Chapter 97: Floor 23

¶97.1 On the night of the fire the six flats on floor 23 were occupied as follows:

Flat 201 by Raymond (Moses) Bernard. Flat 202 by Gloria Trevisan and her partner, Marco Gottardi. Flat 203 by Rania Ibrahim and her two daughters, Fethia Hassan and Hania Hassan. Flat 204 by Hesham Rahman. Flat 205 by Mohammed (Saber) Neda, his wife, Flora (Shakila) Neda, and their son, Shekeb (Farhad) Neda. Flat 206 by Fathia Ahmed Elsanousi and her daughter, Isra Ibrahim. Fathia Ahmed Elsanousi's son, Abufras Mohamed Ibrahim, was visiting.

Conditions and the upward migration from lower floors

¶97.2 The fire reached floor 23 by 01.26. The exterior of Flat 206, in the north-east corner of the tower, was enveloped by flames by 01.30.¹³⁰⁴¹³⁰⁴ Phase 1 Report Volume II paragraphs 10.118 and 10.122; External Fire Spread Report {MET00012593/14}.

¶97.3 Farhad Neda in Flat 205, which had two bedrooms in the north-west corner of the tower, saw smoke entering the lobby from the smoke extraction vents at some time before 01.30. The smoke gradually filled the lobby. The Neda family tried to walk down the stairs but were unable to do so due to a group of people coming up from lower floors who told them that there was a fire. Altogether, 16 people moved up from lower floors to floor 23, only one of whom survived the fire. In the Phase 1 report the chairman set out the possible reasons why that upward movement occurred.¹³⁰⁵¹³⁰⁵ Phase 1 Report Volume II paragraphs 10.284-10.286 and 10.290-10.292. It has not proved possible for us to reach any more confident conclusion.

¶97.4 There is evidence that by 01.39 the lobby on floor 23 was dark, probably due to smoke.¹³⁰⁶¹³⁰⁶ Phase 1 Report Volume II paragraphs 11.29-11.34; External Fire Spread Report {MET00012593/14}.

¶97.5 Between 01.50 and 02.20, Fadumo Ahmed ran to the stairwell from Flat 201. At that time the lobby was full of black smoke with no visibility. There was dark smoke in the stairwell which made her cough and feel dizzy. She had difficulty breathing.

¶97.6 Farhad Neda and Shakila Neda encountered similarly difficult conditions when leaving Flat 205 at some time after 02.15. The temperature in the lobby was higher than in the flat and the smoke caused a burning sensation that made Shakila Neda vomit and choke. The stairs were thick with black smoke and the handrail was not visible. Farhad Neda and Shakila Neda were rescued by firefighters and left the tower by 02.43.¹³⁰⁷¹³⁰⁷ Phase 1 Report Volume III paragraphs 15.64-15.67 and Annex A. They were the last occupants of floor 23 to escape the tower.

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Deployments to Floor 23

¶97.7 There were numerous emergency calls reporting people trapped on floor 23. Some identified specific occupants and flats; others were made by members of the public who could see people signalling and waving from the top floor of the building.¹³⁰⁸¹³⁰⁸ Phase 1 Report Volume II paragraph 14.235. The information received at the incident ground resulted in deployments of firefighters to floor 23 but no firefighters succeeded in reaching it.

¶97.8 One crew was briefed to go to the roof.¹³⁰⁹¹³⁰⁹ Phase 1 Report Volume II paragraphs 11.12-11.13, 13.5, 13.15 and 14.85-14.87; Phase 1 Report Volume III paragraph 15.30. Three other crews were sent to floor 23.¹³¹⁰¹³¹⁰ Phase 1 Report Volume II paragraph 14.117; BA Telemetry Schedule {LFB00023326}; Phase 1 Report Volume III paragraphs 15.54-15.56 and 15.66; Phase 1 Report Volume III paragraphs 16.15-16.20 and Figure 16.6. A fourth deployment to floor 23 was changed to a search and rescue operation just before the firefighters set off.¹³¹¹¹³¹¹ Phase 1 Report Volume III paragraph 18.15 (b). The deployment of FFs Terence Roots and Adam Johnson to Flat 161 on floor 19 at about 02.05 had been to rescue Debbie Lamprell, but by then she had already moved to floor 23.¹³¹²¹³¹² Phase 1 Report Volume II paragraph 12.86.

¶97.9 Having arrived at the incident ground at about 01.35, the Paddington crew (CM Philip Wigley, FFs Martin Gillam, Russell Gonzalez, Andrew Harris and Dean Roberts) equipped with extended duration breathing apparatus were sent by WM Michael Dowden to the roof of the tower to run a jet of water down from the top of the building.¹³¹³¹³¹³ Phase 1 Report Volume II paragraphs 11.12-11.13, 13.5, 13.15 and 14.85-14.87; Phase 1 Report Volume III paragraph 15.30. They tallied out between 01.56 and 01.57. They met FFs Steven Mills and Geoffrey Campbell coming down, who told them that they had been sent to rescue a woman in Flat 175 or a woman on floor 20. At about floor 15 or 16, the Paddington crew realised that they could not reach the roof. They went to floor 20 instead to try to rescue the woman FFs Mills and Campbell had told them about. They found Fadumo Ahmed between floors 20 and 21 and helped her. Fadumo Ahmed had come from Flat 201, where others were also sheltering. FF Gillam told us that she had told him that there was no one left on her floor but that none of the crew had asked her from which floor she had come. The crew's end of wear times were between 02.21 and 02.23.¹³¹⁴¹³¹⁴ Phase 1 Report Volume II paragraphs 11.12-11.13, 13.5, 13.15 and 14.85-14.87; Phase 1 Report Volume III paragraph 15.30.

¶97.10 FFs John Wright, Zade Alassad and Scott Bell were sent to two flats on floor 23, which are likely to have been Flats 201 and 205. It is not clear exactly which emergency call or calls had prompted their deployment, but the call by Jessica Urbano Ramirez from Flat 201 at 01.29 may have prompted it, as messages were passed to the incident ground relating to it. The crew tallied out between 02.08 and 02.10. They stopped at floor 10 and helped other firefighters to carry the bodies of Mohamednur Tuccu and Khadija Khalloufi out of the tower. FF Bell recalled telling someone they had not reached floor 23, but he could not remember to whom he had spoken or what that person had done with the information. Their end of wear times were between 02.28 and 02.29.¹³¹⁵¹³¹⁵ Phase 1 Report Volume II paragraph 14.117; BA Telemetry Data {LFB00023326}.

¶97.11 CM Richard Evans and FF Gemma Bloxham were sent to Flat 205 on floor 23. They tallied out at 02.24. Between floor 18 and floor 20, they came across two occupants, probably Farhad Neda and Shakila Neda, and helped them to escape. Shakila Neda had been on the telephone to members of her family on floor 23. On overhearing the conversation, CM Evans tried to make radio contact with the bridgehead but did not obtain a response. Farhad Neda told the firefighters that his father and four other people were trapped in Flat 205. One of the firefighters wrote that in his notebook. Once CM Evans had got back down, he told the officer in charge at the bridgehead that he and FF Bloxham had not reached Flat 205. The crew's end of wear time was 02.42.¹³¹⁶¹³¹⁶ Phase 1 Report Volume III paragraphs 15.54-15.56 and 15.66.

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¶97.12 FFs Michael Pole, Niki Mitchell, Chris Cheesman and Jessamine Bate from Euston Fire Station were deployed to floor 23, probably to Flats 204 (a west-facing flat) and 205. The crew had tallied out by 02.53. On the stairs, they met FFs Upton and Reddington carrying Malak Belkadi. FF Bates helped them to carry her. FFs Mitchell, Pole and Cheesman continued upwards and reached floor 18. There they realised that they did not have enough air to reach floor 23 and get back down again. Instead they helped to rescue those who had sheltered in Flat 153. FF Mitchell recalled telling WM Louisa De Silvo that they had not reached floor 23. The crew's end of wear times were 03.15 to 03.17.¹³¹⁷¹³¹⁷ External Fire Spread Report {MET00012593/14}; Phase 1 Report Volume III paragraphs 16.15-16.20 and Figure 16.6.

¶97.13 FFs Matthew Harold, David Friend and Richard Peacock tallied out between 03.31 and 03.32. They had originally been sent to Flat 203 on floor 23 in the south-west corner of the tower but their instructions were changed just before they set off. Instead, they were told to carry out search and rescue operations from the ground floor upwards. They searched floors 4 and 5 and found no casualties.¹³¹⁸¹³¹⁸ Phase 1 Report Volume III paragraph 18.15(b); External Fire Spread Report {MET00012593/14}.

Events surrounding Flat 201

¶97.14 Flat 201, the home of Raymond (Moses) Bernard, was a one-bedroom flat facing east.¹³¹⁹¹³¹⁹ Phase 1 Report Volume IV paragraph 32.55; External Fire Spread Report {MET00012593/14}. Those who took refuge there included Fadumo Ahmed (Flat 164, floor 19), Debbie Lamprell and Gary Maunders (Flat 161, floor 19), Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris (Flat 166, floor 19), Berkti Haftom and Biruk Haftom (Flat 155, floor 18), Hamid Kani (Flat 154, floor 18) and Jessica Urbano Ramirez (Flat 176, floor 20). Most of those who moved up to floor 23 probably reached it by around 01.30.¹³²⁰¹³²⁰ Phase 1 Report Volume II paragraphs 10.257, 10.258, 10.260, 10.289 and 14.125.

¶97.15 Amna Idris and Gary Maunders did not live in Grenfell Tower. Amna Idris was visiting her cousin, Amal Ahmedin, and her family. Gary Maunders was visiting Debbie Lamprell.¹³²¹¹³²¹ Phase 1 Report Volume II paragraphs 10.223 and 14.136. He moved from Flat 201 to Flat 203 at around 01.39.¹³²²¹³²² Phase 1 Report Volume II paragraphs 11.30-11.31.

¶97.16 There were three children in the group sheltering in Flat 201: Jessica Urbano Ramirez (12 years old), Biruk Haftom (12 years old) and Amaya Tuccu Ahmedin (3 years old).¹³²³¹³²³ Phase 1 Report Volume IV paragraphs 32.126, 32.154 and 32.198.

¶97.17 Of the 11 people who were in Flat 201 at some point, only Fadumo Ahmed survived. She left the tower at 02.25 with the assistance of firefighters.¹³²⁴¹³²⁴ Phase 1 Report Volume II paragraph 14.131; Phase 1 Report Volume III Annex A.

¶97.18 The remains of Moses Bernard, Debbie Lamprell, Amna Idris, Berkti Haftom, Biruk Haftom, Hamid Kani and Jessica Urbano Ramirez were all recovered from Flat 201.

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¶97.19 The remains of Gary Maunders were recovered from Flat 203. Those of Amal Ahmedin and her daughter, Amaya Tuccu Ahmedin, were recovered from the lobby of floor 23. We do not know when or under what circumstances Amal Ahmedin and Amaya Tuccu Ahmedin left Flat 201.¹³²⁵¹³²⁵ Phase 1 Report Volume II paragraph 14.132.

Conditions in Flat 201

¶97.20 By 01.29 the fire had spread to the eastern and northern sides of floor 23, affecting first Flat 206 in the north-east corner.¹³²⁶¹³²⁶ Phase 1 Report Volume II paragraph 10.107. The fire moved across Flat 206 in a southerly direction along the east face and towards Flat 201, which was next door.¹³²⁷¹³²⁷ Lane, Phase 1 Supplemental Report, Section 12 {BLAS0000012/8-9}; External Fire Spread Report {MET00012593/18-19}.

¶97.21 Smoke had been entering the lobby on floor 23 since before 01.30.¹³²⁸¹³²⁸ Phase 1 Report Volume II paragraphs 10.285-10.286. From about 01.30, Flat 201 filled with smoke from the lobby and from the fire outside the living room windows.¹³²⁹¹³²⁹ Purser, Phase 2 Report, Section 6 {DAPR0000006/9} paragraph 18.

¶97.22 By 01.34, the occupants of Flat 201 were struggling to breathe. There were about ten people sheltering in the hallway of the flat. Fadumo Ahmed and Amal Ahmedin tried unsuccessfully to put out a fire which was burning at the top of the living room window.¹³³⁰¹³³⁰ Phase 1 Report Volume II paragraphs 11.25-11.26; 999 call transcript {LFB00055504/5-10}.

¶97.23 The fire entered the living room and set things alight. The conditions in the flat prompted the group to move from the hallway to the bedroom.¹³³¹¹³³¹ Phase 1 Report Volume II paragraph 11.25. While in the bedroom, both Debbie Lamprell and Jessica Urbano Ramirez had long telephone calls with the emergency services.

¶97.24 By the time Fadumo Ahmed decided to leave thick smoke was coming into the flat from the lobby. At some time between 01.50 and 02.20 she left the flat and ran straight to the stairwell. Both the lobby and the stairs were filled with thick, dark smoke. Due to the smoke, there was no visibility in the lobby and the stairs could not be seen.¹³³²¹³³² Phase 1 Report Volume II paragraphs 14.128-14.130.

¶97.25 By about 01.56, the fire on the outside of the building had spread across the exterior of the living room and kitchen. It then spread outside the bedroom window where the occupants were sheltering.¹³³³¹³³³ Purser, Phase 2 Report, Section 6 {DAPR0000006/9} paragraph 19.

¶97.26 By 02.01 the windows of the bedroom of Flat 201 were cracking. By 02.06, flames were entering the bedroom window and the interior of the flat was on fire.¹³³⁴¹³³⁴ Phase 1 Report Volume II paragraphs 14.134 and 14.138.

¶97.27 By 02.20, towards the end of their respective emergency calls, Jessica Urbano Ramirez and Debbie Lamprell had stopped responding; they both probably lost consciousness at about that time.¹³³⁵¹³³⁵ Phase 1 Report Volume II paragraphs 14.135 and 14.140; 999 call transcript {LFB00055500/42-43}; 999 call transcript {LFB00055504/78-82}; Purser, Phase 2 Report, Section 6 {DAPR0000006/12} paragraph 36.

¶97.28 It is likely that all those in Flat 201 lost consciousness from about 02.15 and had been exposed to a lethal dose of asphyxiant gases by about 02.23.¹³³⁶¹³³⁶ Purser, Phase 2 Note on Toxicity Endpoints {DAPR0000013}.

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¶97.29 The firefighting crews deployed to floor 23 all tallied out after 02.08. Conditions in the stairwell between 02.00 and 02.20 had deteriorated to the point at which they posed a risk to anyone who attempted to escape.¹³³⁷¹³³⁷ Phase 1 Report Volume IV paragraph 25.28. It is therefore doubtful that firefighters would have been able to rescue the occupants of Flat 201, even if they had succeeded in reaching floor 23.

Emergency services calls, information at the incident ground and deployment to Flat 201

¶97.30 Jessica Urbano Ramirez and Debbie Lamprell each made a long emergency call while they were in Flat 201. Although the calls overlapped in time, there does not appear to have been any direct communication between the two callers. Biruk Haftom also made an emergency call from Flat 201.¹³³⁸¹³³⁸ Phase 1 Report Volume II paragraphs 10.289 (d) and 14.127.

¶97.31 Although messages from Flat 201 were passed to the incident ground and recorded in various places, there was only one deployment of firefighters specifically to Flat 201.¹³³⁹¹³³⁹ Phase 1 Report Volume II paragraph 14.117.

Jessica Urbano Ramirez's long emergency call

¶97.32 Jessica Urbano Ramirez used Berkti Haftom's telephone to make an emergency call at 01.27, but it was disconnected before the BT operator could transfer it to the LFB control room.¹³⁴⁰¹³⁴⁰ 999 call transcript {MET00015554}. The BT operator contacted the LFB control room at 01.29 and spoke to CRO Sarah Russell, telling her that the caller was a child who had asked for the fire brigade. CRO Russell called back using Berkti Haftom's number and was connected to Jessica Urbano Ramirez at 01.29. The call lasted until 02.24. Jessica stopped responding towards the end of the call. Early in the conversation she reported her location as floor 23 and said that there were about ten other people in the flat.¹³⁴¹¹³⁴¹ Phase 1 Report Volume II paragraph 10.317. She said that smoke was coming from the floor and that people were having difficulty breathing. She later said that fire had entered the living room and that the group had moved from the hallway to the bedroom. She said she was in Flat 201. She also described the group as containing about 11 people, including a two-year-old child, who must have been Amaya Tuccu Ahmedin.¹³⁴²¹³⁴² Phase 1 Report Volume II paragraphs 11.25, 12.66 (b) and 12.67.

¶97.33 At 01.45, CRO Russell created a service request which sought assistance for 11 people trapped in the bedroom of a flat on floor 23.¹³⁴³¹³⁴³ Phase 1 Report Volume II paragraph 12.84. That was the first service request created as a result of information received from Jessica Urbano Ramirez.¹³⁴⁴¹³⁴⁴ Phase 1 Report Volume II paragraph 12.84. CRO Sharon Darby contacted CU8 at 01.46 and passed on a message about 11 people in a bedroom of a flat on floor 23.¹³⁴⁵¹³⁴⁵ Phase 1 Report Volume II paragraph 12.88. The service request was then marked as completed at 01.47.¹³⁴⁶¹³⁴⁶ LFB Short Incident Log {MET00013830/20}.

¶97.34 The call continued. A further service request referring to 11 persons and a baby in Flat 201 was created at 01.58 (once CRO Russell had become aware of the flat number and the presence of a baby) and messages were passed to CU8 about Flat 201.¹³⁴⁷¹³⁴⁷ Phase 1 Report Volume II paragraph 13.104. The service request relating to 11 persons and a baby in Flat 201 was marked as completed at 02.00.¹³⁴⁸¹³⁴⁸ LFB Short Incident Log {MET00013830/21}. Also at 02.00, CRO Adams rang CU8 to pass on a number of messages to WM Meyrick. One of those messages related to Flat 201 on floor 23 containing 11 adults and one child.¹³⁴⁹¹³⁴⁹ Phase 1 Report Volume II paragraphs 14.230-14.232; LFB Short Incident Log {MET00013830/19-21}.

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¶97.35 While Jessica Urbano Ramirez's call to CRO Russell was going on, there was an unrelated attempt to rescue her. Her sister, Melanie, thought that Jessica was still in Flat 176. At 01.26 she told FF David Badillo that her sister was in Flat 176 on floor 20 and gave him the keys. FF Badillo first tried to reach the flat alone, then recruited CM Christopher Secrett and FF Christopher Dorgu to go with him. They set out by 01.35. Having reached Flat 176 and found it empty, they returned to the ground floor. Their end of wear time was 01.57. No information about the emergency call from Jessica Urbano Ramirez reached the crew during their deployment.¹³⁵⁰¹³⁵⁰ Phase 1 Report Volume II paragraphs 10.79 (b), 10.101 (a), 11.10 and 13.17.

¶97.36 The messages about Flat 201 sent by the control room to the incident ground at 01.46 and 02.00 were passed on to the bridgehead, which was located on floor 2 until 02.17.¹³⁵¹¹³⁵¹ Phase 1 Report Volume IV paragraphs 28.11, 28.84 (b) and 28.86. Shortly after 02.17, CM Charles Batterbee recorded in his notebook the information written on a forward information board that had been used while the bridgehead was located on floor 2.¹³⁵²¹³⁵² Phase 1 Report Volume II paragraph 14.73; Phase 1 Report Volume IV paragraph 28.84 (c). Flat 205 appears in that entry, but not Flat 201. A circled note written on the wall on floor 2 refers to Flats 201 and 205 and the names Alassad, Bell and Wright.¹³⁵³¹³⁵³ Phase 1 Report Volume II Figure 13.2 and paragraph 13.53. That is likely to have related to the unsuccessful deployment of firefighters John Wright, Zade Alassad and Scott Bell to floor 23 before 02.10. There were no further deployments to Flat 201 after that.

¶97.37 From about 02.33 SM Jason Oliff recorded information coming into the LFB control room on two whiteboards. In a photograph taken at the end of the incident the first whiteboard can be seen to include the notation "Flat 201 23rd flr – 2 yr old 11 people – now unconscious".¹³⁵⁴¹³⁵⁴ Phase 1 Report Volume III paragraphs 15.139-15.140 and Figure 15.8. That probably reflected the call from Jessica Urbano Ramirez.

¶97.38 Between about 02.00 and 03.00, a white laminate sheet was being used by firefighters in command unit CU7 at the incident ground to record information about people needing to be rescued. The laminate sheet recorded "Flat 201 Floor 23 1 person lost call".¹³⁵⁵¹³⁵⁵ Phase 1 Report Volume II paragraphs 12.8-12.9 and Figure 12.3; Phase 1 Report Volume IV paragraph 28.85 (d). That message must have related to Jessica Urbano Ramirez's call, during which she had stopped responding towards the end. Firefighters at the incident ground were therefore informed that contact with her had been lost.¹³⁵⁶¹³⁵⁶ As there had been no further update passed on from NWFC to the LFB control room in relation to Debbie Lamprell's call (see below), this must have related to Jessica Urbano Ramirez's call.

Debbie Lamprell's long emergency call

¶97.39 At 01.41, a BT operator connected to North West Fire Control said that a caller for the LFB had hung up after waiting for about five minutes.¹³⁵⁷¹³⁵⁷ 999 call transcript {MET00014977}. That caller was Debbie Lamprell. At 01.41 CRO Aisha Jabin's call back to Debbie Lamprell was connected. The call lasted for over 40 minutes, until 02.21. The group in Flat 201 had by then moved from the hallway to the bedroom. During the call, Debbie Lamprell confirmed her location as Flat 161 on floor 23.¹³⁵⁸¹³⁵⁸ Phase 1 Report Volume II paragraph 12.86. Flat 161 was her home address and was not on floor 23.

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¶97.40 At 01.46, Team Leader Paula Craig at North West Fire Control contacted the LFB control room and spoke to AOM Debbie Real. Based on inaccurate information from Debbie Lamprell's continuing emergency call she reported a call from "Flat 161 on Floor 23" with ten people trapped in the bedroom. AOM Real did not record the information contemporaneously in the incident log, but she appears to have passed it on to OM Alexandra Norman. OM Norman passed the information to the incident ground at 01.47 and at 02.01 recorded having done so in the incident log.¹³⁵⁹¹³⁵⁹ Phase 1 Report Volume II paragraph 12.85.

¶97.41 However, at around 01.52 Debbie Lamprell explained to CRO Jabin that she was in fact in Flat 201 on floor 23. As a result, CRO Jabin made further entries in the incident log, first to record that she was unsure of the flat number and then at 01.53 to record "10 PEOPLE IN FLAT 201 23rd FLOOR".¹³⁶⁰¹³⁶⁰ Phase 1 Report Volume II paragraph 12.86.

