Lakanal House fire: A tragedy waiting to happen?
Six people died when fire swept through a London block of flats in July 2009. But was this a tragedy waiting to happen?
Huddled in a flat as flames spread through the building, their terror can only be imagined.
They had had been advised to stay put by the fire service, who assumed the strength of the building would be able to withstand the blaze.
But as the fire edged closer and choking smoke billowed into the bathroom, Fatima and Rachid Nuhu decided they had to make a move and fled on to the balcony.
It was a decision that would save their lives.
But Dayana Francisquini, 26, her two children Thais, six, and Felipe, three, and Helen Udoaka, 34, and her 20-day-old daughter Michelle died as they waited to be rescued.
Catherine Hickman, 31, also perished after being told not to leave her flat.
Mrs Udoaka's husband Mbet told the inquest into the deaths how he had to stand outside as his family died inside the flats.
He said: "I don't know if they have been able to learn any lessons from this so that it doesn't happen to other occupants of similar buildings in London.
"Every person that made an attempt came out of that building alive. My wife was asked to stay put ... why did you ask her to stay put when you are not going to get to her?"
The fire had broken out at 16:15 BST in flat 65. Resident Jade Spence alerted the fire brigade before leaving the building.
Meanwhile Ms Hickman in flat 79, above flat 65, called 999 and was advised to stay put. She collapsed while still on the phone to the operator.
This guidance was what the London Fire Brigade (LFB) calls fire survival advice.
But the front of flat 65 disintegrated as panels and frames that held the glass failed within five minutes. Firefighters usually work on the principle fire will be contained within a flat for up to 60 minutes.
It is this assumption which is the root of the policy for advising residents to stay put if the fire is not in their flat.
Meanwhile, firefighters reaching the scene had no idea of the block's layout.
They also discovered only one of the two lifts was working and the LFB's key to operate it did not work, leaving them to walk up seven floors.
When firefighters reached flat 65, at about 16:40 BST, the blaze was intense.
Balconies led to exits
Firefighters Lyndan Simons and Charles Fournier said "the front of the building had just gone".
Ten minutes later Ms Hickman collapsed in the flat above.
Meanwhile, Mrs Udoaka and her baby went to neighbour Fatima and Rachid Nuhu's home in flat 80, before they reached Ms Francisquini's home in flat 81 via a balcony.
But when smoke started pouring into the bathroom, the Nuhu family decided to leave with their two children via the balcony.
Most residents and firefighters did not seem to know the balconies on either side of the block led to fire exits on the central staircase and it was a secure way out for residents and a way in for firefighters.
The 10-week inquest heard Southwark Council had not complied with the 2006 law on Fire Risk Assessments.
The evidence painted a scene where the fire incident commanders were becoming overwhelmed with the number of twists and turns, in addition to poor communications and a lack of clarity of where the fires were and how to get access to the trapped families.
The LFB was responsible for carrying out familiarisation visits on unusual premises but no clear information was available.
On their way up, firefighters arrived at balconies and had to smash through each door as none of the fire door keys worked, the inquest heard.
There were also tales of extreme courage. Mark Niblett, who had 18 years of firefighting experience, described the exhaustion and impact of facing "blast furnace" temperatures.
Firefighters, including Christopher Rose, finally entered flat 81 shortly after 18:00 BST.
He became overcome with emotion in realising he had reached the two women and three children too late, he told the inquest jury.
A number of issues, from fire risk assessments, building control to rescue efforts, were highlighted during the inquest.
'Stop others suffering'
It also raised questions about the "stay put" advice given to residents in high-rise buildings by the fire service.
Regulators will also have to decide whether it is appropriate for a local authority to be in charge of building regulations and refurbishments as a landlord, and whether fire risk assessments need independent monitoring.
Ms Francisquini's partner Rafael Cervi said: "I want to be sure that I didn't lose my family for nothing.
"I want to be sure that everything that can be done will be done to stop others suffering like me and Mbet."