Grenfell Tower Inquiry: Phase 1 Report

Baroness Finlay of Llandaff Excerpts

Thursday 31st October 2019 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, the report makes deeply harrowing reading. Memories of the terrible hell of that night and the awful pain of loss are bound to be worsened by the thoughts of “if only” and “what if”. Of course, people are seeking who to blame, but reading the report one senses that a web of failures resulted in disaster, against which incredibly brave humans at many levels risked their lives to try to save others. They now live, day in and day out, haunted by the harsh fact of so many deaths.

From the outset, the noble Lord, Lord Bourne, has done all he could to keep this House updated with unfailing sensitivity. From all Benches, we owe him a debt of gratitude.

In my few minutes, I shall focus on the trigger-point for evacuation. The communications failure seemed to be at many levels, from equipment not working, the way to how calls were handled, where the gas should be in such buildings and, crucially, how survivors were collated and supported immediately and in the long-term.

At the core is the decision to stay put rather than evacuate. As soon as fire gets hold, the risk of rapid spread rises so fast that there seems no reason to avoid immediate evacuation. Sir Martin’s powerful report states:

“The evidence taken as a whole strongly suggests that the ‘stay put’ concept had become an article of faith within the LFB so powerful that to depart from it was to all intents and purposes unthinkable”.


That the commissioner had to ask the rhetorical question, “It is all very well saying, ‘Get everybody out’, but then how do you get them all out?”, emphasises that the London Fire Brigade was inadequately prepared, trained and equipped to lead a total evacuation of such a building. People have to practise evacuation. Should we return to timed fire practice for all buildings where people are grouped together, whether residing, working or studying?

The report refers to the need to have instructions in languages other than English. If you make people do something, they will remember it, but if you hand them a leaflet written in their own language or give them a drawing or cartoon, they will remember it only in part, if at all. Is every first responder in the country now required to stress-test their major incident emergency procedures to the limit and beyond in order to prepare them for dealing with the unthinkable, so that back-up systems are active?

The trigger-point for recognising Grenfell as a major incident and the point at which to evacuate seemed to be remarkably slow, as if protocols were taking precedence over professional, collated judgments. That may be because the information was not being collated rapidly due to the communications failures, but it was terrible to read that some of the same errors were made as those that had occurred in the Lakanal House fire. Let us not forget that failures in communication also hampered rescue efforts in the London Underground bombings.

On the 999 calls coming in, it was not just the number but the rate of calls that should have alerted people that something quite remarkably dangerous and awful was going on. Are 999 call handlers now undergoing thorough stress testing in order to cope with the unthinkable? Communication between those on the ground and people in the control room was inadequate. The military organisation that one would expect was seriously lacking. There was also a lack of compatibility between the systems used. I would ask the Minister whether we are moving towards a national system, with an additional national back-up system, if the first one fails. If the communication systems do not work, everything falls apart.

Sir Martin cites the watch manager, who lacked critical information from the control room, which meant that he was doubly blind to what was unfolding. A relatively junior fire officer had,

“little or no support from more senior officers”,

and was let down by institutional failings. As the report states:

“The behaviour of the fire was outside his experience and nothing he had done appeared to be having any effect. He was at a loss to understand what was happening or to know how to respond”.


When that happens, is it not by definition serious, if not major?

The co-ordination of emergency services was lamentably slow. This lack of communication marked a serious failure to comply with the joint working arrangements and protocols designed for major emergencies in London. The failure to share declarations of a major incident meant that the need for a properly co-ordinated joint response was delayed, conversations that should have happened did not, and there was no single point of contact.

In his opening remarks, the noble Lord, Lord Bourne, eloquently invited us to change behaviours. Will the Government now undertake to amend the JESIP Joint Doctrine to make clear that each emergency service must communicate the declaration of a major incident to all other category 1 responders as soon as possible?

I also wonder about gas in high-rise buildings. While it was not directly implicated, should we be pushing towards the use of electricity in all such buildings, along with trip-switches in place if they overheat or surge?

Perhaps the most worrying aspect relates to the survivors themselves. People had difficulty in establishing the whereabouts of friends and relatives who may have been taken to hospital after escaping from the building. They had no idea where they were and did not know how to contact them. We are meant to see a Metropolitan Police casualty bureau, but we need such bureaux to be set up across the country to establish the identity and whereabouts of people and to provide a central point of contact for gathering and distributing information about individuals who have been or may still be involved in an incident. No register of building occupants will ever be up to date, but there must be rapid contemporaneous information gathering. People were left for days and weeks desperate to know the fate of their nearest.

It has been estimated that more than 11,000 people have been directly affected by Grenfell, so we must take forward the lessons learned. I suggest that we return to this issue year on year for at least five years in order to keep it in our sights. We owe it to Grenfell United.