Closing presentations for Marjorie and Ernie Vital (who died together in flat 202) and Gloria Trevisan and Marco Gotardi (young Italian architects who sheltered the Vitals). Focuses on failures in evacuation planning for disabled residents and the tragedy of four people dying in one flat.
00:00:23 Yes, Mr. B. Yes, Mr. Chairman. I would now invite Danny Freriedman, Queens Council, please to come to the podium and make the presentation on behalf of the family of Majerie Vital and Ernie Vital uh who
00:00:37 Majerie Vital and Ernie Vital uh who lived in flat 162 on floor 19. Ernie was visiting with Major Vital on the night they were both recovered from flat 202 on floor 23. Again, before Mr. Freeman
00:00:49 on floor 23. Again, before Mr. Freeman starts. I should give a general trigger warning that the presentation may contain material or uh discussions which some may find distressing and may wish to leave now or to look away from the live stream as the case may be.
00:01:00 live stream as the case may be. Yes. Thank you very much, Mr. Freedelland. Yes, Mr. Freedelland.
00:01:27 Marjgerie Agnes Vital was born in Sufria, Dominica on the 14th of November 1948. She was 68 years old when she died. She moved into flat 162 in
00:01:41 died. She moved into flat 162 in Grenfell Tower in 1978. She was one of the longest standing residents. The flat was on what became the 19th floor. Her son Ernie
00:01:53 the 19th floor. Her son Ernie Celeststein Vital was born in London on the 11th of January 1967. He was 50 years old when he died. Ernie lived in a North London address, but he
00:02:04 lived in a North London address, but he would often stay with his mother as he did on the night of the fire. Ernie and his brother both grew up at Grenfell Tower.
00:02:14 Tower. Sir, you all will recall that at a commemoration hearing on the 23rd of May 2018, a statement written by Marjgery's sister Paula on behalf of the whole
00:02:26 sister Paula on behalf of the whole family was read by their solister. You also saw a video prepared by Marjgery's other son and Ernie's brother, who is a private person and did not wish to be
00:02:37 private person and did not wish to be identified by name. In the statement, you were told about Marjgerie's childhood in Dominica. You heard how proud she was of her home at Grenfell Tower. So much so that her
00:02:50 Grenfell Tower. So much so that her parents jokingly referred to Grenfell as Marjgery's Tower. From her son, you heard about a life in the tower which he also loved and which
00:03:01 the tower which he also loved and which provided a safe haven growing up. Margie Vital worked to support her family as a seamstress. Her son described how his mother was ambitious and talented but
00:03:13 mother was ambitious and talented but put her children first. He recalls her using her skills as a seamstress to make her own clothes so that they could afford to buy clothes for them. As for Ernie, he was a lively and engaging
00:03:26 Ernie, he was a lively and engaging person, a very good dancer, but also down to earth. Ernie and his mother Marjorie were especially close. and his brother remembered him constantly in
00:03:37 brother remembered him constantly in their mother's arms as a child. And even when grown up, he described it as if the umbilical cord had never been cut. Marjgerie, at 68 years old at the time
00:03:50 Marjgerie, at 68 years old at the time of the fire, had health difficulties which were known to the TMO. A disclosed email of the 31st of October 2014 sent to both Ryden and TMO
00:04:02 2014 sent to both Ryden and TMO recipients described Marjgerie as elderly with a diagnosis of Parkinson's disease.
00:04:09 disease. Based on the information about Marjgery's diagnosis, it is likely that she was significantly impeded in her ability to independently evacuate down the single stairs from flat 19 in the
00:04:20 the single stairs from flat 19 in the event of a need to do so. As with other cases of this type, there is no evidence in the available records of any consideration by any relevant body as to
00:04:32 consideration by any relevant body as to how Marjorie would evacuate in the event of a need to do so in response to a fire. Neither were there any arrangements in place to assist her to do so, such as a personal emergency
00:04:43 do so, such as a personal emergency evacuation plan, nor was there any pre-arrangements with the LFB to ensure assisted evacuation or rescue.
00:04:53 Marjgerie was captured on CCTV footage in the lift lobby at 3:14 p.m. on the 13th of June. Ernie, who was visiting his mother on
00:05:04 Ernie, who was visiting his mother on the night, can be seen in the foyer, first at 1:31 p.m. and then again in the lift lobby on floor 14 13 at 7:07 p.m.
00:05:17 lift lobby on floor 14 13 at 7:07 p.m. As presented last week, the fire spread would have affected floor 19 at approximately 0126. We timed that on the basis that Shah Ahmed, who lived in flat 156 below, made
00:05:31 Ahmed, who lived in flat 156 below, made a call at 0127 when he was already out of his flat due to it being on fire. We know that before 0128, residents of floor 19 began to
00:05:42 0128, residents of floor 19 began to evacuate their flats. This can be timed from the call of Hiro Daginaju from flat 26 who made a call to her niece Maron
00:05:54 26 who made a call to her niece Maron Meccanon who lived in flat 163 to tell her that the building was on fire and that she needed to get out. Records show that the call was made at 0124 and must
00:06:05 that the call was made at 0124 and must have completed between 0127 after which Meiron left her flat. Miss Meccan saw light smoke in the lobby, but a few minutes later both
00:06:16 lobby, but a few minutes later both Nicholas Burton and Feduma Ahmed on the same floor encountered deep black smoke. A potential source of the smoke is that the door of flat 166 where the Chuku
00:06:29 the door of flat 166 where the Chuku family lived was not self-closing. Meron saw Amal Amadin and her cousin Amna Idris rush out of the flat and then back in with the door remaining open.
