Presentations for deceased residents: Isaac Palos (5 years old, Flat 153, floor 18) presented by Imran Khan QC, and Vincent Chener (Flat 144, floor 17) presented by Allison Munroe QC. Details the harrowing circumstances of their deaths and families' experiences.
00:00:22 [Music]
00:00:27 good morning everyone welcome to today's ing today we're going to hear further presentations relating to those who died in the fire yes Mr milet good morning Mr chairman good morning members of the
00:00:38 chairman good morning members of the panel I would now invite Mr Imran Khan QC please to come back to the podium to make the presentation on behalf of the family of Isaac Palos who was from Flat
00:00:49 family of Isaac Palos who was from Flat 153 on floor 18 of grenfell tower as before I would reissue the trigger warning which I normally give there may be material or things said or sh by Mr
00:01:00 be material or things said or sh by Mr Khan during the course of his presentation which those in this room or following the live stream may find difficult and distressing in which case they should leave now or look away from the live stream as the case may be M
00:01:12 the live stream as the case may be M thank
00:01:27 you yes Mr KH good morning sir good morning
00:01:31 morning p uh no parent should outlive or expect to outlive their child no parent should have to risk
00:01:42 child no parent should have to risk their life to save their Childs no parent should have to choose which of their children should risk
00:01:53 which of their children should risk dying no parent should ever have to think about these decisions let alone make
00:02:00 make them yet on the 14th of June 2017 Palos and his wife ganette had to do precisely this and are living with and have had to
00:02:11 this and are living with and have had to live and will live with the guilt of making those decisions forever and more Isaac Palace was the firstborn son
00:02:22 more Isaac Palace was the firstborn son of palus teay and ganette shawa and the older brother of Lucas he was 5 years old at the time of his
00:02:33 he was 5 years old at the time of his death he was born on the 22nd of September 2011 at Chelsea and westmin Hospital in London he lived as we know in flat 153 Grenville tower on the 18th
00:02:46 Grenville tower on the 18th floor he lived there with his mother ganette father Palos and three-year-old brother
00:02:53 brother Lucas the family had moved into the flat only a year earlier on the 1st of June 2016
00:03:01 2016 at the time his mother ganette was concerned the flat was on the 18th floor and she has stated in her phase one witness
00:03:08 witness statement and my son Isaac didn't want to move there when I told him about this I was told this was the last offer that I was going to be given and if it was not
00:03:18 not accepted I would be rehoused outside of the royal bar of Kensington Chelsea ganette like many others reported problems with the flat such as at the front door of the flat not
00:03:31 at the front door of the flat not locking properly and on the 27th of February 2017 she reported that there was a strong draw from all the flat windows so you will recall and we invite
00:03:42 windows so you will recall and we invite the panel members uh to read and listen to the pen portrait on the 29th of May 2018 when Isaac's F father Palos who
00:03:54 2018 when Isaac's F father Palos who finds it too difficult and painful to listen to matters today and he's not here here neither is ganette he spoke of the unimaginable heartbreak following Isaac's death but
00:04:07 heartbreak following Isaac's death but also the Great Joy both his children had brought
00:04:11 brought him he named his first son firstborn son Isaac which in amaric means joy to love the pen portrait I said makes
00:04:23 love the pen portrait I said makes painful listening and viewing and as I said I would urge you to revisit it to listen to it and to read the
00:04:32 read the transcript by all accounts Isaac was a talented Boy Who Loved Taekwondo swimming in football although his mother ganette would say that Isaac was a Chelsea
00:04:44 would say that Isaac was a Chelsea supporter he was in reality a gaser an Arenal
00:04:48 Arenal fan just like his father as his parents and teachers reflected during the pen portrait Isaac enjoyed school and he was particularly gifted at mass and reading and had by
00:05:01 gifted at mass and reading and had by all accounts a bright future ahead of him he was by all accounts a very special young boy with those words so I now turn to
00:05:13 boy with those words so I now turn to the tragic events of the 14th of June which led to Isaac's death it starts with CCTV footage showing Janette ganette Isaac and Lucas in the left lobby at 1829 on 13th of
00:05:27 in the left lobby at 1829 on 13th of June that day Isaac had gone to school and after school he went to taekwondo and then returned home for dinner it was by all accounts just another normal
00:05:39 another normal day but this normality was a change in the early hours of the 14th of June and as we know Mr CET made that call uh of the fire that we have heard about during
00:05:52 the fire that we have heard about during the course of this inquiry at that time Isaac was at home with his mother father and younger brother
00:05:59 brother his father Palos had intended to go to work after Isaac had fallen asleep however when Palos put him to bed Isaac begged him to stay and so Palos
00:06:12 Isaac begged him to stay and so Palos did he stayed and fell asleep next to his
00:06:17 his son as we know within minutes of the fire starting the occupants of the upper floors and floor 18 became aware of it Palace and ganette were woken up when they heard noises outside their flat
00:06:30 they heard noises outside their flat they opened the front door and despite there being no light in the lobby they saw their neighbor Rabia Yaya of flat 152 Palace recalled that Rabia alerted
00:06:43 152 Palace recalled that Rabia alerted ganette to the fire Mr enu who was a lodger in flat5 which was the home of bti haum and her son barook has stated that he was woken at 0115 by the smell of
00:06:57 woken at 0115 by the smell of smoke and at 013 2 pal spoke to his friend Abraham a beby who lived in flat 44 on the seventh floor He was unaware of the fire until
00:07:09 floor He was unaware of the fire until alerted by Pals in terms of cause made that night Rabia Yaya made several 999 calls I deal with a few of those at 0133 she informed
00:07:22 with a few of those at 0133 she informed the call Handler there was no smoke inside her flat and said I tried to get out to go through the fire escape but there's just thick black smoke she made numerous calls to the
00:07:34 smoke she made numerous calls to the fire service and at one point firefighters came to her door and provideed fire safety advice and reassurance but soon after they left the fire had reached her kitchen she left with her children and
00:07:46 kitchen she left with her children and sought Refuge into her neighbor ginette's
00:07:50 ginette's flat also present in the flat was Mr enu who by then had left
00:07:58 flat5 pal and ganette also made and received multiple calls to and from the Emergency Services between 0207 and 032 and we have the benefits of the
00:08:09 and we have the benefits of the transcript these calls and we don't seek to play them here so panel members uh you of course have those and um will listen to those read those
00:08:21 and um will listen to those read those transcripts and appreciate how desperate those calls indicate how desperate people were just in relation to one or two of those at o27 there was a call from ginette's
00:08:33 at o27 there was a call from ginette's phone and pal recollects being told that the fire service in his words were dealing with the fire and they should stay where they were at that stage Palos took the fire
00:08:45 were at that stage Palos took the fire service at their word ganette recollects having spoken with Hashim Kadir on the 22nd floor that he too had spoken with the fire service and he too had been told not to leave
00:08:57 and he too had been told not to leave his flat and to wait for the fire brigade
00:09:01 brigade and so panel members palis and ginett want you to know this that they were convinced that up to this point they would be rescued by the fire service by the London fire brigade based upon the
00:09:12 the London fire brigade based upon the information they were given by them the Emer services and of course by Hashim Kadir who had also been told the same pal also said in the past that he quote trusted the authorities and
00:09:25 quote trusted the authorities and believed they were coming to rescue us he also said this had he known differently he would have taken the children and ganette there and then and they would have
00:09:36 they would have left and he says this that perhaps then if he had done that Isaac would still be here alive
00:09:46 today at 0231 Palos connected to the BT exchange and shouted for help describing the fire as moving from Flat
00:09:56 Flat 154 he was advised to go to the r with the Lea smoke and wait at 0242 Palos called 999 but the BT exchange couldn't connect into the fire
00:10:09 exchange couldn't connect into the fire service Palace also spoke to cro got stating that nine people need to be rescued those nine were the occupants from floor 18 Palos ganette their two children
00:10:23 18 Palos ganette their two children Rabia Yaya and her three children and of course Mr enu they had all gather gathered in flat 153 Palos made a further call at 0251
00:10:35 153 Palos made a further call at 0251 when he was connected to S65 service and even at this late stage now nearly 2 hours since the report fire he was still being advised by the operator to stay
00:10:46 being advised by the operator to stay put if they could not leave and at 0254 the that same operator who he spoke to called pal back and left the following message quote
00:10:58 and left the following message quote hello this is Essex fire service I spoke to you earlier we spoken to London Fire Service who advised us for yourself and your family to make every effort possible to get out of the building and
00:11:10 possible to get out of the building and go to your nearest fire exit they are in attendance dealing with it but if you can get out if you can cover yourselves in a wet Tow and your family and make your way to the fire exit as soon as
00:11:21 your way to the fire exit as soon as possible thank you so as we know that St policy was abandoned shortly before this call but Palace
00:11:29 Palace only heard this message once he had exited the
00:11:36 tower earlier at around 0200 palace's firmly held believe that the fire service was going to rescue him and his family was at breaking
00:11:47 and his family was at breaking point he was about to consider and do the
00:11:51 the unthinkable he was contemplating him and his wife sacrificing their lives for the lives of their children this was not some idle thought or fleeting moment of
00:12:03 fleeting moment of Madness because po slowly climbed onto the balcony of the flat with Isaac in his
00:12:10 his [Music]
00:12:11 [Music] arms and was about to jump to a certain death in order to save his son Palos has said that he considered this more than once and this image of
00:12:24 this more than once and this image of him sitting on his balcony with Isaac in his arms has we suggest become one of the defining moments of the events of that
00:12:33 that day it Inc capitates in a way that words that I cannot the sheer desperation of those who had come to the conclusion that the fire service was not going to help them to escape the
00:12:45 help them to escape the tower that those who needed help and were assured they were going to get it were now on their own it shows the extent to which those who had now lost faith in the Emer
00:12:56 who had now lost faith in the Emer Services would go to protect their loved ones
00:13:00 ones they were so prepared to sacrifice their own lives to save the lives of their children the image of Palos on the balcony was captured on helicopter
00:13:12 balcony was captured on helicopter footage which because of its distressing nature sir we're not showing suffice it to say that we see a man who considered risking his own life to say that of his
00:13:26 to say that of his child one can only Wonder so what was going through Palace his mind and the horrendous Choice he was on the brink of making and sacrificing his life to save that of his
00:13:37 life to save that of his child pal says he told Isaac he would hold him and that they would jump together he suggested to ganette that once he held Isaac she should jump
00:13:50 once he held Isaac she should jump holding
00:13:52 holding Lucas he told her that if they jumped and landed on their backs holding each child they could cushion their fall and this was better than being burnt
00:14:05 alive pal says that in anticipation of what he believed his and ginette's fate to be he made calls to his family to say goodbye but could not get hold of any of
00:14:17 goodbye but could not get hold of any of them ganette did the same and spoke with her F friend
00:14:25 mes we know that earlier at around 0200 firefighters Lawson and Foster arrived on the 18th floor they have stated that they did this only to provide fire safety
00:14:37 this only to provide fire safety guidance pow vividly recall speaking to one of them and had assumed they had come to rescue them and take them
00:14:45 take them out instead they were told to stay put in the flat and just cover the front door with a blanket Palos desperately and repeatedly told the firefighters that there were
00:14:56 told the firefighters that there were children in the flat five in in all to emphasize the urgent need to be rescued and Palace and ganette vehemently dispute that at any point
