Chapter 88: Floor 14

¶88.1 When the fire began, all the flats on floor 14 were occupied apart from Flat 114. Nina Mangoba and her family in Flat 116 were the first residents to leave. As the fire progressed the remaining residents were gathered in Flat 113, the home of Oluwaseun Talabi and Rosemary Oyewole. They were Denis Murphy from Flat 111, brothers Omar Alhaj Ali and Mohammad Alhajali from Flat 112 and Zainab Deen and her son, Jeremiah Deen, from Flat 115. Firefighters subsequently rescued Oluwaseun Talabi, Rosemary Oyewole and their daughter as well as Omar Alhaj Ali. Following that rescue, Mohammad Alhajali, Denis Murphy, Zainab and Jeremiah Deen remained in Flat 113. They died during the fire.

¶88.2 In Phase 1, the chairman made findings about the events on floor 14 and in Flat 113 in particular.²⁶⁰²⁶⁰ Phase 1 Report Volume II paragraphs 14.109-14.111; Phase 1 Report Volume II paragraphs 14.195-14.206; Phase 1 Report Volume III paragraphs 15.91-15.95. He said that the circumstances under which four people, one a child, had been left behind in Flat 113 required a more detailed examination than could conveniently be carried out in the context of the narrative description of the events of 14 June 2017 and proposed to undertake that examination at a later date after further submissions and possibly additional evidence had been received.²⁶¹²⁶¹ Phase 1 Report Volume III paragraph 15.96.

¶88.3 In the end it was not necessary to hear any further evidence. We have, however, been assisted by representations made on behalf of the family of Mohammad Alhajali, the family of Denis Murphy and the LFB, as well as by a further statement from FF Peter Herrera, one of the firefighters involved in the partial evacuation of Flat 113.²⁶²²⁶² Herrera {LFB00032237}.

¶88.4 Since they are of particular importance to understanding the circumstances of the individual deaths on floor 14, we set out first not only our general findings about the events that took place on that floor but also our findings on how four people came to be left behind in Flat 113.

The arrival of the fire

¶88.5 By 01.23, the fire had spread up the eastern face of the tower and had reached the top of floor 15.²⁶³²⁶³ Phase 1 Report Volume II paragraph 10.118. Flat 116 was the first flat on floor 14 to be affected by the fire. When Nida Mangoba and her family left it, there was thick black smoke in the hallway but only light smoke in the lobby.²⁶⁴²⁶⁴ Phase 1 Report Volume II paragraphs 10.233-10.235. In Phase 1, the chairman was unable to decide whether Nida Mangoba's recollection that she had left the front door open was faulty or whether the door had closed sometime after she left; FFs Desmond Murphy and Charles Cornelius later found the front door closed.²⁶⁵²⁶⁵ Phase 1 Report Volume II paragraph 14.206. In any event, the front door did not impede the rapid ingress of smoke into the lobby.

¶88.6 According to Denis Murphy, who made an emergency call at 01.25 to report a fire in the tower, by then there was already significant smoke in the lobby.²⁶⁶²⁶⁶ Phase 1 Report Volume II paragraph 10.236. Oluwaseun Talabi and Rosemary Oyewole found the lobby filled with smoke when they tried to leave shortly before their first call to the emergency services at 01.37.²⁶⁷²⁶⁷ Phase 1 Report Volume II paragraphs 11.91-11.92. The conditions in the lobby were such that those who remained on floor 14 after 01.30 felt unable to cross the lobby and reach the stairs.²⁶⁸²⁶⁸ Phase 1 Report Volume II paragraphs 11.90-11.96 and 14.195; Phase 1 Report Volume IV paragraphs 25.10 (b) and 25.11 (b).

The first deployments to floor 14

¶88.7 By 01.45, Denis Murphy,²⁶⁹²⁶⁹ Phase 1 Report Volume II paragraphs 10.236 and 11.89. Zainab Deen,²⁷⁰²⁷⁰ Phase 1 Report Volume II paragraphs 10.237, 11.93, 12.58 and 12.96. and Rosemary Oyewole,²⁷¹²⁷¹ Phase 1 Report Volume II paragraphs 11.90-11.92. had made six emergency calls of which four were to the LFB control room.²⁷²²⁷² Phase 1 Report Volume II paragraph 14.195. At that stage Omar Alhaj Ali and Mohammad Alhajali in Flat 112 had not made any calls to the emergency services but had communicated to firefighters on the ground by shouting from the windows.²⁷³²⁷³ Alhaj Ali {IWS00000781/6} page 6, paragraph 17.

¶88.8 As a result of emergency calls being made from floor 14, the incident ground was informed that there were occupants trapped on that floor, which probably prompted the following actions: a. At 01.35, having answered the call from Denis Murphy, OM Alexandra Norman in

the LFB control room asked WM Daniel Meyrick in CU8 to arrange for crews to check on people trapped on different floors, including a person trapped in Flat 111 on floor 14.²⁷⁴²⁷⁴ Phase 1 Report Volume II paragraph 11.149. At 01.43, CRO Sharon Darby informed CU8 that smoke was coming into flats on floor 14, although she did not mention any particular flat.²⁷⁵²⁷⁵ Phase 1 Report Volume II paragraph 12.73 (d).

¶b. WM Meyrick passed the information he received to WM Mark Kentfield who was near the tower. WM Kentfield wrote it down on pieces of paper which he passed to SM Brett Loft. That included an A4 sheet of paper, which came to be known as the "Sadler envelope" and on which was written, "111, 115 14th FLOOR". SM Loft passed the information he received to the bridgehead on floor 2, probably by radio.²⁷⁶²⁷⁶ Phase 1 Report Volume II paragraphs 11.5-11.6, 12.18-12.19 and Figure 12.4.

¶c. At the bridgehead information was recorded on a wall and, from some time after 01.50, on a forward information board.²⁷⁷²⁷⁷ Phase 1 Report Volume IV paragraph 28.84 (b); Phase 1 Report Volume II paragraphs 13.52-13.53 and Figures 14.4 and 13.2. Although no written record was made of Flats 111 or 115, it is likely that a message about Flat 111 was received from SM Loft, since two teams of firefighters were deployed to that flat, although none were sent to Flat 115.

¶88.9 FFs Desmond Murphy and Charles Cornelius were sent to Flat 111 on floor 14 to rescue a man. They tallied out at 01.51.²⁷⁸²⁷⁸ Phase 1 Report Volume II paragraph 13.7. At about the same time, FFs Harvey Sanders and Nicke Merrion were also sent to floor 14. FF Sanders recalled that they had been sent specifically to Flat 111, but FF Merrion could not recall whether they had been sent to Flat 111 or Flat 112. FF Merrion recalled that he had been instructed to tell the occupants to remain in their flat.²⁷⁹²⁷⁹ Phase 1 Report Volume II paragraphs 13.11-13.12.

¶88.10 FFs Murphy and Cornelius arrived on floor 14 first. They found Denis Murphy in Flat 111 which was quite heavily smoke-logged.²⁸⁰²⁸⁰ Phase 1 Report Volume II paragraph 13.8. FFs Sanders and Merrion arrived on floor 14 soon afterwards. FF Merrion went to Flat 112, where he spoke to Omar Alhaj Ali and his brother, while FF Sanders went to Flat 113, where he met Rosemary Oyewole and Oluwaseun Talabi with their daughter. Those two flats were relatively clear of smoke.²⁸¹²⁸¹ Phase 1 Report Volume II paragraphs 14.197 and 14.200.

¶88.11 Denis Murphy was moved initially to Flat 112.²⁸²²⁸² Phase 1 Report Volume II paragraphs 13.9 and 14.198. The four firefighters met in the lobby and agreed to move all the occupants remaining on floor 14 to Flat 113, which was furthest from the fire.²⁸³²⁸³ Phase 1 Report Volume II paragraphs 14.88-14.89 and 14.201-14.203. Rosemary Oyewole and Oluwaseun Talabi agreed to their request to bring their neighbours into their flat.²⁸⁴²⁸⁴ Phase 1 Report Volume II paragraph 14.202.

¶88.12 Flat 113 was a two-bedroom flat in the southwest corner of the tower.²⁸⁵²⁸⁵ External Spread of Fire Report {MET00012593/12}. FF Murphy was one of the firefighters who went into the flat. Before leaving it, he counted six adults and two children. He told them that the crew were low on air and were going to change their cylinders. Although the residents wanted to leave, FF Murphy told them to stay in the flat with the door shut and that another crew would come up to them.²⁸⁶²⁸⁶ Phase 1 Report Volume II paragraphs 14.90 and 14.203.

¶88.13 The firefighters' decision to move all the occupants into one flat arose from their belief that conditions in the stairwell made it impossible for eight people to leave safely,²⁸⁷²⁸⁷ Phase 1 Report Volume II paragraphs 13.9, 13.13, 13.64 and 14.90. their view that Flat 113 was the safest place for them to be²⁸⁸²⁸⁸ Merrion {MET000086060/8} page 8; Merrion {Day38/16:4-15}. and their concerns about how much air was left to them.²⁸⁹²⁸⁹ Desmond Murphy {Day38/46:2-7}. Although it was in the stairs that people escaping from floor 14 were most exposed to asphyxiant gases, those who had absorbed only a minimal amount of carbon monoxide in their flats and the lobbies before entering them could at all times survive the descent.²⁹⁰²⁹⁰ Purser {Day296/217:19-22}; Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/7} paragraph 26. Since people were inhaling an increasing amount of asphyxiant gases while in their flats, the longer they remained in them, the greater the danger of their accumulating an amount sufficient to cause collapse and death.²⁹¹²⁹¹ Purser {Day297/7:18}-{Day296/8:2}. We note that some of the occupants of Flat 113 were later able safely to evacuate floor 14 without the assistance of any specialist equipment at a time when conditions were described by Rosemary Oyewole as significantly worse.²⁹²²⁹² Oyewole {Day58/75:5-13}. Although we accept that it might have been possible for the occupants of floor 14 to have escaped safely at that time, we do not consider that the decision made by FFs Merrion, Sanders, Murphy and Cornelius can be criticised, given the circumstances confronting them.

¶88.14 Some time after the firefighters left floor 14, another crew of firefighters visited Flat 113 by chance. They were FFs Luke Cook and Brian Flanagan, who went to Flat 113 between 02.03 and 02.37, probably at around 02.20. They noted that the flat contained eight people, including two children. They left the residents in the flat and returned to the bridgehead. There is no evidence that they reported the location those still on floor 14 to the bridgehead.²⁹³²⁹³ Phase 1 Report Volume II paragraph 14.111.

