a fire risk assessment. Janice Wray confirmed that as a result of that meeting, she was aware of the need to provide fire risk assessors with information about vulnerable residents.¹⁷¹⁸¹⁷¹⁸ Wray {Day142/87:1}-{Day142/88:10}.

¶46.27 On 5 January 2010, Andrew Furness complained to Nicholas Coombe of the LFB that the TMO and RBKC had little or no knowledge of the occupiers of their premises and that Salvus had advised them to gather better information about their residents in order to take appropriate steps in respect of disabled or vulnerable people and, specifically, to help them prepare PEEPs.¹⁷¹⁹¹⁷¹⁹ {SAL00000047/2}.

¶46.28 It is not clear what Mr Furness based his report on. Janice Wray told us that he had not spoken to the Housing team at the TMO, but she did not take any steps herself to obtain information about vulnerable residents. She regarded that as a matter for the Housing team.¹⁷²⁰¹⁷²⁰ Wray {Day142/89:3}-{Day142/90:22}.

¶46.29 On 21 January 2010, there was another progress meeting attended by Salvus, the TMO and RBKC to discuss fire risk assessments for high-rise buildings at which procedures for vulnerable residents were again discussed. Andrew Furness said that a formal documented system needed to be implemented to address the needs of disabled and vulnerable people in the event of a fire.¹⁷²¹¹⁷²¹ Minutes of Progress Meeting dated 26 January 2010 {RBK00052572/5}. Although the recommendation was clear and well made, it was not implemented by the TMO in relation to its general needs housing stock.¹⁷²²¹⁷²² In 2012, TMO prepared a paper on fire safety and housing which addressed fire safety in sheltered housing. This was limited to sheltered housing only and had no application to general housing {CST00005799}.

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Carl Stokes's advice to the TMO: 2010 onwards

¶46.30 Carl Stokes met Janice Wray on 22 June 2010 and on 23 June 2010 he sent her a letter confirming his advice.¹⁷²³¹⁷²³ {CST00001887}. He told her that the PEEPs she had shown him accorded with those described as best practice in the government's guidance on risk assessments. She confirmed that the intention had been to use the PEEPs documents annexed to DCLG's 2007 guide entitled "Means of Escape for Disabled People"¹⁷²⁴¹⁷²⁴ HM Government Fire safety risk assessment supplementary guide, means of escape for disabled people {INQ00014732/46-49}. for TMO residents as well as staff.¹⁷²⁵¹⁷²⁵ Wray {Day142/91:23}-{Day142/93:11}.

¶46.31 Carl Stokes and Janice Wray had a further meeting on 24 September 2010, the substance of which was reflected in a letter he wrote to her on 27 September 2010.¹⁷²⁶¹⁷²⁶ {CST00003061/1}. In it he noted that the TMO had recently introduced a comprehensive programme to gather information about residents, including any disabilities or restrictions on their ability to respond to an emergency. The information would be held on the "TP Tracker system" and used to assess whether residents required any additional devices to provide them with early warning of smoke or fire in their homes. It would also be used to inform the development of a personal emergency evacuation plan.¹⁷²⁷¹⁷²⁷ {CST00003061/3}.

¶46.32 Carl Stokes did not check the TMO's systems for recording vulnerable residents as he thought that was beyond what was expected of him as a fire risk assessor.¹⁷²⁸¹⁷²⁸ Stokes {Day137/81:10}-{Day137/85:20}. He did say, however, that Janice Wray had agreed that when carrying out fire risk assessments she would provide him with information about residents who were especially at risk.¹⁷²⁹¹⁷²⁹ Stokes {Day137/70:19}-{Day137/74:18}. She, on the other hand, could not recall whether she had agreed to provide him with that information. At all events, given that he had noted that they had discussed the identification of vulnerable residents for the purposes of preparing PEEPs and that Salvus had advised her of the need to provide fire risk assessors with information about individuals especially at risk, we think it likely that Janice Wray did agree to provide that information to him. However, there is no evidence that she did so.

¶46.33 Janice Wray thought that Carl Stokes's reference in his fire risk assessments to the residents' newsletters was a reference to the Link magazine, but no edition of Link between 2009 to 2017 made any reference to PEEPs. Janice Wray explained that she was reluctant to use the term "PEEP" because it was not generally understood; she invited those with concerns about being able to leave their homes in the event of fire to contact her or the fire brigade.¹⁷³⁰¹⁷³⁰ Wray {Day142/98:11-22}. No editions of Link from Autumn 2009 to Spring 2017 carried any article inviting residents who were worried about their ability to evacuate their homes in an emergency to contact the TMO.¹⁷³¹¹⁷³¹ None of the Link or Homeowner magazines disclosed to the Inquiry invited residents to contact the TMO to be evaluated for a PEEP. Fire safety advice was contained in the following Link Magazines: Autumn 2009 {TMO00901358}; Winter 2009 {TMO10048206}; June 2013 {TMO00873438}; Summer 2014 {TMO10031098}; Autumn/Winter 2015 {TMO00873549}.

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RBKC's oversight of the TMO's preparation of PEEPs

¶46.34 On 28 September 2010, Jean Daintith sent Robert Black a copy of an article written by Claire Wise about fire safety and the requirements of housing legislation relating to people living in flats in tall buildings. She invited Robert Black to respond with his observations about what lessons could be learnt.¹⁷³²¹⁷³² {RBK00026862}; {RBK00030073}. His response on 30 September 2010 was to reassure her that the TMO had completed fire risk assessments for all its high-risk buildings, including high-rise blocks, and that the evacuation strategy was "stay put – defend in place". He told her that the TMO intended to produce PEEPs for disabled residents but had so far done so only in a small number of cases with advice from the LFB. However, fire risk assessments had identified the need to extend the work to residents known to have disabilities and that the TMO planned to work with Carl Stokes to produce generic PEEPs for larger blocks which could then be adapted to individual needs.

