London Bridge & Borough Market Terror Attack

Chief Coroner 

Royal Courts of Justice  
London  
WC2A 2LL

Dear Sir

17 December 2019 

 Direct dial: 

Re: Inquests arising from the deaths in the London Bridge and Borough Market terror attack

The BVRLA recognises it has an important role to play in ensuring its members take all necessary 
steps to prevent future deaths occurring from terrorism where rental vehicles are used as a weapon. 
We are saddened by the events that took place at London Bridge and Borough Market in 2017 and 
offer our condolences to the families who lost loved ones.  

The BVRLA and its members have been working with the Department for Transport (DfT) and the law 
enforcement counter terrorism community to review what processes are in place to prevent vehicles 
being used as weapons in terrorist attacks and ensure the industry does all it can to protect itself 
and the wider community.  

Significant steps have been taken by the BVRLA to ensure its members adopt a robust security 
culture across their business that will protect the general public as well as their employees, premises 
and their assets. We have done this through training, guidance and engagement opportunities. 
These initiatives have been made available free of charge to anyone involved within our industry.  

We welcome the suggestion in the Prevention of Future Deaths report that consideration is given to 
taking further measures to reduce the risk of rental vehicles being used in terrorist attacks. The 
report notes that measures to be considered should include (a) introducing a scheme for real-time 
reporting of rentals and automated checking of the results against lists of SOIs and (b) making the 
current RVSS scheme mandatory. 

Real-time reporting of rentals 
BVRLA members already carry out robust checks to safeguard their businesses using RISC, the 
BVRLA’s digital risk management tool for rental and leasing companies, and other proprietary 
systems. The vehicle rental industry is prepared to share data and information that can be utilised by 
the authorities to prevent crime. Careful consideration needs to be given to the type of system 
which can communicate with the security services in ‘real time’ and what information could be 
usefully shared. 

The scaling and costing of such a system needs to be considered and it should not place a 
disproportionate burden on the rental sector. We will continue to work closely with counter 
terrorism police, the Home Office and the DfT to look at ways in which information can be shared 
which will not overwhelm the security services. With around 16.2 million car and van UK rental 
transactions per annum the security services would need to set out how any information should best 

BVRLA Ltd 
River Lodge, Badminton Court, Amersham, Bucks HP7 0DD 
tel: 01494 434747  fax: 01494 434499  e-mail: info@bvrla.co.uk  web: www.bvrla.co.uk 

Chairman: Nina Bell         Chief Executive: Gerry Keaney 
A company limited by guarantee         Registered Office as above         Registered in England No. 924401 

 
 
 
 be received and agree on how this could be processed in a timely manner to reduce the risk of a 
future attack.  

A mandatory RVSS  
The BVRLA is delighted to report that we have recently been recognised as an approved authorised 
partner by the Department for Transport. This means that the BVRLA can now effectively make this a 
mandatory requirement for our members through the BVRLA’s Code of Conduct, which is a 
condition of membership. Principle 9 requests that members ensure that staff are trained to recognise 
and report suspicious behaviour, support counter terrorist campaigns and to adhere to the Department 
for Transport’s Rental Vehicle Security Scheme.

The BVRLA monitors adherence with our Code of Conduct via our compliance programme. From 1st
January 2020 we have included additional criteria within our member audits which specifically 
monitor awareness, training and compliance against the key principles set out in the scheme.  

We are delighted to have been recognised as a trusted partner and will be working hard with 
members to ensure they have all the training and support necessary to comply with the RVSS and to 
ensure the benefits of the scheme are fully recognised.  

Yours faithfully,  

Gerry Keaney 
Chief Executive  

Bona-fides  BVRLA, the industry and its members 

•

•

•

Established in 1967, the British Vehicle Rental & Leasing Association (BVRLA) is the UK trade 
body for companies engaged in vehicle rental and leasing.  
BVRLA membership provides customers with the reassurance that the company they are 
dealing with adheres to the highest standards of professionalism and fairness. 
The association achieves this by maintaining industry standards and regulatory compliance 
via its mandatory codes of conduct, inspection programme and conciliation service. To 
support this work, the BVRLA shares information and promotes best practice through its 
extensive range of training and events.   

• On behalf of its 1000 members, the BVRLA works with governments, public sector agencies, 
industry associations and key business influencers across a wide range of road transport, 
environmental, taxation, technology and finance-related issues. 
BVRLA members are responsible for a combined fleet of over five million cars, vans and 
trucks, supporting around 465,000 jobs and contributing £49bn to the economy each year.

•

BVRLA Ltd 
River Lodge, Badminton Court, Amersham, Bucks HP7 0DD 
tel: 01494 434747  fax: 01494 434499  e-mail: info@bvrla.co.uk  web: www.bvrla.co.uk 

Chairman: Nina Bell         Chief Executive: Gerry Keaney 
A company limited by guarantee         Registered Office as above         Registered in England No. 924401

CITY OF LONDON POLICE: OFFICIAL - RECIPIENT ONLY - RECIPIENT ONLY 

INQUESTS ARISING FROM 

THE DEATHS IN THE LONDON BRIDGE TERROR ATTACK 

ON 3rd JUNE 2017 

___________________________________________________________________________ 

CITY OF LONDON POLICE 

RESPONSE TO PFD REPORT 

___________________________________________________________________________ 

INTRODUCTION 

1 

This  is  the  response  of  City  of  London  Police  (CoLP)  to  the  matters  of  concern  (MCs) 

addressed to CoLP in the Coroner’s Prevention of Future Deaths report dated 1st November 

2019. In this response CoLP only addresses those MCs directed at CoLP. 

2 

MC13 – Addressed to the LAS, MPS and CoLP: The evidence in these Inquests gave rise to 

concerns that procedures for emergency response to marauding terrorist attacks were inflexible. 

In particular, the evidence suggested that large areas could be designated hot and warm zones 

for long periods and formally placed out of bounds to most ambulance and paramedic staff. 

This feature of the procedures gave rise to a risk of delay in getting medical help to casualties. 

While  this  lack  of  flexibility  has  apparently  been  addressed  in  the  revised  Joint  Operating 

Principles, I suggest that procedures generally be reviewed to ensure that they accord with the 

requirements  of  speed  and  flexibility  of  response  which  appear  to  be  recognised  in  that 

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document. I also suggest that training exercises be devised which address demanding situations 

with features such as (a) hot and warm zones of uncertain extent; (b) a need for re-assessment 

of hot and warm zones; and (c) a need to locate and assist casualties in dangerous areas. 

Response to MC13 

2.1 

Joint Operating Principles (JOPs) are regularly reviewed and updated. Following the attacks in 

2017 and before the hearings commenced in 2019 significant amendments were made to the 

MTA JOPs to reflect the changing nature in the threats presented.  As the Coroner records, the 

current  MTA  JOPs  recognises  the  requirements  of  speed  and  flexibility  of  response.  The 

Operation Plato guidance has also been amended to reflect the change in approach. CoLP can 

confirm that the new JOPs and guidance are adopted and embedded in the CoLP force area. 

2.2 

The issue is how the JOPs and Plato guidance translate into action on the part of responders. 

CoLP  regards  the  key  to  this  as  being  familiarisation  with  the  new  principles  through 

comprehensive training and exercising in the form of both table top and live exercises.  

2.3 

The City of London police participate in a number of test exercises that assess the operational 

and strategic command and response, including Marauding Terrorist Attack (MTA) specific 

exercises which include Hot/Warm/Cold zone working.  In 2019, CoLP participated in 3 such 

MTA  exercises.    In  2020,  CoLP  officers  are  currently  scheduled  to  attend  4  such  MTA 

exercises, three of which are live play exercises and one which is a table top exercise, with 

further exercises likely to be added to the Training and Exercise calendar.  

2.4 

 CoLP can confirm these exercises will include the issues identified by the Coroner at MC13 

(a)-(c) 

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2.5 

Authorised Firearms Officer training 

In  addition  to  the  above  MTA  exercises  there  is  specific  MTA  training  and  exercising  for 

Authorised Firearms Officers.  All CoLP AFO’s have received the latest JOPs updates.  JOP 

updates  were  refreshed  on  a  recent  phase  of  British  Transport  Police  Command  refresher 

training during September and October 2019.  Many of CoLP’s Tactical Firearm Commanders 

(TFC’s)  participated  in  this  Command  refresher  training  which  included  specific  actions  in 

relation  to  the  new  zonal  guidance.  For  example,  TFCs  were  encouraged  to  utilise  London 

Ambulance Service (LAS) responders directly behind the lead firearms teams attempting to 

confront the subjects in order to safely assess, triage and evacuate victims. This was performed 

with armed protection and jointly involved LAS teams working in warms & hot zones. The 

emphasis  here was on not  designating vast  areas as  hot  zones if precise information  on the 

whereabouts of the subjects are known, for instance, subjects are located on a specific level of 

a building.  

Additionally,  in  November  and  December  2019  CoLP  ARV  teams  participated  in  the  joint 

MTA phase training run by the MPS. 

3. 

MC15 – Addressed to the MPS and CoLP: I suggest that the emergency services give serious 

consideration  to  enhancing  first  aid  capabilities  and  equipment  of  either  police  officers 

generally  or  groups  of  officers  (e.g.  firearms  officers  or  officers  designated  for  advanced 

medical aid training). This should include consideration of training some officers in advanced 

life-saving procedures analogous to battlefield medicine. It should also include considering (a) 

wider provision of equipment such as tourniquets and “stop the bleed” kits and (b) the inclusion 

of more spare equipment in officers’ vehicles.  

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Response to MC15 

3.1 

The size and agility of CoLP, as a relatively small force, and its relationship with the local 

community in the square mile means that it has already taken significant steps to enhance the 

first aid capability of its officers well beyond the national standards, details of that enhanced 

training programme are set out below. However, it should be recognised that the ambulance 

service is the lead agency in casualty management and the overarching aim is to secure their 

attendance upon casualties as soon as practicable. The first aid capabilities of police officers 

are intended to be only a temporary measure, although, as stated, First Aid capabilities have 

been enhanced.  

3.2 

First  Aid  Training:    All  CoLP  Officers  and  front-line  Police  Staff  (PCSO’s,  Detention 

Officers) are first aid trained.  CoLP Officers up to the rank of Chief Inspector are trained to 

the College of Policing standard ‘Emergency First Aider at Work’ (EFAW) module 2 (there 

are  5  in  total  –  Module  1  Basic  Life  Support,  Module  3  Custody,  Module  4  Initial  and 

Requalification, Module 5 – enhanced skills).  The Emergency First Aider at Work is defined 

by the Health and Safety Executive.  EFAW module 2 covers the following: 

1. Manage a first aid scene 

2. Assess a casualty 

3. Perform basic life support (including adult, child and infant) 

4. Demonstrate safe use of an Automated External Defibrillation (AED) 

5. Manage a choking casualty (including child or infant) 

6. Place a casualty in the recovery position 

7. Report casualty information 

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8. Manage a casualty with shock 

9. Manage a casualty with chest pain 

10. Manage a casualty who has fainted 

11. Manage a casualty who is bleeding 

12. Manage a casualty with spinal injury 

13. Manage a casualty who is convulsing 

14. Manage the control of infection 

With effect from 3rd June 2019 CoLP has changed its First Aid training provider to a company 

called Lazarus, whose trainers are ex-Military or ex-Emergency Services in order to reflect the 

most  realistic  injury  scenarios.  All  officers  complete  an  initial  2  day  course,  called  Initial 

Operational First Aid and thereafter attend an annual refresher course. All officers with an AFO 

role  in  CoLP  receive  enhanced  First  Aid  training,  with  emphasis  on  treatment  of  ballistic 

injuries. Following the London Bridge incident, further response officers received the same 

enhanced First Aid Training, the same as CoLP AFOs. CoLP now plans to train all frontline 

officers to an enhanced level. This training commenced in Q3 2019 and will continue into 2020.  

As part of this training, officers receive further training in the use of tourniquets which will be 

issued to each officer upon completion of training. It is anticipated that the training programme 

will be complete by Q2 2020.  In addition, CoLP is rolling out a four day Pre-Hospital Trauma 

Care (PHTC) training course to a further 36 front line officers drawn from Uniform Response, 

Project Servator Teams, Support Group and Roads Policing. Once trained, these officers will 

be issued an enhanced medical kit that includes tough cut scissors, a tourniquet, compression 

dressing,  chest  seals  and  Celox,  a  blood  clotting  agent  for  all  types  of  bleeding  including 

moderate and severe bleeding.   

