What are the key findings of the final report on the Grenfell Tower fire?

Here is a summary of the report’s key findings:

– The government ignored warnings

Almost three decades before the fire, the government had had “numerous opportunities” to identify the risks posed by combustible facade and insulation materials, particularly for high-rise buildings, the report says.

As early as 2016, the year before the fire, the company was well aware of these risks but did not take any action based on its knowledge.

Following the fire at Lakanal House in Camberwell, south London, in July 2009, in which six people died, the coroner's recommendations were met with “no sense of urgency” and “legitimate concerns” were “repeatedly met with a defensive and dismissive attitude from officials and some ministers”.

– A “deregulation agenda” within the government resulted in security issues being “ignored, delayed or disregarded”.

After the Lakanal House fire, the government pursued a “deregulation programme, enthusiastically supported by some of the Secretaries of State and the Minister of Foreign Affairs” that “dominated the thinking of the Department to such an extent that even matters concerning the safety of human life were ignored, delayed or disregarded”.

– There was “systematic dishonesty” in product testing and marketing

Grenfell Tower was wrapped in combustible material because manufacturers and sellers of cladding panels and insulation products were “systematically dishonest”.

These companies had “deliberately and persistently pursued strategies to manipulate testing procedures, misrepresent test data and mislead the market.”

A former government agency, the Building Research Establishment (BRE), which provided advice on building and fire safety, was “complicit in this strategy” when it came to Celotex’s flagship insulation product.

The BRE was privatised in 1997, but years before that, “much of the work it carried out in relation to the fire safety testing of external walls was marred by unprofessional conduct, inappropriate practices, a lack of effective oversight, inadequate reporting and a lack of scientific rigour.”

It concluded that its systems were not “robust enough to ensure complete independence” and it concluded that they “played an important role in enabling Celotex and Kingspan to market their products” for use in the external walls of high-rise buildings.

The certification bodies British Board of Agreement (BBA) and Local Authority Building Control (LABC) “have failed to ensure that the information provided in their product certificates is accurate and based on test evidence”, while UKAS, which is responsible for overseeing the certification bodies, “has failed to apply appropriate monitoring and oversight standards”.

– Legal requirements for fire tests are “fundamentally inadequate”

The legal requirements for compliance with building regulations, which require the external walls of a building to be “adequately capable of resisting the spread of fire through the walls and from one building to another”, have been found to be “fundamentally deficient”.

The use of Class 0 (limited flammability) as a standard for the fire behaviour of products intended to be used on the external walls of tall buildings is “wholly inappropriate” because none of the key tests in the British Standard reflect the development of a fire on the outside of a building or provide the information needed to assess how an external wall incorporating the product would behave in the event of a fire.

– The management of fire safety was considered an “inconvenience” by the tower’s landlords

Between 2009 and the fire, there was a “persistent indifference to fire protection, particularly to the safety of vulnerable people”.

The city council – the Royal Borough of Kensington and Chelsea (RBKC) – and the landlord organisation – the Tenant Management Organisation (TMO) – were jointly responsible for managing fire safety in the tower.

However, the associated requirements “were viewed by the TMO as an inconvenience rather than an essential aspect of its duty to manage its property carefully”.

In turn, the RBKC's oversight of the TMO's performance was “weak and fire protection was not subject to any performance indicator”.

– Unpleasant “carousel of shifting responsibility” during the restructuring

During the renovation of the tower in 2015 to 2016, there was “serious incompetence” and in some cases “downright dishonesty”.

The report states: “Unfortunately, the Grenfell Tower refurbishment was characterised by a significant lack of competence among many of those involved and outright dishonesty among some building product manufacturers.”

Because there was no clear definition of who was responsible for what, including whether the designs met legal requirements, an “unpleasant 'carousel of responsibility allocation' ensued, with construction professionals pointing fingers at each other and blaming each other for one or another of the critical decisions.”

– The London Fire Service suffered from a “chronic lack of effective administration and leadership”

The fire brigade has learned lessons from the fire in the Lakanal house. Their reaction “showed that they immediately understood its significance,” the report says.

But their failure lies “in their inability to implement an effective response.”

This failure has “many causes,” including a “chronic lack of effective leadership,” combined with an “excessive emphasis on processes and a culture of complacency.”

The LFB's senior managers took no steps to ensure that their fire response arrangements complied with national guidelines. Senior officers, on the other hand, were satisfied with the brigade's operational efficiency and did not have the management skills to recognise the problems or the will to correct them.

– Immediately after the fire, the residents felt “abandoned” and “completely helpless”

The government and RKBC's response in the first week was described by the investigation as “confused, slow, indecisive and piecemeal.”

It concluded that the Council should have done more and that some aspects of the response “showed a clear lack of respect for human decency and dignity and left many of those directly affected feeling abandoned by authority and utterly helpless”.

The local authority did not have an effective plan in place and did not adequately train its staff to deal with such an incident. However, the report says, “none of this was due to a lack of financial resources.”

It acknowledged the help provided by the local community immediately after the attacks, which “only highlighted the inadequacy of the official response.”

– Determinations regarding the cause of death

The chairman of the inquiry, Sir Martin Moore-Bick, made findings on the cause of death to assist the coroner and “to spare the relatives of the deceased the stress of a lengthy process”.

“In view of the expert evidence, we are in a position to make findings as to the cause of death. This includes the finding that all persons whose bodies were destroyed by the fire were dead or unconscious when the fire reached them,” the report said.