The Grenfell Tower Inquiry report: what it said about the social housing providers
A culture of concealment, a careless attitude to fire safety, routinely ignoring residents. The report did not paint a pretty picture of the social housing managers involved in Grenfell.
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As promised, as I continue to pick through the 1,700 page Grenfell Tower Inquiry report, I will provide some summaries of what it has found, and (hopefully) a bit of insight into what it all means.
Last week I looked at the recommendations, and this week I’m turning my attention to Volume Three, which looks into the social housing management arrangements at the tower. So what does it say?
Concealing information from the board
Council housing in west London was a fairly run-of-the-mill ‘ALMO’ arrangement - Kensington and Chelsea Tenant Management Organisation (the TMO) was an arm’s-length management company, owned by the Royal Borough of Kensington and Chelsea (RBKC). The TMO was responsible for looking after the council homes, while the local authority set its budgets and scrutinised its work via its committee structure.
The panel’s views are highly critical of several former senior staff members at the TMO’s, particularly Robert Black, who was chief executive from 2009, and Janice Wray, its health and safety manager. Some of the strongest criticism was reserved for what the report called “a culture of concealment”.
It highlighted several instances where Mr Black or Ms Wray (or both) had effectively hidden the true picture of fire safety at the organisation from their own board or executive team, the scrutiny committee at the council or the London Fire Brigade (LFB).
In just one such instance, in 2013, a management report had been commissioned by the council into the TMO’s fire safety arrangements which found serious issues with its performance.
But when Mr Black summarised this report for a board meeting he “did not mention any of the shortcomings identified”. He claimed giving evidence that he’d done this because the management report was not yet finalised, but the inquiry panel rejected this, concluding he had been acting to “ avoid embarrassment” from the board who would have asked “some very difficult questions” if given the true picture. It called this “a very serious failing on his part”, and it was far from the only example.
Fire risk assessment
The report also had stern criticism for the “one-man band” fire risk assessor Carl Stokes, who had risk assessed Grenfell Tower multiple times in the years before the fire.
I wrote about Mr Stokes and his deficiencies previously here, and the report (as expected) was damning of his performance. It called his drafting of risk assessments (which included regular copy and pasting) “lazy and careless” and described some his advice as “foolish” or “unnecessary, confrontational and wrong in law”. Regarding the post-nominals he used on his CV, which related to made up qualifications, it said his behaviour showed “a lack of integrity and reliability”.
It had sterner criticism for KCTMO for appointing him and for not carefully reading the assessments he produced. It said the way he had been allowed to “drift” into the role of assessing all their buildings was “not a proper or safe way” for it to commission a risk assessor, adding that its actions “betrays a fundamental carelessness about fire safety”.
On one occasion staff at the TMO placed Mr Stokes under direct pressure to downgrade the urgency of his advice, which meant the organisation would be under less pressure to act quickly.
The report said this “illuminates so well” KCTMO’s approach to fire safety, as it was “treating fire safety as an inconvenience rather than an essential aspect of its care for those living in buildings under its management”.
Speaking particularly about Mr Stokes’ failure to keep risk assessment up to date with regard to the presence of disabled residents in Grenfell, the report went so far as to say it was it was “bound to conclude” that the risk assessments were “inaccurate and out of date” which meant they were not “suitable and sufficient” and therefore a breach of the relevant requirements in the Fire Safety Order. This means the panel’s view is that, at least in this instance, the TMO was in breach of the law.
Missing self-closers
Those who know the story of the night at Grenfell Tower will be aware that the missing self-closing devices on flat entrance doors were a key part of it. Doors standing open early in the fire allowed the rapid spread of smoke to lobbies, which meant many residents never had the chance to escape into a smoke-free environment.
The story of the shocking number of opportunities everyone involved had to put that right is spelled out in the report. Manse Masterdor (a defunct company who made and sold the doors, which had numerous defects and attained nothing approaching their advertised fire resistance) discovered an inherent problem with its self-closers in 2011, when just 17 doorsets had been fitted in Grenfell Tower.
Mr Stokes spotted it as well not long after, and the TMO and Manse exchanged emails where they discussed fixing the issue, but didn’t. Instead, when the self-closing device malfunctioned (its screws were too short meaning it pulled out), it was often simply removed by TMO staff or contractors.
In 2015, the LFB realised there were vast numbers of missing self-closers in another tower (Adair), and served a deficiency notice. Nineteen days later, a fire started in Adair, with serious smoke spread as a result of the missing self-closers which made national news. But the pre-existing deficiency notice was kept quiet from the TMO’s board and RBKC’s scrutiny panel by Mr Black.
The LFB then upped its action to an enforcement notice, told the TMO to put in borough-wide checks of self-closers (as required by guidance) and to fix all the problem doorsets within a year. They also issued a specific deficiency notice for Grenfell Tower in November 2016.
But RBKC didn’t want to provide the budget for this work, with the report “money was the driving force” of its decision not to.
On the night of the fire 77 of 120 doors in the tower didn’t have self-closers, and the residents of the tower paid the ultimate price.
Tenants not consulted
There was also a long section on a separate (but obviously related) failure - namely the failure to properly engage tenants over the refurbishment.
