Grenfell Tower Inquiry: Phase 2 Report · 2024
Chapter 96: Floor 22
Chapter 96: Floor 22
¶96.1 On the night of 14 June 2017 all six flats on floor 22 were occupied. Only Chia-Yuan (Naomi) Li and her cousin, Chin-Hsuan (Lydia) Liao from Flat 195 survived. Those who died were Nura Jemal, her husband, Hashim Kedir, and their three children who lived in Flat 192, Nadia Choucair, her husband, Bassem Choukair, and their three children, who lived in Flat 193, Sirria Choucair, the mother of Nadia Choucair, who lived in Flat 191, and Anthony (Tony) Disson, who lived in Flat 194. Mariem and Eslah Elgwahry, who lived in Flat 196, died in Flat 205 where they had taken shelter. We deal with the circumstances of their deaths in Chapter 97.
¶96.2 Naomi Li was alerted to the fire at about 01.15 when she became aware of a smell like burning plastic. Having spoken to Lydia Liao, she checked the lobby. Although she could smell smoke, she saw very little sign of it in the lobby. Returning to her flat, she telephoned her husband, Lee Chapman, who was abroad. At 01.21 she made an emergency call and spoke to CRO Yvonne Adams in the LFB control room, who told her that the fire brigade was attending a fire on the fourth floor of the tower and that she should stay in her flat. During that call Naomi Li gave CRO Adams the number of her flat.1105 Phase 1 Report Volume II paragraphs 10.272, 10.276 and 10.308.
¶96.3 Naomi Li decided to tell her neighbours. In the lobby she met and spoke to Nura Jemal, who then returned to Flat 192. She then saw Mariem and Eslah Elgwahry leaving Flat 196. When she told them that there was a fire on floor 4, Mariem Elgwahry replied that the fire was in their kitchen. At that time the door to Flat 196 was closed and Naomi Li could not see any smoke coming from it.1106 Phase 1 Report Volume II paragraph 10.277. She saw Mariem and Eslah Elgwahry enter the stairwell. Naomi Li next spoke to Tony Disson, who then returned to his own flat.1107 Phase 1 Report Volume II paragraph 10.277.
¶96.4 Naomi Li and Lydia Liao tried to leave but could not go down the stairs because a group of people were coming up. Returning to the lobby, they met Nadia Choucair, who invited them into Flat 193.1108 Phase 1 Report Volume II paragraph 10.279. Sirria Choucair was probably already there.
¶96.5 By 01.26, the fire on the outside of the building had reached floor 23. It is likely that from that time Flat 196, like other 'Flat 6s' in the tower, rapidly filled with smoke. The front door of Flat 196, although closed, failed to prevent smoke coming from the flat into the lobby of floor 22. In separate calls made at 01.30, both Naomi Li and Tony Disson reported that there was a lot of smoke on floor 22.1109 Phase 1 Report Volume II paragraphs 11.37-11.40.
¶96.6 In subsequent calls to the emergency services, those trapped on floor 22 referred to the presence of a significant amount of smoke in the lobby.1110 Phase 1 Report Volume II paragraph 12.62; Phase 1 Report Volume III paragraphs 16.33-16.39. That was a significant factor in preventing them from leaving the building, despite their efforts to do so. Nura Jemal, Hashim Kedir and their children were able to move from Flat 192 to Flat 193, arriving there shortly before 03.00.1111 Phase 1 Report Volume III paragraph 16.42. Tony Disson was able to reach the stairwell but collapsed and died on the stairs.1112 Phase 1 Report Volume III paragraphs 18.27-18.28. Only Naomi Li and Lydia Liao managed to escape from the building.1113 Phase 1 Report Volume III paragraphs 17.35-17.36 and 17.104.
138Deployments to floor 22
¶96.7 There were numerous emergency calls to the LFB, to North West Fire Control and to Kent, Essex and Surrey Fire and Rescue Services by and about those trapped on floor 22 during the fire. a. Having made her first call from Flat 195 at 01.21, Naomi Li spoke to the LFB on three more occasions from Flat 193 at 01.30, 02.51 and at 03.07.1114 Phase 1 Report Volume II paragraph 10.280; Phase 1 Report Volume III paragraphs 16.39 and 17.32-17.37.
¶b. Nadia Choucair and Bassem Choukair made six calls from Flat 193 at 01.48, 02.37, 02.43, 02.55, 03.02 and 03.05.1115 Phase 1 Report Volume II paragraphs 12.62, 14.155 and 14.269; Phase 1 Report Volume III paragraphs 16.34-16.35, 16.41, 17.38-39 and 17.126; 999 call transcript {LFB00000396}. At 03.15, Nadia Choucair spoke to a BT operator, but the line cleared before she could be put through to a fire and rescue service.1116 Phase 1 Report Volume III paragraph 17.38. At 03.21, the Metropolitan Police called Nadia Choucair in response to her earlier call to the emergency services, when the line had been disconnected before contact had been established.1117 Phase 1 Report Volume III paragraph 17.39.
¶c. At 01.34,1118 Phase 1 Report Volume II paragraph 11.41. while they were in Flat 192, Hashim Kedir and Nura Jemal spoke to the emergency services and called them again a further seven times at 02.03,1119 Phase 1 Report Volume II paragraph 14.153. 02.10, 02.18, 02.31, 02.34, 02.45 and 02.53.1120 Phase 1 Report Volume II paragraphs 14.153-14.154; Phase 1 Report Volume III paragraphs 16.47-16.50. Shortly after they and their children had moved to Flat 193 a call from Hashim Kedir was put through to Kent Fire and Rescue Service but he did not respond to the call handler.1121 999 call transcript {LFB00000658}. Hashim Kedir and Nura Jemal made another call at 03.08 when they spoke to CRO Gotts in the LFB control room.1122 Phase 1 Report Volume III paragraphs 16.51 and 17.130. The final contact with those in Flat 193 occurred at 03.24 when Hashim Kedir spoke to CRO Peter Duddy.1123 Phase 1 Report Volume III paragraph 18.23.
¶d. Tony Disson in Flat 194 spoke to the emergency services six times between 01.30 and 03.01.1124 Phase 1 Report Volume II paragraphs 11.37, 12.63 and 14.152; Phase 1 Report Volume III paragraphs 16.43-16.46, 16.45-16.46 and 17.41. In five calls made between 02.28 and 03.22, family members and a friend reported that Tony Disson was trapped in the tower.1125 Phase 1 Report Volume III paragraphs 15.148, 15.183, 15.195, 17.44-17.46, 17.127 and 17.131; 999 call transcript {LFB00000549}. A CRO in the LFB control room and one from Surrey Fire and Rescue Service called him back at 02.51 and 03.27 respectively.1126 999 call transcript {LFB00000469}; Phase 1 Report Volume III paragraph 18.27. The latter call was the last contact the emergency services had with Tony Disson.
¶96.8 Despite the information provided in those calls, the only deployment of firefighters to floor 22 was made in response to the call made by Naomi Li at 01.21.
139¶a. At 01.32, a service request was created referring to persons on floor 22 who reported smoke coming into Flat 195. At 01.35, CRO Sharon Darby passed a message to the incident ground that there were persons trapped on floor 22 with "smoke coming into their flat".1127 Phase 1 Report Volume II paragraphs 11.152-11.153. That message reflected the information provided by Naomi Li and Tony Disson in their calls at 01.21 and 01.30.
