Module 4 closing submissions on the aftermath and recovery phase, addressing systemic failures, discrimination, and institutional response
00:00:23 good morning everyone welcome to today's hearing
00:00:27 hearing today we're going to hear closing statements relating to module four and the first of those is going to be made by ms allison monroe queen's council on behalf of those of the
00:00:38 council on behalf of those of the bereaved survivors and residents whom she represents so miss monroe would you like to take your place at the lectern and we're ready to hear you as soon as
00:00:49 we're ready to hear you as soon as you're ready thank you
00:00:53 good morning chair good morning miss estefan good morning mr akbar these are the submissions in closing to module four on behalf of the bereaved survivors and residents
00:01:06 the bereaved survivors and residents represented by the t ii
00:01:09 ii group of lawyers can i start by taking you back as it were back to the opening submissions in this module made by professor thomas queen's council
00:01:22 professor thomas queen's council you may recall that during those opening submissions he took us to the headlines that were at the time circulating in the media
00:01:32 media which spoke of the chaos the lack of leadership the despair of the survivors residents and bereaved families
00:01:41 families our bkc was failing in their responsibilities to the community and they were failing spectacularly there was frustration there were tears
00:01:53 there were tears this abject failure we say by our lbkc added to the trauma that people were already experiencing and for once the headlines were not exaggerations
00:02:05 exaggerations or hyperbole if anything they understated the reality in the course of this module we have gone behind those headlines to
00:02:17 we have gone behind those headlines to the lived experiences of the survivors the residents and the bereaved families who were so appallingly let down by their local council and by central
00:02:29 their local council and by central government the council leader nick padgett brown speaking on bbc radio 4's the world one at the time sought to defend himself and
00:02:41 at the time sought to defend himself and officials against criticisms he said staff had been on the ground since soon after the fire started and added i quote
00:02:52 and added i quote all i'm keen to say is there is an effective coordinated relief effort on the ground and i'm sorry if people have not seen that
00:03:03 not seen that those comments were patently untrue and quite frankly errant nonsense the painful accounts of what people had to endure in the
00:03:14 of what people had to endure in the immediate aftermath of the disaster should make us all ashamed rbkc failed to provide a planned effective emergency response this was a council whose response was
00:03:27 this was a council whose response was chaotic and seemed to be gripped with paralysis and inertia there was a leadership vacuum people who were at the very nadir of their suffering were left without proper
00:03:38 their suffering were left without proper direction
00:03:39 direction they required relief shelter warmth sustenance and psychological support this council's invisibility and failure
00:03:50 this council's invisibility and failure to communicate with the survivors and people who wanted to help exacerbated the trauma in our written submissions we quoted the
00:04:01 in our written submissions we quoted the words of karim musli to whom the inquiry heard at the beginning of this module i would like to revisit those words again they are well worth repeating as
00:04:14 again they are well worth repeating as karen so eloquently articulated the thoughts and experiences of many he said this i thought we lived in a country where
00:04:25 i thought we lived in a country where the people we vote for and the people that are put in place to look after its people its most vulnerable people would help would come swooping in and it never happened
00:04:37 and it never happened the sad part about that they never planned to they don't care about us they care more about themselves their pockets and i won't go into detail
00:04:48 pockets and i won't go into detail because you questioned these crooks you sat there and spoke to these criminals who acted so fraudulently and with this constant detachment i mean how many more politicians
00:05:00 i mean how many more politicians ministers and lords are going to insult our dead families before something is done about what happened to us and it's sad i've almost completely lost faith in
00:05:12 i've almost completely lost faith in humanity
00:05:13 humanity i've almost completely lost faith in the world because it's always the same thing everywhere we suffer and they prosper and i've said this before the system
00:05:25 and i've said this before the system isn't broken it was built this way specifically to benefit them our families died in the most public and horrific way possible
00:05:36 horrific way possible and here we are five years later with no arrests no accountability but yet the ones who were put in charge or the ones who were involved have been able to prosper since
00:05:48 involved have been able to prosper since the fire
00:05:50 the fire and how can we allow this to happen i feel like as time goes on the general public have forgotten about us or every time they hear about us they're fed up
00:06:01 time they hear about us they're fed up and this is a problem people need to see themselves in us people need to understand that what's happened to us and what's happening to us is also happening to them
00:06:13 us is also happening to them putting aside those corporates to behave in the way they behave because it's in their nature it's what they do but the government the government's duty is to protect us to look after its
00:06:25 is to protect us to look after its people
00:06:26 people but yet only last week a lord was sitting here calling our families nameless getting the numbers mixed up with hillsborough and couldn't even say grenfell he said grand bell
00:06:39 grenfell he said grand bell and these are the people put in place to look after us those words they don't care about us have reverberated throughout this entire inquiry
00:06:50 inquiry at every point an intersection between the bsrs local and central governments and the corporate cps our clients have said and continue to say
00:07:02 say the local and central government did not care
00:07:05 care about us when the tower was being refurbished they did not care about us when we were raising issues and warning of the consequences of inaction long
00:07:16 of the consequences of inaction long before the fire they did not care about us when these warnings came to pass so are we surprised that they did not care when people were at their very lowest in the wake of the devastation
00:07:28 lowest in the wake of the devastation they did not care they never have the response by both local and central government to this disaster was unacceptable it was inept it was
00:07:39 unacceptable it was inept it was inhumane
00:07:40 inhumane there was a lack of respect for the residents and engagement with the community
00:07:46 community with the embers of the tower still glowing hot the spin and deflection began
00:07:53 began david kerry made the following comment in his witness statement general community feeling is of hurt and anger
00:08:00 anger this is being stoked by a small number of known local instigators who continue to fabricate stories in order to further their aims one question about that he said that he
00:08:12 one question about that he said that he thought
00:08:13 thought and i quote a suspicion that in amongst a great deal of completely genuine and justified criticisms it was within the scope of a handful of people
00:08:24 people who were all the time well before the fire extremely antagonistic to the council to make matters even worse we ask
00:08:35 we ask why would a responsible authority even seek to raise matters such as this at a time when people were in such physical and emotional pain the community's heart was literally
00:08:47 the community's heart was literally broken and yet some were being characterized as a villains of the peace but was david kerry not articulating the deeply held belief within rbkc that positioned themselves
00:09:00 within rbkc that positioned themselves in opposition to the residents there were no instigators there were no arjun provocateurs sowing the seeds of disk discontent and fabricating stories
00:09:11 disk discontent and fabricating stories these were baseless and deeply offensive slurs
00:09:15 slurs yet there were armed police in place at the westway center rbkc staff were not wearing identification some people were threatened with arrest and made to feel like criminals at the
00:09:26 and made to feel like criminals at the westway center this focus on public order detracted resources and focus away from the relief effort that rbkc felt emboldened and
00:09:38 effort that rbkc felt emboldened and entitled enough to do this is illustrative of their own agenda and motivation at the time
00:09:47 this we find extraordinary inexcusable and unforgivable this attitude was exemplified in the most egregious way at the westway center
00:09:59 most egregious way at the westway center there was the insensitivity of the police cordon which again illustrates a hostile approach by rbkc seeing residents and survivors as the enemy it was aptly described by rupinder
00:10:11 it was aptly described by rupinder harvey as being like a crime scene residents and survivors described the interviews at the west way as robotic and little more than tick box exercises
00:10:23 and little more than tick box exercises this was cooperated by mark sims of rpt the lack of coordination meant that people had to repeat and therefore relive
00:10:32 relive their story and their trauma to myriad individuals and agencies causing further distress it was in the words of mark sims inhumane and cruel
00:10:44 sims inhumane and cruel they did not care about us
00:10:48 professor thomas queens council also mentioned in his opening to this module the elephant in the room that being race ethnicity and discrimination in all its forms
00:11:01 discrimination in all its forms now during the course of this module people have tried to move around the elephant
00:11:06 elephant under the elephant squeezed past the elephant but he very much is still there and is not going away racism and discrimination we say played a very real part in the response to this
00:11:18 a very real part in the response to this tragedy
00:11:19 tragedy the playing field was not level it never has been
00:11:24 has been one of the measures by which we look at whether we as a society are functioning properly is how we treat our most vulnerable members
00:11:35 we treat our most vulnerable members do we treat them with care respect and equality do we make the necessary adjustments now we have set out in detail in our
00:11:47 now we have set out in detail in our written submissions the legal framework of the equality act the public sector equality duty and in regards to the cca issues
00:11:57 issues involving vulnerable people and discrimination so i mentioned now only the highlights and headlines of those acts rbkc as a local authority had um
00:12:09 rbkc as a local authority had um obligations under section 149 of the equality act specifically to have due regard to the aims of the general equality duty when making decisions
00:12:22 equality duty when making decisions and setting policies with respect to the psed this meant having due regard and to the need to a eliminate discrimination harassment
00:12:34 eliminate discrimination harassment victimization and any other conduct that is prohibited by or under the 2010 act b
00:12:42 b to advance equality of opportunity between persons who share irrelevant protected characteristics and persons who do not share it and c to foster good
00:12:53 who do not share it and c to foster good relations between persons who share a relevant protected characteristics and persons who do not share it the cca chapter 5 emergency planning
00:13:04 the cca chapter 5 emergency planning specifically states that plans and i quote should have regard to the vulnerable i.e those with mobility difficulties those with mental health
00:13:15 difficulties those with mental health difficulties or those who are dependent such as children and survivors and others affected those directly affected by the emergency or the anxiety of not knowing what has
00:13:28 or the anxiety of not knowing what has happened
00:13:29 happened chapter seven of the act communicating with the public stipulates that category 1 responders need both to plan their communications and to regularly test
00:13:40 communications and to regularly test their communication arrangements to ensure they are effective the message must be right for the targeted audience and this must be coordinated with other cat one responders and engaging cap two
00:13:54 cat one responders and engaging cap two responders and the voluntary sectors now these pieces of legislation are not there just for show or to look good they are not mere window dressing these are
00:14:07 are not mere window dressing these are overarching pieces of legislation and they must be embedded within public bodies and inform all aspects of public bodies their planning their training
00:14:18 bodies their planning their training their delivery of services their practices
00:14:21 practices this is even more pressing when one examines kensington and chelsea's demographics we said in our opening to this inquiry inquiry
00:14:33 inquiry almost five years ago the very first set of openings that in examining this disaster one must put it in its socio-economic context the royal borough of kensington and
00:14:45 the royal borough of kensington and chelsea is the richest bar in london london is the richest city in the uk the uk is the fifth richest g20 nation based upon gdp per capita
00:14:58 based upon gdp per capita this happened in a very wealthy borough but there's more to it because when one looks at the rbkc borough risk register which is an important document for
00:15:09 which is an important document for emergency planners to assist them to make informed decisions and it was overseen by none other than david kerry the profile for rbkc's population showed
00:15:20 the profile for rbkc's population showed that the borough had an estimated 178 600
00:15:26 600 hundred and seventy eight thousand six hundred um this is from the 2011 census and is quote a borough of extremes with some of the wealthiest neighborhoods in the
00:15:37 the wealthiest neighborhoods in the country as well as some of the most deprived
00:15:40 deprived grenfell tower was in north kensington where a
00:15:44 where a the population varied in age sex and religion
00:15:47 religion b more than a fifth of all households have a first language that was not english
00:15:53 english c
00:15:54 c less than half of the residents 48 were born in the uk d
00:16:00 d 28 of residents had arrived in the uk between 2001 and 2011 and e as a borough rbkc had the second
00:16:11 and e as a borough rbkc had the second highest proportion of arab residents four percent after westminster
00:16:18 rbkc's civil contingency manager david kerry had a duty to ensure that the borough's civil contingency plans and policy reflected its target group
00:16:29 its target group it did not module 4 has laid bare the inadequacy and simple disregard that existed in the borough by the rbkc
00:16:40 that existed in the borough by the rbkc tmo and indeed central government for equality legislation it was not embedded in their thinking indeed we say it formed no part of their thinking
00:16:53 the contingency plans and arrangements and rbkc's response to the fire failed to take into account those in the community with protected characteristics
00:17:04 characteristics mr heard the former mp and former minister would not accept the prejudiced or institutional indifference towards the bsrs played a part in the response
00:17:15 the bsrs played a part in the response we do not propose to take the panel through our detailed written submissions in which we set out the experiences of many many of our clients because we know that you have read that
00:17:27 that you have read that but we say this and we say it loudly and clearly that their evidence the admissions made on behalf of our rbkc and when one looks critically at the evidence of mr kerry
00:17:40 critically at the evidence of mr kerry and mr holgate show that discrimination did indeed play a part in this response it is disappointing to see the former minister mr heard
00:17:51 minister mr heard fail to acknowledge this with we say classic political spin he said this what i do absolutely accept is that the response in the immediate aftermath of the fire was wholly inadequate and might
00:18:05 the fire was wholly inadequate and might have led some people to believe there was institutional indifference people did not misconceive it they did not imagine it
00:18:16 misconceive it they did not imagine it those who felt it knew it nicholas heard so-called minister for grenfell victims can pretend not to see it but the institutional indifference was there the discrimination was there
00:18:28 was there the discrimination was there and it was very real mr kerry and rbkc failed to take appropriate steps having due regard to the needs to advance equality and opportunity
