Prevention of Future Deaths report 2021-0362

Date of report	3 Nov 2021
Reference	2021-0362
Coroner	HH Judge Lucraft QC
Coroner area	London City
Category	Other related deaths · Police related deaths · State Custody related deaths
Source	judiciary.uk record · original PDF
Responses published	9

The report

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

INQUESTS ARISING FROM THE DEATHS

IN THE FISHMONGERS’ HALL TERROR ATTACK

REGULATION 28 REPORT ON ACTION TO PREVENT FUTURE DEATHS

Addressees

This Report is addressed to the following:

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

(i)

(j)

The Secretary of State for the Home Department;

The Secretary of State for Justice;

The Secretary of State for Education;

The Director-General of the Security Service;

The Chief Executive of the Office for Students;

The Chief Executive Officer of the College of Policing;

The Chief Constable of West Midlands Police;

The Chief Constable of Staffordshire Police;

The Vice-Chancellor of the University of Cambridge; and

The Directors of Learning Together CIC.

Coroner

I am the Recorder of London. The Recorder of London is the lead judge at the Central

Criminal Court (the Old Bailey) and the most senior Circuit Judge in England & Wales.

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

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

that nomination, I was also the Chief Coroner of England and Wales, but my appointment

to that post ended on 23 December 2020 before the conclusion of the Inquests.

2. My official address is The Old Bailey, London EC4M 7EH. However, responses to this

report should be sent to the solicitor to the Inquests;

, at BDB Pitmans LLP,

One Bartholomew Close, London EC1A 7BL.

Coroner’s Legal Powers

I make this Report on Action to Prevent Future Deaths under paragraph 7 of Schedule 5

to the CJA and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013

(“the Regulations”).

Investigation and Inquests

The Inquests to which this Report relates include those of the two young people who

were fatally injured in the terror attack which took place at Fishmongers’ Hall on 29

November 2019; Saskia Jones and Jack Merritt. They also include the Inquest of the

attacker, Usman Khan, who was fatally shot by firearms officers on the same date.

5. After my nomination to hear the Inquests, I held Pre-Inquest Review hearings on 16

October 2020, 12 February 2021 and 25 March 2021. I held a hearing of the Inquests of

the victims of the attack with a jury from 12 April 2021, which ended on 28 May 2021.

Immediately afterwards, I held a hearing of the Inquest of the attacker, also with a jury,

from 28 May 2021 until 10 June 2021.

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

unlawfully killed and in each case provided a supplementary narrative conclusion by

means of answers to a questionnaire. Attached to this Report are copies of the

Determinations sheets for the two victims.

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

a further narrative conclusion. Attached to this Report is a copy of the Determinations

sheet for the attacker.

Further details concerning the Inquests, including transcripts of the hearings and copies

of relevant rulings, can be found on the Inquests website:

• https://fishmongershallinquests.independent.gov.uk/

Circumstances of the Deaths

9. A very full factual summary may be found in the transcript of my summing-up on 26-27

May 2021, which appears on the Inquests website. The following paragraphs of this

Report provide a short summary to assist in consideration of the matters of concern raised

below.

Usman Khan: Background

10. Usman Khan was 28 years old at the time of the attack. He had had a history of

involvement in events of violence as a teenager. In 2010 (when he was aged 19), he was

arrested for offences of acts preparatory to terrorism and was remanded in custody. He

pleaded guilty to a number of charges and was sentenced in early 2012, the basis of his

plea being that he had sought to set up a militant training camp in Kashmir from which

in future attacks might be launched on the UK. He was imprisoned and served his

sentence in a number of prisons between mid-2010 and December 2018.

11. While Usman Khan was in prison, intelligence reports consistently showed him to be a

leading extremist figure, involved in bullying, violence, radicalising others and serious

disruption. An Extremism Risk Guidelines (ERG 22+) assessment report prepared on

him in April 2018 by a prison psychologist,

, concluded that his intent

for and engagement with extremism remained strong and that there was a high risk that

he would become involved in extremist activity upon release.

12. At the time of his release, Usman Khan remained a Category A (High Risk) prisoner, one

of very few to be released into the community with that status. An OASys assessment

by his probation officer shortly before his release concluded that he posed a “very high

risk” of serious harm to the public in the community, indicating that a seriously harmful

event was imminent and more likely than not to happen. Shortly before his release from

prison, there were two strands of intelligence indicating that (a) he intended to return to

his old ways upon release (which was interpreted as a reference to some form of terrorist

offending) and (b) he intended to carry out an attack after release.

13. While he was in HMP Whitemoor, from November 2017, Usman Khan began to take

courses provided by Learning Together, a prisoner educational initiative supported by

academics from the Institute of Criminology within the University of Cambridge. The

initiative involved undergraduate students studying alongside prisoners within prisons.

