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

Date of report	19 Dec 2018
Reference	2018-0304
Deceased	Kurt Cochran; Leslie Rhodes; Aysha Frade; Andreea Cristea; PC Keith Palmer.
Coroner	HH Judge Mark Lucraft QC
Coroner area	London Inner (West)
Category	Other related deaths
Source	judiciary.uk record · original PDF
Responses published	7

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

INQUESTS ARISING FROM THE DEATHS
IN THE WESTMINSTER TERROR ATTACK OF 22 MARCH 2017

REGULATION 28 REPORT ON ACTION TO PREVENT FUTURE DEATHS

Addressees

This Report is being sent to the following:

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

The Commissioner of Police of the Metropolis;

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

of Westminster;

The London Ambulance Service;

Transport for London;

The Secretary of State for the Home Department;

The Maritime and Coastguard Agency;

The Secretary of State for Transport;

The British Vehicle Rental and Leasing Association.

Coroner

I am the Chief Coroner of England and Wales. I am also a Senior Circuit Judge. I

heard these Inquests in the capacity of a Judge nominated by the Lord Chief Justice

pursuant to Schedule 10 to the Coroners and Justice Act 2009 (“CJA”).

The address of my office is 11th Floor – Thomas More Building, Royal Courts of

Justice, London, WC2A 2LL.

Coroner’s Legal Powers

I make this report under paragraph 7 of Schedule 5 to the CJA and regulations 28 and

29 of the Coroners (Investigations) Regulations 2013.

Investigation and Inquests

These Inquests included those of the five victims of the attack: Kurt Cochran; Leslie

Rhodes; Aysha Frade; Andreea Cristea; and PC Keith Palmer. They also included

an inquest of the attacker, Khalid Masood. Dr Fiona Wilcox, Senior Coroner for

Inner West London, opened inquests into all six deaths and held a Pre-Inquest

Review (“PIR”) hearing on 19 May 2017. I took conduct of the Inquests and held

PIR hearings on 15 January and 2 July 2018. I held a hearing of the Inquests of the

victims of the attack (without a jury) from 10 September 2018, which ended on 3

October 2018. Immediately afterwards, I held a hearing of the Inquest of the attacker

(with a jury), which ended on 12 October 2018.

In the Inquests of the victims of the attack, I determined that each had been

unlawfully killed and gave further narrative conclusions for each. Attached to this

Report are copies of the Determinations sheets for the five victims.

In the Inquest of the attacker, the jury returned a conclusion of lawful killing and

added further narrative conclusions. Attached to this Report is a copy of the

Determinations sheet for the attacker.

Circumstances of Deaths

On 22 March 2017, Khalid Masood drove a Hyundai Tucson vehicle across

Westminster Bridge from the South Bank side towards the North Bank side. At

14:40:08, his vehicle mounted the pavement several times and struck a number of

pedestrians. Four people sustained fatal injuries as a result: Kurt Cochran; Leslie

Rhodes; Aysha Frade; and Andreea Cristea. A number of others were also struck by

the vehicle as it was driven across the bridge, with 29 further people suffering serious

injury. The vehicle went on to crash into the railings at the perimeter of the Palace

of Westminster, at 14:40:38.

After the vehicle had crashed into the railings, Masood got out and continued on foot.

He ran through the Carriage Gates vehicle entrance to the Palace of Westminster. He

was holding two knives. He attacked PC Keith Palmer, a Metropolitan Police Service

(“MPS”) police officer stationed at the Gates. In the course of a short and brutal

attack, he inflicted stab wounds on PC Palmer, one of which proved fatal. As he

went after PC Palmer, further into the grounds of the Palace, Masood was confronted

by plain-clothed armed police officers. He was shot and killed. The shots were fired

at 14:41:30, which was 82 seconds after the attack had begun.

At the time of Masood’s attack, there were two uniformed Authorised Firearms

Officers (“AFOs”) of the MPS stationed in New Palace Yard. AFOs were routinely

deployed in various locations around the Palace of Westminster, with the area

divided into a number of sectors. Carriage Gates and New Palace Yard fell within

Sector 3. The two AFOs were conducting a patrol around the whole of the sector

prior to and at the time of the attack and were not in close proximity to Carriage

Gates.