¶97.42 The correct location of Flat 201 was not communicated to the LFB control room, nor was it recorded in the incident log or in radio messages, even after CRO Jabin had become quite sure that it was on floor 23. The forward information board at the bridgehead included an entry for Flat 161 on floor 19, which probably reflected the message passed by North West Fire Control to the LFB following Debbie Lamprell's call.¹³⁶¹¹³⁶¹ Phase 1 Report Volume II paragraphs 12.86 and 14.73.

¶97.43 As a result of that message, at about 02.05 FFs Terence Roots and Adam Johnson were deployed to Flat 161 on floor 19, which was empty. Having swept Flat 161, FFs Roots and Johnson helped Nicholas and Pily Burton from Flat 165 to leave the building.¹³⁶²¹³⁶² Phase 1 Report Volume II paragraphs 12.85-12.86 and 14.116.

Other emergency calls and information recorded at the incident ground

¶97.44 At 01.32 CRO Christine Howson answered an emergency call from Biruk Haftom, who was in Flat 201 at the time. He said, "My actual door number is 155 but I'm at someone else's house". Biruk Haftom reported that eight children and a lot of adults were in a flat on the top floor and that the window was already "burning up". He said they could not get out. He also reported a lot of smoke in the flat and in the building. CRO Howson told him and an adult who also spoke to her to try to stop smoke coming into the flat.¹³⁶³¹³⁶³ Phase 1 Report Volume II paragraphs 10.289 (d) and 11.28.

¶97.45 No service request appears to have been created in response to Biruk Haftom's call, but OM Norman rang CU8 at 01.35 and reported that there were eight children and a number of adults on the top floor and that smoke was entering their flat.¹³⁶⁴¹³⁶⁴ LFB Short Incident Log {MET00013830}; Phase 1 Report Volume II paragraphs 11.148-11.149. At 01.36, CRO Darby contacted appliance G261 and passed on that information.¹³⁶⁵¹³⁶⁵ Phase 1 Report Volume II paragraph 11.155.

¶97.46 FF Mandeep Singh arrived at the tower at 01.35 and was instructed to pass information about people needing to be rescued from the command unit to the bridgehead. He recalled having been handed telephones and speaking to residents inside the tower. During one such call, FF Singh spoke to a woman who gave her location as "the 23rd floor, doors 205 and 201". She said that she had brought all the occupants of floor 23 into her flat. FF Singh advised her to stay put.¹³⁶⁶¹³⁶⁶ Phase 1 Report Volume III paragraph 15.16; Singh {MET000083327/16-17} pages 16-17; A page from his notebook contains the following entry "23rd FLOOR ALL OCCUPANTS 205/201 [illegible] WM BRIAN O'KEITH WM (Illegible)".¹³⁶⁷¹³⁶⁷ Singh Exhibit MS/1 - pages from notebook {MET00013089/2}. In his witness statement FF Singh said that he thought the woman he had spoken to was the person who can be heard in a video recording saying that she will let people in. That was probably Rania Ibrahim, who was in fact in Flat 203, not Flat 201 or Flat 205.¹³⁶⁸¹³⁶⁸ Phase 1 Report Volume III paragraph 15.16; Singh {MET000083327/16-17} pages 16-17.

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¶97.47 WM Glynn Williams started to record information on the wall of the lobby on the ground floor at 02.15. He said the information had come from CU7. A photograph of the wall taken much later on in the incident includes the notation "201 23 11".¹³⁶⁹¹³⁶⁹ Phase 1 Report Volume II paragraphs 14.103-14.104 and Figure 14.5.

¶97.48 The bridgehead was moved from floor 2 to floor 3 at about 02.17, where it remained until 03.10.¹³⁷⁰¹³⁷⁰ Phase 1 Report Volume IV paragraphs 28.86-28.87. Messages were recorded on the wall of that floor. There is no reference to Flat 201 on the wall during that time.¹³⁷¹¹³⁷¹ Phase 1 Report Volume III Figure 15.7. Accordingly, it is likely that no further messages about Flat 201 were passed from CU7 to the bridgehead after 02.17.

¶97.49 After 03.00, the laminated sheet in CU7 was replaced by a whiteboard with a grid. A photograph of the whiteboard taken much later in the morning shows Flat 201 annotated with "11 1" and a red mark, which is difficult to read. The "11" is in green indicating 11 people and the "1" is in black indicating a child.¹³⁷²¹³⁷² Phase 1 Report Volume III Figure 16.5; Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}. The red mark may signify a "P" for priority.

People who died in or near Flat 201 Raymond (Moses) Bernard

¶Date of birth: 22 May 1954 (63 years old). Place of birth: Penal, Republic of Trinidad and Tobago. Gender: Male. Occupation: Retired electrical engineer. Usual address: Flat 201, floor 23, Grenfell Tower, London. Place of death: Flat 201, floor 23, Grenfell Tower, London. Time of death: About 02.45 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Background and composition of household

¶97.50 Born in Trinidad on 22 May 1954, Raymond (Moses) Bernard was 63 years old at the time of the fire. He came to the UK in 1969 to join his parents and completed his schooling here. At the age of 16, he began an electrical engineering apprenticeship working, once qualified, at the House of Lords and Buckingham Palace. A father of four, Moses Bernard had lived in Flat 201 for over 30 years. He lived there with his dog, Marley.¹³⁷³¹³⁷³ Tenancy Agreement {TMOH00001235}; Phase 1 Report Volume IV paragraphs 32.55 -32.58.

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Vulnerability

¶97.51 Moses Bernard had been diagnosed with arthritis ten years before his death in the fire. As a result, his mobility had deteriorated and he walked with the assistance of a cane. He had difficulty climbing stairs.¹³⁷⁴¹³⁷⁴ Bernard {IWS00002337/3} page 3, paragraphs 21-23.

¶97.52 Moses Bernard's sister, Sheramin Bernard, wrote to RBKC several years before the fire informing them of her brother's medical and mobility problems in an attempt to have him re-housed on medical grounds. Sheramin Bernard received no reply. No assessment or review was carried out in light of the information provided.¹³⁷⁵¹³⁷⁵ Bernard {IWS00002337/3-4} pages 3-4, paragraphs 21-24.

¶97.53 Rydon carried out surveys of residents during the refurbishment and compiled a list of their vulnerabilities in November 2014. They carried out a survey on Moses Bernard's home on 14 October 2014 and recorded that he had no problems with his health and no pets.¹³⁷⁶¹³⁷⁶ Rydon Residents Survey {RYD00024466/5}.

¶97.54 Moses Bernard was not identified as a vulnerable resident in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system.¹³⁷⁷¹³⁷⁷ Phase 1 Report Volume III paragraphs 20.65-20.66; David Noble Spreadsheet {TMO00862588}.

Events of 14 June 2017

¶97.55 Moses Bernard returned to Grenfell Tower in the early evening of 13 June 2017.¹³⁷⁸¹³⁷⁸ O'Riordan {MET00013136/3} page 3. It is uncertain when he first became aware of the fire but by about 01.30 he had offered refuge in his home to ten people.¹³⁷⁹¹³⁷⁹ Phase 1 Report Volume II paragraphs 10.257, 10.258, 10.260, 10.289 and 14.125.

¶97.56 Moses Bernard did not make any calls to the emergency services himself, but during the course of Biruk Haftom's call to the LFB control room at 01.32 he took over and spoke briefly to CRO Howson, when towards the end of the call she asked to speak to an adult. Moses Bernard told her that the fire was approaching and that smoke was coming through the window.¹³⁸⁰¹³⁸⁰ Phase 1 Report Volume II paragraph 11.28; Presentation relating to Raymond (Moses) Bernard {Day300/77:17}-{Day300/78:14}.

¶97.57 Jessica Urbano Ramirez was sheltering in the bedroom of Flat 201 during her extended call with CRO Russell. About 17 minutes into the call she referred to a man who may have been Moses Bernard. She said he could not talk to CRO Russell because he was struggling to breathe.¹³⁸¹¹³⁸¹ 999 call transcript {LFB00055504/32-33}.

Recovery and identification

¶97.58 The remains of Moses Bernard were recovered from the bedroom of Flat 201¹³⁸²¹³⁸² Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 14.. The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.¹³⁸³¹³⁸³ Interim certificate of the fact of death for Raymond Bernard {MET00065646}.

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Cause and time of death

¶97.59 The post-mortem report on Moses Bernard recorded a cause of death as "consistent with the effects of fire."¹³⁸⁴¹³⁸⁴ Bernard post-mortem report {COR00000150/5}. In the light of Professor Purser's evidence, we find that a more accurate description is inhalation of asphyxiant gases.

¶97.60 We are satisfied that Moses Bernard died at about 02.45 before suffering the direct effects of fire.¹³⁸⁵¹³⁸⁵ Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20.

Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris

Amal Ahmedin

¶Date of birth: 1 January 1982 (35 years old). Place of birth: Sudan. Gender: Female. Occupation: Retail assistant. Usual address: Flat 166, floor 18, Grenfell Tower, London. Place of death: Floor 23 lobby, Grenfell Tower, London. Time of death: Between about 02.20 and 02.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Amaya Tuccu Ahmedin

¶Date of birth: 25 February 2014 (3 years old). Place of birth: London, UK. Gender: Female. Occupation: N/A. Usual address: Flat 166, floor 18, Grenfell Tower, London. Place of death: Floor 23 lobby, Grenfell Tower, London. Time of death: Between about 02.20 and 02.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Amna Mahmud Idris

¶Date of birth: 1 January 1990 (27 years old). Place of birth: Eritrea Gender: Female. Occupation: Student.

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¶Usual address: Grafton Road, London W3. Place of death: Flat 201, floor 23 Grenfell Tower, London. Time of death: About 02.45 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Background and composition of household

¶97.61 Amal Ahmedin was born in Sudan on 1 January 1982 and was 35 years old in 2017. She lived in Flat 166 on floor 19 of Grenfell Tower with her daughter, Amaya Tuccu Ahmedin, who had been born in London on 25 February 2014 and was 3 years old when she died.¹³⁸⁶¹³⁸⁶ Phase 1 Report Volume IV paragraph 32.154. Mohamednur Tuccu, the husband of Amal Ahmedin and the father of Amaya Tuccu Ahmedin, was also in Grenfell Tower on the night of the fire, probably visiting his family. We have dealt with the circumstances of his death in Chapter 86.

¶97.62 On the evening of 13 June 2017, Amna Idris, Amal Ahmedin's cousin, was also visiting the family. Amna Idris had been born in Eritrea on 1 January 1990 and was 27 years old. She had joined her husband Ibrahim in London in March 2016.¹³⁸⁷¹³⁸⁷ Phase 1 Report Volume IV paragraphs 32.163-32.165.

Vulnerability

¶97.63 Amal Ahmedin had no known vulnerabilities. She and Amaya Tuccu Ahmedin both appeared in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system.¹³⁸⁸¹³⁸⁸ Noble {TMO00000884/1} page 1, paragraph 3. Amaya Tuccu Ahmedin's age (3 years) was recorded in the spreadsheet.¹³⁸⁹¹³⁸⁹ David Noble's list {TMO00862588}.

Events of 14 June 2017

¶97.64 Amal Ahmedin, Amna Idris and Amaya Tuccu Ahmedin all entered the tower on 13 June 2017. Mohamednur Tuccu entered the tower at 00.36 on 14 June 2017.¹³⁹⁰¹³⁹⁰ O'Riordan {MET00013136/2-4} pages 2-4.

¶97.65 Meron Mekonnen was a neighbour of Amal Ahmedin and Amaya Tuccu Ahmedin. She lived at Flat 163 on floor 19 and was alerted to the fire at 01.25 by telephone. When she left her flat, she saw Amal Ahmedin and Amna Idris in the lobby of floor 19. She did not see Mohamednur Tuccu. The door to Flat 166 (the home of Amal Ahmedin and Amaya Tuccu Ahmedin) was wide open. It had a door closer but it was not working. Amal Ahmedin and Meron Mekonnen told each other about the fire before Amal Ahmedin ran back into Flat 166.

¶97.66 That was the last time Meron Mekonnen saw Amal Ahmedin. Amna Idris followed Meron Mekonnen and her daughters into the stairwell, probably before 01.30. It is likely that Flat 166 was affected by the fire at an early stage and that Amal Ahmedin and Amaya Tuccu Ahmedin left soon after.¹³⁹¹¹³⁹¹ Phase 1 Report Volume II paragraphs 10.223, 10.255-10.257 and 10.289(e); Mekonnen {Day55/23:25}-{Day55/24:6}; BRE Investigation Report {MET00039807/77}.

172

¶97.67 There is no evidence that Mohamednur Tuccu was in Flat 166 when Meron Mekonnen saw Amal Ahmedin or that he was among those who made their way up the tower. He was, however, in the north lift when Rhea Rojo entered it on floor 12.¹³⁹²¹³⁹² Phase 1 Report Volume II paragraphs 10.219 and 10.224-10.225.

¶97.68 Amna Idris initially went down the stairs with a group of people including Meron Mekonnen and her children. At around floor 15 or floor 16, she heard a man shouting at them to go back and the group (including Amna Idris) began to run back upstairs. When she reached floor 19, Meron Mekonnen stopped and decided to go back downstairs again. She could not recall what Amna Idris had done at that time, but she must have gone upstairs to floor 23, as she was later seen in Flat 201 by Fadumo Ahmed.¹³⁹³¹³⁹³ Phase 1 Report Volume II paragraph 10.258; Mekonnen {IWS00000912/3-4} pages 3-4, paragraphs 17-20; Phase 1 Report Volume III Annex A.

¶97.69 Fadumo Ahmed, who lived in Flat 164 on floor 19, was made aware of the fire at around 01.20. When she left her flat, the lobby was full of thick, dark grey, steamy smoke which was hard to see through. She went up to floor 23 where she found that the smoke in the lobby was worse than it had been on floor 19. She recalled that Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris had been part of the group sheltering in Flat 201 by 01.30.¹³⁹⁴¹³⁹⁴ Phase 1 Report Volume II paragraphs 10.259-10.260 and 10.289; Phase 1 Report Volume III Annex A; External Fire Spread Report {MET00012593/12}.

¶97.70 In her call to CRO Russell that had started at 01.29, Jessica Urbano Ramirez said that the group in the bedroom of Flat 201 included a two-year-old child, whom she also referred to as a baby. Debbie Lamprell also referred to a baby in her call to CRO Jabin that had started at 01.41. It is likely that they were both referring to Amaya Tuccu Ahmedin.¹³⁹⁵¹³⁹⁵ Phase 1 Report Volume II paragraphs 12.66-12.67, 12.86, 14.127 and 14.132; 999 call transcript {LFB00055504/36-37}.

¶97.71 Between 01.50 and 02.20, Fadumo Ahmed left Flat 201. The remains of Amal Ahmedin and Amaya Tuccu Ahmedin were later found in the lobby of floor 23. It is not possible to determine at exactly what time Fadumo Ahmed left Flat 201 or whether Amal Ahmedin and Amaya Tuccu Ahmedin followed her out at the same time or left Flat 201 later.¹³⁹⁶¹³⁹⁶ Phase 1 Report Volume II paragraphs 14.128 and 14.132.

¶97.72 At around 02.00, Jessica Urbano Ramirez was still talking to CRO Russell, and was heard to ask someone in the room not to leave. CRO Russell asked if someone was leaving, and Jessica Urbano Ramirez replied to say she had been mistaken. It is possible though, that she had been referring to Amal Ahmedin and Amaya Tuccu Ahmedin. At about 02.06, Jessica Urbano Ramirez said that the fire was in the flat and later confirmed that flames were coming through the bedroom window. CRO Russell tried to persuade her to move to another room. She told CRO Russell that people had tried to leave but had been unable to do so because of the smoke.¹³⁹⁷¹³⁹⁷ Phase 1 Report Volume II paragraphs 14.132-14.134.

¶97.73 Meanwhile, Debbie Lamprell had told CRO Jabin at 02.01 that the windows were cracking and at 02.06 that the flat was on fire. CRO Jabin spoke to her team leader and told Debbie Lamprell to leave. Debbie Lamprell said she was unable to leave because people on the other side of the room were trying to get out. She confirmed that she was still in the bedroom.¹³⁹⁸¹³⁹⁸ Phase 1 Report Volume II paragraphs 12.86, 14.127 and 14.138-14.140. We do not know whether Debbie Lamprell was referring to Amal Ahmedin.

¶97.74 At some point Amal Ahmedin left Flat 201 with Amaya Tuccu Ahmedin. She was unable to cross the lobby on floor 23 and collapsed there. Amna Idris remained in Flat 201.

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Recovery and identification

¶97.75 The remains of Amal Ahmedin and Amaya Tuccu Ahmedin were recovered from the communal lobby on floor 23.¹³⁹⁹¹³⁹⁹ Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 16. The remains of Amna Idris were recovered from the bedroom of Flat 201.¹⁴⁰⁰¹⁴⁰⁰ Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 14. The coroner was satisfied about the identification of the remains recovered and therefore issued interim certificates of the fact of death in respect of Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris.¹⁴⁰¹¹⁴⁰¹ Interim certificates of the fact of death for Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris {MET00065590}; {MET00065639} and {MET00065591}.

Cause and time of death

¶97.76 Conditions in Flat 201 were deteriorating quite seriously at and after the time that Fadumo Ahmed left. If Amal Ahmedin and Amaya Tuccu Ahmedin left Flat 201 at any time after about 02.00, they would already have accumulated a significant proportion of the amount of asphyxiating gases needed to incapacitate them. We think it likely that they left Flat 201 between about 02.00 and 02.10, when the fire reached the bedroom window and conditions further deteriorated. By that time even the effort involved in getting up and walking from the flat into the lobby could have been sufficient to result in immediate collapse. Their remains were recovered from the lobby just outside Flat 201.¹⁴⁰²¹⁴⁰² Purser, Phase 2 Report, Section 6 {DAPR0000006/10} paragraphs 21 and 24; {DAPR0000006/11} paragraphs 26-28.

¶97.77 The post-mortems on Amal Ahmedin, Amaya Tuccu Ahmedin and Amna Idris recorded the cause of death in each case 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". Toxicological testing was only possible for Amna Idris. That showed a level of blood carboxyhaemoglobin in her blood of 68%.¹⁴⁰³¹⁴⁰³ Amal Ahmedin post-mortem report {COR00000111/5-7}; Amal Ahmedin post-mortem report {COR00000111/5-7}; Amna Idris post-mortem report {COR00000155/3-8}.

¶97.78 We are satisfied that Amal Ahmedin and Amaya Tuccu Ahmedin died between about 02.20 and 02.30 and that Amna Idris died at about 02.45.¹⁴⁰⁴¹⁴⁰⁴ Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20; Purser {Day296/28:15}-{Day296/29:8}.

Berkti Haftom and Biruk Haftom

Berkti Haftom

¶Date of birth: 2 November 1987 (29 years old). Place of birth: Asmara, Eritrea. Gender: Female. Occupation: Cleaner / Catering. Usual address: Flat 155, floor 18, Grenfell Tower, London. Place of death: Flat 201, floor 23, Grenfell Tower, London. Time of death: About 02.45 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

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Biruk Haftom

¶Date of birth: 27 April 2005 (12 years old). Place of birth: London, UK. Gender: Male. Occupation: Student. Usual address: Flat 155, floor 18, Grenfell Tower, London. Place of death: Flat 201, floor 23 Grenfell Tower, London. Time of death: About 02.45 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Background and composition of household

¶97.79 Berkti Haftom was born on 2 November 1987 in Eritrea and was 29 years old. Her son Biruk was born on 27 April in London and was 12 years old. They had lived in Flat 155 on floor 18 of Grenfell Tower since 2007. At the time of the fire, they were living in Flat 155 with Berkti's partner Michele Chiapetto and a lodger, Yehualashet Enyew. Berkti Haftom was pregnant at the time of the fire.¹⁴⁰⁵¹⁴⁰⁵ Phase 1 Report Volume IV paragraphs 32.197-32.198 and 32.203; Tenancy Agreement {TMOH00026234}.

Vulnerability

¶Both Berkti and her son appear on the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system.¹⁴⁰⁶¹⁴⁰⁶ Noble {Day119/77:17}-{Day119/82:5}. Biruk Haftom's age (12 years) was recorded.¹⁴⁰⁷¹⁴⁰⁷ Noble spreadsheet {TMO00866002}. Neither had any known vulnerabilities.

Events of 14 June 2017

¶97.80 Berkti Haftom and Biruk Haftom both returned to Grenfell Tower during the evening of 13 June 2017.¹⁴⁰⁸¹⁴⁰⁸ O'Riordan {MET00013136/3} page 3.

¶97.81 Yehualashet Enyew was awoken at about 01.15 on 14 June 2017 by the smell of smoke. He alerted Berkti Haftom to the fire at about 01.20. As he prepared to leave, he heard Berkti Haftom calling him from the hallway and then heard the door slam. When he left Flat 155, probably at about 01.30 or soon after, Berkti and Biruk Haftom were not in the lobby. At that point he found the stairwell filled with thick, choking smoke.¹⁴⁰⁹¹⁴⁰⁹ Phase 1 Report Volume II paragraphs 10.253 and 11.58-11.60.

¶97.82 At some point before 01.27, Berkti and Biruk Haftom met Jessica Urbano Ramirez. She used Berkti Haftom's phone to make an emergency call at 01.27,¹⁴¹⁰¹⁴¹⁰ 999 call transcript {MET00015554}. but the call was disconnected before the operator could put it through to the LFB.¹⁴¹¹¹⁴¹¹ 999 call transcript {LFB00000481}. When Jessica called her mother, Adriana Ramirez, shortly afterwards, she said that she was on floor 18. Adriana Ramirez could hear voices in the background, which were probably those of Berkti and Biruk Haftom.¹⁴¹²¹⁴¹² Phase 1 Report Volume II paragraph 10.289 (f); Ramirez {IWS00001116/4-5} pages 4-5, paragraphs 21 and 22.

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¶97.83 Shah and Sayeda Ahmed, who lived in Flat 156 on floor 18, were woken by the smoke alarms in their flat. They left their flat at about 01.27 and knocked on their neighbours' doors. There was no answer from Flat 155, so Berkti and Biruk Haftom had probably already left Flat 155 to go upstairs.¹⁴¹³¹⁴¹³ Phase 1 Report Volume II paragraphs 10.249-10.250, 10.254 and 10.289 (b).