It had an alumni network which allowed former prisoners to remain involved in its

activities after their release. Usman Khan proceeded to take a series of Learning

Together courses over his final year in prison, and he remained in contact with Learning

Together staff after his release.

14. From June 2018, Usman Khan was subject to management under statutory Multi-Agency

Public Protection Arrangements (“MAPPA”). These involved meetings being held at

regular intervals involving representatives of police forces, the National Probation

Service (“NPS”) and others with relevant responsibilities for him. Reports were made to

the meetings and decisions were made with a view to mitigating the risks he posed.

15. On his release into the community, Usman Khan was subject to strict licence conditions

which were overseen by an offender manager from the NPS. He was initially required

to live in approved premises in Stafford (a probation hostel) and he had to wear a GPS

tag. In addition, he was subject to statutory notification requirements under terrorism

legislation (Part 4 of the Counter-Terrorism Act 2008), which were managed by

Staffordshire PREVENT team officers. Those officers visited him at intervals and

prepared general reports about him. Usman Khan also had mentors provided for him

under the Home Office Desistance and Disengagement Programme (“DDP”).

16.

In preparation for Usman Khan’s release into the community, the Security Service (MI5)

and West Midlands Police opened a priority investigation into him. Staffordshire Police

Special Branch provided intelligence support to this operation. The investigation carried

out a range of monitoring on Usman Khan over the months that he was living in the

community, but did not detect any significant suspicious activity.

17.

In the months following his release into the community (early 2019), Usman Khan was

apparently compliant with his licence conditions and he did not engage with old

associates. He was seen regularly by his offender manager and by mentors, and he visited

his family in Stoke-on-Trent. His curfew conditions were relaxed progressively. He

applied for a number of jobs, but all without success.

18. Usman Khan remained in contact with the Learning Together initiative. In June 2019,

he attended a Learning Together event at HMP Whitemoor, being taken there by

PREVENT officers. He received a non-networked Chromebook computer for creative

writing, but there was no evidence that he did any actual project work. His search for

employment continued and consideration was given to him applying for a job as a dumper

truck driver, but the MAPPA agencies decided that that should not be permitted because

of the risk he might pose if given access to heavy vehicles.

19.

In August 2019, staff from Learning Together invited Usman Khan to attend an

anniversary and alumni event which was due to take place in London in November 2019.

The event was arranged to take place on 29 November 2019 at Fishmongers’ Hall, a

livery company hall in the City of London adjacent to London Bridge. Prominent figures

from the field of criminal justice were invited to attend, and a number did attend. Usman

Khan was permitted to go to the event by his offender manager. The prospective event

was discussed in either two or three of the MAPPA panel meetings held between August

and November 2019, but it does not appear that the MAPPA agencies gave express

consideration to the risks of Usman Khan attending such an event or expressly approved

his attendance. It is however right to say that none objected.

20.

In September 2019, Usman Khan moved from the probation hostel into a one-bedroom

private flat. He continued to search for work without success, and this became more

difficult when his mentoring arrangements were abruptly ceased and he no longer had

the benefit of supervised access to the internet for job searches. He stopped going to the

gym and appears to have spent much of his time playing video games, watching DVDs

and walking around Stafford. Visits from officers of the PREVENT team became less

regular. Overall, he became more socially isolated.

21. On 14 November 2019, two PREVENT team officers visited Usman Khan at the

suggestion of the MAPPA agencies to take photographs of his DVDs and video games.

He became upset about this, which he apparently regarded as an invasion of privacy.

This reaction provoked some concern on the part of investigating officers.

22. From 20 November 2019, Usman Khan purchased a number of items which he would

later use in the terrorist attack, including various items of clothing and items which he

incorporated into a relatively sophisticated hoax suicide vest. Most of the items were

bought on 28 November 2019, the day before the attack. It is believed that, on that day,

he purchased the kitchen knives that he was to use in the attack. None of these

preparations were known to the Security Service or counter-terrorism police.

Events of 29 November 2019

23. On 29 November 2019, the Learning Together event at Fishmongers’ Hall took place as

scheduled. It was attended by current and former university students and academics; by

supporters of the organisation; and by serving and former prisoners. Saskia Jones

attended as a former Cambridge criminology master’s degree student who had an interest

in the programme and who wanted to pursue a career as a police officer. Jack Merritt

was employed by the University to work full-time for Learning Together.

24. Usman Khan travelled alone by train from Stafford to Euston station, where he was met

by a staff member of Learning Together before travelling on to Fishmongers’ Hall. He

had with him a bag containing knives. It is believed that he had put on the hoax suicide

vest under his coat while in a toilet on the train journey from Stafford to London.

