Module 3 closing statements from bereaved, survivors and residents representatives, examining RBKC and TMO's failures in fire safety management, oversight, and treatment of residents.
00:19:59 [Music] good morning everyone welcome to today's hearing
00:20:05 hearing today we're going to hear closing statements in module 3 from some of the core participants and first off i think is ms barwise on behalf of what we now call team one
00:20:18 behalf of what we now call team one of the bereaved survivors and residents so mrs barwise if you're ready would you like to come up to the council's desk thank you very much good morning mr
00:20:29 thank you very much good morning mr chairman assistant mr akbar the evidence in module 3 has laid bare the sheer extent of failures of both the managerial and physical controls at
00:20:40 managerial and physical controls at grenfell which ought to have been kept in check by the statutory fire risk assessments under the heart under the regulatory reform order or rro
00:20:51 reform order or rro a profoundly worrying sense of any sense of responsibility for fire safety pervaded the dealings of rbkc and tmo with each other and in turn tmo's
00:21:03 with each other and in turn tmo's dealings with its fire risk assessor mr stokes whom dr lane considers in some respects reckless in his approach to fras
00:21:12 fras the issues highlighted by grenfell echo beyond it and more broadly across the housing and fire risk assessment sector and demonstrate the need for adequate
00:21:24 and demonstrate the need for adequate focus on safety rbkc's need to scrutinize i'll be casey's failure i should say to scrutinize tmo adequately or at all
00:21:37 scrutinize tmo adequately or at all created a culture in which tmo felt free to mislead our bkc's housing and property scrutiny committee by tmo's emissions and tardiness in reporting on
00:21:48 emissions and tardiness in reporting on fire safety issues such as fire as deficiency notices an exemplar of the sense of lack of responsibility for safety is the failure of both tmo to advise rbkc and rbkc
00:22:02 of both tmo to advise rbkc and rbkc officers to advise internally of the need to make funding available to tmo for safety critical issues such as flat entrance doors doors are essential to compartmentation
00:22:15 doors are essential to compartmentation which is essential to life in a fire further causes of significant concern are the lack of competence of those involved in installing the gas riser in the stairwell in such a way that it was
00:22:27 the stairwell in such a way that it was in mr hancock's opinion non-compliant and totally inadequate furthermore the gas riser should not have been installed in the stairwell at all given that it is a protected shaft as defined
00:22:39 that it is a protected shaft as defined by adb
00:22:41 by adb the gas industry's ignorance of this in 2016 is profoundly troubling and demonstrates the need for better cross-discipline understanding
00:22:52 cross-discipline understanding residents rightly complained about the installation of the gas riser in the stairwell but residents having to raise the alarm is an indicator of systemic failure
00:23:02 failure i should say at once that we've chosen to focus on that which is causative as we must if we are to learn the lessons of grenfell and prevent recurrence
00:23:14 of grenfell and prevent recurrence whilst we recognize consultation with residents and effective complaints procedures are also important we have confidence that the inquiry will address such matters our bkc has also candidly accepted that
00:23:27 our bkc has also candidly accepted that the residents were not listened to as much as they should have been we emphasize however that clearly it cannot and should not be in any way incumbent on residents to identify
00:23:39 incumbent on residents to identify shortcomings in safety particularly fire safety which is complex and highly building specific obviously residents should be provided
00:23:50 obviously residents should be provided with information and be consulted and have a route by which to express legitimate concerns but they must not be put in a position where they are required or even expected
00:24:02 where they are required or even expected to police building safety the scope for consultation on safety related matters is therefore very limited
00:24:11 limited the truly causative events within module three appear to us to begin with rbkc's failure to prioritize fire safety with consequential trickle-down effect to
00:24:23 consequential trickle-down effect to tmo's leadership and executive this overarching failure led to the other causative failures which i will now outline
00:24:34 which i will now outline first rbkc and tmo's decision not to instigate a flat door entrance door inspection program and lack of effective door closers on many doors
00:24:45 door closers on many doors second rbkc and tmo's failures of oversight which resulted in their over dependence on and lack of scrutiny of two of the people with the greatest influence over fire safety namely dennis
00:24:58 influence over fire safety namely dennis ray as health and safety officer and carl stokes as far risk assessor this in turn led to stokes's inaccurate fire risk assessments going unchecked
00:25:09 fire risk assessments going unchecked critical inaccuracies include failure to take into account the effect of combustible cladding and the presence of vulnerable and disabled people and the consequential failure of tmo and rbkc to
00:25:22 consequential failure of tmo and rbkc to prepare personal emergency evacuation plans
00:25:27 plans rbkc admits a failure of oversight in relation to the peeps third tmo's failure to upgrade lifts to firefighter lifts which failure resulted
00:25:38 firefighter lifts which failure resulted in the inability of the lifts to be used as evacuationness and led to the inoperability of the key given that it appears that the wrong key was used on the night which could never have
00:25:49 the night which could never have happened had the lifts been firefighter lifts
00:25:53 lifts in which a distinctive type of key is used
00:25:56 used fourth failure of the smoke control system
00:25:59 system which appears to have facilitated smoke spread both by the nature of its design and installation bearing in mind however that there are to be further expert reports on this in
00:26:11 to be further expert reports on this in module seven i shall say nothing further about that at this stage i shall also say nothing further about the failures of the other passive and active measures which are explained in detail in our
00:26:22 which are explained in detail in our submissions instead i shall focus on the themes which give rise to these failures and the far risk assessments of carl stokes i begin with two overarching points
00:26:35 i begin with two overarching points first many of the failures particularly the decision not to implement a door inspection programme raise the specter of insufficient funding of social housing which appears
00:26:47 funding of social housing which appears to have led to a defeatist strategy of make do and mend even if that meant compromising safety it appears however that the lack of
00:26:58 it appears however that the lack of funding in the case of grenfell and rbkc was more imagined than real according to the submissions of the department for levelling up housing and communities rbkc had available to it
00:27:11 communities rbkc had available to it sufficient funding to carry out works such as the door inspection program in the form of 4.4 million right to buy receipts which rbkc had returned voluntarily instead of using them to
00:27:24 voluntarily instead of using them to carry out necessary works rbkc also had a borrowing headroom of 11.4 million the inquiry will no doubt wish to explore in module 6 the extent to which
00:27:36 explore in module 6 the extent to which government was aware of such behavior and the extent to which it may have been motivated by deregulatory policy a second broad issue to bear in mind
00:27:47 a second broad issue to bear in mind when considering module 3 is the importance of not conflating the statutory regimes which apply to each stage of the building's lifetime from design and construction through to
00:27:58 design and construction through to occupation building regulations and the construction design and management regulations apply to the design and period of construction but once the building is built then the rro is the
00:28:11 building is built then the rro is the single statutory regime governing fire safety
00:28:15 safety the rro needs no other legislation to support it given that it protects all residents and visitors including vulnerable and disabled people it is important to recognize the
00:28:27 it is important to recognize the centrality of the rro to a building's fire safety since dilution of its importance results in stokes's flawed assertion based on his interpretation of
00:28:38 assertion based on his interpretation of dame judith hackett's review that risk assessors are peripheral in the hierarchy of those involved in building safety stokes's submission is flawed as the
00:28:50 stokes's submission is flawed as the fire risk assessment serves as the foundation for all the fire precautions in the premises according to one piece of article 50 guidance and as is clear as a matter of construction of the rro
00:29:03 as a matter of construction of the rro which requires the responsible person to take general firing precautions to ensure the premises are safe these precautions are necessarily defined by the fire risk assessment
00:29:15 defined by the fire risk assessment this leads me to one of the key themes in module three namely the question of competency of fire risk assessors stokes relying on the evidence of one of
00:29:26 stokes relying on the evidence of one of the inquiries experts mr todd argues in effect that there is no discernible competence standard which applies to risk assessors as they were not required to be competent by the rro given the
00:29:39 to be competent by the rro given the legislative intent was to enable the responsible person to carry out their own fras
00:29:46 own fras todd's analysis conflates the requirements of competency with the requirement to instruct a specialist given dr lane's opinion that the fra is the most fundamental of all fire safety
00:29:59 the most fundamental of all fire safety duties it would be a perverse interpretation of the rro that it's required no competency in carrying out the fra
00:30:09 the fra the better view is that expressed by dr lane namely that every fra must be competently carried out albeit not necessarily by a fire safety specialist
00:30:20 necessarily by a fire safety specialist the inquiry may however wish to question the wisdom of lack of requirement for a fire safety specialist to carry out the risk assessment given the safety of
00:30:31 risk assessment given the safety of others depends upon it the risk assessor is the person best place to judge the safety of the building in question which may well have changed since the time of its
00:30:42 changed since the time of its construction or renovation it seems to us that it would be preferable to recommend the amendment of the rro to expressly require that a competent person carry out the fra
00:30:55 competent person carry out the fra and we would go further and require that such a person be a fire risk assessor which should be a registered profession with defined educational requirements given the risk assessor's centrality to
00:31:06 given the risk assessor's centrality to fire safety this suggestion does not exonerate stokes
00:31:12 stokes his characterization by dr lane is reckless in his unfounded assertions as to the nature of the cladding clearly stands and his conduct was demonstrably inexcusable given gratuitous failings
00:31:25 inexcusable given gratuitous failings such as cutting and pasting even from the fra of another building and for a six-year period referring to peeps as going to be produced when he knew they had not been
00:31:37 knew they had not been to rely as he does on the fire brigade's approval of his fras is particularly distasteful given lfb's criticism both of them and of his tendency to make
00:31:48 of them and of his tendency to make unjustified statements anyone in the business of making far risk assessments knows or should know that they are in the business of life and death
00:31:59 and death that particular metier allows no latitude for the sloppy approach adopted by stokes
00:32:05 by stokes whose assessments were actively misleading in relation to peeps and lifts
00:32:10 lifts his serious misstatement in relation to the cladding is also causative in the sense that it closed down a line of inquiry
00:32:18 inquiry raised by the shepherd's court fire which otherwise may well have been pursued to its conclusion it cannot have been lost on stokes that such statements were dangerous
00:32:30 such statements were dangerous the diametrically opposed opinions of dr lane and mr todd as to the standard of care applicable to fire risk assessors and tmos on questions such as peeps and
00:32:42 and tmos on questions such as peeps and whether the risk assessor was required to consider the risk posed by the external wall raise an important question
00:32:49 question you sir as chair will need to consider whether the usual test of the standard of care as enshrined in bowling and freon is apt in this case
00:33:00 bowling and freon is apt in this case namely whether a person's actions are condoned by a reasonable and responsible body of opinion within a professional sector
00:33:08 sector grenfell is arguably that rare case identified in belief though in which the body of opinion is not capable of withstanding logical analysis and may be rejected as not
00:33:20 analysis and may be rejected as not being reasonable or responsible as lord brown wilkinson said in belitho when the evidence shows that a lacunar in professional practice exists by which risks of grave danger are knowingly
00:33:33 risks of grave danger are knowingly taken then however small the risk the court must anxiously examine that lacuna we submit that where as here there is evidence of a body of opinion supporting
00:33:45 evidence of a body of opinion supporting what appear to be dangerous practices you must anxiously examine the lacunae in the practices of the fire risk assessors and tmo in relation to peeps and fras
00:33:58 and fras whilst mindful that the inquiry is not to determine liability the inquiry must nevertheless measure each protagonist's behavior by reference to an applicable standard of care in order to ascertain
00:34:09 standard of care in order to ascertain responsibility and so that the inquiry's recommendations will be meaningful i turn next to the seminal failures of lack of leadership and failure to scrutinise which infected both rbkc and
00:34:23 scrutinise which infected both rbkc and tmo
00:34:25 tmo leadership on fire safety must emanate from the very top of an organization rbkc did not set a standard for fire safety nor give it priority except by
00:34:36 safety nor give it priority except by lip service it adopted past seven which states that fire leadership must come from the top in a document which in fact related to rbkc's commercial buildings not
00:34:48 rbkc's commercial buildings not residential ones this immediately begs the question why there was not such a document in relation to residential properties and rbkc candidly admits that there should have been one
00:35:00 have been one inevitably the lack of any clear statement on leadership on fire safety led tmo to conclude that fire safety was not a priority which was further reinforced by the lack
00:35:12 which was further reinforced by the lack of key performance indicators for fire safety rbkc admits that it should have required kpis for fire safety the lack of leadership which infected
00:35:24 the lack of leadership which infected rbkc also infected tmo's leadership such that ray was left to develop a fast safety strategy without top management review of it as was required by past
00:35:36 review of it as was required by past seven of which black was ignorant black depended entirely on ray as to whether any fire safety issue should be presented to the board and this absence
00:35:47 presented to the board and this absence of leadership inevitably sent a message within tmo's organisation regarding the importance of fire safety as did the lack of resources allocated to the task
00:35:59 lack of resources allocated to the task similarly tmo's executive team exercised no scrutiny over rey or stokes barbara matthews was ultimately responsible for the discharge of all
00:36:10 responsible for the discharge of all tmos health and safety duties yet lacked any training and as a result deferred to ray and stokes the way tmo's executive team resulted
00:36:22 the way tmo's executive team resulted operated resulted in its board not being privy at the relevant time to important problems such as the adair tower deficiency notice and the hodgson audit
00:36:33 deficiency notice and the hodgson audit of tmo
00:36:35 of tmo rbkc has itself admitted to significant failures of scrutiny of tmo but relies on tmo's board being kept in the dark as being a contributory factor to rbkc's
00:36:46 being a contributory factor to rbkc's inability to monitor tmo effectively such lack of transparency as between tmo's executive and its board originates we suggest in the council's admitted
00:36:59 we suggest in the council's admitted failures to have a policy stating what it and tmo's obligations under the rro were and in the council's failure to ensure that its housing commissioning officers received training on the rro
00:37:12 officers received training on the rro furthermore rbkc housing held an unduly narrow view of the extent of its responsibility for scrutiny and oversight of tmo
00:37:23 oversight of tmo johnson regarded the primary responsibility for monitoring tmo to lie with its board such that the council's role was limited to strategic oversight of the activities of tmo and not the
00:37:36 of the activities of tmo and not the granular detail of what the tmo was doing on a day-to-day basis rbkc exercised no real oversight over the fra process it regarded the process as having been
00:37:48 it regarded the process as having been entirely delegated to tmo the council did not receive or read any fras
00:37:55 fras while ray did not proffer fras for inspection neither did the council seek copies
00:38:01 copies even after the adair fire and the consequent enforcement notices even if the housing department could credibly claim that it lacked expertise to scrutinize fras
00:38:13 to scrutinize fras there were others within the council such as its health and safety team who had sufficient knowledge to assist yet the council remained passive throughout the fra process
00:38:25 throughout the fra process by january 2010 johnson was aware of deficiencies in tmos historic fras and while she and black jointly wrote to the lfb undertaking to address the problem
00:38:38 lfb undertaking to address the problem she could not explain why she did not ensure that tmo delivered on what it promised
00:38:44 promised even the receipt of the deficiency and enforcement notices did not cause rbkc to question the adequacy of tmo's fras the council did not ask stokes in
00:38:56 the council did not ask stokes in discussions with him after the adair tower fire why risk critical items had not been addressed in the fras the lack of scrutiny extended to the top
00:39:07 the lack of scrutiny extended to the top of the rbkc executive paget brown was responsible for ensuring his cabinet were performing their duties properly
00:39:15 properly he simply assumed fielding melon was doing so unless something to the contrary came to his attention padgett brown was unaware that kpis did not cover fire safety he knew a bit but
00:39:28 not cover fire safety he knew a bit but not a lot about tmo's approach to fras and did not keep tabs on the process following the adair tower fire he did not ask what lfb's enforcement notices
00:39:40 not ask what lfb's enforcement notices required or whether they had been complied with although he was unaware of grenfell's deficiency notice in november 2016 he believed this was not something that should have crossed his desk
00:39:52 should have crossed his desk he simply assumed contrary to lfb's advice that the scrutiny committee and laura johnson would scrutinize tmo's management of fire safety and purpose-built blocks of flats
00:40:05 purpose-built blocks of flats rbkc has properly admitted that it allocated insufficient resources to scrutiny of tmo celia calliston was the officer immediately responsible for managing the
00:40:16 immediately responsible for managing the contract with tmo historically there had been two officers allocated to general housing needs but the second requested voluntary redundancy and was not replaced for financial reasons
00:40:27 financial reasons in practice the day-to-day work of supervising the mma was left to kalaskan a considerably greater number of staff were dedicated to temporary accommodation arranging accommodation
00:40:40 accommodation arranging accommodation for 2000 households by contrast just one officer was primarily responsible for a tmo that managed nearly 10 000 properties across the borough the
00:40:52 properties across the borough the cabinet member for housing was inexplicably unaware of this viewed quantitatively alone it was clearly inadequate for proper scrutiny of tmo
00:41:04 of tmo laura johnson thought resources were a bit light
00:41:07 bit light but she did not share this view with anyone at the time and did not ask for more
00:41:12 more the limited resources allocated to monitoring tmo perhaps reflect the limited degree of scrutiny its officers believed they needed to bring to bear but it may be an indicator that no one
