Presentations honoring and remembering those who lost their lives in the Grenfell Tower fire, sharing their stories and the impact of their loss on families and communities.
# Transcribed with OpenAI Whisper (medium model)
# Source: Local audio transcription (no YouTube captions available)
00:00:00 Good morning, everyone.
00:00:26 Welcome to today's hearing.
00:00:29 Today we're going to hear more presentations relating to those who died in the fire.
00:00:33 Yes, Mr Millett.
00:00:34 Yes, Mr Chairman.
00:00:35 Good morning.
00:00:36 Good morning, members of the panel.
00:00:38 I now invite Alison Munro, Queen's Council, please, to come to the podium and to make
00:00:44 the presentation on behalf of the family of Anthony Disson, otherwise known as Tony Disson,
00:00:50 from flat 194 on floor 22.
00:00:53 I should again give a trigger warning that what Ms Munro is about to tell us or show
00:00:59 us perhaps may be distressing to those in the room or those following on the livestream,
00:01:03 and if so, then they should leave the room or look away as the case may be.
00:01:07 Thank you very much.
00:01:08 Ms Munro, thank you.
00:01:09 Yes, Ms Munro.
00:01:10 Good morning, Chair.
00:01:11 Good morning, Ms Efsofan and Mr Akbol.
00:01:16 Anthony Disson was known to everyone as Tony.
00:01:20 He lived a varied and colourful life.
00:01:23 He was, to use a phrase, quite the character.
00:01:28 He'd seen the highs and lows that come with life, and when times were good, they were
00:01:34 really, really good.
00:01:36 He was many things to many people, but one thing that his family wants to say loudly
00:01:42 and clearly is that Tony was not just a victim.
00:01:46 There was so much more to him.
00:01:49 Tony was not the richest man in the world by any stretch of the imagination, but if
00:01:54 his wealth could have been measured by the love he had for those he held dearest to
00:02:00 his heart, Tony would surely have been a multimillionaire.
00:02:05 He was born on the 27th of November, 1951, in North Kensington, into a large working-class
00:02:12 family.
00:02:13 Tony was the youngest of seven children, and he was 65 years of age when he died.
00:02:20 Those closest to him described Tony as a generous man with a good heart.
00:02:26 He was a good dad, a brilliant husband, and a wonderful grandfather.
00:02:32 He would never see anyone go without, because Tony knew what it was like to be without.
00:02:40 As a young man, Tony met his first wife, Anita, in 1967, and they had a son, Lee, who
00:02:47 was born in February of 1970.
00:02:50 They lived together in Shepherd's Bush, and then in 1974 moved to Fulham.
00:02:56 Recently, I asked Lee if he could take himself back to 1976 as a young child, how would he
00:03:04 describe his father?
00:03:06 He said this, my dad was very, very smart and very, very rich.
00:03:13 Looking back now, Lee says, well, of course they weren't very, very rich, but as a child,
00:03:18 he never went without.
00:03:21 His was a very happy childhood.
00:03:24 Tony was old school, and in his early years, his interests and career speak to a time past
00:03:31 and a way of London life now long gone.
00:03:34 Lee remembers the days spent, just him and dad, taking their horse and cart out to shows.
00:03:41 Lee recalls happy weekends and summer holidays spent at the chalet in Laysdown on the Isle
00:03:47 of Sheppey and further afield to Gran Canaria.
00:03:52 Between the ages of 14 to 19, Lee and Tony worked together.
00:03:56 Lee described these years with real tenderness.
00:04:00 Growing up, my dad was my best mate.
00:04:04 Tony and Anita divorced, but it was amicable.
00:04:07 And then in 1987, on New Year's Eve, Tony married Cordelia.
00:04:13 The couple had a beautiful wedding with well-wishers celebrating their union into the New Year,
00:04:19 although Cordelia did say that not many people remembered hearing the clock striking.
00:04:25 Together they had three sons, Harry Boy, Alfie and Charlie.
00:04:31 Tony loved his children and would do anything for them.
00:04:34 He encouraged his sons in their love of boxing, taking them to the Dell Youth Boxing Club
00:04:40 at the bottom of Grenfell Tower.
00:04:43 His sons excelled in the world of amateur boxing, and Tony would drive them all over
00:04:48 the country to take part in competitions.
00:04:52 He always made his voice heard in support of his sons, even in the face of a partisan
00:04:56 local crowd.
00:04:59 At the commemoration hearings, a video was played from his wife Cordelia and his three sons.
00:05:06 Tony's love of sport endured throughout his life.
00:05:09 He coached various sports clubs, including the Brunswick Boys Club in Fulham.
00:05:16 A loyal and some would say a long-suffering supporter of Fulham FC, Tony would nonetheless
00:05:22 be there at Craven Cottage, cheering on his beloved team whenever he could.
00:05:28 Tony had an excellent sense of humour, which he passed on to his sons.
00:05:33 As I mentioned earlier, Tony was old school and not always au fait with the ways of the
00:05:37 modern world.
00:05:39 Cordelia remembered her sons laughing whilst watching their dad trying to turn on a computer
00:05:44 by talking to it.
00:05:46 They had tricked him into thinking that was the way it was done.
00:05:50 They enjoyed teasing their dad, but he was a patient father.
00:05:53 He would happily watch their choice of television programmes just so that he could spend time
00:05:57 in their company.
00:06:00 Tony became a proud grandfather and great-grandfather and idolised the younger members of his family.
00:06:07 Chair, panel, I now turn to describe how Tony Disson lived and died in Grenfell Tower.
00:06:17 Tony moved into his flat, 194, in June 2010, having signed the tenancy agreement with RBKC
00:06:26 on 21 June that year.
00:06:29 So on the night of the fire, Tony had been an RBKC Grenfell Tower tenant for almost exactly
00:06:35 seven years.
00:06:37 As you will recall from the plan, which we are now familiar with having been taken to
00:06:43 it during the presentation of the evidence relating to the Chiquière family, flat 194
00:06:49 was a one-bedroom, west-facing flat between flat 193, the Chiquière flat, on the south-west,
00:06:57 and flat 195, Naomi Lee's flat, on the north-west.
00:07:04 Tony Disson was disabled, and he was registered disabled.
00:07:08 Like many of his friends and neighbours, he was a vulnerable resident.
00:07:13 He'd been diagnosed with a hereditary bone disorder called exostosis between 2000 and
00:07:20 2001.
00:07:22 This affected his legs and his mobility, as well as multiple ligaments and his daily function.
00:07:29 There is no treatment or cure for this condition.
00:07:33 He also had rheumatoid arthritis, varicose veins, and poor circulation.
00:07:39 The combination of these illnesses, in particular the bone disease, caused Tony significant
00:07:44 pain.
00:07:45 He was unable to walk for extended periods without the assistance of a cane, and relied
00:07:51 on the lifts to get to and from flat 194 on the 22nd floor.
00:07:58 Tony's disabilities were known.
00:08:00 In August 15, 2008, the TMO was sent a medical letter and questionnaire dealing with his
00:08:09 diagnosis of exostosis.
00:08:13 On the 29th of June 2009, a priority need assessment was completed.
00:08:18 It noted that Tony's legs were getting worse.
00:08:21 His difficulty was also noted in breathing, and that had significantly become worse, and
00:08:28 that he needed a lift or a ground floor flat.
00:08:34 By the 1st of June 2001, RBKC had responded to Tony's GP's request for further information
00:08:43 about his condition.
00:08:45 No adjustments or adaptations were made to his flat.
00:08:50 And then finally in April 2016, just a year before the fire, his GP again wrote to the
00:08:57 council and the TMO detailing Tony's continuing worsening health.
00:09:03 By now he had increased blood pressure as well, which in turn increased his vulnerability.
00:09:09 The GP's assessment also directly attributed the poor condition of his flat, which included
00:09:16 dampness to Tony's ongoing difficulties.
00:09:20 Tony had repeatedly requested repairs be made to his flat.
00:09:26 Tony Disson did not have a personal evacuation plan.
00:09:32 Being on the 22nd floor of the tower without a functioning lift would have made it nigh
00:09:37 on impossible for Tony to self evacuate via the staircase.
00:09:42 The reality was that Tony, like his neighbours and friends, Moses Bernard, Sirio Shakir,
00:09:49 Elsa Algoari, Sakina Avrasiabi, all to name but a few, were residents of Grenfell Tower
00:09:58 who required and did not have peeps.
00:10:01 Cordelia, his wife, also recalls that the flat door to 194 did not self close.
00:10:09 There was no spring back in the door and when it was opened it stayed opened.
00:10:16 Turning then to the events of the 13th and 14th of June 2017.
00:10:21 On the 13th itself Tony had met up with Cordelia and had travelled down to the family chalet
00:10:26 in Laysdowne.
00:10:27 He had had dinner with his family and Cordelia recalls that he left around about 10.40pm
00:10:35 and made his way back to Grenfell.
00:10:40 Tony returned and we have the CCTV footage showing him in the lift lobby area around
00:10:47 about 004649.
00:10:52 That's less than 10 minutes before Mr. Kibedi's 999 call.
00:10:59 Unbeknown to Tony and indeed his family, that would be the last sighting of him.
00:11:09 Tony was alone inside his flat when the fire broke out and he first learnt that there was
00:11:15 any fire from his neighbour, Naomi Lee, who so you may recall gave evidence during phase
00:11:20 one.
00:11:22 Naomi and Lydia lived in flat 195 and came into the lobby on floor 22 around about 20
00:11:30 past one.
00:11:32 After seeing the external flames spread from their room, Naomi recalls that she was prompted
00:11:38 to check outside to see if both lifts were still working and could hear the ventilation
00:11:45 system.
00:11:47 She said that no one was in the hallway at that point.
00:11:51 She recalls calling 999 at about 1.21 and reporting the smell of smoke in the hallway.
00:11:58 She was also advised to stay inside.
00:12:01 Whilst inside her flat, she heard her neighbours opening their doors in the hallway.
00:12:09 Pausing here, we may wish to remind ourselves that Tony's flat is beside each other and
00:12:15 the location to the entrance doors.
00:12:19 Naomi recalls opening her door to tell her neighbours about the fire on the fourth floor
00:12:24 and give advice about staying inside.
00:12:27 It was then that she saw Tony along with Nura and Miriam and her mum.
00:12:33 Lydia recalls that when they came out into the hallway, lots of things seemed to happen
00:12:38 at the same time.
00:12:40 Tony, to whom she referred as the guy who lived in flat 194, ran out and said, what's
00:12:47 happening?
00:12:48 The lady from flat 196 yelled, my kitchen is on fire.
