Page 94 - When Things Go Wrong

6.3 That observation corresponds with the Grenfell experience. Although the Chair
found in Phase I that the aluminium composite material (ACM) cladding
panels provided the “primary cause” of fire spread up the tower, 263 at time of
writing Government has spent less than a quarter of what it promised to replace
ACM cladding on other structures, leaving 300 high-rise buildings at risk three
years after the disaster. 264

6.4 Moreover, the Grenfell Tower fire itself demonstrates the consequences of
failing to implement previous recommendations. Following the Lakanal House
tower block fire in 2009 that led to the deaths of six people, the coroner issued
Rule 43 letters in 2013 finding inter alia that the “stay put” policy and Building
Regulations were in need of review. 265 These recommendations were not
implemented by the time of the Grenfell Tower fire, over eight years after the
previous incident.

6.5 Rule 43 letters were replaced by Prevention of Future Death (PFD) reports
following enactment of the Coroners and Justice Act 2009 (“the 2009 Act”).
Schedule 5, paragraph 7(2) of the 2009 Act provides that a person to whom a
Senior Coroner makes a PFD report must give a written response to the Senior
Coroner. However, as noted by Dame Elish Angiolini, “coroners are not able
to follow up or enforce recommendations in their PFD reports”. 266 Dame Elish
stressed how in the context of deaths in custody, lack of enforcement creates
an accountability vacuum, exacerbated by the fact that no one is held formally
responsible for implementing recommendations arising from IOPC
investigations. 267

6.6 Consequently, a 2018 INQUEST report on the deaths of 25 women in custody
since March 2007 found “a series of systemic failures around self-harm and

263 The Rt Hon Sir Martin Moore-Bick, Grenfell Tower Inquiry: Phase I Report Overview (October
2019), para 34.4.
264 National Audit Office, Investigation into remediating dangerous cladding on high-rise buildings (HC
2019-21, 370).
265 See HH Frances Kirkham CBE, Letter to the Rt Hon Eric Pickles MP (28 March 2013).
266 Angiolini, supra note 15, para 17.23.

267 Ibid.
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