Chapter 94: Floor 20

¶94.1 On 14 June 2017, all the flats on floor 20 were occupied. Victoria (Vicky) King and her daughter Alexandra Atala, who lived in Flat 172, Mary Mendy and her daughter Khadija Saye, who lived in Flat 173, and four of the five members of the Belkadi family, who lived in Flat 175, died in the fire. Jessica Urbano Ramirez, whose family home was Flat 176, was among those who died in Flat 201 on floor 23. We describe the circumstances of Jessica Urbano Ramirez's death in Chapter 97.

¶94.2 Emma O'Connor and Luke Towner from Flat 171 were the first of those who lived on floor 20 to leave the tower, doing so shortly before 01.20. When they left, smoke was coming through the vents on floor 20, but the lobby was otherwise clear.⁸⁴¹⁸⁴¹ Phase 1 Report Volume II paragraph 10.261.

¶94.3 By 01.26, the fire had reached the outside of Flat 176.⁸⁴²⁸⁴² Phase 1 Report Volume II paragraph 10.118. At that time, the only person there was Jessica Urbano Ramirez. She must have left by or before 01.26, since she spoke to CRO Sarah Russell from Flat 201 at 01.29.

¶94.4 The lobby on floor 20 became full of smoke within minutes after the fire reached the outside of Flat 176.⁸⁴³⁸⁴³ Phase 1 Report Volume IV paragraph 25.10 (b). Farah Hamdan spoke to CRO Alexandra Norman at 01.30 and reported that there was smoke coming into the flat from the lobby.⁸⁴⁴⁸⁴⁴ Phase 1 Report Volume II paragraph 11.47. Petra Doulova and her husband, who lived in Flat 174, left the tower at 01.41. She described the lobby on floor 20 as being pitch black and full of smoke, making it difficult to breathe. The couple had to feel their way across the lobby to the stairwell door.⁸⁴⁵⁸⁴⁵ Phase 1 Report Volume II paragraphs 11.48-11.51.

¶94.5 FF David Badillo was one of the first firefighters to arrive at the tower.⁸⁴⁶⁸⁴⁶ Phase 1 Report Volume II paragraph 10.19. He met Melanie Urbano Ramirez, Jessica Urbano Ramirez's sister, outside the tower and agreed to go to Flat 176 to find her.⁸⁴⁷⁸⁴⁷ Phase 1 Report Volume II paragraph 10.79. After a failed attempt to reach floor 20 alone, FF Badillo returned with CM Christopher Secrett and FF Christopher Dorgu. They tallied out at 01.33⁸⁴⁸⁸⁴⁸ Phase 1 Report Volume II paragraphs 11.10-11.11 and 12.6. and were the first firefighters to reach that floor.

¶94.6 The lobby on floor 20 was so full of smoke that CM Secrett could not see equipment he had put on the floor.⁸⁴⁹⁸⁴⁹ Phase 1 Report Volume II paragraph 12.30. The firefighters moved around the lobby using touch and torches.⁸⁵⁰⁸⁵⁰ Badillo {Day13/154:15}. When they found Flat 176, FF Badillo found the front door slightly ajar. The flat was full of smoke but the contents were not alight, although fire could be seen outside a window which was about to fail. CM Secrett's warning whistle on his breathing apparatus began to sound shortly after they returned to the lobby having searched the flat and found it empty. The crew decided to make their way back to the stairwell and down. They did not knock on the doors of any other flats.⁸⁵¹⁸⁵¹ Phase 1 Report Volume II paragraphs 12.6, 12.31 and 13.6.

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Firefighter deployments to floor 20

¶94.7 Between 01.30 and 03.33 several emergency calls were made to the control room from inside and outside the tower reporting that Flats 173 and 175 were still occupied.⁸⁵²⁸⁵² Phase 1 Report Volume II paragraphs 11.47, 12.60, 14.167, 16.59 and 16.60.

¶94.8 Three crews were deployed to floor 20 between 01.50 and 02.00.

¶94.9 FFs Geoffrey Campbell and Steven Mills tallied out at 01.51 to go to Flat 175, the home of the Belkadi family, but were unable to reach floor 20.⁸⁵³⁸⁵³ Phase 1 Report Volume II paragraphs 13.14-13.15 and 14.85. On their descent they met a Paddington crew led by CM Philip Wigley that had been sent to the roof of the tower.⁸⁵⁴⁸⁵⁴ Phase 1 Report Volume II paragraphs 11.12-11.13. FFs Campbell and Mills told them that they had been unable to rescue a woman on floor 20. Having continued upward but realising that they would not be able to reach the roof, the Paddington crew made their way to floor 20 intending to rescue the woman they had been told about. FF Duane Harris opened the door to the lobby which was full of smoke. Members of the crew shouted but did not go into the lobby to knock on the doors to the flats. At about that time FF Roberts found Fadumo Ahmed on the stairs between floors 20 and 21. The crew assisted her down the stairs and out of the tower.⁸⁵⁵⁸⁵⁵ Phase 1 Report Volume II paragraphs 13.14-13.15, 14.85-14.87 and 14.131-132; Gillam {Day27/71:20}-{Day27/73:16}.

¶94.10 CM Craig Eden and FF Tom Welch were instructed by WM O'Keeffe to go to floor 20 to assess the situation and report to the bridgehead. CM Eden said they had been told that there were persons trapped on floor 20. FF Welch said that they had not been told that there were people who needed rescuing and that he had assumed that the building had been evacuated.⁸⁵⁶⁸⁵⁶ Eden {MET00008019/5} page 5; Welch {MET000080606/7} page 7. The crew tallied out at 01.59. A minute later, FFs Vincent Williams and Agnel Fernandes tallied out with instructions to go to Flat 175 on floor 20.⁸⁵⁷⁸⁵⁷ Phase 1 Report Volume II paragraph 14.80.

¶94.11 CM Eden and FF Welch reached floor 20. By that time, they were running low on air, so they decided to connect a fire hose to the dry riser.⁸⁵⁸⁸⁵⁸ Phase 1 Report Volume II paragraph 14.81. Both firefighters described the lobby as so full of hot smoke that they could not see anything. CM Eden banged loudly on three doors but received no response. FF Welch said that, as they followed a wall left past two flat doors to find the dry riser, CM Eden had banged on those doors and announced that they were firefighters. Given the location of the dry riser, they are likely to have been the doors of Flats 172 and 173.⁸⁵⁹⁸⁵⁹ Eden {MET00008019/10} page 10; Welch {MET000080606/7} page 7.

