Professor Purser's expert evidence on causes of death and incapacitation, analyzing carbon monoxide exposure, toxic fume inhalation, and specific times of death for Grenfell Tower victims.
00:00:24 [Music]
00:00:28 good morning everyone and welcome to today's hearing today we're going to continue hearing evidence from professor persa the toxicology expert instructed by the inquiry
00:00:39 by the inquiry so uh i think professor persona is there would you ask him to come in please
00:00:54 good morning professor persona sit down please and make yourself comfortable
00:01:01 all right ready to carry on yes very good thank you yes yes mr chairman good morning good morning to you good morning members of the panel professor good morning to you i now want to ask you some specific
00:01:13 i now want to ask you some specific questions about section six of your report for phase two where you've set out your analysis of the causes of incapacitation and death in individual cases
00:01:24 cases and i'd like to begin if i may please with floor 23 and if we go please to dapr5013
00:01:34 we should see a table which is a summary of toxicity endpoints for um
00:01:42 for um each 20 each flat on floor 23 which you showed us and explained a little bit of in
00:01:48 in opening your evidence yesterday yes and looking at paragraphs five to seven if we can scroll up the screen please to paragraph five you'll see there that you explain the
00:01:59 you'll see there that you explain the three end points in those three paragraphs and just to go through it is it right that the first endpoint is the latest time that adult flat occupants could safely evacuate the
00:02:12 flat occupants could safely evacuate the flat
00:02:14 flat yes and then the second end point is the likely time to collapse and loss of consciousness for an average occupant in the flat sorry the first end point was um
00:02:24 um the latest time they could leave the flat and still walk down the stair yes yes walk down to the ground floor that's collapsing escape from the tower yes the second end point as you say i think in paragraph six is the estimated
00:02:36 paragraph six is the estimated approximate likely time to collapse and loss of consciousness for an average occupant remaining in the flat yes and then the third endpoint is a paragraph seven and that is the estimated approximate time by which a lethal dose
00:02:49 approximate time by which a lethal dose a threshold of associated gases carbon monoxide and hydrogen cyanide would be predicted to have been inhaled and you say this precedes the actual time of death which may have occurred at variable time later
00:03:01 variable time later so that's the point where they pass the 50 threshold i discussed yesterday yeah exactly
00:03:06 exactly now um
00:03:07 now um uh i'd like to start if i can with floor 23 flat 201 yes
00:03:14 yes and uh you cover this at page six of dapr606
00:03:25 and this is table 20 which
00:03:30 which i'm sorry sorry after you table 20 uh which is entitled 23 third floor occupants by flat location with summary of movements and times of escape or approximate times of death how do you
00:03:42 or approximate times of death how do you set out and just correct me if i'm wrong here so so that we can all understand what you've done you've set out each flat on each floor with each occupant in the flat and in red
00:03:54 and in red type
00:03:55 type you've identified those individuals who lost their lives and the and the rough estimated time of of death i think um now um i'm going to ask you about the occupants first in 201
00:04:07 occupants first in 201 which you can see um halfway down the screen
00:04:11 screen on the right hand side and you have a number of names raymond bernard hamid khani debbie lamprell berketty halftom burek haftam
00:04:22 burek haftam jessica abano ramirez and amne idris now you've set out your analysis for the available evidence relating to this flat from page 8 in section 6 of your report
00:04:33 from page 8 in section 6 of your report and i just want to see if i can just pick through the the main facts that you've referred to can we go please to page 16 in this report
00:04:42 report page 16 paragraph 52 under the heading conclusions and you say that the occupants in flat 201
00:04:52 201 were exposed to increasingly dense smoke and asphyxian gases for an extended period of time from about 1 30 to 224 a total period of about 57 minutes and then at 53
00:05:06 about 57 minutes and then at 53 you give some time points first of all about 129 significant smoke penetration from the lobby into the flat yes yes and then about 136 the exterior fire affects
00:05:19 then about 136 the exterior fire affects the living room yes yes does that mean that it's it's it's burning the cladding structure on the outside yeah it means it just moved across the column from the print next door flat and starting to affect the outside of that flat yes and then you
00:05:32 outside of that flat yes and then you say
00:05:33 say from about uh 1 50 till 2 o'clock the flat occupants remained able to engage in various activities despite those conditions yes
00:05:44 those conditions yes and then from 152 to 156 a period of about four minutes the conditions deteriorated rapidly in the bedroom when the fire spread outside the bedroom yes that's right yes now is it right
00:05:56 yes that's right yes now is it right then building on that chronology that the occupants of flat 201 could have escaped without difficulty if encouraged to do so before 129. yes
00:06:08 to do so before 129. yes yes and i think you say that at paragraph 54 and therefore paraphrasing power 55 from 129 is it right that occupants were inhibited from crossing dense smoke in the lobby of floor 23
00:06:21 dense smoke in the lobby of floor 23 but could have done so if encouraged yes yes
00:06:25 yes and then in the period 150 to 210 is it the case that the accumulated the gradually accumulating dose to that point of the fixing gases on the
00:06:36 point of the fixing gases on the occupants of flat what 201 would be sufficient that they would be in danger of collapse in the lobby and the stair or the stair due to further accumulation in the lobby
00:06:47 due to further accumulation in the lobby and the stair yes that's correct yes and that's power 56. now where you've taken into the and where you've estimated those times have you taken into account any physical characteristics of the occupants no no
00:07:00 characteristics of the occupants no no that's you could regard that as for sort of an average adult occupant right so
00:07:06 so if somebody had mobility difficulties what
00:07:10 what adjustment would one make to those numbers those times well we discussed this a little bit yesterday i it would depend a bit on the on the form of disability and the
00:07:22 on the form of disability and the conditions in the stair at the time they descended
00:07:26 descended but if they were if it was a period when the stare was relatively clear of smoke then you might expect a significant difference in the descent
00:07:37 a significant difference in the descent rate for somebody with a physical disability compared to a more able-bodied person so it's been longer in the stair column so once a stair column starts to fill with
00:07:48 once a stair column starts to fill with smoke
00:07:49 smoke um you might expect them to have a somewhat longer exposure we should remember of course that in the building codes the stair is regarded
00:07:59 regarded conceptually as a temporary safe refuge and a lot of the means of escape requirements in the building
00:08:07 building codes
00:08:08 codes are designed to ensure that you get people into that stair once they're in the stair they're regarded as as in a sort of temporary safe place um of course but that didn't really work
00:08:20 um of course but that didn't really work out very well at rainfall yeah and then if you look at paragraph 56 at the top of the screen you say the l in the last sentence the longer
00:08:29 longer they waited in flat 201 before leaving the earlier the summed dose in the lobby or stare is it right that the longer the occupants remained in the flat the greater the danger of those occupants
00:08:40 greater the danger of those occupants accumulating the total some days yes that's right so we're looking at the total dose and you're building it up all the way through so if you if you have a lot before you start then once you get out you're not going to go very far if you leave before you've accumulated a
00:08:52 you leave before you've accumulated a certain dose then you're going to be able to travel much further so whatever other conditions you meet yes and if we go back to pages 10 and 11 in this part of the report and we can just pick these points out
00:09:03 and we can just pick these points out from the paragraphs paragraph 23 i think you you make the point uh that um the time when uh amel amadin and amaya took uh left in left 201 is unknown but after fadumo
00:09:16 left 201 is unknown but after fadumo ahmed
00:09:17 ahmed but yeah but before about 212 when the accumulated exposure in flat 201 was estimated to reach a day's level predicted to cause collapse for all
00:09:26 for all flat 201 occupants so does that tell us that
00:09:29 that federer ahmed was successful in evacuating the tower because she left earlier
00:09:33 earlier but amala ahmed and amaya were unsuccessful because they tried to leave later essentially yes right yes and then it accumulated the days close to causing collapse by the time they
00:09:45 to causing collapse by the time they left the flat i mean we as we say we don't know precisely when they left but it was a bit later on after fadumo left and
00:09:52 and um we know the condition material deteriorating quite seriously around that time yes so they would have acquired a significant dose in the flat yes yeah let me just say that people can see that this on the page if we turn
00:10:04 see that this on the page if we turn please to um page 10 paragraph 26 you say that the longer amal ahmadine amaya took it remained in flat 201 the greater the dates they inhaled so that
00:10:16 greater the dates they inhaled so that leaving any time after two after about two o'clock they would have accumulated a significant proportion of an incapacitating stage and then at 29 you say
00:10:27 you say uh that if they'd left a few minutes earlier for example soon after fadumo ahmed then the accumulated dates of asphyxians from flat 201 would have been lower enabling them to get the lobby within a few seconds with a minimal
00:10:38 within a few seconds with a minimal intake of lobby smoke and enter the stair as for as did for uma ali now you've also explained that occupants would not have been aware that they were inhaling as fixing gases until they'd
00:10:50 inhaling as fixing gases until they'd reached close to the incapacitating dose you told us that yesterday yes they're aware that of course they could see the smoke component but they wouldn't be aware of the actual fixing gases they
00:11:01 aware of the actual fixing gases they were inhaling no so so the longer they remained in the flat but in this state of ignorance about what they were taking up the greater the risk of collapse on evacuation yes precisely now just one or
00:11:13 evacuation yes precisely now just one or two further clarificatory point about this flat if we gave please to page 15 in this part of your report there are two figures because 27 and 28 we can have those blown up a little please
00:11:24 please um you um if you look at figure 28 this is calculated fractional effective dose and percentage carbo um
00:11:33 carbo um global history for flat 201 occupants now it's a complex uh it's a complex chart but am i right that it shows the lethal threshold for carbon monoxide reached at 223.
00:11:45 carbon monoxide reached at 223. yes and approximately about 223 yeah and is it right that the occupants of flat 201 would have reached the lethal um the lethal death threshold of about 50 percent there yes
00:11:57 percent there yes hemoglobin concentration by about 223. yes would you estimate that the time of death of the occupants would be sometime after about 223 therefore
00:12:08 after about 223 therefore the sorry can you repeat that yes would you estimate that the time of death of the occupants would be some time after about 2 20 yes yes yes and are you able to give them a specific
00:12:19 are you able to give them a specific window of time
00:12:22 right we can give an approximate one but
00:12:28 but as i explained yesterday there's lots of uncertainties about the gradual slow decline
00:12:32 decline once you become unconscious and it depends on the data we have available so for this particular case i think i'm right in saying that we don't have
00:12:43 don't have any carboxyhemoglobin
00:12:46 blood samples from these decedents so we don't know whether they died at around 50 percent through hb or whether they went up to 90 percent so we'd have to be somewhere in that
00:12:57 so we'd have to be somewhere in that window i
00:12:59 window i and what we do know is that um sorry i'm thinking as i'm speaking if that's all right we do know that um jessica abano and uh deborah laprell were on these very
00:13:10 uh deborah laprell were on these very long nine nine nine calls and
00:13:14 and they became unresponsive and comatose as you see there to 218 and 221 so that's just before they become completely unconscious
00:13:26 completely unconscious and then
00:13:27 and then shortly after that um i've estimated that they've passed the lethal threshold doses we just discussed at around 223 now this depends to some extent on the
00:13:40 now this depends to some extent on the assumed extrapolation of the fire conditions so if the
00:13:44 so if the if the carbon monoxide concentration curve
00:13:48 curve due to the fire that's come around for the bedroom is increasing very steeply at that time which i believe it probably was
00:13:55 was then
00:13:56 then they're inhaling an increasing concentration so the dose inhaled increases quite rapidly against that of course their breathing is slowing down as they become deeper
00:14:07 is slowing down as they become deeper and deeper in a comatose state and so um
00:14:14 it's a very uncertain number i've got to give you but i would think we're talking about somewhere around about 20 minutes or so right now if we go then on the basis of that to the overview table at
00:14:26 that to the overview table at page six
00:14:34 uh which we saw a little bit earlier this morning uh you've recorded the time of death for the occupants of flat 201 as about 245
00:14:47 about 245 in the case of raymond bernard hamid khani
00:14:51 khani berkey halftom burek have tom jessica abano ramirez and amna idris uh but 244 for debbie lampro may i
00:15:03 may i i think that's the type of graphical error right there i wouldn't make that just clear just that's fine a distinction so so the figure i've put there which is very very approximate i've said approximately 245.
00:15:15 approximately 245. and how do you arrive at the 245 well by the method i've i've just said really but it's you know very very approximate and would the time be different for
00:15:26 and would the time be different for the children in that list well of course
00:15:30 of course we know that jessica
00:15:32 jessica habano
00:15:34 habano the children the child that child became unresponsive very similar time to the adult who was nearby from the 999 call so there wasn't a huge
00:15:45 from the 999 call so there wasn't a huge discrepancy between those two in their time to loss of consciousness so
00:15:52 so it seems reasonable that there may not may not have been that much distinction in terms of time to death but the i would say that the um if anything the risk
00:16:03 if anything the risk the probability is that a child would succumb first and the other child who was present who was very young child i believe certainly would have been expected to be overcome at a much
00:16:15 been expected to be overcome at a much lower
00:16:17 lower earlier time than her mother yes thank you
00:16:25 does that uh yes that's helpful i'd like to turn next to
00:16:31 next to flat 181 on floor 21.