The second deployments to floor 14

¶88.15 On returning from floor 14, FFs Merrion, Sanders, Murphy and Cornelius told the bridgehead that residents remained on that floor. a. FFs Merrion and Sanders probably reached the bridgehead first at around 02.15.

Information appearing on both the forward information board and on a wall on floor 2²⁹⁴²⁹⁴ Phase 1 Report Volume II paragraphs 13.53, 14.73, and 14.110, Figures 13.2 and 14.4. supports the conclusion that they reported that eight people were in Flat 113 on floor 14.

¶b. FFs Murphy and Cornelius' end of wear times were 02.19 and 02.18 respectively. They told WM Brien O'Keeffe, who was commanding the bridgehead on floor 3 after 02.17, that there were six adults and two children in Flat 113 in safe air, but that crews needed to go back up with second BA sets as the air was not safe for those residents to be brought down. A photograph of a wall on floor 3 shows that the words "113 8 PEOPLE" were written to the left of a sketch plan drawn on the wall.²⁹⁵²⁹⁵ Phase 1 Report Volume II paragraph 14.110; Photograph of wall on floor 3 {MET00016948}.

¶88.16 The LFB control room continued to pass information about floor 14 to the incident ground even after the first deployment of firefighters: a. At 01.48, it received a call from Surrey Police passing on information that

Denis Murphy was trapped in Flat 111 on floor 14 and struggling to breathe. The information had come from Denis Murphy's brother. CRO Christine Howson created a service request and CRO Darby passed the information to the incident ground at 01.53.²⁹⁶²⁹⁶ Phase 1 Report Volume II paragraph 12.95.

¶b. At the same time, Zainab Deen, still in Flat 115, spoke to CRO Howson in the LFB control room. CRO Howson created a service request at 01.54 which led, a minute later, to CRO Darby passing on a message to CU8 about a woman with a baby in Flat 115, which was heavily smoke-logged.²⁹⁷²⁹⁷ Phase 1 Report Volume II paragraphs 12.58 and 12.96-12.97.

¶c. A note on a control information form identified both Flats 111 and 115 as priorities.²⁹⁸²⁹⁸ Control Information Form {LFB00001968/40}. It is difficult to track this through to the bridgehead but it may explain the deployment of FFs McAlonen and Juggins, at 02.31, to which we refer below.

¶d. At 02.09, CRO Angie Gotts took a call from the police reporting that a woman was trapped with her son in Flat 115. That call was the outcome of contact between the police and Zainab Deen which had begun with her first call to the emergency services at 01.29. That call had been put through to the police but had ended abruptly. The police called her back at 02.01.²⁹⁹²⁹⁹ Phase 1 Report Volume II paragraphs 10.237 and 14.249; 999 call transcripts {LFB00000341}; {INQ00000270}. It is difficult to track that information through to the bridgehead.

¶88.17 WM Glynn Williams began recording information on a ground floor wall of the tower at 02.15. He explained that he had written "FSG @2.15" on the wall and had then begun listing information immediately below that heading. (A second list was subsequently created on the wall to the left of the first.) The order in which he listed information initially matched that on the Sadler envelope and included Flats 111 and 115.³⁰⁰³⁰⁰ Phase 1 Report Volume II paragraphs 14.100-14.103 and Figure 14.5; Williams {Day31/100:8}-{Day31/101:10}. That WM Williams was also receiving fresh information, however, is suggested by his having written "1xA 1xK" (for 1 adult and 1 kid) next to Flat 115.³⁰¹³⁰¹ Williams {Day31/113:3-5}; Phase 1 Report Volume II Figure 14.5.

¶88.18 In any event, the information that had been received from returning fire fighters and from the control room prompted the deployment of two more crews to floor 14 within minutes of FFs Murphy and Cornelius reaching the bridgehead.

¶88.19 FFs Herrera and Teresa Orchard tallied out at 02.26 and 02.27 respectively with instructions from WM Louisa de Silvo to go to Flat 113. A sketch of what looks like a football in which is written "113, FL 14th" and "Lambeth PL" (for pump ladder) was made on the wall on floor 3. Although WM De Silvo said that it was not in her handwriting, it may have related to the deployment of FFs Herrera and Orchard, given that the former was based at Lambeth Fire Station.³⁰²³⁰² Phase 1 Report Volume III paragraph 15.91; Photograph of wall on floor 3{MET00015819}; De Silvo {Day30/45:15-25}; Herrera {Day38/97:20-22}.

¶88.20 FF Herrera recalled having been told that a man, woman and child needed to be rescued. On the other hand, FF Orchard recalled that they had been instructed to rescue six people in Flat 113. Although in the Phase 1 report the chairman noted that it was unlikely that WM De Silvo had given two members of the same crew inconsistent instructions relating to the same flat, he was not able to find which account was correct.³⁰³³⁰³ Phase 1 Report Volume III paragraph 15.91.

¶88.21 FF Herrera's recollection of the briefing reflects the emergency call made by Rosemary Oyewole at 01.37. However, although she mentioned that she had a baby, she did not confirm how many people were in the flat.³⁰⁴³⁰⁴ Phase 1 Report Volume II paragraph 11.92; 999 call transcript {LFB00000678}. No other emergency calls were made from Flat 113 until after FFs Herrera and Orchard had set off. Although FF Orchard did not refer to six people in her contemporaneous note, we think that her recollection was more reliable on this point. It is closer in time to the earlier, but still recent, reports to the bridgehead provided by FF Merrion, Sanders, Murphy and Cornelius, even though the information about two children was lost. We find that it was those reports, and in particular the explicit reference of FFs Murphy and Cornelius to the need for crews to return to floor 14, that prompted the deployment of FFs Herrera and Orchard. It is possible, however, that some reference was made during the briefing to a family of three which, amid all the noise and activity at the bridgehead, FF Herrera mistook as his instructions.

¶88.22 CM Benjamin McAlonen and FF Elliot Juggins tallied out at 02.31 shortly after FFs Herrera and Orchard. They had been instructed by WM Paul Watson to find a woman and child in Flat 111 on floor 14.³⁰⁵³⁰⁵ Phase 1 Report Volume III paragraph 15.92. That is, we think, confirmed by the inscription on the wall of floor 3 which referred to Flat 111 and floor 14, together with the word "Lambeth". Since both CM McAlonen and FF Juggins were based at Lambeth Fire Station, the note probably refers to their deployment.³⁰⁶³⁰⁶ Photograph of wall on floor 3{MET00015819}; McAlonen {Day38/160:8-10}; Juggins {Day40/62:16-18}. In our view, this briefing resulted from the information received from the calls to the emergency services made at 01.48. It was wrong in that Zainab and Jeremiah Deen had been in Flat 115 and, more importantly, were by then in Flat 113 together with others.

¶88.23 The two crews were not aware that they were both being deployed to floor 14.³⁰⁷³⁰⁷ Herrera {Day38/105:22-23}; Orchard {Day39/50:18-20}; McAlonen {Day38/167:11-14}; Juggins {Day40/65:18-21} The effect of the separate briefings was that only one crew (FFs Herrera and Orchard) was deployed to Flat 113 and without the spare BA sets that FF Cornelius had said were necessary. Neither member of that crew was aware that their task was to rescue eight people from Flat 113.³⁰⁸³⁰⁸ Phase 1 Report Volume III paragraph 15.91.

The partial evacuation of Flat 113

¶88.24 CM McAlonen and FF Juggins reached floor 14 first. They searched Flat 111 before then searching Flat 112.³⁰⁹³⁰⁹ Phase 1 Report Volume III paragraph 15.93. CM McAlonen tried to make radio contact with the bridgehead to gain more information but could not get through. FF Orchard and FF Herrera had reached floor 14 by then and went to Flat 113.³¹⁰³¹⁰ Phase 1 Report Volume III paragraph 15.94. The two crews described the stairwell as being full of black smoke from the bridgehead up to floor 14 and the lobby on that floor to be smoke‑logged.³¹¹³¹¹ Herrera {Day38/106:13-19}; McAlonen {Day38/168:1-8}; Orchard {Day39/51:13-19}; {Day39/52:6-22}; Juggins {Day40/68:20}-{Day40/69:23}. Rosemary Oyewole and Oluwaseun Talabi said that when they left Flat 113, the lobby was full of acrid black smoke which made it difficult to breathe. The stairs were full of the same smoke but felt much hotter than the lobby. They ran down the stairwell and did not see any light until about floor 3.³¹²³¹² Oyewole {Day58/76:3}-{Day58/79:13}; Talabi {IWS00000851/14-15} pages 14-15, paragraphs 57-62. Omar Alhaj Ali recalled the lobby and stairwell being filled with hot smoke and without any visibility. He did not see any light in the stairwell until he reached floor 2 or 3.³¹³³¹³ Alhaj Ali {Day59/83:18}-{Day59/85:12}.

¶88.25 There was a conflict of evidence relating to much of what happened when the firefighters reached Flat 113, but the following is not disputed. First, the evidence from both firefighters and occupants shows that Rosemary Oyewole and Oluwaseun Talabi (with their daughter tied to his back) left Flat 113 first, followed by Omar Alhaj Ali.³¹⁴³¹⁴ McAlonen {Day38/171:10}-{Day38/173:25}; Juggins {Day40/78:7}-{Day40/81:11}; Orchard {Day39/58:1-16}; Oyewole {Day58/73:24}-{Day58/74:11}; Talabi {Day59/148:6-18}; Alhaj Ali {Day 59/71:9-19}. Second, FF Herrera was the only firefighter to enter Flat 113.³¹⁵³¹⁵ Orchard {Day39/57:9-11}; Herrera {Day38/110:9-12}; McAlonen {Day38/170:20-22}; Juggins {Day40/81:18-23}. Third, as the chairman found in the Phase 1 report, FF Herrera did not conduct a search or secondary sweep of Flat 113.³¹⁶³¹⁶ Phase 1 Report Volume III paragraph 15.96. Fourth, as we have already observed, four people did not leave Flat 113.

¶88.26 That four people were left behind is, on the face of it, an extraordinary state of affairs and makes it necessary to consider how it could have come about. We answer that question by reference to the evidence given by the firefighters and those who were present in Flat 113 at the time and survived the ordeal. In doing so we have considered the representations that we have already mentioned.

¶88.27 Unfortunately, the evidence bearing on the question is rather confusing. Rosemary Oyewole, Oluwaseun Talabi and Omar Alhaj Ali all gave evidence, as did FF Herrera and Orchard, but their accounts were difficult to reconcile with each other and in some cases were internally inconsistent.

