Grenfell Tower Inquiry - Panel statement on the publication of the Grenfell Tower Inquiry Phase 2 report
00:00:23 Good morning everyone. Today the panel in the Grenful Tower inquiry is publishing its final report dealing with the root causes of the fire.
00:00:34 fire. In phase one of the investigations, I examined the events of the 14th of June 2017.
00:00:42 2017. How the fire started, how it escaped from the flat where it had begun, and how it spread over the whole building with tragic consequences.
00:00:53 with tragic consequences. My report on that series of events was published on the 30th of October, 2019.
00:01:01 2019. In the second phase of the inquiry, the panel has been investigating the underlying causes of the fire with a view to identifying where mistakes were made and ensuring that a similar
00:01:13 made and ensuring that a similar disaster cannot occur again. This second part of the investigations has taken longer than we had hoped. Partly because of the broad scope of our
00:01:25 Partly because of the broad scope of our terms of reference and partly because as our investigations progressed, we uncovered many more matters of concern than we had originally expected.
00:01:37 than we had originally expected. As we discovered, it is not possible properly to understand the causes of the fire without understanding the way in which knowledge of the materials and methods of construction employed in the
00:01:50 methods of construction employed in the refurbishment developed over the course of time, what the government and others learned about them, and how the regulations and guidance relating to their use developed during the same
00:02:02 their use developed during the same period.
00:02:04 period. The information obtained in that part of our investigations provided the background to our examination of the refurbishment itself and the various decisions taken in the
00:02:15 and the various decisions taken in the course of it, particularly in relation to the selection of materials. In addition, [clears throat] it has been necessary for us to examine the way in
00:02:26 necessary for us to examine the way in which fire safety at Grenful Tower was managed, including the arrangements for fire risk assessments and the response to them, as well as the relationship
00:02:37 to them, as well as the relationship between the tenant management organization and the residents of the tower.
00:02:44 tower. The firefighting operations of the London Fire Brigade were considered in detail in my first report, but a number of questions relating to organization and training could not be answered at
00:02:57 and training could not be answered at that stage and were deferred for consideration in phase two. Also deferred to phase two were certain questions relating to the development of the fire, including the relative
00:03:10 the fire, including the relative contributions of the different materials used in the cladding. Another important aspect of our terms of reference was to investigate the
00:03:21 reference was to investigate the response of the authorities to the emergency. Finally, but most importantly, it was necessary for us to investigate in as much detail as the evidence would allow
00:03:34 much detail as the evidence would allow the circumstances surrounding the deaths of those who perished in the fire. The report we're publishing today contains our findings on all these and
00:03:45 contains our findings on all these and other matters. However, the simple truth is that the deaths that occurred were all avoidable and those who lived in the tower were badly failed over a number of years and
00:03:58 badly failed over a number of years and in a number of different ways by those who were responsible for ensuring the safety of the building and its occupants. They include the government, the tenant
00:04:10 They include the government, the tenant management organization, the Royal Burough of Kensington and Chelsea, those who manufactured and supplied the materials used in the refurbishment,
00:04:21 refurbishment, those who certified their suitability for use on high-rise buildings, [snorts] the architect, the principal contractor, and some of its subcontractors,
00:04:33 and some of its subcontractors, in particularly Harley Curtain Wall and its successor, Harley facads, some of the consultants, in particular the fire engineer Exover Warrington
00:04:44 the fire engineer Exover Warrington Fire, the local authorities building control department and the London Fire Brigade.
00:04:53 Brigade. Not all of them bear the same degree of responsibility for the eventual disaster, but as our reports show, all contributed to it in one way or another.
00:05:04 contributed to it in one way or another. In most cases through incompetence, but in some cases through dishonesty and greed.
00:05:12 greed. The failings can be traced back over many years and our efforts to get to the bottom of what went wrong and why account for the length of our report and
00:05:23 account for the length of our report and the time it has taken us to produce it. However, if an inquiry of this kind is to produce anything of value, it is necessary for those who can influence the future direction of the construction
00:05:36 the future direction of the construction industry, the fire and rescue services, the management of fire safety in buildings and resilience planning to understand exactly where mistakes were
00:05:48 understand exactly where mistakes were made and how they can be avoided in the future.
