Grenfell Tower fire that killed 72 was result of decades of institutional failings, damning final report finds

All 72 deaths caused by the devastating fire were avoidable, the damning report found, as cladding manufacturers engaged in ‘systematic dishonesty’ and hid the true danger of their products while successive governments failed to act on warnings

The tragic fire at Grenfell Tower that claimed the lives of 72 people was the culmination of decades of failure by successive governments and the construction industry, a damning final report has found.

The west London tower block was covered in combustible products because of the “systematic dishonesty” of firms who made and sold the cladding and insulation, inquiry chairman Sir Martin Moore-Bick said on Wednesday.

He called out “deliberate and sustained” manipulation of fire-safety testing, misrepresentation of test data and misleading of the market.

Disaster struck in the early hours of 1am on 14 June 2017, with flames ripping through the 24-storey tower block and residents fatally told to stay put in their flats, until it was too late.

The fire initially broke out as a result of a faulty fridge, but became the worst structural fire in Britain since the Blitz, with survivor groups saying that those involved have “blood on their hands”. All 72 deaths were avoidable, the report concluded.

The fire at Grenfell Tower was the result of ‘decades of failure’, a report has found (Natalie Oxford/AFP via Getty Ima)

Key findings of the 1,700 page report include:

• All 72 deaths were avoidable and the people who lived there were “badly failed” by authorities and the construction industry through incompetence, dishonesty and greed.
• Successive governments under David Cameron and Theresa May had received numerous warnings about the dangers of certain cladding materials between 2012 and 2017 but had failed to take heed. 
• There had been a “deliberate and sustained” manipulation of fire-safety testing and data by a number of companies such as Arconic and insulation firms Kingspan and Celotex.
• Emergency accommodation plans were “inconsistent”, with families crammed into one room and residents left sleeping in cars or on the grass.
• The response of the government and local council was “muddled, slow, indecisive and piecemeal”, with little done to cater to people from diverse backgrounds, such as providing halal food for Muslims observing Ramadan.
• There had been a “persistent indifference” to fire safety at Grenfell Tower with no finalised evacuation plan. 

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The 72 victims of the Grenfell fire. Not all of the families have shared images (PA) (PA Media)

All of the victims of the Grenfell Tower disaster whose bodies were destroyed by fire were dead or unconscious by the time the flames reached them, the inquiry found.

Grenfell United, which represents some of the bereaved and survivors of the fire, have now demanded that some of the construction firms involved should be banned from government contracts.

Prime Minister Sir Keir Starmer said the seven-volume report identified “substantial and widespread failings” and the Government will carefully consider the report and its recommendations “to ensure that such a tragedy cannot occur again”.

In a statement to Parliament after PMQs, he said the government would write to all companies found by the inquiry to be part of the “horrific failings” at Grenfell Tower “as the first step to stopping them being awarded government contracts”.

Grenfell United have called for construction companies involved to be banned from government contracts (Getty)

Meanwhile, Baroness Theresa May of Maidenhead, who was prime minister at the time of the disaster, said national and local government, regulators and industry “must all acknowledge their part in the history and series of events that led to this tragedy”.

The inquiry found that by 2016, a year before the Grenfell fire, the government was “well aware” of the risks of using combustible cladding panels and insulation, particularly in high-rise buildings, “but failed to act on what it knew”.

Over 800 people were left homeless as a result, with the Royal Borough of Kensington and Chelsea (RBKC) council’s leadership “wholly inadequate” to deal with the scale of the tragedy, leaving many to feel abandoned and helpless.

Families who had lost all their belongings were made to wait days to be allocated emergency accommodation in hotels, with little consideration to groups with particular needs, with one pregnant woman forced to sleep on the floor.

Survivors and local residents holding photographs of their missing or deceased loved ones

The second part of the inquiry, which began in November 2022, heard from a number of survivors who recalled “absolute chaos and confusion everywhere”, with the scene compared to a horror film or akin to a warzone.

One witness, Karim Mussilhy, said he had expected to see people in authority with high-visibility jackets, but saw no one, with little information available from RBKC in the immediate aftermath.

Many survivors and local residents slept in their cars, while others waited for hours for buses that they had been told would take them to a rest centre, but instead they were made to walk during the early hours to centres that had spontaneously opened nearby.

