As phase one of the inquiry into the Grenfell Tower fire ends, and hopes of justice remain in the balance for survivors and the bereaved, it’s time to reflect on the process and ask, have we learned the lessons of past public inquiries?

In giving evidence to the Grenfell Tower inquiry last month, Robert Black, chief executive of the Kensington and Chelsea Tenant Management Organisation (KCTMO), which was responsible for the tower block, could not recall very much of the most fateful night of his life.

Black, a Scot who had worked in housing management throughout his 27-year career, could not confirm to within an hour what time he arrived at the scene of the fire by taxi from his home in south London. He could not remember if he had been asked for plans of the burning building by the London fire brigade, and did not know if any had been sent. Despite having been released on full pay last year to assist the inquiry (before resigning last December), he could bring to mind hardly any detail about the sequence of emails or conversations between himself and his team on the ground that night. And he professed no knowledge of why the information sent to the fire service operations room about the residents of Grenfell, in particular the location of vulnerable or disabled occupants of the tower, was 15 years out of date. Largely, he said, speaking of his role in the emergency operation, “you are almost there as a spare part”.

One detail of the chief executive’s evidence that did emerge in black and white was an email he wrote at 6am, about five hours after the Grenfell fire had been started by a faulty fridge-freezer in a flat on the tower’s fourth floor.

The email was sent from Black’s Samsung phone to colleagues on the executive committee of the KCTMO. The subject of the email was “fire”. It noted that Black was already being asked questions, principally by the leader of the council, Nick Paget-Brown, and its housing director, Rock Feilding-Mellen, “about the cladding and spec. Questions about how [the fire] spread.” His colleagues needed to provide answers and “to pull some of this together pretty fast in terms of health and safety compliance”, Black wrote, with the fire still consuming Grenfell’s 24 storeys in front of him and with the list of dead and missing growing ever longer. “We need all the information about the refurbishment, as this will be a primary focus.”

Inquiries must have a therapeutic value as well as a forensic value

In studying that email, projected on a large screen on the wall of the inquiry’s ad hoc court room, Richard Millett QC, the lead counsel, looked professionally puzzled. Millett is a man who, in questioning fire fighters, survivors, expert witnesses and council employees every working day for six months, has maintained the same polite, inquisitorial tone, like a village GP asking for symptoms from an anxious patient. His chief weapon in indicating mild disquiet during this gruelling evidence-gathering process has been the pregnant pause. Millett employed one of these as he looked at the email on the screen. Why had Black sent that email to his team, he eventually wondered.

“Well,” Black replied, “when Nick Paget-Brown and that came they were asking – because obviously, you know, it looked like the cladding was an issue. All I was trying to do was pull together some pointers of what we would have to prepare for [the council], or ultimately for an inquiry, of which we knew there would be one, by that time.”

That latter understanding, that the “terrible and shocking scene” the chief executive witnessed on arrival at the tower would inevitably lead here, to a nondescript room behind the raw red facade of the old Prudential Assurance building in Holborn, London, seemed to betray a fundamental rule of public life in Britain. In extremis, this is how that world works. When very bad things happen, those directly involved would sit somewhere like this, 18 months or two years down the line, in front of a polite QC and a retired judge and a bank of lawyers with box files, and try, often in vain, over the course of an afternoon, to knot their brows and recall their part in the tragic events in question.

That understanding – that the horrific tragedy would lead inevitably, in the first instance, to a public inquiry – was not immediately grasped by the survivors of the Grenfell fire, or by the bereaved, whose mothers and fathers and sons and daughters and brothers and sisters were among the 72 who died.

One thing the inquiry process could have done better initially, according to Moyra Samuels, a local resident and teacher who has led the pressure group Justice4Grenfell since the day after the fire, was to explain to the families exactly what an inquiry was. Some people assumed it was a grand investigation that could lead directly to prosecutions, like the Mueller inquiry in the US. Others feared it would be an opaque process of information gathering politically designed for obfuscation and delay.

Natasha Elcock escaped from the 11th floor of the tower with her six-year-old daughter and boyfriend. They had been trapped in her flat for 90 minutes, as part of the fire brigade’s “stay put” policy, and rang for help nearly 100 times before the fire crews reached them and helped them, through the black smoke and chaos of the desperate and the dying, downstairs. Elcock, a retail manager, now chairs the Grenfell United group of survivors and bereaved families. “Initially,” she told me last week, “because we had never been involved in something like this, the inquiry was all a bit of the unknown. I suppose I had a sense that the aim of it was to get to how things happen and why things happen – but for us there was the fact that more than 70 people died that night, in our view essentially murdered. We were all about people being arrested and we didn’t want any inquiry to hinder that.”