¶97.84 Berkti Haftom, Biruk Haftom and Jessica Urbano Ramirez probably all reached floor 23 before 01.30.¹⁴¹⁴¹⁴¹⁴ Phase 1 Report Volume II paragraph 10.289. CRO Russell's call to Jessica Urbano Ramirez at 01.29 was made on Berkti Haftom's telephone.¹⁴¹⁵¹⁴¹⁵ Phase 1 Report Volume II paragraph 10.289 (f). By that time, Jessica Urbano Ramirez was in Flat 201. When Fadumo Ahmed reached Flat 201 she joined a group in the hallway that included Berkti and Biruk Haftom.¹⁴¹⁶¹⁴¹⁶ Phase 1 Report Volume II paragraphs 10.259-10.260.

¶97.85 Biruk Haftom spoke to CRO Howson at 01.32 from Flat 201. He told her that he lived in Flat 155 but was calling from someone else's flat. He told her that there were eight children and a lot of adults in a flat on the top floor and that the window was already burning up. He said that there was a lot of smoke in the flat and in the building and that they could not get out. CRO Howson told him and the adult to whom she also spoke briefly to try to stop smoke coming into the flat.¹⁴¹⁷¹⁴¹⁷ Phase 1 Report Volume II paragraphs 10.289 (d) and 11.28. There is no evidence that Berkti Haftom contacted the emergency services.

¶97.86 Michele Chiapetto (Berkti Haftom's partner) and the family of Berkti and Biruk Haftom made several unsuccessful attempts to contact them by phone during the night. Berkti Haftom's phone stopped ringing at about 07.00.¹⁴¹⁸¹⁴¹⁸ Chiapetto {IWS00000679/2-4} pages 2-4, paragraphs 10-17; Semre {IWS00000954/4} page 4, paragraphs 24-25.

Recovery and identification

¶97.87 The remains of Berkti and Biruk Haftom were recovered from the bedroom of Flat 201.¹⁴¹⁹¹⁴¹⁹ Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 14.

¶97.88 The coroner was satisfied about their identification and therefore issued interim certificates of the fact of death for Berkti and Biruk Haftom.¹⁴²⁰¹⁴²⁰ Interim certificates of the fact of death for Berkti and Biruk Haftom {MET00065608}; {MET00065623}.

Cause and time of death

¶97.89 We are satisfied that the occupants of Flat 201, including Berkti and Biruk Haftom, had died by about 02.45 as the result of the inhalation of asphyxiant gases before they suffered from the direct effect of the flames.¹⁴²¹¹⁴²¹ Purser, Phase 2 Report, Section 6 {DAPR0000006/13} paragraph 38; Purser {Day296/28:15}-{Day296/29:8}.

¶97.90 The post-mortem recorded causes of death for both Berkti and Biruk Haftom as "consistent with the effects of a fire",¹⁴²²¹⁴²² Berkti Haftom post-mortem report {COR00000216/5}; Biruk Haftom post-mortem report {COR00000240/3}. but in the light of Professor Purser's evidence we find that a more accurate description is "inhalation of asphyxiant gases".

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Hamid Kani

¶Date of birth: 24 January 1956 (61 years). Place of birth: Shahr-e-Ray, Iran. Gender: Male. Occupation: Retired. Usual address: Flat 154, floor 18, Grenfell Tower, London. Place of death: Flat 201, floor 23, Grenfell Tower, London. Time of death: About 02.45 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Background and composition of the household

¶97.91 Hamid Kani had been the sole tenant of Flat 154 on floor 18 since 10 September 1990.¹⁴²³¹⁴²³ Tenancy agreement {TMOH00026143}. He lived alone. Having been born in Iran on 24 January 1956, he had come to London in the 1970s to study. In the 1980s he had been an actor and comedian but later changed careers, working in restaurants as a chef.¹⁴²⁴¹⁴²⁴ Phase 1 Report Volume IV paragraphs 32.204-23.209.

Vulnerability

¶97.92 Hamid Kani suffered from backache and hip pain, making it difficult for him to climb stairs.¹⁴²⁵¹⁴²⁵ GP Letter dated 23 July 1990 {TMOH00026128}. He included a reference to his disability in the tenancy information form he completed on 23 April 2015.¹⁴²⁶¹⁴²⁶ KCTMO Tenancy Information form {TMOH00026145/10}. He was not identified as vulnerable in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system.¹⁴²⁷¹⁴²⁷ Phase 1 Report Volume III paragraphs 20.65–20.66; David Noble Spreadsheet {TMO00866002}.

Events of 14 June 2017

¶97.93 Hamid Kani returned to Grenfell Tower for the last time in the early evening of 13 June 2017.¹⁴²⁸¹⁴²⁸ O'Riordan {MET00013136/3} page 3.

¶97.94 When Shah and Sayeda Ahmed left their flat and knocked on their neighbours' doors at about 01.27, Hamid Kani opened his door in response. He had therefore been alerted to the fire by 01.27.¹⁴²⁹¹⁴²⁹ This timing is derived from the fact that at 01.27 the MPS operator asked the BT operator for a playback of Shah Ahmed's 999 call, in which Shah Ahmed had not spoken to the BT operator. Phase 1 Report Volume II paragraphs 10.249-10.250 and 10.289 (b).

¶97.95 Hamid Kani went up to floor 23 to take shelter and was able to enter Flat 201. He probably got there by about 01.30 and did not leave.¹⁴³⁰¹⁴³⁰ Phase 1 Report Volume II paragraphs 14.125 and 10.287-10.289.

¶97.96 There is no evidence that he spoke to the emergency services or to relatives or friends during the fire.

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Recovery and identification

¶97.97 The remains of Hamid Kani were recovered from between the bedroom area and the entrance to the bathroom from the hall of Flat 201.¹⁴³¹¹⁴³¹ Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 14. The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.¹⁴³²¹⁴³² Interim certificate of the fact of death for Hamid Kani {MET00065623}.

Cause and time of death

¶97.98 Hamid Kani was in a protected location in the hallway and bathroom area of the flat and was therefore more shielded from exposure to the heat. We are satisfied that he died at about 02.45, before suffering the direct effects of fire.¹⁴³³¹⁴³³ Purser, Phase 2 Report, Section 6 {DAPR0000006/13} paragraph 38; Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20.

¶97.99 The post-mortem report on Hamid Kani recorded the cause of death as "consistent with the effects of fire"¹⁴³⁴¹⁴³⁴ Kani post-mortem report {COR00000566/7}. but in the light of Professor Purser's evidence we find that a more accurate description is "inhalation of asphyxiant gases".

Debbie Lamprell

¶Date of birth: 3 August 1971 (45 years). Place of birth: Walthamstow, London. Gender: Female. Occupation: Personal Assistant / Safety Officer. Usual address: Flat 161, floor 19 Grenfell Tower, London. Place of death: Flat 201, floor 23 Grenfell Tower, London. Time of death: Between 02.20 and 02.45 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Background and composition of household

¶97.100 Debbie Lamprell grew up as an only child in Highams Park. She worked as a safety officer at the Holland Park Opera. She had lived in Flat 161 on floor 19 of Grenfell Tower since 2005.¹⁴³⁵¹⁴³⁵ External Fire Spread Report {MET00012593/12}; Phase 1 Report Volume IV paragraphs 32.186-32.189; Presentation relating to Debbie Lamprell {Day300/1:21}-{Day300/2:20}.

Vulnerability

¶97.101 Debbie Lamprell had no known vulnerabilities.

178

Events of 14 June 2017

¶97.102 Debbie Lamprell returned from work at 22.57 on 13 June 2017. Her friend Gary Maunders was visiting her that night. He also died in the fire.¹⁴³⁶¹⁴³⁶ O'Riordan {MET00013136/4} page 4; Presentation relating to Debbie Lamprell {Day300/2:21-25}; Phase 1 Report Volume II paragraph 14.136; Phase 1 Report Volume III Annex A.

¶97.103 Fadumo Ahmed was Debbie Lamprell's neighbour and lived in Flat 164 on floor 19. She first became aware of the fire at around 01.20. When she left her flat, the lobby was full of thick, dark grey, steamy smoke that was hard to see through. Fadumo Ahmed saw Debbie Lamprell, who said people were going upstairs. Fadumo Ahmed said that Debbie Lamprell was not panicking, but behaved as if she had received instructions to go upstairs. Fadumo Ahmed and Debbie Lamprell went upstairs together. There was only a little bit of smoke in the stairwell between floors 19 and 23. Fadumo Ahmed said that she saw nobody other than Debbie Lamprell on the stairs.¹⁴³⁷¹⁴³⁷ Phase 1 Report Volume II paragraphs 10.259-10.260. However, Debbie Lamprell later told CRO Jabin that she and her friend had gone up together, which suggests that Gary Maunders may have also climbed the stairs with Fadumo Ahmed and Debbie Lamprell.¹⁴³⁸¹⁴³⁸ 999 call transcript {LFB00055500/29}.

¶97.104 Fadumo Ahmed and Debbie Lamprell joined a group of people sheltering in the hallway of Flat 201 on floor 23. Debbie Lamprell probably reached Flat 201 at about 01.30 or soon after.¹⁴³⁹¹⁴³⁹ Phase 1 Report Volume II paragraphs 10.259-10.260 and 10.289.

¶97.105 Gary Maunders moved to Flat 203 at around 01.39.¹⁴⁴⁰¹⁴⁴⁰ Phase 1 Report Volume II paragraphs 11.30-11.31. At about that time, Debbie Lamprell made an emergency call which lasted for under a minute. She was heard to shout for Gary, which indicates that she had lost contact with Gary Maunders by that time.¹⁴⁴¹¹⁴⁴¹ 999 call transcript {COR00000269}.

¶97.106 At 01.41 a BT operator spoke to North West Fire Control and said that a caller asking to speak to the LFB had hung up after waiting for around five minutes.¹⁴⁴²¹⁴⁴² Phase 1 Report Volume II paragraphs 12.66-12.67; 999 call transcript {MET00014977}. The number belonged to Debbie Lamprell. When CRO Aisha Jabin called the number back, Debbie Lamprell answered and they spoke for over 40 minutes. During that call there was a misunderstanding about Debbie Lamprell's location. She first gave her location as Flat 161 on floor 23, but later corrected that to Flat 201 on floor 23. Unfortunately, the correct location was not passed from North West Fire Control to the LFB control room. As a result, just before 02.10 FFs Roots and Johnson were sent to Flat 161 on floor 19 but there was no one there.¹⁴⁴³¹⁴⁴³ Phase 1 Report Volume II paragraphs 12.85-12.86 and 14.116.

¶97.107 At about 01.55, Debbie Lamprell told CRO Jabin that the smoke was making it difficult for everyone to breathe and that the fire was "burning through the windows".¹⁴⁴⁴¹⁴⁴⁴ Phase 1 Report Volume II paragraph 12.64.

¶97.108 At 02.01 Debbie Lamprell told CRO Jabin that the windows were cracking and at about 02.05 she said that she had lost her friend; he had disappeared and she did not know where he was. They had come up together, but he had gone.¹⁴⁴⁵¹⁴⁴⁵ Phase 1 Report Volume II paragraphs 14.127 and 14.138; 999 call transcript {LFB00055500/26-29}. She must have been referring to Gary Maunders, who by then had already moved to Flat 203.

179

¶97.109 At 02.06 Debbie Lamprell told CRO Jabin that she could feel the heat and that the flat was on fire. CRO Jabin spoke to her team leader and then advised Debbie Lamprell to leave. She tried to leave the bedroom and could be heard telling someone to move out of the way of the door. Debbie Lamprell said that people on the other side of the room were trying to get out and that was why she could not get out. She confirmed that she was still on the floor in the bedroom. She stopped responding at about 02.20, just before the end of the call. That was the last known contact anybody had with Debbie Lamprell.¹⁴⁴⁶¹⁴⁴⁶ Phase 1 Report Volume II paragraphs 14.138-14.140; 999 call transcript {LFB00055500/42-43}.

Recovery and identification

¶97.110 The remains of Debbie Lamprell were recovered from the bedroom of Flat 201.¹⁴⁴⁷¹⁴⁴⁷ Archaeology Report Volume 2 {COR00001585/190}. The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death for Debbie Lamprell.¹⁴⁴⁸¹⁴⁴⁸ Interim certificate of the fact of death for Debbie Lamprell {MET00065596}.

Cause and time of death

¶97.111 Toxicology analysis was not possible.¹⁴⁴⁹¹⁴⁴⁹ Coroner's report for Lamprell {COR00000254/7}. The post-mortem on Debbie Lamprell recorded the medical cause of death as "consistent with the effects of fire,"¹⁴⁵⁰¹⁴⁵⁰ Lamprell post-mortem report {COR00000263/6-7}. but in the light of Professor Purser's evidence we find that a more accurate description is "inhalation of asphyxiant gases".

¶97.112 We find that Debbie Lamprell probably lost consciousness due to the effects of asphyxiant gases at about 02.20 when she stopped responding to CRO Jabin. We are satisfied that she died between 02.20 and 02.45¹⁴⁵¹¹⁴⁵¹ Purser {Day297/12:14-25}. before suffering the direct effects of fire.¹⁴⁵²¹⁴⁵² Purser, Phase 2 Report, Section 6 {DAPR0000006/13} paragraph 38; Purser {Day296/28:15}-{Day296/29:8}.

Jessica Urbano Ramirez

¶Date of birth: 4 July 2004 (12 years old).

¶Place of birth: London, UK.

¶Gender: Female.

¶Occupation: Student.

¶Usual address: Flat 176, floor 20, Grenfell Tower, London.

¶Place of death: Flat 201, floor 23, Grenfell Tower, London.

¶Time of death: Between 02.17 and 02.45 on 14 June 2017.

¶Cause of death: Inhalation of asphyxiant gases.

180

Background and composition of household

¶97.113 Jessica Urbano Ramirez lived in Flat 176 on floor 20 with her family. She moved into Grenfell Tower in September 2013 with her mother, Adriana Ramirez, her father Ramiro Urbano and her sister Melanie.¹⁴⁵³¹⁴⁵³ Tenancy Agreement {IWS00002062/7}. At the time of the fire, she was looking forward to celebrating her 13th birthday with her friends.¹⁴⁵⁴¹⁴⁵⁴ Phase 1 Report Volume IV paragraph 32.132.

Vulnerability

¶97.114 Jessica Urbano Ramirez appeared in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system as a child and was known to be under 18. She had no other known vulnerabilities.

Events of 14 June 2017

¶97.115 On 13 June 2017, Jessica Urbano Ramirez returned to Grenfell Tower at 18.20.¹⁴⁵⁵¹⁴⁵⁵ O'Riordan {MET00013136/3} page 3. Adriana Ramirez and Melanie Urbano Ramirez were at home at the time. Adriana Ramirez left at around 18.30 to go to work.¹⁴⁵⁶¹⁴⁵⁶ Ramirez {IWS00001116/4} page 4, paragraph 18; Ramirez {MET00007773/3} page 3. Melanie Urbano Ramirez stayed at the flat until about 22.00 when she also went out.¹⁴⁵⁷¹⁴⁵⁷ Ramirez {IWS00001116/4} page 4, paragraph 20; {MET00007773/3} page 3. Adriana Ramirez returned home at about midnight and checked on Jessica, who was asleep. She left the flat again at about 00.40 to take some medicine to the home of a friend who lived nearby.¹⁴⁵⁸¹⁴⁵⁸ Ramirez {IWS00001116/4} page 4, paragraph 19; {MET00007773/4} page 4. Jessica remained alone in the flat.

¶97.116 At some time before 01.27, Jessica Urbano Ramirez met Berkti and Biruk Haftom. At 01.27 she used Berkti Haftom's phone to make an emergency call¹⁴⁵⁹¹⁴⁵⁹ 999 call transcript {MET00015554}. before calling her mother.¹⁴⁶⁰¹⁴⁶⁰ 999 call transcript {COR00000774}. The call was disconnected before the BT operator could connect it to the LFB. The BT operator contacted the LFB control room at 01.29 and spoke to CRO Russell telling her that the caller was a child and had asked for the fire brigade. CRO Russell agreed to call the number back.¹⁴⁶¹¹⁴⁶¹ 999 call transcript {LFB00000481}.

¶97.117 Jessica Urbano Ramirez then called her mother and told her that she was on the "landing" on floor 18.¹⁴⁶²¹⁴⁶² Ramirez {IWS00001116/4-5} page 4-5, paragraph 21. They agreed that she should come down the stairs.¹⁴⁶³¹⁴⁶³ Ramirez {IWS00001116/4-5} page 4-5, paragraph 21; Phase 1 Report Volume II paragraph 10.289(f). However, instead of continuing down to the ground floor, Jessica went up to floor 23 with Berkti and Biruk Haftom and a group of other residents. She probably reached floor 23 by 01.30.¹⁴⁶⁴¹⁴⁶⁴ Phase 1 Report Volume II paragraph 10.289.

¶97.118 At 01.29, CRO Russell called Berkti Haftom; the call was answered by Jessica Urbano Ramirez.¹⁴⁶⁵¹⁴⁶⁵ Phase 1 Report Volume II paragraph 10.289(f). The call probably interrupted Jessica's call with her mother as she answered the call saying 'Mum' three times and CRO Russell's call overlapped in time with Jessica's call to Adriana Ramirez.

¶97.119 The call between CRO Russell and Jessica Urbano Ramirez lasted 55 minutes. During the first 10 minutes of the call (between 01.30 and 01.40), Jessica told CRO Russell that she was in the hallway of a flat on floor 23 with about 10 other people. She later identified it as Flat 201.¹⁴⁶⁶¹⁴⁶⁶ Phase 1 Report Volume II paragraphs 10.317 and 11.25. She said that smoke was coming "from the floor" and that people were having difficulty breathing. Jessica and the group of people in Flat 201 moved from the hallway to the bedroom.

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¶97.120 Adriana Ramirez said that she spoke to Jessica a second time about 10 minutes later.¹⁴⁶⁷¹⁴⁶⁷ Ramirez {IWS00001116/5} page 5, paragraph 22. The call records for Berkti Haftom's phone show that she called Jessica back and it is likely that they spoke while the call with CRO Russell was on hold for a short period of time.¹⁴⁶⁸¹⁴⁶⁸ 999 call transcript {LFB00055504/19}.

¶97.121 While the call was in progress, FF David Badillo from North Kensington made an attempt to rescue Jessica, who was still believed to be in Flat 176. At 01.26, he met Melanie Urbano Ramirez, Jessica's sister, outside the tower. She gave him the keys to Flat 176 on floor 20 and told him that her sister was still there. At 01.27 FF Badillo went into the tower to rescue Jessica Urbano Ramirez.¹⁴⁶⁹¹⁴⁶⁹ Phase 1 Report Volume II paragraph 10.79 (b). He was not able to make it to floor 20 immediately. He tried to take the lift to floor 20 but it stopped on floor 15 and the lift filled with black smoke. He found his way to the lobby doors and went down the stairs and out of the tower to get BA equipment.¹⁴⁷⁰¹⁴⁷⁰ Phase 1 Report Volume II paragraph 10.101 (a). He returned to the tower with BA equipment and recruited CM Christopher Secrett and FF Christopher Dorgu to go to Flat 176 with him.¹⁴⁷¹¹⁴⁷¹ Phase 1 Report Volume II paragraph 11.10. They tallied out between 01.33 to 01.35.

¶97.122 When the crew reached floor 20 they found that the communal lobby and Flat 176 were smoke logged. They searched Flat 176 after finding the front door slightly ajar.¹⁴⁷²¹⁴⁷² Phase 1 Report Volume II paragraphs 12.6, 12.30 and 13.16. They did not find anyone in Flat 176 and returned to the ground floor. Their end of wear time was 01.57.¹⁴⁷³¹⁴⁷³ Phase 1 Report Volume II paragraph 13.16. No information about the emergency call from Jessica Urbano Ramirez reached the crew during their deployment.¹⁴⁷⁴¹⁴⁷⁴ Phase 1 Report Volume II paragraph 13.17.

¶97.123 At 02.01, Jessica Urbano Ramirez was still talking to CRO Russell.¹⁴⁷⁵¹⁴⁷⁵ Phase 1 Report Volume II paragraph 14.133. She repeatedly said that she was having difficulty breathing.¹⁴⁷⁶¹⁴⁷⁶ Phase 1 Report Volume II paragraph 14.133.

¶97.124 At 02.06, Jessica Urbano Ramirez and Debbie Lamprell each reported separately that the flat was on fire.¹⁴⁷⁷¹⁴⁷⁷ Phase 1 Report Volume II paragraphs 14.134 and 14.138. Jessica said that people had tried to leave but could not do so because of the smoke.¹⁴⁷⁸¹⁴⁷⁸ Phase 1 Report Volume II paragraph 14.134. She stopped responding to CRO Russell at around 02.17 but could be heard breathing until 02.24.¹⁴⁷⁹¹⁴⁷⁹ 999 call transcript {LFB00055504/76-82}.

Recovery and identification

¶97.125 The remains of Jessica Urbano Ramirez and others were recovered from the bedroom of Flat 201.¹⁴⁸⁰¹⁴⁸⁰ Purser, Phase 2 Report, Section 6 {DAPR0000006/8} paragraph 14. The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.¹⁴⁸¹¹⁴⁸¹ Interim certificate of the fact of death for Jessica Urbano Ramirez {MET00065625}.

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Cause and time of death

¶97.126 The post-mortem on Jessica Urbano Ramirez noted that it was not possible to be definite on the cause of death due to the condition of the remains, but that their appearance was consistent with the effects of fire.¹⁴⁸²¹⁴⁸² Ramirez post-mortem report {COR00000770/3}. It was not possible to carry out toxicological analysis or DNA testing.

¶97.127 The post-mortem report recorded the medical cause of death as being consistent with the effects of a fire. However, in the light of Professor Purser's evidence we find that the cause of death is more accurately expressed as inhalation of asphyxiant gases.

¶97.128 Jessica probably lost consciousness due to the inhalation of asphyxiant gases at around 02.17 when she stopped responding to CRO Russell. She would have continued to inhale those gases while unconscious until she died.¹⁴⁸³¹⁴⁸³ Purser, Phase 2 Report, Section 6 {DAPR0000006/13-17} paragraphs 36–58.

¶97.129 Professor Purser estimated that the level of carboxyhaemoglobin in Jessica Urbano Ramirez's blood had exceeded the lethal threshold of 50% by about 02.23 and that she had died by 02.45.¹⁴⁸⁴¹⁴⁸⁴ Purser, Phase 2 Report, Section 6 {DAPR0000006/14} paragraph 48; Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20; Purser, Phase 2 Report, Section 6 {DAPR0000006/15} Figure 28; Purser {Day297/12:14-25}. While the time of death might be different for children, he observed that she had lost consciousness at about the same time as Debbie Lamprell and there may not have been much difference in the time of death.¹⁴⁸⁵¹⁴⁸⁵ Purser {Day297/13:4-18}.

