Chapter 92: Floor 18

¶92.1 All six flats on floor 18 were occupied when Behailu Kebede made an emergency call to report a fire in his flat.⁷³¹⁷³¹ Phase 1 Report Volume II paragraph 10.15. By 01.26, the fire had reached the outside of Flat 156 on floor 18,⁷³²⁷³² Phase 1 Report Volume II paragraph 10.118. the home of Shah Ahmed and his wife, Sayeda Ahmed. Woken by smoke alarms, Shah Ahmed saw fire outside his kitchen window, which then appeared to explode inward. He called the emergency services at 01.27 and was connected to the police. He was not able to speak to the operator before leaving with his wife. Together they knocked on their neighbours' doors. Shah Ahmed left the door of his home shut. He and his wife then left floor 18, leaving the tower by 01.31.⁷³³⁷³³ Phase 1 Report Volume II paragraphs 10.249-10.250; Phase 1 Report Volume III Annex A.

¶92.2 Rabia Yahya, who was in Flat 152 with her children, heard a knocking at her door. When she opened it she saw Shah and Sayeda Ahmed by the door to the stairwell. Sayeda Ahmed warned her of the fire and told her to leave.⁷³⁴⁷³⁴ Phase 1 Report Volume II paragraph 10.251. Shortly after Shah and Sayeda Ahmed had raised the alarm, Hamid Kani, who lived alone in Flat 154, Sakina Afrasehabi and her sister, Fatemeh Afrasiabi, who was staying with her in Flat 151, left their homes. Berkti and Biruk Haftom, who lived in Flat 155, may have decided to leave even before the Ahmeds alerted their neighbours.⁷³⁵⁷³⁵ Phase 1 Report Volume II paragraphs 10.254, 10.289 and 14.125. They all died, having sought refuge on floor 23. We return to the circumstances of their deaths in Chapter 97.

¶92.3 At 01.33, Rabia Yahya made a call to the emergency services which was put through to the LFB. She told CRO Angela Gotts that she was pregnant and trapped on floor 18 with her three children. Rabia Yahya was not asked for the number of her flat. She reported that she had been unable to leave because of thick black smoke which, she later recalled, had been in the stairwell. Rabia Yahya was advised to stay in her flat.⁷³⁶⁷³⁶ Phase 1 Report Volume II paragraph 11.59; 999 call transcript {LFB00000662/1-2} pages 1-2. At 01.36, CRO Gotts created a service request in response to that call, recording that the caller was on floor 18.⁷³⁷⁷³⁷ Short Incident Log Report {MET00013830/19} page 19. OM Alexandra Norman and CRO Sharon Darby then told WM Daniel Meyrick in CU8 and the crew in appliance G261 that there was a person trapped on floor 18.⁷³⁸⁷³⁸ Phase 1 Report Volume II paragraphs 11.148-11.154. At 01.43, during the course of a radio exchange with CU8, CRO Darby again passed on information about a caller on floor 18 with thick smoke outside her flat.⁷³⁹⁷³⁹ Phase 1 Report Volume II paragraphs 12.72-12.73. At 01.45, CRO Darby recorded the service request as complete.⁷⁴⁰⁷⁴⁰ Short Incident Log Report {MET00013830/19} page 19.

¶92.4 WM Mark Kentfield recorded the information reaching CU8 on pieces of paper, which were then passed to SM Brett Loft positioned outside the tower.⁷⁴¹⁷⁴¹ Phase 1 Report Volume II paragraph 11.6; Phase 1 Report Volume IV paragraph 28.84 (a). They included the A4 sheet of paper that later became known as the "Sadler envelope". The last entry in that document reads "152 – 18th pregnant".⁷⁴²⁷⁴² Phase 1 Report Volume II paragraphs 12.18-12.19 and 14.71 and Figure 12.4. How the information passed from SM Loft to the bridgehead is unclear.⁷⁴³⁷⁴³ Phase 1 Report Volume IV paragraph 28.84 (b). A photograph taken by FF Justin O'Beirne shows that after the bridgehead had moved to floor 3 there was written on the wall "18 MOTHER +CHLD NO FLAT NUMBER" followed by the number 152 circled. The number 18 was ticked.⁷⁴⁴⁷⁴⁴ O'Bierne {MET000083321/19} page 19; Phase 1 Report Volume III Figure 16.6.