¶94.12 FFs Williams and Fernandes reached floor 20 shortly after CM Eden and FF Welch and met them there. They too recalled thick smoke and no visibility. They tried to find their way to Flat 175, kicking and banging on doors and shouting through letterboxes as they went.⁸⁶⁰⁸⁶⁰ Williams {MET00010829/6-7} pages 6-7; Fernandes {Day39/176:19}-{Day39/177:4}.

¶94.13 There were no further deployments to floor 20 after 02.00. FFs Luke Cook and Brian Flanagan were sent to floor 20 at some time after about 02.03 but we think it likely that they went to a different floor.⁸⁶¹⁸⁶¹ Cook {MMET00012855/3} page 3; Flanagan {MET00012855/7} page 7.

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Victoria (Vicky) King

¶Date of birth: 12 June 1946 (71 years old). Place of birth: Highgate, London, England. Gender: Female. Occupation: Retired. Usual address: Flat 172, floor 20, Grenfell Tower, London. Place of death: Flat 172, floor 20, Grenfell Tower, London. Time of death: By 3.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Alexandra Catherine Atala

¶Date of birth: 24 April 1977 (40 years old). Place of birth: Reading, England. Gender: Female. Occupation: NA. Usual address: Flat 172, floor 20, Grenfell Tower, London. Place of death: Flat 172, floor 20, Grenfell Tower, London. Time of death: By 3.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Background and composition of household

¶94.14 Born on 12 June 1946, Victoria (Vicky) King was 71 years old in 2017. She had been the registered tenant of Flat 172 since 26 January 1998⁸⁶²⁸⁶² Lancaster West EMB New Letting form {IWS00001930/2}. and lived there with her daughter, Alexandra Atala. Born on 4 April 1977, Alexandra Atala was 40 years old.⁸⁶³⁸⁶³ Phase 1 Report Volume IV paragraph 32.150. Vicky King and Alexandra Atala had a very close relationship and lived together throughout their lives.⁸⁶⁴⁸⁶⁴ Phase 1 Report Volume IV paragraph 32.153.

Vulnerabilities

¶94.15 Both Vicky King and Alexandra Atala had mental health difficulties.⁸⁶⁵⁸⁶⁵ Bennett {IWS00001882/2} page 2, paragraphs 7-8. Alexandra Atala suffered from panic disorder associated with agoraphobia.⁸⁶⁶⁸⁶⁶ Letter from Dr Meena Nathan to Stella Fitzgerald dated 12 December 2017 {BSR00000141}. RBKC and the TMO were aware of their vulnerabilities.

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¶94.16 On 9 July 2006, Janice Jones recorded that both Vicky King and Alexandra Atala had mental health difficulties.⁸⁶⁷⁸⁶⁷ Floating Support Service Referral Form {IWS00001908}. In a survey of tower residents carried out by Rydon in 2014 during the refurbishment both women were recorded as having problems with their mental health.⁸⁶⁸⁸⁶⁸ Rydon Residents Survey {RYD00024466}.

¶94.17 In the spreadsheet produced on the night of the fire by David Noble⁸⁶⁹⁸⁶⁹ Noble {TMO00000884/1} page 1, paragraph 3. based on information held on the TMO's Capita Insight system⁸⁷⁰⁸⁷⁰ Noble {Day119/77:17}-{Day119/82:5}. Vicky King was listed as a resident but there was no reference to any vulnerability. Alexandra Atala was recorded as being vulnerable on the grounds of mental health.

Events of 14 June 2017

¶94.18 Both Vicky King and Alexandra Atala were in Flat 172 when the fire started. Vicky King had returned to the tower in the afternoon of 13 June 2017.⁸⁷¹⁸⁷¹ O'Riordan {MET00013136/2} page 2. Alexandra Atala had not left her home for some time. Neither mother or daughter had any contact, whether by telephone or otherwise, with anyone either in or outside the tower during the fire.

¶94.19 Although firefighters did manage to reach floor 20, none were sent specifically to Flat 172. There is no evidence that Vicky King or Alexandra Atala ever became aware of the fire or that they heard other residents leaving floor 20 or firefighters arriving on that floor.

¶94.20 The fire reached the east side of the kitchen and living room of Flat 172 between about 02.02 and 02.08.⁸⁷²⁸⁷² Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 478. At some time after 02.55 it had spread to the south face of the living room and the two bedrooms of Flat 172.⁸⁷³⁸⁷³ Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 478.

Recovery and identification

¶94.21 The remains of Vicky King and Alexandra Atala were recovered from the second bedroom in Flat 172 (the most southerly room in the flat and so farthest away from the fire).⁸⁷⁴⁸⁷⁴ Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 482; Presentations relating to Victoria King and Alexandra Atala {Day305/15:10}. The coroner, Professor Wilcox, was satisfied about the identification of the remains recovered and therefore issued interim certificates of the fact of death for Vicky King and Alexandra Atala.⁸⁷⁵⁸⁷⁵ Interim certificates of the fact of death for Victoria King and Alexandra Atala {MET00065648}; {MET00065622}.

Cause and time of death

¶94.22 The post mortem examination on Vicky King noted that there was soot in the oesophagus. The carboxyhaemoglobin content of a blood sample taken from her was 58%, which is within the fatal range and indicated that she had inhaled carbon monoxide before her death. It was not possible to test the remains of Alexandra Atala.⁸⁷⁶⁸⁷⁶ King post-mortem report {COR00001454/5} page 5; Atala post-mortem report {COR00000066/6} page 6; Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 481.

¶94.23 Drawing on the evidence of other occupants of floor 20, the evidence of the occupants of flats in a similar location on other floors and the evidence of Professor Purser, we are satisfied that from about 01.30 smoke probably began to enter Flat 172 from the lobby. When the fire reached the east side of Flat 172 shortly after 02.00, smoke began to enter the flat from outside. Until about 02.45 Vicky King and Alexandra Atala could probably have escaped from the building if they had been able to cross the lobby and descend the stairs.⁸⁷⁷⁸⁷⁷ Purser, Phase 2 Report, Section 6 {DAPR0000006/87-88} paragraphs 482 and 484.

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¶94.24 Conditions in the second bedroom began to deteriorate once the fire started to spread across the southern face of Flat 172.⁸⁷⁸⁸⁷⁸ Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 482. Since their remains were found in a bedroom, it is possible that Vicky King and Alexandra Atala were asleep by the time the fire started and slept through it.⁸⁷⁹⁸⁷⁹ Purser, Phase 2 Report, Section 6 {DAPR0000006/87} paragraph 480.

