The Grenfell inquiry concluded today - finally - after hundreds of days of evidential sessions, tens of thousands of exhibits, and a cost to the public purse likely totalling up to £1 billion.
And the lengthy probe - launched in the immediate aftermath of the disaster in June 2017 by then-Prime Minister Theresa May - highlighted a series of missed opportunities involving the state, construction firms, and industry bodies.
Inquiry chairman Sir Martin Moore-Bick criticised the ‘dishonest' manufacturers responsible for Grenfell's exterior renovation a year before the fire, the ‘serious deficiencies' in building standards that allowed combustible material to be used in cladding on the side of the 24-storey tower, and the ‘indifference' to fire safety displayed by Grenfell's owner, the local council.
He surmised that the ‘path to disaster' was set in train by ‘decades of failure' in the state and corporate sector.
It resulted in the deaths of 72 men, women and children, including multiple generations of the same families, living in the 120-apartment tower, built in Kensington - one of London's richest areas.
The fire - the worst residential blaze since the Blitz - triggered mass protests about building standards, following months of concerns from Grenfell Tower residents about safety following its refurbishment.
The first report into what happened on the night itself, published in 2019, identified a litany of failures, including that the ‘principal reason' the flames shot up the building at such speed was the combustible cladding which acted as a ‘source of fuel' and actively helped spread the blaze.
And today's concluding report - a 1,600-page assessment of incompetence, indifference and dishonesty - again points to multiple missed opportunities to have possibly prevented the tragedy from ever happening.
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Smoke pours from the deadly fire at Grenfell Tower in West London in June 2017
Government
No one administration was to blame for state-level failures. Rather, successive governments - going back to the Tory premiership of the early 1990s, through the New Labour years, the Tory-Lib Dem coalition, and then to Mrs May's time in charge - failed to identify the risks posed by combustible cladding panels and insulation.
And there were plenty of warning signs.
In 1991, residents at Knowsley Heights in Liverpool escaped with their lives after their tower block caught fire. It had been covered in cladding during a renovation, which blazed when furniture dumped at the base of the building was set alight.
Read More
Grenfell Tower inquiry RECAP: Starmer apologises to families after damning report into deadly fire
An investigation later found the cladding was illegal.
In 1999, a fire swept through another high-rise block of flats in North Ayrshire, Scotland.
A man died and five others were injured, with witnesses reporting the cladding acting as an effective conductor for the blaze.
And in 2009, six people were killed at Lakanal House in Camberwell, south London, when cladding again caught fire and burned quickly.
The blaze was largely caused by botched and unsafe renovation work.
Even as recently as 2016 - around the time of the Grenfell revamp - the Department for Communities and Local Government was well aware of the risks of combustible cladding, but did not act.
Sir Martin said the Government ‘failed to heed the warning' of the Environment and Transport Select Committee in December 1999 - six months after the Ayrshire blaze - that it ‘should not take a serious fire in which people were killed before steps were taken to minimise the risks posed by some external cladding systems'.
Sir Martin said that in the years that followed the Lakanal House fire, ‘the Government's deregulatory agenda, enthusiastically supported by some junior ministers and the Secretary of State, dominated the department's thinking to such an extent that even matters affecting the safety of life were ignored, delayed or disregarded'.
He added: ‘Our investigations have revealed that some important recommendations affecting fire safety were ignored by the Government in the years leading up to the Grenfell Tower fire.'
The Grenfell Tower fire in West London in June 2017 left 72 people dead in a shocking tragedy
Department for Communities and Local Government (DCLG)
While part of central government, this department came in for particular criticism over the way it handled safety on the state-owned housing portfolio.
It said the DCLG ‘failed to pay due regard' to the striking results of a large-scale test in 2001 involving aluminium composite panels with unmodified polyethylene cores, which burned violently.
Read More
The 72 victims of the Grenfell Tower fire: From an unborn baby to grandmother-of six
And it did not take any steps either ‘to ascertain the extent to which panels of that kind were in use, or to warn the construction industry about the risks they posed'.
It failed to even publish the results of the damning test.