¶88.28 Rosemary Oyewole said that when her neighbours from Flats 111, 112 and 115 had been brought into her flat they had dispersed around the various rooms, as might be expected. However, after having been advised by one of the firefighters who had returned to Flat 113 that they should all go into her bedroom (the larger bedroom opposite the front door) they had congregated in that room. The two children had been sitting on the bed, Denis Murphy on the side of the bed nearer the door and Zainab Deen on the floor near the door into the hall.³¹⁷³¹⁷ Oyewole {IWS00000852/9-11} pages 9-11, paragraphs 31-43; Oyewole {Day58/45:12}-{Day58/52:7}; {Day58/69:23}-{Day58/70:20}.

¶88.29 Rosemary Oyewole said that at the time there had been some smoke in the flat, but not enough to reduce visibility to a significant extent.³¹⁸³¹⁸ Oyewole {Day58/48:4-8}; {Day58/59:4-22}. She said that after they had all gone into the bedroom she had kept the door closed in order to prevent smoke from coming into the room from the hall. Earlier, Oluwaseun Talabi had threatened to leave the flat by the bedroom window using an improvised rope made of bedsheets but had been dissuaded from doing so. As they waited to be rescued, however, they had become more desperate and, with the assistance of Omar Alhaj Ali and Mohammad Alhajali, Oluwaseun Talabi had begun to make a serious attempt to escape from the window with his daughter tied tightly to his back.³¹⁹³¹⁹ Oyewole {Day58/55:15}-{Day58/56:11}; {Day58/57:13}-{Day58/58:23}; {Day58/60:9}-{Day58/65:1}. At that stage, according to Rosemary Oyewole, the bedroom door flew open and she saw a firefighter (who must have been FF Herrera) standing by the front door.³²⁰³²⁰ Oyewole {Day58/67:3}-{Day58/69:22}; {Day58/85:23}-{Day58/86:20}. She rushed out of the room into the hall and out into the lobby, closely followed by Oluwaseun Talabi, who was still carrying their daughter on his back. She did not appear to have a clear recollection of having passed Denis Murphy or Zainab Deen, although she said that she must have done so; nor did she remember having said anything to the others in the room at that time.³²¹³²¹ Oyewole {Day58/72:7-21}; {Day58/73:22}-{Day58/75:23}; {Day58/88:3}-{Day58/89:9}.

¶88.30 Oluwaseun Talabi recalled that when their neighbours had been brought into Flat 113 they had moved around quite a lot but had eventually all congregated in the larger bedroom.³²²³²² Talabi {Day59/127:9}-{Day59/128:19}. He said he remembered Mohammad Alhajali sitting on the side of the bed further from the door reading his Qur'an.³²³³²³ Talabi {Day59/132:8-11}. As he was preparing to make a second attempt to leave from the window he had heard a knock at the front door. As he remembered it, the bedroom door had been open and he could see through to the front door. There was smoke in the flat, but visibility was reasonable.³²⁴³²⁴ Talabi {Day59/137:6}-{Day59/138:21}. He was asked by counsel to confirm that everyone had been in the bedroom at that point. He was clear that Zainab and Jeremiah Deen had been there and also Denis Murphy, as well as himself and Rosemary Oyewole, but he was unsure whether Omar Alhaj Ali and Mohammad Alhajali had also been there or whether they had been elsewhere in the flat. He thought that if the bedroom door had been open it would have been possible to see Denis Murphy and Jeremiah Deen from the hallway.³²⁵³²⁵ Talabi {Day59/139:2}-{Day59/140:23}.

¶88.31 Oluwaseun Talabi thought that the firefighter who had come to the door had not come far into the flat; indeed, he thought that he had scarcely crossed the threshold. Everything happened very quickly. He and Rosemary Oyewole had left the flat hand in hand with their daughter still tied to his back. He did not remember whether any of his neighbours had been ahead of him, or indeed what they had done. Again, he was not sure whether Omar Alhaj Ali and Mohammad Alhajali had been in the bedroom at that critical point.³²⁶³²⁶ Talabi {Day59/141:2}- {Day59/143:25}.

¶88.32 Omar Alhaj Ali recalled that when they had been moved into Flat 113, they had all initially gathered in the lounge.³²⁷³²⁷ Alhaj Ali {Day59/42:8-14}. He remembered Oluwaseun Talabi's first attempt to leave by way of the window, but was not sure whether that had been the window in the bedroom or the window in the lounge.³²⁸³²⁸ Alhaj Ali {Day59/47:6}-{Day59/49:6}. He remembered that they had all gathered in the bedroom, but that it had seemed quite small and that he and his brother had walked around at times.³²⁹³²⁹ Alhaj Ali {Day59/60:18}-{Day59/62:19}. He described smoke coming under the front door and getting thicker in the hallway. Visibility, as he recalled, had reduced significantly.³³⁰³³⁰ Alhaj Ali {Day59/58:17}-{Day59/59:17}; {Day59/67:15}-{Day59/68:22}. He was not sure whether he had been in the bedroom when the firefighters came to rescue them, because people had been moving around in the flat. He said that when the firefighter opened the front door he had seen Oluwaseun Talabi run towards it, so he had followed him. He initially said that he thought Mohammed might have been in the lounge at that time, but later said that he thought he had been with everyone else in the bedroom. When the door was opened, thick black smoke had come into the flat making it difficult to see. He was not very sure whether he himself had been in the bedroom or the living room when the firefighter had opened the door, but he had followed Oluwaseun Talabi; everyone else, including Mohammed, had been behind him. Just before that he had been talking to Mohammed, who had been standing close to him. He did not remember any firefighter going into the bedroom or the lounge and was adamant that he had not had any conversation with FF Herrera. He just remembered being bundled out of the flat and across the lobby.³³¹³³¹ Alhaj Ali {Day59/69:18}-{Day59/80:17}; {Day59/81:2}-{Day59/83:10}.

¶88.33 When he had left the building, Omar Alhaj Ali looked for his brother and, realising that he might still be inside the tower, telephoned him. He told firefighters that Mohammed was still in Flat 113 with two other adults and a child³³²³³² Alhaj Ali {Day59/85:18}-{Day59/93:5}. but denied, as FF Herrera recalled, ever having used words to the effect that he had been mistaken.³³³³³³ Alhaj Ali {Day59/93:21}-{Day59/95:17}.

¶88.34 FF Herrera said that, when he had been briefed by WM De Silvo, he had not been told to search the flat; simply that there were three people there waiting to be rescued, so he had expected them to be ready to leave as soon as he arrived.³³⁴³³⁴ Herrera {Day38/102:22}-{Day38/103:11}; {Day38/120:16-20}; {Day38/128:21}-{Day38/129:7}. As explained above, we consider it more likely that WM De Silvo's briefing had reflected the information most recently received at the bridgehead.

¶88.35 FF Herrera said that he had banged on the door of Flat 113 and had shouted to those inside that they were the fire brigade and had come to take them down. He recalled that the occupants had at first appeared reluctant to open the door, perhaps because inside they were in clean, safe air, but that once they had opened the door a little he had been able to push his way in.³³⁵³³⁵ Herrera {Day38/108:25}-{Day38/110:12}. Although he said that at first he had gone only into the hall, he said that he had then gone as far as the living room. That might suggest that he had gone into the main reception room (at no point did he suggest that he had gone into a bedroom), but when asked whether he had formed an impression of the number of people there he said that there had been four, two men, one woman and a child.³³⁶³³⁶ Herrera {Day38/109:7}-{Day38/112:6}.

¶88.36 In his first statement FF Herrera had said that he had seen the silhouette of a man standing in the living room. He said that he had asked him whether there was anyone else in the flat, to which the reply had been "No, I am the last one". FF Herrera said he had then taken him out into the lobby and towards the stairs. He said that he had not thought it necessary to search the flat because the man had been clear that there was no one else left in it.³³⁷³³⁷ Herrera {MET00010876/5} page 5; Herrera {Day38/112:7}-{Day38/114:22}.

¶88.37 FF Herrera recalled that having told WM De Silvo and WM Williams that Flat 113 was empty, he and the other firefighters left the tower and were approached by Omar Alhaj Ali who told him that his brother was still inside the building. As FF Herrera recalled it, Omar Alhaj Ali had said words to the effect that he had been mistaken, possibly implying that he had been wrong to say that there was no one else in the flat. As a result of that conversation FF Herrera returned to the ground floor lobby and told WM Williams that there was another person in Flat 113. He then went to the bridgehead where he also told WM De Silvo, but he did not know what she had done with the information.³³⁸³³⁸ Herrera {Day38/116:6-20}; {Day38/118:4}-{Day38/120:25}; {Day38/122:23}-{Day38/124:9}. Another witness, Ammar Alkabib, who described himself as a friend of Omar Alhaj Ali and Mohammad Alhajali, provided a statement to the police, in which he said that he had been at the tower when Omar was brought out. He described Omar as asking in desperation where Mohammad was and saying, "It's my mistake, it's my mistake."³³⁹³³⁹ Alkabib {MET00021446/2} page 2. Omar Alhaj Ali denied, however, having said anything of the kind.³⁴⁰³⁴⁰ Alhaj Ali {Day59/94:14-24}.

¶88.38 It is difficult to know what to make of this rather confused body of evidence. We are entirely confident that the man with whom FF Herrera said that he had had a brief conversation inside Flat 113 must have been Omar Alhaj Ali, since he was the only person taken out in addition to Oluwaseun Talabi, Rosemary Oyewole and their daughter, but Omar Alhaj Ali firmly denied that words of any kind had passed between himself and FF Herrera. Although the witnesses gave different descriptions of the amount of smoke in the flat, we think that by the time FFs Herrera and Orchard arrived it had probably become dense enough to restrict visibility to a significant extent. The fact that FF Herrera said that he had seen the silhouette of a man, tends to suggest that that was the case.