¶46.35 Robert Black's assurances were, however, misleading. The first of only two PEEPs to be prepared for TMO residents was still in preparation and was not completed until 18 October 2010, nearly three weeks later.¹⁷³³¹⁷³³ {CST00005610}. Plans to produce generic and individual PEEPs were not fulfilled. Even so, at a joint meeting of RBKC, TMO executives and the LFB on 20 July 2011, Janice Wray gave similar assurances that the TMO intended to identify vulnerable and disabled residents who required PEEPs.¹⁷³⁴¹⁷³⁴ Minutes of RBKC, KCTMO and LFB Meeting dated 20 July 2011 {RBK00053638/6}; Wray {Day142/119:4}-{Day142/120:3}.

¶46.36 Despite having been made aware in late 2010 and July 2011 of the TMO's supposed plans, neither Laura Johnson nor Amanda Johnson asked Robert Black whether any PEEPs had been prepared.¹⁷³⁵¹⁷³⁵ Laura Johnson {Day129/117:5-17}; Amanda Johnson {Day131/44:25}-{Day131/45:12}. Indeed, nobody from RBKC asked whether the TMO had completed any PEEPs. In its written submissions, RBKC rightly acknowledged that fact and admitted that it had been a failure of oversight on its part.¹⁷³⁶¹⁷³⁶ RBKC Module 3 Closing submissions {RBK00068069/29-30} pages 29-30, paragraph 103; Laura Johnson {Day129/117:5-17}; Amanda Johnson {Day131/44:25}-{Day131/45:12}.

¶46.37 Contrary to what had been said by Robert Black and Janice Wray, the TMO did not regularly identify vulnerable residents. Only two residents were assessed for PEEPs between 2010 to 2017,¹⁷³⁷¹⁷³⁷ Stokes {CST00030186/38} page 38, paragraph142. one in Markland House and one in Gillray house.¹⁷³⁸¹⁷³⁸ {CST00005610}; {CST00020896}. Although Janice Wray said that the Health and Safety team were prepared to receive requests for PEEPs from residents in general needs housing,¹⁷³⁹¹⁷³⁹ Stokes {CST00030186/38} page 38, paragraph 143; Wray {TMO00862589/2} page 2, paragraphs 6-7. as far as we can see, none was ever prepared by Janice Wray or her team.

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The TMO's assurances to the LFB

¶46.38 The LFB, like RBKC, received assurances from the TMO about the identification and treatment of vulnerable people. At a meeting on 20 July 2011, Janice Wray told the LFB that the TMO was gathering information about vulnerable and disabled residents in the council's properties with the intention of preparing PEEPs for those who needed them.¹⁷⁴⁰¹⁷⁴⁰ Minutes of RBKC, KCTMO and LFB Meeting dated 20 July 2011 {RBK00053638/6}; Wray {Day142/119:4}-{Day142/120:3}.

¶46.39 On 26 September 2012, Nicolas Comery, Nick Coombe and Andy Jack of the LFB met Janice Wray and Claire Wise.¹⁷⁴¹¹⁷⁴¹ {TMO00863422}. The LFB team asked the TMO to prepare a list of residents with additional needs to be kept close to the fire alarm control panel. They told Janice Wray and Claire Wise that the LFB's view was that the person or organisation managing a building had a duty to develop a plan to be followed in the event of a fire and to collect information on residents with additional needs. A risk assessment would also need to be reviewed if a resident's needs changed significantly or became permanent. Although the discussion was focused on sheltered housing, the LFB's advice related to general needs accommodation as well.¹⁷⁴²¹⁷⁴² Wray {Day142/119:4}-{Day142/120:3}. The LFB's views were passed to RBKC's Housing department.¹⁷⁴³¹⁷⁴³ {TMO00863422}.

¶46.40 Notwithstanding that prompt from the LFB, the TMO did not create a system to collect information about residents with additional needs that could be made available to the LFB in the event of a fire. According to Janice Wray, that was because it was concerned about its ability to keep documents held in a premises information box up to date. It was not discussed with the LFB again.¹⁷⁴⁴¹⁷⁴⁴ Wray {Day142/122:16}-{Day142/123:8}. Critically, it does not appear that the TMO told the LFB why it was difficult to comply with its request.

Correspondence with the LFB

¶46.41 On 30 November 2012, Nick Comery asked Janice Wray for help in identifying vulnerable persons in local authority premises who might be suitable for an LFB initiative promoting sprinklers. Janice Wray passed the request to Carl Stokes who advised her to say that she was not aware of anyone. He did so in order to avoid any questions being asked about why anyone who might qualify had not been identified in the fire risk assessments or received a PEEP.¹⁷⁴⁵¹⁷⁴⁵ {CST00016416}.