¶94.25 Taking into account the presence of soot in Vicky King's respiratory system, the level of carboxyhaemoglobin in her blood and that her remains and those of Alexandra Atala were recovered from a bedroom, we are satisfied that inhalation of asphyxiant gases caused both of them to lose consciousness and die before the contents of Flat 172 caught fire.

¶94.26 The post mortem reports on Vicky King and Alexandra Atala recorded the medical cause of death in each case as "consistent with the effects of fire",⁸⁸⁰⁸⁸⁰ Atala post-mortem report {COR00000066}; King post-mortem report {COR00001454}. but in the light of more recent evidence we find that a more accurate description is "inhalation of asphyxiant gases".

¶94.27 There is not enough evidence to allow us to determine the time of death with any precision but we think that Vicky King and Alexandra Atala had probably both died by about 03.30.

Mary Mendy

¶Date of birth: 11 June 1963 (54 years). Place of birth: Banjul, The Gambia. Gender: Female. Occupation: Carer. Usual address: Flat 173, floor 20, Grenfell Tower, London. Place of death: Stairwell, Grenfell Tower, London. Time of death: Between 03.50 and 04.10 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Khadija Saye

¶Date of birth: 30 July 1992 (24 years). Place of birth: Hammersmith, London. Gender: Female. Occupation: Artist. Usual address: Flat 173, floor 20, Grenfell Tower, London. Place of death: Stairwell, Grenfell Tower, London.

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¶Time of death: Between 03.50 and 04.10 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Background and composition of household

¶94.28 Mary Mendy had been the sole tenant of Flat 173 since 17 January 1994.⁸⁸¹⁸⁸¹ Tenancy Agreement {TMOH00011129}. She lived there with her daughter, Khadija Saye.

¶94.29 Mary Mendy was born on 11 June 1963 in The Gambia and was 54 years old.⁸⁸²⁸⁸² Phase 1 Report Volume IV paragraph 32.142. She had moved to the United Kingdom in the 1980s.⁸⁸³⁸⁸³ Phase 1 Report Volume IV paragraph 32.144. Khadija Saye was born on 30 July 1992 in London.⁸⁸⁴⁸⁸⁴ Phase 1 Report Volume IV paragraph 32.142. She was 24 years old. At the time of the fire Mary Mendy was working as a care assistant. Khadija Saye had attended Rugby School on a scholarship and studied photography at the University of the Creative Arts in London. In May 2017, her work was exhibited at the Venice Biennale.⁸⁸⁵⁸⁸⁵ Phase 1 Report Volume IV paragraphs 32.147-32.148.

Vulnerabilities

¶94.30 There is no evidence that Mary Mendy or her daughter suffered from any vulnerability that would have impeded their escape.

Events of 14 June 2017

¶94.31 Khadija Saye and Mary Mendy returned home during the evening of 13 June 2017. Khadija was seen on CCTV entering the lift lobby on the ground floor of the tower at 21.08. Her mother was seen on CCTV in the lift lobby at 23.06.⁸⁸⁶⁸⁸⁶ O'Riordan {MET00013136/3} page 3. They remained in Flat 173 thereafter.

¶94.32 We do not know when they first became aware of the fire but at 01.49 Khadija Saye posted a message on Facebook saying that there was a fire in the tower and that she and her mother could not leave their flat.⁸⁸⁷⁸⁸⁷ Phase 1 Report Volume II paragraph 12.61. The contents of that post suggest that neither Khadija Saye nor her mother had become aware of the presence on floor 20 of FFs Badillo, Dorgu and CM Secrett, who searched Flat 176 for Jessica Urbano Ramirez at some time between 01.33 and 01.57.⁸⁸⁸⁸⁸⁸ Phase 1 Report Volume II paragraph 11.10 and 13.16. That may be because Flat 176 was in the northeast corner of the tower and Flat 173 in its southwest corner. It appears that Khadija Saye became aware of the presence of one or both of the other crews which later reached floor 20, since she told a friend in a telephone call at 02.50 that she had heard firemen "arguing" outside her door and then nothing else.⁸⁸⁹⁸⁸⁹ Email from Adele Evelyn to Marion Tefler dated 19 June 2017 {BSR00000102}. As Khadija Saye was able to say that those outside were firefighters, she must have heard them announce themselves as such. However, there is no evidence that Khadija Saye or her mother tried to call out to them.

Information to the incident ground

¶94.33 At 02.26, Khadija Saye made an emergency call, in the course of which she told CRO Sarah Russell that a lot of smoke was coming into the flat. She and her mother were in the living room and had shut all but one of the windows. CRO Russell said that they could stay or to try to leave but Khadija Saye told her that they were too high up to leave and that there was too much smoke outside the front door. CRO Russell then advised her to try to prevent the smoke coming in by blocking doors and shutting windows. CRO Russell said she would notify the firefighter crews and explained that they were trying to make their way up but that it would take them some time.⁸⁹⁰⁸⁹⁰ Phase 1 Report Volume IV paragraph 16.59; 999 call transcript {LFB00000355/2}.

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¶94.34 That was the only emergency call Khadija Saye made. She communicated with friends on Facebook who then made emergency calls to the LFB on her behalf reporting that she and her mother were trapped in Flat 173 on floor 20. There were five such calls between 02.50 and 03.33. On each occasion, the caller was advised to tell Khadija Saye to leave her flat.⁸⁹¹⁸⁹¹ Phase 1 Report Volume III paragraph 16.60. No service requests appear to have been generated in response to any of those calls or to Khadija Saye's earlier call. However, an entry reading "173 20th – 2 adults" appears on the second of the two whiteboards which SM Jason Oliff was using in the LFB control room from 02.33 to collate information to pass to the command units.⁸⁹²⁸⁹² Phase 1 Report Volume III paragraphs 15.139-15.140 and Figure 15.9. The position of that entry suggests that it had been prompted by one of the later calls about Flat 173.

