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Grenfell Tower Inquiry diary week 83: ‘They died together as they lived: caring for one another’

Insight15.07.2212.00 PM by Peter Apps

A second week of evidence relating to the circumstances in which the victims of the fire died delivered more heartbreaking stories about their final moments. Peter Apps recaps

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A second week of evidence relating to the circumstances in which the victims of the fire died delivered more heartbreaking stories about their final moments. Peter Apps recaps #UKhousing

The Grenfell Tower Inquiry’s concluding ‘mini-inquest’ section continued this week, with presentations setting out the final moments of 28 of the 72 victims.

These details are being examined by the inquiry in the hope that the resulting findings can be adopted by the coroner investigating the deaths, relieving the families of the burden of another lengthy legal process

The details by nature are upsetting, and the inquiry is careful to issue ’trigger warnings’ at the start of each session. It is worth repeating such a warning for our report, which contains details of the final moments of some of those trapped in the tower.

‘Our final reflection is that this mother and son stayed together’

The presentations this week began with mother and son Majorie and Ernie Vital, who died in Flat 202 on the top floor of the tower.

Majorie was 68 at the time of the fire, and had grown up on the Caribbean island of Dominica before moving into Flat 162 on the 19th floor of Grenfell Tower in 1978.

She worked as a seamstress to support her children and was described as an “ambitious and talented” woman who “put her children first”.

Ernie, who lived in north London, was 50 at the time of the fire. He was visiting his mother that night, as he often did. He was described as “a lively and engaging person, a very good dancer, but also down to earth”. He was especially close to his mother.

Majorie had Parkinson’s disease – a condition that had been disclosed to the Kensington and Chelsea Tenant Management Organisation (KCTMO) in October 2014.

“Based on the information about Majorie’s diagnosis, it is likely that she was significantly impeded in her ability to independently evacuate down the single stairs from Floor 19 in the event of a need to do so,” said Danny Friedman QC, appearing for the family.

“As with other cases of this type, there is no evidence in the available records of any consideration by any relevant body as to how Majorie would evacuate in the event of a need to do so in response to a fire.”

As we discussed in last week’s diary, this failure was systemic and is becoming a major theme of this phase of the evidence.

The pair were alerted to the fire shortly before 1.30am, when a resident on their floor roused them, having just experienced the blaze breaking into his kitchen as it tore up the outside of the tower.

Around this time, many people descended via the stairs or lift and left the tower – a total of 77 between 1.15am and 1.31am.

But 15 residents went up to the very top of the building instead of going down – where 14 of them later died.

Why these residents went up rather than down remains an unresolved issue, and has been a question at the heart of several of the presentations so far.

Lawyers have put forward several possible explanations. Were they advised to go up by firefighters? Several residents who survived the fire recall being told to go back up to their flats by firefighters as they descended – advice that they ignored.

One resident who left her flat at 1.28am recalls hearing a male voice lower down the stairs “shouting in a clear English accent, ‘go back, go back’”.

This was said to have the effect of “causing people to turn around in panic”.

But none of the 999 calls, or calls to relatives, from those who went back up the tower to the top floor referred specifically to an instruction from firefighters.

Some said other residents advised them to go up the stairs. Others explained they believed there was danger below.

It is now known that firefighters were attempting a rescue on Floor 16 at exactly this point, during which a stairwell door was held open and smoke may have spread suddenly into an otherwise relatively-smoke free stairwell.

Mr Friedman said this “could well have contributed to the perception of descending residents that there was a fire in the middle of the building”.

Some also appear to have believed they would be rescued from the roof by a helicopter.

While there is no direct evidence from Majorie and Ernie, Mr Friedman noted: “Majorie, as with others who travelled up… would have found the walk to the top of the building less physically daunting than walking all the way down to the ground floor.”

Whatever the reason, the fact is that this group of 15 residents arrived on the 23rd floor shortly after 1.30am and were welcomed into the homes of those who lived in the flats.

Majorie and Ernie Vital entered the home of Gloria Trevisan, 26, and Marco Gottardi, 27, a pair of young Italian architects who were renting privately in the tower.