Residents from ‘The Walkways’, a number of low-rise buildings adjoining Grenfell Tower, were left wandering the estate throughout the early hours of the morning, while the allocation of accommodation was “confused and inconsistent”.

Survivors were left wandering the estate for hours before being allocated emergency accommodation (AFP via Getty Images)

One resident described feeling like “cattle just coming through”, with interviews lacking in sensitivity and several survivors left distressed after being placed in high-rise rooms.

“The picture we saw was that of a vulnerable group of people facing not only the shock, grief and trauma of the fire itself but also, as an immediate priority, the need to satisfy the most basic of their daily needs. Survivors described it as living in limbo, with no space to heal,” the report said.

Meanwhile, the RBKC’s chief executive Nicholas Holgate, who acted as gold commander for the council’s response, had no clear plan and was “unduly concerned” for the council’s reputation. Mr Holgate has previously come under criticism for failing to hand over command to a London-wide group with more expertise until two days after the fatal fire.

The Prime Minister said the report had identified widespread failings (Lucy North/PA) (PA Wire)

A toxic relationship characterised by “distrust, dislike, personal antagonism and anger” was found to have existed between the residents and the Tenants Management Organisation (TMO) since 2011, with occupants of Grenfell viewing the management as an “uncaring and bullying overlord”.

It was found that the TMO had failed to disclose to the local council the outcome of an independent and highly critical report on fire safety in 2013, and no fire strategy had been finalised for the tower, despite a consultant recommending this in 2009.

Meanwhile, the London Fire Brigade was found to have failed to provide suitable training to their control operators on handling the magnitude of calls, causing confusion at the scene.

Survivor groups and family members have said that companies involved have ‘blood on their hands’ (Flavio Valle)

The organisation had failed to realise its shortcomings during the fatal Lakanal House fire in 2009, in which six people died in Camberwell, and suffered from a “chronic lack of effective management and leadership, combined with an undue emphasis on process”.

The report into phase one, which was published in October 2019, concluded that the tower’s cladding had not complied with building regulations and was the principal reason for the rapid spread of the blaze.

Inquiry chairman Sir Martin Moore-Bick and two other panel members have now found that “unscrupulous manufacturers” had engaged in deliberate and sustained strategies to manipulate testing processes, misrepresent data and mislead the market.

This included the firm Arconic Architectural Products who sold rainscreen panels in the external wall, and “deliberately concealed” the dangers of their product from 2005 until after the Grenfell fire.

Britain Grenfell Fire (Copyright 2019 The Associated Press. All rights reserved)

Other companies such as Kingspan, which provided insulation, had not withdrawn their product from the market despite “disastrous” tests in 2007 and 2008, and their own concern about its fire performance.

The building products company has already apologised for “process and conduct shortcomings” identified during the inquiry.

Setting out 58 recommendations, Sir Martin concluded that the construction industry had become “too complex and fragmented”, and suggested a single regulator should be put in place to be responsible for regulation of construction products, testing and certification.

In response, the group Grenfell United said: “Today marks the conclusion of a painful six years listening to the evidence of the deaths of 54 adults and 18 children, our loved ones, neighbours and friends. It is a significant chapter in the journey to truth, justice and change. But justice has not been delivered.

“The inquiry report reveals that whenever there’s a clash between corporate interest and public safety, governments have done everything they can to avoid their responsibilities to keep people safe. The system isn’t broken, it was built this way.”

It took 24 hours for firefighters to extinguish the blaze (Copyright 2017 The Associated Press. All rights reserved.)

In May, the Metropolitan Police said their investigators need until the end of 2025 to finalise their inquiry, and prosecutors will then need a year to decide whether charges can be brought.

Bereaved and survivors have described that wait, which could stretch to a decade after the catastrophic fire, as “unbearable”.

The report comes just over a week after a major fire in east London at a block which had been undergoing work to have cladding removed as a result of what happened at Grenfell.

The non-fatal Dagenham blaze, coming so many years after the 2017 fire, prompted fierce criticism from various quarters including bereaved and survivors group Grenfell United, which said it showed the “painfully slow progress of remediation across the country, and a lack of urgency for building safety as a whole”.