Chapter 86: Floor 10

¶86.1 By 01.21 on 14 June 2017, the fire had spread up the east face of Grenfell Tower to reach the outside of Flat 76 on floor 10.¹²³¹²³ Phase 1 Report Volume II paragraphs 10.115-10.116; Phase 1 Report Volume IV paragraph 24.18. All the flats on floor 10 were still occupied at that time, but none of the occupants had contact with those who died on that floor.

¶86.2 Hoang Khanh Quang, who lived in Flat 76, and her former husband, Van Quang Ho, who was there that night, were the first to leave floor 10. Having been woken by a smoke alarm, Hoang Khanh Quang saw flames at the kitchen window. Both she and Van Quang Ho then became aware of black smoke filling the hallway. Leaving at speed and in obviously difficult circumstances, neither of them closed the front door of the flat, which did not have an effective self-closing device. They left the tower together at 01.26.¹²⁴¹²⁴ Phase 1 Report Volume II paragraphs 10.197-10.202; Phase 1 Report Volume IV paragraph 24.31.

¶86.3 Flat 76 rapidly filled with smoke, which then entered the floor 10 lobby. Within five minutes the lobby became so full of smoke that when the north lift unexpectedly stopped at that floor it was already dark and full of smoke. Some of the smoke penetrated the closed lift doors. More came in when the doors opened. The volume and density of the smoke that entered the lift made Nadia Jafari, who was in the lift, think that the lights had gone out. In the ensuing panic, three of the five people in the lift, Ali Yawar Jafari, Mohamednur Tuccu and Khadija Khalloufi, stumbled out and became trapped in the lobby of floor 10.¹²⁵¹²⁵ Phase 1 Report Volume II paragraphs 10.215 and 10.221-10.225.

¶86.4 The lift then continued its descent, reaching the ground floor at 01.26. Only Nadia Jafari and Rhea Rojo emerged. The extent of the smoke billowing from the lift as they left it, seen on CCTV, gives an indication of the amount of smoke on floor 10.¹²⁶¹²⁶ Phase 1 Report Volume II paragraphs 10.94 and 10.215-10.219; Phase 1 Report Volume IV paragraph 25.6. Nadia Jafari said that the smoke had been much thicker when the lift was at floor 10. At 01.28, in a call to the emergency services, the occupants of Flat 73, located in the south-west corner of the tower, reported smoke coming through their front door.¹²⁷¹²⁷ Phase 1 Report Volume II paragraph 10.203.

¶86.5 Nagawa (Prossy) Nalukwago, who was staying in Flat 71, next to Flat 76, left the tower at 01.35. On leaving Flat 71, she had been confronted by thick black smoke which felt hot. Despite the conditions, she was able to make her way to the stairwell. While doing so, she stumbled over what she thought were three bodies.¹²⁸¹²⁸ Phase 1 Report Volume II paragraph 11.114. They were the bodies of Ali Yawar Jafari, Mohamednur Tuccu and Khadija Khalloufi, all of whom had by then been overcome by the conditions in the lobby. That none of them had been able to reach the stairs shows how disorientating conditions on floor 10 were.

¶86.6 Clarita Ghavimi was woken at around 01.30 by a smoke alarm. She saw flames from her bedroom window. When she opened her front door, she found the lobby dark and smoky. She made her way to the stairwell door by touch because the lobby was too thick with smoke for her to see her way.¹²⁹¹²⁹ Phase 1 Report Volume II paragraphs 11.115 and 12.40-12.43. She was then rescued by another resident, Branislav Lukic, and carried down. They left the tower at 01.49.¹³⁰¹³⁰ Phase 1 Report Volume II paragraphs 12.41-12.43.

¶86.7 Between 01.40 and 01.42 a group of five firefighters led by CM Guy Tillotson began searching the tower to rescue anyone they could find. They went to floor 10 but found it so full of thick, black smoke that CM Tillotson decided that the firefighters could not enter the lobby without water.¹³¹¹³¹ Phase 1 Report Volume II paragraphs 12.3-12.5 and 12.29.

Ali Yawar Jafari

¶Date of birth: 1 January 1936 (81 years). Place of birth: Kandahar, Afghanistan. Gender: Male. Occupation: Retired jeweller. Usual address: Flat 86, floor 11, Grenfell Tower, London. Place of death: Lobby of floor 10, Grenfell Tower, London. Time of death: By about 01.37 on 14 June 2017. Cause of death: la. Inhalation of asphyxiant gases.