¶88.39 Despite the clear evidence of Rosemary Oyewole that everyone in the flat was together in her bedroom when the firefighters arrived, we think that is unlikely to have been the case. The evidence of Rosemary Oyewole and Oluwaseun Talabi suggests that as soon as the front door had been opened and the bedroom door was at least ajar, they rushed out of the room to be met by FF Herrera. In doing so they may have inadvertently obstructed his view into the room. At that point FF Herrera, who had walked further into the flat than Oluwaseun Talabi remembered and had reached the hall, saw the silhouette of a man in the lounge which caught his attention. That is not something about which he could reasonably have been mistaken and we do not think he was making it up. The man he saw was Omar Alhaj Ali, who had moved out of the bedroom into the lounge. FF Herrera said that he had reached the point at which he could see into the lounge and Omar Alhaj Ali accepted that he and his brother had moved around the flat from time to time, although the evidence suggests that the others had not done so once they had been advised to stay in the bedroom. We think it likely that, after FF Herrera had entered the flat (allowing a cloud of dense smoke to enter the hallway), the door to Rosemary Oyewole's bedroom remained partly closed, thereby obstructing his view of Denis Murphy and Jeremiah Deen, both of whom were sitting on the bed. It is difficult to know why he did not see Zainab Deen or Mohammad Alhajali; it may have been because she was sitting on the floor and he was sitting on the far side of the bed, or perhaps because of a combination of poor visibility and the speed at which events unfolded at that point. We say that because, if the door had been wide open and the room substantially free of smoke, it is difficult to see how FF Herrera could have failed to see them.

¶88.40 We do not think FF Herrera's evidence that he had formed the impression that there were four people in the "sitting room" is reliable. His reference to two men, one woman and a child can in the circumstances only have been to Omar Alhaj Ali, Oluwaseun Talabi, Rosemary Oyewole and their daughter. He was plainly unaware, for whatever reason, of the presence of Mohammad Alhajali, Denis Murphy, Zainab Deen and Jeremiah Deen, but we think it is reasonably clear that they were all in the bedroom when he arrived. No one suggested that FF Herrera had gone into that room at any stage and, for the reasons we have given, we think it quite likely that his view of it was obstructed.

¶88.41 The sharpest conflict of evidence relates to the conversation which FF Herrera said he had had in Flat 113 with Omar Alhaj Ali. We think it very unlikely that Omar Alhaj Ali actually said that he was the last person in the flat, since, knowing that there were others, including his brother, in the bedroom, he had no reason at that stage to think that he was. On the other hand, we do not think that FF Herrera invented the conversation. One has to remember that things were happening very quickly in only moderate visibility and that FF Herrera had been expecting to find only three people. On finding a fourth, it would be natural to ask whether there was anyone else, but the question, spoken through the mask of a BA set, might have been misinterpreted as referring only to the lounge, in which there was indeed no one else.

¶88.42 Although the weight of the evidence suggests that when he had left the tower and realised that his brother had not escaped with him, Omar Alhaj Ali did say that it was his mistake, we do not think that much significance can be attached to that. When describing his escape from Flat 113 Omar Alhaj Ali said he had thought that his brother was behind him, but he did not remember what he had been doing. When saying that he had been mistaken, he may well have been referring to his assumption that Mohammed was following him out of the building and we think it likely that, having himself escaped, he felt responsible for the fact that Mohammad had not. We accept that FF Herrera was anxious to leave the flat as quickly as possible but, having discovered that it contained at least one more person than he had been led to expect, he should not have relied on what he understood to be an assurance that there was no one else there and should have looked in the other rooms.

¶88.43 We have reached these conclusions with varying degrees of confidence, but given the uncertainties inherent in the evidence, we think they provide the most likely explanation of what occurred.

The third deployment to floor 14

¶88.44 Omar Alhaj Ali left the tower at 02.45 followed a minute later by Rosemary Oyewole, Oluwaseun Talabi and their daughter.³⁴¹³⁴¹ Phase 1 Report Volume III Annex A. CM McAlonen and FF Juggins followed them down.³⁴²³⁴² McAlonen {Day38/171:10}-{Day38/172:23}; Juggins {Day40/78:7}-{Day40/79:11}. At the bridgehead on floor 3 CM McAlonen told WM De Silvo which flats he and FF Juggins had visited and reported that three people had been brought down but that they could not confirm that Flat 113 was clear. By then the following had been written on the wall on floor 3: "14, 111, 115, 112, 113". WM Silvo put a tick through Flats 111, 112 (which CM McAlonen and FF Juggins had visited) and 113, against which she wrote "3 rescues".³⁴³³⁴³ McAlonen {Day38/166:8-11}; {Day38/174:2-12}; De Silvo Exhibit LDS/3 - Photograph of wall on floor 3 {MET00015819}. CM McAlonen only mentioned "3 rescues" because, as he explained, he had not seen Rosemary Oyewole and Oluwaseun Talabi's daughter.³⁴⁴³⁴⁴ McAlonen {Day38/173:9}.

¶88.45 FF Herrera told WM De Silvo that Flat 113 had been searched and was empty. He said the same to WM Williams who put a tick next to the flat number on the ground floor wall, indicating that it had been cleared.³⁴⁵³⁴⁵ Herrera {Day38/116:6-9}. That may explain why "113/14" (with 113 circled and ticked) appears next to "3 rescues" on the wall.³⁴⁶³⁴⁶ De Silvo Exhibit LDS/3 - Photograph of wall on floor 3 {MET00015819}. As recorded in the Phase 1 report, a circle indicated that further information had been received and a cross through the number of the flat indicated that it had been searched and a rescue carried out.³⁴⁷³⁴⁷ Phase 1 Report Volume IV paragraph 28.86. It may also explain why a tick and "BA" (to show a crew had been deployed to and reached a flat) appears next to "113 14th" towards the bottom of the first list that WM Williams had made.³⁴⁸³⁴⁸ Williams {Day31/106:17}-{Day31/107:21}; Phase 1 Report Volume II Figure 14.5.

¶88.46 We have mentioned that, on reaching the ground floor of the tower, Omar Alhaj Ali spoke to firefighters. The first of those conversations occurred even before FF Herrera spoke to WM Williams. Omar Alhaj Ali explained, by reference to a set of CCTV stills timed at 02.44, that he had been telling firefighters that other people remained in Flat 113, including his brother.³⁴⁹³⁴⁹ Alhaj Ali {Day59/85:24}-{Day59/90:17}. One of those firefighters was WM Williams.³⁵⁰³⁵⁰ CCTV Stills {INQ00000449}, {INQ00000450}, {INQ00000253}, Williams {Day31/140:18}. In each still, WM Williams is the firefighter without a helmet. That occupants still remained in Flat 113 was reinforced by FF Herrera's return at 02.57³⁵¹³⁵¹ LFB Operational Response Report {LFB00119333/248}. following his conversation with Omar Alhaj Ali outside the tower.

¶88.47 The information now available at the bridgehead probably prompted the deployment of FFs Jon Wharnsby and Terence Lowe, a crew based at Shoreditch, who tallied out at 03.04 to go to Flat 113 on floor 14.³⁵²³⁵² BA Telemetry data {LFB00023326}; Wharnsby {Day38/186:16}-{Day38/187:13}. The word "Shoreditch" appears just above "14 113" on the wall on floor 3, where the bridgehead was located up to about 03.10, which supports the conclusion that the entry relates to the deployment of that crew. However, the two firefighters did not reach floor 14. They encountered people in the stairwell whom they assisted down. FF Wharnsby recalled that by the time he and his colleague returned to the bridgehead it had moved to the ground floor. He said that he had made sure that others were aware that they had not completed their original task.³⁵³³⁵³ Wharnsby {Day38/188:19}-{Day38/189:3}; {Day38/191:18}-{Day38/197:4}.

Information to the incident ground after 03.00

¶88.48 Zainab Deen made two further emergency calls at 03.06 and 03.17, both of which were answered in the LFB control room.³⁵⁴³⁵⁴ Phase 1 Report Volume III paragraphs 17.93 and 17.94. In the first, CRO Sarah Russell took care to confirm her location, which she gave as Flat 113 on floor 14. The call ended abruptly.³⁵⁵³⁵⁵ 999 call transcript {LFB00000405}. In the first call Zainab Deen did not say how many people were in Flat 113, but in the second she said that she was there with her baby. She did not mention anyone else.³⁵⁶³⁵⁶ 999 call transcript {LFB00000418}. That this information reached the incident ground is apparent from the following:

¶a. A reference to Flat 113 appears on the second of two whiteboards used by SM Jason Oliff to collate information to pass from the control room to the command units. The entry includes the following: "Inside can't leave phone went dead.".³⁵⁷³⁵⁷ Phase 1 Report Volume III paragraphs 15.139-15.141 and Figures 15.8 and 15.9.

¶b. A control information form on which is written "Flat 113, line gone dead" and "call from CU". The form is marked priority and timed at 3.21.³⁵⁸³⁵⁸ Control Information Form {LFB00001968/44}.

¶c. The first entry in the second list created by WM Williams on the ground floor wall concerns Flat 113 and has "line dead" written next to it.³⁵⁹³⁵⁹ Phase 1 Report Volume II Figure 14.5; Williams {Day31/137:13}-{Day31/139:21}. WM Williams said that the note "BA" which appears next to"113" was not intended to be linked by an arrow to that flat but to Flat 123 which appears immediately next in the list.

¶88.49 From about that time, friends of Zainab Deen and Mohammed Alhajali, who were in contact with them by telephone, approached police officers and firefighters with information as follows: a. Mahmoud Al-Karad, a friend of Omar Alhaj Ali and his brother who also lived in

Flat 112, spoke to Mohammad Alhajali by telephone several times during the fire. Their last call was at 03.19 during which Mohammad Alhajali said that there had been eight people in Flat 113 and now there were only four. Mahmoud Al-Karad passed that information on to the police at the scene and was told that the control room would be informed.³⁶⁰³⁶⁰ Al-Karad {IWS00000821/8-9} pages 8-9, paragraph 35; Al-Karad Exhibit MAK2 – telephone log {IWS00000791}. Whether it was passed on is uncertain but we observe that among the material found in CU7 was a note from the police recording that four people were in Flat 112 and four in Flat 113.³⁶¹³⁶¹ Metropolitan Police Memo {LFB00001968/26}. That was wrong in part, because there were never four people trapped in Flat 112, but it is possible that the information provided by Mahmoud Al-Karad became confused at some point in transmission. It may also explain a note on the ground floor wall used by WM Williams to record information later in the night that eight people were trapped in Flat 112.³⁶²³⁶² Phase 1 Report Volume II Figure 14.5.