00:18:40 advance equality and opportunity in particular with regards to the need to remove or minimize disadvantage suffered by persons who share a relevant protected characteristics that are connected to that characteristic and b
00:18:52 connected to that characteristic and b to take steps to meet the needs of persons who share a relevant protected characteristics that are different from the needs of persons who do not share it
00:19:03 the needs of persons who do not share it town clerk nicholas holgate perhaps epitomizes indifference and casual disregard with his lack of awareness as to rb casey's ability or inability
00:19:14 to rb casey's ability or inability rather to identify vulnerable persons out of hours mr kerry flagged this problem in emails in march of 2017 so a few months before the fire and it was discussed during
00:19:26 the fire and it was discussed during humanitarian assistance board meetings mr holgate admitted he should have been aware of this issue they did not care about us
00:19:38 they did not care about us race ethnicity and religion it was an obvious and basic need that communication would need to be targeted to non-english speakers in order to provide them with accessible emergency
00:19:50 provide them with accessible emergency advice and information this was not done this is discriminatory there was a delay or failure to provide counsellors who spoke the language of the bereaved survivors and residents
00:20:03 the bereaved survivors and residents this was not done this was discriminatory there was limited or lack of flexibility and accommodation offered to make allowances for muslim meal times during
00:20:14 allowances for muslim meal times during ramadan or attendance at prayers and meeting
00:20:18 meeting and food provided was not culturally appropriate in some instances and in other instances halal food was not provided at all this was discriminatory
00:20:30 this was discriminatory the panel will have recalled nabil shakir's evidence during this module inviting the panel to examine the issue of institutional discrimination and its
00:20:41 of institutional discrimination and its role in the disaster in his words we need to have institutional discrimination looked at as part of the terms of reference members of the panel
00:20:53 members of the panel questions of race are we say inextricably linked with grenfell we need to look no further than the mps is categorizing of risk and threats in the aftermath
00:21:04 the aftermath the nps grenfell community impact assessment created by rbkc police branch to record the actions taken by the police and its partner agencies in the
00:21:15 police and its partner agencies in the aftermath of the fire attributed imminent threats of an outbreak of crime and disorder to the muslim background of the victims the entry of the 18th of june read
00:21:26 june read imminent local national or international events
00:21:30 events taken alone or in combination expected to lead to outbreaks of crime and or disorder within hours rationale there is an expectation that
00:21:41 rationale there is an expectation that the
00:21:42 the final death toll from the fire could rise substantially and with the core still unknown any subsequent disclosure would have the impact of community tensions
00:21:53 tensions especially when the majority of those affected are believed to be or come from a muslim cultural background combined with the incident occurring during the holy month of ramadan
00:22:06 during the holy month of ramadan members of the panel this is islamophobia it's racism the elephant staring back at us in the room disability
00:22:17 disability bsrs with disabilities were known to rbkc and to the tmo they were known to adult services they were known to rbkc disability services
00:22:29 disability services yet still
00:22:30 yet still they too were treated with indignity and disregard
00:22:35 disregard we had in the aftermath people who were frightened they were grieving for friends
00:22:40 friends relatives for neighbours they were bereft of all their worldly possessions these residents were placed nonetheless in hotels on high floors in rooms that were not
00:22:52 high floors in rooms that were not adapted for their most basic needs there was no consideration of mobility issues or non-visible disabilities to use the phrase that mr
00:23:03 to use the phrase that mr sims has used already it was inhumane and cruel
00:23:08 and cruel pregnant women a number of expectant mothers who survived the fire traumatized enough by that found themselves in hotels or shelters which were not equipped to meet their medical
00:23:20 were not equipped to meet their medical needs and requirements they were living and sleeping in entirely inappropriate accommodation this impacted upon their physical and mental wellbeing children
00:23:32 children children are a particularly important group here and we spent some time both in the opening and in the closing written submissions addressing the issue as to children and
00:23:44 addressing the issue as to children and the disproportionate number of children that not only died in the fire but those who suffered as a result of in the aftermath
00:23:52 aftermath the equality and human rights commission report entitled following grenfell was based on interviews with family and they found that many children who lost a friend or family member or their home in
00:24:04 friend or family member or their home in the fire
00:24:05 the fire struggled to access help david isaacs the commission chair said this
00:24:13 this there are so many children going to the same school and still affected one respondent said they just don't know where to turn because there aren't the services available
00:24:25 available supporting families who lost friends and loved ones that night should have been a primary concern but especially the children involved while authorities sought to respond to
00:24:37 while authorities sought to respond to the disaster children received disjointed mental health and educational support their needs and rights were slipped through the cracks families found themselves in hotels
00:24:49 families found themselves in hotels rooms with no facilities to sterilize bottles and cots if they had small children babies and infants school-aged children some of whom had exams to sit that week had no uniforms
00:25:01 exams to sit that week had no uniforms to go to school in they had no room to study
00:25:04 study often whole families were sharing one hotel room so teenagers had no privacy and no space
00:25:12 at the other end of the spectrum are the elderly
00:25:19 and although module four focused on the seven days after the fire the response to the fire is long lasting and far-reaching with greater impact on
00:25:30 and far-reaching with greater impact on vulnerable people such as the elderly and this has been clear from the evidence heard and the news reports that we alluded to in our opening and i've alluded to at the beginning of these submissions
00:25:43 at the beginning of these submissions one of our client else bieta konazuska
00:25:48 konazuska was 80 years of age and on the night of the fire she was evacuated from her home in grenfell walk where she'd lived for the past 35 years she like michael john of whom the
00:26:00 she like michael john of whom the inquiry has heard in the opening was one of the forgotten people by rb casey in this aftermath she received no subsistence or housing support until many months later
00:26:13 support until many months later she was belatedly offered temporary housing and was put through further trauma when later re-housed in a property which had multiple fire safety issues resulting in the decanting of
00:26:24 issues resulting in the decanting of residents
00:26:25 residents the failure to re-house el zabieta in settled accommodation after the fire had a detrimental effect on her health and sadly she died in january of this year
00:26:36 sadly she died in january of this year at the age of 85 four and a half years after the fire awaiting still placement in sheltered accommodation mental health
00:26:47 mental health we have set out in our written submissions the mental health impact on this disaster the aftermath of this fire created a mental health crisis that cannot be understated
00:26:58 cannot be understated or underestimated and is probably still being under reported in august of 2017 so only a few months after the fire bbc news night reported that 600 people
00:27:10 that 600 people had so far received counselling including 100 children that was the tip of the iceberg by october 2017 the guardian was reporting that the mental health response
00:27:21 that the mental health response following the fire was the biggest operation of its kind in europe according to one doctor with a number of people affected likely to exceed 11 000 as with the other provisions of services
00:27:34 as with the other provisions of services for the bsrs psychological and mental health support in the immediate aftermath was woefully inadequate rest centers the alacrity with which the voluntary
00:27:46 the alacrity with which the voluntary sector filled that leadership vacuum created by the inertia of rbkc and tmo was matched only by the speed with which rbkc began to spin malign the names of
00:27:59 rbkc began to spin malign the names of certain residents and their intentions whilst those in positions of authority at the local authority the council dithered and prevaricated arriving on scene many hours after
00:28:11 arriving on scene many hours after finding out about the fire mark sim of rugby portobello trust rpt sprang into action some 120 miles away in nottingham and immediately set about
00:28:23 in nottingham and immediately set about providing aid and support to the bsrs once here in london he summed it up perfectly
00:28:29 perfectly the north kensington community was looking after its own people in the absence of anything coming from anywhere else it's a sad indictment really that people were getting out of bed to help
00:28:41 people were getting out of bed to help their fellow neighbours when other people weren't getting out of their offices to help our citizens pausing there for a moment it's worth perhaps mentioning the mps again
00:28:53 perhaps mentioning the mps again because very little has been said about them in this inquiry in their closing statement they focus on the casualty bureau and family and friends reception center conceding that
00:29:05 friends reception center conceding that it needs to give consideration as to how the role of the casualty bureau should be better communicated in the future it needs to consider how its operation could be improved and how it might fix
00:29:19 could be improved and how it might fix fit into wider systems of disseminating information about those who are missing as part of an improved humanitarian response
00:29:28 response all we would say to that as well an adherence to the equality act the psed would be a very good start the tmo
00:29:38 the tmo whilst brevity in lawyers is always to be commended um it is noted in its very short written closing submissions that the tmo has continued to emphasize that it was not a
00:29:51 continued to emphasize that it was not a category one responder it says that its emergency plan had no effect on the fire or the aftermath we find that statement extraordinary but there's more
00:30:02 there's more it goes on to say that the tmo staff were present in the rest centers and if they did not seem visible to bsrs that might have been down to how busy it was
00:30:13 might have been down to how busy it was no
00:30:14 no that explanation is an affront an insult to the intelligence of our clients it is not an acceptable or credible explanation and we reject it wholeheartedly and we invite the chair
00:30:26 wholeheartedly and we invite the chair and the panel to do likewise the tmo's position has consistently been that it was obvious from the scale of the fire that their emergency plan was not relevant and the rbk's emergency
00:30:38 not relevant and the rbk's emergency plan would prevail its role it says therefore was to support and assist once decisions had been made rather than to make decisions itself and to respond to
00:30:49 make decisions itself and to respond to requests made of it by rbkc and other agencies where appropriate mr black went further by saying that that is how it was planned and operated
00:31:00 that is how it was planned and operated there was quite clearly a lack of coordination between rbkc and the tmo and it is acknowledged by rbkc in its written closing document
00:31:11 written closing document they say and i quote rbkc admits that it and the tmo never formally agreed what the role of the tmo would be in the event of an emergency and it
00:31:23 event of an emergency and it acknowledges that it would have been better if the role of the tmo in the event of an emergency had been set out in writing before the fire this might have enabled better use to be
00:31:35 this might have enabled better use to be made of tmo's willingness to assist firstly we say this shows a fundamental failure on the part of both rbkc and the tmo to appreciate what the tml's role
00:31:48 tmo to appreciate what the tml's role could and should have been in the event of a large-scale emergency planning training and preparation are key to emergency response and the role of the tmo staff should have been firmly
00:32:01 of the tmo staff should have been firmly embedded in rbkc's emergency planning we know from the evidence rbkc simply did not have enough staff who were suitably trained in emergency planning
00:32:12 suitably trained in emergency planning and response this is a gap which could and should have been filled by tmo staff this is because the tmo is not just a
00:32:23 this is because the tmo is not just a tmo it is also an arms length management organisation almo with a responsibility for the management of the entirety of rbkc's housing stock
00:32:34 of the entirety of rbkc's housing stock it therefore needed to perform the functions of a local authority internal housing department an authority's housing department is of course part of the authority itself and
00:32:46 course part of the authority itself and therefore part of a category one responder
00:32:49 responder as such it is fully integrated within the authority's emergency plan and provides staff trained to act as part of a coordinated response with other local authority departments
00:33:00 authority departments secondly rbkc and the tmo should have realized this was an obvious point it should never have been the case that the tmo had quote no formal role except to
00:33:12 tmo had quote no formal role except to provide resource and support on an ad hoc basis the tmo should have been fully integrated within rbkc's emergency response team the failure to ensure this was the case
00:33:26 the failure to ensure this was the case vastly reduced rbkc's capacity to respond effectively to the fire rbkc seeks to shift the blame for its failure to agree
00:33:37 failure to agree with the tmo as to their role by relying on the fact that their rep respective roles were defined by the modular management agreement mma
00:33:48 modular management agreement mma which is issued by government and which fails to address and almost role in an emergency central government therefore also bears some responsibility for the lack of
00:34:00 some responsibility for the lack of coordination between rbkc and the tmo in the response to the fire but that cannot serve to excuse the inadequate planning of both rbkc and the
00:34:11 inadequate planning of both rbkc and the tmo
00:34:14 tmo both rbkc and the tmo also conveniently ignore the evidence of the tmo's own emergency plan which recorded that it was intended to work within the
00:34:25 was intended to work within the framework of rbkc's emergency response to quote
00:34:30 to quote from the plan the plan is primarily for managing local kc tmo emergencies on within or surrounding our properties and estates
00:34:41 estates one which can be managed within the resources available to kctmo however this plan can also be used for large-scale major events
00:34:52 large-scale major events which would overwhelm the kc-tmo's ability to manage on its own and which would involve the rbkc council resources the difference being the scale
00:35:03 resources the difference being the scale of the emergency and the number of people affected by it
00:35:08 when this was drawn to mr black's attention in his oral evidence and this part of the emergency plan he accepted that he had misunderstood the tmo's role and that there was no
00:35:21 the tmo's role and that there was no reason why parts of the tmo's emergency plan could not have been activated alongside rbkcs response
00:35:32 response this is important because as mr black accepted the tmo's role as stated in the emergency plan envisaged that tmo staff
00:35:43 emergency plan envisaged that tmo staff would be available to undertake roles including setting up rest centers rbkc has admitted that it did not have enough trained rest center managers before the fire and that initially it
00:35:56 before the fire and that initially it did not deploy enough council officers of sufficient seniority to rest centers this we say is a crucial failing on the part of both the tmo and rbkc
00:36:08 part of both the tmo and rbkc the tmo should have been able to provide staff trained to establish and run rest centres and rbkc should have known that this was a resource that