00:06:43 back in with the door remaining open. It is known that while residents of floor 19 and the surrounding floors descended the staircase at around 1:30, Marjgerie and Ernie Vitau were among a
00:06:54 Marjgerie and Ernie Vitau were among a number of people that ascended the staircase. At this point in time, the conditions in the stairwell were sufficiently clear for occupants who were able to do so to safely evacuate
00:07:05 were able to do so to safely evacuate via the communal stairs. Those who descended did so without endangering themselves or each other. During the presentation of Debbie Lampril on the 6th of July 2017, we
00:07:19 Lampril on the 6th of July 2017, we referred the panel to the known relevant facts about why some people went up rather than down. For these purposes, I simply refer to the transcript that is day 300,
00:07:31 day 300, page 4, line 12 to page 10, line three.
00:07:38 Fuma Ahmed is a sole survivor of the group that reached floor 23 and what she has to say is important evidence in
00:07:49 has to say is important evidence in terms of understanding what happened to the Vitals. Miss Ahmed from flat 164 and Debbie Lampril and Gary Maers from flat 161
00:08:00 Lampril and Gary Maers from flat 161 went upstairs together. On the top floor, they met with a group of people that Feduma has positively identified to include Raymond Bernard
00:08:12 identified to include Raymond Bernard from flat 2011, Ernie Vitau from flat 162, Amal Amadine and Amna Idrris from flat 166, and Burki and Berick Haftum
00:08:24 flat 166, and Burki and Berick Haftum from flat 155.
00:08:28 We do not have evidence from Marjorie and Ernie about why they went upstairs. But we do know that five other people from their floor went to the top of the building at the same time. Marjorie, as
00:08:41 building at the same time. Marjorie, as with others who traveled up, including Sakina Afrasy and Hamemed Khani from other floors, would have found the walk to the top of the building less physically daunting than walking all the
00:08:52 physically daunting than walking all the way down to the ground floor. Marjorie and Ernie then sought shelter from the deteriorating conditions on the lobby of floor 23 by going into flat
00:09:04 lobby of floor 23 by going into flat 202.
00:09:06 202. That was the home of the young Italian couple Gloria Trevisan and Marco Gautardi whose presentation will follow this one.
00:09:16 this one. We know that Marjorie and Ernie entered flat 202 before 0134. That is because they be can be heard in the background as Gloria Trevan spoke to
00:09:29 the background as Gloria Trevan spoke to her mother Emanuel Daro in Italy during a telephone conversation that begun at that time. There are no telephone calls from Marjgery and Ernie to emergency services
00:09:41 Marjgery and Ernie to emergency services or family members. However, as I return to briefly, and you will hear more in more detail from council this afternoon, Glorio and Marco made a number of calls
00:09:53 Glorio and Marco made a number of calls to their respective parents in Italy. From those calls, the timing and facts of Marjgerie and Ernie's death can be established. Before I do that, there are general
00:10:04 Before I do that, there are general matters relating to all the people who took refuge on floor 23 that I briefly summarize. First, there were calls between 0130 and
00:10:15 First, there were calls between 0130 and 0140, especially from Mariam Elguari, Berick Huff, and Jessica Abano Ramirez, and then from Debbie Lampril, beginning at 0141.
00:10:26 at 0141. All of which indicated that the fourth floor kitchen fire now dangerously affected the top of the building. Every caller was told to stay put and that
00:10:37 caller was told to stay put and that crews were coming. Second, the highest LFB deployment into the building was the Paddington crew at
00:10:48 the building was the Paddington crew at 50 156 in extended duration breathing apparatus. They were deployed to the roof of the building. This was for firefighting and not rescue purposes.
00:10:59 firefighting and not rescue purposes. They saved for Doomer Armed, but only one of their number reached the exit door of floor 22.
00:11:09 Third, other crews were deployed after 0208 and then at 0224, 0251
00:11:17 0251 and 303, but none of them reached the top floor. Fourth, the lift was not technically suitable to enable assisted evacuation
00:11:28 suitable to enable assisted evacuation for people with mobility or other impairment on the night. What assistance a different kind of lift might reasonably provided if it was properly maintained and integrated into
00:11:39 properly maintained and integrated into LFB planning and training is a matter that has been the subject of submissions in other modules. As you will hear further, right from the
00:11:50 As you will hear further, right from the first claw Gloria Trevoran made at 0134 to her mother. She reported that she could not leave due to the lobby being filled with smoke.
00:12:01 filled with smoke. Gloria Trevoran made a video at O213 during which she described smoke coming into the flat through the living room windows and having difficulty breathing. In this video, Marco Gatardi can be
00:12:14 In this video, Marco Gatardi can be heard speaking to another man, which would likely have been Ernie Vitau. The extent of the smoke in the lobby apparently caused them to believe that escape was not possible.
00:12:26 escape was not possible. Gloria made a final call to her parents at 02430
00:12:30 at 02430 0245
00:12:32 0245 which lasted for 22 minutes ending at 0308.
00:12:36 0308. In terms of the conditions in the flat, she said it was full of smoke and she could see fire outside the window. At some point, she told her mother that the fire had come through the window and
00:12:48 fire had come through the window and ended the call. Marco Gutardi spoke to his father at approximately 0245 to say that he had filled the bath with
00:12:59 to say that he had filled the bath with water and could not evacuate as there was too much smoke. He then left a text message with his parents at 0308 and had a last brief telephone exchange with
00:13:10 a last brief telephone exchange with them at 03:15 in which he was hardly able to speak.
00:13:20 The archaeology evidence establishes that Marjgerie and Ernie Vitau died in the bathroom of flat 202 near to one another. Their remains were found positioned in the same direction.
00:13:33 positioned in the same direction. Ernie was in the bathtub with Mar Marjgery in close proxim proximity nearby on the floor.
