Grenfell Tower fire was the final, fatal link in a chain of unimaginable human failure

There is one thing that strikes you about the Grenfell Inquiry report - other than its size.

Throughout its 1,700 pages - that drew on 320,000 pieces of evidence, 1,600 witness statements, and over 300 public hearings - there is no overarching conclusion as to who was ultimately responsible for the disaster.

No person or organisation is found "most" to blame for the entirely avoidable deaths of 72 people - the greatest loss of civilian life in a fire since the Second World War.

Grenfell Inquiry live: Damning report into tragedy released

That's not a criticism of the inquiry chair, Sir Martin Moore-Bick.

It is because the Grenfell Tower fire was the final, fatal link in a chain of human failure so complete, that it is almost unimaginable.

The first link in that chain were the companies Arconic, Celotex, and Kingspan that, in the words of the report, cynically, deliberately, and dishonestly sold what they knew to be flammable construction materials as "fire safe".

First, because without them, everything that followed would have been less consequential, though no less wrong.

Next came the supposedly independent testing and certification bodies, which were "complicit," the report finds, in allowing combustible cladding to be marketed as the opposite.

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Architects, contractors and council staff at fault

Inspectors, partly out of financial necessity, had grown too close to those they were supposed to monitor.

Relying on them, and therefore linked in the chain, were the architects, contractors, and council staff who specified and installed the materials at Grenfell on cost-saving grounds.

The report found that they were at fault themselves for failing in their legal duty to ask whether the combination of materials they chose to use complied with fire regulations.

They were also at fault for design decisions, such as gaps in the window frames filled with material that were more flammable than the cladding itself, the report reveals.

This fatally compromised the 1970s concrete walls which, brutal though they were, had kept Grenfell residents safe from fire for 45 years.

Regulations ambiguous and out of date

Now, to the building inspectors and fire consultants - who either didn't know or didn't care enough about their jobs to spot the glaring problem when they saw it on the outside of the tower. That's if they saw it.

The inquiry heard how the project's main fire safety consultant didn't even visit Grenfell once refurbishment was complete.

Then there were the regulations themselves and the successive governments responsible for them. They were ambiguous, chronically out of date, and fatally flawed in not explicitly banning flammable materials from high-rise buildings despite warnings, near-misses, and even deadly fires elsewhere.

Of course, these links overlap and interconnect.

If fire testing or regulations hadn't been a joke, flammable cladding wouldn't have been allowed on a 24-storey building. If the architect, contractor, or council had known or asked more about fire safety, the problem could have been spotted.

And after the loss of life, that's perhaps the most tragic thing about the Grenfell disaster; the number of missed opportunities for perhaps just one person to do their job properly and break the chain of failure.

Almost no one admitted their fault

At the inquiry - probably on the advice of lawyers - hardly any organisation or individual admitted fault for their part in the disaster.

It should have been where an entire industry hung its heads in collective shame.

It was not within Sir Martin's remit to find criminal responsibility. However, the inquiry identifies much that could meet that definition.

Now its report is done the Metropolitan Police investigation can resume.

For the sake of the victims, but also for anyone with a roof over their heads, it should do so swiftly so those responsible face justice.

On top of the report's 58 recommendations, prosecutions would send the strongest message to the construction industry and its regulators that a disaster like Grenfell can't be allowed to happen again.

The UK Tonight With Sarah-Jane Mee will have a special programme on the Grenfell Tower report at 8pm on Sky News