Chapter 91: Floor 17

¶91.1 All six flats on floor 17 were occupied at the time of Behailu Kebede's telephone call to the emergency services.⁶³⁷⁶³⁷ Phase 1 Report Volume II paragraph 10.15. By 01.30, the occupants of Flats 141, 143, 145 and 146 had left the building safely,⁶³⁸⁶³⁸ Phase 1 Report Volume III Annex A. apart from Khadija Khalloufi, who died on floor 10.⁶³⁹⁶³⁹ See Chapter 86. Those residents who remained on floor 17, Kamru Miah, his wife, Rabeya Begum, and their adult children Mohammed Hamid, Mohammed Hanif and Husna Begum, all of whom lived in Flat 142, and Vincent Chiejina, who lived in Flat 144, all died in the fire.

¶91.2 Rita Tankarian, her nephew, Mesrob Kassemdijan, and his girlfriend, Fung Hee-Cheung, were in Flat 141 and were the first to leave floor 17. Although Rita Tankarian and Mesrob Kassemdijan could smell smoke in the lobby on floor 17, none was visible.⁶⁴⁰⁶⁴⁰ Phase 1 Report Volume II paragraphs 10.239-10.240. They left the tower between 01.25 and 01.26.⁶⁴¹⁶⁴¹ Phase 1 Report Volume III Annex A.

¶91.3 The fire reached the outside of Flat 146 at about 01.24.⁶⁴²⁶⁴² Phase 1 Report Volume II paragraph 10.118. Virgilio (Larry) Castro lived there with his friend, Genaro Batoan. His girlfriend was also staying that night. Shortly before he and his girlfriend followed Genaro Batoan out of the flat, Larry Castro saw flames coming through the extractor fan in the kitchen window. The door to Flat 146 needed to be pulled shut as the self-closing device did not work effectively. Larry Castro thought that he had not pulled it shut. The black smoke that then came into the lobby made him cough.⁶⁴³⁶⁴³ Phase 1 Report Volume II paragraphs 10.242-10.243; Phase 1 Report Volume VI paragraph 24.31 (e).

¶91.4 On leaving Flat 145, Corinne Jones saw Larry Castro outside his front door. Thick black smoke was coming from the top of the door and moving along the ceiling. She briefly went back into her flat and on returning to the lobby found that the amount of smoke had increased significantly.⁶⁴⁴⁶⁴⁴ Phase 1 Report Volume II paragraphs 10.244-10.245. She and Larry Castro both left the tower at 01.30.⁶⁴⁵⁶⁴⁵ Phase 1 Report Volume II paragraphs 10.239-10.240.

¶91.5 At 01.29, Husna Begum made an emergency call which was connected to the police. She reported that there was smoke coming into the flat, that flames could be seen outside, and that the fire was "in the house right next to us".⁶⁴⁶⁶⁴⁶ Phase 1 Report Volume II paragraph 10.247. Like Flat 146, Flat 142 was on the east side of the tower.

¶91.6 It is likely that the lobby of floor 17 rapidly filled with smoke within a few minutes after the fire reached the outside of Flat 146 and then entered it. The contents of Flat 146 were alight between 02.19 and 02.25.⁶⁴⁷⁶⁴⁷ Lane, Supplemental Phase 1 Report, Section 12 {BLAS0000012/19} paragraph 12.3.17.

¶91.7 The kitchen window of Flat 142 faced east; its living room windows faced south and east. The bedroom windows faced south.⁶⁴⁸⁶⁴⁸ External Spread of Fire Report {MET00012593/12} page 12. By about 02.23, the fire was outside the kitchen of Flat 142. By about 02.31, having spread south, it covered the entire east side of the flat. By 02.48, the fire had reached the south-facing windows of the living room. By 03.20 the fire was well established on the south face of Flat 142, affecting both the living room and bedroom windows. By 03.33, it had almost ceased outside the east and south faces of the flat and had spread west to Flat 143.⁶⁴⁹⁶⁴⁹ Purser, Phase 2 Report, Section 6 {DAPR0000006/117} paragraph 640. The evidence does not suggest that the contents of Flat 142 were alight at 03.33.⁶⁵⁰⁶⁵⁰ Purser, Phase 2 Report, Section 6 {DAPR0000006/118-119} paragraphs 640 and 648.