00:15:08 vehemently dispute that at any point they told any of the firefighters that they were at that moment safe we know that firefighters Lawson and Foster decided they could not Evacuate the occupants of floor 18
00:15:19 Evacuate the occupants of floor 18 because of the building's conditions we're told that both firefighters were low on air so they decided to descend the tower and agreed to pass details about floor
00:15:32 about floor 18 unfortunately neither of them relayed this information to any of the occupants on floor
00:15:38 on floor 18 we know that firefighters Lawson Foster reported back to the bridge head and firefighter Lawson drew a plan of for floor 18 identifying the flats and occupants and finally on the issue of
00:15:50 occupants and finally on the issue of course after having received a phone call at around 0256 from Essex fire service advising them to leave the flat they all left the flat
00:16:01 together Palos and ganet have had to painfully recall the details of their precise movements out of the flat and down the
00:16:09 down the stairs and as I've said to you sir today they cannot be here because it's simply too painful to re relive those moments
00:16:21 too painful to re relive those moments again they say that at this point there was a lot of commotion as they were preparing to leave the flat ganette was trying to wet towels and bed sheets in the bath to cover everyone but there was little
00:16:31 little water the youngest Lucas was really distressed lying on the floor screaming Mr enu opened the front door and more smoke entered the
00:16:42 and more smoke entered the flat at the same time Mr enu shouted which one do you want me to hold referring to the two boys because there was a sense of panic
00:16:53 boys because there was a sense of panic and urgency to leave Isaac was standing next to his father and Palace recalls that he picked up Lucas from the floor and as he needed both hands for Lucas he handed Isaac to
00:17:07 both hands for Lucas he handed Isaac to Mr enu the only other adult male close by this was the second profound choice that Palos had to consider that
00:17:19 that Palos had to consider that night as awful as a choice the decision was to jump with Isaac in his arms from the balcony ledge it is this choice this act this decision of handing Isaac to Mr
00:17:33 this decision of handing Isaac to Mr enu which has haunted him most given what was to
00:17:41 follow as they opened the door Mr enu noed firefighters in the lobby these firefighters were the crew of ba team 30 comprising firefighters
00:17:52 of ba team 30 comprising firefighters pole Mitchell and Cheesman who' made the decision to search floor 18 according to Palos and ganette when they left Mr enu and Isaac were in front in
00:18:03 left Mr enu and Isaac were in front in front of them followed by Ria and her children then palus and Lucas and then ganette in the rear ganette had no shoes nor a wet
00:18:14 rear ganette had no shoes nor a wet towel for her face she stated in her witness statement that the firefighters did not help them on the way down and did not take any of the
00:18:26 way down and did not take any of the children they repeatedly described the smoke is overwhelming and said they couldn't see each other they had left with firefighters Mitchell Cheeseman and
00:18:38 Mitchell Cheeseman and Paul the Recollections of firefighters Mitchell achievement and Paul differ as to what happened that night and these differences render it difficult to establish which of the firefighters was at the front of the
00:18:49 firefighters was at the front of the group and therefore who was closest to Mr enu who of course was supposed to be holding
00:18:57 Isaac firefighter Cheesman states that he was unaware of any children becoming detached from the group Paul and Mitchell make no mention of this in their statements and Paul is the only
00:19:10 statements and Paul is the only firefighter to assist with any children from the group and the phase one report volume 3 states that it's likely that Mitchell was firefighter to to assist Mr
00:19:21 to assist Mr enu however firefighter Mitchell statement does not mention a child with the man presumably Mr enu that he was assisting
00:19:30 assisting the phase one report of volume 3 goes on to state that quote the differences of recollection to which I sir to which you sir have referred make it impossible to
00:19:41 sir have referred make it impossible to reach any clear conclusion about how or when Mr enu let go of Isaac Pal's hand palus recalls that at one point on the way down he fell down with Lucas and
00:19:53 the way down he fell down with Lucas and hit his
00:19:54 hit his shoulder he could not get up and slid down the stairs and at some point much lower down ganette took Lucas from Palos ganette
00:20:05 ganette took Lucas from Palos ganette carried him until she came across a firefight and low floors who took hold of
00:20:10 of Lucas at this point ganette asked Palace where Isaac was and Palos told her what he assumed to be the case that he was with Mr enu who'd been in front of them
00:20:22 with Mr enu who'd been in front of them so he Palos assumed that both Mr enu and Isaac were out of the tire Tower once outside they obviously looked
00:20:34 Tower once outside they obviously looked for Mr enu who was at that point receiving help at one of the ambulances and palus asked him where's Isaac Mr enu remembers telling palus the heartbreaking
00:20:46 heartbreaking news that he had lost Isaac halfway down the
00:20:51 stairs palas now wonders how it is that a grown able boded man could have lost a child could have lost a child and why it
00:21:05 child could have lost a child and why it was the case that the firefighters do not hold on to a young vulnerable 5-year-old child rather an adult able boded
00:21:15 boded male it should be noted the firefighter achievement stated this is corroborated by Mitchell and pole that he at least was unaware of any policy to prioritize children in the
00:21:27 policy to prioritize children in the event of a group of adults and children requiring
00:21:32 rescue but I digress a police officer who had spoken to Mr enu did not know how to tell the hysterical ganet Hysterical by this stage that Mr enu had told him that he
00:21:44 stage that Mr enu had told him that he had lost Isaac on their way down in a state of panic Palace and ganette found Rabia with her children and asked them if they had seen
00:21:56 children and asked them if they had seen Isaac Robia eldest daughter stated that she was sure she saw Isaac outside on the lower
00:22:04 floors now even more distraught and agitated ganette was crawling on the ground crying and wailing that she had to find her son she had to find her
00:22:18 son she had to find her son in desperation Palace and ganette tried to get back into the tower to find Isaac but of course given the conditions and the
00:22:26 and the danger they were not allowed to enter enter disbelieving of the account that Isaac was dead Palos and ganette and their friends continued searching for him at various
00:22:37 him at various hospitals and it was not until a few days
00:22:40 days later they found out that he was dead by hearing
00:22:45 hearing it not from a police officer not from a paramedic not from a firefighter but from the media they heard of Isaac's death
00:22:58 media they heard of Isaac's death because it was on the
00:23:04 news Isaac's body was found by firefighters in the stairwell that was subsequently moved to the lobby of floor 13 The Phase 1 volume 3 report did not come to conclusion as to how Isaac came
00:23:17 come to conclusion as to how Isaac came to be found in the stairwell near floor 13 his body was moved his location from point on the stairs by firefighters Lee Perry Andrew Regan and Peter Shackleton
00:23:29 Perry Andrew Regan and Peter Shackleton firefighter Regan said the body was quote on the landing of the stairwell Shackleton Perry said that They Carried the body down the stairs of the floor
00:23:39 the floor Lobby it's unknown at what point in time Isaac's death actually occurred but it was likely to been shortly after Isaac left flat 153 with
00:23:50 shortly after Isaac left flat 153 with his parents Brothers brother and Neighbors from floor 18 Professor P's findings in his report notes that quote carbon monoxide uptake
00:24:01 notes that quote carbon monoxide uptake in young children occurs approximately twice the rate of that in an adult he states that the rate of uptake of carbon monoxide and other smoke constituents for Isaac Palos was
00:24:12 constituents for Isaac Palos was approximately 1.7 times greater than that of an adult and he gives an uncertainty range of approximately 1.5 to2 the initial medical cause of death
00:24:25 to2 the initial medical cause of death as with those who died others who died was given as quote inhalation of products of combustion and this was by Dr Virginia Fitzpatrick
00:24:36 Dr Virginia Fitzpatrick swallow Professor P's findings state that quote after becoming disoriented after becoming disoriented and collapsing in the stair he Isaac
00:24:47 and collapsing in the stair he Isaac lost Consciousness but continued to Inhale Smoke and as fixant gases until he exceeded the lethal threshold blood level of 50% carboxy hemoglobin
00:24:59 level of 50% carboxy hemoglobin and his respiration circulation ceased when he accumulated his final lethal blood level of 67%
00:25:09 carboxyhemoglobin Professor perser concludes that death was therefore due to asfixia from the inhalation mainly of carbon
00:25:18 carbon monoxide but with some contribution from inhaled hydrogen cyanide Professor P continues that Isaac Sin showed heavy soot deposit
00:25:29 Sin showed heavy soot deposit there were such deposits in his Airways with some signs of Airway inflammation he say there's also some heat damage especially to his low legs which is likely to have occur sometime after
00:25:44 death Palos and ganette were devoted to both their children and they cannot put into words the pain of losing their firstborn son on the evening of the 13th of June
00:25:57 son on the evening of the 13th of June pal had taken Isaac to his MTH study program he was said so very good at mass and finished his studies very quickly Palos had intended to celebrate
00:26:09 quickly Palos had intended to celebrate with Isaac the following day but of course he never had the opportunity of doing
00:26:15 doing so his parents have said this Isaac our beloved Son was taken from us when he was only 5 years old we will all miss our kind energetic
00:26:26 old we will all miss our kind energetic and generous little boy he was such a good boy who was loved by his friends and family we will miss him forever but we know that God is looking after him now and that he's safe in
00:26:39 and that he's safe in heaven so pan members Palos and ganette
00:26:46 ganette live and I use that word advisedly live with the horror of the events of the early hours of the 14th of June that led to the death of their son they relieved the moments that led
00:26:57 son they relieved the moments that led them to become separated from one of their sons they tortured themselves with the knowledge that they were unable to carry both their sons out of the town and are left with the thought of if only
00:27:08 and are left with the thought of if only I had done this or if only I had done that it's not just that they could have made different choices that night but that they but that they
00:27:21 night but that they but that they actually don't know what Isaac's final moments
00:27:25 moments were how was it that Mr enu became came separated from Isaac when did this happen why did this happen why didn't the firefighters
00:27:36 happen why didn't the firefighters prioritize Isaac why was an adult looked after by the firefighters rather than a 5-year-old child did Isaac in his disorientated
00:27:47 child did Isaac in his disorientated State call out did he shout out for
00:27:52 help did he shout crying for his mom and dad
00:27:58 dad did anyone look for him and was it not obvious that a 5-year-old child needed looking out for that their child needed help to
00:28:10 for that their child needed help to survive to live not knowing what happened to Isaac in the last moments of his life is on occasion worse than knowing the
00:28:24 occasion worse than knowing the reality Palace and ganed can only hope that Isaac was not in pain when he died it is shocking for them to think that of the nine people that were
00:28:35 that of the nine people that were assisted by firefighters to escape the fire on that night having left flat 153 the only one the only one that did not
00:28:46 the only one the only one that did not survive was a 5-year-old child their son Isaac they say Isaac was the one that needed the most care the most looking after the most
00:28:58 after the most attention the most protection he didn't get it and Palos and ganette wonder and we always wonder
00:29:10 and ganette wonder and we always wonder why as palus told you sir on the six day of the commemoration hearings quote I listen to the authorities and that makes me
00:29:21 that makes me angry why were we kept inside for so long I want answers I want to know why I was physically pleas stop from leaving the flat at 2 a.m. if I had not listened to the fire
00:29:32 a.m. if I had not listened to the fire brigade my son Isaac would likely be alive
00:29:44 today so whilst we all sit in this inquir today and conduct ourselves with decorum and dignity and rightly so Palace and
00:29:55 and dignity and rightly so Palace and Ginette say that in contrast their son wasn't afforded a dignified death he wasn't afforded the protection he deserved and those that were entrusted to care for him appear not to have done
