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Lakanal House tower block fire: deaths 'could have been prevented' Lakanal House tower block fire: deaths 'could have been prevented'
(about 4 hours later)
The deaths of six people, including three children, in Britain's worst-ever tower block fire, could have been prevented by a proper fire safety check by the building's owner, an inquest jury has concluded. The death of six people in Britain's worst tower block fire was largely caused by botched and unsafe renovation work and a council's failure to inspect the building, as well as confusion and chaos during the firefighting operation, an inquest has concluded.
The verdict on the deaths at Lakanal House in Camberwell, south London, on 3 July 2009 also found that 999 operators for the fire service failed to properly pass on repeated warnings that people were trapped in three flats in the 14-storey block. In a carefully worded but ultimately damning narrative verdict into the death of three women and three young children trapped inside Lakanal House in Camberwell, south London, on 3 July 2009, the jury highlighted numerous ways they could possibly have been saved.
Recording narrative verdicts for all six deaths, the jury said Southwark council, which owns the block, missed numerous opportunities to remedy botched renovation work which compromised fire-stopping between flats and into communal areas. The fire, caused by an electrical fault in a television inside a ninth-floor flat, spread through the 1958-built block with a suddenness and ferocity that terrified residents and baffled firefighters.
This included the replacement of asbestos window panels by modern, non-fire-safe ones in 2006, which ignited quickly and helped the fire spread quickly. Six people remained in their flats one level above and were dead within 90 minutes. They were Dayana Francisquini, 26, and her daughter Thais, six, and son Felipe, three; Helen Udoaka, 34, and her 20-day-old daughter Michelle; and 31-year-old Catherine Hickman.
The verdicts also criticised fire service operators, who advised some of those to remain in their flats rather than fleeing, for failing to respond flexibly to a fast-moving situation. Fire crews also appeared not to know the layout of the flats, delaying efforts to rescue those trapped. The 10-week hearing saw some harrowing evidence, including details of the phone calls made by some of those trapped. Hickman, a fashion designer, spent 40 minutes in increasingly panicked conversation with an emergency operator, saying she could not breathe amid choking smoke. She yelled that flames were at the door and that something had fallen on her from the ceiling, before she eventually fell silent.
The judge acting as the coroner in the 10-week inquest, Frances Kirkham, will now give her recommendations to prevent future such tragedies. Hickman was repeatedly urged to remain in her flat rather than fleeing, advice based on the theory of compartmentalisation – that individual high-rise flats should be able to contain a fire for sufficient time for the block to be made safe.
The fire started at about 4.15pm on 3 July 2009 in a ninth-floor flat after an electrical fault in a television. It spread through the 1958-built block with a suddenness and ferocity that terrified residents and baffled firefighters. But, the inquest heard, the Lakanal House blaze moved unusually quickly and in unexpected ways. Within half an hour of the first 999 call it had spread to several other floors, moving downwards as well as up, something so unusual that transcripts show emergency operators initially refused to believe this was happening.
Within about 90 minutes six people were dead after they were trapped in their flats on the 11th floor, in effect one level above the source of the blaze as the building is made up of two-storey maisonettes. They were Dayana Francisquini, 26, and her daughter Thais, six, and son Felipe, three; Helen Udoaka, 34, and her 20-day-old daughter Michelle; and 31-year-old Catherine Hickman.
The inquest heard details of the phonecalls made by some of those trapped. Hickman, a fashion designer, spent 40 minutes in increasingly panicked conversation with an emergency operator, saying she could not breathe amid choking smoke. She yelled that flames were at the door and that something had fallen on her from the ceiling, before she eventually fell silent.
Udoaka followed a 999 operator's advice to shelter in the bathroom with her daughter. She too said she was finding it hard to breathe before she stopped answering her phone.
Hickman was repeatedly urged to remain in her flat rather than fleeing, advice based on the theory of compartmentalisation – that individual high-rise flats should be able to contain a fire for sufficient time for the building to be made safe.
But the inquest heard troubling details about how the Lakanal House blaze moved unusually quickly and in unexpected ways. Within half an hour of the first 999 call it had spread to several other floors, moving downwards as well as up, something so unusual that transcripts show emergency operators initially refused to believe this was happening.
Fire experts told the jury it was partly caused by renovations to the block in the 1980s, during which vital fire-stopping sections between flats and corridors were removed. During later work to replace windows in the block, in 2006 and 2007, asbestos panels under the windows were replaced with PVC-based versions that combusted in little more than four minutes in the blaze, dropping flaming fragments to ignite lower floors.
Southwark council, which owns the block, did not seek building control for this window work as was required, the inquest learned.
The jury heard that a change in the law in 2006 meant Southwark was responsible for fire safety checks at its flats, but by July 2009 the council had carried out no such checks at Lakanal or any other residential blocks. It had, however, managed to carry out the checks at buildings where its own staff worked.The jury heard that a change in the law in 2006 meant Southwark was responsible for fire safety checks at its flats, but by July 2009 the council had carried out no such checks at Lakanal or any other residential blocks. It had, however, managed to carry out the checks at buildings where its own staff worked.
There was some evidence of chaos in the firefighting operation, with six changes of incident commander, one of whom was in charge for three minutes. Southwark council, which owned the block, failed to carry out a proper fire inspection over the three years after it became its legal responsibility, the jury noted. A proper inspection would have picked up work from the 1980s that removed vital fire-stopping material between flats and communal corridors, the inquest said. It also noted that asbestos window panels had been replaced with PVC equivalents, which burned out in less than five minutes, accelerating the spread of the blaze.