00:05:53 future. The report is divided into 14 parts broadly by reference to related subjects.
00:06:00 subjects. Some parts contain several chapters, some only one. As with the phase one report, it begins with an introduction followed by an executive summary.
00:06:13 executive summary. Although the executive summary runs to 24 pages, the length of the report means that it can touch on only the most significant elements of our conclusions.
00:06:24 significant elements of our conclusions. However, it should assist readers in finding their way around the report. Part two describes significant events that provided the background to the
00:06:35 that provided the background to the fire.
00:06:37 fire. It begins by explaining how the regulations and guidance enforced at the time of the refurbishment came into being and the way in which the reaction to fire of materials used in the
00:06:49 to fire of materials used in the construction of modern high-rise buildings was tested. We then consider the involvement of the government in the form of the then department for communities and local
00:07:00 department for communities and local government. the way in which it sought to monitor the causes of fires when they occurred and most importantly the warning signs that were emerging from as early as 1991
00:07:14 that were emerging from as early as 1991 that some kinds of materials in particular aluminium minium composite material panels with unmodified polyethylene cores were dangerous.
00:07:27 polyethylene cores were dangerous. We find that there was a failure on the part of the government and others to give proper consideration at an early stage to the dangers of using combustible materials in the walls of
00:07:39 combustible materials in the walls of high-rise buildings. That including failing to amend in an appropriate way the statutory guidance on the construction of external walls.
00:07:50 on the construction of external walls. That is where the seeds of the disaster were sown. In part three, we set out our findings about the testing and marketing of the
00:08:01 about the testing and marketing of the main products used in the refurbishment, the Rainabond panels, the Celotex RS5000 insulation, and the small amount of Kingsband K15
00:08:12 and the small amount of Kingsband K15 insulation. We discovered that there had been systematic systematic dishonesty on the part of manufacturers involving deliberate manipulation of the
00:08:24 involving deliberate manipulation of the testing processes and calculated attempts to mislead purchasers into thinking that what were combustible materials complied with the provisions
00:08:35 materials complied with the provisions of the statutory guidance that advised against their use. That dishonest approach to marketing was compounded by the failure of two of the
00:08:46 compounded by the failure of two of the bodies that provided certificates of compliance with the building regulations and statutory guidance, the British Board of Agri and local authority
00:08:57 Board of Agri and local authority building control to scrutinize the information provided to them with sufficient care and exercise the degree of rigor and independence that was to be
00:09:09 of rigor and independence that was to be expected of
00:09:13 The tenant management organization was at the heart of events leading up to the fire. In part four of the report, we make our findings about its relationship with the residents of Grenful Tower.
00:09:26 with the residents of Grenful Tower. We find that the organization was badly run and failed to respond to criticisms of its treatment of residents contained in independent reports produced in 2009.
00:09:39 in independent reports produced in 2009. It is clear that for some years uh before the fire, relations between the TMO and residents were marked by distrust, antagonism, and increasingly
00:09:51 distrust, antagonism, and increasingly bitter confrontation. We find that for the TMO to have allowed the relationship to deteriorate to such an extent reflects a serious failure on
00:10:03 an extent reflects a serious failure on its part to observe its basic responsibilities.
00:10:09 Part five of the report is concerned with the management of fire safety at the tower. Again, we find that the residents were badly let down.
00:10:20 residents were badly let down. The picture is one of a persistent failure to give sufficient importance to the demands of fire safety, particularly the safety of vulnerable people, and a failure on the part of the council to
00:10:34 failure on the part of the council to scrutinize that aspect of the organization's activities adequately. Part of the reason for that was the failure of the chief executive, Robert Black, to ensure that the board of the
00:10:46 Black, to ensure that the board of the TMO and the council were kept properly informed of matters affecting fire safety.