¶b. WM Mark Kentfield recorded the information reaching command unit CU8 about people needing to be rescued on pieces of paper, which were then passed to SM Brett Loft who was positioned outside the tower.1128 Phase 1 Report Volume II paragraph 11.6; Phase 1 Report Volume IV paragraph 28.84 (a). SM Loft passed the information he received to the bridgehead, probably by radio.1129 Phase 1 Report Volume II paragraph 12.18. He was receiving information of that kind from about 01.40. Some was written on the A4 sheet of paper that later became known as the "Sadler envelope", at the top of which was written "BRETT LOFT IC". The third entry on that document reads "Flat 195 22nd FLOOR".1130 Phase 1 Report Volume II paragraphs 12.18-12.19, 14.71 and Figure 12.4.
¶c. The bridgehead was located on floor 2 until 02.17.1131 Phase 1 Report Volume IV paragraph 28.84 (b). Shortly after that time, CM Charles Batterbee made a note of the contents of a forward information board used at the bridgehead to record information while it was located on floor 2. It contained no reference to floor 22.1132 Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraph 28.84 (c).
¶d. At 02.17 the bridgehead was moved to floor 3, where it remained until 3.10, when it was moved down to the ground floor.1133 Phase 1 Report Volume IV paragraphs 28.86-28.87. While the bridgehead was located on floor 3, a wall was used to record information about people needing to be rescued. The second entry at the top of this wall read "22 195", next to which was written "CODD + JOSEPH".1134 O'Beirne {MET000083321/19} page 19; Phase 1 Report Volume III Figure 16.6.
¶e. CM Raoul Codd and FF John Joseph were sent to floor 22 by WM Louisa De Silvo but not to a specific flat. They set out between 03.03 and 03.05. CM Codd and FF Joseph did not reach floor 22 because when they came across casualties in the stairs they decided instead to help them escape.1135 Phase 1 Report Volume III paragraph 17.13 (g); LFB Telemetry data {LFB00023326}; Codd {MET00012539}.
¶96.9 Although information about those in Flats 192, 193 and 194 did reach the incident ground, none of it reached the bridgehead, with the result that there were no deployments to those flats. We do not know why information about Flat 195 given in a call made at 01.21 reached the bridgehead only after it had been moved to floor 3 (i.e. after 02.17), but we are satisfied that when it was received it prompted the deployment of CM Codd and FF Joseph.
¶96.10 One firefighter did reach floor 22. FF Dean Roberts was one of the five-member Paddington crew from appliance A216, which included CM Philip Wigley and FFs Martin Gillam, Russell Gonzalez and Andrew Harris. The crew was sent to the roof of the tower to carry out firefighting operations.1136 Phase 1 Report Volume II paragraphs 11.13 and 13.5. They tallied out between 01.56 and 01.57. The crew did not reach the roof because they found Fadumo Ahmed on the stairs between floors 20 and 21 and helped her down. FF Roberts appears to have been able to make his way up to floor 22. He opened the stairwell door and shouted but received no response and re‑joined his crew.1137 Phase 1 Report Volume II paragraphs 14.85-14.87; Roberts {MET00007890/6} page 6.
140The Kedir and Jemal family
Hashim Kedir
¶Date of birth: 7 March 1973 (44 years). Place of birth: Addis Ababa, Ethiopia. Gender: Male. Occupation: Black Cab Driver. Usual address: Flat 192, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Nura Jemal
¶Date of birth: 1 August 1981 (35 years). Place of birth: Silte, Ethiopia. Gender: Female. Occupation: Homemaker. Usual address: Flat 192, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Yahya Hashim
¶Date of birth: 5 August 2003 (13 years). Place of birth: London, UK. Gender: Male. Occupation: Student. Usual address: Flat 192, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
141Firdaws Hashim
¶Date of birth: 13 January 2005 (12 years). Place of birth: London, UK. Gender: Female. Occupation: Student. Usual address: Flat 192, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Yaqub Hashim
¶Date of birth: 18 May 2011 (6 years). Place of birth: London, UK. Gender: Male. Occupation: Student. Usual address: Flat 192, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶96.11 Hashim Kedir, Nura Jemal and their three children lived in Flat 192 on floor 22 of the tower.1138 Phase 1 Report Volume IV paragraph 32.89.
¶96.12 Nura Jemal was born on 1 August 1981 in Silte, Ethiopia. She was 35 years old. Her husband, Hashim Kedir, was born on 7 March 1973 in Addis Ababa, Ethiopia. He was 44 years old. Their three children were all born in London. The eldest, Yahya Hashim was born on 5 August 2003 and was 13 years old. Firdaws Hashim was born on 13 January 2005 and was 12. Their youngest child, Yaqub Hashim, was born on 18 May 2011 and was 6 years old.1139 Phase 1 Report Volume IV paragraph 32.90.
¶96.13 Hashim Kedir had moved to the UK in 2000. He took various jobs before successfully passing the test to become a black cab driver. He and Nura Jemal met in the UK where they married. Their children were thriving at local schools.1140 Phase 1 Report Volume IV paragraphs 32.93-32.98.
Vulnerability
¶96.14 No member of Nura Jemal and Hashim Kedir's family had a known vulnerability.
142Events of 14 June 2017
¶96.15 The family came home at various times on 13 June 2017, Hashim Kedir being the last to return at 23.21.1141 O'Riordan {MET00013136/3-4} pages 3-4. They became aware of the fire at an early stage. Naomi Li spoke to Nura Jemal in the lobby of floor 22 between her two emergency calls at 01.21 and 01.30.1142 Phase 1 Report Volume II paragraph 10.277. At 01.34, Hashim Kedir made his first call to the emergency services. During it he told CRO Duddy that smoke on the stairs had prevented the family from leaving and was now coming into their flat from the lobby. CRO Duddy's advice was to close all doors and windows and to block any smoke coming through the door. He concluded by explaining that firefighters were on their way.1143 Phase 1 Report Volume II paragraph 11.41; 999 call transcript {LFB00000315/3}. When he gave that reassurance, CRO Duddy did not have confirmation that firefighters would attend but assumed that they would do so if they were told that a flat needed to be checked.1144 Duddy {Day42/215:7}-{Day42/216:5}; Phase 1 Report Volume II paragraph 11.157.
¶96.16 CRO Duddy did not create a service request in response to that call but one had already been created following calls from other occupants of floor 22. It recorded "PERSONS ON THE 22ND FLOOR SMOKE COMING INTO FLAT."1145 LFB Short Incident Log {MET00013830}. CRO Darby passed the information to appliance G261 at 01.35, stating that she could not provide flat numbers.1146 Phase 1 Report Volume II paragraph 11.152. The service request was marked as completed at 01.41.1147 LFB Short Incident Log {MET00013830}.
¶96.17 No information relating to floor 22, including that passed on by CRO Darby, reached the bridgehead while it was located on floor 2.1148 Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraphs 28.84b and 28.84c
¶96.18 At 01.43, Hashim Kedir spoke to Genet Shawo, who lived in Flat 153 on floor 18. He told her that the emergency services had told him to remain in his flat and he advised her to do the same.1149 Phase 1 Report Volume II paragraph 11.61.
¶96.19 Hashim Kedir and Nura Jemal continued to make calls to the emergency services. a. At 02.03, Hashim Kedir told CRO Angie Gotts that there was smoke in the corridor
(probably meaning the lobby) and that the fire could be seen approaching the flat. He gave the number of his flat and floor. CRO Gotts did not confirm the number of people in the flat.1150 Phase 1 Report Volume II paragraph 14.153; 999 call transcript {LFB00000339}.