00:41:24 but it may be an indicator that no one believed themselves responsible to request more funding when an issue which directly impacted safety presented itself
00:41:34 itself at rbkc held responsibility for monitoring or scrutinizing the adequacy of provision of evacuation of vulnerable and disabled people from general needs housing in the event of a fire
00:41:46 housing in the event of a fire the focus was on sheltered housing although they discussed peeps for sheltered housing within lfb it did not occur to them to ask whether these were being considered for residents of
00:41:57 being considered for residents of general needs housing councillors appeared similarly under unaware as to whether tmo had a program in place for peeps for his part padgett brown simply
00:42:08 for his part padgett brown simply assumed that lfb would come and rescue disabled residents but he could not explain how he came to that assumption rbkc denies being a responsible person
00:42:20 rbkc denies being a responsible person and seeks clarification from you on whether tmos rather than councils will invariably be the responsible person this is not susceptible to a universal
00:42:31 this is not susceptible to a universal answer
00:42:32 answer the guidance underlying rro makes clear that there may be more than one responsible person and it is always going to be a question of fact as to whether the degree of control exercised
00:42:44 whether the degree of control exercised by a body renders them a responsible person
00:42:48 person we submit rbkc was alongside tmo a responsible person due to its having control over the maintenance budget and exercising decision-making power
00:43:00 exercising decision-making power flat entrance doors are a good example following the adair tower fire lfb reiterated the need to install door closers across tmos stock and to
00:43:11 closers across tmos stock and to implement a regular inspection program the lga guide made clear such a program was required instead johnson delayed the installation program from three to five years and
00:43:24 program from three to five years and refused to fund an annual inspection program without taking legal legal advice
00:43:31 advice she took no other advice as to the safety implications this was as johnson accepts clearly an error
00:43:39 error and worse than that it was reckless barbara matthews took johnson's decision as a direction to tmo matthews challenged lfb's requirement on the basis that the door inspection
00:43:50 the basis that the door inspection policy was not being applied uniformly across london but did not in fact herself seek legal advice
00:43:59 advice turning to stokes and his fras he should never have been selected as risk assessor for grenfell given his lack of membership of a professional of a professional registration scheme and lack of ucas certification meant he
00:44:12 and lack of ucas certification meant he did not meet tmo's requirements despite lfb's burton raising concerns about stokes on two occasions including the quality of his fras with both ray
00:44:23 the quality of his fras with both ray and matthews tmo failed to take effective action in february 2016 ray was expressly made aware of the urgent concerns about the
00:44:34 aware of the urgent concerns about the suitability and sufficiency of stokes's fras by martin dunn a fire risk assessor but ray could not recall what actions she took in response and couldn't
00:44:45 she took in response and couldn't explain why she failed to escalate these concerns
00:44:50 concerns ray had inexplicably forgotten that in may 2017 she was told by raymond hilton that his review of two of stokes's non-grenfell fras showed they were not
00:45:01 non-grenfell fras showed they were not suitable and sufficient and had put tmo at risk
00:45:06 at risk stokes's methodology for his fras was flawed in at least three key respects first he failed to identify the occupancy profile which is critical to any analysis of the risk posed by a
00:45:19 any analysis of the risk posed by a building to its occupants he claimed he was reliant on tmo to inform him of residents with particular needs and therefore did not seek up-to-date information
00:45:30 up-to-date information stokes accepted however that each fra for grenfell contained the same information about residents which he'd used in his first fra of december 2010
00:45:43 fra of december 2010 he'd taken this information from a meeting with ray in september 2010 even though that meeting was unrelated to grenfell and he never updated the information
00:45:54 information in the course of his seven years as fire risk assessor ray told him of only two instances of disabled occupants across the entire stock but it did not occur to him that
00:46:06 stock but it did not occur to him that this was odd this is wholly unreasonable stokes is failure to instigate or advise instigation of any monitoring system of
00:46:17 instigation of any monitoring system of vulnerable residents is characterized by lane as the failure with the highest potential risk to life todd agreed that most fire risk assessors would not simply have assumed
00:46:29 assessors would not simply have assumed there were no disabled persons but instead would have asked about it albeit he thought stokes only needed high level information rather than the details of each resident
00:46:41 each resident as a result of stokes's failure to ascertain the occupancy profile the information on disabled people remained unchanged from 2010 and was wrong and
00:46:52 unchanged from 2010 and was wrong and that outdated by the time of the fire stokes was clearly aware of his failure to identify the occupancy profile given his advice to ray not to answer lfb's
00:47:03 his advice to ray not to answer lfb's request for information on vulnerable residents for its sprinkler initiative although he denied he was advising rey not to identify any individuals as that would prompt lfb to check why they
00:47:15 would prompt lfb to check why they weren't included in fras that is the clear inference to be drawn from the email exchange and is deplorable second stokes failed to link fra actions
00:47:28 second stokes failed to link fra actions to the risk they posed if not cured the most significant purpose of an fra is to estimate the level of risk and provide clear guidance to reduce or maintain the risk as trivial or
00:47:40 maintain the risk as trivial or tolerable
00:47:41 tolerable yet stokes did not nor did he advise how a failure to complete it would impact on risk level for the premises third stokes failed to ask to review the emergency plan for grenfell and did not
00:47:54 emergency plan for grenfell and did not advise that one should be prepared stokes's understanding of the plan was that peeps would be provided for vulnerable residents when this was not so
00:48:03 so by definition stokes's failure to highlight the lack of evacuation procedure for the vulnerable resulted in his fras not being suitable and sufficient because they did not express
00:48:14 sufficient because they did not express the different risk level for those persons
00:48:18 persons in conclusion the collective failings of tmo and rbkc to fulfill their obligations under the rro as responsible persons
00:48:28 persons are shocking both in volume and severity sadly the evidence suggests that the problems witnessed by the inquiry are not confined to grenfell tower and that
00:48:39 not confined to grenfell tower and that industry has much to learn in terms of the proper approach to fras to emergency plans and to fire risk assessments and fire risk management systems and
00:48:50 fire risk management systems and adequate maintenance as with module 2 serious questions arise as to the testing and marketing of products in this case door sets and this issue
00:49:01 and this issue represents a consistent pattern of dishonesty we invite you to keep in mind that the devastating consequences of the fire in terms of its spread breaches of
00:49:13 in terms of its spread breaches of compartmentation and systems failures were in fact foreseeable not by lay people but by tmo and rbkc tasked with keeping residents
00:49:24 and rbkc tasked with keeping residents safe as responsible persons the fact that each of these failed in that endeavor in multiple ways is evidence of the systemic nature of the
00:49:35 evidence of the systemic nature of the problems usually driven by poor culture and lack of competence the rro itself as amended is broadly speaking fit for purpose it does not
00:49:47 speaking fit for purpose it does not depend on the building regulations or building control because its focus is the safety of a building in question for its residents and visitors
00:49:57 visitors instead the issues lie in the flawed culture and systems of the responsible persons and their agents those are my submissions then well thank you very much indeed
00:50:13 the next statement uh is going to be made by mr friedman queen's council we'll just take a moment to wipe down the
00:50:24 council's bench and then we'll be ready for him
00:50:49 thank you very much yes mr friedman well if you're ready that's
00:50:54 that's good from you thank you good morning
00:51:04 the primary duty of any landlord is to ensure their residents are safe in their homes the duty can only be fulfilled where residents views our respected and
00:51:16 where residents views our respected and residents lives are valued that did not happen at grenfell tower we say that it should have and the fact that it did not and that residents were made to suffer before this fire and not just because of
00:51:28 before this fire and not just because of it
00:51:29 it is a truth that needs understanding and recording
00:51:32 recording that suffering was in the conditions in which residents were made to live with no significant investment for 30 years it was in their fears that their building was unsafe
00:51:44 that their building was unsafe and in their helplessness that their concerns were not only ignored but actively opposed by their landlord and managing agent who could act with impunity and did
00:51:55 and did we say act in violation of their human rights
00:51:59 rights when we talk of human rights being at stake at grenfell tower we mean three things
00:52:05 things first there are fundamental rights that are common to all human rights treaties enacted since the second world war the right to life the right to private life respect for a person's home and freedom
00:52:17 respect for a person's home and freedom of information to enable rights to be protected
00:52:21 protected these rights have their roots in all major faiths and cultures but they mean little without deliberate commitment to equal treatment in their application that requires
00:52:33 that requires that everyone's enjoyments of right shall be secured without discrimination on grounds of race language or disability but also other aspects of their situation
00:52:44 situation whether it be their immigration status or their opinions second
00:52:50 second human rights are the reason for the various health and safety laws that the inquiry has looked at across its modules the building regulations the construction design management regulations
00:53:02 management regulations and the fire safety order or rro these texts contain technical rules they are ultimately about the protection of life
00:53:13 about the protection of life and human security of course
00:53:16 of course they are not seen in that way nearly enough and indeed too often treated as unnecessary red tape but they are part of the state's duty to establish a framework of laws precautions procedures and means of
00:53:28 precautions procedures and means of enforcement which are there to protect people finally as we are not all the same our level of safety in buildings can be
00:53:39 our level of safety in buildings can be different
00:53:40 different the equality act formalizes that if you stubbornly treat people uniformly regardless of their differences of race gender and disability then you can risk penalizing them for those differences
00:53:53 penalizing them for those differences likewise
00:53:54 likewise if you deliberately remain ignorant of the characteristics of people under your control such as their disabilities or features potentially connected to their race like language and recent migrancy
00:54:06 race like language and recent migrancy then you will never know if you are discriminating against them drawing matters together fundamental rights health and safety and equal treatment were part of an overall value system
00:54:19 were part of an overall value system that should have served residents rights before the fire but did not the foundation of the system is respect for the inherent value of the individual as a human being
00:54:30 individual as a human being the residents at grenfell trial were not treated with that respect instead the specified consultation rights that required direct resident involvement in the project management of
00:54:42 involvement in the project management of major works on their own home were completely discarded non-compliance with fire safety was deliberately hidden from residents and differences in the resident
00:54:54 and differences in the resident population including race and disability were given no real thought at all in a major capital city in one of its wealthiest boroughs those
00:55:05 in one of its wealthiest boroughs those in government acted beyond the rule of law
00:55:09 law and one of the main things that causes outrage amongst the residents who were ill-treated in this way at the time is that but for the fire nothing would have been done about it
00:55:20 nothing would have been done about it rbkc
00:55:22 rbkc was home to a governing culture that was opposed to residents rights and so abused its powers that abuse contributed to its disaster to this disaster and the inquiry should
00:55:33 to this disaster and the inquiry should document that aspect of the disastrous causation alongside everything else
00:55:41 to understand the sequence of events that led to the disaster it's important to analyse the power structure on which the decision-making process was built most of phase 2 to date has questioned
00:55:53 most of phase 2 to date has questioned the competency and ethics of private actors
00:55:56 actors but grenfell's residents lived under the exercise of public power section 27 of the housing act 1985 permitted rbkc to set up the tmo as its
00:56:08 permitted rbkc to set up the tmo as its agent but the principle of arms length management never allowed the council to relinquish its legal duties equally the tma may have been a private
00:56:19 equally the tma may have been a private limited company acting under the modular management agreement the mma but as the agent of the council exercised public functions and the power it held over residents was
00:56:30 and the power it held over residents was the power of public office this was never an ordinary landlord and tenant dispute it was always about the relationship between individuals and the state
00:56:41 between individuals and the state but without the robust protection of their rights in a local authority that paid them little regard residents could quickly be marginalized and so it turned out
00:56:52 and so it turned out starting with the refurbishment there is a legal duty on local authorities under section 105 of the housing act that requires them to make
00:57:03 housing act that requires them to make arrangements to ensure that secure tenants are consulted about the conduct of major works and that their views are taken into account the details of those arrangements must
00:57:15 the details of those arrangements must be published the way in which rbkc chose to discharge the duty was contained in text in the text of schedule 3 of the mma that dealt with
00:57:27 schedule 3 of the mma that dealt with the rights of residents to directly participate in decision making on major works
00:57:33 works rbkc did not refer you to this schedule in any of their original statements but they now concede that the degree of consultation envisaged in the schedule was not achieved
00:57:44 was not achieved that is a confess and avoid admission which overlooks the illegality unfairness and causal implications of what was denied to appreciate the wrong done you need to
00:57:56 to appreciate the wrong done you need to consider the terms of the schedule under the heading client review group it reads that the project manager was to quote decide whether to establish a client review group or steering group
00:58:08 client review group or steering group for the project to be chaired by a representative of the residents association with the role to act as a client for the project
00:58:17 project review progress in implementing the scheme
00:58:20 scheme and focus on those issues which directly concern residents if it was decided not to establish a client review group then effectively one better the residents association was
00:58:31 better the residents association was required to be asked to nominate a representative to directly join the project team thereafter the residents association was to participate in the appointment of contractors
00:58:43 contractors and to either attend the site meetings or to be briefed before and after them potential savings in the contract were to be discussed with the residents association before any savings were
00:58:54 association before any savings were implemented finally the refurbishment was to undergo a formal post-works review that asked residents for their views on the works panel
00:59:03 panel whatever that was it was not coffee mornings and newsletters residents spent more than two years advocating for the recognition of some form of collective status in order to be
00:59:15 form of collective status in order to be properly consulted when the terms of the schedule positively desired it and to a level very much greater than was ever afforded
00:59:24 afforded the discarding of schedule 3 without any justification or reasoning was an unlawful breach of section 105 of the housing act the failure to tell residents of their
00:59:36 the failure to tell residents of their rights under the schedule was also unlawful
00:59:40 unlawful instead the management arrangements for the refurbishment were allowed to progress with residents effectively locked out of all the practical conversations there's an additional layer to this
00:59:52 there's an additional layer to this the construction design management regulations require the tmo as the client to make suitable management arrangements and the guidance reminded the client that the way it behaves can
01:00:03 the client that the way it behaves can make a difference to the quality of the works
01:00:06 works management arrangements that exclude a party that was anticipated to have a participatory role in the project chain should not be deemed suitable neither should it ever be regarded as
01:00:17 neither should it ever be regarded as suitable for the engagement of the architect and main contractor to deliberately circumvent public procurement rules the evidence shows that resident engagement in these works
01:00:28 that resident engagement in these works was deliberately limited for a number of reasons
01:00:31 reasons there was discrimination against active residents like edward daffan and shah ahmed for the flagrantly abusive purpose that they might query the decisions
01:00:42 that they might query the decisions being made but the tmo especially did not want their critics looking under the detail of these contractor appointments because they did not want to be found out for doing wrong
01:00:54 doing wrong in this entirely unacceptable secrecy motivated by reasons of bad faith the consequence was to prevent residents from discovering three fundamental features of the refurbishment identified
01:01:06 features of the refurbishment identified in the module one evidence as causative of the fire one the lack of experience of the architects two
01:01:14 two the replacement of zinc fr with rena bond acm for reasons of cost and three the draft and qualified terms of the xover fire safety report including the failure to action project
01:01:26 including the failure to action project meeting agreed steps to properly engage a fire consultant as a result of this lack of candor the residents
01:01:34 residents including people who through previous hard knocks were determined to stand up for themselves we're disempowered from securing answers to the following questions one
01:01:45 one have the architects done this before two
01:01:49 two what are the dangers if any from the substituted cheaper cladding materials three
01:01:56 three why have you not completed a fire safety strategy report which in express terms tells us is incomplete and four
01:02:04 and four what happened to the fire consultant you repeatedly said that project meetings should be appointed these questions are blatantly obvious they should have been asked by the tmo
01:02:15 they should have been asked by the tmo transparency would have enabled them to be asked by residents who did not trust what was going on in that refurbishment and had much more incentive to ask when they weren't asked properly
01:02:27 they weren't asked properly and once those questions were asked residents
01:02:31 residents and especially those residents who you know
01:02:34 know would have been more determined to act on any unsatisfactory response at the than the tmo proved to be cumulatively we say that the breach of consultation
01:02:45 we say that the breach of consultation rights and bad faith secrecy we're not just context but cause the failure to ask those four questions allowed the tmo to be unshaken in its alignment with its contractors and not to progress finalization of the x over
01:02:57 to progress finalization of the x over report
01:02:59 report rbkc also avoided being forced into considering these issues even if only to placate public pressure whatever the cause and fate of claire williams's lack no moment email in
