Source · Prevention of Future Deaths

Fishmongers’ Hall Inquests

Ref: 2021-0362 Date: 3 Nov 2021 Coroner: HH Judge Lucraft QC Area: London City Responses identified: 9 / 10 View PDF

This document is a questionnaire for the jury, intended to determine the means and circumstances by which Jack Merritt and Saskia Jones died, focusing on identifying any errors, omissions, or circumstances that may have caused or contributed to their deaths.

Date 3 Nov 2021

56-day deadline 29 Dec 2021 est.

Responses identified 9 of 10

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Coroner's concerns

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_______________________________________________________________ Notes for the jury
• This questionnaire has been prepared by the Coroner after receiving submissions from Interested Persons. By answering the questions, you will give your determinations on the key factual issues in the case. All are intended to address the central question: by what means and in what circumstances did Jack Merritt and Saskia Jones come by their deaths?
• After the inquests, a completed copy of this questionnaire will form part of the Record of Inquest for each of Jack Merritt and Saskia Jones.
• For a number of the questions, you are asked for a “yes” or “no” answer, and you are then given the option to explain further in a box. You are not obliged to fill in the box. Considerations and issues are then listed which you may want to consider, although you should feel free to give your own answers (provided that you follow the legal directions in these Notes and the Coroner’s summing-up).
• For some of the questions, you are first asked whether there was some error, omission or circumstance that (probably) caused or contributed to the two deaths. If you have answered “no” to that, you are then asked whether the same thing may have caused or contributed to the two deaths. If answering the second part of such a question, you will need to consider whether there is a realistic possibility that an error, omission or circumstance as described caused or contributed to the two deaths.
• You may only say that something contributed to the two deaths if you consider that it made a more than minimal contribution.
• You should only give an answer to a question if all of you agree upon the answer. If you find yourselves unable to agree on an answer to one question, you may move on to the next and return to the question later. If a time comes when the Coroner can accept any answer on which you are not all agreed, you will be told.
• In resolving factual issues, you should give your answers in accordance with the “balance of probabilities”; what is more likely than not. (However please note that if you are deciding whether something may have caused or contributed to the deaths, you should consider whether there is a realistic possibility that it did so (see note above).)
• If you choose to give further explanation in any of the boxes where you are given the option to do so, please follow these directions when writing your responses:
i. Your responses should all be directed to answering the question by what means and in what circumstances the deaths occurred. You should not make any statement or comment which does not assist in answering that question.
j. It might help you at each stage to consider the cause(s) of the deaths; any defects in systems and practices which contributed to the deaths; and any other factors which are relevant to the circumstances of the deaths.
k. You should try to be brief and to the point.
l. If you wish to write more than the space in the box permits, you may continue on a separate sheet. At the top of the sheet, you should write the number of the question and the words “Answer Continued”.
m. You should not make any comment on any circumstance, act, omission or event unless there is at least a realistic possibility that it caused or contributed to the deaths.
n. You should not say anything to the effect that a breach of civil law has been committed or that any named person has committed a crime. Because of this legal rule, when writing any explanations, you should avoid using words and phrases such as “negligence / negligent”, “breach of duty”, “duty of care”, “careless”, “reckless”, “liability”, “guilt / guilty”, “crime / criminal”, “illegal / unlawful”. This rule does not prevent you confirming in question 1 that those who died were unlawfully killed: the proposed form of words in that question avoids naming the person responsible.
o. You may use ordinary and non-technical words which express factual judgments. So, you may say that errors or mistakes were made and you may use words such as “failure”, “missed opportunity”, “inappropriate”, “inadequate”, “unsuitable”, “unsatisfactory”, “insufficient”, “omit / omission”, “unacceptable” or “lacking”. Equally, you may indicate in your answer if you consider that particular errors or mistakes were not made. You may add adjectives, such as “serious” or “important”, to indicate the strength of your findings.
p. If you are uncertain about what may be written, you may ask a question in writing to the Coroner during your deliberations. Question 1: Determination on Unlawful Killing of Jack Merritt

Important Note: The Coroner directs that you return an answer of “yes” in response to this question in the answer section, to reflect the primary conclusion that both Saskia Jones and Jack Merritt were unlawfully killed. This direction is given because the evidence clearly supports that primary conclusion and because it is important that the Records of Inquest record that each of them was unlawfully killed.

Question Answer Are you satisfied that, on the balance of probabilities, Jack Merritt was unlawfully killed? Yes Question 2: Basic facts of the attack and the death of Jack Merritt Do you agree with the following statement, which is intended to summarise the basic facts of the death of Jack Merritt? “On 29 November 2019, Jack Merritt was at an event at Fishmongers’ Hall in London. The event was held for the five-year anniversary of Learning Together. Jack was at the event as an employee of Cambridge University, and worked for Learning Together. An attendee of the event, who was on licence having been convicted of an offence under the Terrorism Act 2000, armed with two knives, attacked Jack in the gentlemen’s toilets at Fishmongers’ Hall. Jack suffered a number of injuries when stabbed. This was part of a terrorist attack. The attacker moved from the toilets and began attacking further attendees of the event and a member of staff at Fishmongers’ Hall. Jack moved to a different room at Fishmongers’ Hall and was later removed from the building. His injuries were not survivable. Jack was treated by members of the public, police officers, ambulance staff and HEMS doctors. He was assessed as dead at the scene by a doctor.” In the box below, please either write that you confirm the statement above or state in what respects you would like it to be amended. We agree Question 3: Management of Usman Khan in the Community Was there any omission or failure in the management of Usman Khan (as an offender in the community) by agencies of the state which contributed to the deaths of Jack Merritt and Saskia Jones? Answer “yes” or “no” in the box opposite. Yes If your answer to the question above is “no”, was there any omission or failure in the management of Usman Khan (as an offender in the community) by agencies of the state which may have contributed to the deaths of Jack Merritt and Saskia Jones? Answer “yes” or “no” in the box opposite.