¶94.35 Information about Flat 173 did reach the incident ground. Although no mention of Flat 173 appears on the white laminated sheet used in CU7 to collate information,⁸⁹³⁸⁹³ Phase 1 Report Volume II paragraphs 12.8-12.9; Phase 1 Report Volume IV paragraph 28.86. a reference to it was made on a whiteboard used in CU7 from about 03.00.⁸⁹⁴⁸⁹⁴ Phase 1 Report Volume III paragraphs 15.13 and 16.12; Phase 1 Report Volume III Figure 16.5; Photograph of whiteboard {MET00015924}. That whiteboard used a grid system. The figure "2" appears against Flat 173 indicating two adults. Next to it is a "P" in red, circled, indicating a priority.⁸⁹⁵⁸⁹⁵ Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}. A red tick was used on the grid to indicate that a crew had been deployed. No red tick appears on the grid.

¶94.36 The bridgehead was located on floor 3 between 02.17 and 03.10.⁸⁹⁶⁸⁹⁶ Phase 1 Report Volume IV paragraphs 28.86 and 28.87. No note about Flat 173 appears on the wall of floor 3 where WM Louisa De Silvo recorded information while the bridgehead was located there. That may be because information about Flat 173 did not reach CU7 before 03.00.

¶94.37 WM Glynn Williams began recording information on the wall of the ground floor lobby at about 02.15. Someone had written "173 20 2P".⁸⁹⁷⁸⁹⁷ Phase 1 Report Volume II paragraphs 14.103-14.105 and Figure 14.5. The note was probably made by SM Peter Wolfenden, who entered the ground floor after the bridgehead had been moved there and started recording information on the wall from about 03.21.⁸⁹⁸⁸⁹⁸ Wolfenden {Day40/168:3}-{Day40/172:16}; {Day40/182:14}-{Day40/186:9}. He said that a tick had been used to indicate that a crew had been sent to a particular flat.⁸⁹⁹⁸⁹⁹ Wolfenden {Day40/188:5}-{Day40/190:4}. No tick appears next to the entry for Flat 173.

¶94.38 We are satisfied, therefore, that no crews were deployed specifically to Flat 173 in response to the calls made from or about it.

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The last movements of Khadija Saye and Mary Mendy

¶94.39 The advice for people to remain in their flats was changed at 02.35⁹⁰⁰⁹⁰⁰ Phase 1 Report Volume II paragraph 15.161. after Khadija Saye's call to the LFB. After her first post on Facebook, Khadija Saye next posted at 02.41.⁹⁰¹⁹⁰¹ Telfer Exhibit MT/1 – Facebook timeline {IWS00001188/18}. At 02.55 she learned that the LFB's advice was now to leave the building when a friend, who had called the control room, sent her a message. The same friend, having spoken to the control room again, repeated the advice to leave at 02.57.⁹⁰²⁹⁰² Phase 1 Report Volume III paragraph 17.51; Telfer Exhibit MT/1 – Facebook timeline {IWS00001188/18}.

¶94.40 Khadija Saye replied that she was afraid to leave. At 03.05, as the exchange continued, she said that there was a lot of smoke in the flat. Having been reassured that there was only smoke in the stairwell, Khadija Saye sent another message at 03.14 saying that she had tried to leave but that the smoke had been too strong. Asked if she had found the way to the stairs, Khadija Saye replied that it was too dark and that she had begun to choke after a few steps. At 03.27, she described another attempt to leave, adding that it was impossible and that she had felt as though she was going to faint. At 03.30, in what was her last message, she said "It's in my rooms". We do not know if that was a reference to the fire or smoke. Her friend continued to send her messages, but we do not know if Khadija Saye saw them.⁹⁰³⁹⁰³ Phase 1 Report Volume III paragraphs 17.51-17.55; Telfer Exhibit MT/1 – Facebook timeline {IWS00001188/18-20}.

¶94.41 Between 03.20 and 03.29, the fire reached the outside of the two bedrooms of Flat 173 on the south side of the tower. Between 03.37 and 03.53, it had reached the south side of the living room and moved round to the west side of the living room and to the kitchen of the flat.⁹⁰⁴⁹⁰⁴ Purser, Phase 2 Report, Section 6 {DAPR0000006/102} paragraph 557.

¶94.42 The arrival of the fire outside Flat 173 did not immediately cause Mary Mendy and Khadija Saye to try for a third time to leave their home, but they did so shortly after 03.30. This time they were able to cross the lobby and enter the stairwell.

Recovery and identification

¶94.43 FFs Methusael Sonson and James Cuthbert tallied out at 03.46 with instructions to search floor 5. Their end of wear time was 04.12. After they had been deployed, they were instructed to go to Flat 84 on floor 11. Making their way up the stairs, they found the body of Khadija Saye in the stairwell near floor 10. FF Sonson confirmed that she had no pulse.⁹⁰⁵⁹⁰⁵ Sonson {MET00010824/8} page 8; Cuthbert {MET00012878/11-12} pages 11-12; BA Telemetry Data {LFB00023326/3}. Given where these firefighters found Khadija Saye, that must have been shortly before 04.12.

¶94.44 Khadija Saye's body was subsequently moved to the lobby on floor 9 from which it was later carried out of the tower.⁹⁰⁶⁹⁰⁶ Phase 1 Report Volume III paragraph 17.55. The coroner, Professor Wilcox, was satisfied about the identification of the casualty found by FFs Sonson and Cuthbert and therefore issued an interim certificate of death for Khadija Saye.⁹⁰⁷⁹⁰⁷ Interim certificate of the fact of death for Khadija Saye {MET00065605}.

¶94.45 CM Timothy Cutbill and FF Steven Bolton tallied out at 05.28 as part of a crew of four sent to floor 11 to search for casualties and, if possible, to go further up the tower. Their end of wear time was 05.59. As they ascended the stairs, they came across the body of Mary Mendy between floors 12 and 13.⁹⁰⁸⁹⁰⁸ Cutbill {MET00010872/5} page 5; Boulton {MET000080564/8} page 8. Her body was later moved into the lobby on floor 13 and then taken out of the tower.⁹⁰⁹⁹⁰⁹ Phase 1 Report Volume III paragraph 17.55. The coroner, Professor Wilcox was satisfied about the identity of the casualty found by FFs Cutbill and Bolton and issued an interim certificate of the fact of death for Mary Mendy.⁹¹⁰⁹¹⁰ Interim certificate of the fact of death for Mary Mendy {MET00065585}.

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Cause and time of death

¶94.46 The post-mortems on Mary Mendy and Khadija Saye noted that, although it was not possible to obtain a blood sample from either of them, the presence of soot in their upper airways together with the discolouration of soft tissues showed that they had both inhaled carbon monoxide and hydrogen cyanide.⁹¹¹⁹¹¹ Mendy post-mortem report {COR00001031}; Saye post-mortem report {COR00000855}; Purser, Phase 2 Report, Section 6 {DAPR0000006/103} paragraphs 565 and 567.

