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 the failings can be traced back over many years and our efforts to get to the bottom of what went wrong and why account for the length of our report and the time it has taken us to produce it however if an inquiry of this kind is to produce anything of value it is necessary for those who can influence the future direction of the construction industry the fire and Rescue Services the management of fire safety in buildings and resilience planning to understand exactly where mistakes were made and how they can be avoided in the future