Coroner’s Concerns

10. During the course of the Inquests, the evidence revealed matters giving rise to

concern. In my opinion, there is a risk that future deaths could occur unless action is

taken. In the circumstances, it is my statutory duty to report to appropriate persons

who may be able to take remedial action. In the following paragraphs, I address

various public authorities and I explain what concerns I am reporting to them. Each

matter of concern is denoted by an “MC” reference and is highlighted in bold.

11.

In preparing this Report, I have taken into account the submissions from the bereaved

families of what matters I should consider raising and the responsive submissions

from institutional Interested Persons.

Metropolitan Police Service

Post Instructions and Deployment of Armed Officers at Parliament

12. Post Instructions are the written orders given to police officers as to where and how

to conduct their routine patrols. During the Inquests, concerns arose about

communication of and compliance with Post Instructions for AFOs of the

Parliamentary and Diplomatic Protection (“PaDP”) Command who were posted at

the Palace of Westminster. For example, some officers (a) were unaware of their

Post Instructions; (b) regarded them as open to interpretation; and/or (c) had not been

using the computer system which had been introduced to give access to updated

instructions (ADAM). As regards the ADAM system, it was telling that when usage

was checked in August 2016, only 13% of officers had logged onto the system in the

eight-month period since the previous revision of Post Instructions.

13. With specific reference to New Palace Yard, tactical assessments had determined

that AFOs should be close to Carriage Gates at all times when they were open (i.e.

throughout working hours). This was because Carriage Gates presented a prominent

and vulnerable entrance to the Palace grounds. Nevertheless, there was substantial

evidence that many AFOs were not aware of the requirement to remain close to

Carriage Gates when on duty in Sector 3 and that supervising officers were not

communicating that important instruction. This gave me cause for concern both

about the security of New Palace Yard at the time of the attack and about systems

and practices for ensuring that Post Instructions were understood and followed.

14. The MPS has provided detailed submissions explaining steps taken to address these

problems since the attack and (in some cases) since the Inquests hearing. I have

taken those submissions fully into account. I have also taken account of the fact that

New Palace Yard is now subject to entirely different and improved security

arrangements.

15. 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. I was concerned that, when Post Instructions were updated, they were

apparently not emailed or provided in hard copy to relevant officers directly. The

system relied upon officers’ use of the ADAM System, which was sporadic. I am

aware from the submissions of the MPS that, since the attack, an update is sent to all

relevant officers advising them of a revision of Post Instructions and telling them to

view the new version on ADAM. The MPS has provided a copy of an example email,

which was sent on 11 October 2018. However, it may be valuable for the MPS to go

further than this by supplying revised instructions directly to the officers and in

requiring an acknowledgement of safe receipt is sent back by the officers.

16. 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). I

was concerned that a proportion of officers on the Command had not registered for

the ADAM System despite it having been in use for six years. Furthermore, I heard

evidence that officers were under instructions to access the system “regularly” but

no definition of that term could be given. Given that the ADAM System is the

repository for the authorised versions of Post Instructions, these were troubling

features of the evidence. In short, a proportion of the officers had no means of

accessing their instructions and officers generally had no clear guidance on how

regularly they should be checking the system. Although the MPS has provided

submissions referring to improvements in the ADAM System and improved systems

of supervision, these would be relatively simple rules which would be readily

enforceable through the disciplinary process.

17. 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. Post Instructions are written following a tactical assessment and

security review. It was clear in the evidence I heard that significant work goes into

the formulation of the policing plan at the Palace of Westminster. All of this work

becomes wasted effort if the Post Instructions are not readily accessible by those who

are required to follow them. The MPS may wish to consider (a) whether the current

computer facilities at the Palace of Westminster are fit for purpose and (b) how time

might be specifically set aside in an officer’s routine for maintaining up-to-date

knowledge of his/her Post Instructions. I do not know whether officers at the Palace

of Westminster have access to smartphones or tablet computers in addition to desktop

computer terminals. If such technology has been provided to these officers, the MPS

may wish to consider whether updated Post Instructions can be made available on

those devices for ease of access and reference.

