Source · Prevention of Future Deaths

Kurt Cochran; Leslie Rhodes; Aysha Frade; Andreea Cristea; PC Keith Palmer.

Ref: 2018-0304 Date: 19 Dec 2018 Coroner: HH Judge Mark Lucraft QC Area: London Inner (West) Responses identified: 7 / 8 View PDF

A Prevention of Future Deaths report was issued to multiple authorities following the Westminster terror attack to address systemic issues related to such events.

Date 19 Dec 2018

56-day deadline 13 Feb 2019 est.

Responses identified 7 of 8

Other related deaths

Coroner's concerns

AI summary

A Prevention of Future Deaths report was issued to multiple authorities following the Westminster terror attack to address systemic issues related to such events.

View full coroner's concerns

I am not persuaded that this should be treated as a matter of concern. As the Service has explained in its written submissions, the policy is a prudent one which has important advantages. In particular, the first person on scene will often be an ordinary ambulance officer or paramedic and it may take some time for more senior officers to arrive. There is a clear benefit in having a policy which enables Major Incident procedures to be triggered quickly and without waiting for ranking officers to be on scene. I am aware that this is a matter considered in detail at the recent Hillsborough Disaster Inquests.
38. The same representatives of some families have raised a concern about practices of covering bodies of those who have died in a public place. However, I am satisfied from the submissions of the Service that they are conscious of the proper considerations of dignity, preservation of the scene and prioritisation of paramedic attention. I do not see any need to identify any concern in this respect. However, I should stress that I well understand the distress which families suffer when photographs of their injured or deceased loved ones are taken and later posted on the internet. I deplore this practice in the strongest terms. Transport for London (“TfL”) and the Secretary of State for the Home Department
39. The Inquests heard substantial evidence about the procedures by which protective security in public places is reviewed, advice is given and improvements are made. Protective security measures for buildings are generally the responsibility of the owners. As regards highways, security measures are generally the responsibility of the relevant highway authority. TfL is responsible for many major roads and bridges in Central London. There is a national network of police advisers who identify threats and provide advice to local authorities. Specific security measures apply to areas designated as crowded places and crowded spaces under criteria which are themselves sensitive.
40. There was evidence at the Inquests of a number of pieces of advice given by the police nationally following terrorist atrocities in the years before the attack. However, this advice was largely reactive to the specifics of the attacks elsewhere (e.g. dangers posed to festive markets). It was not clear from the evidence what work is being done at the national level to deliver wide-ranging advice on protective security measures, especially for roadways and public areas in urban areas which may be particularly at risk of terrorist attack. It would obviously be unsatisfactory if such work is limited to a limited group of areas designated as crowded places and crowded spaces.
41. MC14: I suggest that the Secretary of State for the Home Department asks the authorities responsible for preparing and delivering advice on protective security to consider whether any further work can usefully be done on this subject, particularly in preparing and delivering consistent and up-to-date national advice. I also suggest that TfL considers whether there is any further work it can do to improve protective security on major roadways and bridges in the capital, in response to national advice and known threats.
42. The evidence at the Inquests also revealed that there are substantial differences in the heights of parapets on major bridges in central London. Quite apart from the fact that Kurt Cochran may have been saved by a materially higher wall or railing at the side of Westminster Bridge, it is important from a general viewpoint of safety that bridge parapets or railings be of sufficient height.
43. MC15: I suggest that TfL gives consideration to reviewing the height of parapets and railings of bridges for which it is responsible. As part of such review, thought might be given to the question of whether a higher barrier would improve safety materially and whether it would be practicable to create one (e.g. by raising a parapet or adding a railing on top). The Security Service (Secretary of State for the Home Department)
44. The bereaved families represented by Hogan Lovells have submitted that I should make a number of recommendations in respect of operational practices of the Security Service. These include points in respect of record keeping; procedures for reviewing the management of closed subjects of interest (“SOIs”); and processes for obtaining of evidence from the police and other agencies.
45. The Security Service has provided a very significant volume of material to the Inquests Team. It gave access to many highly sensitive documents, including those which underlie the open report written by David (now Lord) Anderson QC. The review carried out by counsel and solicitors to the Inquests for the purposes of disclosure was comprehensive. The Security Service also fielded a senior officer (Witness L) who made a statement and gave evidence for a full day during the Inquests.
46. As part of their work, the Inquests Team considered the Security Service’s Operational Improvement Review which was conducted in the wake of the 2017 attacks across the country. Witness L gave evidence about that review. A particular focus of the Operational Improvement Review was the assessment of SOIs. Based on public information, MI5 had around 3,000 SOIs in March 2017, with around 500 investigations being pursued into individuals and groups linked to Islamist terrorism. There were approximately 20,000 closed SOIs. The scale of work was unprecedented. The Anderson report endorsed as appropriate the processes followed by the review teams. He praised MI5 staff as frank and open to criticism in meetings.
47. The Inquests Team, like David Anderson QC, adopted a rigorous and challenging approach to the Security Service and its evidence. As counsel to the Inquests submitted at the end of the hearing, the procedures developed by the Security Service for review and investigation of SOIs were explained with clarity by Witness L. He explained cogently the key decisions made in respect of Masood and why no realistic action by the Service could have prevented this attack in the circumstances.
48. I do not consider that it would be appropriate or helpful for me to make vague suggestions that the Security Service makes every effort to ensure that its procedures for managing investigations and SOIs are as good as they can be. It is evident that such efforts are being made and that a huge amount of detailed work has been done to extract learning from the attacks of 2017. Neither am I prepared to prescribe particular practices which would micro-manage the work of the experts and would risk wasting their precious resources. In the circumstances of this case, I consider that there is just one limited matter to raise with the Security Service.
49. MC16: I suggest that the Security Service considers whether it would be practicable and beneficial to introduce a procedure whereby any decision to close a person as a Subject of Interest is recorded with brief reasons. In response to this point being raised by the families, the Security Service pointed out that it is not practicable to record reasons for every decision by its officers not to do something. It was suggested that this would not be a good use of finite resources. While I agree that officers need not record reasons for every decision, it strikes me that closing a person as an SOI is a positive decision that further investigation is not justified or necessary. It is not obvious to me that such decisions are so numerous that recording each one with a short rationale would be impracticable. Furthermore, I can see clear operational benefits to corporate memory in having such reasoning recorded which could assist in the fight against terrorist activity. If consideration is given to re-opening a person as an SOI, it would surely be helpful to see easily why the person was closed previously. In this case, when explaining the reason for Masood being closed, the Service had to reconstruct the rationale since it was not documented.
50. It should be stressed that the Security Service are the experts in their craft, and that their work now involves very complex and sophisticated procedures. They have to marshal their scarce resources and I have no wish to drive them to take decisions which would divert resources from their best use. I am simply inviting the Security Service to explore their options.
51. The families represented by Hogan Lovells have asked me to go further and to recommend the form which records should take. I am not prepared to do that, because means of recording investigations and decisions must be left to officers with experience in the field. Knowing the thoroughness with which the Operational Improvement Review was conducted, I am confident that this Report will be treated with appropriate concern and diligence. The Maritime and Coastguard Agency
52. Andreea Cristea was struck by Masood’s vehicle and thrown into the River Thames. As she was unconscious and being carried by the current, she was seen by the crew of a large leisure vessel. One boatman promptly used a boathook to keep hold of her body, whilst he stood on the deck of the vessel some feet above the water level. He did not attempt to lift her, because he did not consider that he could safely and appropriately recover a body or an unconscious casualty with the equipment he had. Andreea was lifted from the water by a Fire Service vessel minutes later, using specialist equipment.
53. MC17: I suggest that the Maritime and Coastguard Agency considers whether it or some other body could provide guidance on the removal of unconscious persons or bodies from the water to those operating on navigable rivers and canals. From the evidence in the Inquests, it was not apparent that there was any available guidance on this subject. Even though Andreea was quite quickly recovered from the water, it is easy to envisage a situation where a Fire Service vessel with special equipment is not fortuitously nearby and only the crew of a leisure vessel are at hand to recover an unconscious person. It would be beneficial for such individuals to have guidance on how to deal with the situation. I should stress that, in making this point, I am not criticising the response of the staff of the leisure vessel in this case. The Department for Transport and the British Vehicle Rental & Leasing Association
54. The evidence showed that Khalid Masood had intentionally hired a powerful vehicle which would serve as a lethal weapon in his attack. Other recent attacks, both in London and across Europe, have shown that like-minded terrorists look to hire large vehicles to cause maximum damage. I am not aware of any vehicle hire companies conducting any form of checks with any policing or security agencies before agreeing to the hire of a vehicle.
55. MC18: I recommend that the Department for Transport and the British Vehicle Rental & Leasing Association consider introducing a Code of Practice (or at least guidance) on checks to be carried out and/or enquiries made before vehicles are rented. This is a matter of particular concern as regards the hire of large vehicles, including heavy and light goods vehicles. However, the Westminster attack makes clear that other vehicles such as large 4x4 vehicles can also cause many fatalities and serious injuries in a short space of time. Miscellaneous Points
56. Some further points have been made in submissions by Interested Persons which I do not consider should be addressed in this Report.
57. First, I have been asked to consider suggesting measures which might be taken to reduce radicalisation by removing extremist material from the internet. While such material is a proper subject for public concern, I do not consider that I can usefully make a meaningful and practical suggestion for particular action to be taken or considered.
58. Secondly, the problem of radicalisation in prison is brought to my attention. I have been asked to consider measures which might be taken to prevent prisoners being radicalised. I do not consider that the evidence in the Inquests allowed me to explore this subject in such a way as to make properly informed observations. I take the same view in respect of a submission about measures to prevent extremists being involved in the teaching profession. Action Should be Taken
59. In my opinion, action should be taken to prevent future deaths. I believe that the various addressees of this Report have the power to take the action relevant to them (as set out above). Your Response
60. Each addressee is under a duty to respond to this report within 56 days of the date of this report, namely by 12th February 2019. Allowing for the Christmas and New Year break, this date will be extended to 26th February 2019. I, as the coroner responsible for the Inquests, may extend the period upon application.
61. Each response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, it must explain why no action is proposed. Copies and Publication
62. I have sent copies of my report to the following: (a) all Interested Persons in the Inquests (identified in the attached list); (b) the office of the Chief Coroner of England and Wales.
63. This report will also be posted on the Inquests website.
64. I am also under a duty to send a copy of any responses to the office of the Chief Coroner.
65. In my capacity as the Chief Coroner of England and Wales, I may in due course publish this Report and/or any responses in complete or redacted or summary forms. I may send a copy of this Report to any further person who I believe may find it useful or of interest. Addressees and others may make representations to me, in my capacity as the nominated Judge responsible for the Inquests, about the wider release or publication of any responses. HH Judge Mark Lucraft QC Chief Coroner of England and Wales (Sitting as a Nominated Judge) 19th December 2018

