Opening of Module 8 focused on the investigation and identification of the deceased. Pathologist Dr Ashley Fegan Earl and forensic anthropologist Gail McKinnon explain the post-mortem and identification processes. Key themes include the challenges of thermal damage, commingling of remains, Article 2 investigation requirements, and the dignified approach to presenting evidence about each victim.
00:00:27 [Music] good morning everyone welcome to today's hearing today we begin module 8 of this phase of the inquiry module 8 differs in some respects from
00:00:39 module 8 differs in some respects from the earlier modules in particular because
00:00:43 because most of the evidence that we are to hear will be presented by lawyers representing those whose relatives died in the fire as many of those
00:00:54 as many of those following the proceedings we'll know the coroner for inner london west has opened inquests into the deaths of those who died in and as a result of the fire
00:01:05 died in and as a result of the fire those inquests have been adjourned pending the conclusion of the inquiry and the publication of its final report it will be for the coroner to decide in
00:01:17 it will be for the coroner to decide in due course what further steps to take in relation to those inquests but if she is satisfied that the scope and depth of the inquiry's investigations match those which she
00:01:28 investigations match those which she would have carried out it will be open to her to adopt its findings thereby relieving her and the families of the burden of any further proceedings as far as she is concerned
00:01:42 that being so i've made it clear on many occasions that the inquiry will do all that it properly can within its terms of reference and in accordance with the procedures appropriate to a public
00:01:54 procedures appropriate to a public inquiry
00:01:55 inquiry to ensure that it finds all the facts which the coroner would need to find when conducting an inquest which complies in all respects with all aspects of domestic law
00:02:07 all aspects of domestic law including the requirements of article 2 of the european convention on human rights
00:02:14 rights the circumstances which give rise to the fire and the events of the night of the 14th of june 2017
00:02:22 2017 have been investigated in phase one of the inquiry and the previous modules of phase two it remains therefore only to ensure that sufficiently detailed findings can
00:02:34 that sufficiently detailed findings can be made about the individual deceased and the circumstances in which they died
00:02:42 much of the evidence is already before the inquiry but it is necessary to gather together the threads in order to enable the full picture to be drawn
00:02:53 be drawn in each case it's also necessary to hear evidence from those who were responsible for the removal of the deceased remains from the tower
00:03:03 tower and the identification of the deceased themselves those witnesses will be examined by council to the inquiry the evidence and indeed this module as a
00:03:14 the evidence and indeed this module as a whole
00:03:15 whole is inevitably sensitive and for some will be distressing the panel has therefore agreed that apart from the witnesses to whom i have just referred the material which we have to consider
00:03:28 the material which we have to consider should be presented by those who represent the bereaved who will draw to the attention of the panel the evidence relating to each individual deceased
00:03:39 relating to each individual deceased in order to ensure that the proceedings are conducted in a dignified and respectful manner there will be significant intervals between the various presentations
00:03:50 between the various presentations yes mr millet mr chairman members of the panel as the chairman has just said
00:03:58 said this is the start of the final module of this phase of the inquiry module 8. i need to explain a little bit more about the origins of module 8 what it is and what it is not
00:04:10 and what it is not in the early stages of this inquiry the the rlrs for the bereaved families asked the chairman to conduct an investigation under article 2
00:04:21 investigation under article 2 of the echr the european convention on human rights after submissions were made in march and september 2018 about the nature and scope of that investigation
00:04:32 investigation he agreed that he would investigate the fact that the coroner professor fiona wilcox
00:04:37 wilcox senior coroner for inner london west would be required in law to find in order to discharge her statutory functions under section 5 of the coroner's and justice act 2009
00:04:50 of the coroner's and justice act 2009 that task now falls to all of you the panel
00:04:55 panel i should explain the background in a little bit more detail the origins of what has now become module 8 help to explain and to characterize the nature of the hearings that are about to follow
00:05:07 that are about to follow the broad history in outline is is as follows
00:05:10 follows on the 20th of december 2017 after reading and hearing opening statements from the bsrs the chairman said that he hoped that the inquiry would be able to achieve an outcome whereby the coroner's statutory
00:05:22 whereby the coroner's statutory obligations to find the facts would be discharged by the inquiry's own work in doing so he raised two notes of caution first that the inquiry can only
00:05:33 caution first that the inquiry can only work within the terms of reference and second that the procedure would be that of a public inquiry and not that of an inquest on the 28th of march 2018 after a
00:05:45 on the 28th of march 2018 after a procedural hearing on the 21st of march 2018 at which further submissions were made on this topic the chairman issued a direction
00:05:54 direction in which he said that on the material then available he saw no significant difficulty in making findings which would be sufficient to meet the requirements of an investigation which
00:06:05 requirements of an investigation which complies with article 2 of the echr he noted in particular the difficulty in making extensive and detailed findings about the movements of each deceased
00:06:16 about the movements of each deceased on the night but expressed some hope that he would be able to make sufficient findings of fact without imposing an unreasonable burden on those involved the offer from some of the families for
00:06:27 the offer from some of the families for cooperation and assistance in the preparation of the relevant material was noted
00:06:33 noted at a further procedural hearing on the 3rd of september 2018 i welcomed the proposal to hold dedicated hearings for the deceased in which the rlrs for the bsrs would tie together the evidence
00:06:45 bsrs would tie together the evidence regarding the deceased in a set-piece oral hearing at which the advocates for the families presented the evidence relating to their loved ones after the expert evidence
00:06:56 expert evidence the hearings were initially anticipated to take place during the phase one report writing period and to be addressed in that report but in the end that did not prove to be necessary because by then so much material and
00:07:09 because by then so much material and crucially the written and oral evidence received from the bsrs was already in the possession of the inquiry it could be analyzed and presented in the phase 1 report
00:07:20 the phase 1 report as it was in fact in part 2 chapters 10 to 20 periods 1 to 11 under the subsections conditions in the tower and movement of occupants
00:07:31 movement of occupants on the 12th of september 2018 the chairman indicated that he welcomed the suggestions that representatives for the bsrs should take the lead in marshalling the evidence surrounding the
00:07:42 the evidence surrounding the circumstances in which their loved ones died but reiterated that although he and now you the mem that the panel would necessarily retain responsibility for the inquiry's findings detailed
00:07:55 for the inquiry's findings detailed submissions supported by a written analysis in whatever form would be most convenient and would likely be likely to be of greatest assistance when it came to drafting that part of the panel's report
00:08:07 drafting that part of the panel's report he also concluded that it was right that in connection with this particular aspect of the inquiry's work council for each of the bereaved families who lost loved ones in the fire should be able to
00:08:18 loved ones in the fire should be able to address the panel on the evidence bearing on the issues relevant to article 2 of the echr so far as relevant to the individual deceased rather than leaving that task to me counsel to the
00:08:30 leaving that task to me counsel to the inquiry further submissions and correspondence followed during 2019 and into 2020
00:08:36 into 2020 and since during which the scope and the nature of this module have been further refined and defined with clarity i turn to the coronal facts
00:08:47 i turn to the coronal facts the inquiry's task thus assumed is to investigate the facts that the coroner would be required in law to find in order to discharge her function under section 5 of the 2009 act
00:08:59 section 5 of the 2009 act and in doing so to adopt a procedure which complies with with section 17 of the inquiries act namely to act with fairness and to avoid any unnecessary cost whether to the public funds or
00:09:11 cost whether to the public funds or witnesses or otherwise the 2009 act restricts the coroner to answering four questions
00:09:18 questions who the deceased was and how when and where the deceased came by his or her death where article 2 of the echr is engaged
00:09:29 where article 2 of the echr is engaged the question of how the deceased came by his or her death is to be interpreted not only as by what means but also as in in what circumstances
00:09:40 in what circumstances the panel has decided that the facts to be investigated in this module are in relation to each deceased ninefold plus or one further first their name gender and age
00:09:52 name gender and age second the number of the flat in which they lived and the floor number third the background and composition of their household fourth what messages if any passed between them and the emergency services
00:10:04 between them and the emergency services or between them and others and what information about them was held by the emergency services fifth
00:10:10 fifth whether the firefighters tried to rescue them
00:10:13 them sixth where they died seventh the time of their death so far as it can be ascertained seventh the movements between uh eighth their movements between outbreak of the
00:10:25 their movements between outbreak of the fire and the time of death and ninth the medical cause of their death to which we had a tenth fact namely whether they had any vulnerabilities and whether those were
00:10:36 vulnerabilities and whether those were known to the tmo or rbkc you the panel will make those factual findings on a deceased by deceased basis in your phase 2 report
00:10:49 in your phase 2 report i turned them to the inquests the coroner opened 70 inquests on various dates between the 21st of june and the 22nd of november 2017 no inquests were opened either for logan
00:11:01 no inquests were opened either for logan gomez the stillborn child of martial gomez and andrea perestrello or for maria del pilar pilly burton who survived the fire but
00:11:12 pilly burton who survived the fire but died in january 2018. the coroner told the police that there would be no inquest for logan gomez because he did not have a life independent of his mother and is therefore outside the coroner's
00:11:24 therefore outside the coroner's jurisdiction although outside the coroner's jurisdiction it does remain possible however for you the panel to investigate the circumstances of logan gomez's death when considering the evidence relating
00:11:36 when considering the evidence relating to the other deceaseds we have or you have received some of the evidence necessary to investigate the death of logan gomez pilly burton died in a different
00:11:48 pilly burton died in a different colonial jurisdiction and no inquest has been opened for her we have received representations to include her death in the investigations of the deceased but no detailed
00:11:59 of the deceased but no detailed submissions or supporting evidence has been provided to show how billy burton's death was related to the fire the circumstances surrounding pilly's death were addressed in the phase one
00:12:10 death were addressed in the phase one report and although there will be no presentation in this module in relation to her nonetheless uh you the panel have offered to include in your report a description of the circumstances of
00:12:23 description of the circumstances of pilly's death in recognition of the regard in which she was held by her community the vast majority of circumstances in which each deceased came by their deaths
00:12:34 which each deceased came by their deaths was in the first place the subject of findings of fact already made in the phase one report both generically and individually and in the second place will be made in the phase two report on the basis of the
00:12:46 the phase two report on the basis of the evidence and the submissions heard in modules one two three five and six there is in addition evidence before the panel of facts relevant to the deaths of
00:12:58 panel of facts relevant to the deaths of each of the individual deceased which would be required to be found by the coroner
00:13:03 coroner now against that background i'd like to explain a little bit about the nature and purpose of this module it is to present to you the panel the facts relevant to the deaths of each individual deceased based on the
00:13:15 individual deceased based on the evidence before you that the coroner is obliged to investigate the facts must be the facts that i as council to the inquiry would otherwise have presented to you in a neutral way
00:13:27 have presented to you in a neutral way based firmly on the evidence in the record or the findings made in the phase one report you the chairman have always been of the view that it would encourage a greater sense of agency and ownership of this
00:13:40 sense of agency and ownership of this very sensitive and personal element of the inquiry for it to be conducted by the bereaved zone representatives and not by council to the inquiry it is for that reason
00:13:51 it is for that reason that the rlrs for the bereaved are going to conduct the presentations in that sense these rlrs are taking on a different role from that which they occupied during other parts of the inquiry
00:14:04 during other parts of the inquiry it's important to make clear that the presentations do not represent the findings of you the panel and although they will refer to findings made in the phase one report there are matters
00:14:16 phase one report there are matters of evidence such as professor purse's evidence heard last week where you the panel have yet to make findings the inquiry has been concerned that some bereaved might perhaps not unnaturally
00:14:27 bereaved might perhaps not unnaturally wish their representatives to point the finger a particular people or organizations who they consider are to blame for the deaths of their loved ones as to that there are two things to say
00:14:39 as to that there are two things to say first so far as concerns generic causes general causes and contributing factors the inquiry has already received voluminous written opening and closing
00:14:50 voluminous written opening and closing submissions and oral submissions from the rlrs in each of their earlier modules and all other core participants have had a fair opportunity to make their own submissions and to respond to
00:15:01 their own submissions and to respond to those allegations that can be supplemented through the procedure adopted for the overarching final submissions now scheduled for the second week in november this year which
00:15:12 second week in november this year which will include provision for updates based on the expert evidence including expert evidence from professor persa secondly
00:15:21 secondly so far as concerns specific individual cases and causes and contributing factors those are essentially physiological derived from the work of professor persa and the work of the
00:15:32 professor persa and the work of the pathologists whose post-mortems could be and were carried out moreover you the panel are not a coroner you're not obliged to adopt any particular procedure that a coroner
00:15:43 particular procedure that a coroner would adopt and it is in any event not permitted for you to exceed the ambit of the terms of reference
00:15:49 reference there will be no submissions in this module seeking to persuade you to consider a particular or indeed any colonial conclusion because the panel does not have you do not have the jurisdiction to make and record any such
00:16:02 jurisdiction to make and record any such conclusion you are not here in place of the coroner but rather to assist her in fulfilling her statutory functions and obligations her her investigation is suspended
00:16:13 her her investigation is suspended though they are remain and must remain a separate independent process accordingly the rlr's presentations in this module will not be seeking to apportion
00:16:24 will not be seeking to apportion responsibility for the deaths to any specific person act event or omission they will not use contentious language nor should there be a need to display documents considered already as part one
00:16:36 documents considered already as part one of the phase report phase one report or which are distressing we are very grateful for an express assurance on behalf of all the rlrs for the families the bsrs
00:16:48 all the rlrs for the families the bsrs directly involved in module 8 that all council making the presentations during the module will present the facts in an uncontroversial way and we'll do we'll avoid making submissions arguments or allegations
00:17:01 submissions arguments or allegations against other core participants or third parties
00:17:05 parties that approach will assist the inquiry team
00:17:08 team and the rlrs for the bereaved together to achieve their shared goal and that goal is to permit a dignified sensitive and
00:17:20 is to permit a dignified sensitive and meaningful presentation of the core facts
00:17:23 facts relevant to each death those in turn will provide a memorable and and fitting a close to the phase one phase two commemorative to phase two as
00:17:34 phase two commemorative to phase two as the commemorations of the deceased did as the opening to phase one in may 2018 it must go without saying that each rlr must be free to address
00:17:47 that each rlr must be free to address you unimpeded and uninterrupted by me or by you
00:17:52 by you the dignity of the deceased and the solemnity of these hearings demands that if there are any occasions on which the presentations touch on matters beyond
00:18:04 presentations touch on matters beyond the scope of the very limited set of facts that have been agreed as relevant then unless already covered in the evidence heard in earlier modules they will not be taken into account in the
00:18:15 will not be taken into account in the report
00:18:16 report if there are contentious allegations on matters within the scope of those facts then no findings will be made in the report without giving those against whom those allegations are made a fair opportunity to address them at a later
00:18:28 opportunity to address them at a later stage
00:18:30 stage on which directions would have then to be given
00:18:33 be given but i hope that the assurances that we've been given will render that unnecessary we will start today by hearing evidence from the forensic pathologist dr ashley
00:18:44 from the forensic pathologist dr ashley feegan earl and from gail mckinnon the forensic anthropologist on the 11th of july 2022 next monday we will hear evidence from dr carl harrison forensic archaeologist those witnesses
00:18:57 forensic archaeologist those witnesses will explain how they went about their work to identify the deceased and the immediate causes of death on the other days from tomorrow we will hear the presentations from the rlrs for the bereaved
00:19:08 the bereaved the rlrs have organized the timetable in consultation with the inquiry team it contains built-in breaks of appropriate length between presentations so that each
00:19:19 between presentations so that each presentation stands alone and is not treated simply as part of a process while balancing the need for a timetable that is proportionate the inquiry team has confirmed with rlrs
00:19:31 the inquiry team has confirmed with rlrs which documents need to be displayed during a presentation which will minimize the risk of any interruption for many bereaved their chance to hear about the
00:19:42 their chance to hear about the circumstances in which their loved ones died