18. 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. On the evidence I heard, Post Instructions are prepared

after careful work by relevant experts within the MPS (firearms tactical assessors, in

the case of AFO Post Instructions). Nevertheless, there were deficiencies in the

expression of some Post Instructions, and some officers when presented with them

found it difficult to interpret parts. It is important that each Post Instruction should

be clear and internally consistent, and should be consistent with the broader tactical

plan for the Estate. It was clear from the evidence of Commander Usher that Post

Instructions should be followed precisely. They should not be subject to personal

interpretation, since that would introduce inconsistent practice and would undermine

the tactical rationale behind the instructions. Where the content of Post Instructions

is ambiguous or not consistent with other orders or practices, security can be

undermined.

19. 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.

It is a defining feature of Parliament that it is open to the public. The Rt Hon Tobias

Ellwood MP described a need for “transparency”, consistent with the democratic

processes of the United Kingdom. Eric Hepburn, the Director of Security for

Parliament spoke about the need to strike a balance between openness and security,

respecting the democratic right of the public to be able to come to Parliament and

meet their representatives. However, it was a recurring feature of reviews of

Parliamentary security that public entrances, including Carriage Gates, presented

vulnerabilities. In the case of Sector 3, particular vulnerability was recognised and

there was a need for armed police to be near to Carriage Gates. Given the nature of

terrorist threats to this country and its Parliament, it is difficult to imagine

circumstances in the near future when an open public entry point to the Palace should

not be protected by armed guards. I am concerned that, as matters stand, there is no

mechanism for preventing inadvertent change to Post Instructions leaving an

entrance without armed police. Furthermore, in the event of uncertainty as to the

content of the Post Instructions, a standing order of the kind mentioned above would

provide clarity and a minimum level of protection.

Supervision of Armed Officers at the Palace of Westminster

20.

In my determinations in the Inquest of PC Palmer, I concluded that had armed police

officers been stationed at Carriage Gates at the time of the attack it is possible that

they may have been able to prevent PC Palmer suffering fatal injuries. I identified

that there were shortcomings in the supervision of police officers at the Palace of

Westminster.

21.

I heard some evidence from unarmed officers, armed officers and a supervisor

suggesting that at least a proportion of armed officers believed Post Instructions (or

some such instructions) to be advisory only. By contrast, I heard unequivocal

evidence from senior police officers that Post Instructions were mandatory and must

be followed to the letter. Moreover, whatever the reason, at least a proportion of

armed police constables were not acting in compliance with the Post Instructions at

the time of the attack. This was the underlying cause of the absence of armed officers

from Carriage Gates. Chief Superintendent Aldworth gave evidence that, whilst

responsible for Parliamentary security, he would have considered it to be a serious

problem were armed officers not positioned in close proximity to an exit point such

as Carriage Gates. Weak supervision of Post Instructions can impair Parliamentary

security and expose those in the Estate to serious danger.

22. 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. As long as the ADAM System remains a principal means

for officers to access and review Post Instructions, supervision ought in my view to

include some review of officers’ use of the System. It is clear from the written

submissions concerning this report on behalf of the MPS that significant remedial

steps have been taken across the Command in respect of supervision, but I am

concerned that no reference is made to regular audit of usage of the ADAM System.

23. 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. On

the evidence, it appeared that many armed officers in an important area of the Palace

were regularly patrolling in a way which was not compliant with their instructions,

and that this was not being effectively corrected by their supervisors. This problem

appeared to have been in existence for some time, but had not been identified. Rather

than leaving identification of such practices to irregular major security reviews, it

strikes me that there could be real benefit in having a periodic unannounced audit or

review by an officer from outside the Command, who could check practical

compliance with Post Instructions and other standing orders. As in other fields of

life, assurance is often best carried out by somebody outside the body or department

under scrutiny.

Training

24. Submissions by the sisters and parents of PC Palmer express some concerns in

respect of training of police officers at the Palace of Westminster. In response, the

MPS makes the point that the detail of MPS training of armed and unarmed officers

was not within the scope of the Inquests. However, I did hear evidence referring to

the training which officers received and I heard evidence about the practices of those

responsible for Parliamentary security (including unarmed officers, AFOs and

security officers). In the circumstances, I am in a position to raise some points of

concern.

25. 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. Some features of the evidence gave rise

to concerns that officers in different groups and areas worked in “silos”. For instance,

Mr Hepburn made reference to concerns of this kind in his evidence. I am aware

that, following the attack and before the Inquests, steps were taken to improve the

situation by introducing joint briefings of police and security officers. In my view,

this concern about officers operating in “silos” might also be usefully addressed

through joint training exercises. It may of course be that the MPS already is already

alive to the need to achieve this objective through joint training.

