The Grenfell Tower fire, which killed 72 people, was the result of decades of institutional failures, according to a damning final report

The tragic fire at Grenfell Tower, which killed 72 people, was the culmination of decades of failures by successive governments and the construction industry, according to the damning final report.

The high-rise block in west London was clad in flammable materials because the companies that manufactured and sold the cladding and insulation were “systematically dishonest”, inquiry chairman Sir Martin Moore-Bick said on Wednesday. He accused the firms of “deliberate and persistent” manipulation of fire safety tests, misrepresentation of test data and misleading the market.

The lengthy investigation into how the west London tower block went up in flames so quickly found that the builders were “systematically dishonest” and clad the 24-storey building in flammable materials. The fire broke out just before 1am on 14 June 2017 when a faulty fridge broke down. But it became the worst building fire in Britain since the Blitz. Survivors say those affected have “blood on their hands”.

Key findings of the 1,700-page report include:

• There was a toxic relationship “fueled by mistrust” between the residents and the Kensington and Chelsea Tenant Management Organisation (KCTMO), which was responsible for managing Grenfell Tower.

• The successive governments under David Cameron and Theresa May received numerous warnings about the dangers of certain cladding materials between 2012 and 2017, but ignored them.

• The survivors felt they had been “completely let down” by the Royal Borough of Kensington and Chelsea Council and its tenant management organisation.

• The plans for the emergency shelters are “inconsistent”: families would be crammed into one room and residents would have to sleep in cars or on the lawn.

• The response from the government and local councils has been “confused, slow, indecisive and piecemeal”. Little has been done to meet the needs of people from different backgrounds, such as providing halal food for Muslims observing Ramadan.

• There was a “persistent indifference” to fire safety in Grenfell Tower and there was no concrete evacuation plan.

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The investigation found that all victims of the Grenfell Tower disaster whose bodies were destroyed by the fire were already dead or unconscious when the flames reached them.

The organisation Grenfell United, which represents some of the relatives and survivors of the fire, has now called for some of the construction companies involved to be excluded from public contracts.

As early as 2016, a year before the Grenfell fire, the government was “well aware” of the risks of using combustible cladding panels and insulation, particularly in high-rise buildings, “but did not act on its knowledge”.

More than 800 people were left homeless as the Royal Borough of Kensington and Chelsea (RBKC) Council leadership was “completely incapable” of dealing with the scale of the tragedy, leaving many feeling abandoned and helpless.

Families who had lost everything they owned had to wait days for emergency accommodation in hotels. There was little consideration for groups with special needs. One pregnant woman, for example, had to sleep on the floor.

The second part of the investigation, which began in November 2022, heard from several survivors who recalled “absolute chaos and confusion everywhere” and compared the scene to a horror movie or a war zone.

One of the witnesses, Karim Mussilhy, said he expected to see authority figures wearing high-visibility vests, but did not see anyone and little information was available from RBKC immediately after the incident.

Many survivors and residents slept in their cars, while others waited for hours for buses that they had been told would take them to a recovery center. Instead, they had to walk in the early hours of the morning to centers that had spontaneously opened nearby.

Residents of the “Walkways”, a row of low-rise buildings next to Grenfell Tower, had to wander through the estate in the early hours of the morning, while the allocation of accommodation was “confusing and inconsistent”.

One resident described feeling like “cattle just passing through.” Interviews lacked sensitivity and several survivors were distressed after being housed in rooms in the high-rise.

“We saw a picture of a vulnerable group of people facing not only the shock, grief and trauma of the fire itself, but also, as an immediate priority, the need to meet the most basic daily needs. Survivors described it as living in limbo, with no room for healing,” the report said.

Meanwhile, RBKC chief executive Nicholas Holgate, who acted as Gold Commander for the council's response, had no clear plan and was “overly concerned” about the council's reputation. Mr Holgate had previously been criticised for handing over command to a London-based group with more expertise only two days after the deadly fire.

It was found that since 2011, residents have had a relationship with the TMO characterised by “distrust, antipathy, personal hostility and anger”. Grenfell residents viewed the administration as a “loveless and tyrannical overlord”.

It was found that the TMO had failed to communicate to the council the outcome of an independent and highly critical report on fire safety in 2013. In addition, no final fire safety strategy had been developed for the tower, despite a consultant recommending it in 2009.

Meanwhile, it was found that the London Fire Service had not adequately trained its emergency services in dealing with the severity of the emergency calls, leading to confusion on the ground.

The organisation had failed to recognise its shortcomings during the fatal fire at Lakanal House in Camberwell in 2009, in which six people died, and suffered from a “chronic lack of effective management and leadership, coupled with an excessive emphasis on processes”.

The first phase report, published in October 2019, concluded that the tower's cladding did not comply with building regulations and was the main reason for the rapid spread of the fire.

The chairman of the investigation, Sir Martin Moore-Bick, and two other members of the panel have now concluded that “unscrupulous manufacturers” had deliberately and persistently manipulated testing procedures, falsified data and misled the market.

This included Arconic Architectural Products, which sold ventilated external wall panels and “deliberately concealed” the dangers of its product from 2005 until after the Grenfell fire.

Other companies, such as insulation manufacturer Kingspan, had not withdrawn their product from the market despite “catastrophic” tests in 2007 and 2008 and despite their own concerns about its fire behaviour.

The building materials group has already apologized for “process and behavioral deficiencies” identified during the investigation.

Sir Martin made 58 recommendations, concluding that the construction industry had become “too complex and fragmented”. He proposed establishing a single regulator responsible for regulating construction products, testing and certification.

In response, Grenfell United said: “Today marks the end of six painful years of listening to the evidence of the deaths of 54 adults and 18 children from our families, neighbours and friends. This is an important chapter in the journey towards truth, justice and change. But justice has not yet been done.”

“The investigative report shows that when corporate interests and public safety conflict, governments have done everything they can to evade their responsibility for the safety of the population. The system is not broken, it was built that way.”

In May, the Metropolitan Police said its investigators would need until the end of 2025 to complete their investigation and that prosecutors would then take a year to decide whether to bring charges.

Relatives and survivors described the waiting period, which could last up to a decade after the devastating fire, as “unbearable”.

The report comes just over a week after the major fire in east London, where work was carried out to remove cladding following the events at Grenfell Stadium.

The Dagenham fire, which resulted in no fatalities and occurred so many years after the 2017 fire, sparked fierce criticism from a number of quarters, including bereavement and survivors group Grenfell United, which said it demonstrated “the painfully slow progress in remediation efforts across the country and a lack of urgency around building safety overall”.