Memorial presentations honoring Logan Isaac Gomez (stillborn), Khadija Khaloufi (flat 143, floor 17), and Ali Yawar Jafari (flat 86, floor 11). Details lift failures and smoke conditions.
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# Source: Local audio transcription (no YouTube captions available)
00:00:00 Good morning, everyone.
00:00:29 Welcome to today's hearing. Today we're going to hear more presentations about the circumstances
00:00:35 relating to some of those who died in the fire. Yes, Mr. Billings.
00:00:40 Yes, Mr Chairman. Good morning. Good morning to you. Good morning, members of the panel.
00:00:44 I now call upon Mr Sam Steen, Queen's Council, please, to come to the podium and to make
00:00:50 the presentation on behalf of the family of Logan Isaac Pelostreo Gomez from flat 183
00:00:58 on floor 21. As before, Mr Chairman, I should give a trigger warning that what Mr Steen
00:01:03 is going to tell us or maybe show us may be upsetting to some or many people in the room
00:01:09 or watching on the live stream, and to them I would invite them to leave or to look away
00:01:13 as the case may be. Thank you very much. Mr Steen, thank you.
00:01:28 On the 14th of June 2017, Logan was stillborn, delivered in King's College Hospital by Cisarean
00:01:46 section with his mum in a coma and his father looking on in grief. No crying baby, no excitement,
00:01:56 no joy. Logan's mum, dad and two sisters had just about managed to escape the horror
00:02:05 of the burning tower. Their survival was at great damage to themselves and with the tragic
00:02:11 consequence of Logan losing his life whilst in his mother's womb. A terrible dilemma had
00:02:19 faced the Gomez family in the Grenfell Tower. They couldn't stay put. No one was coming
00:02:25 to the rescue. They went into the acrid, thick, black smoke not knowing if they would
00:02:33 make it out. The damage caused to his mum, Andrea, by the smoke and toxic fumes, worked
00:02:41 its way through to Logan with fatal consequences. Andrea Perestrello was vulnerable. She was
00:02:51 three months pregnant at the time of the fire. It's created her vulnerability. Andrea
00:02:56 also suffers from asthma. As at the date of the fire, there were no arrangements in place
00:03:03 to enable Andrea and accordingly her unborn child Logan to evacuate or to facilitate her
00:03:12 rescue by the fire brigade. Therefore, the narrow single staircase was the sole means
00:03:20 of escape from the tower in the event of a fire. Before the fire, Logan was healthy
00:03:27 as was his mother. Andrea described that she was seven months pregnant with our son Logan
00:03:34 at the time of the fire and both Logan and I were doing well. I was happy and having
00:03:39 a healthy pregnancy. The 14th of June, sir, was due, Andrea says, to be her last day at
00:03:47 work before starting maternity leave. The family, the lively family, happy mixture
00:03:59 of vibrant characters made for a strong and happy family life. The family comprises Andrea
00:04:07 Perestrello, Marcia Gomez and their two daughters, all living at the time on the 21st floor in
00:04:15 flat 183 of the Rempel Tower and they'd lived there since April of 2007. The family home
00:04:23 had been made ready with loving excitement for the newest member of the family to join
00:04:28 them very shortly. His room had been decorated, his Moses basket was in place and toys were
00:04:34 ready for him. Marcia described the excited anticipation of Logan joining the family.
00:04:46 At the time of the fire, Andrea was seven months pregnant with her unborn son Logan.
00:04:51 He was due to be born on the 21st of August 2017. All of our family and friends were so
00:04:59 pleased that Andrea was pregnant and we were all looking forward to Logan being born with
00:05:03 prepared the nursery room for him in our home in anticipation of his birth. I'm now
00:05:12 going to talk about the night of the 13th and 14th. The family returned to the tower
00:05:18 between about 10 o'clock and 10.30 on the 13th of June, having been out for dinner with
00:05:25 friends. Andrea recalls shortly after getting home she got the children ready for bed and
00:05:34 after putting the children to bed she herself got ready. Marcio recalls Andrea going to bed
00:05:40 at approximately a little after 11 p.m. Marcio had been playing on an Xbox in the living room.
00:05:49 He recalls logging off at about 12.15 a.m. and then himself going to bed and falling asleep
00:05:54 shortly thereafter. As she was falling asleep, Andrea recalls hearing a disturbance outside
00:06:03 and then hearing voices in the communal area outside her flat. And so, family members,
00:06:11 you'll remember that W. N. Dowden noted that around 1.12 the cladding appeared to be burning.
00:06:21 He referred to the fire starting to affect the external fascia, sparking, spitting like magnesium.
00:06:30 By 1.26 the fire spread to reach the 23rd floor spreading over 19 stories on the outside of the
00:06:40 building in approximately 18 minutes. And in the opinion of Dr. Lane, the stay put strategy had
00:06:48 failed by 1.26. At about the same time, the family's neighbour Helen Combrezcal from flat
00:07:00 186 also on the 21st floor made a 999 call which was answered by CRO Duddy. Helen Combrezcal told
00:07:10 him there was a fire in 186 Grenfell Tower and said everyone is out and in the building,
00:07:17 there has been a fire. CRO Duddy explained that the fire brigade were already there and asked
00:07:25 if she was in the flat or outside the building. She said everyone is out, the whole people are
00:07:31 out. Helen Combrezcal was in fact referring to the El Hawabi family who were in the lobby.
00:07:38 At approximately 1.30am the Combrezcal and the El Hawabi families tried to leave the 21st floor
00:07:49 to exit the tower through the Stowall door. They could not go down the stairs as a group of people
00:07:56 were coming up. Ms Combrezcal could not say how many there were in that group. She says that they
00:08:06 told them to go back to their flat and Helen Combrezcal assumed that the instruction had come
00:08:11 from firefighters. Within a matter of minutes Helen Combrezcal then knocked on the front door
00:08:19 of flat 183, the home of the Gomez family. Marcio recalls being woken by a banging on their front
00:08:30 door. He followed his wife Andrea to the front door. When they opened it, Helen Combrezcal told
00:08:38 them that there was a fire in one of the flats in the tower. Ms Combrezcal told Marcio that she and
00:08:45 a group had been sent back by a firefighter. Marcio overheard but did not see Abdul Aziz El
00:08:54 Wahabi speaking to others. He could not hear clearly what was being said. There was a mix of
00:09:02 three or four male and female voices which Marcio assumed were people who had come up from lower
00:09:09 floors but in fact were probably members of the El Wahabi family speaking to each other. There is
00:09:16 in fact no evidence that anyone else was sheltering in flat 182, the El Wahabi family flat.
00:09:22 Through that conversation Marcio Gomez was at his front door standing just behind his wife. From
00:09:34 there he couldn't see the front door of flat 186 or the stairwell door. The family invited Helen
00:09:40 Combrezcal and her daughter with their dog to come into flat 183. As they came in, Marcio could
00:09:53 see a layer of black smoke about two inches thick close to the ceiling of the lobby. He noticed it
00:10:00 because of the light fitting outside his front door. He says that the smoke sort of sparkled in
00:10:06 the light which caught his attention. He couldn't see where it was coming from. He thought that
00:10:12 Helen Combrezcal and her daughter had come into his flat between 1.25 and 1.30. Andrea also recalls
00:10:21 that approximately 1.30 am opening her door to her neighbour Helen Combrezcal who told her that
00:10:27 there was a fire and then Andrea also recalls that Ms Combrezcal and her daughter joined the
00:10:33 family in flat 183. Helen Combrezcal herself in a statement says that she knocked on Andrea's
00:10:39 door at approximately 1.30 and told them about the fire and that they had to get out. This means
00:10:50 that at around 1.30 am the Gomez and Combrezcal families found themselves in the flat of Andrea
00:10:56 and Marcio, flat 183, deciding what to do. Marcio made a number of telephone calls to the emergency
00:11:07 services. Marcio explained that he had a pregnant wife and he was informed that someone would come
00:11:12 and get them. Marcio recalls the conversations with the emergency services. He was saying that
00:11:22 the smoke is really thick. My wife is seven months pregnant and asthmatic and my youngest daughter
00:11:27 is asthmatic. To which they said, you know, we'll send somebody up to help you. Now sit tight,
00:11:33 we'll send somebody up, okay? Helen Combrezcal described that at about 2 am Marcio said that he
00:11:47 was going to knock on the door of the old Filipino lady in the flat opposite. In fact,
00:11:53 he went to her front door and opened it and this was when he realised how bad the conditions were
00:11:58 outside the flat. The smoke outside the front door at this time had become really thick and black.