Determinations – Kurt William Cochran Kurt Cochran was unlawfully killed. On 22 March 2017 Kurt Cochran was on a visit to London. He had been walking with his wife, Melissa, across Westminster Bridge. They had reached a point near the South Bank side when a Hyundai vehicle was driven deliberately onto the pavement where they stood. This was part of a terrorist attack. Showing no concern for himself, Kurt instinctively and courageously pushed Melissa away from the path of the vehicle and as a result was struck with full force by the vehicle. He was thrown over the parapet of the Bridge to the embankment below, falling from a height of 5.12 metres. In the fall, he suffered a serious head injury which was not survivable. Despite early medical attention from a nurse, an ambulance crew and a hospital doctor, he died at the scene.

Determinations – Leslie Arthur Rhodes Leslie Rhodes was unlawfully killed. On 22 March 2017 Leslie Rhodes was walking from the South Bank side of Westminster Bridge towards the North Bank side. He was struck from behind by a Hyundai vehicle which had been deliberately driven onto the pavement where he was walking. This was part of a terrorist attack. Leslie was carried along into the carriageway a distance of 33 metres. As a result of the impact, he suffered a devastating brain injury, which was not survivable. He was unconscious from the time of the impact until his death. Despite early medical attention from a hospital doctor and paramedics at the scene, and despite proper treatment at King’s College Hospital, Leslie died on 23 March 2017 in hospital.