00:12:53 Lydia recalled Tony's response, what, there's a fire?
00:12:57 Clearly in shock.
00:12:58 She said that at that stage, the hallway had very little light and hazy smoke and they
00:13:04 were still able to see everyone okay.
00:13:06 Tony, she sees go back into his flat after she told him about the fire and that was the
00:13:13 last time she saw him.
00:13:17 Now during the course of the following few hours, Tony made a total of seven 999 calls.
00:13:24 In addition to that, various family members including his son Alfie, wife Cordelia and
00:13:31 daughter-in-law Sinead made phone calls and 999 calls as well as calling Tony.
00:13:41 These provide in effect a real time chronicle of the unfolding events.
00:13:46 And his 999 calls provide an insight as to what was happening inside his flat and details
00:13:54 in order to fully appreciate exactly what Tony was going through until his final moments
00:14:00 of life.
00:14:02 Through his calls, you will, we hope, be able to understand Cordelia's description of her
00:14:07 husband changing from initially calm and quite passive to becoming increasingly worried and
00:14:14 eventually desperate.
00:14:19 Before turning to those calls, it's worth noting the condition of the building to put
00:14:26 into context Tony's timeline.
00:14:32 We should remind ourselves that the worsening conditions on floor 22 and the fact that it
00:14:39 was a west face of the tower.
00:14:42 At 130, between 130 and 140, conditions in the lobby continued to get worse and worse
00:14:49 and floor 17 and 22 had become significantly smoke-locked.
00:14:54 So I'm quoting here from the phase one report, volume four at paragraph 2510b.
00:15:04 Then between 140 to 150, there is significant smoke-locking in the lobby area at floor 22.
00:15:12 This is at paragraph 2514b of the report, volume four.
00:15:18 Between 2 o'clock in the morning and 2.20, the lobby was now heavily smoke-locked on
00:15:25 floor 22.
00:15:28 And finally, between 2.40 and 2.50, the NPS helicopter video showed that smoke was emerging
00:15:40 from flats on the west face of the tower at floor 23, indicating that smoke had migrated
00:15:48 across the lobby and into the west-facing flats at the top of the tower.
00:15:56 Moving then to the 9-9 calls and the contacts between Tony and his family.
00:16:01 Cordelia recalls that her first call from Tony was around about 1.22 when he told her
00:16:07 that there was fire in one of the flats below in the tower.
00:16:11 She told him straight away to get out, but he said he would stay in the flat until they
00:16:17 came for him.
00:16:19 She said that he told her that the fire must have been bad because there was a lot of smoke
00:16:24 even at that point.
00:16:26 Cordelia remembers hearing the fire alarms going off in the flat and that it was very
00:16:31 noisy.
00:16:33 In her subsequent calls to Tony that night, he updated her about the conditions in the
00:16:38 flat, his 9-9-9 calls that he was making and the advice that he was being given.
00:16:44 Cordelia says Tony was still calm initially, but as the fire spread and encircled the exterior
00:16:51 of the flat, he became increasingly worried.
00:16:55 He began to report that he could see the plastic surrounds of the window melting in the flames
00:17:02 and he could hear a helicopter.
00:17:05 Cordelia said that she could hear the noise herself in the background during the calls
00:17:09 and at one stage she even heard a neighbour knock on Tony's door.
00:17:14 Tony answered it and she heard the man asking Tony, help my baby.
00:17:19 She heard a baby crying and commotion in the hall.
00:17:24 Tony also spoke to another resident during that night, Sharon Haley.
00:17:28 She managed to self-evacuate.
00:17:31 Sharon too recalls that initially Tony was calm and said that he was alright and that
00:17:37 he could not see any flames.
00:17:39 She also called 9-9-9 herself and reported that Tony was in the tower.
00:17:46 Tony's son Alfie learnt of the outbreak of the fire when his partner woke him up in the
00:17:51 early hours of the morning on the 14th of June, having received a call from her own
00:17:55 mum at around 10 past one saying the tower was on fire.
00:18:01 Alfie looked and he'd missed a call from his dad whilst he was asleep so he rang him back
00:18:05 immediately.
00:18:08 Tony told his son that there was black smoke everywhere and that he was not leaving as
00:18:13 a firefighter had told him to stay.
00:18:17 Between that first call and 3am Alfie made a number of calls to his dad which he remembers
00:18:23 were lengthy calls lasting he says perhaps 20-30 minutes at a time.
00:18:30 He said that on one call Tony was in the passage and kept saying that the smoke was gradually
00:18:35 getting worse and worse.
00:18:38 Whilst he was on the call to Tony he was aware that Tony had opened the entrance door
00:18:43 but then had shut it again because the smoke from the lobby was so thick.
00:18:48 Alfie recalls that during one of the conversations Tony reported that the smoke was filling up
00:18:54 inside his flat and was coughing continuously as he kept on saying I can't breathe.
00:19:01 Alfie recalls telling Tony to go to the bathroom, fill the bath with cold water and block the
00:19:07 doors.
00:19:08 Alfie says that although he doesn't know for sure whether Tony did this he could hear Tony
00:19:13 doing something in the background and he heard a tap running which sounded and it sounded
00:19:19 like Tony at one point had the towel over his mouth.
00:19:25 Alfie's last conversation with his dad was at around 3am.
00:19:30 He had rung his father for an update.
00:19:33 His last call was shorter than the others and only lasted five minutes and he recalls
00:19:37 his dad saying they're not coming so he was going to attempt to get out on his own.
00:19:46 Alfie heard his father opening the door and describing seeing black smoke.
00:19:53 Alfie had also been in touch with the fire services himself via the control room and
00:19:58 They told him that they would talk Tony down and so he ended his call with his dad.
00:20:05 That was the last time he was ever to speak to his father.
00:20:10 When Alfie rang back for an update sometime after 3.30 he was told by the control room
00:20:17 that they had lost contact with Tony around seven minutes past three.
00:20:24 As I said Tony made a total of seven 999 calls.
00:20:29 These document in real time his experiences, actions and emotions.
00:20:36 In Tony's case at times his calls were particularly difficult and distressing to listen to and
00:20:43 to read.
00:20:46 Not least because they document a man in his 60s with a disability progressively becoming
00:20:53 panic-stricken and fearful as he realised that the conditions were not going to get
00:21:01 any better and there is a palpable sense of dread and foreboding as slowly but surely
00:21:08 there's a realisation that no one is coming to save him.
00:21:13 His first call at 1.30 lasted some 33 seconds.
00:21:19 Tony told the operator that he was on the 22nd floor and they told him they were on
00:21:25 their way.
00:21:26 He said it's terrible up here.
00:21:29 He was advised to put down towels to stop the smoke coming in.
00:21:33 Tony replied all right and I'll tell the rest.
00:21:38 That would seem to indicate that Tony was either going to speak to other neighbours
00:21:43 or that neighbours were close by.
00:21:47 In that first call Tony was not asked for his flat number.
00:21:51 We know that at 1.25 Jason Olof in the mobiliser control room at Stratford and was briefed
00:22:00 by DAC Fenton to co-ordinate FSGs and pass them to the command unit seven.
00:22:08 He'd set up two whiteboards in the control room to record information and also was recording
00:22:13 information on pieces of paper that were passed to him by the CROs and he used his
00:22:20 brigade mobile phone to pass FSG information to CU7.
00:22:27 The whiteboard at 1.28 noted Tony's call.
00:22:33 Flat 194, heavy smoke, one adult first picked up, heavy smoke it says.
00:22:41 The second call that Tony made was between 149 and 151.
00:22:48 In this call he gave his flat number and the floor and he reports that I can't get out,
00:22:55 I don't know what to do.
00:22:57 He's told by the operator to remain where he is.
00:23:02 He tells them that his flat is smoky, the smoke is coming in, he can't see anything,
00:23:08 the smoke is coming up through the windows.
00:23:11 He's advised to stay low, below the smoke, cover his face with a wet cloth and if it
00:23:17 gets really bad, don't worry, quote, we've got firefighters coming up to the 22nd floor
00:23:24 already.
00:23:27 Third call, 159 to 202.
00:23:31 Tony informs control that he's got vulnerabilities, he's disabled, he tells them his age and his
00:23:37 mobility difficulties.
00:23:39 He says he's a pensioner and he can't get about.
00:23:43 Tony reports to control that he's on the 22nd floor and he's been waiting now for 15 minutes.
00:23:49 He says these words, the flat is worse, it's black in here and I can't see a thing.
00:23:54 The operator tells him he can't go anywhere and he's safer staying where he is.
00:24:01 The operator also tells him that the fire is on the fourth floor.
00:24:04 Tony reiterates it's black here and he says that his letterbox doesn't close and so the
00:24:11 smoke is coming through the letterbox as well.
00:24:14 There is a real sense of urgency now and worry and Tony uses these words, please, please,
00:24:21 please, get them up here, get me out, please.
00:24:26 He's asked at this stage for his flat number which he gives at 194, not for the first time,
00:24:32 and is told that they are going to get him as quickly as they can.
00:24:36 He is advised again to put a towel or a tea towel or a cushion in the letterbox and go
00:24:41 into a room that's less smoky.
00:24:44 Tony suggests a bathroom as a possibility but then he realises he wouldn't hear if anyone
00:24:50 was knocking on the door.
00:24:54 Fourth call, 0223 to 0224.
00:25:00 This is now over 45 minutes since his first 999 call when Tony was told we're on our
00:25:06 way already.
00:25:08 The conditions now have deteriorated.
00:25:12 As we've just highlighted, the lobby on the 22nd floor is now significantly smoke-logged.
00:25:18 Tony is trapped and clearly desperate.
00:25:21 That's reflected in his call.
00:25:24 He says to the operator that he's really frightened and he begs them to do something.
00:25:29 He gives his flat number again and reports that he's been waiting now for 45 minutes.
00:25:35 The operator says she knows and that if he gets, if he's got fire in the flat and he
00:25:41 says please, I need help, the call ends prematurely.
00:25:50 By this stage we know that the stay put advice has changed in the control room.
00:26:00 Tony meanwhile has been on the phone to Cordelia and Alfie and other members of his family
00:26:05 are now phoning 999.
00:26:08 Sinead Prentice made her first of three 999 calls which was picked up by Surrey Fire and Rescue.
00:26:16 That's at 0228.
00:26:18 She reports that her father-in-law was at Grenfell Tower on Latimer Road and trapped
00:26:23 on the 22nd floor.
00:26:25 She tells him he is 70 years old and is panicking.
00:26:29 She asked for a call back after they received an update from the LFB but they don't do call backs.
00:26:37 Second call Sinead makes is at 0245.