00:16:36 please and this is the death of lagaya more oh yes now um if we go please uh to page 64. this is where you cover
00:16:49 this occupant
00:16:52 and you start by describing the overview of the occupants and the conditions in the flat and just to run through the chronology which you've set out at paragraph 314
00:17:05 which you've set out at paragraph 314 i can do this just with you with me as it were she was alone in her flat in her bedroom throughout the exterior fire would have started to come into the flat living room from about 1 32
00:17:16 about 1 32 which was about the same time was reported by you from and indeed others for flat 201 yes yes and at 136 serious smoke and exterior flame spread could be seen near the
00:17:27 flame spread could be seen near the living room window with a similar pattern of fire spread to that observed on 423
00:17:32 on 423 and i think you say that meant that the flat was likely to have filled with smoke mainly from the exterior and window structures from about 132 to about 152 yes yes and from about 150 to the exterior fire
00:17:45 and from about 150 to the exterior fire spread
00:17:46 spread to the outside of the kitchen in the bedroom say that the smoke and the flames began to enter the bedroom yes so that's the 152 time mark and then like paragraph 315 over on page 65 if we just
00:17:57 paragraph 315 over on page 65 if we just nip to that you note that no pathological or toxicological investigations could be carried out and her remains were recovered from the bedroom area yes yes yes now um if you
00:18:10 bedroom area yes yes yes now um if you look please at um uh
00:18:13 uh paragraphs 316-319
00:18:17 316-319 under the heading analysis of uptake of asphyxian gases it's long i'm not going to read it all out if you just remind yourself of what you've said there take a moment to do that
00:18:51 yes yeah having done that i should just tell you this that they're the inquiry has has some evidence that lagaya more was a hoarder and that she had
00:19:03 and that she had mobility difficulties as well um
00:19:06 um would the fact that there was in her flat
00:19:10 flat perhaps a disproportionately large amount
00:19:13 amount of
00:19:15 of material
00:19:17 of different kinds of chemical contents affect the rate of fire and smoke spread within the flat as i was i was aware of her history i
00:19:30 as i was i was aware of her history i i think one of the points i think i've made here is that comparing it to flat 201 for which we have much more evidence the big a big difference is of course that there were a lot of people in flat
00:19:41 that there were a lot of people in flat 201 who were very aware of what was happening and very quite active now i obviously don't know but
00:19:51 but we know that in flat 201 for a period of time they they went in and out of the living room trying to extinguish the fire
00:19:58 fire before
00:19:59 before uh for several minutes before giving up and retreating to the bedroom and landing area hallway area in flat 201
00:20:08 flat 201 now as they did that they certainly must have shut that door to the living room where the fire was behind
00:20:15 behind and by doing that it brought them some time
00:20:19 time to survive it reduced the smoke contamination of the rest of the flat where they were sheltering now as i say i don't nobody for do mo armored in a statement does not say that she shut
00:20:30 statement does not say that she shut that door but i find it hard to believe they wouldn't have done so the thing about laguire moore is that we have no idea what activities she was carrying out if for example she
00:20:43 if for example she slept through the whole thing and was in her bedroom and the interior doors in her flat were open
00:20:48 open then as the as the fire broke into the living room and there was a fire in the living room that would have just spread throughout the open space of the whole flat in which case
00:20:59 in which case uh she would have been exposed to higher concentrations of smoke from an earlier period
00:21:04 period than those in flat 201 but we don't know now if from to pick up on your point also if in that living room there was a large load of of all sorts of materials
00:21:16 of all sorts of materials that would that would present a big fire load which could have produced certainly produced a much more intense and smoke-rich fire at that early stage if however of course
00:21:27 at that early stage if however of course she'd uh close those rooms off she would have still had some protection while in her bedroom so there are a lot of a lot of uh unknowns really in respect to her situation i think okay really it comes
00:21:39 situation i think okay really it comes to this professor are you able to draw any
00:21:43 any if not firm then reasonably reliable conclusions about the cause of the gaia moore's death
00:21:49 death in light of the fact that her flat was let it be assumed her bedroom was far fuller than would be normal of material well if
00:21:59 well if if we
00:22:01 if we one option is to consider it the effects on her to be similar and exposed to be similar to that for flat 201
00:22:09 201 in which case we would with the interior doors shut she stays in the bedroom until the exterior fire comes outside the bedroom and you've got penetration of stuff from the exterior
00:22:20 penetration of stuff from the exterior fire coming in in that case we i would be looking at a similar time of about 245. if however we had these other scenarios developing
00:22:32 we had these other scenarios developing that we've just discussed then we can pull back from that to uh to earlier times depending on this on how these unknown scenarios might have developed so we'd have a much
00:22:43 might have developed so we'd have a much wider window i think i mentioned in here that she'd been she'd been in a room for an hour after roughly an hour from when the fire first appeared outside her flat living room if if her interior
00:22:56 if if her interior doors were open and you got a significant fire growing quickly in that living room then she could have been overcome within minutes of that occurring
00:23:07 minutes of that occurring so that would put it at um one
00:23:10 one some
00:23:11 some 140 150 something like that you know as the earliest there's quite a wide range of uncertainty obviously and on a slightly different topic have you taken into account
00:23:22 have you taken into account and if not would you would you take into account the fact first first that she had mobility difficulties and second that the presence of uh this disproportionate amount of material in her flat might have impeded
00:23:33 material in her flat might have impeded her escape should
00:23:37 should they might have done we no idea what she considered doing in in on the night do we right
00:23:42 we right and when you say you might have done are you able to fix some sort of oh well probably she had physically if you're telling me that she had physical walking mobility issues
00:23:53 mobility issues then there are two consequences that that might lead to one is that she may have felt an early stage when conditions were if she'd been become aware of the fire at an early time
00:24:04 an early time play before 1 30 and considered evacuating she may have been inhibited from doing so knowing that she would have difficulty negotiating the stairs as other people
00:24:15 negotiating the stairs as other people in the tower who were disabled had mobility issues did so that's one possibility another is if if she had attempted to do so um then obviously she may have her
00:24:27 um then obviously she may have her movement may have been somewhat slower as we've discussed now if we go please to paragraph 319 in the last sentence you say uh
00:24:35 uh there um in the foot of the screen if lagayama had been in her bed where most of her remains were found throughout the incident it is possible that she may have been overcome and died from smoke inhalation while asleep that night
00:24:47 inhalation while asleep that night now um
00:24:48 now um [Music]
00:24:49 [Music] one of the documents that the inquiry has seen
00:24:52 has seen is that the archaeology report records that it was possible that her body was recovered in the bedroom area but may have been located in the vicinity of the bedroom entrance and hallway
00:25:04 entrance and hallway did you when you were doing your work consider the possibility that um she may not have been in bed but may have been somewhere else in her flat
00:25:15 i'd have to i obviously read the electo um
00:25:18 um report that you're referring to and i haven't got the details in front of me but um i i thought they were their main contention was that she was
00:25:29 their main contention was that she was amongst the bed springs her remains were amongst the bed springs on if the extent that that was was the case that means she was basically associated with the bed and possibly in it or on it
00:25:41 the bed and possibly in it or on it and that's the the line i've taken here if you're
00:25:45 if you're now telling me that the uh there's some doubt obviously they faced a great difficulty um exactly saying where some of the remains were and particularly because of
00:25:57 were and particularly because of disturbances to the site and i know there were lots of issues but if if we think of a scenario where her remains were found more in so you're saying in the bedroom doorway area uh in
00:26:08 saying in the bedroom doorway area uh in the yes in the vicinity of the bedroom entrance yes well that would if if so that would obviously imply that she may have got up and tried to move around the flat at some point and been aware of her situation yes would that affect your
00:26:19 situation yes would that affect your conclusion yes so i would well it wouldn't necessarily change the time timing but it would it would mean that she wasn't asleep when she when she uh realized that the
00:26:30 when she when she uh realized that the situation was becoming very serious yes and if you go to page 66 under the heading conclusion with paragraph 321 there you you say
00:26:41 uh that
00:26:43 that since the flat 201 occupants are known to have been overcome by asphyxian smoke and became unresponsive at about 218 to 221 it is likely that the effects on lagaya more in flat 181 were similar and
00:26:56 lagaya more in flat 181 were similar and since her remains were recovered from the bed she may have been overcoming her sleep or if awake may have sheltered in her bedroom yes and it goes on so do you estimate that her time of death should be similar
00:27:07 that her time of death should be similar to that of flat 201 i think you've with that scenario i think so that scenario but as we said there could be other other interpretations right and if we then turn to the next
00:27:19 and if we then turn to the next flat i want to ask you about this is floor 23 flat 202 i've gone back to floor 23 because i wanted to associate uh um the gaia moore's flap with
00:27:30 uh um the gaia moore's flap with a 201 yes let's get back to floor 23. this is now flat 202 gloria trevizzan and marco gutardi uh and also marjorie vitale and ernie
00:27:42 uh and also marjorie vitale and ernie vitale who were also recovered from flat 202 on floor 23. now can we go please to pages 17 to 20 in this report starting at 17
00:27:55 and you've given an overview there
00:28:00 of the occupants and the four there are named
00:28:04 named and you say in the last sentence of paragraph 59 they were part of the group who ascended from the lower floors at around 130. those two were yes those two were yes marjorie vitale and
00:28:16 those two were yes marjorie vitale and ernie vitale yes yes and then at 61 you refer to the conditions in flat 202 and there's some detail about that which runs
00:28:25 runs down to paragraph 70 on page 20. and what i just wanted to do was to pick out the main time marks with you and uh see if you just agree with those so that people watching this can understand it
00:28:37 understand it first is it right about that at about 1 30 marjorie vitale and early vettel moved up to floor 23 and joined marco gutardi and gloria trevizzan in flat 202.
00:28:48 flat 202. yes and then at about 1 34 gloria trevizzan reported to her mother that they could not leave because the lobby was filled with smoke yes uh and then between about 2 45 to 80308
00:29:02 uh and then between about 2 45 to 80308 gloria trevizzan had her last call with her parents that's paragraph 62 on page 18. yes
00:29:09 yes well i can't see it yeah yes yes it should be then yes yes yes and then at 63 you've set out your analysis of the fire spread and some bullet points there 201 to 210
00:29:21 bullet points there 201 to 210 you've got spread across the east face kitchen and living room to the corner column five then continuing 233 to 235 spread around d5 to south face of living room and then across living room to
00:29:32 room and then across living room to column d4
00:29:33 column d4 between living room and bedrooms up to 251 and then 251 to 255 spread across bedrooms to column d3 between flats 202 and 203
00:29:44 between flats 202 and 203 so that's the analysis and then at paragraph 70 we can go to that please on page
00:29:51 on page 19
00:29:53 19 you say this in summary from 1 30 there would have been slow smoke infiltration from the lobby then into the east side kitchen and living room from 202 gloria trevorzen reported dense smoke coming into the flat through the living room
00:30:04 into the flat through the living room windows at 213 during a telephone call to her mother she reported the fire coming into the window some time after her call to her mother began at 2 45. and then um you say um that uh the
00:30:18 and then um you say um that uh the carboxy hemoglobin blood concentration levels for gloria trevizzan measured 78 percent
00:30:24 percent and marco gutardi's tests showed the presence of carboxy hemoglobin but couldn't tests couldn't be carried out um for
00:30:31 um for marjorie and ernie vitale yes yes so that's the background now that we can begin can we go back to page 17
00:30:40 17 paragraph 60.
00:30:45 you say i've reviewed witness evidence and the results from toxicology and pathology reports which have led me to conclude that all four occupants of flat 202 were overcome by asphyxian gases which incapacitated them before the fire
00:30:57 which incapacitated them before the fire affected them
00:31:00 now could you just explain your finding um that they were overcome by us fixing gases which incapacitated them before the fire affected them when you say the fire affected them what did you mean there
00:31:12 can we just um
00:31:16 swing to the paragraph where i noted where their remains were found because that was that's relevant um
00:31:23 um i think we've got two we're two in the bathroom and two in the hallway or something
00:31:28 something yes i think you probably need uh paragraph 65 for that on page 18 page 18
00:31:43 or paragraph 71 on page 19 which is probably the better paragraph
00:31:51 yes we was flashed up earlier then we've moved to yes it's gone he said paragraph 71 on page 19. yeah they've got it the chart remains of the four occupants were recovered from the hallway and bathroom area that's yeah so
00:32:03 hallway and bathroom area that's yeah so they they've taken refuge in that area thank you for that sorry now can we go back to your question was when the previous paragraph you were showing yes let's go let's go back to that that's some paragraph
00:32:14 some paragraph 60 on page 17 and you say in in the last few words there before the fire affected them can you just clarify what you mean i mean i have to say that uh
00:32:25 have to say that uh from the table that i i prepared last week for the for this to summarize what's happening in these flats too these flats too were particular particularly dangerous in in a way you
00:32:37 particularly dangerous in in a way you know compared to some of the other flats and of course the situation with flats too
00:32:43 too are that the fire is is coming um
00:32:47 from the from flat one over column c and it first as we've just been discussing comes to the kitchen
00:32:58 the kitchen comes past the kitchen affects the kitchen
00:33:01 kitchen and then the east face of the living room
00:33:04 room and um
00:33:07 and um when the fire comes into the kitchen kitchen and i've noticed in a number of these flats we seem to get smoke coming from there into the hallway with some ease i don't know something to do with the way
00:33:18 the way people leave their doors or something in there so we often have a situation where the living the kitchen and the hallway of the flat become quite badly smoke logged first
00:33:29 logged first and then of course the living room becomes very badly involved once the fire not long afterwards moves on the east face moves to the living room
00:33:40 to the living room but
00:33:41 but the occupants uh and this has happened in a number of these flats tend to withdraw to the bedrooms bedroom one or bedroom two which face out to the south side of the tower
00:33:54 south side of the tower and therefore away from the fire where they can open windows and shelter quite well for a quite a long period while the conditions are deteriorating
00:34:05 while the conditions are deteriorating in other parts of the flat if they again if they shut the bedroom doors and this sort of thing now in this in this particular case we're fortunate that we do have one
00:34:17 one pretty good blood toxicology result of 74.
00:34:22 of 74. and you recall i'm saying that um that's actually is if we if you remember professor nelson's distribution that was around about the mode it was
00:34:33 that was around about the mode it was the most common sort of finding for somebody who died from smoking inhalation high carbon monoxide in a fire so it's well above the threshold for
00:34:42 for lethality i just paused there yeah you say 74 i think it was 78 in fact i not even even more so it's paragraph so that that is the result for a person who has been overcome by carbon monoxide and
00:34:54 been overcome by carbon monoxide and toxic smoke and then become comatose and continue to inhale uh smoke while comatose containing carbon monoxide for some time until they eventually their systems pack up and
00:35:05 eventually their systems pack up and they they die so it it it's a very strong signal to me that we're dealing here with smoke cases to the extent that they were in that
00:35:16 to the extent that they were in that part of the flat it's one of the areas last affected by fire breaking into the envelope of the building although to the extent they're in the
00:35:27 although to the extent they're in the hallway
00:35:28 hallway it's still quite vulnerable to smoke buildup
00:35:31 buildup from quite an early stage when the fire gets past the kitchen if to the extent that they may have been at some time sheltering in the bedrooms then that could have delayed their uptake
00:35:42 uptake and this happened not some of the other flats too further down the town now you set out at paragraph 74 to 79 on pages 19 to 20 of this section
00:35:54 of this section conclusions here um if we could just pick those up and just read those to yourself please
00:36:00 please foot of 70 foot of 19 and then over to page 20.
00:36:07 return to page 20 now please
00:36:12 if you just read the rest of that down to 79
00:36:25 so to flag this as we go through it so we've got a last call from marco gatardi at 3 15 yes which was 75 minutes after the arrival of the exterior fire outside the kitchen so it's a long time that they were in
00:36:37 so it's a long time that they were in there breathing the smoke yes they could not have survived this long
00:36:44 long it helps me to read it out i'm sorry they could not have survived this long if they'd remain in the living room as i've just been explaining but because this is a two-bedroom flat they could have shelter for some time in the south facing bedrooms
00:36:55 facing bedrooms or in the landing bathroom area until after the fire penetrated the south bedrooms after it spread across the bedrooms
00:37:04 bedrooms between
00:37:05 between 0251 and o255s after this conditions are likely to have become unsurvivable within minutes due to the asphyxiant gases mainly carbon monoxide smoke
00:37:17 carbon monoxide smoke the long period of survival uh because you didn't
00:37:23 i just want you to read that to yourself because i haven't yes i have one or two questions on on this okay um i'll carry on please carry on to the end of 79 if you all right what if you would
00:37:40 okay thank you now um in your document that we saw earlier you provided an estimated endpoint
00:37:47 endpoint for possible evacuation from flat 202 is 245 and in fact we see that at paragraph 78
00:37:55 78 yes about 245. uh now
00:38:00 uh now does that mean that a successful escape from from flat 202 after about 2 45 was possible but unlikely
00:38:11 unlikely yes
00:38:12 yes well up to then it would have been a good chance of being able to come out and walk down after that you're getting into the pre-loading territory where you you're more likely to have collapsed
00:38:23 you you're more likely to have collapsed as you try to walk down right now at paragraph 74 as we've seen and you've read out i think um the you say that the occupants of flat 202 would
00:38:34 say that the occupants of flat 202 would not have survived long after marco gutardi's last call to his father at 3 15.