The department was made aware on many occasions that an old, antiquated product classification for facade products known as Class 0 was inappropriate, but allowed it to remain part of the statutory guidance until after the Grenfell Tower fire.
Sir Martin said: ‘It could and should have been removed years earlier.'
Between 2012 and 2017, the DCLG received numerous warnings about the risks involved in using polymeric insulation and aluminium composite panels with unmodified polyethylene cores.
However, despite what they knew, and the warnings it received from some quarters, the department - led by Eric Pickles - failed to amend or clarify the guidance on the construction of external walls.
The 72 victims of the Grenfell Tower fire in June 2017 are pictured as follows - (top row left to right) Mohammad Al-Haj Ali, Ya-Haddy Sisi Saye, also known as Khadija Saye, Anthony Disson, Khadija Khalloufi, Mary Mendy, Isaac Paulos, Sheila, Gloria Trevisan, Marco Gottardi, (second row left to right) Berkti Haftom, Ali Yarwar Jafari, Majorie Vital, Yahya Hashim, Hamid Kani, Jessica Urbano Ramirez, Zainab Deen, Nura Jemal, Jeremiah Deen, (third row left to right) Yasin El-Wahabi, Firdaws Hashim, Hashim Kedir, cara bermain di sensa138 Debbie Lamprell, Ernie Vital, Sakina Afrasehabi, Denis Mur-phy, Raymond "Moses" Bernard, Biruk Haftom, (fouth row left to right) Yaqub Hashim, Mehdi El-Wahabi, Ligaya Moore, Nur Huda El-Wahabi, Victoria King, Mo-hammed Amied Neda, Maria del Pilar Burton, Hesham Rahman, Gary Maunders, (fifth row left to right) Alexandra Atala, Vincent Chiejina, Steve Power, Rania Ibrahim, Fethia Hassan, Hania Hassan, Fathia Ahmed Elsanousi, Abufras Ibrahim (silhouette), Isra Ibrahim (silhouette), (sixth row left to right) Mariem Elgwahry, Eslah Elgwahry (sil-houette), Mohamednur Tuccu, Amal Ahmedin, Amaya Tuccu-Ahmedin, Amna Mahmud Idris, Abdeslam Sebbar (silhouette) , Joseph Daniels (silhouette), Logan Gomes, (seventh row left to right) Omar Belkadi, Farah Hamdan, Malak Belkadi (sil-houette), Leena Belkadi (silhouette), Abdulaziz El-Wahabi, Faouzia El-Wahabi, Fatemeh Afrasiabi, Kamru Miah, Rabeya Begum, (eighth row left to right) Mohammed Hamid, Mohammed Hanif, Husna Begum, Bassem Choukair, Nadia Choucair, Mierna Choucair, Fatima Choucair, Zainab Choucair and Sirria Choucair
Royal Borough of Kensington and Chelsea council (RBKC) and the Tenant Management Organisation (TMO)
Grenfell Tower was owned by the council, but run by the TMO - and so, of the two, it was the latter who were particularly singled out for criticism by the inquiry report.
Many of the tower's inhabitants were vulnerable due to reasons including health issues, while others were from low-income backgrounds.
Yet two separate reports identified the TMO demonstrated issues with staff attitudes, customer service, and a poor approach to carrying out repairs.
This context perhaps explains why one of arguably the greatest opportunities to prevent the tragedy from taking place was ignored.
Read More
Lord Eric Pickles to be slated over Grenfell disaster after delays to fire safety rules
The TMO regarded some of the residents as ‘militant troublemakers' led on by a handful of vocal activists, including social worker Edward Daffarn - whose prescient blogs on the perilous state of Grenfell foresaw the potential for tragedy.
Sir Martin said the TMO may have found Mr Daffarn's style ‘offensive' but said: ‘However irritating and inconvenient it may at times have found the complaints and demands of some of the residents of Grenfell Tower, for the TMO to have allowed the relationship to deteriorate to such an extent reflects a serious failure on its part to observe its basic responsibilities.'