They had moved into their flat in April 2017 – just three months before the fire – having only arrived in England in March.

“Both were talented, aspiring young architects, who had met while university students in Venice two years before,” said Michael Mansfield QC (pictured above), representing the family. By the time of the fire, they had both recently secured positions in well-known architectural practices in London.

Gloria was working at Peregrine Bryant on the restoration of old buildings, which was said to be “her forte”.

She had been at the firm for only nine days by the time of the fire, but her work had already been deemed “exceptional” by its principal.

When Gloria opened the door to Majorie and Ernie at 1.34am, she was on the phone to her mother. She told her that there was “thick, black, dense smoke” on the landing.

This smoke is important. Mr Friedman said it was “the extent of the smoke in the lobby” on the top floor that caused those trapped in Flat 202 “to believe that escape was not possible”.

Mr Mansfield noted that Gloria and Marco were both young and fit enough to have descended, with the inquiry’s expert toxicologist estimating they could have done so and survived until 2.45am.

“For Gloria and Marco, however, and others on Floor 23, it was the appearance of the black smoke in the lobby which, quite naturally, was forbidding. They saw the thick smoke in the lobby and most likely thought the conditions beyond that were the same or worse,” he said.

But where did it come from? Mr Mansfield drew attention to the witness statement of Farhad Neda, one of the few to escape from the top floor, who recalled seeing smoke entering the lobby through the extraction system at some time before 1.30am.

It has been suggested in earlier modules that smoke may have been pulled up from lower, smoke-logged floors and seeped out on higher floors.

Gloria and Marco phoned their parents in Italy – some of whom were watching images of the tower burning on television – frequently throughout the night.

Marco told the family they had been told to stay where they were. While it is not clear where this advice came from, Mr Mansfield said it was possible the information came from others on the top floor who had been given this advice directly.

Several other residents in flats on the 23rd floor called 999 and told the London Fire Brigade (LFB) that they were trapped, being affected by smoke and fire, and needed urgent help. All of them were advised to stay put and told help was coming.

However, the highest firefighters ever reached was the 22nd floor, when a group who had been deployed to try and fight the fire from the roof rescued a resident they found trapped in the stairs.

There were no deployments to rescue residents from the top floor until 2.08am. None of the crews sent to try and reach those at the top of the building ever made it all the way up.

They were unable to use the lift to assist, as it was not a ‘firefighting lift’, which meant it was not technically suitable for assisting with evacuations.

“What assistance a different kind of lift might reasonably have provided if it was properly maintained and integrated into LFB planning and training is a matter that has been the subject of submissions in other modules,” said Mr Friedman.

The inquiry has heard that part of the reason for not including a firefighting lift was a perceived fear of anti-social behaviour – a belief that the presence of a roof hatch would result in joy riding.

Marco and Gloria spoke regularly to their parents in the hours that followed, as conditions in the flat deteriorated and flame eventually broke through the window.

The last call from Marco to his father was timed at 3.15am, at which point his voice was barely audible.

Describing these conversations, Mr Mansfield said: “There is much, much more on this recording from a young couple facing an inevitable demise with incomparable strength and resilience, and a generosity of spirit which conveyed a loving gratitude to their parents and reflected, really, the community in the tower as well.”

Both lawyers said the evidence, including toxicology samples taken from victims within the flat, indicate they died from the inhalation of fumes. The time of death was estimated between 3.15am and 3.30am by the inquiry's expert.

Marco and Gloria’s families have since established the Grenfellove Marco and Gloria Foundation in their memories.

“Our final reflection is that this mother and son stayed together,” said Mr Friedman, in reference to Majorie and Ernie. “While it is feasible that Ernie could have escaped without assistance, Majorie could not. In his video commemoration, the surviving son and brother told you that there is no way that Ernie would have left his mother. As such, he was as trapped as she was.

“The mother and son died in terrible circumstances, but had the final gift of being together. They were also given shelter in the home of Gloria and Marco, who did not know them but showed them kindness until the end. That is a theme that runs through the tragic events of Floor 23.”

‘They died together as they lived: caring for one another’

On Tuesday the inquiry heard a presentation into the tragic circumstances of the deaths of six members of the Choucair family.