00:36:19 this was a resource that if needed they could call upon miss brown confirmed in all evidence that her staff had no training working at rest centers or collating data in an emergency
00:36:31 data in an emergency while at the tmo mr black received no training in emergency planning and response nor had he attended any joint training with rbkc about how its plans would work in
00:36:43 about how its plans would work in practice
00:36:45 practice likewise miss brown had no emergency training whilst at the tmo she gave evidence that employees on the out of hours rotor had received training however significantly this was not
00:36:58 however significantly this was not corroborated by one of her own employees kieran singh who says in his witness statement that he attended no training or exercises in the emergency plan this is a crucial and critical admission
00:37:12 this is a crucial and critical admission as it was mr singh who was primarily tasked with collating details of residents on the night of the fire including the safe missing list that proved to be something of a
00:37:24 that proved to be something of a disaster
00:37:26 disaster the inquiry took miss brown through that spreadsheet of the safe missing list in its various versions at length and demonstrated how terrible mistakes were made so that residents were recorded as
00:37:39 made so that residents were recorded as being both safe and missing at the same time
00:37:43 time that led to relatives being told that their loved ones had survived when that was not the case such appalling mistakes should have been avoided and could have been avoided had
00:37:54 avoided and could have been avoided had there been proper training and preparation
00:37:59 the tmo had previous friars from which lessons should have been learned following the fire at a dare tower in october 2015 rbkc and the tmo knew that
00:38:11 october 2015 rbkc and the tmo knew that they needed to improve their coordination during an emergency two years before grenfell on the 11th of november 2015 a meeting of the tmo's executive team
00:38:23 a meeting of the tmo's executive team concluded that better integration between rbkc and the tma was necessary despite this on the night of the fire at grenfell tower the tmo still lacked a
00:38:35 grenfell tower the tmo still lacked a clearly and formally defined role in the event of rbkc's contingency planning systems being invoked such was the lack of coordination between the two
00:38:47 between the two that mr black confirmed rbkc didn't even telephone the tmo's out of hours contact number
00:38:55 number his role at rbkc's goal group was he says quote just to be there and see what could you could provide the total lack of coordination is
00:39:06 the total lack of coordination is graphically illustrated by miss brown's evidence that not only did she never have any contact with sue redmond during the emergency but she did not know that
00:39:17 the emergency but she did not know that sue redmond was the halo or or even what the halo's role was following the adair tower fire the key role identified for the tmo in
00:39:29 the key role identified for the tmo in an emergency affecting the homes of council tenants was to attend the scene of the emergency with a list of known residents that was to include identification of residents with any
00:39:41 identification of residents with any vulnerabilities as miss brown accepted in her evidence that was a perfectly good opportunity to update the emergency plan and the annexed set of details for each tower
00:39:52 annexed set of details for each tower block and estate in its written closing the tmo says this it is acknowledged that there were deficiencies in the emergency plan however these did not impact delivery of
00:40:04 however these did not impact delivery of the tmos services during the aftermath that i'm afraid beggars believe the tmo's emergency plan stated it included information on the numbers of
00:40:16 included information on the numbers of known vulnerable residents to be included on the block details which form part of this plan the information specific to grenfell tower was completed in 2002
00:40:27 tower was completed in 2002 and it had not been updated despite the emergency plans purporting to be the 2016 version it therefore took no account of the refurbishment works
00:40:39 refurbishment works and stated there were 120 dwellings not 129
00:40:44 129 approximately 330 to 360 residents and that the likely number of vulnerable residents was between eight and twelve all those figures all those stats are
00:40:55 all those figures all those stats are wrong
00:40:56 wrong it contained no further information about the location of these residents nor the nature of their vulnerability so far from being of assistance to the emergency services and rbkc in
00:41:08 emergency services and rbkc in responding to the fire it was actively misleading and a hindrance although the tma was the obvious first port of call for information on residents
00:41:17 residents rbkc's departments such as adult social care and children's services also have records which should and could have recorded the composition of attendance
00:41:28 recorded the composition of attendance household and more specifically would have assisted in identifying vulnerable residents yet there was no sharing of data held on residence between the tmo and these departments as both mr miss
00:41:41 and these departments as both mr miss brown and miss redmond confirmed it is clearly essential that responders have information about those affected by an emergency which isn't accurate as possible and available as soon as
00:41:53 possible and available as soon as possible it is undoubtedly the case that the quality of the information would have been greatly improved if there had been an existing database which collated all the information available
00:42:05 all the information available to the tmo and to rbkc social services department so why was there no such database created
00:42:14 created well it appears from the evidence given by amanda johnson in module 3 that there were concerns about breaching data protection rules there was however no reason why a data
00:42:26 there was however no reason why a data sharing agreement could not have been put in place between the tmo and rbkc even though sensitive personal data about
00:42:34 about vulnerable residents could not have been shared without their consent surely that consent would have been given if the properly if it was properly explained that it would be used in an emergency
00:42:47 would be used in an emergency we suggest the inquiry should recommend that such collated databases be kept by all social landlords and local authority social services department
00:42:58 social services department but why was the tmos information so very poor
00:43:02 poor there is an obvious answer the distant attitude of the tmo to the residents
00:43:08 residents it was meant to serve the evidence in module 3 demonstrated how the petitions please and warnings of residents were ignored the evidence in module 4 yet again showed that residents
00:43:19 module 4 yet again showed that residents were not giving the respect and dignity that they deserved how can this be given that the tmo was a tenant
00:43:28 tenant management organization emphasis on the tenant
00:43:32 tenant the answer is that it was a tmo but it was as the inquiry is well aware a unique tmo tenant management organizations were envisaged as and
00:43:43 organizations were envisaged as and usually are locally based community bodies formed by groups of tenants and leaseholders imagine how much better the information on residents would have been if the
00:43:54 on residents would have been if the estates had been managed by a tmo set up by and for the residents of the escape and staffed by housing officers who were properly integrated within the local community
00:44:05 community the concept of the tmo is not flawed but kctmo was fatally flawed because it was incapable of proper resident engagement
00:44:16 incapable of proper resident engagement participation and empowerment the tmo says in its written closing that issues of information gathering from residents quote appears to be an
00:44:27 residents quote appears to be an industry-wide social housing problem if that is so the reason is that lack of proper resident engagement and partition participation is also an industry-wide issue
00:44:40 is also an industry-wide issue for far too long residents in social housing have been treated as second-class citizens the current proposals to strengthen the powers of the regulator of social
00:44:52 powers of the regulator of social housing in the social housing regulation bill in relation to tenants empowerments are to be welcomed and we invite the inquiry to make strong recommendations
00:45:03 inquiry to make strong recommendations reflecting the need to ensure that residents of social housing have greater participation in decision making and have a greater access to redress
00:45:15 have a greater access to redress housing duties in our written closing submissions we set out rbkc's duties to the homeless under the housing act 1996.
00:45:26 under the housing act 1996. i do not propose to repeat the legal framework today but emphasize that accommodation secured by a local authority under any of the housing duties must be suitable
00:45:38 duties must be suitable and that in deciding whether accommodation is suitable the psed requires that authority to focus on effects of an applicant's vulnerability and cultural needs
00:45:50 and cultural needs in her evidence laura johnson accepted the many failings rbkc have admitted to in their opening
00:46:00 just a few some residents were entitled to emergency accommodation but were not provided with it because they were not made aware of their rights
00:46:11 they were not made aware of their rights some were misled as to their entitlements others were not provided with transport to get to their hotels and they had to rely on the kindness of strangers in seeking to match accommodation to
00:46:23 in seeking to match accommodation to families
00:46:25 families needs errors were made in relation to the size of the accommodation there were many examples that we've given of accommodation being provided which lacked appropriate facilities for disabled residents and young children
00:46:36 disabled residents and young children and families many were placed in hotels and then left for days without rbkc contacting them to follow up on their support needs leaving them feeling abandoned by the council
00:46:48 them feeling abandoned by the council as many families were reliant on food provided by their hotels as we said many muslim families were unable to get halal food
00:46:57 food extraordinarily in the first few days rbkc gave no consideration to the flaws on which emergency accommodation would be provided so some residents having survived the
00:47:09 so some residents having survived the horrors of a high-rise fire were then placed in high-rise accommodation one can only imagine how that played out
00:47:20 can only imagine how that played out the failings of her department as part of our bkc's broader failure to comply with its duties under the cca 2004 in particular proper training of staff and
00:47:32 particular proper training of staff and adequate planning aside from attending one event in 2015 laura johnson had no formal training in contingency management planning and played no part in two significant
00:47:44 played no part in two significant training exercises which took place in 2015 and 2016. although there was a housing contingency plan dated 2012. laura johnson had failed to update it and was not
00:47:56 failed to update it and was not confident
00:47:57 confident her words that her housing team was even aware of it rbkc's housing department therefore failed to take basic steps which would have prepared them for providing
00:48:08 have prepared them for providing accommodation in a large-scale emergency as laura johnson accepted having standing arrangements with hotels or hotel groups would have helped to avoid
00:48:19 hotel groups would have helped to avoid the difficulty encountered in booking rooms because hotels require payment upfront a small and simple thing to rectify a problem that became very very
00:48:30 rectify a problem that became very very pressing for a large number of people in the aftermath a term then to contingency planning as we have stated in our written
00:48:41 as we have stated in our written closing
00:48:42 closing emergency planning preparedness and the assessment of risks lies at the heart of the civil contingency planning and statutory duties under underpinning
00:48:53 and statutory duties under underpinning the civil contingency act rbkc's failing in relation to its statutory duties pursuant to the cca 2005
00:49:02 2005 was systemic and we invite the panel to find that these systemic failings contributed to the abysmal abysmal response to the fire there was a systemic lack of internal
00:49:14 there was a systemic lack of internal oversight of the contingency arrangements which saw the plans being left unupdated annexes were left black or in draft film
00:49:25 annexes were left black or in draft film they were outdated or they were superseded simple and basic oversight and proper governance would have addressed those very very important
00:49:37 addressed those very very important issues
00:49:39 issues coupled with the systemic lack of oversight there was a lack of investment in contingency planning under resourcing and a culture steeped in this is how it's done
00:49:50 in this is how it's done and a resistance to change we are reminded of rebecca blackburn's evidence of rb casey's response to her concerns about the lack of training in and testing of contingency plans and
00:50:03 in and testing of contingency plans and david kerry's inability to cope with what she raised tony redpath response being that david could cope quote he's been doing this job for this
00:50:16 quote he's been doing this job for this amount of years he's the adviser to the lap panel he's a professional he'll cope the evidence in module 4 has shown that she did not cope
00:50:27 she did not cope the silencing of rebecca burton placing her on secundment following her response to the concerns raised about the cmu also strikes at the heart of rb
00:50:39 heart of rb poor governance and as we have heard she returned from secondment in 2016 to a deteriorated state of affairs with management turning a blind eye to the
00:50:51 management turning a blind eye to the concerns raised given the specialized nature of contingency planning and emergency management there needs to be greater investment in in both
00:51:03 investment in in both local authorities cmr use and that of responder organizations must be staffed with personnel including managers who are trained in emergency and disaster management
00:51:16 emergency and disaster management rbkc's lack of contingency preparedness prior to the fire and its tardy response weaves the familiar thread of neglect of which the
00:51:27 familiar thread of neglect of which the residents of the tower complained during the life of the building and which was sadly the experience of many members of the community in the aftermath the scene was ripe for rb casey's failed emergency
00:51:39 was ripe for rb casey's failed emergency response
00:51:40 response which failed an entire community
00:51:45 although apologies were tended on behalf of rbkc for its failings its contingency planning and its response to the fire the mia culpa has been somewhat
00:51:56 the mia culpa has been somewhat qualified
00:51:57 qualified but passing again and defiance is again obvious this is borne out particularly in david kelly kerry and his response to
00:52:08 kelly kerry and his response to questions
00:52:09 questions asked during the course of his evidence about rbkc's role in the provision of premises for rest centers as set out in rbkc cmp
00:52:22 rbkc cmp although the plan clearly specified that its role in the immediate aftermath included and i quote the provision of premises for body holding centers
00:52:33 premises for body holding centers survivor reception centers friends and relative reception centers david kerry sought and steadfastly sought to deflect responsibility onto the metropolitan police
00:52:46 onto the metropolitan police as he did when asked about the council's duty to coordinate communication and even when confronted with rbkc's own admissions of its spelled communications
00:52:57 admissions of its spelled communications mr carey's response to the inquiry's questions on these very obvious failings is indicative we say of rbc's culture of institutional defensiveness blaming
00:53:08 institutional defensiveness blaming someone in an effort to escape responsibility if lessons are to be learnt from institutional failings and meaningful change implemented
00:53:19 change implemented we as a society must cleanse ourselves of the cancerous culture of institutional defensiveness and back passing canda cannot be lip service it
00:53:30 passing canda cannot be lip service it must constitute the framework of public accountability in their written closing submission rbkc accept that contingency arrangements and managements were indeed
00:53:43 managements were indeed failings that were systemic and were enabled by an inadequate or non-existent oversight framework lrf's terms of reference place the onus
00:53:54 lrf's terms of reference place the onus on the organization to self-report issues of concern and to fulfill their statutory obligations under the cca 2005.
