attach significant importance to fire safety is illustrated by its reliance on a single person, carl stokess for its entire estate. despite his lack of qualifications and experience, by its failure to carry out necessary remedial work, identified in a fire risk assessments promptly, by its failure to provide measures to mitigate the absence of an effective smoke ventilation system, and by its failure to introduce appropriate arrangements for inspecting and maintaining fire prevention systems, in particular self—closing devices on the entrance doors to individual flats. in addition, the tmo failed to maintain a reasonably accurate record of those residents of the tower who are vulnerable for one reason or another, and likely to need help to escape if a fire occurred. part six of the report contains our findings about itself and again, the picture is disturbing. first, the regular tree context in which the work was carried out was in our view, unsatisfactory because the statutory guidance which was treated by many in the construction industry, including those engaged on the refurbishment, as