The Greenfell Tower fire that killed 72 people in London in 2017 was caused by decades of failure at many levels of government, the damming final report from a public inquiry into the catastrophe has warned.

The final 1,700-page, seven-volume report from Grenfell Tower Inquiry chaired by Sir Martin Moore-Brick has been released.

It found that there were widespread failures that occurred over decades – each of which contributed to the tragic event.

“We conclude that the fire at Grenfell Tower was the culmination of decades of failure by central government and other bodies in positions of responsibility in the construction industry to look carefully into the danger of incorporating combustible materials into the external walls of high-rise residential buildings and to act on the information available to them,” the report said.

The Grenfell Tower Fire was Britain’s worst residential fire since World War II and led to the deaths of 72 people.

The fire started in the early hours of June 2017, when fire broke out in the kitchen of Flat 16 of the Tower – a high rise building in North Kensington, West London.

The kitchen fire was nothing out of the ordinary and should have been contained within the confines of the flat.

However, it escaped from the kitchen into the building’s envelop, which was constructed of reinforced concrete to which a highly flammable cladding system had recently been added.

Once established within the cladding, the fire raced vertically up the outside of the building.

Within 20 minutes a vertical column of flame had reached the top of the building on the east side. From there, it progressed around the rest of the structure and had engulfed almost the whole of the building within a few hours.

A particular factor which contributed to the fire’s spread was the construction of the building’s wall.

The building was constructed of reinforced concrete, to which an external cladding system had been added as a result of a recent renovation.

The cladding system comprised of insulation boards attached to the outside of the concrete structure. These were protected from the weather by aluminium composite material rainscreen panels.

The rainscreen panels contained a highly flammable polyethylene core – something which has contributed to the rapid spread of many multi-storey building fires over recent years.

The material from which most of the insulation boards were made, polyisocyanurate foam, is also combustible.

The public inquiry was set up to examine the cause and origin of the fire, how it was able to spread throughout the building and how the building came to be in such bad condition so as to enable it to do so.

The inquiry also looked at the fire brigade response, the scope and effectiveness of building regulations and the response of local and central governments.

(A separate inquiry chaired by Dame Judith Hackitt examined how building regulations particularly in relation to fire safety could be improved. That report found that the Uk regulatory system regarding high-rise and complex buildings was not fit for purpose.)

The public inquiry has been conducted in two phases.

The first phase set out to examine the course of the events from the start of the fire to the escape of the last survivor at 8:07am the following morning.

In the second phase, the Inquiry looked at how it was possible in 21^st century London for a reinforced concrete building (itself structurally impervious to fire) to be turned into a death trap that would enable fire to sweep through it in an uncontrollable way in just a few hours.

In its report, the inquiry panel that the fire was the culmination of decades of failure on many levels.

In particular:

• The UK Government, and in particular the then Department for Communities and Local Government, failed to take appropriate action despite having had many opportunities to identify risks associated with the use of combustible cladding panels and insulation, particularly on high-rise buildings. The department itself was poorly run and displayed a complacent and defensive attitude toward fire safety.
• Work of the Building Research Establishment (BER) in relation to testing of the fire safety of external walls was marred by unprofessional conduct, poor reporting and a lack of scientific rigour. (The BER was a government body that was charged with responsibility to carry out research and testing of construction methods and products.)
• Lax practices from certification bodies including the British Board of Agreement and Local Authority (as well as lax practices from UKAS – the body charged with oversight of certification bodies) resulted in failure to ensure that product certificates were accurate and based on test evidence. This enabled suppliers of rainscreen cladding and insulation products to engage in dishonest practices including misrepresentation of test data and misleading of the market.
• The relationship between the Tenant Management Organisation and its residents had been broken, with problems being identified with the governance, customer services, staff attitudes and a poor repairs service of the TMO.
• The choice of combustible materials for the cladding of Grenfell Tower resulted from a series of errors that were caused by the incompetence of the organisations and individuals who were involved with the building’s aforementioned refurbishment.
• A chronic lack of effective management and leadership within the London Fire Brigade meant that the Brigade had not addressed serious shortcomings in its ability to fight fires in high-rise buildings.
• Response and recovery efforts from the UK Government and the RBKC were muddled, slow, indecisive and piecemeal.
• In the years leading up to the Grenfell Tower fire, test methods available for determining the reaction to fire of materials, products and even external wall systems did not provide designers with the information needed to assess the risk of fire spreading across the external wall of a building. Moreover, the statutory guidance on complying with functional requirement B4(1) of the Building Regulations was fundamentally defective.

In response, the report made 58 recommendations. Thes included recommendations for the government, the construction industry and for firefighters.

Prime Minister Keith Starmer has promised that the government will look at all of the recommendations in detail and will provide a response in six months.

However, the newly elected Labor Government has already promised to speed up the removal of unsafe cladding, block Grenfell companies from being awarded work on government contracts, reform the construction products industry and ensure that social housing landlords are held to account.

Decisions on potential criminal charges are not expected until the end of 2026, and police and prosecutors have said that they will need until the end of 2025 to complete their report.

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