00:12:05 There was a strong smoky smell and it was getting worse.
00:12:10 We were all coughing due to the smoke and it was getting harder to breathe and the heat was
00:12:13 increasing. The kids were finding it particularly bad. Marcio came back to us in the living room
00:12:20 and told us it was serious and that he could not get to the flat of the old Filipino lady.
00:12:31 At 2.19, Marcio was still calling the emergency services,
00:12:39 stating that they were calling from the tower and unable to leave.
00:12:44 He explained that his pregnant wife was with him.
00:12:48 Marcio was advised that the command unit was evacuating flats and that he should put towels down.
00:12:57 Marcio made a further 9-9 call at 2.46, that is roughly 10 minutes later after the previous call,
00:13:05 stating that the fire had reached them. The call had been advised to try and stop the smoke coming
00:13:12 in and that firefighters were heading to their flat. Conditions worsened. The smoke was getting
00:13:22 worse. At 2.54, Marcio made a further call to 9-9-9, saying he could not get out and has tried to use
00:13:36 wet towels but the smoke was still entering. He confirmed his with his children and his pregnant wife.
00:13:43 He was fearing for his and Helen's family lives. 50 minutes later, at 3.09, Marcio called 9-9-9 again,
00:13:57 stating they were on the 21st floor and smoke was in the next door flat.
00:14:03 The call handler advised that they should leave the building and cover themselves in
00:14:07 wet towels as they go down the stairs.
00:14:12 Ms. Cabrasco refers to the worsening conditions in her witness statement.
00:14:21 She says it was now about 2.33am in the flat, there was now a lot of smoke and we were all
00:14:27 coughing. Marcio had given us all a wet towel to cover our faces
00:14:31 and we were all in the bathroom. We were all in the bathroom.
00:14:34 The group opened the door to see if they could escape. Marcio said we need to go.
00:14:44 Ms. Cabrasco recalls in her witness statement that in preparation of their escape,
00:14:49 Marcio had filled the bath up earlier on and smoked towels for us all.
00:14:55 We were soaking wet by now as each time we didn't go out and we got wet from the towels.
00:15:00 The first time we tried to go out, Andrea opened the door.
00:15:03 The second time was Marcio and I'm not sure who opened it the third time, Ms. Cabrasco says.
00:15:12 The conditions outside of flat 183 were such as to initially prevent the families from escaping
00:15:17 and they had to go back into the flat. Andrea describes that when we opened the door
00:15:26 there was a big cloud of black smoke. I've never seen nothing like that in my life.
00:15:33 It's like when you see a horror film.
00:15:37 I just panicked because I couldn't breathe. The smoke was really bad, really thick and I couldn't.
00:15:41 It was hot. It was like the smoke was hot. It burned your nostrils, your throat.
00:15:47 I never felt that in my life so I panic. It's like a hand that goes into your nose and mouth
00:15:53 and you can't breathe and I said no I can't go. The main factor was the smoke.
00:16:05 This was explained by Marcio who gave reasons for not leaving earlier other than the stay put advice.
00:16:14 So we tried twice before the final time to get out. Initially the first time I opened the door
00:16:18 it was pitch black and it was just full of smoke. He thinks it would have been around
00:16:23 two o'clock in the morning give or take. It was already full of smoke. It was pitch black and
00:16:27 something you couldn't breathe it. It was almost like it had a chemical based at smoke. You know
00:16:34 the only other smoke ever really smelt would have been barbecue smoke and all that kind of stuff
00:16:40 which is wood and I guess natural stuff he says but it was nothing like that. It was very much
00:16:46 chemical orientated in terms of the smoke. It was very thick which continuously just made you gag
00:16:53 every time you tried to take a breath of air. There was no emergency lighting or anything like that.
00:17:00 Everybody just turned around as soon as we opened the door and came back we just couldn't get out.
00:17:04 But they had to try again.
00:17:19 Marcio describes the conditions as they stepped out again. There was smoke as soon as we left the
00:17:23 flat. I can't describe how it smelt because I've never come across anything like that.
00:17:28 You're always having gag reflex every single time as soon as you take any breath you were gagging.
00:17:33 I wasn't vomiting but it was always gagging. Just so intense you couldn't see anything. It was black
00:17:39 smoke. Couldn't even see your hand in front of you. So I can't even imagine what my daughters and
00:17:46 everyone else was going through at that time. The smoke was definitely on the hotter side which pits black.
00:17:53 I can't remember.
00:18:00 Andreas remembered at that stage the smoke was so intense and so thick I couldn't see anything. It
00:18:04 was burning. It was so dry that you couldn't even swallow. Marcio further described the smoke
00:18:16 in reference to the toxicity of the fumes which of course they all including Andrea would have
00:18:21 been breathing in.
00:18:28 Smoke is the biggest thing that I remember he says.
00:18:31 That's purely because the continuous gagging reflexes all the way down the stairwell.
00:18:36 I can't even explain the smell. It was just a toxic smell.
00:18:41 I've never experienced anything like it so I've got nothing to compare it to. It was strong,
00:18:45 toxic and overpowering as they then tried to descend.
00:18:52 The tower.
00:18:59 Marcio describes that there were lots of dead bodies in the corridors where people had collapsed
00:19:05 before they'd been able to escape. Andrea recalls the conditions in the corridor and the stairwell
00:19:13 saying on the stairs are stepping over people and there was people that were just letting out
00:19:18 sounds like trying to scream maybe but it was only like a very light sound. Someone grabbed my foot.
00:19:27 I don't know if it was the same person that said help but I couldn't stop obviously.
00:19:35 Miss Kambresco said if we'd stopped at any point it would risk becoming overcome by smoke and
00:19:40 suffering the same fate as those lying on the floor. We knew that our only hope was to keep
00:19:46 moving and not to stop. I could feel that I was suffering the effects of smoke inhalation
00:19:53 and I felt it was just a matter of time before we would also have collapsed on the stairwell
00:19:59 and that we would surely die there.
00:20:03 Helen says I was finding it very hard to breathe.
00:20:09 Nancy says on the night of the fire on our way down the stairwell it was pitch black. I couldn't even
00:20:13 see the doors let alone the loggy areas. I didn't see any flames or fire on my way down.
00:20:22 As the family continued their escape down the tower they noted that conditions improved
00:20:27 somewhat at the 10th and 8th floor.
00:20:32 Marcio says it was only when they started coming down that I could see it was my daughter.
00:20:37 We were between the 10th and the 8th floor at that time give or take. It was still dark but you could
00:20:42 see a bit of light at that point and I could breathe a little bit more.
00:20:48 You still couldn't see much but it was a lot better than being at the higher floors.
00:20:54 During her descent from the flat down the stairs Andrea bumped into a firefighter
00:20:59 called Aldo Diana around the 9th floor. Andrea had been separated from Marcio and was described by
00:21:06 the firefighter as being in a state of shock probably suffering from smoke inhalation.
00:21:12 Firefighter Aldo Diana recorded in his witness statement what he saw of the family at that time.
00:21:25 Firefighter Diana stated that they must not have been able to see them because of the dense smoke.
