Lakanal House Verdict: Deaths Were Avoidable

The jury in the inquest into the 2009 Lakanal House high-rise flats fire returned their damning narrative verdicts on the deaths of six people last week.

The Southwark Council, the London Fire Brigade, and 999 Operators were all heavily criticised for the events that led to the deaths of Catherine Hickman, Dayana Francisquini and her two children, and Helen Udoaka and her three-week-old daughter.

Control operators failed to listen
The jurors concluded that the evidence suggests Hickman “would have been able to escape without assistance,” but operators repeatedly told her to stay in the flat.

There was a clear expectation by Brigade Control operators that persons trapped would be rescued by firefighters.
Their advice to the caller relied heavily on this assumption.

Brigade Control officers “failed to promote active listening” in their training of operators. Also, “evidence suggests that existing training documents are contradictory and inconsistent, particularly in regard to either ‘staying put’ or ‘getting out’ when there is a fire in the building.”

Response to initial fire
The jurors concluded that the response from firefighters to the initial fire in flat 65 was “both adequate and timely,” but serious failures in compartmentation of the building caused the fire to spread far faster than they expected.

The fire spread from flat 65 to Hickman’s flat via the panels under her bedroom windows, which had been replaced with PVC following the removal of asbestos. Southwark Building Design Services (SBDS) was instructed to check the work for fire safety, but the work was not checked. These alterations “may have made more than a minimal contribution to the death of Catherine Hickman.”

Fire risk assessment
Fire was able to enter flat 81, where Fancsiquini, Udoaka, and their children died, because neither the boxing in under the stairs nor the panel above the flat door provided adequate fire resistance. There were no fire seals on the front door, and “there was a lack of fire-stopping on internal pipework from previous renovations.”

As we discussed last month, a fire risk assessment had not been carried out, as was required by the Regulatory Reform Order. Jurors wrote of numerous opportunities to remedy these failures:

Had a fire risk assessment been carried out at Lakanal House, it is possible that these features may have been highlighted for further investigation.
The installation of a new hearing system in the 1980s would have been an opportunity to ensure that the fire-stopping around pipes leading into Flat 81, and segmentation within the suspended ceiling offered adequate protection from fire.
The 2006/7 refurbishment provided numerous opportunities to consider whether the level of fire protection was adequate.

Confusion over the building’s layout also contributed to the deaths. Firefighters struggled to find the victims, and residents did not know the east balcony of the building offered an escape route. The balcony led back the central escape staircase, and jurors concluded that the five people who died in flat 81 could have escaped unaided in the first hour after the fire started. They died in the flat shortly before firefighters reached them.

Recommendations
Frances M. Kirkham, the coroner who investigated these deaths, offered recommendations to Communities Secretary Eric Pickles.

• Review “the ‘stay put’ principle and its interaction with the ‘get out and stay out’ policy.”
• Provide “consolidated national guidance” on high rise firefighting.
• Encourage sprinkler system retrofitting, which “might now be possible at lower cost than had previously been thought.”
• Offer clear guidance on the definition of “common parts,” and to recommend “inspections of a sample of flats or maisonettes to identify possible breaches of the compartment.”

Kirkham also wrote letters to the London Fire Brigade, the Southwark Council, and the Fire Sector Federation. The FSF said in a press release Saturday:

The Fire Sector Federation (FSF) wishes to express profound sadness for the tragic loss of life that occurred at Lakanal House on the 3rd July 2009.
The incident and subsequent investigations have highlighted a number of areas for improvement to ensure safety from fire in the future and the FSF is committed to working with partners from across the sector to secure those improvements and find future solutions.

The narrative verdicts and Kirkham’s reports can be read in full on the Lambeth Council’s website.