00:19:46 died is the culmination of five years of waiting
00:19:49 waiting five years of material that at times must have seemed very far removed from the ones they lost who they were and how they died
00:19:59 they died although we must apply sensible procedures and time keeping to ensure a process that is fair for all the individual need to speak and be heard is paramount and we all allow
00:20:10 heard is paramount and we all allow time and space around this presentation as we did at the commemorations in may 2018 with which we started the inquiry finally i should give a general trigger
00:20:22 finally i should give a general trigger warning now the statements and the materials that will be discussed or displayed during this module may be distressing to some and they may wish to consider whether to listen or to continue to listen or to
00:20:33 listen or to continue to listen or to watch or to continue to watch or not a trigger warning will be given at the start of every session including after all breaks throughout this module mr chairman members of the panel that is
00:20:44 mr chairman members of the panel that is all i propose to say by way of opening module 8. thank you very much mr millet um now i now call hot on the heels of that dr ashley fegan earl please the
00:20:56 dr ashley fegan earl please the pathologist
00:21:12 good morning doctor fingernail i'm here good morning good morning um i understand that you wish to affirm is that right the words should be there on the screen in front of you would you read them out please i do solemnly sincerely and truly
00:21:25 please i do solemnly sincerely and truly declare and affirm that the evidence i shall give should be the truth the whole truth and nothing but the truth thank you very much would you like to sit down please make yourself comfortable indeed
00:21:41 yes mr miller yes thank you mr chairman mr chairman i i perhaps should have done done this before calling dr figano but i repeat the trigger warning that i've just given generally perhaps wasn't necessary uh only a minute or two later
00:21:54 necessary uh only a minute or two later i should explain generally that dr feigenel is being called to provide an overview of the process and the methods by which he and his colleagues proceeded we will not be asking him questions about any individual deceased
00:22:05 about any individual deceased circumstances and i hope that might provide some comfort to the bsrs um dr figano can i please ask you to be shown awf701
00:22:17 uh is that your witness statement prepared for the inquiry yes it is and if we go please to page five we can see that there's a date uh 15th of june 2022 underneath your name and a signature is
00:22:29 underneath your name and a signature is that your signature it is indeed yes uh and can you have you read this statement recently yes i have thank you and can you confirm that the statements made in this statement are true yes and certainly true to the best of your knowledge and belief certainly so
00:22:41 your knowledge and belief certainly so and although you are not here as an expert is it right that in preparing this statement you have remained mindful of your professional obligations in the same way that you would have been or would have done had you been called as
00:22:53 would have done had you been called as an expert yes indeed uh and uh preparing a report to the court indeed now i'm going to take you to a number of points in the statement as we go through your evidence but we will have to jump
00:23:04 your evidence but we will have to jump around a little bit so give me but everything i'm going to ask you about will appear on the screen in front of you
00:23:09 you um can we turn please to page one of your uh statement and the pages one and two contain your professional qualifications and experience and what we just want to do is is invite
00:23:21 and what we just want to do is is invite you in a sense to agree a list of the main uh characteristics of your career and your professional qualifications you completed a bachelor of science bachelor of medicine and
00:23:32 of science bachelor of medicine and bachelor of surgery yes yes and you held a diploma in medical jurisprudence in pathology yes and i think you also hold fellowships in the royal at the royal college of pathologists yes and i think
00:23:44 college of pathologists yes and i think you're a foundation member of that are you not
00:23:47 you not uh not of the royal college of pathologists the the the faculty of forensic and legal medicine i am
00:23:53 am right uh and then the faculty of forensic and legal medicine you're also a member uh and the british association of forensic medicine yes uh and also i think the royal society of medicine yes yes uh if you could turn over to the to
00:24:05 yes uh if you could turn over to the to the top piece of page two um you can see that you are also a member of the british academy of forensic sciences yes yes
00:24:15 yes yes uh and uh you are also saying it's back on page one but we didn't get back to it that you've been involved in the study and the practice of forensic pathology since 1997. yes and you practice as an independent forensic pathologist as a
00:24:27 independent forensic pathologist as a partner in a an organization called forensic pathology services yes indeed yes and in 2002 is this right you were admitted to the home office register of
00:24:38 admitted to the home office register of accredited forensic pathologists yes i was
00:24:41 was and is it also right that to be admitted to that register a candidate would have to meet certain criteria which would include holding a specialist registration in one of four areas of pathology or forensic medicine yes
00:24:53 pathology or forensic medicine yes that's right and i think you would also need to be aware of uh the coronal legislation so far as it affects the work of a pathologist yes absolutely and are you able briefly to outline what
00:25:04 and are you able briefly to outline what the work of a forensic pathologist involves
00:25:07 involves yes uh forensic pathologists are all qualified doctors who've gone on to specialise in forensic pathology which itself considers causation of injuries and causes of
00:25:20 causation of injuries and causes of death
00:25:21 death in
00:25:21 in usually overtly suspicious circumstances but that can involve a very wide range of issues such as murder suicide
00:25:32 of issues such as murder suicide accident
00:25:33 accident and indeed mass disasters
00:25:38 we are independent as pathologists we are not
00:25:43 are not while we may be instructed by a coroner to perform post-mortem examinations our opinions are independent so while we work with police we do not
00:25:55 have to consider their uh specific requirements or opinions we we provide an independent response to our findings
00:26:06 to our findings so
00:26:07 so we're engaged in carrying out those post-mortem examinations commissioning additional investigations collating that providing reports and
00:26:18 collating that providing reports and opinions and expressing those to various courts
00:26:21 courts and would it be fair to say that a forensic pathologist carries out a postmortem on the authority of the coroner or the police uh on always on the authority of the coroner although of course the police
00:26:32 coroner although of course the police may have a specific interest yes and i think you've explained that that happens where there has been a suspicious or unnatural death yes yes and then you report on your opinion
00:26:44 report on your opinion as to the medical course of death yes to the relevant authority we do now you you also say that you've co-authored papers in your own area of expertise and you've lectured to a range of other professionals on forensic
00:26:55 of other professionals on forensic pathology yes it is and i think you maintain your professional accreditation through continuing professional development uh under a scheme organized by the royal college of pathologists yes it's a
00:27:06 college of pathologists yes it's a requirement of all doctors to to carry out that yes would it be a fair summary of your experience over many years that it has included conducting post-mortems and providing expert opinions both in
00:27:18 providing expert opinions both in inquests and in a range of criminal cases yes and other cases too uh yes indeed yes such as
00:27:25 such as uh
00:27:26 uh various appeals uh mass disaster inquiries
00:27:30 inquiries um cold case reviews and the like right now before the grenfell tower fire in june 24 2017 had your work as a forensic pathologist included investigating the
00:27:41 pathologist included investigating the cause of death following a serious fire uh yes
00:27:44 uh yes and
00:27:45 and which which was that well many
00:27:50 well many fires which are deemed to be suspicious including
00:27:54 including murders where arson has been the underlying cause
00:28:01 cause and fire arising from mass disasters for example uh the paddington crane train crash
00:28:08 crash yes and i think it's right also that you gave evidence is this right as a pathologist in the london bridging quest yes i've been involved in all of the london terrorist
00:28:19 involved in all of the london terrorist incidents over the last few years yes
00:28:22 yes now can we go please to page five of your witness statement and let's look together at paragraph 39 you say
00:28:30 you say it is to be noted that all of these examinations were performed by home office registered pathologists several of whom had experience of mass previous mass disasters including road and rail crashes and terrorist incidents in which
00:28:42 crashes and terrorist incidents in which similar basic principles are applied now we'll come back to the basic principles but just to be clear at this stage is it right that those involved with the post-mortems which followed the
00:28:54 with the post-mortems which followed the fire the grenfell tower fire were all registered with the home office yes they were um therefore they they had a broad experience of uh similar uh
00:29:06 a broad experience of uh similar uh types of cases and uh were aware of the principles that are applied to to dealing with such cases and when you say similar types of cases are you what are you referring to
00:29:18 you referring to other other mass disasters such as for example the croydon tram crash the paddington rail crash uh various other rail crashes road crashes um terrorist
00:29:30 rail crashes road crashes um terrorist incidents all of those are unified by um a specific process that we go through in order uh to carry out those examinations and report our findings right
00:29:42 and report our findings right and had you personally had experience of a mass
00:29:46 a mass a mass incident a mass casualty incident involving a serious fire a large where there was a large number of casualties he certainly probably paddington rail crash was was a significant uh
00:29:59 crash was was a significant uh incident like that yes now if we go back to page two of your statement i just want to ask you about your
00:30:06 your process of grenfell in uh in relation to the post-mortem examinations a paragraph six you say this whilst
00:30:14 whilst there exists principles for the management of a mass disaster it is to be recognized that no two disasters are the same
00:30:24 and then you go on to say a paragraph 39 we looked at where there are some principles which would apply what are the basic principles that you refer to in paragraph 39 even though
00:30:36 refer to in paragraph 39 even though mass disasters are never the same the basic principles would involve
00:30:45 preparation of a strategy that is specific to the disaster involved
00:30:53 involved considering which individuals would be best placed to carry out those investigations what interface there may be with other areas of expertise to
00:31:06 areas of expertise to maximize the potential of evidence recovery and information recovery and to ensure that there is a logical staged
00:31:17 staged process
00:31:19 process that goes through each case individually and ensures that all the questions that need to be answered
00:31:27 answered are done so and
00:31:30 and each of those processes accounted for um as the process continues with reporting to the coroner as we go and is having a nominated lead pathologist
00:31:41 nominated lead pathologist one of those principles or yes matter which governs them yes because the the lead pathologist will have an interface with the coroner so that on a day-to-day basis various important
00:31:54 day-to-day basis various important decisions can be made as to how the investigation proceeds and as the nominated lead pathologist was it your role in relation to the grenfell tower
00:32:05 grenfell tower mass
00:32:06 mass incident
00:32:07 incident to apply the basic principles that you've just explained to us yes indeed
00:32:13 and so it was you who made the decisions about the approach that the pathology team would take yes we put forward a strategy that was discussed uh among others with with her majesty's coroner
00:32:24 others with with her majesty's coroner uh in order that uh her requirements were properly fulfilled and the investigation proceeded um in in a logical fashion given its scale
00:32:36 in in a logical fashion given its scale now although you say in paragraph six that you recognize that no two disasters are the same were there any particular challenges that you and your colleagues in your pathology team faced at grenfell
00:32:49 pathology team faced at grenfell uh yes um
00:32:52 the issue of course here is fire fire is a highly destructive medium and so it may be that we are unable to carry out in the
00:33:03 that we are unable to carry out in the conventional sense post-mortem examinations and therefore we may require um to interface with other experts
00:33:15 experts who can provide us with vital information in order to come to a proposed cause of death and that would include for example forensic archaeologists
00:33:26 forensic archaeologists um
00:33:28 um forensic odontologists and forensic anthropologists and therefore it required each case to be considered on merit
00:33:38 on merit as to which expert would be the most best would be best place to carry out that investigation with oversight from a pathologist and when you say each case do you mean each individual each
00:33:49 do you mean each individual each individual sure yes indeed i see uh and did was it you who went about deciding first whether each deceased needed an archaeologist or an anthropologist
00:34:01 archaeologist or an anthropologist or an ontologist and if so deciding who that person should be well to an extent it was decided that the pathologist would
00:34:10 would make the initial examination and from there decide whether a conventional post-mortem examination was possible or appropriate or indeed
00:34:22 or indeed whether it was more in the province of um the anthropologists and odontologists thereafter referrals were made to those experts
00:34:32 experts reports would come back to us so that we could ultimately define a cause of death and to what extent we may come back to this later but to what extent could the anthropologists or the odontologists
00:34:46 anthropologists or the odontologists uh
00:34:46 uh give you any assistance in the decision about the cause of death as opposed to the identity of the person who died and where they died well the odontology is principally
00:34:59 died well the odontology is principally an identification process as is largely the uh the anthropology it's it's taking uh account of each case and very much
00:35:11 uh account of each case and very much placing
00:35:12 placing each individual into the context of the disaster as a whole and
00:35:17 and drawing conclusions as best we can um given the the unique limitations um that we we were facing here yes and was it you who selected the the particular
00:35:29 you who selected the the particular archaeologist and anthropologist and the odontologist no they'd already been engaged there was a team um of both both of all three of those individuals sets
00:35:40 of all three of those individuals sets of individuals and we work alongside those with it within the mortuary i see engaged by the coroner encouraged by the coroner yes i follow
00:35:49 follow um turning to your own team i think it's right isn't it that including you 12 forensic pathologists were involved in conducting post-mortems on the deceased at grenfell yes
00:36:01 deceased at grenfell yes and who chose uh your colleagues did you yes it was it was largely undertaken by um my particular group we cover um the metropolitan area and
00:36:14 we cover um the metropolitan area and many of the home counties and so um given location we we were able to to deploy appropriate individuals to to deal with this and uh were you responsible f for
00:36:26 and uh were you responsible f for picking the individual members of your team yes and you led them did you yes yes
00:36:31 yes and how did you instruct them or monitor their work uh
00:36:36 uh on on a daily basis by discussing the strategies that had been considered on a day-to-day basis and ensuring that those were implemented
00:36:47 ensuring that those were implemented as as we went through and then perhaps modifying the techniques as we were presented with further challenges and how did you ensure consistency of approach across different
00:36:58 consistency of approach across different post-mortem examinations um
00:37:01 um well
00:37:02 well all cases um are are reviewed are peer-reviewed all of the home office pathologists are used to
00:37:11 used to secondary review and
00:37:17 with regard to the anthropology that would be a matter for the anthropologists to internally review their own findings and who conducted the peer reviews on the post-mortems done by your team that would have been um
00:37:29 your team that would have been um various individuals within our our particular unit that's of common feature of all cases conducted by home office pathologists that they are peer reviewed prior to a
00:37:41 that they are peer reviewed prior to a formal report being issued the peer review by your own yes it's it's a what's termed a critical conclusions findings check in other words that the the um
00:37:51 the um broadly speaking the conclusions match the findings um uh in in a consistent manner right but nobody um had a second look at your methodology no
00:38:03 no is it right that in some cases different pathologists conducted examinations of the remains of a single victim but at different stages yes that's because of the uh extent of
00:38:15 yes that's because of the uh extent of disruption of the bodies that then there was overlap in that case is that usual in a mass casualty incident
00:38:28 it depends very much on the extent of damage to bodies but where there is
00:38:35 there is greater disruption yes that that may occur
00:38:39 occur now we know from the available reports that for many of those who died in the fire there was a preliminary post-mortem report which was then followed at a later stage by a final post-mortem report yes and was the two-stage process
00:38:53 report yes and was the two-stage process explained by what you've just told us about disruption uh to an extent yes again in all home office cases we will provide a preliminary report
00:39:05 we will provide a preliminary report which indicates our findings and a cause of death if we can give one it also highlights what further investigations are required such that once those have been received they can
00:39:18 once those have been received they can be reviewed and a final um post-mortem examination report issued i see so just to something so you always provide a preliminary report yes
00:39:29 provide a preliminary report yes and is it the case that sometimes because of further investigations which are required you go on and produce a final report yeah the final report will always be be produced there's almost inevitably
00:39:41 produced there's almost inevitably various additional examinations and investigations will be carried out that need to be taken into account the provision of a preliminary report allows the coroner
00:39:52 allows the coroner the capacity to to open an inquest at the very least yes i see
00:39:58 but it would there would always be a preliminary yes and there would always be a final yes but but um would would it be often the case that the final in the preliminary would be the same
00:40:10 usually they would be a separate document right now if we go to paragraph 20 in your statement please page three uh we can see there that you refer to the early phases of the investigation you say in the early phases of the
00:40:22 you say in the early phases of the investigation the victims were largely intact
00:40:27 intact what did you mean there by early phases
00:40:33 in a way this refers to the
00:40:36 the body recovery from whom you'll undoubtedly hear from appropriate individuals
00:40:45 it was the case that early on
