Grenfell Tower Inquiry
|Date||14 September 2017- (in progress)|
|Location||Holborn, London, United Kingdom|
The Grenfell Tower Inquiry is a British public inquiry into the Grenfell Tower fire, which killed 72 people and destroyed Grenfell Tower on 14 June 2017. It was ordered by Prime Minister Theresa May on the day following the fire. May announced on 29 June 2017 that the inquiry would be chaired by retired judge Sir Martin Moore-Bick, with the immediate priority "to establish the facts of what happened at Grenfell Tower in order to take the necessary action to prevent a similar tragedy from happening again." She promised that "No stone will be left unturned by this inquiry."
The Phase 1 Report from the inquiry was published on 30 October 2019. Hearings are expected to resume in 2020.
- 1 Background
- 2 Announcement of the Inquiry
- 3 Preparation
- 4 Goals
- 5 Proceedings
- 5.1 Phase 1 evidence
- 5.2 Phase 1 evidence week 4
- 5.3 Phase 1 evidence week 5
- 5.4 Phase 1 evidence week 6
- 5.5 Phase 1 evidence week 7
- 5.6 Phase 1 evidence week 8
- 5.7 September 2018
- 5.8 November 2018
- 5.9 December 2018
- 6 Reactions
- 7 Concerns about the order of the inquiry
- 8 Phase 1 Report: October 2019
- 9 References
- 10 External links
The concrete structure's top 20 storeys consisted of 120 flats, with a total of 200 bedrooms. Its first four storeys were nonresidential until its most recent refurbishment in 2015–2016, which converted two of them to residential use, bringing it up to 127 flats and 227 bedrooms. It also received new plastic framed windows and new cladding with thermal insulation.
A major fire seriously damaged the building on 14 June 2017, causing the deaths of 72 of the 293 people who were believed to be in the 129-flat tower that night. The inquiry is to determine the causes and recommend changes to minimise the risk of a similar event occurring ever again. A previous catastrophe at the Ronan Point tower block in 1968 also generated an inquiry.
Announcement of the Inquiry
Theresa May, the prime minister made a statement to Parliament on 22 June announced a judge led inquiry, saying "No stone will be left unturned by this Inquiry". The chosen judge was Sir Martin Moore-Bick, and when she announced his name on 29 June she stated that "Before the Inquiry starts Sir Martin will consult all those with an interest, including survivors and victims’ families, about the terms of reference."
The inquiry was announced on 22 June, and the judge Sir Martin Moore-Bick named on 29 June, he met with residents the same day. Also on 29 June, after Moore-Bick had met some survivors of the tragedy at the site of the fire in North Kensington that day, he said that he was "doubtful" that the process would be as wide-ranging as some residents hoped and that the inquiry could be limited to the cause, how the fire spread, and the prevention of future fires.
On 30 June, Labour Party leader Jeremy Corbyn wrote to Theresa May to say that the inquiry's terms should be broad, because the fire had "much wider implications for national policy issues". Former Lord Chancellor Lord Falconer said that "The inquiry has got to look at how [the regulatory] regime developed, or I think the residents would feel they were let down."
On 5 July, the Inquiry team invited "all those affected by the Grenfell Tower fire and others with an interest" "to help shape the work of the public Inquiry". It issued a consultation document which stated that the Inquiry will need to examine "circumstances well beyond the design, construction and modification of the building itself", including "the role of relevant public authorities and contractors", "the adequacy and enforcement of relevant regulations", "the arrangements in place locally for handling emergencies of this sort," and "the handling of concerns previously expressed by local residents." The deadline for consultation on the terms of reference had initially been 14 July, but was extended (on 11 July) to 28 July.
On 17 July, Corbyn wrote again to Theresa May, saying: "As I set out in my letter dated 30 June, there is considerable concern among residents and others that the judge leading the inquiry has already been directed towards a narrowly defined Terms of Reference, which will not bring residents the answers they seek."
"Following feedback from local residents and survivors", on 19 July, Moore-Bick further extended the terms of reference consultation period to 4 August.
On 15 August 2017, Theresa May announced that the inquiry's role would be to examine "the circumstances surrounding the fire", including its causes, how it spread to the whole building, and the adequacy of the regulations and safety measures in place.
Campaigners argued that the inquiry should include an advisory panel to assist Moore-Bick. In May 2018, it was announced that two panelists would sit alongside Moore-Bick for the second stage of the inquiry.
In May 2018, a series of commemorative hearings were held in which relatives and survivors paid tribute to the 72 who had died.
