Chapter 90: Floor 16

¶90.1 All the flats on floor 16 were occupied on 14 June 2017. Two residents of this floor, Sheila in Flat 132 and Joseph Daniels in Flat 135, died in the fire.

¶90.2 The fire reached floor 16 outside Flat 136 by 01.24.⁵³¹⁵³¹ Bisby, Supplemental Phase 1 Expert Report {LBYR00000001/149} Figure 96. Thereafter, conditions on that floor deteriorated rapidly.

¶90.3 Hamid Wahbi, the sole occupant of Flat 136 on the night of the fire, left his home on seeing smoke and flames enter through the kitchen window. The smoke had already reached the living room and hallway by the time he left. When he did so, Hamid Wahbi found the lobby on floor 16 clear of smoke.⁵³²⁵³² Phase 1 Report Volume II paragraph 10.238. He left his front door open⁵³³⁵³³ Phase 1 Report Volume II paragraph 10.238. and, since it did not have an effective self-closing device, smoke entered the lobby.⁵³⁴⁵³⁴ Wahbi {IWS00001157/6-10} pages 6 and 10, paragraphs 26 and 55; Wahbi {Day62/36:18}-{Day62/37:1}.

¶90.4 In Flat 135, Samuel Daniels, who lived there with his father Joseph Daniels, became aware of a burning smell. That was before Hamid Wahbi had left his flat. Samuel Daniels went into the lobby on three occasions to investigate. Initially, it was clear of smoke. When he next entered the lobby, he saw smoke from the ceiling down to waist level. On the third occasion there was still smoke in the lobby, but it remained possible to breathe. On all three occasions, he found the stairwell clear of smoke.⁵³⁵⁵³⁵ Phase 1 Report Volume II paragraphs 11.68 and 11.70.

¶90.5 When, having failed to persuade his father to leave, Samuel Daniels finally left Flat 135, thick black smoke came into the flat when he opened the front door. The lobby was filled with smoke and visibility was limited. The stairs at that time remained free from smoke.⁵³⁶⁵³⁶ Phase 1 Report Volume II paragraphs 11.77 and 11.78.

¶90.6 The occupants of Flat 131, Richard Fletcher, his wife, Hime Gashaw and their daughter left their flat at about the same time. There was thick black smoke in the lobby when they opened their front door. The family crossed the lobby and left the tower at 01.31.⁵³⁷⁵³⁷ Phase 1 Report Volume II paragraphs 1171-11.73.

¶90.7 Samuel Daniels met FF Justin O'Beirne on the stairs and told him about his father.⁵³⁸⁵³⁸ Phase 1 Report Volume II paragraph 11.79. FF O'Beirne called for assistance for a bedbound man on floor 16.⁵³⁹⁵³⁹ Phase 1 Report Volume II paragraphs 11.79, 10.101 (b) and 10.101 (c). CM Jamal Stern and FF Richard Hippel responded to that call and went to floor 16.⁵⁴⁰⁵⁴⁰ Phase 1 Report Volume II paragraphs 10.101 (b) and (c). CM Stern found the lobby of floor 16 to be smoke-logged when he first opened the stairwell door.⁵⁴¹⁵⁴¹ Stern {MET00012483/10} page 10. FF Hippel recalled black smoke coming out from the open stairwell door.⁵⁴²⁵⁴² Hippel {Day26/63:7}-{Day26/68:21}. On floor 16 they found a man by the lobby door (Hamid Wahbi) and another man in the lobby (Edward Daffarn).⁵⁴³⁵⁴³ Phase 1 Report Volume II paragraphs 10.101 (c), 11.81 and 11.82.

¶90.8 When Edward Daffarn left Flat 134, the smoke in the lobby was so thick it was difficult for him to see. He struggled to find his way out until he was found by CM Stern and FF Hippel. Edward Daffarn left the tower at 01.34.⁵⁴⁴⁵⁴⁴ Phase 1 Report Volume II paragraphs 10.101 (c) and 11.81.