00:40:49 early on the individuals who were recovered were intact and had not been
00:40:56 in the presence of severe fire and for that reason formal post-mortem examinations could be conducted in the normal sense
00:41:08 conducted in the normal sense later on
00:41:10 later on when there was more destruction
00:41:13 that led to the
00:41:16 the diversification of techniques uh
00:41:20 uh which were necessary at that point um was the investigation formally structured into phases so that the early phases would focus on those victims
00:41:32 phases would focus on those victims whose bodies were largely intact no not specifically it it was a function of um
00:41:41 admitting each body into the mortuary
00:41:46 assessing what was the most appropriate investigation and examination and moving forward from there it happened that
00:41:57 it happened that by nature of the recovery the first bodies recovered were the most intact
00:42:04 intact and as further recovery proceeded there was more destruction is that because of the logic of the process yes the logic of the process in that of
00:42:15 the logic of the process in that of course it's likely they would start lower down and move move upwards into more far damaged areas yes i see now if we go to um
00:42:26 now if we go to um uh paragraphs uh 14 and 16 under the heading
00:42:29 heading post-mortem examination process at the top of your screen on page three uh this is the part of the statement where you address the post-mortem examination process
00:42:40 examination process are you able to outline for us the process
00:42:42 process from the recovery of human remains to the receipt of those remains in the designated mortuary yes uh when remains are recovered they're placed into a recovery bag and
00:42:55 they're placed into a recovery bag and they are assigned a unique number that is common across all mass disasters it allows for
00:43:07 a continued study of the individual through the process until identification has been achieved so it ensures there's no um confusion in identification
00:43:20 um confusion in identification or any any form of mix-up so we ensure that we have that number and then that's audited throughout the process by various individuals at paragraph 16 you say upon receipt
00:43:33 at paragraph 16 you say upon receipt into the designated mortuary westminster public mortuary each bag underwent a ct scan
00:43:38 scan yes uh uh
00:43:41 yes uh uh is that
00:43:42 is that uh
00:43:43 uh well um i think the east midlands forensic pathology group then remotely reported on those scans yes yes just to be clear is it right that every recovery bag which is what i think they're called
00:43:54 they're called underwent a ct scan yes that's right and what was the purpose of the ct scan [Music]
00:44:02 [Music] post-mortem ct scans are becoming a more common adjunct to investigations and
00:44:13 and their detail may allow for example to
00:44:18 to consider various positive identifiers for example hip replacements surgical implants
00:44:30 surgical implants anatomical abnormalities equally
00:44:34 equally it allowed for consideration as to whether the bag contained um a single body or whether there was a suggestion of so-called co-mingling of remains
00:44:46 remains um and of course that would be in a later phase when there was more destruction so that there was early consideration of how
00:44:56 of how uh the investigation of that particular recovery bag would proceed and just taking that a little bit more in stages therefore uh use the ct scan assists in
00:45:07 uh use the ct scan assists in identifying human remains through positive identifiers such as you've uh given us examples of is it also for recording purposes yes the audit trail yes indeed and are
00:45:18 yes the audit trail yes indeed and are there any limitations to the use of a ct scan in identifying human remains well
00:45:23 well [Music]
00:45:25 [Music] in so much as
00:45:29 it can look for identifying features but there will become an interface whereby a ct scan
00:45:36 ct scan will not identify as much as a careful examination from a a forensic anthropologist and what safeguards were put in place to maintain the integrity of the remains during that stage of the
00:45:49 of the remains during that stage of the process
00:45:50 process well that the bags were sealed um and and underwent uh scanning in a mobile unit that was present at the mortuary right
00:45:59 right and thereafter where are they kept the the bodies were kept within the the mortuary facility at westminster and was there any particular reason why the east midlands pathology group was asked to
00:46:10 midlands pathology group was asked to report on the ct scan yes professor rutty who's the the head of the unit has a particular interest in post-mortem ct scans
00:46:20 scans as a group um home office pathologists are open to discussing with fellow groups and asking for assistance give you a good example the london bombings we used
00:46:32 bombings we used pathologists from other other units and so
00:46:39 we felt it was a very useful additional investigation that would assist in the smooth running and just to be clear were all the scans reported on yes they were yeah um looking back then at paragraph
00:46:51 yeah um looking back then at paragraph 18 on the screen in front of you you say in some cases this allowed for the identification of unique identifiers just pausing there is that phrase unique identifiers what
00:47:02 is that phrase unique identifiers what you just told us namely positive identifiers such as hip replacements and the like yes so features that might be utilized in as part of the process to secure positive identification of the
00:47:14 secure positive identification of the deceased yes and then you go on or indeed the potential for the commingling of the remains did that does that mean that a ct scan can help identify where there has been commingling of human remains yes potentially and and
00:47:26 remains yes potentially and and therefore as an early stage um that will allow uh intervention by the forensic anthropologist in order to
00:47:37 the forensic anthropologist in order to carefully
00:47:39 carefully separate the remains and ensure that the remains of an individual deceased is as complete as possible and not mixed with any other remains how would a ct
00:47:50 with any other remains how would a ct scan help to identify commingling well
00:47:54 well in terms of identifying perhaps numbers of bones if there's an incorrect number of bones for example
00:48:04 three thigh bones then sticking with page three
00:48:09 three looking at paragraphs 19 to 21 just looking at those paragraphs you explained there that each recovery bag was assessed by a forensic pathologist and then a decision was made uh about
00:48:20 and then a decision was made uh about whether a conventional post-mortem examination could be performed was it just for the individual pathologist to determine whether a conventional post mortem could be performed or was that decision by made
00:48:31 performed or was that decision by made made by you as the lead no that would be for an individual home office pathologist to to make in the they know the limits of their expertise
00:48:42 they know the limits of their expertise and they know when to ask for assistance from further uh further um specific uh specialties i i see so did you get involved in the
00:48:53 i i see so did you get involved in the decision about whether a full post-mortem in the traditional sense could be undertaken with particular recovery not specifically in a sense that was a self-selecting process that
00:49:04 that was a self-selecting process that was undertaken by the individual pathologist and if you look at paragraph 21
00:49:09 21 you say in such cases a full post-mortem examination was undertaken including both external and internal examination and where possible including ancillary investigations such as histology and
00:49:21 investigations such as histology and toxicology can you expand a little bit more on the types of ancillary investigations that would be conducted um yes histology refers to the
00:49:34 um yes histology refers to the microscopic study of tissues
00:49:38 tissues in in a situation such as this for example
00:49:43 example one may be looking for confirmation of deposits in the airways which would confirm inhalation of fire fumes and smoke
00:49:52 and smoke from the environment deep into the lungs equally if samples are available toxicology can be performed in order to consider whether there was
00:50:03 in order to consider whether there was carbon monoxide in the blood which i'm sure you've heard about a highly toxic gas that binds with the blood and which
00:50:14 gas that binds with the blood and which we use convention very frequently to consider causes of death um from smoke inhalation carbon monoxide is is is a very common um cause of poisoning
00:50:27 is a very common um cause of poisoning in such fires in general terms what factors would affect the type of examination or ancillary investigation that a pathologist could carry out
00:50:38 pathologist could carry out uh
00:50:39 uh that would be largely um governed by the integrity of the body or otherwise
00:50:50 so the level of burning or otherwise would
00:50:56 certainly factor in there and it then becomes a decision as as as to whether the pathologists are best placed to investigate or
00:51:07 are best placed to investigate or whether it's more an anthropological investigation
00:51:12 if you turn then to page three paragraph 20 where you've referred to the fact that in the early phases the victims were largely intact as you say
00:51:24 largely intact as you say and then look at page four paragraphs 36 to 37
00:51:31 at the foot of the screen you say where a film post-mortem examination could be performed it was for the individual pathologists to provide a cause of death based on their observations this is why some causes of death appear different or more refined
00:51:43 more refined given the greater detail of the greater level of detail that could be applied to such an examination are you able to say a little bit more about why it was possible to do that in such cases
00:51:55 possible to do that in such cases yes speaking of the refined cause of death
00:51:58 death if you are able to carry out a full external and internal examination you're able to comment on any injuries that may be present
00:52:12 you were able to comment on whether there's positive evidence of inhalation of fire fumes you're able to comment on whether there's any natural disease that may be
00:52:23 there's any natural disease that may be relevant for example heart disease that may make an individual more vulnerable in the setting of a fire you're able to confirm your diagnoses by
00:52:34 you're able to confirm your diagnoses by microscopic examination and you're able to investigate whether there's evidence of carbon monoxide poisoning by submitting samples for toxicological examination
00:52:46 for toxicological examination so in other words from that complete array of investigation you're able to give a very full and accurate cause of death which reflects not only the
00:52:57 death which reflects not only the primary cause but any contributory factors that may be relevant and this is why
00:53:04 why those individuals who had a full post-mortem examination may have what appear to be much fuller causes of death and is it the case that the amount of detail given about the cause of each
00:53:15 detail given about the cause of each death
00:53:16 death uh might
00:53:17 uh might vary depending not only on the variations of level of detail available from each post-mortem of the state of the recovery but also perhaps as a matter of practice as between pathologists
00:53:28 pathologists yes uh it and to an extent uh each pathologist um applies their opinion to each case but in in broad terms that there would
00:53:40 but in in broad terms that there would be
00:53:41 be no discrepancy and and i'd refer back again to the fact that these were cross-checked by other home office pathologists to ensure that there was um uh
00:53:51 uh consistency between conclusions and cause of death given now paragraph 23 if we go back a page to page three you say that a different approach was
00:54:03 you say that a different approach was required
00:54:05 required later in the investigation when remain the remains recovered we're in a more advanced state of heat damage can you outline for us please the pathological approach that was adopted in such cases
00:54:16 yes when when the individuals were presented in a far more disrupted state
00:54:25 the reality is that forensic pathology cannot offer an appropriate investigation in those situations
00:54:36 in those situations it is far more appropriate for a forensic anthropologist to study the remains given their expertise lies in
00:54:47 given their expertise lies in the study of skeletal remains and highly disrupted remains they're able to apply their skills to consider perhaps age sex stature of an
00:54:58 consider perhaps age sex stature of an individual they're able to relate
00:55:05 bones for example to one another and ensure
00:55:10 ensure where possible each individual is completely accounted for as an individual um rather than a mixing this is the term co-mingling i've used before
00:55:22 i've used before of of remains it's very much within their their area of expertise but i just want to be clear that we're drawing a distinction here between identification and
00:55:35 identification and uh cause of death yes uh and is it right that your um
00:55:42 your um well the forensic or dontologists archaeologists and anthropologists uh are called on in those more more disruptive cases yes to identify with with a reasonable level of confidence
00:55:55 with a reasonable level of confidence the deceased rather than to opine upon the cause of death yes that's correct right
00:56:01 right now um are you able to give us some detail about how a number of things assisted in uh formulating the cause of death and i say a number of things i have five
00:56:10 have five let's start with toxicology are you able to tell us about how toxicology assists assisted you as the pathologist or your team in identifying the cause of death
00:56:21 team in identifying the cause of death yes with with toxicology you're able to specifically for carbon monoxide poisoning
00:56:29 poisoning one looks at the level of carbon monoxide
00:56:33 monoxide and what that means for an individual there are generally a series of ranges where you might expect on one end for example some degree of toxicity that
00:56:45 example some degree of toxicity that might cause confusion slowness of movement up to levels that would usually be associated with death so the toxicology may very much inform us to the cause of death
00:56:57 us to the cause of death and is taken into context with the findings of the the other findings of the post-mortem examination because in those cases where toxicology was possible
00:57:08 possible it's likely that a full post-mortem examination was also going to be undertaken the next one is dna testing does that help
00:57:18 help identify the cause of death or or simply i say simply alternatively the uh identity of the nationalists that's a process for identification and similarly ontology
00:57:29 identification and similarly ontology archaeology and anthropologies i think you've confessed same for all of those yes yes i see then let's turn to the medical cause of death in the final post-mortem reports we know from the individual postmortem
00:57:40 we know from the individual postmortem reports that we have that for a majority of those who died in grenfell tower the cause of death was recorded as one a consistent with the effects of fire or similar and in some cases one a
00:57:52 similar and in some cases one a inhalation of fire fumes or similar now i'm going to come back to that formulation in a moment but is it right generally that it's for the registered medical practitioner to provide a medical certificate of cause of death
00:58:04 medical certificate of cause of death yes and is and this is part of the system in this country for the registration of deaths yes it is and is it right that completing such a certificate would be a matter for the medical professional rather than for
00:58:15 medical professional rather than for example a toxicologist that's right are you able to explain the certification system uh used when giving a medical cause of death by which i mean the 1a or 1b
00:58:26 1b or 2 format yes
00:58:29 yes the standard formulation uh has two parts a part one and a part two part one
00:58:37 part one describes what the primary cause of death is
00:58:41 death is and may be subdivided part two
00:58:45 part two i'm sorry for the complexity of it describes conditions that may be contributory as opposed to primarily causative in nature
00:58:56 so to give you an example one might say 1a cardiorespiratory arrest due to 1b carbon monoxide poisoning and the way
00:59:07 carbon monoxide poisoning and the way that follows then is 1a is due to 1b it follows down a line if for example the individual had severe heart disease
00:59:18 heart disease which would have worsened their situation one might put that under part two as a contributory factor so
00:59:28 so in those cases where we were able to conduct a full post-mortem examination and consider the results of toxicology we were able to give a full
00:59:40 we were able to give a full cause of death in the formulation that i've just described and that's what you see in in those various cases yes thank you and it goes without saying or does it go without saying
00:59:52 it go without saying that when giving a medical cause of death a pathologist would be doing so on the evidence available at the time of the post-mortem yes on the evidence available to them together with
01:00:03 available to them together with the results of any additional investigations that allow them to potentially refine or modify the cause of death one has to take account of
01:00:14 has to take account of the totality of the evidence available and if additional information later emerged would it be right that the pathologist might be required to or might be at least willing
01:00:26 required to or might be at least willing to revise or refine the cause of death all pathologists should be willing to revisit a cause of death in the light of novel information yes and sticking with your statement please
01:00:38 and sticking with your statement please page
01:00:39 page uh four if we can go to that you say it paragraph 26
01:00:47 in the purest sense then for many of the victims whose bodies showed advanced heat damage the cause of death could have been given as 1a unascertained however the view was taken that this would be a most unsatisfactory approach
01:00:58 would be a most unsatisfactory approach for relatives of the deceased
01:01:02 what circumstances
01:01:06 would have made it appropriate [Applause] to give an ascertain yes
01:01:14 i think it to an extent that's that's a matter of personal opinion there are cases that we uh engage with where the cause of death simply cannot
01:01:27 where the cause of death simply cannot be found
01:01:29 be found after an exhaustive post-mortem examination or indeed if the body is disrupted for various reasons unascertained is
01:01:41 can be and is used as a formulation when we simply can take matters no further a view was taken that
01:01:52 that given
01:01:54 given the information that we knew that all of these individuals had been recovered from the seat of an intense fire
01:02:02 fire that it would be an absurdity to simply leave unascertained as a cause of death
01:02:10 of death and so
01:02:14 i think it was more reasonable to take a view that one could apply a generic cause of death
01:02:23 death that at least gave a cause of death to a family within the limits of the pathological interpretation
01:02:36 and so if you go to paragraph 27 you say
01:02:42 you say as has been provided for other different disasters it was agreed that in those cases where the full post-mortem examination process could not be performed
01:02:50 performed then a generic cause of death could be applied namely one a consistent with the effects of fire yes can you explain who decided on that term uh that was um a decision that was taken
01:03:06 uh that was um a decision that was taken during a strategy meeting with the coroner
01:03:09 coroner i raised that as an issue basing it on uh previous mass disasters and again my opinion that i think it would be unreasonable
01:03:20 unreasonable to
01:03:21 to provide a bald cause of death as unascertained given the overwhelming evidence of an intense fire from which all of these individuals were recovered
01:03:34 all of these individuals were recovered now in some cases the medical cause of death was recorded as 1a inhalation of fire fumes yes and another inhalation in others inhalation of the products of combustion yes are you able to explain