26. 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. The evidence in the Inquests suggested that attacks by

lone actors and marauding attacks by multiple attackers are a persistent threat to high-

profile sites such as the Palace of Westminster. This feature suggests that further

training is needed to deal with a relatively novel danger. I have been informed in

submissions by the MPS of improvements which have been made to the training

programme since the attacks. However, it is not clear from the summary whether

there has been any specific consideration of training exercises in respect of lone-actor

and marauding terrorist attacks, each of which is clearly a recurring problem. It is

important that those responsible for training consider what exercises can most

usefully be provided to officers working at the Parliamentary Estate in order to deal

with this threat.

Tactical Firearms Reviews

27. Operational decisions and instructions at the Palace of Westminster are informed by

tactical assessments carried out by a Security Coordinator from the MPS. At

appropriate stages, this work is informed by advisory reports by tactical firearms

advisers. For example, in the aftermath of the attack, the assessment recommended

an increase in the number of firearms posts in New Palace Yard and more widely

across the Parliamentary estate. These assessments are essential to the creation and

revision of post instructions. The MPS has explained in submissions that it has

introduced bi-annual “Challenge Panels” at which officers of any rank, both armed

and unarmed, can constructively challenge the details of an individual post note or

the wider security model. As I have already said, the security arrangements at the

Palace at the time of the attack were found wanting. I have some suggestions to make

in respect of tactical firearms advisers’ work which might improve the situation.

28. 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. In my view, the introduction of “Challenge Panels” is a valuable

means both to keep officers informed of amendments and to give front-line officers

some influence over security plans; after all, it is those officers who have first-hand

experience of putting the instructions into practice. As matters stand, however, it

appears that after the assessor has looked in detail at firearms posts and officers’

responsibilities and has given advice on the subject, that assessor has no contact with

the officers carrying out the instructions. The MPS could usefully consider taking

the principle of Challenge Panels a step further, by providing a forum for a firearms

assessor to explain his/her advice and any changes in instructions to the front-line

firearms officers. This may help officers to understand the rationale for changes and

may enable them to point out any respects in which advice or changes may need to

be reconsidered.

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

Reviews. The Inquests heard evidence that the national threat level was raised to

Severe in January 2015, but that no tactical review was carried out between

November 2014 and June 2015. I have suggested above that the MPS considers

instituting audits of Post Instructions and/or of supervision at the Palace. It would

also be sensible to consider whether any periodic audits can address relevant tactical

advice which underpins instructions, to help ensure that it remains up-to-date and fit

for purpose (taking account of any changes in threats and risks).

Other matters

30.

In their submissions, the sisters and parents of PC Palmer suggest that I should

include in this Report a concern about whistleblowing procedures within the MPS.

In response to that argument, the MPS has explained in submissions that there is a

well-developed whistleblowing policy within the organisation. In my view, it is not

appropriate for me to raise any issue of whistleblowing procedures in this Report.

First, the evidence at the Inquests did not identify particular flaws in the existing

procedures. Secondly, I cannot see that the evidence at the Inquests shows that there

is a risk of future deaths by virtue of alleged deficiencies in MPS whistleblowing

procedures. I should stress that I am not making any comment as to whether or not

the MPS’s procedures are satisfactory.

The Parliamentary Authorities

Automation of Carriage Gates

31. At the time of the attack, Carriage Gates at the main entrance from Parliament Square

into New Palace Yard were manually operated and old-fashioned metal gates. Police

officers who were familiar with the gates generally described them as cumbersome

to open and close. During the attack, the gates were open throughout the events. It

was, at the time, the practice that the gates would remain open throughout

Parliamentary sitting hours, with small external crowd control barriers being opened

and closed to allow vehicles to enter and exit. During divisions, those barriers too

would be left open.

32. The Carriage Gates were open until after the time that Masood had been shot. It was

clear in video footage of the events in New Palace Yard that, during the police

activity around Masood, a person on a motorcycle entered through the gates

unchallenged, before the rider saw the scene and immediately left.

