This is worth remembering as the Covid Inquiry embarks on its mammoth investigation. Former prime ministers, chancellors, and, yesterday, the Covid-era health secretary Matt Hancock have taken their oaths of honesty, promising to help us understand what happened and why. As an exercise in modern lesson-learning, it sits on the same shelf as the The Grenfell Tower Inquiry, The Post Office Horizon IT Inquiry, The Undercover Police Inquiry and The Infected Blood Inquiry, all of which have been rumbling away for years now. All have, at times, shown the strength of a statutory public inquiry — its ability to force uncomfortable evidence into the public domain. But all have also demonstrated the fatal weakness of the process. Whatever findings emerge, we still lack the powers to force politicians to do anything to ameliorate their terrible mistakes.

I have spent much of the last four years reporting on the Grenfell Tower Inquiry, which is a perfect illustration of this shortcoming, being in part an investigation into why so many of the inquiries before it were ignored. Parts of the Grenfell tragedy are now fixed in the national-political consciousness, from the cladding which turned the building into a deathtrap, to the governmental bungling of building regulations which allowed its wide use. And so, as our Covid reckoning creaks into action, the appalling chain of state failure over Grenfell provides a painful but useful warning of how far responsible actors can deviate from proper practice — and how difficult it is to force reform.

The story of missed warnings starts in 1999, when the Government was warned of the risks of dangerous cladding on social-housing high rises. Following the death of a pensioner in a cladding fire in Scotland, a select committee of MPs presented a report which said there were potentially hundreds of other buildings around the UK with similar systems. “We do not believe that it should take a serious fire in which many people are killed before all reasonable steps are taken towards minimising the risks,” it said. They called for a rule change to make all cladding systems either entirely non-combustible or proved fire safe by a large-scale test. They also suggested regular monitoring by social housing providers, to ensure the safety of systems already installed was understood.

Neither recommendation was implemented. Behind the scenes, it is now clear there was lobbying against higher standards for cladding — with an industry body warning of “economic consequences for the building industry and the UK as a whole” if tighter standards were imposed. This concern appears to have taken precedence. This is all the more alarming, when you consider that, after the 1999 report, the Government commissioned tests on cladding materials in 2001. In the event, one test had to be stopped after five minutes because it risked setting the laboratory alight. But nothing was done about it. The precise cladding product tested would later find its way onto the walls of Grenfell Tower.

More from this author

When will the Grenfell betrayal end?

By Peter Apps

After another fire in 2009, which killed six residents (three of them children), concerns were raised about the advice conveyed by 999 handlers. The residents of Lakanal House, a tower block in south London, had been told to stay put, as a result of the logic that a blaze in a block of flats would stay in the compartment it started in. After the coroner’s inquest in 2013, the fire service promised better training of its call handlers to prevent a repeat tragedy. But this was downgraded amid budgetary pressure and the call centre would go on to repeat the exact same mistake on a much larger scale at Grenfell Tower in 2017.

The Government, meanwhile, was told by the coroner to encourage the retrofitting of sprinkler systems in ageing social housing blocks. But behind the scenes, officials scoffed at these recommendations. They told ministers their legal responsibility demanded they only reply to the coroner’s letter, not “kiss her backside”. The letter, which ultimately went back to the coroner, signed by then-secretary of state Eric Pickles, rejected the recommendation on sprinklers, adding that it had already “encouraged” them following a previous inquiry into a tower block blaze. But nothing happened.

The review of regulatory guidance, meanwhile, was kicked firmly into the long grass. By the time of the Grenfell Tower fire, it had not even started. This meant the opportunity to make a relatively simple tweak to guidance to remove the same outdated standard identified in 2001 was lost. With it remaining in place, unscrupulous cladding companies were able to sell the material — which burns with a similar ferocity to petrol when ignited — for use on more than 450 towers around England. An entirely avoidable disaster was therefore rendered all but inevitable by a simple failure to learn from prior mistakes.