01:03:46 combustion yes are you able to explain the difference but if any between inhalation of fire fumes and inhalation of the products of combustion i think that's just a matter of of personal wording and reflects the different pathologists carrying out
01:03:58 pathologists carrying out um we all use slightly different wording um
01:04:03 um they're essentially the same in what circumstances would the cause of death be recorded as inhalation of fire fumes or inhalation of the products of combustion rather than consistent with the effects
01:04:14 rather than consistent with the effects of fire
01:04:16 of fire that would be where there is pathological evidence indicating that the individual inhaled fire fumes in other words smoke present
01:04:27 fire fumes in other words smoke present within the airways in the lungs which we can identify both by naked eye examination and we back that up with microscope work or alternatively
01:04:39 or alternatively where toxicology has been performed and confirms that there's a high level of carbon monoxide for there to be that high level of carbon monoxide there has to have been
01:04:51 carbon monoxide there has to have been inhalation of those fumes such that the gas could bind with the blood and circulate and cause cause carbon monoxide poisoning now um
01:05:03 now um i think you know that the inquiry obtained an expert's report from professor david persa yes and he heard his evidence over the course of two days last week yes he's a physiologist and a
01:05:15 last week yes he's a physiologist and a diplomat member of the royal college of pathologists and as a research scientist he has extensive research experience in inhalation toxicology and particularly in relation to the effects of combustion
01:05:27 in relation to the effects of combustion have you seen before today a copy of his report i have yes and i was able to watch some of his evidence i was going to ask you you saw some of his evidence can you just tell me which day you saw do you think on the
01:05:38 me which day you saw do you think on the thursday thursday um are you able to
01:05:43 explain first the physiological effects of coronary artery atheroma increasing one's susceptibility to carbon monoxide poisoning
01:05:55 yes if if we start with carbon monoxide poisoning
01:06:00 poisoning carbon monoxide will bind to hemoglobin which is the red pigment in blood that carries oxygen it binds with it preferentially compared to oxygen so
01:06:12 preferentially compared to oxygen so effectively you are blocking the supply of oxygen to the body
01:06:20 if you have coronary artery atheroma which refers to furring up with fatty deposits of the main arteries that supply the heart
01:06:31 main arteries that supply the heart muscle with blood that further um
01:06:35 um compromises the heart
01:06:38 the heart so in a sense you have a double jeopardy there whereby on one part you are poisoned you're not able to take up oxygen and yet your heart can't even
01:06:49 oxygen and yet your heart can't even supply that because there's narrowing of those arteries so it's it's a
01:06:55 a an increased vulnerability um to those individuals so is it right that the presence of carbon monoxide doesn't affect the functioning of the heart that does affect the
01:07:07 heart that does affect the ultimate delivery of oxygen it does indeed and in those cases you're considering a heart which isn't capable of supplying the normal oxygen to the
01:07:18 of supplying the normal oxygen to the heart muscle because of the narrowing of those arteries
01:07:24 now we know that professor persona's analysis is detailed and he concluded that it was likely that most if not all of those who died in the tower were comatose and in most cases dead before being
01:07:37 and in most cases dead before being exposed to significant heat and i'll just give you and everybody else and indeed ourselves the reference to that that's a dapr 605 page 138 paragraph 584 um they'd
01:07:49 605 page 138 paragraph 584 um they'd been random they've been rendered unconscious through exposure to gases which included carbon carbon monoxide and hydrogen cyanide and he accepted that the effect of carbon monoxide in combination with
01:08:00 carbon monoxide in combination with hydrogen cyanide as a cause of death could be described as asphyxia from asphyxiant gases that was day 269 page one five five
01:08:11 page one five five sorry day two nine six sorry day two nine six that's the wednesday page one five five at line five um
01:08:19 um would you agree with that uh i i would agree that it's if in effect a form of asphyxia although one has to be careful of that term because it has many connotations such as
01:08:30 it has many connotations such as strangling but yes the actual process is asphyxia which in its purest sense means that the tissues of the body are critically deprived of oxygen which are required to
01:08:41 deprived of oxygen which are required to maintain life and would you usually take that kind of evidence into account when deciding on the appropriate formulation for the medical course of debt yes the the toxicological findings um
01:08:54 yes the the toxicological findings um where one can access them are always going to be an important additional feature to take into account uh and if we stick with this page and look at paragraph 31 you say
01:09:06 look at paragraph 31 you say it is therefore much more likely the case that in this disaster individuals succumb to the effects of inhalation of these gases rather than dying specifically from burns and burning
01:09:18 burning and in the paragraph before that you say that fire scientists and toxicologists may provide more details but such gases would include carbon monoxide sulfur dioxide cyanide and of
01:09:29 monoxide sulfur dioxide cyanide and of course the profusion of carbon dioxide and lack of oxygen do you agree that that what you're saying there and professors persons conclusion
01:09:40 persons conclusion are consistent with each other
01:09:43 i i think it's very much the case that the majority if not all died from inhalation of fire fumes
01:09:54 died from inhalation of fire fumes rather than burning that is my experience with a whole range of fires
01:10:01 of fires that i have investigated it's not uncommon of course for bodies to become badly burnt during the course of fire and before they can be retrieved
01:10:13 they can be retrieved but one is frequently able to identify that evidence of inhalation of firefoot in the airways to look at the toxicology
01:10:24 in the airways to look at the toxicology so my view yes would be overwhelmingly that
01:10:29 that the deaths were likely inhalation of fire fumes rather than burning by flame yes thank you now if we leave aside those who fell from the tower given what
01:10:41 those who fell from the tower given what you just said and your observation about about uh asphyxia would it be appropriate now to record the 1a medical course of death as
01:10:52 the 1a medical course of death as asphyxia from asphyxian gases or perhaps inhalation of asphyxiant gases
01:11:01 the difficulty there is how far one goes professor purser has given his evidence based on the scientific analysis of
01:11:12 of grenfell tower and i don't dispute those findings it's how far one can go in providing a medical cause of death
01:11:23 cause of death given the limited pathological materials that were available
01:11:28 the cause of consistent with effects of fire was given as a general term that was able to encompass the various ranges
01:11:39 ranges that were available
01:11:42 while emphasizing that caveat that in my view and certainly in my experience the majority of individuals who die in fires
01:11:51 fires die from inhalation of fire fumes
01:11:57 so that is the dilemma because i haven't got
01:12:08 significant pathological material can one
01:12:13 can one take that further step and move towards an inhalation of fire fumes
01:12:23 and that that that is a a a difficult question
01:12:28 question um
01:12:31 a purist would suggest you you you cannot absolutely confirm that all deaths were inhalation of fire fumes although the scientific evidence would
01:12:44 although the scientific evidence would strongly support that and pathological experience would strongly support that
01:12:56 and would you agree with an approach of providing an approximate time or perhaps a window of time when recording the times of death of those who died
01:13:08 those who died yes you would [Applause]
01:13:22 yes um professor those are all the questions i have for you sorry doctor um figure out these are all the questions i have for you at the moment maybe other questions
01:13:33 maybe other questions uh occur to me uh or others in a break which i'm going to ask for now yes of course subject to that these are the questions that i have mr chairman is that a convenient moment yeah certainly yes and dr friedman just
01:13:44 yeah certainly yes and dr friedman just so you understand where we go from here at this point in the examination we have a break so that council can take stock and others who are following the proceedings not all from this room can have a chance to suggest further
01:13:55 have a chance to suggest further questions we also normally have a break at this stage in the morning anyway so i'm going to suggest that we break now until half past 11 that will give everyone a short break and also time to
01:14:07 everyone a short break and also time to think up any additional questions that's what we'll do we'll resume please at half past eleven and and i should ask you please not to discuss your evidence with anyone should you get the chance to do so while you're out of the room thank
01:14:18 do so while you're out of the room thank you so much thank you very much would you give the ashes please
01:14:36 thank you mr millet half-ass 11 then please thank you
01:30:42 i would would you ask figar nouns to come back in please okay
01:30:59 right
01:31:04 thank you right doctor we'll see if there's any more questions shall we thank you mr chairman there's one question uh uh which is this um are you able to explain the physiological effects of coronary artery atheroma
01:31:16 effects of coronary artery atheroma increasing one susceptibility to hcn intoxication hydrogen cyanide intoxication yes insomuch as
01:31:27 yes insomuch as by slightly different mechanism cyanide is also an what would be termed an asphyxiant gas in other words it prevents the body from appropriately
01:31:38 prevents the body from appropriately utilizing and taking up the oxygen required so in the same setting an individual with coronary heart disease when faced with poisoning with both
01:31:50 when faced with poisoning with both cyanide and carbon monoxide will be far more vulnerable and susceptible to heart issues than an individual who has a normal heart
01:32:01 who has a normal heart so it's it's a broadly similar effect could be possibly summarized with supply and demand the the heart requires that oxygen
01:32:12 the the heart requires that oxygen um
01:32:13 um but it's being prevented from being supplied so the heart muscle is deprived of oxygen and that's compromised by the furring up of the arteries right
01:32:24 of the arteries right and where one has a combination let it be assumed of carbon monoxide and hydrogen cyanide yes and also
01:32:35 and also the
01:32:35 the individual has a coronary artery atheroma
01:32:39 atheroma would the presence of hydrogen cyanide together
01:32:43 together with carbon monoxide be different from the position if there was only carbon monoxide present yes i suspect it would likely exacerbate the situation
01:32:55 would likely exacerbate the situation are you able to quantify that i can't quantify it any further but
01:33:00 both being asphyxiant gases the combination is likely to be additive
01:33:09 yes thank you very much uh mr chairman i've got no further questions uh dr figano thank you very much for your assistance uh we're extremely grateful to you for coming here and explaining your work to us so that those listening
01:33:21 your work to us so that those listening can understand it more clearly thank you thank you it's right that i should thank you as well dr figernel it's very important for all of us on the panel to understand uh the work of the pathologist in general and of course in particular in
01:33:33 general and of course in particular in relation to these deceased so we're very grateful to you for coming along to explain it all to us and um
01:33:41 and um thank you very much for doing so thank you now of course you're free to go that's great thank you
01:34:02 mr millet i understand we have another witness uh who's waiting to be called i think it'd be convenient for us to rise for a couple of minutes while arrangements are made very good thank you very much
01:38:43 yes mr millet yes um mr chairman uh members of the panel in a moment i'm going to call gail mckinnon uh gail mckinnon is a forensic anthropologist who was involved in the recovery and the
01:38:54 who was involved in the recovery and the post-mortem process uh at grenfell tower uh again her evidence contains facts and matters about the deceased's remains and the process of recovery which many will
01:39:05 the process of recovery which many will find or might find distressing and therefore i needed to raise that at this stage
01:39:09 stage by way of a trigger warning so that those watching are aware of the contents of what is to follow and can choose now whether they follow or not i should just also raise at this stage the fact that we intend only to deal
01:39:20 the fact that we intend only to deal with her evidence by way of generalities focusing on process and methodology rather than in individual questions about individual deceaseds yes thank you to that uh general background can i
01:39:31 to that uh general background can i please now call gail mckinnon yeah
01:39:41 good morning uh mr kinnan i i understand you're going to affirm yes thank you now the words should be there on the screen would you read them out please i do solemnly and sincerely truly declare and i affirm that the evidence i should give
01:39:53 i affirm that the evidence i should give should be the truth the whole truth and nothing but the truth thank you very much please sit down make yourself comfortable
01:40:05 yes mr miller yes mr chairman thank you miss mckinnon you've prepared i think a witness statement for the inquiry haven't you yes yes yes can we have that please at gmk601
01:40:20 and it's entitled summary of the forensic anthropology examination and reporting process uh and you can see lower down your screen that there's a date 14th of june 2022.
01:40:32 2022. see that
01:40:33 see that and a signature is that your signature it is indeed can you have you read this uh summary report recently yes i have and can you confirm that the statements made in it so far as their factual are true to the
01:40:45 so far as their factual are true to the best of your knowledge that's correct and can you confirm that you've provided this report in the same way that you would have done to a court if you've been appointed as an expert that's correct thank you now can we please go to page 86 appendix
01:40:59 now can we please go to page 86 appendix 4
01:40:59 4 which sets out your background and experience relevant to the matters we're going to consider today and which were relevant to your role in the fire i want just to pick out one or two
01:41:11 i want just to pick out one or two points if i may first i think you completed your ba in western asiatic archaeology at the institute of archaeology uh ucl yes that's correct and a master of sciences in osteology paleopathology
01:41:24 of sciences in osteology paleopathology and funerary archaeology at the university of bradford that's correct and you're currently an honorary lecturer at cameron forensic medical sciences william harvey research institute bart's and the london school
01:41:35 institute bart's and the london school of medicine and dentistry and also the queen mary university correct yes and a lecturer in forensic anthropology and module leader at the center for anatomy and human identification within the
01:41:46 and human identification within the department of life sciences at the university of dundee until 2016. correct i think that was between 2014 and 2016. that's correct and a chartered forensic anthropologist since 2013 yes and i
01:41:59 anthropologist since 2013 yes and i think you belong to the royal anthropological institute of great britain and ireland that's right i'm a fellow at that institution and if we gave police to page 87 we see that you are a member of the
01:42:10 we see that you are a member of the expert panel for forensic archaeology at the chartered institute for archaeologists and indeed have been since 2011. that's correct uh and is it right also that until its closure in 2010 you were a certified
01:42:21 closure in 2010 you were a certified anthropologist certified forensic anthropologist at the council for the registration for forensic practitioners that's correct was that council replaced by another regulatory body after 2010 no it wasn't
01:42:34 regulatory body after 2010 no it wasn't no no
01:42:36 no no i think the disciplines then had to go to their own accreditation bodies rather than to have the overarching council uh and you've been a consultant in forensic anthropology and archaeology
01:42:47 forensic anthropology and archaeology since 1998. that's correct and i think is it right you are currently the only dually accredited senior reporting forensic anthropologist and archaeologist in the uk that's correct
01:42:58 archaeologist in the uk that's correct and i think between 2013 and december 2021 you were the lead forensic anthropologist and the lead forensic archaeologist at electo forensic services that's correct and that is a forensic ecology service provider
01:43:10 forensic ecology service provider correct
01:43:11 correct and at the bottom of page 87 you say that your previous case workers encumbered investigations of terrorist incidents and disaster victim of identification murder suspicious and unexplained deaths child
01:43:23 suspicious and unexplained deaths child abduction historic child abuse slavery and servitude missing persons and clandestine grave search location and recovery that's correct yes and if we go to page 88
01:43:34 to page 88 is it right that and just to summarize what you say that you've also been involved in international cases including international terrorist incidents mass fatalities and dvi
01:43:45 incidents mass fatalities and dvi disaster victim identification yes and also transport accidents and natural disasters like haiti that's right and in fact i think you'll give us some examples
01:43:55 examples uh in that big middle paragraph just to pick a few out uh rather than reading it through world trade center terrorist attacks 2001 yes yes london terrorist attacks in
01:44:06 yes yes london terrorist attacks in 2005. yes 2010 earthquake in haiti correct and the terrorist attack in army aminos i think in algeria in 2013 correct yes and just a few more
01:44:19 and just a few more pointers um i think you're a member of the british academy of forensic sciences yes that's correct british association for forensic anthropology correct british association in forensic medicine correct
01:44:30 correct chartered institute for archaeologists correct and the royal anthropology institute for great britain and ireland okay
01:44:38 okay now um thank you very much for that introductory um review uh i want to ask you about your role um during the grenfell tower fire investigations now although you are dual quarry
01:44:50 now although you are dual quarry qualified as an anthropologist and an archaeologist is it right that your role in any grenfell tower investigations was confined solely to forensic anthropology that's correct i worked solely in the
01:45:01 that's correct i worked solely in the mortuary
01:45:02 mortuary of the city of westminster public mortuary so it's not at the tower
01:45:10 you weren't at the tower no now before we turn to look at your role in the road of your team following the fire
01:45:16 fire can you explain in general terms the role of a forensic archaeologist sorry anthropology anthropologists um
01:45:23 um generally we're hired uh by the police force or or by depending on the types of work by a non-government organization or the government to
01:45:33 to identify
01:45:35 identify unidentifiable human remains so that's generally human remains that are disrupted
01:45:41 disrupted commingled damaged fragmented in some way and these human remains can emanate from things like terrorist incidents natural disasters or
01:45:53 terrorist incidents natural disasters or indeed it could be a single unidentified individual who may have been found in the woods or maybe buried and and they don't the police do not know who that person is so our role within that
01:46:05 that person is so our role within that investigation would be to construct a biological profile that is looking at the age range of the individual sex ancestry any individuating features that might help