Determinations – Aysha Frade Aysha Frade was unlawfully killed. On 22 March 2017 Aysha Frade was walking across Westminster Bridge towards Parliament Square on her way home from work. While walking on the pavement, she was struck from behind by a Hyundai vehicle which had been deliberately driven towards her. This was part of a terrorist attack. Aysha was thrown into the air and into the path of the nearside rear wheels of a bus. Those wheels passed over her, inflicting injuries which were immediately fatal. Aysha would not have suffered. She was assessed as dead at the scene by a paramedic and by a doctor.

Determinations – Andreea Cristea Andreea Cristea was unlawfully killed. On 22 March 2017 Andreea Cristea was walking across Westminster Bridge with her boyfriend, Andrei Burnaz, from the Parliament Square side. She was stopping at times to take photographs with her mobile phone. While on the pavement, she was struck by a Hyundai vehicle which was being deliberately driven towards pedestrians on the pavement. This was part of a terrorist attack. Andreea was thrown into the air and over the parapet of Westminster Bridge, landing in the river Thames below. She was carried by the current a distance of 100 metres and was in the water for around five minutes before she was recovered by a London Fire Brigade boat. She was treated by fire officers and then by an ambulance crew and paramedics, before being taken by ambulance to hospital. While in hospital, she received extensive and complex medical care over the following days. Despite the best efforts of clinicians, she died on 6 April 2017.

Determinations – Keith David Palmer PC Keith Palmer was unlawfully killed. On 22 March 2017 PC Keith Palmer was on duty as an unarmed police officer stationed at the Carriage Gates entrance from Parliament Square into the Palace of Westminster estate. An attacker who had driven his vehicle into multiple pedestrians on Westminster Bridge entered the Gates. PC Palmer stepped forward to challenge him. He immediately began attacking PC Palmer with knives, driving him back into the New Palace Yard area. PC Palmer stumbled against a low wall and the attacker continued his assault. In the attack, PC Palmer suffered a number of injuries, one of which was a serious stab wound to the chest. Although he was able to move away from the attacker, PC Palmer collapsed shortly afterwards. Despite prompt and capable medical attention at the scene, he suffered a cardiac arrest and could not be saved. Before the start of the attack, the armed officers stationed in New Palace Yard had not been in close proximity to the Carriage Gates entrance. They had been some distance away and out of view of the entrance because they had understood their duty to involve a roving patrol around the Yard. In fact, tactical advice and written instructions stated that armed officers should be stationed close to the Carriage Gates entrance so as to protect those in the Estate and their unarmed colleagues. Due to shortcomings in the security system at New Palace Yard, including the supervision of those engaged in such duties, the armed officers were not aware of a requirement to remain in close proximity to the Gates. Had they been stationed there, it is possible that they may have been able to prevent PC Palmer suffering fatal injuries.

17322125.1

Responses

7 respondents

Parliamentary Authorities

19 Dec 2018 PDF

Action Taken

The Parliamentary Authorities confirm that they already plan to consider the automation of Carriage Gates and their general ease of use as part of the ongoing renewal project; and external reviewers have already been extensively involved in the New Palace Yard project, and will continue to be involved. (AI summary)

View full response

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BEFORE THE CHIEF CORONER HHJ LUCRAFT QC INQUESTS ARISING FROM THE DEATHS IN THE WESTMINSTER TERROR ATTACK OF 22 MARCH 2017 INQUEST INTO THE DEATH OF PC KEITH PALMER GM

___________________________________________________________________________ RESPONSE OF THE PARLIAMENTARY AUTHORITIES TO THE REGULATION 28 REPORT ON ACTION TO PREVENT FUTURE DEATHS ___________________________________________________________________________

Introduction

1. This response is submitted on behalf of the Parliamentary Authorities in reply to the Regulation 28 Report dated 19 December 2018.

Matter of Concern 12
2. The suggestion is that the automation of Carriage Gates and their general ease of use be specifically and expressly considered as part of the ongoing renewal project. The Parliamentary Authorities respectfully agree and already plan to do this.

3. The Parliamentary Authorities can confirm that these issues have been considered as part of the project for improved security in New Palace Yard. Mechanisation to assist with opening and closing the gates (which the Parliamentary Security Department distinguishes from automation, which implies automatic operation in some circumstances and could itself be potentially problematic from a security perspective) is an area that the New Palace Yard project team have discussed.

4. Following extensive discussion, the plan at present is that the original Carriage Gates will be refurbished and returned to replace the current temporary gates that are in place. The Parliamentary Security Department will continue to keep under review whether the mechanisation of the Gates should be pursued as part of a later phase of the project, if the MPS believe that the refurbishment work has not been successful in considerably

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improving the manoeuvrability/ease of operation. They will continue to discuss this question with the MPS.

5. As the Chief Coroner’s report recognises, those responsible for the project will have to take account of a range of considerations in the design and construction of the entrances. There are advantages and disadvantages in mechanisation, and particular concerns that have been raised are ready operation when motors fail, and the speed of closing in emergency situations. The Parliamentary Authorities retain an open mind on this question.

6. Advice has already been sought on this issue from the Centre for the Protection of National Infrastructure, who are also part of the Parliamentary Security Director’s ‘Advisory Panel on Protective Parliamentary Security’ (APPPS); which was established after the Sir Jon Murphy review and which is regularly consulted on physical security plans. Other members of that Panel include the Home Office and Metropolitan Police.

7. To further reinforce the position, Mr Hepburn has issued a formal instruction that the mechanisation of the gates is to be considered in the course of the project.

Matter of Concern 13
8. The suggestion is that consideration be given to an external security reviewer being involved in approval of project plans from a security perspective, before any irreversible steps are taken. Again, the Parliamentary Authorities agree; this has been the approach adopted in the New Palace Yard project, and will continue to be so.