¶97.130 In the light of Professor Purser's evidence we are satisfied that Jessica Urbano Ramirez died between 02.17 and 02.45 before suffering the direct effects of fire.

Flat 202

¶97.131 Flat 202 on floor 23 had two bedrooms and was situated in the south-east corner of the tower. It was the home of Gimja Tekie, who was not present during the night of the fire. Gloria Trevisan and Marco Gottardi had been living in Flat 202 since April 2017.¹⁴⁸⁶¹⁴⁸⁶ External Fire Spread Report {MET00012593/12}; Phase 1 Report Volume IV paragraph 32.50; Disaró {IWS00000543/3} page 3, paragraphs 8-9; External Fire Spread Report {MET00012593/12}; Tekie {IWS00000953/3} page 3, paragraph 16.

¶97.132 By 02.10, Flat 202 had become affected by the spread of the fire on the outside of the building.¹⁴⁸⁷¹⁴⁸⁷ Phase 1 Report Volume II paragraph 14.3. It spread across the east face of the kitchen and living room of Flat 202 from about 02.10. It moved across the south face of the living room between about 02.33 and 02.51 and had spread across the bedrooms by 02.55.¹⁴⁸⁸¹⁴⁸⁸ Purser, Phase 2 Report, Section 6 {DAPR0000006/18} paragraph 63.

Those who sheltered in Flat 202

¶97.133 On the night of the fire, Majorie and Ernie Vital took shelter with Gloria Trevisan and Marco Gottardi. They had moved upstairs from their own flat on floor 19.¹⁴⁸⁹¹⁴⁸⁹ Phase 1 Report Volume II paragraphs 10.287 and 10.289 (g).

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Conditions and events on 14 June 2017

¶97.134 By approximately 01.25 the fire had reached the top of floor 19, where Flat 162, Majorie Vital's home, was situated.¹⁴⁹⁰¹⁴⁹⁰ Phase 1 Report Volume II paragraph 10.118. There is no evidence that Majorie or Ernie Vital made contact with the emergency services, members of their family or friends on the night of the fire. At about 01.30, they went upstairs to floor 23.¹⁴⁹¹¹⁴⁹¹ Phase 1 Report Volume II paragraphs 14.125 and 10.287-10.289; External Fire Spread Report {MET00012593/12}. Fadumo Ahmed identified Ernie Vital as one of the people she had seen gathered inside or outside one of the flats on floor 23.¹⁴⁹²¹⁴⁹² Ahmed post-mortem report {MWP00000034/3}; Ahmed {COR00000103/1} page 1; Foley {COR00000304/1} page 1.

¶97.135 Ernie and Majorie Vital had knocked at the door and sought shelter in Flat 202. When Gloria Trevisan and Marco Gottardi opened the door, they found the lobby filled with a thick, dense smoke.¹⁴⁹³¹⁴⁹³ Phase 1 Report Volume II paragraph 11.35.

¶97.136 Gloria Trevisan's parents were in Italy. Gloria called her mother, Emanuela Disaró, at 01.34 from Flat 202; the call lasted for just under 31 minutes. She told her mother that there were firefighters downstairs. She said they had been told to stay inside. It is not clear where that information came from. She said that they could not leave because of the smoke or go to the roof because the gate to the roof was locked. They made signs to attract attention.¹⁴⁹⁴¹⁴⁹⁴ Phase 1 Report Volume II paragraphs 10.287-10.289, 11.35, 14.125 and 14.141; Disaró {IWS00000543/6} page 6, paragraphs 20-21.

¶97.137 Rania Ibrahim lived in Flat 203, a neighbouring flat on floor 23. At 01.38, she started to live stream on Facebook. A little over one minute into the recording, she opened her front door and called out into the lobby "Hello" and "Come here". When Emanuela Disaró watched the video she thought that she could hear Marco Gottardi responding to Rania Ibrahim's shouts, saying "We are here, we are inside my apartment."¹⁴⁹⁵¹⁴⁹⁵ Phase 1 Report Volume II paragraphs 11.29-11.35; External Fire Spread Report {MET00012593/12}. They remained in Flat 202.

¶97.138 Gloria Trevisan made a video call to her parents at 02.13. She said the fire was large and had reached floor 23. Black smoke was entering the flat through the living room windows. Emanuela Disaró could hear her daughter coughing. Gloria Trevisan was having difficulty breathing. Emanuela Disaró could hear Marco Gottardi speaking to Ernie Vital in the background. She heard Marco Gottardi ask whether there was anyone in another apartment and then say that he would go out to ask. Then Emanuela Disaró heard Marco Gottardi say in English "I tried but there's too much smoke."¹⁴⁹⁶¹⁴⁹⁶ Phase 1 Report Volume II paragraphs 14.142-14.143.

¶97.139 At 02.45 Gloria Trevisan began her last call from Flat 202 to her parents. It lasted for almost 23 minutes, until 03.08. She told her mother that Majorie and Ernie Vital and Marco Gottardi were still with her. Marco was also speaking to his parents. Gloria said that smoke was coming from everywhere and that there was no way out. The flat was full of smoke. She could see the fire outside the window. They had shut the window because pieces of glass had been coming in. Gloria's eyes and throat were burning and hurting. She was having difficulty breathing. She said that the fire had come through the window. That was the last contact she had with either of her parents.¹⁴⁹⁷¹⁴⁹⁷ Phase 1 Report Volume III paragraphs 16.21 and 16.23.

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¶97.140 Marco Gottardi spoke to his father, Giannino Gottardi, at some point after 02.45. He told his father that they had not left the building because there was too much smoke and they had been told to stay put. He said he had filled the bath with water. The last call between Marco Gottardi and his father started at 03.15 and was brief.¹⁴⁹⁸¹⁴⁹⁸ Phase 1 Report Volume III paragraphs 16.25 and 17.30. That was the last known contact with anyone in Flat 202.

Information at the incident ground

¶97.141 Emanuela Disaró asked Gloria Trevisan during their last conversation whether they had made others aware that they were in the flat. Gloria Trevisan said that she had, and she asked the others in the flat the same question. Emanuela Disaró could not hear their responses. There is no record of any calls to the emergency services from any of those trapped in Flat 202.¹⁴⁹⁹¹⁴⁹⁹ Phase 1 Report Volume III paragraph 16.22. Calls to the emergency services were made by and on behalf of people trapped in Flats 201, 203, 204 and 205 on floor 23. Information about people trapped in all of these flats was recorded at the incident ground: Phase 1 Report Volume II Figure 12.3.

¶97.142 The LFB was aware of conditions on floor 23 in general. In response to information received from emergency calls about seven people unable to leave Flat 205 on floor 23 (among other flats on other floors), a message was sent by radio to command unit CU8 at 01.43. CU8 confirmed receipt of that message confirming "the 23rd floor" and "heavy smoke logging".¹⁵⁰⁰¹⁵⁰⁰ LFB Control Room Report {LFB00004790/43-46}.

¶97.143 Between 02.01 and 02.02, CROs Gotts and Howson received calls from members of the public saying that they could see people at the top of the tower waving and signalling for help. In one call people were said to be on top of the building. As a result, a service request was created at 02.05 saying "Reports of people on the roof of the building". CRO Darby passed that message to the incident ground at 02.05.¹⁵⁰¹¹⁵⁰¹ Phase 1 Report Volume II paragraphs 14.235-14.236. Further calls were received until 03.11 from members of the public reporting seeing people on the top floor.¹⁵⁰²¹⁵⁰² LFB Control Room Report {LFB00004790/63-124}.

Gloria Trevisan and Marco Gottardi

Gloria Trevisan

¶Date of birth: 2 December 1990 (26 years old).

¶Place of birth: Camposampiero, Italy.

¶Gender: Female.

¶Occupation: Trainee Architect.

¶Usual address: Flat 202, floor 23, Grenfell Tower, London.

¶Place of death: Flat 202, floor 23, Grenfell Tower, London.

¶Time of death: Between 03.15 and 03.30 on 14 June 2017.

¶Cause of death: Inhalation of asphyxiant gases.

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Marco Gottardi

¶Date of birth: 26 June 1989 (27 years old). Place of birth: Motta di Livenza, Italy. Gender: Male. Occupation: Architect. Usual address: Flat 202, floor 23, Grenfell Tower, London. Place of death: Flat 202, floor 23, Grenfell Tower, London. Time of death: Between 03.15 and 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases; single vessel coronary artery atheroma.

Background and composition of household

¶97.144 Gloria Trevisan was 26 years old, having been born on 2 December 1990 in Italy. Marco Gottardi was 27 years old, having been born on 26 June 1989 also in Italy. They met at university and graduated with degrees in architecture in 2016. Wanting to improve their English and develop their professional skills, they came together to London in March 2017. Both found work with architectural practices in London. They moved into Flat 202 in April 2017.¹⁵⁰³¹⁵⁰³ Phase 1 Report Volume IV paragraphs 32.545-32.54.

Vulnerability

¶97.145 Gloria Trevisan and Marco Gottardi did not have known vulnerabilities.

Events of 14 June 2017

¶97.146 Gloria Trevisan and Marco Gottardi returned to Grenfell Tower at around 19.47 on 13 June 2017.¹⁵⁰⁴¹⁵⁰⁴ O'Riordan {MET00013136/3}. They remained in Flat 202 thereafter.

¶97.147 At around 01.30, Ernie and Majorie Vital knocked on their front door, alerting them to the fire and joining them in Flat 202.

¶97.148 There is no evidence that Gloria Trevisan or Marco Gottardi made contact with the emergency services on the night of the fire, however they did call their families, as described above.

Recovery and identification

¶97.149 The remains of Gloria Trevisan and Marco Gottardi were recovered from the hallway of Flat 202.¹⁵⁰⁵¹⁵⁰⁵ Purser, Phase 2 Report, Section 6 {DAPR0000006/19} paragraph 71. The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death.¹⁵⁰⁶¹⁵⁰⁶ Interim certificates of the fact of death for Gloria Trevisan and Marco Gottardi {MET00065586}; {MET00065617}.

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Cause and time of death

¶97.150 We are satisfied that Gloria Trevisan and Marco Gottardi both died between about 03.15 and 03.30 before suffering the direct effects of fire.¹⁵⁰⁷¹⁵⁰⁷ Purser, Phase 2 Report, Section 6 {DAPR0000006} Table 20; Purser {Day296/28:15}-{Day296/29;8}.

¶97.151 Gloria Trevisan was found to have a blood carboxyhaemoglobin saturation of 78%.¹⁵⁰⁸¹⁵⁰⁸ Trevisan post-mortem report {COR00000546/9}. The post-mortem recorded the cause of her death as "inhalation of products of combustion" but in the light of Professor Purser's evidence we find that a more accurate description of the primary cause of death is inhalation of asphyxiant gases.

¶97.152 The post-mortem report on Marco Gottardi recorded the cause of death as "inhalation of products of combustion" and "single vessel coronary artery atheroma".

¶97.153 Carboxyhaemoglobin was present in Marco Gottardi's blood, but it was not possible to measure the levels.¹⁵⁰⁹¹⁵⁰⁹ Gottardi post-mortem report {COR00000974/8}; Gottardi toxicology report {MET00007684/1}. The single vessel coronary atheroma put Marco Gottardi at risk of collapse and death at a lower carboxyhaemoglobin concentration than would otherwise have been the case.¹⁵¹⁰¹⁵¹⁰ Purser {Day297/33:4-20}.

¶97.154 Although we acknowledge the contribution of single vessel coronary atheroma, we consider that the primary cause of death was inhalation of asphyxiant gases.

Majorie and Ernie Vital

Majorie Vital

¶Date of birth: 14 November 1948 (68 years old). Place of birth: Soufrière, Dominica. Gender: Female. Occupation: Retired. Usual address: Flat 162, floor 19, Grenfell Tower, London. Place of death: Flat 202, floor 23, Grenfell Tower, London. Time of death: Between 03.15 and 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Ernie Vital

¶Date of birth: 11 January 1967 (50 years old). Place of birth: London, UK. Gender: Male. Occupation: Unemployed. Usual address: Amhurst Park, London N16.

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¶Place of death: Flat 202, floor 23, Grenfell Tower, London.

¶Time of death: Between 03.15 and 03.30 on 14 June 2017.

¶Cause of death: Inhalation of asphyxiant gases.

Background and composition of household

¶97.155 Majorie Vital was a retired seamstress and had lived in Flat 162 on floor 19 of Grenfell Tower for nearly 40 years. It was there that she brought up her two sons. Ernie Vital was staying with her on the night of the fire.¹⁵¹¹¹⁵¹¹ Tenancy Information Questionnaire for Flat 162 {TMOH00025319/3}; Phase 1 Report Volume IV paragraphs 32.176-32.182.

Vulnerability

¶97.156 Majorie Vital's mental health vulnerability was recorded by RBKC in 1987 and by the TMO in a memorandum on 14 July 2004.¹⁵¹²¹⁵¹² RBKC letter dated 24 August 1987 {TMOH00025230}; TMO Memorandum {TMO00865242}. Rydon sent an email to the TMO on 31 October 2014 saying that she had Parkinson's Disease and needed support.¹⁵¹³¹⁵¹³ Email from Rydon dated 31 October 2014 {TMOH00025320}. That information was also recorded in November 2014 during the survey of residents carried out by Rydon.¹⁵¹⁴¹⁵¹⁴ Rydon Residents Survey {RYD00024466/14}.

¶97.157 Majorie Vital had declared both a disability and mental health support needs in response to a TMO questionnaire on 17 March 2015.¹⁵¹⁵¹⁵¹⁵ Tenancy Information Questionnaire for Flat 162 {TMOH00025319/9}. She appeared in the TMO list of Grenfell Tower residents created by David Noble on 14 June 2017 from information held on the TMO's Capita Insight system which recorded that she was in the age group "65 plus" and had some mental health problems.¹⁵¹⁶¹⁵¹⁶ David Noble's list {TMO00862588}.

Events of 14 June 2017

¶97.158 Majorie Vital returned to Grenfell Tower at around 15.14 on 13 June 2017. Ernie Vital entered the tower at around 19.07 on 13 June 2017.¹⁵¹⁷¹⁵¹⁷ O'Riordan {MET00013136/2-3} pages 2-3.

¶97.159 Majorie and Ernie Vital had both moved from floor 19 up to floor 23 by around 01.30. They knocked on Flat 202 and sought shelter with the residents of that flat, Gloria Trevisan and Marco Gottardi. They remained in that flat thereafter.

¶97.160 There is no evidence that either Majorie or Ernie Vital contacted anybody outside the tower on the night of the fire.

Recovery and identification

¶97.161 The remains of Majorie and Ernie Vital were recovered from the bathroom of Flat 202.¹⁵¹⁸¹⁵¹⁸ Purser, Phase 2 Report, Section 6 {DAPR0000006/19} paragraph 71. The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death.¹⁵¹⁹¹⁵¹⁹ Interim certificate of the fact of death for Majorie and Ernie Vital {MET00065611}; {MET00065635};

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Cause and time of death

¶97.162 The post-mortem reports recorded the cause of death in the case of both Majorie Vital and Ernie Vital as "consistent with the effects of fire".¹⁵²⁰¹⁵²⁰ Majorie Vital post-mortem report {COR00000934/6}; Ernie Vital post-mortem Report {COR00000309/4}. In the light of more recent evidence we find that a more accurate description of the primary cause of death is inhalation of asphyxiant gases.

¶97.163 We are satisfied that Majorie Vital and Ernie Vital died between about 03.15 and 03.30 before suffering the direct effects of fire.¹⁵²¹¹⁵²¹ Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20; Purser {Day296/28:15}-{Day296/29;8}.

Flat 203

¶97.164 Flat 203 on floor 23 had two bedrooms and was situated in the south-west corner of the tower. It was the home of Rania Ibrahim, her husband, Hassan Awadh Hassan (who was abroad at the time of the fire), and their two daughters, Fethia Hassan and Hania Hassan.¹⁵²²¹⁵²² External Fire Spread Report {MET00012593/12}; Phase 1 Report Volume IV paragraph 32.34. The south-west corner of the tower was farthest from where the fire had started.¹⁵²³¹⁵²³ Phase 1 Report Volume II paragraph 14.145.

¶97.165 Smoke began to enter Flat 203 by 02.05, although at that stage not through the windows.¹⁵²⁴¹⁵²⁴ Phase 1 Report Volume II paragraph 14.146. From about 02.40 smoke increasingly affected the south facing wall of the tower, spreading towards Flat 203.¹⁵²⁵¹⁵²⁵ Purser, Phase 2 Report, Section 6 {DAPR0000006/35} paragraph 159.

¶97.166 Flat 203 was the last of those on floor 23 to be affected by the spread of fire on the outside of the building. By about 03.11 the fire had reached the area between Flats 202 and 203 and continued to move in a westerly direction across Flat 203. By 03.43 Flat 203 was fully affected by the fire.¹⁵²⁶¹⁵²⁶ Lane, Phase 1 Supplemental Report, Section 12 {BLAS0000012/11}; Phase 1 Report Volume III paragraph 18.5; Purser, Phase 2 Report, Section 6 {DAPR0000006/35} paragraph 162.

¶97.167 The fire reached the south-west corner of the tower at the level of floor 23 by 03.58. From 04.07 onwards, there was a rapid deterioration of the conditions in the living room of Flat 203.¹⁵²⁷¹⁵²⁷ Phase 1 Report Volume III paragraph 18.4; Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 165.

¶97.168 The adult occupants of Flat 203 are likely to have become comatose from the inhalation of asphyxiant gases by about 04.13, and to have inhaled a lethal dose of asphyxiant gases by about 04.17.¹⁵²⁸¹⁵²⁸ Purser, Phase 2 Report, Section 6 {DAPR0000006/38} Figure 34. For the children, these events are likely to have happened sooner.¹⁵²⁹¹⁵²⁹ Purser, Phase 2 Report, Section 6 {DAPR0000006/54} paragraph 253; Purser {Day297/65:3-8}.

Those who sheltered in Flat 203

¶97.169 Rania Ibrahim gave shelter in her home to people who had fled from elsewhere in the tower. Those who went to Flat 203 seeking refuge were Fathia Ahmed Elsanousi, Isra Ibrahim, Abufras Ibrahim and Gary Maunders.¹⁵³⁰¹⁵³⁰ Phase 1 Report Volume II paragraph 14.125.

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¶97.170 Fathia Ahmed Elsanousi lived in Flat 206 on floor 23 with her daughter, Isra Ibrahim. Abufras Ibrahim, the son of Fathia Ahmed Elsanousi, had been visiting his mother and sister on 14 June 2017.¹⁵³¹¹⁵³¹ Phase 1 Report Volume IV paragraph 32.7.

¶97.171 Gary Maunders did not live in Grenfell Tower. He had been visiting Debbie Lamprell from Flat 161 on floor 19. They went up to floor 23 and initially took shelter in Flat 201 at about 01.30. Gary Maunders then moved to Flat 203 at about 01.39.¹⁵³²¹⁵³² Phase 1 Report Volume II paragraphs 10.259-10.260, 10.287-10.289 and 11.30-11.31.

¶97.172 All those who were in Flat 203 died. Rania Ibrahim, Fethia Hassan, Hania Hassan, Isra Ibrahim, Fathia Ahmed Elsanousi and Gary Maunders all died there. Abufras Ibrahim fell from the tower and his body was recovered from outside the south side.¹⁵³³¹⁵³³ Phase 1 Report Volume III paragraph 18.22; Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraphs 166-167.

Events in Flat 203

¶97.173 By 01.30 the outside of Flat 206, in the north-east corner of the tower (home to Fathia Ahmed Elsanousi and Isra Ibrahim), had become enveloped by flames.¹⁵³⁴¹⁵³⁴ Phase 1 Report Volume II paragraphs 10.118 and 10.122; External Fire Spread Report {MET00012593/12}. Fathia Ahmed Elsanousi, Isra Ibrahim and Abufras Ibrahim must have left it at an early stage. The precise time of their arrival at Flat 203 is not known but they must have reached it before 01.38 when Rania Ibrahim began to live-stream a video to Facebook. The female voice heard on the video telling Rania Ibrahim not to open the door was probably that of Isra Ibrahim. Abufras Ibrahim also appears in the video and can be heard telling Rania Ibrahim to close the door as she was letting smoke in.¹⁵³⁵¹⁵³⁵ Phase 1 Report Volume II paragraphs 11.30-11.31.

¶97.174 At about 01.39 Rania Ibrahim can be seen opening the front door. Gary Maunders can be seen entering the flat when invited to do so. The video shows that the lobby on floor 23 was dark with smoke at the time.¹⁵³⁶¹⁵³⁶ Phase 1 Report Volume II paragraph 11.32 and Figure 11.9. Shortly afterwards, Rania Ibrahim went out into the lobby where she was able to breathe, speak and stand, at least for a short period. She shouted "Hello" and "Come here". It was probably Marco Gottardi from Flat 202 who responded by saying "We are here. I am inside our apartment".¹⁵³⁷¹⁵³⁷ Phase 1 Report Volume II paragraphs 11.33 and 11.35.

¶97.175 At around 01.43, a voice can be heard coming from outside the building shouting, "This is the fire service. If you are able, exit the building". That was probably FF Patrick Murray.¹⁵³⁸¹⁵³⁸ Phase 1 Report Volume II paragraph 11.34.

¶97.176 FF Mandeep Singh arrived at the tower at 01.35 and was instructed to pass FSG information from the command unit to the bridgehead. He recalled being handed telephones and speaking to residents inside the tower. During one such call, FF Singh spoke to a female occupant of the tower who gave a location of the "23rd floor, doors 205 and 201". She said that she had brought all of the occupants of floor 23 into her flat. FF Singh advised her to stay put.¹⁵³⁹¹⁵³⁹ Phase 1 Report Volume III paragraph 15.16; Singh {MET000083327/16-17} pages 16-17; A page from his notebook contains the following entry "23rd FLOOR ALL OCCUPANTS 205/201 [illegible] WM BRIAN O'KEITH WM (Illegible)".¹⁵⁴⁰¹⁵⁴⁰ Singh Exhibit MS/1 - pages from notebook {MET00013089/2}. In his witness statement FF Singh said that he thought the woman he had spoken to was the same person who can be heard in a video recording, saying that she will let people in. This was probably Rania Ibrahim, who was in fact in Flat 203, and not in

190

¶Flat 201 or Flat 205.¹⁵⁴¹¹⁵⁴¹ Phase 1 Report Volume III paragraph 15.16; Singh {MET000083327/16-17} pages 16-17.

