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The final report into the fire that killed 72 people in 2017 says that it is not possible to identify one single cause of the tragedy and does not apportion blame, instead it sets out the ‘systematic dishonesty’ of the contractors involved in the refurbishment of the tower and ‘the decades of failure’ by government and other organisations to take fire safety seriously.
In a report that spans seven volumes and is over four inches thick, the Grenfell Tower Inquiry has published the findings of a process that took over four years, involving hundreds of witnesses and lays bare the enormity and complexity of how it was possible for a fire in a high rise building to lead to the largest loss of life since the second world war.
Sir Martin Moore-Bick chaired the public inquiry that published its first report in December 2019 with 46 recommendations levelled at London Fire Brigade, the fire and rescue service and government. The second report focuses on the circumstances that led to the fire on 14 June 2017.
‘We conclude that the fire at Grenfell Tower 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 seven volume report says that the government was ‘well aware of’ the risks of cladding ‘but failed to act on what it knew,’ referring to reports and fires going back many years. It criticises the government for allowing fire safety elements of the building regulations ‘to remain in the hands of one relatively junior official’ adding that the department with oversight for this area was ‘poorly run.’
This explains why one of the report’s 58 recommendations is that all aspects of fire safety should come under one government department, a return to the pre 2016 position when building regulations and fire policy both came under a single Secretary of State.
‘One very significant reason why Grenfell Tower came to be clad in combustible materials was systematic dishonesty on the part of those who made and sold the rainscreen cladding panels and insulation products.’
Two firms, Arconic and Kingspan, took advantage of the ‘incompetence’ of the certification bodies, with the report adding that local authority building control ‘was the victim of the dishonest behaviour on the part of unscrupulous manufacturers.’ The BRE is accused of being complicit in the strategies that manipulated the testing process.
Kingspan, the manufacturer of insulation products ‘knowingly created a false market in insulation for use on buildings over 18m’ with the other supplier of insulation, Celotext said to have ’embarked on a dishonest scheme to mislead its customers and the wider market.’
The report says that the refurbishment prime contractor, Rydon, had a ‘casual attitude’ and used an inexperienced team who gave ‘inadequate thought’ to fire safety. The system, the report says, was complex and fragmented and it is this that allowed the dishonesty to thrive.
‘The choice of combustible materials for the cladding of Grenfell Tower resulted from a series of errors caused by the incompetence of organisations and individuals involved in the refurbishment.’
The tenant management organisation, the TMO, commissioned the refurbishment of the tower and the report says it must take its share of the blame for the disaster, failing to take ‘sufficient care’ in its choice of architect to oversee the process.
Fire service scrutiny
While the London Fire Brigade came under intense scrutiny about its response to the fire as part of the first phase of the Inquiry, it also features heavily in this report which steps through the years leading up to the fire and how fire safety was treated by the Brigade’s management. Having already been the subject of many recommendations in the first report, the Brigade will now have to deal with new ones, including another inspection from HMICFRS focused on the control room, the training of incident commanders and how carries out 7(2)(d) inspections of risk.
In a broader discussion about the fire and rescue service, the report makes recommendations about use of fireground radios, hydrant inspection, standards for lift keys for firefighters and tactics for operational discretion. Returning to the proposal for a College of Fire that was discussed in the Fire White Paper published under the last government, the Inquiry urges that this should be created immediately and be independent of government.
More widely, the report commends the importance of the fire engineering profession to the extent that it recommends the profession of fire engineer should be recognised and protected by law and an independent body established to regulate the profession, define standards, maintain a register of members and regulate their conduct. And then, it adds, the government should increase number of masters level courses in fire engineering and have them accredited by that regulator.
Sir Martin also recommends that the government establish a national mechanism for recording and monitoring recommendations from inquiries like this one to ensure there is a public record and a parliamentary scrutiny process for scrutiny about progress.
The Crown Prosecution Service said that they did not expect criminal charges to be brought before the end of 2026.
The full report can be found on the Grenfell Tower Inquiry website.
Read more about the lead up to the fire in our review of the 10-part BBC Radio 4 programme, Grenfell: Building a Disaster.