Facebook Twitter Pinterest Grenfell survivors Natasha Elcock and Shahin Sadafy, leaders of the survivors’ group Grenfell United. Photograph: Alicia Canter/The Guardian

The Grenfell inquiry is now six months into a process that is expected to last two more years. Next week, phase one of its remit, which has gathered documentary evidence and interrogated core participants over statements about the events of the night itself, will come to an end. The presiding chair, Martin Moore-Bick, will publish a preliminary report, which may lead to some immediate statutory changes, for example in building regulations relating to cladding, and in updated guidance to firefighters dealing with high-rise fires. Sometime soon after Christmas, the second phase will ratchet slowly into motion, trying to find answers to the wider questions about why the fire took hold, and to apportion blame for what happened. Criminal prosecutions from a concurrent Met investigation may or may not follow. This is, then, another moment to take stock. To see if the inquiry into an event that was asked by some to act as metaphor for three decades of political failings in social housing policy is likely to provide any meaningful answers.

The precedents are not all encouraging. The public inquiry – first used as an instrument for the Tay Bridge disaster, which killed 75 people in 1879 (it found that the bridge had been “badly designed, badly built and badly maintained”, though no prosecutions followed) – is one of Britain’s genuine growth industries. Between 1990 and 2017, 69 inquiries were launched. Since 1997, there have never been fewer than three running at any one time; in late 2010, a record 16 inquiries were on the go. Those inquiries made thousands of recommendations, but their implementation is largely undocumented and patchy. Lord Shutt of Greetland, chair of the committee on the Inquiries Act 2005 – an inquiry into inquiries – noted that when a new inquiry is carried out, often at huge expense, “it’s as though previous ones had never happened”.

If the Grenfell residents could ever be described as lucky, you might point to the fact that the commissioning of their inquiry coincided with one of the most damning reports into the tone and conduct of British public life ever published. James Jones, the former bishop of Liverpool, who for more than two decades had acted as an advocate and friend of those who lost loved ones at Hillsborough, pulled no punches with his account of how that long process had treated the bereaved. He called his report, commissioned by then home secretary Theresa May, “The patronising disposition of unaccountable power”.

Traditionally, the remit of a public inquiry is concerned with three questions: What happened? Who is to blame? And what can be done to prevent this happening again? In the course of his 25 recommendations, Jones argued for the inclusion of a fourth: a commitment not only to treat bereaved families and survivor families with utmost dignity during the process, but to be seen as treating them with utmost dignity. To recognise that inquiries must have a therapeutic value as well as a forensic value.

The Grenfell inquiry is a test case of those recommendations. Not long after Jones’s report came out, the families of Grenfell United contacted the retired bishop to invite him to come to consult with them. At the same time, the new leader of Kensington and Chelsea council also wrote to Jones, asking if he could visit the council, too, to share insights into what the 200 traumatised families might be going through. One afternoon at the beginning of the year, he shuttled between both groups.

There were subsequent meetings. At one, the families of Grenfell United said they wanted the council to sign up to the charter for families bereaved through public tragedy that had been part of Jones’s report. The charter includes a pledge to “avoid seeking to defend the indefensible or to dismiss or disparage those who may have suffered where we have fallen short”. The council became the first body to sign the charter. A significant number of others have followed, including the Crown Prosecution Service. Lord Kerslake, when conducting his review of the Manchester Arena killings, encouraged all the main agencies involved to sign up to it; some did, some didn’t.

Facebook Twitter Pinterest A schoolgirl writes a message on a wall for victims and survivors of the blaze. Photograph: Alastair Grant/AP

One of the primary impacts of Jones’s insistence of putting the grief and anger of the families at the heart of the process was a change of emphasis in the proceedings. The Grenfell inquiry opened with two weeks of moving commemorative tributes to those who had died, from those who knew them best and loved them most, all attended by the inquiry chair, Moore-Bick, and the team of lawyers.