01:03:10 williams's lack no moment email in november 2014 her sharing of the moment with ryden as well as resident representatives on a project team would have required a more studied and formal
01:03:21 have required a more studied and formal treatment of the issue there was also no pers works post-work satisfaction survey as mandated by schedule three had it occurred there was a further opportunity to learn a potential risk to fire safety
01:03:33 potential risk to fire safety overall it is beyond doubt that the residents were excluded from disclosure of information to enable scrutiny of primary causes of the fire that mattered to their fate
01:03:44 to their fate that fault was wrong in itself and of more than likely causative effect the next body of residents rights concerns fire safety
01:03:55 concerns fire safety to hold the authorities to account residents needed the information to do so
01:04:00 so there is a general legal doctrine that rights protections must be practical and effective and not theoretical and illusory
01:04:08 illusory while the doctrine applies to many aspects of the management of health and safety by rbkc and the tmo it had significant relevant relevance the extent to which fire safety information was deliberately withheld from residents
01:04:21 was deliberately withheld from residents or other oversight bodies whether the tmo board the council scooting committee or the lfb when we say that the failure to consult with residents caused a disaster we include that aspect of the breach of
01:04:33 include that aspect of the breach of their fire safety rights all parties address you in detail about the commercial decision in march 2017 to limit the defective self-closure
01:04:44 limit the defective self-closure replacement program to no less than five year cycles with no inspection arrangements in between the senior relevant officer at rbkc laura johnson
01:04:55 laura johnson defended hercy's decision before the inquiry on the basis that she assumed it would be challenged and pending that did nothing to establish its illegal or safety implications
01:05:07 safety implications we say her approach showed reckless indifference to the illegality of her decision
01:05:12 decision but as regards causation who did she think would challenge it residents knew nothing about it neither did the tmo board she never established whether the lfb would be
01:05:24 established whether the lfb would be told and it wasn't robert black who ran the tmo and was jointly liable under the fire safety order never challenged the adverse safety implications of johnson's self-closer plan
01:05:36 self-closer plan in answers to the chairman's questions he could have registered his scent either with her or with the cabinet but did much worse in an email of january 2017 black
01:05:47 in an email of january 2017 black positively encouraged johnson to galvanize local government politicians against what he characterized and she agreed with the unaccountable and wrongly non-negotiable efforts of the
01:05:58 wrongly non-negotiable efforts of the lfb over the issue this evidence cannot be sugarcoated johnson was a powerful figure in london social housing black was the ceo of the biggest tmo in
01:06:12 black was the ceo of the biggest tmo in the country they were far happier to limit disclosure lobby the establishment for change and wait to see whether anyone would stop them
01:06:22 them not only were residents not told about the decision but throughout these debates about doors there were express and implied blaming of the victim
01:06:33 and implied blaming of the victim rather than edward defan's complaint about door 136 being understood as a matter integral to fire safety it was dismissed not once not twice but through all three stages of the complaint systems
01:06:45 systems both before and during this inquiry tmo witnesses allege that residents would not grant access to check their door closers
01:06:52 closers no one accepts that stokes never raised resident refusals as a problem relying on in his words potluck as to who was in at any given time
01:07:02 time residents were not properly informed of the importance of talk losers and no system was ever implemented to facilitate access all the bsr submissions show that in
01:07:14 all the bsr submissions show that in various ways rbkc and the tma were in continuing non-compliance with the fire safety order before the grenfell tower fire that was wrong in its own right but
01:07:25 fire that was wrong in its own right but they also took steps to conceal their non-compliance from residents that is the impunity part of this aside from the door inspection issue the salvus review of 2009 and the hodgdon
01:07:38 salvus review of 2009 and the hodgdon report of 2013 that told that the tmo was in breach of fire safety law but were bare summarized to the tmo board were withheld from the housing scrutiny
01:07:49 were withheld from the housing scrutiny committee and never made public rbkc and the tmo remain in breach of a deficiency notice on the smoke ventilation system for many months they waited to see if the lfb would follow up with ray and williams writing
01:08:01 follow up with ray and williams writing casual emails hoping that their luck would hold out and that they would be no fires in the meantime williams expressly opposed edward defan's freedom of information request
01:08:12 defan's freedom of information request in october 2014 because she did not want him to find out about the ventilation problems this was organized and deliberate non-disclosure on doors they now accept that the board
01:08:24 on doors they now accept that the board was kept in the dark the november 2016 deficiency notice on grenfell tower including defective doors in the building remained unremedied before the fire and was neither disclosed to the
01:08:35 fire and was neither disclosed to the residents
01:08:36 residents nor the tmo board or the council scrutiny committee going back to 2014 there is a minute of the tmo health and safety meeting attended by madison
01:08:48 attended by madison ray and jevons that detailed a decision not to disclose the level of outstanding fire risk assessment actions to the lfb in order to avoid crude scrutiny and quote possible enforcement action
01:09:01 and quote possible enforcement action the other participants won't recall the event but michael lyons as a qualified health and safety expert must have demanded its recording to reflect a decision which he did not agree with and
01:09:12 decision which he did not agree with and now everyone else is ashamed of francis o'connor and edward daffan only ever saw one fire risk assessment once seen they blogged about it critically that triggered ray for the
01:09:24 critically that triggered ray for the first time preparing a list of outstanding actions but she deliberately withheld the full picture from rbkc the gag blood let's led peter madison to direct his staff in
01:09:36 led peter madison to direct his staff in the future to keep such matters in-house black confirmed that madison was uncomfortable because it showed some of his team hadn't been doing their job properly
01:09:47 properly as with the failure of candor and transparency on the major works the lack of candor on fire safety to residents was causative in that it kept criticism and scrutiny at bay
01:09:58 and scrutiny at bay it excluded the capacity for residents to monitor and influence compliance either by representation or if necessary legal action with greater transparency a campaign for
01:10:09 with greater transparency a campaign for compliance could have been rigorously pursued by residents to protect themselves because they didn't believe others would protect them residents had a right to be informed and
01:10:20 residents had a right to be informed and prepared for a risk on their own terms and not on the secretive and defensive terms of those who governed them that brings us to residents rights to
01:10:31 that brings us to residents rights to equal treatment the duties contained in the plain words of the fire safety order cannot possibly be discharged without knowing the resident profile of the building
01:10:42 resident profile of the building the tmo were advised by salvas in 2009 to develop formal procedures to deal effectively with fire safety issues associated with disabled or vulnerable tenants and leaseholders and to include
01:10:55 tenants and leaseholders and to include options from relocation in severe cases to the provision of specific personal evacuation plans peeps in less serious cases
01:11:04 cases what we now know is that the tmo did nothing overall the tmo's basic answer for doing nothing insofar as it was ever considered was that the stay put
01:11:15 considered was that the stay put principle meant that nothing needed to be done
01:11:19 be done however
01:11:20 however instead of declaring transparency transparently that nothing would be done the tmo pretended that they were doing a lot
01:11:29 lot the fire risk assessments for grenfell tower contained three fictions one the tmo had a comprehensive program to gather information about tenants including those with disabilities and
01:11:41 including those with disabilities and which would be used for the development of peeps
01:11:44 of peeps two
01:11:45 two both lifts were firefighting evacuation lifts which could be used as part of the evacuation strategy for disabled persons and three
01:11:54 and three tmo employees would arrange for a general evacuation of the whole building if appropriate to do so in fact there was no relevant planning or provision at all for disabled
01:12:05 or provision at all for disabled residents no peeps were prepared employees were not briefed in any way about assisted evacuation and description of the libsa's firefighting evacuation list was wrong and janice ray knew it was
01:12:18 and janice ray knew it was and it was a serious assessment flaw because it envisaged that residents could be evacuated that way during a fire when they could not the fulcrum of the continuing fictions contained in the assessments was janice
01:12:30 contained in the assessments was janice ray
01:12:31 ray she knew that the state policy still required consideration of the possibility of evacuation she was aware that the duties of responsible persons under the fire safety order applied to all persons in
01:12:43 safety order applied to all persons in general needs housing she understood that the evacuation planning could not be dependent on the lfb and she was advised that the equality act duties were
01:12:54 that the equality act duties were engaged
01:12:56 engaged importantly ray accepts that she did not consciously justify the tmo's approach to peeps in general needs housing by reference to paragraph 179 to 11 of the lga guide
01:13:10 paragraph 179 to 11 of the lga guide which we say unlawfully suggested that there was usually nothing to be done for vulnerable residents in high-rise buildings because it was unrealistic to make any special arrangements for them
01:13:22 make any special arrangements for them be it peeps or otherwise the tmo's failure to offer peeps had nothing to do with the lga guide there was no reference to it in the fire safety policies there was no tmo
01:13:33 safety policies there was no tmo opposition to lfb advice in 2012 that peeps were required for vulnerable residents in high-rise general needs housing in fact the tmo gave assurances to the lfb around the time of the guides
01:13:45 to the lfb around the time of the guides publication that it would be proactive in identifying vulnerable residents requiring peeps there was though no system to identify the vulnerable no publicity that peeps were available
01:13:58 no publicity that peeps were available and no system let alone training or internal discussion to ensure that when vulnerability was discovered a peep would automatically be considered we say the root cause of this
01:14:10 we say the root cause of this was the disconnect between housing allocation that relied on disability and vulnerability data and housing management which discarded it
01:14:21 which discarded it the disconnect including the need to consider re-allocation based in extreme cases once people were living at risk in the building falls within the terms of reference to
01:14:32 falls within the terms of reference to the inquiry because it was surely causative of death salvas advised the tmo of the link in 2009
01:14:40 2009 the issue was never binary as some residents would have been content to remain in grenfell with peeps and other supports while others would not or even should not because the risk to life was too great
01:14:51 too great the overall failure to conduct any assessments across grenfell tower is what constituted a systemic breach of the right to life of disabled and vulnerable residents this failing breached the fire safety
01:15:03 this failing breached the fire safety order and discriminated against those relevance persons whose additional fire safety needs were disregarded the tmo
01:15:11 the tmo and rbkc now seek to draw comfort in the do nothing approach advocated by paragraph 79 of the lga guide when it was completely out of their mind at the time
01:15:24 out of their mind at the time colin todd's evidence is legally wrong in conflict with all other published guidance and takes no account of equality law however
01:15:33 however the ongoing fault and indeed scandal lies with government which for over a decade now and over four years after the grenfell fire has failed and still fails to declare that
01:15:46 failed and still fails to declare that part of the lga guide unlawful and unacceptable that is why we say to the panel that if you agree
01:15:53 you agree you should write to the secretary of state and express your views now rather than wait to publish it in a final report and of course the importance of the importance of this
01:16:04 the importance of the importance of this is both the more than 41 of adults who died at grenfell tower who were mobility or otherwise impaired and the people who stayed with them
01:16:16 and the people who stayed with them to name only some fatima afrasyabi stayed with her sister sakhina
01:16:22 sakhina mariam al-ghrari stayed with her mother esla
01:16:26 esla sochu abu frass and ibrahim israel ibrahim stayed with mrs alison lucy
01:16:31 lucy all of the shoe cares stayed with their mother and grandmother mrs syria shuker people together who should have been assisted with pre-prepared planning to assist each other to escape
01:16:44 assist each other to escape this again involved a failure to properly consult with residents in a way that caused their death panel
01:16:53 panel that sets out why we say that alongside the module one and two negligence and discrete wrongdoing the grenfell tower fire was a human rights disaster in multiple ways the rights were
01:17:05 in multiple ways the rights were breached and those breaches were causative
01:17:08 causative these are matters that go to the heart of safety in the modern built environment and compliance with them needs to be treated the same as the building regulations or other rules that the inquiry has studied
01:17:19 the inquiry has studied but this is not just about compliance it is about a profound failure of governance in the years before the disaster there was an abuse of power that involved the orchestrated defeat of the residents who
01:17:31 orchestrated defeat of the residents who were in defiance against their ill treatment
01:17:34 treatment that's what we mean when we say that rbkc in the tmo was not just breaching residents rights they were actively opposing them first the residents were largely regarded as an inconvenience to be
01:17:46 regarded as an inconvenience to be managed rather than human beings the fundamental feature of that attitude is the characterization of the refurbishment as an act of generosity in truth money had become available from
01:17:58 in truth money had become available from sales at elm park gardens demolition was more costly and residents had no significant investment in their building for over 30 years the situation had become untenable more broadly
01:18:10 more broadly the negative starts of the tmo to proper resident consultation safety and compliance reflects an organizational culture and a set of attitudes
01:18:21 attitudes its priorities set by rbkc which project manage manage on time and to budget with a view to sustaining its asset management future its deeper definitions of success were to control residential
01:18:33 of success were to control residential dissent protect its own reputational interests and help the council to avoid political embarrassment somewhere along the line a disdainful
01:18:45 somewhere along the line a disdainful attitude to residents became institutionally acceptable within tmo ranks
01:18:49 ranks so when siobhan rumble felt able to express disdain about edward daffan's reference to some like conditions or to say that she had better things to do with her time than deal with miguel
01:19:01 with her time than deal with miguel alves and the gtla it was because she was working in an organization whose culture permitted her to do so second the governing structure was
01:19:12 second the governing structure was presented as resident democracy but it was anti-democratic nicolas paget brown accepted in hindsight that it was far too big the motivation for creating a monopoly borrow ytmo was never about democracy
01:19:24 borrow ytmo was never about democracy but economies of scale the tmo executive deliberately withheld information from its board but also from residents and often on fire safety and it did so in express terms
01:19:36 it did so in express terms because it wanted to evade resident criticism
01:19:40 criticism third
01:19:41 third rbkc was guilty of lack of oversight of an organization they knew was not being managed by a robust board but run by executives without challenge or scrutiny
01:19:52 executives without challenge or scrutiny who did not deserve the arms-length freedom that councillors and the rb or kc officers afforded to them the mamoli report of april 2009 highlighted a main complaint of
01:20:03 highlighted a main complaint of residents to be lack of contractor supervision bad workmanship by contractors and a failure in monitoring of contracts and works
01:20:14 and works in 2012 the tmo was still seen by the council officers as from top to bottom having no experience in regeneration works including the risks associated with them
01:20:25 with them strikingly black's interpretation was that the rbkc was neither particularly keen nor impressed with the mamoli report
01:20:37 mamoli report if that is right that he was getting that message through informal contact with rbkc that effectively residents opinion was not important
01:20:48 not important then that is something that needs to be drawn out
01:20:51 drawn out effectively he was being told his job was to keep resident disquiet under control
01:20:58 control fourth there was a denigration of dissent
01:21:03 dissent claire williams confirmed that upon joining the tmo she was briefed on the grenfell action blog uh which edward defan was described as being the main mover
01:21:13 mover after some pretense by tmo witnesses it was conceded that the blog was being monitored
01:21:18 monitored ryden was equally warned against bla gag from the initial interviews onwards and later encouraged to guard against the so described rebel residents which included that barn but also david collins
01:21:30 that barn but also david collins laura johnson as that day-to-day senior oversight council officer cancelled black in january 2017 that grenfell was a bad tempered place with residents
01:21:42 a bad tempered place with residents complaining about minor matters with their own agenda who were not to be taken seriously given the imbalance of power this was not disagreement amongst equals but
01:21:54 not disagreement amongst equals but flagrant political discrimination over the treatment of issues that directly impacted on safety in edward defan the tmo
01:22:04 the tmo and rbkc were determined to shoot down the messenger you have multiple sources of evidence including a range of people from ethnic minority and disability backgrounds who
01:22:15 minority and disability backgrounds who wanted a collective voice and not just to rely on individual complaints the attempted rubbishing of dafan comes from an organization who knew next to nothing about the needs and vulnerabilities of its residents
01:22:27 vulnerabilities of its residents they were wrong to denigrate an opponent like this a registered social worker who was well connected to people across the estate and who could and did undoubtedly garner the views of numerous residents
01:22:39 garner the views of numerous residents and articulate them to the authorities when the information was made available gagg and others did what they could to hold the tmo and rbkc to account
01:22:51 hold the tmo and rbkc to account in turn the authorities were determined to shut down or shut all of them down and we do mean everyone it did not matter if you criticized with caustic words
01:23:02 words polite ones with the benefit of council elected office or with professional credentials or indeed the experience of living in the tower that these people did not live in
01:23:13 in no one
01:23:14 no one got through and in the end at least until the fire and the outcry that followed the public landlord and their agent had
01:23:25 the public landlord and their agent had won
01:23:26 won there are a number of examples cited of how residents were systematically dismissed before the fire in a way that otherwise might have stopped it we focus on just two
01:23:37 we focus on just two first the tmo and rbkc fixed the outcome of the grenfell compact campaign for an independent assessment of the refurbishment as requested in the petition of november 2015.