If you can give an explanation for your answer, please do so in the box below.
• Unacceptable management and lack of accountability.
• Serious deficiencies in the management of Khan by MAPPA.
• Insufficient experience and training.
• Blind spot to Khan’s unique risks due to ‘poster boy’ image.
• Lack of psychological assessment post release from prison.

Please go to the next page for matters which you may wish to bear in mind when answering. In answering Question 3, you may wish to bear in mind the following considerations and issues:
• The fact that, throughout the time from his release from prison (December 2018) to the time of the attack, Usman Khan was managed by the National Probation Service.
• The fact that, throughout that time, Usman Khan was subject to Multi-Agency Public Protection Arrangements (“MAPPA”) which involved meetings attended by the National Probation Service, counter-terrorist police, police officers responsible for supervising his Part 4 terrorism notifications and other agencies.
• The facts that Usman Khan (a) had committed a serious terrorist offence in 2010; (b) had been the subject of substantial prison intelligence to the effect that he was involved in radicalising others and violence (including when he was apparently engaging positively with staff, and including in the period before release); and (c) had been released from prison as a Category A High Risk offender, with an OASys rating of Very High Risk to the general public (informed by an ERG assessment expressing significant concerns).
• The fact that Usman Khan had complied with his licence conditions and had apparently engaged positively with those responsible for managing him in the community during 2019.
• The facts that, by November 2019, Usman Khan (a) was living away from the probation hostel; (b) remained unemployed; (c) no longer had visits from mentors; (d) had reportedly become increasingly socially isolated; and (e) had not been doing any actual educational work with Learning Together.
• Whether or not some of those responsible for the assessment and management of Usman Khan in the community were properly trained and experienced and had proper access to information (including intelligence).
• Whether or not there were deficiencies in the management of Usman Khan in the MAPPA process, having regard to (a) the Chair’s level of clearance; (b) arrangements for discussions between the Chair and others on sensitive matters; (c) procedures for decision-making; and (d) procedures for circulation of minutes.
• Whether or not those responsible for the management of Usman Khan in the community took a proper approach to the assessment of the continuing risk he posed, having regard to the available risk assessment tools.
• Whether or not the decision to permit Usman Khan to attend the Learning Together event at Fishmongers’ Hall on 29 November 2019 was properly considered and was a reasonable professional decision when it was made (ignoring hindsight).
• Whether or not consideration should have been given to any further measures being taken if Usman Khan was to be permitted to attend the Learning Together event at Fishmongers’ Hall on 29 November 2019 (e.g. arranging an escort, having him met en route or ensuring that security measures were taken at the venue) (again, ignoring hindsight). Question 4: Sharing of Information and Guidance regarding Usman Khan Was there any omission or failure in the sharing of information and guidance by agencies responsible for monitoring / investigation of Usman Khan which contributed to the deaths of Jack Merritt and Saskia Jones? Answer “yes” or “no” in the box opposite. Yes If your answer to the question above is “no”, was there any omission or failure in the sharing of information and guidance by agencies responsible for monitoring / investigation of Usman Khan which may have contributed to the deaths of Jack Merritt and Saskia Jones? Answer “yes” or “no” in the box opposite.

If you can give an explanation for your answer, please do so in the box below.
• Missed opportunity for those with expertise and experience to give guidance. Please go to the next page for matters which you may wish to bear in mind when answering. In answering Question 4, you may wish to bear in mind the following considerations and issues:
• The fact that, throughout the time from his release from prison (December 2018) to the time of the attack, Usman Khan was subject to a priority investigation by the Security Service and West Midlands Police CTU (supported by Staffordshire Police Special Branch).
• The facts that Usman Khan (a) had committed a serious terrorist offence in 2010; (b) had been the subject of substantial prison intelligence to the effect that he was involved in radicalising others and violence (including when he was apparently engaging positively with staff, and including in the period before release); (c) had been the subject of intelligence in late 2018 that he had said that he intended to return to his old ways (terrorist offending) and that he intended to commit an attack after release; and (d) had been released from prison as a Category A High Risk offender, with an OASys rating of Very High Risk to the general public (informed by an ERG assessment expressing significant concerns).
• The facts that Usman Khan had complied with his licence conditions and had apparently engaged positively with those responsible for managing him in the community during 2019.
• The fact that investigation of Usman Khan during 2019 gave rise to no intelligence indicating activity of national security concern.
• The facts that, by November 2019, Usman Khan (a) was living away from the probation hostel; (b) remained unemployed; (c) no longer had visits from mentors; (d) had reportedly become increasingly socially isolated; and (e) had not been doing any actual educational work with Learning Together.
• Whether or not those responsible for the monitoring / investigation of Usman Khan shared information (including intelligence) and guidance properly with other agencies.
• Whether or not those responsible for the monitoring / investigation of Usman Khan should have raised any concerns or given any advice about him being permitted to attend the Learning Together event on 29 November 2019 (ignoring hindsight).
• Whether or not those responsible for the monitoring / investigation of Usman Khan should have given any advice proposing any further measures being taken if Usman Khan was to be permitted to attend the Learning Together event on 29 November 2019 (e.g. arranging an escort, having him met en route or ensuring security measures were taken at the venue) (again, ignoring hindsight). Question 5: Organisation of and Security Measures for the Event at Fishmongers’ Hall Was there any omission or any deficiency in the organisation of and security measures for the event at Fishmongers’ Hall which contributed to the deaths of Jack Merritt and Saskia Jones? Answer “yes” or “no” in the box opposite. Yes If your answer to the question above is “no”, was there any omission or any deficiency in the organisation of and security measures for the event at Fishmongers’ Hall which may have contributed to the deaths of Jack Merritt and Saskia Jones? Answer “yes” or “no” in the box opposite.