¶b. By 02.10 the fire on the outside of the building had begun to affect Flat 192.1151 Phase 1 Report Volume II paragraph 14.3. During a call which began at 02.10, Hashim Kedir told CRO Christine Howson that the fire had reached the kitchen of Flat 192 and that the smoke was making everyone in the flat cough. CRO Howson initially said that firefighters were dealing with a fire on the fourth floor but then said that, although the advice was for people to stay in their flats, the family would have to decide whether they should leave because there was a fire in the flat. Hashim Kedir told CRO Howson that the family was trapped. The line was disconnected before he could clarify what CRO Howson thought she had heard, namely that there were two adults and five children in the flat.1152 Phase 1 Report Volume II paragraphs 14.153 and 14.251; 999 call transcript {LFB00000345}.
143¶c. At 02.18, CRO Howson spoke to Hashim Kedir again. He told her that the kitchen was on fire and that a considerable amount of smoke was entering the living room. Having been told that there were two adults and three children in the flat, CRO Howson told him that the family could either make their way to the stairwell or move to somewhere in the flat with less smoke. Asked when the firefighters were coming, CRO Howson told him that they were on their way but making slow progress. She appeared to mistake Hashim Kedir for a woman, and asked if the caller's husband was present.1153 Phase 1 Report Volume II paragraphs 14.154 and 14.266; 999 call transcript {LFB00000351}.
¶d. At 02.30, the Metropolitan Police contacted the LFB control room to pass on the information that a woman, her husband and their three children were trapped in Flat 192.1154 999 call transcript {LFB00000671}. That information had come from a friend of Nura Jemal who had called on her behalf from outside the tower.1155 999 call transcript {INQ00000289}.
¶e. At 02.34, CRO Howson answered another call from Flat 192. She was told that there were two adults and three children in the flat. The fire had reached the living room and the family were being affected by the conditions. CRO Howson advised them to leave. She said she would alert the firefighters, who would try to meet them.1156 Phase 1 Report Volume III paragraph 16.48.
¶f. At 02.35, a police operator spoke to Nura Jemal who confirmed her location. She said that there were two adults and three children in the flat and that the fire had reached a bedroom.1157 999 call transcript {INQ00000276/3} page 3. There is no record of the police passing on that further message to the LFB.
¶g. At 02.45, Hashim Kedir spoke to CRO Heidi Fox. He told her again that the lobby was full of smoke. The family had tried unsuccessfully to leave and were now trapped in a bedroom. Hashim Kedir asked why a helicopter could not be sent to rescue them. CRO Fox again encouraged him to leave, saying that the firefighters were on different floors.1158 Phase 1 Report Volume III paragraph 16.49; 999 call transcript {INQ00000378}.
¶h. At 02.53, Hashim Kedir spoke to CRO Pam Jones and reported that the family were still in Flat 192. CRO Jones advised them to leave.1159 Phase 1 Report Volume II paragraph 16.50.
Information to the incident ground
¶96.20 Although the calls set out above cannot be traced individually to the incident ground, in light of the following facts we have concluded that information about Flat 192 did get through. a. Although the first three calls did not generate a service request, in a radio message
timed at 02.09, CRO Sharon Darby told CU8 that there was a caller in Flat 192 on floor 22 who was unable to leave.1160 Phase 1 Report Volume II paragraphs 14.247-14.248. That information must have come from the call made by Hashim Kedir at 02.03.
¶b. Between 02.10 and 02.22 CU7 was the command unit designated to receive information about people needing to be rescued.1161 Phase 1 Report Volume IV paragraph 28.84 (d). Initially a laminated white sheet
144was used to record information that had previously been recorded on pieces of paper in CU8.1162 Phase 1 Report Volume II paragraphs 12.8-12.9. The following was noted on that sheet: "192 22 1 woman 3 children unable to leave". That reflects in part the entry on a control information form that records "192 22 1 woman 3 kids".1163 LFB Control Information Forms {LFB00001955/10} page 10. It cannot, however, be linked to any of the three calls made by Hashim Kedir between 02.03 and 02.18, although it is possible that SM Jason Oliff, in the LFB control room, may have passed on information about Flat 192 when he called WM Daniel Meyrick in CU8 on his mobile phone.1164 Phase 1 Report Volume II paragraphs 14.243 and 14.261.
¶c. The information recorded on the whiteboards used by SM Oliff from about 02.33 to collate information coming into the control room included the following: "192 22nd flr – fire entering flat* (left flat) Bedroom Living room 2 women 3 children."1165 Phase 1 Report Volume III paragraph 15.140 and Figure 15.8. It is likely that the calls made by Hashim Kedir at 02.10 and 02.18 were the source of that information.
¶d. From about 03.00, CU7 changed to recording information on a whiteboard using a grid system.1166 Phase 1 Report Volume III paragraphs 15.13 and 16.12. In relation to Flat 192, there was recorded the number "2" in green, the number "5" in black and the letter P in red and circled.1167 Phase 1 Report Volume III Figure 16.5; Photograph of whiteboard {MET00015924}. That indicated that two adults and five children were in the flat and that it was a priority rescue.1168 Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}. The source of that information must have been the call made by Hashim Kedir at 02.10, given the reference to five children.
¶96.21 Information relating to floor 22 did not reach the bridgehead while it was on floor 2. Between 02.17 and 03.10 it was located on floor 3.1169 Phase 1 Report Volume IV paragraphs 28.86 and 28.87. No note relating to Flat 192 appears on the wall used by WM De Silvo to record FSG information while the bridgehead was located on floor 3.1170 Phase 1 Report Volume III Figure 15.7.
The family's move to Flat 193
¶96.22 Having been unsuccessful in their efforts to leave their home, Hashim Kedir, Nura Jemal and their children were able to make their way to Flat 193, reaching it shortly before 03.00. Naomi Li recalled Nura Jemal and her daughter coming into Flat 193 shortly after the Choucair family had tried unsuccessfully to leave. At that time the amount of smoke in Flat 193 made it difficult to see anyone.1171 Phase 1 Report Volume III paragraphs 16.41-42 and 16.50-51. At 03.02 a BT operator put an emergency call from Hashim Kedir through to Kent Fire and Rescue Service explaining that they could not get the caller's attention but could hear coughing and commotion in the background. The call‑handler at the Kent Fire and Rescue Service was also unable to obtain a response.1172 999 call transcript {LFB00000658}.
¶96.23 Naomi Li made an emergency call at 03.07 during which she told CRO Howson that there were 12 people in Flat 193. She said that the smoke was very bad and that they could not leave. CRO Howson's advice was to make their way to the stairwell.1173 Phase 1 Report Volume III paragraphs 16.51 and 17.33; 999 call transcript {LFB00000404}. At that time everyone was in the living room of Flat 193. Naomi Li told them they had to leave. She was unable to see any reaction because of the amount of smoke in the flat. She and Lydia Liao were able to reach the stairwell.1174 Phase 1 Report Volume III paragraphs 17.34-36. Making their way down the stairs, they were found by WM Peter Clarke, WM Alexander Cardy and FF Enrico Beltrami who helped them and Karen Aboud and her two children from Flat 92 to leave the tower.1175 Phase 1 Report Volume III paragraph 17.20 (a).
145¶96.24 Naomi Li said that she had told the firefighters that there were more than ten people still in Flat 193 on floor 22, but that she did not know what the firefighters had done with that information.1176 Phase 1 Report Volume III paragraph 17.104. WM Cardy said that he had made a report to WM De Silvo at the bridgehead but it is not clear whether he gave her any information about Flat 193.1177 Cardy {MET00010085/10} page 10. By that time the bridgehead had been moved to the ground floor where information was being recorded on a green painted wall at the rear of the lobby.1178 Phase 1 Report Volume IV paragraph 28.87. There was no reference to Flat 193 on that wall.
