The Grenfell Tower Inquiry reveals fundamental weaknesses of governance

In 2017, one of us wrote in this journal that “it is impossible to achieve a comprehensive understanding of events such as Grenfell Tower without confronting the political determinants of health and challenging the forces that shape them.” 1 Seven years later, the final report of the official inquiry into this tragedy, which killed 72 people, shows the extent to which this argument holds true.2

When disasters occur, the media and politicians commonly focus on the immediate causes rather than the political decisions that create the conditions that allow them to happen. When refugees drown in the Mediterranean or English Channel, the focus is on people traffickers, who bear much of the responsibility. Yet they ignore the actions of the high income countries, which contribute to both climatic changes and resource related conflicts that can force people to flee from home.3 The 2017 editorial referred to the loss of life in Hurricane Katrina in 2005. The immediate cause was the extreme weather, but it was the political failure to plan for such events that caused so many, mostly marginalised, people to die.1

The Grenfell Tower Inquiry report is different. While it contains much technical detail about the structural and procedural failings that allowed the fire to spread rapidly, it places the blame firmly on politicians and the companies whose interests they failed to challenge.

The report begins with the Westminster government. It notes how ministers were well aware of the risks of high rise fires exacerbated by flammable cladding by 2016. Indeed, a 1999 parliamentary committee drew these risks to their attention, but its recommendations were ignored. This has become the norm, with a recent report from the Levelling Up, Housing and Communities committee complaining that none of its 2022-23 parliamentary session reports had elicited a timely response.4

Another warning sign emerged in 2001 when tests on the cladding systems by the Building Research Establishment (BRE) showed a “catastrophic escalation of fire” with Aluminium Composite Material.5 Established as a government research organisation, the BRE was privatised in 1997, after which it reduced its work on fire safety. Its findings, which should have set alarm bells ringing, were never published, recalling the fate of the exercises that should have informed pandemic planning, but did not.6

A third warning, also ignored, came from a coroner following a similar fire in another tower block, Lakanal House, eight years earlier.7 Coroners can issue a Report to Prevent Future Deaths,8 which in that case included recommendations to strengthen building safety standards and review emergency responses to such fires. This, as with many of these reports, was not followed up, something that those who lost relatives in different circumstances have described as a “systematic scandal.”9

These failings were exacerbated by weaknesses in the then Department for Communities and Local Government (DCLG), which the inquiry describes as “poorly run.” While the inquiry heavily criticises certain individuals, these failings occurred when the civil service had experienced severe cuts and morale was falling, with the greatest decline in DCLG.10

The inquiry is especially critical of the system for regulating the construction of high rise buildings, describing it as “seriously defective.” Given recent problems with other regulators, this should not come as a surprise.1112 A particular concern, also relevant to OFWAT, which has allowed water companies to make vast profits while failing to invest in infrastructure, is the apparent extent of corporate capture of the myriad systems in place to regulate the construction sector. The inquiry describes many examples of manufacturers (such as Kingspan, Arconic, and Celotex) and service providers intentionally manipulating or misrepresenting information on their products’ safety, in some cases with apparent complicity by regulators.13 The inquiry thus represents an important case study of the commercial determinants of health. Their intertwining with political determinants is aptly captured by a description by Peter Apps, contributing editor at Inside Housing, of political actors who “deliberately ran down, neglected and privatised arms of the state,” acting in concert with various corporations’ “almost psychopathic disregard for human life.”14

The inquiry also examines the legislative framework for management of disasters, in particular, the 2004 Civil Contingencies Act.15 This confers wide ranging powers on ministers, who need only declare that they perceive a threat to exist and cannot be challenged in the courts.16 Yet, as in the pandemic,17 this act was not used. The inquiry identified many failings in its implementation, including the absence of any consideration of fires in high rise buildings from the National Risk Assessment, although Grenfell was far from the first.18 The inquiry helpfully recommends that the act be reviewed.

The inquiry is also highly critical of the local government, the Royal Borough of Kensington and Chelsea. Its failings contributed to the disaster occurring in the first place, repeatedly ignoring tenants’ concerns and comprehensively letting survivors down.

Looking ahead, can we be confident that the inquiry’s recommendations will be adopted? As Christina Pagel has pointed out, very few earlier inquiries have.19 This is the second report from this inquiry, and many recommendations in its Phase 1 report have yet to be implemented. Indeed, the last government contested the recommendation that Personalised Emergency Evacuation Plans (PEEPs) for disabled people in high rise blocks be implemented based on cost,20 the same arguments that led to the loss of life at Grenfell, and this remains unimplemented.

We have only been able to scratch the surface of the inquiry’s 1700 page report. However, one thing is clear. While the Grenfell disaster represents a culmination of failures by many individuals and organisations, the inquiry report, like others such as the recent infected blood report,21 raises fundamental questions about how and for whom the United Kingdom is governed.

How can we achieve the transformational changes needed to ensure the voices of ordinary people are heard and not, as with the Grenfell Tower residents, ignored? How can we hold ministers and corporate executives to account? How can we deliver justice for all those who died unnecessarily? And how can we end the need for future inquiries by preventing such devastating events from happening in the first place?