Rajiv Menon QC delivers closing statement to Grenfell Inquiry

Watch the full statement on the Grenfell Tower Inquiry YouTube Channel.

Truth, justice and accountability – those have been the demands of the bereaved and survivors of the Grenfell Tower (GT) atrocity from day one.

But what do they mean in the context of a public inquiry – and specifically what do they mean as far as the Phase 1 terms of reference and list of issues are concerned, noting the distinction you have made between what happened (to be considered in Phase 1) and why it happened (to be considered in Phase 2)? After 6 months of evidence, it is clear that this distinction between what and why is easier said than done. You were right to acknowledge at an early stage that you intended to retain a significant degree of flexibility in relation to the scope of the Inquiry’s two phases. Indeed, you have already heard much evidence that goes to the question of why and you still await much evidence that goes to the question of what, but none of this should delay your Phase 1 findings and recommendations. We stress this because the Inquiry is already way behind schedule. Your initial hope was to complete your Phase 1 report by Easter 2018, and given you still have to consider interim recommendations (hearings for which have recently been postponed and may or may not be re-scheduled) and hold individual Article 2 compliant inquests into the deaths of each of those who died as a result of the fire before Phase 2, it is unlikely that Phase 2 will commence before the autumn of next year at the earliest and possibly not until 2020.

In short, your Phase 1 report is urgent. The bereaved and the survivors and the public at large need you to make the most robust and decisive factual findings and recommendations that you can, on the evidence, so that the criminal and civil liability of those responsible for the GT atrocity can be determined by others as soon as possible – nothing less, with respect, will do.

Some of what I say today will inevitably touch on the why as well as the what, as has been the case in the submissions you have already heard and will be the case in the submissions you hear after me.

Cause and origin

So let’s start at the beginning, namely the cause and origin of the fire – we made a number of assertions about this in our opening statement:

1. After BK heard his kitchen smoke alarm, opened his kitchen door and saw smoke coming from behind his Hotpoint fridge freezer, he did the right thing from start to finish. He shut the kitchen door, woke up his flatmates, woke up his neighbours on the 4^th floor, turned off the main electrical switch in his flat, shut the front door of his flat, telephoned the fire brigade on 999, used the stairs to exit the building, waited outside, spoke to the firefighters when they arrived, filmed the fire from outside on his mobile telephone and just a few hours later went to the police station and gave a full account about what happened.
2. Whatever the precise cause or origin of the fire in BK’s kitchen, it was entirely accidental.
3. Having heard the evidence, the Inquiry must set the record straight and unequivocally declare that BK bears no responsibility, directly or indirectly, for the outbreak of the fire in his kitchen, its spread and its fatal consequences.

Since then, a considerable amount of eyewitness, audio, video and expert evidence has been adduced and all of it, without exception, confirms the honesty and reliability of what BK has always said and confirms that he was indeed blameless for what happened.

There is the evidence of BK and his flatmates, Elsa Afeworki and Almaz Kinfu – there is the evidence of their 4^th floor neighbours – there is BK’s 999 call – there is the evidence of the first responders, Charles Batterbee, Daniel Brown,  John O’Hanlon and Nicholas Barton – there is the first responders’ thermal imaging camera footage – there is BK’s mobile telephone video footage – there are the photographs of BK’s kitchen and its contents taken after the fire by the investigators – and finally there is the expert evidence of Dr Glover and Professor Nic Daeid.

Two things that BK did on the night deserve special mention:

1. Turning off the main electrical switch in his flat before leaving – if BK had not done this, much of Dr Glover’s analysis would have been difficult if not impossible. If BK had not done this, the fire could have tripped many, possibly all of the circuit breakers in his flat – Dr Glover would then have been unable to link the abnormal electrical event that caused the fire to circuit breaker no. 7 specifically. In short, BK’s quick thinking made Dr Glover’s task as an electrical engineer considerably easier
2. Filming the fire in his kitchen as it spread to the external façade – this footage was taken by BK on his mobile telephone whilst he was standing outside GT at ground level, looking up – it was given to the police just hours later. It was heavily relied upon by the Inquiry’s experts, most notably Professor Torero, Professor Luke Bisby and Dr Lane – without it, they and you would have been deprived of crucial video evidence of this most critical stage of the fire’s development.

