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Grenfell Tower Inquiry diary week 38: ‘Well it’s a bit more than that, isn’t it. He’s suggesting that you tell the LFB a lie’

Insight11.06.2112.45 PM by Peter Apps

The inquiry heard the mammoth cross-examination of KCTMO’s health and safety manager Janice Wray this week. Peter Apps reports

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The inquiry heard the mammoth cross-examination of KCTMO’s health and safety manager Janice Wray this week. Peter Apps reports #UKhousing

Janice Wray first started working at the Royal Borough of Kensington and Chelsea (RBKC) in 1986, and at Kensington and Chelsea Tenant Management Organisation (KCTMO) from its formation 1996 to its abolition in 2018 following the Grenfell Tower fire.

Her role was to advise on health and safety issues affecting the organisation. This included a wide range of issues, such as asbestos and accidents, but the important one for the inquiry is fire safety. What was Ms Wray responsible for? What advice did she give? Should she have done more to address some the failures that the inquiry has already uncovered?

These questions were the theme of her mammoth (and not yet complete) cross-examination across the past four days. We pick up some of the key areas investigated below.

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‘Do you know why your report doesn’t comment on the urgent and critical concerns raised by Salvus?’

In 2005, legislative changes required social landlords to carry out fire risk assessments to their blocks for the first time.

Initially, KCTMO tried to carry this out in-house, using members of Ms Wray’s (pictured above) health and safety team to do their risk assessments, despite their lack of formal qualifications.

In 2009, the London Fire Brigade (LFB) took issue with this approach. At a meeting in August 2009, its representatives said told KCTMO “assessments so far had not been up to a satisfactory standard” and warned it would issue an enforcement notice if a professional was not appointed.

Consultancy Salvus was appointed in September 2009 and asked to carry out assessments to KCTMO’s 110 high-risk blocks within six months.

Three weeks after its appointment, Salvus produced a report on general fire safety management arrangements within KCTMO and its conclusions were damning.

The report identified 19 areas where Salvus believed KCTMO was in breach of its statutory obligations. It covered issues such as the lack of an overall fire safety policy for the organisation, emergency plans for its tower blocks and formal policies for disabled and vulnerable residents.

But when Ms Wray prepared a report for the organisation’s board in October 2009, she did not mention these failings, recording that Salvus believed the organisation to “have good fire safety policies and procedures in place” albeit not always “consistently documented”.

“Do you know why your report to the board here doesn’t comment on many of the urgent and critical concerns raised by Salvus in their management report?” asked counsel to the inquiry Richard Millett QC.

Ms Wray claimed she did not see the report until November and did not yet know of its its contents – despite having had a meeting with Salvus two days after it was written in September.

But a further report to the board in December 2009 still did not mention the failures, it simply said the report “sets out the fire safety framework within which we and our [contractors] should be working”.

“Can you account for why, on the face of it, this paragraph says absolutely nothing about any of the statutory breaches or any of the defects in fire safety management that Salvus had identified in that September management report?” asked Mr Millett.

“No, I can’t give you an explanation,” said Ms Wray.

‘I believe they have shown some reluctance to challenge the LFB on thorny issues’

Salvus’ appointment to work for KCTMO did not last long. Rather than reappoint the consultancy to carry out further risk assessments to its medium-risk blocks, Ms Wray and her colleagues elected to reprocure.

They ended up appointing Carl Stokes, a firefighter with 19 years’ experience who had been working for Salvus on the contract but applied to take it on as a sole trader. He would carry out KCTMO’s risk assessments for the next six-and-a-half years, from 2010 until the Grenfell Tower fire.

But why was Mr Stokes chosen?

In February 2010, Ms Wray wrote to staff at RBKC suggesting retendering for the medium-risk programme.

“I have some concerns that Salvus are very rule-bound and despite what they say about being prepared to challenge the LFB and acting on our behalf as we are their client, I believe they have shown some reluctance to challenge the LFB on thorny issues,” she wrote.

She said this email related to a specific issue with some blocks that had been built without dry risers (hollow pipes which can be charged with water from an external hydrant to fill firefighters hoses on upper floors).

She said Salvus had “sat on the fence” about whether these would need to be retrofitted, as the LFB had demanded, and she wanted someone willing to give a “clear steer”.

This answer was challenged by Mr Millett (pictured above). “You’re not really saying that they’re giving you muddy advice or they’re being equivocal; what you’re saying is they’re taking the LFB’s side as opposed to taking your side,” he said. “That’s how I read that. Is that an unfair reading, Ms Wray?”

“That might be what it says, but that wasn’t what I meant it to say, having lived it,” she replied. “My view was I just needed to be absolutely sure [about the advice being given].”

‘This issue is not helped by a breakdown in communication between the health and safety and other departments’

With Mr Stokes appointed, the programme of fire risk assessments was at least being carried out. But the problem – as has been covered repeatedly with other witnesses – is that KCTMO was not very good at carrying out the actions Mr Stokes identified as necessary.