¶46.42 Carl Stokes thought he had spoken to Janice Wray before responding to her email, although he could not be sure about that.¹⁷⁴⁶¹⁷⁴⁶ Stokes {Day137/128:10}-{Day137/129:4}. He said that he had not been suggesting that there were no vulnerable residents in the properties managed by the TMO, but that there were no heavy smokers. His evidence was that he had thought that the LFB were asking for people who were vulnerable because they were heavy smokers. Although automatic fire suppression systems may have been particularly suitable for use by those who were heavy smokers, we do not accept that explanation. Carl Stokes had no information about the smoking habits of TMO residents and had never sought any. The truth is that he knew that PEEPs were required for vulnerable residents, that the TMO had produced only two, and that his fire risk assessments had not recommended any additional fire safety measures for vulnerable people. His advice amounted to a suggestion that she should lie to the LFB.

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¶46.43 Janice Wray agreed that it was not possible to say that there were no vulnerable residents in the properties managed by the TMO,¹⁷⁴⁷¹⁷⁴⁷ Wray {Day142/128:14-23}. but although she said she would not lie to the LFB, she does not appear to have been unduly concerned about Mr Stokes's suggestion that she should.¹⁷⁴⁸¹⁷⁴⁸ Wray {Day142/128:24}-{Day142/130:1}.

¶46.44 Carl Stokes's reaction to the LFB's request for information about vulnerable people ought to have acted as a spur to him and Janice Wray to correct the position quickly. The TMO should have initiated a process of collecting information and should have asked him to carry out a proper risk assessment, taking into account the vulnerable people in each building.

¶46.45 Neither Carl Stokes nor Janice Wray was able to provide a clear explanation for their failure to ascertain the number of vulnerable people living in properties managed by the TMO. Janice Wray had been aware of the need to collect and maintain that information since receiving the advice from Salvus in 2009 and 2010. However, she did not take any steps to review the fire risk assessments or take any action to check whether any of them should contain any reference to vulnerable residents. She said she had had no concerns about Mr Stokes's response, and that if she had, she would have done something about it.¹⁷⁴⁹¹⁷⁴⁹ Wray {Day142/131:5-9}.

Carl Stokes's fire risk assessments of Grenfell Tower

¶46.46 As we have said in Chapter 38, Carl Stokes carried out six fire risk assessments in relation to Grenfell Tower between 30 September 2009 and 20 June 2016.¹⁷⁵⁰¹⁷⁵⁰ Fire risk assessment for Grenfell Tower dated 30 September 2009 {CST00003128}; Fire risk assessment for Grenfell Tower dated 29 December 2010 {CST00003181}; Fire risk assessment for Grenfell Tower dated 20 November 2012 {CST00003084}; Fire risk assessment and schedule of significant findings for Grenfell Tower dated 17 October 2014 {CST00003177}; Fire risk assessment for Grenfell Tower dated 26 April 2016 {CST00003161}; Fire risk assessment for Grenfell Tower dated 20 June 2016 {CST00003145}.Show full note The first, dated 30 September 2009, was carried out as a sub-contractor of Salvus and follows the Salvus template.¹⁷⁵¹¹⁷⁵¹ Fire risk assessment for Grenfell Tower dated 30 September 2009 {CST00003128/11}.

¶46.47 In section 5 on page 11 of that fire risk assessment, Carl Stokes described the measures in place to counter the risk that people on the premises might not be aware of the fire. In section 5.4 he identified as a hazard the possibility that if tenants and others within the building suffered from a hearing impairment they might not receive adequate warning. In relation to control measures he recorded that there was no evidence that any resident or member of staff on the premises suffered from a sensory impairment that would prevent them from hearing a shouted warning of fire. However, he also recorded that he could not confirm that that was the case or whether the TMO had any personal emergency evacuation plans available or policies in place if they were needed.

¶46.48 Mr Stokes said that he had focused on hearing impairments to the exclusion of other disabilities, including mobility and visual impairments, because there had been no communal fire alarm in Grenfell tower so residents would be affected if they could not hear someone trying to warn them of a fire.¹⁷⁵²¹⁷⁵² Stokes {Day137/94:7-20}. However, he failed to consider the full range of impairments that could affect residents who might be required to evacuate.

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Fire risk assessments: 29 December 2010 and later

¶46.49 After Carl Stokes had been appointed by the TMO to carry out its fire risk assessments he used his own templates that were partly, but not consistently, based on PAS 79. Section 13 of his form referred to "Disabled People".

¶46.50 The 2010 fire risk assessment for Grenfell Tower stated that there was no evidence that any residents suffered from a hearing impairment that would prevent them hearing a shouted warning of fire or a warning in the form of a loud knocking.¹⁷⁵³¹⁷⁵³ Fire risk assessment for Grenfell Tower dated 29 December 2010 {CST00003181/16}. It also recorded that the TMO had introduced a programme to gather information about tenants, including any disabilities and their ability to respond to emergency situations. The information was to be recorded in the TP Tracker system and used to decide whether any residents required additional devices or PEEPs.¹⁷⁵⁴¹⁷⁵⁴ Fire risk assessment for Grenfell Tower dated 29 December 2010 {CST00003181/16}.

¶46.51 Aside from minor variations, the text remained substantively the same between 2010 and 2016.¹⁷⁵⁵¹⁷⁵⁵ Fire risk assessment for Grenfell Tower dated 29 December 2010 {CST00003181/16}; Fire risk assessment dated for Grenfell tower dated 20 November 2012 {CST00003084/20-21}; Fire risk assessment for Grenfell Tower dated 17 October 2014 {CST00003157/21}; Fire risk assessment for Grenfell Tower dated 26 April 2016 {CST00003161/22}. Janice Wray could not recall speaking to Carl Stokes about the variations in the text. She admitted that she had probably noticed that he had repeatedly used the same information in section 13 of his fire risk assessments, but she never asked him why. She did not remember being concerned that the information in section 13 might have become out of date, but she admitted that she should have been.¹⁷⁵⁶¹⁷⁵⁶ Wray {Day142/133:7-20}.