00:10:54 safety. That was despite periodic expressions of concern by the London Fire Brigade about compliance with the fire safety order, all of which should have been drawn to
00:11:05 all of which should have been drawn to their attention. The TMO's failure to attach sufficient importance to fire safety is illustrated by its reliance on a single person, Carl
00:11:17 by its reliance on a single person, Carl Stokes, as fire risk assessor for its entire estate, despite his lack of qualifications and experience, by his failure to carry out necessary
00:11:28 by his failure to carry out necessary remedial work identified in fire risk assessments promptly, by his failure to provide measures to mitigate the absence of an effective smoke ventilation system and by its
00:11:41 smoke ventilation system and by its failure to introduce appropriate arrangements for inspecting and maintaining fire prevention systems, in particular self-closing devices on the
00:11:52 particular self-closing devices on the entrance doors to individual flats. In addition, the TMO failed to maintain a reasonably accurate record of those
00:12:03 a reasonably accurate record of those residents of the tower who were vulnerable for one reason or another and likely to need help to escape if a fire occurred.
00:12:14 Part six of the report contains our findings about the refose itself and again the picture is disturbing. First, the regulatory context in which
00:12:26 First, the regulatory context in which the work was carried out was in our view unsatisfactory because the statutory guidance which was treated by many in the construction industry including those engaged on the
00:12:37 industry including those engaged on the refurbishment as containing a sufficient statement of what was required did not make it clear enough that it was subject to the overriding requirements
00:12:48 subject to the overriding requirements of the building regulations. That was a particular problem in relation to the rain panels which although they satisfied the requirement
00:12:59 although they satisfied the requirement in the guidance for a material with a class N surface contained a highly combustible core. But that is only the beginning. The
00:13:11 But that is only the beginning. The tenant management organization as the client manipulated the process of appointing an architect to design the refurbishment in order to avoid the need to invite
00:13:23 in order to avoid the need to invite open tenders for the architectural services.
00:13:27 services. It did so because it wanted to appoint Studio E, the architect for the existing academy and leisure center project despite the fact that it had no experience of overcladding a high-rise
00:13:40 experience of overcladding a high-rise building.
00:13:42 building. That turned out to have significant consequences because Studio E failed to recognize as a reasonably competent architect should have done that the insulation and raincreen chosen for the
00:13:55 insulation and raincreen chosen for the refurbishment were combustible and unsuitable for that purpose. ACM panels were chosen as the raincreen to keep down the cost.
00:14:07 to keep down the cost. Neither Ryden, the principal contractor, nor Harley, its cladding subcontractor, was aware of the properties of the materials specified for use in the
00:14:18 materials specified for use in the refurbishment. Although Harley as a specialist subcontractor dealing with cladding should have been, and Ryden as principal contractor had its own responsibility to
00:14:30 contractor had its own responsibility to ensure the materials were suitable. One of the problems that afflicted the refurbishment was a failure on the part of all concerned to understand where
00:14:42 of all concerned to understand where responsibility for any particular decision lay. That was especially the case in relation to the choice of the raincreen. The generally prevailing view was that
00:14:54 The generally prevailing view was that since aluminium composite material panels had been used on other buildings without apparent problems, they were suitable for use on the tower.
00:15:06 suitable for use on the tower. But no one was prepared to accept responsibility for having chosen them. And when questioned, everyone who was asked said that someone else had been responsible for ensuring that they were
00:15:18 responsible for ensuring that they were suitable.
00:15:20 suitable. We find that Studio E, Ryden, and Harley all took an unacceptably casual approach to contractual relations. None of their employees engaged on the
00:15:31 None of their employees engaged on the project understood the relevant provisions of the building regulations, the statutory guidance, or such guidance from industry sources as was then
00:15:42 from industry sources as was then available.
00:15:45 That might not have mattered quite so much if proper advice had been taken from a competent and experienced fire engineer or if building control had performed its task properly.