01:23:50 petition of november 2015. the joint minutes of the rbkc tmo meeting of december 2015 describe the petition as the negative influence of edward dufan and councillor blakeman you have the evidence panel of the many
01:24:03 you have the evidence panel of the many residents who were involved including 20 who are now dead or bereaved and the events leading up to that petition are killed on film by constantine grass
01:24:14 killed on film by constantine grass robert black was informed over the new year that the rbkc powers that be were set to manage resident opposition this occurred for an email exchange between quentin marshall and rock
01:24:26 between quentin marshall and rock fielding mennon where the chairman of the scrutiny committee assured the cabinet member for housing that a majority of the committee meetings could be pre-briefed to understand how to play it
01:24:37 it the meeting on 6th of january 2016 was julie stage managed laura johnson delivered a summary in response to the petition that played up the very large budget her report claimed
01:24:48 the very large budget her report claimed that the tmo had worked closely with ryden and the residents of grenfell tower and even in evidence of the inquiry she did not treat lack of consultation in general as a serious concern
01:24:58 concern stefan who did complain about consultation in his speech was cut short by marshall in his presentation of the resident's case johnson and black treated the event as a
01:25:09 johnson and black treated the event as a vindicatory moment defun recalls them smiling at the meeting because they knew they had won quinton marshall's attitude was expressed in a private email by the to
01:25:21 expressed in a private email by the to the mp victoria boric written even before the tmo internal review had been completed he euphemistically minimized this as only his initial conclusion but it is clear that he had
01:25:33 conclusion but it is clear that he had already already formed the view that a large sum of money had been spent residents complaints were quote wild unsubstantiated and grossly exaggerated
01:25:44 unsubstantiated and grossly exaggerated and so he was not massively sympathetic the tmo's internal review was cursory and ineffective the review member's only source of information was provided by the executive team they were supposed to
01:25:56 the executive team they were supposed to be reviewing madison admitted important documents showing the tmo's great resistance to any collective consultation complaints detailing bullying and harassment the fire safety concerns about the new floor
01:26:08 fire safety concerns about the new floor numbering and the separate call for an independent assessment of fire safety arrangements review members never met with contact compact members
01:26:19 never met with contact compact members or any grenfell residents in what was a choreographed short trip to the tower the outcome was an internal report by the tmo that praised the works including
01:26:30 the tmo that praised the works including the consultation that underpinned them and took no account of the fire safety features that had been raised councillor blakeman was blocked from speaking against the outcome of both the tmo board and the subsequent scrutiny
01:26:42 board and the subsequent scrutiny committee meeting and for several months until matters died down the report itself was kept confidential the second respect in which residents
01:26:53 the second respect in which residents was dismissed were dismissed was the casting aside of the complaints about fire safety that could be made due to what was visible to them on this we end with the manner in which
01:27:04 on this we end with the manner in which the gag blog was ignored and in particular it's november 2016 post playing with fire that predicted a disaster as the only means that would bring the tmo to account
01:27:18 bring the tmo to account there is an old english legal phrase to raise hue and cry it refers to pursuing a criminal with cries and sounds of alarm
01:27:30 cries and sounds of alarm in ancient times it was the duty of any person wronged or discovering a felony to raise the hue and cry and neighbors were bound to come and assist him or her in the pursuit and apprehension of the
01:27:43 in the pursuit and apprehension of the offender
01:27:44 offender the gag blog was a protest against disempowerment but it was also the raising of hue and cry
01:27:52 cry it sensibly questioned the adequacy of stay put following the shepherds caught fire sensible in the sense that stay put should have been the subject of pressing questioning at that time at all levels
01:28:03 questioning at that time at all levels of central and local government and amongst all management and expert stakeholders in the aftermath of the blog with
01:28:11 with black's knowledge janice ray misled councillor blakeman about the lfb's assessment of adair tower
01:28:19 tower she withheld from her an outstanding deficiency notice critical of the lack of fire action notices and self-closing devices at grenfell tower issued just one week before the blog
01:28:31 issued just one week before the blog she also told blakeman that the refurbishment works had been scrutinized by fire engineering companies but she had not properly considered for herself the x over reports which she now accepts
01:28:42 the x over reports which she now accepts left open the question of whether stay put would be appropriate all in all because they maligned the messenger in a castandra-like tragedy the tmo
01:28:54 in a castandra-like tragedy the tmo discounted and cursed the message and rbkc
01:28:59 and rbkc positively encouraged them to do so i want to conclude with how edward daffan completed his evidence to the inquiry by pressing the relationship between the
01:29:11 by pressing the relationship between the ill treatment of residents and causation he said
01:29:16 he said they didn't treat us with respect or humanity or empathy and if they had done we wouldn't be sitting here now the culture of the kctmo
01:29:27 the culture of the kctmo the lack of scrutiny by rbkc is believed i believe
01:29:32 i believe and i believe many residents believe to be a causative factor of what happened on the night of the fire and what led to the fire and i just ask you to bear that in mind
01:29:45 and i just ask you to bear that in mind panel the constituent parts of that statement are important first the reference of respect humanity or empathy are all complaints of a violation of human dignity
01:29:56 violation of human dignity throughout the evidence there were assumptions not only of residents being difficult but they had nothing worthy to add wouldn't would not understand the technical issues and could not be trusted in their judgment
01:30:07 trusted in their judgment they certainly were not regarded as clients collaborators and co-authors in their destiny all of which are central to a modern notion of human dignity difference
01:30:18 difference including different categories of residents including that different categories of residents would find it difficult to complain or in an emergency find it difficult to escape were damningly given no real
01:30:31 escape were damningly given no real account
01:30:32 account second
01:30:33 second the violation of human dignity was born out of the culture of the tmo and the lack of scrutiny by rbkc this combined form of government involved an elitist mentality that did
01:30:46 involved an elitist mentality that did not regard the governed as their equals but the mentality was also corrupt because it play acted as a resident democracy when it was no more than devolved management
01:30:57 devolved management it manifested flagrant areas of public law and breaches of the basic standards of good administration in its denial of fairness transparency and impartiality and over lunches emails
01:31:09 and impartiality and over lunches emails meetings and after a time without even needing to say it it became the norm to be dismissive of resident critique of the very wrongs it is now unable to defend
01:31:20 defend third disrespect of human dignity contributed to the cause of this disaster
01:31:26 disaster rbkc and the tml held a range of biases and prejudices that underpinned their exclusion of meaningful resident influence over construction and fire safety management including denying
01:31:37 safety management including denying sufficient access to information concerning it this meant that residents were unable to call the landlord manager or contractors to account who in turn prior to the fire
01:31:49 to account who in turn prior to the fire were able to act with impunity a form of government that was truly concerned about life dignity and security would not have acted in this way
01:32:00 way the inquiry decided at its outset not to investigate broader social housing policy instead it has analyzed the fatal harm down to one particular predominantly
01:32:12 down to one particular predominantly social housed community in a single building under the authority of a particular local council however
01:32:20 however an explanatory narrative of the grenfell tower fire inescapably leads to the account of matters that have a further societal reach whether they are able to admit it or not
01:32:32 whether they are able to admit it or not the reason why our bkc and tmo government acted as they did is that they were joined in seeing this refurbishment as an act of municipal generosity
01:32:43 generosity not critical and long overdue investment but a gift they were genuinely affronted that in their eyes the investment in grenfell was treated
01:32:54 the investment in grenfell was treated with anything other than gratitude the residents on the receiving end of this approach were denied a proper voice or agency as equals in their fate the cost of causal consequences to the
01:33:05 the cost of causal consequences to the fire is that the makers of the so perceived gift were unable to comprehend and therefore inhibited in properly examining its inadequate and potentially
01:33:16 examining its inadequate and potentially dangerous qualities the inquiries map towards its final recommendation should be guided by acknowledging that the tmo and rbkc were playing with fire before the disaster
01:33:28 playing with fire before the disaster not just because of their gross failures to manage fire safety but because they lacked respect for the residents that would have civilized their power with recklessness and neglect they led a
01:33:39 with recklessness and neglect they led a line of architects builders corporate interests and other professionals who like them
01:33:44 like them failed to acknowledge that the individual human being and their safety should have been the ultimate focus and absolutely central to all that they did there must be a deeper appreciation and
01:33:55 there must be a deeper appreciation and enforcement of that truth it has to be at the heart of the cultural change that makes real any commitment to ensure the terrible events at grenfell tower never happen
01:34:06 events at grenfell tower never happen again
01:34:10 mr friedman thank you very much indeed well at that point we'll take a break from
01:34:15 from the morning session and we'll resume at half past 11 when we shall hear mr mansfield queen's council on behalf of other
01:34:24 of other reeve survivors and residents so half foster level please
01:51:23 now before we hear from mr mansfield mr millett has one small matter to deal with yes mr chairman members of the panel it's a correction to the transcript from this morning uh
01:51:34 to the transcript from this morning uh during uh miss barwise qc's address to the panel
01:51:38 the panel uh she made a slip of the tongue uh at line 15 of page 15 of the raw transcription this morning um in which uh she um just used the word within
01:51:50 uh she um just used the word within in the context of the lfb she said within lfb and she meant with lfb which is rather different i can see that um so subject to that change that
01:52:02 that um so subject to that change that change should be made on the written transcript but also of course will now appear on the video so everybody knows uh that that correction has been made thank you very much
01:52:13 thank you very much well mr mansfield you're yeah please begin excuse me for sitting down um
01:52:19 um that doesn't indicate i'm going to be pro lex hopefully um and in fact having listened this morning very carefully i've had to do the usual red pen and that maybe shortened matters rather than
01:52:32 that maybe shortened matters rather than lengthen them however i uh with your permission i would like to start with another fire altogether i don't want to worry about the thought of another inquiry but there was a fire this year
01:52:45 inquiry but there was a fire this year which has a relevance to this inquiry in the sense it it begins the process of understanding uh those matters you've already heard about
01:52:56 about and a little more you'll hear about now it it happened in may
01:53:01 in may this year
01:53:02 this year at new providence wharf in london
01:53:08 this was a new build 2005. it was 19 stories high so it's a it's a high rise
01:53:18 and it was during daytime rather than night time
01:53:22 time a fire broke out on the eighth floor
01:53:27 on a fuse board and as you yourself said in the
01:53:32 in the phase 1 report often often the fires that we're talking about begin as
01:53:40 as fairly ordinary perhaps rather small fires of domestic items the fuse board in this case is what happened but what happened thereafter is of
01:53:51 but what happened thereafter is of interest because we talk a lot about compartmentation
01:53:59 but it was breached in a very simple way which is often forgotten when one deals with regulations and whether an exterior wall is comprised with compartmentation or not
01:54:11 compartmentation or not and it happened in another case as well that shepherd's court namely the problem there was
01:54:17 there was an open window very
01:54:20 very simple
01:54:22 simple and
01:54:23 and it so happens an open door so we can see that whatever regulations you may have at the end of the day you are dealing with human situations
01:54:35 are dealing with human situations which have to be countenanced because there's often a tendency to think well these files are not very common and and really they're so uncommon that perhaps we don't need to worry too much but and compartmentation is the answer
01:54:48 but and compartmentation is the answer the
01:54:49 the and one can see straight away it may not be
01:54:53 be but what is even more interesting is that what failed there
01:54:59 there this year
01:55:00 this year was a central failing in this case namely
01:55:05 namely the ventilation system didn't work it wasn't triggered by a smoke detector now this is four years after grenfell
01:55:16 and again i'm not being uh particularly critical about this fire this material is in the public domain the london fire brigade have done a public report which one can read about this
01:55:27 one can read about this however
01:55:29 however the smoke
01:55:30 the smoke and the fire the fire traveled up the outside of the building from the 8th to the 11th floor
01:55:38 and it did so because there was inflammable combustible materials on the outside this time not so much the cladding itself but the decking the
01:55:50 the cladding itself but the decking the wooden decking on all the balconies which had been warned about a year before
01:55:58 but was still there now what's happened since i don't know whether it's actually been got rid of or whatever so there was combustible materials known about on the outside of the building on
01:56:09 about on the outside of the building on the inside of the building the ventilation system wasn't triggered so the smoke traveled up many floors above the original starting point of the eighth floor
01:56:22 following on from that before the fire brigade got there did they stay put no they didn't and what is interesting is that in most
01:56:35 and what is interesting is that in most of the fires if not all that one can trace that have happened since grenfell people have not waited to find out
01:56:46 to find out the scenes are emblazoned on all our memories i i dare say and so the instinct we say natural and important is to get out
01:56:58 out 67 people got out
01:57:02 and the fire and rescue service sent more appliances than they did in grenfell and more people were rescued as well
01:57:10 well but some were hospitalized not many
01:57:15 however what is i finish on in relation to this is an important factor and it it it
01:57:20 it echoes and is redolent of what you've already heard namely there'd been another fire two years before
01:57:29 before again you'll get if you if you are not aware i'm sure you are that is a feature of this case only it wasn't two years before it's a long time before in 2010 and i'll come to that in a moment
01:57:41 and i'll come to that in a moment so there was a fire the tenants that this wasn't social housing but it matters not the tenants and residents had already been
01:57:51 been pointing out that there were deficiencies and they were concerns and that is why we we emphasize what has just been said to you about the vital role
01:58:03 you about the vital role that residents and tenants have to play and it's such a vital role that is we submit equally it is a causative factor and
01:58:14 and when
01:58:16 when a colleague adrian
01:58:19 adrian williamson was making his closing submissions in relation to module one he made it very clear that we wouldn't be sitting here
01:58:31 that we wouldn't be sitting here if
01:58:32 if people had listened and not only listened but acted upon what the tenants were saying and also you'll find that echoed
01:58:43 and also you'll find that echoed by
01:58:44 by and i gather certain others are relying on mr todd well it was mr todd who said effectively he wasn't saying it particularly about grenfell but he was saying it about lachen or house that the
01:58:55 saying it about lachen or house that the sixth death there could have been avoided
01:58:58 avoided in the sense he put it rather differently but this essence of what he was saying was basically he felt it was every prospect that they could have been saved
01:59:07 saved if the tenants had been listened to and he said in addition that he'd been saying that for 20 years it's quite apparent that some people
01:59:19 it's quite apparent that some people have not been listening and so whilst it's possible obviously to to relegate tenants which we say is what's happened they have to be made center stage
01:59:31 they have to be made center stage and so the looking at that one fire that's happened this year and of course you'll be aware because of the
01:59:40 the difficulties facing people living in known buildings with combustible material of which there is at least another 400 blocks probably very many more there's no register because people