If you can give an explanation for your answer, please do so in the box below.
• Lack of communication and accountability.
• Inadequate consideration of key guidance between parties.
• Serious deficiencies in the management of Khan by MAPPA.
• Failure to complete event specific risk assessment by any party. Please go to the next page for matters which you may wish to bear in mind when answering. In answering Question 5, you may wish to bear in mind the following considerations and issues:
• The fact that Fishmongers’ Hall had a number of security measures for the event, including (a) a door requiring opening from inside (with key fob operation); (b) security staff on the door at most times; (c) limitation of entry to invited guests (who were provided on arrival with identity lanyards) and (d) CCTV at the entrance.
• The fact that Fishmongers’ Hall did not own or have in place any metal detector or employ any arrangements for bags to be searched on entry.
• The fact that staff of the Fishmongers’ Company (a) were aware that all attendees had been invited by the Learning Together programme, but (b) some were also aware that attendees might include ex-offenders who had committed serious criminal offences.
• The fact that the Fishmongers’ Company had had a risk register since April 2019 which identified the risk of a lone actor terrorist attack as an important risk to be addressed.
• The facts that (a) Learning Together organised the event, (b) Learning Together staff at the event were employed by the University of Cambridge and (c) Learning Together were aware that Usman Khan was a terrorist offender who had been released as a Category A High Risk prisoner in late 2018.
• Whether or not those involved in organising the Learning Together event properly informed themselves of and assessed the risks of the event and made appropriate arrangements based on any risks (e.g. requesting security measures).
• Whether or not those involved in organising the Learning Together event properly informed the Fishmongers’ Company of the persons or types of persons attending the event, having regard to the information they had at the time (including concerning the approval of Usman Khan’s attendance at the event by his probation officer).
• Whether or not those responsible for managing and/or for investigating Usman Khan ought to have given any advice on security measures to the Learning Together organisers and/or the Fishmongers’ Company.
• Whether or not the Fishmongers’ Company ought to have implemented any additional security measures, based on the information it had at the time. ANNEX 2

Responses

9 respondents

Learning Together Network CIC

3 Nov 2021 PDF

Noted

The Learning Together Network CIC states it cannot take steps on the recommendations as it did not employ staff or run partnerships, and will be dissolved in January 2022. (AI summary)

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INQUESTS INTO THE DEATHS ARISING FROM THE FISHMONGERS’ HALL AND LONDON BRIDGE TERROR ATTACK RESPONSE OF THE DIRECTORS OF LEARNING TOGETHER NETWORK CIC TO PREVENTION OF FUTURE DEATHS REPORT INTRODUCTION
1. This is the response on behalf of the Directors of the Learning Together Network CIC (“the CIC”) in relation to the ‘Regulation 28 Report on Action to Prevent Future Deaths’ (“the PFD Report”)1 made on 3 November 2021 by the coroner in relation to the deaths arising from the attack at Fishmongers’ Hall on 29 November 2019. Recommendations MC1, MC2, MC3 and MC5 in the PFD Report are addressed to the Directors of the CIC. ROLE OF THE CIC
2. Learning Together at the University of Cambridge (“the University”) involved partnership working between the University and three local prisons. It brought together prison-based students and University-based students to study higher education courses (“UC Learning Together partnerships”). These UC Learning Together partnerships were, and always have been, part of an educational initiative based at the University. The staff working on the UC Learning Together partnerships have always been employed by the University and based at the Institute of Criminology (“the Institute”) – a department within the Faculty of Law, which is itself a component faculty of the School of the Humanities and Social Sciences.
3. The CIC did not employ any staff and was not involved in the running of any Learning Together partnerships, at any point, at 29 November 2019 or subsequently. It played no part in arranging the alumni and anniversary event at Fishmongers’ Hall. All UC Learning Together partnership activities, including the Fishmongers’ Hall 1 Under paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 (here)

event, were University activities. The CIC was established in April 2019 as one of the deliverables of the HMPPS Innovation Grant brought into the University. In November 2019, discussions with the University were still ongoing about the relationship between the work of Learning Together within the University and any work that might be done by the CIC in the future.

4. An application to voluntarily strike the CIC off the Companies Register was made on 4 November 2021 and a first notice was published in the Gazette on 16 November
2021. The CIC will be dissolved in January 2022.

RESPONSE ON BEHALF OF THE CIC

5. In light of the above, the CIC is not able to take steps in relation to any of the recommendations in the PFD Report. It has no power to act upon them. It is a matter for the University to respond to these recommendations in so far as they relate to UC Learning Together partnerships.

6. The event at Fishmongers Hall on 29 November 2019 was organised in accordance with and adhered to all of the established risk management, safeguarding and governance frameworks of the University that were effectively communicated to and implemented within the Institute. It is regrettable that relevant risk assessment frameworks were not in place within the Institute at the time of the event at Fishmonger’s Hall. take this opportunity to reiterate that their personal and professional reflection, profound grief, and trauma is deep and ongoing following the tragedy of 29 November 2019. As employees of the University, they have taken every possible opportunity to contribute to the University’s process of reflection, consideration and further action, an update about which was provided in the ‘Submissions on Behalf of the University of Cambridge on a Prevention of Future Deaths Report, dated 28 July 2021’ (published on the website for the inquests).

7. It is hoped the University will further develop its risk management, safeguarding and governance frameworks, and the systems through which their distribution and effective implementation are monitored within University departments in light of the Coroner’s recommendations, so as to provide assurance of appropriate frameworks to support the safety of all employees, and all others involved in University activities.

take very seriously the lessons from the inquest and the PFD Report and give their utmost commitment that these lessons will inform their work moving forwards.