00:54:04 2005. at the time of the grenfell tower fire there was no national or regional oversight body with statutory powers to ensure compliance with the cca 2005 or
00:54:16 ensure compliance with the cca 2005 or standardization of cmp provisions and arrangements this remains the case to date they also accept further failings in relation to the back
00:54:27 relation to the back now it would be churlish not to acknowledge those failings and to welcome them however
00:54:34 however our clients are not going to give rbkc a pat on the back for accepting those failings which we say were blindingly obvious the risk of fire in high-rise
00:54:47 the risk of fire in high-rise buildings was foreseeable and should have been identified as a risk on rbkc's risk register although this risk was ever present given the prevalence of tower block
00:54:59 given the prevalence of tower block fires in london including the adair tower fire which as i've mentioned mr kerry had personal involvement with as the beg
00:55:08 the beg the risk of tower block fires was never raised by rbkc of its own initiative nor with other organizations in the lrf mr kerry's evidence of casual
00:55:19 mr kerry's evidence of casual conversations with the lfb at
00:55:23 at brf or other events generically about matters to the exclusion of risk of fires and tower blocks also supports a systemic lack of oversight risk assessment and management
00:55:37 we do not propose to take the panel through our detailed written submissions on london resilience framework which again
00:55:45 again we are very grateful you have read the panel has heard we say sufficient evidence from which to make findings for the reasons given and the evidence heard we would invite the panel to make
00:55:56 heard we would invite the panel to make findings of the inadequacy of the resilience framework and the need for a national
00:56:02 national regional quality contingency management resilience compliance and quality assurance organization or authority and that needs to have statutory powers
00:56:18 turning then very briefly to central government
00:56:23 we say sound bites and platitudes characterize the response of central government we were
00:56:30 we were and the inquiry we say was subjected to a parade of witnesses who simultaneously espoused regrets and apologies whilst failing to properly take ownership of
00:56:43 failing to properly take ownership of the disastrous manner in which this government dealt with this tragedy the grenfell tower fire was an exceptional national disaster it required and it needed an exceptional
00:56:55 it required and it needed an exceptional national response at governmental level what it got was nicholas heard mp a man only two days into his own ministerial appointment as minister of state for policing and the fire service
00:57:08 state for policing and the fire service in answer to questions as to whether he was adequately briefed the role he not surprisingly admitted he was not i don't see how i could have been given
00:57:19 i don't see how i could have been given this was day two in their written closing submissions dluhc says this the department recognizes that the
00:57:31 the department recognizes that the commitment to re-house all affected individuals in the local area in three weeks was too ambitious and could not be achieved
00:57:41 achieved this was not only an error and it wasn't the only error in its oral opening the department also acknowledged that it should have been quote clearer in the way that it
00:57:55 quote clearer in the way that it commitment was communicated it should have emphasized that effective people would be provided with temporary accommodation before being offered permanent accommodation and that they
00:58:06 permanent accommodation and that they weren't obliged to accept this offer now it is one thing for someone to decide whether to move into temporary accommodation for six months or a year a decision about whether to accept a
00:58:18 a decision about whether to accept a council or housing associate association tendency intended to be your permanent accommodation is a totally different order at a time when absolute clarity was
00:58:29 at a time when absolute clarity was necessary it is truly extraordinary that both central government and local government in the form of rbkc could not send out such confusing messages
00:58:41 confusing messages rbkc should have been clear in its own mind that the commitment was to provide temporary accommodation an email from fiona darby
00:58:52 fiona darby dclg's deputy director of homelessness to laura johnson on the 17th of june summarized what had been promised to rbkc the previous day the government was in effect offering
00:59:05 the government was in effect offering rbkc a blank check to cover the whole cost of temporary accommodation in the private sector until permanent accommodation could be provided abc casey could book everything
00:59:16 abc casey could book everything available even if it was not used because the government would bear the cost
00:59:21 cost in light of this email astonishingly it is clear from laura johnson's written and oral evidence that she understood the commitment to be the provision of permanent housing
00:59:33 permanent housing the three-week target was not just ambitious it was totally irresponsible it should have been obvious to the government that it was impossible to meet the deadline given the commitment
00:59:44 meet the deadline given the commitment to re-house locally the acute shortage of housing and the sensitive decisions that were involved ensuring that accommodation was suitable for each and every family's needs
00:59:56 every family's needs rbkc was placed in a situation where it made offers of accommodation to families even when it knew that those offers were unsuitable as laura johnson put it to no written
01:00:07 as laura johnson put it to no written evidence we were making offers we knew survivors would refuse in order to meet the three-week target and to make sure everyone had been given an offer
01:00:18 everyone had been given an offer indeed many residents moved into temporary accommodation which was subsequently found to be unsuitable and then had to move again and again many waited months or even years to
01:00:29 many waited months or even years to obtain suitable accommodation and many still have not achieved that and have not been provided with proper permanent homes insufficient steps were taken to address
01:00:41 insufficient steps were taken to address these concerns and the lack of leadership was not functioning properly despite consideration considering the issues of an intervention during the weekend
01:00:52 intervention during the weekend following the fire a decision was made against intervention due to the role played by gold command having taken over rbkc's leadership and the replacement of chief executive
01:01:04 and the replacement of chief executive and leader of rbkc this raises further issues regarding the pan london approach the legislation the effectiveness of the legislative framework and clear lines of activating
01:01:16 framework and clear lines of activating the intervention in terms of central government there were clear failings there was a failing by central government to act upon known information the rbkc and its leadership
01:01:29 information the rbkc and its leadership were out of their depth and that people were suffering nick hurt had met with volunteers he knew that they were filling the leadership vacuum in the response
01:01:40 leadership vacuum in the response the system of which mr herd was a part itself failed data provided did not add up it was inconsistent further there were inadequate resources
01:01:51 further there were inadequate resources in place to monitor or oversee rbkc
01:01:59 so in conclusion we say
01:02:05 we say with a large population and complex society that we live in now the probability of something very unlikely happening is actually very high
01:02:16 high in one year alone there was a manchester arena bombing the london bridge terrorist attack and the grenfell tower fire
01:02:24 fire unlikely disasters all of them but they all happened and they were all met with very different responses and very different levels of effectiveness the response to the aftermath of the
01:02:36 the response to the aftermath of the grenfell tower fire was woeful and laid bare a catalogue of breaches and failings
01:02:43 failings the bsrs demand and inspect those responsible to take full ownership of these failings and to acknowledge these and all statutory breaches it is only by
01:02:55 and all statutory breaches it is only by such acknowledgement that the process of accountability can begin no community should have to go through such painful and degrading experiences
01:03:06 such painful and degrading experiences as our clients did in the aftermath of this fire
01:03:09 this fire when they should have been protected and enveloped in the protective arms of the state they were treated as a hindrance second-class citizens who did not warrant the care
01:03:20 warrant the care kindness and support that they should have been given immediately and
01:03:28 unconditionally final words i return again to one of our clients hanan wahhabi a woman whose eloquence and quiet dignity and gravitas embodies
01:03:40 dignity and gravitas embodies this proud brave and resilient community of people
01:03:45 of people this is what hanan said to this inquiry we
01:03:52 we were treated like numbers not humans this is something that we still feel today
01:03:58 today in my experience in the eyes of local and central government our grenfell and north kensington community are second class the people with needs
01:04:09 are second class the people with needs and problems i cannot help but feel that had our community lived in a different part of the borough on the more affluent side had we been
01:04:20 on the more affluent side had we been from a different class had we been less ethnic
01:04:24 ethnic the response in the aftermath would have been immediate it would have been present it would have been felt we may be different we may be diverse but we are people
01:04:36 but we are people think of the different professions in the tower of the challenges that so many from the bain community have overcome prior to the fire in 2017 think of the dignity demonstrated by
01:04:48 think of the dignity demonstrated by those of us impacted over the last five years we are human beings we contribute we pay tax we provide leadership in our communities this tragedy has pierced wounds in each
01:05:01 this tragedy has pierced wounds in each and every one of us in ways that one cannot imagine we may we may now and again put plasters to hide our wounds but they are still there and sometimes indeed many times
01:05:13 there and sometimes indeed many times those plasters fall off to this day the support that we are have been given is only provided after jumping through hoops whether it's fighting to get houses repairs done or
01:05:26 fighting to get houses repairs done or get the medical support we need we are forever asked to prove that we have been impacted forever having to prove our pain
01:05:36 pain this duty of care needs to extend beyond us to the rest of the country to the thousands of families who live in communities like us like we had at grenfell who are still
01:05:49 like we had at grenfell who are still treated as second-class citizens it needs to extend to the thousands impacted by the building safety crisis up and down the country we are all still impacted we still hurt
01:06:02 we are all still impacted we still hurt we still remember we haven't forgotten all the issues we have the ptsd the mental and physical trauma that you see as problems in us this isn't who we are
01:06:16 as problems in us this isn't who we are this is who some of us are now because of what the government did to us because of your absence because you were not there because you did not show that
01:06:27 not there because you did not show that you cared
01:06:28 you cared you have sapped all the energy from us those that cause this tragedy must be held accountable their duty of care to us now has no
01:06:39 their duty of care to us now has no limit
01:06:41 limit thank you very much chair thank you very much um well at this point we're going to take the morning break we'll rise now we'll resume please at 25
01:06:52 we'll rise now we'll resume please at 25 past 11
01:06:53 past 11 as you will all realize we're running slightly behind time and so um i would encourage those who are coming next to keep their remarks within the span allotted thank you very much anyway
01:07:05 span allotted thank you very much anyway 25 past 11 thank you
01:23:45 uh
01:23:49 the next statement is going to be made by mr friedman queen's council on behalf of those of the bereaved survivors and residents whom he represents yes mr friedman good morning
01:24:02 panel if the subject matter of democratic government is the people then the phase two evidence demonstrates something profoundly wrong that people were left so exposed in both
01:24:13 that people were left so exposed in both the origins and the aftermath of the fire
01:24:16 fire while this inquiry must therefore conclude on what is needed to better regulate the built environment and the emergency response to its fragility the study of the fire's aftermath raises an equally important question of this
01:24:28 equally important question of this disaster how can we make democracy more social
01:24:33 social the module 4 evidence focuses on that question through five lenses people community borough
01:24:41 borough city and state and through those lenses we say certain basic features of what might be regarded as a good and just society are missing they include
01:24:52 they include respect for human dignity as an overriding societal value real community engagement as a primary goal of all levels of government effective emergency organization for the
01:25:05 effective emergency organization for the well-being of cities and genuine human and social concern at the heart of state from these missing features flowed the following wrongs in what this
01:25:16 flowed the following wrongs in what this module calls aftermath but which can now be properly viewed as the continuation of the disaster first
01:25:24 first people were resilient but the acts and omissions of government often made them vulnerable second there was a practical and moral collapse of local government for reasons
01:25:35 collapse of local government for reasons foreshadowed in pre-fire relations third whatever its improved contribution to recovery an improvised london command structure took power on the barest of
01:25:47 structure took power on the barest of legal foundations and fourth the modern discourse and practices of civil contingency and particularly its core features of subsidiarity and resilience
01:25:58 resilience had in this instance profoundly anti-social consequences starting with people the bsr's overriding accusation is that
01:26:09 the bsr's overriding accusation is that the system did not care about them consider again hanan wahhabi's declaration we may be different we may be diverse but we are people we are human beings
01:26:20 but we are people we are human beings mahmoud urged i am a human i have feelings
01:26:25 feelings muhammad russell learned that those in power don't care about their constituents because they can't relate to them
01:26:32 to them hana and chabika and those on the walkways discovered we did not matter because we didn't come out of the town we didn't lose anybody muna el ogbani found no understanding no
01:26:45 muna el ogbani found no understanding no empathy or sympathy no culture and what she wanted for people is to be taken seriously and treated with dignity and respect
01:26:54 respect and caring musili the system isn't broken it was built this way
01:26:58 this way and people need to see themselves in us people need to understand that what's happened to us and what's happening to us is also happening to them now these are criticisms
01:27:10 now these are criticisms of contemporary bureaucracy and should be taken seriously as systemic problems and not just the neglect of a rogue borough that rbkc was
01:27:21 neglect of a rogue borough that rbkc was one of the key gaps in the copious central and local government emergency planning documents is they do not speak of people they refer instead to categories of
01:27:32 they refer instead to categories of vulnerable persons of the voluntary community sector of faith groups and of essential services but they do not require focus on the qualities and needs of individuals or everyday groups of
01:27:44 of individuals or everyday groups of people
01:27:45 people this absence of basic human counting flows down through the rest of the emergency system the regime we are told relies on subsidiarity
01:27:56 we are told relies on subsidiarity defining the documents as the principle that decisions should be taken at the lowest appropriate level with coordination at the highest necessary level
01:28:07 level it may have some logic as regards local knowledge but based on what this inquiry has learned across its modules subsidiarity is another species of unaccountable and unmonitored localism
01:28:20 unaccountable and unmonitored localism a powerful example of this is that before the fire central government nav they gave no thought to the fact that following a disaster
01:28:30 disaster mass displacement would likely have a disproportionate effect on lower income groups
01:28:36 groups it was not considered in the compilation of the national risk register or in the lead department planning catherine hammond in the cabinet office and melanie dawes at dclg could
01:28:47 and melanie dawes at dclg could recognize the point when questioned but on grounds of subsidiarity they declared it something exclusively to be dealt with at the local level in one swoop of doctrine
01:28:58 in one swoop of doctrine the major reality of any disaster that those with less financial means will suffer most gets entirely contracted out of central government responsibility and it does so by design
01:29:10 by design and once in the midst of the grenfell disaster
01:29:14 disaster no one in government considered it an obvious problem that the local authority who owned the building and was therefore primarily responsible to account for its lack of fire safety was to lead on response and recovery for the fire's
01:29:26 response and recovery for the fire's victims