01:46:19 individuating features that might help the profile to assist the police in in starting to look and narrow down who that person might be and how does the role of a forensic anthropologist
01:46:30 anthropologist relate
01:46:31 relate to the role of a forensic archaeologist sometimes they're separate so some individuals are forensic archaeologists and not anthropologists but the archaeologists forensic archaeologist is
01:46:42 archaeologists forensic archaeologist is trained in the search and location and ultimately the excavation and recovery of human remains and those human remains can be clandestinely buried or they
01:46:55 can be clandestinely buried or they might be
01:46:56 might be lying on the surface in a woodland or they might be recovered from a disaster or a terrorist incident so the forensic archaeologist is trained to
01:47:05 to record and recover very carefully record locations of bodies so in this instance and in instances of disaster victim
01:47:16 instances of disaster victim incidents
01:47:17 incidents it's looking at those integral and important relationships between one body and another and in this case within grenfell tower looking at the relationships and the positions and the
01:47:28 relationships and the positions and the locations of each deceased victim within a flat or communal space to understand the relationships between one person and another before
01:47:39 another before that person is recovered and brought to the mortuary for further examination can we go to page 20 of your report please
01:47:53 and you tell us there at the top
01:47:58 the forensic anthropologists and archaeologists are routinely deployed to mass fatality disasters particularly when the condition of the bodies of deceased victims may be severely compromised by commingling with the
01:48:10 compromised by commingling with the bodies of other deceased victims or where the remains are affected by varying states of preservation or decomposition trauma disruption fragmentation thermal damage cremation
01:48:21 fragmentation thermal damage cremation or differential body conditions that display a range of these characteristics correct
01:48:29 were those features present
01:48:32 present in relation to some or many bodies of the deceased at grenfell certainly the the bodies of victims that i and my team examined there was
01:48:45 decomposition but certainly trauma thermal damage disruption fragmentation disarticulation of limbs from torsos and cremation so obviously
01:48:58 and cremation so obviously there was a lot of thermal damage to the human remains and this is where the forensic anthropologists would be coming coming in to assist the pathologists in ascertaining
01:49:09 ascertaining what level of examination needed to be undertaken in the short and the longer term to identify those individuals and
01:49:19 and in relation to the way in which anthropologists and archaeologists work together
01:49:24 together are you able to assist us give us some insight into the into their working for example would an archaeologist want to know what an anthropologist was looking for when carrying out their work and
01:49:36 for when carrying out their work and would an anthropologist want to know how an archaeologist is going about their work absolutely so so you know
01:49:43 you know practitioners of both disciplines are um
01:49:47 um if they're not accredited in both disciplines will certainly know the requirements of
01:49:53 of what
01:49:54 what the other discipline needs so for example for myself and my team in the mortuary it was vital to have the forensic archaeology recording forms and the photographs and the illustrations the
01:50:07 photographs and the illustrations the hand-drawn drawings to understand where each individual had been recovered from and understand the destruction within the flat so that was integral to our examinations and
01:50:20 was integral to our examinations and certainly from the forensic archaeologist's point of view they understood very clearly that the relationships between one deceased victim and another were very important if we were to to recover and and return
01:50:34 if we were to to recover and and return as much of the human remains as possible to the families those individuals so it was a symbiotic relationship and there was also a lot of daily
01:50:45 there was also a lot of daily communication through the authorities within the mortuary and within the tower to ensure that any changes or any not difficulties but any questions were relayed between one team
01:50:57 questions were relayed between one team and another through the post-mortem coordinators to ensure that um you know we were aware of what was going on at all times with each other
01:51:08 with each other now if we go to page please
01:51:12 please we can see there that
01:51:18 you described in the first two paragraphs the
01:51:22 the fact that there were four lead anthropologists correct and six anthropology assistants that is the first paragraph on that page yes uh were you the lead anthropologist i
01:51:33 uh were you the lead anthropologist i was yes i led the team and you uh you led the team say when it says there were four lead anthropologists were you the leaders leader i was yes you were so the four
01:51:45 leader i was yes you were so the four does not do not include you the four include me could i could you would you like to scroll further down the page thank you yes so there were four lead anthropologists
01:51:56 so there were four lead anthropologists of which i was one yeah um and also the team leader yes so yes thank you so four including you and then six anthropology assistants that's correct can you say that they
01:52:07 that's correct can you say that they were deployed on a rotational basis between the 19th of june and the 15th of december that's right that's right and i think you were um you could see the names on the page there dr jillian fowler dr nicholas marquez grant and
01:52:20 fowler dr nicholas marquez grant and alan gabriel canada robinson um what did your role as as team leader comprise
01:52:28 comprise the role was really a liaison between um the post-mortem coordinators and uh the coroner and the coroner's team so
01:52:39 the coroner and the coroner's team so often
01:52:39 often i had cases of my own to examine but very often was taken away to meetings and needed to be in an advisory role to
01:52:50 be in an advisory role to to other disciplines and to the coroner and to the metropolitan police service so it was a role where i was undertaking several
01:53:01 several several things at once in terms of advisory roles and how we went forward with the investigation and looking at the three lead forensic
01:53:12 and looking at the three lead forensic anthropologists they're named on the page on the screen yes what was their role
01:53:16 role their role was um essentially to do um each case uh together we i'm sure we'll get onto this but each
01:53:27 i'm sure we'll get onto this but each uh flat was regarded as a fatal fire scene in terms of um looking at the entirety of the flat looking at the entirety of the recovery of uh deceased victims from that flat
01:53:40 of uh deceased victims from that flat and um
01:53:42 and um making sure that we we were examining each person and then each person collectively so that is what uh dr fowler dr marquez
01:53:53 so that is what uh dr fowler dr marquez grant and mr canada robinson were doing on a daily basis and that's what i was participating in when i wasn't having to go to meetings and in advisory roles with other disciplines and did those
01:54:05 with other disciplines and did those lead forensic anthropologists work in each flat within the tower i'm sorry did he did those for rent lead forensic anthropologists work within each flat in the tower
01:54:17 each flat in the tower physically physically no no no so my team were primarily were were in the mortuary so we were looking at all the human remains that had been recovered from each flat on a flat-by-flight basis
01:54:30 from each flat on a flat-by-flight basis so so so your work as anthropology began and ended effectively in the within them absolutely yes i see yeah did you supervise the work of the other anthropologies anthropologists
01:54:43 anthropologies anthropologists uh supervision is the wrong word i think it was uh
01:54:46 it was uh it was a um we were constantly checking in with each other and ensuring that the process was running smoothly and the other disciplines were um able to come and examine remains
01:54:58 were um able to come and examine remains as we were examining them ourselves so it was a
01:55:01 it was a collegiate role rather than a supervisory role these lead and forensic anthropologists are very experienced in what they do
01:55:11 and if you turn to page nine please you can see that you set out there
01:55:18 a list excuse me a list of assistant forensic anthropologists what were what was their role
01:55:25 role their role was to provide assistance with laying out the skeletal remains so the vast majority of
01:55:37 the vast majority of the deceased victims that we examined had been
01:55:41 had been catastrophically disrupted by the thermal damage and the effects of the fire so in many many cases the urn so that's the unique reference
01:55:53 the urn so that's the unique reference number um
01:55:55 number um of
01:55:55 of that
01:55:56 that those particular remains uh might be fragmented skeletal remains so our assistants who were all very
01:56:07 so our assistants who were all very experienced um would lay them out and would be part of the process of preparing each url for examination by the lead forensic anthropologist and ensuring
01:56:18 forensic anthropologist and ensuring that
01:56:20 that the photography initial photography and dvi excuse me police documentation had been completed before the lead forensic anthropologist began their examinations
01:56:32 anthropologist began their examinations if we go to page 13 in the first paragraph on that page at the top of your screen you say
01:56:40 you say the forensic anthropological examination of the victims from the grenfell tower incident was conducted within the multidisciplinary framework of the interpol disaster victim identification dvi and post-mortem pm data collection
01:56:53 dvi and post-mortem pm data collection and documentation systems that's right yes and that's called the interpol disaster victim identification guide 2014 these internationally recognized documentation systems were used in
01:57:04 documentation systems were used in conjunction with the forensic anthropology protocols and working practices that were developed by the grenfell tower forensic anthropology team in order to assist the victim identification process of the victims of
01:57:15 identification process of the victims of this incident uh a number of questions there how does your role interact with that of the dvi teams the ddi team within the mortuary were
01:57:27 the ddi team within the mortuary were police officers who had been trained within the interpol dvi system
01:57:33 system so
01:57:35 so i can't answer to how that training is conducted
01:57:38 conducted but it's certainly the case that dvi trained police officers uh are very used to filling out the the guideline forms and um they are very integral at the
01:57:49 and um they are very integral at the start of the process when the the victim first comes into the mortuary to um log personal effects and log condition of the body and essentially look for for any identifying
01:58:01 essentially look for for any identifying paperwork or documentation that person might have so that's a a police role that occurs um potentially with or without any further expert expertise such as
01:58:12 any further expert expertise such as pathologists anthropologists ontology fingerprints so that is a police process and these forms have been developed by interpol to assist um countries
01:58:23 interpol to assist um countries particularly countries that might not have a dvi capacity um or never been confronted with operational situations such as as this incident right
01:58:35 incident right so
01:58:36 so is this right that the interpol dvi uh
01:58:39 uh guide or the framework brings together a number of different disciplines such as identification from documents
01:58:48 documents uh archaeology yes and anthropology yes personal effects fingerprints yeah and what other disciplines were involved in the multidisciplinary framework well certainly for this disaster and for
01:58:59 well certainly for this disaster and for this operation within the mortuary pathologists odontologists to identify the teeth and the dentitions of deceased victims
01:59:10 victims i believe fingerprints but of course very early on it must be stated that individuals who were recovered by the fire brigade from the stairwells and communal spaces and in some cases
01:59:21 communal spaces and in some cases outside the building we had no part of that examination so i don't know if fingerprints were undertaken um i believe they were
01:59:32 believe they were and molecular biology so that's the dna scientists who were from the metropolitan police um who would come in um certainly in the early stages and
01:59:44 early stages and and take the samples for dna identification and would they come into the mortuary for those would they would they collect the samples at the scene well i can only speak for what i saw when our team started but certainly the
01:59:55 when our team started but certainly the early post-mortems i believe dna was being taken but i'm not sure who did that it was perhaps the pathologist or a combination of pathologists and biologists but i don't know i can't say if we scroll to the bottom
02:00:07 i can't say if we scroll to the bottom of page 13 you say this by reference to the interpol guide part a of the guide contains high-level reference material in respect to the conducted dvi operations although there
02:00:19 conducted dvi operations although there is further extensive detailed information that can be accessed through linked ex annexures in part b of the guide these linked annexures outline operational and procedural information designed to
02:00:31 procedural information designed to inform the main technical aspects of conducting a dvi operation they can also provide standardized approaches for practitioners although the content remains sufficiently broad enough to allow for varying
02:00:42 enough to allow for varying international practices or circumstances yes
02:00:45 yes uh
02:00:46 uh are you able to explain how that general approach worked at grenfell
02:00:53 grenfell or how it informed the work that you and your team carried out it certainly informed the work um that the police officers were tasked the dvi police officers were tasked to undertake at the initial
02:01:04 tasked to undertake at the initial stages of
02:01:06 stages of human remains being examined it's certainly also the case that these standardized approaches for practitioners um are
02:01:15 are reasonable for us to appoint but because the nature of the disaster they necessarily have to be adapted so for us this is why over a period of time
02:01:26 for us this is why over a period of time the forensic anthropology guidelines were developed to
02:01:30 to to encompass the nature of the disaster that we were dealing with so you know co-mingled very co-mingled in some cases disrupted fragmented calcined cremated
02:01:43 disrupted fragmented calcined cremated human remains so obviously if there was another kind of disaster a fairy disaster or an earthquake you wouldn't get that level of disruption or thermal damage and therefore your guidelines for forensic
02:01:55 therefore your guidelines for forensic anthropology and indeed how these annexes for the international dvi guide were filled out would be very different
02:02:06 if we go to page 16 please in the fourth paragraph down there you say
02:02:11 you say following the initial post-mortem examination extensive forensic anthropological examinations were then generally undertaken in a dedicated dvi temporary mortuary facility located adjacent to
02:02:23 mortuary facility located adjacent to the city of westminster public mortuary each examination of human remains was conducted on a flat by flat or communal space basis for the 17 separate recovery locations within grenfell tower where
02:02:36 locations within grenfell tower where human remains were recovered by the forensic archaeological and dvi teams the human remains that were recovered from each of these locations were examined at the same time by forensic anthropologists to ensure that all the
02:02:49 anthropologists to ensure that all the remains from a particular flat or communal space could where possible be physically reassociated now you refer in the middle of the paragraph there to 17 separate recovery locations
02:03:00 locations within the tower what were those there were seven flats where the remains of a single individual were covered there were nine flats where a total of
02:03:12 there were nine flats where a total of 46
02:03:13 46 individuals were recovered and there was one communal space where two individuals were recovered
02:03:23 and when you refer to communal space you're referring up to what the stairs and the lobbies stairs lobbies lift lobbies yes that's right
02:03:34 and when you say that the examination was conducted on a flat by flat or communal space basis yes are you able to expand a little bit on what you mean um
02:03:45 um so the recoveries of the flats of the individuals within the flats disease victims
02:03:51 victims uh was often quite difficult because of the health and safety and structural concerns for the building so
02:03:59 so in some cases the flat would start to be examined and cleared by the dvi and forensic archaeologists and then
02:04:09 and then health and safety or uh
02:04:12 or uh structural issues would would mean that the teams would have to be removed from that individual flat and they would have to be retasked somewhere else until that flat had been made safe
02:04:25 flat had been made safe so
02:04:26 so as far as we could if we had already started examining um deceased victims from a particular flat and then that flat had to be shut down whilst health and safety
02:04:38 shut down whilst health and safety issues were resolved or structural issues were resolved then
02:04:42 then the individuals would be repackaged and returned to um refrigerated storage until
02:04:50 until that flat could be re-examined because it hadn't been finished so at all times we're attempting to have
02:04:57 have completed flats for examination so the forensic archaeologists and the authorities at the tower would say it has now been cleared down to the bare concrete floor there is nothing left
02:05:09 concrete floor there is nothing left here
02:05:10 here so you can start you know looking at the remains of deceased victims from this flat and that's how it worked but as i said sometimes because of these concerns we would have
02:05:22 because of these concerns we would have to stop
02:05:23 to stop examining the remains from these flats and and
02:05:27 and and go back to them when we had confirmation that that flat had then been cleared when when you say cleared you mean cleared by the archaeologists played by the french archaeologists and the the dvi teams yeah yes i see
02:05:45 [Applause]
02:05:49 and
02:05:51 uh
02:05:55 when you concluded your work were you satisfied
02:06:00 satisfied that
02:06:02 that uh as much as possible had been recovered by the archaeologists so that you could carry out your function as an anthropologist it had it was all recovered so on on
02:06:13 was all recovered so on on two separate occasions we visited the tower to see the work of the forensic archaeologists and dvi officers and certainly i'm sure that those individuals will be able to to go
02:06:25 individuals will be able to to go through their processes with you but for us
02:06:29 for us as soon as the deceased victims had been recovered
02:06:32 recovered that was not the end of the recovery process because as you can imagine the catastrophic destruction of the internal aspects of each flat meant that you know furniture plaster concrete all
02:06:44 you know furniture plaster concrete all sorts of structural items needed to be cleared in order to ensure that
02:06:50 that no one else was present and to ensure that every single item was physically examined and then removed and the debris that
02:07:02 and the debris that was left would be sieved through different
02:07:06 different mesh size sieves and again the forensic archaeologist will be able to tell you about that in order to collect the tiny bone fragments
02:07:14 fragments or tiny fragments of human remains that may have been present so once that sieving process had been done it was
02:07:24 it was a bare concrete floors so i'm very confident
02:07:28 confident that everything was recovered
02:07:35 then let's turn down to back rather one page to page 15.