¶91.8 Flat 144 was a one-bedroomed flat situated on the west side of the tower.⁶⁵¹⁶⁵¹ External Spread of Fire Report {MET00012593/12} page 12. By 03.39 the fire was approaching the bedroom of Flat 144 and by 03.44 it was established outside it. By 03.58, the fire was outside the kitchen and was beginning to affect the living room. Flames continued to burn outside the living room but by about 04.30 they had ceased.⁶⁵²⁶⁵² Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraph 667.

¶91.9 Following Husna Begum's emergency call at 01.29, the occupants of Flat 142 made three more emergency calls in the period up to 03.18. Those were the only emergency calls made from floor 17. None resulted in the deployment of firefighters.

The Miah / Begum family

Kamru Miah

¶Date of birth: 12 August 1937 (79 years of age). Place of birth: Sylhet, Bangladesh. Gender: Male. Occupation: Retired. Usual address: Flat 142, floor 17, Grenfell Tower, London. Place of death: Flat 142, floor 17, Grenfell Tower, London. Time of death: Between 03.20 and 03.33 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

¶Ischaemic heart disease.

Rabeya Begum

¶Date of birth: 15 November 1952 (64 years of age). Place of birth: Bangladesh. Gender: Female. Occupation: Homemaker. Usual address: Flat 142, floor 17, Grenfell Tower, London Place of death: Flat 142, floor 17, Grenfell Tower, London. Time of death: Between 03.20 and 03.33 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Mohammed Hamid

¶Date of birth: 19 January 1989 (28 years of age). Place of birth: London. Gender: Male. Occupation: Sales Assistant. Usual address: Flat 142, floor 17, Grenfell Tower, London. Place of death: Flat 142, floor 17, Grenfell Tower, London. Time of death: Between 03.20 and 03.33 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Mohammed Hanif

¶Date of birth: 20 February 1991 (26 years of age). Place of birth: London. Gender: Male. Occupation: Sales Assistant. Usual address: Flat 142, floor 17, Grenfell Tower, London Place of death: Flat 142, floor 17, Grenfell Tower, London. Time of death: Between 03.20 and 03.33 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Husna Begum

¶Date of birth: 4 February 1995 (22 years of age). Place of birth: London. Gender: Female. Occupation: Sales Assistant. Usual address: Flat 142, floor 17, Grenfell Tower, London. Place of death: Floor 17, Grenfell Tower, London. Time of death: Between 03.20 and 03.33 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Background and composition of household

¶91.10 Kamru Miah, his wife Rabeya Begum and three of their adult children, Mohammed Hamid, Mohammed Hanif and Husna Begum lived in Flat 142. The family had moved to Grenfell Tower in August 2016.⁶⁵³⁶⁵³ Hakim {IWS00000019/2} page 2, paragraph 4. Their eldest son, Mohammed Hakim, lived nearby but his wife, Farhana, was staying with his family in Flat 142. She was not there on the night of the fire.⁶⁵⁴⁶⁵⁴ Phase 1 Report Volume IV paragraph 32.240.

¶91.11 Kamru Miah was born on 12 August 1937 and was 79 years old. Respected within his community, he had moved to the United Kingdom in 1963 and was a retired baker and tandoori chef.⁶⁵⁵⁶⁵⁵ Phase 1 Report Volume IV paragraph 32.241. Rabeya Begum was born on 15 November 1952 and was 64 years old. She came to London after marrying Kamru Miah. Committed to her family, she had devoted herself to raising the couple's four children.