00:38:40 15. yes yes then if we go to page six of this part of your report table 20 you provided a window of time there looking at flat 202
00:38:52 there looking at flat 202 at the foot of the screen right um you provided a window of time as about 315 15 to 3 30. is that your estimated
00:39:03 is that your estimated uh window a a band for time of death is that the window for time yes that's what i'm saying yes right i see very approximate uh i see and and why do you say
00:39:14 you say 15 minutes or so after about 3 15. well because
00:39:20 we're through 15 what what did we say happened at 3 15. that was the last call that mark yeah so around about that time we're looking at incapacitation then adding on
00:39:31 adding on uh
00:39:33 uh time for
00:39:34 time for the format for build up after that to the final dose of death
00:39:43 and how do you uh how do you get to 3 30 is the outside time about it it's it's really a very crude estimate just just allowing some time for this extra
00:39:54 time for this extra deterioration to have taken place as i see
00:39:59 now for marco gutardi his post-mortem report contained the finding that a secondary
00:40:05 secondary cause of death after inhalation of products of combustion was a single vessel coronary artery atheroma can you tell us what effect if any that pathological finding would have had
00:40:18 pathological finding would have had on his death is that for my report uh it is uh no it is not it's not okay
00:40:26 um sorry it's hard to keep all this material in your mind yes we
00:40:33 we he did we have his carboxy hemoglobin at death
00:40:36 death uh no we don't oh we don't okay so we had one which was another person we had um gloria trevizzans at 78 that's right sorry i'm
00:40:47 trevizzans at 78 that's right sorry i'm gonna have to write this down so gloria gloria was at 78 so gloria's 78 as far as we know she was otherwise reasonably healthy yes marco gutardi i misled you slightly professor i apologize showed
00:40:59 slightly professor i apologize showed the presence of carboxy hemoglobin but i think a precise percentage and he had this uh uh coronary artery yes he had a single vessel coronary
00:41:10 yes he had a single vessel coronary artery atheroma yes as a secondary cause that's okay i think i'm up to speed right sorry right i can't remember whether i noted any of this in my report but i did and that's hence the question yeah okay the question well yes no
00:41:23 yeah you're gonna have to i'm sorry you are both gonna have to listen to the question or the answer and then respond to it because at the moment the dragon scribe is not getting anything at all i think i beg your partner with any ease
00:41:35 think i beg your partner with any ease so yeah the question yes what effect would or it was if what if any effect would the with the finding uh or with the fact of a single vessel
00:41:47 uh or with the fact of a single vessel coronary artery atherema have had on marco gutardi's death yes so you remember we were discussing yesterday
00:41:54 yesterday that for cases like this i found a clear relationship between coronary artery or heart disease and an increased susceptibility shown by death
00:42:05 increased susceptibility shown by death at a lower carboxyl hemoglobin than other other people so he would have been at risk of collapse and death at a lower carboxyhemoglobin
00:42:16 at a lower carboxyhemoglobin concentration than for example um
00:42:21 the other person we just discussed gloria gloria yes so he he might well have
00:42:28 have died at a lower dose yeah right and does say 50 for example or even lower and does that tell us that he might have died earlier in your 15-minute window yes i would i would say
00:42:40 15-minute window yes i would i would say so yes
00:42:44 i next want to turn to a different floor a different flat and a different occupant anthony dyson flat 194 on floor 22.
00:42:54 22. can we please go to page 56 in this part of the report
00:43:02 and here you've set out a paragraph 265 the overview you say that he was the resident in flat 194 alone on the 14th of june 2017
00:43:13 194 alone on the 14th of june 2017 he remained in the flat until approximately 3 26 to 3 27 when he told the 999 operator that he was on the stairs his remains were recovered from the stair
00:43:24 recovered from the stair yes
00:43:25 yes now then if you look down below that you deal with the conditions in flat 194 and you say anthony dissent was alone in the single bedroom flat 194 located on the west side of the tower as such he was
00:43:36 west side of the tower as such he was protected from the effects of exterior fire spread for more than two hours until fire spread to his flat yes and then you set out in the following paragraphs
00:43:48 following paragraphs um the fact that he was seen by naomi lee in the communal lobby at about 125 and then a series of calls between paragraphs two six eight first one at one thirty
00:44:01 first one at one thirty uh and then over the page to paragraph if you go over the page please
00:44:07 please uh to paragraph 276 uh the last call at 3 27 53 a call lasting 45 seconds where he spoke to the kent fire rescue
00:44:19 where he spoke to the kent fire rescue service
00:44:20 service and that's when he told them that he was on the stairs yes
00:44:27 yes and at 277 if we look at that you give us the the bullet points for the exterior fire spread and the various time marks there exterior images
00:44:39 exterior images uh showing fl fire outside flat 195 that's the one next door at 301 earlier signs of flames crossing b1 to the outside of flat 194 uh bedroom
00:44:52 b1 to the outside of flat 194 uh bedroom of 322 from 322 fully outside the bedroom at 326 but not fully outside the living room until 3 55.
00:45:02 yes and those are all taken from the photographs and the um met evidence um
00:45:08 um and then at paragraph 279 under the heading evidence from toxicology and pathology reports you say he had a very high blood percentage of carboxy hemoglobin level of 71
00:45:20 carboxy hemoglobin level of 71 consistent with death from inhalation of asphyxian gases with carbon monoxide inhalation as the main cause of death and if we go please to page 57 paragraph
00:45:31 and if we go please to page 57 paragraph 280.
00:45:33 280. you say this there was smoke infiltration from the lobby from about 130 increasing significantly by 150 and he said that all smoke was coming in that he could not see and then from about two o'clock
00:45:46 not see and then from about two o'clock when anthony edison reported that it was black in the flat and he quotes can he cannot see anything close quotes from these accounts there was sufficient smoke entering from the lobby during this period to significantly lower
00:45:58 this period to significantly lower visibility in the flat and therefore also some asphyxiant gases
00:46:06 now can you explain your analysis of anti-distance exposure to toxic gases and i want just to show you uh pick figures 39 and 40 on page 59 the next
00:46:17 figures 39 and 40 on page 59 the next page please if you look at those two you've given us calculated smoke and affixing gas exposure history for anthony dissin and then figure 40 is calculated fractional effective dose and
00:46:29 calculated fractional effective dose and percentage carboxy hemoglobin history for anthony distance looking at those are you able to just take us through those and explain your analysis yes i
00:46:40 i i think it might be helpful also if we were to look at the floor plan chart briefly let's do that m e t 3 0 is 1 2 5 9 3 then
00:46:52 should we have that at the same time yes if we can that would be good
00:46:58 that's met three zero is one two five nine three page seven we'll try page seven
00:47:05 seven first
00:47:23 and if we could just have that slightly enlarged
00:47:29 yes that's that's adequate yeah so
00:47:34 so you'll remember i was saying yesterday that for a majority of people that i'd examined
00:47:41 examined if they left their flat where they were sheltering before or soon after the arrival of the exterior fire outside one of the rooms in their flat
00:47:53 in their flat whether and they were sheltering at that time in a different location they really had a pretty good chance of having acquired a low dose while in the flat
00:48:02 flat and and if they crossed the lobby efficiently of um making a successful descent of the stare
00:48:10 stare so
00:48:11 so when we look at the timings for anthony dissent
00:48:15 dissent he he did in fact evacuate his flat and we have quite good data now from the 999 calling the stair he left his flat very
00:48:25 very close to the time that the exterior fire first spread outside his flat so if we look at the diagram of his flat i just wanted to point out some of these features so obviously the fire is coming
00:48:38 features so obviously the fire is coming from the on the down the across the west side of the tower from the north corner
00:48:45 corner it's it's spread past the west face of flat five
00:48:50 flat five and it's just coming past the column there column b column b thank you to attack the bedroom of distance flat
00:49:02 of distance flat now assuming that he was in another part of the flat which i think we have some evidence for and that he would have kept his bedroom door closed we would have expected him to have been
00:49:13 we would have expected him to have been able to avoid considerable uptake of gases up to the time he left but this was obviously not the case because he collapsed after only
00:49:24 because he collapsed after only descending uh i think was two and a half floors in the stair which would only have taken somebody walking down the stair uh a minute or so which wasn't long enough to accumulate a
00:49:36 which wasn't long enough to accumulate a huge dose while in the stair up to that point
00:49:40 point so
00:49:41 so i spent quite a lot of time trying to understand his particular case because it puzzled me somewhat now of course one of the features of a flat 4
00:49:51 flat 4 is that it's a smaller area floor area it's a smaller flat and and of course this part with the front door is the same as any other flat so to the extent you've got smoke leaking in from through the front door
00:50:02 leaking in from through the front door from the very high concentrations in the lobby that we discussed yesterday
00:50:08 yesterday it would be prone to a more rapid build up from the lobby penetration smoke than a two-bedroom flat wood purely on basis of its volume smaller volume
00:50:19 volume also of course because it's in the middle of the side of the tower depending on what smoke and other conditions might be flowing past on the
00:50:30 conditions might be flowing past on the outside you haven't got the option that you have for a two bedroom flat of opening windows on another side of the tower away from the smoke so you have less ability to
00:50:42 ability to um avoid
00:50:43 um avoid exposure
00:50:46 exposure to smoke while in the flat and so i think that may be maybe one factor that he was having and from his description of the conditions that and he's describing a lot of smoke in his
00:50:57 he's describing a lot of smoke in his flat more than you would normally expect to see
00:51:01 to see he may have had a particularly leaky front door which allowed a much bigger build up from the lobby smoke in his flat than others
00:51:10 others but i'm seeing some a slightly similar pattern in other flats for you know so it seems to be a bit of a flat four issue but certainly in his case so
00:51:20 so i've concluded that he and that shows up in these charts here that he had a significant exposure to smoke from some source
00:51:31 some source and the obvious source really is the lobby more than anything else during the time he was in his flat now there is of course another possibility that we have to take into
00:51:42 possibility that we have to take into account
00:51:43 account and that is what did he do as he tried to cross the lobby after he left his flat but before he managed to enter the stair and you remember i was saying yesterday if we look at the
00:51:55 look at the uh plan here you can see that the path from his front door where you see the figure four written in the uh somebody's written on a figure four there that's his front door if he comes out of there he's got to walk
00:52:08 out of there he's got to walk out into the center of the lobby and past all these shoot doors and cupboards that we discussed yesterday to find his way
00:52:16 way to the entrance door to the stair and i i mentioned that from the witness accounts of a number of witnesses had difficulty performing that negotiating that space and we don't know whether that also
00:52:28 and we don't know whether that also applied to to him to anthony distant but it may have that may be another it's another opportunity if you like for him to have an excess exposure before
00:52:39 him to have an excess exposure before getting to the stair but for whatever reason
00:52:43 reason um i feel
00:52:45 um i feel that because he collapsed after such a short distance in the stair he had pre-loaded to a high dose before he got there and that
00:52:56 he got there and that correlates quite well with the descriptions he gave in these various calls the bad conditions in his flat so i think there's something particularly bad about that flat the leakage into that flat possibly from the lobby from the lobby mainly from the
00:53:08 the lobby from the lobby mainly from the lobby with perhaps a little bit from outside but not really from the exterior fire having spread past his flap because it was too early yes now if we go into paragraph 295
00:53:21 yes now if we go into paragraph 295 on page 60 next page please you say there that he
00:53:28 that he uh inhaled a dose level of of 50 carboxy hemoglobin which represents the threshold for the lethal a lethal exposure and he'd done
00:53:39 lethal a lethal exposure and he'd done that by 356 and therefore you estimate that he died uh by approximately 0431 yes yes
00:53:49 yes yes just remind me of his final dose he died at 71 71 yes and to confirm you've estimated that the time of death was 431
00:54:00 time of death was 431 up to very approximately approximately 431 following prolonged exposure in the stairs
00:54:05 stairs i think for more than an hour from 326. yes yes and then we get the 326 per point
00:54:13 point higher up the page at paragraph 289 if we can just scroll up to that please is that right right it's hard to just i'd rather taking this backwards but but
00:54:24 i'd rather taking this backwards but but he has 71 percent carboxy in his blood uh he leaves the flat at approximately three twenty six to three yes seven right
00:54:32 right uh and then i said he died at what time at approximately 431 yes yes because it could because he had to have time to breathe very slowly breathing 1800 past
00:54:43 breathe very slowly breathing 1800 past million in the stair for a prolonged period to have achieved the 74
00:54:49 the 74 where it was at 71 at the time of death yes so just just to break that up into parts
00:54:55 parts at the point yes he enters the stair he's obviously still mobile so he's somewhere around about approaching the 30 percent point yeah he's about the 30 point so you've got to
00:55:06 he's about the 30 point so you've got to get up to
00:55:07 get up to from there to 70. up to 71 or so yes and that's going to take quite some time because he's comatose he's breathing very slowly and he's not breathing especially high concentration of carbon
00:55:19 especially high concentration of carbon monoxide yes thank you now if we then go please to page 41 in this part of your report
00:55:29 just to a final clarificatory point on anthony dissin under 194 you say anthony edison to stare oh yes 326 to 327
00:55:40 326 to 327 um to be clear that's not the time of death absolutely not the time that's the time he estimated he entered the stair
00:55:51 the stair and therefore you could amend this part of table 21 by adding the time of death yes 0431 yes yes thank you
00:56:03 let's then turn next to flat 193 on floor 22
00:56:09 floor 22 the chuca family
00:56:12 now [Music]
00:56:15 [Music] we have a number of time points here and let me just pick this up with you at page 44
00:56:24 paragraph 207
00:56:30 and i in fact i'll i'll pick it up a little bit higher up under
00:56:35 under overview of the occupants and you name them nadia chuca bassem chuca and their children miyana chuker chuca and zynab jucare present in the flat they were
00:56:46 jucare present in the flat they were joined by syriachuker the children's grandmother and naomi lee and lydia liao by 130
00:56:52 by 130 and then you deal with the conditions in flat 193
00:56:57 flat 193 uh and just to summarize this if i can from is it right that i think we picked this up from 207 from 1 30
00:57:07 from 1 30 the lobby was filled with smoke yes
00:57:09 yes and that during the next hour the occupants of flat 193 stayed in the living room which was relatively free of smoke yes
00:57:17 smoke yes and then we know that blood samples could only be taken from two individuals confirming the presence of carboxy hemoglobin but immeasurable concentrations i think yes right well we get that
00:57:29 yes right well we get that let's go to paragraph 47 to pin that down paragraph 220 please
00:57:38 that that's what that is i've summarized very much so what you've what you've set out in detail there
00:57:47 yes yes so this is the hashim this is the family from flat 2 who joined at a later date wasn't it yes we got some chb there was present but they could not measure the
00:57:59 but they could not measure the police toxicology was unable to give a value yes
00:58:07 and uh you note i think uh at paragraph two two one on the same page uh that the the flat 193 occupants were located in the southwest corner of the living room
00:58:18 living room and you say that that meant that they were likely to be subjected to heat exposure after the fire reached that side of the building between about 337 to 338
00:58:29 to 338 yes yes
00:58:31 yes yes and i think you go on to note that due to their prolonged exposure to smoke and asphyxian gases it's likely that the occupants of that flat would already have inhaled a significant dose of asphyxian gases by that time yes yes and
00:58:44 asphyxian gases by that time yes yes and i think you draw an analogy there with abrafras ibrahim in flat 203 the flat immediately above it yeah so we we have a time for him falling
00:58:53 falling and we know what his
00:58:55 what his exactly what his carboxymoglobin was at 20 to that time we we do reasons that you've explained in relation to him in in other parts of your yes report um if we go then please to page 52
00:59:08 um if we go then please to page 52 in this part of the report we have figure 38. let's just look at that together that shows the forward calculated uptake yes they're very busy
00:59:19 yes they're very busy it's very busy can it it just am i right that i mean this is the calculated fractional effective dose and carb boxy hemoglobin history for the occupants of that flat yes
00:59:30 that flat yes and the one above and the one above you've got 23rd flat 2a3 and 22nd 193. now does it show that the occupants of both of those flats were likely to be comatose
00:59:42 comatose by 413 yes and therefore to have crossed the lethal threshold by false 17 yes and i think in your conclusions which we can find on page 54 let's have those up
00:59:53 can find on page 54 let's have those up on at the same time please page 54 paragraph 254 page 54 paragraph 254
01:00:10 yes i'll read it aloud you say by around 417 to 420 the occupants are likely to have inhaled a lethal dose of asphyxian gases as stated since the remains of the flat 193
01:00:22 stated since the remains of the flat 193 occupants were located in the southwest corner of the living room it is likely that they would have been subjected to some heat exposure after the fire reached the south side of the living room
01:00:31 room however due to their prolonged exposure to smoke and asphyxian gases it is likely that the flat occupants would have become comatose then died from inhalation of toxic smoke and due to the
01:00:43 inhalation of toxic smoke and due to the inhalation of asphyxian gases especially carbon monoxide with contributory effects from other toxic gases including hydrogen cyanide
01:00:54 hydrogen cyanide yes
01:00:55 yes now you've given a a a a window of 417 to 420 um you say around 417-420 that's an approximation is it it is approximation
01:01:06 approximation is it it is approximation because at that point in the proceedings we don't really know what the fire was doing how rapidly the curves for the actual fire are are increasing so
01:01:17 are increasing so where whereas i can make a reasonable estimate of the if you like the fire the smoke and toxic gas curve before that where we have the data for naomi and lydia and then
01:01:29 the data for naomi and lydia and then for
01:01:30 for abraham on the floor above so that gives me some fixed points to fit my curves too
01:01:36 too beyond that time other than i think there were one or two phone calls with some accounts of what was going on uh
01:01:44 uh that's that extrapolation of the curve which has some uncertainty about it so we've got some uncertainty about the growth curve of the fire and the conditions after that time we also have
01:01:55 conditions after that time we also have some uncertainty uh
01:01:58 uh about the reasons i've mentioned before about the blood and the time of death issues
01:02:04 issues so again time of actual death is quite hard to
01:02:08 hard to pin down now this may not be a very good example because of the absence of precise carboxy hemoglobin samples but you say in the at the end of the la of
01:02:19 you say in the at the end of the la of that paragraph 254 uh especially carbon monoxide with contributory effects from other toxic gases including hcn hydrogen cyanide are you able to tell us to what extent
01:02:30 you able to tell us to what extent uh to what material extent hydrogen cyanide
01:02:34 cyanide played a part in the deaths well for all these calculations we discussed yesterday i've based my analysis on
01:02:45 on a pretty uh good estimation of what the carbon monoxide was because we have all the blood data and these other bits of information so i can kind of pin down the carbon monoxide