¶90.9 Having assisted Edward Daffarn, CM Stern and FF Hippel then entered the first flat they found on floor 16, which is likely to have been Flat 136. They found it empty, extremely hot and heavily smoke-logged.⁵⁴⁵⁵⁴⁵ Phase 1 Report Volume II paragraph 10.101 (c); Hippel {Day26/93:7}-{Day26/94:14}. As they were low on air, they left before searching any other flats.⁵⁴⁶⁵⁴⁶ Phase 1 Report Volume II paragraph 10.101 (c). CM Stern said that they had knocked on the doors of two other flats, which he thought had been Flats 134 and 135.⁵⁴⁷⁵⁴⁷ Stern {MET00012483/12-13} pages 12-13; Stern Exhibit JAS/3 – Floorplan of Floor 16 {MET00016893}. FF Hippel said that when searching floor 16, he and CM Stern had kicked the front door of each flat and shouted out.⁵⁴⁸⁵⁴⁸ Hippel {Day26/93:7}-{Day26/96:13}. He could not explain why the occupants of Flat 133 had not heard them but suggested that they might have been asleep.⁵⁴⁹⁵⁴⁹ Hippel {Day26/95:19-25}. Sener Macit, in Flat 133, said that he had not heard any knocking on his door or any noises coming from the lobby.⁵⁵⁰⁵⁵⁰ Macit {Day65/130:14-19}.

¶90.10 CM Stern and FF Hippel returned to the bridgehead on floor 2 at about 01.38. CM Stern told WM O'Keeffe that they had rescued one person (Edward Daffarn) but had been unsuccessful in rescuing another (Joseph Daniels). CM Stern was not sure if he had mentioned that the person they had been unable to rescue had been bedbound.⁵⁵¹⁵⁵¹ Phase 1 Report Volume II paragraph 11.15; Stern {Day26/190:3}-{Day26/193:20}. FF O'Beirne said that when he had left the tower, he told SM Brett Loft that there was a bedbound man on floor 16 whom crews had not been able to reach. SM Loft did not recall that exchange.⁵⁵²⁵⁵² Phase 1 Report Volume II paragraph 11.15.

¶90.11 After leaving the tower, Hamid Wahbi spoke to two firefighters, SM Loft and WM Watson.⁵⁵³⁵⁵³ CCTV Stills {INQ00000478}; {INQ00000477}; {INQ00000479}. He told them that there was a man and a woman on floor 16. Although he did not give a flat number, he was referring to Joseph Daniels in Flat 135 and Sheila in Flat 132.⁵⁵⁴⁵⁵⁴ Wahbi {Day62/62:12}-{Day62/64:20}. SM Loft did not recall that conversation.⁵⁵⁵⁵⁵⁵ Loft {Day29/37:17}-{Day28/39:9}.

¶90.12 By 01.45, only Sheila in Flat 132, Joseph Daniels in Flat 135 and Sener and Hanife Macit in Flat 133 remained on floor 16. Sener Macit was the only one to call the emergency services. His first call was at 01.37 and was put through to the police. He told them that he was on floor 16 but was not asked for, and did not give, the number of his flat.⁵⁵⁶⁵⁵⁶ 999 call transcript {INQ00000280}. The police passed the information that people were trapped on floor 16 to the LFB in a call taken by CRO Heidi Fox at 01.43.⁵⁵⁷⁵⁵⁷ Phase 1 Report Volume II paragraph 12.79; 999 call transcript {LFB00000497}. The information was passed to CU8 at 01.46.⁵⁵⁸⁵⁵⁸ Phase 1 Report Volume II paragraph 12.88; Short Incident Log Report {MET00013830/19-20}; LFB Radio Messages {LFB00002952}.