Consequently, we trust you will specifically recognise the importance of what BK did on the night and make the following factual findings on cause and origin in your Phase 1 report:

1. The GT fire began in the southeast area of the Flat 16 kitchen;
2. The fire was electrical in nature;
3. The origin of the fire was in the Hotpoint FF175BP fridge freezer;
4. The cause of the fire was accidental.

We say that none of these factual findings are controversial. There is no evidence suggesting anything to the contrary. Moreover, until Whirlpool’s closing submissions were circulated on Thursday last week, we were unaware that any core participant was arguing anything to the contrary.

So what exactly is Whirlpool now saying?

1. Although the Inquiry can conclude that the fire began in or around the area of the Hotpoint fridge freezer in the SE corner of the kitchen and was caused accidentally, it cannot conclude that the fire was electrical in nature or that it originated in the fridge freezer.
2. As Professor Nic Daeid stated in her final report, the cause of the fire remains undetermined.
3. Dr Glover’s addendum report on the precise cause of the fire is flawed and based on incorrect assumptions.
4. The exemplar fridge freezer that Dr Glover compared with BK’s fridge freezer had some different component parts. Therefore, Dr Glover was not comparing like with like.
5. There is no evidence that points uniquely to the fridge freezer.
6. Potentially significant evidence may have been shovelled from the kitchen into the hallway and down the lift shaft during the original fire scene investigation.
7. Unknown materials in the SE corner of the kitchen remain unidentified and unexamined.
8. Burn patterns to the laminate flooring would have been identical if the fridge freezer had been attacked by fire and therefore do not assist in determining the origin of the fire.
9. Fire may have started non-electrically by somebody throwing something, perhaps a burning cigarette, into the kitchen through the open window that ignited unknown combustible materials in the corner.

Our response to Whirlpool’s submissions is as follows:

1. Assertion by Whirlpool in its closing submissions is not evidence. As far as we are aware, Whirlpool has neither served any expert evidence to counter the evidence and opinions of Dr Glover and Professor Nic Daeid nor applied to the Inquiry for permission to serve such evidence. Whirlpool did serve a preliminary report prepared by a company called Exponent in 1/18, long before Dr Glover was instructed, that says little and takes matters no further, but nothing since then.
2. The most important factual finding on cause and origin that BK wants you to make is that the cause of the fire was accidental. On that narrow issue, there is no conflict between BK and Whirlpool.
3. However, one of the primary objectives of the Inquiry is ensuring that a similar catastrophe never happens again. If the fire at GT that killed 72 people did in fact start in a faulty fridge freezer, then you must find accordingly so that as a society we can try and regulate in the interest of public safety and prevent similar fires in the future.
4. According to Home Office statistics, there were over 27,000 accidental dwelling fires in England between April 2016 and March 2017 – about 16% of those fires (i.e. over 4,360 fires) were caused by faulty electrical appliances and leads – between 2010 and 2016, there were over 300 domestic fires in England annually that were caused by faulty fridges and freezers – all this information is in the public domain – Whirlpool itself has received five prior reports of fire involving the Hotpoint FF175BP model, one of which involved a fridge freezer manufactured in the same month and year as BK’s fridge freezer.
5. An issue of growing public concern is the plastic rear casing on many of the UK’s most popular fridges and freezers – BK’s Hotpoint fridge freezer had such a plastic rear casing – the London Fire Brigade (LFB) has been raising concern about this issue for years, as has the consumer rights group Which. Unfortunately, the government has thus far failed to regulate to ensure that all fridges and freezers have protective metal rear casings. Dr Glover told you that in the US, the rear casing of fridges and freezers must be made of metallic steel – this is a matter to which we will return in due course when you consider interim recommendations arising from Phase 1.
6. Although Professor Nic Daeid did state in her final report that the cause of the fire remains undetermined, she clearly changed her mind by the time she gave evidence, having heard Dr Glover’s evidence the day before. Specifically, she agreed with Dr Glover that the fire was electrical in nature and originated in the Hotpoint fridge freezer.
7. Although potentially significant evidence may have been lost during the original fire scene investigation, there is not a shred of evidence that the fire was caused by a non-electrical event involving e.g. a cigarette or a candle or incense or oil.
8. Whirlpool has completely ignored the evidence in respect of circuit breaker no. 7 tripping. This is clear evidence pointing to an electrical fire and specifically to the Hotpoint fridge freezer.
9. Burn patterns to the laminate flooring would not have been identical if the fire had begun elsewhere in the South East corner of the kitchen and then attacked the fridge freezer. The area under the fridge freezer was clearly subjected to much more heat than the surrounding areas of laminate flooring were. Hence the very different burn patterns.
10. Whirlpool has completely ignored the evidence that all the other electrical appliances in both the South East and North East areas of the kitchen can be discounted as being seats of origin, namely the cooker, the broken freezer, the small fridge and the Ethiopian hot plate. The latter three were not even plugged in.
11. It is hardly Dr Glover’s fault that the exemplar fridge freezer provided to the MPS had some different component parts to BK’s fridge freezer. It was Whirlpool that provided the exemplar. Why didn’t Whirlpool provide the MPS with an exemplar that had the identical component parts? As far as we are aware, Whirlpool has provided no explanation for this.
12. As far as the theory of the fire having started as a result of something thrown through the open window is concerned, this is pure speculation and desperate, to put it politely. There is no evidence in support. It would have been impossible for a cigarette or some other mystery item to have been launched from ground level, 4 floors down. And it is equally impossible to imagine how a cigarette or some other mystery item discarded from a flat above could have entered the kitchen through the open window, let alone set anything in the vicinity alight.
13. I’m afraid that Whirlpool’s closing submissions are a transparent attempt by a multinational corporation with billions in assets to try and avoid liability and minimise reputational damage and financial loss. It is the same strategy that Whirlpool used during the inquests in 2012 into the deaths of 5 members of the Kua family (that I mentioned during my opening statement) to try and deflect attention away in that tragic case from a Whirlpool freezer that failed electrically and caught fire. You may like to know that the Coroner roundly rejected their submissions.