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3.3 

First  aid  kits:    All  CoLP  response  vehicles,  including  ARVs,  contain  an  emergency 

first aid kit, along with a defibrillator.  (CoLP first aid kits and a defibrillator were used by 

officers  responding  to  casualties  at  London  Bridge  in  June  2017).  Following  the  London 

bombings on 7th July 2005, a number of Emergency Dressing Packs were supplied by the NHS 

to mainline railway stations for responders to use following a Major Incident.  There are 17 

Emergency  Dressing  Packs  at  10  stations  across  the  City  of  London  force  area.  CoLP  has 

initiated the Emergency Trauma Pack (ETP) scheme. ETPs have been reviewed by the London 

Ambulance Service and contain specialist medical equipment.  ETPs are not conventional first 

aid kits.  The aim of this scheme is to work alongside businesses to enhance the accessibility 

and availability of industry leading lifesaving medical equipment.  ETPs are embedded into 

businesses that sign up to the scheme and their details are centrally stored by CoLP control 

room staff who would coordinate the response to a mass casualty incident. The location of the 

nearest specialist first aid kits can be ascertained from the CoLP control room. 

3.4 

Bleed Control Kits   

Recognising  the  increasing  prevalence  of  serious  injuries  caused  by  firearms  and  bladed 

weapons,  in  November  2019  CoLP  provided  life-saving  ‘Bleed  Control  Kits’  to  late-night 

venues in the City of London.  A total of 300 Bleed Control Kits are being distributed across 

the City in partnership with The Daniel Baird Foundation. The Bleed Control Kits may help to 

save precious time until paramedics arrive at the scene and help prevent catastrophic bleeding. 

Staff at venues who receive these kits will be given training to ensure they feel confident in 

using the equipment. There are also plans to increase the distribution of kits in 2020 and beyond 

with  the ultimate aim of providing all licensed premises in  the City  of London with  such a 

‘Bleed Control Kit’.  

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3.5 

The future 

Notwithstanding the significant strides already made to improve its First Aid response, training 

and  equipment,  CoLP  is  always  looking  to  improve  first  aid  capability  and  is  currently 

considering the viability of still further enhanced first aid training similar to that of battlefield 

medicine. The need for this level of first aid training, the identification of the officers to be 

trained to this level and the consequential funding, equipment and human resources issues are 

all  being  considered.  However,  whilst  Police  have  core  operational  duties  which  include 

protecting life, and acknowledging that it is a primary responsibility under Article 2 ECHR, it 

should be noted that the first aid offered by police officers is only an interim measure and it is 

not the primary role of the police service.  The LAS are necessarily trained and equipped to a 

higher level than the police, the provision of medical treatment being their primary function 

and  would  retain  primacy  in  responding  to  casualties  requiring  medical  assistance  and 

treatment.  

In  addition  to  its  first  aid  provision  outlined  above,  CoLP  will  be  enhancing  its  front  line 

officers through the recruitment of 61 additional police officers, funded through the City of 

London (Corporation).  

4 

MC16 – Addressed to the MPS and CoLP: The evidence in the Inquests raised a concern that 

there will often be communications difficulties in the early stages of a major incident, including 

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difficulties resulting from multiple officers attempting to make urgent radio transmissions at 

the same time. In the ongoing work of reviewing and improving communications technology 

to address these difficulties, consideration should be given to whether it may be possible for 

control room staff to isolate and record messages so that they can be listened to separately. 

Response to MC16 

4.1 

This is a national issue which will require consideration at a national not local level. Delivery 

of a solution does not sit solely with CoLP.  

4.2 

Notwithstanding  the  above,  the  following  observations  may  be  relevant.  The  technology 

currently allows only one officer/user to broadcast on an Airwave channel or talkgroup at any 

given moment in time.  As only one message at a time on any given channel or talkgroup can 

be transmitted over the radio network, it follows that only the message currently "live" and 

audible to the control room and other officers on that channel or talkgroup can be recorded. 

The ability to record and playback that message already exists. The practical issue in the early 

stages of a fast moving incident is firstly the fact that technology limits the ability of more than 

one officer to transmit on one channel and the fact that there is rarely likely to be time for the 

control  room  to  replay  messages  when  it  is  still  receiving  multiple  messages  in  very  quick 

succession in live time.  

Currently  CoLP  and  the  MPS  are  undertaking  a  joint  piece  of  work  to  establish  a  formal 

collaboration agreement, whereby the command of all initial firearms incidents occurring in 

the  geographical  area  of  the  City  of  London  would  fall  under  the  command  of  the  MO19 

Tactical Firearms Command, MPS based at Lambeth SOR.  Additionally COLP will seek to 

second a qualified Tactical Firearms Commander of the rank of Inspector to be part of the Pan-

London joint command response.       

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. 

MC17  –  Addressed  to  the  LAS,  MPS  and  CoLP:  I  suggest  that  consideration  be  given  to 

introducing  /  improving  technical  measures  to  assist  in  identifying  the  exact  locations  of 

emergency  services  personnel  so  that  they  can  be  communicated  reliably  to  other  first 

responders. 

Response to MC17 

5.1 

A  CoLP  Airwave  Refresh  Project  was  initiated  in  summer  2019  to  refresh  all  the  Airwave 

devices within CoLP, including radio handsets, desktops and in-vehicle devices. GPS location 

of officers through the Airwave network was explored within the scope of  this project. The 

new radios that are available have GPS capability.  In order to enable this functionality within 

CoLP,  a  further  uplift  in  the  control  room  IT  is  required  to  introduce  an  interface  that  will 

extract the location data from the Officers radio onto a map within in the control room. This is 

a capital project which has been approved and the award of contract has now been made by the 

Metropolitan  Police  Service,  with  a  very  tight  delivery  timescale  of  8  months.  CoLP  have 

allocated a control room manager (Police Staff) full time to the MPS project team to ensure the 

interests of CoLP are maintained along with the joint working capability. This will include the 

connectivity between the CAD2 system  and the  CoLP Record Management  System (RMS) 

Niche which holds Intelligence, Crime, Case and Custody data. CoLP has a seat at the executive 

Board.  Through  the  allocated  full  time  member  of  staff  the  interests  of  Business  As  Usual 

(BAU) and Secure City Programme (future operating of the City of London) are addressed and 

maintained. This will provide an interim solution until the ICCS and CAD upgrades referred 

to below are completed and prior to the ESN launch.  

Completion  of  the  ESN project,  which  is  owned  by  the  Home  Office,  is  not  expected  until 

2023.  As  part  of  the  process  of  development  CoLP  and  other  forces  have  requested  that 

geolocation be included. It  is  currently anticipated that ESN will use data rather than voice 

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information. It is therefore considered likely to provide quicker and more reliable information 

as  to  the  location  of  the  assets  of  the  emergency  services.  The  National  programme  is  still 

ongoing with no firm dates set for data or voice. CoLP is part of the Pan London group working 

collectively with monthly Pan London ESMCP Group (PLEG) meetings attended by a CoLP 

representative.  This  group  consists  of  Met  and  British  Transport  Police  as  well  as  London 

Ambulance  and  Fire  Service  representatives.  ESMCP  remains  a  project  with  resources 

allocated to it by CoLP. 

 5.2 

The CoLP Control room uses the MPS Integrated Command and Control System (ICCS) and 

Computer Aided Dispatch Systems (CAD).  CoLP is aware that the MPS, as owner of these 

systems, is carrying out system upgrades and CoLP is engaging with the MPS in the ICCS and 

CAD upgrade projects in relation to CoLP requirements. The interim solution in CoLP, pending 

completion of the upgrade, is set out at 5.1 above. 

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Home Office
2 Marsham Street
London SW1P 4DF
www.gov.uk/home-office
Sian Jones

Partner, BDP Pitmans
50 Broadway

London

SW1H OBL

10 January 2020

Dear Sian
London Bridge and Borough Market: Prevention of Future Death (PFD) Report

Thank you for sending to me the Report on Action to Prevent Future Deaths (PFD Report),
following from your inquests into the tragic events at London Bridge and Borough Market
on 3 June 2017. | am grateful to you for drawing your concerns to my attention. Please
accept this response on behalf of HM Government as a whole, including the Security
Service, Secret Intelligence Service, Home Office and Department for Transport.

Comments on each of the specific recommendations are annexed to this letter. Those
matters on which you have not felt that a formal recommendation is appropriate are also
noted, and we will continue to keep the wider issues under review. Importantly, this
Government has committed to consider the scope of existing legislation, and whether new
legislation is required to improve the safety and security of public venues.

Since you issued this report we have also suffered a horrific attack at Fishmongers’ Hall, in
which two innocent people lost their lives. My highest priority as Home Secretary is to keep
people in the UK safe and my department, and indeed the whole operational community,
will continue to review and adapt our approach to countering terrorism to ensure we are
doing all we can to counter the threat from terrorism.

While much of the report and the response covers issues of policy and practice, we must
not lose sight of those that tragically lost their lives that evening. They will remain at the
forefront of our minds forever.

While | understand that our response to the PFD Report brings the formal process of the
Inquest to a close, if there are any further matters of concern then please do not hesitate
to raise these.

Yours sincerely

Home Secretary

Rt Hon Priti Patel MP

Response to MC1_and MC2 (addressed together as they both concern
sites and criteria for bespoke engagement)

MC1 — Addressed to the Secretary of State for the Home Department and
NaCTSO: | suggest that there be a review of the sensitive national criteria
and tests for identifying sites as priority Crowded Places (or for otherwise
designating sites at a national level as justifying proactive advice on
protective security). In that review, one aim should be to ensure that the
criteria are not excessively rigid so as to exclude sites which may be
particularly attractive and vulnerable to terrorists. If and to the extent that
the Secretary of State considers that any other Government agencies
should play a part in addressing this concern, their assistance should be
enlisted.

MC2 — Addressed to the Secretary of State for the Home Department and
NaCTSO: | suggest that consideration be given to putting in place
systems of periodic review / assurance to ensure that the criteria for
identifying priority sites for protective security advice remain fit for
purpose and that the list of such sites remains appropriate.

The Government accepts these recommendations.

Co-ordination of work on crowded places

The Government's approach to crowded places (which includes crowded
spaces)', is overseen and co-ordinated by the Office for Security and Counter
Terrorism (‘OSCT’) in the Home Office. Through this approach advice and
guidance is provided to all parties responsible for crowded places to:

e Raise awareness of the terrorist threat and attack methodologies;

e Provide advice as to appropriate and proportionate protective security
measures;

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

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

‘ Crowded places encompass a number of different crowded public locations: Permanent buildings which are open to
the public; Temporary events (such as festivals or sporting events). Crowded spaces encompass locations such as
city centre squares, the public realm, bridges or busy streets where there is mixed and diverse ownership. in these
locations, it can be difficult to control and co-ordinate security efforts.

1

There are a variety of mechanisms to provide this advice and guidance. These
include:

Engagement with stakeholders for crowded places by Counter Terrorism
Security Advisers (‘CTSAs’) who provide advice to site owners and
operators, local authorities and others;

Targeted awareness-raising sessions and training courses delivered by
CTSAs and Counter Terrorism Awareness Advisers (‘CTAAs’) with
crowded places managers, front of house and other staff;

Engagement with representatives of leading crowded places sectors
(e.g. sports grounds, shopping centres, entertainment centres), member
associations and organisations who own or are responsible for crowded
places;

Advice provided to local authorities, planners, developers and architects
by CTSAs, the Centre for the Protection of National Infrastructure
((CPNI’), and by the Ministry of Housing, Communities and Local
Government through the National Planning Policy Framework and
associated Guidance,? designed to ensure that proportionate security
measures are considered for appropriate new builds and
refurbishments;

Online advice and guidance, regularly reviewed and updated, for
responsible parties from Counter Terrorism Policing and CPNI; and
Targeted communications to crowded places stakeholders from Counter
Terrorism Policing.

Review of crowded places

As the Government witness for the SSHD at the Inquests acknowledged, the
process for prioritising CTSA engagement at sites at the time of the London
Bridge and Borough Market Attacks was based on the terrorist threat picture at
the time, and its criteria had the potential to exclude a number of locations from
being considered for engagement.

It is estimated that there are over 625,000 organisations which operate at least
one crowded place in the UK. All of these are potentially vulnerable and to
attack by terrorists. It would not be appropriate or proportionate to visit each of
these organisations individually to provide advice and guidance. Advice is
available for all stakeholders through the above highlighted mechanisms.

2 https:/www.gov.uk/government/publications/national-planning-policy-framework--2

2

By definition, any prioritisation system will focus more attention on some
locations and organisations than others. It is also important to acknowledge
that, as the Government witness highlighted at the Inquests, engagement by a
CTSA at a site or with a stakeholder does not necessarily provide any certainty
of protection. This is because currently the decision to implement protective
security advice lies with the owner/operator of the site.

Taking all of the above into account, the Government is reviewing the basis on
which engagement with stakeholders is undertaken in future to report to
Ministers in early 2020. The review is a complete re-examination of the
Crowded Places model including whether it would be appropriate and
proportionate for more to be achieved through a legislative approach.

Periodic review

Counter Terrorism Policing have also committed to institute a periodic review /
assurance process to ensure that the locations and stakeholders identified for
CTSA engagement will be regularly reviewed. The Government will provide
oversight and assurance of this process.