00:26:42 She reports again that her father-in-law is stuck on the 22nd floor in a fire at Grenfell Tower.
00:26:49 She gives Tony's mobile number to the operator and repeats that he's really panicking now.
00:26:56 He's 70 years old she says and he's on his own.
00:27:00 She was told that they would pass the information on to London and have them bring Tony to reassure him.
00:27:08 At 0248 CRO Angie Gotts took a call from Surrey who passed over the message about a person
00:27:18 who had called about their 70 year old father-in-law trapped on floor 22.
00:27:25 CRO Gotts told the operator about the change in the stay put advice.
00:27:30 She said that they had just been told to tell people to put a wet towel over their heads
00:27:36 and to try and get out.
00:27:38 CRO Gotts told this enquiry in evidence that she believed that by that stage she must have
00:27:45 been told about the change in stay put advice but she couldn't remember who had told her
00:27:52 or whether the information had been given to her on a piece of paper.
00:27:57 The call was the first occasion on which the Surrey control room had been made aware of
00:28:03 the change in stay put advice although they did not appear to have noted it on their own
00:28:08 system at the time.
00:28:11 The white board entries at that point for flat 194 stated heavy smoke, one adult.
00:28:18 Tony's fifth call was made at 0249. This was received by CRO Adams.
00:28:30 Tony now tells them flames are coming out of the top of the roof down to his flat and
00:28:36 he asks that they come and get him. He is asked whether he can get out by himself.
00:28:41 Tony replies that he can't because it's too dark. He can't see a thing. He's 67 years
00:28:48 of old and he can't run. He repeats the floor number and says he is desperate now and frustrated.
00:28:56 Oh the times I've told everyone. It's floor 22. Please love, he tells the control room.
00:29:03 He's on his own. CRO Adams informs him that they are advising people to leave the building.
00:29:11 Tony replies I can see the flames. Come and get me. CRO Adams repeats that they are trying
00:29:17 to get you but it's very difficult. You may have to leave the building.
00:29:23 She calls Tony back at 0251 and he reports that the flames are coming from next door.
00:29:30 He's asked if he can put a wet towel over his head. He confirms he's done that and CRO
00:29:36 Guts tells him to put the towel over his head and try and get out.
00:29:43 Tony tells her he's 67. He asks whether he can meet up with neighbours but Tony replies
00:29:51 there's no one up here now. At 0254 CRO Fox takes a call from a member of the public who
00:30:00 reports to her that a friend is stuck in flat 194 on the 22nd floor. The caller is thought
00:30:06 to be Sharon Healy. Tony makes his sixth call at one minute past three. Again it's
00:30:13 picked up by CRO Fox. He reports that the conditions in his flat and bedroom are now
00:30:19 very, very dire. He has asked for his flat number and the floor number. Again he reports
00:30:27 that he cannot see a thing. CRO Fox asks why can't you get out by yourself and he tells
00:30:34 her it's too dark, it's too hot. She tells him to wrap himself in a sheet and a towel.
00:30:41 He repeats his request for someone to come and help him but CRO Fox tells Tony that they
00:30:47 are dealing with others at the moment and it appears that Tony is left on the line.
00:30:54 Sinead then makes her third call at five minutes past three. She repeats her previous reports
00:31:00 about her father-in-law being stuck in the fire in Grenfell Tower and that he has since
00:31:05 reported to her that the fire was now inside his flat and he was screaming. He was telling
00:31:11 her that he was dying and he needed to get out. He couldn't speak properly, he couldn't
00:31:17 breathe. The CRO who answered her call replied that they had given London all the information
00:31:25 and that there was nothing more that they could do. At nine minutes past three Surrey
00:31:29 Fire Service called Alfie back to tell him that just spoken to London about his father.
00:31:37 He is told that the advice is now for people to get out and he is asked if his father is
00:31:44 able to get out of the property. Alfie replies that he is not able to get out. He is stuck.
00:31:51 He is told that they will contact London and inform them to make Tony a priority because
00:31:58 he can't get out. Alfie repeats that his father can't get out. He is stuck, he is on the 22nd
00:32:04 floor, he can't get out. He pleads for help. Please, please help my dad. Alfie is then
00:32:12 asked for more details and he explains that Tony can't go downstairs, that the stairs
00:32:17 are pitch black, he can't see in front of him, that the smoke is underneath him and
00:32:22 is burning through the floor and the fire is all around him and he can't get out. The
00:32:28 operator tells him that he will pass this information on to London. Cordelia then makes
00:32:35 one more 999 call at 323. She is contacted to Dundee and then transferred to Kent. She
00:32:42 reports that her husband is trapped on the 22nd floor and has been like that for over
00:32:49 an hour. He is being advised by the LFB to stay put and she gives his number. Control
00:32:56 records, records the flat number as 249. She said that Tony had phoned her just now and
00:33:03 reported that he couldn't breathe, that smoke and fire had gotten into him and that he was
00:33:10 entering his flat even though he had put a wet towel by the door. In his final call
00:33:20 to Cordelia, Tony told her that the flames had broken into the flat. He said that the
00:33:25 floor was hot and his feet were burning. He said that he could feel the heat coming up
00:33:31 and he didn't want to die like this. Tony's final 999 call was made at 331. It lasted
00:33:39 for about a minute. It was connected to Kent Fire and Rescue Services and the operator
00:33:46 tells him that his wife has just spoken to them and they had informed the LFB. The operator
00:33:52 asks Tony for his flat number and if he is okay. Tony by this point has left his flat
00:33:59 because he is on the stairs and he says, how long are you going to be? I am on the stairs
00:34:04 now. He is told that they are trying to get people out of the flats and asked which floor
00:34:10 he is on again. Tony's response and his final words are a simple plea, help me.
00:34:20 At 346, Cordelia reports that her husband is trapped in a block of flats on Latimer
00:34:26 Road and is told they have not received an update. The operator confirmed that Tony had
00:34:33 tried to exit the flat when they last spoke to him and they tried to call back but received
00:34:38 no answer. The operator suggested that Cordelia should keep looking at the Met website as
00:34:46 they were in the process of setting up a casualty bureau. Those were the 999 calls and the calls
00:34:53 between Tony and his family. Meanwhile, the incident logs and the whiteboards were being
00:35:04 updated. At 136, the first entry in the log says 22nd floor, smoke coming, one person.
00:35:11 It goes on for the rest of that evening, recording Tony's positions and recording his information
00:35:19 about the conditions of the lobby and his flat. At 234, the log entry says, caller concerned
00:35:26 about a male relative who has called her, he is not being rescued. Stated, the incident
00:35:33 is on the BBC News and she asked why we had not rescued him from the 22nd floor. The caller
00:35:40 is advised that they had come through to Surrey but they would inform London of her information.
00:35:48 The caller asked us to call her back with more information but we advised her we would
00:35:53 have to ask to be put through to LFB as we have no information on the incident. The caller
00:36:00 asked us to call her back with more information but we advised her we would have to ask to
00:36:01 be put through to LFB as we have no information on the incident. At 8 minutes past 3, the
00:36:08 log created in relation to Tony says as follows, from LFB, request contact surrounding fire
00:36:17 services to inform of advice, wrap something wet around and exit as quickly as possible.
00:36:24 Meanwhile, some information was being transferred from the control room to CU7 and other CROs.
00:36:34 At 2 o'clock there is an update from the control room to CU8 on the incident ground which includes
00:36:40 information about Tony. 22nd floor, flat 194, a pensioner with heavy smoke there. CU8's
00:36:47 response is, I'm getting the impression it's floor 21 and 23, between 21 and 23 which is
00:36:58 more severe. CRO Adam in turn agrees with that and says that she thinks they are most
00:37:05 worrying along flat 165. This exchange seems to indicate that the severity of the conditions
00:37:12 on the upper floors had been communicated from the control room and in turn to the incident
00:37:19 ground. Meanwhile, the reports and the updates in Surrey from around 2.30 onwards show that
00:37:29 people there were recording the phone calls from Sinead and other members of the public.
00:37:37 There was also connections with North West Fire Service. At 2.41 the BT operator gets
00:37:45 through to the North West Fire Centre and tells them that the caller is trapped in flat
00:37:51 194. The North West Fire Centre passes that message on and asks for a contact number for
00:37:59 Tony which the operator relays. At 2.40, the BT operator is asked to give a contact number
00:38:06 to the operator. At 2.50, Rob Brown from Surrey Fire and Rescue Services calls the
00:38:13 LFB control room and speaks to CRO Angie Gotts. He relays the messages that Surrey have been
00:38:20 getting and the further phone calls from Sinead about her father-in-law being stuck. He asks
00:38:27 CRO Gotts to call him Tony to reassure him. She says, we've just told people to put a
00:38:35 towel over their head and try and get out. CRO Brown says, but I mean he's 70 years old.
00:38:43 But before he continues the sentence, CRO Gotts speaks over him. She says, they are
00:38:48 getting too many calls from floor 22 and appears keen to get off the phone. She says she has
00:38:54 lots of calls waiting but she nevertheless takes the number and that's the end of the
00:39:00 telephone call between Surrey and London. Surrey called one more time at 6 minutes past
00:39:09 3, again updating London about flat 194. SOM Joanne Smith answers a call again from Rob
00:39:19 Brown in Surrey Fire and Rescue. He says that he wants to pass on more information about
00:39:27 a call received from Tony's daughter-in-law. SOM Smith informs him what the current advice
00:39:35 is. So we can see that there are calls being made between the different call centres, Surrey,
00:39:47 London, Dundee and the North West, all about Tony, all informing London that this is a
00:39:55 vulnerable man, a pensioner with mobility difficulties who needs assistance. We know
00:40:04 sir that there were no deployments to floor 22. Firefighters Code and Joseph, it would
00:40:13 appear, did manage to rescue Naomi Lee and Lydia who are in flat 195, but that was while
00:40:21 they were descending. In any event, despite the numerous calls made by Tony and about
00:40:29 Tony, there was no specific deployment on his behalf.
00:40:37 Turning then sir to Professor Purser's evidence. In assessing Tony's exposure to smoke whilst
00:40:44 she was in the flat, Professor Purser considered that it is likely that the exposure would
00:40:49 have come from the lobby through his front door as it is likely that flat 19 floor 4
00:40:56 had a leaky door as well, which allowed a much bigger build-up of smoke from the lobby.
