A scathing public inquiry report into the Grenfell Tower fire has concluded the 72 deaths lost in the tragedy were “all avoidable”.
Inquiry chairman Sir Martin Moore-Bick said those who lived in the 24-story west London tower “were badly failed over a number of years and in a number of different ways”. He laid out a web of failures that led to the 2017 tragedy.
Prime Minister Keir Starmer has vowed to carefully consider Sir Martin’s recommendations “to ensure that such a tragedy cannot occur again”. Grenfell United, which represents some of the families, said the report is a “significant chapter” in the years since the fire but said “justice has not been delivered” as they called for police and prosecutors to hold those responsible to account.
The long-running inquiry’s second and final report spans 1,700 pages and just over a million words long. Here are some of the key points.
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1. ‘Decades of failure’
The Grenfell Tower fire that claimed 72 lives was the result of “decades of failure” by those in power, the public inquiry has found.
In its landmark final report, the inquiry has laid bare how Government complacency and industry dishonesty led to the 2017 tragedy. It spreads blame across society from central to local government, the construction industry, the regulators, and fire and rescue services. Complacency, incompetence and dishonesty are terms that repeatedly come up in the inquiry’s report.
The report said: “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 buildings and to act on the information available to them.”
2. Residents faced ‘uncaring and bullying overlord’
Residents of the 24-story tower block faced an “uncaring and bullying overlord” as their warnings about fire safety were ignored by the local authority tenants’ organisation.
The council’s arm’s-length Tenant Management Organisation (TMO) failed to heed warnings from tenants about fire risks in the tower block. “Some, perhaps many, occupants of the tower regarded the TMO as an uncaring and bullying overlord that belittled and marginalised them, regarded them as a nuisance, or worse, and failed to take their concerns seriously,” the report found.
3. People who warned of tragedy viewed as ‘militant troublemakers’
The TMO also regarded some residents as “militant troublemakers led on by a handful of vocal activists”. The report in particular mentioned how the TMO found Edward Daffarn’s style “offensive”. The now campaigner, who escaped from his 16th floor flat during the blaze, has previously said he was treated with “contempt” after raising multiple complaints about fire safety ahead of the tragedy.
“The TMO lost sight of the fact that the residents were people who depended on it for a safe and decent home and the privacy and dignity that a home should provide,” the inquiry said. “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.”
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4. Fire assessor for tower block ‘invented’ qualifications
The inquiry also revealed the TMO’s incomplete fire safety provisions. The report found the TMO’s only fire assessor was “allowed to drift into that role without any formal selection or procurement process”.
Carl Stokes was found to have misrepresented his experience and even “invented” qualifications, making him “ill-qualified to carry out fire risk assessments on buildings of the size and complexity of Grenfell Tower”. Concerns were even expressed by the London Fire Brigade “his competence” but the TMO “continued to rely uncritically on him”, the inquiry said.
5. ‘Systematic dishonesty’ from cladding firms
Construction manufacturers were found guilty of “systematic dishonesty”, with firms having “deliberately concealed” information about the dangers of its cladding products.
The inquiry had previously concluded that the cladding installed on the Grenfell Tower was the “primary cause” of the fire spread. Kingspan, whose insulation products were used in Grenfell, was found to have “cynically exploited the industry’s lack of detailed knowledge” about cladding tests and classifications. It “knowingly” misled the market over its K15 product, making “false” claims about safety tests. Tests it undertook in 2007 and 2008 were “disastrous” yet Kingspan failed to withdraw the product from markets.
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Manufacturer Arconic was found to have “deliberately concealed” from the market “the true extent of the danger” of its Reynobond 55 cladding in cassette form. By summer 2011, the firm knew using the product in cassette form, as opposed to riveted form, “performed much worse in a fire and was considerably more dangerous” than in riveted form” but was “determined to exploit what it saw as weak regulatory regimes in certain countries (including the UK) to sell it in cassette form “including for use on residential buildings”.
Insulation manufacturer Celotex was also found to have “embarked on a dishonest scheme to mislead its customers and the wider market” in an attempt to break into a market which had been dominated by Kingspan.
