Chapter 95: Floor 21

¶95.1 Except for Flat 185, all remaining five flats on floor 21 were occupied when the fire started. Ligaya Moore, who lived in Flat 181, and all five members of the El Wahabi family who lived in Flat 182, died in the fire.

¶95.2 By 01.26 on 14 June 2017 the fire on the outside of the building had already spread to floor 21.⁹⁷³⁹⁷³ Phase 1 Report Volume II paragraph 10.118. Mustapha Abdu in Flat 184 was the first occupant of the floor to leave. He left the tower at 01.28 and had no contact with anyone else on floor 21.⁹⁷⁴⁹⁷⁴ Phase 1 Report Volume II paragraph 10.271.

¶95.3 Helen Gebremeskel lived in Flat 186 with her daughter. Woken by her kitchen smoke alarm, she went into her kitchen to see black smoke and flames coming through the window. She and her daughter quickly left the flat closing the front door behind them⁹⁷⁵⁹⁷⁵ Phase 1 Report Volume II paragraph 10.265. because it did not have an effective self-closing device.⁹⁷⁶⁹⁷⁶ Gebremeskel {Day68/133:1-2}; {Day68/143:15}.

¶95.4 At 01.26, when she was in the lobby, Helen Gebremeskel called the emergency services to report a fire in her flat. She and her daughter tried to leave together with the El Wahabi family, but they abandoned the attempt and by 01.30 had taken shelter in Flat 183, the home of Marcio Gomes and Andreia Perestrelo.⁹⁷⁷⁹⁷⁷ Phase 1 Report Volume II paragraphs 10.269. By that time there was a layer of black smoke close to the ceiling of the lobby.⁹⁷⁸⁹⁷⁸ Phase 1 Report Volume II paragraph 10.270. The El Wahabi family returned to Flat 182.

¶95.5 From about 01.25 the lobby of floor 21 rapidly filled with smoke to an extent that it deterred those who remained on that floor from trying to leave. a. At about 01.30 Abdulaziz El Wahabi told his sister Hanan Wahabi, who had already

escaped, that the amount of smoke in the lobby had prevented him and his family from leaving.⁹⁷⁹⁹⁷⁹ Phase 1 Report Volume III paragraph 11.42. At about 01.41 in the course of an emergency call to the LFB control room he told CRO Pam Jones that it was very smoky in the lobby.⁹⁸⁰⁹⁸⁰ 999 call transcript {LFB00055498/6}.

¶b. At 02.32, Marcio Gomes used his mobile phone to make a video recording of black smoke coming through the sides of his closed front door. When he opened the door, the lobby was pitch black with no indication that the lighting was working.⁹⁸¹⁹⁸¹ Phase 1 Report Volume II paragraphs 15.74-15.76.

¶95.6 Further emergency calls alerted the control room to the fact that occupants were trapped on floor 21. Those still on floor 21 spoke to the control room on no fewer than 11 occasions. In Flat 182, the El Wahabi family were in contact with the control room in a call which lasted from 01.38 to 02.37.⁹⁸²⁹⁸² Phase 1 Report Volume II paragraph 13.103. They spoke to the control room again at 02.43, 02.46, 02.51, 02.53 and 02.57.⁹⁸³⁹⁸³ Phase 1 Report Volume III paragraphs 15.180 and 15.186-15.187. A call made at 02.39 was connected to the London Ambulance Service.⁹⁸⁴⁹⁸⁴ Phase 1 Report Volume III paragraph 16.53. Marcio Gomes in Flat 183 spoke to the LFB control room at 02.21, 02.46, 02.55, 03.09 and 03.25.⁹⁸⁵⁹⁸⁵ Phase 1 Report Volume III paragraphs 15.130, 16.56, 16.84, 17.48, 17.50, 17.132, 17.139 and 18.29.

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¶95.7 Only one firefighter crew, FFs Nikki Upton and Tom Reddington, was sent to floor 21. They set out at 02.44 but failed to reach floor 21 because they stopped to assist casualties they found on the stairs.⁹⁸⁶⁹⁸⁶ Phase 1 Report Volume III paragraph 15.57.

¶95.8 However, one firefighter did reach floor 21. FF Dean Roberts was part of a five-member crew sent to the roof of the tower⁹⁸⁷⁹⁸⁷ Phase 1 Report Volume II paragraphs 11.12-11.13. that set out between 01.56 and 01.57.⁹⁸⁸⁹⁸⁸ BA Telemetry Data {LFB00023326}. Somewhere between floors 20 and 21, they found Fadumo Ahmed collapsed in the stairwell. While his colleagues helped her, FF Roberts continued up to floor 21 and opened the door to the lobby. He found it to be pitch black with smoke from floor to ceiling. He shouted and kicked the stairwell door but he did not see or hear any reaction before he left that floor.⁹⁸⁹⁹⁸⁹ Phase 1 Report Volume II paragraphs 14.85-14.87; Roberts {Day27/125:5}-{Day27/127:17}. There is no evidence that the occupants on floor 21 heard FF Roberts shout into the lobby.

Ligaya Moore

¶Date of birth: 28 October 1938 (78 years). Place of birth: San Luis, Philippines. Gender: Female. Occupation: Retired. Usual address: Flat 181, floor 21, Grenfell Tower, London. Place of death: Flat 181, floor 21, Grenfell Tower, London. Time of death: Between 01.40 and 02.45 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Background and composition of household

¶95.9 Ligaya Moore was retired and was 78 years old in June 2017. Born in the Philippines, she had moved to London in 1972 and worked as a nanny. She met her husband, James Moore, in London and they moved into Grenfell Tower in 1981. Ligaya Moore continued to live in Flat 181 after the death of her husband.⁹⁹⁰⁹⁹⁰ Phase 1 Report Volume IV paragraphs 32.119 -32.124.