Of course, the fact that we know all this and can openly say it is testimony to the fact that the Grenfell Tower Inquiry has done one part of its job well. It has obtained the documents which show the trail of mistakes which led to the blaze and interrogated the witnesses responsible. No journalist or committee of MPs would ever have got close to the revelations it has brought to light. But the question remains: what is the point if this knowledge does not lead to change? Why drag bereaved families through a tortuous four-year legal process and then let the recommendations rot on a dusty shelf?

Because the savage irony beneath the Grenfell Tower Inquiry’s truth-seeking is that it appears to be headed for the same fate as the ignored warnings it has so assiduously documented. While its final report won’t appear until next year, the inquiry made many recommendations following the publication of its first phase report in October 2019. Crucially, it told the Government to end the total reliance on “stay put” advice in its guidance, and instead require the development of a “Plan B” to get everyone out if a blaze got out of control.

Practically, this was supposed to be achieved through legal obligations on building owners to prepare evacuation plans, install manual alarms which could be activated by firefighters if needed, and make “personal emergency evacuation plans” for disabled residents (who died disproportionately at Grenfell). Boris Johnson promised unequivocally to implement “every recommendation made”. Perhaps unsurprisingly, this promise was quickly forgotten. In April 2020, the Home Office held a behind-closed-doors meeting with industry figures. In it, they slammed the proposals, calling them “not cheap” and “totally impracticable”.

When the government consultation on the implementation was published in the summer, the detail for implementing these key measures had been critically watered down. But this was not made clear. The Home Office press release which announced the abandonment of the recommendation on the evacuation of disabled residents was proudly titled “Home Secretary unveils ambitious plans for fire reform”. But it contained not a single line which made it plain that the recommendation of a seminal, four-year and £170m inquiry was being dropped. If you didn’t already know the detail back-to-front, you would never have known and most of the media didn’t.

Suggested reading

Boris Johnson should destroy the Tories

By Aris Roussinos

And if you want a singular illustration of the weakness of the inquest and inquiry process, consider the death of 23-year-old Emma Waring in 2014. In that instance, the coroner recommended the fitting of sprinklers in flats occupied by residents with particular vulnerabilities. But the government did not even reply to this recommendation, until I submitted a Freedom of Information request seeking its response in 2018. When they finally did, 785 days after the deadline, they still did not accept the recommendation.

All of which suggests the Government cares little for what inquests and inquiries recommend, lending urgency to the launch this week of a campaign for a National Oversight Mechanism — an independent body which would review and report on the Government’s progress in implementing the changes official inquests and inquiries propose. Proposed by the charity Inquest and backed by Grenfell survivors and bereaved and the families of those who died of Covid, such a mechanism would, at least, shine a light on the state’s unwillingness to do what it so blithely promises victims in the aftermath of an atrocity: to learn and apply the lessons from its most deadly mistakes.

None of this is to say that it will solve everything. But as the Covid Inquiry cranks into gear, the very least we can hope is that more people will be paying attention. For unless something changes, history tells us its recommendations will be remembered only when the next disaster strikes, a new inquiry is asked to investigate why the lessons from the last one were ignored, and the whole miserable cycle rolls around again.

Over the next seven hours, the blaze would engulf the entire building, smoke would spread rapidly through its interior and the firefighting operation — despite many instances of individual bravery — would fail to reach many of those who were told by call operators to stay put and wait for help. 

By morning, 70 of the 293 people who were in the tower when the blaze broke out would be dead. Two more would follow: an unborn baby named Logan Gomes and 74-year-old Maria ‘Pily’ Burton. 

Five and a half years on, and the public inquiry into the Grenfell Tower blaze has finally completed its hearings, with closing statements last week. The counsel, Richard Millett KC, summed up by saying one simple conclusion could be definitively made from the evidence: that every single death at Grenfell was avoidable. “There was nothing”, he said, “unknown or not reasonably knowable which caused or contributed to the fire and its consequences.”

“On the contrary, each and every one of the risks which eventuated at Grenfell Tower on that night were well known by many and ought to have been known by all who had any part to play.” The question of how blame should be shared, though, is far less simple.

Each corporate and public body implicated in the disaster has — in effect — pointed the finger at someone else. Where the evidence has made their own failure impossible to deny, they have minimised them with the lawyerly claim that they were not “causative”. 