00:13:42 In his phase 2 report, Professor Perser attributes the likely deterioration in the conditions of the flat to the external fire spread and that
00:13:54 external fire spread and that particularly the spread across the south face of the tower. He explains that the bathroom and hallway would have been the last areas of flat 202 that were not affected.
00:14:06 affected. From 0245
00:14:08 From 0245 the smoke and asphixent gas concentration would have increased rapidly. Based on the evidence of the phone calls, Professor Perser estimates the time of death as between 0315 and
00:14:20 the time of death as between 0315 and 0330.
00:14:23 The cause of death of Marjorie and Ernie Vitau was therefore the inhalation of the toxic fumes from the fire which caused unconsciousness and then death. This is confirmed by a toxicology sample
00:14:36 This is confirmed by a toxicology sample taken from Gloria Trevan in excess of 78%
00:14:41 78% COB which professor Perser explains can be safely assumed to reflect the position of the occu other occupants who died nearby to them.
00:14:52 died nearby to them. taking one Gloria's comparator toxicology together with two the telephone calls that describe the conditions and three the bathroom positions that Marjgerie
00:15:04 the bathroom positions that Marjgerie and Ernie went to in the flat. The evidence establishes that the medical cord of death can be given as inhalation of toxic fumes or a similar formulation rather than the generic conclusion of
00:15:17 rather than the generic conclusion of consistent with the effects of fire as found in the postmortem reports undertaken before this other evidence was known and analyzed.
00:15:29 Our final reflection is that this mother and son stayed together. While it is feasible that Ernie could have escaped without assistance, Marjgerie could not. In his video
00:15:42 Marjgerie could not. In his video commemoration, the surviving son and brother told you that there is no way that Ernie would have left his mother. As such, he was as trapped as she was.
00:15:53 As such, he was as trapped as she was. We want to pay tribute to the surviving son, his wife, and Marjgery's siblings who have attended this inquiry, sometimes bringing the younger generation of the family with them to
00:16:05 generation of the family with them to find out what happened to their loved ones.
00:16:09 ones. The mother and son died in terrible circumstances, but had the final gift of being together. They were also given shelter in the home of Gloria and Marco who did not know
00:16:22 of Gloria and Marco who did not know them but showed them kindness until the end. That is a theme that runs through the tragic events of floor [snorts] 23.
00:16:33 Thank you, sir.
00:16:38 [clears throat]
00:17:00 May I ask for a 30 minute break? Yes. Thank you very much, Mr. Freriedman. We'll say quart to three then, shall we? Thank you very much. We'll rise now and resume, please, at quarter to three. Thank you.
00:45:36 Yes, Mr. Millet. Yes. Thank you, Mr. Chairman. Um, I now call on Michael Mansfield, Queens Council to come to the podium, please, to make the presentation on behalf of the family or families of Gloria
00:45:49 the family or families of Gloria Trevisan and Marco Gatardi who lived in flat 202 on floor 23. As before, I make the trigger warning that during this presentation, those listening to it may
00:46:00 presentation, those listening to it may find its content distressing and may wish either to leave the room here or to look away from the live stream. Thank you very much. Thank you very much. Yes, Mr. Mansfield.
00:46:36 So, good afternoon, Thoria Estan and Ali Akbore. Uh, as has just been announced, I'm
00:46:47 Uh, as has just been announced, I'm presenting for two families, Gloria Trevorson and Marco Gautardi, but I'm going to
00:46:56 going to do it together as a joint presentation because of facts which will become very clear and probably are already as to why I would do that. I also indicate that I
00:47:08 I would do that. I also indicate that I don't intend to show anything that's distressing. There will be no no photographs or anything. Although reference will be made to them, they're not to be shown. The only part so people can be warned
00:47:20 The only part so people can be warned that may be distressing to hear is I I do want to cite an excerpt from one of the telephone calls that Gloria made to
00:47:31 the telephone calls that Gloria made to her mother because although I was going to say it a little later, may I say it now? This is an unusual situation and perhaps it's a reflection
00:47:43 and perhaps it's a reflection o on the way life is lived now that these two families certainly one of them glorious were actually watching the fire
00:47:57 were actually watching the fire on television in Italy.
00:48:01 in Italy. So again, one needs to put oneselves in in their shoes and at the same time as watching what was happening on television globally, no doubt they're
00:48:13 television globally, no doubt they're actually seeing and speaking to both of these two in flat 202 as it happens. I think a moment's
00:48:25 as it happens. I think a moment's reflection indicates just how grave the situation was, how anguish making and how with the instantaneous
00:48:36 and how with the instantaneous communication to which we're all subject now. This was a matter that was in everybody's minds and living rooms, especially uh this family. They can't be here today for for obvious reasons.
00:48:53 [clears throat] May I also say that there will be an element of overlap with the previous presentation because of course there were four people
00:49:05 because of course there were four people in that flat. I don't apologize for repeating some of the material because it is necessary for these families also that some of this material is repeated
00:49:18 that some of this material is repeated from time to time. So h having said that may bearing those observations in mind
00:49:29 observations in mind indicate how they came to be where they were that is Gloria and Marco. Uh they moved into Grenville Tower, this particular flat 202 on floor 23
00:49:41 particular flat 202 on floor 23 together on the 1st of April 2017, just over two months only before the fire. They had both arrived from Italy
00:49:54 fire. They had both arrived from Italy together on the 4th of March just under a month before. So they had been for a very short time in England. Both
00:50:06 Both were talented aspiring young architects who had met whilst university students in Venice
00:50:16 in Venice two years before. The university was the University Institute of Architecture of Venice.
00:50:26 Venice. Following graduation in 2016, different times but in that year they wished to obtain a broader experience and to learn English. So together
00:50:39 and to learn English. So together they enlisted on a language course which at the same time arranged for accommodation in London.