¶92.5 In any event, as a result FFs Katie Foster and Gregory Lawson were deployed at 01.53 to floor 18 in general rather than to a specific flat or to find a pregnant resident.⁷⁴⁵⁷⁴⁵ Phase 1 Report Volume II paragraph 13.47. The crew probably reached floor 18 at or shortly after 02.00. By then, just two flats, adjacent to each other on the south side of floor 18, remained occupied. Rabia Yahya and her children were still in Flat 152. Yehualashet Enyew, Berkti Haftom's lodger, had moved from Flat 155 to Flat 153 to join Paulos Tekle, Genet Shawo and their two sons.⁷⁴⁶⁷⁴⁶ Phase 1 Report Volume II paragraphs 11.60-11.62 and 14.180-14.181.

¶92.6 When they arrived at floor 18, FFs Foster and Lawson found the visibility in the lobby to be restricted by thick black smoke. They conducted a sweep of the floor. The door of the first flat they reached (Flat 151) was locked. When they reached Flat 152, they spoke to Rabia Yahya inside her home, which was still clear of smoke. They told her that they would check on neighbouring flats and get everyone out together. She was advised to put damp blankets against her front door.⁷⁴⁷⁷⁴⁷ Phase 1 Report Volume II paragraphs 13.51, 13.67, 14.181 and 14.182. FFs Foster and Lawson then moved to Flat 153. When Yehualashet Enyew opened the front door, Paulos Tekle was sitting on the ledge of a sitting room window. He moved back into the flat to speak to the firefighters. Their advice was again to block up the front door. Those in Flat 153 then covered the letterbox and front door and sat down to wait.⁷⁴⁸⁷⁴⁸ Phase 1 Report Volume II paragraphs 13.49 and 14.184-14.186.

¶92.7 FFs Foster and Lawson then searched Flat 154 followed by Flat 155. They found the doors to both flats open and their interiors to be pitch black and full of smoke. The door of Flat 156 was closed and they decided not to force an entry, given the indication that there was now fire inside.⁷⁴⁹⁷⁴⁹ Phase 1 Report Volume II paragraph 13.50. The crew concluded that conditions were too difficult to enable them to rescue the nine remaining occupants on floor 18 at that time. They both tried to contact the bridgehead by radio but without success. As they were running low on air, they made their way down the stairs without returning to Flat 152 or 153.⁷⁵⁰⁷⁵⁰ Phase 1 Report Volume II paragraphs 13.51 and 14.182.

¶92.8 The fire reached Flat 152 by about 02.22.⁷⁵¹⁷⁵¹ Phase 1 Report Volume III paragraph 15.3. Rabia Yahya thought that the fire had broken into her kitchen at about 02.30. She immediately left with her children and went to Flat 153. She found conditions in the lobby worse than when she had answered the door to FFs Foster and Lawson. The lobby felt hot and visibility was so poor that she had to use the wall as a guide. There was no smoke in Flat 153 when she arrived there.⁷⁵²⁷⁵² Phase 1 Report Volume III paragraphs 15.79-15.81.

¶92.9 By about 02.30, all those remaining on floor 18 were sheltering in Flat 153. The fire brigade was aware that there were people there, both from information provided by FF Lawson when he returned to the bridgehead and from calls to, and between, the emergency services. However, no more firefighters were sent to floor 18 until shortly after 03.00 and those then deployed had to abandon their task. At about the same time, those in Flat 153 left the building. During the descent from floor 18, Isaac Paulos became separated from the group and died shortly afterwards.

Isaac Paulos

¶Date of birth: 22 September 2011 (5 years old). Place of birth: London. Gender: Male. Occupation: N/A. Usual address: Flat 153, floor 18, Grenfell Tower, London. Place of death: Lobby of floor 13, Grenfell Tower, London Time of death: Between 03.09 and 03.15 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Background and composition of household

¶92.10 Isaac Paulos lived in Flat 153 with his mother, Genet Shawo, and his younger brother. His father, Paulos Tekle, did not live in Grenfell Tower but visited almost every day.⁷⁵³⁷⁵³ Tekle {IWS00001051/1-2} pages 1-2, paragraph 5. Isaac loved Taekwondo, swimming, and football. His teachers described him as especially gifted at maths and reading.⁷⁵⁴⁷⁵⁴ Phase 1 Report Volume IV paragraphs 32.214-32.217.