01:59:53 more there's no register because people are reluctant to obviously indicate what they may have on the outside of the least owners are on the outside of their buildings
02:00:01 buildings so therefore the the centrality of what we're saying is that
02:00:08 that these things can happen again overnight there are other blocks that are susceptible and that this may encourage uh when you're considering this module
02:00:19 uh when you're considering this module perhaps before the end of the inquiry altogether that there are things you might want to say at this stage on an interim basis with regard to how these matters may progress and may has a
02:00:30 these matters may progress and may has a footnote to this say of course we're fully aware that um
02:00:36 that um there is a quarterly review of progress on your recommendations from phase one
02:00:43 phase one and the most recent one in september this year
02:00:46 this year indicated that of course there has been a reappraisal of the stay put policy which i'll have to come back to but it's not an essential feature of what i have to
02:00:58 an essential feature of what i have to say but it is worth noting that it is now recognized even if you have compartmentation that can be compromised
02:01:09 can be compromised with the open window or the open door or for other reasons of which are very familiar
02:01:15 familiar degraded materials or wrong materials in the first place and that therefore that being the case being aware of what's possible through
02:01:27 what's possible through reappraisal of evacuation so you now have the possibility simultaneous evacuation is what happened at providence walk simultaneous partial zonal they're all in the quarterly
02:01:39 zonal they're all in the quarterly review that obviously matters are shifting but these are matters that need to be if i may say so some of them decided rather earlier than the report itself because of the people
02:01:50 the report itself because of the people who are sitting in jeopardy as i speak to you today so may i pass from that example of why it's so important the the issues that
02:02:01 it's so important the the issues that we've raised i i would like to and say straight away that what i'm saying to you is not only tailored to what has already been said this morning it's also tailored to our written
02:02:12 it's also tailored to our written submissions so i'm not going to repeat those word for word at all because that would take another two hours so i'm certainly not intending to do that but i would like to make reference to them just to sort of echo what's
02:02:24 them just to sort of echo what's started in the in the written submissions applies here as well there are some general overview points that uh i i would like to impress upon uh all of you
02:02:35 uh all of you the first one really i can run the two together we say
02:02:42 we say on behalf of the families that the tower grenfell tower was unfit for purpose and we say it was unfit for purpose in
02:02:53 and we say it was unfit for purpose in the sense
02:02:54 the sense that it was not a safe environment
02:02:59 and therefore there should not have been occupancy and we say over actually a rather long time we've put the time as it were frame in the written
02:03:10 as it were frame in the written submissions between 2009
02:03:15 and the fire itself and you may say that is not an arbitrary date
02:03:21 date in fact it's much longer than that but those are dates which are very familiar to you because that's the date or the year
02:03:32 that's the date or the year in which the ceo robert black was appointed
02:03:35 appointed that's the year almost at the same time that the mammalia report is is made and submitted but it is also the time of
02:03:47 but it is also the time of the same year as salvas and all the other things you've heard about so 2009 is a very important year 2010 which i'll be coming to in a moment
02:03:59 2010 which i'll be coming to in a moment of course is the following year but many more things happen after that including a fire at grenfell tower itself so we start with 2009 go up to the fire
02:04:10 so we start with 2009 go up to the fire in relation to the tower itself unfit and
02:04:15 and we can accumulate all the factors but i'm only going to light on one and that is throughout the whole of that time
02:04:24 time there was not a fit for purpose ventilation system
02:04:32 beyond economic repair for most of the time and they knew it by they we adopt the position that our bkc
02:04:43 our bkc and the tmo shared responsibility it really shouldn't take an act of legislation to work this one out because actually if our bake pkc
02:04:55 because actually if our bake pkc effectively the owners of the building they can't delegate everything away to somebody else shut their eyes and say well they're dealing with it sorry the responsibility is jointly shared
02:05:06 responsibility is jointly shared and so therefore the joint responsibility for the unlivability the uninhabitability of grenfell tower lies with that joint authority
02:05:18 that joint authority rbkc and tmo together and we say they weren't fit for purpose either the building wasn't and neither were
02:05:29 the building wasn't and neither were they
02:05:30 they and perhaps it it hardly behaves me now to summarize everything you've been listening to this morning but perhaps just sitting back for one moment basically non-compliance
02:05:41 basically non-compliance with the rro is a starting place the employment of mr stokes we say a disaster
02:05:51 and catastrophic and dangerous for reasons that have been explained that he was reckless with regard to his fras that he was the highest risk when
02:06:03 fras that he was the highest risk when it came to the vulnerable sector of the community that resided in this tower of which we've given details in a schedule already
02:06:13 already so therefore we say there can be little doubt about the unfitness of the tower and the unfitness of that joint authority
02:06:24 authority and they should have faced up to the responsibility and even now they're trying to argue about which of them is really responsible one would have thought by now they'd have worked that out without being
02:06:36 have worked that out without being nudged by regulation so i pass from the unfitness points for the moment to two other related points
02:06:48 to two other related points and these are you you've heard mentioned but we say they come at the top of the overarching um
02:06:56 um if you like precepts that we would ask you to consider firstly there's the the question of mindset is really very important
02:07:05 important a lot is said about it and people acknowledge it but at the end of the day nothing much happens a mindset here is important as i'll come
02:07:17 a mindset here is important as i'll come on to in a moment because it governs how people govern and if you have a mindset that does not include
02:07:27 include health and safety at the top or very near the top as a matter that influences how you approach the building and the community
02:07:38 approach the building and the community living in it then that mindset has to be changed and of course
02:07:44 of course one of the things that the london fire brigade said about the new providence wharf was that the mindset about health and safety has still not shifted not shifted enough
02:07:56 not shifted enough let's talk about it but one needs to see implementation which leads to the last of the four points i'd want to make at the start
02:08:06 the start and this relates to the tenants themselves and we strongly argue uh
02:08:14 uh not just on the back of what mr todd said or what mr williamson said or or for that matter eddie to fund himself but we say it's it's it's an obvious
02:08:25 but we say it's it's it's an obvious feature
02:08:26 feature we say particularly of social housing particularly of i call it the vertical village they're living in the building and if you live in the building you tend to know what's wrong with it you have to be very blind or
02:08:38 you have to be very blind or uninterested not to know what's wrong and once you know what's wrong you want to do usually something about it because it's affecting your daily life and
02:08:49 and that being so you have to make provision to ensure that tenants have not just a voice because we know voices can be
02:09:01 because we know voices can be as you've just been described today can be silenced or can be circumvented or can be marginalized so talking about listening won't be enough they have to be
02:09:13 enough they have to be rather like the mindset you have to change the mindset which becomes embedded in the approach you have to change the role of tenants such that they play a role in decision
02:09:25 such that they play a role in decision and policy making oh some people might find that abhorrent or might find it's not the right place we say quite the opposite interestingly that the mma
02:09:36 that the mma does include a role to be played we say they were right about that but they just didn't implement it so it's not a case just of having a rule you have to make sure that the mindset
02:09:47 you have to make sure that the mindset allows the people who are in charge to ensure that where there is a role to be played and we say there is in decision making as well as listening
02:09:58 in decision making as well as listening because the people are not only living there but as you will see when we just deal with a little bit of detail mr shah's case and i say it once what i say in relation to him he would want it
02:10:10 in relation to him he would want it known and it was known what he was doing was on behalf of all the residents not just the leaseholders he went out of his way to ensure that
02:10:22 to ensure that many of the major requests
02:10:25 requests observations that he were making were signed by residents in the tower and the document i'll come to in a moment is a document at the start of this period 2010
02:10:37 this period 2010 year after and there's another one that comes right at the end in 2017 both of them
02:10:44 of them as it were bookends for this whole period
02:10:47 period written by the gtla exposing the difficulties but they're not just complaints and i appreciate topic one is complaints and i would ask that
02:10:59 and i would ask that that in a sense that
02:11:02 that tenants and residents and occupants are not
02:11:05 not synonymized with complaints because that is what rbk say and others tend to do in other words they're not treated as people who would have a view
02:11:18 treated as people who would have a view about whether it's a technical matter or not well of course if they're not given the information they're certainly not going to be able to give a give a view which of course is the human rights aspect of mr friedman's submissions to
02:11:30 aspect of mr friedman's submissions to you
02:11:31 you so therefore we say when you begin to look at what the the detail
02:11:37 detail of what residents were saying this wasn't just about the color of the wallpaper if there was any nor was it about this just about the signage on the stairs this this was
02:11:49 signage on the stairs this this was these were people who were thinking about how to make their environment habitable for themselves and of course anyone else who should visit or anyone
02:12:01 anyone else who should visit or anyone else who happens to move in so it's about a community and about construction and about positive ideas it isn't about negativity
02:12:12 negativity and of course that ar that concept that way in which they're characterized as negative and negative influence has to change and it can only change we
02:12:23 has to change and it can only change we say
02:12:24 say if in fact it is they are given an embedded
02:12:28 embedded role to play and they cannot be ignored and they have access to information and they have access to decisions and they can make a difference so we say those are important
02:12:40 are important four points we make at the start just before i move to some of the detail as a background to this we say that
02:12:50 that all of this that's the the question of mindset
02:12:54 mindset the question of approach is political in other words one has to look back at the period and i opened it in my very first opening to you
02:13:05 first opening to you my second opening to you and now in this closing it's going to come up in the next module which starts after we've been speaking although not immediately
02:13:16 although not immediately and that is of course that mindset
02:13:20 mindset and i adopt what's been said this morning
02:13:22 morning comes from the top and we all know who was on the top during this period that we're dealing with
02:13:31 with and it was of course a government led by david cameron and he made very specific suggestions about health and safety and killing it off if you set that agenda if you make set
02:13:44 if you set that agenda if you make set that mental environment it's hardly surprising that further down either consciously or unconsciously
02:13:55 or unconsciously the mindset said say oh well health and safety it
02:13:59 safety it gets in the way we don't want to risk adverse society let's just take the risk and make the money so in order to overcome that and we we
02:14:11 so in order to overcome that and we we would
02:14:12 would sincerely hope that questions should be put to david cameron right here about that because it is causative of a mindset the mindset
02:14:25 of a mindset the mindset then has a knock-on effect to
02:14:28 to how residents were treated now before actually dealing with the 2010
02:14:35 2010 example
02:14:37 example there are just a couple of other observations as a kind of preface which originally was going to be in the written opening but there wasn't enough
02:14:48 written opening but there wasn't enough space
02:14:50 space prior to examining some of the detail there are some overriding precautionary observations which are crystallized throughout modules all the modules in fact in phase two principally
02:15:02 principally legislation regulation rules guidance advice is only as good as those who wield the authority it's redolent of what i've just been saying at all level in other words despite the
02:15:14 at all level in other words despite the framework that pertained relating to grenfell tower and its maintenance however deficient it was at the time the disaster was brought about by those who cared not
02:15:25 who cared not and still don't to those who thought lies were their business and laughed witnesses who without exception refused to testify
02:15:38 refused to testify before you and the families without an undertaking
02:15:46 this was the whole point of the family's questions that team two
02:15:53 team two repeatedly requested to be put to at the end of a witness's testimony and it may have been wondered why this was so and i paused for a minute
02:16:04 was so and i paused for a minute because if you were i'm not going to name this person because i think he he will be familiar he lost six members of his family
02:16:16 he lost six members of his family and he's one of the people he's not the only one
02:16:19 only one who felt it important that here in this inquiry which is not just about bricks and mortar but is about families and what they were struggling against
02:16:31 and what they were struggling against that this was going to provide an opportunity for the witnesses who wouldn't come otherwise to answer questions without the undertaking
02:16:42 the undertaking of the kind that what would you have done differently or
02:16:48 or what should have been done differently is there anything you wish to add to your evidence is there anything you'd like to say to the families
02:16:59 the families now
02:16:59 now of course at one point one might think well
02:17:02 well we're not here really to ask witnesses those questions but in our submission it's a relevant question because you're trying to assess whether a
02:17:14 you're trying to assess whether a mindset has changed a mindset begins to change when the people responsible through the rro the joint authority
02:17:26 through the rro the joint authority have the courage to come here and say something along the lines yes you're right we should have done this
02:17:38 you're right we should have done this we should have done that and i'm sorry that i didn't and look at the families sitting here and look them in the eye and that's what they wanted because only then do you begin to see
02:17:50 because only then do you begin to see things have changed that's that's the importance of we say of questions of this kind
02:17:56 this kind and you can look back on this inquiry and
02:17:59 and on the occasions when the questions were put of a kind how many witnesses in this module or any other
02:18:07 other previous two how many witnesses had that courage had that responsibility to admit the responsibility and
02:18:18 to admit the responsibility and to apologize we say you can count them on the fingers of one hand and in the view of the undertaking that has been given to them the families find that quite shocking
02:18:30 the families find that quite shocking and it may be we say an interesting way of measuring where where one is going with regard uh
02:18:39 uh to this aspect and
02:18:41 and in a way the what what the families have been doing before this inquiry
02:18:50 and in order to illustrate the centrality of tenants it was told in a film that was shown in september i i think
02:18:58 i i think the panel was made aware of it grenfell the untold story now what is important about that film is you see
02:19:09 is you see for yourselves in a contemporary film exactly what it was that was going on because although it was commissioned by rbkc no doubt in the
02:19:23 rbkc no doubt in the in the hope that it might manifest a rather different complexion but it didn't because what it showed and some of the people in the film i'm afraid died in the fire
02:19:37 was them having to remonstrate with peter madison
02:19:45 the victoria bulwick the local mp came to as it were mediate between the two but you could see the frustration you could see the irritation
02:19:57 you could see the irritation they were raising not minor matters at all they were raising window frames that didn't fit you could stick your arm while they're exaggerating stick your arm through the gap but you heard in phase one about gaps in windows and so
02:20:09 phase one about gaps in windows and so on they were raising all sorts of issues that were important like that
02:20:16 that and they were getting and you watch the film you see the reaction implacable there's a resistance the body language is there
02:20:27 the body language is there rbkc
02:20:30 rbkc didn't really want to know they were engaging for the purposes of a pr film and by the end of it of course it was clear
02:20:39 clear that that