33. The old gates have since been replaced with a modernised set which are easier to

open and close, but which are not motorised or automatic. I am aware that there is

an on-going project which will involve extensive structural change in the New Palace

Yard area, including at its main public entrance. It is also apparent to me that those

responsible for the project will have to take account of a range of considerations in

the design and construction of the entrance(s). However, the evidence in the Inquests

showed that this is an important entrance to the Palace and that its security should be

a priority for those responsible for the project. I am concerned that this consideration

should not be forgotten in the extensive work being done.

34. MC12: I suggest that the automation of Carriage Gates and their general ease

of use be specifically and expressly considered as part of the ongoing renewal

project. During the attack, the physical features of the gates made it harder for police

officers to keep New Palace Yard and the Palace secure. While I appreciate that it

may ultimately be impossible or inappropriate to have automated gates at this

entrance, and that the design of the entrance will have to take account of many

considerations, I am concerned that those responsible for the project should have this

particular point at the forefront of their minds.

35. MC13: I suggest 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. A review was undertaken by Sir John Murphy

into perimeter security in the wake of the attack, prudently commissioned by the

Parliamentary Authorities. The advantages of an external reviewer conducting such

an assessment are clear to the Authorities and to me. I consider that a person of

similar experience and independence should be involved in reviewing and

commenting on any plans for the re-design of New Palace Yard and its entrance(s)

before irreversible design and construction decisions are taken.

The London Ambulance Service

36.

In my view, it is not appropriate to record any matter of concern in respect of the

London Ambulance Service.

37. The representatives of some of the bereaved families suggest that it is a matter of

concern that any first responder has the power to make a Major Incident declaration.

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)

(b)

all Interested Persons in the Inquests (identified in the attached list);

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.

DETERMINATION SHEET

This is to set out the conclusions of the Jury as to by what means and in what circumstances Khalid
Masood came by his death.

Short-form Conclusion:

Lawful Killing

On March 22nd 2017, having driven at speed over Westminster Bridge, killing four people and injuring

many others (29 seriously), Khalid Masood crashed into the wall of New Palace Yard. He got out of the

car and proceeded to run around the corner to Carriage Gates. Entering New Palace Yard, Khalid

Masood attacked PC Keith Palmer, stabbing and fatally wounding him, he pursued unarmed officers

through the vehicle exit channel, with knives in his hands. Multiple witnesses noted Khalid Masood’s

intention to inflict serious harm and/or take life as he continued his attack. He continued to move towards

Westminster Hall without stopping or changing direction.

Reacting to the initial crash and commotion, two close protection officers (CPOs) walked towards the

vehicle exit channel from the direction of Members’ Entrance. At this point, the unarmed officers ran

towards the CPOs, pursued by Khalid Masood. In accordance with their training, the CPOs shouted

verbal warnings at Khalid Masood, by which time both CPOs had their pistols drawn and aimed at Khalid

Masood- whilst attempting to create distance between themselves and him. The warnings had no effect

on Khalid Masood and he continued to move towards the CPOs at speed with knives still in hand. With

Khalid Masood approaching striking distance of the CPOs, SA74 shot Khalid Masood three times until

he no longer posed a threat. Khalid Masood received immediate first aid and CPR which continued until

he was declared dead at St Mary’s Hospital.

17322125.1

INQUESTS ARISING FROM THE DEATHS IN THE WESTMINSTER TERROR ATTACKS OF 22
MARCH 2017

LIST OF INTERESTED PERSONS

- Family of Aysha Frade

- Family of Leslie Rhodes

- Family of Andreea Cristea

- Family of Kurt Cochran

- Family of PC Keith Palmer

- Family of Khalid Masood

- Commissioner of Police of the Metropolis

London Ambulance Service

- Secretary of State for the Home Department

Independent Office for Police Conduct

London Fire Commissioner

- Transport for London

- Barts Health NHS Trust

- Speaker’s Counsel (the Parliamentary Authorities)

17706664.1

Responses

7 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Bvrla (PDF)

The Coroner
11th Floor,
Thomas More Building
Royal Courts of Justice
London
WC2A 2LL

25 February 2019

Direct line:

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:

Lawfully share data and information with law enforcement
Train staff to identify and report suspicious behaviour

1.
2.
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.

Yours faithfully,

Gerry Keaney
Chief Executive

Response from Home Office (PDF)

Sian Jones 
Partner, BDP Pitmans 
50 Broadway 
London SW1H 0BL 

Dear Sian 

Home Secretary 

2 Marsham Street 
London SW1P 4DF 
www.gov.uk/home-office 

26 February 2019 

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. 