Phase 1 evidence
Evidential hearings began on 4 June 2018. The first week saw opening statements on behalf of the key organizations and the presentation of reports by key expert witnesses. No hearings were held in the week beginning on 11 June 2018, as the anniversary of the fire and commemorations fell within this week. The hearings resumed on 18 June 2018.
The appointed expert witnesses are:
- Dr Barbara Lane, a fire safety engineer from Arup 
- Colin Todd, a fire safety consultant from CS Todd & Associates Ltd
- Professor David Purser, from Hartford Environmental Research
- Professor Edwin Galea, Professor of Mathematical Modelling at the University of Greenwich
- Dr Ivan Stoianov, Senior Lecturer in Water Systems Engineering at Imperial College London
- Dr J. Duncan Glover, from Failure Electrical LLC
- Professor José L. Torero, Director of the Center for Disaster Resilience, University of Maryland, USA
- Professor Luke Bisby, Professor of Fire and Structures at the University of Edinburgh
- Professor Niamh Nic Daeid, from the Centre for Anatomy and Human Identification, University of Dundee
- Rodney Hancox, Director, Gas Distribution Solutions Ltd.
- Steve McGuirk, former Chief Fire Officer of Greater Manchester, Cheshire and South Yorkshire, former President of the Chief Fire Officers Association, and former Lead Adviser to the Local Government Association.
Phase 1 evidence week 4
20 June 2018: Appointment of John Priestley
Architect, John Priestley, was appointed to produce a report into the architectural design of the refurbishment of Grenfell Tower. He was to examine the choice of materials, compliance with legislation and regulations, and the quality of the workmanship on the building.
He was dismissed on Friday 22 June when it was discovered that he was no longer correctly registered.
21 June 2018: Behailu Kebede's evidence: Flat 16
Behailu Kebede evidence was read out. He explained that before the refurbishment he had a lovely flat which he had lived in for twenty five years, but after, none of the residents was happy. He noted that the window had gaps around it, there were gas pipes laid in the corridors restricting their width. There were electricity surges that damaged fridges and laptops. "I had no idea that highly flammable cladding had been installed on the outside of the building." 
On the night of the fire he returned from work, and napped in the living room being woken by a beeping; the kitchen door handle was hot, looking inside there was fire behind the Hotpoint fridge-freezer, which had never been faulty. He alerted his neighbours at 12:59 and called the fire brigade who arrived and seemed confident they could extinguish the fire. Then he watched from the outside as the fire got bigger and out of control.
Since the fire he has been harassed by media and the Daily Mail, and he is living in temporary accommodation to avoid them.
His tenant, Elsa Afeworki, wrote, "It was so quick and so strong. No one could control it. It was like the way petrol catches fire. … I just don’t understand why the council would have put the cladding up on the building that they did." 
The London Fire Brigade incident logs were published. Among transcripts that are to be cross-examined in week five, the "operational response" reveals that more than 140 fire engines and 720 firefighters were deployed; deputy assistant commissioner, Andrew Bell, told the inquiry on Thursday that it was probably the largest deployment of breathing apparatuses ever made in the UK.
Phase 1 evidence week 5
25 June 2018: Fire brigade incident officer's evidence
Michael Dowden gave evidence. He explained he had not been trained to handle a fire of this magnitude, and did not know that flammable cladding had been used on the Tower. He had done a familiarisation visit to the tower when the cladding was close to completion in 2016. He was in charge of the fire-fighting for the first hour. He revealed that his familiarisation visit was not an inspection, and he did not check or recall checking 11 of the 13 issues on a national guideline. These meant that protocols about evacuation were not checked, or whether there were people living in the building whose command of English might obstruct their understanding of those protocols, children who might need help, elderly people and people with mobility issues. No questions had been asked about the exterior cladding, or the nature of the lifts.
He said that he had received no training in what to look for when undertaking familiarisation checks of buildings. In his visit he did not inspect any of the cladding works, or the conditions of the fire doors. He could not remember whether he went up the tower. He did not note it had a single escape route or whether there were any sprinklers.
He revealed that training had been outsourced to the private company Babcock- and was mainly done as a series of computer simulations. He was logged as having completed on one on highrise fire fighting on 23 March 2017- but cannot recall having done so. 