¶97.177 At 01.57 CRO Heidi Fox answered an emergency call from a member of Rania Ibrahim's family.¹⁵⁴²¹⁵⁴² LFB Control Room Report {LFB00004790/57}. That was the first call relating to Flat 203. As a result, she created a service request at 01.59 in relation to "a person with two children" trapped in Flat 203 on floor 23. CRO Darby passed the information to CU8 by radio a few seconds later.¹⁵⁴³¹⁵⁴³ Phase 1 Report Volume II paragraph 13.105. At 02.00, CRO Darby marked the service request as completed.¹⁵⁴⁴¹⁵⁴⁴ LFB Short Incident Log {MET00013830/21}. That was the only service request created in relation to Flat 203.¹⁵⁴⁵¹⁵⁴⁵ LFB Short Incident Log {MET00013830}.

¶97.178 The second emergency call about Flat 203 was made at 02.05 by Isra Ibrahim. She told CRO Howson that there were five adults and two children in Flat 203. They were in the living room and kitchen area. Smoke was coming into the flat, but they were keeping the doors closed. No smoke was coming through the windows. Isra Ibrahim had smoke around her nose. CRO Howson advised her to remain in the flat.¹⁵⁴⁶¹⁵⁴⁶ Phase 1 Report Volume II paragraph 14.146.

¶97.179 At 02.21, Isra Ibrahim spoke to CRO Gotts. She reported that the occupants of the flat were stuck and the flat next door (probably Flat 202) was on fire. She gave her location as Flat 203 on floor 23. CRO Gotts advised her to try to block the doors and to stay away from the side of the flat on fire. Isra Ibrahim asked for someone to come to the flat immediately and whether helicopters could assist. CRO Gotts explained that firefighters were on the lower floors but were on their way up to floor 23. She said that the helicopter was being sent up so that they could see the fire from the air. At the very end of the call, CRO Gotts said "22nd floor, Flat 192. All right?". That was not the location Isra Ibrahim had given, but the call ended before she could respond.¹⁵⁴⁷¹⁵⁴⁷ Phase 1 Report Volume II paragraph 14.147; 999 call transcript {LFB00000663/1-5}. The first image of the fire taken by the National Police Air Support ("NPAS") helicopter was taken at 01.43, therefore it had reached the tower sometime before or around this time: Phase 1 Report Volume II paragraph 12.104 and Figure 12.8.

¶97.180 CRO Gotts passed the information orally to CRO Darby who sent a message to command unit CU7 at 02.26 about persons in Flat 192 on floor 22 who had said that the fire was in the flat next door to them. No service request was created by CRO Gotts in relation to either Flat 203 or Flat 192.¹⁵⁴⁸¹⁵⁴⁸ Phase 1 Report Volume III paragraph 15.144.

¶97.181 At 02.35, the "stay put" advice was revoked in the control room, but it took some time for all the control room operators to be told and for them to begin giving fresh advice.¹⁵⁴⁹¹⁵⁴⁹ Phase 1 Report Volume III paragraph 15.168.

¶97.182 At 02.42, Isra Ibrahim spoke to CRO Howson from Flat 203 and reported five adults and two children in the flat. That was the fourth emergency call relating to Flat 203. She said that the amount of smoke in the flat was increasing and that the flat next door (again, probably Flat 202) was on fire. CRO Howson advised Isra Ibrahim to block out the smoke, told her that firefighters were making their way to her and said that, as long as there were no flames, the flat was the safest place to be "because you don't know what's going on outside".¹⁵⁵⁰¹⁵⁵⁰ Phase 1 Report Volume III paragraph 15.73.

191

¶97.183 At 02.58, an unidentified male caller spoke to CRO Howson. That was the fifth and final call relating to Flat 203. He told her that the police would not let him into the tower and had told him to call the emergency services. The caller said that he had just spoken to someone in Flat 203 with two children. CRO Howson told him that they needed to try to get out of the building and that she would pass on the information that people were still in the flat. The caller must have been referring to Rania Ibrahim. It is not known if he was able to speak to her again to pass on CRO Howson's advice.¹⁵⁵¹¹⁵⁵¹ Phase 1 Report Volume III paragraphs 16.27-16.28. That was the first time those in Flat 203 were advised to leave the building.

¶97.184 Rania Ibrahim appears to have thought that the "stay put" policy was still in place at that time. Munira Mahmud, a close friend who had earlier left floor 5, called her at about 03.00. Rania Ibrahim was coughing a lot and Munira Mahmud could tell that she was finding it difficult to breathe. Munira Mahmud tried to persuade her to leave. Rania Ibrahim said she had called the emergency services and that whoever had answered the call had told her to stay inside and wait for help. She also said that the roof door was locked but that they were sending help, as she could see a helicopter. Munira Mahmud continued to tell Rania Ibrahim that she should try to leave. That was the last conversation she had with Rania Ibrahim; she was unable to reach her by telephone again.¹⁵⁵²¹⁵⁵² Phase 1 Report Volume III paragraph 16.29.

¶97.185 Sayeda Ibrahim spoke to her sister Rania Ibrahim at 01.00, 02.50 and 03.00. The call at 03.00 was the last known contact with anyone in Flat 203.¹⁵⁵³¹⁵⁵³ Phase 1 Report Volume III paragraphs 16.30-16.31; Mahmud {MET00080727/18-19} pages 18-19. Attempts by a friend of Munira Mahmud to call Rania Ibrahim from about 03.15 were unsuccessful.

¶97.186 Information about those needing to be rescued from Flat 203 was recorded at various places at the incident ground.

¶97.187 The information from the first emergency call relating to Flat 203 at 01.57 was passed by radio to CU8 at 02.00.¹⁵⁵⁴¹⁵⁵⁴ LFB Control Room Report {LFB00004790/58}.

¶97.188 We have seen no evidence of messages passed to the incident ground in response to the second call made by Isra Ibrahim at 02.05.¹⁵⁵⁵¹⁵⁵⁵ LFB Control Room Report {LFB00004790}. However, from 02.06, SM Oliff in the LFB control room was passing information to WM Meyrick in CU8 using his personal mobile telephone. The calls were not recorded and there is no record of the information he passed on.¹⁵⁵⁶¹⁵⁵⁶ Phase 1 Report Volume II paragraph 14.243.

¶97.189 The bridgehead was maintained on floor 2 from the beginning of the incident until about 02.17.¹⁵⁵⁷¹⁵⁵⁷ Phase 1 Report Volume IV paragraphs 28.84(b) and 28.86. CM Charles Batterbee copied information from a forward information board at the bridgehead into his own notebook. There is no reference to Flat 203 in that notebook,¹⁵⁵⁸¹⁵⁵⁸ Phase 1 Report Volume II paragraph 14.73 and Figure 14.4. so it appears that the radio message about Flat 203 sent at 02.00 went astray and did not reach the bridgehead.

¶97.190 From 02.17 until about 03.08 the bridgehead was located on floor 3.¹⁵⁵⁹¹⁵⁵⁹ Phase 1 Report Volume III paragraph 17.11; Phase 1 Report Volume IV paragraph 28.86. During that period the third, fourth and fifth emergency calls were made in relation to Flat 203.

192

¶97.191 At 02.21, when the third call made by Isra Ibrahim came to an end, CRO Gotts misunderstood the caller's location as being in Flat 192 on floor 22 and the radio message sent to command unit CU7 at 02.26 referred to persons in Flat 192 on floor 22. No other messages appear to have been passed to the incident ground in relation to Flat 203 as a result of that call.¹⁵⁶⁰¹⁵⁶⁰ LFB Control Room Report {LFB00004790/81}.

¶97.192 The fourth and fifth emergency calls relating to Flat 203 were made at 02.42 and 02.58.

¶97.193 SM Oliff recorded information in the control room on two whiteboards from around 02.33. In a photograph taken at the end of the incident the first whiteboard shows the notation "Flat 203 23rd fl – 5 adults 2 children – smoke logging".¹⁵⁶¹¹⁵⁶¹ Phase 1 Report Volume III paragraphs 15.139-15.140 and Figure 15.8. It is possible that SM Oliff passed information about Flat 203 to WM Meyrick in CU8 using his mobile phone.

¶97.194 Messages about Flat 203 did reach command unit CU7. Between about 02.00 and 03.00, a white laminated sheet was being used in CU7 to record information about people needing to be rescued. The laminated sheet recorded "Flat 203 Floor 23 5 adults 2 children" as can be seen in a photograph taken at 02.59.¹⁵⁶²¹⁵⁶² Phase 1 Report Volume II paragraphs 12.8-12.9 and Figure 12.3.

¶97.195 Messages about Flat 203 were also inscribed on a wall of the lobby on the ground floor. WM Glynn Williams started to record information on the wall of the lobby on the ground floor at 02.15. He said the information came from CU7. A photograph of the wall taken much later in the incident includes the notation "203 23 5A 2C".¹⁵⁶³¹⁵⁶³ Phase 1 Report Volume II paragraphs 14.103-14.104 and Figure 14.5.

¶97.196 After 03.00, the laminated sheet in CU7 was replaced by a whiteboard bearing a grid. A photograph taken of the whiteboard much later in the morning shows Flat 203 and the annotation "5 2 P". The "5" is in green indicating five adults, the "2" is in black indicating two children, and the "P" is in red and is circled, indicating a priority.¹⁵⁶⁴¹⁵⁶⁴ Phase 1 Report Volume III paragraph 16.12 and Figure 16.5; Goodall {MET000083296/11} page 11; Goodall {Day35/78:4}-{Day35/80:1}

¶97.197 Given that no firefighters were sent to Flat 203 before 03.08, when the bridgehead was moved from floor 3 to the ground floor, it appears that messages relating to Flat 203 did not reach the bridgehead while it was on floor 3. However, after the bridgehead had moved to the ground floor firefighters were sent to Flat 203, which suggests that information from at least one of the emergency calls relating to Flat 203 was passed to the bridgehead after 03.08.

¶97.198 FFs Matthew Harold, David Friend and Richard Peacock were initially sent to Flat 203 but at the last minute their instructions were changed and they were sent to carry out search and rescue operations on floors 4 and 5. They tallied out between 03.31 and 03.32.¹⁵⁶⁵¹⁵⁶⁵ Phase 1 Report Volume III paragraph 18.15(b).

¶97.199 None of the other firefighting crews sent to floor 23 succeeded in reaching it.

193

Rania Ibrahim, Fethia Hassan and Hania Hassan

Rania Ibrahim

¶Date of birth: 3 March 1986 (31 years old). Place of birth: Aswan, Egypt. Gender: Female. Occupation: Carer for children. Usual address: Flat 203, floor 23, Grenfell Tower, London. Place of death: Flat 203, floor 23, Grenfell Tower, London. Time of death: Between 03.55 and 04.05 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Fethia Hassan

¶Date of birth: 5 October 2012 (4 years old). Place of birth: Chelsea, London. Gender: Female. Occupation: N/A. Usual address: Flat 203, floor 23, Grenfell Tower, London. Place of death: Flat 203, floor 23, Grenfell Tower, London. Time of death: Between 03.55 and 04.05 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Hania Hassan

¶Date of birth: 4 June 2014 (3 years old). Place of birth: Chelsea, London. Gender: Female. Occupation: N/A. Usual address: Flat 203, floor 23, Grenfell Tower, London. Place of death: Flat 203, floor 23, Grenfell Tower, London. Time of death: Between 03.55 and 04.05 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

194

Background and composition of household

¶97.200 Rania Ibrahim lived in Flat 203 with her husband, Hassan Awadh Hassan, and their two daughters, Fethia and Hania. Hassan Awadh Hassan was away at the time of the fire. Rania Ibrahim and her family moved into Flat 203 in 2016.¹⁵⁶⁶¹⁵⁶⁶ Tenancy Agreement for Hassan Awadh Hassan {TMOH00010399}; Presentations relating to Rania Ibrahim, Fethia Hassan and Hania Hassan {Day299/52:1-22}.

¶97.201 Born in Aswan, Egypt on 3 March 1986, Rania Ibrahim was 31 years old when she died. She had a place to study law in Cairo but had come to London to help her sister, who was unwell. She had met Hassan in London in 2010 and they got married. Fethia was born on 5 October 2012 and Hania on 4 June 2014. They were four and three years old respectively when they died.¹⁵⁶⁷¹⁵⁶⁷ Phase 1 Report Volume IV paragraphs 32.34-32.43.

Vulnerability

¶97.202 The family appeared in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system. The ages of Fethia and Hania were respectively recorded as "5" and "3". No other vulnerabilities were noted.¹⁵⁶⁸¹⁵⁶⁸ David Noble's list {TMO00862588}.

Events of 14 June 2017

¶97.203 Rania Ibrahim, Fethia Hassan and Hania Hassan had all returned to Grenfell Tower for the last time by 18.09 on 13 June 2017.¹⁵⁶⁹¹⁵⁶⁹ O'Riordan {MET00013136/3} page 3.

¶97.204 On the evening of 13 June 2017, Rania Ibrahim and her daughters spent time with a close friend, Munira Mahmud, who lived in Flat 25 on floor 5 of Grenfell Tower. Munira Mahmud's children played with Fethia and Hania and ate dinner. After Rania Ibrahim and her daughters had returned to Flat 203, at about 21.30 Munia Mahmud brought Rania Ibrahim food for the iftar meal ending the Ramadan fast.¹⁵⁷⁰¹⁵⁷⁰ Mahmud {IWS00000776/1-4} pages 1-4, paragraphs 3, 15, 16; Presentations relating to Rania Ibrahim, Fethia Hassan and Hania Hassan {Day299/54:10-15}.

¶97.205 Rania Ibrahim did not make any emergency calls herself. However, she appears to have given her mobile telephone to Isra Ibrahim, who made a number of emergency calls as described above.¹⁵⁷¹¹⁵⁷¹ Presentations relating to Rania Ibrahim, Fethia Hassan and Hania Hassan {Day299/58:15-19}. Calls were also made on behalf of Rania Ibrahim and her daughters by people outside the tower.

Recovery and identification

¶97.206 The remains of Rania Ibrahim, Fethia Hassan and Hania Hassan were all recovered from the bathroom of Flat 203.¹⁵⁷²¹⁵⁷² Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 167. The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death.¹⁵⁷³¹⁵⁷³ Interim certificate of the fact of death for Rania Ibrahim, Fethia Hassan and Hania Hassan {MET00065635}; {MET00065604}; {MET00065636}.

195

Cause and time of death

¶97.207 Toxicology testing for Rania Ibrahim and her daughters was not possible.¹⁵⁷⁴¹⁵⁷⁴ Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 167. The post-mortem reports on Rania Ibrahim, Fethia Hassan and Hania Hassan recorded their cause of death as "consistent with the effects of fire".¹⁵⁷⁵¹⁵⁷⁵ Rania Ibrahim post-mortem report {COR00000444/3}; Fethia Hassan post-mortem report {COR00001724/3}; Hania Hassan post-mortem report {COR00001723/3}. In the light of Professor Purser's evidence we find that a more accurate description is "inhalation of asphyxiant gases".

¶97.208 Given the lack of response to calls made to Rania Ibrahim's telephone after 03.00, we consider it likely that Rania Ibrahim, Fethia Hassan and Hania Hassan had lost consciousness by that time. We are satisfied that they all died between 03.55 and 04.05 before suffering the direct effects of fire.¹⁵⁷⁶¹⁵⁷⁶ Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20; Purser {Day296/28:15}-{Day296/29:8}.

Fathia Ahmed Elsanousi, Isra Ibrahim and Abufras Ibrahim

Fathia Ahmed Elsanousi

¶Date of birth: 1 January 1940 (77 years old). Place of birth: Al Nuhood, West Kordofan province, Sudan. Gender: Female. Occupation: Retired. Usual address: Flat 206, floor 23, Grenfell Tower, London. Place of death: Flat 203, floor 23, Grenfell Tower, London. Time of death: Between 04.20 and 04.40 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Isra Ibrahim

¶Date of birth: 8 August 1983 (33 years old). Place of birth: Khartoum, Sudan. Gender: Female. Occupation: Care worker and sales assistant. Usual address: Flat 206, floor 23, Grenfell Tower, London. Place of death: Flat 203, floor 23, Grenfell Tower, London. Time of death: Between 04.20 and 04.40 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

196

Abufras Ibrahim

¶Date of birth: 8 January 1978 (39 years old) .

¶Place of birth: Khartoum, Sudan.

¶Gender: Male.

¶Occupation: Fishmonger and sales assistant.

¶Usual address: Queensgate, London SW7.

¶Place of death: Outside Grenfell Tower, London.

¶Time of death: Between 03.50 and 03.55 on 14 June 2017.

¶Cause of death: Multiple injuries (consistent with a fall from height).

Background and composition of household

¶97.209 Fathia Ahmed Elsanousi was born in 1940 in Al Nuhood, Sudan and was 77 years old in 2017. She had been a headteacher in Sudan and had moved to the UK to escape the civil war there.¹⁵⁷⁷¹⁵⁷⁷ Phase 1 Report Volume IV paragraphs 32.8-32.12. Her daughter, Isra Ibrahim, was born on 8 August 1983 and was 33 years old. She and her mother had been tenants of Flat 206 since 2008.¹⁵⁷⁸¹⁵⁷⁸ Presentations relating to Fathia Ahmed Elsanousi, Isra Ibrahim and Abufras Ibrahim {Day307/96:7-10}. Abufras Ibrahim was born on 8 January 1978 and was 39 years old. He did not live in Grenfell Tower but was visiting his mother and sister on 14 June 2017.¹⁵⁷⁹¹⁵⁷⁹ Phase 1 Report Volume IV paragraph 32.7.

Vulnerability

¶97.210 Fathia Ahmed Elsanousi suffered from serious health problems that had been recorded in her housing file since 2000. She had breathing problems which required her to use a portable oxygen machine. Her mobility was impaired as a result of a stroke in 2006. She had been unable to manage stairs easily since January 2007.¹⁵⁸⁰¹⁵⁸⁰ Presentations relating to Fathia Ahmed Elsanousi, Isra Ibrahim and Abufras Ibrahim {Day307/99:5-13}; Health Assessment Form {BSR00000110}. Isra Ibrahim did not have any known vulnerabilities. Neither she nor her mother were identified as vulnerable in the spreadsheet of vulnerable tower residents created by David Noble on 14 June 2017.¹⁵⁸¹¹⁵⁸¹ David Noble's list {TMO00862588}.

Events of 14 June 2017

¶97.211 Fathia Ahmed Elsanousi last entered Grenfell Tower on 9 June 2017. Isra Ibrahim and Abufras Ibrahim entered Grenfell Tower in the evening of 13 June 2017.¹⁵⁸²¹⁵⁸² O'Riordan {MET00013136/2-4} pages 2-4.

¶97.212 The Neda family lived in Flat 205. At about 01.25, Farhad Neda and his mother, Flora Neda, looked out into the lobby of floor 23. Flora Neda saw Isra Ibrahim from Flat 206 start running down the stairs. Fathia Ahmed Elsanousi was behind her, walking slowly. That was at about the time that the fire reached the outside of floor 23.¹⁵⁸³¹⁵⁸³ Phase 1 Report Volume II paragraphs 10.283 and 10.118; Farhad Neda {Day61/37:1-25}; Neda {IWS00000887/7} page 7, paragraph 33; Flora Neda {Day61/130:12-18}. By 01.30 the flames had enveloped all the "Flat 6s", including Flat 206.¹⁵⁸⁴¹⁵⁸⁴ Phase 1 Report Volume II paragraph 10.122.

197

¶97.213 By about 01.30, several occupants had reached floor 23, having come upstairs from lower floors. At about the same time, Fathia Ahmed Elsanousi and Isra Ibrahim returned to floor 23. By 01.38 they and Abufras Ibrahim were already sheltering with Rania Ibrahim and her children in Flat 203 when Rania Ibrahim began her live-stream video to Facebook.¹⁵⁸⁵¹⁵⁸⁵ Phase 1 Report Volume II paragraphs 10.289 and 11.29-11.30.

¶97.214 Isra Ibrahim made three emergency calls from Flat 203, at 02.05, 02.21 and 02.42 as described above.

¶97.215 At about 03.50 Abufras Ibrahim fell from the tower. He fell first onto the canopy over the door to the main entrance of the tower on the south side. His body then landed on the south side of the tower close to the walkway connecting it to Grenfell Walk. His body was subsequently moved to a sheltered area by firefighters.¹⁵⁸⁶¹⁵⁸⁶ Phase 1 Report Volume III paragraph 18.22; Moore {MET00010819/10} page 10; Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 166. He was pronounced dead at 06.05 on 14 June 2017 outside the tower.¹⁵⁸⁷¹⁵⁸⁷ Abufras Ibrahim post-mortem report {COR00000049/3}.

Recovery and identification

¶97.216 The remains of Fathia Ahmed Elsanousi and Isra Ibrahim were both recovered from the bathroom in Flat 203.¹⁵⁸⁸¹⁵⁸⁸ Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 167. Abufras Ibrahim's body was recovered from outside the tower. The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death for each member of the family.¹⁵⁸⁹¹⁵⁸⁹ Interim certificate of the fact of death for Fathia Ahmed Elsanousi; Isra Ibrahim and Abufras Ibrahim {MET00065632}; {MET00065593}; {MET00065614}.

Cause and time of death

¶97.217 Toxicological testing for Abufras Ibrahim showed that the level of carboxyhaemoglobin in his blood was 20%, which is significant but not incapacitating. His body showed slight soot stains to the skin and nostrils but no burns. Despite a long period of slow smoke infiltration from the lobby and 40 minutes of serious smoke penetration of the bedrooms, he had been able to limit his exposure until the fire spread to the outside of the room in which he had taken refuge.¹⁵⁹⁰¹⁵⁹⁰ Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 166.

¶97.218 The post-mortem report for Abufras Ibrahim recorded the cause of death as "Multiple injuries (consistent with fall from height)". We are satisfied that Abufras Ibrahim died between 03.50 and 03.55, either instantly when he landed outside the tower or very shortly afterwards.

¶97.219 The post-mortem reports on Fathia Ahmed Elsanousi and Isra Ibrahim recorded the cause of death as "consistent with the effects of a fire"¹⁵⁹¹¹⁵⁹¹ Elsanousi post-mortem report {COR00000443/3}; Isra Ibrahim post-mortem report {COR00000448/5-6}. but in the light of Professor Purser's evidence we consider that a more accurate description is "inhalation of asphyxiant gases".