And when the worst happened, the TMO was catastrophically ill-equipped to deal with it.
The report found its Emergency Plan for Grenfell Tower was out of date and incomplete and did not reflect the changes brought about by the refurbishment.
It also failed to collect crucial information about its vulnerable residents - plenty of who had mobility issues - to enable Personal Emergency Evacuation Plans (PEEPs) to be prepared.
It meant that on the night, information available to the TMO about who was in the building and their individual needs in the event of an evacuation was ‘incomplete'.
The council failed to ‘properly scrutinise' the design or choice of materials used in the refurbishment, and failed to satisfy itself that the building would comply with building regulations on completion of the work.
Grenfell Tower is pictured today as the long-running inquiry's second report is released
London Fire Brigade (LFB)
The first phase of the inquiry found the London Fire Brigade was plagued with ‘institutional failures' and its preparation for a Grenfell-style inferno was ‘gravely inadequate'.
And it said lives were probably lost because crews and 999 operators wasted ‘the best part of an hour' telling the block's occupants to ‘stay put' in their flats - before realising the blaze was wildly out of control.
Today's report added that the Lakanal House fire ‘should have alerted the LFB to the shortcomings in its ability to fight fires in high-rise buildings that revealed themselves once more at Grenfell Tower' eight years later.
Read More
Minute by terrifying minute, how the Grenfell disaster unfolded
The report identified that firefighters were unable to distinguish between different types of hydrant while tackling Grenfell, and that there was a lack of proper training in this area.
He also said that it was a ‘significant' shortcoming that LFB failed to recognise the possibility that in the event of a fire in a high-rise residential building, a large number of calls seeking help, both from within and outside the building, might be generated.
Sir Martin said: ‘The LFB failed to take any steps to enable it to respond effectively to that kind of demand.
‘As a result, when faced with a large number of calls about people needing to be reduced from Grenfell Tower, both those in the control room and those responsible for handling that information' at the scene were ‘forced to resort to various improvised methods of varying reliability to handle the large amount of information they received'.
He said those shortcomings ‘could have been made good if the LFB had been more effectively managed and led'.
Grenfell Tower
And the lengthy probe - launched in the immediate aftermath of the disaster in June 2017 by then-Prime Minister Theresa May - highlighted a series of missed opportunities involving the state, construction firms, and industry bodies.
Inquiry chairman Sir Martin Moore-Bick criticised the ‘dishonest' manufacturers responsible for Grenfell's exterior renovation a year before the fire, the ‘serious deficiencies' in building standards that allowed combustible material to be used in cladding on the side of the 24-storey tower, and the ‘indifference' to fire safety displayed by Grenfell's owner, the local council.
He surmised that the ‘path to disaster' was set in train by ‘decades of failure' in the state and corporate sector.
It resulted in the deaths of 72 men, women and children, including multiple generations of the same families, living in the 120-apartment tower, built in Kensington - one of London's richest areas.
The fire - the worst residential blaze since the Blitz - triggered mass protests about building standards, following months of concerns from Grenfell Tower residents about safety following its refurbishment.
The first report into what happened on the night itself, published in 2019, identified a litany of failures, including that the ‘principal reason' the flames shot up the building at such speed was the combustible cladding which acted as a ‘source of fuel' and actively helped spread the blaze.
And today's concluding report - a 1,600-page assessment of incompetence, indifference and dishonesty - again points to multiple missed opportunities to have possibly prevented the tragedy from ever happening.Your browser does not support iframes.
Smoke pours from the deadly fire at Grenfell Tower in West London in June 2017
Government
No one administration was to blame for state-level failures. Rather, successive governments - going back to the Tory premiership of the early 1990s, through the New Labour years, the Tory-Lib Dem coalition, and then to Mrs May's time in charge - failed to identify the risks posed by combustible cladding panels and insulation.
And there were plenty of warning signs.
In 1991, residents at Knowsley Heights in Liverpool escaped with their lives after their tower block caught fire. It had been covered in cladding during a renovation, which blazed when furniture dumped at the base of the building was set alight.