25. The Learning Together event began at 11am with an opening session, followed by

breakout sessions. During a break and shortly before 2pm, Usman Khan went to the

toilets on the ground floor, near the entrance to the building. In a cubicle he armed

himself with the knives and taped them to his wrists. Jack Merritt went into the toilets,

where Usman Khan attacked him, stabbing him several times. This attack took place

between 1.56pm and 1.57pm.

26. Usman Khan left the toilets. A female member of staff from the Hall was standing near

the door, and he gestured to her to remain silent. He then attacked Saskia Jones, who

was waiting by the cloakroom desk, stabbing her in the neck and seriously injuring her.

Saskia Jones moved to the main staircase, where she collapsed. She quickly received

first aid from other attendees of the event. Meanwhile, Jack Merritt left the toilets in an

injured condition and made his way to the entrance hall. He was helped into the reception

office near the front door. Staff there called the emergency services.

27. Usman Khan continued his attack, stabbing further people on the ground floor and

inflicting further injuries. A number of those at the event fought back, using improvised

weapons from the Hall (including a fire extinguisher and a narwhal tusk). After a short

period of confrontation with them, Usman Khan forced his way out of the building and

headed onto London Bridge. He was pursued by three attendees from the event. Once

on the Bridge, they managed to force him to the floor. Along with members of the public,

they kicked the knives from his grip.

28. Three officers from the City of London Police (“CoLP”) were the first armed officers on

scene. At 2.02pm, they approached Usman Khan together and moved others away from

him. Two of them, seeing him wearing an apparent suicide vest, discharged their

firearms at him. The third discharged a Taser. They then backed away from him, while

they and other officers kept their weapons trained on him.

29. Over the period that followed, further firearms officers from both the CoLP and the

Metropolitan Police Service (“MPS”) arrived on the scene and many kept Usman Khan

covered from a distance with their weapons. Further shots were fired when he made

movements which caused the officers to fear that he may be about to detonate the

apparent suicide vest. After some time, it became clear that he had been incapacitated.

He was checked by explosive officers, who established that the vest was a convincing

fake. Paramedics assessed him and found him to be dead.

30. While the firearms officers were dealing with Usman Khan on the Bridge, first aid was

given to those whom he had attacked. Saskia Jones was treated at the bottom of the

staircase in the Hall. Jack Merritt’s first aid began in the Hall, before he was moved to

the junction of Cannon Street and King William Street where he received more advanced

medical care. Efforts to save Jack Merritt and Saskia Jones were unsuccessful, and each

was declared deceased.

Coroner’s Concerns

Preface

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

In my opinion, there are risks that future deaths could occur unless action is taken to

address those matters. In the circumstances, it is my statutory duty to report to

appropriate persons who may be able to take remedial action. This Report addresses

various topics and sets out matters of concern which are being reported to the addressees.

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

each instance, those to whom the point is addressed are identified. In total there are some

22 detailed MCs set out below divided in to 5 topic areas. There is then a final section

covering other topics that have been raised.

32.

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

families of what matters I should consider raising, as well as the responsive submissions

from other Interested Persons and reply submissions from the families. The need to give

time for those submissions and to consider them explains why this Report is being issued

some months after the end of the Inquests.

33. As well as identifying and explaining matters of concern, this Report also identifies some

points raised by the bereaved families which do not in my view justify inclusion in a

report on prevention of future deaths (“PFD report”). It is not normal practice for

coroners to include such detailed explanations of matters being raised or any account of

why certain matters are not being raised. PFD reports of coroners generally are, and

should continue to be, short and succinct documents produced quickly after inquests.

This Report by contrast is an extensive document, as is appropriate to these exceptional

Inquests (just as Hallett LJ produced a lengthy PFD report following the London

Bombings Inquests, and just as I did after the London Bridge and Borough Market Terror

Attack Inquests). It should not be seen as a model for inquests generally.

34. A number of the concerns raised in this Report relate to initiatives for the rehabilitation

and education of prisoners and ex-prisoners. I would like to emphasise at the outset that

I do not intend, by raising concerns in this way, to cause such valuable programmes to

be discontinued or to make it unduly difficult to manage such programmes in future.

Evidence in the Inquests established that programmes such as Learning Together can

help to move people away from offending behaviour and give them a sense of belonging

to an academic community. Learning Together itself has been highly praised in official

reports, and I saw some examples of offenders who have benefited greatly from its work.

The education and rehabilitation of offenders are aims which I very strongly support, and

they are aims which Jack Merritt and Saskia Jones also supported. We all as a society

benefit from projects which further those aims. To the extent that I raise concerns about

the management of programmes such as Learning Together, I do so with a view to

ensuring that they are operated in a safe and intelligent manner in the future.

Legal Principles

35. Before addressing the particular topics relevant to this Report, I shall set out the

applicable legal principles. In doing so, I shall largely adopt the submissions of Counsel

to the Inquests, which have not been disputed by Interested Persons in their submissions.