Let’s take the manufacturer of the cladding used on the tower: Arconic. Arconic is among those most straightforwardly to blame for the fire. The expert evidence and the conclusion of the inquiry’s first phase (which examined the night of the blaze) was that the cladding panels — which contained a core of what was effectively solid petrol — were the primary cause of the rapid fire spread up and around the tower. 

More from this author

How Grenfell exposed Britain

By Peter Apps

Arconic also had internal testing dating back to 2004 which showed this cladding would perform catastrophically in a fire if bent into a certain shape — the one ultimately used on Grenfell Tower. This testing was repeated with the same results throughout the 2010s, but never released to the market or to regulatory bodies.

Arconic kept selling the material, despite internal warnings from its technical staff that the product was “dangerous on facades, and everything should be transferred to [a more fire resistant product] as a matter of urgency”. With this advice not heeded, one Arconic employee sardonically commented that his opinion was “technical and anti-commercial, it seems…”. This was but one of a series of damning internal emails and documents released by the inquiry, the most startling a 2007 document written by its marketing manager which speculated about the possibility of a cladding fire involving Arconic’s product killing “60 to 70 persons”. 

Yet Arconic’s closing statement contained no acceptance whatsoever that it was to blame for the fire. None. Instead, their barrister complained that the firm was the “victim” of “an agenda” against it. 

He claimed that since the 2004 test was to European standards, and different national categorisations could apply in England, the test was “a non-issue”. He said that since Arconic sold the panel in flat sheet form, for others to bend into the dangerous shape, a certificate it shared claiming a higher fire performance was in no way “misleading”. That since the cladding could be used safely in other buildings, those who designed the Grenfell Tower system were the ones who were really at fault. And that since the UK government had failed to tighten standards to objectively ban the sort of cladding Arconic sold, its actions in selling it in this country were “entirely lawful”. 

This process was repeated over and over by one “core-participant” after another: the manufacturer Celotex said that because the speed of the fire was driven by the cladding panels, the combustibility of the foam boards which sat behind it was irrelevant. This, of course, discounts the impact of smoke — to which both products contributed an equal amount — which was pivotal in trapping residents in their homes, stopping firefighters from reaching them, and ultimately causing their collapse and death.

Along with Kingspan, another insulation manufacturer which made a small quantity of the product used on the tower, the firm apologised for some prior conduct by former staff members, but emphasised that it did not cause the fire. This poor conduct, on Celotex’s part, involved allegedly inserting fire resistant boards to help it pass a commercial fire test.

For Kingspan, it involved a long period of behaviour which included obtaining a certificate claiming (falsely) that its product could be used on tall buildings without restriction. When asked internally how this was obtained, one Kingspan employee wrote: “We threw every bit of fire test data we could at him [the official who wrote the certificate]. We probably blocked his server… We didn’t even have to get any real ale down him!” 

More from this author

Grenfell was no ghetto

By Anna Minton

The inquiry heard more. There were the architects and contractors who designed a cladding system so poor it objectively failed to meet even the watered down standards applicable in government guidance at the time. Each of them blamed one another. They blamed the manufacturers for misleading marketing which their witnesses accepted they had barely read and blamed, in the end, a man called John Hoban, the hapless, overworked official at the local council that signed the whole thing off.   

Even the London Fire Brigade (LFB) took to pointing the finger at this official, suggesting his completion certificate gave the brigade no way of knowing the building would not support the classic ‘stay put’ strategy, on which it was so reliant. But this discounts the crucial failure of the LFB: to have some semblance of a plan for what to do in the totally foreseeable instance where a badly-built building meant this policy failed to hold. 

As for central government, it found the money to hire Jason Beer KC, a barrister who has “appeared in most of the significant public inquiries of recent times”. He presented their acceptance that the government failed “to ensure effective whole-system oversight of the regulatory and compliance regime”. Translate this into normal language. It means that the government believes its primary error was failing to stop others failing — essentially joining the other participants in blaming one hapless building control inspector for the fire. 