¶90.13 Sener Macit's first emergency call led to a conference call at 01.46 between the police operator, Sener Macit and CRO Adams in the LFB control room. Sener Macit told CRO Adams that he was in Flat 133 and that smoke was coming under his front door. He could not escape as it was pitch black.⁵⁵⁹⁵⁵⁹ Phase 1 Report Volume II paragraph 12.89. CRO Adams passed on the details of that call to the incident ground at 01.50.⁵⁶⁰⁵⁶⁰ Phase 1 Report Volume II paragraph 12.90.

¶90.14 Between 02.10 and 03.33, Sener Macit made a further six emergency calls. At 02.10, he was connected to North West Fire Control to whom he spoke for almost half an hour. At a late stage in that call, he was told that firefighters were on their way to floor 16 but was advised to leave his flat.⁵⁶¹⁵⁶¹ Phase 1 Report Volume II paragraph 14.188; Phase 1 Report Volume III paragraphs 15.86-15.87. Following a failed attempt to leave, Sener Macit spoke to the LFB again at 02.41,⁵⁶²⁵⁶² Phase 1 Report Volume III paragraph 15.89. 02.49,⁵⁶³⁵⁶³ Phase 1 Report Volume III paragraph 15.89. 03.02,⁵⁶⁴⁵⁶⁴ Phase 1 Report Volume III paragraph 17.80. and 03.12.⁵⁶⁵⁵⁶⁵ Phase 1 Report Volume III paragraphs 17.80-17.82. His daughter also called the LFB at 03.01⁵⁶⁶⁵⁶⁶ 999 call transcript {LFB00000560}. and 03.45.⁵⁶⁷⁵⁶⁷ 999 call transcript {LFB00000529}. Sener and Hanife Macit eventually managed to escape without assistance, leaving the tower at 03.47.⁵⁶⁸⁵⁶⁸ Phase 1 Report Volume III paragraphs 18.39-18.42.

¶90.15 After CM Stern and FF Hippel had left floor 16, there were two further deployments, both after 03.00. CM Aldo Diana and FF Dean Nelson tallied out at 03:24.⁵⁶⁹⁵⁶⁹ BA Telemetry Data {LFB00023326/2} page 2. They were sent to Flat 133 but failed to reach floor 16 as they stopped to help other residents escape.⁵⁷⁰⁵⁷⁰ Diana {MET00018800/8-12} pages 8-12; Nelson {MET00010926/4-9} pages 4-9; Phase 1 Report Volume III paragraph 18.20 (b). The last crew deployed to floor 16 were SM Gareth Cook and CM Ben Gallagher who tallied out at 04.04.⁵⁷¹⁵⁷¹ BA Telemetry Data {LFB00023326/3} page 3. They were sent to investigate reports of ten people trapped in a flat on floor 16 and 11 people trapped on floor 18. However, SM Cook's alarm sounded between floors 6 and 12 and CM Gallagher's air was low, so they returned to the bridgehead without reaching floor 16.⁵⁷²⁵⁷² Phase 1 Report Volume III paragraph 19.9; Cook {MET00007882/14-15} pages 14-15. It is unclear what prompted that deployment, given the absence of information to support the suggestion that so many people were trapped on floor 16.

Joseph Daniels

¶Date of birth: 10 February 1948 (69 years). Place of birth: Lucknow, India. Gender: Male. Occupation: Retired. Usual address: Flat 135, floor 16, Grenfell Tower, London. Place of death: Flat 135, floor 16, Grenfell Tower, London. Time of death: Between 02.55 and 03.15 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Background and composition of household

¶90.16 Joseph Daniels was born on 10 February 1948 in Lucknow, India. He was 69 years old at the time of the fire.⁵⁷³⁵⁷³ Phase 1 Report Volume IV paragraph 32.255. He came to the United Kingdom from India in 1982 after marrying Lucy Smyth. They moved into Flat 135 in 1983 and had one son, Samuel Daniels. The couple subsequently divorced and Joseph Daniels continued to live in Flat 135. He also had a daughter, Stephanie Hillier, from another relationship.⁵⁷⁴⁵⁷⁴ Presentation relating to Joseph Daniels {Day307/46:19}-{Day307/47:22}; Tenancy Agreement {TMOH00024682}.