¶91.12 Mohammed Hamid was born on 19 January 1989 and was 28 years old. He spent much time caring for his father, who had suffered two strokes.⁶⁵⁶⁶⁵⁶ Phase 1 Report Volume IV paragraphs 32.242 and 32.248-32.249. Mohammed Hanif was born on 20 February 1991 and was 26 years of age. He was particularly creative with a talent for drawing and animation.⁶⁵⁷⁶⁵⁷ Phase 1 Report Volume IV paragraphs 32.242 and 32.251. Husna Begum was born on 4 February 1995 and was 22 years old. Like her mother she was an excellent cook and enjoyed creative writing.⁶⁵⁸⁶⁵⁸ Phase 1 Report Volume IV paragraphs 32.242 and 32.252-32.253. She was the youngest member of the family and the only daughter and was due to marry on 29 July 2017.⁶⁵⁹⁶⁵⁹ Hakim {IWS00000019/7} page 7, paragraph 21. All three siblings worked full-time in the retail sector.⁶⁶⁰⁶⁶⁰ Hakim {IWS00000019/1} page 1, paragraph 3.

Vulnerability

¶91.13 Kamru Miah had previously suffered a heart attack and two strokes. He used a walking stick and easily got out of breath when walking.⁶⁶¹⁶⁶¹ Khanom {COR00001147/7-8} pages 7-8; Hakim {IWS00000019/2} page 2, paragraph 6. Before the family moved to Grenfell Tower, Rohema Khanom, the niece of Rabeya Begum, had helped her complete an assessment form on which they had recorded that Kamru Miah had suffered a heart attack and a stroke and could not manage stairs. Rohema Khanom had also attended a meeting in August 2016 with RBKC to interpret for her aunt and uncle. She recalled that her uncle's health had been discussed at that meeting.⁶⁶²⁶⁶² Khanom {COR00001147/2} page 2.

¶91.14 The spreadsheet produced on the night of the fire by David Noble⁶⁶³⁶⁶³ Noble {TMO00000884/1} page 1, paragraph 3. based on information held on the TMO's Capita Insight system⁶⁶⁴⁶⁶⁴ Noble {Day119/77:17}-{Day119/82:5}. did not identify Kamru Miah as a vulnerable person.

Events of 14 June 2017

¶91.15 The family were all at home on the night of the fire. Mohammed Hakim had visited them so they could break the Ramadan fast together. He left at about 22.00. On arriving at his home, he telephoned his mother at about 23.00.⁶⁶⁵⁶⁶⁵ Hakim {IWS00000019/3} page 3, paragraphs 9-10.

¶91.16 At 01.29, Husna Begum made an emergency call that was connected to the police. She reported that smoke was entering the flat, that the family could see flames from a window and that the fire was in a nearby flat. She asked for help. The police operator told her that the LFB had been informed and that someone would be coming to help them. The sound of a smoke alarm could be heard in the background.⁶⁶⁶⁶⁶⁶ 999 call transcript {INQ00000264}; Phase 1 Report Volume II paragraph 10.247; Phase 1 Report Volume IV paragraph 28.102 (a). The mention of the fire being in a nearby flat must be a reference to Flat 146 and it is clear that smoke had started to infiltrate Flat 142 from the lobby by the time of the call.

¶91.17 At 01.38, the police notified the LFB that a family of five were in Flat 142 on floor 17 and that smoke was coming into the flat. OM Alexandra Norman passed the information to CU8 at 01.43.⁶⁶⁷⁶⁶⁷ Phase 1 Report Volume IV paragraphs 28.102 (b) and 28.102 (c).

¶91.18 How it then reached the bridgehead, then on floor 2, is unclear, but a note recording "17th Fl, 142 FSC" was written on a wall, probably on the second-floor mezzanine.⁶⁶⁸⁶⁶⁸ Photograph of notes made by LFB on walls inside Grenfell Tower {MET00005789}. While the bridgehead was on floor 2 WM Louisa De Silvo used a forward information board to record information about those awaiting rescue.⁶⁶⁹⁶⁶⁹ Phase 1 Report Volume II paragraphs 13.52-13.53. Shortly before the bridgehead moved to floor 3 (at around 02.17), CM Charles Batterbee went to the bridgehead and copied the information on a forward information board into his own notebook.⁶⁷⁰⁶⁷⁰ Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraph 28.84 (c). There was no reference to floor 17 and no deployment was made to that floor before the bridgehead moved to floor 3. Following that move, no information relating to Flat 142 was recorded on the wall on floor 3 used to record information about people needing to be rescued.⁶⁷¹⁶⁷¹ Phase 1 Report Volume IV paragraph 28.102 (c); Phase 1 Report Volume II Figure 15.7.