Bassem and Nadia Choucair and their three daughters Mierna, Fatima and Zainab all lived in Flat 193, and Sirria Choucair, Nadia’s mother, lived on the same floor in Flat 191 as a result of a tenancy swap to bring the family closer together.

Sirria, born in Lebanon, worked for most of her life in the catering industry at the Royal Marsden Hospital.

“No one worked harder than Sirria to care for and support their family,” said family lawyer Mr Friedman (pictured above). “Sirria was remembered as a proud, resilient and devout woman, who was patient and gentle and always thought of others before herself.”

Nadia, 34, was a nursery school teacher assistant at a nursery near the tower and Bassem, 40, worked in a branch of Marks and Spencer in Earl’s Court.

“Nadia had a heart of gold, with the work ethic and resilience of her father and mother. Her cheeky smile brightened up the people around her,” said Mr Friedman. Working with children was said to be her “passion”.

Bassem was described as “an incredibly hard-working and conscientious person”, who had worked his way up to section co-ordinator within his branch of M&S. His work ethic was such that he texted colleagues at 1.55am on the night of the fire to let them know he would not be in the next day and to help arrange back-up plans.

Their daughters were 13, 11 and three at the time of the fire. Mierna, the eldest, wanted to study law and was described as “ bright and confident and loved learning”, a strong swimmer and a talented artist. Fatima, aged 11, was described as “very popular, with a lot of friends” and dreamed of being a gymnast. The youngest, Zainab, known as ‘Zoo-Zoo’, was said to be “adorable, the spark of the family, a showstopper who would steal the limelight no matter the occasion”.

They were described as “an extraordinary, close-knit, joyful and loving family” with “close ties to their community, in the tower”.

Sirria had health problems, including severe arthritis, which required her to walk with a stick. She was unable to leave the home when the lifts in Grenfell Tower were out of order. Her problems were known to her landlord, Family Mosaic (now part of Peabody) at the time of the exchange which took her to the tower.

“The significance of Sirria’s mobility issue for fire safety was not considered within the tenancy exchange application process or during the period of her tenancy at Grenfell,” said Mr Friedman.

Like others in the tower, no arrangements were made for an evacuation plan nor were there any pre-existing arrangements with the LFB to allow for her rescue.

Mr Friedman said Mierna, 13, was first alerted to the fire by a call from her best friend outside the tower. Her immediate response was to go and help her grandmother in the neighbouring flat.

Two women who also lived on the 22nd floor were invited to shelter in Flat 193 by the Choucair family.

After several calls to the LFB control room from other residents on the 22nd floor describing smoke and fire, Nadia made her first call at 1.40am. With the lines overwhelmed, she was placed on hold for seven minutes before being put through to Essex County Fire and Rescue.

Immediately upon connection, she said: “Please help us.”

She explained that conditions were deteriorating and was told at 1.48am: ”We’ll go back through London for you.”

But this did not happen. The call handler could not get through to LFB until 2.18am. When they did, they incorrectly said Nadia had not provided a flat number. A liaison officer did pass on the details to the Metropolitan Police at 2.28am, but it is unclear if they ever reached the LFB.

However, LFB logs showed that the information that residents on the 22nd floor were trapped, with smoke coming into flats, was passed on to the officers at the incident at around 1.43am, due to calls from residents in other flats.

But no deployments of firefighters were specifically made to the floor for the purposes of rescue until shortly after 3am. This was despite other residents on the floor being explicitly told firefighters were on their way.

The two firefighters deployed to the 22nd floor did not reach it, and no other crews were dispatched.

Mr Friedman said that Sirria’s condition meant she would have been unable to descend the stairs without fatal exposure to asphyxiant gas once the conditions deteriorated.

“It is a fact that residents with such mobility impairments and family or friends who were not prepared to leave them were trapped,” he said.

Again, attention was drawn to the lifts, which could not be used for evacuation and which firefighters had been unable to bring under their control.

Nadia called 999 again at 2.36am, explaining that there were eight people in the flat and “repeated throughout the call, with increasing anxiety, that there was too much smoke in the room”.