Vulnerability

¶92.11 Apart from his age, Isaac Paulos was not known to have any vulnerabilities. He was recorded as a child in the spreadsheet produced on the night of the fire by David Noble.⁷⁵⁵⁷⁵⁵ Noble {TMO00000884/1} page 1, paragraph 3; Noble {Day119/75:19-21}; Noble spreadsheet {TMO00862588}.

Events of 14 June 2017

¶92.12 Isaac Paulos returned home from a Taekwondo session at about 18.30 on 13 June 2017.⁷⁵⁶⁷⁵⁶ O'Riordan {MET00013136/3} page 3. The family spent the evening together.⁷⁵⁷⁷⁵⁷ Tekle {IWS00001051/3-4} pages 3-4, paragraphs 11-14. At some time after the fire had started, his parents were woken by sounds from the lobby. Opening the front door, they saw Rabia Yahya, who told them about the fire.⁷⁵⁸⁷⁵⁸ Phase 1 Report Volume II paragraph 10.252. That conversation must have occurred just after Rabia Yahya had spoken to Sayeda Ahmed and before 01.32 when Paulos Tekle telephoned his friend Abraham Abebe who lived in Flat 44.⁷⁵⁹⁷⁵⁹ Phase 1 Report Volume II paragraph 10.252. The call was not answered. At 01.43, Genet Shawo spoke to Hashim Kedir, who lived in Flat 192. He told her that he had been advised by the emergency services to remain in his flat. He advised her to do the same.⁷⁶⁰⁷⁶⁰ Phase 1 Report Volume II paragraph 11.61.

Information to the incident ground after 02.30

¶92.13 After leaving floor 18, FFs Foster and Lawson returned to the bridgehead, which by that time was on floor 3.⁷⁶¹⁷⁶¹ Phase 1 Report Volume III paragraph 17.11; Phase 1 Report Volume IV paragraph 28.86. Their end of wear time was 02.27.⁷⁶²⁷⁶² Phase 1 Report Volume III paragraph 15.31. FF Lawson gave a debrief, drawing a plan on a wall to indicate which flats on floor 18 the crew had visited and which they had found empty. He also explained why they had not brought anyone down and that it was necessary to send more crews to floor 18 immediately.⁷⁶³⁷⁶³ Phase 1 Report Volume III paragraph 15.31. A photograph taken by SM Gareth Cook at 03.08⁷⁶⁴⁷⁶⁴ Cook Exhibit GAC/2 - Grenfell Tower statement notes {MET00015779/16} page 16. shows that the information recorded on a wall of floor 3 while the bridgehead was located there included the following: "18 MOTHER + CHILD, NO FLAT NO 152" with a tick next to the number 18 and with "152" circled.⁷⁶⁵⁷⁶⁵ Phase 1 Report Volume III Figure 15.7. A tick against a particular flat indicated that a crew had been sent there and a circle indicated that the bridgehead had received further information by runner or radio or from a returning crew.⁷⁶⁶⁷⁶⁶ De Silvo {Day30/31:13}-{Day30/32:17}. That information related to the deployment of FFs Foster and Lawson.

¶92.14 Leaving the bridgehead, FF Lawson went out through the ground floor lobby. There he spoke to CM Charles Batterbee, drawing another plan of floor 18 and repeating the information that he had given at the bridgehead. He did not see what CM Batterbee did with the information.⁷⁶⁷⁷⁶⁷ Phase 1 Report Volume III paragraph 15.32. CM Batterbee recalled that FF Lawson had given him the numbers of two flats. CM Batterbee's recollection was that those flats were on floor 18. He wrote the information on a piece of paper and WM Glynn Williams then wrote it on the wall of the ground floor lobby. The information was then passed to WM Paul Watson who took it to the bridgehead.⁷⁶⁸⁷⁶⁸ Batterbee {Day12/156:4}-{Day 12/158:25}.