00:30:09 to care for him appear not to have done so but it's not only Palos and ganette whose lives have been so Shattered by the events of that night the young son Lucas who although only three at the
00:30:20 only three at the time suffers from severe nightmares and he has wanted to know what his brother was like and how he died he has said on seeing family photos
00:30:33 died he has said on seeing family photos in their
00:30:35 in their house I wish he was not in the photos I wish he was here in real life most
00:30:44 life most poignantly we understand I understand that Lucas had begun to ask his father about the night of the
00:30:54 fire and most painfully he asks why his mom and dad had not held Isaac's
00:31:04 hand this is a question sir which we suggest might be one that others who are with Isaac on the night of fire are better placed to answer than Isaac's
00:31:20 parents chair I end on this note that the events of the 14th of June 2017 have touched a great many people as we
00:31:30 we know one of those is Miss Amy kellerer she is the head teacher of St France of AI Primary School in Notting Hill and she's kindly allowed me to say
00:31:42 Hill and she's kindly allowed me to say a few words I these are her words she says this as we left school on the 13th of June 2017 we had no idea that within a few hours the lives of our entire
00:31:54 few hours the lives of our entire Community would change forever the 14th of June is a day that I can still see vividly in my mind 75% of our school Community watched the tower burn that
00:32:06 burn that night when I close my eyes and think back to that day I can feel how hot it was I can smell the burning building I remember the utter sadness and despair that we all
00:32:17 that we all felt one thing that will stay with me forever is hearing that children and family members of our school were missing I remember getting the call sent Isaac in reception was
00:32:29 Isaac in reception was missing that is a call that I will never forget in the weeks that followed as a school our Focus was our children we had to get them through a very difficult time we had to tell them that their friends had died we had to tell them
00:32:41 friends had died we had to tell them that people that we loved would not be coming back to school the death of a child is always extremely difficult and traumatic but how Isaac died and the
00:32:53 traumatic but how Isaac died and the circumstances surrounding his death made this even more traumatic she says he died in the worst possible way as a school we had to endure seeing
00:33:06 way as a school we had to endure seeing the charred remains of the tower as it sh shattered our playgrounds and classrooms and from lessons the children watch the people in white suits go into the tow once they investigate what happened this she says would happen for
00:33:19 happened this she says would happen for a whole year and this caused even further trauma to our children and the local
00:33:25 local community and so she says it was clear that from very early on our therapeutic needs here at school were going to increase significantly and we are she said small school we didn't have the capacity for the amount of an on-site
00:33:38 capacity for the amount of an on-site therapist onsite therapist we would need that we would need it was from this desperate need to help our children that we want to create we wanted to create a well-being and education center something that could be used by our
00:33:50 something that could be used by our children and members of the local community and after trying to get the politicians to listen and help we managed after some time to secure funding funding which ensured that we
00:34:03 funding funding which ensured that we could build our vision of a well-being Center when it came to deciding on a name for the center there was no option this building had to be built in Isaac's
00:34:16 this building had to be built in Isaac's memory when you say his name you think of the horrific way that he died we want to ensure that he's always remembered and that we remember how much he loves School and
00:34:28 he loves School and learning when we think of him we want to remember how beautiful he was Isaac's building will be used to address issues related to mental health
00:34:39 address issues related to mental health trauma poverty and other factors that contribute to Children's Life chances school is one of the most vital experiences as a child would ever have in their lives and it's our duty that is
00:34:51 in their lives and it's our duty that is a best
00:34:52 a best one therapists that currently work in the school supporting men children will use the building as their base we know that children who face mental health challenges will see decline in their ability to focus and concentrate
00:35:03 their ability to focus and concentrate on
00:35:04 on learning therefore it's essential that there is purpose built space on site at the school that would allow children to work through challenges we train professionals to ensure they leave
00:35:15 professionals to ensure they leave Primary School ready for the challenges that life may throw their
00:35:22 way she says our school is situated in the richest burrow in the country but yet North Kensington is one of the most deprived
00:35:33 of the most deprived areas no matter our children starting points we have a duty to ensure that this does not limit how far they can go in
00:35:40 in life with well-being and education at the heart of what we do we will ensure that our children are resilient and ready for their future
00:35:50 lives chair panel members the cruel irony of a well-being Center in Isaac's name will not have been lost on you because of course but for Isaac's death there would
00:36:03 course but for Isaac's death there would be no Center in his name but for his death there would be no support for children facing mental health issues and but for his death
00:36:15 health issues and but for his death hundreds if not thousand children will have a better future than the one Isaac did Sir members the Isaac po Center for
00:36:27 did Sir members the Isaac po Center for education and well-being will be officially opened on the 22nd of September this year on the day that Isaac wood would
00:36:38 year on the day that Isaac wood would have but for his death celebrated his 11th
00:36:44 11th birthday chair panel members Palace and ganet trust that you will agree that this is a fitting Legacy for Isaac Palos who died at the tender
00:36:55 for Isaac Palos who died at the tender age of five in the this awful and tragic of
00:37:00 of circumstances thank you thank
00:37:19 you thank you very much Mr K well at that point we'll take a break uh we'll resume please at 5 11 thank you very much
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01:09:25 he yes Mr milet Mr chairman thank you I would now invite M Allison Monroe QC please to come back to the podium to make the presentation on behalf of the
01:09:38 make the presentation on behalf of the family of Vincent chener from Flat 144 on floor 17 of Grandfield Tower as before I would repeat the trigger warning that I've given before that
01:09:49 warning that I've given before that during the course of this presentation there may be discussion of or presentation of material uh or topics which people listening may find distressing and therefore within this room or watching the live stream they
01:10:01 room or watching the live stream they should either leave or or Look Away accordingly thank you subject to that Miss monre thank you very much yes M thank
01:10:19 you yes good morning chair good morning panel good morning also to Vincent's family his sisters Obie and jindu Maria who are with us in
01:10:32 Obie and jindu Maria who are with us in person an En GOI who's watching
01:10:37 remotely on the 25th of May 2018 Vincent's family presented A Beautiful film which opened with scenes of the sun over the African landscape it
01:10:50 of the sun over the African landscape it was narrated by Vincent's younger sister Obie Vincent was born in Nigeria on the 1st of June 1957 and he spent his early years there
01:11:02 1957 and he spent his early years there before traveling to the UK with his mother Magdalena and his sister jindu Maria and goie recalled that as a teenager Vincent enjoyed nothing more
01:11:15 teenager Vincent enjoyed nothing more than science fiction and was a devoted fan of Star Trek and as an avid treky it was essential viewing for him every Saturday he attended private school in
01:11:26 Saturday he attended private school in Ramsgate where he excelled at mathematics at o Anda level and went on to study electrical and electronic engineering at Sheffield University in the
01:11:37 the 1970s Vincent's sister jindu Maria remembers her brother's love for all things mathematical and Technical she said this Vincent's math was excellent
01:11:49 said this Vincent's math was excellent and I will always be grateful to him for his help in understanding math and calculus which I had to pass in my first and second year of Business Degree if I
01:12:00 and second year of Business Degree if I hadn't got through I would have to study another subject as failure in this element was not an option for the progression I've forgotten it all now of course but my point is Vincent was very
01:12:13 course but my point is Vincent was very generous with his time and in finding a way that made it easier for me he would have been a great teacher as well as other roles if his health had not been
01:12:25 other roles if his health had not been so
01:12:28 fragile having studied electronics and electrical engineering at Sheffield Vincent was the goto Tech person in the family jindu Maria recalls
01:12:40 person in the family jindu Maria recalls that Vincent was very good at sourcing electronic and electrical products for the family to buy if they asked him to he would come and help them select items and then support with the setup I miss
01:12:53 and then support with the setup I miss that very much as we no longer have that contact Obie recalls that her brother was a great cook he was the only person that she knew that could make homemade
01:13:05 that she knew that could make homemade crisps she recalls her brother looking after the younger siblings when their mother went out to work on her night shift as a nurse Vincent would take on
01:13:16 shift as a nurse Vincent would take on that parental role ensuring that all his younger siblings brushed their teeth were ready for bed before he literally tucked them in at night Obie spoke of Vincent's kind nature
01:13:29 Obie spoke of Vincent's kind nature remembering that when she broke her leg as a child he went out and bought her a big bar of chocolate but unfortunately it was a wrong kind but it's a thought that counts these small acts of kindness
01:13:41 that counts these small acts of kindness permeated all aspects of Vincent's life he was someone who was good at looking after people who were vulnerable themselves he would never reject anyone and was Adept at spotting ways in which
01:13:54 and was Adept at spotting ways in which others needed support quietly making them feel good about themselves Vincent was a member of the 50 plus open age group in North Kensington and was particularly good at
01:14:05 Kensington and was particularly good at making new members feel welcome when a new person came into the room whenever he was or whoever he was Vincent would stand up and offer the chair to them to
01:14:17 stand up and offer the chair to them to ensure they felt included he was also an active member of the Roman Catholic church and had been up until the time of of his death Vincent lived in flat 144 and it
01:14:32 death Vincent lived in flat 144 and it might be useful at this stage to reorientate ourselves with the location of the flat by reference to the floor plan for the 17th
01:14:42 Floor thank you we can see that Vincent's flat one of the fours was adjacent to the lifts and we can see the location in terms of
01:14:54 and we can see the location in terms of the stairs and how you would get to them thank
01:15:03 you I've mentioned Vincent's Health being
01:15:08 being fragile and in the course of these presentations sir we've heard from various Council describing various residents who died and who had
01:15:21 various residents who died and who had physical
01:15:23 physical disabilities there were also people who lived in the tower who died who had mental poor health Vincent was one of them he had been diagnosed with
01:15:34 them he had been diagnosed with schizophrenia in 1981 but his condition was being managed and he was able nonetheless to live his life and function at a very high
01:15:46 life and function at a very high level he commenced his tency with rbkc for flat 144 on the 26th of February 200 one prior to this Vincent had been
01:15:58 one prior to this Vincent had been living in supported accommodation for people suffering with mental ill health at Chesterton Road he'd been there for 15 years his sisters note that he was the only black resident at Chesterton
01:16:10 the only black resident at Chesterton Road and the only resident who was subsequently loc relocated to a high-rise
01:16:17 high-rise accommodation his vulnerability and mental ill health was known to the local Authority prior to the commencement of of his
01:16:25 of his tency and was raised as an issue throughout his
01:16:31 tency his housing file shows that prior to actually beginning the tenancy his then social worker wrote to RB casy requesting a delay in its commencement
01:16:43 requesting a delay in its commencement to allow Social Services to help Vincent settle in given his 20-year history of mental ill health as well as the fact that he'd been supported previous l in
01:16:55 been supported previous l in accommodation for 15 years rbkc refused that request stating that there were no health and safety issues in 2009 Vincent submitted an