00:41:02 He also considered that Tony would have been exposed to smoke coming into the flat from
00:41:07 outside. The toxicology examination recorded a COHB level of 71%. In terms of the time
00:41:14 of death, Tony's body was recovered in the stairwell on the 19th floor. Professor Purser
00:41:27 considered it likely that Tony would have inhaled a dose level of 50% COHB representing
00:41:35 the threshold for a lethal dose by 03.56 hours and estimates Tony's time of death to be
00:41:45 at approximately 04.31 hours. Dr Fegan-Earl agrees with that approach as an approximate
00:41:51 time or window of time when recording death. Lee Disson travelled down to Grenfell and
00:42:00 arrived about 7.30am in the morning and started a search for his dad. Alfie and Cordelia and
00:42:07 other members of the family also went to the tower in the morning and began searching for
00:42:12 Tony. Alfie recalls going there and then moving on to seven different hospitals in search
00:42:21 of his father. Cordelia was contacted by a family liaison officer and finally informed
00:42:27 of Tony's death three days later. The full post-mortem examination was conducted by pathologist
00:42:35 Dr Swift on the 22nd of June 2017 and the preliminary medical cause of death based on
00:42:43 the pathological findings was recorded as inhalation of fire fumes which was confirmed
00:42:50 in Dr Swift's final report on the 3rd of January 2018.
00:42:57 Sir, panel, those are the facts and the circumstances of Tony Disson's death. But in concluding
00:43:11 this presentation I would like to return to the man himself and something about him and
00:43:20 where he lived. Big cities are often criticised, particularly London, for the way they have
00:43:28 been treated, for being somewhat cold, lacking in community and a sense of neighbourliness.
00:43:34 A place where people are anonymous and avert their gaze if ever they inadvertently make
00:43:39 eye contact with a stranger on a bus or on the tube. However, as you have heard throughout
00:43:46 this inquiry, Grenfell Tower was a community and in that village in the sky Tony Disson
00:43:54 was an integral member of the Grenfell community. Like so many others in the tower and the surrounding
00:44:00 area, Tony took people as he found them without prejudging who they were, where they had come
00:44:07 from, what they did for a living. His wife Cordelia recalls that Tony knew everyone there
00:44:15 and tragically two of his close friends, Dennis Murphy and Steve Power, also sadly died in
00:44:21 the fire. Tony's family, like so many other families, will always wonder what if. What
00:44:31 if Tony had stayed just a little longer in the chalet in Laysdown, had another cup of
00:44:36 tea before returning to London. He would have arrived later after the fire had broken out
00:44:43 and would not have been allowed back in the tower. He was a disabled man of 67 who paid
00:44:51 patiently, waited for help and then when he finally could wait no longer, he tried
00:44:58 to get out and self evacuate. He will forever be in their hearts. Tony Disson, brave to
00:45:10 the end, their own unique Tony. Thank you.
00:45:21 Thank you very much, Ms Munro. At that point we shall rise to have a short break. We will
00:45:39 resume please at half past 11. Thank you very much.
01:14:21 Yes, Mr Minister. Yes, Mr Chairman, Members of the panel. May I now please invite Mr Michael
01:14:28 Mansfield, Queen's Council, to come back to the podium to make the presentation on
01:14:35 behalf of the family of Ligaya Moore from flat number 181, 181 on floor 21. As before,
01:14:42 I give a trigger warning that what Mr Mansfield may tell you or show you may be distressing
01:14:59 to some in the room or watching on the live stream and if so, then they will be able to
01:15:12 leave or look away accordingly. Mr Mansfield, please. Thank you.
01:15:26 Yes, Mr Mansfield. Good morning, sir and very much to fans.
01:15:42 And thank you, Mr Chairman. Today, none of the family are here for reasons that perhaps
01:15:53 are obvious there in the Philippines. Her mother, Ligaya's mother, Esther Lita is watching
01:16:02 and also a niece called Caroline are watching from there. The person who was present during
01:16:09 the commemoration and presented the presentation to you, again, you may remember, Nanita Bungay,
01:16:17 who had every intention of being here, but unfortunately, she's not well today. So hopefully,
01:16:23 she can watch it remotely. But instead, we do have, yes, sitting in front of you as it
01:16:30 happens, Clarita Gavarmini. Gavarmi, sorry, I'm so sorry, Gavarimi. I've just met her.
01:16:38 She's another resident from the tower, flat 75, and also comes from the Philippines. In
01:16:46 fact, there's just been a conversation between those in the Philippines and herself. And
01:16:51 she was a friend in the sense that they came across each other now and again and also went
01:16:58 to various things that were local, like there's a local market, a night market. And she brought
01:17:02 in, I'm not going to ask them to be displayed, but she brought in photographs of herself
01:17:09 with Ligaya in the same month, earlier in June. And they display, I'm not asked that
01:17:19 they should be kept, but they do depict Ligaya and herself at obviously a moment of happiness.
01:17:26 And one of the ways in which this particular case has been remembered was in the House
01:17:36 of Commons. Because in the debate that followed this disaster, obviously the matter was talked
01:17:42 about, people from the tower went to the debate. And in particular, the plight of Ligaya was
01:17:50 mentioned in the context that the laughter, the joy of the tower in her case and in all
01:18:00 the cases was reduced by the fire to silence. And in a sense, she's one of the many vehicles
01:18:10 of the way in which the tower operated when it was live and obviously what happened on
01:18:14 the night. In fact, there are some, what I might call, if I may call them, singular features
01:18:21 of this case, namely of Ligaya Moore in flat 181 on the 21st floor. The first point I'd
01:18:31 want to make is that she lived alone in that flat, and there were others who lived alone,
01:18:37 she lived alone in the flat for a number of years after her husband died. I'll come to
01:18:44 it because these are important features in relation to how she lived in the tower and
01:18:51 how she died in the tower as well. So she lived in the tower alone and she died alone.
01:18:59 The second feature that is attached to that is that she'd been with a friend, in fact
01:19:06 Anita earlier in the evening, but she had a phone, she had a mobile phone, she had a
01:19:11 landline. Both were working, we know that much, because they were used that evening.
01:19:18 However, when it came to the time of the fire, it appears that no calls were made by her
01:19:27 on either phone to the emergency services, nor to the friends to whom she had their phone
01:19:34 numbers, because they'd been phoning earlier on, and she didn't phone them either. The
01:19:43 final bit of this special feature is this, and I'll return to it because it's important
01:19:48 for the context of her demise, is that they called her, at least Anita did, repeatedly,
01:19:56 but it wasn't picked up. There's an unfortunate and rather obvious inference as to why it
01:20:06 wasn't. In the first place, possibly because she was asleep and slept through everything,
01:20:12 in a sense one always hopes that that was the situation, and it looks as though that
01:20:16 was possible, if not likely, the way matters ended.
01:20:24 There's finally another feature which is unusual in this case, but not unusual generally and
01:20:28 commonly in the community in the way she lived, and if I may call it a special need, because
01:20:37 of the way she lived and the accumulation of her possessions, combined with a deteriorating
01:20:44 78, deteriorating health condition. I'll come to some of the details, but not all of them.
01:20:53 For obvious reasons, a little later, but it's that combination of special features
01:20:58 that no doubt brought about the observations in the House of Commons by one of the parliamentarians
01:21:05 on that day.
01:21:07 So may I begin therefore with a few comments about and observations about her background
01:21:15 before the fire itself. Ligaia Moore was born on the 28th of October 1938 in the middle
01:21:23 of the village of San Luis Pampana in the Philippines. She was the second of four children
01:21:32 and was 78 years old when she died. Her friend, Nanita, who I've mentioned already, who delivered
01:21:39 a pen portrait during the commemoration on the 25th of May 2018, recalls that as a young
01:21:45 woman Ligaia dreamt of travelling the world, of exploring new places. She left the Philippines
01:21:52 in 1972, travelled to London where she secured work as a nanny in the first place. Shortly
01:22:00 after arriving in London, Ligaia met her husband, and this is an important aspect of her life
01:22:06 and her death, Jim Moore. They got married and spent many happy years together travelling
01:22:13 within the United Kingdom because Jim didn't like to fly so they spent their time here.
01:22:21 They signed the tenancy agreement with RBKC on the 1st of December 1981. So in fact, both
01:22:30 with him and then on her own, she'd been in the flat for 26 years. A small one-bedroom
01:22:37 flat which became, after refurbishment, flat 181 on the 21st floor. And she went on living
01:22:48 there, as is the implication of what I said, after her husband Jim died. He died in 2007,
01:22:57 so ten years before the fire. Nanita recalled during the commemoration, Ligaia as a stylish
01:23:04 sociable woman, perhaps I could put it in this way, highly fashion conscious. And today,
01:23:13 some photographs have been brought in by the Clarita friend who saw her from time to time,
01:23:21 and they depict, may I just describe, I'm not asking them to be shown on screen or anything
01:23:27 like that, but the question of how she looked, her actual appearance, given the contrast
01:23:34 with the flat, here was a woman of stature, here was a woman who exudes happiness in one
01:23:41 sense and her clothing, as it was, appears to the world. So she would always wear heels,
01:23:48 claiming she didn't know how to walk in flat shoes. She enjoyed shopping, often visited
01:23:53 the Westfield shopping centre, which is nearby, as you know, with her friend Nanita. Ligaia
01:24:00 had a passion for ballroom dancing and others remarked that she was full of energy, enthusiasm.
01:24:06 She would explore London on foot, often walking, I don't know whether they're in high heels,
01:24:11 but however, from Holland Park all the way to Trafalgar Square. She loved living in the
01:24:17 tower, she enjoyed wonderful views across London from her flat and would often remark
01:24:24 that she lived in all senses of the word on top of the world. Ligaia was heavily involved
01:24:32 in charity work as well and did a great deal to help those less fortunate than herself.
01:24:38 How often have you heard that in relation to the people who lived in the tower alongside
01:24:43 her? She didn't forget her early life in the Philippines and had set up a savings account
01:24:48 to provide help for those in need in her country of origin. Above all, she is remembered as
01:24:56 a wonderful, loving friend who was always generous with her time and her affection.
01:25:03 And if I may say, the photographs produced today reflect that entirely. So it may turn
01:25:11 to another aspect of her background and in a sense you will recall the situation with
01:25:19 this module in particular that you're looking at the means by which people died and in what
01:25:29 circumstances. You will appreciate the particular relevance of those words. And one of the
01:25:35 circumstances in this instance is Ligaia's vulnerability. Now there are two aspects to the
01:25:45 vulnerability. One is a matter I'm going to come to in a moment to do with the possessions in the
01:25:52 flat. The other is the deterioration of her health as she was at 78 at the time but over the
01:25:59 preceding years. So the combination of the two produced a situation which on the night has to be
01:26:05 seen as a context for what actually happened in the flat. So may I take the first aspect? That is,
01:26:12 I'm going to use the word accumulation of possessions and I hope it's acceptable. The term customarily
01:26:18 used to describe this condition in her records is hoarder. Whilst this is the accepted and
01:26:26 recognised term, it is somewhat perfunctory and capable of being misused in a pejorative manner.
