Chapter 87: Floor 11

¶87.1 By 01.22 on 14 June 2017 the fire on the outside of the building had reached the top of floor 11 outside Flat 86.²⁰⁶²⁰⁶ Phase 1 Report Volume II paragraph 10.116. All six flats on floor 11 were still occupied. Except for Ali Yawar Jafari, whose body was recovered from the lobby of floor 10, and Abdeslam Sebbar, who remained in Flat 81, all the occupants of floor 11 survived the fire.

¶87.2 The Jafari family, in Flat 86, were the first to leave. Of that family, Nadia Jafari and her father, Ali Yawar Jafari, left last. By that time, flames and smoke had begun to penetrate Flat 86.²⁰⁷²⁰⁷ Phase 1 Report Volume II paragraphs 10.204-10.206.

¶87.3 The front door of Flat 86 did not have an effective self-closing device and when she left Nadia Jafari left the door partly open.²⁰⁸²⁰⁸ Phase 1 Report Volume II paragraph 10.207. She did not see or smell smoke while she was in the lobby. She and her father then entered the lift when it stopped on that floor.²⁰⁹²⁰⁹ Phase 1 Report Volume II paragraph 10.208. Since Nadia Jafari left the lift at 01.26 when it reached the ground floor,²¹⁰²¹⁰ Phase 1 Report Volume II paragraph 10.216. it is likely that they entered the lift shortly before that time. As we have explained, Ali Yawar Jafari died after leaving the lift on floor 10.²¹¹²¹¹ See Chapter 86.

¶87.4 The occupants of Flat 85 (Youssef Khalloud, Mouna El-Ogbani and their three children) were the next to leave floor 11, followed by the occupants of Flat 84 (Miran Lovsin and Branislav Lukic). They all left the building between 01.27 and 01.49.²¹²²¹² Phase 1 Report Volume III Annex A. That left Abdeslam Sebbar in Flat 81, Natasha Elcock and her family in Flat 82 and Elpidio Bonifacio in Flat 83.

¶87.5 Between 01.28 and 04.41, those on floor 11 or their relatives outside the tower made 22 calls to the emergency services. Abdeslam Sebbar and his grandson made four calls between them.²¹³²¹³ Phase 1 Report Volume II paragraphs 10.91 and 11.106; Phase 1 Report Volume III paragraphs 15.119 and 19.72. Elpidio Bonifacio's daughter-in-law made four calls about him between 02.58 and 05.31.²¹⁴²¹⁴ Phase 1 Report Volume III paragraphs 16.73, 16.90, 18.73, 19.74 and 20.49. Natasha Elcock made 14 calls between 01.28 and 04.33.²¹⁵²¹⁵ Phase 1 Report Volume II paragraphs 10.209-10.210, 10.316, 11.103, 11.105, 11.146, 12.54-12.55, 14.207-14.209, 14.237, 14.257; Phase 1 Report Volume III paragraphs 15.113-15.116, 15.154, 15.182, 17.105-17.108, 17.123, 18.48- 18.50, 18.68, 19.42-19.44 and 19.71. The first two calls from Natasha Elcock showed how quickly conditions worsened in the lobby of floor 11. She described a rapid change in the density of the smoke between her first call at 01.28 (when there was only a small amount of smoke) and her second call at 01.33 (at which time she described the lobby as pitch black).²¹⁶²¹⁶ Phase 1 Report Volume II paragraphs 10.209-10.210 and 11.103-105. When at some time before 01.40, Miran Lovsin and Branislav Lukic made an unsuccessful attempt to leave Flat 84, they found the lobby full of thick black smoke.²¹⁷²¹⁷ Phase 1 Report Volume II paragraphs 11.108-11.112.

¶87.6 No firefighters were deployed to floor 11 before 04.00. Between then and 04.50, firefighters were sent to search Flats 81 to 84. They had difficulty searching floor 11 because of the intense heat in the lobby.²¹⁸²¹⁸ Phase 1 Report Volume III paragraphs 19.18(b), 19.19(c), 19.19(d), 19.19(f), 19.22(b) and 19.29(b). Another team that had been sent to floor 9 miscalculated and arrived on floor 11, where they helped Natasha Elcock, her partner and child, to leave.²¹⁹²¹⁹ Phase 1 Report Volume III paragraphs 19.19(g) and 19.44; Barritt {MET000083284/5-6} pages 5-6. The family left the tower at 04.47.²²⁰²²⁰ Phase 1 Report Volume III paragraphs 19.42–19.44.