01:29:28 victims subsidiary subsidiarity turned out to be to civil contingency what say put is to fire and rescue it's a policy assumption that was allowed to become imprisoning as an
01:29:39 allowed to become imprisoning as an article of faith a further problematic concept that runs across the documents is resilience dictionary definition refers to the innate capacity in nature physics or
01:29:52 innate capacity in nature physics or psychology to rebound or spring back resilience could therefore serve as a marker of the power and creativity of humans to respond to adversity especially with public sector support
01:30:05 especially with public sector support however the cabinet office definition of resilience refers to the ability of the community
01:30:11 community services
01:30:12 services area or infrastructure to detect prevent or if necessary to withstand handle and recover from disruptive challenges its relevant levels including its proper
01:30:24 its relevant levels including its proper noun the community do not include individuals the public or normal community life resilience is essentially reserved for formal organizations structure and
01:30:36 formal organizations structure and services
01:30:37 services what the documents really refer to is resilience of state those who cannot be resilient due to poverty or disability are lumped under a catch-all of the vulnerable
01:30:49 catch-all of the vulnerable no account is given to how inequality creates vulnerability resilience is civ in civil contingency speak it's not about empowering in a human capacity it's a governing ethos
01:31:01 human capacity it's a governing ethos and in truth in the present state of affairs
01:31:04 affairs a suspect term what karim mussouli and others witnessed was not state respect of human resilience but authorities more concerned about an
01:31:16 but authorities more concerned about an uprising or unrest than they were about looking after families for thomasina hessel council officers hiding badges and not wearing lanyards illustrated how residence was perceived
01:31:29 illustrated how residence was perceived as a dangerous threat
01:31:32 threat police risk assessments as you've heard expected community tension especially when the majority of those affected are believed to come from a muslim background
01:31:43 background for several days the west way remained a site of intimidation rather than refuge amidst this rbkc deliberately and consistently
01:31:55 rbkc deliberately and consistently lobbied against local residents as agitators with agendas and on that civil unrest became the official explanation for delay in removing from
01:32:06 explanation for delay in removing from response to recovery that is the justification that john heverington of london resilience provided to chief executives for delayed handover on the 15th of june the same day nicholas holgate told joe
01:32:19 the same day nicholas holgate told joe farah without repudiation that grenfell residents could quote make this worse than it is and the council is worried that they might need assistance from the police
01:32:29 police despite all of the overnight diplomacy to activate london authority gold the scg meeting at 11am on the 16th of june still formally logged the delayed
01:32:40 still formally logged the delayed transition to recovery stage as caused by
01:32:43 by ongoing community tension this false narrative should never have been officially endorsed in that way the delay occurred because rbkc was
01:32:54 the delay occurred because rbkc was incompetent incapable and resistant to external involvement and regional and central government was unable or unwilling to force the issue everyone
01:33:05 unwilling to force the issue everyone knew this but instead of acknowledging it the community were made to take the blame indeed
01:33:12 indeed from town hall to downing street documents show a state of elite panic obsessed with wanting to get a grip grip is not a government term of
01:33:24 grip grip is not a government term of art
01:33:25 art its use reflects a mentality in which real engagement with people as opposed to managing or ordering them has no real prior thought or practice gripping is more about power than
01:33:36 gripping is more about power than welfare and again not about people in the post-brexit electoral storm of june 2017
01:33:44 june 2017 it also spoke to fears of broader collapse of social control when mark said well as national security adviser warned colleagues that without getting a
01:33:56 warned colleagues that without getting a grip this could become our new orleans he was referring consciously or otherwise to a seminal moment of recent history where structural discrimination revealed itself so obviously interwoven
01:34:08 revealed itself so obviously interwoven in a country's social fabric as hurricane katrina showed in 2005 america
01:34:14 america the grenfell aftermath showed britain
01:34:18 britain to be in denial about the effect of economic and race inequality on people's capacity to withstand disaster on this
01:34:28 on this the civil contingency system and its practitioners were at fault because of their indifference to inequality first
01:34:36 first none of the cabinet or london documents as of 2017 referred to the equality act 2010. when cabinet office with obvious witnesses assumed that socioeconomic
01:34:48 witnesses assumed that socioeconomic disadvantage would be considered locally given equality act obligations they overlook that section one of the equality act which would require such consideration has never been brought
01:34:59 consideration has never been brought into force by the post 2010 governments second
01:35:04 second as to other enforce protected characteristics under the act including age sex disability race and religion which often intersect with socioeconomic inequality
01:35:15 inequality central government ought to have known that the public sector equality duty has simply not embedded in local authority culture across the country indeed ccs breached its own duty
01:35:28 indeed ccs breached its own duty in failing to press the point just as london resilience failed to embed the duty as part of its minimum standards third at the local level
01:35:39 third at the local level detailed knowledge of the equal treatment requirements in the equality act and their application to emergency planning was non-existent despite the powerful indices in the population of
01:35:50 powerful indices in the population of north kensington that ought to have made it a priority panel without exception the evidence before the inquiry in every module in phase two
01:36:02 module in phase two has been that breach of the public sector equality duty is the norm the default answer to the equal treatment questions put by your counsel throughout the phase has never done more
01:36:16 throughout the phase has never done more and often less than articulate a general need to think about the vulnerable and otherwise prevent intentional abuse that is not a way to combat discrimination it
01:36:27 is not a way to combat discrimination it signifies incompetency to prevent it
01:36:31 why is it that his sam and nabil shuker both raise discrimination with you but karen mussily says we suffer and
01:36:42 but karen mussily says we suffer and they prosper that muhammad rasool told you they experienced second class exclusion as if refugees in their own country and that they cannot okay escape the
01:36:53 and that they cannot okay escape the conclusion offered by hanan wahhabi that had our community lived in a different part of the borough on the more affluent side had we been from a different class had we been less ethnic the response in
01:37:05 had we been less ethnic the response in the aftermath would have been immediate it would have been present it would have been felt
01:37:10 been felt these are not just opinions they are factual descriptions of a concrete situation as an overwhelming african middle east and caribbean diaspora population
01:37:22 and caribbean diaspora population many with intersecting lower incomes and disabilities and with the vast majority of muslim faith heritage they have suffered because of a failure of human
01:37:33 suffered because of a failure of human accounting that absence of accounting produced an experience for bsr in the first period of the aftermath response that was inhumane
01:37:44 inhumane it treated people as numbers not humans herding them like cattle ticking boxes about them ignoring them as victims requiring them to repeatedly relive their trauma to
01:37:56 to repeatedly relive their trauma to access services containing their anger and pain and even resenting it more than anything the treatment of bsr was felt as abandonment by the state
01:38:07 was felt as abandonment by the state when all aspects of their human geography had been lost neighbors family friends
01:38:13 friends homes possessions and means of access to the rest of life while the civil contingency system at each level of government is to blame for these outcomes there is also a bureaucratic mentality in an era of
01:38:26 bureaucratic mentality in an era of diminished state connection to society that lacks empathy and human responsiveness everyday moral restraints make it hard for people especially public servants to
01:38:37 for people especially public servants to admit to inhumanity or comprehend the inhumanity is not restricted to bad people
01:38:43 people and yet it occurs in bureaucracies and businesses when basic moral restraints become neutralized or otherwise compromised we say that there are powerful examples
01:38:55 we say that there are powerful examples in in this before the inquiry that need to be marked out however uncomfortable for some to acknowledge consider
01:39:02 consider laura johnson she presided over the assignment of residents into hotels with no regard to their human well-being once warehoused in that way
01:39:14 once warehoused in that way johnson's account is about the movement of bodies and things not people and she did this in a fashion that no one would ever do to their own family or friend or anyone whose lives they knew anything
01:39:27 anyone whose lives they knew anything about
01:39:29 about nicholas holgate regrets now the type of leader he was then but when he protested it was not part of his makeup as a career civil servant to refrain from invoking london gold for
01:39:41 refrain from invoking london gold for the undisputed reason in the log that looks like we can't hope what he really means is i am not the kind of person who would want to be seen as refusing help for those reasons
01:39:53 as refusing help for those reasons however
01:39:54 however out of arrogance and a defensiveness that is just what he did and catherine hammond sees no failure in the civil contingency system but only a single unprepared
01:40:05 system but only a single unprepared borough in the face of an unprecedented threat
01:40:08 threat she too
01:40:10 she too has become desensitized to the moral deficits of a regime that she and the secretary were in charge of at the macro level and which even in closing submissions you are told responded well
01:40:24 submissions you are told responded well the lack of human accounting at grenfell has at least been recognized by some the british red cross in self-described soul searching of its own shortcomings has advocated for a quote human centered
01:40:36 has advocated for a quote human centered response that requires all of us to develop new approaches to empower and put people and communities at the heart of emergency response nicholas heard's final reflection to
01:40:48 nicholas heard's final reflection to this inquiry was that the state must think differently about the critical distinction of doing things with people rather than things to people what that should have involved
01:41:00 what that should have involved was collaboration with local people and everyday community respecting their agency and not just their vulnerability and in a more genuine relationship of equals
01:41:12 equals that leads to the subject of real community engagement like people actual communities are also unaccounted for in the system the framework under the civil contingency act limits supportive
01:41:24 contingency act limits supportive reaching to communities in two main ways that are profoundly outdated first communities are not mentioned at all second community interests are indirectly catered for by replicated for
01:41:36 indirectly catered for by replicated for by reference to the voluntary sector which section 25k of the 2000s designates as quote the activities of bodies other than public or local authorities whose activities are not
01:41:48 authorities whose activities are not carried on for profit however the act and regulations only require local authorities to have regard to such activities no more the guidance adds only that such organizations must
01:42:00 adds only that such organizations must be factored into local civil protection arrangements the subsidiarity regime therefore only requires limited consideration of community life it makes the elitist assumption that
01:42:12 it makes the elitist assumption that organizations like the british red cross or the royal voluntary services and places of religious worship will act as the representatives of ordinary people as if they cannot represent themselves
01:42:23 as if they cannot represent themselves the duty to develop community resilience does not exist under the civil contingency regime cabinet office papers described it in 2015 as an untapped resource and michael
01:42:35 2015 as an untapped resource and michael addison adamson puts it in this way it's essential to make friends before you need them but the law of emergency requires no one to do that without a discreet legal duty the
01:42:48 without a discreet legal duty the approach of rbkc management management team on this issue was to do nothing the so-called minimal standards for london a misnomer given that these were neither a duty nor in force only invited
01:43:00 neither a duty nor in force only invited councils to seek out local partners and to put a documented strategy in place with a program of collaborative work rbkc never had a strategy
01:43:11 rbkc never had a strategy david kerry described such a standard as aspirational stuff that wasn't on our gender at the time and unachievable in any pragmatic or sensible way
01:43:23 sensible way he could only recall that his team had visited the local church of england and catholic diocese but not the obviously more relevant almanac cultural center in terms of access to the muslim
01:43:35 terms of access to the muslim demographic of lancaster west panel what community engagement for emergency planning meant for rbkc was team with the vicar and not with the imam
01:43:46 and not with the imam and nothing more
01:43:49 what council what what occurred instead on the 14th of june was there for self-help
01:43:56 self-help human to human community action in the absence of organized places of refuge and decent information channels in the first days of the disaster community created them
01:44:07 community created them the key rest centres were not set up by an arms-length voluntary sector but by people who congregated in trusted places known to them when information was refundedly taken by
01:44:18 when information was refundedly taken by the authorities rather than given bcr began to pull what they knew on social media groups and created their own lists volunteer organizations especially rugby portobello and clement james willingly
01:44:31 portobello and clement james willingly hosted protected and facilitated recovery within their spaces but they did not do it because rpkc asked them or coordinated them with any remote degree of partnership
01:44:42 of partnership parts of the local voluntary community then supported bsr to represent themselves rather than represent them and in doing that they did something more meaningful than the formal and
01:44:53 more meaningful than the formal and mediating role ineffectively assigned to their sector in the present legal framework
01:44:59 framework once in the crisis of disaster our opening address pleaded the imperative for outreach to bsr to discover what was needed the british red cross evidence agreed
01:45:10 the british red cross evidence agreed that this absolutely meant to walk the relatively contained grid of streets and make contact with people and places to build links and learn what otherwise wouldn't be known
01:45:21 wouldn't be known for the bsr director what had been overlooked at grenfell was a lot of social capital in that community a lot of organization a lot of very dynamic people and leaders who already knew each
01:45:32 people and leaders who already knew each other and actually could have been harnessed more effectively more effectively earlier on in the process instead the various communities came together on their own but there was profound cost
01:45:43 profound cost which bsr have explained to you in their evidence
01:45:46 evidence they have described a traumatic experience for them their families and importantly their children that will never go away the damage wreak disproportionate impact
01:45:57 the damage wreak disproportionate impact on working class people predominantly of color who did not have the money networks or options others have it is for that reason that the aftermath and its harm has become a social justice
01:46:10 and its harm has become a social justice issue for bsr that stands side by side with the causes of the fire turning then to the borough
01:46:21 rbk's contra our casey's contribution to the damage done is accepted but its witnesses have continued to hide from the aggravating features of their wrongs
01:46:31 wrongs a fire of this nature would have challenged any council but rbkc's deep-rooted inadequacies made the situation far worse it was incapable of leading recovery not just because it was overwhelmed but it
01:46:43 just because it was overwhelmed but it was because it was culpable for the fire and inhumane because of its long-term disengagement from that escape state even with flaws in planning and
01:46:54 even with flaws in planning and shortcomings in initial response the council that enjoyed pre-existing meaningful community engagement would have coped better not least by correcting errors in real time based on bsr feedback
01:47:06 bsr feedback but in bkc's but rbkc's relations have degraded over the years nicholas heard now accepts the very clear impression that was forming quickly on the first day that the council was going to