Staffordshire Police Police / Law Enforcement

3 Nov 2021 PDF

Action Taken

CTPHQ now has CT Nominal Management specialist trained officers who will attend all future CT MAPPA (Category 4) cases and are responsible for designing and delivering a risk management plan (RMP). West Midlands Police exceeds national guidance for visits to Registered Terrorist Offenders/Pathfinders. (AI summary)

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Dear Sir/Madam Chief Constable of Staffordshire Police Response to HH Judge Lucraft QC’s Regulation 28 Report on Action to Prevent Future Deaths Following the Inquests Arising from the Deaths in the Fishmongers’ Hall Terror Attack Further to His Honour Judge Lucraft QC Regulation 28 Report and the letter from the Solicitor to the Inquest dated the 3 November 2021 I enclose the attached response to the Matters of Concern directed to Staffordshire Police which has been prepared on my behalf. The Coroner has identified seven Matters of Concern for the Chief Constable of Staffordshire Police and others to address. In order to ensure the response to these Matters is as complete as possible Counter Terrorism Policing Headquarters (CTPHQ) and West Midlands Counter Terrorism Unit (WMCTU) have been approached and have provided responses to the Matters of Concern which are incorporated with the Staffordshire response. I would like to offer on behalf of myself and all officers and staff of Staffordshire Police my sincere and heartfelt condolences to the families of Saskia and Jack and to all those affected by the Fishmongers' Hall terror attack.

Office for Students Regulator / Inspectorate

14 Dec 2021 PDF

Action Planned

The Office for Students will write to all registered higher education providers in England, making them aware of the report and asking them to consider changes to their approach to risk assessment of events, programmes, and information sharing. (AI summary)

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Dear

Regulation 28 report on action to prevent future deaths Thank you for writing to me on 3 November 2021, enclosing the regulation 28 report from the Coroner's inquests arising from the deaths in the Fishmonger's Hall terror attack of 29 November 2019. I have read and considered the report and in particular recommendations MC1, MC2 and MC3. We have also engaged with officials in the Department for Education to understand the steps they intend to take in response to these recommendations.

The Office for Students accepts recommendations MC1, MC2 and MC5 in full. Our proposed response to each of these recommendations is to write to the accountable officers at all registered higher education providers in England. In writing to these providers we will make them aware of the report and ask them to consider carefully those recommendations and decide whether they may need to take steps to change their approach to risk assessment of events and of programmes of higher education that involve continued contact with offenders in prisons or after their release into the community. We will also ask them to consider whether further steps should be taken in relation to information sharing with external venues to inform them of high-risk features of events, including for instance the attendance of recently released serious offenders.

We will also make our counterparts in the devolved nations aware of the coroner's report and our response, so that they can determine whether it would be appropriate to take steps in relation to the recommendations. We will write to the sector as set out before 31 January 2021.

I understand that the Secretary of State for Education also plans to take steps to engage with people in the higher education sector to encourage them to take any steps necessary to implement the recommendations in the coroner's report. The OfS will make sure that the Secretary of State knows about the steps we have taken as the principal regulator of English higher education as he engages with the higher education sector. In addition, I understand that the Department for Education (DfE) is also engaging with Her Majesty's Prisons and Probations Service and the Ministry of Justice to design a new framework to clearly define the roles and responsibilities of prisons and universities when they work in partnership to deliver learning where students study

2 alongside serving prisoners or those released on licence. We will of course work with the DfE to signpost to any new guidance for higher education providers in England.

College of Policing Police / Law Enforcement

22 Dec 2021 PDF

Noted

The College of Policing acknowledges the concerns raised and states its commitment to supporting other bodies in achieving improvements in terrorist offender management. They provide broader offender management training products and guidance and will work with partners to ensure they are updated. (AI summary)

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Dear , This response is submitted on behalf of the College of Policing (‘the College’) in reply to the Coroner’s Report to Prevent Future Deaths (RPFD) following the Fishmongers’ Hall terror attack inquests. Firstly, I wish to extend my deepest condolences to the families and friends of those murdered and injured as a result of the terror attack. We also wish to state our appreciation of all of those who contributed to the proceedings. It is incumbent on the College and others in policing to ensure lessons are learned. Before providing a response to the specific matters of concern (MCs) that include the College, I would like to explain our role and remit in the policing landscape. Formed on the 1st December 2012, the College is a company limited by guarantee, owned by the Secretary of State for the Home Department, but operating at arm’s length from the Home Office. Our purpose is to connect everyone in policing to reduce crime and keep people safe by setting standards, providing training and sharing good practice. We have five key areas of responsibility, which were set out in the Explanatory Notes to the Anti-Social Behaviour, Crime and Policing Act 2014. These are also included in the Terms of Reference of the Company’s Board:
a. setting standards and developing guidance and policy for policing,
b. building and developing the research evidence base for policing,

c. supporting the professional development of police officers and staff,
d. supporting the police, other law enforcement agencies and those involved in crime reduction to work together, and
e. identifying and developing the ethics and values of the police. The College’s remit is limited to police officers and staff, other police force employees, and volunteers, such as Special Constables in England and Wales. We work alongside experts from other law enforcement and non-law enforcement agencies to develop expert knowledge that ensures College standards and products, such as Authorised Professional Practice (APP) and training, are well informed, relevant and based on the best available evidence. Staff also represent the College at various meetings established by the National Police Chiefs’ Council, National Crime Agency, Home Office and other bodies. Our role here is to support discussions and identify any work required. The College does not have an operational policing role.

College Response to the Matters of Concern The College is named as a joint addressee for the following MCs: MC10 – Addressed to the Secretary of State for Justice, the College of Policing, the Chief Constable of West Midlands Police and the Chief Constable of Staffordshire Police: The facts of this case give rise to concern that important decisions on approvals, variations and relaxations in relation to licence conditions may be taken without clearly reasoned discussion and decision-making in MAPPA panels. This issue could be addressed by requiring MAPPA minutes to record any discussion or decision on such a matter. In addition, for the benefit of future inquiries and reviews, consideration should be given to having digital audio recordings made of all MAPPA meetings. MC 14 – Addressed to the Secretary of State for Justice, the College of Policing, the Chief Constable of West Midlands Police and the Chief Constable of Staffordshire Police: This case gives rise to concern that an extremist offender may be permitted to attend an event or venue without there having been proper communication between the probation and police officers responsible for managing the offender and the event organisers and/or venue hosts. Consideration should be given to encouraging such communications within the training and guidance given to probation officers and police responsible for managing extremist offenders. MC 17 – Addressed to the Secretary of State for Justice, the College of Policing, the Chief Constable of West Midlands Police and the Chief Constable of Staffordshire Police: Based on the evidence in this case, there is cause for concern that effective procedures