00:50:49 By the time and this is an indication of their enthusiasm and their talent. By the time of the fire, they had both successfully secured positions in
00:51:01 successfully secured positions in well-known architectural practices in London.
00:51:06 London. Marco at the creative ideas and architecture firm. Gloria was thrilled as hers specialized in the restoration of old buildings which was her forte.
00:51:21 of old buildings which was her forte. She began working at Peragrin Bryant in Fulham Palace on the 5th of June. One sees how close this is. Within a remarkably short period,
00:51:32 remarkably short period, both of them had impressed their respective employers and were already held in very high regard and esteem as
00:51:43 held in very high regard and esteem as practitioners displaying considerable promise for the future. Both of them. The excitement was tangible. As Glorian's father, Loris, recalled in
00:51:55 As Glorian's father, Loris, recalled in his phase one witness statement to you, Gloria was so happy to have found the job, this job. She was born to draw and
00:52:06 job, this job. She was born to draw and did the most beautiful drawings and portraits. I pause for a moment because those designs and drawings were shown to you in in a short film compiled for the
00:52:19 you in in a short film compiled for the commemoration. And the principal at Perag Bryant described her work as exceptional.
00:52:31 described her work as exceptional. And I think again like other matters it repays uh looking again at that particular film. Her mother Emanuela
00:52:43 Emanuela remembered when she learned that she'd secured her dream job. She rang me and said, "Mom, I'm happy that they want me." She had
00:52:56 I'm happy that they want me." She had achieved her main aim. It could have taken years, but she managed to find it in a few weeks. Gloria loved where she worked, sent me
00:53:07 Gloria loved where she worked, sent me photographs of the beautiful surroundings around her office on the first day. That's Fulham Palace. On the morning she arrived, the 5th of June,
00:53:18 morning she arrived, the 5th of June, she told me, "Look, Mom, where I'm working, it's a wonderful park. It was stupendous work, exactly what she wanted.
00:53:26 wanted. And the wage matched her capacity. She felt that she had been justified. She was finally doing the work that she dreamed of doing, helping to restore old buildings
00:53:37 doing, helping to restore old buildings to their former glory.
00:53:42 Besides these interests in common, they were also close in age. Both were born in Italy. Gloria at Camp Positam Pierro on the 2nd
00:53:56 Gloria at Camp Positam Pierro on the 2nd of December, the same birth date as her mother, which was as her mother thought a matter of fate for both of them. But her birth date was in 1990. So she's
00:54:09 But her birth date was in 1990. So she's 26.
00:54:10 26. And Marco, who was marginally older, was born on the 26th of June 1989, and he was 27. He'd been born in Ma de Levena.
00:54:23 They were planning to return to Italy shortly after this fire on the 21st of June to celebrate the birthday I've just mentioned of Marco and as it happened
00:54:36 mentioned of Marco and as it happened the wedding anniversary of Gloria's parents Emanuel Daro and Loris Threesan which coincided
00:54:48 with the fateful day the 14th of June. So again, a date that will be etched on their memories. The two families were
00:54:59 their memories. The two families were close-knit and were highly supportive of the ambitions of their children. It's the first time Gloria had lived away from home. She was very close to
00:55:11 away from home. She was very close to her family and would speak to them every day or two. She had a very affectionate relationship with her brother Julio who was seven years older than her. He
00:55:23 who was seven years older than her. He was very protective of her. She was also very close to her cousin Georgia for whom she left a message on the night of the fire.
00:55:36 on the night of the fire. Grenful Tower I turned to. Once the language course was completed, they moved into a spare bedroom in the flat already mentioned 200 202 on the ch 23rd
00:55:49 already mentioned 200 202 on the ch 23rd floor.
00:55:51 floor. Uh Gloria's parents hadn't yet visited the flat, but her mother remembers Gloria would tell me about the incredible views she could see over London from the flat. It's very nice
00:56:02 London from the flat. It's very nice because of the height. They'd never seen such a panorama, such a view. Gloria sent me photographs of rainbows at dawn. She was happy. They had found work, a
00:56:16 She was happy. They had found work, a flat. They loved each other. They were beginning to build a life for themselves in London. I I mention now the flat itself because
00:56:27 I I mention now the flat itself because it's important for the an understanding which you already have of the spread of fire. The flat itself is on the southeast corner of the tower with two
00:56:38 southeast corner of the tower with two bedrooms on the south side, south face. The living room spanning the corner, part south, part east. The kitchen is on
00:56:49 part south, part east. The kitchen is on the east face. There's been scant reference to this flat on floor 23. You've heard a lot about other flats 2011, 205, and so on. mainly because there do not appear to be
00:57:02 mainly because there do not appear to be any calls to the emergency service by either Gloria or Marco or for that matter from the Vitals either who you've heard about this afternoon. I want to turn to the movement as they can be uh
00:57:15 turn to the movement as they can be uh reconstructed on Tuesday or the evening of Tuesday the 13th. They are both seen on the CCV TV
00:57:27 13th. They are both seen on the CCV TV footage as are many others. At about4 to 8 in the evening, uh Marco is on his mobile and Gloria is with him about to
00:57:38 mobile and Gloria is with him about to go up to flat 202. No doubt at the end of a day's work. It was a Tuesday. I then move.
00:57:51 I then move. They go to bed. It's not clear exactly when. However, at
00:58:00 at 54 minutes past midnight, at a time you're very familiar with, the fire is reported in the kitchen on flat 16 in flat 16 on floor on the fourth floor.