02:20:40 that that intention hadn't been achieved however one of the aspects of the film
02:20:46 which is important is that it was introduced and almost framed by a small boy again i'm going to avoid names but the
02:20:58 again i'm going to avoid names but the aunt of this young boy
02:21:02 young boy gave evidence in phase one
02:21:06 he died he's one of 17 children who did die
02:21:12 die because their vulnerabilities it's a protective characteristic of course
02:21:17 of course and children often don't get the attention that they deserve in a health and safety context never mind in others i won't repeat it here but in our
02:21:28 i won't repeat it here but in our written submissions we have devoted quite a lot of time to the provisions both
02:21:36 both in terms of the international provisions and conventions that cover the rights of the child which have been implemented in domestic legislation so it's interesting that that film shows
02:21:47 so it's interesting that that film shows the struggle in a sense through the child talking about
02:21:54 about his experiences of the tar and drawing it in crayons on a wall and then the the adults attempting to get matters changed in
02:22:05 attempting to get matters changed in film was
02:22:06 film was 2015. so it's during the refurbishment period
02:22:13 so that's enough in a sense on on introductory matters what i would like to do as the says that you have an idea of the scheme and i will endeavor to well i will do it by one o'clock but
02:22:25 one o'clock but basically the book ends are the 2010 fire and the letter that was written then it's been mentioned before but its detail has not really been well you may i can't presume that you
02:22:36 well you may i can't presume that you haven't read it at some point but it's easy to forget amongst the thousands of documents here and
02:22:44 and i would start with that particular letter and i'm going to i have alerted those who are going to put the sections up so you can see it on screen rather than not but i'll come to that in
02:22:55 rather than not but i'll come to that in just one moment but before i do may i say we welcome
02:23:01 what appears to be rbkc's acknowledgement about this matter that is the 2010 fire and the 2010 letter
02:23:14 and the 2010 letter [Music]
02:23:16 [Music] and this is what it how it reads at the moment it's very short i just read it out because it vindicates everything that we've been saying that mr shah shah ahmed more
02:23:29 saying that mr shah shah ahmed more particularly has been saying but it's taken all this time before a recognition that this fire and what he had to say not just about the fire but other
02:23:40 not just about the fire but other matters
02:23:41 matters have an important part so they go on to say
02:23:45 say that in relation to shah's 2010 letter the response from anthony parks understated the seriousness of the problems i posed there
02:23:57 problems i posed there understated misled
02:24:01 misled it was a misrepresentation with the smoke control system the result was that an opportunity to learn from those who experienced the april 2010
02:24:14 those who experienced the april 2010 was missed
02:24:17 i pause we welcome this and what one doesn't want to be meanly mounted about it obviously we do welcome that however
02:24:25 however the bigger question is why was it missed why was it missed it was written out in black and white and referred to more than once the
02:24:36 and referred to more than once the attitude of rbkc tmo
02:24:41 rbkc tmo was virtually to deny the fire even existed
02:24:46 existed and we'll come to a moment in mr black's evidence
02:24:50 evidence if i just pause for a minute i'll interpose it now
02:24:55 you may not have noticed it's easy to overlook it but when he first entered the witness box he said something particularly and singularly appropriate
02:25:06 singularly appropriate he'd obviously look carefully by this stage at what he'd already said and what he'd already said was effectively
02:25:18 effectively that there had not been any complaints about fire safety in his statement entirely wrong
02:25:29 entirely wrong and the letters one of them were many more than that but much more important he'd omitted any reference in any of his written statements to the 2010 fire
02:25:41 statements to the 2010 fire they missed the fire i don't think so it it's again illustrative of an attitude that just writes it off
02:25:52 of an attitude that just writes it off oh it's minor it doesn't matter a bit of smoke here and there and one doesn't want to exaggerate it but that does appear to be the situation otherwise how do you miss
02:26:03 the situation otherwise how do you miss something like this you miss it because you're really not that interested and maybe that's what the concession is making the gtla i carry on with the recognition had been set up because
02:26:16 had been set up because leaseholders had lost confidence in the tmo black accepted in oral evidence that the tmo's response to the april 2010 fire gave gtl members further reason to lose trust in the tmo
02:26:29 lose trust in the tmo now we we
02:26:31 now we we are very grateful for that but there's more to it than that
02:26:36 than that and the more to it may i just uh begin the process i'll try and speed it up so otherwise it'll take too long um could we have on screen please
02:26:47 please the first page of the letter
02:26:50 letter that was sent in relation to this fire which had happened in april 2010 it was sent in september 2010 and i'll give the reference which i hope
02:27:02 and i'll give the reference which i hope the operator has it's tmo one zero zero three seven four three nine
02:27:08 nine underscore zero zero one ah yes thank you
02:27:13 you now you
02:27:16 now you if i'm running out of time i'll just cut it short but basically you will see here this is 2010 patients had run out by this time
02:27:29 patients had run out by this time the time of this letter never mind the response to this letter which was i put it bluntly dishonest uh not by mr black as it happened but by mr parks and he was asked about this
02:27:41 mr parks and he was asked about this but one will see straight away that what's happened is that a perfectly legitimate organization with perfectly responsible people had decided that the only way they could get
02:27:52 decided that the only way they could get their message across is to write to the key people anthony parks the director of finance and so on you can see the names there i don't read them all out so
02:28:02 so and then it goes into some points here which are important because of another document we received a written response response dated the 20th of august 2010 from
02:28:13 dated the 20th of august 2010 from daniel wood from the head of home ownership however we were expecting a direct response either from you that's mr black who'd been appointed in 2009 for the simple fact you
02:28:25 for the simple fact you mr black originally made the commitment to look into our issues and concerns in fact he hadn't mr wood in effect refuted and flatly ignored our long-suffering and serious
02:28:36 ignored our long-suffering and serious issues
02:28:37 issues so this is before 2010 obviously and 2009 for that matter this demonstrates his head of home ownership he's not aware of the reality of the situation at grenfell tower and he's out of touch as to what's going on
02:28:49 he's out of touch as to what's going on it seems he's based his response on what appears to be common answers if we simply take the issue of block aesthetics it's clear to see how grenfell tower has been neglected for decades
02:29:01 decades the letter we received indicates the tmo does not adhere to its promise of being a tenant-led organization and then he goes on to deal with other matters
02:29:12 matters may i pause there and ask if if we can have um
02:29:17 have um on screen something that is extremely important in the light of that what he was saying could we have in fact it's been mentioned in passing many times and again this morning
02:29:28 again this morning but the mamoli report please or at least not the whole of it it's the recommendations which i think should be iws
02:29:41 iws four zeroes one four six two slash forty three
02:29:45 three and it's attached to ahmed statement in fact we have the recommendations please
02:29:59 now that maybe that that's
02:30:04 i can deal with it without it going on screen well it might just take a moment to see
02:30:14 i'm only going to put on screen there's documents that we feel do need to be
02:30:21 underscored somewhat
02:30:31 well may i proceed so not to waste any time what i will do is indicate what i'm reading from which is the only the recommendations section of the mamoli report
02:30:42 report which is on the page i've indicated but it may be difficult to find we did provide these in advance but it i understand the difficulties so in the recommendations section
02:30:54 so in the recommendations section there are a number of headings so i'm not going to read the whole of it take too long but there are important observations this is being said in
02:31:03 in 2009 april the time that mr black is appointed as the ceo we mention it because hardly anybody admitted knowing much
02:31:14 hardly anybody admitted knowing much about it including mr black and the leader of the council they sort of heard of it or seen it but they hadn't read it or
02:31:24 or they've been encouraged to as has been pointed out today to really downplay it no wonder it wasn't accepted no wonder it wasn't acted on
02:31:36 it wasn't acted on because it's counter to the culture of the rbkc tmo that's why the culture we've already described and this is what the first heading says customer care
02:31:49 the first heading says customer care by maria mamoli's report customer care pr communication training and development first recommendation the very first one for there to be a process of mediation
02:32:00 for there to be a process of mediation conciliation to build relationships with aggrieved residents and the tmo relationships between certain factions of the residents and the tmo have broken
02:32:11 of the residents and the tmo have broken down irretrievably only an independent process can intervene to try and improve relations that's how bad it was
02:32:22 that's how bad it was in 2009-10 and it was highlighted and it was highlighted to the effect that there should be an independent element
02:32:33 element in the retrieval of the situation and quite rightly because we
02:32:40 we would
02:32:41 would uh interpret here an understanding by mammalia herself that she could not leave it to the tmo or the rbkc to improve relations
02:32:52 the tmo or the rbkc to improve relations and when you watch what's happened since she was right a second recommendation a customer care training program especially for frontline staff whether full-time part-time or temporary all the staff at
02:33:04 part-time or temporary all the staff at tmo should greet and meet residents with the utmost respect and courtesy and always show willing to assist residents in their inquiries and be prepared to take on responsibility for acting on
02:33:17 take on responsibility for acting on those inquiries i hope that doesn't encourage too many rather wry smiles when one reads that and then looks at what actually happened after 2009 2010 and all the way through
02:33:30 after 2009 2010 and all the way through that certainly it could not be said and i'm not going to name particular witnesses from rbk ctmo
02:33:37 ctmo that there wasn't undoubtedly an attitude of hostility uh towards the residents and almost regarded to saw some sort of fee feeble fanaticism
02:33:49 fee feeble fanaticism they were demonized in that way so
02:33:53 so it doesn't reflect this recommendation third recommendation tmo staff appraisals to reinforce customer care and respect for residents and their roles and responsibility both within the
02:34:06 roles and responsibility both within the organization towards residents fourth a re-examination of the core principles of the tmo conduct a skills audit of staff to ensure they have core competency
02:34:17 competency i'm missing out some of it and that that there's a full complement of permanent full-time or part-time skilled staff for continuity and to make use of the long-term consultants in short an
02:34:28 long-term consultants in short an investment in people i mean this we say is
02:34:34 we say is absolutely spot on she's hit the nail on every single occasion
02:34:40 occasion and
02:34:42 and i'll summarize the remaining ones on this page a more proactive approach to be taken by staff and their contractors to share information my goodness that is a situation which i think mr
02:34:54 that is a situation which i think mr ahmed and others and eddie dufan was seeking information so they can no throughout the whole of this period mr ahmed didn't know about the
02:35:07 ahmed didn't know about the the fras they weren't shared with him he didn't know about mr stokes why don't they share it well
02:35:15 well one has a ready answer in the case of mr stokes they probably weren't uh too keen for him to be examined closely so you haven't seen i haven't finished that i'm just saying this is just the first seven
02:35:26 just saying this is just the first seven recommendations but there's a heading dealing with the complaints procedures and how that should be rectified governance and oversight particularly oversight of performance
02:35:38 particularly oversight of performance it's already been referred to but also just one final reference to a heading which is important and that is major works and repairs
02:35:49 and that is major works and repairs which of course occurred after this report the council as freeholder to take more of a proactive role in the monitoring of major works contracts and cyclical repairs and
02:36:01 works contracts and cyclical repairs and to be robust in checking the tmos performance under the mma 2006 couldn't be clearer who's listening
02:36:13 who's listening we say it's certainly not rbkc or tmo that's why we say this was parked this report rather like the film they commissioned they probably didn't like the result
02:36:25 they probably didn't like the result rather like this report with daily commission they didn't like the result and so like the residents it was essentially ignored and put into there were all sorts of robust
02:36:36 there were all sorts of robust monitoring suggestions tightening up procedure regular structural service you read through it it is an indictment in itself of why this letter starting as it did if
02:36:47 of why this letter starting as it did if we could kindly go back i'm sorry to dart back and forth a bit but to go back to the letter itself tmo one zero zero oh thank you very much
02:36:58 tmo one zero zero oh thank you very much there it is that's why the beginning of this letter is the tip of an iceberg because uh as shah ahmed said he was aware of the mammalia report himself even if uh
02:37:11 the mammalia report himself even if uh mr black and the deputy leader of the council fielding mellon didn't know or didn't take it on board so may i then
02:37:22 so may i then ask to go to the next page which should be well underscored yes heating yes right at the top so this is the second page of this letter so i'm
02:37:34 the second page of this letter so i'm not going to go through the many many headings here and they're they're not they can't be categorized as complaints that they can be categorized as participatory in
02:37:45 participatory in informed as far as they were issues to do with tenants as a whole not just the leaseholders anyway at the top secondly we will argue that the recent
02:37:56 secondly we will argue that the recent fire at grenfell tower has raised so many
02:38:00 many health and safety issues with the building
02:38:03 building that it demands an independent investigation and inquiry into the safety of the building i'll read the rest of this safe keep going back to the page
02:38:14 going back to the page will raider points about the school i don't trouble you with we are fully committed to resolve every issue we raised in our letter dated the 28th of july again that's available should you wish to see
02:38:25 that's available should you wish to see it
02:38:26 it amicably
02:38:28 amicably these aren't febrile revolutionaries of any kind these are concerned citizens because it is to do with our homes
02:38:40 because it is to do with our homes well-beings health safety and above all of course unnecessary financial hardship which may be imposed particularly on leaseholders now pause because the one at the top is
02:38:52 now pause because the one at the top is important independent investigation and why we say this is important for a number of reasons
02:39:00 reasons and it may be at the time mr ahmed hadn't really necessarily thought all of them through but he does come back to them later but the central point is
02:39:11 but the central point is because he was unaware of what was going on within the council and the fras and the assessor himself he quite rightly was saying we want an independent investigation
02:39:23 investigation had there been and this is why we say we might not have been sitting here if the council had listened to this and acted on it of course they never in
02:39:35 and acted on it of course they never in a month or sundays were going to do it because they were protecting what was already in place which was
02:39:42 which was unsuitable and insufficient and
02:39:47 and we say that had there been an independent investigation perhaps i don't need with the time constraints rehearse
02:39:54 rehearse all the comments that have been made about mr stokes reckless
02:40:01 reckless and the extent to which he endangered particularly those with protected characteristics one only has to think back to his giving evidence
02:40:13 his giving evidence and the very careful examination by mr millet of him and his nominals and brian stokes and associates what associates and connie
02:40:27 one he's tempted to say sham from start to finish
02:40:32 finish he hasn't got any associates he's not peer reviewed
02:40:36 and and i know the families are very anxious that in the future fire risk assessors are so central to what is happening
02:40:47 to what is happening that they must be and it's already been said so i don't say i say it very quickly they have to be qualified they have to be experienced and if they haven't got the experience that is needed then they better get it or
02:40:58 needed then they better get it or ask for advisors to come in so for example
02:41:01 example when mr stokes eventually was asked about the cladding instead of finding you know just asking a question third hand he might be capable of looking at the outside of a building because as you said yourself at
02:41:13 building because as you said yourself at one point
