30 October 2019

The first report of the public inquiry into the Grenfell Tower fire has today been published in full. The report draws on seven months of hearings from Phase 1 of the Inquiry which concluded in December 2018. Chaired by Sir Martin Moore-Bick, the focus of Phase 1 was to establish the events on the night of 14 June 2017, which led to the deaths of 72 people.

The delayed report, which was initially expected in ‘spring’ 2019, contains detailed description of what happened on the 14 June, including the origins and spread of the fire and the response by the London Fire Brigade and other emergency services. A key and crucial finding by the inquiry is that the external walls of Grenfell Tower failed to comply with building regulations in that they did not adequately resist the spread of fire. On the contrary, they actively promoted it.

The Phase 1 inquiry report makes 46 evidence based recommendations including:

  • The owner and manager of every high-rise residential building be required by law to provide their local fire and rescue service with information about the materials and methods of construction used in its external walls;
  • That the government develop national guidelines for carrying out partial or total evacuations of high-rise residential buildings;
  • That all high-rise residential buildings be equipped with facilities for use by fire and rescue services enabling them to send an evacuation signal to the whole or a selected part of the building by means of sounders or similar devices;
  • The London Fire Brigade, Metropolitan Police and London Ambulance Service and the London Local authorities should investigate ways of improving the collection of information about survivors and making it available more rapidly to those wishing to make contact with them;
  • The London Fire Brigade should urgently take steps to obtain equipment that enables firefighters wearing helmets and breathing apparatus to communicate with the bridgehead effectively, including when operating in high rise buildings;
  • That electronic systems be developed to record Fire Survival Guidance information in the control room and display it simultaneously at the bridgehead and in any command units.

Following the Lakanal House tower block fire in 2009 where six people died, the coroner made recommendations including on reviewing the ‘stay put’ policy and building regulations, due to the spread of the fire on the exterior of the building. The All-Party Parliamentary Fire Safety and Rescue Group wrote to ministers 21 times between 2014 and 2017 to ask for the Lakanal House recommendations to be implemented. When the Grenfell Tower fire happened, these recommendations had still not been actioned.

Recommendations made by public inquiries, and other investigative processes which follow deaths, are not currently binding on the Government. For over 15 years, INQUEST has called for a ‘national oversight mechanism’, an independent public body tasked with the duty to collate, analyse and monitor learning and implementation arising out of all ‘Article 2’ state related deaths.  

Deborah Coles, Executive Director of INQUEST said:The residents of Grenfell Tower were catastrophically failed before, during and after the fire. Key findings of this report are strikingly similar to those which followed the Lakanal House fire in 2009. Had previous recommendations been implemented, those in Grenfell Tower may have been safe.

This fire was predictable and preventable. A national oversight mechanism is urgently needed, to ensure official recommendations from inquiries and inquests are systematically followed up. The lasting legacy of Grenfell must be structural change. This requires meaningful action from the inquiry and government, to ensure those affected are not failed once again.”

Since the fire, the bereaved, survivors and residents have demanded urgent interim recommendations to protect others and prevent a repeat of this disaster. INQUEST held a Family Consultation Day with families bereaved by Grenfell in February 2019. In the report Family reflections on Grenfell: No voice left unheard, they expressed exasperation at the delay. The bereaved families also highlighted a need for future recommendations made by the inquiry to be systematically monitored and followed up.

Remy Mohamed, the Grenfell Project Coordinator at INQUEST said: “For the bereaved and survivors, the worst has already happened. Their ongoing struggle for truth, justice and accountability is a selfless fight for the safety of everyone. Families must be at the heart of this process. Instead they have faced months of silence from the inquiry and uncertainty about the publication of this report. This inevitably has an emotional and physical toll. We hope the suggestions made by bereaved families on the future of this inquiry will be taken into account for the forthcoming phase.”

Phase 2 of the Grenfell Inquiry is due to begin at the end of January 2020 when Sir Martin Moore-Bick will be joined by two panel members, Professor Nabeel Hamdi and Thouria Istephan. In Phase 2, the Inquiry is examining the circumstances and causes of the disaster. It will look at the refurbishment, cladding products, complaints and communication with residents and fire risk assessments.


For further information, interview requests and to note your interest, please contact INQUEST Communications Team: 020 7263 1111 or [email protected]; [email protected]

INQUEST have been working with and supporting bereaved and survivors since the Grenfell fire and coordinates the Grenfell INQUEST Lawyers Group, consisting of lawyers representing those bereaved.

INQUEST held a Family Consultation Day with Grenfell bereaved families earlier this year. Families of 55 of the 72 who died participated and urged the Government and Inquiry team to listen to their voices. The report Family reflections on Grenfell: No voice left unheard contains a number of strong suggestions from bereaved families on the future of this Inquiry and beyond. Media release.

For the inquiry INQUEST has undertaken policy, parliamentary and community based work. More information on the work INQUEST are doing on the Grenfell Tower fire can be found here.

Read our briefing for parliamentarians on the Grenfell Inquiry phase 1 (PDF), for more information on what INQUEST is calling for, including the national oversight mechanism and the Public Authority Accountability Bill.

Timeline of event since the Grenfell Tower Fire

  • 14 June 2017 - The Grenfell Tower Fire.
  • 15 June 2017 - PM announces a Public Inquiry into the disaster.
  • 29 June 2017 - Sir Martin Moore Bick appointed as Inquiry Chair.
  • 5 July 2017 - Inquiry launch consultation for Terms of Reference – this deadline was extended twice and closed on 4 August 2017.
  • 15 August 2017 - Terms of Reference announced.
  • 14 September 2017 - Formal opening of the inquiry.
  • 30 November 2017 - Petition is launched by bereaved families calling for an independent diverse decision-making panel for the Inquiry.
  • 22 December 2017 - PM confirms she will not appoint a panel for the Inquiry.
  • 23 February 2018 - Petition for a panel reaches 100,000 signatures as public and legal pressure mounts.
  • 11 May 2018 - PM announces decision to appoint two panel members but only for Phase 2 of the Inquiry.
  • 21 May 2018 - The Public Inquiry opens with Commemoration hearings at the Millennium Hotel in Gloucester Road.
  • 4 June 2018 - Oral hearings for Phase 1 of the Inquiry begin at Holborn Bars.
  • 12 December 2018 - Oral hearings for Phase 1 of the Inquiry end.
  • 30 May 2019 - Two panel members appointed for Phase 2.
  • 30 October 2019 - Inquiry publishes Grenfell Phase 1 report.
  • 27 January 2020 - Phase 2 of the Inquiry is due to begin.