¶b. Francis Dean, a friend of Zainab Deen, began his last call with her at 03.34.³⁶³³⁶³ Zainab Deen call records. These records were not available to the Inquiry at the time of publication of the Phase 1 Report. During that call, Francis Dean passed the telephone to CM Christopher Batcheldor, who then continued to speak to Zainab Deen for over an hour. He gave her location to WM Thomas Furnell who was organising FSG information. WM Furnell confirmed that he was already aware of Zainab Deen.³⁶⁴³⁶⁴ Phase 1 Report Volume III paragraphs 17.95-17.97; Furnell {Day40/5:8-14}; {Day40/6:7-20}; {Day40/8:20}. CM Batcheldor subsequently took a note on which Francis Dean had written his name and telephone number and the names and ages of Zainab and Jeremiah Deen to CU7.³⁶⁵³⁶⁵ Batcheldor {Day34/172:5}-{Day34/173:10}; Notebook entry {LFB00001968/17}.

¶88.50 In the Phase 1 report the chairman found that CM Mayne and FF Lundquist, a crew wearing extended duration breathing apparatus, were deployed as a result of FF Herrera's report to the bridgehead that he had apparently not rescued all the occupants of Flat 113.³⁶⁶³⁶⁶ Phase 1 Report Volume IV paragraph 28.114. However, having reviewed the evidence further, we now think it more likely that they were in fact deployed in response to the two emergency calls made by Zainab Deen after 03.00. They were instructed to go to Flat 113 on floor 14 and tallied out at 03.29.³⁶⁷³⁶⁷ Phase 1 Report Volume III paragraph 17.20 (d). FF Lundquist recalled that the briefing was to rescue a mother and baby or small child. That must have been Zainab Deen and Jeremiah. When the crew reached the front of the queue of BA wearers at the bridgehead, however, their instructions were changed and they were redeployed to floors 3 and 4.³⁶⁸³⁶⁸ Phase 1 Report Volume III paragraph 17.20 (d). As we have explained above, it is likely that the information FF Herrera gave to the bridgehead prompted the earlier deployment of FFs Wharnsby and Lowe at 03.04. The time of the deployment and the nature of the briefing approximate more closely to the contents of Zainab Deen's calls than the information FF Herrera had given to the bridgehead.

¶88.51 Even without the additional information, the bridgehead was aware shortly after the partial evacuation of Flat 113 that people were still trapped there. The fire did not reach the exterior of the bedroom, where the occupants had sheltered, before 03.35.³⁶⁹³⁶⁹ Purser, Phase 2 Report, Section 6 {DAPR0000006/143} paragraph 769; External Fire Spread Report {MET00012593/78} image 42 (applying a +58 minute correction to timestamp). Even though conditions in the flat began to deteriorate rapidly thereafter,³⁷⁰³⁷⁰ Purser, Phase 2 Report, Section 6 {DAPR0000006/146-147} paragraph 793. Zainab Deen and Mohammad Alhajali were still in contact with friends outside the tower. However, no more firefighter crews were able to reach Flat 113.

Denis Murphy

¶Date of birth: 10 October 1960 (56 years). Place of birth: Hammersmith, London. Gender: Male. Occupation: Painter and Decorator. Usual address: Flat 111, floor 14, Grenfell Tower, London, W11. Place of death: Flat 113, floor 14, Grenfell Tower, London, W11. Time of death: Between 04.05 and 04.35 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Background and composition of household

¶88.52 Born on 10 October 1960, Denis Murphy was 56 years old in June 2017. He was the eldest of four children in a close-knit family and had two brothers and a sister. Denis Murphy had first moved into Grenfell Tower in 1984 with his wife and was still living there when his son was born in 1989. He returned to the tower in 1997 after he and his wife separated amicably. Denis Murphy continued to live at Grenfell Tower for the next 20 years and lived alone in Flat 111. A painter and decorator by trade, he was not working at the time of the fire. His passion for sport was something he maintained throughout his life.³⁷¹³⁷¹ Phase 1 Report Volume IV paragraphs 32.285-32.291.

Vulnerability

¶88.53 Denis Murphy had emphysema.³⁷²³⁷² Murphy {IWS00001049/2} page 2, paragraph 4. The spreadsheet produced on the night of the fire by David Noble based on information held on the TMO's Capita Insight system³⁷³³⁷³ Noble {Day119/77:17}-{Day119/82:5}. identified Denis Murphy as a resident but not as having any particular vulnerability.

Events of 14 June 2017

¶88.54 We have set out our general findings about the events on floor 14 above. We focus here on factual matters of specific relevance to the death of Denis Murphy.

¶88.55 Denis Murphy returned to Grenfell Tower during the afternoon of 13 June 2017.³⁷⁴³⁷⁴ O'Riordan {MET00013136/2} page 2. He did not leave after that.

¶88.56 As we have already observed, Flat 116 was the first flat on floor 14 to be affected by the spread of the fire up the tower. Flat 111 was on the east side of Grenfell Tower located between Flats 116 and 112³⁷⁵³⁷⁵ External Fire Spread Report {MET00012593/7}. and was close to the exterior fire once it reached Flat 116. When he made his first 999 call from floor 14 at 01.25, Denis Murphy told OM Norman that the fire was outside his window. There was no smoke in the flat although he could smell it. Later in the call Denis Murphy reported that smoke was entering the flat from the lobby. The amount of smoke in the lobby was sufficient to deter him from leaving.³⁷⁶³⁷⁶ Phase 1 Report Volume II paragraphs 10.236 and 10.312.

¶88.57 Denis Murphy then called his brother Timothy Murphy and left a message. Timothy returned the call at about 01.36. During the call he could hear a smoke alarm in the background. Denis Murphy was coughing and sounded distressed and in a state of panic. He opened the front door when his brother told him to leave but then told Timothy Murphy that it was pitch black in the lobby and that smoke was coming into the flat. Timothy told Denis that he would call the emergency services and to shelter in the bathroom.³⁷⁷³⁷⁷ Murphy {IWS00001049/2} page 2, paragraph 4.

¶88.58 The conditions in Flat 111 deteriorated rapidly. When at 01.40, Denis Murphy spoke to CRO Howson in his second 999 call, he told her that his flat was full of smoke coming in from the windows and front door and that he was sheltering in the bathroom. CRO Howson advised him to block the bathroom door with towels and reassured him that firefighters were on their way.³⁷⁸³⁷⁸ Phase 1 Report Volume II paragraphs 11.89 and 12.70.

¶88.59 Having spoken to Surrey Police, Timothy Murphy rang Denis Murphy again and reassured him that help was on its way.³⁷⁹³⁷⁹ Murphy {IWS00001049/2} page 2, paragraph 6. Surrey Police spoke to the LFB control room at 01.48. They gave Denis Murphy's name and location and said that he was trapped in the bathroom and struggling to breathe.³⁸⁰³⁸⁰ Phase 1 Report Volume II paragraph 12.95.

¶88.60 As we have explained earlier in this part of the report, these calls to the emergency services (together with calls from other occupants trapped on floor 14) led to the deployment of firefighter crews to that floor.

¶88.61 FFs Murphy and Cornelius were the first crew to arrive on floor 14. They found Flat 111 to be heavily smoke logged. Denis Murphy was conscious but bent over and coughing with soot on his face. The firefighters immediately brought him into the lobby where the air was clearer. They decided not to escort him down the stairs, given the smoke conditions that they had encountered in the stairwell.³⁸¹³⁸¹ Phase 1 Report Volume II paragraphs 13.8-13.9. Following the arrival of FFs Sanders and Merrion on floor 14, Denis Murphy was moved to Flat 112 where the air was clear. Omar Alhaj Ali recalled that he had been coughing and having difficulty breathing when he came into Flat 112.³⁸²³⁸² Phase 1 Report Volume II paragraphs 14.198-14.199. Subsequently, Denis Murphy was moved into Flat 113.³⁸³³⁸³ Phase 1 Report Volume II paragraphs 14.90 and 14.202.

¶88.62 Rosemary Oyewole did not recognise Denis Murphy when he first came into Flat 113; his face was covered in thick, black soot.³⁸⁴³⁸⁴ Oyewole {IWS00000852/9} page 9, paragraph 34. While he was able to move without help, Denis Murphy was quiet and appeared to be in shock.³⁸⁵³⁸⁵ Oyewole {Day58/47:8-13}. Rosemary Oyewole helped him to wash his face and removed some of the soot from his eyes.³⁸⁶³⁸⁶ Oyewole {IWS00000852/10} page 10, paragraph 37; Talabi {Day59/127:17}–{Day59/128:8}. She left him in the living room, but when another set of firefighters (FFs Cook and Flanagan) visited the flat and told them to stay in the bedroom, she and Oluwasean Talabi encouraged Denis Murphy to move there. When he did do so, Denis Murphy sat on the edge of the bed.³⁸⁷³⁸⁷ Oyewole {IWS00000852/11} page 11, paragraph 42; Alhaj Ali {Day59/62:2-5}.

¶88.63 Denis Murphy remained in contact with his family. Timothy Murphy and his partner, Angela, spoke to him several times during the fire, but he could not remember the precise times of those calls or what they had said. The last contact Denis Murphy had with his family was at about 02.30 when he spoke to his sister Anne Murphy and his son Peter Murphy. He told them that he was in a neighbour's flat and that he was struggling with his breathing.³⁸⁸³⁸⁸ Phase 1 Report Volume III paragraph 19.40. Anne Murphy continued to call Denis Murphy's telephone until 06.00 but received no answer.³⁸⁹³⁸⁹ Phase 1 Report Volume III paragraph 19.40.

¶88.64 Although all those in Flat 113 were initially sheltering in different parts of it, most of them began to congregate in the bedroom facing the front door.³⁹⁰³⁹⁰ Phase 1 Report Volume II paragraph 14.206. We have set out above our analysis of their movements and how Denis Murphy came to be left behind during the partial evacuation which followed the deployment of CM McAlonen and FFs Juggins, Herrera and Orchard to floor 14. We conclude that the bridgehead was aware shortly after that partial evacuation that people remained trapped on floor 14. No other firefighters were able to reach that floor.

¶88.65 There was no direct contact with Denis Murphy after the partial evacuation. There is nothing in the 999 calls made by Zainab Deen at 03.06 and 03.17³⁹¹³⁹¹ 999 call transcript {LFB00000405}; 999 call transcript {LFB00000418}; Phase 1 Report Volume III paragraphs 17.93-17.94. or from the longer call that she had with CM Batcheldor³⁹²³⁹² Phase 1 Report Volume III paragraphs 17.95-17.97. which offers any information about Denis Murphy. That call ended at 04.48.³⁹³³⁹³ Zainab Deen call records. These records were not available to the Inquiry at the time of completion of the Phase 1 Report.