01:02:57 the carbon monoxide if i know the carbon monoxide i can try to estimate what the cyanide concentration profile was and as we discussed yesterday the way i do that is by the ratio that we
01:03:10 do that is by the ratio that we discussed between the carbon monoxide and cyanide in these fire gases and as you will recall yesterday i said that from my analysis of the
01:03:21 of the toxicology fire gas data the ratios between carbon monoxide which we now have with some certainty and the unknown hydrogen cyanide
01:03:33 and the unknown hydrogen cyanide would have been very similar for burning flat contents type materials or from burning exterior uh cladding and insulation materials at about 26 27 to 1
01:03:44 insulation materials at about 26 27 to 1 ratio
01:03:45 ratio so using that ratio and knowing with some certainty what the carbon monoxide concentration was i can make a fairly good estimation in my view of
01:03:56 fairly good estimation in my view of what the cyanide exposure was and from that estimated exposure i conclude that the cyanide was there it was making a contribution but it wasn't the main driver of what we're
01:04:07 wasn't the main driver of what we're seeing in front of us the main driver is still the carbon monoxide yes and can you be more precise about what you mean by or what you're identifying by contributory effects what conditions well
01:04:19 what conditions well yes
01:04:19 yes we discussed this yesterday and this is where the science is somewhat uncertain but we know that both of these gases are independently asphyxian gases
01:04:32 independently asphyxian gases resulting in both of which result in some form of tissue hypoxia which causes collapse in the individual so either cyanide on its own or carbon monoxide on its own
01:04:44 own or carbon monoxide on its own produce similar kind of symptoms and effects in the exposed person when they're there in the same time then there are a number of possibilities
01:04:55 then there are a number of possibilities so one possibility is that they act completely independently in which case whatever the outcome is is just dependent on whichever gets there first if you like you know the one that's driving
01:05:06 driving the other is that there's some kind of toxicological additivity some degree of additivity it doesn't have to be one plus one it be maybe some other fraction but there's some interaction activity between the two and we
01:05:18 activity between the two and we discussed this yesterday and there is some evidence that that may be the case and the default assumption if you like that
01:05:25 that all the toxicologists making are in our committees and standards and to be honest to if you like to er on the side of caution is to assume that the fractional doses of these two gases are directly additive
01:05:37 are directly additive but that's not something we know with certainty
01:05:40 certainty and there's a lot of complexity about this
01:05:43 this one of the as i said yesterday the main effect of carbon monoxide is to inhibit the delivery of oxygen to the tissues the main effect of cyanide is to inhibit
01:05:55 the main effect of cyanide is to inhibit the use of oxygen by the tissues but there's a complexity in that the point of action of cyanide is in the mitochondria of the cell it affects oxidative metabolism in fact
01:06:07 it affects oxidative metabolism in fact blocks it
01:06:10 in in the cytochrome chain and it has been shown in recent years that carbon monoxide in addition to the pecs on the blood that we've been discussing yesterday
01:06:21 that we've been discussing yesterday also directly affects the mitochondria so you can see there possible ways of interaction and and metabolic actin additivity between those two gases
01:06:32 additivity between those two gases so there's so there is some uncertainty about this um
01:06:37 um i
01:06:38 i feel that in the uncertainty about all these kind of outcomes is such that uh the presence of the smaller fraction of
01:06:50 fraction of cyanide in these cases means that although it it
01:06:55 it numerically if you like provides us with about a third in some of these cases of a of a incapacitating dose when you've got one
01:07:07 one if we have a if we have a dose it should be on the screen somewhere the um the fed
01:07:13 the fed uh at collapse uh if you go back to page 52 that should show you yeah figure 38 sorry i'm getting a bit too involved here what i'm saying is that we had
01:07:24 here what i'm saying is that we had something like a third of a dose to cause incapacitation of cyanide we have a a whole dose a number a dose of one for carbon monoxide if you add them together you get 1.3 right
01:07:37 together you get 1.3 right so you could argue that we would have expected them to collapse at a carboxy hemoglobin somewhat less than in this case because they're in a flat 40 percent
01:07:49 flat 40 percent because of the added effect of the cyanide but we make i i would say we're trying to make find a distinction here and effectively yes i think that cyanide would have made
01:08:00 yes i think that cyanide would have made some contribution the dominant toxic gas here causing incapacitation is the carbon monoxide i think that's about as far as i can is that a way of telling us that you can't
01:08:12 that a way of telling us that you can't quantify the contributory effects from hydrogen cyanide well like i can i can say that it it's relatively small in this case
01:08:23 relatively small in this case so
01:08:24 so but i i i'm not i can't say with absolute certainty that the com combination of these two gases would shift the time to incapacitation significantly in one direction no but
01:08:35 significantly in one direction no but but if one comes away from the standard of absolute certainty and perhaps uses instead a standard of reasonable confidence would your answer be the same my my
01:08:45 my my answer would be that
01:08:48 that both are making some contribution but the dominant gas in the because of the ratios present in these in these cases here in grenfell
01:08:59 these in these cases here in grenfell is carbon monoxide so the carbon monoxide is dominating the incapacitation it's certainly dominating the death the point of death but that i think we need to leave some
01:09:11 but that i think we need to leave some room for
01:09:12 room for cyanide making some contribution to this incapacitation past partly by increasing breathing to a small amount as we discussed yesterday so i wouldn't want to i wouldn't want to exclude it from it
01:09:24 to i wouldn't want to exclude it from it from having a contribution here but i think it's relatively small
01:09:30 small and just one more go if you like on this if you look at paragraph 254 and your time period for estimated uh time period for
01:09:41 estimated uh time period for the lethal days being inhaled 417-420 would that still be the same estimated time frame in the absence of hcn
01:09:53 time frame in the absence of hcn yes i wouldn't be able to uh change that significantly no right thank you now moving away slightly from that particular point um there is a uh
01:10:04 there is a uh i'll read the reference record i don't need to show it to you there's a transcript of a call from nadia chuca that you've referred to to 999 which connects to british telecom at 3 14.
01:10:15 at 3 14. yes in which nadia chuca says my daughter's unconscious she's dying and the reference for that is cor 40 1081.
01:10:26 1081. now the question is taking that into account 314 is it possible that the child's time of death may have been earlier than the range 417 to 420
01:10:39 been earlier than the range 417 to 420 yes now i hadn't been aware of this particular call up till recently i was in your report i believe i've missed that i'm sorry but um
01:10:49 but um that seems quite early to me because we know lydia and naomi had successfully left the flat at 310 they'd be of course they're adults and of course the other factor which you
01:11:01 and of course the other factor which you may be about to raise with the two care family
01:11:04 family is that they had attempted previously to escape
01:11:08 escape i'm right aren't i in saying that yeah yes somehow yes yes so they they'd they left the flat earlier on and
01:11:18 and uh they were gone for about eight minutes
01:11:22 minutes and so i estimate that in that eight minutes they may have traveled down the stairs several floor levels and then turned around and come back again and then they re-entered the flat
01:11:36 and then they re-entered the flat so
01:11:37 so they would have been exposed to the conditions in the stair during that period
01:11:42 period and their uptake of i i have mentioned this to some extent here that their uptake of
01:11:49 uptake of carbon monoxide would have been somewhat greater
01:11:53 greater than for for example naomi and lydia who'd remained in the flat throughout now my estimates of times to death are mainly based on the chucas and the
01:12:04 mainly based on the chucas and the hashims who who who remained in the flat after that so it's all a little bit difficult but thinking particularly about this child uh the child would have
01:12:16 uh the child would have obviously
01:12:17 obviously can we do we know what age the child was uh i don't know i think the answer is yes but i'm not trying to well i mean what i'm about to say is if the child was carried
01:12:28 was carried or walking would make a difference during the time they were trying to move up and down the stair if there's a small child who was being carried
01:12:38 carried or if there was a child who was walking
01:12:45 i mean if you just tell us what is i think i think she's quite a young child um so as i said as i said yesterday the rate of uptake of fixing gases in a
01:12:58 rate of uptake of fixing gases in a young child is is quite a bit noticeably more rapid than an adult so on that basis and because of the partly because of this history of what they've been doing it is certainly possible that
01:13:09 doing it is certainly possible that zainab could have been overcome and become unconscious some
01:13:15 some considerable time before the adults were yes yes i'm sorry to put it well no to give you a short answer that that's that's helpful thank you um let's then pick up uh page 53 paragraph 249
01:13:29 pick up uh page 53 paragraph 249 [Music]
01:13:31 [Music] uh where you say that that the that's not on the screen if we can just have that on the screen yes thank you that there would have been limited exposure to an uptake of smoking asphyxiant gases
01:13:44 asphyxiant gases up to the time they left the flat at 244 there's some exposure in the lobby and stare during the approximate eight minute period before they return to flat 193
01:13:54 193 yes from their 999 calls they were lucid and physically able when they returned to flat 193 yeah so they were at that time the adults were still in a good condition but of course they had accumulated a
01:14:06 but of course they had accumulated a certain pre-loaded dose in that activity yes and you go on to say they seem lucid and physically able to on their return and their main exposure is likely to have occurred in in flat 193
01:14:17 likely to have occurred in in flat 193 yeah i think that's the point after 311. yes yes and you say that at 249 as i so i've just shown you in the rest of that paragraph now my question professor is with their time in the lobby
01:14:28 lobby have contributed to the accumulation of the fractional effective dose of carboxy hemoglobin well this is a interesting point so
01:14:36 point so we're talking about flat 203 here aren't we
01:14:39 we a flat three yes so i would not expect them to have spent very long in the lobby because the distance again looking at our diagram the distance
01:14:51 looking at our diagram the distance don't worry it's all right the distance the distance from the front door to flat three to the stair door is quite short i think it i think it was actually six meters let's have it up so that people can see what you're explaining met three
01:15:02 can see what you're explaining met three zeros one two five nine three please page seven
01:15:11 okay so somebody's written number three see but then written with a circle number three yes that's the front door of flat three yes and then just to the right to that up a little bit we can see the
01:15:23 up a little bit we can see the curve of the door to the stair leading to the stairs it's a very short distance to travel
01:15:29 to travel so i would have expected them to have spent uh seconds negotiating that distance
01:15:35 distance and therefore i'm possibly holding their breath while i did it because we know that the conditions are bad in that lobby so i would not have expected them to inhale
01:15:46 i would not have expected them to inhale a significant dose while crossing that lobby however in the stair i i we don't know but my understanding i'd have to reread their witness
01:15:58 i'd have to reread their witness statements again but i i certainly found the impression that they must have got into the stare and from the eight minutes that would have given them time to have descended uh quite a number of
01:16:09 to have descended uh quite a number of flaws turned around and reassended in the stair and had quite a significant exposure while in the stairs i think that's where their main exposure would have been
01:16:18 have been in the stairs and would that explain well well first does that
01:16:24 does that uh indicate that the times of death for the chuca family have been earlier than estimated because of accumulated doses of asphyxian gasses taken up in the stair yeah i mean it is possible to that
01:16:35 stair yeah i mean it is possible to that we could shift that time back a little bit but obviously as i've said uh from the
01:16:41 the calls and things they later made from flat 203 if i've got it right
01:16:46 right they
01:16:47 they their main exposure was was during this rapid rise period after lydia and naomi left
01:16:54 left when the conditions were deteriorating quite rapidly in that flat and of course we have the corresponding conditions in the other flat sit on the 23rd floor for comparison
01:17:05 23rd floor for comparison so i
01:17:08 so i that that's the basis in which i did my analysis but i hadn't factored in a specifically added dose for the time they spent in the stair so if we want to factor that in and there are other unknowns of exactly
01:17:19 there are other unknowns of exactly where they're sheltering and things like that
01:17:22 that uh we we could shift their time of incapacitation back a little bit but it has to fit in still with their phone calls of course yeah and does that explain why at 3 14 nadia was telling
01:17:34 explain why at 3 14 nadia was telling the nfb call handler that zinab was unconscious it could well do yes i see yes now in the same paragraph 249 if we can get back to that please uh at page 53
01:17:46 uh at page 53 you refer to the exposure of um the jamal khadir hashem family i call them that compendiously while in flat 192 yes before they move to flat 193
01:17:58 before they move to flat 193 and you say that their main exposure came from after they moved into flat 193 now if we go please to page 43 and look at paragraph 202
01:18:09 at paragraph 202 and over the page to page 44 paragraph 204 it runs down that path that um
01:18:16 that um part of the page and over the page under the heading analysis of uptake of asphyxian gases you identifying what you find here you identify the conditions in the bedroom
01:18:27 identify the conditions in the bedroom in which the kadir family were sheltering in flat 192 deteriorated more rapidly
01:18:32 rapidly from around 242. you say that in 202 in the middle of the paris path and that the conditions would have deteriorated further at around 255 in the next sentence yes yeah
01:18:44 in the next sentence yes yeah and at the final roughly 15 minute period in the flat is likely resulting in them in inhaling a significant dose of asphyxians before moving to flat 193 yes
01:18:55 yes i just um
01:19:01 where where was that well we find that i think in in paragraph two uh
01:19:09 uh 202 and 203 the combination of the both i think
01:19:14 it's hard to digest text quickly i'm sorry i know and uh take your time conditions distributed more rapidly from 242 i i think the best place to find this to be frank professor is at the top
01:19:25 this to be frank professor is at the top of page 44 in paragraph 204 where you say although the flat 190 occupants are able to evacuate about 256 to 259 and crossed a flat 193
01:19:37 about 256 to 259 and crossed a flat 193 they are likely to have inhaled a significant dose of asphyxians before leaving flat 192. right yes sorry so so as i was saying uh half an hour ago
01:19:49 so as i was saying uh half an hour ago there's a real issue here with these flats too that people were able to minimize their exposure quite some time by sheltering in bedrooms as appears to have happened here but it looks as if they
01:20:01 it looks as if they were still in the flat after there was quite
01:20:04 quite considerable spread of fire even outside the bedrooms i think from what we've just been the paradise have just been perusing so they
01:20:13 they are likely to have they were still very active they were able to make the transition without great difficulty so they were they were in good condition at the time they made the transition but they would have had accumulated some
01:20:25 but they would have had accumulated some degree of
01:20:27 degree of asphyxians before they left flat 192 possibly more than if you like lydia and naomi would have been doing in 193 and the two cares before that they did their
01:20:38 the two cares before that they did their it's there now um you say in the next sentence if they had attempted to set to descend the stair they would have been in danger of accumulating a sufficient dose to cause collapse in the stairs
01:20:49 collapse in the stairs sorry yes to cause collapse in the stair before they could have walked down to the ground floor especially the children yes uh are you able to quantify the accumulation of the six in gases and
01:21:01 accumulation of the six in gases and risk of collapse further than you have well
01:21:06 well it's similar to what we've been discussing yesterday that i think from memory the dose you're going to accumulate as you walk down the stair with 1800 ppm in
01:21:17 you walk down the stair with 1800 ppm in from a high high level is something like 20 or so percent carboxyhemoglobin you're going to add to whatever you start with
01:21:28 to whatever you start with and if you start with more than about nine or ten percent before you set off from your flat then you're in danger of getting into trouble
01:21:39 trouble before you reach the bottom of the stair and from the description of the timings of fire spread and the activities of the occupants i feel they were they were in the cusp
01:21:51 i feel they were they were in the cusp of this kind of transition point where they
01:21:53 they where they if they remain much longer they would have pre-accumulated too big a dose to allow head room for them to have
01:22:03 have accumulated the further dose as they walk down the stair yes mr chairman i've got a few more questions to run on on this flat and this one would it be better to have have some letter yes i'd
01:22:15 better to have have some letter yes i'd rather have them now and then have a break if i think that bit more sense
01:22:20 now we know they went into flat 193 and into clearer conditions than those that existed in the stair i think is there a possibility that whatever
01:22:32 is there a possibility that whatever they had accumulated in flat 192 might have washed out over the subsequent period that they spent in the clearer conditions in flat 193 bearing in mind the washout curve that you've yes you've identified yes i
01:22:44 that you've yes you've identified yes i considered that and i i thought i was thinking about this again recently and of course the key point here is that we're talking about them being in air in fact not even fresh not even perfect
01:22:57 in fact not even fresh not even perfect here because there was some contamination in flat three so the washout time if you remember me saying yesterday for a half time for
01:23:07 for air is four and a half hours so if you if you accumulated a dose in flat 192
01:23:14 flat 192 and then spent say 20 minutes or so in flat 193 the decrease breathing pure air in 193 the decrease of your already accumulated dose would have been quite
01:23:26 accumulated dose would have been quite small during that period of time so i don't think there would have been it would have been a little bit yes you're right the processor process would have been off some clearance during that period before the
01:23:38 clearance during that period before the conditions deteriorated in 193 but i don't think it would have unless they'd been breathing oxygen they wouldn't have been a rapid washout right
01:23:50 right it really comes to this it should the residual component of the accumulation from flat 192 which was significant as you say and then the washout thereafter in 193 to the extent that there was as you've
01:24:01 to the extent that there was as you've explained be reflected in the likely times of death for the khadir family so i think i think what we would say is that they probably accumulated a significant
01:24:13 probably accumulated a significant fraction of their total dose while in 192 that would have decreased very slightly during the a few minutes in 193 and then they were all going up together as the conditions in 193
01:24:26 together as the conditions in 193 deteriorated then right so you would you wouldn't make an is this right you would not make an adjustment not really i mean this is fine tuning we there are what if someone could play i
01:24:38 there are what if someone could play i don't think it's going to make a huge difference to the outcome uh now we know that the chuca family had three children and the jamal khadir hashim family also had three children now if you go to um
01:24:50 now if you go to um paragraph 253 on 54 of section 6 you
01:24:58 you 254 page 56.