¶91.19 At 02.27, Husna Begum made a second emergency call, speaking to CRO Heidi Fox in the LFB control room. She told CRO Fox that the family had been waiting for help for an hour and included two elderly adults. Husna Begum told her that the fire was right next to their window and that they were afraid they were going to die. CRO Fox told her that they were not going to die and that she would pass the information to the command unit.⁶⁷²⁶⁷² 999 call transcript {LFB00000354}; Phase 1 Report Volume III paragraph 15.85; Phase 1 Report Volume IV paragraph 28.102 (d). By that time the fire was outside the kitchen window of Flat 142.⁶⁷³⁶⁷³ Purser, Phase 2 Report, Section 6 {DAPR0000006/117} paragraph 640.

¶91.20 At 02.29, CRO Fox created a service request in relation to Flat 142 and CRO Sharon Darby then sent a radio message at 02.30 which referred to five adults, including two elderly persons, being trapped inside Flat 142.⁶⁷⁴⁶⁷⁴ Phase 1 Report Volume III paragraph 15.149; LFB radio message {LFB00002784}. Although Husna Begum's call at 02.27 probably explains the reference to Flat 142 which appears on the white laminated sheet used in CU7,⁶⁷⁵⁶⁷⁵ Phase 1 Report Volume II paragraphs 12.8-12.9; Phase 1 Report Volume IV paragraphs 28.86 and 28.102 (f). there is no evidence about what happened to that information once it had been received by CU7,⁶⁷⁶⁶⁷⁶ Phase 1 Report Volume IV paragraph 28.102 (e). apart from the fact that it was recorded on a control information form.⁶⁷⁷⁶⁷⁷ LFB Control Information Forms {LFB00001955/12} page 12. The forms were used at the incident ground to record messages about people needing to be rescued.

¶91.21 Having spoken to Husna Begum, who told her that there was a fire in the tower, Rohema Khanom made her way there. On the way she telephoned Husna Begum between 02.20 and 02.50 and then spoke to Rabeya Begum, who told her that the fire was now in the flat. Her aunt said that the family were all in the bedroom used by Mohammed Hanif and Mohammed Hamid. She then returned the phone to Husna Begum, who said it was pitch black in the flat, before ending the call.⁶⁷⁸⁶⁷⁸ Phase 1 Report Volume III paragraph 15.84. By that time the fire covered the entire east side of Flat 142.⁶⁷⁹⁶⁷⁹ External Spread of Fire Report {MET00012593/77} Image 25 (applying a +58 minutes time correction); Lane, Supplemental Phase 1 Report, Section 12 {BLAS0000012/10} Figure 12.3; Purser, Phase 2 Report, Section 6 {DAPR0000006/117} paragraph 640.

¶91.22 At about 03.00, Rohema Khanom spoke to Mohammed Hanif, who told her that the family were all together.⁶⁸⁰⁶⁸⁰ Phase 1 Report Volume III paragraph 17.76.

¶91.23 Husna Begum called her brother Mohammed Hakim at 03.08. She told him about the fire and said that the family were trapped in the flat. She said she did not think she would survive. She then ended the call.⁶⁸¹⁶⁸¹ Phase 1 Report Volume III paragraph 17.76. Mohammed Hakim then tried to call all five members of his family, but the calls all went to voicemail.⁶⁸²⁶⁸² Hakim {IWS00000019/1} page 5, paragraph 15.

¶91.24 At 03.09, CRO Adams answered an emergency call from Husna Begum and one of her brothers. That was the third such call from Flat 142. Husna Begum told CRO Adams that there were five people in the flat and that there was fire in the kitchen and the hallway. There is no record of the call being passed to CU7. CRO Adams advised them to leave but was told that it was not possible to do so as the smoke in the stairs was too thick.⁶⁸³⁶⁸³ Phase 1 Report Volume III paragraph 17.77; Phase 1 Report Volume IV paragraph 28.102 (h). That suggests that the family must have tried at some point to leave Flat 142.