are not in place to ensure that all MAPPA meeting attendees receive meeting minutes. Consideration should be given to modifying guidance to ensure that this happens, for example by (a) providing for all MAPPA panel participants to receive minutes by secure email (rather than by having to access an online system); (b) requiring that all acknowledge safe receipt and indicate whether or not they wish to make amendments (to include provision of “nil returns”); and/or (c) requiring attendees at the start of each MAPPA meeting formally to confirm that they have read the minutes of the previous meeting or meetings as appropriate. MC 18 – Addressed to the Secretary of State for Justice, the College of Policing, the Chief Constable of West Midlands Police and the Chief Constable of Staffordshire Police: The facts of this case give cause for concern that some members of MAPPA panels responsible for managing extremist offenders may not be aware of important information from the offender’s time in prison. Consideration should be given to (a) ensuring that the latest MAPPA F form from the prison authorities should be circulated with every subsequent set of MAPPA minutes; (b) including a section in MAPPA minutes for key up- to-date intelligence; and (c) including a further section in MAPPA minutes for a summary of the key conclusions of the most recent ERG assessment (including risk factors identified). MC 19 - Addressed to the Secretary of State for Justice, the Secretary of State for the Home Department, the College of Policing, the Chief Constable of West Midlands Police and the Chief Constable of Staffordshire Police: This case gives cause for concern that counter-terrorism police may be in possession of intelligence or information which may be useful to the management of an offender by the MAPPA panel, but that such intelligence or information may not be brought to the knowledge of or taken into account by MAPPA agencies. This issue should be addressed, preferably by ensuring that a single police officer from any covert investigation (such as the SIO or Deputy SIO) is responsible and accountable for ensuring that intelligence and information is properly shared and taken into account. Consideration should also be given to how intelligence known only to the Security Service may be taken into account for the purposes of MAPPA management. MC 20 – Addressed to the Secretary of State for Justice, the Secretary of State for the Home Department, the College of Policing, the Chief Constable of West Midlands Police and the Chief Constable of Staffordshire Police and the College of Policing: The facts of this case give cause for concern that security sensitive information may not be properly taken into account in decision-making by MAPPA panels concerning the management of terrorist offenders. Consideration should be given to how the new procedures can best be operated to avoid this problem recurring. This might include a requirement that, wherever possible, the MAPPA Panel Chair (or one Co-Chair) should be a member of

the Core Group. It might also include a requirement for the Core Group to consider what intelligence can be supplied (perhaps in sanitised form) to the broader panel. MC 21 – Addressed to the Secretary of State for Justice, the Secretary of State for the Home Department, the College of Policing, the Chief Constable of West Midlands Police and the Chief Constable of Staffordshire Police: The facts of this case give cause for concern that MAPPA panels responsible for managing terrorist offenders may be unaware of the regularity and form of contact with police officers responsible for overt offender management. Consideration should be given to providing guidance that officers with such responsibilities should report to MAPPA panels on the regularity of their meetings with offenders and take account of any recommendations by MAPPA panels.

In developing our response, we are grateful to the other addressees (and national Counter Terrorism policing) who have shared their responses with us. We note from their responses that these addressees have taken forward, or plan to take forward, substantive work to address the seven MCs listed above. While we do not currently provide, or have been approached to provide, specific guidance or training on terrorist offender management, we are committed to supporting the other bodies mentioned in the MCs to achieve improvements. We are also concerned not to replicate work that is being done by others in this area. We will continue to work closely, with these bodies to make sure that the College contributes to managing the risks posed by terrorist offenders. The College also provides broader offender management training products and guidance, for example, on the police role in managing sexual offenders, violent offenders, and potentially dangerous persons (PDPs) as part of major investigation and public protection APP1. Additionally, there are learning products available through the ‘College Learn’ platform that cover:
• training and development
• management responsibilities
• multi agency working (MAPPA)
• staff welfare
• managing workload
• ensuring management of sexual offenders and violent offenders (MOSOVO) units are staffed appropriately. The ‘offender management’ guidance and products have been developed over a number of years and we will continue to work with partners and stakeholders to ensure they are updated to

1 Accessible from https://www.app.college.police.uk/app-content/major-investigation-and-public- protection/?s=

reflect the changes resulting from this report. We will also monitor future policy and legislative developments to ensure our guidance and products continue to support policing to prevent future deaths.

West Midlands Police Police / Law Enforcement

31 Dec 2021 PDF

Action Taken

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Dear Sirs/Madam, Chief Constable of West Midlands Police Response to HH Judge Lucraft QC’s Regulation 28 Report on Action to Prevent Future Deaths Following the Inquests Arising from the Deaths in the Fishmongers’ Hall Terror Attack Further to His Honour Judge Lucraft QC Regulation 28 Report and the letter from the Solicitor to the Inquest dated the 3 November 2021 I enclose the attached response to the Matters of Concern directed to West Midlands Police which has been prepared on my behalf. The Coroner has identified seven Matters of Concern for the Chief Constable of West Midlands Police and others to address. In order to ensure the response to these Matters is as complete as possible Counter Terrorism Policing Headquarters (‘CTPHQ’) have been approached and have provided responses to the Matters of Concern which are incorporated with the West Midlands response. I would like to offer on behalf of myself and all officers and staff of West Midlands Police my sincere and heartfelt condolences to the families of Saskia and Jack and to all those affected by the Fishmongers' Hall terror attack.