00:58:12 flat 16 on floor on the fourth floor. And then shortly after 1:00, it breaks out into the cladding. However, there is another matter before these two young people are awoken having
00:58:24 these two young people are awoken having gone to bed. Farad Nada of flat 205 on floor 23 rings the emergency TMO number and reports the
00:58:37 the emergency TMO number and reports the air vents near the lift landing outside flat 205 are making a loud noise. I pause because that may be of relevance
00:58:49 pause because that may be of relevance in terms of why the smoke was so bad in the lobby area of that floor. It and it plays a crucial critical part in why
00:59:01 plays a crucial critical part in why these two remained in the flat. He fired reports an electrical burning smell and that one of the lifts has stopped
00:59:12 that one of the lifts has stopped working. Again, I don't elaborate the lift's point which has been made many times. He also says, "Sometime before 1:30,
00:59:21 1:30, Vietna notices black smoke entering the lobby from the smoke extractor system.
00:59:32 By 126, I just interpose it because this is a time you've heard many occasions. I mentioned it myself the other day. The fire had reached one of the sixes 156.
00:59:43 fire had reached one of the sixes 156. That's the flat belonging to uh Sha Ahmed and his wife. The reason that's important is because he makes a 999 call shortly after the one I described the
00:59:55 shortly after the one I described the other day. And sometime around this about 1:30 and possibly 134 as you've heard uh Marjgerie and Ernie Vital left their
01:00:08 uh Marjgerie and Ernie Vital left their flat which was one floor above the one I've just mentioned with Sha Amen which was floor 18. They left their flat 162 ascended the staircase for reasons as
01:00:20 ascended the staircase for reasons as we've said uh at least Mr. Freeman said earlier. It's impossible to tell why, but they did to floor 23 and knocked loudly on the door of flat 202
01:00:32 loudly on the door of flat 202 and they're part of a group that's migrated upwards. Now, this is confirmed or supported that that's what's happening at flat 202 by
01:00:45 that's what's happening at flat 202 by the evidence of Fedumo Ahmed who saw Ernie on floor 23 shortly before 134 and by the second of two calls from Gloria
01:00:58 by the second of two calls from Gloria to her parents in Italy. Now, I'm not going to read out all the calls, but there are a sequence of six telephone calls uh uh between
01:01:09 of six telephone calls uh uh between Gloria and her mother. There are others uh towards the end between Marco and his father. But these provide uh besides what's happening on television, these provide an internal
01:01:22 provide an internal uh as it were almost microscopic view of how they were dealing with a situation well beyond their control. In this call at 1:34, Gloria told her mother
01:01:36 at 1:34, Gloria told her mother that they'd been awoken by banging on her door, that is her 202, and a woman shouting outside. When Gloria opened the door, there were two people, the Vitals,
01:01:47 door, there were two people, the Vitals, only she didn't know them, and she believed they lived on the same floor, which is understandable. At the same time as she opened the door
01:01:58 At the same time as she opened the door and she tells recounts all of this to her mother, she was confronted by the thick black dense smoke that I've already mentioned that had been spotted
01:02:09 already mentioned that had been spotted coming from the extracting extraction system.
01:02:16 These smoke conditions are graphically depicted in a live stream Facebook video begun a few minutes later at 138
01:02:27 begun a few minutes later at 138 by Rana Ibrahim from the front door of a neighboring flat. This time it's 203. So they're all in proximity. This was referenced in your phase one reports uh
01:02:40 referenced in your phase one reports uh volume two. I don't go through all the references and the paragraphs, but you may recall that in that phase one report, there's a still photographic clip from this video taken at 138 or
01:02:53 clip from this video taken at 138 or shortly thereafter. Uh, and it shows the photo what can be seen in the lobby or rather not seen the
01:03:04 seen in the lobby or rather not seen the photograph that you have in that report. black. Can't see anything except at the top there is a dim light at ceiling height.
01:03:16 height. Gloria told her mother that they both ran to the window and became aware that there was a fire below and the presence of firefighters. She was quite naturally extremely
01:03:29 She was quite naturally extremely frightened. Emmanuela asked to speak with Marco. She knew him as a calming voice of reason. He confirmed these details, but
01:03:41 reason. He confirmed these details, but it's his belief that everything seemed under control. Gloria added that they'd been told to stay inside. This is part of the phone call. I pause again because it's not
01:03:53 call. I pause again because it's not clear
01:03:55 clear where they had gleaned that information. There was plainly, if I can put you, talk about ambient sound, ambient conversation in the upper floors that it
01:04:06 conversation in the upper floors that it was a matter of staying put. It may have been conveyed by the vitals. We're not able to say, but also I may interpose this. It would appear at some point from
01:04:18 this. It would appear at some point from what she says on the phone call that what they tried to do either Gloria or Marco together or separately is to go up to the roof
01:04:29 to the roof uh where they they obviously thought there may be safer conditions or possibly rescue. However, they had discovered that the gate that leads to the roof, which if you've been to the
01:04:41 the roof, which if you've been to the tower is still there, was locked. If they did that, they might have come across, and I can't put it higher, others who'd migrated upwards who had
01:04:52 others who'd migrated upwards who had also been able to say the general feeling was to stay put. Emmanuela suggested that they place a wet towel around their mouth
01:05:04 wet towel around their mouth [clears throat] to get downstairs, but they said there was too much smoke. Alternatively, her mother said go to the roof. But this wasn't possible. As I've just said, the gate was locked. Gloria
01:05:17 just said, the gate was locked. Gloria was terrified. Marco was trying to remain calm and placed a wet towel at the flat door, which he noticed was very hot, to stop the smoke from the lobby.
01:05:32 During this recording, the one I've mentioned by Rana, at around 139, Rana steps outside flat 203 where she's been taking the film and
01:05:45 203 where she's been taking the film and calls out, "Hello. Hello." And then, "Come here." A response can be heard, "No,
01:05:57 response can be heard, "No, we are here. We are inside my apartment. That's the voice of Marco identified by Emmanuela.