¶96.25 That the information may have been passed on is suggested by an entry on the ground floor wall where, from 02.15, WM Glynn Williams had begun recording information about people needing to be rescued. SM Peter Wolfenden started recording information on the same wall from about 03.21.1179 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.1180 Wolfenden {Day40/188:5}-{Day40/190:4}. SM Wolfenden may well have been responsible for an entry on that wall which recorded "192 22 10 3K",1181 De Silvo Exhibit LDS/5 - Photograph of ground floor wall {MET00015815}. meaning ten people, including 3 children. No tick appears next to the entry. Although it is possible that that information may have been the result of emergency calls from those in Flat 193, and although the flat number is wrong, the reference to ten people reflects Naomi Li's explanation. In any event, however that information came to reach the ground floor, it did not lead to the deployment of a crew to floor 22.
The final calls from Flat 193
¶96.26 At 03.08, CRO Angie Gotts answered a call during which she spoke to both Hashim Kedir and Nura Jemal. They said they were in Flat 193 on floor 22 and that they could see a helicopter; they asked if it could help them to escape. CRO Gotts advised them to try and get out using wet towels to cover their heads.1182 Phase 1 Report Volume III paragraph 17.130; 999 call transcript {LFB00000406}.
¶96.27 At 03.14 Nadia Choucair told a BT operator that her baby was unconscious. The BT operator said the advice was to get out of the tower. As the call was being put through to the LFB, Nadia Choucair could be heard telling everyone that they needed to get to the stairs. The call ended before a call-handler could speak to her.1183 Phase 1 Report Volume III paragraphs 17.37-17.38; 999 call transcript {COR00001081}; 999 call transcript {LFB00000414}. At 03.21, a police operator telephoned Nadia Choucair and told her that she needed to leave. She said that there was too much smoke, but as the call ended she could be heard telling those in Flat 193 that they needed to leave.1184 999 call transcript {LFB00000337} page 3.
¶96.28 The last contact with those still in Flat 193 was a call made by Hashim Kedir at 03.24 that was answered by CRO Duddy. He told CRO Duddy that there were 12 adults and seven children in the flat (in fact there were five adults and six children) and that they were trapped. As the call continued, CRO Duddy repeatedly told him that the only chance of survival was to leave by the stairs; a rescue by helicopter was not possible. Hashim Kedir said that it was not possible to leave; they had tried but had been unable to do so because of the smoke. Towards the end of the call, he could be heard calling out "I love you". He was speaking to his children.1185 Phase 1 Report Volume III paragraphs 18.24-18.26.
146Recovery and identification
¶96.29 The remains of the five members of the Kedir and Jemal family were recovered from the living room of Flat 193.1186 Purser, Phase 2 Report, Section 6 {DAPR0000006/46} paragraph 219. The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death for Hashim Kedir, Nura Jemal and their children, Yahya, Firdaws and Yaqub.1187 Interim certificates of the fact of death for Hashim Kedir, Nura Jemal, Yahya Hashim, Firdaws Hashim and Yaqub Hashim {MET00065640}; {MET00065629}; {MET00065633}; {MET00065587}; {MET00065644}.
Cause and time of death
¶96.30 The medical causes of death in the cases of Hashim Kedir, Nura Jemal, Yahya Hashim and Yaqub Hashim were recorded as "consistent with the effects of fire". The medical cause of death in the case of Firdaws Hashim was recorded as "inhalation of products of combustion". In light of Professor Purser's evidence, we find that a more accurate description of the cause of death in the case of all five members of the family is "inhalation of asphyxiant gases".
¶96.31 It was possible to detect carboxyhaemoglobin in tissue recovered from Yahya Hashim and Firdaws Hashim, although the concentration could not be measured.1188 Purser, Phase 2 Report, Section 6 {DAPR0000006/47} paragraph 220. The fact that two of those sheltering in Flat 193 inhaled smoke containing carbon monoxide indicates that it is likely that all those in the flat also did so.1189 Purser, Phase 2 Report, Section 6 {DAPR0000006/55} paragraph 263. They would all have been exposed to asphyxiant gases entering Flat 193, particularly from the lobby.
¶96.32 Given that Naomi Li and Lydia Liao were able to escape, it is likely that until about 03.11, despite increasing amounts of smoke, those in Flat 193 had accumulated a relatively limited dose of asphyxiant gases.1190 Purser, Phase 2 Report, Section 6 {DAPR0000006/47-51} paragraphs 224 and 240. From about 03.11, however, they accumulated increasing amounts of asphyxiant gases as the fire on the outside of the building reached Flat 193, in particular, when it reached the living room at about 03.37.1191 Purser, Phase 2 Report, Section 6 {DAPR0000006/51-54} paragraphs 238 and 251. From that time, conditions deteriorated rapidly, causing the occupants to lose consciousness by about 04.13 and within a few more minutes they had inhaled a lethal dose of asphyxiant gases. Since children take up asphyxiant gases at twice the rate of adults, they are likely to have lost consciousness soon after 03.50.1192 Purser, Phase 2 Report, Section 6 {DAPR0000006/54} paragraph 253.
¶96.33 We are satisfied that Hashim Kedir, Nura Jemal and their children Yahya, Firdaws and Yaqub all lost consciousness and died from the inhalation of asphyxiant gases between 03.37 and 04.20, before the fire reached their bodies. It is likely that the three children died before their parents.
147The Choucair / Choukair family
Sirria Choucair
¶Date of birth: 25 October 1956 (60 years). Place of birth: Nahle Village, Lebanon. Gender: Female. Occupation: Retired. Usual address: Flat 193, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Bassem Choukair
¶Date of birth: 1 December 1976 (40 years). Place of birth: Nahle Village, Lebanon. Gender: Male. Occupation: Supermarket Section Co-Ordinator. Usual address: Flat 193, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Nadia Choucair
¶Date of birth: 14 January 1984 (33 years). Place of birth: London, UK. Gender: Female. Occupation: Nursery School Teacher Assistant. Usual address: Flat 193, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
148Mierna Choucair
¶Date of birth: 22 November 2003 (13 years). Place of birth: London, UK. Gender: Female. Occupation: Student. Usual address: Flat 193, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Fatima Choucair
¶Date of birth: 1 March 2006 (11 years). Place of birth: London, UK. Gender: Female. Occupation: Student. Usual address: Flat 193, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Zainab Choucair
¶Date of birth: 17 May 2014 (3 years). Place of birth: London, UK. Gender: Female. Occupation: N/A. Usual address: Flat 193, floor 22, Grenfell Tower, London. Place of death: Flat 193, floor 22, Grenfell Tower, London. Time of death: Between 03.37 and 04.20 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
Background and composition of household
¶96.34 Sirria Choucair was born on 25 October 1956 in Lebanon. She was 60 years old. Her daughter, Nadia, was born on 14 January 1984 in London. She was 33 years old. Bassem Choukair, Nadia's husband, was born on 1 December 1976 in Lebanon and was 40 years old. Their three daughters were born in London. Mierna Choucair, born on 22 November 2003, was 13 years old, Fatima Choucair, born on 1 March 2006, was 11 years old and Zainab Choucair, born on 17 May 2014, was three years old.
149¶96.35 At the age of 17 Sirria Choucair moved to the UK, where she married and brought up her family. She worked at the Royal Marsden Hospital until her retirement.1193 Phase 1 Report Volume IV paragraphs 32.76–32.81. Bassem Choukair and Nadia Choucair met when Nadia was visiting members of her family in Lebanon. He moved to the UK following their marriage and was Section Co-ordinator in a supermarket. Nadia Choucair worked at Avondale Park Primary School as a nursery officer. Mierna and Fatima were at school; the couple's youngest daughter, Zainab, attended nursery.1194 Phase 1 Report Volume IV paragraphs 32.82-32.84.
¶96.36 Nadia Choucair, Bassem Choukair and their three children lived in Flat 193. Sirria Choucair lived in Flat 191 on the same floor.