¶87.7 Elpidio Bonifacio was the last surviving resident of the tower to be rescued, reaching the base of the tower at 08.07.²²¹²²¹ Phase 1 Report Volume III paragraph 20.37.

¶87.8 No resident of floor 11 had contact with Abdeslam Sebbar on the night of the fire and there is no evidence to suggest that he ventured from Flat 81.

Abdeslam Sebbar

¶Date of birth: 11 September 1939 (77 years old). Place of birth: Larache, Morocco. Gender: Male. Occupation: Retired. Usual address: Flat 81, floor 11, Grenfell Tower, London. Place of death: Flat 81, floor 11, Grenfell Tower, London. Time of death: Between 3.50 and 04.05 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Background and composition of household

¶87.9 Born on 11 September 1939 in Larache, Morocco, Abdeslam Sebbar was a 77-year-old retired coffee shop owner and chef. He lived alone in Flat 81, a one-bedroom flat on the east side of floor 11 of Grenfell Tower.²²²²²² Phase 1 Report Volume IV paragraph 32.301; Presentation relating to Abdeslam Sebbar {Day301/1:23}-{Day301/2:6}. He had been the tenant of Flat 81 since 1978 and very involved in his local community.²²³²²³ Sebbar {IWS00002375/1} page 1, paragraph 3; Presentation relating to Abdeslam Sebbar {Day301/2:3-18}.

Vulnerability

¶87.10 In a letter to RBKC dated 9 November 2016 the TMO stated that Abdeslam Sebbar was diabetic and frail, had difficulty using stairs and needed accommodation at ground level or with a lift.²²⁴²²⁴ Letter from TMO to RBKC dated 9 November 2016 {BSR00000108}. He appeared in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system,²²⁵²²⁵ Noble {Day119/77:17}-{Day119/82:5}. but it contained no information about his physical limitations.²²⁶²²⁶ Noble spreadsheet {TMO00862588}.

Events of 14 June 2017

¶87.11 Abdeslam Sebbar returned home at approximately 00.23 on 14 June 2017 and did not leave again.²²⁷²²⁷ O'Riordan {MET00013136/4} page 4. He called the emergency services at 01.25, shortly after the fire reached the top of floor 11 at about 01.22.²²⁸²²⁸ Phase 1 Report Volume II paragraph 10.116. In that call, he reported a fire but did not say where he was.²²⁹²²⁹ Phase 1 Report Volume II paragraph 10.91; Phase 1 Report Volume III paragraph 15.117.

¶87.12 Abdeslam Sebbar also called his son, Mohamed Sebbar, who, having learned of the fire, was driving to the tower with his own son, Youness Sebbar.²³⁰²³⁰ Phase 1 Report Volume II paragraph 11.107. Mohamed Sebbar tried to reassure his father and told him to leave, although he believed his father would need help to do so. They were still speaking to each other when Mohamed Sebbar reached the tower at around 01.30.²³¹²³¹ Phase 1 Report Volume II paragraph 11.107.

¶87.13 At 01.33, Abdeslam Sebbar made a second call to the emergency services which was the last direct contact he had with them. Before disconnecting the call, he reported that he was on floor 11 and that the fire was in his flat. He did not give the number of his flat.²³²²³² Phase 1 Report Volume III paragraph 15.117; 999 call transcript {LFB00000312}. By that time the fire had not penetrated Flat 81, but was established in the adjacent flat, Flat 86. As Natasha Elcock reported in the emergency call she made at the same time, smoke had by then reached the lobby of floor 11.²³³²³³ Phase 1 Report Volume II paragraphs 10.116, 10.204-10.206 and 11.102-11.105.