Vulnerability

¶95.10 In 2013 the TMO became aware that Ligaya Moore was prone to hoarding and advised her that it could affect her tenancy.⁹⁹¹⁹⁹¹ RBKC Core Assessment for Ligaya Moore {RBK00059526/2}. The situation did not improve. In October 2014, following their survey of residents, Rydon informed the TMO that the accumulation of items in Flat 181 made it impossible for it to carry out works.⁹⁹²⁹⁹² Report dated 31 October 2014 from Rydon RLO {RYD00022561}. Janice Jones, TMO neighbourhood officer, referred Ligaya Moore to RBKC's social services department for assistance. They tried to carry out an assessment in May 2015, but she was not willing to co-operate. Hoarding was noted to be a possible fire safety risk, the consequences of which would be catastrophic. Ligaya Moore was recorded as being independently mobile and able to call out if in danger. She did agree to a referral to a de-cluttering service but would not consent to social services contacting her doctor or to being contacted by the LFB for a fire safety check.⁹⁹³⁹⁹³ RBKC Core Assessment for Ligaya Moore {RBK00059526/9-13}.

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¶95.11 A care and support plan completed in September 2015 noted that Ligaya Moore had had three sessions with the de-cluttering service and had agreed to be referred to Age UK's de-cluttering service but had refused further involvement with social services. The housing department were to continue to monitor the situation.⁹⁹⁴⁹⁹⁴ RBKC Care and Support Plan Review for Ligaya Moore {RBK00059524/3}. Nerita Bunggay, a friend of Ligaya Moore who saw her every day, described her as so embarrassed by the state of her home that she did not want others to see it. Hoarding was still a problem for her in June 2017.⁹⁹⁵⁹⁹⁵ Bunggay {IWS00002374/2} page 2, paragraphs 7-13.

¶95.12 Ligaya Moore appeared in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system.⁹⁹⁶⁹⁹⁶ Phase 1 Report Volume III paragraphs 20.65-20.66; Noble Spreadsheet {TMO00862588}. It recorded that she was over 65 years of age but did not mention any other vulnerability.

Events of 14 June 2017

¶95.13 Ligaya Moore returned to Grenfell Tower shortly after 22.20 on 13 June 2017.⁹⁹⁷⁹⁹⁷ O'Riordan {MET00013136/4} page 4. She did not leave her home after that.

¶95.14 It is likely that she never became aware of the fire. No other occupant of floor 21 had any communication with her during its course and there is no evidence to suggest that she became aware of the movements of the other occupants trapped on that floor or that she had contact with the emergency services, family or friends by telephone or otherwise.

Recovery and identification

¶95.15 All the combustible contents of Flat 181 were destroyed in the fire.⁹⁹⁸⁹⁹⁸ Purser, Phase 2 Report, Section 6 {DAPR0000006/65} paragraph 315. Ligaya Moore's remains were recovered from the bedroom area. They were associated with the remains of a bed which suggests that she was in bed at the time of the fire. The coroner was satisfied about the identification of the remains recovered and therefore issued an interim certificate of the fact of death.⁹⁹⁹⁹⁹⁹ Interim certificate of the fact of death for Ligaya Moore {MET00065603}; Purser, Phase 2 Report, Section 6 {DAPR0000006/65} paragraph 319.

Cause and time of death

¶95.16 The post-mortem report for Ligaya Moore recorded the medical cause of death as "consistent with the effects of fire", but in the light of more recent evidence we find that a more accurate description is "inhalation of asphyxiant gases".

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¶95.17 Flat 181 was a one-bedroom flat situated on the east side of the tower between Flats 186 and 182.¹⁰⁰⁰¹⁰⁰⁰ External Spread of Fire at Grenfell Tower {MET00012593/7}. The fire had reached floor 21 before 01.30.¹⁰⁰¹¹⁰⁰¹ Phase 1 Report Vol II paragraph 10.118. It was outside the living room of Flat 181 by about 01.32 and from then on smoke began to leak into Flat 181 both from the outside and the lobby. By about 01.52 the fire was outside the bedroom window.¹⁰⁰²¹⁰⁰² Purser, Phase 2 Report, Section 6 {DAPR0000006/64} paragraph 314.

¶95.18 It is very difficult to make a finding with any confidence about the time at which Ligaya Moore died. However, in the light of all the evidence including that of Professor Purser¹⁰⁰³¹⁰⁰³ Purser, Phase 2 Report, Section 6 {DAPR0000006/65} paragraph 319 and {DAPR0000006/66} paragraphs 320-321., we think it likely that she became incapacitated as a result of inhaling asphyxiant gases, including carbon monoxide and hydrogen cyanide, by about 01.40 and that she had died in her sleep by about 02.00, well before fire took hold in her bedroom.

The El Wahabi family

Abdulaziz El Wahabi

¶Date of birth: 01 December 1964 (52 years old). Place of birth: Larache, Morocco. Gender: Male. Occupation: Hospital Porter. Usual address: Flat 182, floor 21, Grenfell Tower, London. Place of death: Flat 182, floor 21, Grenfell Tower, London. Time of death: Between 03.00 and 03.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Faouzia El Wahabi

¶Date of birth: 01 June 1975 (42 years old). Place of birth: Larache, Morocco. Gender: Female. Occupation: Homemaker. Usual address: Flat 182, floor 21, Grenfell Tower, London. Place of death: Flat 182, floor 21, Grenfell Tower, London. Time of death: Between 03.00 and 03.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

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Yasin El Wahabi

¶Date of birth: 09 August 1996 (20 years old). Place of birth: Paddington, London. Gender: Male. Occupation: Student. Usual address: Flat 182, floor 21, Grenfell Tower, London. Place of death: Flat 182, floor 21, Grenfell Tower, London. Time of death: Between 03.00 and 03.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Nur Huda El Wahabi

¶Date of birth: 27 June 2001 (15 years old). Place of birth: Paddington, London. Gender: Female. Occupation: Student. Usual address: Flat 182, floor 21, Grenfell Tower, London. Place of death: Flat 182, floor 21, Grenfell Tower, London. Time of death: Between 03.00 and 03.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Mehdi El Wahabi