The call handler told her: “We are coming to you. We will get to you, OK?”

Bassem phoned at 2.43am and asked if there was any chance they could be rescued by helicopter. He told the call handler fire was about to come into the flat. By this point, the stay put advice had been lifted and the family was told to get themselves out for the first time.

But the call handler also said: “You make the decision whether you think you need to leave or not.”

Mr Friedman drew particular attention to the family’s belief – in common with other victims – that they may be rescued by helicopter. Some call handlers implied that this was a possibility, when it was not.

“The presence of helicopters is of great significance to the members of the Choucair family,” he said. “Like other occupants of the tower, Nadia and Bassem were left with a false hope that a helicopter rescue was possible.”

The family made an effort to escape following this call, but with the severe smoke conditions had to return to the flat.

Another family, the Hashim-Kadirs, also joined the Choucairs in Flat 193 shortly before 3am. With their two neighbours, this brought the population of the flat to 13. Bassem made several further calls where he asked several times for rescue by helicopter and warned that fire was breaking into the flat.

The two neighbours were able to leave and escape down the stairs, where they met the firefighters who had been deployed to Floor 22, who guided them to safety. They told the firefighters at least 10 more people, including children, were trapped in Flat 193.

At 3.21am, the Metropolitan Police phoned Nadia back due to a 999 call being cut off. They told her she needed to “escape by all means necessary”. It appears the family attempted to do so but could not.

The evidence suggests they died, close together, in the south-west corner of the flat. The inquiry’s expert toxicologist estimates the adults lost consciousness between 04.11am to 04.13am, dying shortly afterwards.

“Based on the positions of the family’s loved ones, it appears that the adults had formed a protective shield around the children and, in a very powerful sense, they died together as they lived: caring for one another,” said Mr Friedman.

He read a comment from surviving members of the family, who saw three generations of their family killed that night. They said: “Our loved ones now look down at us to get the justice they deserve in every way. Our loved ones now look down at you, the chair and panel members, for justice. Grenfell must never ever happen again so that no one will ever suffer the way we are suffering now.”

‘She had a richness of life and the richness of heart’

Among the presentations on Wednesday was Ligaya Moore, a 78-year-old woman who lived in Flat 181 on the 21st floor of the tower.

The second of four children, she was born in the Philippines, where many of her family members still live. In 1972, she travelled to London and found work as a nanny.

She was described as “a stylish, sociable woman” who was “highly fashion conscious” and a passion for ballroom dancing.

“Here was a woman of stature, here was a woman who exudes happiness, in one sense, in her clothing, how she, as it were, appears to the world. She would always wear heels, claiming she didn’t know how to walk in flat shoes,” said Michael Mansfield QC, appearing for her family.

Ms Moore lived alone in the flat after her husband, Jim Moore, died in 2007.

She had been identified as a vulnerable resident by KCTMO because of her deteriorating health and an “accumulation of possessions” in her flat, many of which related to her late husband.

Mr Mansfield described this as “a special need which needs care and attention and support”, adding that “her family are anxious that this part of her life should be taken seriously to enable, for the future, the creation of fire safety strategies and contingency plans, especially for high residential blocks like hers in future, and particularly those with special needs, of which she was plainly one”.

Mr Mansfield showed pictures of Ligaya’s flat to the panel, which he said illustrated “really quite dramatic scenes”.

In September 2015, a review by the council’s adult social care team said: “Ms Moore is at a fire safety risk.” It rated the possible risk as holding ”catastrophic” consequences, including death and multiple serious injuries. This position continued until the night of the fire.

Mr Mansfield suggested this may have contributed to “her mobility and ability to move within the flat” as well as contributing fuel to the fire once it reached her flat and meaning doors were likely wedged open.

Ms Moore’s case is a particularly special one, because despite having a working mobile phone she made no calls on the night of the fire – either to the emergency services or to friends or family outside the tower.

A close friend phoned her repeatedly, but she did not pick up. Mr Mansfield said it was “possible, if not likely” that she was asleep and simply never woke up.