01:25:10 two which one sorry um if you go i'm sorry bit
01:25:13 sorry bit power 54 so sorry page 54 paragraph 253 right sorry my fault um and you um you say there in the middle of the paragraph
01:25:24 say there in the middle of the paragraph since the inhaled days of asphyxians in infants and young children accumulates at approximately twice the rate of that in adults it's likely that the children in the chew care and hashim kadir families would have lost consciousness
01:25:35 families would have lost consciousness some time before the adults closer to 353
01:25:39 353 since the flat 2a3 occupants sheltered in the bathroom and toilet they may have survived a few minutes longer than those in the flat 193 living room yes so here we're talking about living room because we're 193. so yes now could times of
01:25:51 we're 193. so yes now could times of death of the children have been earlier than 4 20
01:25:55 than 4 20 if we go to table 21 and recorded here in para 254 except 417-420
01:26:03 417-420 could those times for the children be earlier than that window because of their age yes i think i think we can estimate that there would have been a shift i know it's difficult to quantify but they
01:26:14 it's difficult to quantify but they would have expected to be earlier than the adults if you like the probability is that the the children would succumb before the adults
01:26:23 adults be overcome before the adults and we know i can't tell you the age for zainab because because it's in the phase one report and therefore in the public domain but it was three years old i thought it was three yes so she was so she was probably carried uh when they
01:26:36 so she was probably carried uh when they went down the stair but even so she's still inhaling so simple amounts of these gases excuse me but just to be clear you say that that it's like it's it's likely that
01:26:47 that it's like it's it's likely that they they would have died earlier than the window 417 to 420 but you can't say yes you can't say how much earlier not really but yes earlier a few some minutes earlier thank you very much
01:26:59 thank you very much for that um mr chairman is now a convenient moment for the morning break yes it's a bit later than normal but that's all right it's quite important to get those questions finished on that flat thank you well we'll take the morning break now and professor person
01:27:11 morning break now and professor person we'll uh come back at course the 12th please thank you and as before please don't talk about your evidence or anything related to it with anyone i understand thank you very much
01:27:33 thank you mr millet course to 12 please thank you
01:47:34 hey would you ask professor person to come back in please
01:47:52 all right professor yes yes yes yes thank you mr chairman uh professor i now want to turn please to the el wahabi family in flat 182 on floor 21
01:48:02 floor 21 and can we please go first to page 66 in this part of your report page 66 dapr606
01:48:12 uh and there we have flat182 overview the al-wahabi family remained in flat 182 throughout the duration of the fire they were trapped in their flat due to smoke in the lobby
01:48:23 smoke in the lobby then you deal with the conditions there and i'll just set up the relevant facts and just picking them up from paragraphs 3 2 4
01:48:29 3 2 4 and
01:48:30 and on after meeting helen gabriel mescal in the 21st floor lobby the al-wahabi family went back into flat 182 abdul aziz al-wahabi told hannah wahhabi in the second call at 1 30 that they'd
01:48:42 in the second call at 1 30 that they'd not been able to get out because there was too much black smoke and that comes from the um the evidence of hanan wahabi and the 138th this is para 326 and i'm
01:48:54 and the 138th this is para 326 and i'm going to summarize 138 they called 999 and described developing conditions during the call which lasted for an hour yes
01:49:02 yes yes just remind you of that and then at paragraph 3
01:49:07 60 if we go to that please
01:49:12 at page 67 uh
01:49:15 uh you can see that uh there's a sequence of events there in summary at uh 208 to 209 the fire spread to the east side of the living room
01:49:26 to the east side of the living room which reached the east southeast corner by 211
01:49:30 by 211 and then by 238 the exterior fire had spread across the south living room to the bedrooms yes yes that's the exterior of our spread and then if you go please to paragraph 366 on page 68
01:49:44 366 on page 68 you can see there that it says from a series of 999 calls made from flat 182 over seven minutes from 247 to 254 it is evident that the conditions in the bedroom were deteriorating considerably
01:49:55 bedroom were deteriorating considerably in terms of smoke density the occupants said that they were unable to evacuate a male caller i'm sorry there was too much smoke and they could not breathe they could not see anything a male caller said they were going to faint
01:50:07 caller said they were going to faint once the fire had moved across to the south face of the tower it would have been more difficult to ventilate from the bedroom windows the occupants made several attempts to evacuate but were repelled by the dense black smoke in the lobby with zero visibility quotes we can
01:50:19 lobby with zero visibility quotes we can see nothing and the last call this is 367 uh was uh at 2 57 ending at 258 and 29 seconds yes yes
01:50:31 yes yes and the caller the operator said that the caller was a woman on the line that had gone silent and at 370 at page 69 you say that the toxicology analysis
01:50:44 uh was not possible for any of the family members in that flat now that's the that's the background i've shown you yes and if we next go please to page 70 and look at your conclusions and just remind yourself of
01:50:57 conclusions and just remind yourself of them from paragraph 374 to 378 all on the screen in front of you if you just take a moment to remind yourself of your conclusions there
01:51:15 yes are you able to provide a window of time
01:51:18 time of death or times of death for the elbow harvey family which would be after 258 the last call
01:51:29 so what time did i say they became incapacitated um
01:51:40 at uh i think after 2 45. right so if they became incapacitated about
01:51:48 about 245
01:51:50 245 and from the previous text at this time the conditions were deteriorating quite remarkably in the bedroom area so
01:52:00 they would have had so to 45 they would have had um
01:52:07 a a quite a rapid uptake then once they became comatose of course was a slower period so
01:52:14 period so i would i would probably add on i would start thinking about adding on about 20 minutes to time of actual death as a rough estimate and i'd try to put a window around that right of
01:52:26 window around that right of um
01:52:28 um so
01:52:29 so right let's say 255
01:52:33 255 to
01:52:34 to 320 something like that is the window approximate i'm working on the basis of 3 6 paragraphs 366 and 367 page 68. if we go back to that just to
01:52:47 page 68. if we go back to that just to try to answer your question a bit better myself from your work you've you've taken taken the 999 calls over the seven minutes 247 to 254 and said that the conditions were deteriorating
01:52:59 deteriorating yes
01:52:59 yes and um the last call was at 258. and does that have first of all does that help you identify well so what i seek to do is first of all identify as far as i can
01:53:10 far as i can the point where they became unconscious and obviously it was after the end of the call
01:53:17 the call but
01:53:18 but we have this note here about the bt operator
01:53:21 operator saying the line had gone silent which indicates that they may have collapsed around about this time so that that gives us a time of incapacitation
01:53:32 of incapacitation of
01:53:33 of to round it up about three o'clock doesn't it yes so you
01:53:38 so you you tell me well yes i mean assuming that they uh that they went silent because they become unconscious they're unconscious at all 2 58 29 but you know let's let's so we're
01:53:50 29 but you know let's let's so we're talking about three o'clock essentially yes it's around about the time they they're becoming unconscious and then having then become unconscious and we know that conditions are deteriorating quite markedly around that time
01:54:02 quite markedly around that time they uh
01:54:03 they uh continue to um
01:54:07 inhale uh
01:54:09 uh these gases until they the circulation ceases and they die and that depending that depends on as i said before on the carboxyl hemoglobin at death which we don't know
01:54:20 at death which we don't know um
01:54:21 um so we have to put quite a wide window of time on that but i would i would so
01:54:28 so they're collapsing at about 40 percent carboxyhemoglobin by definition if you like from my our previous discussions so they've got to get up to 50 to to to cross the lethal threshold
01:54:40 cross the lethal threshold so um
01:54:41 so um we could
01:54:42 we could that that would take a few minutes you know depending on the exact concentrations that they're exposed to and would that be shorter for children than for adults so just sorry just to
01:54:53 than for adults so just sorry just to finish the thought so so if we're talking about something like 3
01:54:58 3 [Music]
01:54:59 [Music] 3 15
01:55:00 3 15 and then if they went up to 90 percent then that would we'd have to add on another 20 minutes or so for that to occur so these are sort of windows i'm sorry i can't really give these
01:55:12 i'm sorry i can't really give these precise numbers but for the last question of course yes the children would be overcome before the adults certainly in terms of time to incapacitation quite likely also in terms of time to death subsequent to that and is it
01:55:24 death subsequent to that and is it possible that they could have on the evidence you've seen have become incapacitated before 258 the children yes yes oh definitely yes are you able to estimate
01:55:35 are you able to estimate the latest time for a successful evacuation for the el wahabi family i think i've put something in here about that haven't i well i think it might be in your summary note on endpoints if we can go to that please a
01:55:49 dapr6013 please 5013. so sorry the apr five zeros thirteen oh yeah there's the table so we're talking about well this is for flat 2
01:56:01 well this is for flat 2 202 so we're talking flat two aren't we yeah we're we're talking about flat one eight two yes okay so a two a flat two a flat two and and so the pattern of fire
01:56:12 flat two and and so the pattern of fire spread and the timing of it at these upper floors was pretty close yeah with the slight caveat that as you go down you sort of buy the odd minute or two floor by floor as you go down yeah
01:56:23 two floor by floor as you go down yeah so i've got in a figure there of about 245 that's where i got my 245 yes i think that's a good a good indication yes
01:56:30 yes right okay so that's before the 258 which was the last time of the call yes so they're already you know because we know that that call they're close to unconsciousness so that's too late by then so really
01:56:44 that's too late by then so really yes thank you
01:56:50 then let's go please to uh the belkadi family in flat 175 on floor 20. and for that please let's turn to page 88 in
01:57:01 88 in part 6 of your report dapr606 please
01:57:10 and the overview of paragraph 486 as you can see says this the belkadi family omar balcardi farah hamdan and their three children lived in flat 175 they were present on the night of the fire
01:57:22 were present on the night of the fire uh and we can again run through the the various facts uh which um pertain to that particular family
01:57:30 family uh
01:57:31 uh um is this flaw um
01:57:35 um 21 i think i said 20 is 21. uh if if you go please to paragraph uh um or page 91
01:57:50 visible
01:57:56 um it's floor 20. if we go please to page 91
01:58:03 and um well we can pick this up i think a bit a bit higher up on page 88 first of all which we have uh and you say 487 in there the family remained in flat 175 until firefighters
01:58:16 remained in flat 175 until firefighters attempted to assist their evacuation from the flat at approximately 219. now working back from that if we go to page 91 you say on page 91
01:58:27 you say on page 91 at paragraph
01:58:30 500 that at 1 30 uh the occupants in the in flat 175 reported smoke entering the flat from the lobby uh in a 999 call and then you noted that
01:58:43 uh in a 999 call and then you noted that they reported in that call that they closed the windows to prevent smoke entry from outside that's 501 yes yes just just going through this with me yes at 502 you say that by
01:58:54 with me yes at 502 you say that by keeping the windows open uh by keeping the windows closed rather flat ventilation is reduced yes and then um there were 999 calls between 143 and 208 in which they reported
01:59:07 143 and 208 in which they reported increasing smoke and closed windows that's 503 yes
01:59:12 yes let me just catch my mind up into this creating spoken and the clothes win yes yes
01:59:18 yes yes 503 yes and they refer to smoke entering if the windows are closed don't smoke in the hallway and don't smoke conditions in the flat right but that's that's between those two
01:59:29 that's between those two time marks 143 and 208 and then if you go to paragraph 504 you say that at 2011 211 tara hamdan called 999 and reported
01:59:41 called 999 and reported a lot of smoke coming into the house and she put sheets under the front door and then if you go to [Music]
01:59:49 [Music] the bottom of the page para506
01:59:53 para506 top of the next page page 92
01:59:57 page 92 there's a call at 2 17
02:00:01 brief call still alone in flat 175 and then 507 firefighters come to flat 175 just after 2 18
02:00:13 2 18 and then if you go on down please to paragraph 519 on page 94
02:00:24 we can see the exterior of fire spread pattern and that but in summary between 210 and 223 the exterior fire had reached the bedroom of flat 175.