00:21:29 They were in a state of shock possible smoke inhalation. I have no idea what floor they came
00:21:36 from or what flat. I didn't question them. The more smoke they take in the more they are
00:21:40 survived so it's just get them out. Questions can be asked later when they are down and out with
00:21:46 other firefighters. He went past and was going down the stairs in front of us. I was between him and
00:21:53 the two girls and Dean was behind as we led them down the stairs. Once we got to an area that
00:21:59 was clear light with firefighters we handed them over. This was above the mezzanine floor, maybe
00:22:06 two or three floors above it. We took those three out and then went back up to try to get again to
00:22:11 the 16th floor. Firefighter Dean Nelson stated that see him Diana and I went back up between the
00:22:21 sixth and eighth floor. He says this, this is when we saw three people, a pregnant lady,
00:22:28 another female believed to be her neighbour and a girl. I was in the middle of the room and I
00:22:34 saw a woman and a girl. Visibility was now quite poor and I could only make out silhouettes.
00:22:41 However I could see that the neighbour and the girl were trying to help the pregnant lady down
00:22:45 the stairs. She was clearly heavily pregnant and I believe someone also told me she was pregnant.
00:22:54 I put my arm around the pregnant lady and helped her down the stairs. See him Diana helped the
00:22:58 other lady and the other lady walked herself down.
00:23:03 The only communication we had was us telling them that it was okay and we're here to help.
00:23:08 The pregnant lady had tanned skin, long hair, her neighbour was black and I can't remember what the
00:23:13 girl looked like. We assisted them down to the mezzanine floor where the other firefighters took
00:23:18 over. They were walking the whole time assisted by us. They were disorientated and distressed
00:23:27 and not in a good way. Ms. Combrezco recalls, towards the bottom I guess about the first or
00:23:37 second floor the smoke suddenly got lighter and I felt it easier to breathe. It was almost like
00:23:42 fresh air. I could see it was lighter too. I remember seeing a fireman behind and behind me
00:23:48 was Andrea with one of her daughters. Andrea looked like she was drunk and was staggering.
00:23:56 She sat down on a bench or something I think and then just looked lost. I asked and said,
00:24:00 are you okay? One of her daughters was now sitting next to her and I told the fireman that Andrea was
00:24:06 pregnant. In fact, Marcio had made a call which lasted throughout the descent.
00:24:19 It started at 3.25 and lasted 34 minutes and 55 seconds.
00:24:30 This call to emergency services continued throughout the horrific and terrifying descent
00:24:35 of the family and the families from the 21st floor through the thick poisonous smoke.
00:24:42 It also records the moment when Marcio lost his children wife and you can hear him screaming in
00:24:47 desperation as he realised that he may have lost them on the way down. He tries to go back up to
00:24:57 save them. So you will remember hearing this call in phase one of this inquiry.
00:25:06 Mrs. Van Mist-Ackboren, we don't obviously intend to play that call at this time but we would ask
00:25:14 you to take some time if you haven't heard it already to play it and listen to it yourselves.
00:25:22 Outside, Andrea states she went to an area near some trees
00:25:29 around the tower where Marcio told her that their daughter was with paramedics before being taken
00:25:36 to hospital. The CCTV images from the tower around 3.38 in the morning shows Andrea exiting
00:25:45 the tower into the community room at that time. At the scene, Andrea was attended by
00:25:56 the London Ambulance Service and the ambulance, it's worthy of note that as regards a system
00:26:04 used of ambulance notes, the following codes are used. They're placed into a category either dead,
00:26:12 P1, P2 or P3. P1 is immediately life-threatening and needs treatment and conveyance to hospital
00:26:18 urgently. P2 is urgent, still critical but not as immediately life-threatening as P1. P3 is walking
00:26:28 wounded. A tag is placed around the wrist of a patient stating which category they are in.
00:26:37 The ambulance crew classified Andrea as P3 and was advised that they were pregnant, that she was
00:26:43 pregnant. The ambulance crew were advised by the doctor at the scene handover that the family had
00:26:48 come from the 21st floor and that their problems at the time were smoke inhalation and difficulty
00:26:53 in breathing. There was chest tightness and sore throats and therefore each of the patients
00:26:59 was wearing an oxygen mask. The ambulance crew confirms they left the scene at the fire with
00:27:06 the family at 4.10am arriving at the hospital at 4.24am. Andrea remembers waking up four days later.
00:27:24 Andrea's hospital notes summary report provides that on the 14th of June, the afternoon
00:27:31 of that day at 2.24 in the afternoon, that Andrea's carbon monoxide level was noted to be 18%
00:27:39 at the time of admission. So you'll probably be aware that normal blood levels of carbon monoxide
00:27:44 should be around 2.3. Andrea was reviewed in emergency department by the obstetrics team.
00:27:53 who detected a fetal heartbeat at that time.
00:28:04 At 3.11pm that afternoon following admission to ITU, Andrea was noted to have become increasingly
00:28:10 acidotic. She was subsequently re-reviewed by the obstetrics team who noted fetal
00:28:19 radicardia. That's a heart rate slower than 60 beats per minute.
00:28:24 That was after taking an ultrasound of Andrea's abdomen.
00:28:30 Although there was a high risk of death of the fetus without urgent delivery,
00:28:35 maternal care remained the priority. And there also remained a high risk of hypoxia and disability
00:28:42 as it was not clear how long the fetal radicardia had persisted for.
00:28:49 As Andrea was acidotic at this point, the decision was made to insert a vas cath,
00:28:56 a catheter, a flexible plastic tube if you like, that is inserted into a vein located either in the neck or in the groin.
00:29:06 And then start filtration in theatre.
00:29:10 Unfortunately in the short time it took to insert the vas cath, which takes about 15 minutes,
00:29:15 on re-scanning no fetal heartbeat could be detected.
00:29:22 Andrea was then taken to theatre for a caesarean section on the evening of the 14th June
00:29:27 and the deceased child Logan was delivered.
00:29:30 First, more to reports are always very distressing none more so when dealing with a child or a baby.
00:29:40 The post-mortem for Logan was conducted by Dr Andrea Su Stelle with Women.
00:29:46 His ent vostosto sulphide at 6 kmol the scream was 끝나id in his forehead,
00:29:59 Andreas Marinades, who said, the main disease or condition in the fetus is unknown. The
00:30:06 main maternal disease or condition affecting the fetus was acute carbon monoxide poisoning
00:30:13 and severe acidosis. I take that from the coroner's report.
00:30:19 Further information has been provided from the letter from Dr Leonie Penner, the consultant
00:30:24 and obstetrician for Andrea Perestralo. In a letter from Dr Penner, she writes, we started
00:30:34 by reviewing the results of the post-mortem together. I explained that this showed that
00:30:39 Logan was normally grown, and I commented to you, at 1.5 kilos, he was an extremely
00:30:45 well-grown baby for 30 weeks gestation. But this is consistent with the birth weights
00:30:51 of your daughters, who are also above average size and so normal for you. The post-mortem
00:31:00 showed that he had died recently, as we knew, and that he had no congenital malformations.
00:31:09 Examination showed that he died very suddenly due to some form of stress. And I explained
00:31:16 to you that the most likely explanation for this was that he was very short of oxygen
00:31:21 or had too much acid in his blood. The placenta showed no signs that there was any abruption,
00:31:33 separation or break, which can cause sudden stress for a foetus, of course. And I confirmed
00:31:40 to Andrea that at the time of the caesarean section, there was no suggestion that there
00:31:46 was any problem in the womb. I'm now going to refer to the report from Professor Perser.
00:31:54 Professor Perser's overall findings for Logan Gomez's mother, Andrea, are that she
00:32:04 inhaled a substantial dose of asphyxiant gases, mainly carbon monoxide and some hydrogen cyanide.
00:32:14 And, of course, irritant smoke particles. This was partly while in flat 183,
00:32:24 but mainly when descending the stair. The dose of asphyxiance was at the threshold for collapse,
00:32:31 and she did suffer some weakness at the tower, but was able to walk out.