Yours faithfully 

Rt Hon Sajid Javid MP 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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 

The Government accepts this recommendation.  

As  we  have  seen  in  recent  terrorist  atrocities  and  thwarted  plots  in  the  UK  and 
Europe, any public location is potentially vulnerable to attack.   

The  step  change  in  terrorist  activity  is  matched  only  by  an  increased  effort  from 
Government  (including  the  police  and  the  Security  Service)  to  stop  attacks,  bring 
offenders  to  justice,  protect  the  public,  mitigate  against  attacks  and  stop  people 
being drawn into terrorism.  

A vital part of this work is considering how we ensure the safety and security  of the 
public  at  crowded  places.  The  Government  continues  to  undertake  a  range  of 
communications with those responsible for crowded places and the public to: 

  Raise awareness of the terrorist threat;  
  Provide advice on public vigilance, the reporting of suspicious behaviour or 
activity, and appropriate action to be taken following a terrorist attack; 

  Provide advice as to what constitutes appropriate and proportionate protective 

 

security measures; and  
Inform how planning and preparation for terrorist attacks can take place, for 
example through staff training and awareness raising, and the testing and 
exercising of emergency procedures.    

Our provision of advice, guidance and communications activities is multi-faceted and 
significant  in  its  scope  and  reach.  It  is  reviewed  and  revised  on  a  regular  basis,  in 
particular where there are changes to the nature of terrorist threats. It encompasses 
a range of efforts across Government, the police and Security Service including: 

  Advice provided by police Counter Terrorism Security Advisers (present in 
every police region) and Security Co-ordinators to locations considered 
vulnerable to or attractive to attack. 

  A range of online advice and guidance documents produced by Counter 

Terrorism Policing and the Centre for the Protection of National Infrastructure, 
which are regularly reviewed and refreshed. For example, following the 2017 
attacks, crowded places guidance  from the National Counter Terrorism 
Security Office, was revised and reissued on 8 June 2017. This advice is 
designed to help those charged with security at crowded places to mitigate 
the threat and help make the UK less vulnerable to an attack.  

  Advice provided to local authorities, planners, developers and architects 

through the National Planning Policy Framework and associated Guidance by 
the Ministry of Housing, Communities and Local Government. This is 
designed to ensure the security and resilience of new builds and 
refurbishments. On 12 July 2017, the Chief Planning Officer wrote to all local 
planning authorities to reiterate the role the planning system plays in ensuring 
appropriate measures are in place to help prevent terrorist threats.  

 
 
 
 
 
 
   A range of stakeholder engagement, based around leading sectors (e.g. 
sports grounds, shopping centres, entertainment centres), member 
associations and organisations who own or are responsible for crowded 
places.  

  A range of bespoke Action Counters Terrorism awareness raising events 

undertaken by police Counter Terrorism Security Advisers and Awareness 
Advisers in person with security managers and front of house staff. These 
events to those who manage or work at crowded places, provide them with 
advice on the terrorist threat, help them identify and report suspicious activity, 
and to prepare for the possibility of terrorist attack. Between April – 
September 2018 there were 3,674 such events delivered to 103,210 staff.       

  A counter-terrorism learning product, entitled ‘Action Counters Terrorism 

Awareness e-Learning‘, was launched in April 2018 to increase the scope of 
awareness raising efforts. As at December 2018 563,554 modules have been 
completed by staff from across crowded places organisations.    

A  large  part  of  awareness  raising  efforts  are  provided  through  Action  Counters 
Terrorism  (ACT),  a  major  communications  campaign  led  by  Counter  Terrorism 
includes  messaging  via  regular  high-profile  campaigns,  web 
Policing  which 
platforms,  and  social  media.  Some  indications  of  its  reach  and  outcomes  achieved 
are provided below:    

 

 

In 2017 during its launch week the campaign achieved a 67% increase in calls 
to the anti-terrorist hotline. An LBC special counter-terrorism report week 
reached 1.5 million people, over 29,600 people listened to the campaign 
podcast, and the campaign information films achieved over 1.8 million views. 
In 2018, the Communities Defeat Terrorism ACT campaign achieved 3.8m 
views of the new counter-terrorism awareness film, reached over 11.26 million 
people through police social media channels alone, and over 57,000 people 
visited www.gov.uk/ACT . Within the first week of the campaign, the average 
number of online public reports doubled, and awareness of reporting online 
increased from 14% to 24% throughout the campaign. 