Other Government action since the 2017 attacks

Government's efforts to provide advice to the range of individuals and
organisations responsible for crowded places continues to evolve and improve.
Changes since the 2017 attacks have included:

e A programme of sectoral and regional engagement days (branded
Action Counters Terrorism: Corporate) initiated by Counter Terrorism
Policing to provide advice and guidance to a range of parties responsible
for crowded places;

e An e-learning awareness training programme (covering spotting the
signs of suspicious behaviour and what to do if an attack should take
place) has been broadened so that it is freely available to all;?

e New and revised training and awareness products for managers, front
of house and other staff at crowded places, delivered by CTSAs; and

3 https:/Awww.gov.uk/government/news/act-awareness-elearning

e A range of new advice and guidance provided by Counter Terrorism
Policing and CPNI, including for certain sensitive issues to trusted
stakeholders.

Government will continue to consider how and where our engagement
approaches can be improved to ensure we deliver appropriate advice to all
stakeholders using cross-Government levers. We are exploring more tailored
guidance and communications to different target audiences. We are also
considering how the crowded places programme can better evaluate the
effectiveness of our activity (in particular where and how it leads to meaningful
learning or security improvement activity), and based on this, how and where
we can most efficiently focus our future efforts.

Response to MC3 and MC4 (addressed together as they both concern
public authorities: their roles and responsibilities, and_ how they are
provided with expert advice)

MC3 — Addressed to the Secretary of State for the Home Department: |
suggest that consideration be given either (a) to introducing legislation
governing the duties of public authorities (including highway authorities)
regarding protective security or (b) to producing guidance indicating what
existing legal duties require in practice of public authorities regarding
assessment of sites for protective security needs and implementing
protective security measures.

MC4 — Addressed to the Secretary of State for the Home Department and
NaCTSO: | suggest that consideration be given to producing guidance for
CTSAs explaining what existing legal duties require in practice of public
authorities regarding assessment of sites for protective security needs
and implementing protective security measures.

The Government accepts recommendation MC3.
With respect to recommendation MC4, the Government is considering the

scope of existing legislation and whether new legislation is required to improve
the safety and security of public venues.

Existing legislation and current public authority actions

Section 17 of the Crime and Disorder Act 1998 (as amended) requires all public
authorities to exercise their functions with due regard to their likely effect on
4

crime and disorder, and to do all they reasonably can to prevent crime and
disorder. Crime for these purposes includes terrorism. This requirement was
noted by Transport for London in the Inquests as the basis upon which they
undertake considerations of protective security in all their schemes. The
Government is aware of other public authorities which also undertake
considerations of terrorism threats and their mitigation with relevant local
partners through their Community Safety Partnerships (or County Strategy
Partnerships in county councils) or CONTEST Boards. However, it is unlikely
that all public authorities have comprehensive systems and processes in place
to assess the threat from terrorism as it affects their interests, and to consider
reasonable mitigation to these threats through their systems and processes.

The Government's role in this process is to engage and provide advice to all
crowded places’ stakeholders to develop an understanding of attack
methodologies, threat assessment processes, the range of appropriate and
proportionate protective security measures and how to plan and prepare for
terrorist attacks. For those stakeholders with an interest in public spaces, such
as public authorities, these differ vastly in their nature, and each has different
organisational structures, staff skills and capabilities, business processes and
plans, and funding cycles. It is for each responsible party to consider specific
details regarding the requirements for sites, staff awareness and training, their
organisation’s security systems and processes, including how they assess
threats and mitigating measures.

The Government's actions to improve engagement with crowded places
stakeholders who own, operate or have an interest in public spaces

The Government recognises that more can be done to improve the co-
ordination and consistency of our engagement with stakeholders, including
public authorities, who own, operate or have an interest in security at public
spaces. With specific regard to public authorities, since the 2017 attacks efforts
have been increased to improve this position including:

e Establishing regular engagement with Local Authority Chief
Executives and others in key strategic positions, in order to ascertain
how considerations of threat can be undertaken and to share best
practice;

e Developing the Security Considerations Assessment* to provide
robust, evidence-based and documented processes relating to the
identification and, where applicable, development and ongoing
management of security-related vulnerabilities; and

4 https://www.cpni.gov.uk/security-considerations-assessment
5

¢ Writing to all local planning authorities® and revised and updated the
National Planning Policy Framework and Guidance®, both of which
emphasise the role the planning system plays in ensuring that
appropriate security measures are in place to help mitigate terrorist
threats.

The Government will continue to evaluate how and where our engagement,
advice and communications can be improved, to assist public authorities and
other stakeholders to understand threats, and analyse how they can better
assess and effectively mitigate them through their processes. Government is
considering the effectiveness of the existing system by which security outcomes
are realised through the exercise of their functions, and whether it would be
appropriate to revise or develop new legislative requirements.

Guidance to highways authorities

The Department for Transport (DfT), working with the UK Roads Liaison Group
and CPNI, will by the end of 2020 provide additional guidance to all local
highways authorities in the United Kingdom. This will build on guidance already
available to highway authorities as set out in the Well Managed Highway
Infrastructure Code of Practice and other channels. The existing guidance
encourages local highways authorities to adopt a security-minded approach to
their assets, information and people to ensure appropriate and proportionate
security measures are applied to deter and/or disrupt hostile, malicious,
fraudulent and criminal behaviours or activities.

Response to MC5

MC5 — Addressed to the Secretary of State for the Home Department and
NaCTSO: | suggest that consideration be given to taking measures to
make CTSAs, police forces and local authorities aware of protective
security equipment / infrastructure which can be installed in response to
emerging threats (including the criteria and timescales for making
particular forms of asset available). | also suggest that consideration be
given to encouraging highway authorities and other public bodies,
especially in metropolitan areas, to adopt security boards similar to the
PRSAB adopted in London, with a view to ensuring that there is good
understanding of what measures can be taken in the short and longer
term to protect sites and areas assessed to be vulnerable.

Shttps://assets.publishing.service.qov.uk/government/Juploads/system/uploads/attachment_data/file/627395/Chief_Pla
nner letter - security and_planning.pdf
§ https://www.gov.uk/quidance/health-and-wellbeing

Awareness of protective security equipment / infrastructure

The first part of this recommendation will be addressed by CT Policing, who will
give details of the training and continuous professional development provided
to CTSAs and briefings provided to Counter Terrorism Security Co-ordinators
and other relevant police functions on vehicle threats and the means to mitigate
them.

The Government's role is one of strategic oversight. This is predominantly an
operational issue, and whilst we would not be sighted on the detail of measures
which are the responsibility of CT Policing and other partners, we will consider
more broadly, through the review of the crowded places model where working
with stakeholders across Government can improve engagement and advice to
responsible parties, including local authorities.

Consideration of security boards similar to the PRSAB

First, it is important to consider the existing legal landscape.

Section 17 of the Crime and Disorder Act 1998 (as amended) requires all public
authorities in England and Wales to exercise their functions with due regard to
their likely effect on crime and disorder, and to do all they reasonably can to
prevent crime and disorder. Crime, for these purposes, includes terrorism. This
statute also established the Community Safety Partnerships (CSPs) for local
authorities, the police and other partners to work together to tackle identified
safety problems. Legislation in Scotland provides for similar local authority led
planning, taking into account the resilience and safety of communities. In
Northern Ireland, Policing and Community Safety Partnerships were
established under the Justice Act (Northern Ireland) 2011, as local independent
statutory bodies, which focus on policing and community safety issues.

Second, defining the issues to be addressed is the responsibility of each local
authority. The Government is aware of a range of mechanisms through which
protective security issues are addressed, including using CSPs, local
CONTEST boards, and sometimes Local Resilience Forums.

The Government therefore considers that there are a number of local
mechanisms, including statutory bodies, which are able to deliver local
coordination of effort.

That is not to say that if there is a need, particularly in metropolitan authorities,
for an additional specific group to focus on the consideration of threats in the
public realm and their mitigation, that we would not welcome such

7

developments. The Government considers, however, that the appropriate
forum for consideration of protective security issues, ought to be decided by the
relevant local authority based upon the specific requirements of its area.

Itis important that all local protective security forums receive appropriate advice
regarding assessment processes which can be undertaken to consider terrorist
threats, and what constitutes appropriate and proportionate mitigation. Expert
security advice has already been provided to the types of forum mentioned
above by CTSAs and CPNI, for example to advise on physical and personnel
security measures or products which can be used by local authorities. This
provision of engagement and advice continues at a local level. There is also
ongoing engagement by CPNI, for example, with institutions of engineering and
other professionals responsible for the creation, maintenance and improvement
of the public realm, providing advice through their publications and advice, and
speaking at their regional lectures and conferences.

If groups such as the PRSAB were to become more widely established,
Government would consider how it could best continue to provide specialist
expert input to them as required.

Recommendation MC6 to the Secretary of State for the Home Department
and the Director General for the Security Service:

The Chief Coroner has made a recommendation which relates to the
suspension of investigations. The MI5 investigation into Khuram Butt was
suspended twice: from 26 February 2016 to 24 March 2016; and from 21 March
2017 to 5 May 2017. The Chief Coroner concluded in his Article 2 determination
that no criticism of the decisions to suspend the investigation on those two
occasions is justified. The Chief Coroner notes in his Preventing Future Deaths
Report that it is possible however, but for the latter suspension, further useful
intelligence about Butt could have been obtained, including more information
about his links to the other attackers. The Chief Coroner has recognised that
although MI5 must be able to prioritise and divert resources at times of
greatest demand, the suspension of priority investigations is a matter of
legitimate public concern. Accordingly, the Chief Coroner has recommended
that the systems for suspending such investigations (including the
criteria for suspension, recording of suspension decisions and systems
for re-building intelligence after suspensions) should be specifically
considered in the continuing work of review and improvement. That work
should also give consideration to the potential value of flexible systems
for scaling back, rather than necessarily suspending, investigative work
at times of high demand.

Whilst this recommendation and MC7, 9 and 10 are addressed to both the
SSHD and the Security Service, it is the Security Service which leads on these
matters and hence the responses to these recommendations reflect this.
However, and for the avoidance of doubt, the SSHD agrees with and adopts
the response of the Security Service to recommendations 6, 7, 9 and 10.

Security Service Response

Although the suspension decisions in this particular case were sound, as the
Chief Coroner found, the Security Service acknowledges that the suspension
of priority investigations is a matter of legitimate public concern. MI5 has
reviewed and refined its processes and the assessment of risk relating to
suspension to encourage further good practice.

The Security Service has, since 2017, reviewed and revised the guidance
relating to the process of suspension that is provided to its investigators and to
management. That suspension process expressly includes, amongst a number
of other steps, consulting with management, informing CT Police of the
suspension decision, and recording the reason for suspension.

Since 2017, the Security Service has also reviewed and refined the process for
the assessment of the suspension risk posed by an investigation which feeds
into the consideration of its suitability, or otherwise, for suspension.

As Witness L explained in evidence, the suspension of an investigation does
not necessarily mean that intelligence gathering will cease.” Whilst typically
during a suspension monitoring, investigative and analytical activities will be
substantially scaled back, flexibility is built into the suspension process to allow
the investigator the choice to suspend the collection of certain types of
coverage and to keep other intelligence streams active, depending on what is
possible and appropriate on the facts of that particular investigation.

Under the existing model, all counter-terrorism investigations are reviewed
quarterly, including those which are suspended at the end of the quarter. In
addition there are measures in place during a suspension to capture particular
types of intelligence of a high level of concern. An investigation can then be
unsuspended very quickly if reported intelligence reveals a particular threat or
other point of concern.

The Security Service has also, since 2017, revised the way in which the team
with an internal overview of all suspensions tracks the overall suspension

7 Day 24 page 24-35 and witness statement paragraph 124.

picture to effectively manage resource. This allows that team, and senior
management, a view of the spread of suspended investigations including why
they have been suspended, how long for, by which investigative teams and
team capacity, and recognises trends or insights.

It has been considered whether a system of partial suspension, or a scaled
back form of investigation, should be developed as an intermediate option
between suspended and open investigations. In light of the flexibility within the
suspension process and open investigations, the Security Service concludes
that a new category of scaled back investigation is not required at this point and
would not achieve the important aim of properly diverting specialist resource to
those investigations deemed to be of the highest priority at the time in order to
minimise the risk from attack plans judged to be imminent or which are deemed
on the information available to pose the greatest threat to the public.

Suspension has been an effective tool in the Security Service's investigative
risk management process for many years, and is likely to remain a necessary
part of maintaining an agile Counter Terrorism response to a high volume and
dynamic threat environment for the foreseeable future.

Recommendation MC7 to the Secretary of State for the Home Department
and the Director General for the Security Service:

Khuram Butt was the subject of a Potential Lone Actor assessment twice during
the investigation into his activities. In September 2015 he was assessed to have
strong intent but weak capability, and was assessed to be of medium risk. In
May 2017 he was tentatively assessed to have moderate capability and
moderate intent and had an overall assessment of unresolved risk. The PLA
assessments did not result in any downgrading of investigative work. Witness
L acknowledged however that PLA assessments can be imprecise and have
inherent limitations. The Chief Coroner's view is that investigators must be able
to have confidence in the tool if it is to be used effectively. Accordingly, the
Chief Coroner has suggested that MI5, in its continuing work of review and
improvement give consideration to some form of assurance to test the
reliability of the Potential Lone Actor process.