¶91.25 Husna Begum also spoke to Rohema Khanom again, but we do not know when. She told Rohema Khanom that it was smoky and dark and that she could not see anything. She was having difficulty breathing and was coughing continuously.⁶⁸⁴⁶⁸⁴ Phase 1 Report Volume III paragraph 17.76.

¶91.26 The fourth and last emergency call from Flat 142 was made at 03.18. Husna Begum spoke again to CRO Fox, who advised the family to leave. Husna Begum said that they were unable to do so because it was too hot outside the door, probably meaning in the lobby. She said that there were five adults in the flat, including two elderly people, and that they were near the front door. Husna Begum asked for someone to come to the flat. CRO Fox said that she would pass the information on by radio. However, there is no entry on the LFB Short Incident Log of any service request to that effect and no other record of any radio call.⁶⁸⁵⁶⁸⁵ 999 call transcript {LFB00000419}; Phase 1 Report Volume IV paragraph 28.102 (i). After that, no one in Flat 142 contacted the emergency services or anybody else outside the tower.⁶⁸⁶⁶⁸⁶ Phase 1 Report Volume III paragraph 17.79.

¶91.27 The second of the two whiteboards used by SM Jason Oliff to collate information in the LFB control room to pass to the command units contained a reference to Flat 142.⁶⁸⁷⁶⁸⁷ Phase 1 Report Volume III paragraphs 15.139-15.141 and Figures 15.8 and 15.9. It is likely, in view of its low position on the second whiteboard, that that reflected one of the later calls made by Husna Begum at 03.09 and 03.18. Flat 142 also appeared on the whiteboard grid on CU7, showing five persons and a "P" for priority, which might have indicated the presence of elderly persons. The photograph of the whiteboard grid was taken between about 03.15 and 04.00. It is therefore at least possible that it recorded the information given in Husna Begum's call at 03.18.⁶⁸⁸⁶⁸⁸ Phase 1 Report Volume IV paragraph 28.102 (j).

¶91.28 By the time Husna Begum made her last call at 03.18 the bridgehead had been moved to the ground floor (at around 03.10). After that, a green wall by the stairs was used to record information about those needing to be rescued.⁶⁸⁹⁶⁸⁹ Phase 1 Report Volume IV paragraph 28.87. A photograph of that wall taken at about 04.45 shows the number "142".⁶⁹⁰⁶⁹⁰ Mulholland Exhibit MBM/02 - Photograph of green wall {MET00018739}; Phase 1 Report Volume IV paragraph 28.102.(l). It is not clear when it was put there.

¶91.29 The last crew that would have been able to reach floor 17 or above consisted of FFs Michael Pole, Niki Mitchell and Chris Cheesman, who were deployed to floor 23 between 02.51 and 02.53. However, having stopped at floor 18 to help evacuate the occupants of Flat 153, they realised that they did not have enough air to reach floor 23.⁶⁹¹⁶⁹¹ See Chapter 92. The last opportunity of rescue for the family in Flat 142 lay in the timely communication to the bridgehead of the information provided in Husna Begum's second call at 02.27 and its being acted upon swiftly. The information did eventually arrive, but there is no evidence that it was acted on.⁶⁹²⁶⁹² Phase 1 Report Volume IV paragraph 28.103.

Recovery and identification

¶91.30 The body of Husna Begum was recovered from the lobby of floor 17. Those of the other members of the family were recovered from the bedroom nearest the front door of Flat 142, which was the last area to be affected by the westward spread of the fire.⁶⁹³⁶⁹³ Purser, Phase 2 Report, Section 6 {DAPR0000006/117} paragraph 638. The coroner, Professor Wilcox, was satisfied about the identification of the remains recovered, and therefore issued interim certificates of the fact of death for all five members of the family.⁶⁹⁴⁶⁹⁴ Interim certificates of the fact of death for Kamru Miah, Rabeya Begum, Mohammed Hamid, Mohammed Hanif and Husna Begum {MET0006560}; {MET00065588}; {MET00065642}; {MET00065628}, {MET00065594}.

¶91.31 Husna Begum probably tried to leave after making her call to the emergency services at 03.18. We do not know whether other members of the family also tried to leave at the same time but were forced to return to Flat 142 by the conditions they encountered.