01:06:10 Emmanuela. By 142, again, it's all happening in fast movement, matters of minutes. The external fire has spread across the east elevation and across flat 2011
01:06:25 elevation and across flat 2011 [clears throat] by 157. 210 is an important time because the horizontal spread by that time has reached their flat and
01:06:38 by that time has reached their flat and it's a significant moment that's reflected in the calls that they are making. Gloria made two calls either side of this time. The third one, the third call in order.
01:06:50 The third one, the third call in order. At 8 minutes past 2, 2 minutes before the 2:10 spread, a distressing and brief WhatsApp message was left by her to her
01:07:01 WhatsApp message was left by her to her group of friends saying goodbye.
01:07:07 The next call, again short, the fourth one at 12 minutes past 2 after that 210 spread. a short call, 34 seconds,
01:07:19 spread. a short call, 34 seconds, in which Emanuel could hear Gloria and Marco discussing what they should do.
01:07:30 Again, a few minutes after this, there's a fifth call. This one lasts from 213, so it's a minute or so later, until 320.
01:07:44 It was in fact split into two parts. There it's a video call. So this is why I say watching on television in Italy and also over a video car call. While
01:07:56 and also over a video car call. While this call is continuing her parents can hear an alarm in the background. Gloria continued to be extremely
01:08:09 Gloria continued to be extremely fearful. They were waiting to see what they should do. Emanuela thought they might breathe fresh air out of a window, but they weren't keen to do that. And these are verbating, some verbatim
01:08:21 And these are verbating, some verbatim remarks from Gloria. She says this to her mother. It's not a small fire. It's a very large look. Look. And what she does is she puts the mobile phone
01:08:34 she does is she puts the mobile phone out of the window so her mother can actually see what she's already seeing on television. and she can see it from inside the flat as it were. She put the phone out of the window to show the fire
01:08:45 phone out of the window to show the fire and the fire engines. They're never going to put out a fire. It's too big. It's impossible. Smoke is coming in through the living room windows. Thick black smoke of the kind
01:08:58 windows. Thick black smoke of the kind that was in the lobby outside. I can't understand how this fire is so big. We're trying to understand what we can do and where we can go.
01:09:10 do and where we can go. Gloria's mother kept recommending that she kept the wet towel in over her mouth. By now, the smoke was coming in from everywhere, and Gloria was coughing continuously. She can be heard shouting
01:09:21 continuously. She can be heard shouting on this phone call for help out of the window and wanted to know whether the London Fire Brigade extending ladders would reach them. Manuel Emanuela didn't
01:09:32 would reach them. Manuel Emanuela didn't know [clears throat] what to say or how to respond. And Gloria says, "I don't know what to do, Mom. I'll call you later."
01:09:45 Again, just for a moment to reflect the unimaginable anguish of all of them, possibly unprecedented,
01:09:57 possibly unprecedented, captured on screens large and small around the world. contemporaneous, instantaneous, within reach, but out of reach.
01:10:10 within reach, but out of reach. 242
01:10:12 242 Gloria recorded a WhatsApp measure me messages to her mother and her cousin Georgia that I mentioned before. 245. Emmanuela called Marco's family and
01:10:24 Emmanuela called Marco's family and Marco's father, Dianino, who immediately contacted Marco, who described how they were unable to leave because of the smoke. They've been told to stay put,
01:10:35 smoke. They've been told to stay put, same as before, still unclear where from, and he' taken the precautions of filling the bath in the flat. There were 10 further calls between Marco and his
01:10:47 10 further calls between Marco and his father up till the time of 3:15, the last call. Although only four of the the 10 calls actually connected. I turn now to the last part of the call
01:10:58 I turn now to the last part of the call at 2:45
01:11:00 at 2:45 which lasted for 22 minutes. We've called it call six. In fact, the phone was on loudspeaker and it was recorded by her father,
01:11:12 and it was recorded by her father, Loris.
01:11:14 Loris. And again, one can't imagine what they must have been going through in order to see what was happening,
01:11:23 the escalating events all around. Gloria says this, as no doubt others thought, and some did.
01:11:35 did. I'm throwing myself out of the window. I swear to you, the fire is here. It's in the sitting room. The fire is everywhere. We're just waiting. The fire
01:11:46 everywhere. We're just waiting. The fire is outside my window. Pieces of glass are coming in through the window, which we've closed. We need a miracle. I'm sorry I came here and left you. It seems
01:11:57 sorry I came here and left you. It seems impossible that everything is over for both of us. I can't get out. I don't believe it's ending like this. I don't want to believe it. I can't see
01:12:09 don't want to believe it. I can't see anything outside. My eyes are burning. I can't breathe. She asked her mother finally
01:12:20 finally to take care of her cousin Georgia. And at the end of her last call, after thanking her parents, she said, "I just want to stay with
01:12:33 she said, "I just want to stay with Marco now." And in that moment, you see an element of respect, of generosity to for her
01:12:44 of respect, of generosity to for her parents, the kind of generosity that Mr. Freeman indicated had been exercised in relation to the two who'd come up from the four bel two floors below. There is
01:12:56 the four bel two floors below. There is much much more on this recording from a young couple facing an inevitable demise with incomparable strength and resilience and a generosity of
01:13:09 and resilience and a generosity of spirit which conveyed a loving gratitude to their parents and reflected really the community in the tower as well. They cut the call short. This is the one
01:13:23 They cut the call short. This is the one to to Emanuela at 8 minutes past 3 for reasons that are obvious. And Marco spoke finally to his father at
01:13:35 And Marco spoke finally to his father at 3:15,
01:13:36 3:15, hardly able to speak.