¶Date of birth: 22 February 2009 (8 years). Place of Birth: Chelsea, London. Gender: Male. Occupation: Student. Usual address: Flat 182, floor 21, Grenfell Tower, London Place of death: Flat 182, floor 21, Grenfell Tower, London. Time of death: Between 03.00 and 03.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

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Background and composition of household

¶95.19 Abdulaziz El Wahabi and Faouzia El Wahabi lived in Flat 182 on floor 21 of Grenfell Tower with their three children, Yasin, Nur Huda and Mehdi. Abdulaziz El Wahabi was born on 1 December 1964 in Larache, in northern Morocco. He was 52 years old and had worked as a hospital porter at University College Hospital for 22 years.¹⁰⁰⁴¹⁰⁰⁴ Phase 1 Report Volume IV paragraphs 32.106 and 32.109. His wife Faouzia was born on 1 June 1975, also in Larache. She was 42 years old and was a homemaker.¹⁰⁰⁵¹⁰⁰⁵ Phase 1 Report Volume IV paragraphs 32.106 and 32.110.

¶95.20 The couple's three children were all born in London. Yasin was 20 years old, having been born on 9 August 1996. A trained football referee, he was studying accountancy at Greenwich University.¹⁰⁰⁶¹⁰⁰⁶ Phase 1 Report Volume IV paragraphs 32.106 and 32.113. Nur Huda was 15 years old, having been born on 27 June 2001. She was studying for her GCSEs at Holland Park Secondary School.¹⁰⁰⁷¹⁰⁰⁷ Phase 1 Report Volume IV paragraphs 32.106 and 32.115. Mehdi was eight years old, having been born on 22 February 2009. He was a pupil at Oxford Gardens Primary School.¹⁰⁰⁸¹⁰⁰⁸ Phase 1 Report Volume IV paragraphs 32.106 and 32.118.

Vulnerability

¶95.21 None of the family had a disability that affected their ability to respond to an emergency. Nur Huda and Mehdi El Wahabi were both under 18 years of age at the time of the fire. In the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system Nur Huda was recorded as being under 18 but Mehdi did not appear.¹⁰⁰⁹¹⁰⁰⁹ Noble Spreadsheet {TMO00862588}.

Events of 14 June 2017

¶95.22 Nur Huda El Wahabi was the first member of the family to return home on the evening of 13 June 2017, coming into the tower at 18.16. Abdulaziz, Faouzia and Mehdi El Wahabi returned at 21.17. Yasin El Wahabi was the last of the family to return to the tower, at 00.47 on 14 June 2017.¹⁰¹⁰¹⁰¹⁰ O'Riordan {MET00013136/3} page 3.

The first evacuation attempt

¶95.23 Hanan Cherbika, a friend of the El Wahabi family, called Nur Huda El Wahabi soon after 01.10. She told her that there was a fire in the tower and that the family needed to leave. Nur Huda El Wahabi reassured her that the fire was downstairs. Hanan Cherbika encouraged her to wake her mother and to let her decide what to do.¹⁰¹¹¹⁰¹¹ Hanan Cherbika {IWS00000016/5} page 5, paragraph 18. Yousra Cherbika, Hanan Cherbika's daughter, also spoke to Nur Huda El Wahabi, who told her that she was going to come down.¹⁰¹²¹⁰¹² Yousra Cherbika {IWS00001032/6} page 6, paragraph 21.

¶95.24 Hanan Wahabi, Abdulaziz El Wahabi's sister, who lived in Flat 66 on floor 9, left the tower at 01.21. She called her brother just after 01.25 to warn him of the fire. She advised the family to leave the tower.¹⁰¹³¹⁰¹³ Phase 1 Report Volume II paragraph 10.266. Shortly afterwards, Helen Gebremeskel saw the El Wahabi family in the lobby on floor 21 and warned them there was a fire in her flat, Flat 186. They told her the whole building was affected. Together with Helen Gebremeskel and her daughter, the El Wahabi family then tried to leave the tower. They reached the stairs but could not go down as a group of people were coming up. Those coming up told them that they should all go back to their flats.¹⁰¹⁴¹⁰¹⁴ Phase 1 Report Volume II paragraphs 10.267 and 10.268. The El Wahabi family returned to Flat 182. Helen Gebremeskel and her daughter went to Flat 183, the home of Marcio Gomes, Andreia Perestrelo and their two daughters.¹⁰¹⁵¹⁰¹⁵ Phase 1 Report Volume II paragraph 10.270.

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¶95.25 Hanan Wahabi spoke to her brother again at about 01.30. He said the family had tried to leave but there had been too much smoke and they had been unable to see or breathe.¹⁰¹⁶¹⁰¹⁶ Phase 1 Report Volume II paragraph 11.42.

The first emergency call from Flat 182

¶95.26 Flat 182 was in the south-east corner of the tower. The windows of the living room faced east and south.¹⁰¹⁷¹⁰¹⁷ External Spread of Fire at Grenfell Tower {MET00012593/7}. The El Wahabi family had converted it into a three-bedroom flat, with the bedroom of Abdulaziz and Faouzia El Wahabi being opposite the front door with a window facing south.¹⁰¹⁸¹⁰¹⁸ Wahabi {IWS00000074/3} page 3, paragraph 9 and {IWS00000074/22} page 22, Appendix I.

¶95.27 The first emergency call from Flat 182 was made at 01.38 and lasted for just over 59 minutes. It was answered by CRO Pam Jones in the LFB control room. While various members of the family spoke to CRO Jones at different times, Abdulaziz El Wahabi spoke to her for most of the call.¹⁰¹⁹¹⁰¹⁹ Phase 1 Report Volume II paragraphs 13.103 and 14.157; 999 call transcript {LFB00055498/7}; {LFB00055498/16}; Wahabi {IWS00001146/9} page 9, paragraph 29. He told CRO Jones that he was with his wife and three children in Flat 182.¹⁰²⁰¹⁰²⁰ 999 call transcript {LFB00055498/8}.