9. The Parliamentary Authorities can confirm that external reviewers have already been extensively involved in the New Palace Yard project, and will continue to be involved. The Security programme as a whole undergoes a formal Gateway review process (based on three independent expert reviewers visiting Parliament to assess progress). The first review took place in January 2018 and the next one is taking place this month (February 2019). In addition to this Sir Jon Murphy has been invited back later this year to carry out a further independent assessment of the progress of the physical security

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projects within the Security Programme. The mitigations that each project will be putting in place are discussed with the members of the APPPS, described above.

Note on Matter of Concern 8
10. This was principally directed towards the Metropolitan Police Service, with the suggestion that the MPS, with the Parliamentary Authorities, reviews the adequacy of training to ensure that it involves AFOs, unarmed officers and security officers and their co-ordination. The Parliamentary Authorities can confirm that the Parliamentary Security Department liaises regularly with police colleagues and has the opportunity to comment and make suggestions about the training provided to officers working on the Parliamentary Estate. This close working relationship will continue into the future.

SAIRA SALIMI Speaker’s Counsel

15 February 2019

Metropolitan Police Service Police / Law Enforcement

18 Feb 2019 PDF

Action Planned

The MPS will revise Post Instructions to relevant groups by direct emails, in hard copy and/or via electronic devices; MPS is working with MO19 and the National Police Chief’s Council to provide additional training on de-escalation techniques; and the MPS will ensure that there is appropriate input from tactical advisers at challenge panels, and the newly appointed PaDP OFC Sergeant will ensure that AFOs fully understand not only relevant changes to post instructions but also the rationale behind the changes. (AI summary)

View full response

Dear HH Judge Lucraft QC,

I write on behalf of the Metropolitan Police Service (MPS) in response to your Regulation 28 Report to prevent future deaths dated 19th December 2018. This followed the conclusion of the inquests into the circumstances of the deaths of Kurt Cochran, Leslie Rhodes, Aysha Frade, Andreea Cristea, PC Keith Palmer and the attacker Khalid Masood on 22 March 2017. The Coroner’s report to prevent future deaths has been read and considered by the Commissioner and at the highest level within the PaDP command. It will also be disseminated and discussed widely with officers on the command. In this letter I will address the specific recommendations within the report. This response should be read alongside the representations made by the MPS in advance of the report being issued. A copy of the MPS’ submission is attached to this letter. Recommendations: MC1: I suggest that the MPS gives consideration to providing revised Post Instructions to relevant groups by direct emails, in hard copy and/or via electronic devices (as well as their being accessible through ADAM) and to providing them in a way that requires the recipient to respond indicating safe receipt.

METROPOLITAN POLICE

1. ADAM is an IT system, with limited storage space and there are therefore restrictions on the volume of data that can be put on it. ADAM is a comparatively slow system and it can be difficult for officers to quickly log in and check for updates. Furthermore, the set-up of the ADAM system presents difficulties for an effective audit of some functions. Whilst space has now been cleared to improve the audit function, it is accepted that the data provided does not easily enable analysis.

2. The Commissioner accepted at the inquests that there were deficiencies with the ADAM system and in particular that there was too great a reliance upon ADAM which at the time was the primary means of communicating changes to post instructions.

3. Following the inquests, a great deal of work has been carried out within PaDP in relation to the ADAM system, post instructions and auditing compliance. A temporary system has been introduced whereby officers sign a form before they take over a post to say that they have read the post instructions and are aware of their role. This must be completed before an officer can sign out a firearm. Changes to post instructions are now emailed directly to all officers on PaDP, not just supervisors (see para 7 below). Further improvements will be made following the introduction of a digital system currently on trial called AIRBOX (see para 6 below). All Sergeants and Inspectors have been briefed on their operational responsibilities for supervision of officers on posts. Supervisors are set performance targets for post knowledge checks on every shift.

4. As stated above, the MPS is currently procuring a system to replace ADAM and a trial of a new system called AIRBOX will begin in February 2019. This system will not only be able to store post instructions but is also capable of allowing the command (i.e. supervisory officers within PaDP) to view the location of every officer, to identify any officer who is not on post and any officer who is on a post and ought not to be. It is a system which is already being used by other forces nationally, by counter terrorism specialist firearms officers (CTSFOs) nationally, and is soon to be rolled out in the MPS within the Firearms Command (MO19). Should this system be adopted in PaDP, all officers will be issued with a mobile data device to view and use AIRBOX. The finance to procure and purchase devices has already been approved in advance of the trial.

5. As the Chief Coroner notes, whenever post instructions are updated, all AFOs on the command are now emailed directly informing them of this and a voting button is attached to the email for an officer to confirm that they have read the email and will log into ADAM to read the revised post instruction(s). The voting response forms part of a compliance audit. Previously, notifications were routinely sent to supervisors for briefing purposes. Officers are now required to log in to MPS information systems on a monthly basis. Supervisors monitor

whether emails have been read. This is audited where an email relates to an update to post instructions.

6. Supervision and knowledge checks are carried out on posts by all supervisors on a daily basis. A minimum of five checks each shift for armed and unarmed officers are completed, which amounts to a minimum of 20 checks each day. Since the new system was implemented in October 2018, 2643 checks have been completed. This represents an 86% increase since the introduction of new processes and the results of these checks are shared with the senior leadership team (SLT) in a fortnightly report and discussed at the SLT meeting. The data forms part of monthly, quarterly and annual performance reports for the command. The data is broken down and shared with supervisors and teams. It is used to identify any key learning themes and these are then disseminated and addressed within the command.

7. As the MPS stated at Annex 1, all post instructions are now available to officers in hard copy form at every post location on the POW estate and at every diplomatic post location where suitable storage is available. These are also available in hard copy in the Sergeant’s office at the Palace of Westminster and in every base room in PaDP buildings (Apex House, Lillie Road base, Kensington base). Previously, hard copies of the post instructions were only available in the mess and armouries at Palace of Westminster.

8. It is not possible to provide individual hard copies of post instructions to all officers due to the security sensitivity of these documents. There are also restrictions upon emailing such documents to large groups. The MPS has introduced the procedure detailed above as a means of ensuring compliance without compromising security.