¶87.14 Having reached the tower, Mohamed Sebbar spoke to his father twice more, the first time between 01.45 and 02.30.²³⁴²³⁴ Sebbar {IWS00002375/2} page 2, paragraph 7. At 02.46, Youness Sebbar made a call to the emergency services which was connected to Merseyside Fire and Rescue Service. He said that his grandfather was stuck in Flat 81 and had stopped talking and that help was needed urgently. That information was passed on to the LFB in a call timed at 02.47.²³⁵²³⁵ Phase 1 Report Volume III paragraph 15.119; 999 call transcript {INQ00000532}. The Phase 1 report concluded that Abdeslam Sebbar stopped responding to his family shortly before 02.46.²³⁶²³⁶ Phase 1 Report Volume III paragraph 15.119. However, in a statement dated 20 May 2022, Mohammed Sebbar recalled that his last call with his father had taken place after Youness Sebbar had made an emergency call at about 02.46. In that last call, Abdeslam Sebbar was sheltering in the lavatory of Flat 81 and was struggling to breathe. The call continued until approximately 03.30 when Abdeslam Sebbar stopped responding.²³⁷²³⁷ Sebbar {IWS00002375/2} page 2, paragraph 8.

¶87.15 Youness Sebbar made a second emergency call at 04.39 that was taken by CRO Pamela Jones, in which he asked if there was any information about his grandfather. Youness Sebbar gave the number of his grandfather's flat and asked if it could be checked. He also asked where casualties were being taken. CRO Jones was not able to provide any information.²³⁸²³⁸ Phase 1 Report Volume III paragraph 19.72.

Information to the incident ground

¶87.16 Two of the emergency calls made by or about Abdeslam Sebbar (his own call at 01.33 and that of his grandson at 02.46) included information about his location and the fact that he was still in his flat. However, information about Abdeslam Sebbar did not reach the incident ground until 03.00: a. Although Natasha Elcock's first two emergency calls at 01.28 and 01.33 prompted

service requests relating to Flat 82,²³⁹²³⁹ LFB Short Incident Log Report {MET00013830/18}. none was generated in response to the calls relating to Abdeslam Sebbar.

¶b. Flat 81 was not listed on the whiteboards which SM Jason Oliff was using between about 02.33 and 06.41 to collate information to pass from the LFB control room to the command units, although information relating to Flats 82 and 83 was recorded.²⁴⁰²⁴⁰ Phase 1 Report Volume III paragraphs 15.139-15.141 and 20.54 and Figures 15.8 and 15.9.

¶c. No information about Flat 81 appears on the white laminated sheet used in Command Unit 7 (CU7) to collate information about those needing to be rescued.²⁴¹²⁴¹ Phase 1 Report Volume II paragraphs 12.8-12.9 and Figure 12.3.

¶d. WM Glynn Williams began recording information about people needing to be rescued on a wall of the ground floor lobby from 02.15. Nothing was recorded in relation to Flat 81.²⁴²²⁴² Phase 1 Report, Volume II paragraphs 14.103-14.105 and Figure 14.5; Photographs of ground floor wall {MET00005774} and {MET00005776}.

¶e. After the bridgehead had been moved from floor 3 to the ground floor at about 03.10,²⁴³²⁴³ Phase 1 Report Volume III paragraph 17.11; Phase 1 Report Volume IV paragraph 28.86. SM Gareth Cook photographed the wall on floor 3 where information about those needing to be rescued had been recorded. Although "11" had been written on the wall (denoting floor 11), nothing else had been recorded.²⁴⁴²⁴⁴ Cook Exhibit GAC/2 - Grenfell Tower statement notes {MET00015779/16} page 16; Phase 1 Report Volume II Figure 15.7.

¶87.17 From about 03.00, CU7 moved to recording information on a whiteboard using a grid system.²⁴⁵²⁴⁵ Phase 1 Report Volume III paragraphs 15.13 and 16.12. Photographs of that whiteboard,²⁴⁶²⁴⁶ Phase 1 Report Volume III Figure 16.5; Photograph of whiteboard {MET00015924}. taken much later, show that the following had been entered on the grid: "81 1 1 P" with the first "1" in green indicating an adult, the second "1" in black indicating a child, and the "P" in red and circled, indicating a priority.²⁴⁷²⁴⁷ Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}. A red tick was used on the grid to indicate that a crew had been deployed. No red tick appeared in the entry. The mention of a child is an error but, in any event, we do not know when the entry was made or how the information reached CU7. It was probably sent after Youness Sebbar made his call at 02.46.