¶88.66 Mohammad Alhajali's friends and family gathered outside the tower and were able to reach him by telephone. His last conversation was with his brothers Omar and Hashem, during which Mohammad said that others in the flat were no longer responding to him. The precise time at which the call ended is uncertain. Hashem Alhajali thought that it had ended between 04.00 and 05.00, but Omar Alhaj Ali was taken to hospital at 04.26.³⁹⁴³⁹⁴ Hashem Alhajali {MET00007745/4} page 4; Phase 1 Report Volume III paragraphs 19.32-19.33 A friend and flatmate, Mahmoud Al-Karad, was with Omar when he was speaking to Mohammad. Mahmoud Al-Karad was unable to reach Mohammad Alhajali after 04.26.³⁹⁵³⁹⁵ Phase 1 Report Volume III paragraph 19.34. A cousin, Aesem Alhajali, said that there came a time between 04.00 and 05.00 when no one was able to reach Mohammad Alhajali. It was as if his phone had been switched off.³⁹⁶³⁹⁶ Aesem Alhajali {MET00039851/6} page 6. In a 999 call at 05.05, Ammar Al Kabir, a cousin, said that he had last spoken to Mohammad Alhajali an hour earlier (evidence which we think is more reliable than his later recollection that the call had taken place at 04.30). In the circumstances, we conclude that the last contact with Mohammad Alhajali probably occurred at about 04.05. Following that contact, Mohammad Alhajali fell to his death from the tower.

¶88.67 The fire first reached the outside of the bedroom where those in Flat 113 had sheltered at about 03.33.³⁹⁷³⁹⁷ Purser, Phase 2 Report, Section 6 {DAPR0000006/146} paragraph 792; External Spread of Fire Report {MET00012593/78} Images 41-42 (applying a +58 minute correction to timestamps). If they had not already done so, it would have caused them to move into the living room, which, being the most south-westerly part of the flat, would have been furthest away from the approaching fire. The fire reached the south side of the living room at about 03.52 but the west side of the flat remained unaffected.³⁹⁸³⁹⁸ Purser, Phase 2 Report, Section 6 {DAPR0000006/146} paragraph 792; External Spread of Fire Report {MET00012593/78} page 78, Image 47 (applying a +58 minute correction to timestamps). The fire did not begin to affect the west side of the flat until sometime between 04.23 and 04.28.³⁹⁹³⁹⁹ External Spread of Fire Report {MET00012593/85} Images 44-47 (applying a +58 minute correction to timestamps). In calls with friends and family outside the tower, Mohammed Alhajali asked that firefighters continue directing water at the part of the tower where Flat 113 was located.⁴⁰⁰⁴⁰⁰ Phase 1 Report Volume III paragraphs 17.88 and 19.35. From 03.28 a ground monitor was used to apply a jet of water to the south side of the tower although its reach varied.⁴⁰¹⁴⁰¹ Stoianov, Chapter 5 {ISTRP00000006/141}, {ISTRP00000006/142}; {ISTRP00000006/148-153}.

Recovery and identification

¶88.68 Denis Murphy's remains were recovered from the kitchen area of Flat 113.⁴⁰²⁴⁰² Purser, Phase 2 Report, Section 6 {DAPR0000006/151} paragraph 826. The coroner was satisfied about the identification of those remains and so issued an interim certificate of the fact of death.

Cause and time of death

¶88.69 The post-mortem report on Denis Murphy recorded the medical cause of death as "consistent with the effects of fire", but in the light of more recent evidence we find that a more accurate description is "inhalation of asphyxiant gases". Toxicological testing was not possible.

¶88.70 We accept Professor Purser's conclusion that Denis Murphy had suffered significant exposure to smoke by the time he was moved to Flat 113.⁴⁰³⁴⁰³ Purser, Phase 2 Report, Section 6 {DAPR0000006/139} paragraph 748. In the time that he sheltered in Flat 113 he continued to be exposed to asphyxiant gases in the smoke coming into the flat, particularly from the lobby. That exposure increased significantly with the arrival of the fire outside the bedroom where he was sheltering. Conditions in Flat 113 continued to worsen as the fire spread to the south side of the living room.

¶88.71 The location of Denis Murphy's remains is consistent with his having moved from the bedroom once the fire had reached that point. Although we do not have a record of the level of carboxyhaemoglobin in his blood, we note that in a sample taken from Mohammad Alhajali it had reached the threshold lethal level of 50%.⁴⁰⁴⁴⁰⁴ Purser, Phase 2 Report, Section 6 {DAPR0000006/154} paragraph 845. That supports our conclusion that the level of asphyxiant gases in Flat 113 after 03.33 was sufficient to cause Denis Murphy to lose consciousness. He continued to inhale those gases until his respiration and circulation ceased and he died at some time between 04.05 and 04.35. We are satisfied that Denis Murphy died before suffering any direct effects of fire.

Zainab Deen

¶Date of birth: 25 May 1985 (32 years). Place of birth: Freetown, Sierra Leone. Gender: Female. Occupation: Unemployed. Usual address: Flat 115, floor 14, Grenfell Tower, London, W11. Place of death: Flat 113, floor 14, Grenfell Tower, London, W11. Time of death: 04.35 to 04.50 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Jeremiah Deen

¶Date of birth: 4 December 2014 (2 years). Place of birth: London, UK. Gender: Male. Occupation: N/A. Usual address: Flat 115, floor 14, Grenfell Tower, London, W11. Place of death: Flat 113, floor 14, Grenfell Tower, London, W11. Time of death: Between 03.30 and 04.00 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Background and composition of household

¶88.72 Zainab Deen lived in Flat 115 with her son Jeremiah Deen. She was born on 25 May 1985 in Freetown, Sierra Leone and was 32 years old. She had moved to the UK at the age of 16. Jeremiah was born on 4 December 2014 in London. He was two and a half years old at the time of the fire and attending a local nursery.⁴⁰⁵⁴⁰⁵ Phase 1 Report Volume IV paragraphs 32.266-32.273.

Vulnerability

¶88.73 Zainab and Jeremiah Deen moved into Flat 115 in February 2015. When signing her tenancy agreement with RBKC Zainab Deen confirmed that she did not have a disability.⁴⁰⁶⁴⁰⁶ Tenancy Agreement for Zainab Deen {TMOH00013271}. The spreadsheet produced on the night of the fire by David Noble based on information held on the TMO's Capita Insight system⁴⁰⁷⁴⁰⁷ Noble {Day119/77:17}-{Day119/82:5}. identified Zainab and Jeremiah Deen as residents. Jeremiah was identified as being under 18.

Events of 14 June 2017

¶88.74 We have set out our general findings about the events on floor 14 above. We focus here on factual matters of specific relevance to the deaths of Zainab and Jeremiah Deen.

¶88.75 On 13 June 2017, Zainab Deen had had a successful job interview.⁴⁰⁸⁴⁰⁸ Dean {IWS00001048/2} page 2, paragraph 10. She returned to the tower with Jeremiah and her friend, Francis Dean, between 21.30 and 22.00.⁴⁰⁹⁴⁰⁹ Dean {IWS00001048/3} page 3, paragraph 11. Zainab and Jeremiah Deen were seen on CCTV in the lift lobby at 23.20 having come down with Francis Dean when he left the tower.⁴¹⁰⁴¹⁰ O'Riordan {MET00013136/4} page 4; Dean {IWS00001048/3} page 3, paragraph 14.

¶88.76 Zainab Deen made her first call to the emergency services a few minutes after the fire had reached floor 14.⁴¹¹⁴¹¹ Phase 1 Report Volume II paragraph 10.118. Having been connected to the police control centre at 01.29, she reported that she was on floor 14 and had a baby with her. The call then disconnected.⁴¹²⁴¹² Phase 1 Report Volume II paragraph 10.237; 999 call transcript {INQ00000270/3-4}.

¶88.77 At 01.38, Zainab Deen spoke to CRO Yvonne Adams in the LFB control room. She sounded distressed. She was able to tell CRO Adams that smoke was coming into her flat through the door and windows. CRO Adams advised Zainab Deen to block up the doors and shut the windows, which she did. She was not able to confirm Zainab Deen's location before the call ended abruptly.⁴¹³⁴¹³ 999 call transcript {LFB00000321/7}.

¶88.78 At 01.48, Zainab Deen spoke to CRO Christine Howson in the LFB control room and was able to say that she was in Flat 115 on floor 14 with her baby. There was now smoke throughout the flat. CRO Howson advised her that the flat was "the safest place" and to keep trying to stop smoke coming in. She told Zainab Deen that the fire was not on floor 14 and said that she would alert the firefighters who would come to her.⁴¹⁴⁴¹⁴ Phase 1 Report Volume II paragraphs 12.58 and 12.96.

¶88.79 As we have explained earlier in this part of the report, Zainab Deen's calls to the emergency services (together with those from others trapped on floor 14) led to the deployment of firefighter crews to that floor, albeit none were sent specifically to Flat 115.

¶88.80 At 02.01 and before any firefighters had visited Flat 115 the police operator who had spoken to Zainab Deen at 01.29 called her back. Zainab Deen was very distressed. The operator advised her that the fire brigade was trying to evacuate everyone and asked whether she could go downstairs.⁴¹⁵⁴¹⁵ 999 call transcript {INQ00000270/3-4}. At 02.12 the operator told the LFB control room that Zainab Deen and her son were trapped in Flat 115.⁴¹⁶⁴¹⁶ 999 call transcript {LFB00000341}.

¶88.81 FF Murphy recalled that, when they found Zainab Deen in Flat 115, she was very frightened and asked the firefighters not to leave her and her son alone.⁴¹⁷⁴¹⁷ Phase 1 Report Volume II paragraph 14.203. Others sheltering in Flat 113 describe her as panicking for much of the time she was there.⁴¹⁸⁴¹⁸ Oyewole {Day58/46:16}; Omar Alhaj Ali {Day59/46:17-18}. Rosemary Oyewole carried Jeremiah Deen to the bedroom opposite the front door and put him on the bed with her own daughter.⁴¹⁹⁴¹⁹ Oyewole {Day58/46:19-23}. Once in Flat 113, Zainab Deen spent much of her time on the telephone.⁴²⁰⁴²⁰ Oyewole {Day58/46:24}-{Day56/Day47:4}. After she had moved to the bedroom opposite the front door she got up three or four times to open the door believing she could hear that help had arrived. Zainab Deen was very frightened and so Rosemary Oyewole had to be forceful when shouting at her to close the door. At that time, there was already smoke in the hallway of Flat 113.⁴²¹⁴²¹ Oyewole {Day58/59:4-15}. After that Zainab Deen remained sitting on the floor by the door to the bedroom.⁴²²⁴²² Oyewole {Day58/61:19-20}; {Day58/69:23}-{Day58/70:20}; {Day58/87:15}.