Cause and time of death

¶91.32 It is possible that until the time of the last emergency call, the family in Flat 142 were able to reduce their exposure to asphyxiant gases by keeping a bedroom window open.⁶⁹⁵⁶⁹⁵ Purser, Phase 2 Report, Section 6 {DAPR0000006/118-119} paragraphs 645 and 646. However, once the fire had reached the window of the bedroom where they were sheltering, conditions in the room deteriorated rapidly within a few minutes.⁶⁹⁶⁶⁹⁶ Purser, Phase 2 Report, Section 6 {DAPR0000006/119} paragraph 646. The fire had reached the bedrooms of Flat 142 by 03.20 and had passed them by 03.33.⁶⁹⁷⁶⁹⁷ Bisby, Phase 1 Expert Report {LBYR00000001/175} Figure 116; Lane, Supplemental Phase 1 Report, Section 12 {BLAS0000012/11} Figure 12.4; Purser, Phase 2 Report, Section 6 {DAPR0000006/118} paragraph 640. In the circumstances, we are satisfied that Kamru Miah, Rabeya Begum, Mohammed Hamid and Mohammed Hanif all died at some time between 03.20 and 03.33.

¶91.33 Husna Begum's last emergency call to CRO Fox lasted one minute and 20 seconds.⁶⁹⁸⁶⁹⁸ LFB Operational Response Report dated July 2020 {LFB00119333/289} page 289. By then the fire was affecting both the living room and bedroom windows on the south side of Flat 142.⁶⁹⁹⁶⁹⁹ Purser, Phase 2 Report, Section 6 {DAPR0000006/118} paragraph 640. It is likely that from about 01.29 to 03.20, Husna Begum (and indeed the other members of her family) was increasingly exposed to asphyxiant gases. Husna Begum had therefore already been exposed to a significant level of asphyxiant gases while she remained in Flat 142. On leaving the bedroom where she had been sheltering with her family, she encountered a high concentration of smoke and gases in the hallway of Flat 142 and then in the lobby.⁷⁰⁰⁷⁰⁰ Purser, Phase 2 Report, Section 6 {DAPR0000006/119-122} paragraphs 647 and 662-663.

¶91.34 We find that Husna Begum sought to leave Flat 142 shortly after she had made her last emergency call and while the fire was still outside the bedroom where the family was sheltering. We are satisfied that she also died between 03.20 and 03.33.

¶91.35 The remains of the members of the family found in Flat 142 were extensively charred.⁷⁰¹⁷⁰¹ Miah post-mortem report {COR00000814/4}; Rabeya Begum post-mortem report {COR00001322/5-6}; Hamid post- mortem report {COR00001153/4}; Hanif post-mortem report {COR00000812/4}; Purser, Phase 2 Report, Section 6 {DAPR0000006/119-121} paragraphs 649-652 and 657. Heavy soot deposits were found in Kamru Miah's airways. There was evidence of mild heat-related damage to the lining of the trachea which would have occurred while he was alive.⁷⁰²⁷⁰² Miah post-mortem report {COR00000814/6-8}; Purser, Phase 2 Report, Section 6 {DAPR0000006/119} paragraph 650. Soot deposits were also found in the airways of Rabeya Begum⁷⁰³⁷⁰³ Rabeya Begum post-mortem report {COR000001322/8-9}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 652. and Mohammed Hamid.⁷⁰⁴⁷⁰⁴ Hamid post-mortem report {COR00001153/4-5}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 653.

¶91.36 The level of carboxyhaemoglobin in a blood sample taken from Kamru Miah was 47%;⁷⁰⁵⁷⁰⁵ Miah toxicology report {COR00000822/1}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 651. that in a sample taken from Mohammed Hanif was 69%.⁷⁰⁶⁷⁰⁶ Hanif toxicology report {MET00039589/1}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 651. Both are within the range associated with death from carbon monoxide poisoning. Toxicological analysis confirmed that Mohammed Hamid's blood contained carboxyhaemoglobin but the concentration could not be measured.⁷⁰⁷⁷⁰⁷ Hamid post-mortem report {COR00001153/8}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 653. It was not possible to conduct a toxicological examination of Rabeya Begum.⁷⁰⁸⁷⁰⁸ Rabeya Begum post-mortem report {COR00001322/9}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120} paragraph 652.

