The following is the conclusion of a two-part series on the coroner’s inquest into the 2009 tower block fire at Lakanal House in south-east London, which killed six people. Part 1 was posted September 16. Central and local government ignored the recommendations from the coroner, centred on implementing basic fire safety measures in high-rise buildings. This callous disregard for the safety of the public was a central factor in the Grenfell Tower inferno, west London, in June in which more than 80 people died.
The inquest into the 2009 Lakanal House fire concluded on March 28, 2013. Judge Frances Kirkham made a number of recommendations, under Rule 43 of the Coroners Rules, to the London Borough of Southwark, the Department of Communities and Local Government, the London Fire Brigade (LFB) and then conservative secretary of state for communities and local government, Eric Pickles.
Central to the coroner’s advice was the recommendation that national consolidated guidance be provided regarding advice to “stay put” in the event of a tower block fire, and its interaction with the more universal “get out and stay out” principle. This revised guidance was supposed to take into account familiarisation visits by fire brigade crews, awareness that fire may spread laterally and downwards in a building, awareness of the risk of “fire spread” above and adjacent to a fire flat, and awareness that insecure compartmentation may allow the transfer of smoke and fire into common parts of high-rise tower blocks.
To improve fire safety assessments, the coroner recommended that the government provide clearer guidance on the definition of “common parts of a building” containing multiple dwellings, on the inspection of maisonettes that have been internally modified and on the inspection of a sample of maisonettes, all to ensure effective compartmentation.
It was recommended that Approved Document B—statutory guidance on building regulation covering fire safety matters—be altered to make Regulation B4 of the Building Regulations clearer. Of particular concern was the spread of fire over the exterior of the building and the circumstances in which proposed modifications reduce existing fire safety protection. The coroner urged that such revised guidance be unambiguous and accessible to the vast array of people and bodies engaged in the construction, maintenance and refurbishment of buildings. But her recommendation did not require any substantive changes to the Building Regulations regime. However, even the minor modifications as recommended by the coroner did not take place.
Recommendations from a coroner possess no legal force. The Conservative government, then in coalition with the Liberal Democrats, chose to ignore virtually all of the inquest’s findings. Pickles claimed that matters to do with fire safety were being dealt with by the Department of Communities and Local Government’s generic risk assessment guidance on fire safety. Published in 2011 and 2014, the guidance made no mention of Lakanal House and did nothing to correct the LFB’s strict adherence to the “stay put” principle.
Pickles rejected the coroner’s recommendation that all landlords responsible for residential high-rise buildings must provide an information box for fire crews with guidance about building layout and construction, including fire exits and numbering systems, claiming such regulation would be “unnecessary and disproportionate.”
Perhaps the most reported recommendation was that sprinkler systems be retrofitted nationally in high-rise residential tower blocks. In a cynical box-ticking exercise, the Department of Communities and Local Government wrote to all social housing providers about the coroner’s Rule 43 recommendation that providers of high-rise residential buildings “consider” the retrofitting of sprinklers. The real attitude of the state towards this suggestion was epitomised by then Tory housing minister, Brandon Lewis, who told his fellow MPs in 2014, “It is the responsibility of the fire industry, rather than the Government, to market fire sprinkler systems effectively and to encourage their wider installation. The cost of fitting a fire sprinkler system may affect house building.”
The legality of aluminium composite panels that contributed greatly to the spread of the fire at Lakanal House was questioned during the inquest. The coroner adjudicated that although the cladding was legally required to have a surface spread of flame performance of class 0, there was no legal requirement that the composite panels be fire-resistant to 60 minutes (FR60). The FR60 legal requirement (in force since 1952) was removed by the Thatcher government as part of wholesale deregulation of the building industry. Thatcher’s Building (Inner London) Regulations 1985 gutted basic fire prevention measures that are designed to save lives.
The jury in the Lakanal House inquest found that the cladding panels fitted in the 2006-2007 refurbishment had fewer fire resistant properties than the panels removed. The jury explained that “this was due to a serious failure on the part of Southwark Council’s building design services, its contractors and its subcontractors.” The parallels with Grenfell are harrowing.
In January 2017, the LFB brought criminal proceedings against Southwark Council, alleging that 22 offences under the 2005 Order had been committed in relation to Lakanal House. The Regulatory Reform (Fire Safety) Order 2005 allowed the LFB to bring proceedings in a crown court against “the responsible person” (the owner of premises) for committing offences listed in the 2005 order. The possible sentences include an unlimited fine or a maximum custodial sentence of two years.
In February 2017, the LFB agreed to a revised indictment, reducing the list of offences committed by the council from 22 to just the following: failure to carry out suitable and sufficient risk assessments; failure to take general fire precautions; and failure to ensure that Lakanal House was subject to a suitable system of maintenance.
Southwark Council was fined just £270,000 (reduced from £400,000) with £300,000 in legal costs. The revised indictment was agreed by the LFB, despite evidence that Southwark Council had failed to conduct fire risk assessments or to correct multiple breaches of fire safety regulations under the 2005 order.
Dan Daly, assistant commissioner of the LFB, claimed that “bringing this prosecution against Southwark Council has been about ensuring that lessons are learned so we can reduce the likelihood of such a devastating fire ever happening again.” In reality, the reduced indictment against Southwark Council was a cover-up that helped pave the way for an even more terrible crime at Grenfell Tower just four months later.
Speaking in 2013, after the 11-week Lakanal House inquest had ended, Mbet Udoaka, who lost his wife Helen and their baby daughter, said: “Nearly four years later and after a long inquest, no organisation or authority have said sorry to us or accepted the blame. We feel very much that lessons have not been learned.”
In the aftermath of the Lakanal House fire, the Labour-controlled council promised £62 million for improved fire safety and maintenance, but residents are still living in death traps. Not a single sprinkler has been retrofitted in the council’s 174 high-rise towers. It was only in June, after the Grenfell Tower fire exposed criminal negligence by the Royal Borough of Kensington and Chelsea Council (RBKC), that Southwark Council officials went into damage control.
On June 21, council officials called for “a full review” into whether sprinklers should be fitted. In August, a surveyor’s report suddenly emerged revealing that “strengthening works” at Ledbury Estate—that should have gone ahead after the deadly Ronan Point tower block collapse in 1968—were not carried out. The revelations meant the group of 13-storey blocks, with 200 households, could collapse in the event of a gas explosion.
Not a single measure was implemented nationally in the aftermath of the Lakanal House inquest to make safe hundreds of tower blocks across the UK. As a consequence, the criminal indifference displayed by Southwark Council, the government and other supposedly responsible authorities in 1999 paved the way for an even greater horror in West London.
Concluded