00:32:38 Dr. Perser explains, carbon monoxide in a mother's blood gradually spreads to the baby's circulation
00:32:49 via the placenta. There is a time lag of approximately an hour between the blood concentration in the
00:32:55 mother and that in the foetus. Due to the relatively short period of exposure of Andrea to high
00:33:03 concentrations of CO in the tower, carbon monoxide in the tower, and her subsequent oxygen treatment,
00:33:09 it is likely that the significant transfer and accumulation of carbon monoxide or hydrogen cyanide
00:33:15 in the blood of her baby was avoided. The concentration measured in the baby after death
00:33:23 was very low. It is possible that the concentration in the baby's blood may have been somewhat higher,
00:33:28 but it is unlikely to have reached toxicologically significant concentrations in the baby's blood.
00:33:38 The baby will also have been protected from potential hypoxia by benefiting from the
00:33:42 mother's oxygen treatment. For these reasons, Professor Perser says, it is unlikely that the
00:33:51 baby was directly affected by carbon monoxide or hydrogen cyanide accumulating in the baby's blood.
00:34:01 Professor Perser says this, the main cause of stress to the baby
00:34:06 is therefore likely to have been the hypoxia and acidosis of the mother
00:34:09 during and after exposure in the tower.
00:34:12 Professor Perser concludes. Baby Logan Gomez died sometime during the day on the 14th of June,
00:34:20 while his mother was treated for acidosis and was delivered stillborn by caesarean section
00:34:26 on the evening of the 14th of June. The postmortem findings for the baby were of terminal
00:34:32 pathophysiological stress in several organs. The baby was then taken to hospital in the
00:34:39 postmortem and was treated for acidosis.
00:34:51 Summary therefore, Logan was alive having arrived at the hospital.
00:34:58 Dr Penner put it this way. We know that Logan died in the womb sometime during the day on the 14th of June.
00:35:05 Logan's last detected heartbeat was at 1511, therefore it is likely that Logan died after that time during the vas cath procedure.
00:35:17 Logan was delivered stillborn at King's College Hospital on the 14th of June, 2303, 1103 at night.
00:35:28 We're now going to read some words from Marcio.
00:35:39 It was with the deepest sadness and indescribable pain that I was told by the staff at King's College Hospital
00:35:48 that our unborn son had died as a result of the effects of the smoke and toxic fumes from the fire.
00:35:56 The death of Dr Penner was a result of the death of his mother,
00:36:02 and we know that our unborn son had died as a result of the effects of the smoke and toxic fumes from the fire.
00:36:10 Logan was stillborn in King's College Hospital, whilst Andrea was still in an induced coma after the fire.
00:36:17 He was delivered by Caesarean section. I was there to witness his stillbirth. I held him in my arms.
00:36:27 I cannot even start to describe how crushingly sad I felt at the loss of our baby.
00:36:33 When Andrea awoke from her coma, the first thing she asked me was, how's the baby?
00:36:47 It was devastating to have to tell her that he was gone.
00:36:53 She had never got to hold him in her arms.
00:36:58 It was a terrible time.
00:37:02 Thank you very much, Mr Steen.
00:37:30 Well, it's time that we had a break. We shall rise now and we shall resume at 5 past 11.
00:37:36 Please. Thank you very much.
01:30:29 Yes, Mr Millett.
01:30:36 Yes, Mr Chairman. I now call upon Mr Danny Friedman QC to come back to the podium, please,
01:30:43 to make the presentation on behalf of the family of Khadija Khaloufi from flat 143 on floor 17 of
01:30:51 Grenfell Tower. As before, I would give the trigger warning so that the presentation may contain
01:30:57 material or discussions or images which some may find distressing, and they should leave the room
01:31:04 now or look away from the livestream as the case may be. Mr Friedman, thank you.
01:31:16 Yes, Mr Friedman.
01:31:25 Khadija Khaloufi was born in Mohamedaya, Morocco on the 6th of September 1964.
01:31:33 She was 52 years old at the time of her death. She lived in flat 143 of Grenfell Tower with her
01:31:41 husband, Sabah Abdallah, on what became floor 17 after the refurbishment.
01:31:48 Mr Abdallah moved to Grenfell Tower in 1989 with his son, Alex Abdallah, who was aged 14 at the
01:31:56 time. Khadija Khaloufi moved in permanently to join Sabah and his son in 1990 after their marriage.
01:32:06 She happily looked after Sabah and treated Alex like her own son until the date of the fire.
01:32:12 Khadija was solemnly supported by Mr Abdallah when they lived together.
01:32:19 Khadija is survived by her husband and also her mother Zohra Rabai and siblings, Amal Khaloufi,
01:32:28 Ilhan Khaloufi, Bohra Khaloufi, Hicham Khaloufi, Karim Khaloufi and Nawal Khaloufi,
01:32:36 and her stepchildren, Alex Abdallah and Alia Abdallah.
01:32:43 Sir, you will recall that Sabah Abdallah appeared at a commemoration hearing on the 25th of May 2018.
01:32:51 He introduced a video commemoration that he had prepared as a loving tribute to his wife and their
01:32:58 27 happy years of marriage. On the 30th of May 2018, a commemoration statement was read to you
01:33:06 by Khadija's youngest brother, Karim Khaloufi, on behalf of him, his mother, his brother and sisters.
01:33:14 As you heard, Khadija was from Mohamedia, Morocco. She was the eldest of seven siblings.
01:33:22 She was remembered as the apple of her mother's eye and like a second mother to her younger siblings.
01:33:30 Having successfully completed school, she went on to obtain a degree in Casablanca
01:33:35 before returning to Mohamedia to manage a pharmacy. She loved working and used her salary
01:33:43 to support her family. Khadija took the opportunity to live and work in Holland
01:33:49 before moving to London. There she met Mr. Abdallah at a centre assisting immigrants to
01:33:55 integrate through learning, as Khadija herself had initially struggled to do upon arrival in London.
01:34:02 Throughout her life, Khadija remained close to her family in Morocco and never ceased to be a
01:34:08 source of support to them. She and Sabah enjoyed nearly a month-long visit to her home just weeks
01:34:15 before the fire. Khadija was remembered by her family with gratitude for her big heart,
01:34:22 her sense of responsibility and her enormous concern for their wellbeing. In Sabah's
01:34:30 commemoration video, you heard of the unique person Khadija was and the irreplaceable part of
01:34:36 his life that he had lost. This was a poignant video with photos of their many happy times together,
01:34:43 of Khadija decorating their home at Grenfell and of the couple travelling,
01:34:48 free as birds, to visit family and friends abroad. You also heard how Khadija selflessly cared for
01:34:57 all of those around her, Sabah's children to whom she became a mother, Sabah's mother in her ill
01:35:03 health before her death and Khadija's many friends who she was always ready to help.
01:35:09 Residents of Grenfell Tower and the Lancaster West Estate likewise describe a person who in
01:35:15 Mushtaq Lashari's words was beautiful, friendly and kind and who Rita Tankarian told you was
01:35:24 something, was everything to Sabah, her husband. As I will return to, it may well be that the reason
01:35:31 why Khadija entered the 11th floor on the night of the fire rather than continuing to safety down
01:35:37 the stairwell with her husband was to warn a young Moroccan family with children of the need to evacuate.
01:35:49 CCTV footage shows Khadija in the lift lobby of Grenfell Tower at 1602 58,
01:35:57 waiting to go up into the building on the 13th of June. The inquiry is familiar with the evidence
01:36:05 of the rapid vertical spread of the fire up the tower from flat 16. Events on floor 10 are relevant.
01:36:14 Before 0120, Hongkang Kwong, one of the tenants of flat 76 on floor 10, was woken by a smoke alarm
01:36:23 and witnessed fire entering her kitchen window. She and the other occupant, Van Kwong Ho, fled the
01:36:30 flat shortly after, which was by then filling with smoke. She would leave the building at 0126.
01:36:43 Due to the absence of a functioning self-closing device, the flat 76 front door did not close
01:36:49 behind the fleeing occupants and the communal lobby rapidly filled with dense, deadly toxic
01:36:56 fumes from the fire. The inquiry found at volume 2, paragraph 10.205, that the smoke that Mrs Kwong
01:37:05 saw in the lobby before she exited was smoke coming out of her own burning flat with the door not closed.