¶92.15 Three control information forms contain information that relates to floor 18. The first refers to about four people being in Flat 153. The second, timed at 03.01, refers to Flat 153 but also records "People in Flat C+B waiting by window. CAME FROM BA CREW." (The form then names FF Lawson as the source of information. A note in a different hand referring to four adults and 5 children appears on the blue copy of the form). The third (a yellow copy) is timed at 03.02 and refers (wrongly) to a family waiting in Flat 154. Again, FF Lawson is given as the source of the information.⁷⁶⁹⁷⁶⁹ Control Information Forms {LFB00001955/21-26} pages 21-22 and 26. The forms were used at the incident ground to record messages about people needing rescue. The references to Flats 153 and 154 may explain why those flats were recorded by CM Batterbee.⁷⁷⁰⁷⁷⁰ Phase 1 Report Volume II paragraph 14.73.

¶92.16 WM Williams had begun putting information on the ground floor wall at about 02.15.⁷⁷¹⁷⁷¹ Phase 1 Report Volume II paragraph 14.103. Photographs of that wall⁷⁷²⁷⁷² Wolfenden Exhibit PFW/2 - Photograph of ground floor wall {MET00017597}; De Silvo Exhibit LDS/5 - Photograph of ground floor wall {MET00015815}. taken at a later stage show that it included references to Flats 154, 153 and 152. The letters "BA" appear against each flat number with ticks next to 153 and 152. All three flats are linked by a bracket to Floor 18 (written as "18th"). A reference to four people is written by Flat 152 (i.e. Rabia Yahya and her three children). These details reflect information provided by FF Lawson.

¶92.17 FF Lawson's debrief did not prompt any further deployment to floor 18.

¶92.18 Rabia Yayha and her children had reached Flat 153 by 02.32, when Paulos Tekle made an emergency call reporting that there were four adults and five children in his flat. He told CRO Yvonne Adams that the fire was coming nearer and that they could not leave. CRO Adams told him that everyone should move to the room with the least smoke, that the fire service would get to them as soon as possible and that he should ring back if conditions got worse. Paulos Tekle later recalled that there had been no smoke or fire in Flat 153 at the time but that he had been able to see flames outside coming from the direction of Flat 152.⁷⁷³⁷⁷³ Phase 1 Report Volume III paragraph 15.82; 999 call transcript {LFB00000361/5-6} pages 5-6.

¶92.19 Paulos Tekle's call to the emergency services overlapped with a similar call made by Rabia Yahya at 02.34. She told CRO Heidi Fox that she was in Flat 153 and that the fire had reached Flat 152. CRO Fox told her that they should all try to leave. Rabia Yahya said they could not do so because of the thick black smoke and added that the firefighters had said they would return but had not done so. When asked who was there, Rabia Yahya told CRO Fox that there were four adults and five children sheltering in Flat 153 and that she was pregnant. CRO Fox said that she would alert the command unit to go to them.⁷⁷⁴⁷⁷⁴ Phase 1 Report Volume III paragraph 15.81; 999 call transcript {LFB00000365}.

¶92.20 Although no service request was created following Paulos Tekle's call at 02.32,⁷⁷⁵⁷⁷⁵ Phase 1 Report Volume III paragraph 15.152. CRO Fox did create one at 02.40 following the call from Rabia Yahya and repeated it a minute later. However, neither call led to a radio message being sent to the incident ground.⁷⁷⁶⁷⁷⁶ Phase 1 Report Volume III paragraphs 15.152 and 15.173; Short Incident Log Report {MET00013830/23} page 23. References to both calls appear on the whiteboards used from about 02.33 by SM Jason Oliff to collate information coming into the LFB control room. It is likely therefore that he passed information about Flat 153 to the incident ground by mobile telephone.⁷⁷⁷⁷⁷⁷ Phase 1 Report Volume III paragraphs 15.139-15.141, 15.152 and 15.173 and Figure 15.8.