Security Service Response

The Security Service accepts the Chief Coroner's recommendation that the
Potential Lone Actor process should be subject to an assurance exercise to test
its effectiveness and reliability, as Witness L acknowledged in his evidence®.

® Day 25 page 16.
10

The Potential Lone Actor process is part of MI5's wider risk assessment
framework which includes risk assessment methodologies, processes and
capabilities. A review of this wider framework, which includes the Potential Lone
Actor process, is currently underway within MI5. The review is supported by
MI5's Behavioural Science Unit, which is a team of behavioural scientists and
risk management specialists with close links with external academics, the latest
academic research and international partners.

MC8 - Addressed to the Secretary of State for the Home Department: |
suggest that consideration should be given to legislating for further
offences of possessing the most serious material which glorifies or
encourages terrorism.

The Government accepts this recommendation and is currently considering the
necessity for a further offence of possessing the most serious extremist material
which glorifies or encourages terrorism.

The UK has a robust legislative framework on terrorism. The Government is
committed to ensuring that this keeps pace with the threat. The current
legislative framework includes an ideology-neutral definition of terrorism in
addition to a broad range of terrorism-specific powers and offences, including
the offence of collecting information of a kind likely to be useful to a person
committing or preparing an act of terrorism (s.58 Terrorism Act 2000). The
Government and its law enforcement partners recently strengthened the
legislation through the Counter-Terrorism and Border Security Act 2019
(CTBSA), which (i) updated offences for the digital age and modern patterns of
radicalisation, (ii) extended extra-territorial jurisdiction, and (iii) strengthened
sentencing and offender management powers. As to the s.58 offence, the
CTBSA:

¢ amended s.58 so that it is clear that it is an offence to view or otherwise
access information of a kind likely to be useful to a person committing or
preparing an act of terrorism online without a reasonable excuse; and

e increased the maximum sentence available for those convicted under
s.58 (an increase from 10 to 15 years).

Our operational partners must have the tools and powers they require to tackle
terrorism. The Government notes the Chief Coroner’s comments regarding the
evidence at the Inquests, the existence of the offence for a person in
possession of a prohibited image of a child, and the perception that the lack of

11

a comparative counter-terrorism offence may sometimes prevent Counter
Terrorism Policing from taking disruptive action. Consideration is ongoing
between the Home Office and representatives from Counter Terrorism Policing
HQ as to whether there is a gap in the current legislation from an operational
perspective. Government is currently considering their views and deciding next
steps, including further stakeholder engagement in relation to this complex
issue.

The Government will continue to work closely with the police, the Security
Services and other partners to ensure that the tools needed to counter the
evolving terrorist threat are kept under review and up to date, whilst also
ensuring that a proper balance is struck between robust powers and civil
liberties.

Recommendation MC9 to the Secretary of State for the Home Department
or General for the Securit ice:

The Chief Coroner acknowledged the effective cooperation between MI5 and
CTP. He noted, however, that on a number of occasions during his evidence
Witness M accepted that he had been unaware of information in the hands of
MI5, and that the Post Attack Review and ISC recognised that more can be
done in promoting communication and coordination between MI5 and CTP
teams on an investigation. The Chief Coroner notes that further work is being
carried out in this area, including a project leading to co-location of elements of
CTP and MI5, and encourages efforts to develop and improve co-working
arrangements, including sharing as much information as possible which is
relevant to post-attack investigations. As such, the Chief Coroner has identified
a need to improve communications and co-working between MI5 and CTP
officers working on the same investigation. The ongoing work to improve
joint working is to be welcomed. There is in particular a need for the police
senior investigating officer in an intelligence-led investigation to be
briefed regularly and thoroughly by MI5, especially if JOT meetings are
not being held regularly. For the sake of completeness, efforts to improve
communications between MI5 and CTP should extend to communications
between MI5 and post-attack investigation teams.

urit i onse
The Security Service recognises that continuing to develop joint working is an

important priority and that there is scope for further improvement to the
excellent working relationship between MI5 and CT Policing.

12

The Security Service and CT Policing have a strong track record of working and
communicating together to counter the threat from terrorism in the UK, allowing
them to disrupt together 25 terrorist attacks since March 2017. This is thanks in
part to the considerable progress made over the past ten years with, in
particular, the introduction and refinement of the Intelligence Handling Model,
and further developments in how they operate together and how they review
themselves jointly.

Since 2017, detailed consideration has been given during the course of the
Operational Improvement Review (OIR) to the nature and extent of the joint
working arrangements between the Security Service and CT Policing focusing,
as Lord Anderson recognised, on operational issues. That review highlighted
the strength of the relationship, and made a number of specific and technical
recommendations for its improvement. By way of example, the Security Service
(alongside SIS and GCHQ) and CT Policing are committed, through the "CT
Step Up" programme to sharing their knowledge to enable a single, common
understanding of SOls, and of capabilities and objectives. Further, the OIR also
prompted a review of information sharing arrangements, with particular regard
to sharing information relating to SOls.

A world-leading and unprecedented project is underway to significantly
increase the colocation of CTP and Security Service teams. This major multi-
year project seeks to strengthen the working relationship between CTP and the
Security Service and facilitate further collaboration. CT Policing and the
Security Service also continue to work together to build IT structures that
facilitate more collaborative ways of working.

When considering information sharing between them, it must be appreciated
that CT Policing and the Security Service each have distinct roles, expertise
and strengths within Counter Terrorism investigations. As Witness L explained
in his evidence, there must always be as much sharing as possible of
information between MI5 and CTP (which applies equally to post-attack
investigation teams).° There must, however, always be a threshold applied by
an investigator and/or management as to what is deemed to be of significance
to the investigation such that it needs to be shared with the Senior Investigating
Officer (SIO). That threshold will be dependent on the particular facts and
context of the investigation. Because of the amount of information at the hands
of the investigator it will often not be a practical or proper use of the SIO's time
for MI5 to share every piece of information with that officer. To do so would risk
significant duplication in the role of the investigator and the SIO, creating

° Day 25 page 84.
13

substantial inefficiencies in a system where the appropriate use of finite expert
resource is essential.

Recommendation MC10_ to the Secretary of State for the Home
De nt and the Director General for the Securit rvice:

Two communications were made by members of the public to report concerns
about Khuram Butt to the authorities. One was madé anonymously to MIS
before Butt became an SOI, and the other by a call from Usman Darr to CT
Policing's Anti-Terror Hotline in September 2015. Neither made their way to the
MI5 or CTP investigative teams (when formed) looking into Butt's activities. The
Chief Coroner recognised that there was no opportunity for MI5 to follow up the
communication made to them, since the report was made anonymously and
included an express desire not to be contacted in future. Further, the Chief
Coroner acknowledged that it is debatable how much more intelligence could
have been obtained from Usman Darr even if he had been willing to co-operate
at a later stage. Nevertheless, the Chief Coroner has recommended, because
of the concern that public reporting was not directed to the relevant CT Policing
and MI5 investigative teams, that in the continuing work to improve
information management, efforts should be made to avoid recurrence of
this problem.

ri rvice Response

As Witness L explained in evidence”®, the report relating to Khuram Butt from
an anonymous member of the public was received before mid-2015, before the
investigation into Butt's activities was opened, and before he was a Subject of
Interest. The report was to the effect that Butt was an extremist, and was made
by an individual who was clear that they did not wish to be contacted further.
The content of the report did not reach the threshold requiring it to be made a
Lead, and thus requiring investigation by MI5 and CTP."* Further, there was no
MI5 or CTP investigation into Butt's activities in existence at the time to which
the report should or could have been directed, nor would it have added new
information to what was known of Butt when the investigation was opened.

MI5 defers to CT Policing in relation to reporting received by the police run Anti-
Terror Hotline, but notes as the Chief Coroner recognises, that it is debatable

10 Day 24, pp.86-87

11 See Witness L witness statement paragraph 27 and footnote.

14

the extent to which more intelligence would have been obtained from Mr Darr
had his reporting been passed on to the relevant CTP and MI5 teams.

Notwithstanding the above, the Security Service would wish to assure the Chief
Coroner that the issue of information management is recognised as being of
the utmost importance to its work and has been extensively and robustly
addressed by MI5 in the form of the Operational Improvement Review (as to
which Lord Anderson noted that there had been detailed recommendations
made relating to improvement of systems, guidance and practices). Many of
those recommendations have been implemented, constituting a significant
development in MI5's information management capability, and work is ongoing
to further continuous improvement in this area.

Recommendation MC11 to the Chief of the Secret Intelligence Service and

Director-General of the Security Servi

Recommendation MC11 - Addressed to the Chief of the Secret Intelligence
Service and the Director- General of the Security Service: | suggest that
consideration be given to improving facilities for translating
communications received from foreign security and intelligence services,
since the evidence in this case reveals a troubling delay in the translation
of such a communication.

SlS/Security Service Response

SIS and the Security Service accept that there is a need for improvement in this
area. A number of improvements have been made in this respect since June
2017. Since the London Bridge attack, the UK Intelligence Community (UKIC)
has enhanced its secure messaging capability with Counter Terrorist Group
partners in relation to counter-terrorism investigations. There is also stronger
cooperation on language capability across UKIC. In addition, SIS has formed a
team of linguists dedicated to supporting counter-terrorism work - working
alongside operational officers - and simplified processes for tasking them. SIS
has updated its guidance, in consultation with MI5, relating to the appropriate
and timely dissemination of information or requests from foreign liaisons,
providing a clear set of handling guidelines concerning responsibilities towards
data and issuing tactical reporting. SIS also continues to upskill overseas
officers with language capability.

MC12 — Addressed to the Secretary of State for the Home Department, the
Secretary of State for Transport and the BVRLA: | suggest that

15

consideration is given to taking further measures to reduce the risk of
rental vehicles being used in terrorist attacks. The measures should
include (a) introducing a scheme for real-time reporting of rentals and
automated checking of the results against lists of SOls and (b) making the
current RVSS scheme mandatory.

Measures being taken to reduce the risk of rental vehicles being used in terrorist
attacks

The RVSS Scheme: Working with BVRLA to increase RVSS membership

The Government agrees consideration should be given to what further
measures could be put in place to reduce the risk of rental vehicles being used
in terrorist attacks.

To this end, the Department for Transport (DfT) continues to work with industry
to increase the take up and impact of the Rental Vehicle Security Scheme
(RVSS). From 1 January the British Rental Vehicle and Leasing Association
(BVRLA) has introduced the RVSS criteria as a requirement within its own
conditions of membership’2. BVRLA will also include compliance with the terms
of RVSS within its audit regime.

In addition, DfT has been working with the United Rental Scheme (a vehicle
rental network that reaches some of the companies that are not BVRLA
members) to promote RVSS with its members at roadshows and through
newsletters and on-line communications. This has led to new members joining
the scheme. DfT will continue to use this approach to increase RVSS
membership.

DfT has also set up an industry-led Advisory Panel, bringing together industry
leaders and cross-government and law enforcement representatives to develop
the requirements in the RVSS code and explore how the code could be adapted
to make it relevant for other parts of the vehicle rental sector such as peer-to-
peer rental and car clubs.

This work is achieving positive results without regulation and we will continue
to push these approaches. We will keep the coverage and impact of RVSS
under review and if steps with industry bodies do not result in the vast majority
of UK based rental companies joining RVSS, we will consider legislating to

32 The DfT entered into an agreement to this effect with the BVRLA on 5 November 2019
16

make mandatory some or all of the elements of the Scheme. A progress review
is planned for summer 2020.

Real time reporting

The recommendation on data and real time reporting of rental vehicles is
addressed, inter alia, to the Home Office and the Dff. However, the Home
Office and DfT work in close collaboration on these issues with the Police and
the Security Service. Hence this response is on behalf of the Home Office, DIT,
Counter Terrorism Policing and the Security Service.

Any scheme for real-time reporting of rentals and checking against SOI
databases would need to be driven by a law enforcement requirement and any
case for intervention would rest upon this. As the witness for the Home Office
noted in evidence during the Inquests‘® there are a myriad of different ways of
obtaining a vehicle (including stealing, borrowing and purchasing as well as
renting). Further, as Witness L explained in evidence at the Inquests™, there
are considerable challenges surrounding the introduction of processes of this
kind. The Government continues to work with law enforcement agencies and
the Security Service to understand how we can support their objectives.
Requirements would first be discussed with the Home Office, which would
coordinate considerations, engaging with other Government Departments as
appropriate.

Other measures

More broadly, DfT is also leading a wider programme of work to develop vehicle
focussed initiatives to mitigate the threat from ‘vehicle as weapon’ attacks. This
includes: commissioning research and working with industry partners to identify
existing technologies that can provide mitigations in ‘vehicle as weapon’
attacks. One project is looking into the feasibility of a range of vehicle
technologies that could be developed to promote earlier crowd dispersal during
a vehicle as a weapon attack. These insights will be shared with the rental
sector in future, to inform their fleet choices.