9. PaDP has developed an Innovation and Development Team (IDT) who are responsible for compliance, audit and governance. This reports to and provides a performance pack for the PaDP senior leadership team. This (initially temporary) team is currently one Sergeant and 12 constables. Agreement has been made for a permanent team comprising two Sergeants and seven full time PCs.

10. A knowledge management manual has been produced online and the link shared with all officers. Officers are also sent the relevant sections of the knowledge manual in advance of the scheduled knowledge management checks conducted by supervisors, so that they are able to familiarise themselves with the area about to be checked. An annual audit schedule is in place, which enables oversight of all themes over a 12 month period. Each audit takes place over periods of 14 to 21 days. It is planned that this manual will be stored on a system which will enable the MPS to monitor which officers have logged into the manual, at what time and for how long. This will be audited by the IDT. The command is looking for a suitable

system to provide this data as it must be compliant with the requisite security levels. These improved procedures are already in place. The timeframe for the improved IT system is addressed elsewhere in this response.

MC2: I suggest that the MPS considers making it mandatory for officers on the Command to register for ADAM and to access it at specified intervals (perhaps supplemented by an instruction to confirm review of material on the system).

11. Registration on ADAM was mandatory at the time of the attacks. The Commissioner accepts that the inquests revealed that an unacceptable number of officers had not registered at the time of the attack and that the number of officers who had accessed ADAM in the months before the attack was also unacceptable.

12. Compliance has substantially improved and the proportion of officers on the PaDP command who have now registered on ADAM is 100%. This is a mandatory element of the induction course into the command which takes place in the first week of joining PaDP. This sets the tone around knowledge requirements when officers arrive at PaDP. For existing officers, separate instructions have been issued around registering and logging into the ADAM system regularly. In addition, there is a separate regime of supervision checks conducted on posts to check that officers are aware of the post instructions and complying with them. These checks are recorded, analysed and produced in a performance report by the IDT. In addition, PaDP has developed a ‘Skills Loss Policy’ to enable officers to be exited from the Command where there is a loss of confidence due to a failure to comply with instructions. There has been a significant amount of work in the background to clear enough space on the ADAM server to be able to enable the audit functionality. This is now complete and the audit functionality is live.

13. The recommendation in MC2 will be communicated to all PaDP supervisors and the Professional Standards Unit to ensure that this improvement continues and that steps are taken in the event of non-compliance. There are already formal sanctions in place through the Unsatisfactory Performance Procedure (UPP) and Misconduct regulations. In addition, please see Para 12 above regarding the skills loss policy which will be instigated following UPP or misconduct proceedings. The “Skills Loss Policy” will be in place within one calendar month.

MC3: Given the figures for usage of the ADAM System, it is a matter of concern whether officers have (a) adequate time to access the System regularly and review their Post Instructions and (b) adequate facilities to do so (e.g. ready access to computer terminals). I therefore suggest that the MPS considers the time and facilities available for officers to access the ADAM System and review their instructions.

14. As a result of matters which came to light at the inquest, the briefings for AFOs at the POW have changed. A bespoke briefing is mandatory whenever there has been an update to post instructions. This is auditable through the METBATS system which is the system used by the MPS to brief officers.

15. AFOs have periods of standby time between posts of at least one hour, but this can be two hours or more. Officers are aware of their postings three weeks in advance and this time must be used to refresh and improve familiarity with post instructions. All officers are reminded of the need to refresh their knowledge when they come on duty and sign to accept their postings for the day. An agenda item will be raised at the next challenge meeting on
01.03.19 as to whether this time is sufficient. This has also been raised with supervisors on the PaDP command.

16. As set out above, all officers must now sign a declaration before commencing duty confirming that they have read and understood their post instructions. Officers are not permitted to commence post duties or sign out a firearm without singing the declaration. Auditing of this requirement has shown a 100% compliance rate.

17. As stated above, a bespoke IT solution is being developed for the command as a priority. It is anticipated that this will include the use of hand held devices upon which post instructions can be viewed.

18. Work to upgrade the network at POW is ongoing and has been delayed due to cabling and heritage issues at the POW. There are already 30 terminals currently available across PaDP and following the upgrade and completion of works, there will be over 40 terminals available to officers across 4 sites, 24 hours a day. More terminals are available overnight and at weekends when office based staff are off duty. Additionally, 140 officers have personal issue mobile tablet devices and there are docking stations at the Lillie Road base and at Charing Cross police station.

MC4: I suggest that the MPS considers a periodic audit of all extant Post Instructions for the Parliamentary Estate to ensure their consistency and fitness for purpose. This might be part of the supervisory audit discussed at MC7 below, or separate from it.

19. It is accepted that different opinions were expressed at the inquests as to whether post instructions were “open to interpretation” or not. To the extent that there was uncertainty and a lack of precision in the wording of a small number of post instructions relating for example to phrases such as “short patrol”, this has been addressed and such wording is no longer used.

20. The increased and improved communication between AFOs, supervisors and tactical advisors (as detailed in these submissions) is also used as a means of ensuring understanding and compliance with post instructions.

21. A review of post instructions is currently taking place with the inclusion of the Counter Terrorism Command (SO15) and the National Counter Terrorism Policing Headquarters (NCTPHQ) to ensure that there is no ambiguity in post instructions. This has already resulted in the creation of orders and instructions which have been separated from the specific post instructions. This will be further reviewed by MPS senior managers and lawyers who were present at the inquests, who will be able to assist in light of matters which emerged in evidence and to ensure that the Chief Coroner’s recommendation is fully addressed. It is expected that this will take three months to implement.

22. A new post has also been created at PaDP for a Sergeant with responsibility for reviewing posts and post instructions. The skills criteria for this role include the requirement to be an Operational Firearms Commander (OFC) with the ability to provide day to day tactical advice on posts. This post reports to the Inspector with responsibility for operations and post instructions. This post has been created, ratified and advertised internally. A Sergeant has been selected and is in the post with support pending his OFC Course scheduled for May
2019.