He revealed that a routine document with essential details about the building to guide firefighters during a fire, was not created for Grenfell Tower. It would have told them of the dimensions of the building, number of flats, hydrant and dry riser locations, fire lift locations, stairwells, entrances, exits, sprinklers and the surrounding streets. The information that Dowden did print off was last updated in 2009. It said "the building had a 'stay put' policy but little else." 
26 June 2018: Fire brigade incident officer's evidence
Michael Dowden continued with his evidence. He had fourteen years experience as a fire officer and under London Fire Brigade guidance he was too junior to be left in charge of the fire as it raged out of control, that he felt out of his depth and was "consumed by sensory overload". He was the most senior officer until 1.50am, and by 1.28am he had ordered 15 fire engines to the scene. Normally he wouldn't be expected to put in charge of a six-pump fire. He didn’t know the tower was wrapped in combustible cladding and could not understand why it was "sparking and spitting" as it burned. The fire burnt though the UPVC glazing and had reached the top of the tower by 1.30 am. The residents were told the policy was to stay put, though some thought that Dowden should have reversed the instruction and executed full-evacuation. 
In his testimony, Dowden said that even if he had reversed the instruction, there were not the resources available to him to do so. He went in to fight a compartment fire, with 6 engines and one crew with breathing apparatus. He was faced with a fire raging 20 storeys above the fire-floor. There were a limited number of breathing apparatuses available. The building was designed with a solitary central staircase. Its design meant water was not available above 50m. He attached engine pumps to two dry risers, (the system of pipes designed to fight a fire on a single floor) this sent 230l/min to floor 3 and floor 4. Doing this for each floor was beyond the capacity of the system. 
27 June 2018: Fire brigade incident officer's evidence
Michael Dowden continued with his evidence. He said he felt helpless, and questioned whether there were not other officers in brigade who would have been better placed to fight this fire. Even when people were emerging he did not question the stay-put instruction; he had no reason to believe the fire could have spread internally outside flat 16. He ordered 25 engines to the blaze but did not have a plan on how they could be deployed. BA Crews arrived from Paddington, he ordered them to get hoses to the top floor, this didn't happen because they couldn't be sure that the stairs were still safe. The smoke was so toxic, that two inhalations rendered the victims unconscious. When a helicopter arrived it was deployed to drench the east elevation. Ladders could only reach the tenth floor and hose water up a further five.
Some of the questions he answered were repetitous- as they had been independently asked by the victims families. He could not continue when Richard Millett QC, counsel to the inquiry asked about Jessica.
Sir Martin Moore-Bick, the inquiry chairman, praised Dowden for his three days of testimony, saying he had shown "courage and candour". The Fire Brigades Union described the line of questioning about Fire Brigade Policy as "at times absurd" given Dowden's relatively low rank. Matt Wrack, the FBU general secretary said, "There clearly are important and difficult questions to ask but they should not be directed at those who do not have the power or authority to have altered policies, operational procedures or training," 
29 June 2018: Fire officer's Badillo's evidence: Jessica Urbano
David Badillo, who has served at North Kensington fire station for 20 years, said he met a teenager coming into the building who was distressed because her younger sister, Jessica Urbano, was alone in flat 176 on the 20th floor. He attempted to enter the building and rescue her.
The first attempt was aborted when the lift opened in floor 15 and was engulfed in black smoke. He didn't have any breathing apparatus so descended. The second time he jogged up the stairs to floor twenty and entered the flat. The door was open and it was empty- oxygen was running out so he descended. He was not aware she had fled to the top floor- or would have gone there too. Radio communications did not work on the night of the fire, he said. "They completely failed. Firefighters rely on communications to do their job properly."
He described incidents he had witnessed: use of shields to fend of falling debris. burning debris setting a fire engine alight, the noise was similar to fireworks, the fire fizzing like sparklers, the fire going sideways. "It looked as though the fire was catching from the cladding", he observed. 
Phase 1 evidence week 6
2 July 2018
Thomas Abell, drove one of the first pumps that arrived at the scene early on 14 June 2017. He wrote in a statement there was no sign of smoke or flames when he arrived. An hour later fire had spread across the face of the tower. He thought ‘This is going up like rocket fuel.’ The inquiry watched a video recorded from 01:15. Abell said that about 1.45am the ferocious flames had consumed more than half of one side of the tower; a fire in a tower block should not spread in that way, fires are normally fought from the inside and not the outside. All established firefighting techniques were not working.
Justin O’Beirne, a firefighter with 20 years experience, gave evidence of poor radio communications. He sent reports to his superiors but did not get an acknowledgement- he assumed they had heard him but they hadn't. He cannot recall hearing any radio traffic. He found the stair column strangely silent with no alarms sounding and an unbelievable amount of smoke. 