02:41:15 one point it doesn't need the ff the the rro to come to this conclusion if you're a fire risk assessor what do you think you've got to assess well you've got to assess
02:41:26 you've got to assess possible sources of a fire and you say well i look at the whole building but i won't look at the outside seems a bit odd doesn't sound very common sensical never mind the rules for
02:41:38 common sensical never mind the rules for the moment we say the rules did include the facade however
02:41:42 however um we we're not going to spend scholastic time on the uh on a pinhead to work out that it would be necessary to look at sources
02:41:53 sources and sources of a fire and then spread of a fire
02:41:57 a fire and then how you escape from that you put put it very simply that's it that's what they've got to do and it's absolutely vital that you get the proper advice about all of these stages which
02:42:08 advice about all of these stages which you so
02:42:09 you so succinctly summarized as the job of a fire risk assessor and in fact if we'll see in this letter what was happening was that shah ahmed had become the fire risk assessor as
02:42:21 had become the fire risk assessor as best he could be suggesting things that had to change and he was performing the rule and the role
02:42:30 role of
02:42:31 of of supervision scrutiny because it wasn't happening within our bkc and he had a he had a particular motive of course he's a leaseholder he's responsible to them for
02:42:43 leaseholder he's responsible to them for money being spent on
02:42:45 on matters related to the tower itself whether it be safety or not so he was doing this role himself essentially but he wasn't alone because as i said he was acting on behalf of
02:42:58 as i said he was acting on behalf of others
02:43:00 others in the town nearly all the people in the tower at the end and even that was belittled oh well somehow or another was suggestion that he what he and and mr defana pressured people into signing
02:43:11 defana pressured people into signing these petitions no it's the same story all along that if you come up with a petition well it's not a legitimate one if you come up with an idea well it's him he's on about
02:43:23 with an idea well it's him he's on about that again one of mr blacks the sides is it that old stuff again so what one sees that mindset is the theme that runs through the whole of
02:43:35 theme that runs through the whole of this but there's another reason why this particular sentence is important and i hope it doesn't stray too far because you see this letter is broad in its remit itself it's not
02:43:48 is broad in its remit itself it's not just about um
02:43:50 um you know the door hand handle let alone the closest because this deals with inspections appreciate uh you've been dealing with
02:44:02 uh you've been dealing with module
02:44:03 module five and there's other modules to come but
02:44:08 and we've put it in written submissions it comes at the end we put reflections on
02:44:14 on principled priorities we call it so we haven't framed them as a recommendation although there will be before the end we will try and put into one document recommendations throughout
02:44:26 one document recommendations throughout but i raise it now because it links to this
02:44:30 this if there had been an authorized independent expect inspectorate of fire safety then
02:44:42 then it would have hopefully it's another as it were safeguard
02:44:48 safeguard been detected if there'd been an inspection of the bill independent of the fire brigade independent of the council and that is in fact um just briefly looking at the bill
02:45:00 just briefly looking at the bill building safety legislation that is going through at the moment inspectors of the built environment are now countenanced and we would welcome that and we would
02:45:11 and we would welcome that and we would welcome your you and your colleagues observations on how the inspectorate should work because we think
02:45:18 we think that uh shah ahmed in this just this one paragraph put his finger exactly on what was needed and this is not the only time he raises it i'm not going to mention all the other times we'll come to one
02:45:29 all the other times we'll come to one other time in a moment the letter that comes at the end of this period so
02:45:35 so in inspectorate then could we turn to the next page which is three safety security and reception services now
02:45:49 it has a again repercussions for now in the future
02:45:56 uh he's talking about security guards for a number of reasons and they're not doing their job but the second paragraph the incident of the fire at grenfell tower is a perfect
02:46:08 the fire at grenfell tower is a perfect example of how security guards are inept at fulfilling their duty when the fire alarm was ringing in the reception area which is one of the few areas where it was and the lift was automatically out of
02:46:21 and the lift was automatically out of service the security guard was unaware of what was happening she didn't advise people to avoid using the staircase and didn't take control of the situation we're confident
02:46:32 we're confident that if you were able to review cctv coverage
02:46:36 coverage footage sorry of the event you would be able to note the fact that she actually opens the door to provide access to the staircase
02:46:45 staircase for a resident of the building to use the staircase to reach his flat this is despite the fact staircases were filled with smoke but she was oblivious to this fact so one can imagine the seriousness of the situation she put individuals
02:46:56 of the situation she put individuals life in danger and this resembles serious negligence by incompetent security staff and the tmo has to bear the responsibility your eye might be caught just in the
02:47:08 your eye might be caught just in the next paragraph there's a sentence a patrol log should be written noting any such behavior that's anti-social behavior and safety issues such as flooring dry rises
02:47:22 such as flooring dry rises now dry rises is a point that you will recall
02:47:25 recall it was blocked between 2013 2014 so again he had a point he didn't know that but that's being blocked or any general maintenance work so i pause there on this page because
02:47:37 so i pause there on this page because the significance of this is
02:47:41 it's again in our principled priorities it's again a sort of theme that he mr ahmed and others have brought up and it relates to peeps as well
02:47:54 so may i extrapolate as to what the essence of this is it is in fact where you have a high-rise block where you have difficulties with
02:48:05 where you have difficulties with um
02:48:06 um people in the block who are not going to be able to as it were evacuate very quickly or at all by themselves are going to need help
02:48:16 help who's going to help them
02:48:19 and we say of course a misleading statement saying oh we'll evacuate the bloc that wasn't true they weren't going to be able to do that
02:48:30 be able to do that the only way you can begin to think about the possibility of
02:48:36 of as it were affording safety to the tenants and the occupants is that there is somebody a concierge who is on duty not just ticking off and falling asleep
02:48:47 not just ticking off and falling asleep but someone who's actually qualified in fire safety so as he's got here patrols the building these are constructive suggestions that
02:48:58 that residents were making patrol the building yes absolutely and not just see whether there's a bit of litter on the floor or worse but actually are things working
02:49:10 are things working they have to be trained to do this of course
02:49:12 course but then you begin to get practical answers
02:49:15 answers to the the say and that's why the residents and i'm using the prism of the residents to illustrate the things that have to be done this is one person's narrative
02:49:25 narrative of
02:49:27 of reflecting the thoughts of many others who live in the tower so one a concierge would be in a position to supplement and implement safety in
02:49:39 supplement and implement safety in future
02:49:40 future particularly with regard to the vulnerable but also with regard to safety
02:49:44 safety all we had from witnesses well if i happen to notice something i might do something about it no it has to be there has to be
02:49:52 has to be a fire safety strategy of which there wasn't one and no doubt had there been an impen independent investigation they might have actually uncovered that there
02:50:03 have actually uncovered that there wasn't a strategy in place a holistic strategy an integrated strategy part of which of course is repairs door closes and all the rest of it is also ensuring
02:50:15 and all the rest of it is also ensuring that you've made provision on the ground with somebody who's able to assist so i think probably the point is made as clearly as possible now
02:50:26 now could i ask now for the next page
02:50:37 the next page has two headings of importance yes consultation and summary of costs
02:50:42 of costs consultations is another issue again these are all paragraphs that have not been read out before as we mentioned in our earlier lesson we must be consulted
02:50:54 must be consulted in detail in relation to any major work and he cites rightly the 1985 landlord and tenant act and common hold and leasehold reform act
02:51:05 and common hold and leasehold reform act 2002 section 153 and so on that's to do with service charges we need to be notified and so on because that's linked cost
02:51:14 cost but he was on to a much bigger issue of course
02:51:18 of course the issue of consultation of which you've heard a great deal of which we say should be central not just decision making or listening but actual consultation and if if i may just elaborate a little
02:51:31 and if if i may just elaborate a little more because mr friedman has already touched on it but it couldn't get worse than this
02:51:39 and it links to the mma it contained provisions this module agreement and which is why we say you've got to have the right people as well as the right provisions
02:51:50 right provisions contained provisions which if implemented would have ensured that the residents were at the heart of decision-making decision-making during the refurbishment
02:52:01 the refurbishment including establishing a client review group
02:52:04 group chaired by a representative of the residents association to act as the client for the project just imagine for a moment the client of the project
02:52:15 a moment the client of the project rather than the one that they had
02:52:19 and a representation of residents on the project team involvement in the appointment of consultants exactly a point that mr albert was making and others about the appointment of architects and so on
02:52:31 appointment of architects and so on including architects representation at site meetings rbk ctmo completely ignored these obligations and although it's now admitted
02:52:43 and although it's now admitted uh
02:52:45 uh it's it's difficult to really excuse it because these were obvious obligations mentioned in mamoli so we say flagrant
02:52:56 so we say flagrant omissions by rbkc and when mr madison took over responsibility for the project he's fully aware that there'd been a failure to engage residents and his wordings were inadequate and intermittent communication has also
02:53:08 intermittent communication has also given residents cause for distrust and they've resorted to making foi requests to obtain information just imagine they believe has been denied them well they were right had been denied them not
02:53:19 they were right had been denied them not believed they were right had been denied the tmo chose not to have public meetings giving excuses about some people who spoke rather more loudly than others
02:53:30 others primarily relying on newsletters to update residents on progress these were actively misleading zinc was consistently identified as the cladding material and residents were
02:53:41 cladding material and residents were never told that acm was to be used so again it's the point you've heard this morning it is about non-disclosure it is about non-transparency
02:53:53 non-transparency and essentially the human right if you're going to protect a human right you need the information these
02:54:00 these these were act actively uh misleading statements i don't need to perhaps go um further except to also mention
02:54:08 mention uh hius the units that were residents were misled about where they were going to be they weren't consulted that's also in the film untold story of grenfell
02:54:19 grenfell so therefore that paragraph is extremely important
02:54:26 we then come to a long paragraph and perhaps given the time uh i won't read all of it but i think that
02:54:33 that three paragraphs here that are acutely important back in 2010 as we mentioned
02:54:40 mentioned in our previous letter prior to 2005 the suffering of the residence due to lift malfunctioning was caused by inadequate services and maintenance provided by the tmo
02:54:53 provided by the tmo we agree 100 is right to replace the lifts when their useful life came to an end what we're unhappy about is your choice of contractor which was hired to carry out the work every resident is aware of the fact it
02:55:05 every resident is aware of the fact it took about a year and a half to replace the two lifts and so on and he goes on about poor management in relation to installation as well as maintenance
02:55:16 installation as well as maintenance we are also shocked to hear that your lift engineers have told you that the response time for lift repairs is normally two hours and four hours out of normal hours this is simply not the case we've experienced a lift being out of
02:55:27 we've experienced a lift being out of service for a week far more than your suggested two or four hours
02:55:32 hours and he talks about being trapped other people being trapped in the lift now lyft is a perennial theme you've heard it many times all the way through 2009 all the way through even after
02:55:45 2009 all the way through even after refurbishment because when the fire brigade come as uh stephanie barwise indicated possibly because they got the wrong key lifts were always a problem
02:55:57 lifts were always a problem what was at the heart of the lifts situation well i think it was mr stokes was partly he didn't know what a firefighting lift was
02:56:06 was this comes from mr todd himself
02:56:10 and mr todd went on in a sense using your invitation to be frank about it he still doesn't know
02:56:22 doesn't know he still doesn't know and then one wonders why he gets classed as dangerous because in a building of this height that has to be a compliant
02:56:34 a compliant fire fighting evacuation lift because it's one of the many as it were systems that make a package of safety and yet
02:56:45 and yet 2017 still hadn't got there so you see that when he raised this issue and could we turn over the page quickly because at the top of the next page
02:56:57 right at the top of that page the new lift paragraph the new lift was installed about five years ago resulting in hefty bills for these soldiers but if you look at the condition of the lift now they look as though they've been
02:57:08 now they look as though they've been used for over 20 years dire need of maintenance half the buttons no longer light up the inside of the lift is scratched in several places the doors of one lift take a lot longer to close than the other
02:57:19 to close than the other this is all due to poor maintenance as misuse i mean this is the refrain maintenance maintenance because there was no system no proper system of follow-ups and so on
02:57:30 no proper system of follow-ups and so on and of course an inspection might have revealed that might also have revealed the backlog huge backlog of repairs uh and fras that hadn't been actioned
02:57:42 uh and fras that hadn't been actioned why because there wasn't a system and all that mr stokes does go so long enough and doesn't follow it up no follow-ups nothing so
02:57:50 so again this doesn't require legislation or it shouldn't one would imagine that if you're doing a job in which you're saying
02:57:57 saying x is wrong next time you go you want to find out whether x is right and if it isn't right why isn't it right but this kind of approach to fire and safety doesn't seem to have percolated through
02:58:08 through now may i just turn quickly those common parts electricity is the
02:58:15 uh and
02:58:19 yeah common parts electricity this is important as well because it's another factor which he's lighted upon
02:58:26 and this is very important what he what he constructs it's very constructive proposals
02:58:31 proposals it is understandable that areas that are not naturally lit will need lighting such as the fire escape and shoot room it is is it not conceivable and reasonable idea to put in motion sensor
02:58:42 reasonable idea to put in motion sensor lighting in the shoot rooms and in the in between landings of the fire escape a stairwell that way the shoot room light will only come on once it is you in use
02:58:53 will only come on once it is you in use then 20 or so floors will have lighting 24 hours a day throughout the st throughout on their stairwell with the in-between floors being lit only when in use this would not only help the leaseholders
02:59:04 would not only help the leaseholders financially but also environmentally friendly
02:59:08 friendly well he's right about the lighting because when the report eventually came 2014 you will recall 25 of the
02:59:17 of the luminaries as they were called illuminaes didn't work so
02:59:22 so he he's again put his finger it's lifts and so on and of course we get to the key passage
02:59:30 passage at the bottom of this page fire alarm and health and i'm going to just read some of this because it's very right at the bottom thank you very much far alarm and health and safety we're
02:59:42 far alarm and health and safety we're very shocked to learn from you that you considered the defects in the building exposed by the fire as a minor fault when it had it had potentially fatal consequences the minor fault caused so
02:59:53 consequences the minor fault caused so much damage to individuals living in grenfell it's difficult to imagine how serious an event has to be for you to consider it a major fault if the fire alarm system is not functioning and the vents are not
03:00:04 functioning and the vents are not working then it should be considered no doubt as a major fault they are useless measures to save lives so they're not working then obviously you're endangering the lives of the residents well he's right that's why we
03:00:15 residents well he's right that's why we say from 2009 onwards it was not safe not a safe building and he goes on to deal but before i leave this page may i just reflect on