00:15:58 performed its task properly. In fact, the tenant management organization did instruct Exova Warrington Fire to produce a fire safety strategy for the refurbishment, which should have included advice on the
00:16:09 which should have included advice on the effect of the overcladding and the compliance of the external walls with the functional requirements of the building regulations. Exover produced three versions of a fire
00:16:22 Exover produced three versions of a fire safety strategy, but each version was stated to be a draft and was incomplete because it did not deal with that particular question, which it said would be covered in a
00:16:34 which it said would be covered in a future issue of the report. It was clear, therefore, that the fire safety strategy was incomplete, but no one asked Exover to finish its work, nor
00:16:46 one asked Exover to finish its work, nor did anyone provide it with details of the proposed cladding to enable it to do so.
00:16:52 so. Exover itself failed to ask for the missing information or to complete the work it had been instructed to carry out.
00:17:02 out. The failure to obtain a final report uh was probably critical because if Exx had considered the proposed cladding, it should and probably would have
00:17:13 should and probably would have identified the fact that the insulation and the rainscreen did not comply with the statutory guidance or more importantly the building regulations.
00:17:26 In part eight, we set out our findings on the management and training of the London Fire Brigade in the years leading up to the fire. That part of our investigations
00:17:37 That part of our investigations represented a continuation of the work started in phase one in which I described the response of the LFB on the night.
00:17:47 night. I was critical of certain aspects of that response. In particular, the way in which the control room handled calls from people trapped in the building and the actions of some of the incident
00:17:59 the actions of some of the incident commanders who had not been properly trained to deal with a fire of that nature.
00:18:06 nature. that made it necessary for us to examine the uh London Fire Brigade's management and training in the period leading up to the fire as well as the way in which it made use of the information available to
00:18:19 made use of the information available to it.
00:18:21 it. In our report, we find that there were deficiencies in the organization and management of the control room, the training of control room officers, and in the commissioning and delivery of
00:18:32 in the commissioning and delivery of training to operational crews. in particular in relation to incident command.
00:18:39 command. There were also deficiencies in the collection of information needed to enable crews to prepare effectively to respond to fires in individual buildings.
00:18:50 buildings. The primary cause of those problems was a chronic lack of effective leadership combined with an undue emphasis on process and an attitude of complacency.
00:19:03 process and an attitude of complacency. We have also returned to investigate some aspects of the firefighting operations on the night of the fire on which I was unable to make findings in phase one. In particular, problems with
00:19:16 phase one. In particular, problems with communications and the supply of water. I shall return to part nine of the report in a moment, but for now I move to part 10 in which we examine the
00:19:29 to part 10 in which we examine the authorities's response to the fire. Once again, we have found that those who lost their homes as a result of the fire were badly let down by the organizations
00:19:40 were badly let down by the organizations that should have provided the support they desperately needed. The primary responsibility for that lay with the council which as a category 1 responder under the civil contingencies
00:19:53 responder under the civil contingencies act should have had plans in place to enable it to respond effectively to the emergency. In the event, however, it had failed to put in place suitable plans or to
00:20:06 put in place suitable plans or to provide the training to its staff that was required to enable it to respond effectively to the situation it faced. In addition, its chief executive was
00:20:17 In addition, its chief executive was ills suited to taking control of what was undoubtedly a very serious challenge. The council did not have the capacity to identify those who needed accommodation
00:20:30 identify those who needed accommodation and other important forms of assistance. Nor did it have arrangements in place for communicating with those affected by the disaster or the wider public.
00:20:42 the disaster or the wider public. As a result, it was not capable of meeting the immediate needs of those who had been displaced and from their homes for food and shelter.
00:20:52 shelter. In the end, it was local, voluntary, and community organizations that filled the gap by providing rest centers and temporary shelter.
00:21:04 temporary shelter. Uh the Londonwide resilience structures that were intended to enable the capital to respond to an emergency affecting more than one burough did not operate effectively. Partly because they were
00:21:17 effectively. Partly because they were not designed to provide central direction to the response [clears throat] and partly because the Royal Burough of Kensington and Chelsea did not seek assistance promptly.
00:21:28 assistance promptly. In the event the government in the form of a senior official in the department for communities and local government brokered an arrangement under which the
00:21:39 brokered an arrangement under which the experienced town cler of the city of London took control of the operation.