01:26:33 And therefore that term will not be repeated by me. However, she was identified as a vulnerable
01:26:42 resident in the RBKC list of residents sheet, it's all cited we can show, produced by David Noble in
01:26:51 the aftermath of the fire. So what was that vulnerability? Part of it was this, the mounting
01:27:00 accumulation of personal items, what I call a mountain of items over a long period, without the
01:27:11 ability to reduce or rationalise the encroaching element of her life. It's not an uncommon situation,
01:27:22 its origins are not clearly understood but it's often associated with and can itself induce depression.
01:27:29 For again obvious reasons, if you're not able to control the situation you've created, it may have developed
01:27:37 and it looks from the evidence that we've seen almost certainly it is linked to the demise of her husband
01:27:43 ten years before in 2007. Nanita alludes to this in a statement, she has produced a statement for this module,
01:27:53 may I just give the reference number so that it's clear, it's dated earlier this year in March but its reference
01:28:01 number for the record is 00002374 and much of the detail upon which we rely in relation to what happened
01:28:13 earlier in the evening and so forth comes from Nanita. And the belongings in the flat, again will not surprise you,
01:28:29 a large quantity of them relate to her husband and the feature here is, again that you can extrapolate from a situation
01:28:40 in which this accumulation happens, it's a substitution, it's a form of reaffirmation of the relationship she once had,
01:28:49 it provides security, it provides reassurance and it provides some form of connection with the past.
01:28:57 So it's understandable but it is, we say, a special need which needs care and attention and support.
01:29:06 But unfortunately by the time of the fire had not been resolved entirely.
01:29:12 However her family are anxious that this part of her life should be taken seriously to enable for the future,
01:29:22 the creation of fire safety strategies and contingency plans especially for high residential blocks like hers in future
01:29:32 and particularly those with special needs of which she was plainly one. And it has, as we've already implied,
01:29:40 a distinct relevance to the circumstances in which she died. However it isn't just a few belongings in this case.
01:29:48 The gravity of the situation, again I'm not asking for photographs to be shown but I'm going to cite the photographs.
01:29:55 We would ask if you haven't managed to in the plethora of material that you have that you may not have seen
01:30:03 or if you did see it was some time ago, look at the photographs I cite because when you see them
01:30:09 you recognise immediately the problem that she faced that night which I'm going to come to in a moment.
01:30:16 So I'm going to give a brief summary, not all the detail and it's only going to be the years just before the fire
01:30:23 so it's not going back into a long history, back to 2007. I'm going to start, if I may, in 2013
01:30:30 because there are records of all of this so it was known. In the wake of the power surges
01:30:37 that will be a memory that you have of other evidence, particularly from Shah Ahmed.
01:30:44 The surges in 2013 which extensively damaged her electrical goods. The TMO carried out an inspection
01:30:53 of her flat at that time and they noted in the records accumulated items and they deputed Janice Jones,
01:31:00 I mention her because her name comes up again, to follow up with the resident, these are words from the records,
01:31:06 to help move rubbish stored within the flat. However, the following year another inspection took place
01:31:15 as part of the refurbishment programme by Ryden and the General Power Report in relation to that
01:31:24 reads as follows about the flat, full of old items and the resident is over 60.
01:31:32 It was really impossible to enter the property. Please see photo for your attention, this is Ryden speaking to TMO.
01:31:42 The matter has been referred to Janice and Siobhan housing team. There are more photographs of 181
01:31:52 that were sent to the TMO with a further explanation that they could not carry out the works
01:31:58 and that Mrs Moore would be unable to remove all the old stuff within her flat.
01:32:03 Part of the problem is she's way up the tower and getting them out and there was nowhere else in the flat
01:32:10 to put items because of so many other things she'd already occupied the space with.
01:32:16 There are four photographs, I have the reference numbers, I'm not going to ask for them to be shown
01:32:21 and I'm not going to take up time giving you the reference numbers but they are there to be seen.
01:32:27 And I would urge you to look at the really quite dramatic scenes that you see.
01:32:34 In 2015 the ongoing and un-remediated situation was the subject of communications between the TMO,
01:32:44 RBKC and the adult social services. On the 7th of May 2015, Jan Jones who I've already mentioned,
01:32:52 the TMO estate officer for Lancaster West estate, wrote an urgent note to RBKC,
01:32:59 really on the same theme, no works can be done to her flat currently so I urgently require your assistance
01:33:06 with this matter. Later the same month, still in 2015, there was an exchange between Janice Williams,
01:33:13 the TMO and Raiden to chase those in social services responsible for helping to clear the flat
01:33:20 so that works can be completed by the middle of July. This was compounded by the impending installation
01:33:27 of the HI units which you will recall certain residents had issues with that for very good reason.
01:33:35 There was a talk of ensuring at least, this will tell you to some extent when you look at the photograph,
01:33:41 what they wanted was at least a one metre, what they call it a concession, around her goods as it were
01:33:48 and her accumulated, as a working area, that would have been enough, but that shows you how bad
01:33:56 the situation had become. During this period some help was obtained through an agency called Clouds End
01:34:05 with visits in July of 2015 and it was noted, and I just put this in so that it ties in with the observations
01:34:15 already made, that the psychological effect on Ligaya, namely depression, was noted and they also noted
01:34:23 that a large or substantial amount of the property there related to her past and to her deceased husband.
01:34:33 By the following month, still in 2015, September, there was this critical assessment and I pause with emphasis
01:34:44 on this because this assessment is a critical one, is a crucial one and really does indicate the gravity
01:34:52 that this wasn't some kind of dilettante hobby that was being indulged and I'm not suggesting for a moment
01:34:58 that you will think that. It was made by RBKC, the Adult Social Care Safeguarding Team.
01:35:05 This is what they wrote in September 2015, two years before the fire.
01:35:11 Ms Moore is at a fire safety risk. She's unable to manage the issue herself and was rated as a possible risk
01:35:22 with catastrophic consequences including death and multiple serious injuries.
01:35:31 However, nothing had changed by 2016 in January, the following year, when there was a need for an electrical certificate
01:35:43 for the kitchen extractor works couldn't be issued because, same reason as before, the flat was full of residents' belongings
01:35:51 and they were unable to, and this again demonstrates just how the severity, they weren't able to unplug accessories
01:36:01 in relation to the certificate that had to be issued.
01:36:05 This was repeated again in July that year when a more general test in relation to electrical items and a full review
01:36:13 was being done by RJ Electrics. They wrote this, unable to carry out any tests as we were prevented from accessing any areas,
01:36:22 outlets within the premises due to the volume of the residents' belongings.
01:36:29 Before I pass to the events of the night, just two other matters.
01:36:35 The evidence provided by her close friend, Anita, who'd been seeing her every day for a couple of years through to 2017,
01:36:45 she gives a graphic account in her statement of the state of affairs with regard to the property at the time of the fire.
01:36:56 These are her words, Anita's words. Her flat was really disastrous.
01:37:02 There were plastic bags, piles of stuff everywhere. Her bedroom was full of things, an important aspect because of where her remains were found.
01:37:12 Around the bed, it made it difficult for her to get out of bed. There was nowhere to sit.
01:37:18 I found it very difficult to get inside her flat. In fact, the guy was so embarrassed about the fact that her flat was in that state.
01:37:29 Such a contrast to the woman you see in these photographs. She felt unable to rectify it. No more space to put anything.
01:37:38 She didn't want anyone coming in. Anita, I think, was the only one who managed to access the flat.
01:37:46 Anita went there for a number of reasons, obviously keeping her company. They were very close friends.
01:37:53 But she noticed, and this comes to the second aspect of the vulnerability, what Anita had noticed is that the guy was beginning to struggle with her mobility.
01:38:05 And of course, being, well, certainly getting towards age, she's 78.
01:38:11 She attributed that immobility not only to her age, but problems with her knees, sort of thing, very familiar.
01:38:18 It exacerbated that condition by constant defective lifts and having to walk up to the 21st floor.
01:38:26 So, Anita stepped in and began to bring her food and meals, because again, cooking in the flat wasn't easy,
01:38:33 and doing the shopping and washing her clothes back at her place so she'd take them back to Ligaya.
01:38:38 So there was a very important support from her.
01:38:42 There is a record in 2015 on the 17th of September by Janelle Davies, a social worker, concerning Ligaya, complaints about pain in her leg.
01:38:55 So it does look as though things are, as it were, making life difficult for her at that stage.
01:39:02 Her medical records have become available, and it appears, I'm not going to read them out for, again, sensitive reasons,
01:39:11 but by May of 2017, she was on six daily medications.
01:39:24 And this may have a relevance to what happened on the day.
01:39:29 She was on six daily medications, and they were, for at least, what we can discern from the records, three major conditions.
01:39:39 I don't read those out, but she didn't go to the walk-in centre the end of May because of those,
01:39:45 but it may be as a result of the medication that she goes in because she's experiencing recurrent bouts of dizziness,
01:39:56 and she's feeling unsteady and that the room is spinning.
01:40:03 She went back to the clinic, the walk-in clinic, on the 13th, the day before the fire, again about the dizziness,
01:40:11 and on the 14th she had arranged to see her general practitioner.
01:40:18 We can't say whether it was to do with the dizziness, but it looks as though that's one of the logical inferences that can be drawn.
01:40:27 We say, therefore, that this background material of her age, her medical deterioration,
01:40:36 and what's happening around her in the flat are relevant to the death on the night in three different ways.
01:40:43 May I just explain the ways and the relevance to the, in what circumstances did she die?
01:40:50 Firstly, it relates to her mobility and ability to move within the flat,
01:40:56 were she to have awoken in time to see what was going on, and of course it relates to her general wellbeing and her resilience.
01:41:05 Secondly, it relates to a contribution that can be made to the fire by those belongings
01:41:13 because of the space being covered there everywhere, and obviously they can have made,
01:41:21 and almost certainly did make, a contribution to the fire, to the flame, to combustion, and to fumes, because they're different items.
01:41:28 They're not the same as the cladding, but there will have been a contribution.
01:41:32 And thirdly, there is a likelihood that internal doors, it's a small flat, one of the ones as it were, a small flat, one bedroom,
01:41:41 that the internal doors could not be closed because of the belongings,
01:41:46 which is relevant to the flow of smoke within the flat into the bedroom, permitting quantities of smoke to circulate.