MC5: It was a matter of concern that, at the time of the attack, one of the most vulnerable and public entrances to the Parliamentary Estate was not protected by armed police. In my view, the MPS should consider (a) imposing a standing order that there should be armed officers stationed at all open public entry points to the Palace of Westminster (and possibly to some other buildings on the Parliamentary Estate) and (b) introducing a provision that this standing order may only be varied with the written approval of an officer of very senior rank.

23. At the time of Masood’s attack, Carriage Gates should have been protected by two AFOs in accordance with the post instructions. Steps have since been taken to ensure that this entrance has a static armed post (two AFOs) at the gates and the gates are always protected by at least this number of armed officers during sitting hours. This was introduced as a result of a new tactical assessment which was conducted immediately after the attacks. The Chief Coroner will also be aware of what he observed on the site visit and the Sir Jon Murphy report.

24. Carriage Gates presents unique challenges for the police in providing protection and security. The balance between the democratic symbolism of an open Parliament and the need to protect those who work and visit the estate has been reviewed after the attack. It remains the commitment of both the MPS and the Parliamentary authorities to ensure that terrorists do not change our way of life or the operation of Parliament which remains open to the public. The Chief Coroner’s observations in this regard are respectfully endorsed. As the Chief Coroner will be aware, this is an area upon which the MPS requires the consent of the Parliamentary Authorities.

25. The MPS does not have a relevant system of “standing orders” which could precisely and effectively deliver that which the Chief Coroner has recommended. However, the Commissioner recognises and accepts the rationale behind recommendation MC5.

26. The present armed policing model ensures that all open public entrances to the Parliamentary Estate are protected by armed guards when Parliament is sitting.

27. The Commissioner can confirm that in the unlikely event that tactical advice were received and accepted which recommended that a public entrance would not be protected by armed guards during sitting hours then this would require the authority of an officer of at least the rank of Chief Superintendent before implementation. At present this would be the PaDP Commander. To the extent that this requires action it will be implemented immediately.

MC6: It was a matter of concern that officers were unaware of their Post Instructions and that supervisory systems had not identified limited usage of the ADAM System. I therefore suggest that the MPS considers auditing use of the ADAM System periodically, by checks to confirm use at sufficiently regular intervals over the period.

28. This is noted. The Commissioner respectfully submits that the answers to MC1 and MC2 above deal with this recommendation. ADAM registration and usage will continue to be regularly audited and supervision and knowledge checks by supervisors will continue on a daily basis until such time as a new system is commissioned and delivered.

MC7: I suggest that the MPS considers instituting regular supervisory audits of policing at the Palace of Westminster (and perhaps other parts of the Parliamentary Estate), preferably by officers outside the PaDP Command.

29. As the MPS explained in the Regulation 28 submission, supervision of armed officers at the Palace of Westminster has been substantially improved. This has taken the form of increased training for AFOs and supervisors and a significant increase in the number of checks of AFOs by supervisors with clearly auditable records kept and monitored by senior management.

30. The review of risk assessments for posts is conducted by a Tactical Advisor from MO19. As explained in the response to MC4 above, an additional OFC Sergeant post has been created within the PaDP command to review posts on an ongoing basis in addition to the tactical advice received from MO19.

31. The recommendation for an external (non PaDP) audit is noted. The MPS will introduce a system which will require a supervisory audit to be completed at least bi-annually by officers who are not part of the PaDP command on a trial basis. The first external audit will take place in the summer of 2019, by which time the review of post instructions will have been completed and any revisions implemented.

MC8: I suggest that the MPS, with the Parliamentary Authorities, reviews the adequacy of training to ensure that it involves AFOs, unarmed officers and security officers and their co-ordination.

32. All armed and unarmed officers on the PaDP command undergo joint officer safety training and emergency life support training every year.

33. The MPS currently provides joint training involving AFOs, unarmed officers and security officers. There is an extensive joint training, testing and exercising programme with Parliament. This includes monthly table-top operations. This programme commenced in April
2018. Plans are in place to undertake a significant live testing exercise this year. These exercises include armed and unarmed officers at all ranks and Palace Security.

34. The PaDP command has created two new roles for specialist Firearms Instructors who will form part of the command. The instructors will advise and assist in the training of all officers, armed and unarmed, and any training which is negotiated with Parliament to include, in light of the Chief Coroner’s recommendations, security officers. Finance has been agreed for these posts which will be advertised imminently. It is anticipated that due to the recruitment, selection and workforce planning process it will take approximately three months for these officers to be in post.

35. All unarmed supervisors on the PaDP command have observed tactical refresher training for armed officers at the MPS firearms training facility at Milton and this will form part of the induction to the command for unarmed supervisors going forward. The inclusion of all unarmed officers, at all ranks, will now be factored into ongoing training.

36. Joint training with security officers will require assistance from the Parliamentary authorities, who we are in discussion with. The MPS will negotiate with the Parliamentary authorities to ensure that this recommendation is implemented. There are joint exercises scheduled for March and July 2019.

MC9: I suggest that the MPS reviews the adequacy of training of officers stationed in the Parliamentary Estate to ensure it includes lone actor and multi actor marauding attacks.

37. Police officers within the Parliamentary Estate are trained in tactics which relate to both lone and multi actor marauding attacks as well as knife defence. This training will be built upon at the next round of officer safety training where it will include scenario based input and will be

shared with Royalty and Specialist Protection and Aviation Policing. The training has been observed and noted by MO19. The Chief Coroner will appreciate that this is a matter which is regularly reviewed at the highest level both within the MPS and nationally.

38. The MPS constantly seeks to improve training of this kind and PaDP is currently discussing the Chief Coroner’s recommendation with MO19 and the National Police Chief’s Council. This will feed into MPS training forthwith.

MC10: I suggest that the MPS considers the possibility of the firearms assessor /adviser briefing officers as to the rationale for any changes to their Post Instructions.

39. As the Chief Coroner notes, trained tactical advisers attend challenge panels and are available to discuss post instructions and tactical planning with the PaDP Operations team.

40. The MPS notes and accepts the Chief Coroner’s recommendation and will ensure that there is appropriate input from tactical advisers at challenge panels which are held bi-annually or in the event of an incident requiring such.