¶97.220 We are satisfied that Fathia Ahmed Elsanousi, Isra Ibrahim and Abufras Ibrahim all died before suffering the direct effects of fire.

¶97.221 Fathia Ahmed Elsanousi and Isra Ibrahim died from inhalation of asphyxiant gases between 04.20 and 04.40.¹⁵⁹²¹⁵⁹² Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20.

198

Gary Maunders

¶Date of birth: 4 January 1960 (57 years).

¶Place of birth: Hammersmith, London.

¶Gender: Male.

¶Occupation: Painter and decorator.

¶Usual address: Lancaster Road, London W11.

¶Place of death: Flat 203, floor 23, Grenfell Tower, London.

¶Time of death: Approximately 04.20 – 04.40 on 14 June 2017.

¶Cause of death: Inhalation of asphyxiant gases.

Background and composition of household

¶97.222 Gary Maunders was born in London on 4 January 1960; in 2017 he was 57 years old. He was the father of two children. A talented footballer in his youth, Gary worked as a painter and decorator.¹⁵⁹³¹⁵⁹³ Phase 1 Report Volume IV paragraphs 32.191-32.196. On the night of the fire he was visiting Debbie Lamprell at her home in Flat 161 on floor 19 of the tower.

Events of 14 June 2017

¶97.223 Gary Maunders was one of those who went up to floor 23 to take shelter. He probably reached it by about 01.30.¹⁵⁹⁴¹⁵⁹⁴ Phase 1 Report Volume II paragraphs 14.125 and 10.287-10.289; External Fire Spread Report {MET00012593/12}. He initially went into Flat 201, the home of Raymond (Moses) Bernard.

¶97.224 Fadumo Ahmed, Debbie Lamprell's neighbour, left her flat at 01.20 and saw Debbie Lamprell near the lifts. She gained the impression that she had been told to go upstairs. They both walked up the stairs to floor 23. There was only a little bit of smoke in the stairwell at that time. Fadumo Ahmed said she did not see anyone else in the stairwell, but Debbie Lamprell later told CRO Jabin that she and her friend had come up together, which suggests that Gary Maunders may have also climbed the stairs with them.¹⁵⁹⁵¹⁵⁹⁵ 999 call transcript {LFB00055500/29}. Fadumo Ahmed saw people at the door to Flat 201 and joined a group in the hallway that included Gary Maunders and Debbie Lamprell.¹⁵⁹⁶¹⁵⁹⁶ Phase 1 Report Volume II paragraphs 10.259-10.260.

¶97.225 The occupants of Flat 201 were soon having difficulty breathing. The fire was at the window and then entered the living room.¹⁵⁹⁷¹⁵⁹⁷ Phase 1 Report Volume II paragraphs 10.289 (d), 11.25 and 11.28.

¶97.226 We do not know how Gary Maunders and Debbie Lamprell became separated. Nor do we know at what time he left Flat 201. He entered Flat 203 at about 01.39,¹⁵⁹⁸¹⁵⁹⁸ Phase 1 Report Volume II paragraphs 11.29-11.30. which coincides with Debbie Lamprell's emergency call from Flat 201, during which she was shouting for "Gary". That suggests she may already have lost contact with him.¹⁵⁹⁹¹⁵⁹⁹ 999 call transcript {COR00000269}. Debbie Lamprell remained in Flat 201 and at 02.05 during a 999 call she referred to having lost her friend, saying they had come up together, but he had gone: 999 call transcript {LFB00055500/26-29}.

199

¶97.227 Gary Maunders made no calls to the emergency services on the night of the fire.

Recovery and identification

¶97.228 Gary Maunders' remains were recovered from the bathroom of Flat 203. Toxicological testing was not possible.¹⁶⁰⁰¹⁶⁰⁰ Purser, Phase 2 Report, Section 6 {DAPR0000006/36} paragraph 167. The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.¹⁶⁰¹¹⁶⁰¹ Interim certificate of the fact of death for Gary Maunders {MET00065624}.

Cause and time of death

¶97.229 The post-mortem report on Gary Maunders recorded the cause of death as "consistent with the effects of a fire"¹⁶⁰²¹⁶⁰² Maunders post-mortem report {COR00000521/3}. but in the light of Professor Purser's evidence we find that a more accurate description is "inhalation of asphyxiant gases".

¶97.230 We are satisfied that Gary Maunders died between 04.20 and 04.40.¹⁶⁰³¹⁶⁰³ Purser, Phase 2 Report, Section 6 {DAPR0000006/1} Table 20.

Flat 204 Hesham Rahman

¶Date of birth: 30 January 1960 (57 years old). Place of birth: Cairo, Egypt. Gender: Male. Occupation: Retired. Usual address: Flat 204, floor 23, Grenfell Tower, London. Place of death: Flat 204, floor 23, Grenfell Tower, London. Time of death: Between 03.45 and 04.00 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Background and composition of household

¶97.231 Hesham Rahman was born on 30 January 1950 in Egypt and was 57 years old in 2017. He was a retired hairdresser.¹⁶⁰⁴¹⁶⁰⁴ Phase 1 Report Volume IV paragraphs 32.29-32.32. Flat 204 had been his home since August 2012. He lived there alone.¹⁶⁰⁵¹⁶⁰⁵ Tenancy Agreement {TMOH00013384/6-7}.

Vulnerability

¶97.232 Hesham Rahman had diabetes and associated serious mobility problems which pre-dated his move to Grenfell Tower. His cousin said that his health had deteriorated after 2012. He had difficulty using stairs and relied on the lifts at Grenfell Tower. He had a disability blue badge for his car and a parking space at the tower for drivers with disabilities.¹⁶⁰⁶¹⁶⁰⁶ El-Baghdady {IWS00001535/2-4} pages 2-4, paragraphs 7-14.

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¶97.233 RBKC was aware of Hesham Rahman's health conditions and mobility difficulties. RBKC's assessments of 19 December 2006, August 2009 and 7 December 2010 all recorded his difficulty in managing stairs.¹⁶⁰⁷¹⁶⁰⁷ {BSR00000133/3-5}; {BSR00000130/3-5}; {BSR00000131/3-4}. The assessment dated 7 December 2010 noted the contents of a letter from a consultant confirming his diagnoses and their interference with his ability to walk. He recommended an upper or lower ground floor property with no more than six steps to obtain access to the premises or a property up to fourth floor level with lift access.¹⁶⁰⁸¹⁶⁰⁸ {BSR00000131/2-3}.

¶97.234 A housing officer visited Hesham Rahman on 9 October 2012 and 28 June 2013 and on both occasions recorded that he had problems with mobility. A question whether any signs of a need for support had not been picked up when he was signed up for a tenancy was not completed in relation to the first visit and answered "No" in relation to the second.¹⁶⁰⁹¹⁶⁰⁹ {TMOH00013422/1}; {TMOH00013423/1-2}.

¶97.235 Hesham Rahman was not identified as vulnerable in the spreadsheet of tower residents created by David Noble on 14 June 2017.¹⁶¹⁰¹⁶¹⁰ David Noble's list {TMO00862588}.

Events of 14 June 2017

¶97.236 Hesham Rahman returned to Grenfell Tower at 20.54 on 13 June 2017.¹⁶¹¹¹⁶¹¹ O'Riordan {MET00013136/3} page 3.

¶97.237 At about 01.20, Anna Krivsoun, the daughter of Hesham Rahman's former partner, called to tell him that the tower was on fire and that he should leave. He agreed and said he would get dressed.¹⁶¹²¹⁶¹² Krivsoun {MET00039926/1} page 1.

¶97.238 At some point before 01.30, Farhad Neda from Flat 205 saw smoke entering the lobby on floor 23 through the smoke extraction system vents. He also saw Hesham Rahman open and close the door to Flat 204.¹⁶¹³¹⁶¹³ Phase 1 Report Volume II paragraphs 10.149 and 10.283-10.286. That was the last contact anyone in the tower had with Hesham Rahman; no one else took shelter in Flat 204.

¶97.239 Hesham Rahman spoke to the emergency services on five occasions during the fire. He made his first call at 01.39 and spoke to OM Norman. He reported that a little smoke was coming into his flat and that he could smell it. He said that he could not see outside at all.¹⁶¹⁴¹⁶¹⁴ Phase 1 Report Volume II paragraph 11.36.

¶97.240 When Hesham Rahman received a call from OM Norman at 01.46, he said the fire had not reached his flat but was next door. The flats immediately next door to his were Flats 203 and 205. OM Norman said the fire was on floor 4 and he replied, "I think it's gone upstairs". OM Norman advised him to stay put, saying firefighter crews would get to him.¹⁶¹⁵¹⁶¹⁵ Phase 1 Report Volume II paragraph 12.68; External Fire Spread Report {MET00012593/12}. Of the two neighbouring flats, the exterior fire affected Flat 205 first, by 02.09-02.10: Lane, Phase 1 Supplemental Report, Section 12 {BLAS0000012/9-11}.

¶97.241 Although no service requests were created in response to Hesham Rahman's first two emergency calls, it appears that information about a person needing to be rescued from Flat 204 was passed by telephone to command vehicle CU8 by OM Norman at

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¶01.47. OM Norman recorded the message in the incident log afterwards at 02.01.¹⁶¹⁶¹⁶¹⁶ Phase 1 Report Volume II paragraph 12.76; LFB Short Incident Log {MET00013830/21}; LFB Control Room Report {LFB00004790/50}.

¶That is the first record of Hesham Rahman's situation and location being passed to the incident ground.

¶97.242 CRO Russell took Hesham Rahman's third emergency call at 02.36. He reported smoke coming into his flat and said that he was finding it difficult to breathe. CRO Russell advised him to try to make his way out of the building. He told her that he had a disability and needed assistance. No service request was created in response to his call, but a note of his disability was added to a whiteboard in the control room. By the time she took that call CRO Russell had received the instruction from SOM Smith to change the "stay put" advice. She recalled that the new advice had been for people to cover themselves, not to breathe in the smoke and to make their way down the stairs.¹⁶¹⁷¹⁶¹⁷ Phase 1 Report Volume III paragraph 15.169; LFB Short Incident Log Report {MET00013830}.

¶97.243 Hesham Rahman's fourth call to the emergency services was taken by CRO Russell at 03.10. He was then in the living room of his flat. He had blocked the front door but a lot of smoke was still coming in. He was advised to leave but said that he could not do so because he could not walk properly due to his disability. He told CRO Russell that he was lying on the floor with a wet cloth over his nose and that his windows were shut. CRO Russell told him that the crews were coming up to him. No service request appears to have been created in response to that call.¹⁶¹⁸¹⁶¹⁸ Phase 1 Report Volume III paragraph 17.26; LFB Short Incident Log Report {MET00013830}.

¶97.244 At 03.16, a person who identified herself as Hesham Rahman's daughter spoke to CRO Yvonne Adams. When told to call him back and tell him that he needed to leave, the caller explained that he could not leave because of his disabilities.¹⁶¹⁹¹⁶¹⁹ Phase 1 Report Volume III paragraph 17.28.

¶97.245 Hesham Rahman's fifth and final emergency call at 03.20 was also taken by CRO Adams. It lasted 2 minutes and 38 seconds. By that time the flat was full of black smoke and he could not see anything. The fire was coming into his flat. No service request was created in response to the call.¹⁶²⁰¹⁶²⁰ Phase 1 Report Volume III paragraphs 17.27 and 18.21; LFB Short Incident Log Report {MET00013830}.

¶97.246 Anna Krivsoun made emergency calls on Hesham Rahman's behalf from outside the tower, probably including calls made at 03.38 and 04.01. It was reported to CRO Gotts during the call at 03.38 that he had not been able to leave his flat and was struggling to breathe. At 04.01 the caller told CRO Russell that he was no longer responding and that it had been clear that he was struggling to breathe.¹⁶²¹¹⁶²¹ Phase 1 Report Volume III paragraph 18.21.

¶97.247 Anna Krivsoun had last spoken to Hesham Rahman by telephone at 03.43. She could hear him coughing and struggling to breathe.¹⁶²²¹⁶²² Phase 1 Report Volume III paragraph 18.21. That appears to be the last contact Hesham Rahman had with anyone outside the tower.

¶97.248 At the incident ground, there were references to Hesham Rahman and Flat 204 in various places. WM Meyrick in command unit CU8 was receiving information by radio from the control room which he was passing to WM Kentfield.¹⁶²³¹⁶²³ Phase 1 Report Volume II paragraph 11.5. At some point between 01.40 and 01.49 SM Loft received a piece of paper from WM Kentfield on which messages had been recorded. That piece of paper later became known as "Sadler's Envelope". One of the notes recorded on the paper was "FLAT 204 23 FLOOR".¹⁶²⁴¹⁶²⁴ Phase 1 Report Volume II paragraphs 12.18-12.19 and Figure 12.4.

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¶97.249 Between about 02.00 and 03.00, a white laminated sheet was being used on CU7 to record emergency calls.¹⁶²⁵¹⁶²⁵ Phase 1 Report Volume IV paragraph 28.85(d). It contained the notation "FLAT 204 FLOOR 23 1 PERSON disabled light smoke".¹⁶²⁶¹⁶²⁶ Phase 1 Report Volume IV paragraph 28.102(f); {MET00015930}.

¶97.250 At about 02.17, CM Batterbee went to the bridgehead on floor 2. He made a note of the entries on a forward information board, which included the note "204 (tick) 21st".¹⁶²⁷¹⁶²⁷ Phase 1 Report Volume II paragraph 14.73 and Figure 14.4. (Flat 204 was in fact on floor 23.)

¶97.251 WM Glynn Williams started to record information on the wall of the lobby on the ground floor at 02.15. A photograph of the lobby wall taken much later on in the incident shows the notation "204 21" with "21" circled.¹⁶²⁸¹⁶²⁸ Phase 1 Report Volume II paragraphs 14.103-14.104 and Figure 14.5. That is another example of inaccurate recording of the location of Flat 204.

¶97.252 Between about 02.20 and 03.08, WM Louisa De Silvo recorded information about people needing to be rescued on the wall of the lobby of floor 3 when the bridgehead had been re-located on that floor. A photograph of that wall from later in the incident shows the notation "EUSTON – 23 205 204" with 204 circled and ticked. The writing also included the expression "21 (tick) 204".¹⁶²⁹¹⁶²⁹ Phase 1 Report Volume II paragraph 14.108; Phase 1 Report Volume III paragraph 15.23 and Figure 15.7 A tick against a particular flat indicated that a crew had been sent there and a circle indicated that further information had been received, by runner, by radio or from returning crews.¹⁶³⁰¹⁶³⁰ De Silvo {Day30/14:18}-{Day30/15:15}. The floor on which Hesham Rahman's flat was situated seems to appear both correctly and incorrectly on the wall.

¶97.253 WM Sadler described being given an "envelope" ("Sadler's Envelope"), which was in fact an A4-size piece of paper. He immediately photographed it, at 02.19.¹⁶³¹¹⁶³¹ Phase 1 Report Volume II paragraph 14.71. As noted above, that piece of paper had written on it "FLAT 204 23 FLOOR".

¶97.254 From about 02.33 SM Oliff recorded information in the control room on two whiteboards.¹⁶³²¹⁶³² Phase 1 Report Volume III paragraph 15.139. Following Hesham Rahman's call to CRO Russell at 02.36, to the first whiteboard he added the details "1 disabled male" to the entry "204 23 flr".¹⁶³³¹⁶³³ Phase 1 Report Volume III paragraph 15.169.

¶97.255 After 03.00, the laminated sheet used on command unit CU7 was replaced by a whiteboard with a grid. Flat 204 was annotated with "1 disabled P" with "1 disabled" in green and "P" in red and circled.¹⁶³⁴¹⁶³⁴ Phase 1 Report Volume IV paragraph 28.85 (d); {MET00015924}.

¶97.256 FFs Pole, Mitchell, Cheesman and Bate from Euston Fire Station were sent to floor 23, probably to Flats 204 (where Hesham Rahman lived) and 205. A photograph of the wall on floor 3 where the bridgehead was by then positioned shows that the word "Euston" had been written against Flats 204 and 205 on floor 23. In the bottom right-hand corner of the photograph can be seen the words "23rd Euston 204 205".¹⁶³⁵¹⁶³⁵ Phase 1 Report Volume III paragraph 16.15 and Figure 16.6. We therefore conclude that the emergency calls by and on behalf of Hesham Rahman did lead to an attempt to reach his flat.

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¶97.257 The crew tallied out by 02.53. They came across another crew at about floor 12 and FF Bate was handed a child casualty, whom he decided to take out of the tower. FFs Mitchell, Pole and Cheesman continued upwards and reached what they thought was floor 18. There they realised that they did not have enough air to reach floor 23 and get back down again; they therefore helped to rescue seven residents from that floor. FF Mitchell recalled telling WM De Silvo that they had not reached floor 23. The crew's "end of wear times" were between 03.15 and 03.17.¹⁶³⁶¹⁶³⁶ Phase 1 Report Volume III paragraphs 16.15-16.20.

¶97.258 Flat 204 on floor 23 faced west and had one bedroom.¹⁶³⁷¹⁶³⁷ External Fire Spread Report {MET00012593/12}. The exterior fire spread to the outside of the bedroom of Flat 204 by 03.20 and to the outside of the living room by 03.34. By 03.42 it was spreading to the column between Flats 204 and 203 and affecting Flat 203 next door.¹⁶³⁸¹⁶³⁸ Purser, Phase 2 Report, Section 6 {DAPR0000006/24} paragraph 93 and {DAPR0000006/32} paragraph 139.

Recovery and identification

¶97.259 The remains of Hesham Rahman were recovered from a partitioned area, which may have been a cupboard, in the living room of Flat 204.¹⁶³⁹¹⁶³⁹ Purser, Phase 2 Report, Section 6 {DAPR0000006/33} paragraph 143. The coroner was satisfied about the identification of those remains and therefore issued an interim certificate of the fact of death.¹⁶⁴⁰¹⁶⁴⁰ Interim certificate of the fact of death for Hesham Rehman {MET00065606}.

Cause and time of death

¶97.260 Hesham Rahman was exposed to a slow increase in smoke and asphyxiant gases from about 01.29, followed by a more rapid increase after about 03.20 as the fire spread past his bedroom. The increase was even more rapid after the fire reached his living room.¹⁶⁴¹¹⁶⁴¹ Purser, Phase 2 Report, Section 6 {DAPR0000006/33} paragraph 145.

¶97.261 Hesham Rahman is likely to have lost consciousness at about 03.43, which was the time of the last reported communication with him. He died at some point between about 03.45 and 04.00¹⁶⁴²¹⁶⁴² Purser, Phase 2 Report, Section 6 {DAPR0000006/6} Table 20. from the inhalation of asphyxiant gases and before suffering the direct effects of fire.¹⁶⁴³¹⁶⁴³ Purser, Phase 2 Report, Section 6 {DAPR0000006/33-34} paragraphs 146-147 and 153.

¶97.262 The post-mortem report on Hesham Rahman recorded the cause of death as "consistent with the effects of fire,¹⁶⁴⁴¹⁶⁴⁴ Rahman post-mortem report {COR00001718/4}. but in light of Professor Purser's evidence we find a more accurate description to be "inhalation of asphyxiant gases". The latest time at which he could have been rescued successfully was 03.15.

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¶Flat 205

¶Mohammed Amied (Saber) Neda

¶Date of birth: 3 May 1960 (57 years).

¶Place of birth: Afghanistan.

¶Gender: Male.

¶Occupation: Chauffeur.

¶Usual address: Flat 205, floor 23, Grenfell Tower, London.

¶Place of death: West Side of Grenfell Tower, London.

¶Time of death: 02.41 on 14 June 2017.

¶Cause of death: Multiple injuries (consistent with a fall from height).

Background and composition of household

¶97.263 Mohammed Amied (Saber) Neda lived in Flat 205 with his wife, Shakila (Flora) Neda, and his son, Shekeb (Farhad) Neda. His family and friends knew him as Saber.¹⁶⁴⁵¹⁶⁴⁵ Phase 1 Report Volume IV paragraph 32.22.

¶97.264 Saber Neda was born on 3 May 1960 in Afghanistan. In 2017 he was 57 years old. One of 10 children, he grew up in Afghanistan where he met his wife, Flora, in 1989. They married in 1991 in Kabul. The family moved to the UK in 1998 with their young son, Farhad. The family moved into Flat 205 in 1999.¹⁶⁴⁶¹⁶⁴⁶ Phase 1 Report Volume IV paragraphs 32.22–32.27. Saber Neda established his own chauffeur business, which by 2017 he had operated for 10 years.¹⁶⁴⁷¹⁶⁴⁷ Phase 1 Report Volume IV paragraphs 32.22–32.27.

Vulnerability

¶97.265 Saber Neda did not have any known vulnerabilities.

Events of 14 June 2017

¶97.266 Saber Neda returned home with his wife and son at 00.52 on 14 June 2017. On reaching floor 23 they noticed that a noise was coming from the vents of the extractor fans located in the lobby. Farhad Neda called the TMO at 01.10 to report it and also reported that there was an electrical burning smell. The call responder told him that they had received a call about the fire alarms and that the fire brigade was on its way.¹⁶⁴⁸¹⁶⁴⁸ Phase 1 Report Volume II paragraph 10.148.

¶97.267 At the time the lobby was clear of smoke.¹⁶⁴⁹¹⁶⁴⁹ Phase 1 Report Volume II paragraph 10.150. About 15 minutes later the family decided to leave the tower. Saber Neda had looked out the window and thought there was a fire downstairs. A burning smell was still detectable in the lobby. Visibility in the lobby was still clear when the Neda family tried to leave but Farhad Neda saw black smoke coming into the lobby from the smoke extraction vents.¹⁶⁵⁰¹⁶⁵⁰ Phase 1 Report Volume II paragraph 10.283.

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¶97.268 The family reached the stairwell but were prevented from going down the stairs by people coming up from the lower floors.¹⁶⁵¹¹⁶⁵¹ Phase 1 Report Volume II paragraph 10.284. Among those coming up were Mariem and Eslah Elgwahry from floor 22 and Sakina Afrasehabi and Fatemeh Afrasiabi from floor 18. The Neda family returned to their flat and took in the Elgwahrys and Sakina Afrasehabi and Fatemeh Afrasiabi shortly before 01.30.¹⁶⁵²¹⁶⁵² Phase 1 Report Volume II paragraph 10.284.

¶97.269 The Neda family took them into the living room. Black smoke slowly began to enter the flat underneath the front door. Within 10 to 15 minutes there were black marks around people's noses due to the smoke.¹⁶⁵³¹⁶⁵³ Phase 1 Report Volume II paragraph 13.79.