¶87.18 Once the bridgehead had been moved to the ground floor, information was recorded on a green wall at the bottom of the stairs.²⁴⁸²⁴⁸ Phase 1 Report Volume IV paragraph 28.87. The inscription "BABY 81 82 83 84 – 11" appears in photographs of that wall taken by SM (now GM) Michael Mulholland at about 04.45.²⁴⁹²⁴⁹ Mulholland Exhibit MBM/02 - Photograph of green wall {MET00018721}; Mulholland Exhibit MBM/02 -Photograph of green wall {MET00018731}. It is not clear when that information was put there. It may have been after 04.05 as one of the manuscripts notes delivered to WM Brien O'Keeffe by runners refers to "81 11" together with what appears to be a time stamp of "04.05".²⁵⁰²⁵⁰ O'Keeffe {MET00013967/15} page 15; O'Keeffe notes {LFB00001929/1} page 1.

Recovery and identification

¶87.19 The remains of Abdeslam Sebbar were recovered from the bathroom of Flat 81.²⁵¹²⁵¹ Purser, Phase 2 Report, Section 6 {DAPR0000006/159} paragraph 877. The coroner, Professor Wilcox, was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.²⁵²²⁵² Interim certificate of the fact of death for Abdeslam Sebbar {MET00065630}.

Cause and time of death

¶87.20 The post-mortem on Abdeslam Sebbar found soot in his airways and no clear evidence of burns or trauma before death.²⁵³²⁵³ Sebbar post-mortem report {COR00000009/10} page 10; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/119} Table 17. The level of carboxyhaemoglobin in his blood was 90%,²⁵⁴²⁵⁴ Sebbar first toxicology report {COR00000020/1} page 1; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/116} Table 16. indicating that he must have inhaled a considerable amount of carbon monoxide before he died. Later analysis of the same blood sample detected cyanide at a level of 0.17 milligrams/litre.²⁵⁵²⁵⁵ Sebbar second toxicology report {INQ00011094/1} page 1; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/116} Table 16. That is only slightly elevated compared to naturally occurring levels, probably as a consequence of degradation of the sample over time.²⁵⁶²⁵⁶ Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447. While the level of cyanide in his blood at the time of death is therefore unknown, its presence shows that he had been exposed to hydrogen cyanide before he died.

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

¶87.22 By 02.46, Abdeslam Sebbar had been sheltering in the bathroom for some time. Its location meant that it was one of the last parts of the flat to be affected by internal fires. While that afforded Abdeslam Sebbar some protection, he was still exposed to asphyxiant gases entering the flat from the lobby and the outside. By 02.53 the fire had reached the outside of Flat 81.²⁵⁷²⁵⁷ Phase 1 Report Volume III paragraph 16.3. Flames could be seen inside the windows of Flat 81 from about 03.45.²⁵⁸²⁵⁸ External Spread of Fire Report {MET00012593/78-79} Images 45-56 (applying a +58 minute correction to timestamps).

¶87.23 Mohamed Sebbar's evidence about the last time he spoke to his father was not available when Professor Purser was preparing his report. However, the evidence did not affect his conclusion that Abdeslam Sebbar died from the inhalation of asphyxiant gases. Professor Purser estimated that Abdeslam Sebbar died within 20 to 30 minutes of losing consciousness.²⁵⁹²⁵⁹ Purser {Day297/145:10}-{Day297/148:6}.

¶87.24 In the light of Mohamed Sebbar's evidence, Professor Purser's evidence of the effect of asphyxiant gases and the post-mortem evidence, we find that Abdeslam Sebbar lost consciousness at about 03.30 due to the inhalation of asphyxiant gases. He continued to inhale those gases until his respiration and circulation ceased some minutes later and he died before any flames reached his body. Although he must have inhaled hydrogen cyanide, the level of carboxyhaemoglobin in his blood was such that his exposure to carbon monoxide alone would have been fatal. Abdeslam Sebbar died between 03.50 and 04.05.