01:47:18 day that the council was going to struggle to have the moral authority to lead
01:47:22 lead from the beginning rbkc's leadership understood it would be criticized both for its culpability and its disconnection from lancaster west kerry recalled the sprinklers were
01:47:34 kerry recalled the sprinklers were quickly on holgate's mind holgate was reluctant for outside pr to be appointed because he thought this would be seen as the act of a guilty party
01:47:44 party we have given you the references for when rbkc and tmo deflected blame onto bsrs
01:47:51 bsrs central government and the media holgate's admission in evidence of suspicion only i.e prejudice that bsr instigators were fabricating stories in order to further
01:48:03 fabricating stories in order to further aims should be seen in its true light as part of a pattern of bias against bsr amongst senior rbkc and tmo officers it is important not to overlook the
01:48:15 it is important not to overlook the pre-fire animosity towards grenfell residents by those with power over them laura johnson had made it clear to the tmo as recently as march 2017 that they
01:48:28 tmo as recently as march 2017 that they would be protected against residents from grenfell the bad tempered place complaining about minor matters with their own agenda who were not to be taken seriously
01:48:41 taken seriously in an email on the 16th of june 2017 she stoked the suggestion that residents would sabotage recovery by assuming without any foundation that edward daffan would lead the town hall protests
01:48:52 daffan would lead the town hall protests robert black allowed his tmo staff across the regeneration period to require regard daffon and councillor blakeman as a negative force repeatedly warned blakeman for breaching
01:49:04 repeatedly warned blakeman for breaching a purported conflict of interest and would sack her from the tmo board for her criticisms of it immediately after the fire
01:49:13 the fire a second in command and the principal adviser to holgate during the emergency when kerry was away tony redpath's inquiry statement is
01:49:24 tony redpath's inquiry statement is littered with victim blaming he articulates the view that as the emergency plans were premised on the borough being seen as a positive presence by the affected community and
01:49:36 presence by the affected community and that turned out not to be the case because people maligned the borough with anger hatred and blame then the delivery of effective services in the aftermath was in his view not possible
01:49:48 possible his fallacious reasoning is exposed by the is exposed by the principle issue rbkc did not immediately act on nor plan for its own conflict of interest firstly
01:50:00 for its own conflict of interest firstly in being culpable for the fire and second in long-term conflict with residents over low quality works and fire safety standards cumulatively this combination of defensiveness and prejudice rendered
01:50:12 defensiveness and prejudice rendered holgate preoccupied with appearing to retain control of the response rather than activating the massive london support that was needed although he resisted this in evidence
01:50:23 although he resisted this in evidence the inquiry he was obviously concerned with optics reputation and blame and for that reason issued improper assurances well into the thursday evening and beyond
01:50:35 beyond on incompetency we say that contingency planning in rbkc was a low priority function presided over by a traditional town hall staffing staffing structure one which lacked in
01:50:47 staffing structure one which lacked in diversity and showed disinterest in issues
01:50:53 issues priestly and red path line managed to carry without expertise in their own right and no experience to carry out the roles expected of them after the fire
01:51:04 roles expected of them after the fire holgate had neither real experience nor training
01:51:08 training kerry progressed through the ranks of contingency management largely due to serving time in the area rather than as a result of developing expertise through educating training or experience
01:51:20 educating training or experience he combined long years in post with evident ability to speak the cabinet office lexicon and to navigate the convoluted byways of london resilience acquiring the status
01:51:31 london resilience acquiring the status as official advisor when his abilities clearly did not merit that role by contrast rebecca blackman educated younger female and less deferential shun a light
01:51:44 female and less deferential shun a light on the weakness of the service she rightly regarded kerry as overly bureaucratic and organizationally conservative she had repeatedly pointed out the risks
01:51:55 she had repeatedly pointed out the risks associated with the failure to conduct exercises to test the adequacy of the contingency managing plan and the cadre of volunteers both of which she thought the borough was doing the very least we
01:52:07 the borough was doing the very least we had to do
01:52:09 had to do she correctly predicted superiors that kerry would not cope in the event of a major incident red path told her to defer to her manager's experience she understood the role of the team was
01:52:21 she understood the role of the team was not just to put the plans in place and make sure we look good on paper but to ensure the organization was able to respond effectively rather than have these issues addressed
01:52:32 rather than have these issues addressed blackman was seconded out of the team for 18 months as of june 2017 she was the outlier in her workplace and stood out for a relative competence
01:52:45 and stood out for a relative competence during the crisis many of the leading personnel leaned on her capability meanwhile kerry broke down from exhaustion by the first morning thereafter he left inexperienced
01:52:56 thereafter he left inexperienced colleagues profoundly exposed to operate the day shifts and did pain-free little himself during the nights proper prior monitoring would have shown that local government was chronically
01:53:07 that local government was chronically unprepared as a result rbkc made fundamental mistakes in the first 48 hours following the fire from which it never recovered kerry was embarrassed by his own phrase
01:53:19 kerry was embarrassed by his own phrase we were what we were we did what we did but it revealed the truth his many years preparing for an emergency could not ready the borough for anything more than a bus crash on
01:53:30 for anything more than a bus crash on the high street or a minor fire and finally at the level of borough for all its self-aggrandizing descriptions of being a resident democracy the tmo's contribution to the
01:53:42 democracy the tmo's contribution to the emergency response was essentially reduced to providing delayed incomplete and inaccurate commit information on residents and conducting delayed and inconsistent repairs for the walkway blocks
01:53:53 blocks thus in the aftermath any pretense the tmo had in being a representative and functional organization and one that was well integrated within its community simply fell away
01:54:05 simply fell away turning then to the view from regional government beneath the complexity branding and multiple stakeholding of london resilience lies the void that a
01:54:16 london resilience lies the void that a major capital city does not have its own emergency agency instead it has a duty rotor system of chief executives available to provide ad
01:54:27 chief executives available to provide ad ad hoc advice from a london-wide perspective with additional bodies with various acronyms able to provide guidance and support but without power or intent to discharge an emergency
01:54:39 or intent to discharge an emergency recovery function that required the required leadership at grenfell by selection of london civil contingency specialist was therefore delayed because
01:54:50 specialist was therefore delayed because arby said rbkc did not ask for it and london local authority gold had no power to impose it the stages by which the hierarchy of london resilience delayed even advising
01:55:02 london resilience delayed even advising nicholas holgate that there was a serious problem nevertheless reflect the fundamental shortcomings of the subsidiarity system at first
01:55:11 at first they kept their distance because the london gold function in herrington's words was limited to scenarios requiring pan london participation and on subsidiarity doctrine grounds the local
01:55:23 subsidiarity doctrine grounds the local chief executives were deemed to know better how to use his resources this led to offers of help without insistence with rbkc taking none of them
01:55:34 insistence with rbkc taking none of them up
01:55:35 up but soon
01:55:37 but soon london resistance resilience became complicit in rbkc's competence incompetence by taking the council's assurances at face value they supported arby casey to
01:55:48 face value they supported arby casey to continue to lead when it could not damage was particularly done by the telephone call between holgate and the key london figures at 5 30 pm on the 14th of june
01:55:59 14th of june this discussion extended to facilitating political support for a council that needed in holgate's words to be given a chance to do its job and in circumstances where public
01:56:11 and in circumstances where public criticism in the febrile post-election political climate was as heverington assessed starting to swell after the call heverington commended holgate to be quote extremely logical
01:56:23 holgate to be quote extremely logical and sensible and going through the right steps
01:56:27 steps barrydale registered a relatively pogest positive picture that they were within their capability and within their capacity
01:56:35 capacity sawyer held back from what he saw as a chief executive chief exec call john baridal accepts now that he should have been far more assertive in testing
01:56:47 have been far more assertive in testing what he was told at the time no one confronted the obvious rbkc would never succeed alone and the potentially culpable london landlord should not be leading on recovery
01:56:59 recovery during the second day complicity moved to disquiet not just about events in grenfell but about london's role across regional and central government it became clear that arby casey could
01:57:11 it became clear that arby casey could not do the job but the emails of thursday night still speak of john barretta planning to visit rbkc officers the following day on a scoping exercise with great uncertainty as to what london
01:57:24 with great uncertainty as to what london resilience would actually do there was never a formal letter sanctioning baridale taking control instead there was an email sent by
01:57:35 instead there was an email sent by heverington to london chief executive executives on behalf of holgate and baridale at 1327 on the 16th of june that quote following a request from rbk
01:57:48 that quote following a request from rbk rb kensington and chelsea for strategic support the london local authority gold operations have been activated this is the document that rbkc relied on in their opening as making clear that
01:58:01 in their opening as making clear that the formal transfer to london gold had been completed by 13 27 hours on the 16th of june when heatherington sent that email the email does not say in terms that
01:58:12 the email does not say in terms that paradise has taken over many people did not realize he had and nicholas padgett brown was told about it at lunchtime rather than ordering it the decision was never put to cabinet or council or formally
01:58:24 to cabinet or council or formally endorsed by reference to any legal framework
01:58:28 framework what in fact happened on the friday is that joe farah arrived from dclg in late morning to find baridol still in a support role armed with a mobile phone to call the
01:58:41 armed with a mobile phone to call the chief executive of london councils and then text her permanent secretary farah essentially improvised the takeover of rbk
01:58:49 rbk kc recovery in the corridor outside holgate's office the press release issued on the saturday evening condemned the initial responses simply not good enough and introduced
01:59:01 simply not good enough and introduced the new grenfell tower response team this was not london authority gold it was a joint creature of regional and central government whatever improvements
01:59:12 central government whatever improvements it made in the long run the power of this improvised construct was founded upon the barest of legal foundations the inquiry needs to reveal the extent of this improvisation so that londoners
01:59:24 of this improvisation so that londoners and others do not live under the assumption that there is a rigorous organized regional emergency service that will kick in when needed likewise london resilience and central
01:59:35 likewise london resilience and central government leadership share responsibility for hiv tolerating the absence of a genuine mechanism that could scale up response when a humanitarian predicament made it necessary
01:59:48 viewing the disaster through the lens of people and community up through the layers of state truly brings home that the uk does not have a disaster management system
02:00:00 have a disaster management system the major flaw of the existing civil contingency act requires its unjustifiable gamble on a given local authority being sufficiently effective
02:00:11 authority being sufficiently effective in its preparation especially in the aftermath of a place specific disaster that has led to mass displacement of socially economic and otherwise disadvantaged populations
02:00:22 disadvantaged populations grenfell has shown how subsidiarity provides several government with great discretion even when the system is manifestly failing first
02:00:34 first government departments are not scheduled responders under the cca that leaves them with various powers but not duties powers include that government can make
02:00:45 powers include that government can make orders to require or permit responders third parties or itself to take action with such orders subject to affirmative resolution by parliament however in a case of urgency a minister may make a
02:00:57 case of urgency a minister may make a written direction to act in place of orders that remain in force for up to 21 days and which require no prior legislative consent before and during the grenfell aftermath
02:01:10 before and during the grenfell aftermath these powers lay unused and instead holgate
02:01:16 holgate had a new system pushed upon him in that corridor
02:01:20 corridor second central and regional government had no means of effectively predicting the resilience of the local government response because there was no national inspector or oversight function and
02:01:31 inspector or oversight function and there still isn't it is especially untenable that subsidiarity should prevail without proper independent auditing and inspection that left rbkc not on the radar of
02:01:43 that left rbkc not on the radar of dclg's rare team barra dale by his own admission being overly impressed by rbkc's positive posture and sawyer's ignorance so we're being ignorant of the weakness in rbk
02:01:55 being ignorant of the weakness in rbk system rbkc system until he physically attended the town hall third the lack of accountability of contingency planning places ordinary people at risk because they cannot
02:02:07 people at risk because they cannot easily complain to courts any public law challenge to state failure in response and recover recovery would face litigation difficulty in that the executive is legally regarded as
02:02:19 the executive is legally regarded as enjoying a discretionary area of judgment in the governance of security and emergency samartin
02:02:27 samartin with respect will know as a judge that a 5 30 application for interim relief on that wednesday afternoon would have got pretty much nowhere
02:02:39 would have got pretty much nowhere what that means is that if planning does not take place in an effective and accountable way beforehand then once the emergency begins people and communities are dramatically
02:02:50 people and communities are dramatically exposed to the discretion of the state particularly when it collapses in its function
02:02:56 function without its own planning and conduct duties under the cca the cabinet secretariat and dclg were able to play by their own rules and on that basis they floundered because they did not
02:03:08 they floundered because they did not appreciate in time that the system had crashed
02:03:11 crashed hammond has consent convinced herself that a pick and mix approach to the central government concept of operations conops made no difference we disagree
02:03:22 conops made no difference we disagree conops requires a formal assessment of large-scale emergencies to establish whether severity levels require government intervention via cobra and in accordance with a set of policy actions
02:03:34 accordance with a set of policy actions those actions include joint operations with local responders and sharing in the provision of information to the public that is what the civil contingency secretariat should have coordinated and
02:03:45 secretariat should have coordinated and they failed to do so as doors would put it to the cabinet secretary once the event was recognized as more complex than seven seven there was one clear lesson we should have had
02:03:56 was one clear lesson we should have had a pm chaired cobra on the wednesday that must be correct and rather than mere branding as the cabinet office now suggests the consequences were stark
02:04:07 suggests the consequences were stark first
02:04:08 first a minister-led meeting limited the weight of oversight to a junior minister in nicholas heard two days in office who had no relevant experience second it sent a key message to local
02:04:22 second it sent a key message to local responders that central government oversight vested in junior ministerial monitoring as opposed to senior prime ministerial and cabinet-level intervention third
02:04:33 third it stored the extent of cross-departmental assessment and common understanding of the magnitude of what was going on fourth it allowed government to maintain a stance of expecting to be asked for