01:37:14 Panel, I start in this way by focusing on the deterioration of the conditions on floor 10
01:37:20 because as you know this is where the lift containing Khadija Khaloufi would stop shortly
01:37:26 after with fatal consequences. Analysis of the footage of the fire spread on the flat 6
01:37:35 column of the tower confirms that the fire had reached the top of floor 17 by 0124.36.
01:37:43 Virgilio Castro, one of the occupants of flat 146 on floor 17, described being woken at around 0115
01:37:54 by smoke alarms and both his flatmate Gennaro Botoan and girlfriend shouting,
01:38:00 fire, fire, fire. Mr Castro went into the hallway and saw the fire already outside the kitchen window
01:38:08 and then flames came through the ventilation fan. Gennaro Botoan fled the flat first,
01:38:15 followed by Virgilio Castro and his girlfriend shortly after. They were all in a state of panic.
01:38:21 They exited the building shortly after 0130.
01:38:27 The phase one report has already concluded at volume 4, paragraph 24.31, that the front door
01:38:33 of flat 146 was defective and did not close behind the occupants as they fled.
01:38:40 Corrine Jones, the resident of flat 145, saw Virgilio Castro before he left the floor.
01:38:47 He was standing outside his front door with thick black smoke emerging from the top of the door
01:38:52 and moving along the ceiling. After briefly going back into her flat for a period of seconds,
01:38:58 Corrine came back out to find a massive deterioration in the conditions of the lobby.
01:39:04 She and her children exited the building at 0130. The occupants of flat 141 were the first survivors
01:39:13 from floor 17 to leave the tower. They were prompted by the sound of the arriving fire engines.
01:39:21 Mesrob Kassemjian was in the flat with his girlfriend Fung He Chung. His aunt Rita
01:39:28 Tankarian was asleep in the bedroom. Out of concern for the fire engines outside and the glowing
01:39:37 reflection of fire, the occupants decided they needed to leave.
01:39:43 Rita Tankarian was a close friend of Khadija Khaloufi. Before evacuating from floor 17,
01:39:50 she and the other residents of flat 141 made sure that they had alerted Khadija and Sabah
01:39:55 that they must immediately leave. After trying to ring the doorbell, Rita told Mesrob to
01:40:02 knock hard until someone answered. He did so until Khadija came to the door. He told her that there
01:40:09 was a fire and that they must leave. Khadija went to get Sabah. This is the last time Mesrob saw Khadija.
01:40:17 Rita Tankarian exited the building at 0126.48. She and the others believed that Khadija and Sabah
01:40:25 would be exiting behind them. However, only Sabah Rabdallah exited at 0127.38. The timings are
01:40:35 important because they point to the likelihood that the woman who was seen by Nadja Jafari
01:40:41 to enter the lobby on floor 11 at around 0124 was Khadija Khaloufi.
01:40:51 The evidence, which I will develop in the next presentation, suggests that the point at which
01:40:58 Khadija was separated from Sabah Rabdallah is on their descent down the stairs at the level of the
01:41:04 floor. Although it cannot be known for sure, it appears that Khadija entered floor 11 in order to
01:41:09 ensure that the Moroccan family who lived at flat 85 had safely left the building. This was Muna
01:41:17 El Ogbani and Youssef Khaloud and their three children. Khadija and Muna were friends. As you
01:41:25 have heard from the commemoration, it would have been just like Khadija, but it was a different
01:41:31 situation. It would have been just like Khadija to try to help her friends in this way.
01:41:37 However, Muna's family had left their flat just a few minutes earlier and exited the building at 0128.
01:41:45 In fact, they saw Sabah Abdulla while they were still on the stairs and described him as looking
01:41:52 frightened. Nadja Jafari, as you will hear in the next presentation, had fled flat 86 with her
01:42:01 father after 0121 in response to the fire in their kitchen and spent time on the lobby
01:42:10 banging doors and Mr Jafari calling his friend on the 23rd floor. Nadja's evidence was that there
01:42:19 was suddenly a woman who entered floor 11 from the stairwell before entering the lift at the same time
01:42:25 as Nadja and her father.
01:42:30 Nadja Jafari thought that there were six people in the lift in total once she, her father and the
01:42:35 woman from the stairwell had entered. However, the phase one report concluded at volume two,
01:42:41 paragraphs 10.221 to 10.225 that there were likely only five, identifying the people as
01:42:51 Ali Jawa Jafari, Nadja Jafari, Ria Rojo, Mohamed Dour Tuku and Khadija Khaloufi.
01:43:01 Ria Rojo, the only other female in the lift, had entered it on floor 12 after leaving flat 91
01:43:09 as confirmed by Roy Smith so it could not have been her who Nadja saw entering the lift on floor 11.
01:43:17 Professor Persa identifies the point in time that the lift left floor 11 as around 01.24.
01:43:28 The Chair has found in his phase one report at volume four, paragraphs 25.6 and 33.13,
01:43:37 that Crew Manager Secret attempted unsuccessfully to use a drop key to bring the Grenfell lifts
01:43:43 under the firefighters exclusive control, leaving residents who use the lift exposed
01:43:49 to the fatal risk of being taken to the floor affected by fire. Moreover, the lift did not
01:43:58 meet the technical standards of firefighting lifts which may have avoided this problem.
01:44:05 The inquiry's findings on the reasons and responsibility for this following evidence
01:44:10 and submission in other modules are important to the circumstances of the death of Khadija Khaloufi
01:44:16 as they are to Ali Jawa Jafari's death and also Mohamed Nadja Tuku. The presentations
01:44:24 for both of them will follow. The lift containing Khadija Khaloufi and the four other occupants
01:44:32 stopped unexpectedly on floor 10 and the lift doors opened. The inquiry has the evidence of
01:44:40 the survivor Nadja Jafari. Dense toxic smoke flooded in and filled the lift. The evidence of
01:44:49 those that survived suggests the smoke was so dense that it entirely eclipsed the lift lights.
01:44:55 It had a bitter chemical smell and made it very difficult to breathe. Nadja Jafari began
01:45:02 to cough and felt like vomiting. Eventually the lift doors closed and the lift descended to the
01:45:08 ground floor. It is unclear how long the lift remained on floor 10 before the doors closed
01:45:15 but Professor Persa suggests that it may have been in the order of 25 seconds.
01:45:23 On the ground floor CCTV footage shows only Nadja Jafari and Ria Roggio emerging from the lift at
01:45:31 0126. Even though the smoke cleared on the way down to the ground floor black smoke can be seen
01:45:38 billowing from the lift as it opens. There is a photograph at figure 10.28 in volume 2 of the
01:45:47 phase 1 report at page 143 that gives a powerful indication of how thick the smoke on floor 10 must
01:45:56 have been given the situation once at ground floor level and may I ask the panel in their own time
01:46:04 to remind themselves of that image. Nadja Jafari emerged coughing and choking from the building
01:46:13 and was subsequently hospitalized for emergency treatment.
01:46:21 Once outside the building Sabar Abdullah drew attention to the fact that he had lost his wife
01:46:26 this included speaking to PC Alex Jacobs at 0155 36. A number of residents also saw Sabar Abdullah
01:46:36 in a distraught state outside the building. He told them how he and his wife became separated on
01:46:42 the stairs. Rita Tankarian recalls Mr Abdullah saying that he had lost Khadija between floors 14
01:46:50 and 17. When Nadja and Maria Jafari realized that their father Ali Jawah Jafari had not evacuated
01:46:58 they tried to re-enter the building but were stopped by a policewoman for their own safety.
01:47:04 Maria Jafari relayed that her father was stuck in the lift she was told not to worry and that the
01:47:09 firefighters would bring everyone downstairs. As a matter of fact there is no evidence of LFB
01:47:16 deployments to floor 10 during much of the next hour despite the Jafari sisters information and
01:47:23 a number of residents making emergency calls from that floor. Sometime after 1 40 a BA team
01:47:31 including crew manager Tillerson and firefighter Betterson went to floor 10. Their instructions
01:47:39 from the bridgehead were to go where they could to affect search and rescue. Once at floor 10 they
01:47:45 judged it to be too dangerous to enter the lobby without water supplies due to the level of smoke
01:47:50 and heat and they returned to floor 9 where they found Sharon Lacey and her daughter.