01:17:08 issues in 2009 Vincent submitted an application to be rehoused on the ground floor because of his mental health he said he was being severely impacted by the noise from the lifts which as we've
01:17:19 the noise from the lifts which as we've just seen were located next to his flat this request was reported by a letter dated the 5th of June 2009 by Vincent's psychiatric team and the
01:17:31 Vincent's psychiatric team and the consultant psychiatrist at the Community Mental Health Center at St Charles's Hospital not withstanding the supporting medical evidence of significant deterioration of Vincent's mental health
01:17:43 deterioration of Vincent's mental health directly affected by the location of the flat next to the lift and Associated noises his application for a transfer was
01:17:53 was refused Vincent was also identified as a vulnerable resident on the Ry and spreadsheet dated the 1st of December 2014 listing grenal Tower residents
01:18:04 2014 listing grenal Tower residents profiles and
01:18:07 vulnerabilities home fire safety visits these were carried out by the lfb between April 2011 and 2016 the lfb used the following
01:18:20 2011 and 2016 the lfb used the following criteria to identify individuals who were at high risk of death or injury in the in the event of fire they were people who lived alone had physical disabilities incl and mental health
01:18:33 disabilities incl and mental health disabilities were over 60 were a single parent a smoker or someone who lived in social housing the criteria for identifying highrisk changed in
01:18:44 identifying highrisk changed in September
01:18:45 September 2016 and a highrisk individual was someone who also carried risk of um high risk of fire Behavior less likely to react to a fire alarm unless able to
01:18:58 react to a fire alarm unless able to escape from a fire Vincent had a number of those markers he lived alone suffered from mental illness and he lived in social housing
01:19:10 illness and he lived in social housing at least two home fire safety visits were carried out on flat 144 one on the 13th of August 2014 and one on the 10th of June 2017
01:19:23 2014 and one on the 10th of June 2017 Just 4 days before the the fire the visit 4 days before the fire did not record Vincent as an in individual who was at high risk of death
01:19:34 individual who was at high risk of death or injury in the event of a fire although he presented with the three markers and had more risk factors identified he was not recorded as a
01:19:45 identified he was not recorded as a resident with mental health issues although his mental illness was diagnosed and had been recorded and was already known
01:19:58 it is worth also highlighting that on that visit 4 days before the fire it the entry in relation to escape
01:20:09 fire it the entry in relation to escape the guided notes reads does the occupier have an Escape Plan has the occupier practiced the Escape Plan in the last 6 months does anyone know what to do if a
01:20:20 months does anyone know what to do if a fire breaks out the box was ticked yes confirmation that the the occupier had an escape plan that was not the case as we know Vincent along with other
01:20:33 we know Vincent along with other vulnerable residents did not have a peep Vincent's vulnerability because of his mental ill health was known and remained an ongoing risk throughout his
01:20:47 remained an ongoing risk throughout his tency pausing there sir during the course of not just this module but the whole of this inquiry we have seen many images we've heard descriptions of fire
01:20:58 images we've heard descriptions of fire and smoke we've heard descriptions and eyewitness accounts from individuals what we haven't heard a lot about is
01:21:10 noise this incident this fire on the 14th of June was not a silent one noise and unusual noises were everywhere the
01:21:21 and unusual noises were everywhere the fire itself roared melting cloud that fell from the building crashed onto the ground below windows cracked and imploded when the fire got to them there
01:21:33 imploded when the fire got to them there was banging there was shouting fire engines were blaring police sirens were woring firefighters with heavy equipment were making noise and shouting to each
01:21:44 were making noise and shouting to each other residents people were screaming those were noises that would have been heard by Vincent alone in his flat that night
01:21:55 night Night Vincent a person who was particularly sensitive to noise I I say that sir because when one looks at individuals with mental health
01:22:08 looks at individuals with mental health difficulties yes physically they are mobile physically they could Escape but it's the psychological impact of what is happening to them and what they are
01:22:20 happening to them and what they are hearing and seeing that needs to be remembered and for Vincent those were the objective circumstances that he was faced that night alone in his
01:22:33 flat the events of the 14th of June Vincent was last seen on the CCTV footage at 10615 he's in the lift lobby area
01:22:45 10615 he's in the lift lobby area walking towards the lift waiting to go up to his
01:22:50 flat that's the last sighting Vincent made no 999 calls Vincent makes no calls to family and friends that night it is completely
01:23:05 and friends that night it is completely silent we know from the fire external spread that at as the night progressed and particular in reference to his
01:23:16 and particular in reference to his flat some markers may be of assistance at 209 to 210 the east side of the town hour was affected by the spread of fire across the East
01:23:28 spread of fire across the East face by
01:23:30 face by 0251 Flames had appeared at the top column
01:23:33 column A1 by
01:23:35 A1 by 0303 furthest extent of the horizontal Flames spread on the west face and was at the base of the architectural crown and there were Flames across the full
01:23:46 and there were Flames across the full height of the crown the flame front was mobbing horizontally across the West face from the north to south by 0312 there were Flames at the edge in the
01:23:57 there were Flames at the edge in the very top of column B1 the internal column to the north side of the West face by 0320 to 0321 some of
01:24:08 of the West face by 0320 to 0321 some of the flats in the fours including flat 1 194 and flats um on the 21st to the 23rd floor in the center of the West space
01:24:20 floor in the center of the West space had become affected by the fire for the first time 0334 the further extent of the horizontal flame had spread to the West face and was still at the base of the
01:24:33 face and was still at the base of the crown between 0334 and 0342 there were Flames at the top of the column C1 the internal column on the south side of the West face the
01:24:45 south side of the West face the firefront was also moving diagonally across the face of the building from north to
01:24:52 north to south by 034 43 flat 144 and others on floors 15 to 20 had become affected by fire by
01:25:04 fire by 0352 the furthest extent of the horizontal flame spread on the west face was still at the level of the crown the fire moving horizontally across the face of the building from north to south and
01:25:18 of the building from north to south and finally by 0402 the fire on the so South and West face began converging at at the top of the Southern corner of the West face between column C1 and
01:25:30 face between column C1 and D1 as I said Vincent made no calls so telling his part of the story we can only piece it together by looking at the conditions those that were
01:25:44 at the conditions those that were deteriorating within the building and what other occupants on that floor were
01:25:50 doing the three occupants of flat one 141 were the first survivors to leave floor
01:25:59 floor 17 mzra kasm Jan was in the flat with his girlfriend Fong when they heard fire sirens and saw fire engines near the bottom of the tower this was about 1:00
01:26:11 bottom of the tower this was about 1:00 F initially walked down the stairwell and down the stairs and returned saying that she'd met a woman who said that she was scared because she could smell smoke so she was evacuating mesrob decided to
01:26:24 so she was evacuating mesrob decided to leave the building as well after seeing firefighters at the bottom of the tower directing water at a globe which exploded resulting in heat rising up the outside of the tower before leaving the
01:26:36 outside of the tower before leaving the 17th Floor miserab knocked on kad's door and shouted very loudly he thought that everyone would have heard him as you heard yesterday Kadija
01:26:47 him as you heard yesterday Kadija eventually opened the door and he said there is a fire you must leave now Mis Rob calls that there was no visible smoke but the smoke in the stairwell St started around the 14th floor which he
01:27:00 started around the 14th floor which he described as white and getting stronger and thicker as they descended he says they were engulfed by the eighth floor but it was still possible to see and he saw a fireman coming up the stairs with
01:27:12 saw a fireman coming up the stairs with the hose when they got to the sixth floor and he recalls seeing a Filipino person who lived on the 17th Floor also coming down the stairs at the time they exited at 012
01:27:24 exited at 012 6 whether or not Vincent would have heard those shout his shouting and not when he knocked on khadija's jaw we simply do not
01:27:36 simply do not know we know that there were no sightings of Vincent on the 17th Floor he didn't come out of the flat he was not seen in the lobbies he was not heard
01:27:47 not seen in the lobbies he was not heard by any of his neighbors so as you also recall during the presentation for Kadija um vigilo Castro who lived at flat 146
01:27:59 um vigilo Castro who lived at flat 146 with janaro Bon and his girlfriend Elisa rabaya they were also in the flat Larry had woken up at 0115 by the sound of smoke alarms in the
01:28:10 0115 by the sound of smoke alarms in the flat and Elisha shouting fire he could see fire outside the closed window the kitchen and when he went into the kitchen he saw Flames coming through a
01:28:22 kitchen he saw Flames coming through a circular fan in the EXT dract toan in the kitchen window there was also a strong smell of smoke in the flat and he described smoke that was gray in color and that was cealing height they exited
01:28:34 and that was cealing height they exited the tower at 0130 52 finally in relation to other people on that floor um at 0130 we also heard
01:28:45 on that floor um at 0130 we also heard about the actions of Karin Jones she lived in flat 145 she was awoken by the smell of burning plastic she went back to sleep and was later awoken by one of
01:28:56 to sleep and was later awoken by one of her sons telling her that there was a fire she saw lights and Embers from her window got herself and her children dressed to leave she opened her door and there was quote a plume of smoke that
01:29:09 there was quote a plume of smoke that came into the flat that set off an alarm in the hallway she saw Larry Castro standing outside his front door and she saw the thick black smoke that was coming from the top of the door and
01:29:21 coming from the top of the door and moving along the ceiling she returned to her flat to collect her handbag and when she returned the smoke had quadrupled and had covered most of the ceiling although the lights were on the smoke
01:29:33 although the lights were on the smoke had made the lobby look darker there were other people in the stairwell and there seemed to be a lot of confusion some people were going down the stairs but there were a group of about 10 to 12
01:29:45 but there were a group of about 10 to 12 people going up Larry Castro was just ahead of her and she made her way down with her
01:29:51 with her sons with the evacuation of the other residents from the 17th Floor by
01:29:57 Floor by 0130 Flats the only flats that remained occupied were Flats 144 Vincent and flat 142 the beum family whose presentation
01:30:08 142 the beum family whose presentation we heard yes on the 7th of July everyone else had managed to escape in terms of deployment to the 17th
01:30:18 17th Floor although Vincent made no calls to the control room we do know that um there were calls from persons in flat 142 and that the conditions of the 17th
01:30:30 142 and that the conditions of the 17th Floor were made known by those calls however no Crews were deployed to the 17th floor in response and so there were no one to locate
01:30:47 Vincent Vincent made no phone calls as we've said but there were four recorded calls from Flat one 142 the Bon family which we've heard extensively
01:30:58 which we've heard extensively about the first was at 01292 and lasted for 8 minutes and 51 seconds in that call it is believed that H husab beam reported the extent of the
01:31:10 H husab beam reported the extent of the smoke coming into the flat and the smoke alarm being heard in the background during the call they're given advice to remain and to block up the um Airways at
01:31:23 remain and to block up the um Airways at 01
01:31:24 01 3802 there is a call that is taken by C CR hous and passes on details from Flat 142 reporting a family stuck on the 17th
01:31:36 142 reporting a family stuck on the 17th floor as a result of that call there is the following action an incident log is created and it records the um phone call that has been made and that there are
01:31:47 that has been made and that there are people trapped on the 17th floor and smoke coming into flat 142 there is also FSG information that was passed onto command Unit 8 reporting