¶88.82 At 02.12, Zainab Deen made another 999 call. It could not be put through to the LFB control room and the operator was in the course of transferring it to North West Fire Control when it was abandoned.⁴²³⁴²³ Phase 1 Report Volume II paragraph 14.255. When that fire service called Zainab Deen back at 02.21, she gave her address as Flat 115 on floor 14, although she had by now been moved to Flat 113.⁴²⁴⁴²⁴ 999 call transcript {MET00017520}. Francis Dean also spoke to North West Fire Control at 02.17 and told them that a woman and her son (he described them as his sister and her son) were trapped in Flat 115 on floor 14.⁴²⁵⁴²⁵ 999 call transcript {LFB00000694}. It does not appear that North West Fire Control passed the information from those calls to the LFB, but by then Zainab and Jeremiah Deen had already been moved to Flat 113.

¶88.83 Francis Dean had returned to the tower when Zainab Deen called him at 01.38 to tell him of the fire. They remained in contact, speaking again at 02.00 and 02.03, when she said she was now in Flat 113.⁴²⁶⁴²⁶ Phase 1 Report Volume III paragraph 17.91. As well as making calls to the emergency services, Francis Dean spoke to firefighters and police officers telling them that Zainab Deen and her son were still in the tower.⁴²⁷⁴²⁷ Phase 1 Report Volume III paragraph 17.92.

¶88.84 While initially all those now sheltering in Flat 113 were in different parts of the flat, they began to congregate in the bedroom facing the front door.⁴²⁸⁴²⁸ Phase 1 Report Volume II paragraph 14.206. We have set out above our analysis of their various movements and how Zainab and Jeremiah Deen came to be left behind during the partial evacuation of Flat 113 which followed the deployment of CM McAlonen and FFs Juggins, Herrera and Orchard to floor 14.

¶88.85 Following that partial evacuation, Zainab Deen made two further 999 calls, both of which reached the LFB control room. At 03.06, Zainab Deen spoke to CRO Sarah Russell who was able to confirm that she was in Flat 113 on floor 14. It appears that Zainab Deen was still in the bedroom (she is heard to tell someone not to open the door). She also said that they were covered with smoke and that her baby was unconscious. When CRO Russell asked if they could leave, Zainab Deen replied: "No, we can't leave. Nobody is coming for us."⁴²⁹⁴²⁹ Phase 1 Report Volume III paragraph 17.93. At 03.17, Zainab Deen made her last 999 call. She told CRO Howson that she was in Flat 113. CRO Howson advised her to cover herself with a towel and make her way down the stairwell. She told Zainab Deen to expect smoke in the stairwell. Zainab Deen appeared to agree to leave with Jeremiah.⁴³⁰⁴³⁰ Phase 1 Report Volume III paragraph 17.94.

¶88.86 Those 999 calls led to the deployment of CM Mayne and FF Lundquist. However, no firefighter was able to reach floor 14 after the partial evacuation of Flat 113.

¶88.87 Zainab Deen's final call to Francis Dean was the last contact with her. The call began at 03.34 and ended at 04.48.⁴³¹⁴³¹ Zainab Deen call records. These records were not available to the Inquiry at the time of completion of the Phase 1 Report. She told Francis Dean that Jeremiah had collapsed. Francis Dean tried to tell Zainab Deen to cover herself and her son in wet blankets and leave but she refused to do so because of the smoke.⁴³²⁴³² Phase 1 Report Volume III paragraphs 17.94-17.95.

¶88.88 As the call continued, Francis Dean encountered CM Batcheldor and passed his telephone to him. CM Batcheldor remained on the call with Zainab Deen for what he estimated to be over an hour. Shortly after beginning to speak to her, CM Batcheldor gave her location to WM Furnell who confirmed he was already aware of a call from her. He did not know that firefighters had already been sent to Flat 113 but had then had their instructions changed before they set out.⁴³³⁴³³ Phase 1 Report Volume III paragraphs 17.96-17.97.

¶88.89 Zainab Deen told CM Batcheldor that she could not get out and that she had been told to stay in the flat, which he took to mean that the stay put policy was still in place. His view was that Zainab Deen was trapped in the flat. CM Batcheldor sought to reassure her and concentrated on keeping her safe by advising her to move to the least smoky room, to lie down on the floor and to cover Jeremiah's face with a cloth. When their conversation began, Zainab Deen said there was smoke in the flat but made no mention of fire.⁴³⁴⁴³⁴ Batcheldor {Day34/162:3}-{Day34/164:20}.

¶88.90 When he first began speaking to Zainab Deen, CM Batcheldor was able to hear Jeremiah Deen in the background. About 35 minutes into the call, she told him that her son had died. At this point CM Batcheldor passed the phone to Francis Dean for a few seconds, asking him to encourage Zainab Deen not to give up.⁴³⁵⁴³⁵ Batcheldor {Day34/164:23}-{Day34/168:24}. He returned to WM Furnell to ask what the position was and was told that firefighters could not get past floor 12.⁴³⁶⁴³⁶ Batcheldor {Day34/168:24}-{Day34/169:22}.

¶88.91 CM Batcheldor remained on the line speaking to Zainab Deen for about another 35 minutes. She was coughing and spluttering but became increasingly quiet. He could not hear anyone else in the background. There was silence for about five or 10 minutes before CM Batcheldor then heard her screaming before becoming silent again. After about another 10 minutes he believed Zainab Deen had died. He waited a few more minutes before disconnecting the call.⁴³⁷⁴³⁷ Batcheldor {Day34/170:3}-{Day34/171:9}; Batcheldor {MET00007511/7} page 7.

¶88.92 CM Batcheldor did not tell Francis Dean that the line had gone silent, just that the battery had died. Francis Dean tried to call Zainab Deen again, but she did not answer.⁴³⁸⁴³⁸ Phase 1 Report Volume III paragraph 17.99.

¶88.93 The fire first reached the outside of the bedroom where those in Flat 113 had sheltered at about 03.33.⁴³⁹⁴³⁹ Purser, Phase 2 Report, Section 6 {DAPR0000006/146} paragraph 792; External Spread of Fire Report {MET00012593/78} page 78, Images 41-42 (applying a +58 minute correction to timestamps). If they had not already done so, that would have caused them to move into the living room, which, being the most south-westerly part of Flat 113, was farthest from the approaching flames. The fire reached the south side of the living room at about 03.52 but the west side of the flat was not affected.⁴⁴⁰⁴⁴⁰ Purser, Phase 2 Report, Section 6 {DAPR0000006/146} paragraph 792; External Spread of Fire Report {MET00012593/78} Image 47 (applying a +58 minute correction to timestamps). It did not begin to affect the west side of the flat until sometime between 04.23 and 04.28.⁴⁴¹⁴⁴¹ External Spread of Fire Report {MET00012593/85} Images 44-47 (applying a +58 minute correction to timestamps). In calls with friends and family outside the tower, Mohammed Alhajali asked that firefighters continue to direct water at the part of the tower where Flat 113 was situated.⁴⁴²⁴⁴² Phase 1 Report Volume III paragraphs 17.88 and 19.35. From 03.28 a ground monitor was used to apply a jet of water to the south side of the tower although its reach varied.⁴⁴³⁴⁴³ Stoianov, Chapter 5 {ISTRP00000006/141}, {ISTRP00000006/142}; {ISTRP00000006/148-153}.

Recovery and identification

¶88.94 The remains of Zainab and Jeremiah Deen were recovered from the living room of Flat 113.⁴⁴⁴⁴⁴⁴ Purser, Phase 2 Report, Section 6 {DAPR0000006/152} paragraph 827. The coroner was satisfied about the identification of those remains and so issued interim certificates of the fact of death for both Zainab Deen and her son.⁴⁴⁵⁴⁴⁵ Interim certificate of the fact of death for Zainab Deen {MET00065637}; Interim certificate of the fact of death for Jeremiah Deen {MET00065619};

Cause and time of death

¶88.95 The post-mortem for Zainab Deen found evidence of soot inhalation. Analysis of a blood sample detected carboxyhaemoglobin but it was not possible to measure its concentration.⁴⁴⁶⁴⁴⁶ Zainab Deen post-mortem report {COR00001553}; Zainab Deen toxicology report {MET00039590}; Purser Phase 2 Report, Section 6 {DAPR0000006/152} paragraph 827. The post-mortem for Jeremiah Deen found soot stained mucus in the respiratory system. Carboxyhaemoglobin was detected in a blood sample at a high concentration albeit the level could not be measured.⁴⁴⁷⁴⁴⁷ Jeremiah Deen post-mortem report {COR00000735}; Jeremiah Deen toxicology report {MET00039530}; Purser Phase 2 Report, Section 6 {DAPR0000006/152} paragraph 828.

¶88.96 In both cases, the examining pathologist was able to give the medical cause of death as "inhalation of fire fumes". In light of more recent evidence, we find that a more precise description is "inhalation of asphyxiant gases".

¶88.97 The exposure of Zainab and Jeremiah Deen to asphyxiant gases increased once the fire reached the west side of Flat 113 with the consequent deterioration of conditions inside. They and the other occupants were able, at least initially, to move to those parts of the flat which the fire had yet to reach. However, conditions worsened once the fire reached the south side of the flat.

¶88.98 During the call with CM Batcheldor, Zainab Deen was increasingly affected by the significant levels of toxic smoke permeating Flat 113 and as a result she struggled to respond to him. At a relatively late stage of the call Zainab Deen screamed out. We think that is more likely to have been because she realised that the fire was very close (and may even have begun to penetrate the flat) rather than because she was being directly affected by the fire itself. A significant period of time then elapsed (we think it could have been as much as 10 to 15 minutes) before CM Batcheldor disconnected the call, during which Zainab Deen made no response at all. We think that she died during that period, probably between 04.35 and 04.50. We are satisfied that Zainab Deen died before suffering the direct effects of fire.

¶88.99 The rate at which a child absorbs asphyxiant gases is roughly twice that of an adult,⁴⁴⁸⁴⁴⁸ Purser, Phase 2 Report, Section 6 {DAPR0000006/153} paragraph 834. which supports our conclusion that Jeremiah died before his mother. He was already beginning to be unresponsive by 03.06 when she spoke to CRO Russell. In the light of CM Batcheldor's evidence we conclude that Jeremiah Deen died at some time between 03.35 and 04.10. Like his mother he would have lost consciousness but continued to inhale asphyxiant gases until his respiration and circulation ceased and he died. Jeremiah Deen died before suffering the direct effects of fire.