6. Government was ‘complacent’ on warnings’
In a scathing conclusion, Inquiry chairman Sir Martin Moore-Bick’s report found the Government received “numerous warnings” about cladding risks over years – and yet failed to take them. The Department for Communities and Local Government was found to have “displayed a complacent and at times defensive attitude to matters affecting fire safety”.
The report referenced the fire at Knowsley Heights in 1991, Britain’s first high-rise cladding fire in Liverpool, saying: “There were many opportunities for the Government to identify the risks posed by the use of combustible cladding panels and insulation, particularly to high-rise buildings, and to take action in relation to them. Indeed, by 2016 the department was well aware of those risks, but failed to act on what it knew.”
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7. Cabinet minister’s evidence rejected by inquiry
Lord Pickles, who served as Communities Secretary between 2010 and 2015, was the target of personal criticism in the report. In an extraordinary conclusion, the inquiry was “unable to accept” part of his evidence after it was “flatly contradicted” by his officials and other documents from the time.
Lord Pickles, who served under a David Cameron government that was tearing up red tape, told the inquiry it was “ludicrous” if officials believed deregulation applied to building regulations. Yet the final report has rejected this instead finding that officials were under “pressure because of the policy of deregulation” and were “inhibited” from advising ministers on the issue. Lord Pickles was criticised during the inquiry when he confused Grenfell’s death toll with the number of those who died in the Hillsborough disaster during his evidence session.
8. Council boss was ‘unduly concerned’ about reputation
At a local level, the Royal Borough of Kensington and Chelsea (RBKC) was also heavily criticised in the report. Its chief executive, Nicholas Holdgate, was found to have been “unduly concerned for RBKC’s reputation” and had “no clear plan” in the aftermath of the fire.
“RBKC’s chief executive, Nicholas Holdgate, was not capable of taking effective control of the situation and mobilising support of the right kind without delay,” the inquiry said. “He had no clear plan and did not receive all the information needed… He was reluctant to take advice from those with greater experience and was unduly concerned for RBKC’s reputation.”
Local voluntary and community organisations are the ones who emerge from the event “with the greatest credit”, the report said.
9. Racial discrimination during aftermath
The inquiry acknowledged that it was not within its remit to assess how it came to be that a disproportionate number of disadvantaged and ethnic minorities were affected by the disaster.
But it did identify “evidence of racial discrimination” in the treatment of the survivors in the days after the fire, such as a lack of effort to cater to Muslims observing Ramadan. “Certain aspects of the response demonstrated a marked lack of respect for human decency and dignity and left many of those immediately affected feeling abandoned by authority and utterly helpless,” it said.
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10. Absence of prosecutions glaring
A key limitation of the report is that the Inquiries Act 2005 “expressly prohibits us from ruling on questions of legal liability, civil or criminal”. After the report’s release, bereaved and survivors of the Grenfell Tower fire said the inquiry’s final damning report shows they were “failed by calculated dishonesty and greed”.
But Grenfell United said “justice has not been delivered” as they restated their call for police and prosecutors to “ensure that those who are truly responsible are held to account and brought to justice”.
Frank Ferguson, head of the Crown Prosecution Service’s special crime and counter-terrorism division, said they “do not expect to be in a position to make any charging decisions until the end of 2026”.
“We have been working closely with the Metropolitan Police Service throughout their investigation and will therefore be in a strong position to review the completed evidential file, which they anticipate will be passed to us in 2026,” he said. “Our team of specialist prosecutors will then carefully review the file… Due to the sheer volume of evidence and complexity of the investigation, we will need to take the necessary time to thoroughly evaluate the evidence before providing final charging decisions.”
Timeline of events since the Grenfell Tower fire
June 14 2017: At 12.54am, a call is made to the London Fire Brigade reporting a fire has broken out in a fourth-floor flat. Barely half an hour later, at 1.29am, flames had climbed to the top floor of the 24-storey block.
June 28 2017: Then PM-Theresa May appoints retired Court of Appeal judge Sir Martin Moore-Bick to lead a public inquiry into the disaster.