Read More
Grenfell Tower inquiry RECAP: Starmer apologises to families after damning report into deadly fire
An investigation later found the cladding was illegal.
In 1999, a fire swept through another high-rise block of flats in North Ayrshire, Scotland.
A man died and five others were injured, with witnesses reporting the cladding acting as an effective conductor for the blaze.
And in 2009, six people were killed at Lakanal House in Camberwell, south London, when cladding again caught fire and burned quickly.
The blaze was largely caused by botched and unsafe renovation work.
Even as recently as 2016 - around the time of the Grenfell revamp - the Department for Communities and Local Government was well aware of the risks of combustible cladding, but did not act.
Sir Martin said the Government ‘failed to heed the warning' of the Environment and Transport Select Committee in December 1999 - six months after the Ayrshire blaze - that it ‘should not take a serious fire in which people were killed before steps were taken to minimise the risks posed by some external cladding systems'.
Sir Martin said that in the years that followed the Lakanal House fire, ‘the Government's deregulatory agenda, enthusiastically supported by some junior ministers and the Secretary of State, dominated the department's thinking to such an extent that even matters affecting the safety of life were ignored, delayed or disregarded'.
He added: ‘Our investigations have revealed that some important recommendations affecting fire safety were ignored by the Government in the years leading up to the Grenfell Tower fire.'
The Grenfell Tower fire in West London in June 2017 left 72 people dead in a shocking tragedy
Department for Communities and Local Government (DCLG)
While part of central government, this department came in for particular criticism over the way it handled safety on the state-owned housing portfolio.
It said the DCLG ‘failed to pay due regard' to the striking results of a large-scale test in 2001 involving aluminium composite panels with unmodified polyethylene cores, which burned violently.
Read More
The 72 victims of the Grenfell Tower fire: From an unborn baby to grandmother-of six
And it did not take any steps either ‘to ascertain the extent to which panels of that kind were in use, or to warn the construction industry about the risks they posed'.
It failed to even publish the results of the damning test.
The department was made aware on many occasions that an old, antiquated product classification for facade products known as Class 0 was inappropriate, but allowed it to remain part of the statutory guidance until after the Grenfell Tower fire.
Sir Martin said: ‘It could and should have been removed years earlier.'
Between 2012 and 2017, the DCLG received numerous warnings about the risks involved in using polymeric insulation and aluminium composite panels with unmodified polyethylene cores.
However, despite what they knew, and the warnings it received from some quarters, the department - led by Eric Pickles - failed to amend or clarify the guidance on the construction of external walls.
The 72 victims of the Grenfell Tower fire in June 2017 are pictured as follows - (top row left to right) Mohammad Al-Haj Ali, Ya-Haddy Sisi Saye, also known as Khadija Saye, Anthony Disson, Khadija Khalloufi, Mary Mendy, Isaac Paulos, Sheila, Gloria Trevisan, Marco Gottardi, (second row left to right) Berkti Haftom, Ali Yarwar Jafari, Majorie Vital, Yahya Hashim, Hamid Kani, Jessica Urbano Ramirez, Zainab Deen, Nura Jemal, Jeremiah Deen, (third row left to right) Yasin El-Wahabi, Firdaws Hashim, Hashim Kedir, cara bermain di sensa138 Debbie Lamprell, Ernie Vital, Sakina Afrasehabi, Denis Mur-phy, Raymond "Moses" Bernard, Biruk Haftom, (fouth row left to right) Yaqub Hashim, Mehdi El-Wahabi, Ligaya Moore, Nur Huda El-Wahabi, Victoria King, Mo-hammed Amied Neda, Maria del Pilar Burton, Hesham Rahman, Gary Maunders, (fifth row left to right) Alexandra Atala, Vincent Chiejina, Steve Power, Rania Ibrahim, Fethia Hassan, Hania Hassan, Fathia Ahmed Elsanousi, Abufras Ibrahim (silhouette), Isra Ibrahim (silhouette), (sixth row left to right) Mariem Elgwahry, Eslah Elgwahry (sil-houette), Mohamednur Tuccu, Amal Ahmedin, Amaya Tuccu-Ahmedin, Amna Mahmud Idris, Abdeslam Sebbar (silhouette) , Joseph Daniels (silhouette), Logan Gomes, (seventh row left to right) Omar Belkadi, Farah Hamdan, Malak Belkadi (sil-houette), Leena Belkadi (silhouette), Abdulaziz El-Wahabi, Faouzia El-Wahabi, Fatemeh Afrasiabi, Kamru Miah, Rabeya Begum, (eighth row left to right) Mohammed Hamid, Mohammed Hanif, Husna Begum, Bassem Choukair, Nadia Choucair, Mierna Choucair, Fatima Choucair, Zainab Choucair and Sirria Choucair
Royal Borough of Kensington and Chelsea council (RBKC) and the Tenant Management Organisation (TMO)
Grenfell Tower was owned by the council, but run by the TMO - and so, of the two, it was the latter who were particularly singled out for criticism by the inquiry report.