  The ACT campaigns focused on crowded places are regularly run. In summer 

2017, the Run Hide Tell, Stay Safe Abroad campaign reached 9 million 
people with public safety advice. In summer 2018, the crowded places safety 
advice during the football world cup used credible voices such as Alan 
Shearer, David Seaman and Paul Parker to reach 350,000 people on Twitter 
during the first launch weekend, and 1.98 million impressions across Counter 
Terrorism Policing social media channels. 

These  awareness  and  communication  efforts  are  focussed  on  a  range  of  terrorist 
threats, however there is also advice developed on specific threat types, such as the 
malicious use of vehicles and what can be done to mitigate these.  

The  Centre  for  the  Protection  of  National  Infrastructure  (CPNI)  guidance  document 
“Integrated  Design  for  Hostile  Vehicle  Mitigation  in  the  Public  Realm”  provides 
information  and  stimulus  to  those  responsible  for  integrating  protective  security 
measures.  In  addition,  the  Department  for  Transport  and  CPNI  have  issued  three 
transport advisory leaflets (revised in September 2017) regarding mitigating vehicle 
threats  for  those  responsible  for  public  spaces.  Following  the  2017  attacks,  in 
September  2017  detailed  higher  classification  guidance  (as  it  contains  detailed 

 
 
 
 information  on  methodologies)  regarding  mitigating  vehicle  attacks,  was  developed 
by  CPNI  and  provided  to  trusted  partners  (e.g.  local  authorities,  owners  and 
operators of crowded places).  

in 
These  and  other  communication  efforts  by  Government  are  undertaken 
partnership  with  a  range  of  organisations  from  across  industry  and  other  sectors. 
These  strong  relationships  help  ensure  that  we  reach  a  broad  audience,  and  that 
messaging is appropriately targeted.    

Through  all  this  work,  Government  is  mindful  of  the  audiences  to  whom  advice, 
guidance  and  communications  are  provided  or  targeted,  the  effectiveness  of 
messaging (in particular that it leads to meaningful learning or activity), and how and 
where  we  can  most  efficiently  focus  our  efforts.  This  is  ongoing  work  and  we 
continue to actively consider the effectiveness of our strategic approach and within it 
communications activities.  

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. 

Security Service Response 

recorded  and  accepts 

Interest  was  not  always 

The Security Service acknowledges that the reason for closing a person as a Subject 
of 
the  Chief  Coroner’s 
recommendation.  In the period between closure of Masood as a Subject of Interest 
in  December  2010  and  the  Westminster  attack,  MI5  made  improvements  to  the 
Subject  of  Interest  closure  process.  and  its  ability  to  identify  and  manage  any 
ongoing risk posed by Closed Subjects of Interest.  In the Operational Improvement 
Review conducted after the 2017 attacks, the Security Service carefully considered 
its processes for record-keeping and management of Closed Subjects of Interest and 
identified further improvements that could be made. 

This  led  to  a  number  of  initiatives  that  encompass  record-keeping,  information 
management  and  management  of  Closed  Subjects  of  Interest.    Those  initiatives 
actively  seek  to  embed  further  good  practice  and  technology  in  those  areas.    In 
particular, in 2018 the Security Service implemented improvements to the Subject of 
Interest closure process.  The current closure process ensures that a record is made 
of the details why the individual should be closed. 

Commitment to continuing improvement and oversight 
As  the  Director  General  said  in  his  evidence  to  the  Intelligence  and  Security 
Committee  last  year, the  Security  Service  will  continue  to  strive  for  improvement  in 
its  information  management.    Implementation  of  the  initiatives  flowing  from  the 
Operational  Improvement  Review,  including  the  improvements  to  the  Subject  of 
Interest  closure  process,  is  being  independently  assessed  by  Lord  Anderson  QC.  
Lord Anderson QC will report publicly in due course of the work that is being done. 

 
 
 
 
 
 
 
 
 
 
 MC-18: I recommend that the Department of Transport and the British Vehicle 
Rental Leasing Association consider introducing a Code of Practice (or at 
lease guidance) on checks to be carried out and/or enquiries made before 
vehicles are rented. 