01:13:42 The calls also reveal that there came a point after 3:00 when they thought that firefighters were no longer on their way and there was no rescue helicopter.
01:13:53 and there was no rescue helicopter. They were right. Again, these times are now familiar. But may I just say in their case between 133 and 157, so I just flash back for a
01:14:05 and 157, so I just flash back for a moment, the London Fire Brigade were made aware of smoke and fire penetrating flats on floor 23. The overall position concerning search
01:14:16 The overall position concerning search and rescue has been outlined many times, so short summary will suffice. No deployments were made to this floor for the those purposes that search and rescue until after 8 minutes past 2 and
01:14:29 rescue until after 8 minutes past 2 and that one didn't reach that floor. There were others at 224, 251, 303, none of them reached floor 23. The Paddington crew which were going up to the roof to
01:14:41 crew which were going up to the roof to try and extinguish the external fire, they didn't even get to do that. So therefore, their their observation that basically it was over was entirely correct.
01:14:53 correct. Gloria and Marco were both fit and healthy despite conditions in the floor 23 lobby. According to Professor Perser, it would have been possible
01:15:05 it would have been possible to escape at the latest by 245 or thereabouts. Stay put, you will recall, wasn't revoked until 247. any later than that
01:15:18 any later than that and the toxic preload, in other words, what they've been breathing in the flat already and from the lobby would probably have prevented negotiating the stairs. The most favorable time,
01:15:29 stairs. The most favorable time, however, was earlier between 129 and 150 when smoke conditions on the stairs were lighter, remembering that the front doors of the twos were closest to the
01:15:40 doors of the twos were closest to the stairs. 202 is close to the stairs. For Gloria and Marco, however, and others on floor 23, it was the appearance of the black smoke in the lobby, which
01:15:52 of the black smoke in the lobby, which quite naturally was forbidding. They saw the thick smoke in the lobby and most likely thought the conditions beyond that were the same or worse. This
01:16:06 beyond that were the same or worse. This predicament and in each of these presentations is a point at which one steps back and reflects for the future. This predicament highlights the need for
01:16:18 This predicament highlights the need for a system which enables the communication of authoritative and authenticated information and advice at the time of the emergency by internal
01:16:31 at the time of the emergency by internal and external broadcast services. It's worth exploring whether such messages could be flashed onto the screens of mobile phones, a public
01:16:43 screens of mobile phones, a public service announcement in line with clear and practiced fire safety strategy and procedures which we've pro proposed in future for high-rise residential blocks. We say that because of course mobile
01:16:55 We say that because of course mobile phones are being used by many generations now almost uh on a daily and hourly basis and if they managed to get a message that in fact the conditions on
01:17:08 a message that in fact the conditions on the stairs were different in a obviously a different set of circumstances they might have managed to get away at a much earlier time with the veiles for that
01:17:19 earlier time with the veiles for that matter. This is also why it's important for the control officers to share real time information with each other as it is received during largecale incidents
01:17:30 is received during largecale incidents and to update residents who call although they didn't so that accurate up-to-date information is passed on to residents and that this is disseminated to others. If Gloria and Marco knew or
01:17:44 to others. If Gloria and Marco knew or had known that the stairs were less smoky than the lobby, they may have risked crossing the smoky corridor to make their escape. They just needed to know that the stairs were not as bad as
01:17:57 know that the stairs were not as bad as the lobby. The last moments finale. Gloria
01:18:04 Gloria and Marco
01:18:06 and Marco died as they had lived together next to each other in the corridor south of the flat entrance door and north of
01:18:18 of the flat entrance door and north of the south facing bedrooms. According to Professor Per Pers's evidence and a report which I cite in here, these are classic exemplifications
01:18:31 here, these are classic exemplifications of the effects of smoke and smoke inhalation of the toxic combustible products of fire.
01:18:42 Following the final call at 3:15 by Marco,
01:18:47 Marco, Professor Pers gives a very rough, I think he uses the word crude estimate that between 3:15 and 330,
01:18:56 and 330, so very soon after they would have first become incapacitated and then comeos reaching the lethal dose threshold. Soon after that,
01:19:10 threshold. Soon after that, Marco suffered from a single vessel coronary atheroma which increased his vulnerability. Neither of them would have been a aware
01:19:23 Neither of them would have been a aware of exactly what they were inhaling. Neither of them would have been conscious at the point of their joint deaths.
01:19:33 deaths. The configuration of flat 202 played a singular role in how matters had unfolded during these final moments. Professor Perser pointed out that the flat twos were especially dangerous
01:19:45 flat twos were especially dangerous because of the fire spread and conccommatant smoke intrusion, starting its progress across the east facing kitchen and living room corner and then
01:19:58 kitchen and living room corner and then around that corner to the southacing part of the living room towards the bedrooms outside of which they were found. And finally, the bedrooms between 251 and 255.
01:20:11 251 and 255. So shortly before the final calls, final call at 3:15. The path of progress meant that the kitchen and the hallway became quite mo smoke logged first, there
01:20:23 quite mo smoke logged first, there having been slow infiltration from the lobby since 1:30, and then the living room, and created a considerable period of roughly 75 minutes between its
01:20:35 of roughly 75 minutes between its initial arrival and the final telephone call. At 3:15,
01:20:43 I turned to the final stage of recovery.