¶91.37 Given the high levels of carboxyhaemoglobin in Kamru Miah and Mohammed Hanif's blood and the fact that the four members of the family were together in the bedroom, we find that they were all exposed to a level of asphyxiant gases which was so high that it caused loss of consciousness and death before their bodies suffered any serious effects of direct heat or fire.⁷⁰⁹⁷⁰⁹ Phase 2 Report, Section 6 {DAPR0000006/119-121} paragraphs 650-653 and 658. In Kamru Miah's case, significant heart disease made him more vulnerable to collapse and death from the effects of asphyxiant gases.⁷¹⁰⁷¹⁰ Miah post-mortem report {COR00000814/8}; Purser, Phase 2 Report, Section 6 {DAPR0000006/119} paragraph 650.

¶91.38 The body of Husna Begum was recovered intact. There was no obvious soot staining to her airways. Carboxyhaemoglobin appeared to be present in the blood, but it was not possible to measure the concentration due to the condition of the sample. There was significant heat damage to the body that is unlikely to have occurred while Husna Begum was still in Flat 142.⁷¹¹⁷¹¹ Husna Begum post-mortem report {COR00000636/4}; Husna Begum toxicology report {COR00000642}; Purser, Phase 2 Report, Section 6 {DAPR0000006/120-122} paragraphs 654, 659 and 664.

¶91.39 Although the examining pathologist could not completely exclude the possibility that some heat damage had occurred before death, we think it more likely that it occurred after Husna Begum had died. We think that the extent of her exposure to asphyxiant gases (carbon monoxide with some hydrogen cyanide) and the physical exertion involved in leaving Flat 142 caused her to collapse and lose consciousness soon after entering the lobby. She continued inhaling those gases while unconscious and died shortly after.⁷¹²⁷¹² Purser, Phase 2 Report, Section 6 {DAPR0000006/119-122} paragraphs 647 and 662-663.

¶91.40 The medical cause of death in the case of Kamru Miah was recorded as: Ia. Inhalation of products of combustion. II. Ischaemic heart disease. In the light of Professor Purser's evidence, we find that a more accurate description of the primary cause of death is "inhalation of asphyxiant gases".

¶91.41 The post-mortems on Rabeya Begum, Mohammed Hamid, Mohammed Hanif and Husna Begum recorded the medical cause of death in each case as "consistent with effects of fire". A more accurate description would be "inhalation of asphyxiant gases".

Vincent Chiejina

¶Date of birth: 1 June 1957 (60 years old). Place of birth: Nigeria. Gender: Male. Occupation: Retired. Usual address: Flat 144, floor 17, Grenfell Tower, London Place of death: Flat 144, floor 17, Grenfell Tower, London Time of death: Between 04.00 and 04.15 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Background and composition of household

¶91.42 Vincent Chiejina was born on 1 June 1957 and was 60 years old at the time of the fire. He spent his early years in Nigeria before travelling to the United Kingdom with his mother, Magdalene, and his sister, Jindu Maria. The eldest of four siblings, Vincent Chiejina and his family had lived on the Lancaster West estate between 1974 and 1981. He studied Electrical and Electronic Engineering at Sheffield University.⁷¹³⁷¹³ Phase 1 Report Volume IV paragraphs 32.228-32.230; Chiejina {IWS00002348/2} page 2, paragraphs 6 and 10. Vincent Chiejina had lived alone in Flat 144 on floor 17 of Grenfell Tower since February 2001.⁷¹⁴⁷¹⁴ Tenancy Agreement for Vincent Chiejina {TMOH00025056}. He was an active member of the Roman Catholic Church⁷¹⁵⁷¹⁵ Presentation relating to Vincent Chiejina {Day307/27:17-18}. and a men's group.⁷¹⁶⁷¹⁶ Phase 1 Report Volume IV paragraph 32.232.