¶46.52 Although the TP Tracker was discontinued in 2013, the fire risk assessments in relation to Grenfell Tower continued to refer to its being used to identify residents in need.¹⁷⁵⁷¹⁷⁵⁷ {RBK00057527}. Janice Wray could not say why Carl Stokes had not been told that it had been discontinued in 2013. She accepted that it had been part of her responsibility to identify vulnerable residents, but she said that she had not been aware of how the Housing department was recording them. She failed to ask Carl Stokes whether he had that information when he was preparing the fire risk assessments, but she did try to clarify what information was held by the TMO when she reviewed the fire strategy in December 2016.¹⁷⁵⁸¹⁷⁵⁸ Wray {Day142/135:24}-{Day142/137:13}; {TMO00865834/2}. We return to her attempt to do so below.

Leon Taylor's fire risk assessment: June 2014

¶46.53 Leon Taylor, an independent fire risk assessor, carried out a fire risk assessment in respect of Grenfell Tower on 14 June 2014. He noted that the vulnerabilities of the occupants were unknown, but that as the building was designated as "general needs" he assumed that the occupants were typical of the general population.¹⁷⁵⁹¹⁷⁵⁹ {TMO10001286}, Cell E39.

¶46.54 In section K13 of his fire risk assessment Mr Taylor noted that the TMO Housing department should have a record of all those who had special needs in relation to evacuation and should make arrangements in accordance with the Housing Act 2004 for evacuation plans and any PEEPs that might be required. No action appears to have been taken by the TMO in response to that fire risk assessment.

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Carl Stokes's fire risk assessments relating to other TMO properties

¶46.55 A sample of Carl Stokes's fire risk assessments for other high-rise buildings managed by the TMO revealed that it was his practice not to identify vulnerable residents.¹⁷⁶⁰¹⁷⁶⁰ Fire risk assessment for Adair Tower dated 28 October 2010 {CST00004307}; Fire risk assessment for Adair Tower dated 20 February dated 2014 {LFB00027631}; Fire risk assessment for Adair Tower dated 11 November 2015 {CST00025478}; Fire risk assessment for Adair Tower dated 28 September 2016 {TMO00843943}; Fire risk assessment for Gillray House dated 19 November 2012 {TMO00854930}; Fire risk assessment for Gillray House dated 28 January 2016 {CST00025186}; Fire risk assessment for Hazlewood Tower dated 20 February 2014 {TMO10043804}; Fire risk assessment for Hazlewood Tower dated 25 November 2015 {TMO10044598}; Fire risk assessment for Hazlewood Tower dated 3 October 2016 {TMO10048023}; Fire risk assessment for Markland House dated 16 November 2010 {CST00009754}; Fire risk assessment for Markland House dated 29 November 2012 {CST00017016}; Fire risk assessment for Markland House dated 21 January 2016 {TMO10047159}; Fire risk assessment for Trellick Tower dated 11 June 2012 {CST00017807}; Fire risk assessment for Trellick Tower dated 6 March 2014 {TMO00842081}; Fire risk assessment for Trellick Tower dated 26 April 2017 {TMO00842255}.Show full note Only the fire risk assessment carried out in relation to Gillray House in 2010 recorded that there was a resident with impaired mobility.¹⁷⁶¹¹⁷⁶¹ Fire risk assessment for Gillray House dated 8 October 2010 {CST00012048/15}. Moreover, as he accepted, the first three paragraphs of the text in section 13 of each of his fire risk assessments for Adair Tower (2011), Gillray House (2012), Hazlewood Tower (2014), Markland House (2016) and Trellick Tower (2017) were identical to each other and to that section of the assessment carried out in relation to Grenfell Tower in 2010.

¶46.56 Carl Stokes drew up a PEEP for a resident of Gillray House on 18 October 2010.¹⁷⁶²¹⁷⁶² {CST00005610}. The same resident asked for a copy of the PEEP in November 2013, indicating that she was still living in the property.¹⁷⁶³¹⁷⁶³ {CST00005609}. Her presence in Gillray House was reflected in the 2010 fire risk assessment but not in the assessment prepared in 2012. He also drew up a PEEP for a resident of Markland House on 8 March 2014,¹⁷⁶⁴¹⁷⁶⁴ {CST00020896}. but it was not noted in the 2016 fire risk assessment.¹⁷⁶⁵¹⁷⁶⁵ Fire risk assessment for Markland House dated 21 January 2016 {TMO10047159/21}. He was unable to explain why those two fire risk assessments did not record that PEEPs had been produced for residents of those properties.¹⁷⁶⁶¹⁷⁶⁶ Stokes {Day137/117:3}-{Day137/122:5}.

¶46.57 Janice Wray did sometimes comment on fire risk assessments,¹⁷⁶⁷¹⁷⁶⁷ On 2 December 2015, Janice Wray asked Carl Stokes to correct a sentence on page 5 of the Hazlewood fire risk assessment: email from Janice Wray to Carl Stokes dated 2 December 2015 {CST00006647}. but she does not appear to have questioned the inclusion of identical text in section 13 of the fire risk assessments relating to those five different buildings at different times over the course of some six years. It is difficult to believe that she failed to notice the fact or the fact that he continued to refer to the system used to record information on vulnerable residents years after it had been discontinued.