01:47:57 However as I will return to Professor Pearse's phase two evidence has indicated that there
01:48:02 would have been a very narrow window to rescue Khadija Khaloufi once she entered the fatal
01:48:08 conditions on the floor 10 lobby. Firefighters Deforge and Mitchell were deployed to one of the
01:48:17 top floors after approximately 0 to 18 but ended up entering floor 10. There they discovered the
01:48:26 body of a female and a black male who were later identified as Khadija Khaloufi and Muhammad
01:48:32 Dortoukou. Both were described as unconscious and not breathing. It appears that their bodies were
01:48:39 found in the small corridor leading to the entrance to flat 71. Other firefighters Wright, Bell and
01:48:49 Assad joined firefighters Deforge and Mitchell in assisting to recover the bodies from the building.
01:48:55 CCTV evidence shows Khadija Khaloufi being carried into the foyer by firefighters at 02 29 15.
01:49:05 A large DKNY bag was attached to her body. It appears to be the same bag seen in the CCTV shot
01:49:14 at 16 02 44 that Khadija carried when she came into the tower for the last time on the afternoon
01:49:22 of the 13th of June. Khadija's body was passed by firefighters to paramedics working outside of the
01:49:32 building near the leisure centre at around 02 30. Once outside efforts to resuscitate Khadija were
01:49:40 commenced by London ambulance service paramedics and continued for 10 minutes. Life was pronounced
01:49:46 extinct at 02 41 by paramedic Stuart Matthews. The postmortem found soot deposits in Khadija's
01:49:58 airways indicating that she inhaled a considerable amount of toxic smoke. A toxicology sample found
01:50:06 a high 66 percent carbo oxyhemoglobin concentration in her blood. This was well in excess of a
01:50:14 concentration causing incapacitation and within the lethal concentration range.
01:50:19 Based on this the final postmortem report identified the medical cause of death to be inhalation of
01:50:26 fire fumes. Professor Persa has examined the circumstances of the three people who came out
01:50:33 of the lift on floor 10 that is Ms Khaloufi, Mr Jafari and Mr Tuku. He has explained how the
01:50:42 time period to collapse for an adult of good health in the toxic conditions of the floor 10
01:50:47 lobby was very short. He calculates a period of around 2.5 minutes but acknowledges that at the
01:50:54 upper limit of the possible toxic range this could have been as short as 30 seconds.
01:51:01 The short time window until collapse for the three occupants who came out of the lift on floor 10
01:51:07 is confirmed by the fact that tragically none of them managed to find the stairwell door.
01:51:12 Before they became incapacitated. On Professor Persa's expert evidence
01:51:18 Khadija died within minutes thereafter by around 01.44.
01:51:28 Prasi Nalakwago left flat 71 on floor 10 at some point before 01.3503 which is the time caught by
01:51:40 the CCTV image when she exits the tower from the ground floor having gone down the stairs.
01:51:47 Almost immediately after exiting flat 71 Prasi stumbled over two bodies and then what she thought
01:51:54 was a further two that we now know it was a total of three. That suggests that all three of those
01:52:01 who died on the floor were at a minimum unconscious at a point before 01.35 and at a time closer to
01:52:10 01.30. Khadija became unconscious at a point physically close to flat 71 indicative of
01:52:19 trying to make it to the stairs but going too far and then collapsing.
01:52:28 What was the fatal difference between the occupants who wholly unexpectedly and
01:52:32 chaotically emerged from the lift when it stopped on floor 10 and those such as Prasi Nalakwago
01:52:39 who managed to cross the toxic conditions of the lobby from their flats. Those who came out of the
01:52:46 lift laboured under the inability to pre-plan and orientate themselves in order to rapidly locate
01:52:53 and exit into the stairs before being overcome by the effects of the toxic gases. Prasi was able to
01:53:00 run that gauntlet. Nadia Jafari and Rio Rojo were lucky not to stumble out of the lift.
01:53:08 The immediate cause of death here was caused by the accidental opening of the lift. A lift that
01:53:14 remained outside of regulated control and the consequences that flowed from those deficiencies.
01:53:20 However as with other floors the toxic and disorientating condition of the floor 10 lobby
01:53:27 was contributed to by door the door to flat 76 and number six flat not closing.
01:53:37 At the end of his video for his commemoration of his beloved and loving wife,
01:53:44 Sabar Abdullah told the chair that when Khadija died I lost a part of me. His face on the video
01:53:53 of a proud but openly affectionate man is powerful even if it is gentle. Khadija's death was an
01:54:03 unbearable loss to her husband as it was to her wider family and friends. Khadija was her mother's
01:54:10 soulmate, confidant and advisor. For her sisters and brothers Khadija was their second mother who
01:54:18 they all loved and respected. Khadija cared for her friends even to the point of risking her life
01:54:25 although like so many others in the tower that night she did not realise how truly dangerous
01:54:32 the conditions were until it was too late. Thank you sir.
01:54:45 Thank you very much Mr Friedman. Now at this point I think we ought to have another break.
01:55:06 May I ask for 20 minutes? Yes of course. Shall we say 12.15? Yes.
01:55:13 Unless you send a message to the contrary. I'm grateful thank you. Thank you very much. 12.15 please.
02:15:43 Yes Mr Millet. Mr Chairman I now ask Mr Danny Friedman QC please to come back to the podium
02:16:05 to make the presentation on behalf of the family of Ali Yawar Jafari from flat 86 on floor 11
02:16:13 of Grenfell Tower. As before I would repeat the trigger warning that what Mr Friedman is about
02:16:19 to tell us or show us may be distressing to those watching or here in the room and if so then people
02:16:25 are free to leave this room or to look away from the live stream as the case may be. Mr Friedman thank you.
02:16:44 Mr Ali Yawar Jafari was born on the 1st of January 1936 in Kandahar Afghanistan.
02:16:58 He was 81 years old at the time of his death. He and his wife Fatima had six children
02:17:05 Farid, Bashir, Farida, Maria, Hamid and Nadia. Before his retirement Mr Jafari worked as a jeweller.
02:17:19 He and his wife came to the UK in 1999 and built a happy life in London with five of their six children.
02:17:28 The family moved into flat 86 of Grenfell Tower in 2003 as tenants of Notting Hill Housing Trust.
02:17:38 The home provided was by way of temporary accommodation. The family lived under that
02:17:44 housing status for the next 14 years. At the time of the fire Ali Yawar Jafari was living in the flat
02:17:54 with his wife and two daughters Maria and Nadia.
02:18:00 Mrs Fatima Jafari appeared at the commemoration hearing on the 23rd of May 2018 together with
02:18:07 Maria, Hamid and Nadia. Maria and Hamid addressed you. A film prepared by the family was played
02:18:17 in which each family member recalled Mr Jafari in life and conveyed the pain of their loss.
02:18:23 The family remembered the husband and father as a particularly happy, generous, gentle,
02:18:30 calm and caring person. By all accounts Mr Jafari was a man who put others before himself,
02:18:38 a man who would go out of his way to help people even if he could not communicate with them in
02:18:43 English. He lived his life that way to the end making every effort on the night of the fire
02:18:49 to warn neighbours and friends. At 81 years of age Mr Jafari suffered from a number of long
02:18:59 standing physical health conditions. These included diagnosed heart disease that required
02:19:05 an arterial stent. He also had diabetes and pain in his knees. Due to these difficulties with his
02:19:13 health Mr Jafari's mobility was significantly limited. He was unable to descend unassisted
02:19:19 via the single staircase at Grenfell and therefore dependent on the lift to enter and exit his home
02:19:25 on floor 11. These challenges were recorded in his housing file. As early as 2001 his housing record
02:19:34 identified mobility issues due to his medical diagnoses and acknowledged that he was medically
02:19:40 assessed as requiring a property with no more than 10 steps to access in total.
