Grenfell Tower Inquiry Phase 1 recommendations progress update

Letter information

From:
Sir Andy Cooke QPM DL
His Majesty’s Chief Inspector of Fire & Rescue Services
His Majesty’s Chief Inspector of Constabulary

To:
The Rt Hon Dame Diana Johnson DBE MP
Minister of State for Policing, Fire and Crime Prevention

Copied to:
Alex Norris MP
Parliamentary Under-Secretary of State at the Ministry of Housing, Communities and Local Government

Sarah Gawley
Home Office, Director, Fire and Major Events

Sent on:
12 February 2025

Background

The Grenfell Tower Inquiry Phase 1 report, published in October 2019 following the tragic fire in June 2017, made recommendations to improve fire and rescue services’ (FRSs) responses to major incidents. These recommendations focused on communication, co‑ordination, and staff training. Since then, we have been monitoring the overall progress that FRSs have made against these, although there is no formal requirement to do so.

In August 2020, we were commissioned by the then Home Secretary to review what progress the London Fire Brigade had made against the recommendations. This resulted in our February 2021 report, Inspection of the London Fire Brigade’s progress to implement the recommendations from the Grenfell Tower Inquiry’s Phase 1 report.

In February 2023, we began our third round of FRS inspections. In my letter of 17 July 2023 to the previous Minister of State for Policing, Fire and Crime Prevention, I committed to providing:

“An update on progress against the recommendations, based on our findings from our third round of inspections.”

In a further letter of 12 September 2023 to Sarah Gawley, Home Office Director of Fire and Major Events, I said:

“As I set out in that letter [17 July 2023], our Round 3 methodology has been designed to consider services’ general progress. It has not been designed to inspect, in detail, the progress each service has made against each recommendation.

Our update will therefore include a national overview of our findings, and our general assessment of progress against the Phase 1 recommendations. It will not provide a view on the accuracy of services’ national reporting to the NFCC.”

This letter provides our general assessment of the progress made by 25 of England’s 44 FRSs (see Appendix 1) on the implementation of the Phase 1 recommendations. (These were the first 25 services we inspected in this round.) It highlights positive steps made, and identifies areas that require further improvement. The letter also outlines how future inspections will address recommendations from the Grenfell Tower Inquiry Phase 2 report, published in September 2024.

Our inspection approach

Our current Round 3 methodology includes an assessment of FRSs’ progress on implementing eight Phase 1 recommendations (see Appendix 2). This includes several steps:

• Action plan review: we gather and analyse services’ action plans to identify important lines of enquiry for our inspections.
• Evacuation and communication testing: we carry out exercises to evaluate services’ capabilities in these areas for high-rise incidents.
• Building safety regulations: we consider services’ responses to the changes which followed the Hackitt review.

Our methodology assesses various aspects of how well services are prepared for incidents. These include policy implementation, staff training, and the use of electronic systems. Our inspection findings highlight progress, challenges, and innovative and promising practices. These are outlined below in the section ‘Findings from our recent inspections’.

As I explained in my letter of 12 September 2023, in our current Round 3 inspection methodology we don’t extensively evaluate how an FRS has implemented each recommendation. But we do provide a broad assessment. Services are expected to address these findings to make tangible improvements. Our next inspection round, which will take place between 2025 and 2027, will continue to cover these areas.

In addition, at the Home Office’s request the National Fire Chiefs Council (NFCC) has monitored FRSs’ self-reported progress against all the Phase 1 recommendations, providing quarterly updates.

Findings from our recent inspections

Summary

In our Round 3 inspections, we found progress on implementing the Grenfell Tower Inquiry Phase 1 recommendations across fire and rescue services. Many services have made improvements in how they train for, communicate about, and plan operations for major incidents. Some have adopted promising and innovative practices, such as using electronic systems to manage fire survival guidance (FSG).

But some challenges remain, particularly in providing training, maintaining accurate records, and using electronic systems to manage incidents. We found that some services had worked with another service to develop these electronic systems. But often, what they learned wasn’t shared or acted on more widely. This lack of co-ordination has resulted in services using a range of different solutions, and in some not having this kind of electronic system at all. The development of the Multi-Agency Incident Transfer system is a promising step forward. But fully implementing it will require focused commitment from FRSs and more resources.