02:07:40 page 15. and on page 15 you've given us an overview of the op of the operation northland dvi forensic anthropology process yes and if we zoom in on that as we just have
02:07:50 have um are you able to talk us through that flow diagram sure this flow diagram is is purely from my team's perspective my disciplines
02:08:01 team's perspective my disciplines perspective so
02:08:03 so the arrival at the mortuary was conducted and overseen by the dvi police officers uh the
02:08:13 uh the each individual victim and each um urn containing fragmented commingled human remains was then sent through a mobile
02:08:24 through a mobile computed tomography unit which came every week or every two weeks and was positioned outside the mortuary those images were sent up the line to
02:08:35 images were sent up the line to professor guy ratty and his team at the university of leicester who
02:08:40 who who reported on them in advance of the post-mortem examination the preliminary assessment could be as simple as um
02:08:51 could be as simple as um the urn being opened by police officers to check
02:08:55 to check you know what was inside and to check whether an individual had clothing or any ids or documentation that might give an indication of who it was obviously that didn't happen for the
02:09:07 obviously that didn't happen for the fragmented co-mingled skeletonized uh remains
02:09:12 remains then it went to the post-mortem examination we were present at the post-mortem examination if there were complete
02:09:20 complete and whole bodies of disease victims we weren't necessarily required it was if there was any fragmentational disruption or disarticulation of the limbs or parts
02:09:32 or disarticulation of the limbs or parts of the body uh and separate bone fragments that the pathologists might need assistance with um to reconstruct or to look at reconstruction after the post-mortem examination
02:09:45 after the post-mortem examination uh the remains were returned to the refrigerated storage and
02:09:50 and we would conduct a preliminary anthropology assessment that could occur at the post-mortem examination or it might occur immediately after but nevertheless we we knew
02:10:02 but nevertheless we we knew from um our involvement in this process that each urn vaguely vaguely nothing was meticulously examined at this point we needed to know did we have one person in
02:10:15 needed to know did we have one person in this urn and if we had more than one person how many more persons might there be
02:10:21 be as a triage before the full anthology assessments were undertaken and that would give us an idea of of how many people we were dealing with and therefore how long time
02:10:34 dealing with and therefore how long time that we would take and then referring back to grenfell tower teams had they finished that particular location and could we start um on the people from on their
02:10:45 um on the people from on their deceased victims from that flat then we would go into the anthropology reporting stage so this is um this was conducted in the temporary disaster victim identification
02:10:57 temporary disaster victim identification mortuary
02:10:58 mortuary next to uh the mortgage at westminster and
02:11:03 and it was a very large space so we had 12
02:11:07 12 13 tables where we could lay out each victim from each flat and then lay out and examine every single urn that contained
02:11:19 examine every single urn that contained human remains in order to start to understand who we might have and how many people we had and how
02:11:29 and how much of the fragmented material would need to be laid out and physically reconstructed piece by piece now if you look at the top right hand corner of the diagram you can see that
02:11:41 corner of the diagram you can see that there are three pink boxes dna fingerprints and odd ontology why are those disciplines not joined with lines in the flow diagram they were separate to our process so
02:11:52 they were separate to our process so they were um they were
02:11:56 they were we weren't involved in anything with fingerprints that the the material from the deceased victims that we examined was too
02:12:03 was too badly damaged so we had no fingerprints but certainly for dna in odontology it was all always the question how can we identify the people that you're examining
02:12:16 on your tables and this is odontology and dna are primary identifying identifying disciplines so our dna was possible in a number of
02:12:27 so our dna was possible in a number of cases
02:12:28 cases but again this was very much dependent on whether there was tissue soft tissue left and whether the soft tissue would yield a dna profile that would could be matched
02:12:40 could be matched to the sample from the deceased victim or the deceased victim's family and odontology are the forensic dentists who look at all the fragmented teeth because
02:12:51 look at all the fragmented teeth because often teeth were not in uh maxillas upper jaws or mandibles lower jaws so they would have to be reconstructed and then returned potentially to
02:13:03 returned potentially to the upper or lower jaws from which they'd originally come so
02:13:07 so those processes were being undertaken as we were doing our work and so they were in tandem but not part of our process per se right are you able to tell us at what
02:13:18 right are you able to tell us at what point during the flow diagram flow dna or odd ontology played a part it could be at any point in time so it could be at the post-mortem examination
02:13:29 could be at the post-mortem examination with forensic pathologists or it could be during
02:13:33 be during the anthropology assessment or it could be once things are cleaned and and laid out that there's potential for dna from a particular bone fragment
02:13:44 for dna from a particular bone fragment once it's reunited back to a deceased victim so it really was you know a rolling program of considering the other disciplines as in when we could
02:13:56 other disciplines as in when we could get them into to examine the remains and was it invariably the case that you used dna and odd ontology as uh methods for identification they were the
02:14:07 methods for identification they were the primary methods i believe yeah yeah and this was uh orchestrated under the aegis of um post-mortem coordinators in the senior identification manager and if you had a clear and reliable identification
02:14:18 had a clear and reliable identification based on dna or odontology or a combination of the two would you need to go any further in your anthropological assessment yes because what we what what our remit was was to to
02:14:30 what what our remit was was to to reconstruct the bones uh because the dna or the odontology will only identify the piece that's being analyzed so what we need to do is return
02:14:41 analyzed so what we need to do is return um or repatriate that piece to the rest of the body to ensure that the identification is is that person is is the rest of the body and so a lot of
02:14:52 is the rest of the body and so a lot of the the skeletal fragments had to be reconstructed into limbs um and and uh and the rest of the body in order that that primary identification could
02:15:04 that that primary identification could be matched to that particular set of human remains can i ask you please to go to page 20 paragraph four fourth paragraph down on that page
02:15:15 that page uh and you say there
02:15:21 given the catastrophic uh nature uh
02:15:27 uh of the uh given the catastrophic nature and the subsequent effect that caused to the bodies of the deceased victims forensic anthropologists were asked to examine all cases where the remains of
02:15:38 examine all cases where the remains of the deceased victims had been affected by thermal damage which would cause skeletonization extensive fragmentation cremation and commingling correct yes um just the word thermal damage which would
02:15:49 just the word thermal damage which would cause skeletonization can you explain what thermal damage is in that context thermal damage is the damage that that is created is caused to the human body
02:16:00 is created is caused to the human body in this in this instance by the fire so it the fire was at such temperatures um that
02:16:09 that it was
02:16:10 it was in some cases like a commercial crematorium um in terms of temperature so
02:16:16 so so the the thermal damage that is caused to the human body at those temperatures means that once the soft tissue has been burnt away the bones are then exposed
02:16:27 burnt away the bones are then exposed and as the bones are exposed they necessarily fragment and and start to become very calcined so they they go from shades of black in color right through
02:16:39 shades of black in color right through to
02:16:39 to shades of blue uh blue gray and white and once they get to the the end of that process the blue gray and the white the calcination is is such that um it is
02:16:50 the calcination is is such that um it is similar to what would occur in a commercial crematorium and so therefore at that point you can't um at the moment recover dna from
02:17:00 from remains that are that severely burned and thermally damaged so in this context that's what thermal damage means
02:17:12 and if you uh go please to page 50 in the context of the word commingling which you use at the end of the paragraph i've just read yeah just read together
02:17:23 together the word commingle is identified and defined at the bottom of page 50 here and it says bone assemblage containing remains of multiple individuals often comprising incomplete or fragmentary
02:17:34 comprising incomplete or fragmentary bones that's correct that that's what you mean by commingling context that's right yeah yes
02:17:45 now if we go back to page 20
02:17:51 you say in the penultimate paragraph as i've just shown you um
02:17:59 when the human remains of the deceased victims were recovered how did you establish whether the remains of the deceased victims had been commingled
02:18:08 um it's repetition of skeletal elements so for example if if a urn was opened and you could see that there were the the heads of three
02:18:21 the the heads of three femurs it would give you an indication that there are a minimum of three people within that uh unique reference number um obviously it doesn't preclude the fact that there
02:18:32 it doesn't preclude the fact that there might be other people inside but that's your at the moment that's your minimum number of individuals it might be the case once you lay out that skeletal material from that
02:18:43 lay out that skeletal material from that urn that you have three heads of the right femur but you might also have a juvenile bone which would you know so you've got three adults and
02:18:54 you know so you've got three adults and and one juvenile and therefore your minimum number of individuals is four it's not to say that you don't have more than that but then of course you need to lay out and examine every single urn
02:19:06 lay out and examine every single urn from that recovery space to ensure that you've you've got the minimum number of individuals from that space and at the foot of page 20 you go on to say the devastation
02:19:19 20 you go on to say the devastation wrought to the interior of many of the flats and communal spaces where single individuals had died and those locations where multiple individuals had died together
02:19:29 together inevitably resulted in the commingling of the bodies of the deceased victims this phenomenon has previously been described as disaster-induced commingling where human remains may initially appear to belong to a single
02:19:40 initially appear to belong to a single individual but closer examination reveals that the remains of one or more individuals are embedded or commingled with another yes correct
02:19:50 how was the anthropological assessment carried out in cases where the deceased victims bodies had commingled
02:20:00 it depended on the preservation of the bodies so in some cases we had
02:20:06 we had um
02:20:08 um fragments or potentially burnt torsos of an individual where um the head and neck uh the upper and lower limbs might not be present so we might have
02:20:21 not be present so we might have a number of of burnt torsos that were separate individuals but then the urns from that entire flat would then have to be laid out one table per urn to establish
02:20:35 one table per urn to establish what material what skeletal material we had inside and then to start reconstructing the bones from each urn in order that once you've reconstructed
02:20:46 once you've reconstructed a bone
02:20:47 a bone to a length to it to a virtually complete or partially complete bone to try and then look at um whether we had bones that are anatomically or
02:20:58 bones that are anatomically or mechanically physically fitted or anatomically fitted mechanically fitted um and then it's a process of elimination and uh and you know taking one bone at a time
02:21:10 and you know taking one bone at a time across
02:21:11 across your your range of torsos in attempt to reassociate those bones and is that the way you ensure that the remains of a deceased victim were reconciled to the individual to whom
02:21:22 reconciled to the individual to whom they belonged yes and and so everything was reconstructed and then the process of of looking to see what uh what actually um mechanically fitted or physically
02:21:34 um mechanically fitted or physically fitted in terms of fitting limbs back together and limbs back to joint space joints
02:21:40 joints was undertaken um and this was this this process could go on for three or four weeks depending on the number of victims
02:21:49 victims and depending on the level of fragmentation and disruption of the bodies yes in the next paragraph which starts the nature and extends you go on two-thirds of the way through that to say when the commingling of
02:22:01 that to say when the commingling of human remains was identified the remains of each deceased victim was examined individually and then collectively with the other victims recovered from the flat to ensure that all of the human remains of each deceased victim were
02:22:12 remains of each deceased victim were reconciled where possible to the individual to whom they belong yes in all cases did you receive a satisfactory confirmation that the remains of a deceased victim were
02:22:23 remains of a deceased victim were reconciled to the individual to whom they believe no and and so you know in cases where you're not sure um and and there's a descending hierarchy of surety that i've given in
02:22:34 hierarchy of surety that i've given in the report um it's made
02:22:38 it's made much more difficult and in some ways impossible if you've got individuals from
02:22:43 from a flat or recovery space who are not related to one another if you can't be sure where the limb or the fragment comes from then it has to be retained
02:22:54 from then it has to be retained for the identification commission and the coroner's decision on on what to do so it's those flats where multiple victims that were not related to one another were recovered that was
02:23:06 another were recovered that was far more problematic um because obviously if if the deceased victims are from the same family and it's known that this there's you know no one else in that uh recovery
02:23:18 know no one else in that uh recovery space then then conversations can be had by the family liaisons officers and the family to to decide the material that i can't attribute
02:23:29 i can't attribute to victim a b c or d uh i can't attribute that to one particular person but they're all your family members so how would you like this to be
02:23:41 this to be returned
02:23:43 returned would you like this to be returned to the matriarch of the family if the matriarch is the person you know the elder of the family who may have died or the patriarch and that's how it was done yes i see
02:23:54 how it was done yes i see and
02:23:56 and in
02:23:57 in those cases where you did not or could not receive a satisfactory confirmation that the remains of a deceased victim could be reconciled to the individual to whom they belong did that affect your conclusions
02:24:09 did that affect your conclusions about that individual
02:24:12 in what way did it introduce an element of doubt that you had probably identified them as an individual and as separate from others no it didn't i mean nothing was was repatriated to an individual that we
02:24:24 was repatriated to an individual that we weren't sure about and certainly we had we had a process called anthropology grand rounds that was instigated by the coroner professor fiona wilcox
02:24:36 coroner professor fiona wilcox whereby
02:24:37 whereby she and the senior investigation manager who is also the deputy senior investigating officer dci chalmers andrew chalmers and the post-mortem coordinators and the
02:24:49 and the post-mortem coordinators and the operational forensic managers we would have a collective examination meeting within the mortuary and each individual and their bones and the unattributed
02:25:02 and their bones and the unattributed material that we could not return back to an individual were examined and the case was discussed the recovery locations of the individuals were projected onto a
02:25:13 individuals were projected onto a television and any drawings or archaeological recovery or context documentation that was integral to interpreting the original positions as found of the
02:25:25 the original positions as found of the individuals was projected so that in each case within each flat um
02:25:31 um the the anthropology grand rounds identified uh the surety or or the lack of surety for some of the smaller fragments
02:25:40 fragments for each
02:25:41 for each particular victim or that came in in in uh
02:25:46 uh urns that we couldn't return back to any one person but nonetheless looking at the matter in the realm
02:25:55 the realm uh were you satisfied yeah are you satisfied that the work you carried out to identify all the individual deceased yes
02:26:03 who were examined by you and the team were identified yes i am you are can we look then at lower down paragraph our pet or page 21.