But myriad government failures were presented by the inquiry, all unaddressed by Mr Beer. Consider the government’s failure to act after a test in 2001 that showed the exact cladding used on Grenfell failing disastrously in laboratory conditions. Officials knew from this moment on that this cladding was on the market, on buildings and apparently permitted by a defunct standard in official guidance. They did not amend the guidance to objectively ban it until two years after Grenfell. Neither did the government’s KC address the fact that deregulation, often presented with the bitterly portentous framing of a bonfires of red tape, was prioritised above an urgent call from the coroner investigating six deaths at Lakanal House in 2013 to review guidance “with particular regard” to the risk of external fire spread. 

More from this author

The scapegoating of the Grenfell firefighters

By Paul Embery

Mr Millet described the government’s position as a “ship of fools”. Government building guidance was fatally weak, and made weaker when it ought to have been tightened. The result was builders empowered, even allowed, to build dangerous buildings. The legacy of this failure is all around us. Five years on from Grenfell, we still have thousands of buildings around the country with combustible cladding.

At the end of Mr Millett’s speech, he presented diagrams for how each party has sought to blame the others. He blended them into a “spider’s web” of vastly complex interlocking arrows. He implored the inquiry panel to find a way through. “The families of those who died and the wider public want to know who is to blame for this tragedy, how culpability is shared, and what will be done about it,” he said. “You can and you must help them answer that question.”

The inquiry will now pause for around 10 months as the panel prepares a report which seeks to do this. There are those in the community who are, justifiably, frustrated by the length of time this has taken and how criminal prosecutions have had to wait as a result. 

But if the inquiry can provide some answers, some definitive truths, then it will set the ground for the wheels of justice to begin to turn. Failed so many times before, during and after the fire, the community of Grenfell Tower deserve at least this.

The inquiry turned out to be much more than a simple examination of a botched refurbishment on a West London estate. Instead it has given the public a rare glimpse of the various structures whose failures contributed to the fire. None of them ought to escape with reputation intact. Not the housing sector, not the construction industry, nor the fire service or central government.

What has emerged is a profoundly depressing portrait of a private sector with a near psychopathic disregard for human life, and a public sector which exists to do little more than serve or imitate it.

Sadly, though, pandemic, unending political turmoil, and a major war have pushed the revelations about defective building regulations, cost-cutting, and missed warnings away from the public eye. Aside from an excellent BBC podcast, there has barely been a ripple in the national media about these revelations.

The first module of the inquiry focused on the refurbishment work that took place at Grenfell. Architects, sub-contractors and surveyors took to the stand. The most important information regarded the way in which the tower’s deadly cladding was selected for use. Original designs had specified a zinc product for the system, which would not have been combustible.

But the council had only set a budget of £8.5 million for the tower’s refurbishment — including cladding, new windows, a new communal heating system and the conversion of commercial units to new flats. The original contractor priced the work at closer to £12 million.

The council was advised by its consultants to either increase its budget or abandon the project, warning that it would “fail” if it continued. That advice was ignored. Instead, the council’s management company (the Kensington and Chelsea Tenant Management Organisation (KCTMO)) procured a new contractor, Rydon, which agreed to take it on at the knock-down price of £9.2m. This was still above the council’s budget — so KCTMO and Rydon held a secret “offline” meeting without minutes to discuss making further cost savings, going outside the normal procurement rules. A big money saver which appears to have been agreed at this meeting was the cladding — switching to a product called “aluminium composite material (ACM)” would save around £300,000.

It would emerge that the savings were actually more substantial than this, but Rydon disguised the true value from KCTMO in order to maximise its own profits. “We will be quids in,” wrote one manager in an email.

ACM was widely used in the UK at the time, but its fire risks were no secret: it had been linked to several huge fires globally. The team who refurbished Grenfell all claimed to have no knowledge of this — although one did email internally to note that “the ACM will be gone very quickly in a fire” during a debate about the necessary strength of fire breaks.

Next, the inquiry turned to how the organisations which sold highly combustible cladding and insulation had tested and marketed them in the years before the fire.

Suggested reading

Grenfell was no ghetto

By Anna Minton

We heard that the French arm of the multinational giant Arconic had tested its ACM cladding panels in 2004. These tests revealed that when bent into a “cassette” shape they burned 10 times as quickly and released seven times as much heat, and could not even obtain the minimum European fire classification.