¶92.21 Paulos Tekle made another call to the emergency services at 02.35 which was taken by CRO Peter Duddy. He did not respond to CRO Duddy's requests for information and the line then dropped out.⁷⁷⁸⁷⁷⁸ 999 call transcript {LFB00000362}. Shortly after, at 02.42, a further call from someone in Flat 153 was connected to the control room. The caller was probably Yehualashet Enyew. He told CRO Gotts that there were about nine people in the flat, that smoke was coming in and that the fire had reached Flat 152. Her advice was to block out the smoke if they could not leave and that the fire service would be informed to come and find them.⁷⁷⁹⁷⁷⁹ 999 call transcript {LFB00000371}. The call did not result in a service request.

¶92.22 At 02.45, CRO Christine Howson took a call from the police passing on information that three children and a pregnant woman were still in Flat 152 on floor 18.⁷⁸⁰⁷⁸⁰ 999 call transcript {LFB00000541}. That information, which plainly referred to Rabia Yahya and her children, had come from calls to the police made from outside the tower.⁷⁸¹⁷⁸¹ 999 call transcripts {INQ00000265}; {INQ00000266}. Shortly afterwards, at 02.47, CRO Gotts took a call from a relative of Rabia Yahya who was concerned that her sister-in-law was trapped on floor 18. The caller did not give the number of the flat. CRO Gotts replied that the control room had just received a message about floor 18 and told the caller that, if she spoke to Rabia Yahya, she should tell her to leave.⁷⁸²⁷⁸² 999 call transcript {LFB00000542}.

¶92.23 That information from these calls reached the incident ground is apparent from the white laminated sheet used in CU7 to collate information.⁷⁸³⁷⁸³ Phase 1 Report Volume II paragraphs 12.8-12.9 and Figure 12.3. It contained the following notations:

"152 18 3 kids, 1 PREGNANT adult". There is a red asterisk next to the entry. And a little lower: "151 18 3 kids, 1 adult"

¶And as the last entry: "153 18 4 adults 5 children can't escape".⁷⁸⁴⁷⁸⁴ It is not clear what that was intended to indicate, but it may have been priority.

¶92.24 At 02.48, CRO Howson answered a call in which Rabia Yahya said that they were trapped in Flat 153 on floor 18. When told that the fire had reached Flat 152, CRO Howson told her that the fire service would not be able to reach the flat and that its occupants should leave.⁷⁸⁵⁷⁸⁵ Phase 1 Report Volume III paragraphs 15.83 and 15.192. They spoke over each other at the relevant point in the call, so Rabia Yahya can only be heard saying that there were four people in Flat 153.⁷⁸⁶⁷⁸⁶ 999 call transcript {LFB00000384/3} page 3.

¶92.25 At about that time, radio messages were being exchanged between CRO Sharon Darby and CU7, during which she said that about four people were trapped in Flat 153.⁷⁸⁷⁷⁸⁷ LFB Radio messages {LFB00002340}; {LFB00002128}; {LFB00002031}; LFB Operational Response Report dated July 2020 {LFB00119333/234-235} pages 234-235. The calls from Yehualashet Enyew at 02.42 and Rabia Yahya at 02.48 were probably the source of the information.

¶92.26 At 02.51, Essex Fire and Rescue Service received a call from Paulos Tekle, who reported that smoke was entering Flat 153. CRO Russ White told him to block out the smoke, to try to get some fresh air, or to leave if it was safe to do so.⁷⁸⁸⁷⁸⁸ 999 call transcript {LFB00000691}; Phase 1 Report Volume III paragraph 16.79. Having been advised by the LFB control room that callers from the tower should be told to leave, CRO White telephoned Paulos Tekle at 02.54 and left a message telling him that he and his family should cover themselves with wet towels and try to leave. He repeated that advice when he spoke to Paulos Tekle at 02.56.⁷⁸⁹⁷⁸⁹ Phase 1 Report Volume III paragraphs 17.57-17.58; White {MET00012847/5} page 5. Those in Flat 153 began to collect wet towels.