¶90.17 By June 2017, Joseph Daniels was retired and in poor health. He shared Flat 135 with his son, Samuel Daniels, who was registered as his father's full-time carer.⁵⁷⁵⁵⁷⁵ Presentation relating to Joseph Daniels {Day307/47:24}-{Day307/48:3}.

Vulnerability

¶90.18 By June 2017, Joseph Daniels was suffering from dementia and diabetes and had limited mobility.⁵⁷⁶⁵⁷⁶ Phase 1 Report Volume II paragraph 11.67. He was not, however, bedbound. He needed the lift to leave the tower.⁵⁷⁷⁵⁷⁷ Daniels {IWS00000608/2} page 2, paragraph 8. Samuel Daniels said his father had not been able to walk up and down the stairs for about a year and a half before the fire and had not left the flat at all for the last two months of his life.⁵⁷⁸⁵⁷⁸ Daniels {Day56/5:8-22}; Phase 1 Report Volume II paragraph 11.67.

¶90.19 Rydon's resident survey of November 2014 did not identify Joseph Daniels as having any known physical or mental health vulnerabilities, although it was noted that he had some vulnerabilities associated with his self-care.⁵⁷⁹⁵⁷⁹ Rydon Residents Survey {RYD00024466/20}.

¶90.20 The TMO was aware of Joseph Daniels' vulnerability. In 2015, it had referred him to an occupational therapist as he was having difficulty getting in and out of the bath. The referral recorded that he had mobility problems but did not want to use a walking stick or glasses for his poor vision.⁵⁸⁰⁵⁸⁰ TMO Referral Form {TMOH00024715}; Daniels {IWS00002065/9} page 9, paragraph 55. An assessment in May 2015 carried out by RBKC's social services department noted that he suffered from dementia, brain damage, type 2 diabetes, breathlessness and tremors.⁵⁸¹⁵⁸¹ Daniels {IWS00002065/8} page 8, paragraph 52; Email from RBKC regarding adult social care {RBK00038674}; Care and Support Plan Review of Samuel Daniels {RBK00059536/4}.

¶90.21 The spreadsheet produced on the night of the fire by David Noble⁵⁸²⁵⁸² Noble {TMO00000884/1} page 1, paragraph 3. based on information held on the TMO's Capita Insight system⁵⁸³⁵⁸³ Noble {Day119/77:17}-{Day119/82:5}. did not identify Joseph Daniels as having any vulnerability.

Events of 14 June 2017

¶90.22 Joseph Daniels was at home with his son, Samuel Daniels, on the evening of 13 June 2017.⁵⁸⁴⁵⁸⁴ Daniels {IWS00000608/8} page 8, paragraph 47.

¶90.23 Samuel Daniels first became aware of the fire when he noticed a faint burning smell. He checked the flat, lobby and stairs but could not find its source. Nonetheless, he was sufficiently concerned to decide that he and his father should leave. Between efforts to persuade his father to leave, Samuel Daniels went into the lobby twice more, noticing an increasing amount of smoke there on each occasion.⁵⁸⁵⁵⁸⁵ Phase 1 Report Volume II paragraphs 11.68 and 11.70. The smoke entering the lobby at that stage was coming from Flat 136, the door to which had not closed after Hamid Wahbi left.⁵⁸⁶⁵⁸⁶ Phase 1 Report Volume IV paragraph 24.31; Wahbi {IWS00001157/10-11} pages 10-11, paragraph 55.