¶46.58 We are bound to conclude that the fire risk assessments carried out by Mr Stokes that we examined, including those relating to Grenfell Tower, were inaccurate and out of date in relation to the presence of vulnerable persons and were not suitable and sufficient for the purposes of Article 9 of the Fire Safety Order.

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TMO Policies relevant to vulnerable persons

The TMO fire safety strategy

¶46.59 The TMO had no formal fire safety strategy at all until November 2013. The strategy was later reviewed in 2016 and approved in June 2017.¹⁷⁶⁸¹⁷⁶⁸ {TMO10004485}; {TMO00832724}.

¶46.60 Although the original fire safety strategy made express provision for PEEPs for the TMO's staff,¹⁷⁶⁹¹⁷⁶⁹ {TMO10004485/14} section 24.1 ("Fire Procedures"). it contained no reference to PEEPs for vulnerable residents. Similarly, the TMO's Health and Safety Policy (dated February 2016 and in force in June 2017) referred to PEEPs only in relation to staff.¹⁷⁷⁰¹⁷⁷⁰ {TMO10024402/6} sections 7-10.

¶46.61 The 2017 version of the fire safety strategy also referred to PEEPs in relation to staff, but not in relation to residents.¹⁷⁷¹¹⁷⁷¹ {TMO00832724/15} section 25.1. A new section (paragraph 28) was added, to cover both hoarders and vulnerable residents. Paragraph 28.3 stated that efforts were made to collect information about a resident's vulnerability when the tenancy was signed and thereafter as part of the TMO's continuing contact with residents. The purpose of the exercise was said to be providing a service which better met the resident's needs, including fire safety. The new paragraph therefore acknowledged to some extent the TMO's obligation to identify vulnerable residents in order to meet their needs in respect of fire safety, but it did not extend to the provision of PEEPs.

¶46.62 Janice Wray was unable to explain why the 2013 and 2017 fire safety strategies did not refer to PEEPs being produced for residents and accepted that they should have done so.¹⁷⁷²¹⁷⁷² Wray {Day142/149:23}-{Day142/152:1}. Robert Black could not remember why there had been no reference in the fire safety strategies or the Health and Safety policy to producing PEEPs for residents, but thought the TMO had probably decided not to follow Salvus's advice about that.¹⁷⁷³¹⁷⁷³ Black {Day149/169:22}-{Day149/170:1-14}. We agree that that is the most likely explanation.

¶46.63 Given Salvus's clear advice in 2009 about the need for procedures to ensure the safety of disabled or vulnerable persons in the event of a fire it is difficult to understand why none were ever included by the TMO in any of its policies.¹⁷⁷⁴¹⁷⁷⁴ {SAL00000013/18}.

The "Supporting Residents" policy and procedure

¶46.64 The TMO recognised the need to identify vulnerable residents living in its properties and to make them known to the appropriate support services. David Noble and Teresa Brown started preparing a policy for vulnerable residents in December 2014.¹⁷⁷⁵¹⁷⁷⁵ {TMO00880460}; {TMO00880458}; {TMO00880463}. The first draft of the Vulnerability Policy adopted the definitions of vulnerable persons already used by the TMO. It recorded that the process for identifying residents who required PEEPs depended on chance or a request from the relevant resident.¹⁷⁷⁶¹⁷⁷⁶ {TMO00880461/2}. In that regard, the document reflects Janice Wray's evidence, but the position was not recorded in any of the later drafts of the Vulnerability Policy or the "Supporting Residents"' policy. None of the draft policies relating to vulnerable residents dealt with fire safety.

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¶46.65 The final version of the "Supporting Residents" policy was drafted by David Noble and dated April 2016 .¹⁷⁷⁷¹⁷⁷⁷ {TMO00880481}. Neither he nor Teresa Brown was able to explain why it had taken nearly two years to complete.¹⁷⁷⁸¹⁷⁷⁸ Noble {Day119/69:12}-{Day119/70:4}; Brown {Day126/89:25}-{Day126/91:22}. The purpose of the policy was to provide an agreed approach to recognising vulnerable residents and referring them to the neighbourhood teams who could provide them with support.¹⁷⁷⁹¹⁷⁷⁹ Brown {Day126/77:5-13}. It was accompanied by the "Supporting Residents" procedure dated April 2016.¹⁷⁸⁰¹⁷⁸⁰ {TMO00880482}. The policy and procedure described certain potential indicators of vulnerability and identified steps that might be taken to provide assistance to those who required it. There was no mention of fire safety in either the policy or the procedure.

¶46.66 The senior management team discussed the "Supporting Residents" policy at a team meeting on 18 February 2016.¹⁷⁸¹¹⁷⁸¹ Minutes of Senior Management Team Meeting dated 18 February 2016 {TMO00866011}. Teresa Brown did not recall having discussed it with the Health and Safety team, but she noted that Barbara Matthews, who had overall responsibility for health and safety, had been present at the meeting and had not raised any concerns.¹⁷⁸²¹⁷⁸² Brown {Day126/94:12}-{Day126/95:1}. Apparently, no one asked how fire safety procedures might apply to vulnerable residents. Although the revised policy was presented to the senior management team on 17 March 2016,¹⁷⁸³¹⁷⁸³ Minutes of Senior Management Team Meeting on 17 March 2016 {TMO00880549/1}. it was not presented to the executive team for approval.