01:31:58 was passed onto command Unit 8 reporting persons trapped on the 17th Floor specifically flat 142 the next call from Flat 142 is logged to 0227 and received by c fox
01:32:11 logged to 0227 and received by c fox again reports about fire in the building and that no one had come to help them and they'd been waiting for over an hour at 0229 sio Fox creates a service
01:32:23 hour at 0229 sio Fox creates a service request in response to the call the extract from the incident log reads 17th Floor five adults including two elderly inside the
01:32:35 inside the flat again this is passed on to cu7 the third call from that flat is at 0318 by which stage the caller has reported fire in the kitchen and the
01:32:47 reported fire in the kitchen and the hallway and the fourth 99 call is at 0318
01:32:54 the reports from the flat clearly reached the incident ground because watch manager Myrick identified a laminate sheet with the FSG information from that
01:33:05 from that flat sadly none of this resulted in a crew attending the 17th floor and crucially anyone noticing that Vincent was still in his
01:33:16 was still in his flat as I said what happened to Vincent we can only surmise his family say this though Vincent was a man who
01:33:27 say this though Vincent was a man who liked
01:33:29 liked routine he was a creature of habit he would expect certain things to happen at certain times Vincent we know from the
01:33:41 times Vincent we know from the pathological evidence and the archaeological evidence was found in his living room he often waited in the living room for people to come around and to be collected when he has specific
01:33:53 collected when he has specific appointment
01:33:56 his family simply Wonder did Vincent remain sitting in his living room expecting and waiting for somebody to come and collect him and take him to safety does that explain why
01:34:09 take him to safety does that explain why he made no phone calls to the emergency services and made no phone calls to them they'll never know the answer to that question but it one that haunts
01:34:21 that question but it one that haunts them and will continue to haunt them
01:34:28 jindu Maria was the first person in the family to know that something had gone very badly wrong on the 14th of June she
01:34:39 very badly wrong on the 14th of June she went to work as usual and a work colleague told her there hadd been a fire in West London and it was quite bad she mentioned the name of the building at that point jindu Maria left work she
01:34:51 at that point jindu Maria left work she realized that's Vincent's home
01:34:56 the rest of the family were informed there Then followed a familiar story of difficulties and obstacles in trying to find out more about their
01:35:08 trying to find out more about their brother and whether or not he was safe jindu Maria was looking for Vincent for two to three days they had received no contact from any official person or
01:35:21 any official person or body in gozy had to resort to reporting Vincent as missing through a helpline that she saw on the television she was given a reference number with the
01:35:33 given a reference number with the Manchester police and advised to ring back if Vincent made contact in the coming days a family attended West London police stations and reported Vincent missing like other
01:35:46 reported Vincent missing like other families that we've heard of they visited various Hospital including St Charles's Hospital one that Vincent knew well it was reported that survivors of the fire had been sent there they went
01:36:00 the fire had been sent there they went more in Hope than anything else that Vincent might be there he was not they also visited the rest centers close to latima Road each day the sisters waited
01:36:11 latima Road each day the sisters waited for news of Vincent hoping that he had been found but there were no updates this exacerbated their anxiety and distress Obie recalled that as they spent the weekend watching the news
01:36:23 spent the weekend watching the news reports and the harrowing images of the fire their anxiety became worse whenever someone knocked at the door their elderly mother would rush to open it thinking that Vincent would just turn
01:36:36 thinking that Vincent would just turn up the family were eventually informed that Vincent had died in the fire that notification came on the 19th of
01:36:46 June turning then to Professor P's analysis in his analysis of Vince last movements Professor perser noted that it
01:36:57 movements Professor perser noted that it is likely that Vincent was awake and conscious at some time during the fire since his remains were recovered from the living room rather than the bedroom he also noted that the living room would
01:37:09 he also noted that the living room would have been the last area affected by the exterior fire after the bedroom and after the
01:37:15 after the kitchen the toxical examination of Vincent's remains recorded an appropriate approximate carboxy hemoglobin level of
01:37:26 approximate carboxy hemoglobin level of 39% the pathologist Dr Fitzpatrick swallow noted in the report dated the 25th of September 2017 that whilst the quoted fatal range usually is above 40%
01:37:40 quoted fatal range usually is above 40% a concentration of 39% would have at least rendered Vincent unconscious Professor perser agreed with this finding stating in his evidence
01:37:52 this finding stating in his evidence that um the region of 39% was not particularly high and there were concerns about the quality of the sample but this still was a very high and incapacitating
01:38:04 incapacitating level the pathology examination also showed that Vincent had a very mild coronary artery arhythmia to one of the three main vessels supplying blood to
01:38:15 three main vessels supplying blood to his heart Dr Fitz Patrick swallow confirmed that this did not cause Vincent's death and Professor pers noted that it was a mild coronary artery
01:38:26 that it was a mild coronary artery arhythmia and which may have increased his sus his susceptibility to carbon monoxide
01:38:34 monoxide intoxication the pathology examination also showed findings of heat damage to Vincent's respiratory system and significant findings included the presence of suot within his lower traa
01:38:47 presence of suot within his lower traa both lungs were affected by heat damage and there were suits in his terminal bronchials
01:38:55 also um an examination of his gastro intestinal system showed presence of possible s in his stomach putting those all together
01:39:06 stomach putting those all together Professor perser considered that the pathological findings were indicative of possible heat exposure in particular he he identified the presence of s which
01:39:17 he identified the presence of s which suggested that Vincent had spent a considerable amount of time inhaling smoke before he died and this was supportive of evidence that Vincent did not die from Rapid exposure to heat or
01:39:31 not die from Rapid exposure to heat or Flames taking the evidence of the external fire spread and the pathological findings Professor perser was able to assess that Vincent became incap incapacitated around about
01:39:44 incap incapacitated around about 0405 and death would have followed perhaps 10 minutes or so after incapacitation thus putting the window at 0405 to
01:39:55 at 0405 to 0415 Professor perser also considered whether Vincent's mild underlying uh heart condition may have increased his susceptibility to carbon monoxide
01:40:07 susceptibility to carbon monoxide intoxication resulting in a shorter window between incapacitation and death it is therefore possible that Vincent may have died within a shorter period of time after the arrival of the external
01:40:19 time after the arrival of the external fire at
01:40:21 fire at 0358 Dr fanel agreed agrees with that approach of an approximate time or window when recording death would be appropriate as I mentioned Vincent's
01:40:33 appropriate as I mentioned Vincent's remains were recovered from the living room
01:40:35 room area and he was um initially identified through
01:40:41 DNA and dental
01:40:46 records Dr Nat Kerry has recorded the medical cause of death as consistent with the effects of Fire in his final report of the 23rd of October
01:40:57 October 2018 and Dr Virginia Fitzpatrick swallow had previously recorded inhalation of products of combustion as a medical cause of death in her report dated the
01:41:08 cause of death in her report dated the 25th of September
01:41:17 2017 so those are the facts and circumstances of Vincent death perhaps there are more questions raised than are
01:41:29 raised than are answered the one thing that is answered for the family is that he's gone death breaks a circle of life it brings finality to Shared experiences
01:41:40 brings finality to Shared experiences which had become routine and which we expect to share indefinitely but when that circle of life is broken we are left with what Memories en GOI shared this treasure
01:41:53 Memories en GOI shared this treasure memory of her brother I used to go and meet Vincent every Saturday at Sainsbury's at ladbrook Grove and we always used to have breakfast it was our
01:42:06 always used to have breakfast it was our thing and it was our chance to have a chat about different things this is one of the shared experiences with my brother that I will dearly Miss we were due to meet for
01:42:17 dearly Miss we were due to meet for breakfast and catch up as we customarily did but we didn't have a chance to do so because he passed away now I won't ever have that opportunity to do this
01:42:30 again Vincent Chena was a quiet man he was a good man he survived by his mother Magdalena and his siblings jindu Maria
01:42:42 Magdalena and his siblings jindu Maria Obie and
01:42:44 Obie and enoi in closing sir I will leave you with the family's Words which embody Vincent as a person and were shared at the commemoration ation because of and in spite of his own
01:42:59 ation because of and in spite of his own vulnerabilities Vincent was ahead of the curve he made sure he guided other people to their paths for that his family thank him thank you thank you
01:43:30 well thank you very much Miss Monro we'll take a break at that point we'll rise now and resume at quarter 12 pleas thank you very
01:43:52 much
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02:14:07 yes just a minute Mr chairman thank you very much I would now invite Miss Allison Monroe please QC please to come back to the podium and make the presentation on behalf of the family of
02:14:18 presentation on behalf of the family of Joseph Daniels from Flat 135 live on floor 16 of grenfell tower again I would repeat the trigger warning that there may be things said or shown during Miss Monro qc's presentation which people
02:14:31 Monro qc's presentation which people here in the room or on live stream may find distressing and they may wish to leave the room or to look away from the live stream as the case may be right thank you very much that thank you very much Miss
02:14:43 much Miss monre thank you chair panel good afternoon and good afternoon in particular particular to Joe's
02:14:54 in particular particular to Joe's family his son Sam and Lucy Sam's
02:15:03 mother of the total residents of greld tower 37 were registered disabled 15 of that number died in the
02:15:15 disabled 15 of that number died in the fire in other words 41% of the disabled residents who lived in the tower dieded on the night of the fire that is a
02:15:26 on the night of the fire that is a shockingly high and disproportionately high
02:15:30 high figure these residents were the most vulnerable within the greenfell community we have listened now to the horrific stories of how many of these
02:15:41 horrific stories of how many of these individuals could not escape and died in their homes in the lobbies and in the stairwells the very thought thought of being caught in a flat where the
02:15:54 being caught in a flat where the building is on fire is frightening being in a flat in a high-rise block that is on fire heightens that fear now imagine if you will you're living in one of the the
02:16:06 will you're living in one of the the upper floors in a flat in a building that is on fire your anxiety would now be
02:16:13 be rocketing to add to that you have a disability a Mobility problem or poor mental
02:16:21 mental health see where your fear goes then that was the reality for disabled and vulnerable people in grenfell Tower Joseph Daniels known as Joe was
02:16:35 Tower Joseph Daniels known as Joe was one of
02:16:38 one of them Joe Daniels was born in LNA India on the 10th of February 1948 and was therefore 169 in June
02:16:49 169 in June 2017 Joe moved to the UK from India in 1982 after marrying Lucy Smith who had been living temporarily in India from
02:17:00 been living temporarily in India from 1981 through to 1982 together they had one son Samuel who I'll refer to as Sam Hereafter Joe and Lucy moved into
02:17:12 Hereafter Joe and Lucy moved into grenfell Tower in 19983 where they brought up their son Sam Joe was retired at the time of his death the tency of the flat 135 was a
02:17:25 death the tency of the flat 135 was a joint tenancy in both Lucy and Joe's name Sam was only one years old at the time so he literally grew up in grenfell
02:17:36 time so he literally grew up in grenfell Tower Joe also had a daughter Stephy hilia from another
02:17:45 relationship what people remember most about Joe was firstly his faith he read the Bible daily and could quote from any part of it he referred himself
02:17:57 from any part of it he referred himself as something of a barroom Preacher secondly they remember his Larger than Life character joking and chatting to anyone
