Lakanal House: 'Missed opportunities to make tower safe'
The jury at an inquest into the deaths of six people killed in a south-east London tower block fire found "numerous opportunities" were missed to carry out fire safety checks inside the building.
Narrative verdicts into the victims' deaths at Lakanal House in Camberwell in July 2009 were returned.
Southwark Council and London Fire Brigade (LFB) were criticised.
A lack of fire resistance around doors meant the fire could not be contained for long enough.
Dayana Francisquini, 26, and her children, six-year-old Thais, and Felipe, three, were among the victims.
Helen Udoaka, 34, her three-week-old daughter Michelle and 31-year-old Catherine Hickman were also killed.
They all lived on the 11th floor.
Southwark Council was responsible for a "serious failure" over materials used in Miss Hickman's flat that were below the required standard for fire safety, the jury found.
'Failed to react'
They went on to state that firefighters could have concentrated more on rescuing people rather than putting out flames.
The jurors also found LFB personnel who took emergency calls from some of the victims failed to react to the situation when they told them to stay where they were.
It would have been possible for them to escape without assistance, according to the jurors.
The jury said the LFB should have advised Mrs Francisquini to get out with her children once it was clear how smoke-logged her flat had become.
The jury said the LFB also failed to prioritise the rescue of Miss Hickman in flat 79.
Confusion over the layout of the building and flat numbers prevented firefighters getting to her quickly enough, the jury said.
In fact, residents could have got out of the building via communal balconies leading onto the main stairway, the inquest heard.
Coroner Frances Kirkham has written to communities secretary Eric Pickles and Southwark Council with a list of recommendations.
In her letter to Mr Pickles, she has recommended the government publishes national guidance on fire safety for residents in high-rise buildings and urged local authorities to install sprinkler systems.
In her letter to Southwark Council she has recommended that it reviews its policies concerning fire risk assessments of its high-rise buildings, that it trains staff and liaises with emergency services about access to property.
During the inquest jurors heard detailed information about the layout and structure of the tower block and how emergency services dealt with the fire.
Questions were raised over why some residents were told to stay in the building and some to leave, and over whether some firefighters knew the layout of the block.
The fire started in a faulty piece of electronic equipment in flat 65, and spread to flat 79 where Miss Hickman lived with her boyfriend Mark Bailey.
She had previously asked about how to escape in the case of a fire. Smoke and flames also spread to flat 81, where the other five victims were sheltering.
Firefighters said the huge blaze involved the first case they had seen of flames spreading downwards in a building.
Pathologists said Miss Hickman died from inhalation of fumes and burns, and the other five from inhalation of fire fumes.
Following the verdicts Councillor 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.
"The Council has put fire safety and improvements to our housing stock at the top of our priorities. First and foremost was the creation of a dedicated housing department with clear accountability.
"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."
London Fire Commissioner Ron Dobson said: "This was a tragic fire and I would like to express my personal sadness and offer condolences from all at the London Fire Brigade to the families and loved ones of those who died on 3 July 2009.
"From the outset we have worked with the police to investigate the cause of the fire and have welcomed the opportunity that these inquests have provided to help find out what happened.
"We will now consider the jury's verdict and the recommendations that the coroner has made."
A Department for Communities and Local Government spokesman said it would "carefully consider the recommendations" and "respond shortly".