¶92.27 At 03.02, as the occupants of Flat 153 were preparing to leave, CRO Duddy telephoned Paulos Tekle to tell him that everyone in the flat had to leave.⁷⁹⁰⁷⁹⁰ Phase 1 Report Volume III paragraphs 17.58 and 17.122; LFB callback transcript {INQ00000193}. CRO Duddy's call was prompted by a conversation with Essex FRS {LFB00000557}. At the same time, FF Joe Worley set out⁷⁹¹⁷⁹¹ BA Telemetry data {LFB00023326/2} page 2. together with three other firefighters to rescue a family of four from Flat 153 on floor 18.⁷⁹²⁷⁹² Worley {MET00007891/5} page 5; LFB Operational Response Report dated July 2020 {LFB00119333/286} page 286. However, the crew had to be stood down shortly after as they did not have extended duration breathing apparatus.⁷⁹³⁷⁹³ Grant {MET00007883/4-5} pages 4-5. That deployment was probably prompted by the radio message sent by CRO Darby at 02.48.

¶92.28 From about 03.00, the crew of CU7 began recording information on a whiteboard using a grid system.⁷⁹⁴⁷⁹⁴ Phase 1 Report Volume III paragraphs 15.13 and 16.12. At some point they became aware that there were nine people in Flat 153, which was marked as a priority.⁷⁹⁵⁷⁹⁵ Phase 1 Report Volume III Figure 16.5; Photographs of whiteboard {MET00008663}; {MET00015924}.

The evacuation of Flat 153

¶92.29 Yehualashet Enyew was the first to leave Flat 153 holding Isaac Paulos by the hand. Rabia Yahya and her children followed. Paulos Tekle, carrying his youngest son, and Genet Shawo were at the rear of the group as they all left.⁷⁹⁶⁷⁹⁶ Phase 1 Report Volume III paragraph 17.58.

¶92.30 Coincidentally, a group of firefighters arrived on floor 18 at that time. FFs Michael Pole, Niki Mitchell and Chris Cheesman had tallied out at 02.53, to go to floor 23. As they went up the stairs, the crew realised that they would not have enough air to get to floor 23 and back. They therefore decided to rescue anyone they could from the floor they had reached (floor 18) rather than continue going up. When they entered the lobby of floor 18, the crew came across the people leaving Flat 153. The group then formed a chain descending the stairs.⁷⁹⁷⁷⁹⁷ Phase 1 Report Volume III paragraphs 16.15-16.20 and 17.66-17.69.

¶92.31 By that time conditions were hazardous and disorientating. The lobby of floor 18 was dark and full of smoke. Dense smoke in the stairwell made it hot and difficult to breathe. Both Paulos Tekle and Yehualashet Enyew felt themselves beginning to lose consciousness. Rabia Yahya's asthmatic son collapsed on the stairs and was carried down by firefighters.⁷⁹⁸⁷⁹⁸ Phase 1 Report Volume III paragraphs 16.19 and 17.58-17.71.

¶92.32 At some point during the descent from Flat 153, Isaac Paulos became separated from Yehualashet Enyew.⁷⁹⁹⁷⁹⁹ Phase 1 Report Volume III paragraph 17.61. In the Phase 1 report the chairman found that the body of Isaac Paulos had been recovered from floor 13.⁸⁰⁰⁸⁰⁰ Phase 1 Report Volume III paragraph 17.72. Further evidence suggests that he collapsed and died in the stairwell at the level of floor 13 and that his body was later moved into the lobby on that floor.⁸⁰¹⁸⁰¹ Tyldesley {MET000083333/7} page 7; Stevenson {MET00012860/2} page 2; Gray {MET00010806/14} page 14; Hiscock {MET00010877/4} page 4; Simpson {MET00008040/10} page 10; Purser, Phase 2 Report, Section 6 {DAPR0000006/112} paragraph 616.

¶92.33 In the Phase 1 report the chairman found that it was not possible on the evidence to reach a clear conclusion about how and when Yehualashet Enyew lost his grip on Isaac Paulos' hand.⁸⁰²⁸⁰² Phase 1 Report Volume III paragraphs 17.56-17.74. We have not received any further evidence that allows us to reach a more positive conclusion.

¶92.34 Paulos Tekle, Genet Shawo and their youngest son, Rabia Yahya and her three children and Yehualashet Enyew all left the tower between 03.13 and 03.18.⁸⁰³⁸⁰³ Phase 1 Report Volume III paragraph 17.72.