¶II. Coronary and hypertensive heart disease.

Background and composition of household

¶86.8 Born on 1 January 1936 in Kandahar, Afghanistan, Ali Yawar Jafari was an 81-year-old retired jewellery maker. He lived in Flat 86 on floor 11 of Grenfell Tower with his wife, Fatima Jafari, and their two adult daughters, Maria and Nadia Jafari. The family had lived there since 2003.¹³²¹³² Phase 1 Report Volume II paragraph 10.204; Phase 1 Report Volume IV paragraph 32.293.

Vulnerability

¶86.9 Ali Yawar Jafari suffered from diabetes and heart disease.¹³³¹³³ Phase 1 Report Volume II paragraph 10.204. Rydon's survey of residents, prepared in November 2014 and provided to the TMO, recorded that he suffered from diabetes.¹³⁴¹³⁴ Rydon Residents Survey {RYD00024466/33}. On the night of the fire, David Noble, a policy and diversity advisor with the TMO,¹³⁵¹³⁵ Noble {TMO00000884/1} page 1, paragraph 3. produced a spreadsheet listing the residents of the tower which was designed to record any known vulnerability or disability.¹³⁶¹³⁶ Noble {Day119/75:19-22}. That spreadsheet was compiled from information held on the TMO's Capita Insight system.¹³⁷¹³⁷ Noble {Day119/77:17}-{Day119/82:5}. It did not identify Ali Yawar Jafari as a vulnerable resident.

Events of 14 June 2017

¶86.10 Ali Yawar Jafari was last seen entering the tower at 19.40 on 13 June 2017.¹³⁸¹³⁸ O'Riordan {MET00013136/3} page 3. He remained in his home preparing to break the Ramadan fast with his family.¹³⁹¹³⁹ Nadia Jafari {IWS00000683/3} page 3, paragraph 10.

¶86.11 By 01.22 the fire had reached the top of floor 11 outside the kitchen of Flat 86.¹⁴⁰¹⁴⁰ Phase 1 Report Volume II paragraph 10.116; Phase 1 Report Volume IV paragraph 25.6. By then the Jafari family were already aware of it and Fatima and Maria Jafari had started to make their way out of the building. Before doing so, Fatima asked Nadia to wake her father and help him outside. Nadia and her father were still in the flat when she saw flames push through the extractor fan of the kitchen window, the glass in that window shatter and the frame fall out. She shut the kitchen door and together with her father left the flat.¹⁴¹¹⁴¹ Phase 1 Report Volume II paragraphs 10.204-10.206.

¶86.12 In the lobby, Nadia Jafari and her father knocked on the doors of neighbours. She spoke to Natasha Elcock in Flat 82 and even tried to go back into Flat 86. She was not able to lock the door of the flat, which was left partly open. The smoke emerging from Flat 86 did not immediately fill the lobby of floor 11 and the lights were still visible. Nadia suggested to her father that they use the lift to leave the tower.¹⁴²¹⁴² Phase 1 Report Volume II paragraphs 10.206-10.209. By that time, Ali Yawar Jafari had been exposed to only a limited amount of smoke.

¶86.13 Mohamednur Tuccu and Rhea Rojo were already in the north lift when it stopped at floor 11. Khadija Khalloufi, who had made her way down from her own flat on floor 17, entered the lobby of floor 11 and got into the lift at the same time as the Jafaris.¹⁴³¹⁴³ Phase 1 Report Volume II paragraphs 10.208 and 10.221-225. There appears to have been no smoke in the lift when it reached floor 11.

¶86.14 The lift started to descend but suddenly stopped at floor 10. Smoke began to seep in through the closed doors. When they opened, the inward rush of smoke filled the lift obscuring the lights. The occupants were left coughing and shouting. In the panic Ali Yawar Jafari, Mohamednur Tuccu and Khadija Khalloufi went into the lobby, which by then was filled with dense black smoke.¹⁴⁴¹⁴⁴ Phase 1 Report Volume II paragraph 10.225. Unable to find a way out, Ali Yawar Jafari became trapped in the lobby on floor 10.