Many of the tower's inhabitants were vulnerable due to reasons including health issues, while others were from low-income backgrounds.
Yet two separate reports identified the TMO demonstrated issues with staff attitudes, customer service, and a poor approach to carrying out repairs.
This context perhaps explains why one of arguably the greatest opportunities to prevent the tragedy from taking place was ignored.
Read More
Lord Eric Pickles to be slated over Grenfell disaster after delays to fire safety rules
The TMO regarded some of the residents as ‘militant troublemakers' led on by a handful of vocal activists, including social worker Edward Daffarn - whose prescient blogs on the perilous state of Grenfell foresaw the potential for tragedy.
Sir Martin said the TMO may have found Mr Daffarn's style ‘offensive' but said: ‘However irritating and inconvenient it may at times have found the complaints and demands of some of the residents of Grenfell Tower, for the TMO to have allowed the relationship to deteriorate to such an extent reflects a serious failure on its part to observe its basic responsibilities.'
And when the worst happened, the TMO was catastrophically ill-equipped to deal with it.
The report found its Emergency Plan for Grenfell Tower was out of date and incomplete and did not reflect the changes brought about by the refurbishment.
It also failed to collect crucial information about its vulnerable residents - plenty of who had mobility issues - to enable Personal Emergency Evacuation Plans (PEEPs) to be prepared.
It meant that on the night, information available to the TMO about who was in the building and their individual needs in the event of an evacuation was ‘incomplete'.
The council failed to ‘properly scrutinise' the design or choice of materials used in the refurbishment, and failed to satisfy itself that the building would comply with building regulations on completion of the work.
Grenfell Tower is pictured today as the long-running inquiry's second report is released
London Fire Brigade (LFB)
The first phase of the inquiry found the London Fire Brigade was plagued with ‘institutional failures' and its preparation for a Grenfell-style inferno was ‘gravely inadequate'.
And it said lives were probably lost because crews and 999 operators wasted ‘the best part of an hour' telling the block's occupants to ‘stay put' in their flats - before realising the blaze was wildly out of control.
Today's report added that the Lakanal House fire ‘should have alerted the LFB to the shortcomings in its ability to fight fires in high-rise buildings that revealed themselves once more at Grenfell Tower' eight years later.
Read More
Minute by terrifying minute, how the Grenfell disaster unfolded
The report identified that firefighters were unable to distinguish between different types of hydrant while tackling Grenfell, and that there was a lack of proper training in this area.
He also said that it was a ‘significant' shortcoming that LFB failed to recognise the possibility that in the event of a fire in a high-rise residential building, a large number of calls seeking help, both from within and outside the building, might be generated.
Sir Martin said: ‘The LFB failed to take any steps to enable it to respond effectively to that kind of demand.
‘As a result, when faced with a large number of calls about people needing to be reduced from Grenfell Tower, both those in the control room and those responsible for handling that information' at the scene were ‘forced to resort to various improvised methods of varying reliability to handle the large amount of information they received'.
He said those shortcomings ‘could have been made good if the LFB had been more effectively managed and led'.
Grenfell Tower