Advice to "stay put" during the Grenfell Tower fire had "effectively failed" within around half an hour of the blaze starting, a report has found.
Dr Barbara Lane said there was "an early need for total evacuation of Grenfell Tower", but she added it was not an "easy decision to make".
Her comments are in one of five reports published at the start of the fact-finding stage of the public inquiry.
Seventy-two people died as a result of the blaze, the inquiry has said.
This includes Maria Del Pilar Burton, 74, who died in January. She had been in hospital since she was rescued from the 19th floor.
The inquiry is expected to last around 18 months.
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What happened at Grenfell Tower?
Grenfell Tower inquiry: What is happening?
Who were the victims?
Having already heard seven full days of tributes to the tragedy's victims, the public inquiry has turned to the cause and spread of the fire.
Five expert reports were published on Monday morning, looking at the tower's safety measures and the evacuation on 14 June last year.
The reports include three studies of how the fire spread - including one examining the contribution of the highly flammable cladding and insulation which had been installed as part of a refurbishment.
Another report considered the building's own fire protection measures, and another the safety regulations in place at the time of the tragedy.
When the fire was first reported at 00:54 BST, residents were initially given advice to "stay put" inside the building.
In her report, Dr Lane said this advice had "effectively failed" by 01:26.
A change in policy recommending residents try to leave wasn't made until 02:47 BST, one hour and 53 minutes after the first emergency call.Prof Jose Torero's report said a "stay put" strategy was appropriate while the fire was contained to flat 16, but not once the fire started to spread up the building.
He said that once the fire had breached the flat - the "second phase" - it would have been better for residents to have left their flats and exited the building.
Prof Niamh Nic Daeid's report stated that the fire began in the south-east corner of the kitchen in flat 16 on the fourth floor of the tower but there was "insufficient" evidence to determine the exact cause.
She said the "cause of the fire remains undetermined" but the origin was more than likely around a fridge-freezer in the flat.
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Dr Barbara Lane said there was "an early need for total evacuation of Grenfell Tower", but she added it was not an "easy decision to make".
Her comments are in one of five reports published at the start of the fact-finding stage of the public inquiry.
Seventy-two people died as a result of the blaze, the inquiry has said.
This includes Maria Del Pilar Burton, 74, who died in January. She had been in hospital since she was rescued from the 19th floor.
The inquiry is expected to last around 18 months.
Lenovo Support Number
What happened at Grenfell Tower?
Grenfell Tower inquiry: What is happening?
Who were the victims?
Having already heard seven full days of tributes to the tragedy's victims, the public inquiry has turned to the cause and spread of the fire.
Five expert reports were published on Monday morning, looking at the tower's safety measures and the evacuation on 14 June last year.
The reports include three studies of how the fire spread - including one examining the contribution of the highly flammable cladding and insulation which had been installed as part of a refurbishment.
Another report considered the building's own fire protection measures, and another the safety regulations in place at the time of the tragedy.
When the fire was first reported at 00:54 BST, residents were initially given advice to "stay put" inside the building.
In her report, Dr Lane said this advice had "effectively failed" by 01:26.
A change in policy recommending residents try to leave wasn't made until 02:47 BST, one hour and 53 minutes after the first emergency call.Prof Jose Torero's report said a "stay put" strategy was appropriate while the fire was contained to flat 16, but not once the fire started to spread up the building.
He said that once the fire had breached the flat - the "second phase" - it would have been better for residents to have left their flats and exited the building.
Prof Niamh Nic Daeid's report stated that the fire began in the south-east corner of the kitchen in flat 16 on the fourth floor of the tower but there was "insufficient" evidence to determine the exact cause.
She said the "cause of the fire remains undetermined" but the origin was more than likely around a fridge-freezer in the flat.
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