41. The newly appointed PaDP OFC Sergeant with responsibility for internal tactical advice will ensure that AFOs fully understand not only relevant changes to post instructions but also the rationale behind the changes. This will happen as and when post instructions change.

MC11: I suggest that the MPS considers a periodic audit of Tactical Firearms Reviews.

42. Tactical firearms plans are constantly reviewed on at least an annual basis. The Commissioner notes the Chief Coroner’s recommendation MC11 and will ensure that this continues.

Conclusion

43. As Assistant Commissioner Basu said at the conclusion of the inquests: even the possibility that the MPS lost the chance to prevent the murder of a brave and courageous officer is unacceptable. For the loss of that possibility to protect him from Khalid Masood, we are deeply sorry. On behalf of the Commissioner those comments are repeated and endorsed. It

is hoped that the Chief Coroner and PC Palmer’s family will recognise from this document and our earlier response that everything possible is being done to protect both the public and police officers in the future.

Maritime Coastguard Agency Central Government

25 Feb 2019 PDF

Noted

The MCA states sufficient guidance already exists in the public domain for operating commercial vessels and leisure boats on navigable rivers and canals, referring to existing codes and training courses. (AI summary)

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Dear Ms Jones Thank you for your letter of 19 December; enclosing the Chief Coroner's Regulation 28 report to prevent further deaths, following the Westminster terror attack on 22 March 2017 . Following the inquest into the death of Andreea Cristea, which concluded in October 2018, HH Judge Mark Lucraft QC recommended that the Maritime and Coastguard Agency (MCA) considers whether it or some other body could provide guidance on the removal of unconscious persons or bodies from the water to those operating on navigable rivers and canals. The MCA has considered this matter in depth and has had discussions with a number of interested parties including the RNLI; the RYA, the Association of Inland Navigation Authorities (AINA) and our partner emergency service providers_ This is complex matter and we have considered whether any potential guidance would be for professional crews or for members of public operating pleasure craft on navigable waterways, taking account of the suitability of equipment on the many vessel types that operate on navigable waterways It has become clear through our research that there is a need to balance encouragement to take quick and decisive action, against the very real risk that such action might do more harm than good and may also endanger those attempting an impromptu rescue. Thankfully, the scenario highlighted by the coroner is rare occurrence, but in these situations our advice is always to call the emergency services who have the specialist equipment and trained crew: The RNLI advise that removing unconscious persons or bodies from the water can be hazardous, it is a specialist task which requires specialist equipment and knowledge to minimise the risks of harmlinjury to the crew Appropriate training is also required to ensure the casualty is treated in the most effective way to ensure the best possible INVESTORS X " IN PEOPLE Iine Quean!Dtamono HM Coastguard Veluntatting 47amd oin the very

chances of survival. The training methods for RNLI lifeboat crew for both unconscious and conscious casualties are the same and advise that no set method applies as it is dependent on the geography; local conditions, and environmental factors at the time of each incident. The RYA provide advice on their training courses about recovering unconscious persons from the water and do not differentiate methods of recovery between inland and coastal waters _ Taking the points above into consideration, we believe that sufficient guidance already exists in the public domain for those operating commercial vessels on navigable rivers and canals through the Inland Waters Small Passenger Boat Code, which is published by AINA and available on gov.uk2_ For leisure boat users training that covers emergency situations is available from the RYA? and the Canals and Rivers Trust provides information for boaters to keep safe"_

BVRLA

25 Feb 2019 PDF

Action Taken

The BVRLA has increased counter terrorism training and guidance made available to vehicle rental and leasing firms, and routinely shares data and intelligence with police and counter terrorist authorities. The Department for Transport launched its Rental Vehicle Security Scheme in December 2018. (AI summary)

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Dear Sirs, Re: Inquest Arising from the deaths in the Westminster terror attack of 22 March 2017 The BVRLA and its members are very aware of the potential to misuse hire vehicles, turning them into instruments that kill and maim innocent people. As a result, the BVRLA and its members have been working closely, and more frequently, with the Department for Transport, counter terrorist and law enforcement organisations as well as policymakers in recent years. We have increased the amount of counter terrorism training and guidance made available, and we have offered this resource to all vehicle rental and leasing firms, not just those in BVRLA membership. Furthermore, it is available free of charge. BVRLA and its members have and maintain excellent relations with police and counter terrorist authorities and routinely share data and intelligence. We work as a community of businesses to protect our assets and staff, and to deny fraudsters and extremists opportunities to take advantage of our business services by raising barriers to participation. With regards to data sharing, it is our policy stance that consideration should be given to introduce enhanced background checks and bulk data sharing. The vehicle rental industry is willing to share bulk data so that the authorities can cross-reference such data against their own crime and terrorist indices. There would, however, need to be protocols and safeguards in place to ensure that personal data is processed in a legally compliant way. Furthermore, we believe considerable resource would need to be allocated to explore any technical solution to integrate external data with internal police and counter terrorism databases. In December 2018, the Department for Transport launched its Rental Vehicle Security Scheme which aims to increase counter-terrorism awareness and preparedness across the sector and mitigate the risk of rental vehicles being used as weapons in acts of terror. The voluntary scheme, which is open to all UK vehicle hire firms offering short-term rental to consumers, has been developed in collaboration with the BVRLA and other key industry partners, and requires participating firms to meet a set of requirements outlined in a 10-point Code of Practice, including a commitment to:
1. Lawfully share data and information with law enforcement
2. Train staff to identify and report suspicious behaviour
3. Appoint a recognised security contact
4. Only accept electronic payment for all or part of the transaction Although not the mandatory scheme that the BVRLA initially called for, the association believes that the scheme will demonstrate participating firms’ commitment to taking security seriously and will help in the fight against terrorism.