¶94.47 Professor Purser calculated that, if Mary Mendy and Khadija Saye had entered the stairs at 03.36, the latest time at which they could have safely left the building without collapsing was about 03.16.⁹¹²⁹¹² Purser {Day297/91:22}–{Day297/94:1}. We accept his conclusion that, taking account of the conditions on floor 20 and in Flat 173 and the experience of survivors from flats in similar locations, Mary Mendy and Khadija Saye died from the inhalation of asphyxiant gases, mainly carbon monoxide but some hydrogen cyanide. They were exposed to a substantial amount of such gases while still in Flat 173, though not enough to incapacitate them. Conditions in the flat deteriorated by 03.30, when the fire had reached the bedrooms on the south side of the flat. Once they had left their home, their exposure to asphyxiant gases increased as they ventured into the smoke-filled lobby and then, albeit to a lesser degree, the stairwell. That exposure, coupled with the physical exertion required to descend from floor 20, caused them to collapse in the stairwell.⁹¹³⁹¹³ Purser, Phase 2 Report, Section 6 {DAPR0000006/104} paragraphs 568-574.

¶94.48 Mary Mendy probably collapsed and lost consciousness between floors 12 and 13. Khadija Saye was able to continue for a short distance before she lost consciousness near floor 10. Thereafter, they both continued inhaling asphyxiant gases for a short time until their respiration and circulation ceased some minutes later and they died.

¶94.49 The post-mortem report on Khadija Saye recorded the medical cause of death as "inhalation of fire fumes and burns".

¶94.50 The post-mortem report on Mary Mendy recorded the medical cause of death as "consistent with the inhalation of fire fumes".

¶94.51 In the light of Professor Purser's evidence we find that in each case a more accurate description is "inhalation of asphyxiant gases".

¶94.52 Although Professor Purser estimated that Mary Mendy and Khadija Saye died between 04.00 and 04.20,⁹¹⁴⁹¹⁴ Purser {Day297/91:22}–{Day297/94:1}. having regard to the evidence as a whole, including the time at which Khadija Saye made her last post on Facebook, we find that Mary Mendy had collapsed before FFs Sonson and Cuthbert found Khadija Saye. We therefore conclude that Mary Mendy and Khadija Saye both died between 03.50 and 04.10.

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The Belkadi Family

Farah Hamdan

¶Date of birth: 23 February 1986 (31 years). Place of birth: London, UK. Gender: Female. Occupation: Nursery Assistant. Usual address: Flat 175, floor 20, Grenfell Tower, London. Place of death: Stairwell between floors 19 and 20, Grenfell Tower, London. Time of death: Between 02.45 and 03.10 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Omar Belkadi

¶Date of birth: 1 August 1984 (32 years). Place of birth: Morocco. Gender: Male. Occupation: Courier. Usual address: Flat 175, floor 20, Grenfell Tower, London. Place of death: Stairwell between floors 19 and 20, Grenfell Tower, London. Time of death: Between 02.45 and 03.10 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Malak Belkadi

¶Date of birth: 26 September 2008 (8 years). Place of birth: London. Gender: Female. Occupation: Student. Usual address: Flat 175, floor 20, Grenfell Tower, London. Place of death: St Mary's Hospital, Paddington, London. Time of death: 15:01 on 15 June 2017. Cause of death: Inhalation of asphyxiant gases.

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Leena Belkadi

¶Date of birth: 12 December 2016 (6 months). Place of birth: London. Gender: Female. Occupation: N/A Usual address: Flat 175, floor 20, Grenfell Tower, London. Place of death: Stairwell between floors 19 and 20, Grenfell Tower, London. Time of death: Between 02.45 and 03.10 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Background and composition of household

¶94.53 Farah Hamdan and Omar Belkadi had lived in Flat 175 on floor 20 since 18 November 2013.⁹¹⁵⁹¹⁵ Tenancy Agreement {TMOH00011495}. They lived there with their three daughters, Malak Belkadi, Leena Belkadi and their middle daughter who survived the fire.

¶94.54 Farah Hamdan was born on 23 February 1986 in London.⁹¹⁶⁹¹⁶ Phase 1 Report Volume IV paragraph 32.134. She was 31 years old and a teacher. Omar Belkadi was born on 1 August 1984 in Morocco. He was 32 years old and was working for a restaurant in June 2017 while training to be a taxi driver.⁹¹⁷⁹¹⁷ Phase 1 Report Volume IV paragraph 32.139; Presentation relating to the Belkadi family {Day305/44:12-13}. Malak, their eldest daughter, was born on 25 September 2008 at St Mary's Hospital, London. She was eight years old when she died. Leena was born on 14 December 2016 at St Mary's Hospital, London. She was six months old when she died.⁹¹⁸⁹¹⁸ Phase 1 Report Volume IV paragraph 32.134.

Vulnerability

¶94.55 Farah Hamdan and Omar Belkadi did not have any known impairments. Their three children were under 18 years of age. The two elder daughters were recorded as living in the tower in the spreadsheet produced on the night of the fire by David Noble⁹¹⁹⁹¹⁹ Noble {TMO00000884/1} page 1, paragraph 3. and were known to be under 18. Leena was not listed.

Events of 14 June 2017

¶94.56 The family were at home on the night of the fire. Farah Hamdan was seen on CCTV entering the lift lobby of the tower at 18.31 with her daughters.⁹²⁰⁹²⁰ O'Riordan {MET00013136/3} page 3. Omar Belkadi returned home later and was seen on CCTV in the lift lobby at 00.12.⁹²¹⁹²¹ O'Riordan {MET00013136/4} page 4. They became aware of the fire at an early stage, since Farah Hamdan called her sister, Samira Hamdan, at about 01.00 to tell her of a fire at the tower.⁹²²⁹²² Phase 1 Report Volume II paragraph 14.168.

¶94.57 At 01.30, OM Alexandra Norman answered an emergency call from Farah Hamdan, who told her that the family were in the living room, that smoke was coming into the flat and that the fire was in a neighbour's flat. That must have been a reference to Flat 176; the smoke was probably coming from the lobby. OM Norman's advice was to stay in the flat unless it was safe to leave. She added that she did not know what conditions were like in the stairs.⁹²³⁹²³ Phase 1 Report Volume II paragraph 11.47.