02:18:08 character joking and chatting to anyone and everyone his laughter was always the loudest in the room thirdly his physical strength since his youth he had had a passion for
02:18:20 his youth he had had a passion for exercise
02:18:21 exercise and made stronger after a back injury he was in the gym when he could almost daily working out with weights before his body and mind
02:18:34 before his body and mind disintegrated fourthly his tenner singing
02:18:38 singing voice he played the guitar loudly and not very well but he sang
02:18:47 beautifully following Joe and Lucy's divorce Joe remained living in the flat at grenfell Tower Sam moved out for a relatively
02:18:58 Tower Sam moved out for a relatively short
02:18:59 short period but then in 2015 Sam moved back into grenfell Tower to care for his father eventually becoming his registered carer Sam had given up work in order to
02:19:12 carer Sam had given up work in order to care for his
02:19:15 dad chair you and the panel will be very much alive to the plight of vulnerable and dis disabled residence which has been a recurring theme throughout the course of this inquiry Joe suffered from both physical
02:19:28 inquiry Joe suffered from both physical and mental health conditions in respect of his physical health he suffered from diabetes and problems associated with an injury he had sustained as a Young Man
02:19:40 injury he had sustained as a Young Man he'd broken his back this led to a lifetime of complications his Mobility was significantly impaired and he was dependent on the lift to enter and exit
02:19:52 dependent on the lift to enter and exit the tower in the absence of the lift Joe was able to only navigate a maximum of a couple of flights of stairs and progress would be slow Joe would take a
02:20:03 would be slow Joe would take a significant period of time to climb or descend even a few steps moving would be exceptionally slow slow in staccato requiring several breaks and
02:20:14 requiring several breaks and stops by 2015 Joe was unable to manage stairs and only left his flat if the lift was
02:20:24 working this perhaps explains why there is no CCTV footage on the 13th of June showing Joe entering the tower Joe had mental health difficulties
02:20:37 tower Joe had mental health difficulties as well and with the passage of time he had developed dementia this meant that Joe found it increasingly difficult to care for himself as often happens with dementia
02:20:49 himself as often happens with dementia the sufferer in this instance Joe did not have a great deal of insight into his condition and found it difficult to accept mental health
02:21:01 accept mental health disabilities and his diagnosis of dementia Joe's conditions both physical and mental deteriorated over the ye over the years but especially during the
02:21:13 the years but especially during the period of time following the commencement of the refurbishment of grenfell tower he found the constant noise and disruption particularly difficult to cope with as a result of
02:21:24 difficult to cope with as a result of this his conditions Joe required a high level of supervision and monitoring Sam's responsibilities included ensuring that his father took his medication providing regular healthy
02:21:36 medication providing regular healthy meals for him and instilling healthy living habits it was also necessary for Sam to closely supervise Joe for safety reasons and put in place protective
02:21:48 reasons and put in place protective measures to stop Joe from carrying out think Reckless such as throwing items out of the window Joe also had a tendency to leave the aanon and to leave the front door
02:22:01 the aanon and to leave the front door open Joe was known to the TMO and rbkc adult and Mental Health Services rbkc Social Services files
02:22:12 Services rbkc Social Services files record that Sam was his father's full-time
02:22:16 full-time carer Sam had a raft of concerns regarding his father 's physical ailments Mobility impairment and mental health difficulties and how these impacted on his health and
02:22:28 impacted on his health and safety he was also very troubled by the obvious difficulties that these would lead to regarding escaping and evacuating the tower in the event of an
02:22:40 evacuating the tower in the event of an emergency Sam became an advocate for his father dealing with various agencies and bodies TMO rbkc adult social services
02:22:51 bodies TMO rbkc adult social services Mental Health Services in order to try and secure assistance and services for his
02:22:57 his dad the Tio neighborhood Support Officer made a referral to occupational therapy the referral form states that a visit would be made to Joe's at his flat as he
02:23:10 would be made to Joe's at his flat as he had difficulty getting in and out of the bath the referral form recorded that Joe had physical health and mental health vulnerabilities this form had a r system
02:23:21 vulnerabilities this form had a r system by which risk was evaluated the form rated the scale of the issues arising from managing his mental health safeguarding concerns and possible risk to himself
02:23:34 concerns and possible risk to himself and to others as 27 this according to the rating system is a high score the referral also note that Joe had a walking stick and poor
02:23:46 that Joe had a walking stick and poor vision but he refused to wear glasses which support Sam's written and oral evidence to the inquiry in phase one that his father had difficulties
02:23:57 one that his father had difficulties understanding his own vulnerabilities in his phase one evidence Sam does recall that in the few months after the OT visit someone de
02:24:08 months after the OT visit someone de delivered some Mobility AIDS including a raised toilet seat and a Zimmer frame despite several formal assessments by the
02:24:17 by the authorities The Familiar story is here again Joe did not have a peep none was in place and none had been
02:24:29 peep none was in place and none had been considered in terms of adaptations to the flat Sam had requested that rbkc install handrails and other permanent fixtures fixtures to assist his dad um
02:24:41 fixtures fixtures to assist his dad um but these were not um acted on Joe was provided with AIDS such as the toilet which in Sam's view as his care promoted the potential for more hazards
02:24:53 promoted the potential for more hazards than actually helping him Joe Daniels was also known to adult social care and appears on a list of adults known to Social Services a care
02:25:05 adults known to Social Services a care assessment and support plan were provided for both Joe and Sam by rbkc that document states that Joe had a mosaic number and a care plan it also
02:25:18 mosaic number and a care plan it also stated that Joe appears on the rbk's email chain that postat a fire which lists grenfell residents known to adult social
02:25:29 social care he was on a rbkc 1A occupational therapy
02:25:36 therapy list the email also noted that he was missing post safire Joe was also in the etiis report for emergency
02:25:47 for emergency planning that was the report of services users for adult social
02:25:54 Care Home safety visits on the 12th of April 2016 Joe was subject to a home fire
02:26:06 2016 Joe was subject to a home fire safety visit from the lfb they came to Joe's flat and met him no fire safety risks specific to Joe were identified
02:26:21 Joe's known physical and mental health difficulties meant that he was at a heightened risk in the event of fire both to himself and others being unable to independently evacuate from the 16th
02:26:34 to independently evacuate from the 16th floor via the single staircase the sole means of Escape in the event of a
02:26:40 fire structural features on the 16th floor sir we've heard and it's recorded in the phase one report about defective
02:26:52 doors now Joe and Sam did not live in one of the sixes their flat was 135 however in his um statement to the
02:27:03 135 however in his um statement to the inquiry Sam noted that there were issues with their front door to Flat 135 he says this we used to have a thick
02:27:14 135 he says this we used to have a thick heavy fire door that would close themselves if they were left open the new ones were flimsy and the locking mechanism on my door kept breaking a few months before the fire one of the hinges
02:27:26 months before the fire one of the hinges came out I called the TMO repair line they sent a man out to fix it he took the middle hinge out of the door and said that he would need a whole new door
02:27:37 said that he would need a whole new door he said that he would make a booking for the replacement door to be F fitted but it never got changed this meant that even though there were supposed to be self-closing doors mine was not
02:27:49 self-closing doors mine was not self-closing at the time of the fire and there is a repair log dated the 4th of April 2017 which noted front door not closing
02:28:00 2017 which noted front door not closing and then on the 5th of April 2017 the the log reports overhaul complete upvc front door with a priority of 20 working
02:28:11 front door with a priority of 20 working days and a target of the 8th of May 2017 for that to be rectified
02:28:21 the priority is recorded as needed to be done and the target date is the 5ifth of April but the job status was subsequently reviewed
02:28:32 the job status was subsequently reviewed and quote fully
02:28:37 abandoned as well as flat 135 on that floor Edward Defan also made a complaint about his flat door which is 136 in August 2015
02:28:50 136 in August 2015 that complaint was Sum summarily and baselessly dismissed without proper investigation at all and all three stages of the tmo's complaint
02:29:03 stages of the tmo's complaint procedure now it has been accepted that defects in the doors as reported by Mr defon was not resolved contrary to the initial evidence from Peter Madison that
02:29:15 initial evidence from Peter Madison that g he gave to this inquiry and the inquiry evidence of Sasha jevans on the same subject indeed there is no documentary
02:29:26 subject indeed there is no documentary evidence to show that the necessary repair work was done to that door between August 2015 and June
02:29:35 2017 Sam and Joe's flat was not one of those that have been identified previously in phase one but on the night of the fire the door to Flat 135 was not
02:29:47 of the fire the door to Flat 135 was not self-closing
02:29:55 Sam Daniels notes in his phase one statement as I mentioned the hinge in the middle of our front door had come loose before the fire and as a temporary
02:30:06 loose before the fire and as a temporary fix the repair man had ripped out part of the bottom of the door which makes the door close automatically as a result at the time of the fire our front door did not close by
02:30:18 the fire our front door did not close by itself the net effects of the sixes and flat
02:30:23 flat 135 and flat 13 FL 4 on the 16th floor as identified by Sam by Edward jafan meant that there were at least two
02:30:35 jafan meant that there were at least two perhaps three doors that were defective on that
02:30:39 on that floor and we know that two residents Joe Daniels and Sheila died on that floor the rapid decline of the conditions on floor 16 led to a buildup of smoke and
02:30:52 floor 16 led to a buildup of smoke and noise associated with the emergency response in the staircase which likely influenced the occupants movements events of the 14th of June at
02:31:04 movements events of the 14th of June at the outbreak of the fire Joe and Sam were at home in their flat Joe was in the bedroom asleep he was not aware of any fire or any
02:31:16 was not aware of any fire or any commotion until Sam alerted him Sam was in his bedroom when at 045 he noted a faint burning
02:31:28 045 he noted a faint burning smell it seemed to be electrical or plastic in nature he could not find the source of the smell in their flat so he went to investigate outside the stairs were at that time normal without any
02:31:42 were at that time normal without any smell when Mr kabed made his emergency Call at
02:31:47 Call at o54 to report the fire in his kitchen on floor four there were no warnings to alert Sam or Joe of an emergency Sam recalls
02:31:58 emergency Sam recalls this after another 10 minutes the smell became stronger however there were no alarms going off so I thought the fire must be outside the block prior to the
02:32:09 must be outside the block prior to the refurbishment if there was a fire in the block you would hear a loud bell ringing outside the front door it was loud enough to wake you up if you were asleep it didn't go off that night nothing told
02:32:22 it didn't go off that night nothing told me about a change in the policy Joe and Sam lived in one of the fives by 1:35 in the morning the fire had spread
02:32:33 the morning the fire had spread vertically upwards on the East face alongside and horizontally to The North Face Professor Bisby in his analysis indicates that the fire spread northward
02:32:45 indicates that the fire spread northward on the East face and that by 135 it had spread spread horizontally Sam went back to bed in his flat at that
02:32:57 point and he looked he went to the front door he looked out of the window he could not see fire it had come around the corner by now and it was now the fire was on our side of the block to the
02:33:09 fire was on our side of the block to the right on on the east corner however it was much lower down the building around about the fourth or sixth floor it is clear from the tesy of those
02:33:20 floor it is clear from the tesy of those on the 16th floor and the expert analysis that the spread of smoke was a crucial Factor affecting the ability of residents to safely evacuate their