02:19:48 As was the case in respect of all such other residents at Grenfell there was no arrangements
02:19:55 in place to assist Ali Jawa Jafari to evacuate the building in the event of a need to do so
02:20:00 such as a personal emergency evacuation plan. Nor were there any pre-existing communications
02:20:07 or arrangements with the LFB to secure his assisted evacuation or rescue. Chair has of course
02:20:15 already recognised the imperative for all residents to have the benefit of an evacuation plan in his
02:20:22 urgent phase one recommendation. How it was that Mr Jafari came to be without a plan or means of
02:20:29 escape and responsibility for this situation are of course matters which the inquiry will make
02:20:35 further findings on following the phase two modules. Mr Jafari was at home with his wife and
02:20:45 daughters Maria and Nadia on the night of the fire. Nadia who gave evidence in phase one was
02:20:53 recovering from an operation five days before. Like her father her mobility was impaired. It was
02:21:01 still difficult for her to even walk between the rooms in the flat. Also like her father
02:21:07 she would need to use the lift in order to get out of the building.
02:21:12 Ali Jawa can be seen on the CCTV at 19.40 pm in the lift lobby waiting to go up into the tower.
02:21:22 Mrs Jafari's family recall him as being very happy that night and enjoying their family dinner to
02:21:28 break the fast eating two plates of rice rather than his usual one. He took medication prescribed
02:21:35 for his heart condition and went to bed. The medication here has an added significance.
02:21:41 It tended to make him drowsy. In fact one of the pills was designed to help him sleep.
02:21:47 These factors affected the speed with which Mr Jafari could be woken up and exit the flat in an
02:21:53 emergency. The inquiry is familiar with the evidence of the rapid vertical spread of the
02:22:00 fire up the tower from flat 16. The family became aware of the existence of a fire before it reached
02:22:07 floor 11. Mrs Jafari was still awake and in the sitting room. She heard noise from outside,
02:22:15 looked out of the window and saw that a crowd gathered. She went to Maria and told her daughter
02:22:22 to wake the rest of the household. Maria woke Nadia. Nadia went to wake her father.
02:22:30 Mrs Jafari wanted to go downstairs to check what was going on. Maria still thought it was a small
02:22:36 fire but her mother insisted that they needed to find out. Mrs Jafari and Maria therefore
02:22:42 descended the tower in the lift. Nadia stayed behind to help her father who due to his condition
02:22:48 would take longer to rouse and ready himself.
02:22:54 Timing of the mother and older daughter leaving the flat can be linked to the exit of Emma O'Connor
02:23:02 and Luke Towner who used the same lift to come down from floor 20 and saw two women wearing hijab.
02:23:10 With Emma's mobility impairment and without any other plan to evacuate, she too needed to use the
02:23:17 lift to get out early rather than stay put and wait and see what might occur. Mrs Jafari, Maria,
02:23:25 Emma and Luke can be seen on the ground floor CCTV images from 0119 onwards. Those from floor 20
02:23:33 exited the building at 0120 and Mrs Jafari and Maria exited at 0121.
02:23:41 The fire began to threaten flat 86 as early as 0120 after Fatima and Maria had left the flat
02:23:49 but while Nadia and Mrs Jafari remained. As anticipated, Mrs Jafari was slow to wake after
02:23:57 Nadia went to him. While he was rousing, Nadia saw flames reach and cover their kitchen window
02:24:04 and witnessed the window pane break. You will recall, sir, her important evidence in phase one
02:24:13 about the manner in which the fourth floor appliance fire dramatically entered the kitchen on floor 11.
02:24:23 Nadia and her father rushed out of the flat. Once in the lobby, at Mrs Jafari's insistence,
02:24:31 they knocked on neighbours' doors and called a family friend in the tower to warn him.
02:24:37 The friend was Mohammed Saber Nida in flat 205 who would also tragically die.
02:24:45 As the phase one report was found at volume two, paragraphs 10.221 to 10.225,
02:24:53 Mrs Jafari and Nadia entered the lift on floor 11 with one other person, Khadija Khilufi, who had
02:25:00 descended from her flat on floor 17 and joining two others already in the lift, Rio Rojo and Muhammad
02:25:08 Nador Tuku. Whilst in the lobby, Nadia saw her father sweating and shaking. Having literally fled
02:25:17 the flat, neither Nadia or her father had the spray he ordinarily carried and would use to help
02:25:22 his blood flow when he presented in this way. Mrs Jafari and Nadia, father and daughter,
02:25:30 were presented with no alternative but to take the lift. Ali Jawa was unable to independently
02:25:36 descend the staircase and Nadia, so soon after her operation, was not in a position to try to assist
02:25:44 him. Meanwhile, Mrs Jafari and Maria, who had reasonably gone ahead to check that all was well,
02:25:52 now found themselves at ground floor level, confronting for them the unimaginable sight of
02:25:58 a whole tower block increasingly on fire. The timing of when Mr Jafari and Nadia were on the
02:26:07 corridor and stood by the lift can be identified by them seeing Muna El Ogbani and Yusuf Khaloud
02:26:14 from flat 85. That couple had seen a firefighter at the fire exit door on floor 11,
02:26:21 who had told them to leave. This would have been likely firefighter O'Byrne. He was caught on CCTV
02:26:28 camera at floor 7 at 012157, which suggests that he would have been at floor 11 level to about 0123.
02:26:38 Consistent with this, Professor Persa identifies the point in time that the lift left floor 11
02:26:44 as around 0124. As the Chair has found in his Phase 1 report, at Volume 4, paragraphs 25.6
02:26:55 and 33.13, Crew Manager Secret attempted to use a drop key to bring the Grenfell lifts under
02:27:02 control under the firefighters' exclusive control, but was unable to do so. Consequently, the lifts
02:27:09 remained available for uncontrolled use by residents with the associated fatal risk of
02:27:15 exposing them to the effects of a fire on another floor. At the time of the fire, the Grenfell lifts
02:27:23 had not been upgraded to the technical standard of firefighting lifts either during the refurbishment
02:27:29 or during prior lift works. They therefore did not have either the superior emergency unlocking
02:27:35 triangle, which the inquiry has heard reduces problems with bringing the lift under exclusive
02:27:41 control. They also did not have the technical features to be safely used to assist with the
02:27:47 evacuation of mobility impaired persons such as Mr. Jafari. The reasons and responsibility
02:27:56 for this state of affairs are being investigated by the inquiry and have been the subject of
02:28:01 submission in another Phase 2 module. Those findings will be of obvious importance to the
02:28:07 circumstances of Ms. Jafari's death and the other two people who died there. And for the record,
02:28:15 sir, can I ask that the way I've presented it in this presentation be considered in relation to
02:28:22 Khadija Khaloufi, who I presented for before, and Mohammed Nodour Touka, who Mr. Khan's Queen
02:28:28 's counsel will present for this afternoon. On Floor 10, the residents from the flat 6
02:28:40 side of the building, flat 76, were forced to flee their home when the fire reached and penetrated
02:28:47 their kitchen shortly before it reached Jafari's home on the floor above. Due to the absence of a
02:28:55 functioning self-closing device, the flat 76 front door did not close behind the fleeing occupants.
02:29:02 The inquiry has already established that as a result of the communal lobby rapidly,
02:29:07 as a result, the communal lobby rapidly filled with dense deadly toxic fumes from the fire.