When you go up there, it’s a room full of lawyers, and the families somewhere off to the side Natasha Elcock

The format softened the attitude that many of the Grenfell survivors and bereaved had toward Moore-Bick. Initially, he had seemed an establishment chair out of central casting (between 1990 and 2017 there have only been six inquiries with a female chair, for example; 14 of the inquiries over that period were chaired by someone called either Anthony or William.) The choice of Moore-Bick was questioned by groups including Justice4Grenfell because of a 2014 judgment, dug up from the archives, in which he had allowed Westminster council to rehouse a tenant in Milton Keynes, 50 miles away from her home. Confronted with the case, the judge said: “I was rather surprised to see myself described as controversial.” At his first public meeting with the families, he left the stage with questions still being yelled from the floor. The commemorations changed that relationship.

The survivors I have spoken to expressed their sense that hearing firsthand about those who had lost their lives changed the body language of the judge (who sometimes appears to have modelled his studied courtesies on those of John Major). “When you sit up close to him now in that room,” Elcock says, “there are lot of signs that you can see in how he takes evidence. He often asks additional questions to make sure he has a full understanding. Since the commemorations I think he is really engaged with this and has a real commitment to get it right.”

If the tone of the questioning has proved empathetic to the core participants in the tragedy, there are other aspects of the proceedings that in their eyes still fall short. The choice of Holborn as a venue for the inquiry was bitterly opposed by the family groups, who have to travel half way across London to attend. And the geography of the room itself seems to marginalise their involvement. “When you go up there,” Elcock says, “it’s a room full of lawyers, and the families somewhere off to the side.”

Other recent inquiries have changed this traditional arrangement. In the ongoing inquiry into contaminated blood, Sir Brian Langstaff, the chair, announced in his opening remarks that “this won’t be run for the benefit of lawyers but for the benefit of those affected. So the room won’t be designed so the view of the public is obscured by ranks of lawyers.” The Grenfell survivors still hope that some greater accommodation of this kind can be made for them in phase two of the proceedings.

Facebook Twitter Pinterest Tony Blair at a press conference at Admiralty House, responding to the report of the Chilcot inquiry. Photograph: WPA Pool/Getty Images

At the heart of James Jones’s analysis of the “patronising disposition” of public inquiries was the identification of “a mindset which defines how organisations and people within them behave… One of its core features is an instinctive prioritisation of the reputation of an organisation over the citizen’s right to expect people to be held to account for their actions.”

It would be fair to say that, so far in the Grenfell inquiry, the authority figures from various agencies who have appeared to give evidence are still struggling with that principle. The quotation out of all the days of evidence that most seemed to define that mindset came from Dany Cotton, commissioner of the London fire brigade.

After weeks of evidence from firefighters who had performed often heroic actions despite a lack of breathing apparatus and with broken radio communications, despite the contentious delay in ordering the evacuation of the tower and an absence of previous checks on the building, Cotton bluntly told the inquiry that, with hindsight: “I wouldn’t change anything we did on the night.”

Sitting in the courtroom along with other members of Grenfell United, Elcock recalls how she felt “the angriest on hearing that that I had felt since 14 June 2017. She wouldn’t change a thing? She did an injustice to the people that she manages by saying that. Because they still go out every day risking their lives, and she thinks nothing should be changed?”

The tight-lipped testimony from figures such as Cotton and Black stood in contrast to the 32 days of deposition from survivors and their relatives. They relived the minute details of the trauma that had haunted them for more than a year. On the days I sat listening, in the adjoining media room, the repetitive account of smoke-filled corridors and the orange glow outside their windows was punctuated in each case by sudden and terrible human drama. The heartbreaking account of Paulos Tekle, who lost his young son, Isaac, who had been holding the hand of a neighbour as they descended the stairs from their 18th-floor flat; or the final words, played to the courtroom, of Mohammed Neda, 57, who was among those who fell to their deaths from the upper floors of the building: “We are leaving this world now, goodbye. I hope I haven’t disappointed you. Goodbye to all.” Most of the recorded conversations between those who lost their lives in the fire and the control room operators who sought to give them advice or comfort were told in transcript rather than played as audio, because they were too traumatic to hear, but their contents were no less devastating.

Those days of evidence have rarely made headline news. The inquiry, like everything else, has been swamped and overwhelmed by Brexit, except – as with the appalling bonfire night party – when something beyond the confines of the process disturbs its steady progress. The BBC’s daily podcast has offered an often telling summation of events, but the survivors and the bereaved are understandably dismayed that days and weeks of startling testimony have gone by at the inquiry with barely a ripple on the surface of the national conversation.