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¶94.58 At 01.31, CRO Peter Duddy created a service request telling the incident ground that there was a fire on floor 20 and that people were trapped there.⁹²⁴⁹²⁴ Phase 1 Report Volume II paragraph 11.144. A little later, following a call from Natasha Elcock at 01.33, he created another service request containing the same information and including a reference to Flat 82.⁹²⁵⁹²⁵ Phase 1 Report Volume II paragraphs 11.145 and 11.146.

¶94.59 At 01.35, OM Norman spoke to WM Daniel Meyrick in CU8, which had just arrived at the incident ground. She told him that five people were in Flat 175 on floor 20 with a lot of smoke entering the premises.⁹²⁶⁹²⁶ Phase 1 Report Volume II paragraph 11.149. WM Meyrick was passing the information he received to WM Mark Kentfield at the incident ground by radio. He was also recording the information on a piece of paper.⁹²⁷⁹²⁷ Phase 1 Report Volume II paragraph 11.5. It is likely that WM Meyrick recorded the information he received from OM Norman on such a piece of paper, which was subsequently used to populate a white laminated sheet in CU7. That sheet included the following notation: "175 20 5 PERSON".⁹²⁸⁹²⁸ Phase 1 Report Volume II paragraphs 12.8-12.9 and Figure 12.3.

¶94.60 While OM Norman was speaking to WM Meyrick, CRO Sharon Darby contacted appliance G261 with the information that there were persons on floor 20 reporting that smoke was coming into their flat. CRO Darby was not able to give the numbers of the flats affected.⁹²⁹⁹²⁹ Phase 1 Report Volume II paragraphs 11.147-148 and 11.152. At 01.35, she noted that the service requests relating to floor 20 were being acted upon and at 01.41 she marked them as completed.⁹³⁰⁹³⁰ Short Incident Log Report {MET00013830/19}.

¶94.61 The calls made by OM Norman and CRO Darby were the first messages to reach the incident ground. At around 01.40, SM Brett Loft, who was positioned at the front of the tower to handle incoming information, received a piece of A4 paper from WM Kentfield containing a list of flats from which people needed to be rescued. It included a reference to Flat 175 on floor 20. SM Loft passed the information he received to the bridgehead.⁹³¹⁹³¹ Phase 1 Report Volume II paragraphs 11.6 and 12.8-12.9 and Figure 12.4.

¶94.62 At that time the bridgehead was on floor 2, where it remained until 02.17. While it was there, WM Louisa De Silvo recorded information on a forward information board.⁹³²⁹³² Phase 1 Report Volume II paragraphs 13.52-13.53. At about 02.13, CM Charles Batterbee went to the bridgehead and copied the information on a forward information board into his own notebook. It included Flat 175 on floor 20, against which a tick appeared. CM Batterbee explained that this indicated a flat to which crews had been deployed, as reported by WM De Silvo.⁹³³⁹³³ Phase 1 Report Volume II paragraphs 14.73-74 and Figure 14.4. We find that the tick related to the deployment of FFs Mills and Campbell who had been sent to Flat 175 but did not reach floor 20.⁹³⁴⁹³⁴ See Chapter 89.

¶94.63 At 01.43, Farah Hamdan's second emergency call was connected to North West Fire Control. She gave the number of her flat and the floor and reported that the fire had reached the floor below. She said that the family had tried to leave but that black smoke in the lobby had prevented them from doing so. Farah Hamdan also said that there was now smoke inside her own flat. She was advised to block the smoke from coming in and was told that her location had been passed to the crews.⁹³⁵⁹³⁵ Phase 1 Report Volume II paragraph 12.60.

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¶94.64 At about the same time, OM Norman in the LFB control room took a call from Team Leader Paula Craig at North West Fire Control, who told her that five people were in Flat 175 on floor 20.⁹³⁶⁹³⁶ Phase 1 Report Volume II paragraphs 12.75-12.76. It is unclear how that information was passed to the incident ground. No service request was created and when CRO Yvonne Adams called CU8 by telephone at 01.50 and 02.00 she did not refer to Flat 175.⁹³⁷⁹³⁷ Phase 1 Report Volume II paragraphs 13.86 and 14.230. However, an entry at 02.01.43 in the LFB's short incident log notes that CU8 was told at about 01.50 that five people were trapped in Flat 175 on floor 20.⁹³⁸⁹³⁸ Short Incident Log Report {MET00013830/21} page 21. It may be that SM Jason Oliff, who was in contact with CU8 throughout on his personal mobile, passed the information on.⁹³⁹⁹³⁹ Phase 1 Report Volume II paragraph 14.243.

¶94.65 At around 02.00 CM Eden and FF Welch left the bridgehead to investigate the situation on floor 20 while FFs Williams and Fernandes were sent to Flat 175 on floor 20.⁹⁴⁰⁹⁴⁰ Phase 1 Report Volume II paragraphs 14.80-14.81. That may have been the result of the emergency call made by Farah Hamdan at 01.43 or of information received from FFs Campbell and Mills on their return to the bridgehead.⁹⁴¹⁹⁴¹ Campbell {MET00010788/12} page 12; Mills {MET000080584/7} page 7.

¶94.66 At 02.11, CRO Heidi Fox answered a third emergency call from Farah Hamdan. She told CRO Fox that, despite having put sheets under the front door, there was now a lot of smoke in the flat. Farah Hamdan gave her the number of the flat and the floor on which it was situated and said that the five people sheltering there included three children. CRO Fox confirmed that she was passing the information on. She advised Farah Hamdan to keep trying to stop smoke coming in with damp towels and sheets and to call back if the situation worsened.⁹⁴²⁹⁴² Phase 1 Report Volume II paragraph 14.167; 999 call transcript {LFB00000342}.

¶94.67 The notation "175 20th Flr – 2 adults 2 children" appears on a whiteboard in the LFB control room used by SM Oliff to record information about people needing to be rescued. Despite the error about the number of children, that note was probably made in response to Farah Hamdan's call at 02.11, since that was the last call in which she provided her location.⁹⁴³⁹⁴³ Phase 1 Report Volume III paragraphs 15.138-15.140.

