Part 9: The deceased

Chapter 84: Introduction to Part 9

¶84.1 In the preceding chapters we have examined the circumstances in which the fire at Grenfell Tower came about. Most of the facts we have found and the conclusions we have drawn are relevant to all the deaths that occurred that night. The only exceptions are our findings about the treatment of those who for one reason or another were vulnerable and in respect of whom we have identified particular shortcomings. In this Part of the report, we set out our findings about the circumstances in which each person who died came to lose his or her life, a matter which it is the coroner's duty to investigate. We begin by explaining our purpose in doing so.

¶84.2 Grenfell Tower is in an area of London which falls within the jurisdiction of Professor Fiona Wilcox, His Majesty's Senior Coroner for London (Inner West). Between 20 June and 22 November 2017, Professor Wilcox opened 70 separate inquests into the deaths of those who died in the fire. She subsequently suspended those investigations pending the conclusion of this Inquiry and, if necessary, the police investigation. An inquest was not opened for Logan Gomes, the son of Marcio Gomes and Andreia Perestrelo, who was delivered stillborn following his mother's escape from the tower. Professor Wilcox concluded that Logan did not have a life independent of his mother and so was outside her jurisdiction. We have, however, included in this Part of our report findings relevant to Logan. Maria del Pilar (Pily) Burton survived the fire but died in January 2018. The cause of her death was not found to be related to the fire. Pily Burton died within the jurisdiction of a different coroner and no inquest has been opened into her death. Nonetheless, in recognition of the regard in which she was held by the community at Grenfell Tower, we have included in this Part of our report the facts concerning her experience on 14 June 2017.

¶84.3 An inquest, whether conducted by a coroner alone or with a jury, is required to answer the four questions set out in section 5 of the Coroners and Justice Act 2009: who the deceased was and how, when and where the deceased came by his or her death. When the inquest is one in which article 2 of the European Convention on Human Rights (the Convention) is engaged, the question "how" is to be interpreted as including the circumstances in which the deceased came by his or her death.

¶84.4 At an early stage of the Inquiry, the chairman decided that, in discharging its Terms of Reference and insofar as it was properly permissible to do, the Inquiry would investigate the deaths caused by the fire to the same extent as would be required of the coroner. The chairman's hope was to minimise the need for Professor Wilcox to conduct further detailed investigations, so sparing the relatives of those who died the stress of prolonged proceedings.¹¹ Phase 1 Report Volume I paragraph 1.9; Fegan-Earl {Day298/4:9-17}.

¶84.5 Subsequently, the chairman issued a direction in which he said that, on the material then available, he saw no significant difficulty in making findings sufficient to meet the requirements of article 2 of the Convention. He proposed that while the Phase 1 report was being written the Inquiry would hold an oral hearing in which those representing the bereaved families could present the evidence relating to those who had died in order to enable him to make the appropriate findings in that report. In the end, however, it did not prove necessary to hold such a hearing. As is evident from the Phase 1 report, the Inquiry obtained a considerable amount of material, in particular the written and oral evidence of the firefighters, the bereaved and those who had survived the fire, that was analysed and presented in that report. Further, there were some aspects of the circumstances in which people had died, principally the physiological causes of death, that called for more detailed examination than was possible at that stage. Accordingly, further consideration of the circumstances of the deaths was deferred to Phase 2. The chairman made it clear that it remained his intention in Phase 2 to make the findings necessary to assist the coroner.²² Fegan-Earl {Day298/4:18-24}; Phase 1 Report Volume IV paragraph 34.2.

¶84.6 Following further submissions and correspondence in 2019 and 2020, we concluded that the facts that we should investigate and record in relation to each deceased were: 1. Their name, gender and age. 2. The number of the flat in which they lived and the floor number. 3. The background and composition of their household. 4. What messages, if any, passed between them and the emergency services or

between them and others and what information about them was held by the emergency services.

¶5. Whether the firefighters tried to rescue them. 6. Where they died. 7. The time of death, as far as it could be ascertained. 8. Their movements between the outbreak of the fire and their death. 9. The medical cause of death. 10. Whether they had any vulnerabilities and if so, whether they were known to the TMO or RBKC.

¶84.7 We began hearing evidence about those matters on 4 July 2022. The hearings took a slightly different form in that, although Counsel to the Inquiry retained responsibility for adducing evidence, the greater part of them were taken up by a series of presentations of the essential circumstances surrounding the individual deaths by those representing the bereaved.

¶84.8 Those presentations were very helpful, not only in assisting us to identify the essential facts to be found in each case but also in reminding all those present and those watching the proceedings remotely of the personalities of the deceased and the lives they had led until the night of the fire. Our findings are based in part on evidence that had not been considered in any detail at the time the presentations were delivered, as well as on findings made in the Phase 1 report, none of which were disputed.

¶84.9 We have borne in mind throughout that we are not conducting an inquest; that remains the responsibility of the coroner. For that reason we have refrained from expressing any view about the conclusions a coroner might record. However, we continue to hope that our findings about the circumstances in which each of the deceased died will assist her in fulfilling her statutory obligations. It will be for her to decide what to make of our findings.

¶84.10 The Inquiry opened in May 2018 with a public commemoration of the deceased through the voices of their relatives and friends. Those reflections and memories are recorded in Chapter 32 of the Phase 1 report. As the Inquiry began, so it ended, by remembering those who lost their lives that night. It is of the utmost importance that our description of the circumstances in which people died are placed in the larger context of their lives and the pictures of them painted at the memorial hearings. Only in that way can they be remembered as the people they really were.

¶84.11 Many of those who died on 14 June 2017 were found in their own homes; others had sought shelter elsewhere in the tower or were overcome while trying to leave the building and were found in the lobbies or on the stairs. Three fell from the tower. Our findings are set out floor by floor and deal in turn with each of those who died on, or fell from, the particular floor. For those who died on the stairs we have described the circumstances relating to the floor on which their flat was located. None of the occupants of floors 12 or 13 died in the fire.

¶84.12 In making our findings we have relied on the following: a. the evidence of survivors; b. transcripts of emergency calls; c. the way in which fire and smoke spread around and through the building; d. the accounts of those who spoke to the deceased in the period before their deaths; e. the record of communications between the LFB control room and the fire ground and within the fire ground, including the building; f. the evidence of individual firefighters; g. telemetry data recording the deployment of firefighters within the tower; h. the evidence of the expert witnesses.

¶84.13 Almost all of that evidence was heard in Phase 1 and was the subject of findings made in chapters 9 to 20 of the Phase 1 report.

¶84.14 In some cases the deceased could be identified only by scientific means but in each case the coroner was satisfied that identification had been correctly established and was therefore able to issue an interim certificate of the fact of death. In those cases we have not thought it necessary to describe in detail the way in which the identity of the deceased was established.