¶90.24 Samuel Daniels could not persuade his father to leave. He left on his own, leaving the door open for his father to follow. Samuel Daniels had told the TMO on 4 April 2017 that the front door of Flat 135 did not close itself. A recommendation for a complete overhaul was made on the following day but the job was later recorded as "fully abandoned".⁵⁸⁷⁵⁸⁷ Daniels {IWS00000608/6} page 6, paragraph 40; Daniels {Day56/18:18}-{Day56/20:4}; Daniels Exhibit SD/02 -TMO repairs log for Flat 135 regarding front door not closing {IWS00002067}; Daniels Exhibit SD/03 - TMO dashboard snapshot of front door repair at Flat 135 {IWS00002068}; Daniels Exhibit SD/04 - TMO dashboard snapshot of the repairs log for Fat 135 {IWS00002069}. However, it is likely that Joseph Daniels shut the door after his son had left because CM Stern and FF Hippel found it closed when they searched floor 16.

¶90.25 Samuel Daniels met FF O'Beirne in the stairwell at around floor 11 at some time between 01.28 and 01.38.⁵⁸⁸⁵⁸⁸ Phase 1 Report Volume II paragraph 11.79. He told FF O'Beirne that his father was trapped in his flat on floor 16. FF O'Beirne told the bridgehead by radio that a man was bedbound on floor 16 and asked for assistance.⁵⁸⁹⁵⁸⁹ Phase 1 Report Volume II paragraph 10.101 (b). CM Stern and FF Hippel responded to that request.

¶90.26 On arriving at floor 16, CM Stern and FF Hippel found the lobby full of thick smoke and visibility very limited.⁵⁹⁰⁵⁹⁰ Stern {MET00012483/10} page 10; Hippel {Day26/63:7}-{Day26/68:21}. Having first helped Edward Daffarn, they searched the first flat they came to, probably Flat 136.⁵⁹¹⁵⁹¹ Phase 1 Report Volume II paragraphs 11.81 and 10.101 (c). They could not search other flats, because they were running low on air,⁵⁹²⁵⁹² Phase 1 Report Volume II paragraph 10.101 (c). but they did knock on other doors. There was a difference in recollection between them about how many doors they knocked on, but there is no evidence that Joseph Daniels was aware of the presence of the firefighters on floor 16.⁵⁹³⁵⁹³ Stern {MET00012483/12-13} pages 12-13; Stern Exhibit JAS/3 - Floorplan of Floor 16 {MET00016893}; Hippel {Day26/69:19}-{Day26/73:7}.

¶90.27 Samuel Daniels was waiting on the stairs when he saw the firefighters return from floor 16. He tried to ask them about his father but was told to leave the tower. He did so at 01.38.⁵⁹⁴⁵⁹⁴ Phase 1 Report Volume II paragraph 11.82.

Information to the incident ground

¶90.28 CM Stern and FF Hippel returned to the bridgehead on floor 2 at around 01.38. CM Stern told WM O'Keeffe that he and FF Hippel had rescued one person (Edward Daffarn) but had not been able to rescue another (Joseph Daniels). He was not sure if he had said that that person was bedbound.⁵⁹⁵⁵⁹⁵ Phase 1 Report Volume II paragraph 11.15; Stern {Day26/190:3}-{Day26/193:20}. FF O'Beirne said that he told SM Brett Loft that there was a bedbound man on floor 16 who the crews had been unable to reach. SM Loft did not recall this exchange with FF O'Beirne.⁵⁹⁶⁵⁹⁶ Phase 1 Report Volume II paragraph 11.15.

¶90.29 Shortly after 02.17, CM Charles Batterbee made a note of the information on a forward information board that had been used while the bridgehead was located on floor 2.⁵⁹⁷⁵⁹⁷ Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraph 28.84 (c). His note did not include any reference to floor 16, which may explain why the information provided by the firefighters on their return from floor 16 did not lead to a further deployment before the bridgehead moved from floor 2 at about 02.17.⁵⁹⁸⁵⁹⁸ Phase 1 Report Volume IV paragraph 28.84 (b).

¶90.30 The bridgehead was located on floor 3 between 02.17 and 03.10.⁵⁹⁹⁵⁹⁹ Phase 1 Report Volume IV paragraphs 28.86 and 28.87. During that time information about people needing to be rescued was recorded on a wall in the lobby of floor 3. The only information about floor 16 on the wall was a note relating to Flat 133.⁶⁰⁰⁶⁰⁰ Phase 1 Report Volume II Figure 15.7; The photograph was taken at 03.08 when the bridgehead was about to be relocated to the ground floor: Cook Exhibit GAC/2 - Grenfell Tower statement notes {MET00015779/16} page 16.