Rather than removing this particular product from the market, they branded the test a “rogue result”. They kept on selling it. Internal emails warned of the risks, with technical staff warning “we are in the know” and that the true nature of the panels needed to be kept “very confidential”. One senior member of the team even speculated about a tower block fire clad in its panels killing “60 to 70” people.

Changes in fire regulations did start to limit the use of ACM in much of Europe. But due to a defunct fire standard which was never removed from UK guidance, it was able to keep selling the product here. It would be sold for use on Grenfell in the particularly dangerous cassette form. The manufacturers of the insulation boards which sat behind the external cladding — Kingspan and Celotex — also had testing which revealed a potential risk in systems involving their products.

Suggested reading

The vultures behind London's housing crisis

By Niamh Mulvey

Kingspan drastically failed a large-scale test in 2005, with a system containing its foam insulation described as a “raging inferno” in an internal document. Yet it was able to obtain certification to continue targeting high rise jobs for the next 12 years, without disclosing this test. A small amount of the insulation ended up on Grenfell.

A larger amount was provided by Celotex, which also failed a test in early 2014, before passing a repeat. This second test featured additional fire resisting boards placed around key temperature monitors, which were never disclosed in its marketing. One of its former employees accepted that this behaviour amounted to a “fraud on the market” when questioned.

One of the most shocking moments of the inquiry was within the third area of its investigation. This looked broadly at the many failures in the tower’s management. Grenfell housed 37 residents who had disabilities that hindered their ability to escape in an emergency. On the night of the fire, 15 of them died, several alongside friends and relatives who would not leave them in the burning building.

The inquiry heard that the management company had done nothing to identify these residents, or plan for their escape. In fact, when the London Fire Brigade asked if there were any disabled residents in their housing stock, the building’s risk assessor advised that KCTMO should “say you have nobody”, otherwise “questions like why were they not included in the building’s [risk assessment] spring to mind”.

Suggested reading

The Left is wrong about housing

By David Swift

KCTMO staff defended not producing plans for the evacuation on the basis that they were following government guidance from 2011 which said doing so was “usually unrealistic”. This went against other legal provisions, but does appear to have become standard practice in the housing sector — with thousands of disabled people living in high rises with a similar lack of protection.

Startlingly, the Home Office recently announced it would not implement the inquiry’s recommendation that housing providers should be legally obliged to provide such plans.

Westminster has been consistently found out during the inquiry. The UK government department responsible for building regulations knew from cladding tests conducted in 2001 that ACM systems — like the one on Grenfell tower  — were flammable. The result of this testing was delivered to ministers in September 2002, along with a warning that the highly combustible cladding was, perversely, acceptable under standards included in official guidance.

But amid industry resistance to higher standards — which were said to “limit market choice” — the guidance was never altered. The testing which revealed the horrendous fire performance of the cladding was “deliberately covered up” to “avoid triggering a cladding crisis”. A former senior civil servant said he could “see why people might think that” but insisted it is not what happened.

Other warnings were missed. Eight years before Grenfell, an extraordinarily similar tragedy killed six people at the Lakanal House block in south London. The ensuing coroner’s inquest concluded in spring 2013 and recommended changes to building regulations. But the Government had strict rules preventing the introduction of new regulations (or “burdens on industry” as they were termed) and chose not to tighten the rules.

Suggested reading

Can London be saved?

By Henry Wismayer

In July 2014, civil servant Brian Martin — who was responsible for the building regulations guidance — attended an industry seminar which specifically warned the guidance needed to be tightened to rule out the use of ACM on tall buildings. Nothing was done.

And in February 2016, a cladding contractor emailed him to express concern that “there are many such buildings [with ACM] and their numbers are growing”. But Martin did not pass this “red alert” warning on to his seniors, despite having personally assured them that an ACM fire could not happen in the UK. He was well aware of the risk of this product writing in one email: “It’s very rigid and makes nice shiny buildings. Sadly when it gets exposed to a fire the aluminium melts away and exposes the polyethylene core. Whoosh!” He never checked if the cladding was being used in the UK, or acted to remove the standard from the guidance which permitted its use.