Vulnerability
¶96.37 Sirria Choucair had severe arthritis and back pain that affected her mobility.1195 Sawson Choucair {IWS00001799/9} page 9, paragraph 9; Hisam Choucair {IWS00001851/2} page 2, paragraph 8; Nabil Choucair {IWS00002365/2} page 2, paragraph 8. The survey of residents prepared by Rydon in November 2014 recorded that she had high blood pressure, back pain and difficulty in walking.1196 Rydon Residents Survey {RYD00024466/17}. She was recorded as a resident of Flat 191 in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system,1197 Phase 1 Report Volume III paragraphs 20.65-20.66; Noble Spreadsheet {TMO00862588}. but not as having any vulnerabilities. Nadia Choucair, Bassem Choukair and their eldest daughter, Mierna, were recorded as residents of Flat 193. Their younger daughters did not appear in the spreadsheet.
Events of 14 June 2017
¶96.38 On the evening of 13 June 2017, the Choucair family were at home. CCTV shows Bassem Choukair returning to the tower at 15.02, shortly before his three children came back with Sirria Choucair at about 15.38. Nadia Choucair returned to the tower at 16.13.1198 O'Riordan {MET00013136/2-3} pages 2-3.
¶96.39 It is unclear when the family became aware of the fire. Shortly before 01.30 Nadia Choucair opened her front door and saw Naomi Li from Flat 195 in the lobby. Naomi Li told her that the fire brigade had said that there was a fire on floor 4 but their neighbour said it was in her kitchen. (Naomi Li was referring to Mariem Elgwahry from Flat 196.)1199 Phase 1 Report Volume II paragraphs 10.279-10.281. Nadia Choucair invited Naomi Li and her cousin, Lydia Liao, into her home, which was still free of smoke.1200 Phase 1 Report Volume II paragraph 10.279.
¶96.40 Naomi Li made her second emergency call from Flat 193 at 01.30. She told CRO Gotts in the LFB control room that she was in a neighbour's flat on floor 22.1201 Phase 1 Report Volume II paragraph 10.281.
¶96.41 Between 02.17 and 03.00, the LFB control room received further emergency calls relating to eight people trapped in Flat 193.
150¶96.42 Nadia Choucair made her first emergency call at 01.40. After seven minutes trying to connect her to the LFB, the BT operator redirected the call to Essex Fire and Rescue Service at 01.48.1202 999 call transcript {MET00015407}. Nadia Choucair spoke to CRO Sharon Lancaster and gave her address as Flat 193 Grenfell Tower. She said that she was on floor 22 and that it was smoky in the flat.1203 999 call transcript {LFB00000325}. CRO Lancaster told her that the fire service was at the scene and that she would report to London for her.1204 Phase 1 Report Volume II paragraph 12.62.
¶96.43 CRO Lancaster and her colleague CRO Katrina Marshall tried to contact the LFB to pass on the information from Nadia Choucair but were unable to get through until 02.18.1205 Phase 1 Report Volume II paragraph 12.94. CRO Marshall spoke to CRO Adams in the LFB control room and told her that they had received a call from a person on floor 22 who said that it was starting to get smoky. Although she said that they had not obtained a flat number from the caller, that was incorrect as Nadia Choucair had told CRO Lancaster that she was in Flat 193. It appears that the information had not been entered on the incident log.1206 Phase 1 Report Volume II paragraph 14.269. CRO Adams told CRO Marshall that they had given the correct advice when telling Nadia Choucair to stay put.1207 Phase 1 Report Volume II paragraph 12.94; 999 call transcript {LFB00000347}.
¶96.44 Nadia Choucair and Bassem Choukair made two separate emergency calls at 02.37 and 02.43. On each occasion they were connected to the LFB control room and each spoke to CRO Adams. In both calls, CRO Adams was told that there were eight people in the flat (i.e. the six members of the Choucair family and Naomi Li and Lydia Liao).1208 Phase 1 Report Volume III paragraph 16.36.
¶96.45 When she called at 02.37, Nadia Choucair was advised to block any smoke coming in to the flat and to close the windows.1209 Phase 1 Report Volume III paragraph 16.34. CRO Adams reassured her that the firefighters were on their way and would get to her.1210 Phase 1 Report Volume III paragraph 16.34. When Bassem Choukair called at 02.43, CRO Adams encouraged him to try to find the stairs and get out.1211 Phase 1 Report Volume III paragraph 16.35. He said that it was not possible to leave because of the smoke. CRO Adams said that he should make the decision whether to leave or not.1212 Phase 1 Report Volume III paragraph 16.35.
¶96.46 At about 02.35, DAC Adrian Fenton in the LFB control room decided to revoke the stay put advice and tell people to try to leave the building. He was aware that at the time crews could not get above floor 15.1213 Phase 1 Report Volume III paragraphs 15.161–15.163. It took some time for the change in advice to be disseminated to, and implemented by, the CROs.1214 Phase 1 Report Volume III paragraph 15.168. That might explain why at 02.37 CRO Adams advised Nadia Choucair to stay put, but at 02.43 she told Bassem Choukair to try to leave.
¶96.47 The information from the calls was passed to the incident ground. a. From 02.33 SM Jason Oliff began recording information about those in the tower
151needing rescue on two whiteboards in the LFB control room.1215 Phase 1 Report Volume II paragraphs 15.140-15.141 and Figure 15.8. The following was recorded on one of the boards: "193 22 fl – 8 adults 3 children get out advice." The number of people recorded as being in Flat 193 was incorrect, since until 03.00 there were only eight people in the flat, including three children. That may have led to command unit CU7 being told that more people were present in Flat 193.
¶b. Until about 03.00 officers in CU7 were using a white laminated sheet to record information about people needing to be rescued. On it was the notation "193 22 10 people."1216 Phase 1 Report Volume II Figure 12.3. The number of persons recorded must have been a mistake, as only eight people were in Flat 193 before 03.00.
¶96.48 In any event, that information did not reach the bridgehead, which from 02.17 was on floor 3.
Attempts at evacuation
¶96.49 After Bassem Choukair had spoken to CRO Adams at 02.43 the family tried to leave the flat covering their heads with wet towels.1217 Phase 1 Report Volume III paragraphs 16.36-16.37. They reached Flat 194 and spoke to Tony Disson but then returned to Flat 193.1218 Phase 1 Report Volume III paragraph 16.45.
¶96.50 Soon after they had returned, Hashim Kedir, Nura Jemal and their children came into Flat 193.1219 Phase 1 Report Volume III paragraph 16.42. There were now 13 people in the flat. Those sheltering there spoke to the LFB control room on a number of occasions. They were encouraged to try to get out. a. At 02.55, Nadia Choucair and Lydia Liao spoke to CRO Duddy who told them to leave
and get to the stairwell. Lydia Liao told us that by then the smoke in the flat had become so dense that they could not see each other. She was now aware of the fire approaching Flat 193.1220 Phase 1 Report Volume III paragraph 16.41; Liao second witness statement {IWS00001191/2} page 2, paragraphs 7, 8 and 9.
¶b. At 03.02, Bassem Choukair spoke to CRO Howson, telling her that there were 20 people in Flat 193 on floor 22. He asked for a helicopter. CRO Howson told him they should leave the building.1221 999 call transcript {LFB00000396}.
¶c. At 03.05, Bassem Choukair told CRO Duddy that they had been unable to reach the stairwell as there was too much smoke and they could not see. CRO Duddy told him to cover himself in wet towels and feel his way along the wall. He was told that their only chance of survival was to get to the stairwell.1222 Phase 1 Report Volume III paragraph 17.126.