¶90.31 The bridgehead was moved to the ground floor lobby at about 03.10. Once it was there, a green wall by the stairs was used to record information about those needing to be rescued.⁶⁰¹⁶⁰¹ Phase 1 Report Volume IV paragraph 28.87. A photograph of that wall taken at about 04.45 shows the numbers "134" and "135" on the wall.⁶⁰²⁶⁰² Mulholland Exhibit MBM/02 - Photograph of green wall {MET00018739}. We do not know who put that information on the wall but its limited detail reflects that recorded on a control information form provided to the Inquiry. The forms were used at the incident ground to record messages about people needing to be rescued. The relevant form recorded just the following, "133+134+135 16".⁶⁰³⁶⁰³ LFB Control Information Forms {LFB00001955/10} page 10. On the form, "133" is scrubbed out and marked "left", indicating that those in Flat 133 had got out but that Flats 134 and 135 remained occupied. It is not possible to say with any confidence who wrote on the form. (WM Sadler used a pad of such forms⁶⁰⁴⁶⁰⁴ Phase 1 Report Volume IV paragraph 28.84 (e). but they were also used, for example, by those in CU7.)⁶⁰⁵⁶⁰⁵ Phase 1 Report Volume IV paragraph 28.84 (g).

¶90.32 We cannot say when the information was put on the green wall (save that it must have been after 03.10) or indeed when the control information form was completed. If the information on the wall is associated with the control information form, it may have been recorded after Sener and Hanife Macit left the tower at 03.47. The information recorded in the control information form and the green wall may have come from more than one source. It is unlikely that Hamid Wahbi was the source of the information relating to Flat 135, as he did not provide the firefighters he spoke to outside the tower with the numbers of any flats.⁶⁰⁶⁶⁰⁶ Wahbi {Day62/63:5}-{Day62/65:18}; CCTV Stills {INQ00000476}; {INQ00000477}; {INQ00000478}; Loft {Day28/37:17}-{Day28/39:9}. It is more likely that the source, at least in relation to Flat 135, was Samuel Daniels. Once outside the tower, and having found his mother, he told someone, who may have been either a firefighter or a police officer, that his father was still in Flat 135. That was at about 02.00.⁶⁰⁷⁶⁰⁷ Daniels {IWS00000608/14} page 14, paragraph 85; Daniels {Day56/71:13-23}. His mother gave the officer the number of the floor and the flat.⁶⁰⁸⁶⁰⁸ Daniels {Day56/71:20}-{Day56/72:3}.

¶90.33 The information that someone might still be in Flat 135 did not prompt any further deployments. The two deployments which took place after 03.24 were not sent to Flat 135 and neither of them reached floor 16. CM Diana and FF Nelson tallied out at 03.24⁶⁰⁹⁶⁰⁹ BA Telemetry Data {LFB00023326/2} page 2. to go to Flat 133 but stopped to help other occupants escape. They reported that to the bridgehead.⁶¹⁰⁶¹⁰ Diana {MET00018800/8-12} pages 8-12; Nelson {MET00010926/4-9} pages 4-9; Phase 1 Report Volume III paragraph 18.20 (b). SM Gareth Cook and CM Ben Gallagher set off at 04.04 to investigate reports of 10 people trapped in a flat on floor 16, but a shortage of air prevented them from reaching that floor.⁶¹¹⁶¹¹ Phase 1 Report Volume III paragraph 19.9; Cook {MET00007882/14-15} pages 14-15.

¶90.34 There was no further contact from Joseph Daniels after his son left Flat 135.