The inquiry was full of bitter of lessons and terrible news. The evidence comes together to weave a tapestry of staggering failure across the public and private sectors. Sitting behind these errors is a story of decay that can be traced back to an absence of state intervention. Inadequate funding, hands-off regulation, and privatisation — all contributed to the deterioration of these sectors. At times, it is difficult to know how the inquiry can even approach making recommendations without telling us to rip up our entire political model and start again.

Suggested reading

The rot at the heart of Westminster

By Aris Roussinos

At the very least, degrees of change are needed. Testing and certification should be removed from the hands of private bodies. Deregulation should always be moderated by the need to protect life. Residents need more power to challenge their landlords (whether social or private), in order to hold them to account. Progress in all of these areas is slow and partial. Hearing ministers boast about the prospect of cutting red tape after Brexit suggests it may be short-lived.

The inquiry itself is still running: final expert evidence is being heard and it will move to what will doubtless be a painful examination of the circumstances of each death, in order to fulfil obligations under the Coroner’s Act. Then there will be a pause while we await the final report, and then, finally, the police investigation will take over.

Should anyone be taken to trial, the process will stretch out for years. The inquiry may have given us something approaching the ugly truth about what happened, but five years after the fire, the road to the justice and change that bereaved and survivors are desperate to see is fraught.

The picture built up by Nathaniel McBride’s documentary drama is one of unremitting institutional failure on the part of the local authority and the quango responsible for housing in the borough. The well-documented failures of fire safety in the years running up to the tragedy date as far back as 2010, when the ventilation system was exposed as not good enough after a fire melted a front door.

In 2013, Grenfell residents experienced a night of power surges and the threat of a serious fire when laptops and computers in some of the flats “literally exploded”. Their desperately concerned emails to the council were met with denials of responsibility and claims that no one else had reported such occurrences.

In 2015, the infamous contractor Rydon was tasked with refurbishing the tower, installing the flammable cladding, new boilers, and defective windows. This is when the pivotal decision was taken by the Kensington & Chelsea Tenants Management Organisation (KCTMO) to switch from fire resistant zinc cladding to the cheaper, but lethal, aluminium, to cut costs. Shockingly, a test on the safety of the cladding was performed but discontinued because it was deemed too dangerous.

A year later, the KCTMO carried out its own very positive review of the work they had commissioned; but in April 2017, just three months before the fire, the Fire Brigade warned that the building facades were not compliant with health and safety regulations. Over in Westminster, David Cameron’s promise to wage war on excessive health and safety set the tone. “We need to realise, collectively, that we cannot eliminate risk and that some accidents are inevitable,” the former prime minister said. The late David Amess, the chair of the All-Party Parliamentary Group on fire safety regulations asked for fire regulations to be reviewed a heroic 13 times, but his calls fell on deaf ears.

The two questions running through the play are: why did Grenfell fire happen, and could it happen again? The Government’s Grenfell Tower Inquiry is making it very clear that there were many instances of specific failure related to fire safety and building regulations. There is relief that there is now a ban on combustible cladding on tall buildings but that is set against the difficulties of achieving that ban, with the Government initially resistant to it.

Suggested reading

Why we have to let the morons laugh at Grenfell

By Paul Embery

And while mitigating steps relating to cladding have been taken, other significant risks remain. There are serious concerns about lightweight timber frame construction, while the UK remains an international outlier by continuing to permit single staircases in tall buildings. Peter Apps, the deputy editor of Inside Housing, believes there are hundreds of thousands of buildings which have similar levels of risk to Grenfell and warns that “we are drifting back to the same attitudes”.

These are the specifics, but the broader question relates to democratic accountability and the failure to listen to residents’ repeated concerns about safety. In a horrifyingly prescient blog post written just months before the fire, the Grenfell Action Group stated: “It is a truly terrifying thought but the Grenfell Action Group firmly believe that only a catastrophic event will expose the ineptitude and incompetence of our landlord, the KCTMO, and bring to an end the dangerous living conditions and neglect of health and safety legislation.”