01:20:51 Initially, in the aftermath, her brother Julio and his wife, well, to be at the time, Julia, immediately traveled to London in the firm belief
01:21:03 traveled to London in the firm belief that Gloria might have survived. They visited the tower whilst it was still smoldering and scoured every hospital, every
01:21:15 and scoured every hospital, every location without success. An increasingly distressing mission and they returned to Italy with nothing. No Gloria, no information. She was reported
01:21:26 Gloria, no information. She was reported missing by the family. Meanwhile, the painstaking, rigorous, and meticulous task of recovery and identification had begun. And some of
01:21:37 identification had begun. And some of that, of course, you've heard well quite a lot of it this morning in terms of the archaeology. The care and attention to every detail employed in the general process were also explained besides this morning with
01:21:49 also explained besides this morning with admirable clarity before you by Gail McKinnon, forensic anthropologist and team leader. It involved the interplay of several other disciplines besides her
01:22:00 of several other disciplines besides her own archaeology this morning, odontology and DNA.
01:22:05 and DNA. The conditions with which the experts had to contend in flat 202 after the fire can be viewed in a video which was part of the commemoration for Marjorie and Ernie. I have the reference. It can
01:22:17 and Ernie. I have the reference. It can be seen. It was shown at the commemoration. And it doesn't take much to to envisage what they faced.
01:22:28 what they faced. This process in relation to Gloria commenced with the initial discoveries on the 19th of June 2017 and continued until further confirmatory anthropological reports in
01:22:41 confirmatory anthropological reports in December 2018. However, it had been possible to make a reliable identification for Gloria through odintology and anthropology on the 23rd
01:22:54 odintology and anthropology on the 23rd of June. So much sooner on uh June 2017 by the identification commission attended by the senior coroner for inner west London, Dr. Fiona Wilcox.
01:23:07 west London, Dr. Fiona Wilcox. The gold heart pendant Gloria was wearing and her jeweled naval stud were recovered from the scene and returned to
01:23:18 recovered from the scene and returned to her family. The preliminary post-mortem report recorded provisional primary cause of death as consistent as you've heard with
01:23:29 death as consistent as you've heard with many other or nearly all the other cases with the evidence or effects of fire with the evidence of soot inhalation that was reported on the 21st of June.
01:23:41 that was reported on the 21st of June. There was a second one on the 25th of September which recorded inhalation of products of combustion. However, it had been possible in her
01:23:52 However, it had been possible in her case to examine a blood sample. Caroxyhemoglobin was detected at a very high level 78%. The saturation level associated with
01:24:05 The saturation level associated with death as you know from carbon monoxide poisoning is is lower than that 40 to 50%.
01:24:11 50%. Professor Perser provided this summary in evidence about this result. So that is the result for a person who's been overcome by carbon monoxide and toxic smoke and then
01:24:25 carbon monoxide and toxic smoke and then becomes
01:24:28 becomes and continued to inhale smoke while comes containing carbon monoxide for some time until they eventually their systems pack up and they die. So, it's a
01:24:41 systems pack up and they die. So, it's a very strong signal to me that we're dealing here with smoke cases. In Marco's case, the process was also commenced on the same day as it was for
01:24:53 commenced on the same day as it was for Gloria, the 19th of June, his remains being alongside Gloria. By the 21st of June, significant items were found amongst his personal effects,
01:25:05 found amongst his personal effects, namely mobile phone and a wallet containing photographic identification. By the 30th of June, a DNA database
01:25:16 By the 30th of June, a DNA database comparison had been made and could be asserted to be Marco. The cause of death and its description is the same as Gloria. fire effects and the inhalation
01:25:29 Gloria. fire effects and the inhalation of combustion product products namely [clears throat] excuse me toxic carbon monoxide fumes save for the additional feature of the atheroma which I've
01:25:41 feature of the atheroma which I've already mentioned a blood sample was obtained in his case but merely revealed the presence of hemoglobin but it couldn't be measured
01:25:53 measured may I close with this may I call it an ep epit half for the two families.
01:26:02 The narrative itself that I've just been through
01:26:06 through is a tribute to the inddehaticable and enduring human spirit of those in Granville Tower
01:26:17 human spirit of those in Granville Tower who died.
01:26:19 who died. others of course beyond these two as well as those who lived and continue to live with searing memories and
01:26:32 to live with searing memories and unending love. When Gloria's mother came to give evidence before you towards the end of what [clears throat] she said,
01:26:44 she said, she had mentioned respect for all again a theme like generosity o of all the people who you've heard from and she also wanted to emphasize the
01:26:57 and she also wanted to emphasize the need for responsibility and accountability. And then she looked up to see everyone who was at that venue for that commemoration.
01:27:09 commemoration. And she said words to this effect that she'd listen to their stories that day and realized in hearing those stories that it was
01:27:21 in hearing those stories that it was Gloria and Marco's story as well. The pain they felt was the pain she felt. It was in everyone's faces and in that
01:27:33 It was in everyone's faces and in that sense the community was brought together and she felt that unity and she felt that strength.
01:27:43 Marco's parents uh have sent in a sense just a message which because they they didn't come before you at that time but they have since wanted to say
01:27:56 time but they have since wanted to say this to you about Marco and Gloria Gianino Gutardi and Daniel Bichoto have created something called the Grenfell
01:28:09 created something called the Grenfell Love Marco and Gloria Foundation.
01:28:14 Its objects to remember the two young people as well as the other 70 victims of the tragedy. To raise awareness of the safety of
01:28:26 To raise awareness of the safety of buildings and the protection of the environment and habitats.
01:28:32 To provide educational tools to schools. to help young people by providing scholarships to the most deserving
01:28:44 to the most deserving because we believe that knowledge will be able to make our society better. Thank you.
01:29:21 Thank you very much, Mr. Manfield. Well, that brings us to the close of today's proceedings. We shall rise at that point, but we
01:29:33 We shall rise at that point, but we shall resume tomorrow at 10:00 when we shall hear further presentations relating to those who died in the fire. Thank you all very much. 10 o'clock tomorrow, please.