02:26:14 our pet or page 21. um two-thirds of the way down your screen and perhaps scroll down a bit further
02:26:19 further you say
02:26:20 you say now the top of your screen middle of page 21 the anthropology and ontology examinations of multiple deceased victims from a single recovery location initially presented several operational
02:26:32 initially presented several operational challenges and then you've set them out all in that page and over the page the first information was gathered by the police from phone calls made by individuals trapped in the building this provided
02:26:43 trapped in the building this provided the authorities with an initial indication of where people were in the building and how they may have moved between floors and flats during the fire however in some locations the remains of unknown individuals were found that did
02:26:55 unknown individuals were found that did not fit the profile of people who were believed to be in that location at the time correct and just just pausing there how did you overcome that challenge
02:27:05 i think because the the individuals that uh the individuals this information was coming from the police and so when we looked at a flat and and laid
02:27:16 when we looked at a flat and and laid out all the the bodies of the fragments of the deceased victims we we could say
02:27:21 could say actually we've got three more additional victims here then you're aware of from your last known telephone call that you've told us about so at that point
02:27:32 so at that point um
02:27:33 um we would we would be uh either adding people to the number of individuals thought to be in that flat at the time and
02:27:44 and and sometimes removing individuals but but it i think it depended and this would need to be asked if the police really who made the phone call and where the information came from which we
02:27:55 the information came from which we weren't aware of all we were told was you know we suspect uh there are a number of individuals in here and and we would come back and and give them the number once the examinations had taken place yes
02:28:08 examinations had taken place yes and secondly you say due to structural issues and health and safety concerns associated with working in grenfell tower there could also be a considerable time delay between initial body recovery operations within an
02:28:20 body recovery operations within an individual flat and final body recovery of the remains of all deceased victims within that flat yes these delays were unavoidable however it inevitably affected the time that it took for all
02:28:31 affected the time that it took for all of the anthropology examinations of human remains from the flat to be completed and this in turn sometimes delayed the victim identification process yes now apart from affecting the
02:28:42 process yes now apart from affecting the time that it took for all the anthropological examinations uh from the flat and the victim identification process did the structural problems and the health and safety problems
02:28:52 problems uh adversely affect the recovery operations in grenfell tower and the victim identification process in any other way no it was a it was a time constraint um
02:29:04 was a time constraint um really and unfortunately the delay it's very difficult for families to have to wait as long as they do have to wait for positive identification of their loved
02:29:15 positive identification of their loved ones so we were very much aware that you know although the delays were unavoidable um you know there was no the delay to the process was unavoidable but that the way that the process was
02:29:27 but that the way that the process was undertaken was exactly the same it was rigorous and very assiduous and and everything was recovered
02:29:34 recovered if you turn onto page 22 you can see a fifth challenge which says this dna analysis could not be undertaken on many of the deceased victims that the
02:29:45 on many of the deceased victims that the forensic anthropology team were asked to examine as the catastrophic nature of the fire that caused severe calcination and cremation of the bodies thereby preventing dna analysis therefore detailed anthropological examinations of
02:29:57 detailed anthropological examinations of the often extensively commingled human remains of deceased victims needed to first take place in order to separate the remains of one victim from another before odd ontology examinations could be undertaken yes now when you refer to
02:30:10 be undertaken yes now when you refer to the calculation and cremation of bodies is that what you were referring to before that's right essentially cremation as in a commercial crematorium that's right and so so at those temperatures um
02:30:22 temperatures um the the bones will fragment and then they'll change color that as it gets hotter and hotter and the bones become more calcined that there's no dna left
02:30:33 that there's no dna left to in order to amplify for a profile and therefore um therefore that's and you also get severe shrinkage often get severe shrinkage um of the bone so so that that was the
02:30:46 um of the bone so so that that was the challenge of um
02:30:48 um of the nature of this particular incident and and why the guidelines had to be adapted particularly to this um
02:30:56 um this particular uh problem with with the uh thermal damage
02:31:03 and once you get to that stage calculation and effectively cremation is there anything that the material will tell you about the identification of the
02:31:14 about the identification of the person yeah so it's so it you can still reconstruct these remains which which is the point so um you know skulls can be reconstructed and and
02:31:26 skulls can be reconstructed and and bones can be reconstructed so it does as long as the uh reconstruction process takes place and you have the time and the rigor and the experienced people
02:31:38 and the rigor and the experienced people to do it
02:31:39 to do it you are actually reconstructing um the victims and so uh yeah it's more challenging and it takes more time but ultimately it can still be
02:31:50 more time but ultimately it can still be done and what's done in cases
02:31:54 in cases where
02:31:55 where you tell us this lower down the same page but i can summarize it i think in cases where the remains of a deceased victim couldn't be identified by either on ontology or dna and fingerprints you
02:32:06 on ontology or dna and fingerprints you say that those deceased victims were identified by secondary indicators what do you mean there by secondary indicators well the interbol dvi guidelines identify primary and secondary identifiers of which
02:32:18 secondary identifiers of which odontology dna and fingerprints are the primary so secondary and certainly apology is regarded as a um a secondary identifier so if for example
02:32:31 a secondary identifier so if for example we had
02:32:32 we had a number of victims we had a female victim and children of different ages then the biological profile and in this case would be very particular to aging the children
02:32:46 very particular to aging the children providing an age age for the children and the mother and any individual skeletal characteristics are has that individual sustained anti-immortal injuries during life
02:32:57 life and number of occasions this was correct um you know does that indicate one person over another if there's more than one female in in the space so it's really using the
02:33:10 in in the space so it's really using the information provided by um us during our examination of the the age range the sex the ancestry the individual characteristics of that of
02:33:21 individual characteristics of that of that particular individual um looking at fractures or hip replacements or any kind of um additional surgical implements that might be present or or indeed odontology um that
02:33:35 present or or indeed odontology um that might be present um in terms of bridges and and think dentures things like that and um
02:33:41 and um and building a profile of each person but then each person within that flat and then comparing that this wasn't our job but of course then the reconciliation team
02:33:53 reconciliation team from the metropolitan police would be looking at the information they had that we didn't have in terms of who they believed to be in that particular space at the time and if you scroll down on page 22 a
02:34:05 and if you scroll down on page 22 a little bit lower down i just want to show you the paragraph there now in the middle of your screen which starts the desired end result uh
02:34:14 uh can you explain what that is and then um you say in a small number of cases the remains of deceased victims were identified via secondary indicators biological profile individuating
02:34:26 biological profile individuating skeletal characteristics archaeological context and recovery location just pausing there what do you mean there by archaeological context um how one person was uh related to
02:34:38 um how one person was uh related to another so the recovery location is obviously the flat or the communal space and the um archaeological context was literally
02:34:50 literally where was that person in the flat and where was that person in relation to other persons so it's known that a number of individuals you might have a flat that had three or four or five
02:35:02 flat that had three or four or five people who may have been related to each other so you may have had any individuals who
02:35:09 like a mother and daughter or mother and a son and then other individuals who are from a different family but were also related so again you're looking at um
02:35:20 um is it likely and and it's not a likelihood ratio to say but is it likely that the two females in this location within this flat are related
02:35:31 are related and separate to the three other people in the flat who are also related but they're not related families to one another does that mean yes thank you uh and you go on to say
02:35:42 yes thank you uh and you go on to say as there were no dental records or all remains all records all the remains were too degraded to yield a dna profile in these instances a more detailed social and osteoporostia biological profile of
02:35:53 and osteoporostia biological profile of the victim was required to match the skeletal characteristics recorded in the remains of the victim what is this what do you mean by a more detailed social and osteobiological
02:36:04 detailed social and osteobiological process this was this was sending um the family liaison officers back to the families to say let's talk about any dental work or any
02:36:15 let's talk about any dental work or any medical treatments or you know does your son or daughter or family member have anything that could help us um in terms of uh anti-motion collection so it was
02:36:28 uh anti-motion collection so it was sending um the flows back the family liaison officers back into the families to say you know we've found we've found a spine that's very degraded here it looks like it's suffered a lot of trauma
02:36:40 of trauma is you know is there anything about that you can you tell us anything about your family member would what what did they do in life how active were they what kind of physical characteristics did they have
02:36:51 physical characteristics did they have that might be impacting on the skeleton of the person so that's what that means and that that assists does it in identification it it helps it helps assist build up the profile of the
02:37:03 assist build up the profile of the person that we have in front of us on the examination table and certainly you know it's it you have to be very careful
02:37:11 careful because you don't want to be cognitively biased by that information but indeed you also want to know by sending the family liaison officers back to families we often got
02:37:24 officers back to families we often got more families involved in the discussion and then someone might come and say oh yeah well you know there was an injury or there was something else or do you remember the time that that person broke their toe so that it was really asking
02:37:35 their toe so that it was really asking the right questions once we knew what we had
02:37:39 had can we then go to page 23
02:37:43 and you've set out there the standard operating procedures put in place for the forensic anthropological examinations uh and uh if we look down at the next heading down preliminary anti-anthropology assessment
02:37:54 anti-anthropology assessment um you've set out a list of of matters there you say if a preliminary anthropology assessment was required this took place during the post-mortem examination in which one
02:38:05 post-mortem examination in which one euro urm was examined at a time and generally encompassed the following procedures and then there is a list there and if you go down it runs from one to six and people just or you can just look at
02:38:17 and people just or you can just look at that
02:38:18 that to yourself and then go over to the next page page 24 paragraph six there [Applause] and then you say following the preliminary anthropology assessment
02:38:31 preliminary anthropology assessment the remains were returned to a refrigerated storage facility and was subsequently examined by the forensic anthropology team on a flat by flat or a communal space basis where upon a complete anthropology assessment of the
02:38:43 complete anthropology assessment of the human remains from the recovery location was conducted yes what would warrant a preliminary anthropology assessment because it was being conducted at the
02:38:54 because it was being conducted at the post-mortem examination it was providing assurance to the forensic pathologist that there was only one person
02:39:05 the skeletal remains of one person that we could see in that urn it's not to say that um there wasn't an additional person but we could certainly flag up that look you have co-mingled remains in these urns so
02:39:19 have co-mingled remains in these urns so uh you know the post-mortem examination that you're conducting on on perhaps you know a torso or a partial torso or partial body uh is not necessarily related to the skeletal remains you have
02:39:33 related to the skeletal remains you have in these separate urns yes and who would make the decision to conduct a preliminary anthropology assessment this was under the aegis of the forensic pathologists they they would request our
02:39:44 pathologists they they would request our presence
02:39:45 presence um
02:39:47 um and it was it was done at their request and what framework would be used to make that decision do you know i don't you would have to ask them can we look at page 25
02:39:58 we look at page 25 where you deal with the forensic anthropology unique reference number or urn there yes and
02:40:05 and you say the anthropological examination of human remains within each urn uh recovered from the grenfell from the grenfell tower sorry from grenfell tower was classified as either a primary or
02:40:16 was classified as either a primary or secondary urn and could you just explain the difference between a primary and a secondary urn so so the primary urn contained the remains of one distinct individual that we could
02:40:28 one distinct individual that we could see
02:40:28 see um and it was a complete or partially complete individual fleshed remains or burnt flesh remains or sometimes a highly fragmented skeleton
02:40:41 a highly fragmented skeleton that if you you took a look at it there were no repeated elements skeletal elements that would suggest that there was an additional person
02:40:49 person that might be your preliminary investigation and assessment but of course until you open the secondary urn which are all the other
02:41:00 which are all the other urns that come in from that flat so you can imagine the conditions within some of the recovery flats uh was so catastrophic that what the
02:41:11 uh was so catastrophic that what the forensic archaeologists and dvi teams were doing was recovering what they could see as an individual but it might be the case that
02:41:22 individual but it might be the case that um the bone fragments particularly if the individuals are close together are co-mingled with one another so we provided this classification so that
02:41:33 we provided this classification so that we couldn't we knew that if you had five primary urns from a flat location you had a minimum of five people that is not to say when you open the secondary urns which might be a
02:41:45 the secondary urns which might be a single bone or it might be a smaller assemblage of bones or a single body part like an arm or a hand
02:41:52 or a hand or it could be multiple fragmented bones so that was our way of of giving uh a preliminary assessment saying okay i think we have a minimum of five people
02:42:05 i think we have a minimum of five people here but we haven't examined everything yet that's that's an advisory number at the moment during the examination and then that information gets fed back to the reconciliation teams and the
02:42:18 the reconciliation teams and the teams collating all the intelligence around that flat and as we work through the secondary urns and all the single elements in the body parts and the fragmented remains
02:42:30 the fragmented remains that number might go up and down would you use a secondary urn in a case where remains were commingled yes you would
02:42:39 would no when you say no fleshed human remains i mean is it does that is that what it sounds like no flesh
02:42:47 no flesh yes so so the thermal damage to um the majority of human remains that we examined
02:42:55 examined were very often times a torso that may or may not have upper and lower limbs attached it may not have a vertebral column connected to a head
02:43:08 a vertebral column connected to a head so um
02:43:11 in in those cases you can you can lay these remains out and say well we do have the remains of five complete or partially complete or very disrupted but still identifiable as a
02:43:24 disrupted but still identifiable as a single person in this primary urn right
02:43:29 right and in the last sentence in the middle paragraph there you you say for example where there were no flesh with human remains or where there was no distinct highly fragmented skeleton
02:43:40 skeleton assessed to be present within the urn yeah
02:43:43 yeah when you say no distinct highly fragmented skeleton what about a distinct but not highly fragmented skeleton or is there no such thing well there's no such thing really because it would if there was a distinct
02:43:56 would if there was a distinct skeleton within that you are in it would not be a secondary you are in it would be a primary you are i see now you go on to say at the foot of the page and over the next page the use of
02:44:08 page and over the next page the use of the secondary urn system and the number of urns designated under this classification that may have been recovered from an individual flat or communal space was also necessarily influenced by the level of destruction
02:44:19 influenced by the level of destruction to the internal structure and or contents present within a flat or communal space for example in a number of cases extensive destruction of the structure and contents within an individual flat
02:44:30 and contents within an individual flat or communal space often further contributed to the disarticulation extensive fragmentation commingling and dispersal of the bodies of deceased victims with the result that human
02:44:41 victims with the result that human remains may not be specifically attributed to any one victim at the point of recovery are you able to explain precisely how the secondary urine system allowed that challenge to be overcome
02:44:53 challenge to be overcome well the secondary uin system was was certainly instigated with uh with information from the forensic archaeologists and dvi teams so
02:45:04 so when they've recovered the main body part if i can use that term of an individual that becomes the primary urn we're dealing with but they
02:45:15 but they the bodies might be so close closely uh located together that the secondary urns cannot be attributed to any one person and so the documentation and paperwork that would come in and the
02:45:27 and paperwork that would come in and the photographs from the archaeology and dvi teams would reflect that
02:45:33 that issue really and and so every secondary urn was regarded was not was not attributed to any primary urn without
02:45:43 without um
02:45:45 um examination and reconstruction yeah so further work would have to be done much further work yes i see i'd like to look next with you please at page 26 and the forensic anthropology
02:45:56 page 26 and the forensic anthropology examination that you carried out and you deal with here uh you say the forensic anthropology examination generally encompass the following procedures note that if a
02:46:07 following procedures note that if a forensic anthropology reassessment occurred this is this examination also generally followed the same examination procedures and then you set out at the bottom of 26 and over
02:46:19 at the bottom of 26 and over through 27 we can just look at that a long list of matters we turn to page 27 uh um and then
02:46:30 uh um and then please down continuing to page 28
02:46:35 and then over to 29
02:46:41 which is where it ends and you start with thermal damage
02:46:46 looking at the entire list on those pages that i've put up on the screen we can perhaps go back a page to the last of the lists and does that accurately describe the
02:46:57 and does that accurately describe the stages in the process for forensic anthropology examination it does yes you conducted
02:47:03 conducted yes
02:47:04 yes and that is for each individual is it yes yes
02:47:13 and how does the reconstruction of each individual skeletal element inform the anthropological process more broadly in other words what do you what information do you get out of it
02:47:24 information do you get out of it well well you have you have a reconstructed skeleton in most cases that you can then conduct a biological profile on so you have the entirety of of of what you've
02:47:35 have the entirety of of of what you've reconstructed and then you can look at an age range sex ancestry
02:47:41 ancestry you can understand the association potentially between single dental elements and and the mandibles and maxillas you might have in the reconstruction so it it then
02:47:52 the reconstruction so it it then provides the basis from which the profile can then be constructed yes i see and looking at that a little bit more closely can we go please to page 33 on page 33
02:48:05 on page 33 you
02:48:06 you deal with biological profile yeah and you summarize the techniques the anthropological techniques and standards used to construct the biological profile for the remains of the deceased victims yes recovered from grenfell tower
02:48:19 yes recovered from grenfell tower and
02:48:20 and you
02:48:22 you you say
02:48:24 you say in the middle of the next paragraph for example most standards used for the estimation of age and sex have been established using modern european and american skeletal series
02:48:35 american skeletal series these standards have not been shown to apply equally to human populations in other parts of the world it has also been established that not only is there variation within single populations in the rate of skeletal maturation for age
02:48:46 the rate of skeletal maturation for age at death estimation but there is also significant variation between populations please note that wherever possible multiple methods of age estimation will utilize in order to provide an age of
02:48:57 utilize in order to provide an age of death or age range category for the human remains and what method very briefly if you can it may not be possible to take briefly but do your best what methods did you
02:49:08 but do your best what methods did you use to estimate age of death in this case
02:49:11 case well obviously at death is what we're looking at is skeletal maturation so
02:49:17 so um an adult human skeleton that the human skeleton of an adult will be generally uh have completed fusion and completed its
02:49:28 have completed fusion and completed its final shape by the age of 30 years of age it can start earlier in some individuals so what we're looking at is do we have a juvenile
02:49:39 do we have a juvenile do we have an infant what is the rate of you know what is the development state or status of the bone that you have in front of you um and
02:49:50 um and how best can you identify an age range for this person and again we go back to reconstruction laying out the skeleton in anatomical position and
02:50:00 and looking at the states of fusion of the bones particularly in juveniles that will give you and separate one child from another for example or separate an individual who might be you
02:50:13 separate an individual who might be you know
02:50:14 know recently fused a young a young adult young to medium-range adult from an older person where you've got degenerative changes on the skeleton that would indicate an older person so the age of death is