Recovery and identification

¶90.35 The remains of Joseph Daniels were recovered from the living room of Flat 135.⁶¹²⁶¹² Purser, Phase 2 Report, Section 6 {DAPR0000006/126} paragraph 678; Presentation relating to Joseph Daniels {Day307/71:3-6}. The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.⁶¹³⁶¹³ Interim certificate of the fact of death for Joseph Daniels {MET00065647}.

Cause and time of death

¶90.36 The post-mortem on Joseph Daniels found soot deposits in his respiratory system. Analysis of a sample of his blood confirmed the presence of carbon monoxide, but the condition of the sample meant that its concentration could not be measured.⁶¹⁴⁶¹⁴ Daniels post-mortem report {COR00000793/10}; Daniels supplementary post-mortem report {COR00000791/2}; Daniels toxicology report {MET00039529}; Purser, Phase 2 Report, Section 6 {DAPR0000006/127} paragraph 688. The medical cause of death was recorded 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".

¶90.37 If, as we think likely, the front door of Flat 135 was closed after Samuel Daniels left, it would have slowed the passage of smoke from the lobby into the flat. Exposure to asphyxiant gases was limited until the fire reached the outside walls of the bedrooms at between 02.32 and 02.34. Conditions in the living room deteriorated rapidly when the fire on the outside of the building reached the north side of the living room between 02.49 and 02.55.⁶¹⁵⁶¹⁵ Purser, Phase 2 Report, Section 6 {DAPR0000006/127} paragraph 686.

¶90.38 It is likely that Joseph Daniels lost consciousness and died from the inhalation of asphyxiant gases at some time between 02.55 and 03.15.⁶¹⁶⁶¹⁶ Purser, Phase 2 Report, Section 6 {DAPR0000006/127} paragraph 686; Purser {Day297/111:4-5}. Accordingly, the last chance to rescue him was some time before 03.00. That was well before the deployments of CM Diana and FF Nelson at 03.24 and of SM Cook and CM Gallagher at 04.04.

Sheila

¶Date of birth: 17 September 1932 (84 years). Place of birth: Market Harborough, Leicestershire. Gender: Female. Occupation: Retired. Usual address: Flat 132, floor 16, Grenfell Tower, London. Place of death: Flat 132, floor 16, Grenfell Tower, London.

¶Time of death: Between 03.09 and 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Background and composition of household

¶90.39 Sheila was born on 17 September 1932 and was 84 years old.⁶¹⁷⁶¹⁷ Phase 1 Report Volume IV paragraph 32.257. In life, she made the decision to use only her first name, a decision that we have respected during the Inquiry. Retired, Sheila was a mother and grandmother, living alone in Flat 132. She had lived there since 23 April 1984.⁶¹⁸⁶¹⁸ Tenancy Agreement {TMOH00018942}. Sheila led an independent life with a longstanding interest in meditation, yoga and alternative therapies.⁶¹⁹⁶¹⁹ Presentation relating to Sheila {Day304/58:24}-{Day304/59:18}.

Vulnerability

¶90.40 Sheila was physically fairly mobile but her health had deteriorated before the fire.⁶²⁰⁶²⁰ Smith {COR00001396/4} page 4. Like some other residents, she struggled when the lifts in the tower were not working,⁶²¹⁶²¹ Video footage of the meeting with residents on 17 July 2015 {MET00078076}. but she did not appear in the TMO's records as being vulnerable. Rydon's resident survey of November 2014 recorded that she was over 80, had slight deafness and a poor memory.⁶²²⁶²² Rydon Residents Survey {RYD00024466/21}.

¶90.41 The spreadsheet produced on the night of the fire by David Noble⁶²³⁶²³ Noble {TMO00000884/1} page 1, paragraph 3. based on information held on the TMO's Capita Insight system⁶²⁴⁶²⁴ Noble {Day119/77:17}-{Day119/82:5}. did not identify Sheila as having any vulnerability.