¶d. At 03.06, CRO Darby sent a radio message to CU7 passing on information from the NPAS helicopter, which had identified the presence of people on floors 17, 21 and 22.1223 Phase 1 Report Volume III paragraph 17.128. e. At 03.07, Naomi Li spoke to CRO Howson who told her to leave.1224 Phase 1 Report Volume III paragraph 17.33.
¶f. At 03.08, CRO Gotts answered another call from Flat 193, which overlapped with Naomi Li's call to CRO Howson.1225 Phase 1 Report Volume III paragraph 17.37. The callers asked for a helicopter to rescue them. They said the fire had reached the flat. CRO Gotts told them to use wet towels and leave. She said she would pass the information on to the firefighters.
152¶96.51 Following her call at 03.07, Naomi Li told everyone in the flat that they had to leave. She was not able to see their reactions because there was too much smoke in the room. Naomi Li and Lydia Liao did then leave. On the stairs they encountered WM Peter Clarke, WM Alexander Cardy and FF Enrico Beltrami, who helped them, and also Karen Aboud and her two children from Flat 92 to leave the building.1226 Phase 1 Report Volume III paragraph 17.20 (a).
¶96.52 Naomi Li said that she told the firefighters that there were more than ten people in Flat 193 on floor 22. She did not know what the firefighters did with that information.1227 Phase 1 Report Volume III paragraph 17.104. WM Cardy said that he had reported to WM De Silvo at the bridgehead but it is not clear if he passed on any information about Flat 193.1228 Cardy {MET00010085/10} page 10. From 03.10, the bridgehead was on the ground floor and a green painted wall at the rear of the lobby was being used to record information about those still trapped in flats.1229 Phase 1 Report Volume IV paragraph 28.87. No reference to Flat 193 appeared on that wall.
¶96.53 Separately, from 02.15, WM Glynn Williams had begun recording information about those needing rescue on a different wall on the ground floor. SM Peter Wolfenden began recording information on the same wall from about 03.21.1230 Wolfenden {Day40/168:3}-{Day40/172:16}; {Day40/182:14}-{Day40/186:9}. He may well have been responsible for an entry on that wall that recorded "192 22 10 3K",1231 De Silvo Exhibit LDS/5 - Photograph of ground floor wall {MET00015815}. meaning ten people including three children. SM Wolfenden explained that a tick had been used to show that a crew had been sent to a flat1232 Wolfenden {Day40/188:5}-{Day40/190:4}. but no tick appears next to that entry. Although the entry refers to Flat 192, the reference to ten people indicates that the source may have been Naomi Li, but it is also possible that the information came from calls made by others on floor 22. In any event, however the information recorded on the wall came to reach the ground floor, it did not lead to a deployment to floor 22.
The final calls from Flat 193
¶96.54 At 03.08, CRO Gotts answered a call during which she spoke to both Hashim Kedir and Nura Jemal. They said they were in Flat 193 on floor 22. They said they could see a helicopter and asked for it to help them escape. CRO Gotts told them to try to get out using wet towels to cover their heads.1233 Phase 1 Report Volume III paragraph 17.130; 999 call transcript {LFB00000406}.
¶96.55 At 03.14 Nadia Choucair told a BT operator that her baby was unconscious. She was speaking of her youngest daughter, Zainab. The operator said the advice was to get out of the tower. As the call was being put through to the LFB, Nadia Choucair could be heard telling everyone in the room that they needed to get to the stairs. The call ended before someone in the control room could speak to her.1234 Phase 1 Report Volume III paragraphs 17.37-17.38; 999 call transcript {COR00001081}; 999 call transcript {LFB00000414}. At 03.21, a police operator telephoned Nadia Choucair and told her that she needed to leave. She said that there was too much smoke, but as the call ended she could be heard telling those in Flat 193 that they needed to leave.1235 999 call transcript {LFB00000337/3} page 3.
¶96.56 Hashim Kedir's call at 03.24 was the last contact with those still in Flat 193. He told CRO Duddy that there were 12 adults and seven children trapped in Flat 193 (in fact there were five adults and six children). As the call continued, CRO Duddy repeatedly told him that the only chance of survival was to leave by the stairs and that it was not possible to rescue them by helicopter. Hashim Kedir told CRO Duddy that it was not possible for them to leave; they had tried but had been unable to do so because of the smoke.1236 Phase 1 Report Volume III paragraphs 18.24-18.26.
153¶96.57 Information received by the LFB control room after 03.00 was passed on to the incident ground but did not result in any deployments. It was recorded in the following places: a. SM Oliff in the control room recorded on the second whiteboard in green "193 22th
10 people" followed by "Told to leave flat" in black ink. The floor number had been rubbed out making it possible that it had been written as 23. A note in grey ink had been added just above "10 people" stating "12 adults 3 children". That additional information may have come from a further call.1237 Phase 1 Report Volume III Figure 15.9.
¶b. After 03.00, a whiteboard with a grid system was used in CU7 to record information about people needing to be rescued. Next to Flat 193 there was a notation reading "12 3 P", indicating that 12 people and 3 children were trapped in Flat 193. The letter 'P' written in red and circled indicated that it was a priority destination.1238 Phase 1 Report Volume III Figure 16.5.
¶c. WM Williams wrote "193 22 10P" at the bottom of the central column of notes he made on the wall of the ground floor lobby. He accepted that that information may have come from a control information form that records that ten people were in Flat 193 on floor 22 and gives the source as "unknown via CU".1239 De Silvo Exhibit LDS/5 - Photograph of ground floor wall {MET00015815}; Williams {Day31/155:18}-{Day31/157:8}; Control information form {LFB00001922/20}. Later entries were made to the left of that central column,1240 Williams {Day31/99:13-16}; Wolfenden {Day40/183:24}-{Day40/184:25}. including one which read "Flat 222" on floor 22.1241 Phase 1 Report Volume II Figure 14.5. (This note seems to have been made before that relating to Flat 192).
¶d. At some time before 03.47 WM Tom Furnell had made a note in his notebook that there were 11 people in Flat 193 on floor 22.1242 Furnell Exhibit TGF/2 - original notes {MET00017035}; Furnell {Day40/37:2-25}. He was not sure how he had obtained that information but suspected that it had come from CU7.1243 Furnell {Day40/24:15-24}. He said he had sent the information to the bridgehead but did not know who would then have been responsible for sending a crew to Flat 193.1244 Furnell {Day40/38:9-19}.
Recovery and identification
¶96.58 The remains of the six members of the Choucair / Choukair family were recovered from the living room of Flat 193.1245 Purser, Phase 2 Report, Section 6 {DAPR0000006/46} paragraph 219. The coroner was satisfied about the identification of the remains and issued interim certificates of the fact of death for Sirria Choucair, Bassem Choukair, Nadia Choucair and their three daughters, Fatima, Mierna and Zainab.1246 Interim certificates of the fact of death for Sirria Choucair, Bassem Choukair, Nadia Choucair, Mierna Choucair, Fatima Choucair and Zainab Choucair {MET00065600}; {MET00065610}; {MET00065613}; {MET00065651}; {MET00065599}; {MET00065618}.
154Cause and time of death
¶96.59 The medical cause of death in the case of the members of the Choucair / Choukair family was recorded as consistent with the effects of fire. In light of Professor Purser's evidence we find that a more accurate description of the cause of the deaths of all six members of the family is "inhalation of asphyxiant gases".
¶96.60 Although there is no toxicological analysis available for any member of the family, the fact that carboxyhaemoglobin was found in tissue recovered from the remains of Yahya Hashim and Firdaws Hashim (who also died in Flat 193) makes it likely that all those in Flat 193 had inhaled carbon monoxide,1247 Purser, Phase 2 Report, Section 6 {DAPR0000006/55} paragraph 263. particularly as a result of gases entering the flat from the lobby of floor 22.