¶97.270 Saber Neda did not make any calls to the emergency services on 14 June 2017, but Mariem Elgwahry made a number of calls from Flat 205. Her first two calls were made at 01.30¹⁶⁵⁴¹⁶⁵⁴ Phase 1 Report Volume II paragraph 10.289 (a). and 01.38.¹⁶⁵⁵¹⁶⁵⁵ Phase 1 Report Volume II paragraphs 11.27 and 11.163. As a result, a message about persons trapped in Flat 205 on floor 23 was passed to the incident ground.¹⁶⁵⁶¹⁶⁵⁶ LFB Short Incident Log Report {MET00013830/19}; Phase 1 Report Volume II paragraphs 12.72 and 12.73 (b). SM Loft was in front of the tower passing information he had received from WM Kentfield on command unit CU7 to the bridgehead, probably by radio.¹⁶⁵⁷¹⁶⁵⁷ Phase 1 Report Volume II paragraph 12.18. He said that the first message he had received related to Flat 205. He passed it to the bridgehead at about 01.40.¹⁶⁵⁸¹⁶⁵⁸ Phase 1 Report Volume II paragraph 12.19. Flat 205 and floor 23 were recorded on the forward information board used to record information about people needing to be rescued while the bridgehead was located on floor 2.¹⁶⁵⁹¹⁶⁵⁹ Phase 1 Report Volume II paragraph 14.73 and Figure 14.4.

¶97.271 Although information about Flat 205 reached the bridgehead soon after 01.40, firefighters were not sent to floor 23 until 02.08.¹⁶⁶⁰¹⁶⁶⁰ Phase 1 Report Volume IV paragraph 28.101. FFs Zade Alassad, Scott Bell and John Wright tallied out between 02.08 and 02.10 to go to Flats 201 and 205 on floor 23.¹⁶⁶¹¹⁶⁶¹ Phase 1 Report Volume II paragraph 14.117. Their names were written next to a circled note on a wall of floor 2 which read "Wandswor 23rd flts 201 205."¹⁶⁶²¹⁶⁶² Phase 1 Report Volume II Figure 13.2 and paragraph 14.117; Phase 1 Report Volume IV paragraph 28.101. However, the crew did not reach floor 23 because they stopped to help other firefighters take down casualties found on floor 10.¹⁶⁶³¹⁶⁶³ Phase 1 Report Volume II paragraph 14.117. FF Bell said that he had told someone that they had not reached floor 23 but he could not remember to whom he had spoken or what that person did with the information.¹⁶⁶⁴¹⁶⁶⁴ Phase 1 Report Volume II paragraph 14.117.

Contact with others outside the tower

¶97.272 Farhad Neda was in contact with friends outside the tower who were able to speak to firefighters and pass advice back to him. He also spoke directly with a firefighter who gave him advice. The collective advice was for those in Flat 205 to cover their faces with wet towels, wet the carpets, put wet towels against the doors and remain in the flat until firefighters came.¹⁶⁶⁵¹⁶⁶⁵ Phase 1 Report Volume II paragraph 13.81. The Nedas filled buckets with water which they threw on the carpets and soaked towels to cover their mouths when they saw smoke coming into the flat.¹⁶⁶⁶¹⁶⁶⁶ Phase 1 Report Volume II paragraph 13.80.

206

¶97.273 Mariem Elgwahry made a third emergency call from Flat 205 at 01.54 and spoke to CRO Gotts.¹⁶⁶⁷¹⁶⁶⁷ Phase 1 Report Volume II paragraphs 13.78 and 13.98. At 01.57 CRO Darby sent a message to the incident ground about a caller in Flat 205 on floor 23 who had reported the fire coming up to the flat.¹⁶⁶⁸¹⁶⁶⁸ Phase 1 Report Volume II paragraph 13.98.

¶97.274 When Saber Neda saw that the fire had reached the bedroom in Flat 205 he closed the door and told everyone not to enter it.¹⁶⁶⁹¹⁶⁶⁹ Phase 1 Report Volume III paragraph 15.64. At around 02.15 Farhad Neda decided that they needed to leave. He seized his mother and shouted for his father to follow.¹⁶⁷⁰¹⁶⁷⁰ Phase 1 Report Volume III paragraph 15.64. Saber Neda agreed and said he would be behind them. He handed out wet towels to Eslah and Mariem Elgwahry and sisters Sakina Afrasehabi and Fatemeh Afrasiabi in preparation for them all to leave.¹⁶⁷¹¹⁶⁷¹ Phase 1 Report Volume III paragraph 15.64. Farhad Neda and Flora Neda then left the flat thinking that the others would follow them.

¶97.275 However, Saber Neda did not follow his family out but remained in Flat 205 with Fatemeh Afrasiabi, Sakina Afrasehabi and Mariem and Eslah Elgwahry.¹⁶⁷²¹⁶⁷² Phase 1 Report Volume III paragraph 15.65.

Further deployment to Floor 23

¶97.276 In a further emergency call at 02.25, Mariem Elgwahry described the conditions in the flat as having deteriorated significantly.¹⁶⁷³¹⁶⁷³ Phase 1 Report Volume III paragraph 15.143 She said that they were running out of air and the whole flat was black.¹⁶⁷⁴¹⁶⁷⁴ Phase 1 Report Volume III paragraph 15.61. The fire had reached the bedroom and the door to that room had been closed. Mariem Elgwahry said that they had tried to leave but it was totally black outside the front door.¹⁶⁷⁵¹⁶⁷⁵ Phase 1 Report Volume III paragraph 15.61.

¶97.277 CRO Adams called CU8 at 02.28 to pass on a message about that call. She was unaware of a request that all information about people needing to be rescued should now be sent to CU7. We do not know whether a message was sent to the bridgehead from CU7.¹⁶⁷⁶¹⁶⁷⁶ Phase 1 Report Volume III paragraph 15.147.

¶97.278 In any event, a message reached the bridgehead sometime after 02.17 when it had moved to floor 3, since Flat 205 was included in the information on the wall on that floor.¹⁶⁷⁷¹⁶⁷⁷ Phase 1 Report Volume III Figure 15.7. As a result CM Richard Evans and FF Gemma Bloxham were sent to Flat 205 on floor 23 after 02.24.¹⁶⁷⁸¹⁶⁷⁸ Phase 1 Report Volume III paragraph 15.54.

¶97.279 CM Evans and FF Bloxham had reached floor 20 when they came across Farhad and Flora Neda, whom they then helped to leave the tower.¹⁶⁷⁹¹⁶⁷⁹ Phase 1 Report Volume III paragraphs 15.54-15.56; Phase 1 Report Volume IV paragraph 28.101. Farhad Neda told the firefighters that his father and four others were trapped in Flat 205, which one of them recorded in a notebook. As they left the main entrance Farhad Neda told the firefighters again that there were still people in the flat. CCTV shows him and his mother leaving the tower between 02.42 and 02.43.¹⁶⁸⁰¹⁶⁸⁰ Phase 1 Report Volume III paragraphs 15.66-15.67.

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¶97.280 CM Evans returned to the bridgehead and told the officer in charge that they had not reached Flat 205 but that they had brought two people down.¹⁶⁸¹¹⁶⁸¹ Phase 1 Report Volume III paragraph 15.56. That report may have led to a further deployment of firefighters to the top floor. At 02.51, FFs Niki Mitchell, Jessamine Bate, Michael Pole and Chris Cheesman from Euston Fire Station were sent to floor 23.¹⁶⁸²¹⁶⁸² Phase 1 Report Volume IV paragraph 28.101. On the wall of the bridgehead, then on floor 3, was written the word "Euston" against Flats 204 and 205 on floor 23.¹⁶⁸³¹⁶⁸³ Phase 1 Report Volume III paragraph 16.15 and Figure 16.6. The notation was repeated further down where the words "23rd Euston 204 205" can be seen. The firefighters did not reach floor 23 but helped casualties escape from Flat 153 on floor 18.¹⁶⁸⁴¹⁶⁸⁴ Phase 1 Report Volume III paragraphs 16.17-16.20; Phase 1 Report Volume IV paragraph 28.101. FF Mitchell recalled telling WM Louisa De Silvo that they had not reached floor 23 but had got fairly high up the tower and had rescued a family of seven. The crew's end of wear times were between 03.15 and 03.17.¹⁶⁸⁵¹⁶⁸⁵ Phase 1 Report Volume III paragraphs 16.17-16.20. Although they did not reach floor 23, their deployment was too late for them to have had any prospect of rescuing Saber Neda.

¶97.281 No firefighter successfully reached floor 23 on 14 June 2017.¹⁶⁸⁶¹⁶⁸⁶ Phase 1 Report Volume IV paragraph 28.101.

Last contact with Saber Neda

¶97.282 At 02.37, Saber Neda called his nephew Lotfrahman (Massi) Abdulrahman. He was still in Flat 205 at the time and asked why no one had come to help. Massi Abdulrahman could hear female voices in the background. After the call ended he tried to call his uncle back, but without success.

¶97.283 At 02.40, Saber Neda left a message for his brother-in-law, Habibirahman Abdulrahman. He said: "Goodbye. We are now leaving this world, goodbye. I hope I haven't disappointed you. Goodbye to all." There was no further contact with Saber Neda.

Recovery and identification

¶97.284 At 02.41, the body of Saber Neda was found in the children's playground on the west side of the tower. He had fallen from the tower.¹⁶⁸⁷¹⁶⁸⁷ Phase 1 Report Volume III paragraph 15.70. A paramedic formally pronounced him dead at 02.50.¹⁶⁸⁸¹⁶⁸⁸ Matthews {COR00001112/5} page 5. The coroner was satisfied about the identification of his remains and therefore issued an interim certificate of the fact of death.¹⁶⁸⁹¹⁶⁸⁹ Interim certificate of the fact of death for Saber Neda {MET00065621}.

Cause and time of death

¶97.285 The post-mortem on Saber Neda recorded the cause of death as multiple traumatic injuries consistent with a fall from a significant height. The injuries were unsurvivable and death, which occurred at or just before 02.41, was instantaneous.¹⁶⁹⁰¹⁶⁹⁰ Neda post-mortem report {COR00001210/15}. The level of carboxyhaemoglobin in his blood was 20%, significantly lower than the level associated with death from carbon monoxide poisoning.¹⁶⁹¹¹⁶⁹¹ Neda post-mortem report {COR00001210/14}.

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Eslah Elgwahry and Mariem Elgwahry

Eslah Elgwahry

¶Date of birth: 1 December 1952 (64 years). Place of birth: Alexandria, Egypt. Gender: Female. Occupation: Retired. Usual address: Flat 196, floor 22, Grenfell Tower, London. Place of death: Flat 205, floor 23, Grenfell Tower, London. Time of death: Between 02.50 and 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Mariem Elgwahry

¶Date of birth: 11 April 1990 (27 years). Place of birth: London, United Kingdom. Gender: Female. Occupation: Marketing Manager. Usual address: Flat 196, floor 22, Grenfell Tower, London. Place of death: Flat 205, floor 23, Grenfell Tower, London. Time of death: 02.50 to 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Background and composition of household

¶97.286 Eslah Elgwahry lived in Flat 196 on floor 22 with her daughter Mariem. She was born on 1 December 1952 in Alexandria, Egypt and was 64 years old. Her daughter, Mariem was born on 11 April 1990 in London. She was 27 years old.¹⁶⁹²¹⁶⁹² Phase 1 Report Volume IV paragraphs 32.61-32.63.

¶97.287 Eslah Elgwahry had lived in Grenfell Tower for 34 years. She raised her two children, Mariem and her older brother, Ahmed, alone after their father died when they were young. She instilled in them a strong bond.¹⁶⁹³¹⁶⁹³ Phase 1 Report Volume IV paragraphs 32.61-32.63. Eslah Elgwahry had retired by the time of the fire. Mariem Elgwahry graduated from Roehampton University and had established a successful career as a marketing manager.¹⁶⁹⁴¹⁶⁹⁴ Phase 1 Report Volume IV paragraphs 32.64-32.65.

209

Vulnerability

¶97.288 Eslah Elgwahry had a complex range of health problems which resulted in her having difficulty walking.¹⁶⁹⁵¹⁶⁹⁵ Elgwahry {IWS00001757/7} page 7, paragraph 19. She was not able to climb many stairs without assistance. Mariem Elgwahry had no known vulnerabilities. She was Eslah Elgwahry's carer.¹⁶⁹⁶¹⁶⁹⁶ Elgwahry {IWS00001757/7} page 7, paragraph 19.

¶97.289 Rydon's survey of residents, prepared in November 2014 and provided to the TMO, recorded that Eslah Elgwahry had mental health problems and high blood pressure.¹⁶⁹⁷¹⁶⁹⁷ Rydon Residents Survey {RYD00024466/6}. On 24 June 2015, she completed a TMO Tenancy Information Form as part of a tenancy audit on Flat 196, in which she reported that she considered herself to have a physical disability and to need the support of a carer.¹⁶⁹⁸¹⁶⁹⁸ Tenancy Audit Form for Flat 196 {IWS00001778}.

¶97.290 Both Eslah and Mariem Elgwahry were recorded as residents in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system. Eslah Elgwahry was identified as being over 65 but there was no record of her vulnerabilities.¹⁶⁹⁹¹⁶⁹⁹ Noble spreadsheet {TMO00866002}.

Events of 14 June 2017

¶97.291 Eslah Elgwahry was alone in Flat 196 on 13 June 2017 until 22.14 when Mariem Elgwahry returned to the tower.¹⁷⁰⁰¹⁷⁰⁰ O'Riordan {MET00013136/3} page 3. Eslah Elgwahry was seen on CCTV in the lift lobby of the tower at 15.21. O'Riordan {MET00013136/2} page 2. It is not clear when they first became aware of the fire but its rapid spread up the "Flat 6s" prompted them to leave their home. (The fire on the outside of the building had passed Flat 196 by 01.26.)¹⁷⁰¹¹⁷⁰¹ Phase 1 Report Volume II paragraph 10.118.

Movement to Flat 205

¶97.292 Mariem Elgwahry and Eslah Elgwahry left Flat 196 at about 01.25.¹⁷⁰²¹⁷⁰² Phase 1 Report Volume II paragraph 10.277. Naomi Li, who lived in Flat 195, met them in the lobby of floor 22. Mariem told Naomi that the fire was already in their kitchen. Naomi said that they had closed the door to Flat 196 and Mariem Elgwahry was locking it before they left through the stairwell door.¹⁷⁰³¹⁷⁰³ Phase 1 Report Volume II paragraphs 10.277 and 10.281.

¶97.293 Mariem Elgwahry and Eslah Elgwahry were prevented from going down the stairs by a group of other people going up.¹⁷⁰⁴¹⁷⁰⁴ Phase 1 Report Volume II paragraph 10.282. They went up to floor 23 instead.¹⁷⁰⁵¹⁷⁰⁵ Phase 1 Report Volume II paragraph 10.284. Together with Sakina Afrasehabi and Fatemeh Afrasiabi, who had come up from Flat 151 on floor 18, Eslah and Mariem Elgwahry were able to shelter in Flat 205, the home of the Neda family.¹⁷⁰⁶¹⁷⁰⁶ Phase 1 Report Volume II paragraphs 10.284 and 10.288-10.289.

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The first emergency messages from Flat 205

¶97.294 At 01.30, Mariem Elgwahry made her first call to the emergency services. She spoke to CRO Peter Duddy in the LFB control room¹⁷⁰⁷¹⁷⁰⁷ Phase 1 Report Volume II paragraph 10.289 (a). and told him that she was with others on floor 23. Mariem Elgwahry said that the fire had broken into her flat on floor 22 and that they had been forced to run to a neighbour's flat. She said there was smoke everywhere. The call was cut off before CRO Duddy could give her any advice.¹⁷⁰⁸¹⁷⁰⁸ Phase 1 Report Volume II paragraph 11.141.

¶97.295 Mariem Elgwahry's second emergency call followed shortly afterwards at 01.38, when she spoke to CRO Fox in the LFB control room.¹⁷⁰⁹¹⁷⁰⁹ Phase 1 Report Volume II paragraphs 11.27 and 11.163. She said that there was no smoke coming into Flat 205 and that there were seven people in the flat. CRO Fox told her to "put things on the door" and to keep the windows closed if smoke started to come in.¹⁷¹⁰¹⁷¹⁰ Phase 1 Report Volume II paragraphs 11.163-11.164.

¶97.296 CRO Fox then created a service request which read, "Seven people in flat 205 on 23rd floor; persons unable to leave property."¹⁷¹¹¹⁷¹¹ LFB Short Incident Log {MET00013830/19}. CRO Darby passed the information to WM Meyrick in CU8 at 01.43.¹⁷¹²¹⁷¹² Phase 1 Report Volume II paragraphs 12.72 and 12.73 (b). She then marked the service request as completed.¹⁷¹³¹⁷¹³ LFB Short Incident Log {MET00013830/19}.

¶97.297 WM Kentfield was passing messages received by WM Meyrick in command unit CU8 to SM Loft, who was in front of the tower passing information to the bridgehead, probably by radio.¹⁷¹⁴¹⁷¹⁴ Phase 1 Report Volume II paragraph 12.18. He said that the first message he had received related to Flat 205.¹⁷¹⁵¹⁷¹⁵ Phase 1 Report Volume II paragraph 12.19.

¶97.298 Flat 205 and floor 23 appeared on the forward information board used to record information about people needing to be rescued while the bridgehead was located on floor 2.¹⁷¹⁶¹⁷¹⁶ Phase 1 Report Volume II paragraph 14.73 and Figure 14.4.

¶97.299 Although information about Flat 205 reached the bridgehead soon after 01.40, firefighters were not sent to floor 23 until 02.08.¹⁷¹⁷¹⁷¹⁷ Phase 1 Report Volume IV paragraph 28.101.

Further emergency messages from Flat 205

¶97.300 At 01.54, Mariem Elgwahry made a third call to the emergency services and spoke to CRO Gotts. She reported that she was one of seven people in Flat 205. She said that the flat was full of smoke and that the fire was approaching; they could see the flames outside the window. CRO Gotts told her that the firefighters were trying to send people up and that she would make them aware of their location and the urgency of the situation.¹⁷¹⁸¹⁷¹⁸ Phase 1 Report Volume II paragraphs 13.78 and 13.98.

¶97.301 After the call had ended, CRO Gotts went to check that the earlier message about Flat 205 had been sent to the incident ground. Although she did not create a service request, CRO Darby sent a radio message at 01.57 saying that the caller in Flat 205 on floor 23 had reported that the fire was coming right up to her flat.¹⁷¹⁹¹⁷¹⁹ Phase 1 Report Volume II paragraph 13.98. We cannot say whether that further message reached the bridgehead or, if it did, whether it added to the information about Flat 205 already held there.

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The first deployments to floor 23

¶97.302 FFs Zade Alassad, Scott Bell and John Wright were sent by WM Watson to two flats on floor 23.¹⁷²⁰¹⁷²⁰ Phase 1 Report Volume II paragraph 14.117. They tallied out at between 02.08 to 02.10. Their names were written next to a circled note on the wall of floor 2 which read "Wandswor 23rd flts 201 205."¹⁷²¹¹⁷²¹ Phase 1 Report Volume II Figure 13.2 and paragraph 14.117; Phase 1 Report Volume IV paragraph 28.101. It is likely that they were sent to Flats 201 and 205.¹⁷²²¹⁷²² Phase 1 Report Volume II Figure 13.2 and paragraph 14.117, Phase 1 Report Volume IV paragraph 28.101.

¶97.303 FFs Alassad, Bell and Wright did not reach floor 23. They stopped at floor 10 and helped to carry down casualties found on that floor.¹⁷²³¹⁷²³ Phase 1 Report Volume II paragraph 14.117. FF Bell said that he told someone they had not reached floor 23 but he could not remember to whom he had spoken or what that person did with that information.¹⁷²⁴¹⁷²⁴ Phase 1 Report Volume II paragraph 14.117.

Contact with others outside the tower

¶97.304 Mariem Elgwahry spoke to her brother, Ahmed Elgwahry, at about 01.43. She told him that there was a fire in the kitchen and that she was with their mother. Ahmed Elgwahry told her to get out of the building. He then left his home and went to the tower.¹⁷²⁵¹⁷²⁵ Ahmed Elgwahry {IWS00000988/2} page 2, paragraphs 5 and 6.

¶97.305 Mariem Elgwahry called Ahmed Elgwahry again at 01.48 and then 01.49. She told him that they had tried to go down the stairs but could not do so as others had been coming up and telling her to go back. She explained that she was now in Flat 205 after a neighbour had let them into his flat.¹⁷²⁶¹⁷²⁶ Ahmed Elgwahry {IWS00000988/3} page 3, paragraph 9.

¶97.306 Mariem Elgwahry spoke to her sister-in-law, Ferzana Elgwahry, at 01.56. She was distressed and crying and coughed a lot during the call. She confirmed that they had already covered their mouths with damp towels.¹⁷²⁷¹⁷²⁷ Ferzana Elgwahry {IWS00000995/3} page 2, paragraph 10.

¶97.307 Mariem Elgwahry was also in contact with her close friend, Lucy Ho. At about 02.00, Lucy Ho called her and tried to persuade her to leave. She told Lucy Ho that the emergency services knew where they were and would come for them. Lucy Ho went to find a firefighter who told her to speak to a police officer. She told the police officer that her friend, her mother and four others were in Flat 205.¹⁷²⁸¹⁷²⁸ Phase 1 Report Volume II paragraph 14.149. It has not been possible to identify that police officer.

¶97.308 Ahmed Elgwahry arrived at the tower at about 02.13 and then called Mariem Elgwahry. A police officer took Ahmed Elgwahry to a command unit, where a firefighter told Mariem Elgwahry to lie low and breathe through the drain in the bathroom and block out smoke using wet towels. The firefighter then told her to call the emergency services. The firefighter has not been identified.¹⁷²⁹¹⁷²⁹ Phase 1 Report Volume II paragraph 14.150.

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Farhad and Flora Neda evacuate Flat 205

¶97.309 Saber Neda saw that the fire had reached the bedroom in Flat 205 and closed the door. He then told everyone not to enter it.¹⁷³⁰¹⁷³⁰ Phase 1 Report Volume III paragraph 15.64. Farhad Neda decided that they needed to leave at around 02.15 and grabbed his mother and shouted for his father to follow.¹⁷³¹¹⁷³¹ Phase 1 Report Volume III paragraph 15.64. Saber Neda agreed and said he would be behind them. Saber Neda handed out wet towels to Eslah and Mariem Elgwahry and sisters Sakina Afrasehabi and Fatemeh Afrasiabi in preparation to leave.¹⁷³²¹⁷³² Phase 1 Report Volume III paragraph 15.64. Farhad and Flora Neda then left the flat at this time believing that the others would follow them.