¶94.68 The final emergency call from Flat 175 at 02.17 was incomplete. The BT operator heard the caller say, "No Malak, it's not safe" and then ask for the fire brigade. The call was then put through to the LFB but there was no further response from the caller.⁹⁴⁴⁹⁴⁴ Phase 1 Report Volume II paragraph 14.169. It was at about that time that CM Eden and Welch and, shortly after them, FFs Williams and Fernandes reached floor 20.⁹⁴⁵⁹⁴⁵ Phase 1 Report Volume II paragraph 14.170. Although the visibility there was extremely limited the two crews were aware of each other.⁹⁴⁶⁹⁴⁶ Williams {MET00010829/3-8} pages 3 and 8; Fernandes (Day39/171:14-22}; Eden {MET00008019/11} page 11.

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¶94.69 When FF Williams and Fernandes reached Flat 175, FF Williams went in and spoke to Omar Belkadi and Farah Hamdan. He told them they needed to leave but they made no move to do so. FF Williams called the bridgehead to ask for assistance but could not hear the response. He then took the couple's second daughter by the hand to encourage the rest of the family to follow him.⁹⁴⁷⁹⁴⁷ Phase 1 Report Volume II paragraph 14.82; Williams {MET00010829/7-9} pages 7-9.

¶94.70 FF Fernandes had also tried to use his radio to report that they had located a casualty but discovered that it was not working. CM Eden and FF Welch were still on floor 20. Both FF Williams and Fernandes shouted out to them for assistance. CM Eden positioned himself at the stairwell door while FF Welch moved closer towards Flat 175. In conditions of near zero visibility, FF Fernandes made his way to the stairwell door to hold it open. There was a similar lack of visibility in the stairwell.⁹⁴⁸⁹⁴⁸ Fernandes {MET000083292/4-5} pages 4-5; Williams {MET00010829/10} page 10; Eden {MET00008019/11} page 11.

¶94.71 CM Eden's recollection was that, while on floor 20, he had become aware that there were five people needing to be rescued from Flat 175.⁹⁴⁹⁹⁴⁹ Eden {MET00008019/11} page 11; Welch {MET000080606/9} page 9. He heard a man (Omar Belkadi) shouting for help and a woman (Farah Hamdan) calling out for her baby. FF Fernandes heard something similar. He first saw the family when they arrived at the stairwell door but was not aware how many of them there were. When FF Williams reached the stairwell, they began their descent. FF Fernandes went down first backwards, so that he could guide FF Williams, who was carrying the Belkadis' second daughter.⁹⁵⁰⁹⁵⁰ Phase 1 Report Volume II paragraph 14.83; Fernandes {Day39/181:5-20}. He could not recall any conversation with CM Eden and FF Welch about evacuating the family.⁹⁵¹⁹⁵¹ Fernandes {Day39/183:2-14}.

¶94.72 CM Eden and FF Welch tried to help Omar Belkadi. In response to CM Eden, Omar Belkadi said that apart from himself, the group was made up of his wife, two children and a baby. Omar Belkadi was, understandably, panicking and finding it difficult to breathe. CM Eden and FF Welch helped him down the stairs. CM Eden described the stairwell as full of smoke and hot. FF Welch thought that without breathing apparatus one would struggle to breath there.⁹⁵²⁹⁵² Eden {MET00008019/11} page 11; Welch {MET000080606/9} page 9.

¶94.73 Although we are satisfied that FF Fernandes and Williams, carrying the Belkadi's second daughter, entered the stairwell first, the evidence does not enable us to make a finding about the order in which the Belkadi family, supported by the firefighters, left floor 20. They did so in conditions that were particularly difficult and the firefighters were conscious that they were low on air.⁹⁵³⁹⁵³ Eden {MET00008019/11} page 11; Williams {MET00010829/7} page 7. FF Welch recalled that Omar Belkadi had collapsed as soon as they began descending. On CM Eden's account they had got no further than the half landing between floors 20 and 19. At about that time, the low-pressure warning on the firefighters' breathing apparatus began to sound.⁹⁵⁴⁹⁵⁴ Phase 1 Report Volume II paragraph 14.83; Eden {MET00008019/11} page 11; Welch {MET000080606/9} page 9.

¶94.74 CM Eden and FF Welch decided that CM Eden would return to the bridgehead to seek help while FF Welch stayed with Omar Belkadi. In the event, FF Welch was able to leave Omar Belkadi with another crew as he had to return to the bridgehead because his air was running low.⁹⁵⁵⁹⁵⁵ Phase 1 Report Volume II paragraph 14.83.

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¶94.75 FF Williams carried the second daughter of Farah Hamdan and Omar Belkadi out of the tower at 02.26.⁹⁵⁶⁹⁵⁶ Phase 1 Report Volume III Annex A. FF Fernandes provided a debrief on reaching the bridgehead but could not remember what he had said.⁹⁵⁷⁹⁵⁷ Fernandes {Day39/184:22-24}. The end of wear time for CM Eden and FF Welch was between 02.27 and 02.29.⁹⁵⁸⁹⁵⁸ BA Telemetry Data {LFB00023326/1} page 1. Neither of them said that he had provided any kind of debrief to the bridgehead on his return.⁹⁵⁹⁹⁵⁹ Phase 1 Report Volume II paragraph 14.83.

¶94.76 When the bridgehead moved to floor 3 after 02.17, WM De Silvo started recording information about people needing to be rescued on a wall. There was a list of floors from 3 to 23 against which the numbers of specific flats were written as information came in. WM De Silvo put a tick against a flat number to show that a BA crew had visited it, a circle to indicate when further information was received and a cross to show that it had been searched and a rescue carried out. There was a tick to show that that Flat 175 had been visited. Given that there were no deployments to that flat after 02.00, it is likely that the information recorded on floor 3 was brought across from floor 2.⁹⁶⁰⁹⁶⁰ Phase 1 Report Volume IV paragraph 28.86; Phase 1 Report Volume II paragraphs 15.23 and 15.25, Figure 15.7.

¶94.77 No firefighters were deployed to look for Omar Belkadi, Farah Hamdan or their two children after CM Eden and FF Welch returned. At 02.44, FFs Tom Reddington and Nikki Upton tallied out to go to floor 21. They had reached what they believed was floor 18, when they came upon Farah Hamdan. She was unresponsive and the firefighters were unable to move her body as her leg was trapped in the banister railings. FF Upton found Malak Belkadi near her mother. They were able to move her and made the difficult decision to take her down since they could not free her mother.⁹⁶¹⁹⁶¹ Phase 1 Report Volume III paragraph 15.57.