01:41:56 And Council, Mr Millett, specifically asked Professor Perster about all this, a number of questions,
01:42:03 about the impact of one, immobility, and two, the disproportionate amount of material of different kinds of chemical contents
01:42:14 in relation to the rate of fire and smoke spread in the flat, day 267.
01:42:20 The answer that Professor Perster gave, may I just quote this from him, you heard it about a week ago,
01:42:27 The thing about Ligaya Moore, he said, is that we've no idea what activity she was carrying out.
01:42:32 He'd been comparing her flat with 201, where they knew a lot more about what was happening.
01:42:37 If, for example, and we say this is an important example, she slipped through the whole thing and was in her bedroom,
01:42:46 and the interior doors in her flat were open, then as the fire broke into the living room,
01:42:53 that would have just spread throughout the open space of the whole flat,
01:42:57 in which case she would have been exposed to higher concentrations of smoke at an earlier period than those in 201.
01:43:06 But we don't know. Now, just to pick up on your point, he's mentioning Mr Millett's point,
01:43:12 if in that living room there was a large load of all sorts of materials that would present a big fire load,
01:43:20 which could have produced a much more intense and smoke rich fire at that earlier stage.
01:43:26 We say those are very realistic reflections on the fire itself.
01:43:32 May now turn to the fire and the night, 13th, 14th of June.
01:43:37 As I've already indicated, she made no calls on the landline or a mobile, and she received none on it either.
01:43:47 It means, of course, that this flat, 181, did not appear on any whiteboard,
01:43:54 and the fire brigade would not have been alerted to somebody being in trouble in that flat, as a matter of course.
01:44:01 And no fire crew was deployed to her flat.
01:44:06 No witnesses spoke to her on the night. In other words, in some cases, obviously, doors opened and all the rest.
01:44:14 That didn't happen in her case. And in particular, the aspect of this which rings true and hard is that her friend,
01:44:24 Nanita, once she got alerted to the fire by another friend, tried to ring consistently for over an hour without an answer.
01:44:34 And Nanita herself is able to assist with what happened during the evening of the 13th.
01:44:41 They, in fact, had been together on the 13th, Nanita and Ligaia.
01:44:45 They'd been shopping, and Ligaia had also been to the walk-in centre I've already mentioned, the clinic, about her dizziness.
01:44:56 The centre is a stone's throw away from Grenfell Tower, and they parted company in the evening after 10 o'clock.
01:45:04 Although, as if apportant, and this comes from the most recent statement,
01:45:09 Ligaia wasn't keen to go back to her flat that night.
01:45:16 Now, there can be a lot of, I don't want to speculate unreasonably, but if she's having problems with dizziness,
01:45:22 and she has the psychological barriers at the flat, begins to explain why she might have been reluctant.
01:45:30 She was kept on the CCTV in the lobby waiting to go up at 23 minutes past 10 after she'd left Nanita to the 21st floor.
01:45:41 But she was still troubled about going to the flat, and the reason we know that is that Nanita has discovered
01:45:54 from another friend, whose name I have, I'm not going to mention it publicly, that this other friend was telephoned at 11.30.
01:46:04 So the phones were still working, she was still awake, still troubled about being back in the flat.
01:46:10 This was the last contact, this one, the phone call at 11.30 about her troubles, was the last contact anyone had with her.
01:46:21 So, turning to the timeline, and again, because you're so familiar with these, I just touch on them as keystones, as it were,
01:46:31 in the way the fire spread. You know about the original 999 call by Mr. Kibade, a few minutes before 1 o'clock in the morning,
01:46:42 54 minutes past midnight, and then after that, that's the fire in the kitchen, it spreads to the cladding.
01:46:49 But then the next time you've heard, which is a key time, is 1.26, flat 156, one of the sixes, Shah Ahmed is making his 999 call,
01:47:00 recording therefore how far the fire had reached by that time, and by 1.27 it had reached the crown of the building.
01:47:10 So, that's the general framework. Meanwhile, back on the 21st floor, Mustafa Abu, flat 184, same floor, at 01.10,
01:47:23 he's awoken by a phone call from his brother telling him that the tower was on fire and to get out.
01:47:31 Mustafa reports, this is important because of the smoke infiltration into 181, reports smelling and seeing smoke on the 21st floor landing.
01:47:43 Flat 186, another one on the 21st floor, Helen Gebrameski, at 01.20, was awoken by a smoke alarm.
01:47:55 So, this is one that was working, we can't say they were all working on that floor.
01:48:01 She saw fire in her kitchen, well, she's one of the sixes, so she would.
01:48:07 She made a 999 call at 1.26, 54, whilst in the lift lobby of the 21st floor.
01:48:16 Helen reported that when she went to the fire exit door leading to the stairwell at around 01.30,
01:48:23 there was smoke, quote, but not so much that we could not see each other.
01:48:28 Marco Gomez invited Helen into his flat, 183, at about this time, and he noted a layer of thick black smoke,
01:48:39 two inches close to the ceiling of the lobby, and those are matters that are in your Phase One report.
01:48:45 The kitchen window of 186, as you're now familiar with the configuration of this block,
01:48:52 is adjacent to the living room window of 181, so one begins to see the proximation of,
01:49:00 and the proximity of the fire to, Ligaya.
01:49:04 And therefore, the external spread would have been swift,
01:49:08 and this is demonstrated by the Metropolitan Police external fire spread, which can be accessed.
01:49:14 It's estimated in this report that the fire had covered the external wall of 181 between 129 and 142,
01:49:24 and impacting the inside of the flat with smoke about 153.
01:49:31 Sometime around 1.30, Nanita received a call from a friend of hers who lived near the town to say the tower was on fire.
01:49:42 Nanita immediately, so it's shortly after 1.30, she begins telephoning Ligaya,
01:49:49 who she's obviously been with during the evening, as you know, on her mobile and on the landline,
01:49:55 because even if Ligaya turned the mobile off because she's going to sleep, the landline worked,
01:50:01 but we don't know whether the mobile was on or not.
01:50:05 But she phoned over and over again, so it wasn't just one call.
01:50:08 From that time up to about three o'clock when she realized by then, obviously, no hope at all.
01:50:14 Thereafter, Nanita herself went to the tower more than once, took a photograph,
01:50:21 but as you might, you just continue calling the number in the hope that maybe she did survive.
01:50:29 That's in her Nanita's latest statement.
01:50:33 So if I pause for a moment, the sequence you've just been told about is one that gives rise to what we would suggest
01:50:43 is the first possible scenario for Ligaya, and we say perfectly reasonable on the evidence,
01:50:50 is that after the troubled telephone call at 11.30, she finally did get to sleep.
01:50:57 And because of all the medications, I've no doubt it's possible to surmise she had fell into a deep sleep.
01:51:03 She didn't hear the onset of the fire, nor her telephones.
01:51:08 We can't say whether the alarm was working or not, but even if it was, there's a real possibility she didn't hear that either.
01:51:18 And that whilst she was sleeping, obviously, she'd be inhaling smoke that has come into the flat under the front door,
01:51:26 small flat, doors open on the inside and from the lobby.
01:51:32 And then the smoke and the fumes coming in from outside her windows, followed by fire and smoke inside the flat,
01:51:41 again, as we said, augmented by the overload of the materials in every room.
01:51:47 And you will have noticed that in Operation Northley, the archaeology report, and you've heard about archaeology very recently,
01:51:55 I just use these words, what they recorded when they came to this flat, not alone in this sense,
01:52:02 it displayed, it's recorded as 21.1 for reasons that they obviously know the real numbers,
01:52:09 displayed evidence of a complete burn with no internal walls remaining.
01:52:16 That will be of no surprise, but tells you the vigor and rigor of the fire accelerated, no doubt, by some of the things in the flat.
01:52:26 Professor Purser accepts this as a possibility in both his report and his evidence last week,
01:52:34 laying particular evidence, emphasis upon the archaeological findings relating to the bed springs.
01:52:42 Now, I mention that because the majority is in the area of the bed and the springs that she was found,
01:52:51 and I come to recovery in a moment.
01:52:53 The course of the fire on floor 21 can be traced through contact with the control room by other residents.
01:53:00 At 1.38, the El Wahabi family began a 59-minute call with CRO Jones.
01:53:07 This call made clear early on that there was smoke in the lobby and entering flat 182, the next door flat.
01:53:15 By 1.45, the flames were to the left of 182 and specifically 181,
01:53:22 and the description that's given again merely emphasizes the nature of the conflagration for Ligaya.
01:53:30 Next door to us, that's Ligaya.
01:53:33 For example, it's bad, bad, bad. These are words from the call at that time.
01:53:39 It's burning, burning, it's burning next door to us, really burning.
01:53:45 Now, we know from the deployments that none went to 181,
01:53:50 and you've heard on numerous occasions now about the Paddington crew going to the roof but not reaching it for a different purpose.
01:53:57 You've also heard about other crews being sent up to higher floors but not reaching, so I don't add to any of that detail.
01:54:06 By 12 minutes past 2, the fire reached floor 20 where Fadumo Ahmed was located,
01:54:14 and the firefighter who went to that floor, Dean Roberts, carried on up to 21 and 22.
01:54:22 He opened the doors to each floor and found the lobbies were heavily smoke-laden.
01:54:28 So that's again just reinforcing the situation in the lobbies outside Ligaya's flat.
01:54:35 At 2.32, Marco Gomez in flat 183, again another neighbor, made a 30-second video recording on his mobile telephone of his front door,
01:54:47 and that part of the lobby immediately outside his door, very similar to the one I mentioned two days ago,
01:54:54 and that's referenced and again you will have seen it.
01:54:57 The video shows smoke coming through the gap under the front door that he's talking about,
01:55:04 and on the left-hand side of the door, and a pitch black area in the lobby with no functioning lighting in this case.
01:55:11 The other one I cited was just a photograph with a dim light.
01:55:16 This is again a different floor but same situation.
01:55:19 Just before he started the recording, Marco had tried to reach flat 181, but he didn't get much further than his own front door.
01:55:31 And then at 2.46, he, Marco, made another 999 call about the situation, the fire had reached 182.
01:55:44 The finale for Ligaya, the time of death, as always it is approximate and the best anyone can do,
01:55:53 because there's so little evidence from other people in relation to her.
01:55:58 He's used a comparator, in other words what had happened in another flat one, two floors above, 201, which you've heard about,
01:56:08 where there was smoke from the lobby from about 130, the exterior fire would have started to enter the living room at 132,
01:56:16 as reported by Biruk Haftam, more serious smoke and exterior flame by 136 to 152.
01:56:23 From 152, fire spread across the kitchen and the bedroom.