Events of 14 June 2017

¶90.42 Sheila returned to the tower at 14.22 on 13 June 2017. She does not appear to have left her flat again.⁶²⁵⁶²⁵ O'Riordan {MET00013136/2} page 2. She usually went to bed between 20.00 and 21.00 and wore an eye mask and ear plugs.⁶²⁶⁶²⁶ Smith {COR00001396/4} page 4.

¶90.43 It is possible that Sheila never became aware of the fire. CM Stern and FF Hippel reached floor 16 sometime before 01.38,⁶²⁷⁶²⁷ Phase 1 Report Volume II paragraph 10.101 (c). but there is no evidence that she was aware of their presence. Sheila is not known to have made any telephone calls to friends or family. Nor did she make any calls to the emergency services.

¶90.44 Despite the repeated emergency calls made by Sener Macit in Flat 133 and the information reaching the incident ground about a man (Joseph Daniels) and a woman (Sheila) still on floor 16, only two crews were deployed there after CM Stern and FF Hippel. CM Diana and FF Nelson tallied out at 03.24⁶²⁸⁶²⁸ BA Telemetry Data {LFB00023326/2} page 2. but stopped before reaching floor 16 to assist other occupants to escape. They reported back to the bridgehead.⁶²⁹⁶²⁹ Diana {MET00018800/8-12} pages 8-12; Nelson {MET00010926/4-9} pages 4-9; Phase 1 Report Volume III paragraph 18.20 (b). SM Gareth Cook and CM Ben Gallagher tallied out at 04.04. They were sent to investigate reports of 10 people trapped in a flat on floor 16, but a shortage of air prevented them from reaching it.⁶³⁰⁶³⁰ Phase 1 Report Volume III paragraph 19.9; Cook {MET00007882/14-15} pages 14-15.

¶90.45 Neither crew was briefed to find Sheila and neither crew reached floor 16. Even if they had done so and had been able to search it, it is likely that Sheila would already have been dead.

Recovery and identification

¶90.46 Sheila's remains were recovered from the bedroom of Flat 132. She was lying on her back with her head towards the window and near the remains of the mattress, indicating that she had probably been in bed when she died.⁶³¹⁶³¹ Purser, Phase 2 Report, Section 6 {DAPR0000006/130} paragraph 702; Presentation relating to Sheila {Day304/68:14-19}. The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.⁶³²⁶³² Interim certificate of the fact of death for Shiela {MET00065609}.

Cause and time of death

¶90.47 The post-mortem examination on Sheila found that it was not possible to obtain samples suitable for toxicology analysis.⁶³³⁶³³ Sheila post-mortem report {COR00001397}. Although the examination concluded that it was not possible to give a definite cause of death, the medical cause of death was recorded as "consistent with the effects of fire", but in the light of Professor Purser's evidence we find that a more accurate description is "inhalation of asphyxiant gases".

¶90.48 Sheila was in her bedroom throughout the fire. By 02.22, the fire was outside the living room and by 02.29 it had spread across the outside wall of that room. Between 03.09 and 03.17 it had begun to spread across the outside of the bedroom.⁶³⁴⁶³⁴ Purser, Phase 2 Report, Section 6 {DAPR0000006/129} paragraphs 696-698. From the time the fire reached floor 16, Sheila was exposed to an increasing level of asphyxiant gases infiltrating her home, initially from the lobby. That exposure and the rate of absorption of asphyxiant gases increased rapidly once the fire reached the outside of her bedroom.⁶³⁵⁶³⁵ Purser, Phase 2 Report, Section 6 {DAPR0000006/129} paragraphs 699-701. Given her prolonged exposure to asphyxiant gases, Sheila may have been unconscious before the fire reached her bedroom. If not, she became unconscious shortly after. She then continued to inhale asphyxiant gases until she died sometime between 03.09 and 03.30.⁶³⁶⁶³⁶ Purser, Phase 2 Report, Section 6 {DAPR0000006/130} paragraphs 704-705.

¶90.49 We are satisfied that Sheila died through the inhalation of asphyxiant gases before suffering any direct effects of flames entering her bedroom.