Coroner in tower block fire inquest urges action by council and DCLG

April 2, 2013

The coroner at an inquest into the deaths of six people in a tower block fire in London has made a series of recommendations to both the council and the Department for Communities and Local Government.

The rule 43 letters were sent by Frances Kirkham after the jury returned narrative verdicts into the deaths at Lakanal House in Camberwell in 2009. The victims were Catherine Hickman, Dayana Francisquini, Felipe Francisquini Cervi, Helen Udoaka and Michelle Udoaka.

In delivering the verdicts, the jurors criticised the London Borough of Southwark and the London Fire Brigade.

In the letter to Secretary of State Eric Pickles, the coroner made a range of recommendations. She said:

Evidence at the inquests indicated that there was insufficient clarity about advice to be given to residents of high rise residential buildings in case of fire within the building. Kirkham recommended that the DCLG publish consolidated national guidance in relation to the ‘stay put’ principle and its interaction with the ‘get out and stay out’ policy, including how such guidance is disseminated to residents.
Consideration should be given to reviewing Generic Risk Assessment 3.2 “High Rise Firefighting” to provide consolidated national guidance as to a number of issues, including familiarisation visits by fire brigade crews.
Evidence indicated that notwithstanding guides published by the DCLG in 2006 and the Local Government Association in 2011, there remained uncertainty about the scope of inspection for fire risk assessment purposes which should be undertaken in high rise residential buildings. The coroner recommended that the Government provide clear guidance on issues such as the inspection of ‘common parts’ of buildings containing multiple domestic premises and inspection of a maisonette or flat which has been modified internally to determine whether compartmentation has been breached.
The DCLG should encourage providers of housing in high rise residential buildings containing multiple domestic premises to consider the retro fitting of sprinkler systems.
A review should be undertaken of Approved Document B which is “a most difficult document to use”. This would be to provide clear guidance in relation to Regulation B4 of the Building Regulation and also so that it becomes “intelligible to the wide range of people and bodies engaged in construction, maintenance and refurbishment of buildings, and not just to professionals who may already have a depth of knowledge of building regulations and building control matters”.

The letter to Southwark Council also made a series of comments and recommendations. These included that:

Of those former residents of Lakanal House who gave evidence at the inquests, few recognised the extract from the council’s handbook containing advice about fire safety in the home and few knew about the fire safety features of the maisonettes.
In relation to residents of high rise residential buildings, the council should demonstrate to those about to enter into occupation the fire safety features of their dwelling and the building generally. “This should include walking residents through relevant features such as escape balconies and demonstrating how to open fire exit doors and where these lead.”
The council should give residents clear guidance as to how to react if there is a fire in the building, “namely to explain whether they should attempt to get out of their flat or maisonette and leave the building, or whether they should remain in their flat; that guidance should clearly explain how to react if circumstances change, for example, if smoke or fire enters their flat or maisonette”.
The council should consider additional ways in which information might be disseminated to residents, for example, by fixing inside each flat and maisonette a notice about what to do in case of fire.
A review should be undertaken of signs in common parts of high rise residential buildings “to ensure that these are sufficiently prominent and provide useful information”. The coroner made a number of specific further recommendations in relation to signage.
The local authority should review its policies and procedures concerning fire risk assessments of high rise residential buildings, including prioritising such buildings for regular rigorous review, considering the skills and experience needed to undertake an assessment of higher risk residential buildings, and considering the training required for members of staff considered to be competent to carry out assessments.
Consideration should be given as to the training needs of personnel who will be involved in procuring or supervising work to existing high rise residential buildings to ensure that materials and products used in such work have appropriate fire protection qualities. “Staff should, for example, be trained to understand the significance of the compartmentation principle and to appreciate when Building Control should be notified about work to be undertaken”.
There should be liaison with emergency services to consider access for emergency vehicles to high rise residential buildings, having particular regard to obstructions such as vehicle parking in locations which emergency services might need to use.
The council should consider the question of retro fitting of sprinkler systems in its high-rise residential buildings.

The DCLG , Southwark Council and the London Fire Brigade (which also received a rule 43 letter) are required to respond within 56 days of the day on which the report was sent.

Copies of the narrative verdicts and rule 43 letters can be viewed here.

Commenting on the narrative verdicts, Cllr Ian Wingfield, Deputy Leader and Cabinet Member for Housing at Southwark, said: "The Lakanal fire on 3 July 2009 was a dreadful tragedy and one of the darkest days in Southwark’s recent history. Our sympathies are, as always, with the families, who have lived through this ordeal a second time at the inquests, and all those affected by the fire.

“On behalf of Southwark Council, I apologise unreservedly to the families of the deceased and the former residents of Lakanal for the failings of the council that have been identified through this process.”

Cllr Wingfield added: "We have always supported all investigations and a thorough inquiry to get to the facts of what happened on 3 July 2009. It was vital that the families got answers to the many questions about the fire, how it was tackled and what happened to their loved ones.

“During the inquests, we have heard in great detail how many different factors contributed on that dreadful day, including in relation to some areas where we failed and that is why I can only say how sorry we are. We have learned immediate and enduring lessons from this tragedy and have improved what we do to make our residents and homes safe.”

The Deputy Leader added that Southwark had put fire safety and improvements to its housing stock at the top of its priorities.

“First and foremost was the creation of a dedicated housing department with clear accountability,” he said. “In addition, over £48m has been allocated to the council’s fire risk assessment programme and associated fire safety works across the borough. In particular, all similar properties have an up to date fire risk assessment that is available to the public, and we are spending £326m making all our council homes warm, dry and safe.”

Cllr Wingfield said the council would need some time to take stock of what the coroner had said.

“We will do so carefully and will act upon any recommendation that she has made, and we urge everyone in the country that has a responsibility in this area to do the same, not least to try to ensure that nothing like this ever happens again and in order that those who tragically lost their lives did not do so in vain.”