¶86.15 The lift probably stopped on floor 10 shortly before 01.26 (the time when Nadia Jafari and Rhea Rojo are seen leaving the lift on the ground floor).¹⁴⁵¹⁴⁵ Phase 1 Report Volume II paragraph 10.216. Initially, Nadia Jafari thought her father had left the lift on the ground floor ahead of her.¹⁴⁶¹⁴⁶ Phase 1 Report Volume II paragraph 10.217.

¶86.16 When they had left the tower and realised that their father had not escaped the building, Nadia and Maria Jafari tried to re-enter it but were stopped by a police officer, possibly PC Kiran Sangha, who recalled being told by a family he had prevented from entering the tower that their grandfather was stuck in the lift. The officer told a fireman outside the tower that there were people stuck in a lift but was told that the fire brigade had control of the lifts in the tower.¹⁴⁷¹⁴⁷ Sangha {MET00007837/3} page 3. There is no evidence of what, if any, further steps were taken in response to what the officer had said.

Recovery and identification

¶86.17 CM Martin Hoare and FF Matthew Tanner tallied out at 02.55.¹⁴⁸¹⁴⁸ Phase 1 Report Volume II paragraph 10.225. Having originally been sent to search Flat 74 on floor 10, they were reassigned with other firefighters to search for a missing firefighter on floor 12. Once that emergency had been resolved, they returned to their original task. When they reached floor 10 and opened the door to the lobby, they were confronted by intense heat with smoke extending down to a foot above the floor. Crawling into the lobby, they found Ali Yawar Jafari's body near the lift and brought him out into the stairwell. CM Hoare accepted that he had originally wrongly identified the casualty as Mohamednur Tuccu.¹⁴⁹¹⁴⁹ Hoare {MET00008027/15-25} pages 15-16 and 25; Phase 1 Report Volume II paragraphs 10.224-10.225; Phase 1 Report Volume III paragraphs 17.13 (e) and 20 (c).

¶86.18 As he and FF Tanner were carrying Ali Yawar Jafari down the stairs, CM Hoare realised that he was running out of air.¹⁵⁰¹⁵⁰ Standard duration breathing apparatus provides a working time of about 30 minutes depending on a range of factors, including workload and environmental conditions: Phase 1 Report Volume I paragraph 7.63. Concluding that Ali Yawar Jafari had already died, the firefighters laid his body on the stairs.¹⁵¹¹⁵¹ Phase 1 Report Volume III paragraph 17.20 (c). Returning to the bridgehead, they reported where they had left him. FFs Charlie Rawlings, Andrew Brooks and James Morcos were sent to recover his body.¹⁵²¹⁵² Rawlings {MET00005588/2} page 2; Brooks {MET00005262}; Morcos {MET00005585/1} page 1. It was carried out of the tower at 03.34.¹⁵³¹⁵³ Phase 1 Report Volume II paragraph 10.225. At 03.35, paramedic Mark Hodson confirmed that he was dead.¹⁵⁴¹⁵⁴ Hodson {MET00017061/5} page 5.

¶86.19 The coroner, Professor Wilcox, was satisfied that the casualty recovered by CM Hoare and FF Tanner was Ali Yawar Jafari and therefore issued an interim certificate of the fact of death.¹⁵⁵¹⁵⁵ Interim certificate of the fact of death for Ali Yawar Jafari {MET00065589}.

Cause and time of death

¶86.20 The post-mortem on Ali Yawar Jafari found that his body was intact. There were soot deposits around his nose and mouth and some superficial burns and heat damage to the skin. The post-mortem also confirmed that he had suffered from severe heart disease which affected the blood supply to his heart and made him more vulnerable to the conditions produced during a fire, so contributing to his death.¹⁵⁶¹⁵⁶ Jafari post-mortem report {COR00000088/11}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/122} Table 17.

¶86.21 The level of carboxyhaemoglobin in a blood sample taken from Ali Yawar Jafari was found to be 47%.¹⁵⁷¹⁵⁷ Jafari toxicology report {COR00000092/1}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/124} paragraph 493. That is within the toxic range for someone whose pre-existing heart disease made him more vulnerable to conditions in the lobby.¹⁵⁸¹⁵⁸ Jafari post-mortem report {COR00000088/11}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/125} paragraph 493. No cyanide was detected in the sample when it was later tested. As cyanide was found in samples taken from Mohamednur Tuccu and Khadija Khalloufi, its absence in the case of Ali Yawar Jafari was probably due to degradation of the sample over time.¹⁵⁹¹⁵⁹ Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447. It is likely therefore that Ali Yawar Jafari inhaled hydrogen cyanide, although we cannot say how much.