We will continue monitoring and working with services to address areas requiring improvement. Insights from current inspections, as well as recommendations from the Phase 2 Inquiry, will help shape our inspection methodology for the 2025 to 2027 round.

Recommendations 33.15c and 33.15e

All 25 services that we inspected have brought in policies for handling multiple and simultaneous FSG calls (recommendation 33.15c), and for managing the transition from a “stay put” policy to a “get out” policy (recommendation 33.15e). Some control room operators expressed concerns about handling a large volume of calls. But they felt confident that the buddy system, which pairs fire control teams from different services, would support them effectively in such situations. This system was in place in all the services we inspected.

Recommendation 33.10b

In all the services we inspected, we found evidence of training being completed to make sure staff understand the risk of fire spreading in external cladding. But when we spoke to staff, we found that in some services this was being provided inconsistently, or wasn’t understood. For example, not all staff we spoke to could show us they understood the risk of fire taking hold in the external walls of high-rise buildings, or knew how to recognise this when it occurs.

Recommendation 33.15f

This recommendation calls for control room staff to receive training on handling changes in evacuation strategy. All the services we inspected provided evidence of carrying out some form of this training. But we found shortcomings in a few services:

• In one service, training had taken place, but not all the relevant staff had attended.
• In another, a lack of confidence led to control room staff waiting for a more senior staff member to update incident logs (indicating that the training hadn’t been effective).
• In a third service, training took place, but it wasn’t centrally co-ordinated.
• Finally, one service had completed training but couldn’t provide records of it.

These deficiencies highlight the need for consistency in, and proper documentation of, the provision of training in some services.

Recommendation 33.12c

This recommendation requires all FRSs to be equipped to receive and store digital floor plans and make them accessible to incident commanders and control room managers. In some services we found that plans weren’t consistently updated, or were difficult for control room staff to access. We have identified areas for improvement in the way records are managed and made accessible.

Recommendations 33.15d and 33.22b

Recommendation 33.15d requires FRSs to develop electronic systems to record FSG information in the control room and display it simultaneously at the bridgehead located inside the building and in any command units.

In relation recommendation 33.22b, we found that all the services we inspected had developed procedures for managing the full and partial evacuation of a large number of people. And training exercises to practise these procedures were evident across all the services. But at the time of inspection, only 11 out of 25 services had an electronic system in place to support these processes. Most relied on manual methods such as whiteboards. In some cases, this meant control room staff weren’t kept up to date with information about casualties.

All the services that had put in place an electronic system were able to effectively manage evacuations, including calls back to residents to tell them about the need to evacuate. These systems have been featured as examples of innovative or promising practice in our service inspection reports, and submitted to the NFCC’s positive practice portal.

One service had a robust paper-based system capable of managing a high number of calls. This involved grouping calls together under one record. An FSG officer was responsible for communicating with the incident ground command unit and initiating calls back to residents. However, this was an exception. In all other services without an electronic system, there were some problems with miscommunication.

Recommendation 33.16

This recommendation called for steps be taken to investigate how assisting control rooms could access information available to a host control room.

The Multi-Agency Incident Transfer system offers a way for control rooms at different services to share information about incidents digitally. There is little information that we can currently provide relating to the implementation of this system. This is because, at the time of our inspections, services were waiting for the national project, led by the Government and the NFCC, to reach a stage where it could provide guidance and support.

The project has recently made significant progress at a national level. But challenges with its implementation remain, particularly in relation to capacity in FRSs’ technical and procurement teams. Further local progress will require focused commitment from services and more resources.

Phase 2 recommendations

We welcome the findings and recommendations in the Inquiry’s Phase 2 report. We accept the three recommendations directed to us, which we have already addressed through our recent inspection of London Fire Brigade. The report for this inspection was published on 29 November 2024.