The correspondence between the council and the KCTMO reveals the casual contempt with which residents’ concerns were treated. Residents claimed that they were not given the opportunity to comment on the refurbishment and during the works repeatedly said they faced intimidation and harassment by Rydon and the KCTMO, including abusive emails. During this time, one of the residents reporting intimidation was implicitly threatened with eviction when he found out that he was being investigated by the council for the “unclear circumstances” through which he had inherited his tenancy agreement.

Where contrition might have been expected, astonishingly the same attitude to residents continued after the fire, when the contracts manager for Rydon told the government’s Inquiry that residents who raised complaints about fire safety and cladding were “vocal and aggressive” and “regardless of what work was being carried out would still have found a reason to complain”.

Suggested reading

Scotland's poor are left to die

By Darren 'Loki' McGarvey

But the complete breakdown of relations between community and local authority is not limited to what happened at Grenfell. It is replicated in many other London boroughs where both homeowners and social housing tenants on housing estates find it impossible to communicate with their councils. In Southwark, a homeowner on the Aylesbury Estate who was opposed to the regeneration of the estate found herself with no electricity, no internet access, no lift services and no hot water or heating, while the postman was told nobody lived at her address. Beverley Robinson, chair of the Aylesbury Leaseholders Action Group, recalled: “I had no heating for weeks and weeks and then they wouldn’t let the people in to fix it.”

Loretta Lees, Professor of Human Geography at Leicester University and former Chair of the London Housing Panel, describes this trend towards open conflict between local authorities and housing estate residents as reflecting the “Rachman-like tendencies” of the state. Peter Rachman was a slum landlord who operated in Notting Hill in the Fifties and Sixties and who became notorious for the exploitation and intimidation of his tenants who lived in terrible conditions.

The bigger picture is that all over London, and in many other cities, residents are failing to benefit from the wholesale regeneration and reconfiguration of their areas. Entire districts are witnessing the demolition of estates, which are replaced by ubiquitous developments of luxury apartments. In Elephant and Castle, the Heygate Estate was demolished and replaced by Elephant Park where two-bedroom apartments are on sale for more than £1 million. Roughly 25% of the scheme is designated affordable housing but as the definition of affordable housing has been changed to mean up to 80% of market value, that is far from affordable for the majority of Londoners.

The refurbishment of Grenfell Tower was also part of an area-wide regeneration, laid out in the “Notting Barns Masterplan”, which planned to create “a more successful urban neighbourhood through selective demolition of existing housing stock and the provision of high-quality new homes”. The aim was to drive up land values in the area by making it a more attractive place to live, which is regeneration speak for increasing property prices. The project also included the demolition of the neighbouring Silchester Estate, the leasing of the local library to the £22,000-per-year Notting Hill Prep School and the replacement of a popular community facility, the West London Stables, with luxury apartments, all of which aroused community opposition.

Suggested reading

The heroic failure of Cumbernauld

By Daniel Kalder

On the morning of the fire, a features editor emailed me to ask if I would write a piece “on the housing apartheid in London, how London’s poor end up living in death trap towers”. The narrative of poverty-stricken deprivation in a tower block ghetto, a stone’s throw from one of the richest parts of London, persisted throughout the media in the weeks after the disaster, with newspapers running with the need to demolish more social housing like this. It was only through the sheer level of interest in the story that it became clear that Grenfell had not only been structurally sound, but a much-loved place to live with a thriving and mixed community.

When the Government announced its Inquiry into the fire, the local community were disappointed by its limited scope, and demanded that it be widened, to “seek to understand how residents’ voices have been systematically ignored for so long”. Michael Mansfield QC, who is representing survivors and relatives, has highlighted that the Inquiry is only investigating how the fire came about and who should be accountable, rather than looking at the experience of living in social housing. He has pointed out that while the experience of living in social housing is crucial to what happened at Grenfell, it is “off limits”, with families given very limited opportunities to speak or ask questions. The consequence is that they feel excluded from the Inquiry, raising uncomfortable parallels with the reality of living in social housing.

The Inquiry is producing invaluable evidence about what happened and why, which means the likelihood of another incident related to the specific failures uncovered seems unlikely. But the broader question of elected councils listening to residents who voice uncomfortable truths has escaped scrutiny. This means that the next time concerns around potentially fatal issues are raised, there is still no certainty they will be listened to.