¶95.28 During the call, the family told CRO Jones that they had tried to go down the stairs but had been forced to return as it was too smoky.¹⁰²¹¹⁰²¹ 999 call transcript {LFB00055498/3}; {LFB00055498/9-10}. CRO Jones advised them to stay in the flat if it was too smoky to leave, to block up any places where smoke was coming in and to get fresh air from a window.¹⁰²²¹⁰²² 999 call transcript {LFB00055498/4-6}; {LFB00055498/10}. She said that she would let the firefighters know which flat the family were in and that they would try to reach them as soon as possible.¹⁰²³¹⁰²³ 999 call transcript {LFB00055498/11-12}; {LFB00055498/14-15}. At 01.47, the family reported that, despite the use of blankets, smoke was still coming into the flat through the front door. At this time they were sheltering in the living room.¹⁰²⁴¹⁰²⁴ 999 call transcript {LFB00055498/16-17}; {LFB00055498/20}.

¶95.29 At about 01.55, Abdulaziz El Wahabi told CRO Jones that someone outside had told the family that the fire had reached the flat next door (i.e. Flat 181).¹⁰²⁵¹⁰²⁵ 999 call transcript {LFB00055498/31-32}. Over the next few minutes the family were able to see the fire next door and smoke began to come into the living room. CRO Jones advised them to move to another room and they then moved to the bedroom of Abdulaziz and Faouzia. By then the fire had reached the kitchen of Flat 182.¹⁰²⁶¹⁰²⁶ 999 call transcript {LFB00055498/35-50}; Phase 1 Report Volume II paragraphs 14.159-14.160.

¶95.30 Hanan Wahabi called her brother for the last time at 02.15. Faouzia El Wahabi answered the telephone and Hanan Wahabi urged her to leave. Faouzia said they were trying to do so. She said that the fire was in the kitchen of Flat 182 and that the family had been told to go to the bedroom.¹⁰²⁷¹⁰²⁷ Wahabi {IWS00000074/16} page 16, paragraph 55. Meanwhile, the call with CRO Jones was continuing. She ascertained that the bedroom was smoke-free and advised the family to remain there with the door shut and a window open for air. She assured them that firefighters would come to them.¹⁰²⁸¹⁰²⁸ 999 call transcript {LFB00055498/57-67}; {LFB00055498/73-76}.

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¶95.31 Throughout the call with CRO Jones, members of the El Wahabi family were in contact with friends and family outside the tower who were telling them to leave. The family responded that they had been advised to remain in their flat.¹⁰²⁹¹⁰²⁹ Phase 1 Report Volume II paragraph 14.162. However, at about 02.24 smoke began to enter the bedroom through the open window and CRO Jones advised them to close the window.¹⁰³⁰¹⁰³⁰ 999 call transcript {LFB00055498/80}. At about 02.34, having been told by OM Alexandra Norman that those in the tower should now be advised to leave, CRO Jones told the El Wahabi family to cover themselves with wet clothes and towels and to leave the flat.¹⁰³¹¹⁰³¹ Phase 1 Report Volume III paragraph 15.156; Jones {LFB00032090/6} page 6, paragraph 30. She continued to encourage the family to leave until the call was disconnected at 02.37.¹⁰³²¹⁰³² 999 call transcript {LFB00055498/95-101}.

Information to the incident ground

¶95.32 The LFB control room passed messages about Flat 182 to the incident ground while CRO Jones was speaking to the El Wahabi family.

¶95.33 At about 01.47, CRO Jones told them that a message had been passed to firefighters about Flat 182 but she did not create a service request.¹⁰³³¹⁰³³ 999 call transcript {LFB00055498/15}; LFB Short Incident Log {MET00013830}. At about 01.50, CRO Jones told them that the control room was calling the firefighters again.¹⁰³⁴¹⁰³⁴ 999 call transcript {LFB00055498/23}. At that time, CRO Yvonne Adams, who was sitting next to CRO Jones, spoke to command unit CU8 and passed on information about two flats, one of which was Flat 182. CRO Adams told CU8 that those in Flat 182 had not been able to stop smoke coming under the front door, were in the living room and sounded "panicked".¹⁰³⁵¹⁰³⁵ Phase 1 Report Volume II paragraphs 13.85-13.86; Transcript of call between LFB control room and CU8 {INQ00000203}.

¶95.34 WM Mark Kentfield recorded the information reaching CU8 on pieces of paper which were then passed to SM Brett Loft who at that time was positioned outside the tower. He had taken charge of managing information about people needing to be rescued and was passing it to the bridgehead, probably by radio.¹⁰³⁶¹⁰³⁶ Phase 1 Report Volume II paragraph 11.6 and Phase 1 Report Volume IV paragraphs 28.84 (a) and 28.84(b). The information provided to SM Loft included an A4 sheet of paper at the top of which was written "BRETT LOFT IC". The seventh entry down on that document read: "182 – 21st FLOOR".¹⁰³⁷¹⁰³⁷ Phase 1 Report Volume II paragraphs 12.18-12.19 and figure 12.4. Given that SM Loft recalled receiving information on paper from WM Kentfield at around 01.40,¹⁰³⁸¹⁰³⁸ Phase 1 Report Volume II paragraphs 11.7 and 12.19. it is likely that the mention of Flat 182 was the result of CRO Adams's call to CU8.

¶95.35 At 02.00, CRO Adams made a second call to CU8, during which she passed on information about several flats, including Flat 182. She reported that there were two adults and three children trapped in the flat, that the fire was next door to them and that smoke was pouring in. An officer in CU8 replied that they had the impression that floors 21 to 23 were the most severely affected.¹⁰³⁹¹⁰³⁹ Phase 1 Report Volume II paragraphs 14.230 and 14.231; Transcript of call between LFB control room and CU8 {INQ00000195}.