Response to MC13-MC18

® Day 31, 21 June 2019, pp217-220
4 Day 25. 13 June 2019, pp 124-125

Recommendations MC13 to MC18 are not specifically directed to Government
but are addressed variously to the London Ambulance Service, the City of
London Police and the Metropolitan Police Service. However, these
recommendations do relate to the Prepare strand of the CONTEST strategy for
which OSCT (within the Home Office) has national responsibility. We provide
some comments below from Government regarding these recommendations as
appropriate.

The recommendations which are directed at the emergency services are
specifically directed to the London emergency services. We address them
below on behalf of Government as we consider it important that a national
perspective be included in the response from each service as well as, where
appropriate, a Government perspective.

Emergency response to terrorist attacks

MC13 - Addressed to the LAS, MPS and CoLP: The evidence in these
Inquests gave rise to concerns that procedures for emergency response
to marauding terrorist attacks were inflexible. In particular, the evidence
suggested that large areas could be designated hot and warm zones for
long periods and formally placed out of bounds to most ambulance and
paramedic staff. This feature of the procedures gave rise to a risk of delay
in getting medical help to casualties. While this lack of flexibility has
apparently been addressed in the revised Joint Operating Principles, |
suggest that procedures generally be reviewed to ensure that they accord
with the requirements of speed and flexibility of response which appear
to be recognised in that document. | also suggest that training exercises
be devised which address demanding situations with features such as (a)
hot and warm zones of uncertain extent; (b) a need for re-assessment of
hot and warm zones; and (c) a need to locate and assist casualties in
dangerous areas.

As indicated in MC13, changes have been made to the multi-agency Joint
Operating Principles (‘JOPS’) since the Manchester attack. These changes
draw on learning from the 2017 attacks in Manchester and London, as well as
wider exercising and learning, and place greater emphasis on the importance
of flexibility and on the use of the Joint Emergency Service Interoperability
Principles (‘JESIP’). JOPS is now in its fifth edition, reflecting a continuous
process of reviewing procedures and preparedness. There is already
considerable training and exercising on the response to a range of terrorist
attack types across the country within all three emergency services. The
Government agrees that it is important to ensure that the JOPs are being
exercised and applied locally.

18

MC14 - Addressed to LAS: The evidence in these Inquests highlighted the
importance of identifying the location of casualties at an early stage ina
marauding terrorist attack. | suggest that LAS review its guidance
documents and training exercises to ensure that they stress this point
and indicate practical means of locating casualties (e.g. from information
in emergency call records).

The Government considers that this recommendation applies to organisations
beyond the ambulance service. While medical responders would normally take
the lead on medical aspects of the response, in the early stages of an attack
information about the /ocation of casualties is provided and received by a
number of organisations (e.g. by phone or from responders at the scene). While
there may be improvements individual emergency services may wish to make
in terms of technical matters, it is the Government’s view that this issue should
be sufficiently addressed by the emphasis in the JOPs and related doctrine of
the importance of effective multi-agency communication. However, as chair of
the cross-Government and Emergency Service Joint Operational Working
Group, the Government will consider this element as part of its continuous
review of doctrine.

MC15 - Addressed to the MPS and CoLP: | suggest that the emergency
services give serious consideration to enhancing first aid capabilities and
equipment of either police officers generally or groups of officers (eg.
firearms officers or officers designated for advanced medical aid
training). This should include consideration of training some officers in
advanced life-saving procedures analogous to battlefield medicine. It
should also include considering (a) wider provision of equipment such as
tourniquets and “stop the bleed” kits and (b) the inclusion of more spare
equipment in officers’ vehicles.

Armed police already have first aid training appropriate to their role, however
we refer to the police response for detail on this issue.

MC16 - Addressed to the MPS and CoLP: The evidence in the Inquests
raised a concern that there will often be communications difficulties in
the early stages of a major incident, including difficulties resulting from
multiple officers attempting to make urgent radio transmissions at the
same time. In the ongoing work of reviewing and improving
communications technology to address these difficulties, consideration

19

should be given to whether it may be possible for control room staff to
isolate and record messages so that they can be listened to separately.

This is a technical issue for the police and will be considered by them, in
collaboration with the Emergency Services Network programme.

MC17 - Addressed to the LAS, MPS and CoLP: | suggest that
consideration be given to introducing / improving technical measures to
assist in identifying the exact locations of emergency services personnel
so that they can be communicated reliably to other first responders.

The Government understands that considerable work has been undertaken in
relation to this issue within the emergency services, and that there is some
capability for asset tracking within the emergency services. However, this is
largely single service in approach and there is currently no clear technical
solution. The National Police Chiefs’ Council is leading work in this area on
behalf of the police.

MC18 - Addressed to the MPS and LAS: The evidence at the Inquests
indicated that life-saving efforts of the emergency services, especially in
major incidents, are improved by better communications between them.
Given the challenges of communications in the early stages of incidents,
| suggest that consideration be given (including through the Blue Light
Collaboration Programme) to the possibility of having a small number of
LAS and London Fire Brigade staff stationed in the MPS control room at
all times.

The JOPs emphasise the importance of an early three-way communication link
between the emergency services and sustained effective communications
throughout an incident. The JOPs do not prescribe where or how this should
occur, to preserve the principle of flexibility that is required. The principles of
coordination and co-location are also emphasised in the JOPs. The emergency
services will respond on the practicality of the specific recommendation.

20

Her Majesty’s Chief Coroner Mark Lucraft  

The Royal Courts of Justice   
London 
WC2A 2LL 

And by email:  chiefcoronersoffice@judiciary.uk 

Dear Sir 

Legal Services 
Headquarters 
220 Waterloo Road 
London 
SE1 8SD 

Tel: 
Fax: 

www.londonambulance.nhs.uk 

9th January 2020   

Regulation 28; Prevention of Future Deaths Report arising from the inquests into the deaths of Xavier Thomas; 
Christine Archibald; James McMullan; Alexandre Pigeard; Kirsty Boden; Sébastien Bélanger; Sara Zelenak; and 
Ignacio Echeverria Miralles de Imperial. 

Thank you for your Regulation 28 Report dated 1st November 2019 setting out matters of concern regarding the 
circumstances creating a risk of future deaths.    

I would like to begin by again expressing sincere condolences on my own behalf and on behalf of the LAS Board 
to the families of the eight deceased victims, Xavier Thomas; Christine Archibald; James McMullan; Alexandre 
Pigeard; Kirsty Boden; Sébastien Bélanger; Sara Zelenak; and Ignacio Echeverria Miralles de Imperial.   

I  would  like  to  also  express  my  thanks  for  the  rigorous  investigation  into  the  facts  and  evidence  that  was 
presented at the inquests.  

I hope that this reply will be helpful in detailing the consideration given and actions taken to demonstrate how 
the matters of concern have been addressed and the ongoing work to make improvements within the London 
Ambulance Service NHS Trust (LAS). It remains our intention to continue working with our fellow emergency 
service partners both locally and on a national level on the issues raised.  

I will address your concerns, as directed to the LAS as follows: 

MC13 – “Procedures generally be reviewed to ensure that they accord with the requirements of speed and 
flexibility of response.…. I also suggest that training exercises be devised which address demanding situations 
which features such as (a) hot and warm zones of uncertain extent (b) a need for re-assessment of hot and 
warm zones and (c) a need to locate and assist casualties in dangerous areas.” 

Joint Operating Principles of the Emergency Services (JOPs) 

As previously reported to you, the Joint Operating Principles of the Emergency Services (JOPs) were completely 
reviewed and updated in February 2019 and have now been implemented as a new first edition. This new edition 
JOPs  is titled “Responding to a Marauding Terrorist Attack (MTA)”, rather than “Marauding Terrorist Firearm 
Attack (MTFA)” as was the case in the 2017 edition. The new edition covers various types of attack methodology, 

Page 1 of 6 

 
 
 
 
 
 
 
 
 
  
 
 
 
 rather than only firearms attacks.  These new JOPs also incorporate wider learning from the incidents of 2017, 
in that the principles are now designed to be more adaptable and flexible to allow a scalable response for varied 
methods of terrorist attack and include the deployment of both specialist and non-specialist responders.   

With  regard  to  the  issues of  the  identification  and  flexibility  of  zoning,  the  new  JOPs  now  include  additional 
clarifications on each of the following specific definitions:  

The Hot Zone; an area assessed to contain a credible and continuing threat to life, including the presence of 
attackers with weapons. Therefore, the hot zone will initially include both specialist and non-specialist police 
responders, dependent upon the nature of the threat(s) present and attack methodology.  LAS resources will not 
proactively be deployed into this zone, unless the situation warrants an exceptional deviation from guidance. 

The Warm Zone; an area where the attackers are not believed to be present at this time, but an identified threat 
remains.  In  the  light  of  learning  from  the  incidents  in  2017,  the  response  in  the  warm  zone  will  now  vary 
depending  on  the  attack methodology,  the  threat, and  measures  in  place  to mitigate  that threat.  Therefore, 
multi-agency responders in the warm zone can now include a combination of both specialist and non-specialist 
responders.  Such changes in the  JOPs enable  the LAS to initiate a more flexible  and dynamic approach at  an 
incident,  thus  achieving  a  greater  speed  of  deployment  and  increasing  the  availability  of  clinicians  to  treat 
patients.  

In addition to this, the principles further state that the availability of armed police officers to escort responders 
is  not  guaranteed  and  should  not  delay  responder  deployment,  again  allowing  the  LAS  greater  flexibility  of 
response as required and as indicated by dynamic risk assessments on scene. 

The  Cold  Zone;  an  area  where  no  known  threat  exists  or  where  appropriate  control  measures  have  been 
implemented. Potential control measures and their necessity will be  determined by attack methodology and 
proximity to the hot and warm zones. Some cold zones will not require any control measures.  It is expected that 
Forward Command Points will be established on the edge of cold and warm zones. 

The updated JOPs sets out that the size, location and necessity for zones should be continuously reviewed and 
every  effort  should  be  made  to  reclassify  zones  to  accurately  reflect  constantly  evolving  threat  and  risk.  It 
specifies that zones should be no larger than absolutely necessary and their size should relate directly to the 
attack methodology. It provides an example where there is a firearms threat, the hot and warm zones may be 
considerably larger than those for an incident involving bladed weapons or a hostile vehicle attack. 

The aim is to move the hot zone to warm as soon as practicable to enable the rapid deployment of responders 
to deliver clinical care to save life. As soon as it is confirmed that any threat has been mitigated, this information 
should be shared immediately with responding organisations.    

National Ambulance Resilience Unit (NARU) 

The National Ambulance Resilience Unit (NARU) acts as a central support unit for all UK ambulance services, to 
ensure that they as a whole can respond to a variety of hazardous and challenging incidents in the safest and 
most effective way possible. NARU’s key role is to maintain and develop the high standards expected of all the 
NHS ambulance service’s specialist interoperable capabilities so they are always high quality and always fit for 
purpose.  

Page 2 of 6 

 
 Maintaining contract standards, ensuring safe systems of work, training and equipping specialist operational staff 
from each service so that they have the right tools, knowledge and attitude to be able to enter challenging and 
hazardous situations with the confidence and ability to save lives (while mitigating the risks to their own safety) 
is key to NARU’s work. Accordingly, NARU works closely with a range of stakeholders to support the national 
development of Emergency Preparedness, Resilience and Response (EPRR) related policy.  

Given  NARU’s  role  the  LAS  continues  to  work  closely  with  it  to  develop  guidance  and  standard  operating 
procedures to support the deployment of staff into appropriate zones at future incidents. This will ensure the 
broadest  experience  and  input  is  secured  for  this  work.    NARU  will  be  providing  greater  clarity  on  the 
expectations of how and when Ambulance responders should deploy into the warm zone of incidents. This will 
be  in  the  next  edition  of  the  JOPs,  subject  to  the  agreement  of  all  relevant  agencies.  It  remains  the  LAS’ 
expectation that its staff will receive support from Police and Fire Service responders under the Joint Emergency 
Services Interoperability Principles (JESIP) when operating in a warm zone. NARU has representation on the JESIP 
MTA  JOPs  working  group  who  will  ensure  these  issues  on  behalf  of  ambulance  services  continue  to  be 
represented and reviewed. 

In line with NARU responsibility for maintaining contractual standards it has agreed to undertake a formal review 
of the national contract standards for ambulance services’ MTA interoperable capability.  An audit of the current 
national  MTA  capability  has  been  completed,  which  included  a  compliance  assessment  for  every  Ambulance 
Trust in England, including the LAS.  Both the findings of this audit and the recommendations in the Regulation 
28  Report  will  inform  NARU’s  review  of  the  MTA  capability  contract  standards.    The  updated  MTA  contract 
standards will be in place for the new commissioning period (start of the new financial year 2020). 

Furthermore, NARU is also undertaking a formal review of the national MTA Standard Operating Procedures (and 
corresponding  generic  rescue  plan,  generic  operational  risk  assessment,  equipment  data  sheets  and  training 
information sheets including core competencies) which enable the local implementation of the JOPs, with the 
intention to include further clarification of warm zone responders and deployments.   The formal process for 
making changes to national provisions is clearly defined within the NARU ‘National Provisions for Interoperable 
Capabilities’ and will be followed.   