Vulnerability

¶91.43 Vincent Chiejina had a history of mental health difficulties. He had been diagnosed with schizophrenia, for which he received medication.⁷¹⁷⁷¹⁷ Chiejina {IWS00002348/2} page 2, paragraphs 11-13. Rydon's survey of Grenfell Tower residents carried in November 2014 and provided to the TMO recorded that he suffered from learning disabilities and schizophrenia.⁷¹⁸⁷¹⁸ Rydon Residents Survey {RYD00024466/18}.

¶91.44 The spreadsheet produced on the night of the fire by David Noble⁷¹⁹⁷¹⁹ Noble {TMO00000884/1} page 1, paragraph 3. based on information held on the TMO's Capita Insight system identified Vincent Chiejina as a vulnerable person but contained no information about his mental health or learning difficulty.⁷²⁰⁷²⁰ Noble spreadsheet {TMO00862588}.

Events of 14 June 2017

¶91.45 Vincent Chiejina remained in his home throughout the course of the fire. He did not contact the emergency services and there is no evidence of his having contact with anyone else, either inside or outside the tower.⁷²¹⁷²¹ Phase 1 Report Volume II paragraph 11.64.

¶91.46 There is no direct evidence of what Vincent Chiejina did during the course of the fire but it is possible that he may have been awake for part of the time, since his remains were recovered from the living room rather than the bedroom. The living room was affected by the fire later than the bedroom and kitchen.⁷²²⁷²² Purser, Phase 2 Report, Section 6 {DAPR0000006/122} paragraph 666.

Recovery and identification

¶91.47 The remains of Vincent Chiejina were recovered from the living room of Flat 144 close to the window.⁷²³⁷²³ Purser, Phase 2 Report, Section 6 {DAPR0000006/122} paragraph 665. The coroner, Professor Wilcox, was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.⁷²⁴⁷²⁴ Interim certificate of the fact of death for Vincent Chiejina {MET00065620}.

Cause and time of death

¶91.48 The post-mortem on Vincent Chiejina recorded that he had mild coronary heart atheroma (heart disease). His remains were extensively charred. Soot was found in his respiratory system, including the lungs. There was evidence of damage to the lungs which could have been caused by the inhalation of hot smoke.⁷²⁵⁷²⁵ Chiejina post-mortem report {COR00001473/10}; Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraphs 669-670. Toxicological analysis of a sample of his blood showed a carboxyhaemoglobin level of about 39%, but that must be regarded as little more than an estimate because of the condition of the sample.⁷²⁶⁷²⁶ Chiejina toxicology report {COR00001483/1}; Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraphs 669-670.

¶91.49 Over the course of the fire, the quantity of smoke in Flat 144 increased, with smoke initially penetrating the flat from the lobby from about 01.30. The rate at which smoke entered the flat increased from about 03.44, when the fire became established outside the bedroom before spreading to the outside of the kitchen.⁷²⁷⁷²⁷ Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraph 672.

¶91.50 Vincent Chiejina was therefore exposed to a rising level of asphyxiant gases that increased even more when the fire reached the outside of his living room at about 03.58, resulting in a rapid deterioration of conditions in that room. The level of carboxyhaemoglobin in his blood indicates that he inhaled a considerable amount of asphyxiant gases before his death, probably sufficient to cause a loss of consciousness within minutes. The exposure to asphyxiant gases could of itself have been sufficient to cause death. The inhalation of hot gases before death may have contributed by causing breathing difficulties, again leading to rapid collapse followed shortly thereafter by death due to asphyxia.⁷²⁸⁷²⁸ Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraphs 670 and 673-674; Purser {Day297/102:13} -{Day297/103:18}. It is possible that Vincent Chiejina's mild heart disease increased his susceptibility to carbon monoxide.⁷²⁹⁷²⁹ Purser, Phase 2 Report, Section 6 {DAPR0000006/123} paragraph 670; Purser {Day297/103:19}-{Day297/104:11}.

¶91.51 The post-mortem report recorded the medical cause of death as "inhalation of products of combustion" but in the light of more recent evidence we consider that a more accurate description is "inhalation of asphyxiant gases".

¶91.52 We are satisfied that Vincent Chiejina died between 04.00 and 04.15 before suffering the direct effects of heat or fire.⁷³⁰⁷³⁰ Purser {Day297/99:3}-{Day297/103:18}.