Recovery and identification

¶92.35 Isaac Paulos probably collapsed on the stairs. His body was recovered from the lobby of floor 13.⁸⁰⁴⁸⁰⁴ Phase 1 Report Volume III paragraph 17.72. The coroner, Professor Wilcox, was satisfied about the identification of his remains and therefore issued an interim certificate of the fact of death for Isaac Paulos.⁸⁰⁵⁸⁰⁵ Interim certificate of the fact of death for Isaac Paulos {MET00065641}.

Cause and time of death

¶92.36 The post-mortem report on Isaac Paulos noted soot deposits over much of his body. Soot was also present in his airways and lungs. The signs of heat damage to his body were consistent with its having occurred after death. There was no sign that he had sustained any recent injuries before he died.⁸⁰⁶⁸⁰⁶ Paulos post-mortem report {COR00000675/9} page 9; Purser, Phase 2 Report, section 6 {DAPR0000006/111} paragraphs 607 and 609.

¶92.37 The level of carboxyhaemoglobin in a blood sample taken from Isaac Paulos was found to be 67%, which is within the toxic range. Cyanide was detected at a level of 0.060 milligrams/litre.⁸⁰⁷⁸⁰⁷ Paulos toxicology report {MET00053154}; Purser, Phase 2 Report, Section 1-4 {DAPR0000005/121} Table 17. That is below what is normally considered to be a toxic level but, since the sample is likely to have degraded over time,⁸⁰⁸⁸⁰⁸ Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112-113} paragraph 447. it is not a reliable indication of the level of cyanide in the blood at the time of death. However, the presence of cyanide shows that Isaac Paulos was exposed to hydrogen cyanide before he died.

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

¶92.39 Professor Purser observed that, if those in Flat 153 had left by about 01.40, the concentration of asphyxiant gases in the stairwell would have been considerably lower. However, if they had waited until FFs Foster and Lawson reached floor 18, conditions in the stairwell might have been similar to those they encountered when leaving about an hour later.⁸⁰⁹⁸⁰⁹ Purser, Phase 2 Report, Section 6 {DAPR0000006/108} paragraphs 601–602. The occupants had had minimal exposure to asphyxiant gases before they left the flat.⁸¹⁰⁸¹⁰ Purser, Phase 2 Report, Section 6 {DAPR0000006/108-109} paragraphs 588 and 593.

¶92.40 If the occupants of Flat 153 began to leave at about 03.04, as Professor Purser estimated,⁸¹¹⁸¹¹ Purser, Phase 2 Report, Section 6 {DAPR0000006/109} paragraph 593. it must have taken them at most 15 minutes to leave the tower. He thought that the group had been exposed to a significant dose of asphyxiant gases as they crossed the lobby on floor 18 and descended the stairs, but not enough to incapacitate them.⁸¹²⁸¹² Purser, Phase 2 Report, Section 6 {DAPR0000006/111-112} paragraphs 609 and 614-615.

¶92.41 However, the rate of uptake of toxic gases is more rapid in children than in adults.⁸¹³⁸¹³ Purser, Phase 2 Report, Section 6 {DAPR0000006/112} paragraph 611. Taking into account his size and the physical activity involved in descending the stairs, we are satisfied that Isaac Paulos is likely to have absorbed asphyxiant gases at almost twice the rate of an adult,⁸¹⁴⁸¹⁴ Purser, Phase 2 Report, Section 6 {DAPR0000006/112-113} paragraph 618-623. leading to rapid incapacitation and collapse.⁸¹⁵⁸¹⁵ Purser, Phase 2 Report, Section 6 {DAPR0000006/112} paragraph 611. We are therefore satisfied that he collapsed and lost consciousness within a few minutes of entering the stairs. Having lost consciousness, he continued to inhale asphyxiant gases until his respiration and circulation ceased shortly afterwards and he died.⁸¹⁶⁸¹⁶ Purser, Phase 2 Report, Section 6 {DAPR0000006/111-112} paragraphs 607 and 617; Purser, Phase 2 Report, Section 6 {DAPR0000006/114} paragraphs 627-628. Death was rapid and occurred between 03.09 and 03.15.