NARU  has  confirmed  that,  once  updated,  these  provisions  will  become  mandatory  for  all  NHS  Ambulance 
commanders, HART and MTA responders.  They will be required to be included on all subsequent MTA training 
courses (national and local) and they will be communicated to all relevant responders via the existing Proclus 
Standard Operating Procedures platform.  The updated MTA standard operating procedures and safe system of 
work provisions will be in place by July 2020, subject to NARU’s workplan being agreed by NHS England. 

LAS policies and procedures  

In order to embed the changes in the February 2019 JOPs, the LAS training and exercise packages, action cards 
and procedures were reviewed. March 2019.   These will be undergoing a further review following the detail of 
your Regulation 28 Report and following the formal review by NARU.  This further review will be complete by 
September 2020.   

Training of LAS staff 

Upon implementation of the updated JOPs in February 2019, the LAS commenced a 10 week specialist training 
programme  for  specialist  responders  and  commanders  (Hazardous  Area  Response  Team  (HART),  Tactical 
Response  Unit  (TRU)  and  commanders)  to  ensure  they  are  all  fully  up  to  date  with  the  changes  and  new 

Page 3 of 6 

 
 provisions within the JOPs.   This training, which is the consolidation of the theoretical learning form the JOPs 
and  its  practical  application  in  a  multi-agency  scenario  setting  includes  classroom  based  learning,  table  top 
exercises and physical MTA live exercises conducted on a multi-agency basis (alongside the Metropolitan Police 
Service (MPS) and London Fire  Brigade (LFB)).   Currently, 100% of TRU staff, 94% of HART  staff and 100%  of 
commanders  have  completed  the  training.    In  addition  to  specialist  teams  and  commanders,  the  LAS  is  also 
training  front  line  (non-specialist)  staff  through  its  annual  Core  Skills  Refresher  (CSR)  training  programme, 
identified as CSR 2019.3. This particular module started on 1st December 2019 and will run through to 31st March 
2020.    

Alongside classroom based learning, the LAS also continues to instigate and engage in multi-agency MTA training 
exercises with both specialist and non-specialist responders, including the ‘Yellow Penguin’ Exercise which took 
place at Chessington on 6th March 2019, Exercise ‘Red Botham’ at Lords cricket ground on 30th March 2019 and 
Exercise  ‘Eleanor’  on  28th  October  2019.  In  addition,  the  LAS  has  undertaken  further  live  exercises  to  test 
particular elements of the JOPs. An example of this is the ‘Autumn Falls’ Exercise which specifically included the 
identification and response to hidden casualties. This took place on 29th September 2019 and was a large scale 
Chemical Biological Radioactive and Nuclear (CBRN) training exercise. 

Exercise  ‘Autumn  Falls’  was  located  at  a  sporting  stadium;  information  relating  casualty  locations  within  the 
stadium was fed into the LAS Specialist Operations Centre (SOC) and venue control room to test the information 
flow  between  these  areas  and  the  exercise  commanders  and  responders  on  the  ground,  to  ensure  that 
information was received and acted on, finding the exercise casualties hidden within the stadium. The exercise 
debrief is currently being finalised, and by the end of January 2020 the relevant SOC action cards will be updated 
to ensure that learning is incorporated in LAS response to incidents.  Further information can be found below 
regarding the location and assistance of casualties.  

In addition to multi-agency training exercises, the LAS is providing a teaching session to MPS staff on their tactical 
firearms commander course, which explains the LAS response to MTA incidents and the principles of casualty 
management from an LAS perspective. The session covers the LAS duty of care to patients, the incident response 
structure and the LAS’ pre-determined response to a MTA or major incident. It also includes information relating 
to casualty collection points, the purpose and benefit of these and how the MPS and LAS work jointly during a 
major  incident.  It  stresses  the  importance  of  recognising  and  understanding  the  use  and  process  of  casualty 
collection points and how patients can be brought directly to them for medical treatment.  

Effective  joint  decision  making  is  crucial  for  multi-agency  working  during  an  MTA  or  major  incident  and  the 
session also covers best practice in this respect and sets out examples of how working well together will increase 
the speed of deployment of ambulance resources to provide life-saving intervention.  

The LAS commends the actions of police officers who worked bravely and tirelessly on scene to treat the many 
injured patients and the LAS fully supports the work being undertaken to expand the police first aid training and 
provision of equipment, recognising the benefit this will bring to those officers who may arrive first on scene.  

MC14 – “the LAS review its guidance documents and training exercises to ensure that they stress this point 
and indicate practical means of locating casualties (e.g. from information in emergency call records)” 

Locating and assisting casualties – changes to LAS guidance and procedures as a result of training exercises  

The  location  and  assistance  of  casualties  in  dangerous  areas  has  been  a  clear  area  of  focus  for  all  agencies 
responding to an MTA, as evidenced by the “Autumn Falls” Exercise and training programmes referenced above.   

Page 4 of 6 

 
 In response to the issues raised by the 2017 incidents and the learning from the ‘Autumn Falls’ Exercise, when 
faced with a MTA or major incident, the LAS has decided to designate specific roles SOC Manager (to ensure the 
information  is  considered  and  actioned),  a  Critical  Loggist  and  a  SOC  Allocator)  within  its  control  room  to 
undertake the task of identification and recording of casualty locations to prevent any oversight.  Those within 
these  roles  are  tasked with  ensuring  that  identification  of casualty  locations  is  prioritised,  with  a  designated 
person responsible for constantly monitoring, reviewing and linking up information coming from members of the 
public via 999 calls, the MPS CAD link, ES5 (emergency services radio communication channel) and the call log so 
that it can be actioned.  By operating in this manner the LAS can mitigate against a single point of failure and in 
smaller incidents where not all roles are filled, at least one of these roles will be present.  

All patient information received will be cross referenced to ensure that a full picture of patients’ injuries and 
locations  is captured.    Action  Cards will  also  detail  the  process of  passing  the  information  to  the  Ambulance 
Commander at the Forward Command Point.  Once in receipt of patient location information, the commander 
at the Forward Command Point will coordinate extraction of the patient. It is detailed in the JOPs that this type 
of information will form part of the commander’s casualty management plan. 

Control room staff will be updated in the use of this process so that, by March 2020, there will always be a staff 
member on shift on a 24/7 basis with the capability of undertaking these roles.  Training for control room staff 
will be provided via a bulletin for Emergency Operations Centre (EOC) staff with the updated Action Cards.  It is 
also currently being explored whether a session can be incorporated into the EOC Core Skills Refresher training 
for the coming year.  

MC17 – “consideration be given to introducing/ improving technical measures to assist in identifying the exact 
locations  of  emergency  services  personnel  so  that  they  can  be  communicated  reliably  to  other  first 
responders” 

NARU is nationally responsible  for the  development and introduction/improvement of technical measures to 
assist in the identification of casualties and emergency service responders during an MTA. Its aim is to ensure 
that a nationally-appropriate solution is adopted, which can be accessible by all emergency services (fire, police 
and ambulance).  In light of its experience in responding to these and other major incidents, the LAS has been 
asked by NARU to take the lead in the practical assessment of these technical measures.  Over the course of 
2020, the LAS will therefore  be working to review the  technical solutions currently  available, including those 
which are already in use by different emergency services.  As the successful roll out of these technical solutions 
will be dependent on their interoperability with current or any new Computer Aided Dispatch (CAD) systems, it 
is not anticipated that a solution will be implemented before 2023. 

MC18 – “consideration be given (including through the Blue Light Collaboration Programme) to the possibility 
of having a small number of LAS and London Fire Brigade staff stationed in the MPS control room at all times” 

The LAS continues to work together with the MPS and the LFB through the Blue Collaboration Programme to 
explore all possibilities for improved joint-working and communication, including the implications of co-locating 
a small number of LAS and LFB staff in the MPS control room on a permanent basis.   

A table top exercise to explore co-location of some staff in the MPS control room has already been completed in 
November 2019.  The involved operational staff from LFB, LAS and MPS.  The team examined calls during a six-
hour late duty in October, to see what effect the immediate triaging of calls may have had on deployments for 
each of the services during this period.  

Page 5 of 6 

 
 A further live trial is planned for seven days in February 2020. This will see a member of LAS staff based in the 
MPS control room with a member of the LFB, 24 hours a day. The focus on this test of concept is on timely and 
accurate situational information sharing.   The outcome of this trial will be analysed and a recommendation based 
upon the results will be considered for approval by the Autumn of 2020. 

Finally, I very much hope this response helps in setting out the ongoing work that the LAS is engaged with to 
ensure front line and command personnel are fully up date and trained in the latest JOPs, when faced with a 
major incident or MTA in the future. Learning and development from Serious Incidents are never a finished task 
and  the  LAS  will  continue  to  work  with  its  emergency  service  partners  to  promote  best  practice  in  sharing 
information and collaborating as part of a multi-agency approach.  The LAS is committed to continuing its local 
and national work in its ongoing effort to perform at its best for all patients, whenever they need it.  

The LAS Board takes its responsibilities very seriously and has emphasised the importance of ensuring that the 
organisation’s ongoing capability to respond to MTA and other major incidents remains a matter of focus.  To 
this end it has increased its visibility of the HART and TRU teams through visits to these teams and enhanced 
reporting on their readiness and performance.  A lead Non-Executive Director for EPRR issues has been identified 
and the Board will be receiving regular updates on the progress of the actions set out in this response. 

My thoughts and those of my colleagues at LAS remain with the families of the victims. 

Yours sincerely 

Garrett Emmerson 

Chief Executive, London Ambulance Service NHS Trust   

Page 6 of 6

IN THE CENTRAL CRIMINAL COURT  

INQUESTS ARISING FROM THE DEATHS IN THE LONDON 

BRIDGE AND BOROUGH MARKET ATTACKS OF 3rd JUNE 2017 

______________________________________________________ 

WRITTEN RESPONSE ON BEHALF OF 

THE METROPOLITAN POLICE SERVICE 

REGULATION 28 

______________________________________________________ 

1.  This  is  the  response  submitted  on  behalf  of  the  Commissioner  of  Police  for  the 
Metropolis  (MPS)  to  the  Chief  Coroner’s  Report  to  Prevent  Future  Deaths  (RPFD) 
following  the  inquests  into  the  terrorist  attacks  on  London  Bridge  and  at  Borough 
Market. 

2.  On behalf of the Commissioner may I once again express our deepest sympathies to 
those  who  were  murdered  and  injured  in  these  terrible  attacks.  The  police  work 
tirelessly to prevent all terrorist attacks and it is a source of profound regret when we 
are unable to do so. We are determined to do everything possible to protect the public 
in future.  

3.  This document provides the response both on behalf of the MPS and National Counter 
Terror  Policing  which  includes  the  National  Counter  Terrorism  Security  Office 
(NaCTSO). 

4.   NaCTSO  is  a  police  unit  that  sits  under  the  National  Counter  Terrorism  Police 
Headquarters and reports to the National Coordinator for Protect and Prepare.  NaCTSO 
is responsible for producing guidance and training materials for protective security in 
crowded  places.  NaCTSO  also  trains,  licences  and  coordinates  the  CTSA  network, 
NaCTSO falls under the Protect and Prepare strands of CONTEST.  

MC1 – Addressed to the Secretary of State for the Home Department and NaCTSO: 
I  suggest  that  there  be  a  review  of  the  sensitive  national  criteria  and  tests  for 
identifying sites as priority Crowded Places (or for otherwise designating sites at a 
national level as justifying proactive advice on protective security). In that review, 
one aim should be to ensure that the criteria are not excessively rigid so as to exclude 
sites which may be particularly attractive and vulnerable to terrorists. If and to the 
extent  that  the  Secretary  of  State  considers  that  any  other  Government  agencies 
should play a part in addressing this concern, their assistance should be enlisted. 

MC2 – Addressed to the Secretary of State for the Home Department and NaCTSO: 
I suggest that consideration be given to putting in place systems of periodic review / 

 
 
 
 
 
 
 
 
 assurance  to  ensure  that  the  criteria  for  identifying  priority  sites  for  protective 
security  advice  remain  fit  for  purpose  and  that  the  list  of  such  sites  remains 
appropriate 

5.  Due to the close alignment of these recommendations, NaCTSO is responding to both 

collectively.  

6.  As  it  is  not  possible  to  deliver  bespoke  advice  to  every  crowded  place,  access  to 
guidance works on a process of scaled options and differing delivery mechanisms. It is 
important to note that CT security measures for crowded places do not only begin when 
a site is identified as a “priority site”. A huge amount of work has been and is being 
done across the sector. Free security advice is available to everyone as envisaged by 
the Lord West report. This is delivered in particular by NACTSO and the Centre for 
the Protection of National Infrastructure (CPNI). 

7.  Protective security guidance and training operates on three broad levels; the first two 
levels provide access to information for sectors and individuals, whilst the third layer 
comprises bespoke CTSA engagement with specific sites (the priority crowded places 
identified by the Chief Coroner in MC1). These three levels are each addressed in turn 
below. 