The Government accepts this recommendation.  

On 6th December 2018 the Department for Transport (DfT) launched the Rental 
Vehicle Security Scheme (RVSS). Vehicle Hire Companies joining this voluntary 
scheme agree to follow a 10 Point Code of Practice, including: 

  Ensuring licence verification checks are undertaken when handing vehicles 

over to customers;  

  Sharing data and information appropriately with law enforcement agencies 
  Appointing a Recognised Security Contact; 
  Training staff to identify and report suspicious behaviours; 
  Only accepting electronic payment for all or part of the rental transaction. 

The RVSS was developed with and is supported by government partners, including 
law enforcement, and industry stakeholders, including the British Vehicle Rental 
Leasing Association and United Rental System. The scheme is designed to support 
the development of a security culture in the vehicle hire industry and to support 
deterrence and potential detection of those seeking to use rental vehicles in attacks.  
Details of the scheme are available on the gov.uk website: 
https://www.gov.uk/government/publications/apply-to-the-rental-vehicle-security-
scheme 

Companies join the scheme by submitting a completed application form and 
declaration that they will produce a security plan outlining how they will meet the 
requirements of the Code of Practice. Plans may be subject to assurance checks by 
DfT. There has been an encouraging level of take-up of the scheme since its launch, 
including by market leaders. 

In January an industry led Advisory Panel was launched to oversee the development 
of the scheme. DfT will review the impact and take-up of the RVSS within 12 – 18 
months of its launch, including the case for putting some or all of the points in the 
code on a mandatory footing.

Response from London Ambulance Service (PDF)

Ms Sian Jones
Solicitor to the Inquests 
BDB Pitmans LLP 
50 Broadway 
London 
SW1H 0BL 

By Email
Email Address:

Dear Madam 

26th February 2019 

Your ref:  
Our ref:  PJH/115779/22751265

Your contact:  
Philip Hatherall 
T
F
E

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. 

Yours faithfully 

Capsticks Solicitors LLP

Response from Maritime Coastguard Agency (PDF)

Bay 3/13

Spring Place
ote 105 Commercial Road
A Southampton
p S015 1EG
Maritime &

Coastguard co

Agency

Partner, BDB Pitmans LLP Your ref: SMJ/166829.0001
50 Broadway Our ref: CE 30/2018
London

SW1H OBL 25 February 2019

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 a complex
matter and we have considered whether any potential guidance would be for
professional crews or for members of the 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 a very 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 harm/injury to the crew. Appropriate training is also required to
ensure the casualty is treated in the most effective way to ensure the best possible

os INVESTORS
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HM Coastguard -

chances of survival. The training methods for RNLI lifeboat crew for both unconscious
and conscious casualties are the same and they 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.uk?. 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’.

Yours sincerely

OH 3H_=

Brian Johnson
Chief Executive

‘ https://www.aina.org.uk/wp-content/uploads/2018/04/SPBC-1.pdf

2 https:/Awww.gov.uk/government/publications/inland-waters-small-passenger-boat-code

> https://www.rya.org.uk/courses-training/courses/inland-waterways/Pages/hub.aspx

4 https://canalrivertrust.org.uk/enjoy-the-waterways/safety-on-our-waterways/water-safety-tips-for-boaters

“INVESTORS
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Response from Metropolitan Police (PDF)

METROPOLITAN

POLICE

Deputy Assistant Commissioner
Specialist Operations HQ

New Scotland Yard
1 - 8 Richmond Terrace
Victoria Embankment
London
SW1A 2JL
Telephone:
Email:

Reference: 24/DACSO/2019/RW

18th February 2019

By email

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.

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.

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.

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.

Yours sincerely,

Lucy D’Orsi - Deputy Assistant Commissioner

Response from Parliamentary Authorities (PDF)

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

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

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.

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.

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

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.

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

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.

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

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

Response from Transport for London (PDF)

26 February 2019 

BDB Pitmans 
50 Broadway  
London  
SW1H 0BL  

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.   

Yours sincerely, 

 
 
 
 
 
 
 
 
 
 Director 
Compliance, Policing and On-Street Services  

Email:

The report

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Track HH Judge Mark Lucraft QC