02:00:38 bedroom of flat 175. and i'm summarizing professor yes you've said this help for you yes just to recall to remind you uh and then if you look at paragraph 520 just below that under the heading
02:00:49 just below that under the heading evidence from toxicology and pathology reports you say that omar balcardi farah hamdan and lena belcardi were recovered from the landing between the 20th and the 19th floors there yes yes yes
02:01:02 the 19th floors there yes yes yes uh and that um belcardi's second daughter had been carried out while the first daughter was found later in the morning yes now the toxicology results are set out at paragraphs two five
02:01:13 are set out at paragraphs two five five two two uh and below just to summarize those for you um in your own work uh omar balcardi had 87 carboxy hemoglobin concentration levels
02:01:24 levels faraham dan this is paragraph 523 had 85 carboxy hemoglobin um the youngest belcardi a baby had 84 carboxy hemoglobin concentration levels
02:01:37 carboxy hemoglobin concentration levels and that's over the page at five at page 95 524
02:01:44 and the the eldest daughter of the belcardis this is 525 was found in the stairs by firefighters and taken to hospital
02:01:55 and taken to hospital and her carboxy hemoglobin saturation levels were measured at 45.3 percent which decreased to 24 percent as you can see there yes yes yes
02:02:07 percent as you can see there yes yes yes now um that's that's what you set out in relation to that family i have a number of further questions about that family um if we go please to page 89
02:02:19 and just look at paragraph 490.
02:02:25 you you say there from the evacuation histories of fadumo ahmed floranida and farhad nida naomi lee and lydia lao as i've described i've determined that the concentration of
02:02:37 determined that the concentration of asphyxian gases in the stair was moderate with a carbon monoxide concentration of approximately 1800 parts per minute c-section 2. at this concentration i have calculated that a descending adult with no previous
02:02:48 descending adult with no previous exposure would be able to remain walking down the stair for a period of 15 minutes before accumulating an incapacitating dose level of 30 percent carboxy hemoglobin now i've read you
02:02:59 carboxy hemoglobin now i've read you that because we we know that from your evidence i think repeatedly over the last day and a half it's good to see that imprint there in this context if we then go please to page 100
02:03:10 then go please to page 100 page 100 and go to page paragraph 545
02:03:18 uh you you say there from under your conclusions that uh faraham done lena bilcardi omobelcardi and malek
02:03:28 and malek all experienced a similar exposure to toxic smoke and asphyxian gas is sufficient to cause collapse almost as soon as they entered the stair and then death on the stair after a further exposure they were not exposed to
02:03:39 exposure they were not exposed to significant heat while in the flat or lobby the minor heat damage is likely to have occurred after death before the bodies were recovered from the stairs they collapsed almost immediately after entering the stairs so they had already inhaled an incapacitating dose it was
02:03:52 inhaled an incapacitating dose it was fixing gases by this time approximately 30 to 40 percent carboxy hemoglobin while in flat 175 and the 20th lobby some of this was accumulated while in
02:04:03 some of this was accumulated while in flat 175.
02:04:05 flat 175. now against that background can i ask you to look please at figures 43 and 44 in which we will find uh on um
02:04:14 on um the next page
02:04:18 sorry page 99 apollo the previous page apologies there it is um 43 and 44 which is the calculated smokiness fixing gas exposure for flat 175 occupants in 43 and in 44 the calculated fed a
02:04:30 and in 44 the calculated fed a percentage carboxy hemoglobin history for those occupants and we may need to have those expanded a little bit so that they're clear now looking at those figures i have a question now
02:04:43 i have a question now is it possible that the balcardi stroke hamdan family could have successfully evacuated flat 175 if they'd left earlier than 217
02:04:56 they'd left earlier than 217 which is your turn
02:05:04 so they left at 219. we we established earlier didn't we
02:05:11 yes
02:05:14 and you're asking me
02:05:18 sorry sorry it's hard to keep up with all this so so yes why do you pick 217 uh because that is the last time they called 217
02:05:30 called 217 and we get that from right uh paragraph five okay i showed you [Music]
02:05:36 [Music] this this
02:05:38 this this cardi family history is really quite a complex one as i'm sure you appreciate we've covered a lot of ground in the last five minutes
02:05:49 so i might be helpful if i just explain how i approach this so basically what i'm saying is
02:05:56 saying is they evacuated uh
02:06:00 uh what time did we say the fire got there uh the exterior fire reached the bedroom of flat 175 at between 210 and 223. that's coming to the first bedroom
02:06:12 that's coming to the first bedroom and we already established that in in these flats as with the nadar family even though there may have been a fire outside the bedroom it was still possible to shelter successfully in other parts of flat for some
02:06:23 other parts of flat for some extended period if you remember the nada
02:06:27 the nada uh um son and uh his mother were in that flat one of 205 for about 20 minutes or more than 20 minutes while
02:06:38 20 minutes or more than 20 minutes while there was a fire attacking the bedroom with the bedroom door closed before they left and they then made a very successful descent all the way from the 23rd floor
02:06:49 23rd floor so uh and they left i believe at 2 23 wasn't it something like that so in theory it would be it should have been possible for someone to leave
02:07:01 been possible for someone to leave one of these flats around this time and having not accumulated a significant dose while in the flat and then successfully walked down and it hasn't happened for the two cases so why
02:07:13 hasn't happened for the two cases so why hasn't it happened and i obviously put quite a lot of effort into trying to understand why their experience was different i'm sorry i'm giving a straight up
02:07:24 i'm sorry i'm giving a straight up simple answer to your question but i think it's a complicated case so as we've established from what you were reading earlier um
02:07:31 um there are some differences between what was going on in flat 175 compared to for example flat 205 or some of the other ones in the flat 5 column
02:07:43 ones in the flat 5 column because they reported quite a bit of smoke outside as you said and they closed the all the exterior windows and whereas in other flats because you were on a corner location here people
02:07:55 were on a corner location here people were opening windows on the side away from the fire in order to keep the flats clear they felt unable to do that which is why i particularly made a note of that point and they also had
02:08:07 and they also had report various degrees of smoke penetration so point one i think they had a some
02:08:15 some somewhat higher pre-exposure while in their flat before they left it at 219. so instead of notching up maybe nine percent carboxyhemoglobin before they
02:08:27 percent carboxyhemoglobin before they set off
02:08:29 set off as you can see in my uh estimated uh analysis here i'm predicting that they were closer to 20 percent maybe at the time they left their flat
02:08:41 at the time they left their flat then you've got the point that they've got this complex just just pulls them so yeah yeah is that figure 43 in the figure 44 yes 44 and the you can see the pink curve which is the carboxyl
02:08:52 pink curve which is the carboxyl hemoglobin you can see the point where they
02:08:55 they where where it's a gentle curve going up and then it suddenly becomes very steep where the first vertical uh line is of 02 18 30.
02:09:04 02 18 30. so up to that point i feel that they're
02:09:09 they're making that what's exceptional about this flat but one is this pre-history there's something going on there so that's one strike against them then
02:09:19 then from the description of the activities and the conditions in the lobby by the firefighters and i illuminated some of this in my report i feel they uh there was some bit of com
02:09:30 i feel they uh there was some bit of com well the firefighters came to the front door
02:09:33 door and they opened the front the door to the flat and let them in at that time they were all quite uh in a good condition
02:09:40 condition and they were all preparing themselves to go they were ready to evacuate they had one of them had a baby attached to a back or something or holding a baby so they they weren't they weren't in any state incapacitated
02:09:52 state incapacitated at the time they left the flat they were in a reasonably good condition however they were on the wa they had accumulated a sub incapacitating dose so there's a strike against them if you like before
02:10:03 strike against them if you like before they've entered the lobby while the front door is open and the firefighters do emphasize the conditions in the lobby were really bad from a smoke perspective then obviously smokes coming in from the
02:10:15 then obviously smokes coming in from the lobby so they're gonna while they're lining up and sorting themselves out ready to with to go out with the firefighters they're accumulating um some of this more intense smoke in the hallway of their
02:10:26 the hallway of their flat then there seems to be a bit of confusion in the lobby and one of the things that's um this is helpful i mean i think we need to go through this detail
02:10:36 detail the um
02:10:39 the um one clear point is that the firefighters went down with with the omar isn't it so he
02:10:47 so he he he walked down initially across the lobby well he was sort of pulled out of the lobby by one of the firefighters sort of found him in the lobby and he was saying oh i've got to get my family worth of that effect so
02:10:59 get my family worth of that effect so there was i have this mental picture of him being in the lobby for some period of time
02:11:04 of time you know concerned about his family behind him and trying to interact with the firefighters coming into a system quite a complex and difficult situation and in the complex route as we mentioned
02:11:15 and in the complex route as we mentioned earlier from a flat five location to the front door is all rather complicated so i i can see some something going on at that point then
02:11:25 then he goes into the stair and i think it's he said he walked down between two firefighters and was told to put his hand onto the pack of the one in front walk down with
02:11:37 pack of the one in front walk down with them so we know he was in a good condition reasonably good condition at that point he was walking about the key point is he he only walks a short distance down about one half a
02:11:50 a short distance down about one half a flight or something before he collapses and all this is described in some detail by the firefighters so we know pretty well exactly when this adult
02:12:01 adult male collapsed in the stair from the asphyxians that he inhaled and he certainly hadn't had time to accumulate any of that to any significant degree while in the stair
02:12:13 significant degree while in the stair urgo he must have got it before he got to the stair and the two are two places for him to get it are in the flat before leaving the flat and i think that is one element
02:12:24 think that is one element and the other is while in the lobby and i think and you can see in my in my analysis here i've drawn
02:12:30 drawn that little pink curve goes almost vertical at that point where they're in the lobby because they're exposed to very very high concentrations i believe of carbon monoxide
02:12:41 of carbon monoxide so if you spend two or three minutes in that lobby inhaling that smoke you're really loading uh up a big dose so
02:12:51 so i
02:12:52 i so so then the question you're really asking me is what is the earliest what is the latest time in this particular circumstance that this family might have been able to do
02:13:03 this family might have been able to do it yes so if we first of all assume that they were able to make an efficient and rapid transfer of the lobby and not get a dose in the lobby they would have had to if we follow my
02:13:14 they would have had to if we follow my curve back we want to get to the point where they're at roundabout nine say ten percent
02:13:19 percent so that's well it's hard to calculate but it's we're looking somewhere nearer to two o'clock so so
02:13:27 so so 217 would be too late in in this particular flat because of the greater degree of previous contamination in this flat i think that's my answer to your question
02:13:38 your question does that uh cover it
02:13:40 cover it 217 would be too late because because this flat was more contaminated than the other equivalent flats yes but of that type so 217 would be too late but you would
02:13:52 so 217 would be too late but you would say to answer the question somewhere near 2am yes yes thank you but that that would still mean if they got delayed and stayed in that
02:14:03 if they got delayed and stayed in that lobby
02:14:04 lobby still would have would have not made it out you know that that that's predicated on them making a rapid and efficient transfer of the lobby which i don't think they did so even if they left earlier if they'd
02:14:16 so even if they left earlier if they'd still got caught in the lobby they could have been in trouble i mean it emphasizes the possibilities of an escape but also the extreme hazards that are occurring
02:14:27 the extreme hazards that are occurring in in these locations around this time on many floors just to pick up one point though about deflat about distances from front doors and you referred to some difficulty yeah
02:14:38 and you referred to some difficulty yeah look at the floor plan which might help you professor there are some floor plans with the actual numbers of meters on but i haven't got one in front of me well let's look at met three zeros one two five nine three which we looked at
02:14:49 five nine three which we looked at before
02:14:50 before page seven yeah and we looked at tony yeah tony distance flat 194 which was a flat four
02:14:57 flat four and we looked at a a flat three um
02:15:00 um we're now looking at one seven five a five
02:15:04 five and i think you can identify the front door there yes um
02:15:09 um is that more or less does that present more or less difficulty yes to cross the lobby than tony distance well it's very similar as you can see because the four and the five are quite
02:15:20 because the four and the five are quite close together i mean the absolute distance isn't enormous but it's it's it's a long way to go under these circumstances and it's the complexity of the route and the danger of getting confused and lost on the way yeah now
02:15:32 confused and lost on the way yeah now moving on then can we get back to your section 6 report please dapr606 page 99 paragraph 543 you say
02:15:44 you say there that
02:15:47 in the third line since um
02:15:51 since um uh farah hamdan and malek belcardi also collapsed just but just beyond the flat this confirms that the three adults of both children had acquired doses of inhaled asphyxian gases mainly carbon
02:16:02 inhaled asphyxian gases mainly carbon monoxide capable of causing collapse by these times 30 to 40 percent uh and uh
02:16:09 uh and uh and then you um go on to say uh
02:16:14 uh a third two thirds of the way down the paragraph uh after they are all likely to have become unconscious at 132 oh
02:16:23 oh that must be a mistake that's a mistake i found that yesterday it should be 232 thank you that corrects that there would have been a slow gradual uptake of carbon monoxide on the stair with a slowly increasing carbon monoxide
02:16:35 slowly increasing carbon monoxide uh
02:16:36 uh carboxy hemoglobin until they had exceeded the lethal threshold about 50 carboxy hemoglobin around 249 based on an estimated average 1800 ppm ceo in the stair yes um now um
02:16:50 stair yes um now um is that correct yes that is correct and is that a window of time can you give an estimated window oh that's a point in time so
02:16:58 time so this is for this is for the time to pass the lethal threshold so
02:17:05 so i i would i would probably put that time fairly tightly around there you know obviously there's some uncertainty a few minutes either way but to get to 50 percent uh
02:17:18 well i don't know you might add or subtract three or four minutes either way either side of that but that's a good figure to work to i think 249. that's very helpful can we then go
02:17:30 can we then go to table 23 please on page 85
02:17:34 which shows this family in flat 175 and
02:17:40 and it says
02:17:41 it says uh there um that all that all the times are to stare at about 2 20. yes that is just to be clear that that's the time the end of the stairs not the time of death yes
02:17:52 death yes and you would add the time of death i think yes as at 249. something like that at the time at which time at time of which they exceeded the legal threshold yes
02:18:02 yes right
02:18:03 right thank you
02:18:05 thank you now that's then turned to another flat on the same floor flat 173 this is khadija say and mary mendy can we please turn first for them to
02:18:18 can we please turn first for them to page 101.