¶86.22 The medical cause of death was recorded as: Ia. Inhalation of fire fumes. II. Coronary and hypertensive heart disease.

¶86.23 In the light of Professor Purser's evidence we find that a more accurate description of the primary cause of death is "inhalation of asphyxiant gases".

¶86.24 Given his poor health, the manner in which he came to leave the lift on floor 10, the conditions in the lobby on that floor and the fact that his body was recovered near the lift, we find that Ali Yawar Jafari probably collapsed due to the inhalation of asphyxiant gases within a minute or so of stepping out of the lift. While unconscious, he continued to inhale those gases until his respiration and circulation ceased some minutes later and he died at about 01.37,¹⁶⁰¹⁶⁰ Purser, Phase 2 Report, Section 6 {DAPR0000006/167-170} paragraphs 925-935; Purser, Phase 2 Report, Section 6 {DAPR0000006/172} paragraph 943 and Figure 46. mainly from the effects of carbon monoxide poisoning.¹⁶¹¹⁶¹ Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/136} paragraph 568; Purser, Phase 2 Report, Section 6 {DAPR0000006/171-172} paragraphs 942 and 946. He would have had to be rescued before about 01.35 to have had a reasonable prospect of survival.¹⁶²¹⁶² Purser, Phase 2 Report, Section 6 {DAPR0000006/172} paragraph 945.

Mohamednur Tuccu

¶Date of birth: 24 May 1973 (44 years). Place of birth: Eritrea. Gender: Male. Occupation: Security Officer. Usual address: Arne House, Tyers Street, London Place of death: Lobby of floor 10, Grenfell Tower, London Time of death: By 01.46 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Background and composition of household

¶86.25 Born in Eritrea, Mohamednur Tuccu had lived in the United Kingdom since 1991. Aged 44 years (born 24 May 1973), he was working as a security guard at the time of the fire. Mohamednur Tuccu is not listed as a resident in the spreadsheet¹⁶³¹⁶³ Noble {Day119/75:19-22}. produced on the night of the fire by David Noble.¹⁶⁴¹⁶⁴ Noble {TMO00000884/1} page 1, paragraph 3. His wife, Amal Ahmedin, and daughter, Amaya Tuccu- Ahmedin, lived in Flat 166 on floor 19. On the evening of 13 June 2017, Amna Idris, Amal Ahmedin's cousin, was visiting the family.¹⁶⁵¹⁶⁵ Phase 1 Report Volume IV paragraphs 32.154-32.163.

Events of 14 June 2017

¶86.26 Mohamednur Tuccu was seen on CCTV entering Grenfell Tower at 00.36.¹⁶⁶¹⁶⁶ O'Riordan {MET00013136/4} page 4. His movements thereafter are unknown, but it is very likely that he visited his family. By 01.25, the fire had reached the top of floor 19 and was outside Flat 166.¹⁶⁷¹⁶⁷ Phase 1 Report Volume II paragraph 10.118. Shortly after 01.25, Meron Mekonnen, who lived in Flat 163, left her home having been alerted to the fire. She saw Amal Ahmedin and Amna Idris in the lobby of floor 19. They told each other that there was a fire in the building.¹⁶⁸¹⁶⁸ Phase 1 Report Volume II paragraphs 10.255-10.257. Meron Mekonnen left the tower at 01.32. Amal Ahmedin, with her daughter, and Amna Idris subsequently made their way up to shelter in Flat 201 on floor 23. It is likely that they reached it by about 01.30.¹⁶⁹¹⁶⁹ Phase 1 Report Volume II paragraphs 10.260 and 10.287-10.289. They died on floor 23 and we deal with the circumstances of their deaths in Chapter 97.

¶86.27 There is no evidence that Mohamednur Tuccu was in Flat 166 when Meron Mekonnen saw Amal Ahmedin or that he was among those who made their way up the tower. He was, however, in the north lift when Rhea Rojo entered it on floor 12.¹⁷⁰¹⁷⁰ Phase 1 Report Volume II paragraphs 10.219 and 10.224-10.225. It is not known where Mohamednur Tuccu entered the lift, but it would have been somewhere above floor 12. Since the lift stopped at floors 11 and 10 and reached the ground floor at 01.26,¹⁷¹¹⁷¹ Phase 1 Report Volume II paragraphs 10.216-10.217. it is reasonable to conclude that he left Flat 166 before the fire had reached floor 19.