In short, there is more than sufficient evidence for you to conclude that the fire was electrical in nature and originated in BK’s Hotpoint fridge freezer, in addition to concluding that the cause of the fire was accidental.

As far as the precise cause of the electrical fault that ignited the fire is concerned, we accept that is more complicated. In his addendum report, Dr Glover concludes that the probable cause was a poor crimp connection within the compressor relay compartment of the Hotpoint fridge freezer that caused overheating and arc damage to the run capacitor wires, a short circuit to circuit breaker no. 7 and a subsequent short circuit to the residual current circuit breaker. Professor Nic Daeid, whilst conceding that she is not an electrical expert, was not in full agreement as to the precise cause. She did not clarify any further. It is a matter for you whether or not you make a factual finding as to the precise cause. Suffice to say that you do have the necessary evidence if you wish to make such a finding. Ultimately, you may think that the precise cause is of less importance from the perspective of the public interest and public safety than the question of how an ordinary domestic fire that happens every day in the UK and is entirely foreseeable managed to penetrate the exterior façade of the building and spread with such ease, speed and ferocity.

Beyond Flat 16

Turning then to more general matters about what happened beyond the confines of Flat 16, the extent to which GT complied with the requirements of the relevant legislation and the response of the firefighters – unsurprisingly, some of these matters are simple and straightforward and others are far more complex and nuanced.

Other counsel for the bereaved and the survivors have addressed you on flame and smoke spread once the cladding and insulation caught fire and how the cladding, the insulation, the architectural crown at the top of the building, the window installations, the doors and the ventilation system all played their part in flame and smoke spread – I do not wish to be repetitive and consequently have nothing to add.

Compliance

On compliance, I’ll be brief as this too has been addressed by others. GT as refurbished was non-compliant in multiple respects with the Building Regulations and Approved Document B, regardless of how unfit for purpose and impenetrable those regulations are. There is simply no rational basis for concluding there was compliance. This is not a borderline case – this is a case of flagrant and extensive non-compliance. The evidence of Professor Torero, Professor Bisby and most importantly Dr Lane is unequivocal on this. Specifically, there is no evidence to counter Dr Lane’s important conclusion that GT should never have been handed over to its residents and occupied with such a combustible rainscreen cladding system, given the stay put policy. Consequently, it is unthinkable that you will conclude GT was anything other than non-compliant and it is equally unthinkable that you will conclude you need to delay until the end of Phase 2 before making definitive findings on non-compliance. This fundamental issue needs to be decided as soon as possible, so that we can start to get to the bottom of why and how this was ever allowed to happen.