It is estimated that fire reached the outside of her flat between 1.29am and 1.40am and impacted the inside by 1.53am. Ms Moore’s friend began calling her at 1.30am on a landline and mobile, which were known to have worked.

“The first possible scenario for Ligaya, and we say perfectly reasonable on the evidence, is that… she finally did get to sleep, and because of all the medications, I’ve no doubt it’s possible to surmise she fell into a deep sleep. She didn’t hear the onset of the fire, nor her telephones,” said Mr Mansfield.

He said it was possible that she inhaled smoke during her sleep and passed away without ever waking up. After the fire, her flat was described as having suffered “a complete burn with no internal walls remaining”.

Her remains were located in the bedroom, near the bed, although Mr Mansfield said there was a “mild inference” from the location that she may have “tried to move, possibly in a semi-conscious state” and was deterred from leaving by the fire before being overcome.

Mr Mansfield summed up his presentation saying: “She had a richness of life − these are the words of the family − and the richness of heart, that she will be dearly missed by [all of] them.”

The evidence surrounding Ms Moore may become important if and when criminal investigations begin in earnest. There has been some suggestion by those familiar with the process that a tactic of any parties charged with manslaughter will be to claim that the ‘stay put’ advice given to residents represents “a break in the chain of causation”, relieving them of criminal responsibility for the deaths.

But this argument – should it be put forward – is extremely hard to make for some residents, given the circumstances of their deaths. Ms Moore, who received no advice to stay put whether directly from the LFB or indirectly is certainly one of those.

‘Was there any area of the building which had been affected by the fire which was not sieved and searched?’

Before all these presentations, the week began with evidence from Dr Karl Harrison (pictured above), a forensic archaeologist who has several decades’ experience helping police investigate crime scenes, such as clandestine graves and burial grounds.

He began work at Grenfell Tower on 16 June – two days after the fire – managing a team of 36 forensic archaeologists.

The team undertook a search of the building, followed by “comprehensive sieving of all debris within the tower” in a programme of examination that ran until December 2017.

“Was there any area of the building which had been affected by the fire which was not sieved and searched?” asked Richard Millett QC, lead counsel to the inquiry.

“No, I’m not aware of any area that wasn’t sieved and searched, to the extent that we pumped out the water from the two sub-basements and any material within that was gathered and sieved,” replied Dr Harrison.

For quality control purposes, a pen lid was hidden in one of the flats due to be searched for the day, and each day it had to be found to ensure the searches were completely thorough.

A challenge, though, was the structural stability of the tower. It was fitted with collapse alarms that blared if they detected any structural movement during the operation – which happened several times.

Some flats also required steel support frames to be put in place to support the ceiling above. But this meant sweeping away debris which may have included human remains.

Asked if this hindered his work, Dr Harrison said: “Were there to have been a highly fragmented body directly where that shoring needed to be put, our ability to reconstruct where that body is, other than to say it’s within that sector, would be hampered. We would still find the elements, but they would be dispersed within that sector.”

Any human remains that were discovered were sealed, transferred to the local mortuary by private ambulance and assigned a unique reference number to ensure they were properly reunited with the bereaved families.

As well as those described above, the inquiry also heard presentations on Tuesday for Hashim Kedir, Nura Jemal and their children Yahya, Firdaws and Yaqub, who died in Flat 193 alongside the Choucair family. It also heard one for Gary Maunders, who was visiting a friend in the tower on the night of the fire. The transcript for those presentation can be found here.

On Wednesday, the inquiry also heard presentations relating to Tony Disson and Shelia, an 84-year-old woman who went by her first name only, as well as Ligaya Moore. The transcript for those presentations can be found here.

On Thursday, the inquiry heard details relating to Victoria King, Alexandra Atala, Mary Mendy and Khadija Saye, as well as the shockingly tragic story of the Belkadi family. The transcript for those presentations can be found here.

The inquiry returns next week for the final presentations for 23 further victims, which will also mark the end of the mammoth second phase.

Grenfell Tower Inquiry phase two: weekly diaries

Module one: the refurbishment

Week one: A vivid picture of a broken industry

After a week of damning revelations at the opening of phase two of the Grenfell Tower Inquiry, Peter Apps recaps the key points