Mohammad Alhajali

¶Date of birth: 27 November 1993 (23 years). Place of birth: Damascus, Syria. Gender: Male. Occupation: Student. Usual address: Flat 112, floor 14, Grenfell Tower, London, W11. Place of death: Grenfell Tower, Grenfell Road, London, W11. Time of death: Between 04.30 and 04.56 on 14 June 2017. Cause of death: Multiple injuries consistent with a fall from height.

Background and composition of household

¶88.100 Mohammad Alhajali was born on 27 November 1993 in Damascus, Syria. He grew up in Darra, a small city in the south of Syria, with his parents and four siblings. In 2014, he left Syria with his brother Omar and came to the United Kingdom. He remained in close contact with his family in Syria, speaking to them every day.⁴⁴⁹⁴⁴⁹ Phase 1 Report Volume IV paragraph 32.279.

¶88.101 In June 2017, Mohammad Alhajali was 23 years old. He was studying engineering at university and working part-time. He was engaged to be married and was looking forward to building a life for his family in the United Kingdom.⁴⁵⁰⁴⁵⁰ Phase 1 Report Volume IV paragraph 32.281.

¶88.102 Mohammad Alhajali lived in Flat 112 with his brother, Omar Alhaj Ali, and their childhood friend, Mahmoud Al-Karad.⁴⁵¹⁴⁵¹ Phase 1 Report Volume IV paragraph 32.274.

Vulnerability

¶88.103 Mohammad Alhajali did not have any known vulnerabilities. He was not recorded in the spreadsheet produced on the night of the fire by David Noble based on information held on the TMO's Capita Insight system⁴⁵²⁴⁵² Noble {Day119/77:17}-{Day119/82:5}. because he was a tenant of a private landlord.

Events of 14 June 2017

¶88.104 We have set out our general findings about the events on floor 14 above. We concentrate here on factual matters of specific relevance to the death of Mohammad Alhajali.

¶88.105 On the evening of 13 June 2017, Omar Alhaj Ali and Mohammad Alhajali went to their cousins' house to break the Ramadan fast together.⁴⁵³⁴⁵³ Alhaj Ali {IWS00000781/4} page 4, paragraph 12. They returned to the tower at around midnight.⁴⁵⁴⁴⁵⁴ Mohammad Alhajali appears on CCTV returning to the tower at 00.07. O'Riordan {MET00013136/4}. Mohammad Al-Karad was still at work.⁴⁵⁵⁴⁵⁵ Phase 1 Report Volume II paragraph 11.94. He returned after the fire had started.

¶88.106 The two brothers were alerted to the fire when they heard shouting outside and smelt smoke. The sight of flames at the level of floors 4 and 5 prompted them to leave. When they approached the front door of Flat 112, they saw smoke coming into the flat under the door. Finding the lobby dark and full of smoke, they decided not to leave. That was at about 01.30. The brothers then began to call for help from a window until a firefighter shouted back telling them to stay where they were.⁴⁵⁶⁴⁵⁶ Phase 1 Report Volume II paragraphs 11.94 - 11.96. They continued calling for help and firefighters next to the main entrance told them to stop shouting and that they were coming up to help them.⁴⁵⁷⁴⁵⁷ Alhaj Ali {IWS00000781/7} page 7, paragraph 20. Given the absence at that time of information indicating that the occupants of Flat 112 needed to be rescued, it appears that the brothers' calls for help did not result in a message being sent to the bridgehead.

¶88.107 The brothers opened their front door again at around 02.00 to see if it was now easier to leave. There was still smoke in the lobby with limited visibility. Flat 112 was still clear of smoke and they remained in the flat.⁴⁵⁸⁴⁵⁸ Phase 1 Report Volume II paragraphs 14.196 - 14.197.

¶88.108 We have described how calls to the emergency services made by those trapped on floor 14 led to the deployment of FFs Merrion and Sanders and FFs Cornelius and Murphy to that floor. When FF Merrion entered Flat 112, the brothers pleaded with him to take them out but he told them to remain in the flat.⁴⁵⁹⁴⁵⁹ Phase 1 Report Volume II paragraphs 13.12 and 14.197. Subsequently, they agreed to a request from FF Murphy to be allowed to move Denis Murphy into Flat 112, which had clean air.⁴⁶⁰⁴⁶⁰ Phase 1 Report Volume II paragraphs 13.9-13.10 and 14.198. At that time the visibility in the lobby had improved to the point at which Omar Alhaj Ali was able to make out firefighters there.⁴⁶¹⁴⁶¹ Phase 1 Report Volume II paragraph 14.199. The firefighters then returned and moved Omar Alhaj Ali, Mohammad Alhajali and Denis Murphy from Flat 112 and Zainab Deen and Jeremiah Deen from Flat 115 to Flat 113.⁴⁶²⁴⁶² Phase 1 Report Volume II paragraph 14.88. Omar Alhaj Ali recalled that at that time the smoke in the lobby was not as thick as before.⁴⁶³⁴⁶³ Phase 1 Report Volume II paragraph 14.202. For the reasons we have already given we conclude that no criticism can be made of the decision not to evacuate those on floor 14 at that time.

¶88.109 Although all those sheltering in Flat 113 were initially in different parts of the flat, most of them eventually congregated in the bedroom facing the front door.⁴⁶⁴⁴⁶⁴ Phase 1 Report Volume II paragraph 14.206. We have set out above our analysis of their various movements and how Mohammed Alhajali came to be left behind during the partial evacuation of Flat 113, following the deployment of CM McAlonen and FFs Juggins, Herrera and Orchard to floor 14. We have also concluded that the bridgehead was aware shortly after the partial evacuation that people remained trapped on floor 14. However, no other firefighters were able to reach that floor.

¶88.110 Gathered outside the tower, Mohammad Alhajali's friends and relations were in contact with him by telephone. Mahmoud Al Karad's last conversation with Mohammad Alhajali was at 03.19. He told Mahmoud Al-Karad that he could not leave because he was with a mother and child. (He did not mention Denis Murphy.)⁴⁶⁵⁴⁶⁵ Phase 1 Report Volume III paragraph 17.88. His last conversation was with his brothers Omar and Hashem. In that call Mohammad said that the others in the flat were no longer responding to him. The evidence of the precise time at which the call ended is uncertain. Hashem Alhajali estimated that it ended between 04.00 and 05.00, but Omar Alhaj Ali was taken to hospital at 04.26.⁴⁶⁶⁴⁶⁶ Hashem Alhajali {MET00007745/4} page 4; Phase 1 Report Volume III paragraphs 19.32-19.33. Mahmoud Al-Karad was with Omar when he was speaking to Mohammad. He was unable to reach Mohammad Alhajali after 04.26.⁴⁶⁷⁴⁶⁷ Phase 1 Report Volume III paragraph 19.34. A cousin, Aesem Alhajali, said that no one was able to reach Mohammad Alhajali after some time between 04.00 and 05.00.⁴⁶⁸⁴⁶⁸ Aesem Alhajali {MET00039851/6} page 6. In a call to the emergency services at 05.05, Ammar Al Kabir, a cousin, said that he had last spoken to Mohammad Alhajali an hour earlier (evidence which we think is more reliable than his later recollection that the call had taken place at 04.30). In the circumstances, we conclude that the last contact with Mohammad Alhajali probably occurred at about 04.05.

¶88.111 Following that contact, Mohammad Alhajali fell to his death from the tower. His body was found by WM Steven Collins⁴⁶⁹⁴⁶⁹ Collins {MET00010086/5} page 5. by the gate on the elevated walkway leading to Grenfell Tower from Grenfell Walk and at the base of a 13.5 metre ladder. The ladder was not in use at the time but was leaning against the south face of the tower. The body of Mohammad Alhajali was covered in debris suggesting that he had fallen some time before his body was found. Together with CM Jamal Stern and FF William Murphy, WM Collins moved the body to a protected area inside the lobby of one of the walkways. No sign of life was found, and WM Collins then assigned another firefighter to locate a paramedic.⁴⁷⁰⁴⁷⁰ Collins {MET00010086/10-13} pages 10-13; Collins Exhibit SMC/5 - Photographs of Grenfell Tower {MET00015914/24}. That paramedic pronounced life extinct at 04.56.⁴⁷¹⁴⁷¹ Sibthorpe {MET00015658/5} page 5.

¶88.112 The coroner, Professor Wilcox, subsequently issued an interim certificate of the fact of death for Mohammad Alhajali.⁴⁷²⁴⁷² Interim certificate of the fact of death for Mohammad Alhajali {MET00065645}.

Cause and time of death

¶88.113 The post-mortem for Mohammad Alhajali recorded injuries consistent with a fall from a height. The injuries were such that there would have been a near-instantaneous collapse and loss of consciousness with no protracted suffering. There were no signs of burns to the skin or airways were recorded. Soot deposits were found in the respiratory system, consistent with the inhalation of fire fumes. The level of carboxyhaemoglobin in a blood sample was found to be 50%, which confirms that Mohammad Alhajali had inhaled sufficient carbon monoxide to bring him within the fatal range.⁴⁷³⁴⁷³ Alhajali post-mortem report {COR00001135}; Purser, Phase 2 Report, Section 6 {DAPR0000006/152} paragraphs 829-831. Later analysis in

¶April 2019 did not detect the presence of cyanide but that may simply have been due to the degradation of the sample over time.⁴⁷⁴⁴⁷⁴ Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447.

¶88.114 The reporting pathologist concluded that the inhalation of a potentially lethal dose of carbon monoxide was not inconsistent with an attempt by a fit young man to jump from the building.⁴⁷⁵⁴⁷⁵ Alhajali post-mortem report {COR00001135}; Purser, Phase 2 Report, Section 6 {DAPR0000006/152} paragraphs 830. The medical cause of death was recorded as "Multiple injuries consistent with fall from height". We accept that conclusion.

¶88.115 The absence of any burns to Mohammad Alhajali's skin suggests that he jumped before the exterior fire had enveloped the south side of Flat 113 and before a fire had developed in the interior of the flat. The time it took for WM Collins and his colleagues to move the body of Mohammad Alhajali, check for signs of life and then find a paramedic means that some minutes elapsed between finding the body and pronouncing life extinct. Taking these factors into consideration, we are satisfied that Mohammad Alhajali fell from the tower at some time between 04.05 and 04.30.