Response of the firefighters

What about the response of the firefighters? Having read and heard the closing submissions of other CPs, I’m afraid I do wish to speak to this issue at some length as it is, in our submission, far more complex and far more nuanced than some are suggesting. It is very easy with the benefit of hindsight, gained from all the evidence served in Phase 1 and adduced in the relative comfort of Holborn Bars, for lawyers and judges who have almost certainly never been in a towering inferno to pass sweeping, over-simplistic judgments about what the firefighters, working under the most extreme conditions, did or did not do on the night. What we need is a fair, balanced and reasoned assessment that recognises just how difficult it is to predict with any degree of certainty or precision what might have happened on the night if different decisions had been made and different actions had been taken, e.g. if there had been better contingency planning (as there undoubtedly should have been) or if stay put had been abandoned earlier (as it undoubtedly should have been).

We are acutely conscious that this issue of the firefighters is a contentious one amongst the bereaved and survivors. You would have gleaned from their evidence that whereas there is unity on other matters, there are a variety of differing views as to the response of the firefighters on the night. Some believe the firefighters are heroes who did everything they possibly could in an impossible situation – some believe that fundamental errors were made that contributed to lives being lost – and some are on the spectrum somewhere in between – so this is troubled water to navigate but navigate it we must, with great care and fairness.

Were mistakes made on the night? Yes, of course mistakes were made on the night.  How could mistakes not have been made, given the nature of the building and the fire? Should lessons be learned from those mistakes? Yes, of course lessons must be learned from those mistakes. It was most unfortunate that Dani Cotton, the Commissioner, when praising the firefighters for all their efforts (which she was absolutely right to do, by the way), added that she would not go back and change anything the LFB did on the night. That was not only deeply insulting to the bereaved and survivors but also indicative of an inability to appreciate, even with the benefit of hindsight, the LFB’s institutional failings and deficiencies pre-Grenfell, as identified by the Fire Brigades Union and others in their closing submissions.

However, if the primary focus of your Phase 1 report degenerates into a wholesale attack on the response of the firefighters, institutionally or individually, that in any way weakens or detracts from your all-important condemnation of the transformation of GT during its refurbishment into a combustible, non-compliant death trap unsafe for human occupation, then that would be perverse and would play straight into the hands of those statutory and corporate CPs who in reality bear full responsibility for the spread of the fire, the failure of the building and the dreadful consequences that followed. That would not be a fearless reckoning with what went wrong and what must be different in future. The firefighters on the ground at GT were part of the solution, not part of the problem, whatever mistakes they made. They must not be scapegoated for not knowing on the night what the Inquiry’s experts have concluded after they and teams of scientists and engineers have spent literally months studying the remains of the building and its contents, conducting experiments and tests, reading the evidence of the firefighters, the bereaved and the survivors and investigating what exactly happened at GT on the night of the fire. If the firefighters on the ground at GT are unfairly scapegoated, the only beneficiaries will be the aforementioned statutory and corporate CPs. That is neither justice nor accountability.

There are seven issues we wish to discuss about firefighting in general and the response of the firefighters on the night:

1. You cannot ignore the wider context that allowed the GT fire to happen, namely the systematic deregulation of fire safety in this country under successive governments since the Thatcher era or the draconian cuts of over 30% to central funding of fire and rescue services under austerity. Laws and regulations have been weakened in the name of cutting red tape, all for the benefit of the construction industry. Government-funded fire research has virtually ceased – fire safety standards have dropped – and the lessons of countless inquiries, inquests and investigations have been ignored by the state. As far as cuts are concerned, in London alone since 2010, 10 fire stations have been closed, 27 fire engines have been scrapped and over 600 firefighters have lost their jobs. This is madness. We are one of the richest countries in the world – as a society, there is no point in producing endless reports unless we reverse fire safety deregulation by re-regulating and unless we reverse cuts by substantially investing in the fire and rescue services and ensuring that they have the very best resources and equipment they need to fight fire and save life in the 21^st century. As a society, we must prioritise people and safety over profit. We have the money. The question is how we decide to spend it.
2. When assessing the performance of the firefighters, you need to make a clear distinction between the institution of the LFB and those in senior management positions on the one hand and the rank-and-file firefighters on the other. The rank-and-file (including watch managers like Mike Dowden) are not responsible for the inadequacy of their training on high-rise fires, combustible cladding, compartmentation breach, stay put and evacuation. The rank-and-file are not responsible for the inadequacy of contingency planning. The rank-and-file are not responsible for the non-existence of a high-rise evacuation strategy. The rank-and-file are not responsible for poor quality equipment, in particular unreliable communication equipment.
3. Council to the Inquiry put to a number of senior officers that firefighters should always expect the unexpected. A fair point – they should. But what does the unexpected mean? What does it encompass? Surely the unexpected must be reasonably foreseeable? Or should the firefighters expect the unforeseeable too? Forget Dany Cotton’s absurd example of a space shuttle landing on the Shard. Let’s consider a real example. Should the New York firefighters have expected two airplanes to fly into the World Trade Centre on 9/11 and had a specific contingency plan for such an event? That cannot be right or proportionate. The need to plan specifically for a major disaster of a kind that has happened before and is therefore foreseeable is one thing; the need to plan specifically for an unforeseeable event that no firefighter in London has experienced or contemplated is another thing altogether.
   