00:21:47 An important chapter of this part records the evidence given by those who were personally affected by the fire. We are acutely aware that giving
00:21:58 We are acutely aware that giving evidence, particularly giving evidence in public, was a difficult and daunting experience. We should therefore like to thank all of those who contributed to our
00:22:09 those who contributed to our investigations by giving evidence both in the form of witness statements and by being willing to speak about their experiences in public. By doing so, they ensured that we
00:22:21 By doing so, they ensured that we received the fullest possible account of the events that unfolded in the days following the fire.
00:22:31 In parts 11, 12, and 13 of the report, we deal with a number of different matters, including the experiments carried out by Professor Bisby and Professor Terrarero on the materials
00:22:43 Professor Terrarero on the materials used in the refurbishment. They confirmed that the Rainabond aluminum composite material panels were the primary reason for the fire's
00:22:54 the primary reason for the fire's devastating progress.
00:22:58 Part 14 contains our recommendations. Although some steps have already been taken to respond to the many failures that we have identified, we think that
00:23:10 that we have identified, we think that more can and should be done to bring about a fundamental change in the attitudes and practices of the construction industry. Only such a change can ensure that in
00:23:22 Only such a change can ensure that in future buildings in general and higher risk buildings in particular are safe for those who live and work in them. We think that in different ways,
00:23:33 We think that in different ways, implementation of our recommendations, will improve fire safety, particularly in high-rise buildings, and ensure that dangerous materials cannot be used in construction in the future. They will
00:23:47 construction in the future. They will also improve the efficiency of fire and rescue services nationally. Our recommendations include, but are not limited to the following. The appointment of a construction
00:23:59 The appointment of a construction regulator to oversee all aspects of the construction industry. Bringing responsibility for all aspects of fire safety under one government department.
00:24:11 department. The establishment of a body of professional fire engineers properly regulated and with protected status. and the introduction of mandatory fire safety strategies for higher risk
00:24:23 safety strategies for higher risk buildings. A licensing scheme for contractors wishing to undertake the construction or refurbishment of higher risk buildings. The regulation and mandatory
00:24:35 The regulation and mandatory accreditation of fire risk assessors. the establishment of a college of fire and rescue to provide practical educational and managerial training to
00:24:48 educational and managerial training to fire and rescue services and the introduction of a requirement for the government to maintain a publicly accessible record of recommendations made by select
00:25:00 recommendations made by select committees, coroners, and public inquiries describing the steps taken in response to them or its reasons for decline. ing to implement them.
00:25:14 I now return to part nine of the report which is the most personal part and contains the most difficult reading. It contains a detailed account of the
00:25:25 It contains a detailed account of the circumstances surrounding the deaths of those who perished in the fire. I did not refer to it earlier because it seemed to me fitting to end these proceedings as they began in May 2018
00:25:40 proceedings as they began in May 2018 with a reminder that the fire at Grenful Tower was above all a human tragedy in which many lives were lost, families were torn aunder, homes were destroyed,
00:25:53 were torn aunder, homes were destroyed, and a community was shattered. The detailed reconstruction we have provided will be for many one of the most important parts of our report.
00:26:06 most important parts of our report. Although it may make painful reading, those who lost relatives and friends naturally feel a need to know as much as possible about their loved ones last moments.
00:26:18 moments. I said on many occasions that I hoped we could find sufficient facts to satisfy the coroner of the circumstances surrounding their deaths and avoid the need for any further proceedings.
00:26:31 need for any further proceedings. I'm now able to say that we've been able to make detailed findings about the circumstances in which people died, including calls made to the emergency services, the transfer of information
00:26:44 services, the transfer of information from the control room to the incident ground, the recording of that information on its way to and at the bridge head, and the steps taken to rescue those who were trapped.
00:26:57 rescue those who were trapped. We are satisfied that all those who died in the building were overcome by toxic gases produced by the fire. And with expert assistance, we've been able to establish a reasonably accurate time of
00:27:10 establish a reasonably accurate time of death in each case. We're satisfied that all those whose bodies were damaged by the fire were already dead by the time it reached them.