In fact, by 2014 the organisation had an enormous backlog of 1,400 actions outstanding. It chipped away at this list over the next three years but never got it under control and had 287 actions still outstanding at the time of the Grenfell Tower fire.

What was Ms Wray’s explanation for the backlog? She described the process as “frustrating”.

“I was chasing people and meeting with team leaders and taking along stats and escalating further up the organisation, and it sometimes felt that things were still not moving as swiftly as they should. So it’s a frustration in that it’s out of my control, yet I really need to try and achieve it,” she said.

Like other KCTMO witnesses, she cited difficulties with external contractors required to complete some of the actions. “We had poorly performing contractors that we were trying to take action against,” she said. “Sometimes it was that contractors were getting towards the end of their contract and were sort of a bit disinterested.”

In 2013, KCTMO was criticised for its health and safety performance by internal auditors in the council who monitored its work. This led chief executive Robert Black to commission a specific audit of the health and safety operation by an external consultant.

This report, published in September 2013, was critical of the organisation’s health and safety performance. “The governance of health and safety requires a serious review,” he wrote. “This issue is not helped by a breakdown in communication between the health and safety and other departments specifically in relation to the completion of actions as raised in statutory reports [fire risk assessments].”

Ms Wray said she did not agree there had been a “breakdown in communication” but did accept that there was “frustration”.

As the organisation continued to struggle to reduce the backlog, minutes from a meeting in 2014 show Peter Maddison (pictured above), director of assets at KCTMO, asking Ms Wray to “clarify which of the actions could be defined as absolute requirements and which were best practise [sic]”.

Ms Wray insisted that this did not mean she should “tinker” with the actions that had been listed as high priority by the risk assessor Mr Stokes – given a colour grading of red.

“Was the truth here that he was really seeking to get you to say that those marked red by Carl Stokes weren’t really red or a sort of slightly lighter shade of red?” asked Mr Millett.

“I don’t believe so,” said Ms Wray.

‘It is difficult to justify committing limited resources to a programme which would then be ongoing indefinitely’

One crucial fire safety defect that this section of the inquiry has spent a lot of time on is flat entrance doors and the specific issue of missing self-closing devices.

This was a major problem at Grenfell Tower: post-fire investigations estimate 64% of the door closers were broken or missing meaning smoke from fires in flats spread rapidly around the tower when residents fled.

What makes this particularly serious is that RBKC and KCTMO had been asked to carry out a replacement programme of door closers across its entire stock by the LFB before the fire, but had not done so by the time of the tragedy.

Ms Wray was first asked what procedures KCTMO had in place for monitoring the performance of the door closers – as required by various pieces of government guidance.

She said that this was limited to checking doors at the end of residents’ tenancies and during major work programmes, but outside of these times there was no major system in place. Why not?

She cited “resource” and “access” and called it a “sector-wide issue”. “I’m not aware of anyone [in the housing sector] who had a six-monthly inspection programme in place,” she said.

In 2015, the urgency of this issue was stepped up by a fire at Adair Tower, around a mile from Grenfell Tower. Self-closers failed, resulting in a major evacuation of the block and several injuries.

As a result, the LFB put pressure on KCTMO to carry out a programme of checking and fitting self-closers in the rest of its high-rise stock.

In March 2017, Ms Wray recommended to a joint management team meeting that the organisation put in place a programme of dedicated inspection and maintenance, but RBKC – which set its budget – decided against this. Why?

In a report she wrote for KCTMO’s health and safety committee, Ms Wray set out the reasoning as follows: “Concern was expressed that the real value of such a programme in terms of improving resident safety is impossible to quantify and so it is difficult to justify committing limited resources to a programme which would then be ongoing indefinitely.”

She said she was simply passing on what she had been told about the decision of Laura Johnson, director of housing at RBKC (pictured above).

“Did you express your disagreement with the reasoning?” asked Mr Millett.

“Most likely I did, but it would have been to no avail,” Ms Wray replied.

At a meeting on 13 June 2017, the day before the Grenfell Tower fire, another meeting of the health and safety committee repeated the position that had been in place for years: checking when properties became void and during major works. This specific approach had been criticised by the LFB as insufficient in January 2016.

Ms Wray accepted that it was not sufficient, not in compliance with guidance and a breach of the organisation’s statutory responsibility.

‘You knew by June 2017 that abandoning stay put was not never-never land’

Another major theme of this phase of the inquiry’s work has been the question of why KCTMO did not prepare evacuation plans for its tower blocks and did not provide personal emergency evacuation plans (PEEPs) for disabled residents.

This failure was consistent with many other social landlords at the time, and official guidance documents were split.

The government’s 2006 ‘Sleeping Accommodation’ guide, for example, had a lengthy and highly specific passage on evacuation planning. But the government-endorsed ‘Fire Safety in Purpose-Built Blocks of Flats’ guide, published by the Local Government Association (LGA) in 2011, encouraged reliance on the stay put policy and said it was “usually unnecessary” to prepare PEEPs.