02:33:31 residents to safely evacuate their Flats by 130 the communal Corridor which was a primary means of Escape for residents on that floor was becoming filled with thick black smoke making it
02:33:44 filled with thick black smoke making it difficult for residents to escape Sam says this of the conditions the smoke was so thick I could not see anything so I had to feel my way around Edward defon
02:33:56 I had to feel my way around Edward defon in flat 134 had a similar experience of the smoke he opened his door to his flat and I quote stepped outside and shut the door behind me I also wrapped
02:34:08 shut the door behind me I also wrapped the towel around my mouth and nose holding the towel with one hand behind my head I both shut my door and wrapped the towel around my mouth and nose because that's what you were told to do
02:34:20 because that's what you were told to do in the event of fire the smoke was so thick I couldn't see beyond the end of my nose the smoke was aggressive and billowing against
02:34:31 billowing against me we also have the accounts from other individuals on that floor as to the Smoke
02:34:40 Smoke hammed Wabi at flat 136 said this when I went into the landing the lights were on there was a bit of smoke already there and the smoke was coming out of my flat
02:34:52 and the smoke was coming out of my flat and coming into the landing and blocking everything it was still black and Thick Smoke smoke was spreading quickly from The Landing into the stairwell and still
02:35:04 The Landing into the stairwell and still coming out of my flat into the landing the smoke was intense it was burning my eyes and my
02:35:15 throat hot said having looked out the window and seeing fire I went out of our front door and I opened it as I did so smoke came pouring in through the open
02:35:28 smoke came pouring in through the open door from the communal area outside Landing the smoke outside the door was black and thick and even in the brief time the door was opened smoke poured into the
02:35:40 into the flat senet at flat 133 recalled initially opening the door at 0137 and observing thinner smoke in in
02:35:51 0137 and observing thinner smoke in in in the floor 16 lobby but when he and his wife tried to exit only 5 minutes later the smoke was thick and black and filled the entire
02:36:02 filled the entire Lobby in response to the changing circumstances Sam opened and then closed the flat 135 front door a number of times between 115 and
02:36:15 times between 115 and 125 before he finally exited over the this period the conditions in the lobby were rapidly worsening Sam remembers hearing shouting and panicked voices from the floor as he
02:36:28 and panicked voices from the floor as he told his father they needed to leave now Sam told Joe put your shoes on but his dad was very disorientated and confused by the unfolding
02:36:40 confused by the unfolding situation the smoke alarm went off and Sam opened the front door shouting now at his father to forget about the shoes and just follow him and leave job was frozen to the spot he couldn't
02:36:53 job was frozen to the spot he couldn't move and he didn't leave in desperation Sam tried to physically move his dad but he couldn't move him by himself the only option left was to run
02:37:05 himself the only option left was to run for help to get someone to come and assist him and help him remove his dad from the flat so Sam left his father was standing next to his bedroom directly
02:37:17 standing next to his bedroom directly opposite the front door that was the last image that Sam would ever have of his dad as he exited the flat he left the
02:37:28 dad as he exited the flat he left the door slightly open in the hope that this would encourage his dad to see him and follow
02:37:35 follow him Sam did not make any 999 calls he decided instead to go straight for help down the stairs himself at 1:25 in the morning he headed
02:37:47 himself at 1:25 in the morning he headed downstairs and he met a lone firefighter who was covered in sweat this was firefighter o burn and he was on the ninth floor firefighter a burn says that he'd
02:38:00 floor firefighter a burn says that he'd made his way floor by floor up the tower by himself without a ba kit on he'd reached about the 11th or 12th floor he thinks and then he saw a woman running
02:38:11 thinks and then he saw a woman running out but couldn't get into the lobby area due to the thick black smoke so he went up another flight he says this at the time two guys came down the stairs to
02:38:22 time two guys came down the stairs to where I was standing they were both of Middle Eastern appearance I can't remember the exct floor of the stairwell I was on when I saw these two guys but I think it was on the 10th or the 11th
02:38:33 think it was on the 10th or the 11th floor although I may have walked a bit further down stairs with them Sam explained to firefighter a bur that his dad had dementia and that he'd been
02:38:44 dad had dementia and that he'd been unable to get him out of flat 135 on the 16th floor he needed help firefighter of burn said that it was too dangerous for him to do anything by himself but he
02:38:56 him to do anything by himself but he would use his radio and call for a ba crew I radioed down using my handheld radio and requested a ba crew to go to the 16th floor to rescue a male there
02:39:08 the 16th floor to rescue a male there who was
02:39:10 who was bedbound the gravity of the situation within the tower was becoming all too apparent to firefighter o bur he'd recently seen woman crawl out of the FL
02:39:21 recently seen woman crawl out of the FL the floor 12 and he said in his witness statement at that point he thought people were going to die because of the amount of smoke in the lobbies on the different floors and because they
02:39:33 different floors and because they wouldn't be able to get enough fire engines and firefighters up those stairs to get everyone out Sam was able still to have a conversation with firefighter a burn in
02:39:44 conversation with firefighter a burn in the stairwell on the 11th floor so at this point that stairwell was still relative
02:39:50 relative passible having radioed down that there was a bedbound resident on the 16th floor something appears to have filtered through to those on the incident ground
02:40:01 through to those on the incident ground because watch manager Dowden over his radio certainly recalled being told that there were people with mobility issues on floor 11 and floor 16 that would have
02:40:13 on floor 11 and floor 16 that would have been
02:40:14 been Joe the original forward information board was filled in with the words man 16th
02:40:22 16th floor importantly the residents of flats 131 134 and 136 had by now all evacuated
02:40:33 131 134 and 136 had by now all evacuated certainly by 0138 the remaining residents were therefore Joe in flat 135 Mr and Mrs Masset in flat 133 and
02:40:45 135 Mr and Mrs Masset in flat 133 and Sheila in flat 132
02:40:49 a crew of two firefighters hipple and Stern were dispatched from the bridge head with their ba kits in answer to firo a bur's
02:41:02 firo a bur's message what followed was unfortunately a series of confused and confusing events Sam and firefighter o burn both
02:41:13 events Sam and firefighter o burn both say that they remain together on around the 9th or the 11th floor whilst theba crew of hipple and Stern went to look for
02:41:22 for Joe firefighter o burn recalls I said to them up to the 16th floor there's a guy who's bedbound and they replied asking
02:41:33 who's bedbound and they replied asking me what floor is this in order to check which floor we were on I went down and opened the lobby door on the floor below that floor was clear of smoke therefore I knew it was the ninth floor I then
02:41:46 I knew it was the ninth floor I then went up onto the half Landing where they were standing and said to them this is the ninth you're on you're about to go to the 10th the ba crew then continued
02:41:57 to the 10th the ba crew then continued climbing the stairwell while I stood waiting on the stairs I was on the half landing above the ninth floor and the two guys were standing directly outside the ninth
02:42:10 standing directly outside the ninth floor Lobby Sam recalls the fireman State stating that they could not tell which floors they were on as there were no signs they asked him which floor and
02:42:21 no signs they asked him which floor and oburn went and showed them because Sam did not know one of the firemen opened the door to the landing on the floor to try and see the number but it was too smoky he then ran down a level and
02:42:34 smoky he then ran down a level and returned saying that they were on the 11th the fireman then went up the stairs again now there was some confusion in the evidence of firefighters Stern and
02:42:45 the evidence of firefighters Stern and hipple as to whether or not they went up the stairs looking for Joe with Sam and with firefighter oburn but in their oral evidence on the 19th of July of
02:42:59 evidence on the 19th of July of 2018 crew manager Stern said that he traveled up with firefighter hipple firefighter hipple for his part
02:43:10 hipple firefighter hipple for his part said he doesn't recollect why firefighter Stern would originally have said that Sam traveled up with them and where he would have got that
02:43:21 and where he would have got that information from firefighter Stern had initially observed when he first spoke to Sam that quote the 16th floor I just thought
02:43:35 quote the 16th floor I just thought honestly it's a bit of smoke he must be overexaggerating because it's 10 floors above well 12 floors above from the flat where the fire was but we made our way
02:43:47 where the fire was but we made our way up
02:43:51 that initial reaction that Sam was exaggerating was soon to be disabused because upon arrival on the 16th floor firefighters Stern and hipple were
02:44:03 firefighters Stern and hipple were greeted with smoke that was very bad indeed they were unfamiliar with the layout and unaware of the numbers and could not work out which was
02:44:14 could not work out which was which firefighter Stern described arriving on the 16th floor and being faced with a smoked fi Lobby the smoke had now reached the ceiling so he shut
02:44:25 had now reached the ceiling so he shut the door
02:44:30 again he says that firefighter hipple was in front with firefighter Justin sent Oben again in his oral evidence he clarified that Justin was in fact Justin
02:44:43 clarified that Justin was in fact Justin o bur and now he wasn't sure whether or not Sam had been with them on the 16th floor or whether he had remained behind with firefighter oburn firefighter
02:44:54 with firefighter oburn firefighter hipple likewise resiled from his earlier statement and said it is likely that they were on that 16th floor by themselves and St Sam and firefighter o burn had remained on the lower
02:45:07 burn had remained on the lower floors firefighter Stern said this when he gave his evidence in phase one I remember confirming it was someone but since that incident I spoken to other
02:45:18 since that incident I spoken to other firefighters and so I just don't know whether I'm mixing up my memory from what was said or what was done so I don't know if there was a resident in question with us I remember
02:45:29 resident in question with us I remember trying to confirm with somebody I thought there was someone there I may have been mistaken I don't know if my memory was playing tricks on me but I did try to speak to someone to confirm
02:45:41 did try to speak to someone to confirm if it might even have been fire find a hipple that I spoke to I don't know five F A hipple notes that when they arrived on the 16th floor there was
02:45:52 they arrived on the 16th floor there was the same black smoke they had encountered Below on the sixth floor there was Zero visibility in fact it was so poor that when he put his hand up to his mask he could not see
02:46:05 it Sam remained waiting with firefighter a burn on the lower floor after about 5 minutes hipple and Stern returned and said they could not tell which floors
02:46:16 said they could not tell which floors they were on there were no signs this meant they could not find Joe they asked which again which floor Sam and no bur were on Sam did not know one of the
02:46:28 bur were on Sam did not know one of the firemen opened the door to the landing on the floor to try and see the numbers but again it was too SN Smokey and he ran down again to look they went up the stairs Again Sam
02:46:39 look they went up the stairs Again Sam recalls shortly after they came running down looking quote petrified Sam asked the last firefighter about his father and was told that could not do anything this firefighter told
02:46:52 not do anything this firefighter told Sam that no one could go up there and Sam had to leave Sam turned to fir fighter a bur who also told Sam to get out the visibility was poor and that may
02:47:04 out the visibility was poor and that may well explain why identifying people was so NY on Impossible firefighter hipple erroneously described a man as Sam being present and holding the door open on the
02:47:15 present and holding the door open on the 16th FL Landing this could not be and was not Sam firefighter Stern states that the man whom they refer to incorrectly as Sam directed them to the
02:47:26 incorrectly as Sam directed them to the flat to the right door again that was not
02:47:30 not Sam so what happened on the 16th floor to cause these two experienced firefighters to come running back down panicked and looking petrified well according to Firefighters
02:47:42 petrified well according to Firefighters Stern and hipple once they got to the 16th floor they crawled through the lobby on their hands and knees firefighter Stern in fact on his belly