3 July 2018
Dan Egan, a senior fire safety officer with 25 years’ experience, said he believed the tower should have been evacuated when he arrived just before 2am on 14 June 2017, Pete Wolfenden and group manager Tom Goodall, senior firefighters overseeing the response, agreed. The stay-put policy had been based on the tower's original design and was intended to limit fires to individual flats. With combustible cladding the flames spread quickly, jumping 19 floors in 12 minutes. The stay-put instruction was only changed to evacuation at 2.47 am. 
4 July 2018
Grenfell firefighter prepared to die when oxygen almost ran out. Christopher Scarlet reports the fire lift was jammed, how he ran out of oxygen while trying to save Jessica Urbano, and the heat in her flat, 176. He expected flashover, which is when the temperature increases and increases so everything in the room self-combusts. With no air left he asked Baudillo to escort him down. How on the ground how an officer was hit by a body jumping from a high floor, and that the stay put policy was wrong.
John O’Hanlon described the effect of carrying the body of a three-year-old girl, had on him. He said that it reminded him of a YouTube video of a cladding fire in Dubai, he had seen. They had had a slide show, in 2016, of that fire but no training on how to fight that type of fire. He was one of the first officers to enter the flat where the fire started. They pumped at least 240 l/min of water at the burning plastic window surround. The flames would not go out; outside of the building was '“roaring” like a burning gas main'.
Daniel Egan, a fire safety manager who was responsible for relaying information from 999 calls from people inside the tower to the firefighters said there were “heated discussions” between firefighters over whether enough was being done to save people. He was effected by not being able to get help to flat 133 on the 17th floor.
5 July 2018
Grenfell firefighters ran out of the most basic equipment, inquiry hears. Watch manager Brian O’Keefe described how firefighters risked their lives to save people by going up the burning building without proper equipment and how radio communications had failed. He revealed the anguish of colleagues who told eight people to stay in a 14th-floor flat for their safety, four of whom died.
At one point he sent colleagues without “firefighting media (water) and breaking-in kit because we didn’t have enough of it”; he told them to use any discarded equipment they could find on the stairs. “We had used all of our resources … I knew it was too dangerous and that their lives were in danger". For a time, there were no BA crews left to deploy. This was not controlled operation but a desperate bid to rescue people."
Firefighters were overwhelmed by the number of calls from people inside the tower; a failure in communications meant the details from the 999 calls were being ferried in on slips of paper, under falling debris. A four man crew went to rescue a solitary man from a 15th floor flat- and discovered eight people, four of whom subsequently died. O’Keefe had to physically stop some residents from reentering the building to try to save their children. Firefighters could not see and were moving around by touch, some had given their breathing masks to the children they were helping and were abandoning kit to get out alive themselves. Firefighters were collapsing from heat, smoke and exhaustion. At around 4am and 4.30am, there was a final rush through the lobby of mainly unconscious children and teenagers. 
Phase 1 evidence week 7
10 July 2018
Daniel Meyrick, who was the watch manager at Dowgate fire station, on 14 June 2017 gave evidence. He was part of the first command unit mobilised. He said the Control Room officers were handling a large number of calls from the public but the radio link to the crews was failing. He intercepted the calls, and transferred them to paper. These were passed to the firefighters, but communication was one way, and he had no way of knowing if a rescue had been successfully made. 
Phase 1 evidence week 8
14 July 2018: Jason Oliff, station manager evidence
Control was usually at Merton, but as it was unavailable, control that night was at Stratford; the TV was switched off, it was broken. “Merton always has a large-screen television switched on and I believe this is an invaluable tool in decision-making when an incident like this is unfolding,” said officer Jason Oliff, station manager at Chiswick and Feltham north-west area. He recalled that he had to advise an operator to tell a father to go back up the stairs to search for his family while strongly believing he would not survive. In fact, the man's family had already been assisted out of the building by firefighters. The man's unborn son later died, but the rest of the family survived. 
On the 5 September, fire officer, Peter Johnson, a station manager from Hammersmith, claimed that the building plan was not in the fire box in the lobby hindering rescuers attempts to control the fire and rescue residents. They were aware that gas pipes and service ducts had been relocated during the cladding and refurbishment, and the floorplans of the upper storeys were different to those below. "The plans themselves would have fed into the operational plan, it has a vital part and a vital role detailing fixed installations and detailing everything within the building. It would detail the pipeline of gas, of water, where electricity was – it was vital that we needed those plans."
