Grenfell Tower Inquiry Report

Lord Carter of Haslemere Excerpts

Friday 22nd November 2024 Lords Chamber

[Lord Carter of Haslemere (CB)]

My Lords, I declare an interest, as I played a role, as general counsel in No 10, in assisting Cabinet Office officials in setting up the Grenfell inquiry.

Sir Martin’s report is withering in its criticisms of almost everyone who could have prevented but failed to prevent a tragedy like this, and he makes many essential recommendations on how to stop it happening again. There must, and will, be accountability for the manufacturers, designers, contractors, developers, regulators, et cetera. The inquiry’s findings of systemic dishonesty and incompetence speak for themselves, and I understand that criminal investigations may be afoot.

My focus today, however, is not on the private sector but on the question of why successive Governments were not legally required to take effective preventive measures after previous high-rise block fires, and especially after the coroner’s detailed report on the prevention of future deaths following the Lakanal House tragedy. This raises a wider public law issue for the Government, as the noble Baroness, Lady Sanderson, touched on, since these prevention of future deaths reports arise in a multitude of different contexts. Each one records a real tragedy leading to one or more deaths, with invaluable lessons to be learned for the future on how to prevent such deaths. The tragedy of Grenfell is a shocking illustration of what can happen when lessons are not learned from these reports.

As we know, Grenfell was not the first high-rise block of flats to catch fire. In 1991, there was a fire at the 11-storey Knowsley Heights in Merseyside. By the time firefighters arrived, the entire external wall of the 11-storey building was alight, with flames coming out of windows and from the roof. New but combustible cladding had been installed three years earlier, as part of a pilot scheme intended to improve the appearance of high-rise blocks. To anyone who has read the Grenfell inquiry report, this sounds awfully familiar. Although no one died at Knowsley Heights when the cladding caught fire, the Grenfell public inquiry found that the Knowsley Heights fire “laid the ground” for the 2017 Grenfell Tower tragedy.

But before that, we must come to Lakanal House. The 14-storey Lakanal House caught fire in 2009 and six people died, including three children. The resulting inquest found that the fire spread because of combustible cladding on the building. The coroner made a prevention of future deaths report on 28 March 2013 to the Secretary of State for Communities and Local Government. She recommended that the department review Approved Document B to ensure that it provided clear guidance, giving, as she said, particular regard to the spread of fire over the external envelope of the building. She also recommended that it be drafted in such a way as to be intelligible to everybody engaged in construction, maintenance and refurbishment of buildings, and not just to professionals who may already have a depth of knowledge of building regulations and building control. Finally, she recommended that encouragement be given to providers of high-rise accommodation to consider the retrofitting of sprinklers, and that guidance be given to residents on when to stay and when to “get out and stay out”.

Officials in the Department for Communities and Local Government gave the Secretary of State a draft letter to send in response. After internal discussion, it was sent by the Secretary of State on 20th May 2013; the details are in the inquiry report. It is easy with hindsight to criticise it, but this is what public inquiries are for, and the Grenfell inquiry found that it was an inadequate response.

The coroner’s prevention of future deaths report had provided a golden opportunity to consider whether the construction industry understood or applied the regulations and guidance, especially in respect of tall buildings with external walls containing combustible materials. But the inquiry found that the coroner’s recommendations were not treated with any sense of urgency and officials did not explain clearly to the Secretary of State what steps were required to comply with them. The department therefore failed to learn the lessons, which were there for all to see in the prevention of future deaths report, about the inadequacy of the regulatory regime itself, so dominated was it by the Government’s deregulatory agenda.

The omens were not therefore promising for the Grenfell Tower renovation in 2016. The Royal Borough of Kensington and Chelsea and the tenant management organisation for Grenfell established value for money and appearance, not safety, as the key drivers for the project. So, the cheapest cladding option was chosen: aluminium composite material with unmodified polyethylene cores. The various regulators involved, which approved, certified, inspected and otherwise accredited the cladding, were allowed to act without sufficient vigour and competence—and that is putting it mildly. This was in no small part because of the failure of the Department for Communities and Local Government properly to implement the recommendations of the prevention of future deaths report following Lakanal House, especially concerning the need to provide clear guidance in Approved Document B on the risks of fire spreading over the external envelope of the building.

What exactly are prevention of future deaths reports? Regulation 28 reports, as they are now known, are made under the Coroners and Justice Act 2009. A coroner has a duty to make such a report where circumstances exist which create a risk that future deaths will occur and, in the coroner’s opinion, action should be taken to prevent such an occurrence. It is not for the coroner to identify the remedial action. It is for the person responding to a report to set out details of any action which it is proposed will be taken and to set a timetable for that action; otherwise, the response must explain why no action is proposed.

There is an obligation on the person to respond within 56 days and, in the Lakanal House case, the department did that, but there was, and is, no mechanism for holding to account those who respond to such reports. Nothing is more serious than preventing future deaths, and it stands to reason that there should be proper accountability. It should not take a devastating tragedy such as Grenfell and a public inquiry to hold those responsible to account.

The same is true with public inquiry reports, to which the noble Baroness alluded. We all know that public inquiries can cost tens or hundreds of millions of pounds of taxpayers’ money, but there is no legal requirement to implement their recommendations, to give reasons for not implementing them or even to track the extent to which there has been implementation. This is a shocking lack of accountability.

The Grenfell inquiry itself noted in its recommendations that the department had no system for recording recommendations made to public bodies or keeping track of its response to them. It recommended in chapter 113 that it be made

“a legal requirement for the government to maintain a publicly accessible record of recommendations made by … coroners and public inquiries together with a description of the steps taken in response”.

It went on to say:

“If the government decides not to accept a recommendation, it should record its reasons for doing so. Scrutiny of its actions should be a matter for Parliament, to which it should be required to report annually”.


Similarly, the recent House of Lords Statutory Inquiries Committee recommended a new committee of Parliament to hold Ministers to account in the case of public inquiries and Regulation 28 reports. The House of Lords committee noted that

“if the recommendations from the inquest into the Lakanal House fire had been implemented, then the Grenfell Tower fire may have been less likely to have occurred”.

That is an understatement, given the more recent findings that we now know from the Grenfell inquiry itself.

In conclusion, my question to the Minister is: will the Government implement the recommendation in the Grenfell inquiry report on introducing proper accountability for responding to prevention of future deaths reports and public inquiry recommendations, and, if not, why not? It might prevent another tragedy.