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¶95.36 Between 02.10 and 02.22 CU7 was designated as the command unit responsible for handling information about people needing to be rescued.¹⁰⁴⁰¹⁰⁴⁰ Phase 1 Report Volume IV paragraph 28.84d. Initially the crew used a laminated white sheet to record information previously recorded in CU8 on pieces of paper.¹⁰⁴¹¹⁰⁴¹ Phase 1 Report Volume II paragraphs 12.8-12.9. The entries on that sheet included a reference to Flat 182 where two adults and three children were trapped (although the flat was incorrectly recorded as being on floor 18). The reference to the composition of the family makes it likely that the call made by CRO Adams to CU8 at 02.00 was the source of that information. Indeed, the information on the laminated sheet appeared on a control information form on which was also written "From CU list".¹⁰⁴²¹⁰⁴² Control Information Form {LFB00001922/6}.

¶95.37 Shortly after 02.17, CM Charles Batterbee made a note of the contents of a forward information board used while the bridgehead had been located on floor 2 of the tower to record information about people needing to be rescued. There was no reference to Flat 182 but there was a reference to Flat 204 on floor 21.¹⁰⁴³¹⁰⁴³ Phase 1 Report Volume II paragraph 14.73 and Figure 14.4; Phase 1 Report Volume IV paragraphs 28.84(b) and 28.84(c). That suggests either that the message about Flat 182 that had been passed to CU8 at 01.50 and then again at 02.00 did not reach the bridgehead on floor 2, or that the information was passed on incorrectly. In any event, there was no deployment of firefighters to floor 21 while the bridgehead was located on floor 2.

¶95.38 At about 02.33, SM Jason Oliff began recording information about people needing to be rescued on two whiteboards in the LFB control room. The first entry, and the first information he passed to the command unit, was recorded as "182 21st Flr – 3 children 2 adults. Leave."¹⁰⁴⁴¹⁰⁴⁴ Phase 1 Report Volume III paragraphs 15.139-15.141 and Figure 15.8. That follows the change of advice communicated to the El Wahabi family by CRO Jones.

¶95.39 That information did reach the bridgehead on floor 3, as is confirmed by a reference to Flat 182 on the wall used by WM Louisa De Silvo at the bridgehead to record information about those needing to be rescued.¹⁰⁴⁵¹⁰⁴⁵ O'Beirne {MET000083321/19} page 19; Phase 1 Report Volume III Figure 16.6. Flat 182 was circled and ticked to indicate that a crew had been deployed. (A circle indicated that she had received further information, including information from a returning crew.)¹⁰⁴⁶¹⁰⁴⁶ Phase 1 Report Volume IV paragraph 15.25. In this case, the tick referred to the deployment at 02.44 of FFs Nikki Upton and Tom Reddington wearing EDBA to floor 21.¹⁰⁴⁷¹⁰⁴⁷ Phase 1 Report Volume III paragraph 15.57. FF Upton recalled that she and her colleague had been briefed by WM de Silvo and WM O'Keeffe but she could not remember whether they were to go to Flats 182 and 183 or to Flats 183 and 184.¹⁰⁴⁸¹⁰⁴⁸ Upton {MET00007524/5} page 5; Upton {Day38/144:22}-{Day38/147:21}. We think it was probably the former, because her contemporaneous note¹⁰⁴⁹¹⁰⁴⁹ Upton {MET00005625/1} page 1. records that the crew were deployed to Flats 182 and 183. Moreover, no call for help had been received from Flat 184, whose occupant, Mustapha Abdu, had already escaped.

¶95.40 The two firefighters did not reach floor 21 because as they were going up the stairs they found Farah Hamdan and Malak Belkadi and brought Malak Belkadi down. On returning to the bridgehead, FF Upton told a crew manager that she and her colleague had not been able to reach floor 21. She could not recall to whom she had spoken.¹⁰⁵⁰¹⁰⁵⁰ Upton {Day38/150:24}- {Day38/151:11}.

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Further emergency calls from Flat 182

¶95.41 After the call with CRO Jones had been disconnected at 02.37, the El Wahabi family made a series of short emergency calls. At 02.39, they were put through to the control room of the London Ambulance Service,¹⁰⁵¹¹⁰⁵¹ Phase 1 Report Volume III paragraph 16.53. which at that time was not aware that the LFB had revoked the stay put advice.¹⁰⁵²¹⁰⁵² Phase 1 Report Volume III paragraph 15.172. The caller said that five people were trapped in Flat 182 and was told that help was on the way. The call handler then put the call on hold to ask a manager what instructions to give the caller, but at that point the connection was lost. The call handler did not call back as the protocols of the London Ambulance Service required.¹⁰⁵³¹⁰⁵³ 999 call transcript {INQ00000383}; Woodrow {LAS00000009/12} page 12; Woodrow {Day72/129:10}-{Day72/131:22}.

¶95.42 At 02.43, Nur Huda El Wahabi spoke to CRO Heidi Fox in the LFB control room. She reported that there were two adults and three children in Flat 182 and, when asked, said that they could not leave. CRO Fox was in the course of advising her to cover herself in wet blankets when the call was disconnected.¹⁰⁵⁴¹⁰⁵⁴ Phase 1 Report Volume III paragraph 16.53; 999 call transcript {LFB00000374}.

¶95.43 Nur Huda El Wahabi made another emergency call that was answered by CRO Adams at 02.46. She confirmed that there were five people in Flat 182 and said there was too much smoke for them to get out. CRO Adams said they should try to cover themselves in wet towels and leave, as the fire brigade could not reach them. Nur Huda replied: "… too much smoke, I can't breathe."¹⁰⁵⁵¹⁰⁵⁵ Phase 1 Report Volume III paragraphs 15.186 and 16.54; 999 call transcript {COR00000376/6}.

¶95.44 When the call was disconnected, the line remained open to the BT operator who reconnected the call to the LFB on three further occasions at 02.51, 02.53 and 02.57.¹⁰⁵⁶¹⁰⁵⁶ Phase 1 Report Volume III paragraph 16.54. The transcripts of those calls,¹⁰⁵⁷¹⁰⁵⁷ 999 call transcript {COR00000376/8} and {COR00000376/10}. including the family's exchanges with the BT operator,¹⁰⁵⁸¹⁰⁵⁸ 999 call transcript {COR00000376/1-5}. show that they were coughing, having difficulty breathing and saying that they were feeling faint. We conclude from that that by that time there was a significant amount of smoke in the bedroom.