¶96.61 The fact that Naomi Li and Lydia Liao were able to escape from the tower makes it likely that until about 03.11 those in Flat 193 had accumulated a relatively low dose of asphyxiant gases, despite the increasing amounts of smoke in the flat.1248 Purser, Phase 2 Report, Section 6 {DAPR0000006/47-50} paragraphs 224 and 235. Their accumulation of such gases increased as the fire on the outside of the building reached Flat 193 and particularly when it reached the living room at about 03.37.1249 Purser, Phase 2 Report, Section 6 {DAPR0000006/51-54} paragraphs 238 and 251. From that time onwards conditions deteriorated rapidly, with the result that the inhalation of asphyxiant gases caused them to become unconscious by about 04.13. Within a few more minutes they had acquired a lethal dose. Since children absorb asphyxiant gases at twice the rate of adults, they are likely to have lost consciousness sooner, at about 03.50 or shortly after.1250 Purser, Phase 2 Report, Section 6 {DAPR0000006/54} paragraph 253.
¶96.62 We find that Sirria Choucair, Bassem Choukair and Nadia Choucair and their three children, Mierna, Fatima and Zainab had all lost consciousness and died from the inhalation of asphyxiant gases between 03.37 and 04.20 before the fire reached their bodies. It is likely that the three children died before their parents.
Anthony (Tony) Disson
¶Date of birth: 27 November 1951 (65 years). Place of birth: Hammersmith, London, UK. Gender: Male. Occupation: Retired. Usual address: Flat 194, floor 22, Grenfell Tower, London. Place of death: Stairwell, Grenfell Tower, London. Time of death: By 04.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.
155Background and composition of household
¶96.63 Anthony (Tony) Disson was born on 27 November 1951. In June 2017 he was 65 years old and had retired. He and his wife, Cordelia, had three sons, Harriboy, Alfie and Charlie.1251 Phase 1 Report Volume IV paragraphs 32.68- 32.69. Tony Disson had lived in Flat 194 since June 2010.1252 Tenancy Agreement {TMOH00000779}. His son, Charlie, lived with him but was not at home on the night of the fire.1253 Charles Disson {IWS00000239/1} page 1, paragraph 2.
Vulnerability
¶96.64 A priority needs assessment for RBKC completed in June 2009 in support of Tony Disson's application for emergency housing recorded that he had problems with his legs, which were getting worse, and that he needed access to a lift or a ground floor flat.1254 Priority Needs Assessment {TMOH00000849}. Tony Disson's tenancy agreement for Flat 194 recorded that he did not suffer from any disability.1255 Tenancy Agreement {TMOH00000779}.
¶96.65 In April 2016, a doctor at his local surgery wrote to the TMO in support of Tony Disson's request for repairs to be carried out in his flat. The letter indicated that the current condition of the flat was having a detrimental effect on his health and well-being but did not refer to his having any difficulties with mobility.1256 GP Liaison letter to KCTMO dated 26 April 2016 {TMOH00000861}.
¶96.66 Tony Disson was not identified as having any vulnerabilities in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system.1257 Noble Spreadsheet {TMO00862588}.
Events of 14 June 2017
¶96.67 Tony Disson returned to the tower shortly before the fire began on 14 June 2017,1258 O' Riordan {MET00013136/4} page 4. having spent the day with his son, Alfie, and his wife, Cordelia.1259 Alfie Disson {IWS00000241/4} page 4, paragraph 60; Cordelia Disson {IWS00000242/9} page 9, paragraphs 113-114. He became aware of the fire at an early stage, having spoken briefly to Naomi Li in the lobby on floor 22 at about 01.25.1260 Phase 1 Report Volume II paragraph 10.277. Conditions on floor 22 had deteriorated by 01.30 when he made his first call to the emergency services. He described conditions in the lobby as terrible and told CRO Heidi Fox in the LFB control room that he could not see anything. Although he said that he was on floor 22, he did not give her the number of his flat. She told him to use towels to block any smoke coming into his flat and said that firefighters were on their way.1261 Phase 1 Report Volume II paragraphs 11.37-11.39; 999 call transcript {LFB00000459}.
¶96.68 At 01.32 a service request was created which recorded "PERSONS ON THE 22ND FLOOR SMOKE COMING INTO FLAT."1262 LFB Short Incident Log {MET00013830}. That was probably the result not only of Tony Disson's first call but also of a call at 01.30 from Naomi Li, in which she reported that she was trapped on floor 22.1263 999 call transcript {INQ00000472}. CRO Darby passed that information to appliance G261 at 01.35, confirming that she could not provide the number of the affected flats.1264 Phase 1 Report Volume IV paragraph 28.84 (b). The service request was marked as completed at 01.41.1265 LFB Short Incident Log {MET00013830}. The information was not passed to the bridgehead, which at that time was on floor 2, where it remained until 02.17.1266 Phase 1 Report Volume IV paragraph 28.84 (b). The forward information board used on floor 2 to record information about people needing to be rescued contained no reference to floor 22.1267 Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraph 28.84 (c).
156¶96.69 Tony Disson next spoke to the LFB control room at 01.50. He told CRO Peter Duddy that smoke was coming into his flat. CRO Duddy told him to close all the windows and said that firefighters were making their way to floor 22.1268 Phase 1 Report Volume II paragraph 12.63. That call did not prompt a message to the incident ground.
¶96.70 At 02.00, Tony Disson made his third emergency call. He told CRO Howson that conditions were deteriorating in his flat. He gave the numbers of his floor and his flat and was reassured that firefighters were coming to him.1269 Phase 1 Report Volume II paragraph 14.152; 999 call transcript {LFB00000337/3}. CRO Adams, who was speaking to command unit CU8 at the time, passed on the information that a pensioner was trapped in Flat 194 on floor 22.1270 Phase 1 Report Volume II paragraphs 14.230-14.231; 999 call transcript {INQ00000195/5}. However, that information did not reach the bridgehead.
¶96.71 Tony Disson made further calls to the emergency services. a. In a call at 02.24 he told CRO Adams that he was frightened and that he had been
waiting for 45 minutes; he threatened to jump out of the window. The line was disconnected before he could be given any advice.1271 999 call transcript {LFB00000352}.
¶b. A call made at 02.40 cleared before the operator could put it through to North West Fire Control. Nonetheless, the operator was able to pass on the message that the caller was in Flat 194 and had said that he could not breathe.1272 999 call transcript {LFB00000695}. It appears that that information was not passed to the LFB control room.
¶c. At 02.49, Tony Disson spoke again to CRO Adams. He asked for someone to come and get him. For the first time he was told to leave the tower.1273 Phase 1 Report Volume III paragraphs 16.43 and 17.41.
¶96.72 It was probably after the last of those calls that Bassem Choukair knocked on Tony Disson's door, having left Flat 193 with his family. At the time Tony Disson was on the telephone to his wife, Cordelia. She heard Bassem Choukair ask him for help and Tony Disson reply that he could not help himself. She described Tony Disson as becoming more desperate from that point.1274 Phase 1 Report Volume III paragraphs 16.44-16.45. The Choucair / Choukair family were back in Flat 193 by 02.55 when Nadia Choucair made another emergency call.1275 Phase 1 Report Volume III paragraph 16.41.