8.  In terms of protective security advice available to all, the NaCTSO website provides 
access to an array of protective security advice, including the Crowded Places Guidance 
which can be accessed openly and without charge. It also includes a gateway to “ACT 
(Action Counters Terrorism) e-learning UK” which is specifically designed to provide 
information  to  those  without  direct  access  to  a  CTSA.  ACT  e-learning  was  initially 
launched  for  private  sector  organisations  to  use,  and  was  free  from  the  point  of 
registration.  From December 2019, the e-learning has been made freely accessible to 
anyone,  removing  the  registration  requirement.    Currently  nearly  2  million  modules 
have been completed across the UK.   

9.  NaCTSO  also  provides  communications  and  briefings  for  business  and  others  with 
responsibilities  or  interest  in  this  area.  This  includes  regular  protective  security 
communications delivered under the brand “UK Protect” and disseminated through the 
Cross  Sector  Security  Communications  (CSSC)  network  to  any  business  who  has 
signed up. It also includes regular updates and specific messages at times of increased 
risk. Between January 2017 and December 2019, 110 messages were disseminated to 
the network. 

10. Other  measures  include  engagement  with  representatives  of  leading  crowded  places 
sectors (for example shopping centres, hotels, visitor attractions) through the Crowded 
Places Information Exchange. This is supported through ACT Corporate events where 
CT advice and guidance is delivered by experts directly into sector groups on both a 
national and regional basis. 

11. Providing bespoke, site specific CT advice is the primary focus of the national Counter 
Terrorism Security Advisor (CTSA) network which is overseen by NaCTSO. CTSAs 
work under a framework to provide advice on protective security measures that could 
be  taken  to  improve  security  at  a  specific  site.  CTSA  delivery  is  predicated  on 
identifying which sites are considered to be most at risk of attack. In the absence of 

 
 
 
 
 
 
 
 specific protective security legislation (covered in more detail in MC3 and MC4), these 
measures are implemented at the discretion of the owner subject to other non-CT legal 
obligations as imposed by for example the Crime and Disorder Act 1997 or the Health 
and Safety at Work etc Act 1974.  Sites are selected through a process of prioritisation. 

12. The  2017  attacks  have  brought  into  focus  consideration  of  which  locations  receive 
which level of advice. NaCTSO recognises that this is a complex area and not an exact 
science.  The  terrorist  threat  continues  to  evolve  and  is  increasingly  multi-layered, 
covering not just the iconic location targeting preferred by Al Qaeda and the IRA but 
new threats from extreme right wing terrorism and Daesh which promotes the concept 
that anything is a target and anything a weapon. It is not possible (in terms of CTSA 
network reach) or desirable (in terms of creating so called “barrier Britain”) to offer 
every location in the UK the same level of protective security advice or protection and 
therefore there must be a system of prioritisation and flexibility to ensure the advice 
provided is appropriate and proportionate to the intelligence and threat assessment.  

13. Any system of prioritisation will require an assessment criteria which will result in risk 
based inclusion and exclusion. NaCTSO accepts that flexibility in this approach is very 
important  and  as  such  has  been  working  closely  with  the  government  to  review  the 
crowded places policy and delivery model.   

14. To address this challenge NaCTSO is seeking to expand both the advice and training 
we provide and how that advice is delivered. Since 2017 NaCTSO has worked hard to 
expand the range of products available and sought to adapt these to multiple audiences. 
The strategic approach is to reach as many people as possible with protective security 
advice. As outlined above, this ranges from CT awareness suitable for all members of 
the public, to detailed bespoke security advice appropriate for large corporations with 
professional security expertise. We will continue to grow and develop the advice and 
accessibility of these measures.  

15. NaCTSO also recognises the need to develop a review process and for greater flexibility 
within the prioritisation model. The 2014 Crowded Places Model allows a degree of 
flexibility, such as for example the ability to add additional sites at a local level or to 
place  a  location  into  a  maintenance  phase  once  all  desirable  protective  security 
solutions have been achieved. NaCTSO agrees with the recommendation to review the 
model to ensure the overall system, and prioritisation process addresses the threat from 
terrorism. The full details of this process are under consideration with Government and 
we refer the Chief Coroner to HMG’s response on this point. 

16. Finally, it is important to recognise the limits of protective security.  Protective security 
solutions provide the ability to deter, detect or delay a terrorist attack, but they cannot 
alone  prevent  every  attack.  We  cannot  protect  everyone  all  of  the  time.  Target 
hardening one area can deflect an attack into another as was seen in Halle, Germany in 
October 2019, when the attacker was unable to access his initial target, a synagogue, 
but then proceeded to attack people on the streets nearby. Protective security measures 
reduce rather than negate impact.  

MC3 – Addressed to the Secretary of State for the Home Department: I suggest 
that  consideration  be  given  either  (a)  to  introducing  legislation  governing  the 
duties of public authorities (including highway authorities) regarding protective 

 
 
 
 
 
 
 security or (b) to producing guidance indicating what existing legal duties require 
in  practice  of  public  authorities  regarding  assessment  of  sites  for  protective 
security needs and implementing protective security measures. 

MC4  –  Addressed  to  the  Secretary  of  State  for  the  Home  Department  and 
NaCTSO: I suggest that consideration be given to producing guidance for CTSAs 
explaining  what  existing  legal  duties  require  in  practice  of  public  authorities 
regarding  assessment  of  sites  for  protective  security  needs  and  implementing 
protective security measures. 

17. MC3 rests with the Secretary of State for the Home Department, but leads into MC4, 

so has been included for completeness. 

18. The  Chief  Coroner  notes  the  provisions  of  the  Crime  and  Disorder  Act  1997  which 
require  public  authorities  to  exercise  their  various  functions  with  due  regard  to  the 
likely  effect  of  the  exercise  of  those  functions  on,  and  the  need  to  do  all  that  it 
reasonably  can  to  prevent  (inter  alia)  crime  and  disorder  in  its  area.  This  has  been 
interpreted  by  some  authorities  (including  TfL)  as  including  terrorism.  The  Chief 
Coroner has noted that there is reason to believe this interpretation is not uniform across 
the UK. 

19. Counter Terrorism Policing has for some time supported the introduction of legislation 
to govern protective security standards. Moving  from the  current approach which is 
predicated upon persuading the owners  and operators  of  crowded places  to consider 
and implement protective security (including public bodies to which MC3 and MC4 
are addressed), to one where this is mandatory would be game-changing and we believe 
is  the  most  effective  means  to  deliver  protective  security  consistently  across  the 
country. Any legislation should reflect the key principles of our current approach of 
appropriateness and proportionality. 

20. As outlined in MC3, there is an absence of specific protective security legislation. There 
is also an absence of case law or guidance in this area. Consequently, provision of clear, 
definitive guidance for the CTSA network is challenging. Ultimately we can provide as 
much CT advice as we want but absent a clear legal duty, implementation of that advice 
is optional. NaCTSO is currently reviewing the various legal provisions which might 
impose a duty in the public and private sector, but we can only provide (further) advice 
to the CTSA network internally. Providing legal advice directly to public authorities or 
others would fall outside the scope of our role. In the event that legal advice received 
by  NaCTSO  yields  further  useful  guidance  to  CTSAs  and  others  then  this  will  be 
provided as soon as possible and certainly in 2020, however, given the uncertainty as 
to the nature and extent of such a legal duty there is at present likely to be very limited 
if any guidance which NaCTSO can usefully provide.  

21.  As  set  out  above,  NaCTSO  would  welcome  the  provision  of  clear  guidance  from 
relevant Government departments as to the applicability of existing legalisation.  

MC5  –  Addressed  to  the  Secretary  of  State  for  the  Home  Department  and 
NaCTSO:  I  suggest  that  consideration  be  given  to  taking  measures  to  make 
CTSAs, police forces and local authorities aware of protective security equipment 
/ infrastructure which can be installed in response to emerging threats (including 

 
 
 
 
 
 
 
 the criteria and timescales for making particular forms of asset available).  I also 
suggest that consideration be given to encouraging highway authorities and other 
public bodies, especially in metropolitan areas, to adopt security boards similar to 
the  PRSAB  adopted  in  London,  with  a  view  to  ensuring  that  there  is  good 
understanding  of  what  measures  can  be  taken  in  the  short  and  longer  term  to 
protect sites and areas assessed to be vulnerable. 

22. MC5 poses two recommendations. The majority of the first section sits with NaCTSO. 
With regards  to  the second section and the  adoption of security boards,  NaCTSO is 
likely to have a role but would not be the lead agency responsible. As such this sits 
outside the scope of this response and is better addressed by the government. 

23. The  CTSA  network  undertakes  a  comprehensive  training  programme  which  takes  a 
minimum of two years to complete. This course is accredited to City and Guilds level 
and courses are delivered by both NaCTSO and CPNI trainers. All CTSAs must attain 
this standard and are supported and mentored until this is achieved. Some CTSAs also 
opt to continue to a further graduate level qualification.  Both courses cover the security 
mitigations  that  are  available  in  protective  security.  The  course  content  is  regularly 
updated  and those  undertaking  that  task will be fully briefed on all relevant matters 
including the Chief Coroner’s report. 

24. Advances  in  technology  and  capabilities  present  a  need  to  ensure  continued 
professional  development  of  the  network.  This  is  achieved  through  a  number  of 
different channels.  All CTSAs must attend an annual training event which provides a 
forum to deliver the latest innovations and share best practice. Additionally, NaCTSO 
operates a tasking process whereby any changes and developments are sent out to the 
CT network through the Protect & Prepare leads who also ensure that the network is 
aware of any relevant new publications by CPNI. 

25. Hostile Vehicle Mitigation (HVM) and the National Barrier Asset (NBA) represent an 
evolving capability that is managed centrally within NaCTSO by the National Vehicle 
Threat Mitigation Unit (NVTMU). All CTSAs and officers working in CT policing are 
briefed on HMV and NBA capability. As set out above this is covered by inputs at the 
CTSA annual training event and as part of the formal CTSA training.  

26. Additionally,  a  brief  is  distributed  to  all  CTSAs,  CT  SecCo  Leads  (who  support 
temporary events), and the Protect and Prepare network covering relevant changes in 
capability and procedure in relation to HVM. 

27. Further, the NVTMU has recently presented directly to Protect and Prepare leads, the 
National CT SecCo board and nine of the eleven CTSA regions. The remaining two 
regions  will  receive  presentations  in  early  2020.  The  subject  matter  of  these 
presentations includes the types  of asset available,  information on the  new, modular 
HVM, VAW attack methodology and VAW tactics. We will deliver updates and advice 
on other evolving capabilities in a similar manner. 

28. We are therefore confident that the matters raised in MC05 are already in hand. 

 
 
 
 
 
 
 
 
 
 MC10:  Addressed  to  the  Secretary  of  State  for  the  Home  Department  and  the 
Director-General of the Security Service: The evidence in this case gave cause for 
concern that calls made by members of the public reporting on a significant SOI 
were not being communicated to MI5 and CTP officers working on the relevant 
investigation(s).  In  the  continuing  work  to  improve  information  management, 
efforts should be made to avoid recurrence of this problem. 

29. Whilst MC10 is  not  addressed  to  the  MPS,  it  raises  concerns  about  calls  from  the 
public not  being  passed  on  to  MI5  and  CTP  officers  working  on  the  relevant 
investigation. At paragraph 45 of the MPS submission dated 06.09.19, the following 
response was provided: 

A learning point in relation to the call handling was identified by Lord Anderson and 
this has been implemented. Intelligence handling systems have been reviewed, and new 
processes  are  in  place  to  ensure  intelligence  is  recorded  and  disseminated 
appropriately.  ATH technology has been upgraded including an automated answering 
system and messaging facility. SO15 has placed an extra level of supervision into the 
process of intelligence handling from the hotline which will ensure that in the event 
that a human and supervision error occurs again this will be picked up by the extra 
supervisory check and the intelligence will then be passed on to the appropriate team 

30. In  addition  to  the  matters  set  out  above,  there  have  been  other  improvements  in 
intelligence  handling  which  are  relevant  to  the  matters  the  Chief  Coroner  raises  in 
relation to MC10.  

31. Since April 2019, SO15 intelligence has been governed by the National Standards of 
Intelligence Management (NSIM). Relevant data once received, will now be placed on 
a National CT database. Where intelligence is matched to the subject of an ongoing CT 
investigation, it will now be placed directly into that operational intelligence unit and 
flagged for assessment. 

32. All staff working in intelligence assessment have completed NSIM assessor training 
which  provides  guidance  on  trace  checks  and  development  of  intelligence.  If  for 
whatever  reason  (such  as  a  missing  “selector”)  analysed  intelligence  is  not  matched 
with  a  subject  in  a  CT  investigation  then  sophisticated  systems  are  in  place  for  the 
matter  to  be  escalated.  Due  to  sensitivities  involved  in  relation  to  this  form  of 
intelligence handling, it  would be inappropriate to include further details within this 
document. 