Facebook Twitter Pinterest BBC journalist Andrew Gilligan arrives at the Royal Courts of Justice for the Hutton inquiry into the death of Dr David Kelly. Photograph: Dan Chung/The Guardian

They retain a moving faith in the process, however. Tiago Alves escaped from the fire with his young sister and parents, who helped to evacuate their floor of Grenfell, ignoring the “stay put” advice. Alves is studying physics at King’s College London but has taken a year out to try to help keep on top of the scientific aspects of the 378,000 documents that have been submitted. “I have done my best to use the scientific method to try to explain some of it to the Grenfell United committee or the membership,” he says. “My primary subject is physics, but I have done a lot of chemistry, so I hope that is helpful.”

I wonder, talking to him, what he has made of the pedantic manner in which Millett, the lead counsel, has asked survivors to relive their trauma, dwelling in endless detail on the nature of the smoke or the remembered layout of rooms.

“I will answer this in two hats,” Alves says. “From my survivor perspective, quite often I feel frustrated that they are homing in on the wrong details. But with my scientific hat, I believe that they are collecting this evidence to use at a later stage with another witness. It may seem very pedantic, but I want to believe that they know what they are doing. With the expert reports they are constantly cross referencing. You see them starting to weave a story…”

And he is confident that they are pulling at the right threads?

“You hope so. It is not until you see the finished work that you will know. This is the thing, though. We are the real experts on what happened that night. If we don’t use our expertise in the right way, nothing will change.”

The first test of that belief will come in the interim report from Moore-Bick, to be delivered in the coming weeks. The second phase of the inquiry, along with criminal investigations by the Metropolitan police, is where the survivors place their true faith, however. The questions it seeks to answer are many of those voiced in incredulity and anger on the night of the blaze itself, the kind of questions that Robert Black hoped his colleagues might be able to answer in his 6am email.

Again, there is a hope that the process might be alive to a change in emphasis of the kind recommended by James Jones. In the past, the expected outcomes of an inquiry have often been ludicrously vague. The terms of reference for the 2003 Hutton inquiry merely stated that the inquiry was to “urgently conduct an investigation into the circumstances surrounding the death of Dr Kelly.” For the Chilcot inquiry, which lasted seven years and cost £13m, it was “to identify the lessons to be learnt from the Iraq conflict”.

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Following consultations with all parties, there are 13 stated specific areas of investigation for the second phase of Grenfell, and multiple subsets of specific questions to be answered in each. Some of these questions jump out more than others. The judge may pay particular attention, for example, to: “What elements or aspects of the exterior of the building at the time of the fire failed to comply with what elements or aspects of what regulations, legislation, British Standards, guidance, industry practice, and in each case to what extent?” And: “Who was responsible for such failures?” Or: “Assess the adequacy of the LFB’s actions (including the application of the “stay-put” policy)…”

Andrew O’Hagan’s controversial report in the London Review of Books, which was published the day before the inquiry opened, sought to pre-empt Moore-Bick’s efforts. Based on dozens of interviews with many of those who subsequently gave evidence to the inquiry, O’Hagan’s 60,000-word story came to reflect a frustration with subjectivity itself. Everyone, it seemed to the author, sought to use the fire to reinforce his or her own ideology. That he has not been forgiven for the perceived hubris of that conclusion – he acquired the nickname Andrew O’Hateful at Justice4Grenfell – in some senses adds weight to it. “Tories,” O’Hagan wrote, of those seeking to find lessons in the fire, “bestowed on themselves a pure paternalism that forgave their remoteness from a portion of the people they were employed to serve. The Corbynites took every opportunity to make the tragedy exemplify their core message, but they had to be selective in order to do that. The firefighters, and the unions, argued that every failing on the night could be put down to government cuts, closures and privatisations. The ordinary punters meanwhile pinned their colours either to group heroism on the night or to individual acts of depravity – as if the tower was pre-eminently a locus of truth about Britain today.”

In one respect, no doubt, O’Hagan’s pre-emptive report performed a useful function for the inquiry proper. The reaction to it was a further sobering example for the intensely sober Moore-Bick. The judge will know that there is nothing he can conclude that will please everybody. He will also know too, perhaps, from the moment that the inquiry began with its commemorations, that he has a unique opportunity to do right by the survivors and the bereaved and the 72 dead and, in doing so, return some real confidence to the inquiry process itself. Elcock and the families of Grenfell United have to believe that is the case. In what they know will be a long fight for nuanced truth, a fight that began in the choking smoke on the stairwells of the tower block, they are fully prepared, she says, “to keep holding our breaths until justice is done”.