¶86.28 When the lift stopped at floor 11, Khadija Khalloufi, who had made her way down the stairs from her home on floor 17 and had entered the lobby on floor 11, got into the lift together with Nadia Jafari and her father, Ali Yawar Jafari.¹⁷²¹⁷² Phase 1 Report Volume II paragraphs 10.208 and 10.221-10.224.

¶86.29 The lift probably stopped on floor 10 shortly before 01.26, when Nadia Jafari and Rhea Rojo can be seen leaving the lift on the ground floor.¹⁷³¹⁷³ Phase 1 Report Volume II paragraph 10.216.

¶86.30 It is unlikely that Mohamednur Tuccu had been exposed to any smoke before the lift reached floor 10. When the doors opened, the inward rush of smoke filled the lift obscuring the lights. Those in the lift were left coughing and shouting. In the panic Mohamednur Tuccu, together with Ali Yawar Jafari and Khadija Khalloufi, entered the lobby on floor 10, by then filled with dense black smoke.¹⁷⁴¹⁷⁴ Phase 1 Report Volume II paragraph 10.225. Unable to find a way out, he was trapped there.

Recovery and identification

¶86.31 At 02.04,¹⁷⁵¹⁷⁵ BA Telemetry Data {LFB00023326/1} page 1. FFs Oliver Desforges and Robert Mitchell were deployed with other firefighters to rescue Mariko Toyoshima-Lewis and her family from Flat 9 on floor 3. They were then deployed to floor 24. Climbing the stairs, the two firefighters realised that they did not have enough air to get there. They decided to search a floor they could reach,¹⁷⁶¹⁷⁶ Phase 1 Report Volume II paragraphs 14.225-14.227; Mitchell {MET000086063/4-5} pages 4-5; Desforges {MET00008013/4-5} pages 4-5. which turned out to be floor 10.

¶86.32 FF Desforges said that the heat they encountered on opening the door from the stairwell into the lobby was the most intense he had ever experienced. The lobby was filled with hot black smoke and it was impossible to see anything. Keeping low to the ground, the two firefighters found and were able to recover two casualties, Mohamednur Tuccu and Khadija Khalloufi.¹⁷⁷¹⁷⁷ Mitchell {MET000086063/5} page 5; Desforges {MET00008013/5-6} pages 5-6.

¶86.33 With the assistance of other firefighters, Mohamednur Tuccu was carried down the stairs and out of the tower at 02:28.¹⁷⁸¹⁷⁸ Phase 1 Report Volume II paragraph 10.224. At 02.37, paramedic Stuart Matthews formally confirmed that he was dead.¹⁷⁹¹⁷⁹ Matthews {MET00013948/4} page 4.

¶86.34 The coroner, Professor Wilcox, was satisfied that the casualty recovered by FFs Desforges and Mitchell was Mohamednur Tuccu and therefore issued an interim certificate of the fact of death.¹⁸⁰¹⁸⁰ Interim certificate of the fact of death for Mohamednur Tuccu {MET00065634}.

Cause and time of death

¶86.35 The post-mortem on Mohamednur Tuccu recorded that his body was intact without any burns and that there were significant soot deposits on his face, in his nostrils and in his respiratory system.¹⁸¹¹⁸¹ Tuccu post-mortem report {COR00001106/10}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/136} paragraph 570. There was bruising on the back of the head consistent with minor blows sustained during an attempt to escape.¹⁸²¹⁸² Tuccu post-mortem report {COR00001106/10}.

¶86.36 The level of carboxyhaemoglobin in a blood sample taken from him was found to be 73%,¹⁸³¹⁸³ Tuccu first toxicology report {COR00001119/1}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/137} paragraph 571. which indicates that he had inhaled a considerable amount of carbon monoxide before he died. Later analysis of the blood sample measured a cyanide concentration of 0.18 milligrams/litre.¹⁸⁴¹⁸⁴ Tuccu second toxicology report {INQ00011095/1}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/141} paragraph 604. That is not in the toxic range but is elevated by comparison with the level naturally occurring in the blood.¹⁸⁵¹⁸⁵ Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447. It is likely that it was affected by degradation of the sample and did not reflect the level of cyanide in the blood at the time of death.¹⁸⁶¹⁸⁶ Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447. Its presence shows that Mohamednur Tuccu had inhaled some hydrogen cyanide at the time of his death but it is not possible to say how much.