Despite residents such as Eddie Daffarn repeatedly trying to set up a body through which residents of the tower could speak collectively over the works which were proving extremely disruptive and unpleasant, the TMO repeatedly rebuffed their efforts and refused to recognise a group.
This only changed in 2015 with the involvement of the local MP, but by this point the refurbishment was materially complete and key decisions (most significantly the substitution of the cladding for the cheapest available option) had taken place without any resident involvement at all - in breach of the management agreement between the TMO and RBKC.
The report concluded that that residents of Grenfell regarded the TMO as “an uncaring and bullying overlord, which belittled and marginalised them, regarded them as a nuisance [and] failed to take their concerns seriously”, and placed the blame for this with the TMO’s management.
What to make of it all?
A few thoughts which occurred to me reading and summarising these findings include:
The major failure of the door closers is - in my view - a pivotal part of this story and it’s something that the wider discussion around Grenfell fails to properly appreciate. We already knew the degree of missed warnings from the oral evidence, but this report paints a shameful picture. It was a truly staggering failure given the many opportunities presented to put it right, and blame is rightly attached to all those involved: manufacturers Manse Masterdor, KCTMO management, Carl Stokes and RBKC.
I have said this before, but it bears repeating: on the evidence the report dug up and the conclusions it reached, the absence of a specific recommendation for resident empowerment is a major miss. It appears to be crying out for some sort of recommendation to the effect of: during major works, a portion of the budget must be set aside to fund a collective resident scrutiny panel to whom the project team must report or social housing residents should be given a statutory right to form a collective group with rights to be consulted, raise and escalate complaints if certain thresholds are met (eg, a minimum number of residents on an estate or in a tower signing a petition).
Raising the competency of fire risk assessors with mandatory accreditation is a good thing, but there is another problem. Mr Stokes was not just doing his job badly, he was doing his client’s bidding. I have heard plenty about other clients putting pressure on their assessors to do similar. It is also worth the government considering how it might address this when it brings the new rules in. Competency is one thing, but commercial incentives - and their impacts on ethical behaviour - are another.
I’m regularly asked about the potential for criminal prosecutions. I need to be careful about how I phrase this, for obvious reasons, so to be clear: being criticised in the report is not the same as criminal liability. Just because the panel has found wrongdoing, doesn’t mean a jury would. The standards of proof for an inquiry and a criminal trial are different and no one has been charged yet. They deserve the opportunity to argue their innocence if they are, so no one should be prejudged as guilty based on what is in the report.
Nonetheless, it is worth explaining the sort of offences under consideration for the Grenfell fire, and how they might relate here.
The police have said they are pursuing investigations into fraud and misconduct in a public office, as well as the more serious offences of manslaughter and the more basic breaches of fire safety rules or health and safety law. All could potentially be engaged by some of the behaviour described above.
Fraud, for example, requires someone to dishonestly make a false representation in order to gain for themselves. Lying on a job application can amount to fraud.
As for misconduct in a public office, the TMO staff involved in this story would be very likely to be considered public officials, under the definition set out in this case. To obtain a conviction prosecutors would then need to show they had carried out wilful neglect, breach of duty or misconduct and prove to a jury that it was “serious”. All of these are subject to long and complex legal definitions, with many different precedents, which I’m simply not qualified to assess and apply to these facts. But that is the job for prosecutors and detectives in deciding whether or not it is worth bringing that charge.
And then there is manslaughter. Here prosecutors would need to show that there had been an unlawful act (such as a breach of the fire safety order) or gross negligence (a negligent act, where there was a duty of care, and one which fell far below normal standards and came with an obvious risk of death). They would then need to prove that these actions were a cause of the deaths. It appears to me that this last bit - causation - is going to be the trickiest, given the number of different factors which contributed to the deaths at Grenfell. But in regard to the self-closers on fire doors in particular, you would feel the question can at least be asked by investigators and prosecutors.
A final point is that of austerity. We are of course talking here about a resource starved public sector in the early and mid-2010s. While it would be dangerous and cliched to pin this all on austerity (no amount of budget cuts can make you mislead your board), it would also be wrong to view the story completely separately from it. This was the hollowed out state in action: overworked, under-budgeted, failing. “The responsibilities she [Ms Wray] was given were probably too much for one person to discharge properly without substantial assistance and effective oversight. Unfortunately, she had neither,” the report said of Ms Wray. How many other public servants can relate to that description? And when we see what appears to be unforgivable negligence from them, how often is this the backdrop?
While RBKC had reserves on its housing revenue account, and could have chosen to spend more, it was restricted by central government edict from borrowing. That limited its options when it came to things like a major replacement of fire door self-closers.
I particularly emphasise that because local authority housing budgets are very likely to enter a new austerity round. A huge budget blackhole looms for stock owning London boroughs, and they warned last week this will result in £170m of cuts to supervision, management, maintenance and repairs over the next four years without government help, of which there is currently no sign. I wonder which preventable tragedies - big or small - will slip through the net as a result of these latest cutbacks.
This content is not behind a paywall, but since it takes time to create and upload each piece, do please consider becoming a paid subscriber (especially if this project is something that you value, and you have the means to do so), which is either billed monthly at £3.50 or annually at £35. A paid subscriber has full access to the back catalogue of posts.
If you pay £40 or more for an annual subscription, I will send you a signed copy of my book. Or you can buy a copy here.