We will continue the approach we have taken to addressing the Phase 1 recommendations in relation to those from Phase 2. This will involve continuing to generally assess FRSs’ progress on implementing eight Phase 1 recommendations and continuing to give a general assessment of all services’ progress in the areas covered in the three recommendations directed to us, relating to London Fire Brigade. As with the Phase 1 recommendations, our approach will not involve an assurance of capabilities, such as physical inspections of equipment. I understand that the Home Office has asked the NFCC to assess progress in the two areas covered by the fire Phase 2 recommendations aimed at FRSs. (These areas are radios and water.) Therefore, they have advised that it will not be necessary for us to assess whether services are meeting these recommendations.

We share the Government’s ambition of addressing the Inquiry’s recommendations to reduce the risk of similar tragedies happening. While our resources and capacity are limited, we remain committed to contributing to this goal through our inspections. The valuable insights that these provide can support improvements across the sector, and help make sure the recommendations are implemented effectively.

Appendix 1

Services inspected as part of this report:

• Avon
• Bedfordshire
• Buckinghamshire
• Cambridgeshire
• Cheshire
• Cornwall
• Dorset & Wiltshire
• Essex
• Gloucestershire
• Greater Manchester
• Hereford & Worcester
• Lincolnshire
• London
• Merseyside
• Norfolk
• Northamptonshire
• Northumberland
• Nottinghamshire
• Oxfordshire
• Staffordshire
• Surrey
• Tyne & Wear
• Warwickshire
• West Sussex
• West Yorkshire

Appendix 2

Below, we have summarised the recommendations we considered as part of our Round 3 inspections. We have edited the recommendations to only include the relevant sections for our reports. The full list is available in the Grenfell Tower Inquiry Phase 1 report.

Fire and rescue services: knowledge and understanding of materials used in high‑rise buildings

Recommendation 33.10b

A sound understanding of the materials used in the construction of any high-rise building is essential if the fire and rescue service is to be properly prepared to carry out its function in relation to that building. The risk of fire of the kind that occurred at Grenfell Tower may be low, but knowledge is the key to proper planning and effective training. I therefore recommend:

That all fire and rescue services ensure that their personnel at all levels understand the risk of fire taking hold in the external walls of high-rise buildings and know how to recognise it when it occurs.

Plans

Recommendation 33.12

No plans of the internal layout of the building were available to the London Fire Brigade until the later stages of the fire. However, because each floor of the building above floor 3 was laid out in the same way, the London Fire Brigade was not unduly hampered in its attempt to fight the fire and rescue occupants by the absence of those plans. In another case, however, the lack of floor plans might easily have far more serious consequences. It should be a simple matter for the owners or managers of high-rise buildings to provide their local fire and rescue services with current versions of such plans. I therefore recommend that the owner and manager of every high-rise residential building be required by law to provide this.

I also recommend, insofar as it is not already the case, that all fire and rescue services be equipped to receive and store electronic plans and to make them available to incident commanders and control room managers.

Emergency calls

Recommendation 33.15c

Even allowing for the fact that the control room was operating under great pressure, it is clear that in many cases control room operators failed to handle FSG calls in an appropriate or effective way. I therefore recommend:

That all fire and rescue services develop policies for handling a large number of FSG calls simultaneously.

Recommendation 33.15d

That electronic systems be developed to record FSG information in the control room and display it simultaneously at the bridgehead and in any command units.

Recommendation 33.15e

That policies be developed for managing a transition from “stay put” to “get out”.

Recommendation 33.15f

That control room staff receive training directed specifically to handling such a change of advice and conveying it effectively to callers.

Recommendation 33.16

The handling of emergency calls by other fire and rescue services was hampered by their lack of information about the nature of the incident and the way in which it had developed. Those who respond to emergency calls on behalf of the London Fire Brigade need to have as much information as possible about the incident in order to be able to give appropriate advice.

I therefore recommend that steps be taken to investigate methods by which assisting control rooms can obtain access to the information available to the host control room.

Evacuation

Recommendation 33.22b

There were no plans in place for evacuating Grenfell Tower should the need arise. I therefore recommend:

That fire and rescue services develop policies for partial and total evacuation of high-rise residential buildings and training to support them.

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Grenfell Tower Inquiry Phase 1 recommendations progress update