¶97.310 Eslah Elgwahry and Mariem Elgwahry remained in the flat with Saber Neda, Sakina Afrasehabi and Fatemeh Afrasiabi.¹⁷³³¹⁷³³ Phase 1 Report Volume III paragraph 15.65.

Final FSG message from Flat 205

¶97.311 Mariem Elgwahry's last call to the LFB was connected to CRO Howson at 02.25.¹⁷³⁴¹⁷³⁴ Phase 1 Report Volume III paragraph 15.143 Mariem Elgwahry said she was one of seven adults who were sheltering in the kitchen. They were running out of air and the whole flat was black.¹⁷³⁵¹⁷³⁵ Phase 1 Report Volume III paragraph 15.61. She said that she was with her mother, who was diabetic and had asthma. The fire had reached the bedroom and the door to that room had been closed. CRO Howson advised her to leave, if necessary. Mariem Elgwahry told her that they had tried to leave but that it was totally black outside the front door.¹⁷³⁶¹⁷³⁶ Phase 1 Report Volume III paragraph 15.61. Ahmed Elgwahry tried to call her while she was still speaking to CRO Howson.¹⁷³⁷¹⁷³⁷ Phase 1 Report Volume III paragraph 15.62.

¶97.312 CRO Adams called CU8 at 02.28 to pass on the information she had received from Mariem Elgwahry. She was not aware that a message from CU7 recorded in the incident log a few minutes earlier had asked for all information about people needing to be rescued to be sent to CU7 instead of CU8.¹⁷³⁸¹⁷³⁸ Phase 1 Report Volume III paragraph 15.147.

¶97.313 Mariem Elgwahry called Ahmed Elgwahry again at 02.31. She told him that she was with six or seven people in the kitchen of the flat. She said they could not leave because the lobby was full of black smoke and it was impossible to see.¹⁷³⁹¹⁷³⁹ Phase 1 Report Volume III paragraph 15.62.

The second deployment to Flat 205

¶97.314 The next deployments to floor 23 were after 02.24. CM Richard Evans and FF Gemma Bloxham were sent to Flat 205 on floor 23. They had reached floor 20 when they came across Farhad and Flora Neda on their way down. CM Evans and FF Bloxham stopped to help them out of the tower, not knowing that they had left the flat that they had been sent to.¹⁷⁴⁰¹⁷⁴⁰ Phase 1 Report Volume III paragraphs 15.54-15.56; Phase 1 Report Volume IV paragraph 28.101. Farhad Neda told the firefighters that his father and four others were trapped in Flat 205, which was recorded by one of the firefighters in a notebook. As they left the main entrance, Farhad Neda told the firefighters again that there were still people in the flat. They are recorded on CCTV leaving the tower between 02.42 and 02.43.¹⁷⁴¹¹⁷⁴¹ Phase 1 Report Volume III paragraphs 15.66-15.67.

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¶97.315 The crew's end of wear time was 02.42, which must have been at about the time that CM Evans told the officer in charge at the bridgehead that they had not reached Flat 205.¹⁷⁴²¹⁷⁴² Phase 1 Report Volume III paragraph 15.56.

¶97.316 CM Evan's message to the bridgehead may have led to a further deployment of firefighters to the top floor. At 02.51, FFs Niki Mitchell, Jessamine Bate, Michael Pole and Chris Cheesman from Euston Fire Station were sent to floor 23.¹⁷⁴³¹⁷⁴³ Phase 1 Report Volume IV paragraph 28.101. At the bridgehead, then on floor 3, the word "Euston" had been written on the wall against Flats 204 and 205 on floor 23.¹⁷⁴⁴¹⁷⁴⁴ Phase 1 Report Volume III paragraph 16.15 and Figure 16.6. The message was repeated further down. That crew did not reach floor 23 but helped casualties evacuate from Flat 153 on floor 18.¹⁷⁴⁵¹⁷⁴⁵ Phase 1 Report Volume III paragraphs 16.17-16.20; Phase 1 Report Volume IV paragraph 28.101. FF Mitchell recalled telling WM Louisa De Silvo that they had not reached floor 23 but had got fairly high up the tower and had rescued a family of seven. The crew's end of wear times were between 03.15 and 03.17.¹⁷⁴⁶¹⁷⁴⁶ Phase 1 Report Volume III paragraphs 16.17-16.20.

¶97.317 No firefighter reached floor 23 on 14 June 2017.¹⁷⁴⁷¹⁷⁴⁷ Phase 1 Report Volume IV paragraph 28.101.

Last contact with Mariem Elgwahry

¶97.318 The last telephone call between Ahmed Elgwahry and Mariem Elgwahry began at 02.33 and ended at 04.27. Ahmed Elgwahry said that there had been no background noise in the flat. He could hear coughing and his sister's coughing increased. He tried to encourage her to leave but she said she could not leave as the landing was filled with thick black smoke. Ahmed Elgwahry believed that his sister did not want to leave their mother behind.¹⁷⁴⁸¹⁷⁴⁸ Phase 1 Report Volume III paragraph 17.21.

¶97.319 Ahmed Elgwahry could see that the kitchen of Flat 205 was the last room to be affected by the fire on the outside of the building. He heard Mariem Elgwahry begin to panic. She started mumbling and making a deep humming sound. She was initially able to make banging sounds in response to requests from her brother but stopped responding soon after. Ahmed Elgwahry then heard his mother say in Arabic, "I can't breathe." He thought that that was at about 03.10. He did not hear from them again. Five to ten minutes later he could hear the sound of glass windows breaking and the fire entering the flat. He kept the line open until 04.27, long after he had ceased to hear from them.¹⁷⁴⁹¹⁷⁴⁹ Phase 1 Report Volume III paragraphs 17.23-17.24.

¶97.320 The fire reached the west face of Flat 205 by around 03.14.¹⁷⁵⁰¹⁷⁵⁰ Bisby, Supplemental Phase 1 Expert Report {LBYS0000001/221} paragraph 1043; Purser, Phase 2 Report, Section 6 {DAPR0000006/29} paragraph 119. By 03.33, there was evidence of a large fire throughout Flat 205.¹⁷⁵¹¹⁷⁵¹ Phase 1 Report Volume III paragraph 17.4 and Figures 17.3 and 17.4; Purser, Phase 2 Report, Section 6 {DAPR0000006/29} paragraph 120.

Recovery and identification

¶97.321 The remains of Eslah and Mariem Elgwahry were recovered from the kitchen area of Flat 205.¹⁷⁵²¹⁷⁵² Purser, Phase 2 Report, Section 6 {DAPR0000006/24} paragraph 100 The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death for Eslah and Mariem Elgwahry.¹⁷⁵³¹⁷⁵³ Interim certificate of the fact of death for Eslah and Mariem Elgwahry {MET00065607}; {MET00065615}.

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Cause and time of death

¶97.322 The pathologist who carried out the post-mortems on Eslah and Mariem Elgwahry attributed their deaths to the effects of fire but could not be more precise.¹⁷⁵⁴¹⁷⁵⁴ Eslah Elgwahry post-mortem {COR00001002/4}; Mariem Elgwahry post-mortem {COR00000337/3}. However, in the light of the evidence as a whole, including that of Professor Purser, we are satisfied that they died from the inhalation of asphyxiant gases.

¶97.323 It is likely that they had lost consciousness by 02.50 and that the concentration of asphyxiant gases in their blood had exceeded the lethal threshold a few minutes later.¹⁷⁵⁵¹⁷⁵⁵ Purser, Phase 2 Report, Section 6 {DAPR0000006/28} paragraph 117; Purser Summary table of toxicity endpoints in each 23rd floor flat {DAPR0000013}.

¶97.324 We are satisfied that Eslah and Mariem Elgwahry died between 02.50 and 03.30 before suffering the direct effects of fire.

Sakina Afrasehabi

¶Date of birth: 4 April 1952. Place of birth: Abadan, Iran. Gender: Female. Occupation: Homemaker. Usual address: Flat 151, floor 18, Grenfell Tower, London. Place of death: Flat 205, floor 23, Grenfell Tower, London. Time of death: Between 02.50 and 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

Fatemeh Afrasiabi

¶Date of birth: 15 November 1957. Place of birth: Abadan, Iran. Gender: Female. Occupation: Homemaker. Usual address: Martin Close, Edmonton, London, N9. Place of death: Flat 205, floor 23, Grenfell Tower, London. Time of death: Between 02.50 and 03.30 on 14 June 2017. Cause of death: Inhalation of asphyxiant gases.

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Background and composition of household

¶97.325 Sakina Afrasehabi was born on 4 April 1952 in Abadan, Iran. She was 65 years old in June 2017.¹⁷⁵⁶¹⁷⁵⁶ Phase 1 Report Volume IV paragraphs 32.218–32.227. She was the sole tenant of Flat 151 and had lived there since February 2016.¹⁷⁵⁷¹⁷⁵⁷ Aghlani {IWS00000774/1} page 1, paragraph 3. Her younger sister Fatemeh Afrasiabi was born on 15 November 1957 in Abadan, Iran. She was 59 years old in June 2017. Fatemeh Afrasiabi was staying with her sister on the night of 13 June 2017.¹⁷⁵⁸¹⁷⁵⁸ Phase 1 Report Volume IV paragraphs 32.218–32.227.

¶97.326 Sakina Afrasehabi and Fatemeh Afrasiabi grew up in Iran with four other siblings. They had a happy childhood before living through the revolution and the Iran-Iraq war. They moved to the UK from Iran and were very close.

Vulnerability

¶97.327 Sakina Afrasehabi suffered from diabetes, high blood pressure and arthritis. Due to an accident in Iran, she could walk only with the aid of a walker. It was difficult for her to walk a short distance without assistance.¹⁷⁵⁹¹⁷⁵⁹ Aghlani {IWS00000774/1-2} pages 1-2, paragraphs 5-6.

¶97.328 Sakina Afrasehabi was recorded as a resident in the spreadsheet produced by David Noble on the night of the fire from information held on the TMO's Capita Insight system. She was identified as being over 65 and as vulnerable because of her mental and physical health.¹⁷⁶⁰¹⁷⁶⁰ Spreadsheet of residents {TMO00866002}.

Events of 14 June 2017

¶97.329 Fatemeh Afrasiabi and Sakina Afrasehabi spent the evening of 13 June 2017 in Flat 151 with family. Their other relatives left before 22.00 but Fatemeh Afrasiabi stayed the night with her sister.¹⁷⁶¹¹⁷⁶¹ Sattar {IWS00000769/2} page 2, paragraph 7; Afrasehabi {IWS00000767/2} page 2, paragraph 7.

¶97.330 Sakina Afrasehabi was first alerted to the fire by her neighbours from Flat 156, Shahid and Sayeda Ahmed. They had evacuated their flat after the fire broke into their kitchen at around 01.27 and had then knocked on the doors of all the other flats on that floor, including Flat 151.¹⁷⁶²¹⁷⁶² Phase 1 Report Volume II paragraphs 10.249-10.250.

¶97.331 Sakina Afrasehabi and Fatemeh Afrasiabi left their flat and were told by others they met on the stairs to go up to floor 23.¹⁷⁶³¹⁷⁶³ Phase 1 Report Volume II paragraph 10.289 (c). There the Neda family invited them to shelter in their home, Flat 205. Mariem and Eslah Elgwahry, who had also come up to floor 23, joined them in Flat 205. By 01.30 there were seven people in Flat 205.¹⁷⁶⁴¹⁷⁶⁴ Phase 1 Report Volume II paragraphs 10.284 and 10.288-10.289.

¶97.332 Neither Sakina Afrasehabi nor Fatemeh Afrasiabi themselves called the emergency services on 14 June 2017, but nonetheless a message was passed by the LFB control room to the incident ground about persons trapped in Flat 205.¹⁷⁶⁵¹⁷⁶⁵ Phase 1 Report Volume II paragraphs 12.18-12.19, 12.72 and 12.73 (b); LFB Short Incident Log Report {MET00013830/19}. Phase 1 Report Volume II paragraphs 12.72 and 12.73 (b). Phase 1 Report Volume II paragraphs 12.18-12.19. That was in response to calls received from Mariem Elgwahry at 01.30¹⁷⁶⁶¹⁷⁶⁶ Phase 1 Report Volume II paragraph 10.289 (a) . and 01.38.¹⁷⁶⁷¹⁷⁶⁷ Phase 1 Report Volume II paragraphs 11.27 and 11.163. The fact that there were people trapped in Flat 205 was communicated to the bridgehead on floor 2 and recorded there on a forward information board.¹⁷⁶⁸¹⁷⁶⁸ Phase 1 Report Volume II paragraph 14.73 and Figure 14.4.

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¶97.333 The first team of firefighters sent to floor 23 in response to those messages set out between 02.08 and 02.10. FFs Zade Alassad, Scott Bell and John Wright were sent to Flats 201 and 205 on floor 23.¹⁷⁶⁹¹⁷⁶⁹ Phase 1 Report Volume II paragraph 14.117; Phase 1 Report Volume II Figure 13.2 and paragraph 14.117; Phase 1 Report Volume IV paragraph 28.101. A photograph taken of the wall on floor 2 shows writing which reads "Wandswor 23rd flts 201 205." Next to this are the names of Alassad, Bell and Wright.¹⁷⁷⁰¹⁷⁷⁰ Phase 1 Report Volume II Figure 13.2. FFs Alassad, Bell and Wright did not reach floor 23. They stopped at floor 10 and helped to carry down casualties found on that floor.¹⁷⁷¹¹⁷⁷¹ Phase 1 Report Volume II paragraph 14.117. FF Bell said that he told someone they had not reached floor 23 but he could not remember to whom he had spoken or what that person did with the information.¹⁷⁷²¹⁷⁷² Phase 1 Report Volume II paragraph 14.117.

Conditions in Flat 205

¶97.334 Farhad Neda said that conditions in Flat 205 had changed rapidly.¹⁷⁷³¹⁷⁷³ Phase 1 Report Volume IV paragraph 25.17. By 01.54, Mariem Elgwahry described Flat 205 as full of smoke in a 999 call. He saw black smoke beginning to enter the flat beneath the front door. Within 10 to 15 minutes of the sisters' coming into the flat there were black marks around people's noses from the smoke.¹⁷⁷⁴¹⁷⁷⁴ Phase 1 Report Volume II paragraph 13.79.

Contact with others outside the tower

¶97.335 Solmaz Sattar, the niece of Fatemeh Afrasiabi, had several telephone conversations with her aunt during the night. In a call which occurred after Solmaz Sattar had reached the tower, Fatemeh Afrasiabi said they were in Flat 205. Solmaz Sattar passed the information to a police officer and a firefighter standing nearby. The firefighter advised that they should remain in the flat and that they should make everything wet, including themselves. The Nedas had filled buckets with water which they threw on the carpets and soaked towels to cover their mouths when they saw smoke coming into the flat.¹⁷⁷⁵¹⁷⁷⁵ Phase 1 Report Volume II paragraph 13.80. Later, Fatemeh Afrasiabi told her niece that the water had stopped.¹⁷⁷⁶¹⁷⁷⁶ Phase 1 Report Volume II paragraph 13.82.

¶97.336 Fatemeh Afrasiabi and Sakina Afrasehabi were also in contact with Sharokh Aghlani, Sakina Afrasehabi's son. Fatemeh Afrasiabi first called him around 01.20 to tell him of the fire. He went to the tower and told police officers there that his mother and aunt were on floor 23.¹⁷⁷⁷¹⁷⁷⁷ Phase 1 Report Volume III paragraph 17.25. (It has not been possible to identify with any confidence which officer Sharokh Aghlani and Solmaz Sattar spoke to.) It is possible that his message was passed to the bridgehead. At the same time, Mariem Elgwahry in Flat 205 had made further calls to the LFB control room at 01.54¹⁷⁷⁸¹⁷⁷⁸ Phase 1 Report Volume II paragraphs 13.78 and 13.98. and 02.25.¹⁷⁷⁹¹⁷⁷⁹ Phase 1 Report Volume III paragraph 15.143 The information from both calls was passed to the incident ground at 01.57¹⁷⁸⁰¹⁷⁸⁰ Phase 1 Report Volume II paragraph 13.98. and 02.28 respectively.¹⁷⁸¹¹⁷⁸¹ Phase 1 Report Volume III paragraph 15.147.

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¶97.337 At least one of the messages about Flat 205 reached the bridgehead while it was still on floor 3 (between 02.17 and 03.10). That led to a further deployment of firefighters. At 02.24 CM Richard Evans and FF Gemma Bloxham set out to go to Flat 205.¹⁷⁸²¹⁷⁸² Phase 1 Report Volume III paragraph 15.54.

¶97.338 Shortly before that, Saber Neda had seen that the fire had reached the bedroom of Flat 205. He closed the door and told everyone not to enter it.¹⁷⁸³¹⁷⁸³ Phase 1 Report Volume III paragraph 15.64. At about 02.15 Farhad Neda decided that it was time to leave. He seized his mother and shouted for his father to follow.¹⁷⁸⁴¹⁷⁸⁴ Phase 1 Report Volume III paragraph 15.64. Saber Neda agreed and said he would be behind them. He gave wet towels to Sakina Afrasehabi and Fatemeh Afrasiabi in preparation to leave.¹⁷⁸⁵¹⁷⁸⁵ Phase 1 Report Volume III paragraph 15.64. Farhad and Flora Neda then left the flat thinking that the others would follow them. Instead, Sakina Afrasehabi and Fatemeh Afrasiabi remained in the flat with Saber Neda and Mariem and Eslah Elgwahry.¹⁷⁸⁶¹⁷⁸⁶ Phase 1 Report Volume III paragraph 15.65.

¶97.339 CM Evans and FF Bloxham had reached floor 20 when they came across Farhad and Flora Neda. CM Evans and FF Bloxham stopped to help them out of the tower.¹⁷⁸⁷¹⁷⁸⁷ Phase 1 Report Volume III paragraphs 15.54-15.56; Phase 1 Report Volume IV paragraph 28.101. Farhad Neda told the firefighters that his father and four others were trapped in Flat 205, which was recorded by one of the firefighters in a notebook. As they left the main entrance between 02.42 and 02.43, Farhad Neda told the firefighters again that people were still in the flat.¹⁷⁸⁸¹⁷⁸⁸ Phase 1 Report Volume III paragraphs 15.66-15.67.

¶97.340 At about 02.42 CM Evans told the officer in charge at the bridgehead that they had not reached Flat 205 but that they had brought two people down.¹⁷⁸⁹¹⁷⁸⁹ Phase 1 Report Volume III paragraph 15.56. That may have led to a further deployment of firefighters to the top floor.

¶97.341 At 02.51, FFs Niki Mitchell, Jessamine Bate, Michael Pole and Chris Cheesman from Euston Fire Station were sent to floor 23.¹⁷⁹⁰¹⁷⁹⁰ Phase 1 Report Volume IV paragraph 28.101. The wall of the bridgehead, then on floor 3, shows that the word "Euston" had been written against Flats 204 and 205 on floor 23.¹⁷⁹¹¹⁷⁹¹ Phase 1 Report Volume III paragraph 16.15 and Figure 16.6. The message was repeated on the lower right hand corner of the photograph where the words "23rd Euston 204 205" can be seen. They did not reach floor 23 but helped casualties evacuate from Flat 153 on floor 18.¹⁷⁹²¹⁷⁹² Phase 1 Report Volume III paragraph 16.17-16.20; Phase 1 Report Volume IV paragraph 28.101. FF Mitchell recalled telling WM De Silvo that they had not reached floor 23 but had got fairly high up the tower and they had rescued a family of seven. The crew's end of wear times were between 03.15 and 03.17.¹⁷⁹³¹⁷⁹³ Phase 1 Report Volume III paragraphs 16.17-16.20.

¶97.342 No firefighter successfully reached floor 23 on 14 June 2017.¹⁷⁹⁴¹⁷⁹⁴ Phase 1 Report Volume IV paragraph 28.101.

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Last contact with Fatemeh Afrasiabi and Sakina Afrasehabi

¶97.343 Shahrokh Aghlani spoke to his mother, Sakina Afrasehabi, and his aunt, Fatemeh Afrasiabi, several times in the early hours of 14 June 2017. During his last call he could hear them wheezing. He heard his aunt say "forgive us" before the line was disconnected. About 50 seconds before that he heard the sound of an explosion. It is difficult to determine when that conversation took place.¹⁷⁹⁵¹⁷⁹⁵ Phase 1 Report Volume III paragraph 17.25.

¶97.344 Ahmed Elgwahry was on the telephone to Mariem Elgwahry from 02.33 until 04.27. He said that he had last heard Mariem and Eslah Elgwahry respond to him at between 03.10 and 03.15. He also heard the sound of windows breaking about 5 to 10 minutes later.

¶97.345 Sakina Afrasehabi and Fatemeh Afrasiabi are likely to have become unconscious from the effects of asphyxiant gases at about the same time as Eslah and Mariem Elgwahry, given their close proximity to each other in the kitchen of Flat 205.

Recovery and identification

¶97.346 The remains of Sakina Afrasehabi and Fatemeh Afrasiabi were recovered from the kitchen area of Flat 205.¹⁷⁹⁶¹⁷⁹⁶ Purser, Phase 2 Report, Section 6 {DAPR0000006/24} paragraph 94. The coroner was satisfied about the identification of those remains and therefore issued interim certificates of the fact of death for Sakina Afrasehabi and Fatemeh Afrasiabi.¹⁷⁹⁷¹⁷⁹⁷ Interim certificate of the fact of death for Sakina Afrasehabi and Fatemeh Afrasiabi {MET00065598}; {MET00065612}.

Cause and time of death

¶97.347 The pathologist who carried out the post-mortems on Sakina Afrasehabi and Fatemeh Afrasiabi attributed their deaths to the effects of fire but could not be more precise.¹⁷⁹⁸¹⁷⁹⁸ Afrasehabi post-mortem report {COR00000425/5}; Afrasiabi post-mortem report {COR00001380/5}. However, in the light of the evidence as a whole, including that of Professor Purser, we are satisfied that they died from the inhalation of asphyxiant gases.

¶97.348 It is likely that Sakina Afrasehabi and Fatemeh Afrasiabi lost consciousness at about 02.50 and died at some time between 02.50 and 03.30 before suffering the direct effects of fire.