   So what was reasonably foreseeable in terms of a high-rise, residential fire in London in June 2017?
   
   Cladding fire was reasonably foreseeable to firefighters. It had happened before, notably at Knowsley Heights in Liverpool in 4/91 (the first high-rise cladding fire in the UK where the fire spread upward and vertically), at Garnock Court in Irvine, Scotland in 6/99 (where the fire also spread upward and vertically) and at Lakanal House in south London in 7/09 (where there was both cladding fire spread and internal fire spread through combustible false ceilings in between floors that undermined compartmentation).
   
   Compartmentation breach was also reasonably foreseeable to firefighters. It too had happened before, notably at Garnock Court, at Lakanal House and most recently at Shepherds Court in Shepherds Bush in 8/16 (where the fire was extinguished).
   
   Fire behaving unusually was also reasonably foreseeable to firefighters.
   
   What about lateral fire spread and downward fire spread to the external cladding?Professor Torero’s evidence is significant on this point. He stated that lateral fire spread and downward fire spread are rare in high-rise cladding fires. Usually, the fire spreads upwards and vertically and then proceeds to decay and eventually extinguish once it reaches the top of the building. GT was clearly different, in large part because of the design and combustibility of its unique architectural crown.
   
   What about total building failure? Total building failure was certainly not reasonably foreseeable to the rank-and-file firefighters, pre-Grenfell. It played no part at all in any training they had received about high-rise firefighting. What about the LFB as an institution, pre-Grenfell? That is a tough one. Even if it was a foreseeable event for the LFB, it was clearly not in fact foreseen.
   
   Additionally, you may wish to bear in mind that none of the high-rise fires in the UK that I have already mentioned or others that were mentioned in the course of the evidence resulted in total building failure, not one of them. Furthermore, none of the recent, well-known, international high-rise fires resulted in total building failure (e.g. the Mermoz fire in Roubaix, France in 5/12, the Lacrosse fire in Melbourne, Australia in 11/14, the Marina Torch fire in Dubai in 2/15 and the Address Downtown fire in Dubai in 12/15). There is some information online to suggest that there may have been high-rise fires in China, Iran and Azerbaijan that resulted in total building failure but, as Professor Torero stated, there is very little detailed publicly available information about most international fires. Even a leading fire expert like Professor Torero does not apparently have access to the necessary information.
   
   In short, despite the undoubted similarities between the GT fire and previous high-rise fires in the UK and around the world and the undoubted lessons that could and should have been learned from those previous fires, the GT fire was unprecedented in that it involved total building failure whereas none of the other high-rise fires did. Consequently, it is hardly surprising that many prominent, experienced fire investigators have publicly stated that they have never seen a high-rise building completely consumed by fire like GT was.
   
   It is important to recognise that total building failure is not simply a question of scale. A large cladding fire that causes a significant number of compartmentation breaches and behaves unusually is not tantamount to total building failure. Total building failure involves the failure of all or most of the fire safety features in the building, such that the fire becomes un-extinguishable. At GT, everything failed with the exception of the concrete core structure of the building.
   