¶94.78 It is likely that FFs Upton and Reddington found Farah Hamdan and her daughter on the stairs higher than floor 18. As they were descending with Malak Belkadi, they encountered a four-person crew who were ascending to go to floor 23. They told them that they had left a female casualty who needed assistance. One of that crew, FF Jessamine Bate, then assisted FFs Upton and Reddington to carry Malak Belkadi down the stairs. The remaining three firefighters, FFs Michael Pole, Niki Mitchell and Chris Cheesman, continued upwards. When they realised that they had insufficient air to reach floor 23, they stopped at floor 18 and helped evacuate occupants in Flat 153. None of these firefighters describe seeing a female casualty on the stairs.⁹⁶²⁹⁶² Phase 1 Report Volume III paragraph 15.58; LFB Operational Response Report dated July 2020 {LFB00119333/263} page 263.

¶94.79 Malak Belkadi was carried out of the tower at 03.07.⁹⁶³⁹⁶³ Phase 1 Report Volume II paragraph 14.172.

Recovery and identification

¶94.80 After the fire the bodies of Farah Hamdan, Omar Belkadi and their daughter, Leena, were found on the stairs between floors 20 and 19.⁹⁶⁴⁹⁶⁴ Phase 1 Report Volume II paragraph 14.172. The coroner was satisfied about their identification and therefore issued an interim certificate of the fact of death for each of them.⁹⁶⁵⁹⁶⁵ Interim certificates of the fact of death for Omar Belkadi, Farah Hamdan and Leena Belkadi {MET00065583}; {MET00065592}; {MET00065638}.

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Cause and time of death

¶94.81 The post-mortem on Omar Belkadi noted significant soot staining of the body and minor heat damage, both of which had occurred after death. Similarly, there was heavy soot staining and minor heat damage to Farah Hamdan's body. Leena Belkadi had soot staining to her face and again some minor heat damage. In all three cases, there was soot staining of the respiratory airways, indicating inhalation of smoke-filled air. Toxicological analysis of blood samples taken from Farah Hamdan, Omar Belkadi and Leena Belkadi found the levels of carboxyhaemoglobin in their blood to be 85%, 87%, and 84% respectively,⁹⁶⁶⁹⁶⁶ Omar Belkadi post-mortem report {COR00001303/11}; Hamdan post-mortem report {COR00000397/9}; Leena Belkadi post-mortem report {COR00000876/9}; Leena Belkadi toxicology report {COR00000885}; Purser, Phase 2 Report, Section 6 {DAPR0000006/94} paragraph 522-524. in each case significantly higher than the lethal threshold.

¶94.82 Malak Belkadi was unconscious and in cardiac arrest when carried from the tower. Resuscitation efforts began at the scene and continued at St Mary's Hospital where, at 03.41, a return of circulation was recorded. With treatment, the concentration of carboxyhaemoglobin in her blood dropped from 45% on arrival at hospital to 26%. Toxicological analysis of a sample taken five hours after the start of the fire recorded the level of carboxyhaemoglobin in her blood to be approximately 10%. As the post-mortem report for Malak Belkadi observes, that followed treatment in an oxygen-enriched environment. The level of cyanide in her blood, when first measured some hours after she had been brought out of the tower, was 0.19 milligrams/litre. That reflected the elimination half-life of cyanide being one to two hours. A CT scan showed general cerebral oedema with possible superimposed hypoxic ischaemic brain injury. No brain activity could be found. At 15.01 on 15 June 2017, Malak Belkadi was declared dead.⁹⁶⁷⁹⁶⁷ Report of paediatric intensive care consultant concerning Malak Belkadi {COR00001720/3-9} pages 3-9; Malak Belkadi toxicology report {COR00000966/1}; Purser, Phase 2 Report, Section 6 {DAPR0000006/95} paragraphs 525-527. The coroner, Professor Wilcox, also issued an interim certificate of the fact of death for Malak Belkadi.⁹⁶⁸⁹⁶⁸ Interim certificate of the fact of death for Malak Belkadi {COR00001713}.

¶94.83 The reports of the post-mortems carried out on Omar Belkadi, Farah Hamdan, Malak Belkadi and Leena Belkadi gave the medical cause of death as "inhalation of fire fumes" but in the light of Professor Purser's evidence we find that a more accurate description is "inhalation of asphyxiant gases".

¶94.84 In the light of the evidence as a whole, including that given by Professor Purser, we are satisfied that the family entered the stairwell at about 02.19. They all collapsed soon after doing so because they had already had a significant exposure to asphyxiant gases entering from the lobby rather than from the outside. Their departure from Flat 175 was made in difficult circumstances into a lobby which was heavily smoke logged. As the family crossed the lobby, they inhaled hot smoke and asphyxiant gases and continued to do so on entering the stairwell. The result was that they quickly accumulated an incapacitating dose of asphyxiant gases. The inhalation of hot gases contributed by causing breathing difficulties. The family continued to inhale asphyxiant gases (mainly carbon dioxide but also hydrogen cyanide) until their breathing ceased and they died. In the case of Malak Belkadi, she continued to breathe until she suffered cardiac arrest and fatal brain damage.

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¶94.85 A blood carboxyhaemoglobin level of 30–40% is enough to cause a person to lose consciousness.⁹⁶⁹⁹⁶⁹ Purser, Phase 2 Report, Section 6 {DAPR0000006/97} paragraph 535. The lethal threshold is around 50%.⁹⁷⁰⁹⁷⁰ Purser, Phase 2 Report, Section 6 {DAPR0000006/99} paragraph 543. In children, because of their smaller body size, the rate of absorption of asphyxiant gases is more rapid than in adults.⁹⁷¹⁹⁷¹ Purser, Phase 2 Report, Section 6 {DAPR0000006/99} paragraph 543. It is likely that the blood carboxyhaemoglobin level of the Belkadi family reached the lethal threshold by about 02.49; it is unlikely that anyone would have survived if rescued after that time.⁹⁷²⁹⁷² Purser, Phase 2 Report, Section 6 {DAPR0000006/98} paragraphs 541-543.

¶94.86 All the times mentioned above are to some degree conjectural. All we can say with any confidence is that Omar Belkadi, Farah Hamdan and Leena Belkadi died between 02.45 and 03.10, probably closer to 02.45, and that both Farah Hamdan and Leena Belkadi were already dead by the time FFs Upton and Reddington found them. By that time Malak Belkadi was close to the point of death. Having been carried from the tower and despite the treatment provided at hospital, she died at 15.01 on 15 June 2017.

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