02:47:54 firefighter Stern in fact on his belly firefighter hipple followed they didn't have any firefighting media with them and the visibility was Zero they couldn't see their hands in front of their
02:48:05 front of their faces they tried to do a methodical search keeping contact with the wall as they went
02:48:11 they went around and they did find someone a man together they pulled that person out of the L which took a few seconds because they were close to the
02:48:23 were close to the door firefighter hippo says this when we were back in the relatively smokefree stairwell I saw a male who I now know to be Edward Defan he was
02:48:36 now know to be Edward Defan he was coughing but conscious and able to walk so after a moment we guided him to the stairs and told him to leave he was able to do so without assistance from us we decided to finish our search on floor 16
02:48:49 decided to finish our search on floor 16 but I believe that it was likely that Edward was the male that we had been told to go and assist who had been reported as trapped on the 16th floor so tragically and sadly the
02:49:01 floor so tragically and sadly the firefighters believed they had successfully helped the male that was trapped on the 16th floor namely Joe sadly that was not the case they continued their search with
02:49:14 case they continued their search with their hands on the wall and they did enter a flat and immediately to their right the door was open this was flat 136 it did not have a self-closing
02:49:29 136 it did not have a self-closing device firefighter Sterns states that when they entered that flat the conditions did not allow any successful search or Rescue It was heavily smoked log on a scale of 10 the floor and the
02:49:42 log on a scale of 10 the floor and the ceiling visibility was Zero the firefighters had no water no thermal imaging cameras and it was getting hotter and hotter the extent of the heat caused them to
02:49:53 caused them to retreat firefighter hipple stating that they completed a right hand search shouted and kicked each door on the floor which were all closed and then
02:50:04 floor which were all closed and then left because there were no further responses firefighter Stern describes kicking all the doors Sam had left his front door open slightly a jar when he
02:50:17 front door open slightly a jar when he initially left to find helped the fact that the firefighters likely knocked and kicked on the front door of 135 and both recall all doors except 136
02:50:29 135 and both recall all doors except 136 which they searched being closed suggest that Joe May well have closed the front door after Sam went to get help Sam believes that his father would
02:50:40 help Sam believes that his father would have answered the door if it been knocked as he believed it was he would have believed Sam was knocking particularly as he'd left his father in the hallway and it's only been 5 to 8
02:50:52 the hallway and it's only been 5 to 8 minutes
02:50:54 minutes previously the phase one report found that the flat which the firefighter had entered on that floor was likely to be 136 this follows from the fact that flat
02:51:06 136 this follows from the fact that flat 136 was the first flat to the right of the lobby entrance in the direction of Sam and Joe's flat and it was the only flat then on fire
02:51:20 flat then on fire the firefighters were unable to send any messages regarding floor 16 and decided to hurry back down the stairs to the bridge
02:51:29 bridge head when they came back they affectedly said that they'd not been able to do a Thor search of floor 16 due to the Thick Smoke in the lobby and the fact that they were low on air and that it was so
02:51:41 they were low on air and that it was so hot and they had no firefighting equipment Sam was still with firefighter a burn when they got back and he was told we'll have to send another crew up
02:51:52 told we'll have to send another crew up there conditions on the 16th floor due to the smoke and the escalation of the fire were becoming fatal firefighter O notes the following unsuccessful
02:52:04 notes the following unsuccessful deployment and says in relation to Joe the guy wouldn't be able to survive in those conditions for more than 3 minutes I knew that the guy's dad wasn't going
02:52:15 I knew that the guy's dad wasn't going to make it out alive Sam calls that shortly thereafter they when they had come running down the stairs the firefighters left and signal to firefighter oburn that the conditions
02:52:28 to firefighter oburn that the conditions were dire when Sam asked about his dad oburn responded that it was too dangerous and they all needed now to get out Sam asked the last firefighter again
02:52:39 out Sam asked the last firefighter again about his father but they said there was nothing they could do Sam was then faced with the awful decision that he would have to leave as
02:52:54 well the firefighters and Sam left the building Joe remained in flat
02:53:03 135 one postcript when they went back to the bridge head firefighter oburn went to warn SM Loft that there
02:53:15 oburn went to warn SM Loft that there was still a man on the 16th floor who was bed bound his re recollection was such that he exhibited a site plan indicating where the conversation had taken place and he says I told some
02:53:28 taken place and he says I told some officer inside about the guy on the 16th floor SM Lo Loft could not recall this exchange firefighter
02:53:40 exchange firefighter oburn says that in relation to the attempts to rescue Joe on the 16th floor that having informed Med SM Loft about this one person quote he probably had
02:53:54 this one person quote he probably had bigger problems to worry about I thought if I gave him the information then I don't have to worry about it anymore and I can find something else to
02:54:06 do given the conditions on the 16th floor it was now so hot and Smokey there was no follow-up rescue no other firefighters were sent to the 16th floor
02:54:18 firefighters were sent to the 16th floor on exiting the tower Sam recalls that the stairwell even at Floor 2 and three was now heavily smoked log
02:54:28 log CCTV images show that hammed Wabi was speaking to SM Loft and watch manager Watson at
02:54:38 Watson at 13816 hammed recalled that he told those firefighters that there was an elderly man and an elderly woman on the 16th floor and both needed help this would
02:54:49 floor and both needed help this would have been Joe Daniels and Sheila hammed was clear that he told officers about his neighbors the images at 13851 show SM Loft and watch manager
02:55:03 13851 show SM Loft and watch manager Watson continuing to talk at the main entrance neither of them could recall speaking to hammed or the nature of that
02:55:15 conversation Sam recalls trying one more time once he was outside of the building to tell a firefighter or a police officer at The Cordon that some point
02:55:27 officer at The Cordon that some point that his father was still in flat 135 this would have been about 2:00 in the
02:55:33 the morning he or his mother gave the floor and the flat number again but they were told they needed to move away from the scene before any information could be
02:55:45 scene before any information could be given
02:55:48 given neither Joe nor Sam made 999 calls Joe made no calls to friends or loved one during the fire Sam did call his mother Lucy and his girlfriend upon getting out
02:56:01 Lucy and his girlfriend upon getting out of the tower at
02:56:09 138 he was then faced with the prospect of remaining at the scene knowing that no one was going to go to fleld 15 16 and that his father would not be
02:56:22 and that his father would not be rescued on the 14th of June Lucy Daniels contacted the MPS casualty Bureau to report Joe missing the primary identification
02:56:35 missing the primary identification evidence during the postmortem was bya DNA examination on the 3rd of July by pathologist Dr Randall
02:56:49 the flat displayed evidence of complete burn damage with no internal walls or wall coverings remaining the ceiling covering was intact but very damaged in places and displayed smoke damage most
02:57:02 places and displayed smoke damage most of the window frames were still present but not complete they were badly damaged and not secure within the window apertures flat 135 featured complete
02:57:13 apertures flat 135 featured complete fire
02:57:15 fire damage according to the archaeological examin ation undertaken between the 2nd of July and the 18th of July 2017 it can be established with high confidence that
02:57:26 be established with high confidence that Joe died in the living room area of the
02:57:32 flat a postm Morton was conducted by Dr Randall on the 3rd of July in terms of the provisional cause of death it was recorded as consistent with the effects
02:57:44 recorded as consistent with the effects of fire this was confirmed in the final postm
02:57:48 postm that was conducted on the 8th of October 2017 and the 23rd of October
02:57:55 2017 on the 14th of November 2018 and the 22nd of November 2018 tox toxicology exam analysis indicated that carbon monoxide appeared
02:58:08 indicated that carbon monoxide appeared to be present in Joe's blood but it was not possible to establish the levels of concentration due to the condition of the blood
02:58:16 the blood sample the result indicated that Joe Daniels may have inhaled carbon monoxide prior to his death but it was not possible to say how much and whether it contributed to his
02:58:27 contributed to his death Dr perser Professor perser rather in his analysis in relation to Joe says as follows it is likely there was some smoke penetration in flat 135
02:58:40 was some smoke penetration in flat 135 around the FL flat entrance door from the lobby after the door was opened by Sam at approximately 125 if the flat door remained opened after Sam left it is likely that the flat
02:58:52 Sam left it is likely that the flat would have filled with dense smoke within minutes uh this could have resulted in Joe inhaling a significant dose of aient gases capable of causing
02:59:03 dose of aient gases capable of causing collapse after 10 to 15 minutes and death some minutes later if the door was closed by Joe and bearing in mind the firefighters noted that all doors on
02:59:15 firefighters noted that all doors on floor 16 were closed save the one they entered then there was a likelihood that it could have been a gradual penetration of gas smoke from the lobby resulting in
02:59:28 of gas smoke from the lobby resulting in a gradual slow uptake of axient gases over the next hour but that would have been insufficient to cause incapacitation the smoke penetration
02:59:39 incapacitation the smoke penetration from the exterior fire would have continued until about 0232 to 0234 when the fire spread outs side the flat 135 bedrooms the conditions in the
02:59:52 flat 135 bedrooms the conditions in the living room would then have deteriorated rapidly as the exterior fire spread pass the north side of the living room to the corner column A1 around 0249 to
03:00:05 corner column A1 around 0249 to 0255 Professor perser further notes that the conditions in 135 are predicted to have deteriorated more rapidly after the exterior fire spread outside the
03:00:16 exterior fire spread outside the bedrooms from approxim 0234 onwards so that based on his analysis the flat fives higher up the tower he would estimate that Joe if in
03:00:27 tower he would estimate that Joe if in the living room would be likely to have lost Consciousness from the inhalation of aient gases by approximately 300 a.m. to 3:10 a.m. with death occurring a few
03:00:40 to 3:10 a.m. with death occurring a few minutes
03:00:42 minutes later evidence of inhalation of axient gases is provided by the presence of cohb in his tissues and s in his Airways these findings were
03:00:55 and s in his Airways these findings were considered consistant with death due to the effects of fire most likely from asphyxiant effects of inhalation of fire fumes the findings confirms that Joe
03:01:06 fumes the findings confirms that Joe Daniels inhaled smoke and it fient gases before he
03:01:12 before he died so sir in conclusion Joe Daniels was a longstanding Landing an established resident of grenfell Tower and the community
03:01:22 community there he lived to the age of 69 he hadd been a husband he was a father of two adult children Joe had struggled for many
03:01:33 children Joe had struggled for many years with his physical and mental health difficulties he had a diagnosis of dementia but he was not defined by his
03:01:41 his disabilities in this country we have a long history of disability legislation and yet as a society do we actually treat our fellow citizens with
03:01:52 treat our fellow citizens with disabilities with the respect equality and dignity they deserved do we really care the disproportionate number of disabled residents who lost their lives
03:02:03 disabled residents who lost their lives in the fire should give everyone cause for concern and would seem to suggest that we don't care Joe had a lifetime of experiences and memories both in India and the UK
03:02:16 and memories both in India and the UK and the many other countries that he traveled to his son Sam tried his best to provide his father with a safe contented existence in the tower and to
03:02:27 contented existence in the tower and to secure for him the help and assistance that he was entitled to on the night of the fire Sam tried his very best to protect his father in almost impossible
03:02:41 protect his father in almost impossible circumstances Joe Daniels was loved and he is dearly missed by his family thank you sir thank you very much M Monroe well at that point we will
03:02:55 much M Monroe well at that point we will break everyone can get some lunch and we'll resume at 5 2 please thank you