   For completeness sake, I should mention the one fire that did involve total building failure, although the building was neither high-rise nor residential and the walls and roof were made of plastic and not aluminium with a polyethylene core, namely the fire at the Summerland Leisure Centre on the Isle of Man in 8/73. Summerland was a huge, indoor holiday park wrapped in a combustible, acrylic material without any sprinkler system. When it caught fire from a discarded cigarette, the flames spread quickly. Once the flames became visible to the approximately 3,000 people inside the building at the time, there was mass panic, crushing and trampling as the crowds headed for the exits – but the fire was too ferocious. It killed 50 and seriously injured another 80. Although it led in the short term to the strengthening of out-dated building regulations in the UK, the lessons were not learned by the powers that be. By the early 1980s, the deregulation of fire safety was in full swing.
4. Others have already addressed you on the section 7(2)(d) familiarisation visits to GT. They were clearly deficient. However, let’s not exaggerate what a firefighter conducting a perfect familiarisation visit would have been able to discover. Even if scientists or engineers like Professor Torero or Dr Lane or Professor Bisby had visited GT on 13/6/17 and spent a few hours familiarising themselves with the building, they would not have known that it was a death trap wrapped in highly combustible cladding or that it had a number of other dangerous, design characteristics that accelerated the speed of fire spread. They would have seen the cladding but would not have known, without research and testing, how combustible it was. They would have noted the ventilation system, the doors, the window installations, the single stairs, the absence of sprinklers and the absence of a central tannoy or alarm system but would not have known the impact of any of these features in the event of a fire. They would have obtained general insights about the building but the extent to which such insights would have assisted in fighting a fire of the nature and magnitude of the GT fire is debatable.
5. The stay put policy at GT
   
   The starting point is of course that there should never have been a stay put policy at GT in the first place, given the cladding system and the fact the refurbished building should not have been occupied. But this is the fault of those who refurbished the building, not the LFB.
   
   However, given there was a stay put policy, when should it have been abandoned, without the benefit of hindsight? Dr Lane was extremely fair about this, recognised the dangers of attributing what we now know to what the firefighters could actually see at different times and what Mike Dowden, the initial incident commander, actually knew at different times. Consequently, even though the fire had spread from inside the Flat 16 kitchen to the external façade by about 1.08 am, begun to climb vertically by about 1.13 am and breached compartmentation by about 1.15 am, Dr Lane was of the view that the fire was still localised and there was no reason for the firefighters to think the fire could not potentially be mitigated. However, once it continued to climb, went beyond the 11^th floor and reached the top of the building by about 1.26 am, the building design condition for stay put had failed substantially. In other words, at or around 1.26 am, stay put should have been abandoned and an evacuation of the building organised. We agree. By about 1.26 am, notwithstanding the fire had yet to spread laterally, Mike Dowden should have realised there was a real risk of multiple compartmentation breaches across multiple floors from what he himself could see happening to the east face of the building or at the very least should have made enquiries with the bridgehead over the radio as to what firefighters and residents inside the building were saying about internal fire and smoke spread. However, given Dr Lane’s cogent reasoning, we do not believe you should make a factual finding that stay put should have been abandoned earlier than 1.26 am, as others have suggested. The fact that Mike Dowden deployed a covering jet externally and ordered a more aggressive hydraulic pump by about 1.15 am does not mean that he had already concluded that defend in place on which stay put depends was no longer viable throughout the building. The mere fact that he recognised that he was fighting an external fire of substance does not mean he should have ordered the immediate evacuation of the building.
   
   One final note on this issue – this may not be popular with some but I have a great deal of sympathy for Mike Dowden. It is not his fault that the building behaved as it did after the fire spread beyond its compartment of origin. It is not his fault that he was inadequately trained to be an incident commander for a fire of this nature or magnitude. It is not his fault that the LFB failed to replace him with a more senior and experienced incident commander much sooner than they in fact did. It is not his fault there was no LFB evacuation strategy in the event that stay put was no longer viable. As Mike Dowden acknowledged when he gave evidence, he was overwhelmed on the night. I trust that you will not make him the sacrificial lamb.
6. Evacuation
   
   I don’t want to spend too long on evacuation because the evidence as to how a mass evacuation of the building at or about 1.26 am would have been organised and implemented, how long it would have taken and what practical difficulties and environmental complications would likely have arisen is thin indeed. I trust you agree that it would be wrong to speculate and make factual findings as to what might have happened without the most careful consideration of all the available evidence and all the likely variables that might have affected a mass evacuation of the building.
   