University of Cambridge University

7 Jan 2022 PDF

Action Taken

The University of Cambridge has created a new policy and guidance for staff and students working with people who have offended, and the Institute of Criminology has developed a Risk Assessment Form for all activities. The University has also stopped delivering the Learning Together programme. (AI summary)

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Dear Ms Lester

Re: Inquests into the deaths arising from the attack at Fishmongers' Hall on 29 November 2019

Thank you for your letter of 3 November 2021, enclosing the coroner’s ‘Regulation 28 Report on Action to Prevent Future Deaths’ in connection with the above inquests. I now enclose the response on behalf of the University of Cambridge. I also enclose two further documents, as follows:

• The University’s new ‘Policy and Guidance for staff and students working, managing or engaging with activities involving people who have offended’; and

• The Institute of Criminology’s ‘Risk Assessment Form for All Activities (including Fieldwork)’.

These documents are both referred to in the University’s response and will be refined and enhanced over time.

Home Office Central Government

7 Jan 2022 PDF

Action Planned

The government is legislating a new power of personal search through the Police, Crime, Sentencing and Courts Bill, allowing police to stop and search terrorist offenders on license under certain circumstances. (AI summary)

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Dear Sinead Fishmongers’ Hall Inquest: Prevention of Future Deaths (PFD) Report Thank you for sending to me His Honour Judge Mark Lucraft QC’s Prevention of Future Deaths (PFD) Report, following the inquest into the appalling attack at Fishmongers’ Hall on 29th November 2019. I am grateful to HHJ Lucraft for drawing his concerns to my attention. As Home Secretary, I am responsible for ensuring that matters of concern and recommendations relating to national security are properly addressed. Please accept this response on behalf of the Home Office and Security Service collectively. Comments on each of the specific recommendations addressed to the Secretary of State for the Home Department are annexed to this letter. Those matters on which you have not felt that a formal recommendation is appropriate are also noted, and we will continue to keep the wider issues under review. While much of the Report covers issues of policy and practice, the Determination Sheets for the two victims underline the sobering circumstances of the inquest. It is right to keep in our thoughts Saskia Jones and Jack Merritt: two innocent young people who tragically lost their lives in this attack; as well as consider what steps we should take in response.

Department for Education Central Government

7 Jan 2022 PDF

Action Planned

The Secretary of State will engage with the higher education sector to encourage action to implement the recommendations and officials have spoken to the Office for Students to encourage them to take action. Officials have also engaged with HMPPS to design a new framework to define roles and responsibilities of prisons and higher education providers. (AI summary)

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Dear , I am responding to your letter dated 3 November 2021 regarding the inquests into the deaths arising from the attack at Fishmongers' Hall on 29 November
2019. Thank you for bringing these findings to my attention. I am committed to working with colleagues across Whitehall and the higher education sector to ensure these tragic events are not repeated. My sympathies are with the families of the victims of the attack, Saskia Jones and Jack Merritt, and all those affected. I have taken note of the recommendations addressed to me in the Coroner’s Prevention of Future Deaths (PFD) report and accept them in full. I have responded in detail below. If I can be of any further assistance please do not hesitate to contact me.

Ministry of Justice Central Government

7 Jan 2022 PDF

Action Taken

MoJ accepted recommendations relating to the Fishmongers' Hall attack. A new framework is being designed for Learning Together activity in prisons. Statutory guidance on MAPPA meetings will be strengthened, and the Police, Crime, Sentencing and Courts Bill includes a power for police to search terrorist offenders on licence. (AI summary)

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Dear , FISHMONGERS’ HALL INQUESTS: RESPONSE TO PREVENTION OF FUTURE DEATHS REPORT ISSUED BY HHJ MARK LUCRAFT QC Thank you for sending me the Report on Action to Prevent Future Deaths (PFD), issued by His Honour Judge Mark Lucraft QC, following the completion of the Inquests arising from the deaths into the Fishmongers’ Hall terror attack. I am grateful to you for bringing these matters to my attention, and for the work of HHJ Lucraft QC in thoroughly exploring the tragic events of 29 November 2019. My sympathies are with all the victims of the attack, including the families of Saskia Jones and Jack Merritt, and with all those affected. Please accept this response on behalf of the Ministry of Justice. Comments on each of the specific recommendations are annexed to this letter. If there are any further matters of concern, then please do not hesitate to raise these.