00:27:20 them. In a moment, my fellow panel members, Mistfan and Mr. ator wish to add some comments of their own. Before they do so, however, I should like to thank the
00:27:31 so, however, I should like to thank the inquiry team without whom it would not have been possible to carry out an investigation of this kind. It would be invidious to single out individual names for mention on this
00:27:43 individual names for mention on this occasion because everyone involved, whatever their particular task, has played an essential part in enabling us to do our work. With their help, we have
00:27:54 to do our work. With their help, we have followed up many lines of inquiry, some of which led to surprising revelations and have collected and digested a huge number of documents and statements, not
00:28:05 number of documents and statements, not to mention hearing many days of oral evidence.
00:28:09 evidence. All those who worked for the inquiry over the years are named in an appendix to the report, and we owe them a deep debt of gratitude.
00:28:20 debt of gratitude. I now invite Mr. Esther fund to say a few words. Thank you sir Martin. [clears throat] Good morning.
00:28:29 Before I joined the inquiry panel I spent nearly 30 years as an architect. [clears throat] In that role I developed a particular interest in health and safety, fire and
00:28:40 interest in health and safety, fire and accessibility matters. Returning home from a holiday in June 2017,
00:28:47 2017, I flew over West London and saw the burning tower in the early hours from the air.
00:28:55 the air. As for so many others, this was a profound shock. First, of course, as a human response, but also as a professional who had spent their career
00:29:06 professional who had spent their career working to make buildings safe. Throughout this inquiry, we have been determined to find out how such a disaster was possible and what needs to
00:29:17 disaster was possible and what needs to be done to save lives in the future. As Sir Martin has just summarized, we have found many failings across a wide range of institutions, organizations,
00:29:30 range of institutions, organizations, and individuals that spann many years, which together have led to the terrible fire at Grenful Tower. They include many failures of the
00:29:41 They include many failures of the construction industry, my own sector, which is where I will focus my comments on today.
00:29:50 Since the fire, the government has passed the building safety act. The act is welcome, but we need to go further. Our report identifies what we think is
00:30:03 Our report identifies what we think is needed to make sure the legacy of Grenell is real and brings about lasting and progressive change. Our recommendations place new burdens
00:30:14 Our recommendations place new burdens and responsibilities on people and organizations. I make no apologies for that. Put simply, if you work in the construction industry and you do not feel the weight
00:30:27 industry and you do not feel the weight of responsibility you have for pe for keeping people safe, you are in the wrong job. The change we need to bring about is partly about structures and regulations.
00:30:40 partly about structures and regulations. Sir Martin has set out the key points in what we have proposed and the report explains our recommendations in detail. But the necessary change is also one of
00:30:52 But the necessary change is also one of culture and behaviors. Change on this scale needs to be owned and led by those of us working in the sector. It is not enough to pass an act
00:31:03 sector. It is not enough to pass an act of parliament and to sit back and think the work is done. Without change in behavior and a recognition that the needs of the people who use our buildings must be placed at the center
00:31:15 buildings must be placed at the center of our work, the lessons of Grenful will not truly be learned in full. One of the core themes of our report is technical incompetence of many of those
00:31:27 technical incompetence of many of those involved in the refurbishment project. As hundreds of other buildings are now known to have similar cladding systems, it is clear that the problem of incompetence is widespread.
00:31:40 incompetence is widespread. It follows that part of the change that is needed to the culture of the industry is an ongoing commitment to the development of professional skills.
00:31:51 development of professional skills. If we are not professionally curious, we will not become technically competent. Again, this change needs everyone in the construction industry to play their part
00:32:03 construction industry to play their part in the implementation of the inquiry's recommendations. We must also keep at the very forefront of our minds our responsibilities towards those who are most vulnerable.