02:04:45 a stance of expecting to be asked for assistance rather than proactively seeking it or imposing it and fifth
02:04:51 and fifth government was ridiculously hands off with holgate on the first day so much so that no one important even noticed his non-attendance at the first ministerial
02:05:02 non-attendance at the first ministerial meeting
02:05:04 meeting when government intervention finally came
02:05:06 came it did so through joe cavara in the town hall corridor no official direction or orders were required whatever benefits derived from this informal seizure of power the event cannot be regarded as
02:05:18 power the event cannot be regarded as evidence of the subsidiarity resilience system working well as has been portrayed to this inquiry neither should the ccs be content with the quality of its coordinating
02:05:29 the quality of its coordinating oversight and expert advice across the days of the emergency css has been critical of rbkc's lack of grip but as melanie dawes accepted the failure to grip the situation extended to central
02:05:42 grip the situation extended to central government and could have been prevented if it had been clearer in the way that central government systems and decisions operated
02:05:51 the policies and lexicon of the cabinet office and london resilience involve only a few stakeholders who speak the language of resilient subsidiarity
02:06:02 resilient subsidiarity like all specialist languages it can have implications for separating the speaker from others but this language risks being particularly disconnecting especially here where it caused officials in whitehall and london to
02:06:15 officials in whitehall and london to view themselves primarily as allies in waiting to the subsidiarity state below them rather than in humanitarian service to people and community this last evidence gathering module for
02:06:27 this last evidence gathering module for the inquiry has followed several years of investigating industry and government for you to have heard bso our evidence is a profound reminder that the
02:06:38 is a profound reminder that the foundation of government economics and law should be the people respect for the inherent dignity of people did not function as an overriding objective in the bureaucracies that dealt with bsr before during and after
02:06:51 dealt with bsr before during and after the fire
02:06:52 the fire the rationalist professional outlook of modern bureaucracy has taught itself to be distant and disconnected from people and communities and especially those who may be marginalized on grounds of class
02:07:05 may be marginalized on grounds of class race and disability the damage done by such discrimination is profound it is anti-social what is needed is a discipline and practice of respecting dignity as a
02:07:16 practice of respecting dignity as a fundamental feature of what it means to be in civil political and social service people suffered in the aftermath of grenfell tower because of an inhumane
02:07:27 grenfell tower because of an inhumane borough
02:07:28 borough but that suffering was also caused by the design of the civil contingency system and its ambivalence towards equality and human dignity the fact that this inquiry is not a
02:07:39 the fact that this inquiry is not a commission into social housing or the future of the welfare state should not stop it from reporting on how government became anti-social in its indifference and how that indifference
02:07:50 and how that indifference caused the people who lived survived or lost loved ones from this fire to pay such a terrible price
02:07:58 thank you very much mr friedrich
02:08:02 the next statement is going to be made by mr james maxwell scott queen's council on behalf of the royal borough of kensington and chelsea say mr maxwell scott when you're ready
02:08:13 scott when you're ready we should be pleased to hear from you
02:08:26 mr chairman ms istafan mr akbar the council had a central role in this module
02:08:33 module not because it was the owner and landlord of grenfell tower but because as a local authority it was a category one responder under the civil contingencies act
02:08:44 contingencies act this meant that in the event of an emergency within the borough it was expected to take the lead in providing rest centers welfare and other forms of humanitarian assistance
02:08:56 assistance the council was also under a duty to undertake contingency planning the inquiry called six witnesses from the council in this module although none of them had read the
02:09:08 although none of them had read the council's opening statement before it was submitted to the inquiry the evidence of each of them was consistent with the admissions made in it the council's chief executive at the
02:09:19 it the council's chief executive at the time
02:09:20 time expressly stated that he accepted all the admissions made by the council in that opening statement we invite inquiry to find that all six
02:09:31 we invite inquiry to find that all six witnesses gave their evidence candidly and did their best to assist the inquiry as you know the council has made a commitment to candor
02:09:42 commitment to candor in the light of it we have reviewed the entirety of the opening statement the council's position is one but it remains factually accurate and two but it stands by all the
02:09:54 and two but it stands by all the admissions made in it in the course of reviewing the opening statement
02:10:00 statement any evidence heard in this module the council has identified further areas where it fell short and therefore considers that it should make further admissions
02:10:13 make further admissions admissions which it considers it right to make
02:10:16 to make are set out in full in its detailed written closing statement at this stage i will identify some of the most significant admissions which the council makes in this module
02:10:30 the borough emergency command center should have been operational in the town hall
02:10:36 hall earlier than it was it should have been more organized and efficient than it was there were times on the 14th of june when it was overwhelmed
02:10:50 council officers should have been deployed to premises known to be operating as rest centers earlier than they were
02:10:58 the council failed to have in place an adequate system for registering the details of individuals
02:11:07 nicholas holgate should have activated the london gold arrangements earlier than he did these are all new admissions they are made in the light of the evidence heard during this module
02:11:21 the following admissions from the council's opening statement are worth repeating at this stage there should have been more internal reporting up the management chain by the
02:11:33 reporting up the management chain by the contingency planning team
02:11:37 there should have been greater oversight by the council of that team and of the council's emergency response capability
02:11:46 the council should have had a humanitarian assistance plan the arrangements which the council had in place before the fire failed to set out how different parts of
02:11:58 failed to set out how different parts of the council would coordinate their communications
02:12:03 the council failed to provide the public with clear consistent communications and
02:12:10 and as a result individual residents missed out on receiving support to which they were entitled
02:12:19 entitled council had not trained enough rest centre managers
02:12:24 the council did not run an adequate number of emergency response training events and exercises there was insufficient attendance at the
02:12:35 there was insufficient attendance at the training events and exercises that were held
02:12:40 these failings were not technical or abstract failings but procedures and processes
02:12:46 processes they were failings that had a real and detrimental impact on individuals the council fully acknowledges this this is why we included in our closing
02:12:58 this is why we included in our closing statement some examples of the impact on the bereaved survivors and residents
02:13:06 the council acknowledges that its failings had a disproportionate impact on people from diverse backgrounds and people with disabilities
02:13:17 and people with disabilities for example people who were fasting because they were observing ramadan people for whom english was not their first language people with specific
02:13:28 people with specific accommodation needs council apologizes unreservedly for its failings
02:13:37 a council has made changes since the fire
02:13:41 fire we identified some of them in a document serve shortly before the oral opening statements and i outlined some of them in my opening statement you will recall that these changes were
02:13:53 you will recall that these changes were in a wide range of areas including oversight of contingency planning communications community engagement training and exercising
02:14:04 training and exercising the council is committed to making improvements and changes continue to be made we will update inquiry further in the recommendations part of phase 2 later
02:14:15 recommendations part of phase 2 later this year
02:14:18 finally in this introduction i would like on behalf of a council to thank a number of people all the people from the local community and further afield who assisted at a
02:14:31 and further afield who assisted at a time of great need all the local community organizations faith groups and charities who worked with the local community to deliver that assistance
02:14:43 assistance and those councillors and council officers
02:14:46 officers who worked long hours and willingly took on challenging tasks there are five topics which i will address you on today they are one
02:14:57 address you on today they are one activation of a contingency management plan
02:15:01 plan two
02:15:02 two problems experienced by the bereaved survivors and residents three
02:15:07 three activation of the london gold arrangements four
02:15:12 four the impact of a council's failings five the future of emergency planning in london
02:15:21 my first topic is the activation of a council's contingency management plan david kerry was informed about the fire shortly before 2 30 a.m
02:15:32 shortly before 2 30 a.m he took on the role of council silva and began to activate the council's contingency management plan as council silva he was responsible for determining the level of a council's
02:15:43 determining the level of a council's initial response rather than mobilizing all relevant officers in the middle of the night he opted for a more gradual mobilization this was because he wanted to reduce the
02:15:55 this was because he wanted to reduce the risk of them being tired later in the day when he felt they might be needed more
02:16:00 more one noticeable feature of kerry's evidence was that he did not turn on his television or see any visual images of the fire for some hours had he done so he would have taken a
02:16:13 had he done so he would have taken a different approach and would have initiated the highest possible level of response
02:16:20 looking objectively at the issue of the activation of a contingency management plan the council admits that the borough emergency command center should have
02:16:31 emergency command center should have been operational in the town hall earlier than it was council also admits that council officers should have been deployed to premises known to be operating as rest
02:16:42 premises known to be operating as rest centers earlier than they were council witnesses who spent time in the borough emergency command center were asked about how effectively it
02:16:53 were asked about how effectively it operated once it was set up in the light of their evidence the council admits that it should have been more organized and efficient than it was
02:17:05 and efficient than it was the council also admits that there were times on the 14th of june when it was overwhelmed
02:17:14 i turn next to the problems experienced by the bereaved survivors and residents starting with what happened at rest centers on the 14th of june officers did not start arriving at the
02:17:26 officers did not start arriving at the rugby portobello club or the clement james center in significant numbers until around 10 am by then both had been up and running for several hours
02:17:39 several hours many of the bereaved survivors and residents
02:17:42 residents gave evidence about the situation in those rest centers on the morning of the 14th of june the picture that emerged was one of confusion
02:17:53 confusion disorganization lack of visibility of council officers and lack of leadership from the council the council's admitted failings were a
02:18:04 the council's admitted failings were a significant cause of these problems
02:18:09 the council had not trained enough rest centers before the fire on the 14th of june it did not deploy enough officers of sufficient seniority to rest centers
02:18:21 to rest centers it deployed officers to rest centers later than it should have done
02:18:27 the council's plans place too much reliance on the british red cross an example of this is the registration of individuals at rest centers and at the west way
02:18:39 rest centers and at the west way registering individuals was ultimately the responsibility for council the fact that local community organizations and the british red cross assisted in attempts to record the
02:18:51 assisted in attempts to record the details of individuals did not alter that position the council admits that it failed to have in place an adequate system for registering the details of individuals
02:19:04 registering the details of individuals the lack of an effective registration system
02:19:09 system and the council's admitted communications failures were two major underlying causes of problems
02:19:16 problems experienced by some of the bereaved survivors and residents during the first seven days
02:19:25 a small number of grenfell tower residents were not told but should have been told that the council was offering them emergency hotel accommodation on the night of the 14th 15th of june
02:19:38 on the night of the 14th 15th of june some residents were allocated hotel accommodation that was not suitable for their personal circumstances there was inconsistency in the information provided by the
02:19:50 in the information provided by the council to residents some residents were not aware of the full extent of the support which the council was offering as a result some residents
02:20:01 as a result some residents through no fault of their own missed out on elements of a support package which they were eligible for and entitled to receive one example of this is the fact that
02:20:13 one example of this is the fact that some residents were not aware of the full range of services they were entitled to receive while they were staying in hotels another example is that some residents were not aware
02:20:25 is that some residents were not aware how much money they were entitled to and did not receive as much as they should have done the council deeply regrets the problems experienced by the bereaved
02:20:36 the problems experienced by the bereaved survivors and residents and apologizes to them
02:20:48 my next topic is the activation of the london gold arrangements in our opening statement we suggested that the terminology used in relation to mutual aid could give
02:20:59 in relation to mutual aid could give rise to confusion what became clear during the hearings in this module is that the terminology used to describe the activation of a london gold arrangements also gives rise to
02:21:11 arrangements also gives rise to confusion
02:21:13 confusion the reasons for this are simple a chief executive from one borough taking over the leadership of another borough's emergency response was something that had never happened
02:21:24 was something that had never happened before
02:21:26 before and under the terms of the gold resolution was never intended or expected to happen if one puts the confusing terminology to one side it is possible to identify four
02:21:39 one side it is possible to identify four key stages in the council's reliance on assistance from other london local authorities the first was before 9am on the 14th of
02:21:50 the first was before 9am on the 14th of june
02:21:51 june when the council began to receive assistance from its tribal partner london borough of ham smith and fulham the evidence suggests that it was supplying the council with rest center
02:22:03 supplying the council with rest center managers by 8 30 that morning
02:22:07 the second stage was the email sent by the council to the london local authority coordination center just after 4 30 on the afternoon of 15th
02:22:18 just after 4 30 on the afternoon of 15th of june
02:22:19 of june during the hearings heatherington agreed with our analysis that this was the first request by the council to llacc for mutual aid
02:22:31 llacc for mutual aid as such
02:22:32 as such it represented activation by the council of the london gold arrangements
02:22:40 the third stage was reached about an hour and a half later following the telephone call between holgate and baridale by that point holdgate had activated the london gold
02:22:51 holdgate had activated the london gold arrangements to the full extent envisaged by the london gold resolution
02:22:59 the fourth stage was what happened at 2pm the next day barrydale took over leadership of a council's response from hulgate and became the local authority gold
02:23:10 became the local authority gold commander
02:23:11 commander as i said earlier nothing like this had ever happened before according to the arrangements which existed and still exist within london it is something that was never meant to
02:23:23 it is something that was never meant to happen
02:23:26 going back to the beginning the council's position is that holgate was right to take on the role of council gold on the 14th of june he was the most senior officer employed
02:23:37 he was the most senior officer employed by the council and under its contingency management plan was expected to be council gold it was clear from his evidence that holgate believed that it was his duty to
02:23:49 holgate believed that it was his duty to lead the council's response to the fire
02:23:54 having reflected on the evidence heard in this module council's position on the activation of the london gold arrangements is as follows
02:24:05 is as follows 1.