Home Office Central Government

26 Feb 2019 PDF

Action Taken

The Home Office states the government accepts the Chief Coroner's recommendations and has taken action. The Department for Transport (DfT) launched the Rental Vehicle Security Scheme (RVSS) on 6th December 2018, and an industry led Advisory Panel was launched in January to oversee the development of the scheme. (AI summary)

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Dear Sian

Response to Prevention of Future Death (PFD) Report issued by the Chief Coroner

Thank you for your letter of 19 December enclosing a copy of the Prevention of Future Death (PFD) Report issued by the Chief Coroner, His Honour Judge Mark Lucraft QC, following the completion of the Westminster Bridge terrorist attack inquests.

I am grateful to you for bringing these matters to my attention, and for the work of the Chief Coroner in thoroughly exploring the tragic events of 22 March 2017. My sympathies are with the victims of the attack, including PC Keith Palmer, and with all those affected.

The Chief Coroner makes three recommendations to which I am replying as Home Secretary: these affect the interests of the Home Office, the Security Service and the Department for Transport. A full response is attached, but the Government agrees with the Chief Coroner’s recommendations and has taken action to address these.

If I can be of any further assistance, please do not hesitate to contact me.

Transport for London Transport / Rail

26 Feb 2019 PDF

Action Taken

TfL implemented internal changes in October 2017 to improve communication of security advice. TfL is currently reviewing the height of all its bridge parapets to identify those that are below 1m high, with high priority bridges expected to be completed by April 2019. (AI summary)

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Dear Ms Jones

Inquests arising from the deaths in the Westminster Terror Attack of 22 March 2017

We write with regard to the Coroner’s Regulation 28 Report on action to Prevent Future Deaths dated 19 December 2018 following the inquests arising from the deaths in the Westminster Terror Attack of 22 March 2017.

We would like to extend again our sincere condolences to the families and friends of those killed and injured in the Westminster terror attack.

We respond below to the two concerns that the Coroner has reported to TfL.

MC14: … I also suggest that TfL considers whether there is any further work it can do to improve protective security on major roadways and bridges in the capital, in response to national advice and known threats.

In October 2017 TfL implemented internal changes to ensure that any security advice received from the Metropolitan Police Service (MPS) or other agencies is properly communicated to TfL. At the time of the Westminster Bridge and London Bridge terror attacks, there were no dedicated counter-terrorism security advisors (CTSAs) assigned to provide security advice to TfL. Since October 2017, TfL has an agreed arrangement with the MPS whereby two CTSAs assigned to London boroughs act as points of contact and provide advice to TfL. TfL also proactively seeks advice and guidance from the Centre for Protection of National Infrastructure (CPNI) and the National Counter- Terrorism Security Office (NaCTSO) via the CTSAs and British Transport Police to shape its approach to protecting our streetscapes.

All requests and recommendations regarding forms of protective security, such as Hostile Vehicle Mitigation (HVM), are now considered by TfL’s Crime Reduction and Operational Security Team. These requests are usually received from local authorities in relation to projects they are leading on which have some form of interface with part of TfL’s road network. The MPS and private businesses also approach TfL with recommendations or requests.

The Crime Reduction and Operational Security Team was created in October 2017 after the Westminster Bridge and London Bridge terror attacks to provide technical expertise so TfL can better understand the changing nature of terrorist and other security threats and the risks that need to be considered as part of developing the road network, the public realm and the appropriate measures to mitigate. This team is staffed by suitably trained and qualified individuals with experience in situational crime prevention and crime prevention through environmental design.

In relation to how TfL considers and responds to national advice, it is our understanding that the Office for Security and Counter-Terrorism (OCST), NaCTSO in the Home Office and others are producing guidance on reducing risk in crowded spaces, such as highways, bridges and the public realm. TfL awaits with interest this updated guidance and will fully consider and respond to its recommendations when it is issued.

MC15: I suggest that TfL gives consideration to reviewing the height of parapets and railings of bridges for which it is responsible. As part of such review, thought might be given to the question of whether a higher barrier would improve safety materially and whether it would be practicable to create one (e.g. raising a parapet or adding a railing on top).

TfL is currently reviewing the height of all its bridge parapets to identify those that are below 1m high. The information collected will be used to identify if any bridges require a more detailed safety assessment and if any practical steps could be taken to raise the height in such circumstances.

This review commenced in October 2018 and is being led by Garry Sterritt, Head of Asset Investment at TfL. The existing data held in the bridge management system did not capture data on parapet height so changes are being commissioned to this system to include such data. It is anticipated that the review of parapet height for high priority bridges will be completed by April
2019. All other bridges will be completed as part of a 2 year cycle inspection regime.

As noted in TfL’s submissions to the Coroner dated 8 November 2018, this exercise will require the involvement and co-operation of other organisations including relevant local planning authorities. Westminster Bridge is Grade II listed and therefore any proposed changes to it (including to the parapets) will require listed building consent from Lambeth Council and Westminster City Council who are both the relevant local planning authorities.

Please contact us if we can be of any further assistance.

London Ambulance Service NHS Trust

26 Feb 2019 PDF

Noted

The London Ambulance Service states that the Chief Coroner found no matters of concern regarding their actions, so they will not be taking any further action. (AI summary)

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Dear Madam Inquests arising from the deaths in the Westminster Bridge Terror Attack of 22 March 2017 We act for the London Ambulance Service (LAS) and write to respond to the Chief Coroner’s regulation 28 report on action to prevent future deaths. The report is addressed to eight recipients including the LAS but we note that the Chief Coroner found that it was not appropriate to record any matter of concern in respect of the LAS. In the circumstances, there is no need for LAS to respond further or to take action to prevent future deaths. The LAS refers again to its written submissions dated 8 November 2018, which the Chief Coroner accepted and LAS repeats their admiration for the immense dignity and stoicism that all of the families have shown throughout these inquests.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2018-0304
Date of report: 19 December 2018
Coroner: HH Judge Mark Lucraft QC
Coroner area: London Inner (West)

Responses identified

Responses identified 7 of 8

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 13 Feb 2019 (estimated).

Sent to

Department for Transport

Home Office

Metropolitan Police

Speaker’s Counsel, for the attention of the Parliamentary Authorities at the Palace of Westminster

British Vehicle Rental and Leasing Association

London Ambulance Service

Maritime and Coastguard Agency

Transport for London

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.