Fire crews were told several times that people were trapped in their flats. One fire watch manager, John Howling, was asked why he had not sent out search teams to these flats. He replied: "It was an enormous amount of information I was trying to absorb and process." The failure to carry out inspections amounted to "a serious failure" by Southwark and its contractors, the jury said, and in the case of Hickman, something which made "more than a minimal contribution" to her death. Despite warnings from health and safety officials, the council "did not prioritise carrying out fire-risk assessments" on residential properties.
The inquest has been enormously difficult for those who lost loved ones, a typically mixed south London group comprising people with origins in Brazil, Nigeria and Hampshire. The start of the inquest was delayed for almost four years for deliberations over possible corporate manslaughter charges, something eventually decided against. While each of the six verdicts was worded neutrally – no party has accepted legal liability, which inquests are not allowed to assign – the ultimate message was clear, as was its emotional impact. Perhaps the most difficult moment came as a juror read out the details for Michelle Udoaka: "Born: 13 June 2009. Died: 3 July 2009.
The inquest heard agonising evidence from relatives. Rafael Cervi, Francisquini's husband, told the jury he had lost "everything that I built, everything that I dream of" with the death of his wife and their two children. He told the jury that the agony was magnified by initially believing that some of his family had survived, only to learn of their deaths successively over more than 12 hours. The fire brigade, meanwhile, was criticised for confusion among its 999 operators, who urged some victims to remain sheltering in smoke-filled flats when they should have fled. There was also confusion among controllers at the scene who failed to search the relevant flats in time despite the urging of relatives and neighbours of those trapped, partly because they did not understand the layout of the block.
Mbet Udoaka told the inquest that after losing his wife and infant daughter his religious faith made him hope that "some day, hopefully, we'll get to live together". Those who died could all have probably saved themselves but were either advised to remain in their flats or did not seem to know about escape routes along communal balconies.
The tragedy spread even more widely, the inquest heard. Helen Udoaka's father died of a heart attack on the night he learned of her death. One firefighter, Christopher Rose, broke down as he described finding the tiny body of Michelle Udoaka in a smoke-filled bathroom and how he had been forced to take seven months off work with post-traumatic stress. The coroner in the 10-week inquest, judge Frances Kirkham, has written to the communities secretary, Eric Pickles, as well as Southwark and the London fire brigade with a series of recommendations. These include that fire services visit high-rise blocks to learn their layout, and landlords consider fitting them with sprinkler systems. Residents should also get better fire safety information, she said.
Mbet Udoaka, whose wife and infant daughter died, read a statement welcoming the verdict. Standing next to Rafael Cervi, Dayana Francisquini's husband, he said: "Nearly four years later and after a long inquest, no authority, organisation or body has said sorry to us or accepted the blame. We fear very much that lessons have not been learned and that it could happen again."
The Labour MP for Camberwell, Harriet Harman, said: "It's evident from the jury's verdict that these were unnecessary deaths. They shouldn't have died. A perfectly safe building became unsafe because of the way they did the refurbishments. Then there was no fire inspection that would have shown what the problems were."
Later, however, Southwark said it did "apologise unreservedly" for it failings. Ian Wingfield, the council's deputy leader, said: "We have learned immediate and enduring lessons from this tragedy and have improved what we do to make our residents and homes safe."
Ron Dobson, the head of the London fire brigade, expressed his "personal sadness" but stopped short of apologising on behalf of the service. He said: "We will now consider the jury's verdict and the recommendations that the coroner has made."
The victims
The six people who died in the Lakanal House fire were an arbitrary selection, both hugely disparate in their origins and typical of modern-day inner south London.
The three women and three children trapped in three smoke-logged flats on the 11th floor came from Brazil, Nigeria and Hampshire. On the first day of the inquest Rafael Cervi told the jury how "everything that I built, everything that I dream of" – his 26-year-old wife, Dayana Francisquini, her six-year-old daughter, Thais, and the couple's son, three-year-old Felipe – was wiped out in little more than an hour.
He first saw his wife, Cervi said, as she danced in a Brazilian nightclub. While Thais was sensible and studious, her younger brother was "always doing crazy things", he added, recounting an incident just before his death when the mischievous toddler covered himself with an entire jar of hair gel.
His evidence was followed by that of Mbet Udoaka, who recalled meeting his future wife, Helen, at Lagos University before the couple moved to London. Just 20 days before the fire their first child, Michelle, was born. He said his religious faith had helped to keep him going: "I am really hoping that one day I'm going to see them. This is what I keep saying to Helen each time I visit the cemetery."
Finally, Mark Bailey described being in New York for work when he heard about the fire inside the building where he shared a flat with his girlfriend of six years, fashion designer Catherine Hickman, 31. He described the wait for firefighters to recover his partner's body: "During that time, I was feeling indescribable. I was overwhelmed by grief and I would wake up every night screaming and crying. I would think Cat was next to me and then realise what had happened and break down."
The inquest also heard of the wider impact of the fire. Helen Udoaka's father died of a heart attack the night he heard the news, the inquest was told.
Among the firefighters who gave evidence was Christopher Rose, who discovered Michelle Udoaka's body. He broke down as he described finding the girl's body in a smoke-filled bathroom and how he had subsequently had to take seven months off work with post-traumatic stress.