The second and final part of a major inquiry into the June 14, 2017, Grenfell Tower fire in London said that all 72 deaths could have been avoided.

"The simple truth is that the deaths that occurred were all avoidable, and those who lived in the tower were badly failed over a number of years and in a number of different ways by those who were responsible for ensuring the safety of the building and its occupants," inquiry chair Martin Moore-Bick said while presenting the almost 1,700-page report on Wednesday.

The damning report said that failures by government, regulators and the construction industry turned the building into a "death trap." 

What started as a small fridge fire on the fourth story, as was concluded in the first installment of the inquiry in 2019, turned into a firestorm engulfing the vast majority of the 24-story building within around half an hour.

Prime Minister Keir Starmer apologized on behalf of the state in comments in parliament a few hours after the publication. 

"I want to start with an apology on behalf of the British state to each and every one of you, and indeed, to all of the families affected by this tragedy," he said. "It should never have happened. The country failed to discharge its most fundamental duty: to protect you and your loved ones, the people that we are here to serve, and I am deeply sorry." He also promised justice for the victims.

Use of cladding in sharp focus

The fire's rapid spread was in large part because of combustible "cladding" panels on the exterior of the building. 

"We conclude that the fire at Grenfell Tower was the culmination of decades of failure by central government and other bodies in positions of responsibility to look carefully into the danger of incorporating combustible materials into the external walls of high-rise residential buildings and to act on the information available to them," the inquiry said.

"Not all of them bear the same degree of responsibility for the eventual disaster, but as our reports show, all contributed to it in one way or another, in most cases, through incompetence, but in some cases, through dishonesty and greed," Moore-Bick said.

The case drew sharp attention to wealth inequality in London. Grenfell Tower was a social housing bloc in one of the richest areas of West London. The cladding was used primarily to improve the aesthetics of its exterior at a cut price during a renovation.

"How was it possible in 21st century London for a reinforced concrete building, itself structurally impervious to fire, to be turned into a death trap?" the report asked. "There is no simple answer to that question." 

The report was highly critical of the companies suppyling the cladding, saying they engaged in "systematic dishonesty," manipulating safety tests and misrepresenting the results to claim the material was safe, even amid allegations that it was not.

"Today's report speaks to the lack of competence, understanding and fundamental failure to perform the most basic duties of care. We paid the price for systematic dishonesty, institutional indifference and neglect," said Natasha Elcock from Grenfell United, a group of survivors of the fire and bereaved family members of those who died. 

Fire brigade 'complacent' about cladding risks and response limitations

The fire was the deadliest in the UK since World War II.

The London Fire Brigade (LFB) also comes in for hefty criticism in the report, with officials described as "complacent."

It had failed to ensure that the danger posed by the use of cladding "was shared with the wider organization and reflected in training," it said, and had failed to learn lessons from a previous 2009 fire in London "which should have alerted the LFB to the shortcomings in its ability to fight fires in high-rise buildings."

Residents who called the emergency services were told to stay in their flats to await rescue. This "stay-put" advice was standard issue at the time but has since been changed given how it led to people who might have escaped becoming trapped in their homes.

Prime Minister Keir Starmer pledged to learn from the failings highlighted.

"The Government will carefully consider the report and its recommendations, to ensure that such a tragedy cannot occur again," Starmer said in a written statement to parliament following the report's release on Wednesday.

The previous government announced plans in 2022 to accelerate the removal of cladding in other buidlings and require developers to contribute more to the costs, but another large fire last week in Dagenham in London pointed to the continued usage and risks in places.

London's Mayor Sadiq Khan said that while the publication of the second phase of the inquiry "is an important step on this journey, it is not the end." 

"Those responsible must now be immediately held to account for their systematic dishonesty, corporate greed, insitutional indifference and neglect," Khan said. 

msh/nm (AFP, AP, Reuters)