¶96.73 Tony Disson was also in contact with his son, Alfie, and his partner, Chanade Prentice. She made two emergency calls at 02.28 and 02.45 which were connected to Surrey Fire and Rescue Service.1276 Phase 1 Report Volume II paragraph 17.44. Surrey in turn contacted the LFB control room saying that a man was trapped in Flat 194 on floor 22.1277 999 call transcript {LFB00000357}; 999 call transcript {LFB00000544}. At 02.54, Sharon Haley, a friend and resident of the tower who had already left the building, also spoke to the LFB control room and gave it the same information.1278 999 call transcript {LFB00000549}; Haley {IWS00001219/11} page 11, paragraph 123.
157¶96.74 Surrey gave the LFB control room Tony Disson's mobile number. CRO Gotts called him at 02.51 and told him to leave.1279 999 call transcript {LFB00000469}. When Tony Disson called the LFB control room again at 03.01, CRO Fox gave him the same advice. He told CRO Fox that it was too dark and hot for him to leave.1280 999 call transcript {LFB00000395}; Phase 1 Report Volume II paragraph 17.41. In calls to his family, Tony Disson described the conditions in his flat as worsening and said that it was filling with smoke.1281 Phase 1 Report Volume II paragraph 17.43
Information to the bridgehead
¶96.75 The bridgehead was located on floor 3 between 02.17 and 03.10, when it was moved to the ground floor.1282 Phase 1 Report Volume IV paragraphs 28.86-28.87. Notwithstanding the significant number of calls to the emergency services from and about Tony Disson, information about him did not reach the bridgehead while it was on floor 3. a. From about 02.33, SM Jason Oliff began using two whiteboards to collate information
received by the LFB control room about people needing to be rescued to enable him to pass it to the incident ground. One of the earliest entries read "194 22 flr – Heavy smoke 1 adult."1283 Phase 1 Report Volume III paragraphs 15.139-15.141 and Figures 15.8 and 15.9. However, we do not know whether that information reached the incident ground before 03.00.
¶b. The white laminated sheet initially used in CU7 to record information about people needing to be rescued contained a reference to Flat 193 but no reference to Flat 194.1284 Phase 1 Report Volume II paragraphs 12.8-12.11 and Figure 12.3.
¶c. From 03.00, CU7 began to record information on a whiteboard using a grid system.1285 Phase 1 Report Volume III paragraphs 15.13 and 16.12. Against Flat 194, the number "1" had been written on the grid in green (indicating an adult) with next to it the letter "P" in red and circled,1286 Phase 1 Report, Volume III Figure 16.5; Photograph of whiteboard {MET00015924}. indicating a priority.1287 Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}. A red tick was used in CU7 to indicate that a crew had been despatched. No red tick appears against Flat 194. It is possible that information about a person trapped in Flat 194 had been passed to CU7 by SM Oliff.
¶d. WM Glynn Williams began recording information about people needing to be rescued on a wall of the ground floor lobby from 02.15. Nothing was recorded in relation to Flat 194.1288 Phase 1 Report, Volume II paragraphs 14.103-14.105 and Figure 14.5; Photographs of ground floor wall {MET00005774} and {MET00005776}.
¶e. During the period that the bridgehead was located on floor 3, similar information was recorded on a wall there. Flat 194 is not listed on that wall.1289 Phase 1 Report Volume III paragraphs 15.23-15.24; Phase 1 Report Volume II Figure 15.7.
¶96.76 It follows that the emergency calls concerning Flat 194 did not prompt the decision to send CM Raoul Codd and FF John Joseph to floor 22 shortly after 03.00.1290 Phase 1 Report Volume III paragraph 17.13 (g).
158Final contact with Tony Disson
¶96.77 At about 03.00, Tony Disson told his son Alfie that the firefighters were not coming for him and that he was going to try to leave.1291 Phase 1 Report Volume III paragraph 17.43. Chanade Prentice spoke to Surrey Fire and Rescue Service again at 03.05 telling CRO Caili Beckham that the fire had now reached Tony Disson's flat and that he was struggling to breathe.1292 Phase 1 Report Volume III paragraph 17.44.
¶96.78 When Surrey Fire and Rescue Service passed the information on to the LFB control room, they were told that the occupants of the tower were now being advised to leave. At 03.09, CRO Beckham called Alfie Disson to tell him of the change of advice. He said that his father would not leave because he could not see well enough to reach the stairs. CRO Beckham said that she would let the LFB know, as Tony Disson should be treated as a priority. She spoke to CRO Jones in the LFB control room at 03.10. CRO Jones could not offer any more advice but did call Tony Disson at 03.15. The call was not answered.1293 Phase 1 Report Volume III paragraphs 17.45 and 17.131.
¶96.79 By about 03.20, Flat 194 was being affected by the fire on the outside of the building.1294 Phase 1 Report Volume III paragraph 17.7. Cordelia Disson spoke to Kent Fire and Rescue Service at 03.22. She said that she had just spoken to Tony Disson, that the fire had reached his front door and that he was having difficulty breathing. CRO Zoe Martin said that she would call him.1295 Phase 1 Report Volume III paragraph 17.46.
¶96.80 CRO Martin's call to Tony Disson was the last contact anyone had with him. By that time, he had left his flat and had reached the stairs. The call ended abruptly.1296 Phase 1 Report Volume III paragraph 18.27; 999 call transcript {LFB00000660}. In the Phase 1 report the call is said to have been made at 03.31 but evidence received since shows that it was in fact made at 03.27.
Recovery and identification
¶96.81 Tony Disson's body was found in the stairwell at the level of floor 18.1297 Phase 1 Report Volume III paragraph 18.28. The coroner was satisfied about his identity and issued an interim certificate of the fact of death.1298 Interim certificate of the fact of death for Anthony Disson {MET00065649}.
Cause and time of death
¶96.82 The medical cause of death was recorded as "inhalation of fire fumes" but in the light of more recent evidence we find that a more accurate description is "inhalation of asphyxiant gases".
¶96.83 The post-mortem on Tony Disson noted that there were heavy soot deposits on his head, face and arms. Soot was also found in the airways consistent with the inhalation of smoke‑filled air. There was some heat damage to the skin. Toxicological analysis found the level of carboxyhaemoglobin in Tony Disson's blood to be 71%. The post-mortem noted that such a level would be associated with death in any individual, even without the pre‑existing widespread coronary artery disease from which he suffered.1299 Disson post-mortem report {COR00000181/12}; Purser, Phase 2 Report, Section 6 {DAPR0000006/57} paragraphs 278-279.
159¶96.84 The carboxyhaemoglobin level in his blood shows that Tony Disson had inhaled a significant quantity of carbon monoxide before he died. Later analysis in April 2019 of the blood sample did not detect any cyanide.1300 Disson toxicology report {INQ00011096/1} page 1; Purser, Phase 2 Report, Section 6 {DAPR0000006/61} paragraph 296. However, it is likely that the sample had degraded over time, so the finding does not necessarily reflect the level of cyanide in his blood at the time of death.1301 Purser, Phase 2 Report, Sections 1-4 {DAPR0000005/112} paragraph 447.
¶96.85 Tony Disson was still in Flat 194 when he spoke to Cordelia Disson shortly before 03.22 and had not got very far down the stairs when CRO Martin spoke to him at 03.27. That suggests that he did not spend long in the lobby after leaving his flat. We conclude that by the time he left his flat Tony Disson had inhaled close to an incapacitating dose of asphyxiant gases.1302 Purser, Phase 2 Report, Section 6 {DAPR0000006/61} paragraphs 296-304. He lost consciousness and collapsed shortly after the call with CRO Martin. Tony Disson had probably suffered a lethal exposure to asphyxiant gases by about 03.56 and died before 04.30.1303 Purser, Phase 2 Report, Section 6 {DAPR0000006/60} paragraph 295; Purser {Day297/43:3-7}. In our view, the heat damage to the skin noted at the time of the post-mortem very probably occurred after death.
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