00:32:17 towards those who are most vulnerable. As Grenful, a significant number, sorry, at Grenful, a significant number of those who died were children, had disabilities, or were vulnerable in other ways. The risks posed by a
00:32:31 other ways. The risks posed by a particular building, and the right response to those risks are always as diverse as the people who live or work in it. That is why we recommend that the government thinks again about defining
00:32:43 government thinks again about defining higher risk buildings solely by reference to their height. It is why the fire safety strategies must be provided for safety of all occupants.
00:32:55 occupants. And it is why a stay put strategy will never be appropriate where there is a risk of fire spreading over the building's external walls. It is why we recommend that the
00:33:06 It is why we recommend that the government guidance should be reviewed so that the safety and re resilience of a building is prioritized. And it is why we stand by the inquiry's
00:33:17 And it is why we stand by the inquiry's phase one recommendation that the need for PEEPS personal emergency evacuation plans for residents with mobility issues or other impairments.
00:33:30 or other impairments. As a inquiry panel, we have acted throughout with fairness, independence and impartiality. That is what the law requires. At the same time, the losses so many
00:33:43 At the same time, the losses so many people have suffered and my involvement in this process has left a mark on me as a person
00:33:56 as a person and as
00:33:58 and as as a professional which will last far beyond this inquiry.
00:34:05 And although this inquiry is now ending, we know that for many people their journey continues. We wish them strength for the future.
00:34:17 for the future. I will now pass sorry I will now hand over to my colleague Ali. Thank you Thor. Good morning everyone. My role as a panel member has been to
00:34:29 My role as a panel member has been to listen to the evidence to consider what I have heard and work with Sir Martin and Thoria to agree findings and recommendations.
00:34:40 Firstly, I would like to express my own heartfelt sympathy to all those whose lives have been affected by this tragic fire.
00:34:49 fire. We know that an inquiry can feel like a very slow process. But what I can say is that we have been painstakingly thorough and that we present our our report to you with
00:35:00 present our our report to you with confidence in its veracity.
00:35:05 Secondly, I would like to say that I grew up in council housing. I was involved in creating social housing organizations. I was chief executive of a housing association for over 20 years.
00:35:18 association for over 20 years. What I can say is that working on the inquiry has had a profound impact on me personally and as a social housing professional.
00:35:29 In social housing, we often say that we put our tenants at the heart of what we do. But it is not enough just to pay lip service to that ideal. In our report, we look at the
00:35:41 In our report, we look at the relationship between Kensington and Chelsea Tenant Management Organization and its residents before the fire. We find that it was one of distrust,
00:35:52 We find that it was one of distrust, dislike,
00:35:54 dislike, personal antagonism and anger. Residents deserve to be treated with understanding and respect. The TMO failed to do that.
00:36:09 We saw a similar failure to treat residents as people and as individuals in the aftermath of the fire, including in the way that those with religious,
00:36:20 in the way that those with religious, cultural, or social needs suffered discrimination as a result of RBK's failure to prepare properly for emergencies.
00:36:31 emergencies. It was obvious to me from watching and listening to evidence being given at the hearing that there were two different groups of people. Those who lived at Granfell and those who worked for the
00:36:42 Granfell and those who worked for the TMO RBKC and their agents.
00:36:49 [clears throat] In our report, we set out how the government's focus on deregulation dominated the department's thinking such that even matters affecting the safety of life were ignored, delayed or disregarded.
00:37:03 ignored, delayed or disregarded. The deregulation agenda had a parallel impact on social housing on the h social housing sector particularly in terms of consumer standards and protection for
00:37:14 consumer standards and protection for tenants.
00:37:16 tenants. The effects of that can be seen in the many failings of the TMO which we set out in our report and which were not prevent and which were not prevented or addressed by the regulatory system then
00:37:29 addressed by the regulatory system then in place.
00:37:32 Parliament has now passed the social housing regulation act which will enhance [snorts] the powers of the regulator in support of stronger consumer standards and which stresses
00:37:43 consumer standards and which stresses the need for involvement and empowerment of tenants and the reintroduction of inspection of landlords. In my view, this was not a moment too
00:37:54 In my view, this was not a moment too soon. Our report underlines why its full implementation is so important and so urgent.