¶86.37 The post-mortem recorded the medical cause of death as "inhalation of fire fumes" but in the light of more recent evidence we find that a more accurate description is "inhalation of asphyxiant gases".

¶86.38 Given the circumstances in which Mohamednur Tuccu left the lift on floor 10, the conditions in the lobby on that floor and the level of carboxyhaemoglobin subsequently found in his blood, we are satisfied that he probably collapsed due to the inhalation of asphyxiant gases within a few minutes of stepping out of the lift. While unconscious, he continued to inhale those gases until his respiration and circulation ceased some minutes later and he died. The level of carboxyhaemoglobin in his blood indicates that the exposure to carbon monoxide alone would have been fatal, although he also inhaled some hydrogen cyanide.¹⁸⁷¹⁸⁷ Purser, Phase 2 Report, Section 6 {DAPR0000006/173-174} paragraphs 948-949. He would have had to be rescued before about 01.35 at the latest to have had a reasonable prospect of survival.¹⁸⁸¹⁸⁸ Purser, Phase 2 Report, Section 6 {DAPR0000006/172} paragraph 945.

¶86.39 Having considered the evidence, we find that Mohamednur Tuccu had died by 01.46 before being exposed to the direct effect of the flames.

Khadija Khalloufi

¶Date of birth: 6 September 1964 (52 years). Place of birth: Mohammedia, Morocco. Gender: Female. Occupation: Homemaker. Usual address: Flat 143, floor 17, Grenfell Tower, London.

¶Place of death: Lobby of floor 10, Grenfell Tower, London. Time of death: By 01.44 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Background and composition of household

¶86.40 Born in Mohammedia, Morocco on 6 September 1964 as the eldest of seven siblings, Khadija Khalloufi was 52 years old at the time of her death. A graduate, she had managed a pharmacy in Morocco before moving to Holland to live and work and ultimately settling in London. At the time of the fire, Khadija Khalloufi lived in Flat 143 on floor 17 with her husband Sabah Abdullah. They had married in 1990.¹⁸⁹¹⁸⁹ Phase 1 Report Volume IV paragraphs 32.234-32.239; Presentation relating to Khadija Khalloufi {Day306/24:22}-{Day306/26:19}.

Events of 14 June 2017

¶86.41 Khadija Khalloufi returned to Grenfell Tower on 13 June 2017 at 16.02¹⁹⁰¹⁹⁰ O'Riordan {MET00013136/3} page 3. and remained in her home. Mesrob Kassemdjian, who lived in Flat 146 with his aunt, Rita Tankarian, alerted Khadija Khalloufi to the fire before leaving floor 17. She then turned back into her flat to speak to her husband, Sabah Abdullah. Mesrob Kassemdjian left the tower at 01.25 just ahead of Rita Tankarian. She recalled Sabah Abdullah telling her outside the tower that he had lost his wife on the stairs at some point between floors 14 and 17.¹⁹¹¹⁹¹ Phase 1 Report Volume II paragraph 10.222.

¶86.42 Khadija Khalloufi was next seen by Nadia Jafari. She entered the lobby of floor 11, called the lift and waited for it with Nadia Jafari and her father, Ali Yawar Jafari.¹⁹²¹⁹² Phase 1 Report Volume II paragraph 10.208. We do not know why Khadija Khalloufi chose to enter floor 11. It is unlikely that at that stage she had been exposed to any smoke.

¶86.43 Mohamednur Tuccu and Rhea Rojo were already in the lift when it reached floor 11 and Khadija Khalloufi, Nadia Jafari and her father all entered it. When the lift suddenly stopped at floor 10, smoke began to seep in through the closed doors. When they opened, the inward rush of smoke filled the lift obscuring the lights. Those in the lift were left coughing and shouting. In the panic Khadija Khalloufi, together with Ali Yawar Jafari and Mohamednur Tuccu, came out into the lobby of floor 10, by then filled with thick black smoke.¹⁹³¹⁹³ Phase 1 Report Volume II paragraph 10.215. Unable to find her way out, Khadija Khalloufi became trapped.

