1. Many were at fault for the disaster
The fire “was the culmination of decades of failure by central government and other bodies in positions of responsibility in the construction industry to look carefully into the danger of incorporating combustible materials into the external walls of high rise residential building and to act on the information available to them”.
The report says the architects Studio E, the builders Rydon and Harley Facades, and the Royal Borough of Kensington and Chelsea’s building control department all bear responsibility for the fire.
Arconic, the US corporation that supplied the plastic-filled cladding panels that were the main cause of fire spread, Celotex, which made most of the combustible foam insulation, and Kingspan, which made a small proportion of the insulation, were strongly criticised.
2. The landlord’s role
The Kensington and Chelsea Tenant Management Organisation was directly in charge of the refurbishment. It was appointed by the Royal Borough of Kensington and Chelsea to run its council housing stock. Its chief executive, Robert Black, established a “pattern of concealment … in relation to fire safety matters” and the TMO “treated the demands of managing fire safety as an inconvenience”. The inquiry established that the landlord’s “initial motive for cladding Grenfell Tower was to improve its physical appearance and to prevent it looking like a poor relation” to a building next door. Any suggestion it was to improve energy efficiency came later. The inquiry detailed a relentless focus on cost.
3. The ‘rebel residents’
There was particular conflict with Ed Daffarn, a resident organiser who was described by the inquiry as “an intelligent, articulate and motivated individual”. Daffarn had questioned the appointment of the architect and ran a blog that vigorously challenged what he and others saw as a failing landlord body.
“His language and approach in his dealings with the TMO caused resentment among its staff,” the inquiry found. “One thing is clear, however: those in the TMO who were responsible for managing the refurbishment were nervous of him and allowed him to become a barrier to proper communication with the rest of the community.”
The inquiry suggested a more conciliatory approach by Daffarn “might have been reciprocated” but the TMO “ought to have reacted less defensively”.
4. The dead and the survivors ‘living in limbo’
The report talked about the “long-lasting trauma” of survivors, the bereaved and those evacuated from nearby homes “whose lives have been changed forever”. The inquiry provides a detailed account of the circumstances in which each person died, mostly on the upper floors trying in vain to escape the smoke and flames. There are short biographies of each victim and it reminds us that three fell from the building.
The panel said the survivors were “comprehensively failed” and “left to fend for themselves”. It said they were “abandoned” without information in the wake of the fire, adding that the scene had been described as a “horror film” and “war zone”. Those looking for loved ones experienced feelings of “utter helplessness and despair”.
In many cases, the Royal Borough of Kensington and Chelsea failed to provide adequate emergency accommodation. The arrangements for obtaining food at some hotels made some people “feel like refugees”.
“Survivors described it as living in a limbo, with no space to heal,” the panel said.
5. Independent testing failures
The Building Research Establishment, a now-privatised former government facility that runs full-scale fire tests, was involved in checking the insulation provided by Celotex and Kingspan. But the inquiry concluded its work on fire-testing walls had been “marred by unprofessional conduct, inadequate practices, a lack of effective oversight, poor reporting and a lack of scientific rigour”.
Its weaknesses “exposed it to the risk of manipulation by unscrupulous product manufacturers”, the inquiry found.
6. The response from accused organisations
So far Arconic has said it rejects any claim it sold an unsafe product and said it was legal for sale in the UK. It said it “regularly conducted tests of its materials using third-party testing bodies and that reports on these results were all publicly available” and made these reports available to its customers.
It said it “did not conceal information from or mislead any certification body, customer, or the public”.
7. Delays impacting the inquiry
The public inquiry took evidence over 400 days, spanning seven years. It was interrupted by the Covid-19 pandemic, faced a refusal by witnesses from the cladding company Arconic to attend, and uncovered a “merry-go-round of buckpassing” among about 35 companies and organisations involved. In the end the inquiry had to contact 250 people who faced criticism who needed to be informed in advance of the final conclusions, causing a delay. The process has cost the taxpayer at least £200m.
8. Misleading test certificates
The inquiry said the fact that Arconic, Kingspan and Celotex “were able to obtain misleading certificates relating to their products is evidence of a serious failure of the system and points to a need for a different approach for the certification of construction products”.
It wants a construction regulator to be responsible for assessing the conformity of construction products with laws, regulations and industry norms and to issue certificates so the same thing cannot happen again.
9. The state of regulations
One of the reasons the Grenfell disaster happened was that the building regulations were unclear. But Sir Martin Moore-Bick, the inquiry chair, said the guidance on how to meet the fire section of the regulations still did not provide “the information needed to design buildings that are safe in fire”. The inquiry panel said this guidance “needs to be reviewed … and amended annually or promptly”.
10. Next steps
The government will have to respond to the recommendations made by Moore-Bick and the inquiry panel to prevent a repeat of the disaster. Bereaved, survivors and residents want a guarantee they will be followed up. Amajor police inquiry is under way with potential crimes under investigation including corporate manslaughter, fraud and misconduct in public office. Any trials are not expected until at least 2027.