02:18:24 uh flat 173 and you say under the under the overview of occupants that mary mendy and her daughter khadija say were both residents of flat 173 and
02:18:35 say were both residents of flat 173 and present present on the 14th of june 2017 they remained in their flat until sometime after 3 30 when they tried to evacuate and then you you cover the conditions uh at paragraph 551 and following
02:18:49 uh at paragraph 551 and following and i'll just pick the again as i have with the others pick through these uh just to pick up the time marks um we start with khadijah says posting on facebook at 149 reporting of fire in
02:19:01 on facebook at 149 reporting of fire in the block
02:19:02 the block you see you say that yes and if we go to page 102 please
02:19:10 paragraph 552 there's an absence of facebook and then at 2 27 khadija say made a 999 call when she reported a lot of smoke coming in when
02:19:22 reported a lot of smoke coming in when she opened the door that's five five three
02:19:25 three and then at five five six if we go to that you say and you record the fact that um that katie jose and mary mendy appear to make two unsuccessful attempts to escape
02:19:39 make two unsuccessful attempts to escape yes you see that uh and the message is at 3 14 and then there's another message and another facebook message at 3 27 so 3 14 and 3 27 are the recorded mark times
02:19:52 and 3 27 are the recorded mark times for the message recording the attempts and then at 5 5 8
02:20:00 5 you you say at 3 30 she texted the words it's in my rooms this may be a reference to smoke all to the exterior fire which spread outside the flat 173 bedrooms by approximately
02:20:11 the flat 173 bedrooms by approximately 320 to 329. then you say by 337 to 353 the south faces fire is outside the living room as the west face fire begins
02:20:22 the west face fire begins begins to spread outside the kitchen in the west living room you see that sorry i can repeat that i'm i'm i'm taking you through five five seven five five seven yes
02:20:34 seven five five seven yes yes does this look i i just yes yes i'll just give you my yeah i've read into the record there that's right so by 03 37 to 53 the fire is outside the
02:20:45 03 37 to 53 the fire is outside the living room that's that's the team okay that you've given yourself there and then at 5 5 8 you say this was the last communication from flat 173 so the occupants must have evacuated
02:20:57 so the occupants must have evacuated the flat sometime after 3 30 and that's a reference to the text in 557
02:21:04 557 from khadijah say where she texts towards it's in my rooms you see this that's the last communication from her just after 3 30 and then there's a
02:21:15 just after 3 30 and then there's a there's a 999 call from charlie craggs at 333
02:21:20 at 333 who said that could you just say and mary and mendy was still in the flat the smoke was thick and that they could not breathe and felt as if they were going to faint that's a 999 call transcript that we have which you've identified
02:21:32 that we have which you've identified there
02:21:33 there now if we go to page 103 and look at paragraph 565 we know from that that mary mendy was recovered from the 13th yes law lobby
02:21:46 you see that yes but there were no toxicology tests possible either the khadijah say or mary mendy
02:21:57 now if we go to page 103 paragraph 560 there's a long paragraph there if you go up please scroll up please if you just read that to yourself remind
02:22:08 if you just read that to yourself remind yourself of what you've said
02:22:22 yes okay um are you able to estimate the latest
02:22:26 latest uh
02:22:27 uh latest time in a window of time perhaps in which khadija say mary mendy would have been able safely to evacuate okay let's try and do that so
02:22:40 the sort of point is i'm looking for is did they leave the flat before or after the arrival of the exterior fire as we've been discussing and if so how much
02:22:51 we've been discussing and if so how much after and i'm i'm sort of homing in on something like around 03 36 that they actually
02:23:02 that they actually entered the stair per heart perhaps or maybe a minute or two before that and at roundabout and we've just said that from around about 0.29 i think we said the uh
02:23:13 said the uh exterior fire was without that with the exterior had been out there outside their flat for up to about 16 minutes around about this time so
02:23:23 time so so they had remained in their flat for a period after the arrival of the xdfi but not for a long period but it's likely they had some exposure
02:23:34 likely they had some exposure from that pre-exposure from that also you read out reference to the fact that they
02:23:41 they shut the windows and so they weren't ventilating the flat as other people had been which would enhance the accumulation of smoke within the flat before they left it so we
02:23:53 the flat before they left it so we we have to take into account the consideration conditions in their specific flat so
02:23:59 so um
02:24:00 um assuming they actually left at about 0.30
02:24:06 3 36
02:24:09 36 they succeeded in walking
02:24:12 walking down for about five four or five minutes in the stair for quite a number of floors so they were well on their way down when they collapsed
02:24:23 collapsed so my interpretation of what's going on here is that a bit like the previous case we've been discussing there was some preex some degree of pre-exposure perhaps not enormous but some degree of
02:24:35 perhaps not enormous but some degree of pre-exposure in the flats before they left then we have this issue about how efficiently they cross the lobby but we're coming from a
02:24:46 cross the lobby but we're coming from a flat
02:24:47 flat three so they shouldn't have had too much difficulty crossing the lobby but we also had reference the fact they'd made previous attempts when they'd been out into the lobby area and had some which
02:24:58 had some which again adds to their accumulated pre leaving the flat dose
02:25:04 and then um
02:25:08 at that point they then attempt to go with some degree of success to negotiate and walk down the stair so
02:25:17 so obviously by leaving at round about 0 3 36
02:25:24 3 36 was too late if they'd if they'd left maybe 20 minutes or so earlier they might have had some
02:25:34 some success in in walking down so
02:25:38 so before the fire the fire reached the exterior of the flower yes which it had done by possibly by 330 but certainly by 337. yes but i think i'll say that that
02:25:50 yes but i think i'll say that that special case for them is again that there's they're flat it was more contaminated than other flats three
02:25:58 three uh that some of the other flats three that we've discussed which which which means that in order to survive they've got to leave that much earlier in other words before that smoke accumulates in their flat yeah now
02:26:10 smoke accumulates in their flat yeah now if we go please to page uh 103 561-564 just read those to yourself
02:26:19 six 561-564 yes yeah so yes so they weren't suffering from anything very much they were still lucid but the their background levels in their blood were increasing around about then yeah yeah
02:26:30 yeah yeah and you say in 563 having left that they were able to descend several floors in the stair until mary mendy collapsed and died on the stair at the 13th floor level while her daughter could just say
02:26:41 level while her daughter could just say was able to continue down to the ninth floor before she also collapsed and died in the stair yes there was dense smoke in the 20th floor lobby and signifi and a significant and hazardous concentration of smoke and is fixing
02:26:53 concentration of smoke and is fixing gases in the stair at this time which added to the already accumulated dose in khadija say and her mother as they descended the official the additional physical effort required to descend the stair compared to sitting in their flat would also have contributed to their
02:27:05 would also have contributed to their collapse in the stair around this time yes now two questions flow from that first are you able to give an estimated window of time of death for each of khadija say and mary mendy
02:27:17 and mary mendy so
02:27:19 so first thing we have to try and estimate is the time of collapse and
02:27:26 and if we say they entered the stair for example 03 36
02:27:32 36 then
02:27:33 then the time required to descend those number of flaws through smoke is going to be four or five minutes so if we add five four or five minutes onto that that takes us to the time of
02:27:45 that that takes us to the time of collapse
02:27:46 collapse in the stair estimated at somewhere about 0 3 40 stroke 41 right
02:27:54 right so the 03 40 41 they are
02:28:05 well yes so i'm starting with a time of 0.336 to enter this for yes i'm looking at five six two here i've got another time mentioned in there o340 we don't know precisely when they entered the
02:28:16 know precisely when they entered the stair but let's let's assume for a moment it's o336 then they're gonna the time of collapse is about o340 right so o340 they've collapsed in the stair they both have something of around
02:28:28 stair they both have something of around about 30 percent carboxyhemoglobin in their blood we don't have uh their cohbs at death for some reason
02:28:39 uh their cohbs at death for some reason so we don't know what the level was at the time of their death
02:28:45 but it's likely to have been somewhere between 50 and 90 percent caboxing hemoglobin so we have to allow time for that to accumulate after
02:28:57 allow time for that to accumulate after 3
02:28:58 3 40.
02:28:59 40. so i think we should add something like 20 to 30 minutes as a so the earliest time of death might be something like 0 3
02:29:11 something like 0 3 of 400 right and
02:29:15 and um
02:29:16 um if they continue to breathe for a longer period we
02:29:20 period we we might put something like oh 4 10 04 20 something like that as the time they actually stop breathing because um obviously it's very approximate but that's the sort of
02:29:32 approximate but that's the sort of situation i think we're looking at and given
02:29:35 given the fact that khadijah say got lower in the building she she went on for about another minute after the her mother
02:29:44 mother before collapse yes are you able to say who died first whether khadija or men no and and from memory i mean another variable in uptake is
02:29:56 i mean another variable in uptake is body size
02:29:58 body size and from memory one of the these persons was uh had a high body weight which would take longer to accumulate a dose and so that's another factor that
02:30:10 dose and so that's another factor that may have affected this case to some extent right i think that was khadijah yeah right
02:30:17 right now
02:30:18 now um
02:30:19 um yes thank you then let's turn to another flat another floor uh another occupant vincent shagina flat 144
02:30:29 144 on floor 17. we've set
02:30:32 we've set well you've set out the relevant facts in section six from page one two two if we go to one two two please
02:30:41 plot one four four
02:30:47 uh and you say they're at paragraph 665 page one two two vincent chagina was alone in flat 144 on 14th of june 2017. his remains were recovered from the
02:30:59 his remains were recovered from the living room area of flat 144 near the window
02:31:02 window and then you say under conditions although the movements of vincent shigena are unknown it is likely that he was awake and conscious at some time during the fire since his remains were recovered from
02:31:13 since his remains were recovered from the living room rather than the bedroom and the living room would have been the last area affected by the exterior fire after the bedroom and kitchen the flat was burnt out with essentially all combustible material consumed
02:31:25 combustible material consumed and then if you go down to 667 you've got the analysis of the external fire spread over the west face of the tower uh and for flat 144 you have the timing first bullet point of the foot there is
02:31:36 first bullet point of the foot there is 332 exterior fire had spread across column b1 but not yet reached flat 144. if we turn the page to one page one two three
02:31:45 three three thirty nine it had started to spread outside flat one four four bedroom and by three forty four established outside the bedroom by 358 the fire had spread outside the kitchen and were starting to affect the
02:31:57 kitchen and were starting to affect the living room and then fire continued to spread
02:32:00 spread across outside the living room until approximately 4 30. so that's the time chronology for the external fire spread if we go down to 669 just below that
02:32:11 if we go down to 669 just below that under the heading evidence from toxicology and pathology reports you identify that the body of vincent regina consisted of child remains
02:32:20 remains and soot etc and then you say in the last sentence that carboxy hemoglobin was detected at a level of approximately 39
02:32:29 39 although this concentration should be regarded as an estimate due to the the condition of the blood sample yes can you please go to page one two four then next and read uh your
02:32:41 four then next and read uh your conclusions at paragraphs six seven two to six seven four just to remind yourself of what you say there
02:33:02 yeah so the key timing on this set is o358 when the fire spread past his living room yes
02:33:10 yes so um are you able to provide an estimated time of death for vincent to gina
02:33:16 gina right
02:33:26 right so for vince georgina
02:33:31 we have not a particularly high blood
02:33:37 blood carboxyhemoglobin although as as indicated there's a issue with the sample um
02:33:44 um so we have some uncertainty about what the true level of his blood was it's still a very a high dose and an incapacitating dose but we also have some pathology indicating
02:33:56 some pathology indicating uh some possible heat exposure yes 3674. one you know i don't i would go back and look at it again if you need to but he's
02:34:06 he's he is one of the very few if perhaps the only
02:34:09 only person that i think i've said that some significant heat exposure may have occurred and this would have been when the fire spread or after the fire spread outside his
02:34:21 spread outside his living room so we're talking about collapse
02:34:27 collapse assuming he collapsed due to these fixing gases which are high enough certainly to do that we would expect collapse to have occurred sometime around about 0-400 to
02:34:39 0-400 to 0-405-ish something like that that's collapse at which time he would have had about 40 percent where you've expected him to have had about in reality about 40 carboxyl
02:34:51 about in reality about 40 carboxyl hemoglobin in his blood if it was purely due to the smoke um
02:34:59 um and then one would
02:35:04 well it's possible to die at these lower levels you know it depends on your individual susceptibility and ruling out even if we rule out the possible
02:35:15 even if we rule out the possible contribution of heat so
02:35:17 so he he may have died as early as uh about
02:35:23 uh about what did i just say oh four oh four hundred to o4 yes he could have died as early as that or
02:35:33 or if he died if that co2 is wrong if you like and he lit and he went on to go above fifty percent carboxyl hemoglobin in reality when we want to add a few minutes to that but i think this
02:35:45 minutes to that but i think this particular case we have some issues about the heat exposure
02:35:51 exposure what effect would the inhalation of hot gases have had before death
02:35:56 death yes
02:36:00 well i have gone into this topic obviously quite a lot in my work and
02:36:09 and this is where we have quite complicated situations going on unlimited information as you might imagine
02:36:17 imagine and
02:36:18 and you might find this a bit distressing but the um the key studies that were done on this kind of situation many many years ago i think in the 1940s
02:36:29 many many years ago i think in the 1940s by a gentleman called dr moritz
02:36:33 dr moritz who exposed pigs to any size pigs eyes to add to extreme heat conditions to
02:36:43 to measure the time to death for various heat exposures now
02:36:48 now what
02:36:49 what he discovered was that death tended to occur
02:36:53 occur when the temperature of the blood entering the heart increased by a certain number of degrees it was a few degrees centigrade i forget the exact figure
02:37:04 the exact figure and after the time of severe burns that could take some minutes so
02:37:16 if if the temperatures if they exposed i if the exposure to heat was extreme we'll be talking about some minutes to death due to heart heart i see a heart attack
02:37:27 attack is the main actual cause of death from heat exposure instant death you know rapid death at the scene from heat exposure and severe burns but
02:37:38 exposure and severe burns but in order to acquire a dose sufficient to do that
02:37:41 do that uh and i i have got some charts i could show you on this that i did bring with me you have on your we have on our document list um there's a considerable difference between the time
02:37:53 between the time to pain from heat exposure and the
02:37:57 and the a bit like the gases the effect of heat is a dose related phenomenon and so the dose if you like in terms of temperature and time
02:38:08 temperature and time to
02:38:09 to get first second and third degree full thickness burns goes up by a batter of three by each burn severity so you have to be exposed to
02:38:20 so you have to be exposed to quite severe heat conditions for some time to get these severe burns which is why in most cases because the the heat
02:38:31 the heat and the gases are if you like racing together
02:38:34 together and in most cases the gases get to you first
02:38:40 it's we're not seeing we're not seeing particularly in these grenfell cases that people are being overcome by heat before they become comatose comatose
02:38:51 before they become comatose comatose due to gases so it's likely that he was comatose
02:38:56 comatose before
02:38:58 before if if he was exposed to a lot of heat before he was exposed a lot of heat um
02:39:04 um i'm struggling a bit as you can see with this because it's quite difficult to say can we just go back to the pathology again to remind me how badly these burns were
02:39:13 were yes uh let's just do that i can show you that
02:39:17 that um you can see six six nine on page one two three i'll show you that i think
02:39:29 yeah so unfortunately was only child remains and limited tissues remained but the pathologist was able to identify soot so he had again a sign that he
02:39:40 soot so he had again a sign that he spent considerable time inhaling smoke before he died so he wasn't rapidly caught he wasn't killed by rapid exposure to flames we're certain of that right
02:39:51 certain of that right relation of hot smoke and there was pulmonary edema and hemorrhage
02:39:58 so i think there is some indication that he was inhaling some hot gases at the time of death but there's at the same time
02:40:10 but there's at the same time he has a considerable uptake dose of carboxyhemoglobin so
02:40:18 so it's it's possible that he died purely from the gases and this is a sort of secondary
02:40:23 secondary finding
02:40:24 finding or it's possible that he became comatose due to the gases and then
02:40:31 and then the heat started to become significant in addition to the gas or as at the same time as the gases at the time of his death i think we're talking about
02:40:42 i think we're talking about uh
02:40:43 uh relatively few minutes here so we were saying incapacitation 0405 weren't we yes so we might say death is likely occurred within a
02:40:55 say death is likely occurred within a further 10 minutes or so
02:40:59 or so is that
02:41:01 is that helpful enough yes it's quite very difficult with this yes i understand and if we look at paragraph 670 you can al you also
02:41:08 you also identify the fact that uh it's possible this is two-thirds of the way through the paragraph that his mild coronary artery atheroma may also somewhat have increased his
02:41:20 somewhat have increased his susceptibility i was looking for that and i couldn't see where i'd written it yes so he's not in addition to that he had heart disease which is as we've already discussed a risk factor for collapse and death at
02:41:32 a risk factor for collapse and death at a lower carboxyl hemoglobin concentrations i i thought i'd read that somewhere and i thank you for bringing that to my attention again so this is another
02:41:40 another thing to put into them into the mix and again it it narrows that time down to not long after the arrival after the of the exterior fire at o358 so we're talking about a fairly
02:41:51 at o358 so we're talking about a fairly short window i feel here thank you no that's then thank you no ju you referred to some graphs heat graphs i feel like just to show you them just in case there's something you you can
02:42:03 in case there's something you you can tell us
02:42:04 tell us of extra value from them so that no stone is left unturned so to speak dapr603
02:42:12 at page 28.