Ms Wray was taken through this guidance at length and accepted that she “made a conscious choice” to follow the LGA’s guide. The primary author of this guide is Colin Todd, one of the independent experts advising the inquiry on this phase of its work.

This was despite the 2009 review of KCTMO’s safety procedures by Salvus (mentioned above) specifically noting that its lack of evacuation plans was out of step with the sleeping guide.

Asked why she did not go through the high rises in KCTMO’s stock and develop emergency plans – as recommended by Salvus – Ms Wray said: “I suspect it was a resource issue. That’s a huge bit of work.”

She explained that she believed any evacuation would be led by the LFB and as a consequence KCTMO did not need to plan for it and could instead rely on the stay put policy.

In fact, fires at Adair Tower (noted above) and Trellick Tower (pictured above) in 2017 did require evacuation.

“You knew by June 2017 that abandoning stay put, wholly or partly, was not never-never land; it sometimes happened and had happened to you twice?” asked Mr Millett.

“Yes, I think everybody knows that,” said Ms Wray.

‘Well it’s a bit more than that, isn’t it. He’s suggesting that you tell the LFB a lie’

So why had the organisation not prepared PEEPs for disabled residents? Ms Wray claimed that she was reliant on neighbourhood officers to refer residents for PEEPs.

But the evidence of neighbourhood officers questioned by the inquiry is that they did not know these referrals could be made.

Ms Wray also said that she believed there was little the organisation could offer, as they did not have staff onsite to assist residents to evacuate.

Throughout the six years Mr Stokes (pictured above) was engaged by KCTMO, he only prepared PEEPs for two residents.

However, in his risk assessments he continually ticked a box that said the building was “provided with reasonable arrangements for means of escape of disabled people”.

Next to this box, he copy and pasted a statement repeatedly across at least six blocks saying there was “no evidence of any resident within the premises who suffers from sensory impairment that would prevent them hearing a shouted warning of fire”.

Mr Millett described this as a “mantra-like” statement. “Cut and paste, no change, one size fits all, as it appears,” he said.

“As it appears,” agreed Ms Wray.

What is especially surprising about this is this statement was even applied to the two blocks where Mr Stokes had prepared PEEPs.

“Can you explain why all of these FRAs [fire risk assessments] that we’ve looked at do not record any vulnerable residents in those properties across the time period we’ve been looking at, despite the presence of at least two?” Mr Millett asked.

“I can’t,” Ms Wray said.

She was also shown a specific email relating to Grenfell Tower from February 2016, where the fire brigade noted the presence of Elpidio Bonifacio on the 11th floor.

Mr Bonifacio, who was registered blind, would go on to be the last resident to be rescued from the tower at 8.07am.

“Did you consider whether to contact Mr Bonifacio to offer him an assessment for a PEEP?” asked Mr Millett.

“I should have done,” said Ms Wray.

“Do you know why you didn’t?” asked Mr Millett.

“I don’t know,” she replied.

She was also asked about an email exchange from December 2012, which emerged last week, in which Mr Stokes had advised her to “say you have nobody” when the fire brigade asked for some examples of vulnerable residents living in high rises to avoid “questions like why were they not in the building’s [risk assessment]”.

Asked about this email, Ms Wray said it “seems a bit bizarre”. “Well it’s a bit more than that, isn’t it,” Mr Millett said. “He’s suggesting that you tell the LFB a lie.”

Ms Wray claimed to have had a telephone conversation with Mr Stokes in which she explained that his suggested approach was inappropriate. Mr Stokes has denied the email was encouragement to lie.

Ms Wray will continue giving evidence when the inquiry resumes on Tuesday next week. It is paused on Monday to mark the fourth anniversary of the Grenfell Tower fire.

Grenfell Tower Inquiry headlines: week 38

RBKC said no to fire door inspections as safety benefit ‘impossible to quantify’

The council that owned Grenfell Tower rejected calls from the London Fire Brigade to implement a fire door inspection programme as it felt the benefit to residents’ safety was “impossible to quantify”.

KCTMO did not prepare evacuation plans despite being asked about blind Grenfell resident by firefighters in 2016

The head of health and safety at the organisation managing Grenfell Tower did not question repeat statements in fire risk assessments suggesting no residents needed help evacuating despite being notified about a blind man on the 11th floor by firefighters in 2016.

KCTMO health and safety lead claims failure to deal with fire risk assessment actions was ‘out of her control’

The former head of health and safety at the organisation that managed Grenfell Tower has told the inquiry that its failure to deal with a huge backlog of fire risk assessment actions was “out of my control”.

KCTMO housing lead sought new fire risk assessor ‘more willing to challenge fire brigade’

The former health and safety advisor for the organisation that managed Grenfell Tower sought a new fire risk assessor after concluding that its existing consultants were reluctant to challenge the fire brigade on “thorny issues”.

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