¶46.67 In December 2016, before the final version of the policy had been circulated to the senior management team, Janice Wray asked David Noble how the TMO obtained and stored information on vulnerability, as she was reviewing the fire safety strategy.¹⁷⁸⁴¹⁷⁸⁴ {TMO00865834}. Although the review of the fire safety strategy (which culminated in the 2017 version) took place when the "Supporting Residents" policy was being completed, neither the TMO's senior management team nor Janice Wray nor David Noble thought that there were matters, such as fire safety, that ought to be covered in both documents.

Gathering information about vulnerable residents

¶46.68 The TMO's regular means of gathering information about residents' vulnerability was by talking to them at the time of granting a tenancy and during a tenancy audit. When registering a new tenant, the TMO recorded whether that person or anyone in the household suffered from any disability. Any disabilities were recorded in the tenancy agreement, Tenancy Information forms and in a data entry form that all new tenants were required to complete. The forms were all stored on the W2 system. The way in which the information was recorded was not consistent and in most cases the Neighbourhood Officers that helped to complete the forms recorded that no support was required, even if a vulnerability of some kind was recorded.¹⁷⁸⁵¹⁷⁸⁵ Lane, Module 3 Report {BLARP20000034/173} Table 10-1.

¶46.69 On 29 April 2014, David Noble and Teresa Brown told the executive team that there were gaps in some of the information held on tenants, particularly relating to disabilities.¹⁷⁸⁶¹⁷⁸⁶ Noble {Day119/51:11-23}. They suggested that the collection of information could be improved by the use of a detailed questionnaire.¹⁷⁸⁷¹⁷⁸⁷ Minutes of Executive Team Meeting dated 29 April 2014 {TMO00851128/1}. The proposal was approved; a new tenancy questionnaire was introduced and a programme of tenancy audits was put in place.

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¶46.70 From 2015 onwards, housing officers were required to carry out about 30 tenancy audits a month.¹⁷⁸⁸¹⁷⁸⁸ Jones {TMO00873924/3} page 3, paragraph 11. Janice Jones carried out tenancy audits at Grenfell Tower.¹⁷⁸⁹¹⁷⁸⁹ Jones {TMO00873924/3} page 3, paragraph 11. She collected information about residents, such as their names, contact details, ethnicity, vulnerabilities or disabilities, support needs and whether any repairs needed to be carried out to their properties.¹⁷⁹⁰¹⁷⁹⁰ Jones {TMO00873924/3-4} pages 3-4, paragraphs 13-15. Information gathered in tenancy audits was entered on the W2 system.¹⁷⁹¹¹⁷⁹¹ Jones {TMO00873924/3} page 3, paragraph 13. A spreadsheet dated 13 April 2016 recorded that 547 audits of TMO properties had been completed between 1 April 2015 and 1 April 2016.¹⁷⁹²¹⁷⁹² {TMO00860130}.

¶46.71 The TMO gathered information on vulnerable residents in Grenfell Tower during the refurbishment. Rydon spoke to tenants to ask them, among other things, whether any member of the household had any health problems. The information was recorded in a report dated November 2014¹⁷⁹³¹⁷⁹³ {RYD00024466}. which identified 57 residents as having a sensory, cognitive or mobility impairment.¹⁷⁹⁴¹⁷⁹⁴ Lane, Module 3 Report {BLARP20000034/177} paragraph 10.6.10.

¶46.72 The report was discussed with Rydon at Housing Management Liaison Meetings and there is some evidence that it was sent to Siobhan Rumble at the TMO.¹⁷⁹⁵¹⁷⁹⁵ Minutes of Housing Management Liaison Meeting with Rydon dated 28 January 2015 {TMO00852169}. There is no evidence, however, that it was used to revise any of the TMO's records. Most importantly, the information was not included in the spreadsheet from which attempts were made on the night of the fire to extract information about vulnerable residents.

Premises information box

¶46.73 During a visit to Grenfell Tower on 12 March 2014, representatives of the LFB fire safety team and a local fire station crew asked for a premises information box to be installed.¹⁷⁹⁶¹⁷⁹⁶ {CST00000178/2-3}. The intention was that it should contain fire safety information specific to Grenfell Tower, such as floor plans, that would assist the LFB in the event of a fire.¹⁷⁹⁷¹⁷⁹⁷ {CST00000178/2-3}; {TMO10013186/1}.

¶46.74 On 18 March 2014, Carl Stokes strongly advised Claire Williams against installing a premises information box, in essence, because he thought that the onus was on the LFB to gather the information themselves during section 7(2)d and familiarisation visits.¹⁷⁹⁸¹⁷⁹⁸ {CST00003100/4}; Stokes {CST00030186/42} page 42, paragraph 160. According to Colin Todd, it was not common at the time for premises information boxes to be installed in general needs blocks of flats, but both he¹⁷⁹⁹¹⁷⁹⁹ Todd, The Fire Risk Assessments of Carl Stokes Report {CTA00000011/102-103} paragraph 10.3. and Dr Lane¹⁸⁰⁰¹⁸⁰⁰ Lane, Module 3 Report {BLARP20000027/346-347} paragraphs 15.2.31-15.2.42. thought that they could be of assistance to fire and rescue services.¹⁸⁰¹¹⁸⁰¹ Lane, Module 3 Report {BLARP20000027/347} paragraphs 15.2.39-15.2.41; LGA Guide, Fire safety in purpose-built blocks of flats {HOM00045964/120} paragraph 79.12. We agree. In the face of a request from the LFB we can see no good reason for Carl Stokes to oppose the suggestion.