01:56:28 Smoke came into the bedroom at that time, it had reached the external wall of 182,
01:56:38 the one next door that I've already been talking about at 10 minutes past two, therefore,
01:56:42 Ligaya would have been exposed to increasing smoke and asphyxiant gases throughout this period,
01:56:50 with an addition from the interior contents in the living room igniting as the fire reached the outside of the bedroom,
01:56:57 by which time there's a rapid deterioration in the conditions inside.
01:57:02 Fire developed later in the bedroom, possibly between 222 and 254.
01:57:08 By this time, Ligaya would have been exposed to toxic smoke for up to an hour approximately
01:57:13 and would have passed through the stages of collapse, unconsciousness followed by death, before the fire consumed the whole flat.
01:57:22 It is likely her death occurred between 152, 222, although in the light of Professor Peirce's observations
01:57:31 about flat contents, the fire load and so forth, the time window could be as early as 140.
01:57:39 And just again, making it clear for all relatives and friends that she would not have known what she was inhaling,
01:57:48 particularly if she was asleep, and she particularly would not have been aware of, as it were, not only her collapse,
01:57:58 but also her final demise. The recovery stage, Ligaya, she was reported missing by Nanita on the 14th of June,
01:58:09 still holding hope, as one would expect from anyone.
01:58:13 On the 15th of June, the flat was made safe because it was a complete burnout,
01:58:18 and an archaeological investigation in great detail that you've heard about recently took place over 17 days.
01:58:25 Recovery, I'm going to use that term, was principally from her bedroom, from the area of the bed and the bed springs
01:58:33 I've already mentioned, although there is a secondary, excuse my voice, a secondary location,
01:58:38 may have been in the entrance of the bedroom and the hallway.
01:58:43 The reason for that is that the alignment, there's a diagram to this effect in the report.
01:58:50 The diagram of where some of the remains was found doesn't align exactly with the bed,
01:58:55 so it's not one parallel to the other, and is not in alignment. It may indicate, can't go higher.
01:59:01 It's not a strong inference, it's a mild one that in fact she may have tried to move.
01:59:07 Possibly in a semi-conscious state.
01:59:12 There isn't any pathological or toxicological examinations that were possible in this case.
01:59:18 Her identity was established through odontology and anthropology,
01:59:22 confirmed by the senior coroner on the 29th of September 2017.
01:59:28 The cause of death at that time was given because there was a paucity of forensic materials,
01:59:35 and it was attributed to the familiar phrase that you have now, being consistent with the effects of fire.
01:59:43 So I pause again for the second scenario.
01:59:46 The second scenario, not the one where she slept through it all, is that she did wake up or was semi-conscious,
01:59:53 but by the time there was any kind of realisation by her that the fire was either outside the flat or inside the flat,
02:00:01 it was already too late. The smoke penetration in the flat would have been forbidding,
02:00:07 particularly if she was conscious and awake, especially if the interior doors were open,
02:00:13 compounded by her age, her knee problems, cramped conditions in the home, particularly around the bed,
02:00:20 creating a situation in which she didn't have the strength or the purpose to get much beyond the bed itself.
02:00:28 This has some support from the tentative findings of Dr Harrison,
02:00:33 in the way I've already described of the alignment of the body in the bed.
02:00:38 Professor Purser considered these constraints, they were put by Mr Millett,
02:00:42 that might have inhibited her from even contemplating trying to get out of bed and down the stairs,
02:00:49 and it might suggest, if she did move, that she was at least half-awake at the time.
02:00:56 Finally this, for her to be remembered, she was remembered in the words I've already mentioned in the House of Commons,
02:01:04 and the photographs that have been very kindly brought today display a woman that had a presence,
02:01:11 a woman who had a life commitment, who was herself generous and happy.
02:01:20 But she had a richness of life, these are the words of the family,
02:01:25 and the richness of heart that she will be dearly missed by them and obviously by Nanita,
02:01:34 all of them watching remotely today.
02:01:37 And Nanita said in the statement, she was not only my friend, my mother, my sister, my everything,
02:01:44 the last thing she said before they parted on the evening of the 13th,
02:01:51 I love you, take care of yourself, when in fact she was the one at the end of the day that needed the care.
02:02:00 Thank you.
02:02:15 So I understand 15 minutes is sufficient.
02:02:20 Yes, well thank you very much, Ms Mansfield.
02:02:22 We'll rise for a short break now, we'll resume shortly after our first 12.
02:02:27 Thank you very much.
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02:14:44 Thank you.
02:15:14 Yes, Mr. Millett.
02:15:20 Mr Chairman, Members of the Panel, I would now invite Danny Friedman, QC, to come back to the podium please to make a presentation on behalf of the family of Sheila from flat 132 on Floor 16.
02:15:35 I would repeat the trigger warning that the presentation may contain material or statements
02:15:41 which some may find distressing and therefore they can leave the room now or look away from
02:15:46 the livestream as the case may be.
02:15:48 Thank you very much.
02:15:49 Mr. Friedman, thank you.
02:15:50 Yes, it's true.
02:16:09 Sheila was born on the 17th of September 1932 in Market Harborough and grew up in Sheffield.
02:16:17 At the time of her death she was 84 years old.
02:16:22 In life, Sheila elected to use only her given first name, a decision which the inquiry has
02:16:28 been good enough to respect.
02:16:31 She is survived by her two sons and six grandchildren.
02:16:36 Sheila lived alone in flat 132 on what became floor 16 after the refurbishment.
02:16:44 She moved into the tower in 1984 making her one of the longest standing residents.
02:16:51 She was known to many on the Lancaster West estate and the surrounding area.
02:16:56 The family did not provide a formal commemoration in May 2018 because they wished to respect
02:17:03 the privacy that Sheila particularly valued in her life.
02:17:08 However, the family do wish the panel to know that their mother and grandmother, known
02:17:14 to her grandchildren as nanny Sheila, is dearly missed.
02:17:20 I'm also now asked by the family to tell you today a little bit more about Sheila and how
02:17:26 they remember her.
02:17:28 She was a character, flamboyant and outspoken.
02:17:33 Sheila had what her family described as a shock of white hair and nearly always wore
02:17:38 bright modern clothes.
02:17:42 She was a complete extrovert and unfiltered.
02:17:45 To her two sons growing up and even in maturity desperately wanting to be what they thought
02:17:51 was normal, this could sometimes be awkward.
02:17:55 Sheila was a free thinker, rarely speaking in a linear fashion.
02:18:01 She led a highly independent life with a long standing interest in meditation, yoga and
02:18:07 alternative therapies.
02:18:10 As is often the way, it is only since Sheila's death that some of her particular qualities
02:18:16 and characteristics have shone out which has surprised and added to the family's appreciation
02:18:22 of her.
02:18:25 Sheila always had strong opinions about the way residents were treated by the TMO.
02:18:31 She was never phased by those in apparent authority.
02:18:36 Management of Grenfell Tower and the estate was often a topic of conversation between
02:18:40 Sheila and her family.
02:18:43 She was a well known and active member of the community and had been a member of a group
02:18:48 representing tenants' views and concerns to the TMO, the Inquiry Know This Group, as
02:18:54 the Grenfell Compact.
02:18:59 Sheila was always a very active person.
02:19:02 She had cycled in London, attended yoga classes and swam.
02:19:06 However, prior to the fire, her physical health had deteriorated and she was reliant on the
02:19:12 lifts to get to and from the 16th floor.
02:19:15 TMO staff were aware of her reliance on lifts from her complaints about the difficulties
02:19:21 caused when they broke down.
02:19:23 The Inquiry has available to it evidence of a meeting on 17 July 2015 attended by the
02:19:31 then Member of Parliament Lady Victoria Borwick and TMO offices.
02:19:36 It is captured on footage filmed by Constantine Grass.
02:19:41 Sheila outlined in some details difficulties she faced.
02:19:47 The family had also supplied to the TMO in early 2017.
02:19:53 Information that would require a walk-in shower in store due to the deterioration
02:19:58 in Sheila's health.
02:20:00 This entailed supplying supporting medical evidence which had been obtained from Sheila's
02:20:05 GP.
02:20:07 As with all other residents at Grenfell, there were no arrangements in place such as a personal
02:20:12 emergency evacuation plan to address Sheila's difficulties descending the single stairs
02:20:19 in the event of a necessity to do so.
02:20:23 There was also no advance communications or pre-arrangements for assisted evacuation
02:20:28 or rescue of Sheila by the LFB.
02:20:34 CCTV footage shows Sheila entering Grenfell for the last time at 2.22pm and then in the
02:20:42 lift lobby at 2.25pm on 13 June.
02:20:51 There was no contact with Sheila on the night of the fire.
02:20:55 According to her eldest son, in a statement that he provided to the Metropolitan Police,
02:21:01 Sheila always went to bed early between 8pm and 9pm and she often slept wearing an eye
02:21:08 mask and earplugs.
02:21:11 For the record, may I say this is the statement of Martin Smith dated 30 June 2019, page 4
02:21:19 provided to the Metropolitan Police.
02:21:23 The Phase 1 report found at Volume 2, paragraphs 10, 116 to 117, that from 0120, the rate at
02:21:32 which the flame spread vertically up the north east corner of the building accelerated considerably,
02:21:39 travelling at 0.75 floors per minute, it reaching the top of Floor 15 by 0123.36.
02:21:49 Aziza Rehani had evacuated from flat 126 on Floor 15 below and left the building by 0121.42.
02:21:59 This was likely in response to the effects of the rapidly approaching fire which would
02:22:03 have broken into flat 126 very shortly thereafter.
02:22:09 Hamid Wabi lived in flat 136 on Floor 16.
02:22:15 He was the only member of his family at home that night.
02:22:19 Hamid 40 became aware of encroaching flames as early as 0115 when he heard a crackling
02:22:24 sound.
02:22:25 Soon after, the fire entered the kitchen.
02:22:30 After that, Hamid Wabi rapidly dressed and left the flat.
02:22:34 At the time, there was thick black smoke in the kitchen that had also come into the living
02:22:39 room and hallway.
02:22:42 The Phase 1 report has already determined at Volume 4, paragraph 24.31, that the door
02:22:50 to flat 136 was left open by Mr Wabi as he fled due to the absence of a functioning self-closing
02:22:58 device.
02:23:01 This allowed smoke to flow into the communal lobby.
02:23:04 The lobby of Floor 16 was clear of smoke at the time Hamid Wabi fled his flat.
02:23:10 However, on returning a matter of minutes later, Mr Wabi recalls the lobby had become
02:23:16 full of very thick black smoke which felt hot.
02:23:21 The other residents of Floor 16 who evacuated around this time, all exiting before 0138,
02:23:28 described similar conditions in the lobby.