¶95.45 The first two calls were answered by CRO Adams and CRO Christine Howson respectively. Both advised the El Wahabi family that they had to leave. During the calls the CROs were told that the family could not breathe and that they had tried to leave but had been unable to see because of the smoke. In the second of those calls, the family said that they were again trying to leave.¹⁰⁵⁹¹⁰⁵⁹ 999 call transcript {COR00000376/8} and {COR00000376/10}.

¶95.46 At 02.57, the El Wahabi family was connected to the LFB control room for the third and last time. The call ended at 02.58, the line going silent before CRO Howson could speak to any member of the family.¹⁰⁶⁰¹⁰⁶⁰ Phase 1 Report Volume III paragraph 16.54 (c). That was the last contact anyone had with the El Wahabi family.

¶95.47 The whiteboard used in CU7 from about 03.00 to record information about people needing to be rescued shows that those later emergency calls may have resulted in information reaching that command centre.¹⁰⁶¹¹⁰⁶¹ Phase 1 Report Volume III paragraphs 15.13 and 16.12. Photographs taken later show that Flat 182 appeared on the grid with "5" in green and "2" in black next to it.¹⁰⁶²¹⁰⁶² Phase 1 Report, Volume III Figure 16.5; Photograph of whiteboard {MET00015924}. There was no red tick, which would have indicated a deployment.¹⁰⁶³¹⁰⁶³ Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}. We conclude that those later emergency calls did not prompt a deployment to Flat 182.

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Recovery and identification

¶95.48 The remains of the five members of the El Wahabi family were recovered from the bedroom of Abdulaziz and Faouzia El Wahabi.¹⁰⁶⁴¹⁰⁶⁴ Purser, Phase 2 Report, Section 6 {DAPR0000006/68} paragraph 369. The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death for all members of the family.¹⁰⁶⁵¹⁰⁶⁵ Interim certificate of the fact of death for Abdulaziz El Wahabi, Faouzia El Wahabi, Yasin El Wahabi, Nur Huda El Wahabi and Mehdi El Wahabi {MET00065595}; {MET00065626}; {MET00065631}; {MET00065627}; {MET00065652}.

Cause and time of death

¶95.49 The post-mortem reports for all five members of the El Wahabi family recorded the medical cause of death as "consistent with the effects of fire", but in the light of Professor Purser's evidence we find that a more accurate description is "inhalation of asphyxiant gases".

¶95.50 Toxicological analysis was not possible.

¶95.51 We are satisfied that the members of the El Wahabi family probably lost consciousness shortly after the last emergency call from Flat 182 ended at 02.58 and perhaps rather earlier in the case of the younger members of the family. Death due to inhalation of asphyxiant gases, particularly carbon monoxide and hydrogen cyanide, occurred a few minutes later and before any internal fires had become established in the bedroom. Death probably occurred within 20 minutes of loss of consciousness, that is, by 03.20, and before suffering the direct effects of fire.¹⁰⁶⁶¹⁰⁶⁶ Purser, Phase 2 Report, Section 6 {DAPR0000006/69} paragraphs 371 and 373 and {DAPR0000006/70} paragraph 378; Purser {Day297/69:11}-{Day297/72:6}.

Logan Gomes

¶Date of birth: 14 June 2017. Place of birth: London, UK. Gender: Male.

Background and composition of household

¶95.52 Andreia Perestrelo and Marcio Gomes lived in Flat 183 on floor 21 with their two daughters. At the time of the fire, Andreia Perestrelo was pregnant with the couple's son Logan whose birth was expected on 21 August 2017.¹⁰⁶⁷¹⁰⁶⁷ Phase 1 report Volume IV paragraphs 32.101-32.102. It had been a healthy pregnancy and Andreia was intending to begin her maternity leave on 14 August 2017.¹⁰⁶⁸¹⁰⁶⁸ Perestrelo {IWS00000349/1} page 1, paragraph 5. The whole family was eagerly awaiting the new arrival.¹⁰⁶⁹¹⁰⁶⁹ Phase 1 report Volume IV paragraphs 32.102-32.103.

¶95.53 Logan Gomes was delivered stillborn on 14 June 2017 following his mother's evacuation from the tower.

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Events of 14 June 2017

¶95.54 The family returned home on the evening of 13 June 2017 after dinner with friends.¹⁰⁷⁰¹⁰⁷⁰ Perestrelo {IWS00000349/8} page 8, paragraph 46. They became aware of the fire shortly before 01.30, when Helen Gebremeskel knocked on their door following her attempt to leave floor 21 with the El Wahabi family. Helen Gebremeskel and her daughter were invited to shelter in Flat 183.¹⁰⁷¹¹⁰⁷¹ Phase 1 Report Volume II paragraphs 10.267-10.269.

¶95.55 Some 20 minutes later, Marcio Gomes began to use wet towels to block out smoke which was by then seeping around the sides of the front door to Flat 183.¹⁰⁷²¹⁰⁷² Phase 1 Report Volume II paragraph 14.163. He was in contact with Miguel Alves, another resident of the tower, who had already left. Miguel Alves passed on the advice of a policeman that Marcio Gomes should stay in the flat.¹⁰⁷³¹⁰⁷³ Phase 1 Report Volume II paragraph 14.164.

¶95.56 The two families then in Flat 183 decided to try to leave but were deterred by the amount of smoke in the lobby.¹⁰⁷⁴¹⁰⁷⁴ Phase 1 Report Volume II paragraph 14.165. Marcio Gomes then made his first emergency call at 02.21 and spoke to CRO Heidi Fox in the LFB control room. She explained that firefighters were going to the flats and that she would tell them about Flat 183. At 02.24, CRO Fox created a service request recording that three adults, including one pregnant lady and three children, were trapped. CRO Sharon Darby passed the message by radio to CU7 at 02.24.¹⁰⁷⁵¹⁰⁷⁵ Phase 1 Report Volume II paragraph 14.165; Phase 1 Report Volume II paragraph 15.130; LFB Short Incident Log {MET00013830/22}.