¶46.75 Following a demonstration of the smoke ventilation system at Grenfell Tower on 28 April 2016, the LFB renewed its request for a premises information box or other secure information box to be installed in the foyer of the tower,¹⁸⁰²¹⁸⁰² {CST00001131/2}. but on 4 May 2016 Carl Stokes again told Janice Wray that the TMO had no obligation to provide an information box.¹⁸⁰³¹⁸⁰³ {CST00001131/1-2}. He may have been right, but there was no obvious reason to refuse the LFB's request and in our view his advice was foolish.¹⁸⁰⁴¹⁸⁰⁴ Wray {Day144/198:19-22}.

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¶46.76 At the regular meeting between the TMO and the LFB fire safety team on 5 May 2016, Nick Davis, the local station manager, asked Janice Wray again for a premises information box to be installed at Grenfell Tower. He agreed to confirm what information the LFB wanted to have stored in it but said that it would include at least information about the operation of the smoke ventilation system.¹⁸⁰⁵¹⁸⁰⁵ Minutes of the Bi-Monthly Meeting dated 5 May 2016 {TMO10013185/3} item 8. On 6 May 2016, he sent her a list of the information that he wanted to see made available.¹⁸⁰⁶¹⁸⁰⁶ {TMO10013186/1}.

¶46.77 At the next meeting on 13 July 2016, which was attended by Janice Wray and Rebecca Burton, the TMO told the LFB that arrangements had been made to store the documents to which the LFB needed access in a secure box in the lobby, the key to which would held in a key safe secured by a padlock in the bin room.¹⁸⁰⁷¹⁸⁰⁷ Minutes of the Bi-Monthly Meeting dated 13 July 2016 {LFB00032335/3} item 7. Despite that assurance, however, by the time of the fire no premises information box or any other secure box containing the relevant fire safety information had been installed at Grenfell Tower. Janice Wray thought that was because Claire Williams had made arrangements for the information to be kept in an existing secure box in the lobby, as contemplated by the minutes of the meeting on 13 July 2016,¹⁸⁰⁸¹⁸⁰⁸ Wray {TMO00000890/13} page 13, paragraph 60; Wray {Day144/195:20}-{Day144/198:1}. but she did not check whether the box did in fact exist or, if it did, what information it contained.¹⁸⁰⁹¹⁸⁰⁹ Wray {Day144/195:20}-{Day144/198:1}. Claire Williams said that there had been a "fire panel" at Grenfell Tower which described how to operate the smoke ventilation system, but she could not identify anything else.¹⁸¹⁰¹⁸¹⁰ Williams {Day122/33:13-21}. There was nothing else. The TMO simply never complied with the LFB's request for a secure box containing information about the building. There was no good reason for its failure to do so.

TMO's systems for recording data about vulnerable residents

¶46.78 Between 2010 and 2017 Carl Stokes's fire risk assessments for Grenfell Tower stated that the TMO used the TP Tracker for recording information about vulnerable residents. An entry dated 8 June 2013 recorded that one resident of Grenfell Tower had visual and hearing impairments, three had impaired mobility and one had a mental health illness, but none of those residents was recorded in the fire risk assessment made in October 2014.¹⁸¹¹¹⁸¹¹ Fire Risk Assessment for Grenfell tower dated 17 October 2014 {CST00003157}. That tends to show that, although Carl Stokes was aware of the TP Tracker, he did not take into account the information it contained when making his assessments.

¶46.79 In 2013, there were proposals for replacing the TP Tracker with the Civica W2 electronic document management system¹⁸¹²¹⁸¹² {TMO00862586}. that held electronic copies of documents relating to residents. The information could then be entered manually into Capita, the housing management system maintained by the TMO.¹⁸¹³¹⁸¹³ Noble {Day119/54:11-18}. In 2016 the Customer Relationship Management platform (CRM) was introduced with the intention of replacing W2. By 14 June 2017, therefore, information about vulnerable residents was recorded in three different places: on documents held in W2, on the Capita housing management system and on the CRM database.¹⁸¹⁴¹⁸¹⁴ Noble {TMO00899669/1} page 1, paragraph 2 (a) and (b).

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¶46.80 There was some confusion about how information recorded on Capita was transferred to CRM. However, it appears that, although some of the information was transferred to CRM, most of it was not.¹⁸¹⁵¹⁸¹⁵ Noble {Day119/54:19}-{Day119/55:8}; {TMO00899673}. That turned out to be significant, because on the night of the fire there was some uncertainty about the reliability of the information held by the TMO about the number of vulnerable residents in the tower.

¶46.81 Of the 297 people present in Grenfell Tower on the night of the fire, 67 were children and 37 were adults with sensory, mobility or cognitive impairments.¹⁸¹⁶¹⁸¹⁶ Lane, Module 3 Report {BLARP20000034/237} paragraph 14.2.3. There were a further 17 residents who had a sensory, mobility or cognitive impairment that was not recorded in the tenancy records, tenancy audit documents or David Noble's spreadsheet. The TMO ought to have had a readily accessible system for collecting and maintaining information about its residents' vulnerabilities which would not only have enabled it to decide whether in any case a PEEP was necessary but would also have assisted in responding to emergencies.