02:50:27 an older person so the age of death is looking at um various parts of the the human body in terms of development and and i'm comparing them to population
02:50:38 i'm comparing them to population standards which as i've i've pointed out um are mostly european and american there are some skeletal series that are being developed for other populations but you know this is this is easier to
02:50:52 but you know this is this is easier to apply if you know who your individual is if you don't know who your individual is you have to um you have to be very cautious about how you apply the age of
02:51:03 cautious about how you apply the age of death which is why the categories we've provided were very broad yes and in relation to the categories i think we can pick those up on page 34 where you
02:51:15 where you identify
02:51:16 identify those categories juvenile adolescent young adult adult and then over the page uh to 35 over adults and in each case you've identified the main
02:51:27 you've identified the main um identifying factors and principles yes yes yes when it came then to identification according to sex of the deceased victims i think you cover that on page 35 on this in the way you have
02:51:40 on page 35 on this in the way you have on the screen in front of you yes yes uh and
02:51:44 and that as you say relies on the differences of sexual dimorphism uh and some cranial morphology as well that's right primarily the pelvic girdle yes
02:51:56 yes but more difficult when reliably estimating sex in juvenile remains yes yes and one of the reasons you've given yes well if you go to page 36 you say there
02:52:10 under the heading skeletal variation and individuating features individuating features are features or variations that can be seen within the human skeleton that differ from one person to another these features can
02:52:21 person to another these features can include the identification of pathological processes antimortem trauma and the presence of non-metric traits i'm just pausing that what is a non-metric trait
02:52:32 non-metric trait a non-metric trait means it's it's a trait that you uh a morphology you see in the human skeleton that i might have that you may not have so in some populations um you
02:52:45 not have so in some populations um you non-metric traits might be the difference in the angle of a particular bone or it might be an additional foramina or a hole in a skeletal
02:52:56 foramina or a hole in a skeletal structure it might be the bridging of a hole
02:53:00 hole with a piece of bone so there are non-metric traits that these think traits are recorded
02:53:07 recorded particularly if they're fragmented and you and you put things back together and you you might may see that reflection um from one bone on one side of the body to one bone on the
02:53:18 side of the body to one bone on the other where you have the same non-metric trait present but sometimes they are unilateral and not bilateral right and where i mean perhaps you could illustrate it by the case of um acute arthritis you might
02:53:31 case of um acute arthritis you might have it in one shoulder but not the other would that be a non-metric trait or would that be a pathologist no that's a pathological process but then you wouldn't just have uh likely wouldn't just have problems in
02:53:42 likely wouldn't just have problems in that shoulder girdle you'd probably have problems with your back or other joint surfaces right and then
02:53:51 and then you've um the references there and if you go to page 37 you have a heading attribution of human remains and you say there attribution of remains to an individual is based on six
02:54:03 to an individual is based on six categories and these are generally made in reference to a main body part under identified dental or skeletal remains these categories are outlined below in a descending order of confidence of attribution and there you have the the categories
02:54:16 and there you have the the categories physical and or mechanical fit most likely associated consistent with exclusion under unattributed and dissociated yes
02:54:25 yes and
02:54:27 and are you able to give us a distinction in between each of these categories in levels of certainty that you would use to establish each one
02:54:38 to establish each one well certainly if if we can go back to the previous page um certainly that the highest level of certainty is a physical or mechanical fit so that's when you're actually
02:54:49 fit so that's when you're actually fitting one bone fragment back to another and they fit um they fit perfectly
02:54:55 perfectly um
02:54:56 um mechanical fit we're looking at joint surfaces so you know it's the bottom of my humerus that the larger arm bone of the arm
02:55:04 the arm is a congruent with fitting with the um the bones of the lower arm that you might have so physical and mechanical fit
02:55:12 fit even whilst you have thermal damage and you you have shrinkage is is is a a reasonably confident way of um of reassociating remains as you go down
02:55:24 reassociating remains as you go down this
02:55:25 this number you know one two six two six you're looking at most likely associated you're looking at um does the biological profile of this particular skeletal elemental body part match the rest of
02:55:37 elemental body part match the rest of the body that you have in front of you or does the color or degree of calcination of the bones so is it all fairly uniform or is it not uniform now that can be a bit tricky
02:55:49 uniform now that can be a bit tricky because you might have a an item overlying the body like a piece of furniture or or a structural element that might um shield the body from changes in color
02:56:01 shield the body from changes in color occurring but you'll then look you're looking at the visual pair so you're looking at size does this bone match the morphology the shape and function that you can see from one side to another
02:56:15 you can see from one side to another and
02:56:16 and and
02:56:17 and yeah and so you're you're laying out everything and considering every bone in relation to the
02:56:24 the identified uh bone or body part that you have in front of you consistent with we're going down the the scale now is well it's an adult bone or
02:56:35 scale now is well it's an adult bone or it's a juvenile bone or it's a male or a female
02:56:38 female but
02:56:39 but if you've got multiple
02:56:41 multiple age groups and multiple sexes within that
02:56:46 that cohort of individuals from that flat then again that's all you can say it's consistent with a male or a female and if you have multiple males or females that doesn't help you but at least it gives you
02:56:58 help you but at least it gives you uh
02:56:59 uh an idea of if it's male then it's certainly not related to your female victims so you're fighting that process and looking down these number of different categories are you applying judgment
02:57:10 are you applying judgment a professional judgment when you distinguish the categories yes professional judgment and and everything was discussed with the other lead anthropologists so it wasn't uh conducting each case on your own it
02:57:23 uh conducting each case on your own it was certainly collaboration and frequent discussion to to get
02:57:30 to get other people's opinions on on the level of certainty you had applied
02:57:36 applied to those particular elements at the time and then on page 38 your last category six is dissociated and dissociated you say refers to remains that are not associated with the individual
02:57:49 associated with the individual however as these skeletal elements have been recovered with the remains following anthropological examination they're separated from the remains and stay within the same urn but are designated with the letter d
02:58:00 designated with the letter d for example dissociated from
02:58:04 dissociated bone from pm four four four zeroes becomes pm four four four zeros d
02:58:12 zeros d to await coronal review during the anthropology grand rounds process the dissociated material within an urn is reviewed during anthropology grand rounds to determine whether the material
02:58:23 rounds to determine whether the material can ultimately be released or conversely must be retained by the coroner i will come back to ground grounds shortly but um
02:58:31 um you go on i think to say uh on the top of the next page under the heading dissociation of human remains
02:58:39 remains an individual case will be inventoried and laid out in anatomical position wherever possible any remains that are not considered to belong to that individual recorded as additional bones under that urn number before
02:58:51 under that urn number before reassociation takes place yes additional bones are recorded when we've got four cases one there's a clear recognition of a repeated skeletal element for example two proximal right
02:59:02 element for example two proximal right tibia two the size and shape of a skeletal skeletal element is considered to be morphologically different three there's a difference in the assessment of biological profile such as
02:59:13 assessment of biological profile such as the presence of adult human remains commingled with a juvenile skeletal element or age stroke sex differences and four recovery position of the remains after review of the scene photographs
02:59:24 photographs now
02:59:25 now when you've established that a bone is not associated with a particular individual do you then go on to see whether those remains can be associated with a different individual yes you do and is that the process you describe as as
02:59:37 that the process you describe as as reassociation correct i see can you explain how that's undertaken it is literally picking up that element and
02:59:47 and and going to each uh particular body with your dvi officer who doesn't let you out of their sight to to see if that bone can be matched to something else that someone has
02:59:58 something else that someone has reconstructed or that has a morphological or a structural um
03:00:04 um appearance about it that might suggest it comes from someone else so being taken from let's say a gracile female adult female to a robust adult male if that's what the bone
03:00:16 adult male if that's what the bone fragment that you have in your hand is suggesting you use the word gracile there i've seen that in the report what is that graceful is is just uh uh i guess fine boned would be another
03:00:27 uh i guess fine boned would be another another description uh and uh if you look please at page 39 under the heading reassociation of remains and then scroll down to the foot of that page and then to the top of the next page
03:00:38 next page that's the process that those are the principles is it that's right are they absolutely you're going through these principles at every point to see whether you can reassociate this bone fragment or the
03:00:50 reassociate this bone fragment or the body part to another individual and once is it right that once all the examinations and reassociations have been completed for a flat or a communal space
03:01:01 space a total minimum number of individuals or mni is estimated correct and how is the mni calculated it's calculated on on the number of the same element elements that you have so in this case
03:01:13 elements that you have so in this case i've given the example of four right adult femora which is thigh bone um produces an mli count of four individuals but then if you have a juvenile bone uh it cannot come from an
03:01:26 juvenile bone uh it cannot come from an adult so therefore you have a minimum number of five what is the purpose of the mni as a concept the purpose of the nmi mni is is to to make sure that that every fragment
03:01:39 to to make sure that that every fragment is checked and that you don't have an additional individual so
03:01:43 so in this case you know your m i counts might be on several different types of bones so you might have let's say five different types of bones
03:01:54 let's say five different types of bones that all give you different numbers but the highest number in this case the m i count of four individuals is what you're basing um
03:02:03 basing um your m and i count on but at any point in time if you find another bone fragment that doesn't fit or is in addition to your four individuals then you have five
03:02:15 your four individuals then you have five so this is yeah and and so these m i counts are photographed and recorded so that at any one time um if the coroner or the authorities wanted to
03:02:26 coroner or the authorities wanted to know how the m i for that flat was established there's documentation photographic and written to demonstrate how that was achieved yes thank you mr chairman i know that
03:02:37 yes thank you mr chairman i know that it's gone one o'clock i've got about 10 minutes more questions for the for the uh witness um i think i'm in your hands it's probably best
03:02:48 i'm in your hands it's probably best to break now and come back and have the 10 minutes plus the break if that's convenient too well let's take some standings i suspect mr killing you were told to expect to be finished by
03:02:59 told to expect to be finished by lunchtime weren't you yes but that's first person how um difficult is it for you to
03:03:06 you to stay on over lunch and let's say until half past two that's fine all right
03:03:12 all right that's helpful thank you no i'm going to ask a stenographer um
03:03:17 um whether half an hour now would be more than she can really cope with
03:03:22 right so the the options then and how long do you think you actually got for questions uh no more than 10 minutes no more than 10 minutes well about 10 minutes
03:03:35 right um i think we the options are not to break nerve for the usual hour or to expect to finish your evidence by half past one which i sense you would prefer is that right
03:03:47 is that right i have no preference i can do either way that's fine right carry on karen
03:03:54 karen yeah we think it would be sensible to try and finish the evidence now but that's
03:03:59 that's you are not to feel rushed in that if it takes more than ten minutes we shan't hold it against you thank you mr chairman
03:04:08 chairman uh can i ask you please to go to page 17.
03:04:11 17. fifth paragraph down there
03:04:16 uh you explain in that paragraph as follows on completion of the forensic anthropology and old ontology examinations for each deceased victim recovered from a specific flat or
03:04:29 recovered from a specific flat or communal space the human remains and the recovery and mortar examination and documentation case files were reviewed in a process called anthropology grand rounds this process was led by a
03:04:41 rounds this process was led by a majestic senior coroner professor fiona wilcox deputy senior investigating officer and seen senior identification manager detective chief inspector andrew chalmers metropolitan police service
03:04:52 chalmers metropolitan police service post-mortem coordinator the operational forensic manager ofm andrew langley metropolitan police service and the lead anthropologists and ontologists
03:05:03 the lead anthropologists and ontologists now first can you explain what the purpose of the grand rounds was it was
03:05:09 it was it was a um it was instigated by a professor wilcox and it was a way of talking through the logistics and the recovery space and
03:05:21 the logistics and the recovery space and the examinations that had been undertaken within the temporary mortuary and it gave everyone the opportunity to see the human remains laid out as they
03:05:32 see the human remains laid out as they were completely completed and repatriated the bones repatriated to those individuals with whom we could do that
03:05:39 that and
03:05:41 and to really assess the
03:05:43 the recovery location to look at the photographs we had very large televisions where all the imagery from the archaeologists and the dvi officers could be
03:05:52 could be could be reviewed so was there a was this a process that you'd encountered before the grenfell tower yes at the world trade center right and was there a grand round or an anthropological grand round held
03:06:04 or an anthropological grand round held in relation to each deceased yes and what did i think you've explained actually what the the grand round process involved um who designed the anthropology grand rounds
03:06:16 anthropology grand rounds well it was professor wilcox who came he requested that we do this and it very quickly became a vital part of the um of the process which ultimately informed
03:06:29 of the process which ultimately informed the identification commission which which occurred after grand rounds yes i see and were there reports made from the grand rounds which then fed into the dvi yes so we produced interim reports on each individual following the ground
03:06:41 each individual following the ground rounds and uh or during the ground rounds and they were used as a preliminary paperwork uh in order to inform the subsequent identification commission yes thank you
03:06:53 identification commission yes thank you and in cases where there were more than one deceased recovered from a single location that was reviewed i think during the grand rounds process yes and then if you go to the top of page 18
03:07:04 and then if you go to the top of page 18 you say
03:07:06 this review included confirmation of the minimum number of victims from the flat or communal space the context and recovery position of each of the victims the nature and extent of the commingling of human remains identified at that
03:07:18 of human remains identified at that particular location together with any additional information that may be deemed to be pertinent to the particular flat or communal space under review and what sorts of information would you
03:07:29 and what sorts of information would you consider pertinent to the particular flat or communal space under review it might be the number of times the dvi and forensic archaeology teams had to go back into that flat a number of the
03:07:41 back into that flat a number of the flats were in far worse structural condition than others so it might be that a number of weeks or sometimes months had passed between an initial examination and the final clearance
03:07:54 examination and the final clearance of the flat and and whether you know some flats were more catastrophically uh
03:08:03 uh destructed in a way than other flats so it really did depend on um and that informed the level of fragmentation sometimes you know if you had a flat that was had really been
03:08:15 had a flat that was had really been destroyed by the fire um that would obviously have an effect on the fragmentation of the remains and so the coroner and the attending officers needed to know that about that
03:08:26 officers needed to know that about that particular flat and based on the process that you adopted how confident can you be that you appropriately id or properly identified the relevant information in relation to each deceased very confident
03:08:38 relation to each deceased very confident when you go on to say in the next paragraph that the information reviewed during the anthropology grand rounds process was subsequently used to inform the deliberations of the identification commission which was conducted under the
03:08:50 commission which was conducted under the direction of emergency senior coroner professor fiona wilcox is it right to say that you yourself did not have any direct input into the formal identification of the deceased no
03:09:02 formal identification of the deceased no the the results of the team the anthropology team were were submitted to the identification commission but no we weren't part of that um that process in terms of sitting
03:09:13 that um that process in terms of sitting on the commission and who appointed that commission i don't know i'm afraid do you have any information or knowledge about how it operated no i didn't attend and i don't know no yes
03:09:25 and i don't know no yes yes thank you very much um well um i think i've done better than the ten minutes that i gave the chairman uh but um mr mckenna i've come to the end of my
03:09:34 end of my questions for you that i prepare but there may be other questions so i'm going to ask the chairman to take the usual break if i may yes well as you may know we have to have a break at this stage so that mr millett can check he's not left anything out and
03:09:46 can check he's not left anything out and to enable others who are following the proceedings to suggest further questions so we'll stop there we'll resume at 20 past would that be enough long enough yes
03:09:55 yes we'll come back at 20 past one and then we'll see if there's any more questions for you then thank you all right thank you would you like to go to the usher please
03:10:12 thank you mr twenty-four swan and thank you
03:19:53 would you ask mr mckinnon to come back in please
03:20:06 all right mr kitten we'll see if there's any more questions for you yes yes mr chairman um can the witness please be sharing paragraph or page 40. and on page 40 you refer to the mni
03:20:19 and on page 40 you refer to the mni yes uh the minimum number of individuals and you've explained the concept and under the heading you uh say in the third line excuse me however given the nature of
03:20:30 excuse me however given the nature of this particular disaster in that the deceased victims from grenfell tower were recovered from specific locations within flat straight communal spaces and each location was comprehensively excavated and examined the m i for each
03:20:42 excavated and examined the m i for each flat stroke commodore space could be confidently obscribed yes can you explain why you were confident that you would correctly identify the actual number of individuals at grenfell tower
03:20:54 number of individuals at grenfell tower because each fragment of bone and each body part of each deceased victim was examined and
03:21:02 and in this case in grenfell tower we had forensic archaeologists and dvi officers recovering and removing the structural debris and
03:21:13 and removing the structural debris and the bodies of the deceased victims down to the concrete floor so unlike something like the world trade center where the remains of victims from that incident
03:21:23 incident were
03:21:25 were blown over lower manhattan the recovery spaces were very particular and confined within each flat i see
03:21:35 i see and this may be a question for the archaeologist but help me if you can how confident are you that there was nobody left in the tower unidentified very confident
03:21:46 in the tower unidentified very confident and that's based on that's based on the bodies that i examined and the rigor um with which the recoveries and the clearance of the of the flats following
03:21:57 clearance of the of the flats following each recovery um were undertaken and was that a specific question addressed in the anthropology grand rounds or the grand rounds more generally
03:22:08 i'm sorry what do you mean well during the grand rounds yes did that question come up yes it did yes yes thank you very much uh i have no further questions for you mr mckenna thank you so it remains for me only to thank you very
03:22:20 remains for me only to thank you very much for your report uh for the inquiry and for coming here today and assisting us with your evidence we're extremely grateful to you thank you very much very much and before you go let me say thank you as well please on behalf of the panel i think
03:22:32 please on behalf of the panel i think we've all found your evidence extremely interesting and i speaking for myself i can say that i wasn't really fully aware of the significant part played by the
03:22:43 of the significant part played by the anthropologists in the extremely difficult and delicate task of identifying the deceased so your evidence has been very interesting very helpful and we're very grateful to you for coming and i'm
03:22:55 very grateful to you for coming and i'm sorry we kept you beyond the usual hour but absolutely and you're not free to go of course thank you very much
03:23:09 and i'd like to thank the others who who've been um supporting our proceedings and whom we've kept sitting later than usual and i'm very grateful that we could finish that witness's evidence before we break
03:23:20 that witness's evidence before we break for lunch and indeed i think for the day is that right mr mr chairman yes can i say thank you very much both to the witness who's gone anyway to you as well on the panel for sitting a little bit later into the lunch to accommodate the witness and of course
03:23:31 to accommodate the witness and of course the transcriber and document manager yes as well thank you and um that's all we shall be doing today yes we have one more factual witness next monday yes dr carl harrison
03:23:42 witness next monday yes dr carl harrison who is the archaeologist he will come and give evidence yes scheduled next monday but from tomorrow onwards
03:23:49 onwards we have the family's presentations and we shall start those at 10 o'clock tomorrow morning thank you thank you very much turner talk tomorrow morning
03:24:02 you