¶95.57 Between 02.10 and 02.22 CU7 began handling information relating to people needing to be rescued.¹⁰⁷⁶¹⁰⁷⁶ Phase 1 Report Volume IV paragraph 28.84d. Initially, a white laminated sheet was used to record information. The entries on that sheet included "183 21 6 adults, 1 pregnant" (the number 6 was written in red pen and appeared to replace an erased 3).¹⁰⁷⁷¹⁰⁷⁷ Phase 1 Report Volume II Figure 12.3 and paragraphs 12.8-12.9; Phase 1 Report Volume III Figure 15.6 and paragraphs 15.11-15.13. At about the same time, WM Paul Sadler was instructed to collate information about people needing to be rescued for onward transmission to the bridgehead which, from 02.17, was located on the third floor of the tower. He communicated with the bridgehead either by radio or through paper control information forms.¹⁰⁷⁸¹⁰⁷⁸ Phase 1 Report Volume I1 paragraph 14.65-14.72; Phase 1 Report Volume IV paragraph 28.84e.

¶95.58 No note relating to Flat 183 appears on the wall on floor 3 used to record information about people needed to be rescued during the period when the bridgehead was located on that floor.¹⁰⁷⁹¹⁰⁷⁹ Phase 1 Report Volume II Figure 15.7. However the existence of a control information form which contains information consistent with the service request created by CRO Fox (in particular the reference to a "pregnant lady") suggests that the message did reach the bridgehead.¹⁰⁸⁰¹⁰⁸⁰ Control Information Form {LFB00001922/10}. The consequence was the deployment at 02.44 of FFs Nikki Upton and Tom Reddington to Flats 182 and 183 on floor 21, which was prompted not only by information about those needing to be rescued from Flat 182, but also, we find, by similar information relating to Flat 183.

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¶95.59 However, FFs Upton and Reddington did not reach floor 21. They found Farah Hamdan and Malak Belkadi in the stairwell and brought Malak Belkadi down. On returning to the bridgehead, FF Upton told a crew manager that she and her colleague had not been able to reach floor 21. She could not recall to whom she had spoken.¹⁰⁸¹¹⁰⁸¹ Upton {Day38/150:24}-{Day38/151:11}.

¶95.60 Marcio Gomes made a second emergency call from Flat 183 at 02.46. He reported that the fire had reached the flat next door and was coming through the windows. CRO Christine Howson advised him to leave if he no longer considered it safe to remain. When he replied that there was too much smoke to leave, she advised him to use wet clothes as protection against the smoke and to get to the stairwell. It was not clear whether CRO Howson had been told of the change in the "stay put" advice at that time, as she gave the impression during the call that firefighters were still on their way up the building.¹⁰⁸²¹⁰⁸² Phase 1 Report Volume III paragraphs 15.78, 15.189 and 15.191.

¶95.61 The two families made a further attempt to leave Flat 183 but could not cross the lobby. Marcio Gomes then made a third emergency call at 02.55 and spoke to CRO Angela Gotts. He told her that they were unable to leave and that smoke was coming into the flat despite towels being used to block it out. During that call, Marcio Gomes said that there were "...three kids and three adults and one heavily pregnant wife" in the flat. CRO Gotts said she would let the firemen know to come up to them. She did not create a service request but passed a message to CRO Sharon Darby, who then sent it by radio to CU7 at 02.58. The message stated that there were six persons in the flat, one of whom was pregnant. The information was also entered on a whiteboard in the LFB control room by SM Jason Oliff.¹⁰⁸³¹⁰⁸³ Phase 1 Report Volume III paragraphs 15.139-15.141, 16.56 -16.57, 16.84, Figures 15.8 and 15.9; 999 call transcript {LFB00000392}; Radio transcript {LFB00002017}.

¶95.62 At 03.09, Marcio Gomes made a fourth emergency call and spoke to CRO Howson again. He was advised to leave but said it was not possible to do so. He said that there were six people in the flat, including someone who was pregnant. CRO Howson said she would inform the crews and make reaching him a priority. She asked him again to try to leave.¹⁰⁸⁴¹⁰⁸⁴ Phase 1 Report Volume III paragraph 17.48; 999 call transcript {LFB00000412}. By that time conditions in Flat 183 had deteriorated, with more smoke entering the flat.¹⁰⁸⁵¹⁰⁸⁵ Phase 1 Report Volume III paragraphs 17.50 and 17.132.

¶95.63 Although we cannot trace the passage of the information given in the three emergency calls made by Marcio Gomes between 02.46 and 03.09 individually to the bridgehead, the fact that information about Flat 183 was reaching it is indicated by the following: a. Entries for Flat 183 appeared on the whiteboard used in CU7 after 03.00 to record

information about people needing to be rescued. The number of entries for Flat 183 suggests that more than one message was received and that the information on the whiteboard was revised accordingly.¹⁰⁸⁶¹⁰⁸⁶ Phase 1 Report Volume III paragraphs 15.13 and 16.12 and Figure 16.5; Photograph of whiteboard {MET00015924}.

¶b. The completion of control information forms that refer to six people, one pregnant, in Flat 183.¹⁰⁸⁷¹⁰⁸⁷ Control Information Forms {LFB00001922/12-15}. One of the forms contains a reference to floor 23 and a list of other flats in the tower identified as priorities.¹⁰⁸⁸¹⁰⁸⁸ Control information form {LFB00001922/14}. WM Sadler may have amended the form to include floor 23 following the receipt of fresh information. The list of priorities was added after the form left him,¹⁰⁸⁹¹⁰⁸⁹ Sadler {Day29/95:5}-{Day29/100:20}. but we cannot say with any confidence when that was done or whether Flat 183 was one of the flats designated as a priority.