03:00:26 leave this page may i just reflect on one thing he's already said but in the context of lighting i say it now because of uh trying to bring forward matters that we put later you'll see reference to the shoot in the
03:00:38 you'll see reference to the shoot in the common parts electricity section before we turn over the page in the middle of that paragraph lighting in the shoot rooms
03:00:45 rooms now i don't know and it's none of our business whether you have all had an opportunity to go up the tower and we hope that at some stage you have managed to do that and i'm going to insert this because
03:00:57 and i'm going to insert this because what struck some of us and this is in a sense giving evidence but others have seen it when you went up the tower there were interesting spaces on every floor
03:01:09 interesting spaces on every floor which had been untouched by fire they were the shoot rooms and why were the shoot ones rooms protected because they had a metal door there was only one where the door had been left open where the pharah got in
03:01:22 been left open where the pharah got in and
03:01:23 and we say although that wasn't the purpose of him putting shoot rooms in there he may not have thought about it but
03:01:30 but one of the principal priorities we want considering here
03:01:36 here is if
03:01:37 is if we appreciate in new buildings there are areas called safe havens which another if you like protective measure particularly in commercial buildings
03:01:48 particularly in commercial buildings well why not residential buildings as well
03:01:51 well safe haven so if you are stuck on an upper floor it may be the only chance of survival is a is not a shoot room as such but a safe haven
03:02:01 haven of the kind that could have been adapted here
03:02:05 here needs a little bit of imagination and a little bit of provision in order to do that so i mentioned it because uh it was a feature of the tower when everybody
03:02:16 a feature of the tower when everybody went up and assumes the doors are still there
03:02:19 there however moving back to this letter over the page
03:02:25 he's uh i'm on page six now at the top we are certain that out of 120 families living in the block no one is aware of the evacuation procedure
03:02:35 procedure we have never had an evacuation procedure booklet sent to us for the past 36 years
03:02:45 and it's we say stunning that it's quite as bad as this is it not necessary by law to test the fire alarm and associated equipment on a regular basis to check whether the system is fully
03:02:56 to check whether the system is fully functional and then he talks about many people couldn't hear the alarm that that that did go off and they weren't aware of the fire
03:03:04 fire and then
03:03:05 and then a passage which i have read before but i just that was in opening i don't i ask you to mark it up as you know fire does not kill
03:03:14 not kill as much as the effects of smoke and the devastating consequences and to our knowledge some of the residents nearly died this is the april fire due to smoke inhalation and suffocation on top of this many
03:03:26 suffocation on top of this many residents found the whole experience traumatic and mentally damaged in damaging and then it compares what hammersmith had done so again
03:03:37 what hammersmith had done so again he has
03:03:38 he has on behalf of residents and other residents put his finger exactly on what the problem was and this is in the absence of cladding this was a fire that had nothing to do with cladding this is a this was a fire to do
03:03:49 this is a this was a fire to do with
03:03:50 with um i think it was rubbish on a higher floor which spread above that internally irrespective of compartmentation
03:04:02 irrespective of compartmentation so it was a situation they should have been looking into but they were regarding as a minor event
03:04:11 event and he notices immediately after the fire that they installed a new fire alarm system so
03:04:18 so but we say that doesn't make very much difference because you have to look at a whole system in an integrated form if you're going to have a smoke detector or alarm that sets off
03:04:29 a smoke detector or alarm that sets off a vent that then sets off as it were extraction then they're all interrelated there have to be
03:04:37 to be regular checks of the alarms out of the lifts of the keys to make sure they work and he finishes this section by saying essentially
03:04:48 essentially the
03:04:49 the residents of grenfell tower have been treated as subhuman and your handling of the incident has been unacceptable and we we say that
03:05:00 and we we say that this is not an exaggeration this is not hyperbole this is exactly what maria mamoli had been talking about had not changed and as you go through the whole period
03:05:12 and as you go through the whole period and i'm going to do it if i may rather quickly at this stage after the inferno you have a number of i just list them because you're very familiar
03:05:23 familiar and i don't um i want to overburden you with things you've heard so many times 2013
03:05:30 2013 lachenal inquest four months recommendations march the 28th sent to councils so
03:05:40 so that's that's a key event
03:05:44 the same time well not quite the same time about a month or so later in the same year it fortunately wasn't another fire
03:05:55 it fortunately wasn't another fire but it was in the tower and it affected a number of residents again denied to begin with they had to take them to court as far as
03:06:06 they had to take them to court as far as the fire in 2010 was concerned in order to get liability admitted that's why the 2010 is important and it was still being basically denied
03:06:17 and it was still being basically denied the 2010 file when we get to 2017. but in 2013 from the 11th to the 29th of may
03:06:29 from the 11th to the 29th of may various electrical equipment exploded
03:06:34 we're not dealing as i i may have put in another context i'm not dealing with toasters we're not dealing with kettles we're dealing with computers and electoral commitment equipment of some importance and again
03:06:46 and again uh the residents including uh mr defan as well had to
03:06:52 had to persuade
03:06:54 persuade the authority that this was serious matter and in the end the authority had withheld
03:07:00 withheld information that they had they had an electrical fault report
03:07:05 report in 2013
03:07:08 in 2013 which indicated essentially that there were covers missing to the paxolene covers in other words
03:07:19 to the paxolene covers in other words were the the um ryfield boards which deal with uh surge arresting
03:07:27 arresting for false 11 12 13 14 15 all the floors up to 18.
03:07:33 up to 18. so they were in a very bad condition that means nobody was bothering to look at that let alone mr stokes so therefore 2013 they get a report from lack of they get the surges report so they must know
03:07:45 get the surges report so they must know about and in july of that year this is we're still in 2013 they get the the already referred to the hodgson safety report with 39 issues listed
03:07:57 safety report with 39 issues listed 2014
03:07:59 2014 they get a deficiency notice as you've heard the march one which has the 25 of events not working 25 of le lighting not working
03:08:11 25 of le lighting not working and then was in november 2014 um claire williams has her luck in the moment it's i wish some we all wish some of others had luck and all moments it might have shed light on something that the things
03:08:23 shed light on something that the things were going on in 2015 there's a deficiency notice i know the families are particularly anxious about the adair court example uh the ada house example on at a
03:08:36 example uh the ada house example on at a tower and its sister building hazelwood there actually was a fire in adair tower it
03:08:43 it closes are right at the center of it evacuation is quite at the center of it so
03:08:49 so the deficiency notices and the enforcement notices are served on both authorities jointly so they have to know what are they saying oh well it's not exactly the same as our tower or grenfell tower or whatever so that's
03:09:01 or grenfell tower or whatever so that's in 2015 2016 just around the corner shepard's court and mr ahmed actually happened to see that he was there or nearby and and that leads into really
03:09:13 and and that leads into really essentially i've gone through this because
03:09:17 because it was in 2016 there was the deficiency notice
03:09:20 notice served on grenfell tower with a return date of the 18th of may 2017 on the 20th of november was the um the
03:09:31 um the playing with fire blog you've heard about
03:09:34 about so the signposts are dramatic and there and therefore in the closing moments just before lunch may i just turn to really the other bookend i i haven't got
03:09:45 really the other bookend i i haven't got a time in the in this context to go through it all which may be a relief i will just give the reference to it and ask you
03:09:54 ask you in the fullness of time to have a look at it this is this is a letter that was sent and it's contained in his statement mr ahmed's statement
03:10:05 ahmed's statement the letter was sent on the 21st of april 2017
03:10:09 2017 just prior to the
03:10:13 the fire
03:10:14 fire and it was a letter like the first letter only this one was sent to laura johnson and sasha jeffers and it was dealing with the fact and i'm not going to bring it up in these moments but what they were essentially
03:10:27 moments but what they were essentially saying was how would you like to live in a flat with this sort of pipe going through it then there was a photograph of the pipe and they were saying it's not just artistic it's not just that it's not
03:10:39 artistic it's not just that it's not what something you want to live with we're actually worried about safety we're worried about safety interim protections i don't think at any stage because there wasn't a fire
03:10:50 at any stage because there wasn't a fire safety
03:10:52 safety strategy
03:10:53 strategy that the council ever thought that the tmo ever thought about interim measures while you haven't got vents at work while you haven't got a fire safety lift well while essentially
03:11:04 while essentially you're inserting gas pipes and you're putting them up essentially the shaft for the fire fire brigade to use shouldn't have been
03:11:15 fire brigade to use shouldn't have been really put preferably as you may remember we would have liked to put the pipes outside but we couldn't why because we were worried about the cladding
03:11:27 cladding well
03:11:28 well it gives you a sense of the priorities here
03:11:31 here uh aesthetics before safety there are ways of putting pipes on the outside of buildings which would have been safer in fact they were right and this letter which goes through in some detail again
03:11:42 which goes through in some detail again asking for an independent investigation not just to the pipes is it right that they're being put in unprotected is it right to keep the gas on
03:11:50 on while they're unprotected there's no no corrosive protection another of the experts no corrosive protection so here you have these pipes going up the main shaft going into flats
03:12:01 going up the main shaft going into flats breaking into possibly breaking into compartmentation and what he's actually doing in this letter as well is he's saying oh by the way cladding
03:12:12 way cladding interesting he's raising cladding not for the reasons that he realized but because he and others at the top of the building
03:12:21 building thought there was some peculiarity a noise that couldn't be located interestingly of course had there been an inspection
03:12:32 had there been an inspection bearing in mind all the things he said please look at cladding might even at that very late stage have been isolated as a possible route to a fire
03:12:43 route to a fire and given that our contention is that uh cladding was something to be looked at in any event by the fire assessor this was an important point but even
03:12:56 important point but even perhaps more important i'd read this out without getting it up on screen what they say in this letter is also not only do we want an independent investigation and certification
03:13:07 investigation and certification the defense apparently to this is oh well
03:13:10 well we did take that on board and we're very grateful for another acknowledgement this time from the tmo acknowledging the concerns relating to the gas riser raised by the residents including the
03:13:23 raised by the residents including the grenfell leaseholders association with a request for an appointment of an independent health and safety advisor to consider the works in relation to the concerns raised tmo passed these on to the contractor no no no wait a minute
03:13:36 the contractor no no no wait a minute wait a minute it's not about passing it on to somebody else that's what they do all the time what they should have been doing and your experts indicated that
03:13:47 that gtla and others were quite right because
03:13:52 because it was their action of pointing it out to the tmo and rbkc that this was an unsafe exercise
03:14:03 exercise that caused them to do something about it although they should have done something about it before they started inserting these pipes because they've been a gas leak in september 2013 they
03:14:14 been a gas leak in september 2013 they had to switch the gas off and you wonder why
03:14:17 why you wonder why in the end the frustration of not being taken seriously of not being listened to what did he have to do what did miss the gtla
03:14:29 did he have to do what did miss the gtla have to do what did he have to do in person as well as mr tiffany and well as others
03:14:34 others in the film he had to put all this together in a dossier he had to employ a lawyer just as he had to in relation to 2010
03:14:46 to in relation to 2010 to fight the council over safety issues and he had to take because they didn't tell him what they got he took the dossier
03:14:57 he took the dossier and all the observations i don't call them complaints their observations for the future in the 2017 letter as well as the one in 2010 he takes them to the council
03:15:09 one in 2010 he takes them to the council but
03:15:10 but to ensure they don't get stuck in a complaints procedure where they might be escalated or de-escalated he takes the dossier to the town hall he's taking it right to the center because he knows unless he hands it in
03:15:22 because he knows unless he hands it in himself
03:15:24 himself somehow or another it may go missing it may not get attended to or whatever and he did that on the at the end of the month of may just before the fire
03:15:35 just before the fire so right up as it were to the doors of grenfell tower and the fire the residents were having to fight a battle and
03:15:46 battle and a section in the letter which there is time just just to read to you because this is astonishing if you need any persuading that the rbk
03:15:57 if you need any persuading that the rbk ctmo
03:15:59 ctmo were just not wanting to confront their shortcomings it's this uh it's a paragraph in the 2017 letter sent to laura johnson they refer the
03:16:11 sent to laura johnson they refer the letter to an email from laura johnson dated the 28th of march in which she says about what they're saying about the 2010 fire
03:16:22 fire this is a serious allegation which i've reviewed with the kc tmo and i can confirm that rbkc and the kctmo
03:16:33 kctmo do not
03:16:36 do not and i read it carefully do not have any record
03:16:40 record or report
03:16:42 or report of this
03:16:43 of this that's the fire which they're now admitting of course and they did in a legal action where they had forgotten we have no record of three people being injured it's in the fire brigade report
03:16:55 injured it's in the fire brigade report and we have no report which links this poor mate to poor maintenance and yes they do and finally we have no record or letter from the fire brigade mentioning this or providing any formal notification
03:17:08 providing any formal notification to which
03:17:10 to which the letter writer who happens to be uh lee chapman and mr tunde agudero
03:17:18 agudero having to say they're going to take legal action as a result of the so right up until 2017 the 2010 fire the liability for the fire
03:17:29 the 2010 fire the liability for the fire in the sense of the smoke spread and so on that happened there was still being resisted that is why the acknowledgement by rbkc uh well i
03:17:40 the acknowledgement by rbkc uh well i say today but perhaps uh well yes later today
03:17:44 today it is welcome at long last that he can rest back on on at least a rather late acknowledgement of the fact that all along all through those years and you can believe through his
03:17:57 years and you can believe through his own
03:17:58 own passion he he wasn't able to give evidence as you know but
03:18:02 but the passion of the letters the passion of the files and the dossiers that he's put together for your assistance thousands of pages he bothered to keep things
03:18:13 things so that
03:18:14 so that even after the fire he had some record of of
03:18:20 of of what had happened this is how assiduous he and others he's not the only one and so we say he's been vindicated that's why we say in future
03:18:31 that's why we say in future there should no no longer be the ahmeds of this world who have to fight every inch of the way to get any movement to get any recognition to bring about change
03:18:42 change and i'd like to end with not his words and i haven't named them in the written
03:18:50 written but it may be you can guess who spoke them it's not from a source you will necessarily recognize but you might do
03:18:57 might do these are words one of the few occasions when a reflective question was asked of this witness
03:19:05 witness it's a woman she said i grew up in council housing and i've seen its demise since the 1980s
03:19:16 since the 1980s when right to buy was brought in there's been deregulation on the sector there's a lack of investment going into council housing and i hope that you will look at this in
03:19:29 and i hope that you will look at this in a wider context addressed to the panel council housing is a really important community asset that should be valued
03:19:40 that should be valued those are the words of amanda johnson so it might not have been appreciated or expected that somebody on the inside has recognized
03:19:51 on the inside has recognized the point of what we've been trying to suggest to you both in the written and the oral form thank you well thank you very much mr mansfield
03:20:02 well thank you very much mr mansfield and at that point i think we'll break so that we can all have some lunch and um we'll resume at two o'clock when we're going to hear a closing statement from the tmo
03:20:15 statement from the tmo yes thank you very much two o'clock peace