Recovery and identification

¶86.44 At 02.04,¹⁹⁴¹⁹⁴ BA Telemetry Data {LFB00023326/1} page 1. FFs Oliver Desforges and Robert Mitchell were deployed with other firefighters to rescue Mariko Toyoshima-Lewis and her family from Flat 9 on floor 3. They were then deployed to floor 23. Climbing the stairs, the two firefighters realised that they did not have enough air to reach that floor. They decided to search a floor that they could reach.¹⁹⁵¹⁹⁵ Phase 1 Report Volume II paragraphs 14.222-14.227; Mitchell {MET000086063/4-5} pages 4-5; Desforges {MET00008013/4-5} pages 4-5. That turned out to be floor 10.

¶86.45 FF Desforges described the heat they encountered on opening the door from the stairwell into the lobby was the most intense he had ever experienced. The lobby was filled with hot black smoke and it was impossible to see anything. Keeping low to the ground, he and FF Mitchell found and were able to recover two casualties, Mohamednur Tuccu and Khadija Khalloufi.¹⁹⁶¹⁹⁶ Mitchell {MET000086063/5} page 5; Desforges {MET00008013/5-6} pages 5-6.

¶86.46 Khadija Khalloufi was carried out of the tower at 02.28.¹⁹⁷¹⁹⁷ Phase 1 Report Volume II paragraph 10.224. At 02.41, paramedic Stuart Matthews formally confirmed that she was dead.¹⁹⁸¹⁹⁸ Matthews {MET00013948/4} page 4.

¶86.47 The coroner, Professor Wilcox, was satisfied that the casualty recovered by FFs Desforges and Mitchell was Khadija Khalloufi and therefore issued an interim certificate of the fact of death.¹⁹⁹¹⁹⁹ Interim certificate of the fact of death for Khadija Khalloufi {MET00065597}.

Cause and time of death

¶86.48 The post-mortem on Khadija Khalloufi recorded that her body was intact without any burns and that there was dense soot staining around the nostrils and ears and extensive soot contamination in the respiratory system. There were some minor abrasions and bruising which she probably sustained during attempts to find her way out of the lobby on floor 10.²⁰⁰²⁰⁰ Khalloufi post-mortem report {COR00000840/14}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/122} Table 17.

¶86.49 The carboxyhaemoglobin level in a sample of blood taken from Khadija Khalloufi was 66%,²⁰¹²⁰¹ Khalloufi first toxicology report {COR00000842/1}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/136} paragraph 569. which indicated the inhalation of a significant amount of carbon monoxide. Later analysis of the sample showed a cyanide concentration of 0.59 milligrams/litre.²⁰²²⁰² Khalloufi second toxicology report {INQ00011089/1}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/141} paragraph 604. That is significantly higher than the background level of cyanide found naturally in the blood.²⁰³²⁰³ Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447. That it was detected shows that Khadija Khalloufi had inhaled hydrogen cyanide, but since the sample is likely to have degraded over time,²⁰⁴²⁰⁴ Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447. we do not know how much cyanide was in her blood at the time of her death.

¶86.50 The post-mortem recorded the medical cause of death as "inhalation of fire fumes" but in the light of more recent evidence we find that a more accurate description is "inhalation of asphyxiant gases".

¶86.51 Given the circumstances in which Khadija Khalloufi left the lift when it reached floor 10, the conditions in the lobby and the level of carboxyhaemoglobin in her blood, we find that she probably collapsed due to the inhalation of asphyxiant gases within a few minutes of exiting the lift. While unconscious, she continued to inhale those gases until her respiration and circulation ceased some minutes later and she died. The level of carboxyhaemoglobin subsequently found in her blood indicates that the degree of exposure to carbon monoxide alone would have been fatal, but she must have also inhaled some hydrogen cyanide.²⁰⁵²⁰⁵ Purser, Phase 2 Report, Section 6 {DAPR0000006/172} paragraph 947.

¶86.52 Having considered the evidence, we are satisfied that Khadija Khalloufi had died by 01.44. She would have had to be rescued no later than 01.35 to have had a reasonable prospect of survival. We are satisfied that she died before being exposed to the direct effect of the flames.