   As yet, you have no sophisticated computer modelling on how a hypothetical evacuation would work in practice. I assume that the Inquiry’s expert, Professor Galea, will be doing an in-depth report on evacuation modelling for Phase 2. All you have at the moment is the evidence of Professor Purser, the Inquiry’s expert on toxicology, who estimated that the ideal nominal evacuation time of all 293 occupants of the building to the lobby was 7 minutes, if they all suddenly went into the stairs simultaneously. In his report, he qualifies that estimate by adding that given the presence of slower, more elderly occupants and young children and the need to assist those with limited mobility, a better estimate was about 15 minutes.
   
   To be fair to Professor Purser, he never suggested that his calculations are particularly scientific and they clearly are not. They were based on the fact that it took him 3.5 minutes to descend the stairs from top to bottom, the dimensions of the stairs and his opinion as to the likely standing density per square metre on the stairs. He was frank that his figures required a scenario that was in fact impossible at GT, namely alerting all those present in the building to evacuate simultaneously by means of a general alarm system in the common areas. Furthermore, he did not consider a number of other obvious variables that would have slowed down any hypothetical evacuation such as the inevitable presence of firefighters under BA ascending the stairs in large numbers to assist with the evacuation and the inevitable impact of fear, panic, noise, disorientation and smoke inhalation on those evacuating.
   
   In the circumstances, you cannot possibly at present put a figure on how long a hypothetical evacuation would have taken or reach any non-speculative conclusions as to how many of those who died in the fire might have survived if stay put had been abandoned earlier. There is no alternative, I’m afraid, but to defer your assessment of a hypothetical evacuation until Phase 2.
7. The future of stay put
   
   In a sense, this is a largely academic issue. The reality is that the next time there is a fire in a high-rise residential building in the UK (and sadly there will be a next time, sooner rather than later, given the sheer number of tower blocks with similar cladding), most residents will evacuate as soon as they find out about the fire, regardless of whether the building has a stay put policy and regardless of the extent of any compartmentation breach or external fire spread. For the foreseeable future, the memory of what happened at Grenfell will drive residents to get out and stay out.
   
   Nevertheless, given your remit includes making recommendations so that a similar catastrophe never happens again, you are going to have to engage with stay put more generally. So should stay put be consigned to the dustbin of history? Should it be replaced in all high-rise residential buildings with a policy of get out and stay out, whenever there is a fire of any nature?
   
   I don’t want to labour the point but in a safe, compliant high-rise building, stay put has an inherent logic, however counter-intuitive it may be. It works, saves lives and has been doing so for decades, not just in this country but internationally. In the vast majority of high-rise fires, there is either no compartmentation breach or very limited compartmentation breach confined to a localised sector of the building. To evacuate the entire building in such circumstances is not only unnecessary but can also carry its own dangers in terms of promoting panic and chaos and exposing residents to smoke inhalation and injury that they would not otherwise face.
   
   Consequently, getting rid of stay put altogether, because it should never have been in force at Grenfell post-refurbishment, would in our view be throwing the baby out with the bathwater, so to speak. What we need is a more reasoned approach involving a proper review and risk assessment of every tower block, its fire safety features and the viability of a stay put policy, given the building’s design, carried out by a suitably qualified person.
   
   And despite stay put being a principle of building construction, firefighters have to be properly trained in how stay put applies, how to identify when it is no longer viable and how to facilitate the evacuation of different types of tower blocks, depending on their design and fire safety features.

Conclusion

Friday is the 18-month anniversary of the fire. So far, there have been no prosecutions and no bans. There has been a lot of talk and very little action. Throughout, the bereaved and survivors (including BK who I represent) have shown great patience, great integrity and great courage, despite the trauma and the rage and the hardship. Now they need you to be bold and brave too. Are you going to challenge vested interests? Are you going to expose corporate wrongdoing? Are you going to recognise how austerity destroys lives? Are you going to demand the re-regulation of fire safety? Are you going to speak truth to real power in this country? Or are you going to blame the working men and women who risk their lives every day and did their very best on the night but were unable to fight a fire that could not be fought? The time has come. Please use your power wisely and do the right thing!

Rajiv Menon QC is a member of the Garden Court Chambers Inquests and Inquiries Team.