On 6 September it was described how 4 people had been directed to a smoke free flat to await rescue; and then missed due to a communication problem and subsequently perished.
In his evidence on 15 November the chief executive of the company that managed Grenfell Tower, Robert Black, revealed emailed senior officials at the Kensington and Chelsea Tenant Management Organisation (KCTMO) on the morning of 14 June as the fire still burned. He had been at the site at 2.45, and could not understand how a refurbished building could be engulfed in flames. He was warning there were "questions about the cladding and specifically questions about how the fire spread".  He said; "We need to pull some of this together pretty fast in terms of health and safety compliance. We need all the information about the refurbishment as this will be a primary focus."
Richard Millett QC, counsel to the inquiry, asked Black to confirm that on the night of the fire KCTMO’s emergency plan for the building was 15 years out of date and was not changed to reflect the refurbishment. Black agreed but pointed out that it was not activated, the RBKC plan was activated. The company actually has no role in the emergency plan "as the local authority liaison officers are the key part."
It was revealed that in July 2014 an official from the TMO emailed the project team: “We need good costs for Cllr Feilding-Mellen.” At that point £300,000 was removed from the cladding budget and zinc panels were replaced with the aluminium composite material with a plastic core, which the government has now banned from use on high-rise residential blocks.
On 12 December, the inquiry concluded phase one. In their final submissions, Stephen Hockman QC, the barrister for Arconic claimed that the Reynobond aluminium composite panels cladding had not been responsible for the disaster. If the replacement windows and sub frames had been installed correctly the flames from a simple kitchen fire could not have bridged the gap into the cladding, and could have been put out with a simple fire extinguisher.
Martin Seward counsel for the Fire Brigades Union said that the Royal Borough of Kensington and Chelsea had failed to make an evacuation plan for Grenfell Tower and relied on an outdated "stay put" strategy, leaving it to the fire brigade on the ground to devise an evacuation strategy. He urged the inquiry to give his members from "protection from unwarranted criticism".
But the Kensington and Chelsea Tenants Management Organisation’s counsel, Alice Jarrett, said that although the building only had a single stairway "it managed to continue supporting evacuations and firefighting activities throughout the life of the fire" and that expert evidence suggested that 239 people could have got out after seven minutes.
Alice Jarrett, counsel representing Kensington and Chelsea Tenants Management Organisation said, "The inquiry will want to consider that the stairs at Grenfell Tower could have coped with a full building evacuation." They remained operational throughout the fire; 239 people could have exited within seven minutes if so instructed. Expert Dr Barbara Lane, had said the stay put policy effectively failed at 1.23am, but it was kept in place until 2.37am when 107 people were still inside; 36 lived.
It was announced that Phase Two was unlikely to start before 2020. Time is needed to collate the 200,000 items of evidence and to allow time for the separate inquests on each of the 72 individuals to be concluded in accordance with Human Rights legislation.
The appointment of Sir Martin Moore-Bick to lead the inquiry was questioned on 3 July by lawyers acting on behalf of the families and on 4 July by the MP for Kensington, Emma Dent Coad. They all called for him to stand down, with the local MP saying that Moore-Bick lacked "credibility" with victims, who needed "somebody we can trust." Having spoken, she said, with hundreds of those affected, "We need somebody who can do the detail but we need somebody who can actually understand human beings as well." Lord Chancellor David Lidington said Moore-Bick would lead the inquiry "with impartiality and a determination to get to the truth and see justice done".
On 25 July, at the second public meeting held by the Inquiry before finalisation of the terms of reference, various residents criticised the lack of diversity of the Inquiry panel, saying that it did not represent the community. Citing the Westminster City Council case, in which Moore-Bick allowed a local resident to be rehoused 50 miles away with no explanation, a resident said "Your very presence is an affront to this community." There were calls for Moore-Bick to recuse himself. Moore-Bick responded, "We are going to investigate and find the facts in relation to the whole course of events" leading up to the fire.
Labour Party politicians and some survivors have argued that the inquiry should include an examination of national policy in national policy towards social housing. In his letter to Theresa May proposing the Terms, which were agreed without amendment, Moore-Bick had noted that many of those affected by the fire and others had been in favour of this. He argued, however, that this would add significantly to the time required to complete his work, and that such an examination was better suited to a different kind of process and not to a judge-led inquiry. in her response, Theresa May said that the Housing Minister Alok Sharma would "personally meet and hear from as many social housing tenants as possible" both in the immediate area and further afield.