September 19 2017: The Metropolitan Police announce a widening of their criminal investigation, as detectives consider individual as well as corporate manslaughter charges.
January 29 2018: Maria del Pilar Burton, a 74-year-old survivor known as Pily, dies in palliative care. She had been in a care home, unable to return to her husband Nicholas, since the fire. She comes to be considered the 72nd victim of the fire.
May 17 2018: Dame Judith Hackitt, who was asked to carry out an independent review into building regulations, recommends “fundamental reform” to improve fire safety. Ministers promise to consult on banning flammable cladding.
June 4 2018: Sir Martin’s inquiry begins hearing opening statements from lawyers and a batch of expert reports are released.
June 21 2018: Firefighter evidence begins. It ends with then London Fire Brigade commissioner Dany Cotton telling the inquiry she would change nothing about her team’s response on the night of the fire. Survivors and the bereaved react with anger.
September 30 2018: The Government bans the use of combustible cladding on all new residential buildings above 18 metres, as well as schools, care homes, student accommodation and hospitals.
October 3 2018: Survivors, those who lost family in the fire and local residents begin giving evidence at the inquiry, with the first phase of the inquiry coming to a close the following month.
June 10 2019: Met Police Commander Stuart Cundy says there is no guarantee criminal damages will be brought over the fire.
June 18 2019: Survivors and bereaved families project a message on to the Houses of Parliament reading: “Two years after Grenfell, this building still hasn’t kept its promises #DemandChange.”
July 18 2019: A Commons Housing, Communities and Local Government Committee report accuses the Government of “not doing enough” to remove dangerous cladding from buildings, more than two years on from the blaze.
October 30 2019: The inquiry’s phase one report is published and concludes that the principal reason the flames shot up the building so quickly was the combustible aluminium composite material (ACM) cladding with polyethylene core which acted as a “source of fuel”. It also finds the London Fire Brigade (LFB)’s preparation for a tower block fire such as Grenfell was “gravely inadequate”.
November 6 2019: Jacob Rees-Mogg apologises for suggesting Grenfell victims should have used “common sense” and ignored fire service guidance not to leave the burning tower block.
March 11 2020: Then Chancellor Rishi Sunak announces a £1billion fund to remove unsafe cladding from high-rise residential buildings.
April 28 2020: Remediation work to address unsafe cladding on high-rise residential blocks pauses “on as many as 60% of sites” after the Covid-19 outbreak, then communities secretary Robert Jenrick says.
November 17 2020: Robert Jenrick said he hopes dangerous cladding like that used on the outside of Grenfell Tower will be removed from the majority of other buildings by the end of the year
April 29 2021: Campaigners condemn the Government’s “indefensible” Fire Safety Bill, which will become law and leave hundreds of thousands of leaseholders paying to remove dangerous cladding from their buildings.
October 27 2021: The Government decides to charge property developers with profits of more than £25million a levy, to raise the £5billion fund to remove unsafe cladding, at a rate of 4%.
November 8 2021: Newly-appointed Housing Secretary Michael Gove says the Government “failed people at Grenfell” and did not always appreciate the importance of fire safety, in his first address to MPs in the role.
January 7-10 2022: Michael Gove says thousands of flat owners living in buildings taller than 11 metres will be spared the cost of removing dangerous cladding, and says developers must agree to a plan to fix it.
January 27 2022: The Grenfell Tower Inquiry enters Phase 2, which is investigating how the building came to be in a condition which allowed the fire to spread so quickly.
July 2023: The long-awaited Social Housing (Regulation) Act passes into law, including a requirement for social housing managers to have professional qualifications – a measure which had been called for by campaign group Grenfell United.
May 2024: Police confirm bereaved families and survivors face waiting until the end of 2026 for a decision on potential criminal charges over the fire. It means any convictions would likely follow the year after.
June 14 2024: On the seventh anniversary of the fire, campaigners from the infected blood scandal and the Covid Bereaved group join for the memorial walk.
August 26 2024: A non-fatal fire at a block of flats in east London which had been undergoing work to have cladding removed prompts fierce criticism of the slow pace of remediation works on dangerous buildings.
September 4 2024: The inquiry’s final report is published.