02:24:06 1. holgate should have activated the london gold arrangements earlier than he did
02:24:13 with a benefit of hindsight one can see that holgate focused too much on operational considerations and expense of strategic ones if he had found or made
02:24:26 if he had found or made more time to reflect on strategic considerations it is likely that he would have activated the london gold arrangements earlier
02:24:35 earlier three
02:24:36 three holgate should have done so at some point after the 1730 meeting on the 14th of june
02:24:44 of june we have identified this time rather than an earlier time because of the following factors each of which would legitimately have discouraged him from activating the
02:24:56 discouraged him from activating the london gold arrangements earlier than that
02:25:00 that first
02:25:01 first the fact that activating london gold had historically happened so rarely
02:25:09 secondly the viewpoint commonly held within london at the time that the london gold resolution was more pertinent to an emergency which affected
02:25:20 pertinent to an emergency which affected several local authorities and one which was geographically limited to a single borough thirdly
02:25:27 thirdly the council's contingency management plan encouraged the view but activating london gold was not a step intended to be taken immediately
02:25:38 be taken immediately fourthly
02:25:40 fourthly the existence of a triborough agreement meant that the council would more easily be able to draw on resources from two neighbouring local authorities
02:25:51 neighbouring local authorities fifthly
02:25:52 fifthly nobody involved in the conference call with holgate at 5 30 pm on the 14th of june advised him that he should activate the london gold arrangements
02:26:03 the london gold arrangements the evidence was that activation was not discussed
02:26:08 sickly heverington's evidence was that he personally did not think that holgate's decision was wrong at the time heverington was the deputy
02:26:19 at the time heverington was the deputy head of london resilience he has been head of it since 2018. his views therefore carry weight so that is the council's position and the reasons for it
02:26:31 the reasons for it i end this topic by making it clear that the council stands by the admission made in its opening statement that its leadership was unable to cope in the days after the fire
02:26:47 my next topic is the impact of a council's failings mr chairman as you know our written closing statement contains a lengthy section entitled
02:26:58 section entitled reflections on the impact of a council's admitted failures today i'm not going to repeat the detailed analysis in that section but i'm going to summarize the key points
02:27:10 points there are two main themes the first is that had the council performed to the level that it should have done
02:27:20 have done the experiences of the bereaved survivors and residents would overall have been significantly better during the first seven days the second
02:27:31 during the first seven days the second is that it would be unwise to assume that everything would have been fine if only the council had performed to an adequate level that sort of thinking breeds complacency
02:27:42 that sort of thinking breeds complacency about the robustness of the current national and local system for dealing with emergencies it also runs the risk of ignoring an excellent opportunity to learn valuable
02:27:53 excellent opportunity to learn valuable lessons for the future
02:27:57 taking the first theme first the following are important respects in which an adequate level of performance by the council would have significantly improved the
02:28:10 would have significantly improved the experiences of the bereaved survivors and residents during the first seven days
02:28:17 days first training the council has made substantial admissions in relation to its program of training and exercises it fully accepts
02:28:28 it fully accepts but its response would have been better if it had conducted training and exercises to an appropriate standard the following measures which should have been in place would all have assisted in
02:28:41 been in place would all have assisted in improving the quality and effectiveness of the response one
02:28:48 one a formal training program for council gold
02:28:51 gold council silver and officers who worked in the borough emergency command center two
02:28:59 two more senior officers trained as council girl
02:29:03 girl three more trained back officers four
02:29:07 four more training events five
02:29:10 five a higher level of attendance at training events
02:29:13 events six
02:29:14 six more trained rest center managers seven
02:29:18 seven a training program which ensured that a contingency management plan was exercised at all levels at least once a year
02:29:29 second rest centers getting both more people and the right people to rest centers earlier on the 14th of june would have made a real difference at a crucial time
02:29:42 difference at a crucial time more trained rest center managers would have made a difference in the absence of a trained cohort of such managers within the council the deployment of senior council
02:29:53 the deployment of senior council officers in greater numbers and at an earlier time would have made a difference the full deployment of the council's crisis support team would have made a
02:30:04 crisis support team would have made a difference earlier deployment of the housing officers and social workers who arrived at around 10 am would have made a difference
02:30:15 third communications having a communications plan in place which was fit for purpose and had been exercised would unquestionably have
02:30:26 exercised would unquestionably have improved matters had the council's communications function performed at an appropriate level
02:30:33 level the number of residents who through no fault of their own missed out on elements of a support package would undoubtedly have been reduced
02:30:43 fourth better pre-existing relationships with local community organizations it was clear from the evidence heard in this and other modules but community was
02:30:55 this and other modules but community was very important to the residents of grenfell tower the lancaster west estate and north kensington local community organizations played an
02:31:06 local community organizations played an important part in building that sense of community and supporting its members many local community organizations have been providing valuable support to local
02:31:17 been providing valuable support to local residents for decades the council has previously acknowledged that it did not lessen to residents as much as it should have done
02:31:29 much as it should have done council should have done more before the fire
02:31:32 fire to build effective relationships with local community organizations and residents and to include them within its emergency plans had it done so it would have been better
02:31:44 had it done so it would have been better placed to coordinate and direct local community organizations this would have addressed the problem described by many witnesses
02:31:55 described by many witnesses of local community organizations being willing and able to help but experiencing a lack of overall direction from the council
02:32:10 i now turn to my second theme but it would be unwise to assume that everything would have been fine if a council had performed to an adequate level
02:32:21 adequate level there were many respects in which the support provided to the bereaved survivors and residents could and should have been better in our submission it is appropriate
02:32:32 in our submission it is appropriate to ask the question whether what went wrong was specific to rbkc
02:32:38 rbkc or whether some elements of what went wrong
02:32:41 wrong reveal problems with the systems in place across london as a whole at the time
02:32:47 time only by engaging with this question can one ensure that anyone caught up in a disaster on a similar scale in london in the future is better served and
02:32:58 in the future is better served and supported
02:33:00 supported only by engaging with this question can one ensure that all relevant lessons are learned
02:33:08 in our written closing we have done a detailed analysis of respects in which what went wrong revealed wider problems what i'm going to do now is to summarize
02:33:19 what i'm going to do now is to summarize the main points of that analysis of the wider problems i will summarize points relating to emergency planning before turning to points relating to the response to the fire
02:33:33 point one how the council's contingency planning team compared to that in other london local authorities in our submission the size of the team
02:33:44 in our submission the size of the team was fairly normal and all members of a team were suitably qualified and experienced point two reporting an oversight in practice
02:33:55 in practice the council's contingency planning team reported in more detail to london resilience than it did to the council senior management this reporting was done through the
02:34:06 this reporting was done through the minimum standards for london system in reality the phrase minimum standards for london was somewhat misleading the way the minimum standards for london
02:34:17 the way the minimum standards for london system worked was as follows each year every local authority in london
02:34:23 london would send london resilience itself assessment of how it should be scored against the so-called minimum standards in one year out of two
02:34:34 in one year out of two that self-assessment was peer-reviewed by members of the sub-regional resilience forum regardless of whether it was peer reviewed or not the scores were converted into a traffic
02:34:46 the scores were converted into a traffic light format so for example in 2016 each local authority ended up with approximately 35 separate ratings of red
02:34:57 approximately 35 separate ratings of red amber or green the reason why we say that the phrase minimum standards for london was somewhat misleading was that london resilience expressly stated
02:35:08 stated that quote it was never intended or expected but the msl would be 100 green in all boroughs unquote
02:35:18 unquote so local authorities were not expected to comply with all the minimum standards but it goes beyond that because there was no minimum number of
02:35:30 because there was no minimum number of minimum standards which an individual local authority was required to meet and there was no mechanism available to london resilience or any other pan london organization
02:35:44 or any other pan london organization to take action to improve the performance of a local authority which was getting large numbers of reds and ambers
02:35:52 in 2016 which was a peer review year rbkc achieved one red seven amber's and 25 greens
02:36:03 25 greens this was far from the worst performance one local authority achieved three reds 16 amperes and 16 greens yet the evidence heard in this module
02:36:14 yet the evidence heard in this module was that london resilience had no power whatsoever to enforce the minimum standards
02:36:22 point three emergency plans emergency plans are not procedures or protocols they are plans they represent attempts to plan for how
02:36:35 they represent attempts to plan for how best to address unlikely future events of an unpredictable nature written protocols and procedures are appropriate for tasks which arise frequently and which benefit from being
02:36:47 frequently and which benefit from being carried out in the same way on each occasion
02:36:50 occasion major emergencies are rare and no two emergencies are alike an effective response to an emergency requires flexibility
02:37:01 requires flexibility and the ability to adapt pre-existing plans
02:37:04 plans to fit the situation being faced
02:37:08 point four training training raises similar issues about the need for flexibility training is important i would go firm and say that it is
02:37:20 i would go firm and say that it is essential
02:37:22 essential but it would be naive to think that an adequate program of training and exercises will prevent all problems
02:37:32 problems however hard one tries to make training exercises realistic they can never replicate the experience of a real life emergency training exercises are not a substitute
02:37:44 training exercises are not a substitute for first-hand experience but many people working in senior positions in local government will through no fault of their own ever have had to respond to an emergency
02:37:56 ever have had to respond to an emergency it would be highly unusual and resource intensive to create a scenario for an exercise which was realistic and on the scale of a grenfell tower fire
02:38:07 fire the only exercise we are aware of which fitted both of those criteria was exercise unified response in 2016.
02:38:17 in 2016. that was a london-wide exercise which took two years to plan as can be seen from the london risk register
02:38:25 register there is a wide range of potential emergencies scenarios although it did not identify a tower block fire as a risk it did identify flooding drought storms
02:38:39 it did identify flooding drought storms heat waves aviation accidents public disorder terrorist incidents and rail strikes to name just a few it is quite simply impossible to train
02:38:51 it is quite simply impossible to train for all potential emergency scenarios and there is no expectation that local authorities will do the system is premised on the idea that
02:39:02 the system is premised on the idea that staff who have exercised one scenario will have the flexibility to apply their skills and training to what may be a very different scenario
02:39:14 point five information about persons who may be vulnerable following an emergency this is an area where there is a significant gulf
02:39:25 significant gulf between what people understandably believe the national system should be and the system itself in 2017
02:39:36 in 2017 no local authority was expected to maintain a consolidated master list of every vulnerable person in the borough the relevant cabinet office guidance
02:39:47 the relevant cabinet office guidance stated that it would be impossible to maintain a central up-to-date list of vulnerable people emergency planning in respect of
02:39:58 emergency planning in respect of vulnerable persons has proved to be a long-running challenge across london heverington told the inquiry that the problem had still not been cured and
02:40:09 problem had still not been cured and that an interagency data sharing agreement was still being worked on
02:40:16 point six local community organizations the council has admitted that it should have done more before the fire
02:40:27 fire to build effective relationships with local community organizations and to include them within its emergency plans
02:40:35 plans the context to this admission is that very few council officers lived within the borough whereas local organizations have been embedded within the north kensington
02:40:47 embedded within the north kensington community for decades these local factors increased the need for the council's emergency plans to include and make use
02:40:58 include and make use of the capabilities of local community organizations
02:41:04 this should not disguise the fact that the level of engagement with the voluntary sector required by legislation was low
02:41:14 was low regulation 23 of the 2005 regulations states that category 1 responders must have regard to the activities of voluntary organizations
02:41:26 voluntary organizations this is a most vaguely phrased obligation which sets the bar extremely low
02:41:33 low it was notable but unsurprising but several of the witnesses called from community and voluntary organizations emphasized the need for more legislation
02:41:44 emphasized the need for more legislation to address this issue
02:41:48 i now turn to points relating to the wider problems in relation to the response to the fire i start with what is the logical starting point
02:41:59 starting point the implications of how events unfolded in the first few hours people who fled from the tower did so in all directions they did not have their details recorded
02:42:11 they did not have their details recorded systematically inside the cordon once outside the cordon if they were not taken to hospital they were free to go wherever they wished
02:42:22 wished many made their way to local premises that had opened as unofficial rest centers
02:42:28 centers at least five such unofficial rest centers had opened and provided support to residents by 9 am this turn of events had the following implications
02:42:41 implications implication one it would never have been possible for the council or indeed anyone else to have ensured that there was at all times a single rest center
02:42:53 rest center implication two reaching a point where there was a single official rest center was desirable
02:43:00 desirable but the transition to that point was always going to be difficult my next point my second point is about communications which are incredibly important in an
02:43:11 which are incredibly important in an emergency
02:43:13 emergency even with a good plan and a good team effective communication in an emergency is a challenge in our submission whoever was tasked
02:43:24 in our submission whoever was tasked with communicating the message about available humanitarian assistance would have faced the following challenges the challenge to be heard the challenge of reaching all
02:43:37 heard the challenge of reaching all residents
02:43:39 residents a challenge of communicating an accurate and up-to-date message in a situation that was inevitably fast moving the challenge of resources being diverted to address questions which were
02:43:51 diverted to address questions which were understandably being posed about the causes of the fire a challenge of resources being diverted to address questions about effectiveness of the response to the fire
02:44:03 of the response to the fire the challenge of dealing with negative sentiment and in some instances hostility
02:44:09 hostility my third point is about individuals registration of individuals and sharing information about vulnerable persons
02:44:19 persons michael adamson the chief executive of the british red cross told the inquiry that data sharing is always an issue
02:44:29 creating a comprehensive list of individuals and then making best use of the information in it would always have been a complex task this is particularly so
02:44:41 this is particularly so given that people who fled from the tower did so in all directions some went to one unofficial rest center some went to another some went to multiple centres and some went to family or friends that
02:44:53 and some went to family or friends that did not go to any centres
02:44:57 moving then to the related issue of vulnerable persons the expectation of a time would have been that the council adopted and followed the list of lists approach
02:45:09 the list of lists approach has two inherent limitations first it will not produce information instantly
02:45:18 instantly even in circumstances in which it works as intended there will be some delay in information being provided secondly it is unlikely that the information provided will be completely
02:45:30 information provided will be completely accurate and up-to-date
02:45:34 my fourth and final point is about the activation of the london gold arrangements
02:45:41 if one wants to assess how robust the system was one has to consider how the arrangements were meant to operate rather than the unprecedented course that events took
02:45:54 that events took if holgate's activation of the london gold arrangements had followed the hypothetical normal case there would have been no takeover by baridol
02:46:03 baridol hullgate would have continued to lead the council's response to the fire with support from whichever chief executive happened to be on the on-call rotor at the time
02:46:20 drawing the threads together free overarching themes emerge the first is that there is always a gap between what survivors and residents
02:46:31 between what survivors and residents need and expect and the level of response a local authority can achieve in the first 24 hours
02:46:38 hours the second is that the solution to addressing those needs and expectations was not found by carefully implementing the existing framework within london
02:46:50 the existing framework within london it was found by operating outside of the existing framework by breaking boundaries and by people in effect making up a new framework as they went along
02:47:03 framework as they went along the third
02:47:04 the third is that in the event of a large-scale emergency in london even one confined within a single borough
02:47:12 borough it is highly likely that the local authority will need to rely on assistance from other london local authorities this brings me to my final short topic
02:47:24 this brings me to my final short topic the future of emergency planning in london
02:47:28 london the evidence heard in this module has revealed serious limitations in the formal arrangements that existed within london for responding to an emergency for
02:47:39 for responding to an emergency for complexity of the grenfell tower fire in our submission serious consideration needs to be given to improving the london wide arrangements for contingency planning
02:47:53 arrangements for contingency planning because there will be a separate recommendations part to phase two of the inquiry i don't want to go into too much detail today about what changes might be desirable
02:48:03 desirable we will make detailed submissions about recommendations in accordance with the inquiry's request at the relevant stage later this year however i can indicate at this stage but
02:48:16 however i can indicate at this stage but in our view careful consideration should be given to the following three ideas having a cohort of persons trained and available to provide urgent humanitarian
02:48:29 available to provide urgent humanitarian assistance 24 hours a day across london
02:48:35 greater external oversight and auditing of the emergency planning capabilities in london
02:48:44 improving the training of those on the london gold on-call rotor
02:48:52 the council is very conscious of the recent anniversary although this is the aftermath module it does not address events that took
02:49:03 it does not address events that took place
02:49:04 place after the 20th of june 2017. the council is fully aware that the aftermath of the fire did not end on that day
02:49:15 end on that day the bereaved survivors and residents continue to experience the impact for many weeks months and years many of them still experience the impact
02:49:27 many of them still experience the impact today
02:49:29 today the council apologizes for its failings in pre-planning and in its response to the fire i would like to finish with what its leader
02:49:40 leader elizabeth campbell wrote in her open letter to mark the fifth anniversary she said
02:49:48 she said i want you to know that i am deeply sorry for the council's failings and the suffering that so many people experienced at grenfell
02:49:59 experienced at grenfell and in the aftermath
02:50:03 thank you very much mr maxwell scott
02:50:09 the next statement is going to be made on behalf of the london fire commissioner but that on the timetable will be at two o'clock and i think given the time that we've now reached the right course would
02:50:21 we've now reached the right course would be to
02:50:22 be to adjourn at this point and we'll resume at two o'clock please thank you very much