02:42:15 yes i had included these in my 2018 flight presentation yes so they come from i think yeah this is that's right and i'm looking at patients
02:42:26 and i'm looking at patients sorry
02:42:27 sorry right so is that what you were asking yes thank you yes so the right hand one these are these are experimental results from human exposures so the right hand one is
02:42:39 so the right hand one is showing
02:42:40 showing time
02:42:41 time of uh
02:42:43 of uh tolerance to heat before a subject experiences pain or incapacitation from heat now
02:42:51 now the the suffering from pain to the skin from heat
02:42:55 from heat uh
02:42:57 uh occurs at temperatures of air temperatures sorry let me just give you a bit background the right hand set of data are for human volunteers who went into a room
02:43:08 room under hot heated air conditions i think they were unclothed so these are unclothed people in a sort of saunery situation except there's no steam it's just hot air
02:43:19 there's no steam it's just hot air they're in hot air so they're obtaining heat by contact with hot air they're standing in bathing if you like in hot air
02:43:27 air and
02:43:28 and once the temperature of that air gets above 121 centigrade then after a period of time sufficient dose if you like of heat is taken up by the skin and the body that you start to
02:43:41 the skin and the body that you start to feel pain and you can see that at 121 degrees that happens after about seven or eight minutes of exposure that's that's the onset of pain if the
02:43:53 that's that's the onset of pain if the temperature is below 121 you don't experience any pain but eventually your body core temperature increases and you suffer from hyperthermia
02:44:05 hyperthermia and you may recall cases where
02:44:09 marines exercising on dartmoor with heavy clothing have died from hypothermia very dangerous condition that can occur just from being exposed too long to too much heat
02:44:20 too long to too much heat so in case of fires we're mostly concerned with the
02:44:25 the higher temperatures where you might be exposed to rate to heat hot gases or smoke and and suffer from pain
02:44:35 pain now
02:44:36 now the
02:44:37 the so this is this curve is a useful curve for for predicting tolerance design
02:44:44 design in a design context for how how high temperature dare we let let in a particular compartment the temperature get and still ex people expect people to escape without suffering
02:44:55 escape without suffering pain or just difficulty can i just interrupt you yes sorry in a nutshell how does that help us understand the cause well the left hand one shows uh the effect of
02:45:06 left hand one shows uh the effect of radiant heat uh and this is where people will stand in front of a radiant heat panel so now the air isn't hot but the heat from the flames is radiating towards them
02:45:17 flames is radiating towards them and this this is the axis here is in terms of kilowatts per meter squared instant heat flux and what i draw your attention to is the three curves and the the left hand curve is the green
02:45:30 and the the left hand curve is the green one is time to pain the blue is timed to second degree burns and the red is to time to third degree full thickness burns and you can see that for example at um
02:45:43 that for example at um 10
02:45:44 10 kilowatts per meter squared the time difference between the time to pain and that before you start to experience actual burns is quite large so you so it really this emphasizes the
02:45:55 so you so it really this emphasizes the fact that if you're exposed to hot conditions you have to be exposed for some considerable time before there's sufficient uptake of heat by the body to cause the really serious problem that's
02:46:06 cause the really serious problem that's about us
02:46:07 about us that's really the only point i'm making here
02:46:10 here and i would use this in my fed calculations normally yeah let's then turn to a different flat different floor different occupant joseph daniels flat 135 floor 16. can we
02:46:23 joseph daniels flat 135 floor 16. can we please go to back to your report please at section six page one two six now joseph daniels lived at flat one three five on floor 16 with his son sam
02:46:34 three five on floor 16 with his son sam daniels
02:46:36 daniels oh yes and you've recorded your analysis and your conclusions about joseph daniels from page one two six onwards
02:46:42 onwards uh here as you can see paragraph six seven eight uh uh and uh you've um
02:46:52 you've um got the details there at 679 about the conditions in flat 135 can we please go to page one two six paragraph six eight three two six eight six so foot of
02:47:03 so foot of page one two six six eight three and just remind yourself of what you say there
02:47:10 and then turn the parentheses to one two seven
02:47:13 seven and read down to six eight six
02:47:19 yes i'll recall this yes carry on thank you and then if we go to page one two eight and look at paragraph six nine one
02:47:29 under conclusions uh you uh you say that you look at your conclusions and you say days of joseph daniel remained daniel's remained in flat 135 when his son samuel daniels and left the flat
02:47:41 son samuel daniels and left the flat entered and crossed dense smoke in the 16th lobby and then entered the stair in an attempt to find assistance to evacuate his father samuel daniel stated that he left the flat entrance door open
02:47:52 that he left the flat entrance door open when he left the flat so that his father could follow him if the door remained open for several minutes flat 135 would have filled rapidly with very toxic smoke from the lobby when firefighters checked they found the
02:48:04 when firefighters checked they found the door shut so it's likely that joseph daniels shut the door before sheltering in the living room and then at 692 you go on to say that once the flat entrance door was
02:48:16 that once the flat entrance door was closed there may have been some continued slow smoke penetration from the lobby but exposure to toxic smoke and uptake of this fixing gases should have been limited as in other flats until the exterior fire spread outside bedrooms from
02:48:27 bedrooms from 0.234
02:48:29 0.234 when increased penetration of smoke into the flat would have resulted in more rapid uptake of asphyxiates and then you go on exposure would then increase very rapidly once the exterior fire spread outside the living room
02:48:41 fire spread outside the living room resulting in incapacitation due to inhalation of carbon monoxide and some hydrogen cyanide leading to death from asphyxiation following further exposure evidence of inhalation of asphyxian gases is provided by the presence of
02:48:53 gases is provided by the presence of carboxyhemoglobin in his tissues and soot in his airways these findings were considered considered consistent with death due to the effects of fire most likely from the asphyxiant effects of ventilation of
02:49:04 asphyxiant effects of ventilation of fumes that's the pathologist's conclusion yes yes now my question for you uh is uh whether um you can um provide a
02:49:17 uh whether um you can um provide a window for the time of death based on two hypotheses first of all the front door being left open and second it being shut yes so so we know that uh joseph left at 0 2 0
02:49:29 so we know that uh joseph left at 0 2 0 1 25 don't we right over 125. so
02:49:36 so and the conditions were already quite bad in the lobby at that time so if that door remained open and of course we remember that his father had some quite serious health
02:49:47 basically behavioral and mental health problems
02:49:51 problems if he left the door open and just just withdrew into the flat leaving the door open and it didn't close then is in danger the flat would be flooded within a few minutes with this dense smoke from the lobby
02:50:03 dense smoke from the lobby and then over another and then without doing the calculations over another five ten minutes or so he could have been exposed to incapacitating conditions and then another for ten
02:50:15 conditions and then another for ten minutes or so to have died in the flat if the door had been left open throughout if the door was closed then the conditions in flat 135 should be
02:50:28 the conditions in flat 135 should be somewhat similar to those in other flats five
02:50:31 five and
02:50:33 the key point we're looking for is when did the exterior fire spread past that flat on outside it and the figure we've got at the moment in front of us is
02:50:44 in front of us is 0.234
02:50:46 0.234 when it's spread outside the bedrooms
02:50:52 about 20 minutes or so after that it would be coming past the living room so that takes us to 0 to 45ish
02:51:03 45ish for the for the far outside the living room unless we've got you know without looking it up i think that's probably about right six eight six on page one two seven is that am i you are because
02:51:14 am i you are because yeah so about 245 is when conditions were starting to become extreme and within uh 10 minutes so so of that he's like to
02:51:25 uh 10 minutes so so of that he's like to become unconscious so let's say this is very rapid thinking going on here so 002 55 ish
02:51:35 ish uh incapacitation and then 03 15 we're getting into lethal territory
02:51:46 15 we're getting into lethal territory and is that on the hypothesis hypothesis that the front door was shut that's on the hypothesis it was shut yes and if it was open so it's open so we've got oh 125 the door was open started to be open
02:51:58 125 the door was open started to be open and the flat started to fill with smoke
02:52:03 say oh 135
02:52:07 135 incapacitation i'm doing this on the fly here o1
02:52:14 o1 let's say let's put a window up to about oh 200-ish we're looking for death round about 0.200.0215 something like that why were you unable to provide a time of debt in your report
02:52:28 to provide a time of debt in your report i don't know i don't know that i was particularly because it's such an inexact thing to try to do
02:52:34 try to do and obviously in my report i'm really concentrating on the time of incapacitation and the late and the latest times when you might be rescued
02:52:45 latest times when you might be rescued or survive so as we discussed this the time at which breathing and circulation actually cease
02:52:53 cease is a very indeterminate and you know you you've already passed the point of no return so
02:52:59 return so i didn't feel i
02:53:01 i in this case i hadn't tried to calculate it
02:53:05 it but uh did what i just said was that helpful yes and particularly in the absence of any measured compound label in the blood yes yes
02:53:14 yes yes yes thank you it's very uncertain i think in this case because we don't really know exactly what was going on in that flat
02:53:20 that flat then let's turn to another flora another flat another occupant steve power in flat 122 on floor 15 can we go to page one three two
02:53:33 one three two [Music]
02:53:35 [Music] and uh the overview says records that steve power was in [Music]
02:53:43 [Music] the flat
02:53:44 the flat at one two two
02:53:49 uh and if you go to the overview need a little bit further down uh please a paragraph four thirty five seven thirteen apologies flat one two two
02:54:00 two rebecca ross and stephen power were both in both present in flat one two two on 14th of june rebecca ross was able to evacuate at 253 but her father stephen power remained in the flat
02:54:12 power remained in the flat uh relied on her description of the conditions in flat 122 up until her evacuation and analysis of the spread of fire to analyze the causes of incapacitation and death of stephen power and um just i'm going to pick
02:54:24 power and um just i'm going to pick through the um
02:54:26 um uh
02:54:28 uh if you if you look at page 135 um and pick through paragraphs 724-731 there
02:54:38 there it's quite a lot there just remind yourself of what you've said there you could probably pick it up at paragraph 726 222-248 when the flat's suddenly filled
02:54:49 222-248 when the flat's suddenly filled with smoke yes i remember her description of the conditions yes yes so like these other flats too they were sheltering essentially in the bedrooms
02:55:00 essentially in the bedrooms and then the fire of local fires coming through the kitchen you just remind yourself of what you say there down to paragraph 731 please
02:55:19 right so the key point is that she left the flat she left the flat at around about 02 49 at a time when conditions were deteriorating very rapidly and i remember from the her account that her father was very
02:55:30 her account that her father was very reluctant to leave the flat and i think there were some dogs involved as well he was there was he wanted to
02:55:37 wanted to stay with the family pets or something yes and um
02:55:43 so from 249 he
02:55:47 he was exposed to quite extreme conditions so i've said here i consider stephen powell would have been exposed to concentrations like to cause loss of consciousness within a few minutes after
02:55:58 consciousness within a few minutes after she left at o249
02:56:02 during these these minutes after o 49 249 and especially after 0312 when the exterior fire then spread around the bedroom so we've got it's
02:56:13 around the bedroom so we've got it's coming from two directions um
02:56:17 um then that's when the conditions would have been
02:56:21 have been very bad when where when and he's like to have died so i think we can estimate that he may still have been alive up to 03 12.
02:56:31 12. yes
02:56:33 yes um what what comes on the next page anything if we turn the page please look at page
02:56:41 136 that you're concluding yeah so he did suffer some mild heat really related damage
02:56:48 damage but there was a health condition wasn't there
02:56:52 there didn't i
02:56:53 didn't i know that he had heart issues uh well paragraphs based on his pre-existing health condition sorry yes page 135 paragraph 730
02:57:07 you identify hispanics he had coronary artery disease so that would uh tend to make him collapse at a lower carboxymoglobin than might otherwise have occurred yes so
02:57:18 have occurred yes so i think we're looking we're looking at the window sort of
02:57:23 sort of maybe 03
02:57:25 maybe 03 15 to 0 400 something like that for the time of death yes yes and the incapacitation you say not long after 248 yes
02:57:37 yes now can we go please two d apr
02:57:42 six zeros five
02:57:50 this is back to a part of your report we were looking at yesterday dapr605 section 5 page 131
02:58:01 this is where you deal with stephen power in this part of your report
02:58:06 right and
02:58:09 and you can see that you you say that in paragraph 540 that the flat filled with irritant smoke yeah
02:58:18 yeah yes and rebecca evacuated at 249. um what effects including psychological effects or behavioral effects would the irritant smoke have had on steve power between
02:58:30 smoke have had on steve power between 223 and 249 when rebecca ross left
02:58:37 i think this is a particular behavioural case if you like in that throughout this period rebecca was quite keen for them both to evacuate the flat from an early stage
02:58:49 evacuate the flat from an early stage and he
02:58:50 and he he was rep this is nothing to do with particularly he was very reluctant to do so
02:58:57 so um no my question is not the the social effects
02:59:01 effects or what wider it makes but it's the irritant smoke what effects would that have had okay well it would behaviorally it would further deter any attempts he might have considered in
02:59:12 attempts he might have considered in escaping it would make it make things uh distressing and uncomfortable but what we're really i you know i think we really need to focus on here is the fact that we're
02:59:25 focus on here is the fact that we're going to have high concentrations of the 16 gases which is then going to inhale and collapse and at 541 you've identified underneath uh about halfway through the paragraph that the lining of
02:59:36 through the paragraph that the lining of the trachea showed evidence of mild heat related damage occurring in life in keeping with inhaling hot fumes prior to death yes and and similar to um vincent gina which we looked at yes
02:59:48 vincent gina which we looked at yes in his case they've got quite a lot of similarities because they've both got coronary artery disease as well haven't they well i was going to ask you just to repeat repeat answer the question again in respect of steve power what would what would have
02:59:59 steve power what would what would have been the effects of the inhalation of the hot gases before his death on what you can see from the smoke in the flat right
03:00:10 the smoke in the flat right i i'm not sure that the inhalation of hot gases in these these two cases has necessarily hastened death
03:00:21 hastened death obviously it's going to be painful and distressing it's another another factor that may have contributed but
03:00:29 but the fact that well although it could have i suppose affected the possibility of having a heart attack as we talked about earlier with the pig
03:00:40 we talked about earlier with the pig experiments so so it it it could have caused them to have some kind of fatal circulatory collapse at
03:00:51 at an inhaled carboxyhemoglobin dose because that's also contributing to this effects on the heart because the carbon monoxide is interfering with oxygen supply to the heart muscle and everything
03:01:02 heart muscle and everything so we have a combination of things here coming in
03:01:05 coming in the other thing is of course that i've just said that the conditions in terms of heat and fire penetration in the if he was in the bedroom
03:01:16 uh we're going to deteriorate quite rapidly after 3 15 when the fire came round to that bedroom outside that bedroom
03:01:23 bedroom so
03:01:25 so then that's when we would expect hot gases in the bedroom and we now have some evidence he may have inhaled hot gases which suggests he may still have been alive around about alive around about 3
03:01:38 alive around about alive around about 3 15.
03:01:40 15. um
03:01:42 um so it's an indicator rather than a cause of anything it's it's a signal to us yes am i getting anywhere we're getting there thank you very much yes that is very helpful so i think you
03:01:53 yes that is very helpful so i think you know we're talking about sometime 3 15 to 4 o'clock death and and there are several factors coinciding here we've got we seem to have inhalation of hot gases we've certainly got a significant
03:02:05 certainly got a significant we'll have had we've got no chb oh no there was evidence of chp in his blood but didn't get a value but so he had inhaled significant would have inhaled significant amounts of asphyxian gases he was predisposed to
03:02:18 gases he was predisposed to uh problems because of his pre-existing heart condition so sums it up thank you that sums it up thank you very much professor mr chairman is now a convenient moment for the lunch break yes just a minute thank you very much
03:02:29 yes just a minute thank you very much we'll uh
03:02:30 we'll uh break them uh professor persona so we can all have some lunch we'll come back at two o'clock please and as before please don't discuss your evidence with anyone when they're away understand all right thank you
03:02:45 [Music]
03:02:53 thank you thank you very much for listening two o'clock please thank you