In response, Jeremy Corbyn wrote an open letter to Theresa May saying: "The fire has raised profound concerns about the way that social housing is provided and managed in this country, and I as well as many survivors worry that without a wider focus, the inquiry will fail to get fully to grips with the causes of the fire." Corbyn also said May should "immediately set out a clear, independent and thorough process for identifying and addressing the broader failings that led to the Grenfell fire." Matt Wrack of the Fire Brigades Union said, "Central government has created the housing and fire safety regime and central government must be held to account for any failings in it. Yet the terms of reference signed off by Theresa May appear designed to avoid this."
Anna Stec was appointed as additional expert witness to the inquiry 19 September 2018. She had been doing independent research on the long term effects of the smoke and the fumes on the surrounding soil. She had briefed Public Health England in February that it was not sufficient to monitor large particles in the air but small particle that had landed a long distance from the tower and been absorbed into the soil. She was sufficiently concerned by her interim findings to warn Public Health England who had been monitoring the air, that the soil samples she had taken up to a mile away from the tower were hugely toxic. The so-called "Grenfell Cough" suffered by survivors, near residents and firefighters indicated the presence of carcinogenic polycyclic aromatic hydrocarbons (PAC)s, and the black soot that fell, and is now in the soil probably contains asbestos. Hydrogen cyanide was also present. When this was not acted on, a synopsis of her interim report was published in the Guardian- she calls for addition soil samples to be taken by PHE and Royal Borough of Kensington and Chelsea, and the groups named to be monitored for long term effects through saliva, blood and urine tests.
On 7 January 2018, an open letter to the Prime Minister signed by 71 academics and several politicians was published. This described concern for a possible conflict of interest of the auditors KPMG, who audited the Royal Borough of Kensington and Chelsea and companies responsible for the cladding on Grenfell Tower. This was viewed by signatories as a conflict with their neutrality on the enquiry. In response, KPMG agreed to immediately withdraw from the enquiry and waive its fees.
Concerns about the order of the inquiry
The first part of the inquiry to be published will report on the performance of the rescue effort. Matt Wrack, the general secretary of the Fire Brigades Union, claimed the inquiry process risked becoming a "whitewash" as the key issue, ministers’ deregulation of building standards and the roles of companies involved in the tower’s £10m refurbishment will be addressed in the second phase when public interest has faded. 
Phase 1 Report: October 2019
Sir Martin Moore-Bick issued the first part of the report Wednesday 30 October 2019, though some parts had been leaked days earlier. He found that :
- Behailu Kebede, in whose fourth floor flat the fire started, was not at fault.
- The principal reason the fire spread was the aluminium composite cladding filled with plastic used on the building exterior.
- Firefighters showed “courage and devotion to duty” and 999 call operators were “unstinting” in their efforts to help trapped residents.
- Incident commanders were not trained to cope with the fire and there was no contingency plan for evacuation.
- The LFB failed to lift the “stay put” advice when the stairs remained passable, which cost lives.
- The brigade suffered “significant systemic failings”.
- Communications systems failed and there were serious deficiencies in command and control.
- Pictures transmitted on the night of Grenfell could not be viewed by the LFB because the encryption was incompatible with its receiving equipment.
He highlighted the Dany Coton's rhetorical question “It’s all very well saying ‘get everybody out’, but then how do you get them all out?”, saying that it demonstrated that the London Fire Brigade had never considered that question before the night of the fire
There were 46 recommendations embedded within 35 paragraphs of chapter 33 of the four volume full report, and published again in the executive summary. The press have printed a selection. For example the Guardian published: 
- A law requiring owners and managers of high-rise residential buildings to provide their local fire and rescue service with information about external wall materials and building plans.
- Fire brigade inspections of high-rise buildings to be improved and crews trained to carry out more thorough risk evaluations. Regular inspections of lifts intended to be used by firefighters are needed.
- Communications between fire brigade control rooms, where emergency calls are received, and incident commanders must improve and there must be a dedicated communication link.
- Government should develop national guidelines for carrying out partial or total evacuations of high-rise residential buildings.
- Fire doors in all multi-occupancy, residential properties should be urgently inspected.
- Improvements should be made to the data links provided by helicopters of the National Police Air Service. 
On 6th December, Dany Cotton announced her early retirement effective from 31 December 2019 after 32 years of service. This followed calls from bereaved families and survivors of the disaster for her to quit.
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