Report sections

Investigation and inquest

_______________________________________________________________

QUESTIONNAIRE FOR JURY DETERMINATIONS IN THE INQUEST CONCERNING THE DEATH OF JACK MERRITT

_______________________________________________________________ Notes for the jury
• This questionnaire has been prepared by the Coroner after receiving submissions from Interested Persons. By answering the questions, you will give your determinations on the key factual issues in the case. All are intended to address the central question: by what means and in what circumstances did Jack Merritt and Saskia Jones come by their deaths?
• After the inquests, a completed copy of this questionnaire will form part of the Record of Inquest for each of Jack Merritt and Saskia Jones.
• For a number of the questions, you are asked for a “yes” or “no” answer, and you are then given the option to explain further in a box. You are not obliged to fill in the box. Considerations and issues are then listed which you may want to consider, although you should feel free to give your own answers (provided that you follow the legal directions in these Notes and the Coroner’s summing-up).
• For some of the questions, you are first asked whether there was some error, omission or circumstance that (probably) caused or contributed to the two deaths. If you have answered “no” to that, you are then asked whether the same thing may have caused or contributed to the two deaths. If answering the second part of such a question, you will need to consider whether there is a realistic possibility that an error, omission or circumstance as described caused or contributed to the two deaths.
• You may only say that something contributed to the two deaths if you consider that it made a more than minimal contribution.
• You should only give an answer to a question if all of you agree upon the answer. If you find yourselves unable to agree on an answer to one question, you may move on to the next and return to the question later. If a time comes when the Coroner can accept any answer on which you are not all agreed, you will be told.
• In resolving factual issues, you should give your answers in accordance with the “balance of probabilities”; what is more likely than not. (However please note that if you are deciding whether something may have caused or contributed to the deaths, you should consider whether there is a realistic possibility that it did so (see note above).)
• If you choose to give further explanation in any of the boxes where you are given the option to do so, please follow these directions when writing your responses:
i. Your responses should all be directed to answering the question by what means and in what circumstances the deaths occurred. You should not make any statement or comment which does not assist in answering that question.
j. It might help you at each stage to consider the cause(s) of the deaths; any defects in systems and practices which contributed to the deaths; and any other factors which are relevant to the circumstances of the deaths.
k. You should try to be brief and to the point.
l. If you wish to write more than the space in the box permits, you may continue on a separate sheet. At the top of the sheet, you should write the number of the question and the words “Answer Continued”.
m. You should not make any comment on any circumstance, act, omission or event unless there is at least a realistic possibility that it caused or contributed to the deaths.
n. You should not say anything to the effect that a breach of civil law has been committed or that any named person has committed a crime. Because of this legal rule, when writing any explanations, you should avoid using words and phrases such as “negligence / negligent”, “breach of duty”, “duty of care”, “careless”, “reckless”, “liability”, “guilt / guilty”, “crime / criminal”, “illegal / unlawful”. This rule does not prevent you confirming in question 1 that those who died were unlawfully killed: the proposed form of words in that question avoids naming the person responsible.
o. You may use ordinary and non-technical words which express factual judgments. So, you may say that errors or mistakes were made and you may use words such as “failure”, “missed opportunity”, “inappropriate”, “inadequate”, “unsuitable”, “unsatisfactory”, “insufficient”, “omit / omission”, “unacceptable” or “lacking”. Equally, you may indicate in your answer if you consider that particular errors or mistakes were not made. You may add adjectives, such as “serious” or “important”, to indicate the strength of your findings.
p. If you are uncertain about what may be written, you may ask a question in writing to the Coroner during your deliberations. Question 1: Determination on Unlawful Killing of Jack Merritt

Important Note: The Coroner directs that you return an answer of “yes” in response to this question in the answer section, to reflect the primary conclusion that both Saskia Jones and Jack Merritt were unlawfully killed. This direction is given because the evidence clearly supports that primary conclusion and because it is important that the Records of Inquest record that each of them was unlawfully killed.

Question Answer Are you satisfied that, on the balance of probabilities, Jack Merritt was unlawfully killed? Yes Question 2: Basic facts of the attack and the death of Jack Merritt Do you agree with the following statement, which is intended to summarise the basic facts of the death of Jack Merritt? “On 29 November 2019, Jack Merritt was at an event at Fishmongers’ Hall in London. The event was held for the five-year anniversary of Learning Together. Jack was at the event as an employee of Cambridge University, and worked for Learning Together. An attendee of the event, who was on licence having been convicted of an offence under the Terrorism Act 2000, armed with two knives, attacked Jack in the gentlemen’s toilets at Fishmongers’ Hall. Jack suffered a number of injuries when stabbed. This was part of a terrorist attack. The attacker moved from the toilets and began attacking further attendees of the event and a member of staff at Fishmongers’ Hall. Jack moved to a different room at Fishmongers’ Hall and was later removed from the building. His injuries were not survivable. Jack was treated by members of the public, police officers, ambulance staff and HEMS doctors. He was assessed as dead at the scene by a doctor.” In the box below, please either write that you confirm the statement above or state in what respects you would like it to be amended. We agree Question 3: Management of Usman Khan in the Community Was there any omission or failure in the management of Usman Khan (as an offender in the community) by agencies of the state which contributed to the deaths of Jack Merritt and Saskia Jones? Answer “yes” or “no” in the box opposite. Yes If your answer to the question above is “no”, was there any omission or failure in the management of Usman Khan (as an offender in the community) by agencies of the state which may have contributed to the deaths of Jack Merritt and Saskia Jones? Answer “yes” or “no” in the box opposite.

If you can give an explanation for your answer, please do so in the box below.
• Unacceptable management and lack of accountability.
• Serious deficiencies in the management of Khan by MAPPA.
• Insufficient experience and training.
• Blind spot to Khan’s unique risks due to ‘poster boy’ image.
• Lack of psychological assessment post release from prison.

Please go to the next page for matters which you may wish to bear in mind when answering. In answering Question 3, you may wish to bear in mind the following considerations and issues:
• The fact that, throughout the time from his release from prison (December 2018) to the time of the attack, Usman Khan was managed by the National Probation Service.
• The fact that, throughout that time, Usman Khan was subject to Multi-Agency Public Protection Arrangements (“MAPPA”) which involved meetings attended by the National Probation Service, counter-terrorist police, police officers responsible for supervising his Part 4 terrorism notifications and other agencies.
• The facts that Usman Khan (a) had committed a serious terrorist offence in 2010; (b) had been the subject of substantial prison intelligence to the effect that he was involved in radicalising others and violence (including when he was apparently engaging positively with staff, and including in the period before release); and (c) had been released from prison as a Category A High Risk offender, with an OASys rating of Very High Risk to the general public (informed by an ERG assessment expressing significant concerns).
• The fact that Usman Khan had complied with his licence conditions and had apparently engaged positively with those responsible for managing him in the community during 2019.
• The facts that, by November 2019, Usman Khan (a) was living away from the probation hostel; (b) remained unemployed; (c) no longer had visits from mentors; (d) had reportedly become increasingly socially isolated; and (e) had not been doing any actual educational work with Learning Together.
• Whether or not some of those responsible for the assessment and management of Usman Khan in the community were properly trained and experienced and had proper access to information (including intelligence).
• Whether or not there were deficiencies in the management of Usman Khan in the MAPPA process, having regard to (a) the Chair’s level of clearance; (b) arrangements for discussions between the Chair and others on sensitive matters; (c) procedures for decision-making; and (d) procedures for circulation of minutes.
• Whether or not those responsible for the management of Usman Khan in the community took a proper approach to the assessment of the continuing risk he posed, having regard to the available risk assessment tools.
• Whether or not the decision to permit Usman Khan to attend the Learning Together event at Fishmongers’ Hall on 29 November 2019 was properly considered and was a reasonable professional decision when it was made (ignoring hindsight).
• Whether or not consideration should have been given to any further measures being taken if Usman Khan was to be permitted to attend the Learning Together event at Fishmongers’ Hall on 29 November 2019 (e.g. arranging an escort, having him met en route or ensuring that security measures were taken at the venue) (again, ignoring hindsight). Question 4: Sharing of Information and Guidance regarding Usman Khan Was there any omission or failure in the sharing of information and guidance by agencies responsible for monitoring / investigation of Usman Khan which contributed to the deaths of Jack Merritt and Saskia Jones? Answer “yes” or “no” in the box opposite. Yes If your answer to the question above is “no”, was there any omission or failure in the sharing of information and guidance by agencies responsible for monitoring / investigation of Usman Khan which may have contributed to the deaths of Jack Merritt and Saskia Jones? Answer “yes” or “no” in the box opposite.