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¶c. A reference to Flat 183 on the wall on the ground floor where, from 02.15, WM Glynn Williams had started recording information about people needing to be rescued.¹⁰⁹⁰¹⁰⁹⁰ Phase 1 Report Volume II paragraphs 14.103-14.105 and Figure 14.5; Photographs of ground floor wall {MET00005774} and {MET00005776}. The notation "183 21" appeared in a list created on the left hand side of the wall. It is likely that that list was begun after the bridgehead had been moved down to the ground floor and that the first entry on it was made some time after 03.21.¹⁰⁹¹¹⁰⁹¹ Williams {Day31/137:13}-{Day31/139:21}.

¶95.64 In any event, there was no further deployment of firefighters to Flat 183 or even to floor 21.

¶95.65 At 03.25, Marcio Gomes spoke to CRO Fox in what was his fifth emergency call. It lasted for 33 minutes and 53 seconds.¹⁰⁹²¹⁰⁹² Phase 1 Report Volume III paragraph 17.50; 999 call transcript {LFB00055501}. By the time the call began conditions in Flat 183 had worsened, with smoke continuing to come through the front door. Initially, Marcio Gomes told CRO Fox that it was not possible to leave and that they had tried three times to do so. CRO Fox told him that she would try to make them a priority. After the call had continued for about a minute and a half, Marcio Gomes told CRO Fox that the fire had entered the flat. The two families then covered themselves with wet towels and made their way to the stairwell.¹⁰⁹³¹⁰⁹³ Phase 1 Report Volume III paragraphs 18.29-18.31.

¶95.66 They found the lobby and the stairwell to be hot and full of smoke; there was no visibility or breathable air. CRO Fox continued talking to Marcio Gomes and encouraged him to continue through the lobby and down the stairs. While doing so she spoke to a colleague in the control room, passing on information and telling her that he was struggling to breathe. CRO Fox told him that firefighters were aware of their location and making their way up to them.¹⁰⁹⁴¹⁰⁹⁴ Phase 1 Report Volume III paragraphs 18.30-18.34; 999 call transcript {LFB00055501/17}; {LFB00055501/6-21}. Although CRO Fox said that a message was being sent to the incident ground by radio, we have not been able to confirm that that was done or whether any information reached the incident ground either by radio or telephone.

¶95.67 As he went down the stairs Marcio Gomes lost contact with his wife and daughters. He tried to make his way back up but encountered firefighters who said they would find them. He also spoke to a firefighter who asked which flat and which floor his family had started from.¹⁰⁹⁵¹⁰⁹⁵ Phase 1 Report Volume III paragraph 18.35; 999 call transcript {LFB00055501/30}. That contact may explain how WM Louisa De Silvo came to write "183 – Daughter" (underlined), with "21 or 22" written underneath on the green wall used on the ground floor to record information about people needing to be rescued after the bridgehead had moved there.¹⁰⁹⁶¹⁰⁹⁶ De Silvo {Day30/63:1}; De Silvo Exhibit LDS/7 - photo of green wall {MET00015820}. CM Aldo Diana and FF Dean Nelson were the firefighters who told Marcio Gomes that they would find his family. Originally sent to Flat 133 on floor 16, they found Andrea Perestrelo, her younger daughter and Helen Gebremeskel, who were all close to collapse. The two firefighters then went up again to find Helen Gebremeskel's daughter and Andrea Perestrelo's elder daughter, both of whom had collapsed on the stairs. They carried them down.¹⁰⁹⁷¹⁰⁹⁷ Phase 1 Report Volume III paragraph 18.20; Nelson {MET00010926/6} page 6; Diana {MET00018800/10} page 10.

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¶95.68 The group left the tower between 03.37 and 03.55.¹⁰⁹⁸¹⁰⁹⁸ Phase 1 Report Volume III paragraph 18.37. Andreia Perestrelo, her daughters and Marcio Gomes were taken by ambulance to King's College Hospital.¹⁰⁹⁹¹⁰⁹⁹ Perestrelo {IWS00000349/14} page 14, paragraph 83. Andreia Perestrelo and her daughters were put into induced comas. An emergency caesarean section was performed on Andreia Perestrelo at 23.03 on 14 June 2017. Sadly, Logan Gomes was stillborn.¹¹⁰⁰¹¹⁰⁰ Perestrelo {IWS00000349/14} page 14, paragraphs 84-87.

Cause of death

¶95.69 The post-mortem on Logan Gomes found features of terminal pathophysiological stress and nothing to suggest developmental abnormality, malformation or any other underlying pathology. There was less than 5% carboxyhaemoglobin in his blood.¹¹⁰¹¹¹⁰¹ Purser, Phase 2 Report, Section 6 {DAPR0000006/80} paragraph 433.

¶95.70 When admitted to hospital, Andreia Perestrelo had significant carbon monoxide poisoning and possible hydrogen cyanide poisoning. The resulting severe acidosis is likely to have been the cause of Logan's death at some time during the day on 14 June 2017.¹¹⁰²¹¹⁰² Letter from Dr Leonie Penna to Andreia Perestrelo dated 28 July 2017 {BSR00000140}; Purser, Phase 2 Report, Section 6 {DAPR0000006/84} paragraph 462. An extract from Dr Penna's letter was read out during the presentation concerning Logan Gomes {Day306/19:8}.

¶95.71 It is likely that those who were sheltering in Flat 183 absorbed a relatively small amount of asphyxiant gases before they left the flat.¹¹⁰³¹¹⁰³ Purser, Phase 2 Report, Section 6 {DAPR0000006/77-84} paragraph 416 and 460. However, their exposure to the conditions in the lobby and the stairs, coupled with the physical effort involved in making their way down, resulted in their accumulating a quantity of asphyxiant gases by the time they reached the ground floor that was nearly sufficient to incapacitate them.¹¹⁰⁴¹¹⁰⁴ Purser, Phase 2 Report, Section 6 {DAPR0000006/76-79} paragraphs 426-431.

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