Governments of all stripes have long talked about the need to create mixed communities. Grenfell was a successful mixed community which found itself labelled as a ghetto, as part of a narrative of managed decline perpetuated by the institutions which wanted to regenerate the area. This is the end result of treating housing simply as financial asset, which combined with a complete failure to listen to the voices of the community, led to the tragedy of the fire.

So when it was finally published, the report on Phase 1 of the Inquiry took people by surprise. Far from the whitewash many had feared, it went further than any had dared hope. Even though the media spotlight immediately fell on the report’s criticisms of the London Fire Brigade, the most significant finding was in fact, that, at the time of the fire, the external walls of the building failed to comply with statutory building regulations.

As that chorus of accusatory voices busily castigated the LFB, there were some who argued in their defence, including Jeremy Corbyn, saying that the Inquiry should have started with an investigation into the bodies responsible for making and applying the cladding to the building. However, if it had done it that way round, then those manufacturers and contractors would surely have been just as indignant, arguing that if the LFB had changed their stay-put policy earlier, then fewer people would have died. If the finger points at me, I will quickly point it at someone else to deflect the blame.

That’s why this finding is a game changer. It means that Phase 2 of the inquiry, rather than leaving open the question of whether the building complied with regulations or not, will start from the assumption that it was faulty. It will immediately set out to determine who exactly was responsible for the hazardous state in which the tower stood on the night of 14 June two years ago.

Suggested reading

Why we have to let the morons laugh at Grenfell

By Paul Embery

People died in Grenfell Tower because of a tragic and complex series of causes. They include the electrical fault in the fridge freezer, the stay-put advice of the LFB, the material used to make the cladding, the lack of proper regulation to prevent it being used, fire doors and extractor fans that didn’t work properly, and numerous other factors which have only now begun to emerge.

Because the causes are many, responsibility will surely be dispersed. It seems likely that there was no one person or body guilty for it all, but each strand of what caused the fire will end up leading to the door of a person responsible. The temptation in such a situation, as we have seen in recent weeks, is to try to shift the fault onto someone else. Out of fear of loss of face, we are as quick to blame others for their mistakes as we are to hide our own.

Matthew Syed’s book, Black Box Thinking contrasts the approach of the medical profession with the aviation industry. Too often, when a mistake is made in the world of healthcare, the instinct is to cover up failure for fear of litigation, or in order to protect reputations. As a result, he suggests, the same mistakes are often repeated, which means that thousands of people continue to die in hospitals every year due to preventable error.

When a plane crashes, however, the ‘black box’ is recovered, data painstakingly analysed, and no stone is left unturned in order to determine the exact causes of the disaster to make sure that it never happens again. As a result, plane travel has become one of the safest means of transport we have.

More from this author

The perfect power of weakness

By Graham Tomlin

The moral of Sayed’s story is that failure is not something to be feared, rather an opportunity to change and improve. It is the individuals and institutions with the resilience and flexibility to face up to failure, learn the lessons and to be open to change which ultimately excel. It is what the Christian church calls repentance — the willingness to admit when we have got something wrong, bear the consequences, ask for forgiveness, resolve to learn from the error of our ways and to become a better person through it. Repentance is not wallowing in self-pity or hiding in a corner from the wagging finger of guilt; it is an invitation to honesty, to growth and to transformation.

This is exactly what is needed as the story of Grenfell unfolds. No doubt over the coming months, that wagging finger will also be pointed at those who were in government before the fire, the Royal Borough of Kensington and Chelsea, the Tenant Management Organisation that was responsible for the building, the manufacturers of the cladding, the contractors who installed it, and many more.

But rather than deflecting the blame onto another party, as we are all tempted to do, what if those who bear some responsibility for the tragedy were to make the choice to see Grenfell as, yes, a tragedy, but also an opportunity to be honest about mistakes?

What if all parties were to learn from it so that it could be ensured that such an event becomes far less likely in future.  Not only would they improve as institutions, but also, finally, those who have been most deeply affected by this scar on our national life might find some peace and reassurance that their painful struggles have not all been in vain.