02:29:14 As the Phase 1 report found at Volume 10.200, the evidence of the resident Hong-Kuan
02:29:21 Kwan, who exited the building at 0126, is that her front door did not close by itself
02:29:29 and she did not think she had closed it. Neither did Van Kuan Ho believe that he closed the door
02:29:36 as he fled the building with her. Hong-Kuan Kuan added that at some time before the fire,
02:29:42 the TMO had removed the automatic closing mechanism from the door to enable it to close
02:29:48 properly. According to the Phase 1 report, at 10.205, the smoke that Mrs. Kuan encountered in
02:29:56 the lobby before she left it at speed under difficult circumstances was the smoke that came
02:30:02 from her own flat. At 0128, the family in flat 73 called 999. Adam Sipurio-Gasanod told the control
02:30:16 room that smoke was seeping into the flat. His cousin, Ann Chance, from the same flat gave
02:30:24 evidence that the smoke was entering under the front door from the lobby. The panel is now well
02:30:30 reminded of the consequences of non-self-closing doors throughout the building and especially
02:30:36 from the flat 6 dwellings. The Phase 1 report at Volume 4, paragraph 20.31, recognised that the
02:30:45 door to flat 76 fell into that category. As such, for reasons outlined in paragraph 20.35 of the
02:30:54 report, this was a non-self-closing front door that contributed to the fatal internal spread of smoke
02:31:02 from the external cladding fire. Can I turn to the lift containing Ali Jawah Jafari, his daughter,
02:31:13 and the three other occupants? Having stopped at floor 11, the lift then stopped again unexpectedly
02:31:21 on floor 10. The doors opened. Despite dense toxic smoke, sorry, dense toxic smoke flooded in
02:31:33 and filled the compartment. The smoke was so dense that it entirely eclipsed the light lifts.
02:31:41 It had a bitter chemical smell and it was very difficult to breathe. Nadia, as one of the surviving
02:31:47 occupants, recalls beginning to cough and that she felt like vomiting. In that moment of suddenly
02:31:55 being engulfed in dangerous smoke in that confined space, Nadia momentarily lost contact with her
02:32:02 father. Eventually the lift doors closed and the lift descended to the ground floor.
02:32:09 It is unclear how long the lift remained on floor 10 before the doors closed,
02:32:14 but Professor Purser suggests that it may have been in the order of 25 seconds.
02:32:20 CCTV footage on the ground floor shows only Nadia Jafari and Rio Rojo emerging.
02:32:28 Even though the smoke cleared on the way down to the ground floor,
02:32:32 black smoke can be seen billowing from the lift. As I said earlier this morning, the photograph
02:32:39 at figure 10.28 in volume 2 of the phase 1 report at page 143 gives a powerful indication of how
02:32:49 thick the smoke on floor 10 must have been due to the conditions that still existed by the ground
02:32:55 floor level. As to the intensity of the smoke, Nadia emerged coughing and choking from the building.
02:33:03 She was subsequently hospitalized for emergency treatment.
02:33:10 Grenfell Tower was now obviously alight. Upon realising that her father and sister had not
02:33:17 emerged at around 0122, Maria Jafari rushed back to the mezzanine landing in Grenfell Tower
02:33:25 and then up the spares to where she spoke to firefighters at the bridgehead.
02:33:30 She provided them with her family's flat and floor number and handed over the keys to the flat.
02:33:37 She explained that her sister was ill and that her father had heart problems.
02:33:42 She heard the fireman she spoke to relay over his radio that there were people trapped in flat 86
02:33:49 on floor 11. In all the many events of that night, watch manager O'Keefe could quite clearly recall
02:33:58 with distress the difficult task of taking the keys from Maria but having to resist this daughter's
02:34:05 frantic attempts to herself return to assist her father. He had to persuade her in the gentlest way
02:34:13 possible that it was too dangerous but he also recalled when thinking back about it how
02:34:18 overwhelming and emotional it was to have been the one to stop her. The reference from the phase one
02:34:26 transcripts is day 18 page 117 lines 3 to 12. Before she went to hospital, Nadia too along with
02:34:37 Maria also frantically tried to get back into the building. There is a count from police officer
02:34:43 Sanga who had to stop the daughters for their own safety. As a matter of fact, there is no evidence
02:34:53 of firefighter deployments to either floor 11 or floor 10 during much of the next hour despite Maria's
02:35:00 information and a number of residents making calls from those floors. However, Professor Purser
02:35:07 also indicated that there was a very narrow window to rescue Mr Jafari once he entered the fatal
02:35:13 conditions in floor 10. I now turn to that issue. Professor Purser has focused on the situation
02:35:24 that befell the three people who came out of the lift on floor 10. That is Ali Jawah Jafari,
02:35:30 Khadija Khaloufi and Mohammed Nadour Tuku. He's explained how the time period to collapse for an
02:35:36 adult of good health in these toxic conditions was very short. He calculates a period of around 2.5
02:35:43 minutes but acknowledges that at the upper limit of the possible toxic range this could have been
02:35:49 as short as 30 seconds. Of added significance for Mr Jafari, which I will come to, was his heart
02:35:57 condition. He was not in good health. As I mentioned in the previous presentation,
02:36:04 what we also know is that Prossie Nalekwago left flat 71 on floor 10 at some point before 01.3503,
02:36:14 which is the time caught by the CCTV image when she exited the tower from the ground floor,
02:36:22 having walked down the stairs. Before leaving her lobby, Prossie stumbled over what she believed
02:36:29 were four bodies and the enquiry now knows were three. That suggests that all three residents who
02:36:35 came out of the lift on the floor 10 were at a minimum unconscious by a point in time before
02:36:41 01.35 and closer to 01.30. Mr Jafari's body was found by firefighters Hoare and Tanner at around
02:36:53 03.05 in the floor 10 communal lobby, lying on his back near the lift. His head was positioned
02:37:01 towards the lobby entrance door with his feet towards the lift. That position suggests a rapid
02:37:08 collapse once Mr Jafari had exited the lift. The firefighters who recovered his body found
02:37:15 no signs of life and neither did the paramedics outside the building who formally pronounced
02:37:21 life extinct at 03.35. The postmortem toxicology tests indicated a carbihoxy hemoglobin level of
02:37:30 47% that is within the fatally toxic range for a person with Mr Jafari's heart condition.
02:37:38 As the postmortem explains, his heart condition had the effect of compromising blood supply to
02:37:43 the heart which meant increasing susceptibility to the asphyxiant effects of the toxic conditions.
02:37:51 Taking together those toxic conditions, Mr Jafari's significant physical vulnerability
02:37:58 and the location and position in which his body was found near the lift, the family believes that
02:38:04 Mr Jafari was lightly rendered unconscious almost immediately and in any event very soon after he
02:38:11 emerged from the smoke-filled lift. That short time window until collapse for the three occupants
02:38:21 who came out of the lift on floor 10 is yet further confirmed by the fact that tragically
02:38:26 none of them managed to find the stairwell door before they became incapacitated.
02:38:32 On Professor Purser's expert evidence, Mr Jafari died within minutes thereafter by around 01.37.
02:38:40 Professor Purser is clear that Mr Jafari was certainly unconscious and most likely dead
02:38:45 before he was exposed to the limited effects of heat evident from the postmortem examination.
02:38:51 All of this is properly reflected in the current medical cause of death in the postmortem report
02:38:57 dated 13 September 2018 which identifies 1A inhalation of fire fumes contributed to
02:39:07 two coronary and hypertensive heart disease. All of the evidence suggests that Mr Jafari,
02:39:15 aged 81, died on the floor 10 lobby of Grenfell Tower during the fire shortly after 01.27
02:39:23 and at some point before 01.37.
02:39:31 Can we end by paying tribute to Mr Jafari's family?
02:39:35 They suffered great trauma early on in the fire. They slept in the westway for several days even
02:39:42 though they were one of the early families to discover that their loved one was dead.
02:39:47 Just as Mr Jafari's daughter's daughters did everything they possibly could
02:39:52 to try to get their father out of their building, they have also done much to assist the inquiry
02:39:58 in the statements they have given to enable the findings of the phase one report to be so
02:40:03 comprehensive. Mrs Jafari and the children have lost a dear and kind man as she told you,
02:40:12 the love of Mrs Jafari's life. And even though they're even through their suffering,
02:40:18 they have continued to show great kindness and generosity and touched many people who have met
02:40:24 them from the first days after the fire until now. Thank you, sir. Thank you.
02:40:49 Thank you very much, Mr Friedman. Well, at that point, we shall have a break.
02:40:57 There is one more presentation to be made in the course of the day. That will take place at two
02:41:02 o'clock. So thank you all very much. We rise down until two o'clock.