MC13 – Addressed to the LAS, MPS and CoLP: The evidence in these Inquests 
gave  rise  to  concerns  that  procedures  for  emergency  response  to  marauding 
terrorist attacks were inflexible. In particular, the evidence suggested that large 
areas  could  be  designated  hot  and  warm  zones  for  long  periods  and  formally 
placed out of bounds to most ambulance and paramedic staff. This feature of the 
procedures gave rise to a risk of delay in getting medical help to casualties. While 
this  lack  of  flexibility  has  apparently  been  addressed  in  the  revised  Joint 
Operating Principles, I suggest that procedures generally be reviewed to ensure 
that they accord with the requirements of speed and flexibility of response which 

 
 
  
  
 
 
 
 
 appear to be recognised in that document. I also suggest that training exercises be 
devised  which  address  demanding  situations  with  features  such  as  (a)  hot  and 
warm  zones  of  uncertain  extent;  (b)  a  need  for  re-assessment  of  hot and warm 
zones; and (c) a need to locate and assist casualties in dangerous areas. 

33. As  recognised  within  MC13,  changes  were  made  to  the  MTA  Joint  Operating 
Procedures (JOPs) following the 2017 attacks. The changes reflected the broader range 
of  attack  methodology  experienced  and  the  applicability  of  the  guidance  to  a  wider 
range  of  circumstances  than  the  previous  Marauding  Terrorist  Firearms  Attack 
(MTFA) guidance, which it replaced. 

34.  The revised MTA JOPs place greater emphasis on flexibility in applying the hot, warm 
and cold zones and in deploying non-specialist responders from all three emergency 
services within the zones where appropriate. 

35. Operational Plato national guidance was also reviewed and is fully reflective of these 
changes. The new Plato guidance recognises that unarmed responders will play a vital 
role in the initial stages of the response and that this may include activity within each 
of the three zones. There is no rigid or inflexible approach taken.   

36. CTPHQ staff have undertaken a national programme of assurance visits to all police 
forces (including the MPS and CoLP) to ensure that the new MTA JOPs and Operation 
Plato  guidance  have  been  fully  embedded  within  local  policies,  procedures  and 
practices.    

37. The  MTA  JOPs  and  Operation  Plato  guidance  are  regularly  reviewed,  drawing  on 
learning from major incidents and exercises. This is an ongoing process. The current 
edition of the MTA JOPs is the fifth edition to be produced, reflecting a continuous 
process  of  reviewing  procedures  and  preparedness.  We  are  satisfied  that  there  is  no 
learning from the 2017 attacks which requires further changes to the current edition of 
the MTA JOPs and Operation Plato guidance.    

38. There has been, and continues to be, a significant amount of training and exercising 
conducted across the country on the response to a MTA. Individual police forces are 
regularly  conducting  joint  MTA  training  and  exercising  with  their  local  emergency 
service partners. CTPHQ agrees that it is important to ensure that this continues and 
regularly reminds forces of the importance of this. The matters the Chief Coroner raises 
at MC13 are reflected in this work. 

39. In terms of the MPS; training, testing and exercising is a key focus of the MPS ‘prepare’ 
strand of CONTEST. The MPS carries out a wide range of CT testing and exercising. 
As  the  Chief  Coroner  would  expect  these  are  very  significantly  above  the  levels 
required of policing bodies by CTPHQ and OSCT. These tests and exercises frequently 
involve multiple agency participation and since 2017, learning from the attacks of that 
year has been incorporated. 

40.  Establishing,  reviewing  and  operating  within  warm  and  hot  zones  under  the  “new” 
JOPs is a key feature of both the “live play” and “table top” exercises undertaken by 
both commanders and emergency responders. 

 
 
 
 
 
 
 
 
 
 41. The emergency services within London have made a significant investment to MTA 
training  and  exercising  over  recent  years  and  are  recognised  by  CTPHQ  as  being  a 
model of good practice in terms of the quality, complexity and frequency of their MTA 
exercising programme.     

42. We are therefore confident that the important matters raised in MC13 have already been 

addressed by existing policy and training. 

MC15: Addressed to the MPS and CoLP: I suggest that the emergency services give 
serious  consideration  to  enhancing  first  aid  capabilities  and  equipment  of  either 
police  officers  generally  or  groups  of  officers  (e.g.  firearms  officers  or  officers 
designated for advanced medical aid training). This should include consideration of 
training  some  officers  in  advanced  life-saving  procedures  analogous  to  battlefield 
medicine. It should also include considering (a) wider provision of equipment such 
as  tourniquets  and  “stop  the  bleed”  kits  and  (b)  the  inclusion  of  more  spare 
equipment in officers’ vehicles. 

43. In the MPS  all officers up  to the  rank of  Chief Inspector  have  to complete  standard 
emergency lifesaving training once a year. The training includes (but is not limited to) 
inputs on the use of tourniquets, defibrillators, compression bandages, dealing with cuts 
and lacerations, knife wounds and other penetrating trauma. 

44. All  armed  response  vehicle  (ARV)  officers  are  mandated  to  undertake  ‘standard’ 
firearms officer first aid training set to national standards. The National Police Firearms 
Training  Curriculum  (NPFTC)  provides  a  list  of  learning  outcomes  that  must  be 
achieved, and the training must be provided within the context of an armed incident or 
operation to prepare officers for operational circumstances. Due to the specialist nature 
of  the  training  the  medical  content  is  not  detailed  within  the  NPFTC.  Each  force  is 
required  to  train  officers  to  meet  the  identified  NPFTC  outcomes  using  material 
approved  by  the  medical  profession  and  with  appropriate  clinical  governance.  This 
ensures that the training and first aid provision given by armed officers is current and 
based on medical advice. In addition to a number of general first aid interventions, such 
as dealing with broken bones, convulsions, spinal injury and choking, officers are also 
required  to  ‘Identify  ballistic  injuries  –  primary,  secondary  and  tertiary  injuries, 
cavitation, exit and entry wounds and blunt trauma’.  

45. In addition to this ‘standard’ level of first aid training provided to all ARV officers, 
individual forces may  choose (based upon  a  local  assessment of strategic  threat and 
risk) to train some (or all) of their ARV officers to an ‘enhanced’ level. In addition to 
the  ‘standard’  training,  the  ‘enhanced’  level  provides  the  ability  to  undertake 
interventions such as; haemostatic dressings, airway management and oxygen therapy, 
stroke, abdominal wounds and anaphylactic reaction.  

46. In the MPS once standard training has been completed, AFOs are required to undergo 
continuation training every five weeks (ARV officers) or six months (all AFOs). During 
this training officers will deal with a medical situation using these skills and associated 
equipment whilst under fire or in a simulated life threatening situation. This is akin to 
“battlefield medicine”. 

 
 
 
 
 
 
 
 
 47. The  MPS  also  undertakes  regular  MTA  tri-service  exercises  which  includes 
participation by the  London Helicopter Emergency Medical Service (HEMS). AFOs 
(and  others)  will  in  these  exercises  carry  out  realistic  battlefield  triage  whilst 
commanders will receive tactical medical advice to test and improve their response. 

48. The  most  highly  trained  AFOs  are  Counter  Terrorism  Specialist  Firearms  Officers 
(CTSFOs).  These  officers  receive  an  even  higher  level  of  medical  training  which 
includes the use of oxygen cylinders and casualty  extraction. These officers spend a 
week with HEMS doctors in A&E. 

49. Some of the most advanced AFO medics will also attend training events in Hungary 
every  six  months  for  advanced  field  medicine  training  where  they  learn  procedures 
including needle thoracostomy. These officers then use that expertise in exercises and 
testing and to assist in the development of training in this area. 

50. It is a nationally mandated requirement that all ARVs carry a suitably equipped first 
aid kit commensurate with the level of training of the officers crewing the vehicle. In 
August  2018  advice  was  provided  to  forces  that  consideration  should  be  given  to 
ensuring that all ARV officers have immediate access to tourniquets and haemostatic 
wound packing products. The Chief Coroner will recall the evidence from Dr Wrigley 
that tourniquets are being “rolled out” for use by police officers across London. 

51. It should be noted that the primary role of armed police officers during a MTA will be 
to identify, locate and confront subjects in order to neutralise the threat. The provision 
of  first  aid  may  be  a  secondary  role  for  armed  officers  once  the  threat  has  been 
neutralised, or where there is sufficient armed capacity to enable some armed officers 
to support other lifesaving activity. It is important that this role is not confused with 
that of the ambulance service. 

52. The MTA JOPs make clear that the ambulance service retains the lead responsibility 
for  casualty  management.  The  ambulance  on  scene  commander  will  direct  and 
coordinate  the  casualty  management  process,  including  joint  working  with  non-
ambulance  emergency  responders  to  deliver  life  saving  care.  It  is  recognised  that 
responders from the three services have received different levels of first aid training 
and will be tasked appropriately. 

MC16: Addressed to the MPS and CoLP: The evidence in the Inquests raised a 
concern that there will often be communications difficulties in the early stages of 
a major incident, including difficulties resulting from multiple officers attempting 
to  make  urgent  radio  transmissions  at  the  same  time.  In  the  ongoing  work  of 
reviewing and improving communications technology to address these difficulties, 
consideration should be given to whether it may be possible for control room staff 
to isolate and record messages so that they can be listened to separately. 

53. This is a technical issue and one that should be considered by the NPCC Operational 
Communications  in  Policing  (OCiP)  portfolio  as  part  of  the  Emergency  Services 
Network Programme (ESNP). 

MC17:  Addressed to the LAS, MPS and CoLP: I  suggest  that  consideration be 
given  to  introducing  /  improving  technical  measures  to  assist  in  identifying  the 

 
 
 
 
 
 
 
 
 exact locations of emergency services personnel so that they can be communicated 
reliably to other first responders. 

54. Police forces currently have the ability, within control rooms, to track the location of 
their own assets via their Airwave communication and command and control systems.  

55. Work is currently underway, led by Chief Constable Simon Chesterman on behalf of 
NPCC, to enable all police force control rooms to have visibility of armed officers who 
arrive into their force area to provide operational support. However this is a complex 
technical area and the identification of a viable and affordable solution is challenging.  

56. At this stage, owing to the technical limitations, it is not possible for all three emergency 
services to have full visibility in their control rooms of other emergency service assets. 

MC18: Addressed to the MPS and LAS: The evidence at the Inquests indicated 
that life-saving efforts of the emergency services, especially in major incidents, are 
improved  by  better  communications  between  them.  Given  the  challenges  of 
communications in the early stages of incidents, I suggest that consideration be 
given  (including  through  the  Blue  Light  Collaboration  Programme)  to  the 
possibility  of  having  a  small  number  of  LAS  and  London  Fire  Brigade  staff 
stationed in the MPS control room at all times. 

57. The  ‘core’  Joint  Emergency  Services  Interoperability  Principles  (JESIP),  the  MTA 
JOPs and the Operation Plato national guidance all stress the importance of effective 
communication, sharing of information and joint working between the three emergency 
services. These documents identify the critical importance of establishing an initial ‘tri-
service’ communication link between the control rooms, subsequent co-location of on-
scene  commanders  and  the  establishment  of  combined  tactical  and  strategic 
coordinating groups as soon as practicable during a MTA. This was the case during the 
London Bridge attacks. 

58. The  permanent  embedding  of  (a  small  number  of)  representatives  from  the  fire  and 
ambulance services in police control rooms has been  carefully  considered but is not 
currently thought to present sufficient operational benefits. The critical requirement is 
to effectively link the relevant command points at all levels and during all phases of the 
response.  During  the  control  room  based  initial  coordination  of  the  response,  it  is 
critical that the activity being undertaken by the three emergency service control rooms 
is coordinated and information is shared effectively. This is delivered by the immediate 
opening of a conference call between the control rooms of the MPS, LFB, LAS, CoLP 
and BTP to share critical information and the dispatch of LFB and LAS officers to the 
MPS control room as soon as an Operation Plato declaration is made. However the co-
location  of  appropriately  qualified  commanders  from  all  three  services,  under  the 
tactical and strategic coordinating group arrangements should continue to be a priority 
activity.     

59. As the Chief Coroner notes these matters have been discussed between the emergency 
services under the auspices of the London Resilience structures. This includes a joint 
control room group which reviews inter-operability performance at major incidents and 
a  “Blue  lights  Panel”  which  considers  broader  joint  working  arrangements  at  major 
incidents and last sat on 10.12.19. 

 
 
 
 
 
 
 
 60. Despite the above the MPS continues to seriously consider these matters to see whether 
there might be opportunity to improve communication between the emergency services. 
Work is underway to trial a “London Emergency Services Contact Centre”. This will 
involve representatives from the LFB and LAS being deployed within the Specialist 
Operations Room. A table top exercise will be conducted with real CADs to finalise 
working practices followed by a real life 7 day trial early in 2020. 

61. The police will learn wherever possible from tragedies such as these evil terror attacks. 

We will never stop working to protect London and the UK from terrorism. 

Assistant Commissioner Neil Basu