00:38:07 I have focused so far on the TMO's role as a social housing provider. The TMO played an important part in the refurbishment of Grrenville Tower in its role as the project's client.
00:38:21 role as the project's client. We have found that the TMO paid insufficient care in its choice of architect and failed to pay enough attention to fire safety. I hope that our report acts as a
00:38:33 I hope that our report acts as a reminder to the clients of future building projects, including social housing providers, that they have a responsibility to the users of their buildings to ensure that safety is not sacrificed to the demands of speed and
00:38:46 sacrificed to the demands of speed and cost.
00:38:48 cost. Regulation should not be treated as boxes to be ticked but as a way of giving residents confidence that their homes are safe.
00:39:00 Finally, I would like to echo something that Thoria has said. We cannot in a few words here today do full justice to the totality of our report. What is needed is for those with
00:39:11 What is needed is for those with responsibility for building safety in my sector as in Thoras to read the report to reflect on it and to treat Grenfell as a touchstone in all that they do in
00:39:22 as a touchstone in all that they do in the future and that is to act with professionalism with competence and to put people first. I will now pass you back to Sir Martin.
00:39:33 I will now pass you back to Sir Martin. Thank you very much. Thank you. We should all remember that the Grenful Tower fire was and remains an intensely personal tragedy for all those who lived
00:39:46 personal tragedy for all those who lived in and around the tower and above all for those who died, their families and friends.
00:39:54 friends. We invite you therefore to join us in remembering them while I read out their names.
00:40:03 Fathia Ahmed Elsanusi Abufras Muhammad Ibraim Isra Ibraim Muhammad Amid Sabah Nada
00:40:18 Muhammad Amid Sabah Nada Hasham Rakman Rana Ibrahim Fthia Hassan Hana Hassan
00:40:30 Hana Hassan Marco Gautardi Gloria Trafisan Raymond Herbert Moses Bernard
00:40:41 Raymond Herbert Moses Bernard Esla El Guri Mariam El Guri Anthony Keith Disson Basm Shukare
00:40:52 Basm Shukare Nardia Shukare Ma Shukare Fatima Shukare Zen Inab Shukare,
00:41:03 Zen Inab Shukare, Syria, Shukare, Hashim Kadir, Nura, Jamal, Yak, Hashim,
00:41:15 Yak, Hashim, Federos, Hashim, Yakub, Hashim, Abdulaziz Elwahhabi, Faza El Wahhabi,
00:41:27 Faza El Wahhabi, Yasin Elwahhabi, Nur Huda El Wahhabi Mei El Wahhabi Lega Moore
00:41:39 Lega Moore Jessica Obano Ramirez Omar Belcadi Farah Hamdan Malac Belcadi
00:41:51 Malac Belcadi Lena Belcadi Mary Mendy [cough and snorts] Kadija Se
00:41:59 Kadija Se Victoria King, Alexandra Atala, Muhammad Natuku, Amal Ahmedin,
00:42:11 Amal Ahmedin, Amaya Tuku Ahmedin, Amna Mahmood, Idris, Maji Vital, Ernie Vital,
00:42:23 Ernie Vital, Debbie Lampril, Gary Maers, Bey, Haftton, Baroo Hafttom
00:42:34 Baroo Hafttom Hamid Khani Isaac Palos Sakina Afraabi Fatime Afrasiab
00:42:46 Fatime Afrasiab Vincent Chaja Kadijah Kufi Camru Mia
00:42:55 Camru Mia Raba Beum
00:42:57 Raba Beum Muhammad Hamid
00:43:00 Muhammad Hanife, Husna Beum, Joseph Daniels, Sheila,
00:43:11 Sheila, Steve P,
00:43:13 Steve P, Zanabdan,
00:43:16 Zanabdan, Jeremiah Dean, Muhammad Al-Hajali, Dennis Murphy, Ali Yw Jafari,
00:43:28 Ali Yw Jafari, Abest Islam Sabar Logan Gomez Py Burton.
00:43:37 Thank you all very much.