If you can give an explanation for your answer, please do so in the box below.
• Missed opportunity for those with expertise and experience to give guidance. Please go to the next page for matters which you may wish to bear in mind when answering. In answering Question 4, you may wish to bear in mind the following considerations and issues:
• The fact that, throughout the time from his release from prison (December 2018) to the time of the attack, Usman Khan was subject to a priority investigation by the Security Service and West Midlands Police CTU (supported by Staffordshire Police Special Branch).
• The facts that Usman Khan (a) had committed a serious terrorist offence in 2010; (b) had been the subject of substantial prison intelligence to the effect that he was involved in radicalising others and violence (including when he was apparently engaging positively with staff, and including in the period before release); (c) had been the subject of intelligence in late 2018 that he had said that he intended to return to his old ways (terrorist offending) and that he intended to commit an attack after release; and (d) had been released from prison as a Category A High Risk offender, with an OASys rating of Very High Risk to the general public (informed by an ERG assessment expressing significant concerns).
• The facts that Usman Khan had complied with his licence conditions and had apparently engaged positively with those responsible for managing him in the community during 2019.
• The fact that investigation of Usman Khan during 2019 gave rise to no intelligence indicating activity of national security concern.
• The facts that, by November 2019, Usman Khan (a) was living away from the probation hostel; (b) remained unemployed; (c) no longer had visits from mentors; (d) had reportedly become increasingly socially isolated; and (e) had not been doing any actual educational work with Learning Together.
• Whether or not those responsible for the monitoring / investigation of Usman Khan shared information (including intelligence) and guidance properly with other agencies.
• Whether or not those responsible for the monitoring / investigation of Usman Khan should have raised any concerns or given any advice about him being permitted to attend the Learning Together event on 29 November 2019 (ignoring hindsight).
• Whether or not those responsible for the monitoring / investigation of Usman Khan should have given any advice proposing any further measures being taken if Usman Khan was to be permitted to attend the Learning Together event on 29 November 2019 (e.g. arranging an escort, having him met en route or ensuring security measures were taken at the venue) (again, ignoring hindsight). Question 5: Organisation of and Security Measures for the Event at Fishmongers’ Hall Was there any omission or any deficiency in the organisation of and security measures for the event at Fishmongers’ Hall which contributed to the deaths of Jack Merritt and Saskia Jones? Answer “yes” or “no” in the box opposite. Yes If your answer to the question above is “no”, was there any omission or any deficiency in the organisation of and security measures for the event at Fishmongers’ Hall which may have contributed to the deaths of Jack Merritt and Saskia Jones? Answer “yes” or “no” in the box opposite.

If you can give an explanation for your answer, please do so in the box below.
• Lack of communication and accountability.
• Inadequate consideration of key guidance between parties.
• Serious deficiencies in the management of Khan by MAPPA.
• Failure to complete event specific risk assessment by any party. Please go to the next page for matters which you may wish to bear in mind when answering. In answering Question 5, you may wish to bear in mind the following considerations and issues:
• The fact that Fishmongers’ Hall had a number of security measures for the event, including (a) a door requiring opening from inside (with key fob operation); (b) security staff on the door at most times; (c) limitation of entry to invited guests (who were provided on arrival with identity lanyards) and (d) CCTV at the entrance.
• The fact that Fishmongers’ Hall did not own or have in place any metal detector or employ any arrangements for bags to be searched on entry.
• The fact that staff of the Fishmongers’ Company (a) were aware that all attendees had been invited by the Learning Together programme, but (b) some were also aware that attendees might include ex-offenders who had committed serious criminal offences.
• The fact that the Fishmongers’ Company had had a risk register since April 2019 which identified the risk of a lone actor terrorist attack as an important risk to be addressed.
• The facts that (a) Learning Together organised the event, (b) Learning Together staff at the event were employed by the University of Cambridge and (c) Learning Together were aware that Usman Khan was a terrorist offender who had been released as a Category A High Risk prisoner in late 2018.
• Whether or not those involved in organising the Learning Together event properly informed themselves of and assessed the risks of the event and made appropriate arrangements based on any risks (e.g. requesting security measures).
• Whether or not those involved in organising the Learning Together event properly informed the Fishmongers’ Company of the persons or types of persons attending the event, having regard to the information they had at the time (including concerning the approval of Usman Khan’s attendance at the event by his probation officer).
• Whether or not those responsible for managing and/or for investigating Usman Khan ought to have given any advice on security measures to the Learning Together organisers and/or the Fishmongers’ Company.
• Whether or not the Fishmongers’ Company ought to have implemented any additional security measures, based on the information it had at the time.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2021-0362
Date of report: 3 November 2021
Coroner: HH Judge Lucraft QC
Coroner area: London City

Responses identified

Responses identified 9 of 10

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 29 Dec 2021 (estimated).

Sent to

College of Policing

Department for Education

Home Office

Learning Together Network CIC

Ministry of Justice

Office for Students

Staffordshire Police

Security Service

University of Cambridge

West Midlands Police

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.