PEEPs for Vulnerable Residents

¶46.82 Janice Wray said that the Health and Safety team would prepare PEEPs for residents in general needs housing if it were asked to do so, but that there was no established procedure for identifying circumstances that would result in consideration of the need for a PEEP and residents were not told that they could ask for one.¹⁸¹⁷¹⁸¹⁷ Wray {TMO00862589/2} page 2, paragraph 6; Wray {Day142/32:4-21}; {Day142/66:5}-{Day142/67:4}; {Day142/69:1}-{Day142/71:11}; {Day142/71:12-18}. For its part, the members of the Housing team did not know that they could refer a resident to the Health and Safety team to be assessed for a PEEP.¹⁸¹⁸¹⁸¹⁸ Brown {Day126/65:9}-{Day126/67:3}; Rumble {Day120/70:8-24}; Bartholomew {Day120/163:3-10}; Williams {TMO00879804/11} page 11, paragraphs 79-80; Jones {TMO00873924/6} page 6, paragraph 27.

¶46.83 Neither Siobhan Rumble nor Nicola Bartholomew was aware that she could ask for residents to be given PEEPs. Janice Wray said that was because she did not use the expression "PEEP" with the Housing team. She told them that if residents were concerned about fire safety generally, they could be referred to the Health and Safety team.¹⁸¹⁹¹⁸¹⁹ Wray {Day142/72:7-17}. If the Health and Safety team expected to have residents referred to them by the Housing team for assessment for a PEEP, even if described in other terms, the Housing team should have been aware of that and it should have been covered in one of the policies, such as the fire safety strategy or the "Supporting Residents" policy.

¶46.84 Residents were not told that they could ask to be assessed for a PEEP and the possibility was not drawn to their attention in any of the literature they were given. Janice Wray could not say why that was and we cannot see any reasonable explanation for it. The first draft version of the fire safety letter to new tenants dated December 2010 did include the offer of a personal emergency evacuation plan for those who were not able-bodied or had special requirements,¹⁸²⁰¹⁸²⁰ {TMO00870665}. but it is unclear whether the letter was ever finished and distributed to residents between 2010 and 2013.

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¶46.85 Janice Wray did not prepare a PEEP for any resident while working at the TMO,¹⁸²¹¹⁸²¹ Wray {Day142/72:18-24}. perhaps because no one in the Housing team knew that a resident could be referred to the Health and Safety team for a PEEP. Nonetheless, there is evidence that even when Janice Wray was made aware of a resident in Grenfell Tower with a particular vulnerability, she took no steps to ascertain whether that resident needed a PEEP. That was Elpidio Bonifacio in Flat 83.

¶46.86 On 4 February 2016, Charles Batterbee of the LFB and Janice Wray exchanged emails about a resident of Flat 83, Elpidio Bonifacio, whom the LFB had met during a home fire safety visit and believed to be blind.¹⁸²²¹⁸²² {LFB00001057}. Janice Wray said that she should have asked whether he needed a PEEP or some other form of assistance in the event of a fire and could not explain why she had not done so.¹⁸²³¹⁸²³ Wray {Day142/163:4}-{Day142/165:24}. Moreover, Mr Bonifacio's disabilities were not recorded on the spreadsheet produced by David Noble on 14 June 2017.¹⁸²⁴¹⁸²⁴ {TMO00866002}.

¶46.87 Elpidio Bonifacio was the last person to escape from Grenfell Tower at 08.07 on 14 June 2017. Although he had been encouraged by his family to leave his flat from about 02.00, he had had to wait for more than six hours to be rescued by firefighters because he was blind, elderly and unable to escape without help.¹⁸²⁵¹⁸²⁵ Bonifacio {IWS00001085/5-6} pages 5-6, paragraphs 31-32. There is no reason to think that he was an isolated example or that Grenfell Tower was different from the other buildings managed by the TMO, given the deficiencies in the TMO's system of creating and maintaining accurate records of vulnerable residents.

Vulnerable residents in Grenfell Tower on 14 June 2017

¶46.88 The list of residents that David Noble produced on 14 June 2017 identified only ten residents of Grenfell Tower as having mental or physical impairments. That was only half the number recorded as vulnerable by the TMO in the tenancy creation and tenancy audit documents.¹⁸²⁶¹⁸²⁶ Lane, Module 3 Report {BLARP20000034/188-189} paragraphs 10.8.32-10.8.34. A result of its failure to maintain an adequate record of residents' vulnerabilities was that the TMO was unable to provide the LFB with an accurate list of vulnerable residents,¹⁸²⁷¹⁸²⁷ Phase 1 Report Volume III paragraphs 20.65-20.66. although by the time the list reached the LFB all those who died in the tower had already lost their lives.¹⁸²⁸¹⁸²⁸ Phase 1 Report Volume III paragraphs 20.67-20.68.

¶46.89 Of the ten residents recorded in the spreadsheet as vulnerable, three, Sakina Afrasehabi, Majorie Vital and Alexandra Atala, died in the fire.¹⁸²⁹¹⁸²⁹ {TMO00866002}. They lived on the top floors of the tower. The remaining seven lived on floors 2 and 3. They were able to escape as their flats were below the fire line. It is impossible to say what effect an accurate list of vulnerable residents would have had on the outcome of the tragedy, but it might have provided the LFB with valuable information about the locations and numbers of vulnerable residents when considering the deployment of crews.

¶46.90 On any view, the Grenfell Tower fire revealed the importance of ensuring that the responsible person collects sufficient information about any vulnerable occupants to enable PEEPs to be prepared, when appropriate, and, in the event of a fire, appropriate measures to be taken to assist their escape. The TMO's failure to collect such information illustrates a basic neglect of its obligations in relation to fire safety.