02:23:32 In contrast, they noted relatively smoke-free conditions in the stairwell.
02:23:40 Next week, you will hear further about the conditions in Floor 16 and on the lobby in
02:23:46 the presentation for Joseph Daniels, who died in flat 135 on this floor.
02:23:52 The circumstances and causation of the absence of an effective self-closing device on the
02:23:58 front door of flat 136 and other flat front doors has been the subject of submissions
02:24:04 in other modules.
02:24:06 For present purposes, may I note two points.
02:24:10 First, it is a fact that a previous complaint was made by Edward Daffan from flat 134 about
02:24:18 the defective self-closing device on the flat 136 front door in August 2015.
02:24:27 The complaint was rejected at all three stages of the TMO's complaint process.
02:24:32 There is no evidence that any repair work was done to ensure that the door had a functioning
02:24:38 closer prior to the fire.
02:24:41 Second, our understanding of the available evidence is that if one considers every floor
02:24:50 from floors 14 to 20, the only flat 6 door that had a working self-closer was flat 156
02:24:59 on the 18th floor, belonging to Shah and Saeed Ahmed, leaseholders.
02:25:07 As you will hear about further in the presentation for Joseph Daniels, fires fighters Stern and
02:25:12 Hipple reached Floor 16, having been alerted by Sam Daniels to the presence of his vulnerable
02:25:18 father in flat 135.
02:25:22 The Phase 1 report at Volume 2, paragraph 11.82, recorded the evidence that around this
02:25:29 time the Floor 16 stairwell door was held open.
02:25:34 Firefighters Stern and Hipple discovered and assisted in rescuing Edward Daffan from the
02:25:39 floor of the densely smoked, logged lobby, but they were unable to rescue Joseph Daniels.
02:25:46 The firefighters suggest that before leaving the floor, due to low air gauges on their
02:25:51 BA sets, they knocked on flat front doors.
02:25:56 Firefighter Sterns told you he knocked on two further doors, both of which were closed,
02:26:01 likely to have been flats 135, the Daniels' home, and flat 134, Edward Daffan's now empty
02:26:09 home.
02:26:11 Firefighter Hipple, however, recalled completing the right-hand search, stopping at each door
02:26:17 hitting, kicking and shouting out.
02:26:20 If that is right, this may have included the front door of flat 132, Sheila's front door,
02:26:27 Senemur Seat, who lived in flat 133, who did devise this fire, did not recall any knocking
02:26:35 on his door.
02:26:39 Firefighter O'Byrne then recalls radioing that there was a bed-bound resident on Floor
02:26:46 16 while he was still in the tower and some information appears to have filtered through
02:26:52 to watch Manager Dowden over the radio.
02:26:56 Mr Dowden at this time was still the incident commander.
02:27:00 He recalled being told that there were people with mobility issues on Floor 11, which would
02:27:06 likely be the Ali Jawa Jafari, and Floor 16, which would be Joseph Daniels.
02:27:15 Firefighter O'Byrne also recalled speaking to Station Manager Lough once outside the
02:27:20 tower and specifically telling him, there's a guy on the 16th floor, he's bare-bound,
02:27:27 the crew can't get to him because it's too hot and smoky up there.
02:27:33 Following the evacuation of residents from Floor 16 and the unsuccessful rescue attempt,
02:27:38 the remaining residents on the floor were therefore Joseph Daniels in flat 135, Mr and
02:27:44 Mrs Masit in flat 133 and Sheila in flat 132.
02:27:52 CCTV images show that Hamid Wabi, just outside the entrance of the tower, was speaking to
02:27:59 Station Manager Lough and Watch Manager Watson at 0138 and 16.
02:28:07 Mr Wabi recalled that he told the firefighters that there was an elderly man and an elderly
02:28:12 woman on flat 16 who needed help and by that he meant Joseph Daniels and Sheila.
02:28:20 He was clear that he had told them about these neighbours.
02:28:24 With the benefit of his mother being away from the building that night, he was particularly
02:28:29 anxious about the elderly.
02:28:33 Videos at 0138 50 show SM Loft and WM Watson continuing to talk at the main entrance.
02:28:43 Neither recalled that they spoke about nor mentioned Hamid Wabi's warning.
02:28:48 No information was documented to identify that Sheila was still on Floor 16.
02:28:54 The only relevant reference to anyone in need of help in this time is the original Forward
02:29:00 Information Board used at the bridgehead that was filled in with the words Man 16th
02:29:07 Floor.
02:29:08 The remaining elderly woman Sheila, who Hamid Wabi had mentioned, would never be documented
02:29:14 at the fire ground.
02:29:19 At 0137 27 Senemaseet made his first 999 call to the MPS from flat 133.
02:29:29 He was conference called into the LFB control room by 0148 28.
02:29:40 He told them that smoke was entering the flat and he and his wife had been unable to exit
02:29:45 through the lobby.
02:29:47 CRO Adams told him that the fire was on Floor 4.
02:29:51 She advised him to put wet blankets around the doors, to stay where he was and to call
02:29:57 if things got worse.
02:30:00 Service requests and radio messages were made at 0145 42 and 0146 05 which included information
02:30:10 that persons were trapped on Floor 16.
02:30:14 The Masseeds subsequently made further 999 calls at 0210 until 0238, at 0241, at 0249,
02:30:26 at 302 and at 312.
02:30:31 After a number of previous attempts, Mr and Mrs Masseed eventually evacuated when the
02:30:36 fire entered their home in flat 133.
02:30:40 They exited the building at 0347.
02:30:45 As a result of the Masseeds call, the flip chart sheet in command unit 8 contained a
02:30:51 to quote, two adults in living room fire in flat.
02:30:57 Some of the information was conveyed to the third floor bridgehead before it moved at
02:31:01 03 AM.
02:31:04 All that could be found on the wall was 16 and the number 133 circled.
02:31:11 Down on the same wall it reads, Fsg 16th, flat 133.
02:31:22 On the piece of paper provided by watch manager Sadler working outside the tower are the entries
02:31:30 133, 16th floor.
02:31:34 I'm not going to ask to bring these documents up because they only ever make a reference
02:31:39 to flat 133, never 132.
02:31:45 Mr and Mrs Masseed were not rescued.
02:31:47 They had to self evacuate in circumstances where they had watched and analysed the fire
02:31:52 and supported each other to leave when they judged they had to.
02:31:57 Indeed, after firefighters O'Byrne, Stern and Hipple returned from the floor at around
02:32:04 No further BA team is known to have been deployed to floor 16 in response to the various Fsg
02:32:12 calls and information.
02:32:15 The next known deployment to floor 16 was the deployment of station manager Cook and
02:32:22 crew manager Gallagher at 04 04 27.
02:32:27 The deployment was conducted in consultation with group managers Goldbourne and Welsh with
02:32:32 the purpose of investigating reports of 10 people trapped on floor 16 and 11 people trapped
02:32:38 on floor 18.
02:32:41 The information was not correct and unsupported by the Fsg information written on the ground
02:32:46 floor.
02:32:47 The deployment could not reach the upper floors.
02:32:51 Both firefighters were wearing standard duration breathing equipment and therefore could not
02:32:55 have been able to carry out a detailed sweep at a level as high as floor 16 at the relevant
02:33:02 times.
02:33:04 The deployment happened however very late on in the fire and for reasons I now turn
02:33:09 to it would likely have been too late for Sheila.
02:33:16 Sheila's remains were recovered from the bedroom located opposite to the bathroom in
02:33:21 flat 132.
02:33:24 Several investigation establishes that she was lying on her back with her head towards
02:33:30 the window she was on or just by the location of the still intact mattress springs.
02:33:39 These detailed findings are therefore consistent with an elderly woman lying in the position
02:33:44 she would have been in if she had passed away in her bed.
02:33:50 Sheila's time of death cannot be identified with precision given the lack of contact with
02:33:56 her on the night.
02:33:59 Professor Perser explains based on the evidence of fire spread that conditions in the bedroom
02:34:05 where Sheila was recovered would have deteriorated very rapidly once the fire spread across the
02:34:11 south face of flat 132 at around 309 to 312.
02:34:18 Prior to that and from approximately 0126 Sheila would have been exposed to an increasing
02:34:24 concentration of toxic gases.
02:34:27 The extent of this exposure depends on whether she was in her bedroom throughout and if the
02:34:32 bedroom door was shut which is not known.
02:34:36 Once the fire reached the bedroom the exposure to toxic gases would have increased rapidly.
02:34:43 Professor Perser concluded that it is likely that Sheila was overcome by exposure to toxic
02:34:48 gases from the external fire within a few minutes of the fire spreading outside the
02:34:54 bedroom and died within a few further minutes thereafter.
02:34:58 That would have been before the interior fire which burnt out the flat.
02:35:03 Based on the position she was lying in Professor Perser specifically notes the possibility
02:35:09 that Sheila was overcome and died in her bed unaware of the situation.
02:35:15 In terms of that I would add she had a phone and we know from how she complained about
02:35:20 lifts not working she was someone who could have used it if she was aware of the situation.
02:35:28 The final post-mortem report for Sheila gave the provisional cause of death as 1A consistent
02:35:34 with the effects of fire.
02:35:36 However based on the phase two section six analysis of Professor Perser the medical cause
02:35:42 of death can be properly given as the more specific and informative conclusion of inhalation
02:35:48 of fire fumes or an equivalent formulation to that can be added the archaeological evidence
02:35:55 that I have just summarised.
02:36:03 The video footage you have of Sheila from July 2015 filmed by Mr Grass shows a lively
02:36:11 and articulate person living her life on her own terms.
02:36:17 She was frank saying that she was going to get upset if she talked about the faceless
02:36:21 way the building was being run.
02:36:24 She was proud that she had lived in Grenfell for 32 years.
02:36:29 She was also aware of and worried about her fragility.
02:36:34 Her presence and what she said in the meeting shows that Sheila was not an isolated resident.
02:36:40 She was part of her community.
02:36:43 But as one of its elderly members who lived alone she required a strategy for emergency
02:36:49 evacuation if the need arose.
02:36:52 That did not exist at the time of the Grenfell fire.
02:36:56 The family of this independent and unique woman would wish as would Sheila that the
02:37:03 legacy of her death can contribute to profound societal rethinking on that very issue.
02:37:14 Thank you.
02:37:34 Thank you very much Mr Friedman.
02:37:37 Well that concludes our proceedings for today but we shall be sitting again tomorrow at
02:37:42 ten o'clock in order to hear more presentations relating to those who died in the fire.
02:37:50 So ten o'clock tomorrow please.
02:37:52 Thank you very much.