It is not normal practice for coroners to set out the law in PFD reports, but the wide public

interest in this Report warrants including an explanation of the law for the benefit of the

general reader.

36. Schedule 5 to the CJA, which is given effect by section 32, provides as follows at

paragraph 7:

“(1) Where –

(a)

(b)

(c)

a senior coroner has been conducting an investigation under this
Part into a person’s death,

anything revealed by the investigation gives rise to a concern that
circumstances creating a risk of other deaths will occur, or will
continue to exist, in the future, and

in the coroner’s opinion, action should be taken to prevent the
occurrence or continuation of such circumstances, or to eliminate
or reduce the risk of death created by such circumstances,

the coroner must report the matter to a person who the coroner believes
may have power to take such action.”

37. Part 7 of the Regulations contains provisions for the making of PFD reports. Regulation

28 provides as follows:

“(1) This regulation applies where a coroner is under a duty under paragraph

7(1) of Schedule 5 to make a report to prevent other deaths.

(2)

In this regulation, a reference to ‘a report’ means a report to prevent
other deaths made by the coroner.

(3) A report may not be made until the coroner has considered all the
documents, evidence and information that in the opinion of the coroner
are relevant to the investigation.”

38. The following principles govern the making of PFD reports:

The regime provides for a coroner to make a report if he or she forms the opinion

that a risk of future deaths can be identified and that preventive action ought to be

taken in all the circumstances. If he or she forms that opinion, it is necessary to

make a report with the relevant content. That is the effect of the words “must

report” in paragraph 7(1). See R (Lewis) v Mid and North Shropshire Coroner

[2010] 1 WLR 1836 at [14]-[16] and [19].

The power and duty to make a report only arise where the coroner forms the

opinion, based on the inquiry, that particular risks of death exist for which

preventive action is required. As Silber J said in R (Cairns) v HM Deputy Coroner

for Inner West London [2011] EWHC 2890 (Admin) at [74], the statutory

expression “in the coroner’s opinion, action should be taken…” reflects a

discretionary judgment by the coroner.

The jurisdiction to make PFD reports is not limited to reporting circumstances and

risks which were causally relevant to the particular deaths under investigation: see

Lewis (cited above) at [14]-[19]; Rule 43 Report of Hallett LJ following the London

Bombings Inquests, [161]; Chief Coroner’s Guidance No. 5, [17]. However, it

does require that the material in the particular investigation has highlighted general

or systemic risks or failures which may recur or continue, with potentially fatal

consequences: see R (Francis) v HM Coroner for Inner South London [2013]

EWCA Civ 313 at [7]-[8], Davis LJ.

d. A coroner may properly decide not to make a PFD report on an issue on the basis

that he or she is not satisfied that further action is necessary. If, for example, it

appears that a risk or issue has been addressed by action of some kind, or if

circumstances have changed substantially since the death in question, the coroner

may reasonably say that he or she is not satisfied further action is required. Equally,

a coroner may decide that there is simply insufficient material to form a view that

there are particular risks of future deaths and/or that further action is required. See,

for example, the approach taken by Hallett LJ to various issues in her Rule 43

Report after the London Bombings Inquests (e.g. [70] and [217]). See also Jervis

on Coroners (14th ed.) at [13-125].

The purpose of death investigation in both domestic law and the law of the

European Convention on Human Rights includes a concern to identify systemic

failures and risks. See, for example R (Amin) v SSHD [2004] 1 AC 653 at [31]; R

(Sacker) v West Yorkshire Coroner [2004] 1 WLR 796 at [11]. The domestic legal

scheme deliberately confers on a professional adjudicator (the coroner) the

judgment whether such risks exist and whether they need to be addressed by action:

see Lewis (cited above) at [40]; R (Middleton) v West Somerset Coroner [2004] 2

AC 182 at [38].

39. Chief Coroner’s Guidance No. 5, updated in November 2020, also addresses PFD reports.

As that document explains:

PFD reports are important, but they are ancillary to the inquest procedure and not

its mainspring. See Guidance at [6] (and see, to the same effect, Dove v HM Asst

Coroner for Teesside [2021] EWHC 2511 (Admin) at [73]).

“Broadly speaking reports should be intended to improve public health, welfare

and safety. They should not be unduly general in their content; sweeping

generalisations should be avoided. They should be clear, brief, focused,

meaningful and, wherever possible, designed to have practical effect.” See

Guidance at [4].

If a report is made, it need not (and generally should not) prescribe particular action

to be taken. It need not (and generally should not) apportion blame or be prejudicial

(see, to the same effect, Jervis at [13-123]). The content of the report should be

focussed and limited to the statutory remit. See Guidance at [27]-[30].

40.

In summary:

a. A coroner should make a PFD report if satisfied of two propositions: (i) that there

is a concern that circumstances creating a risk of other deaths will occur, or will

continue to exist, in the future; and (ii) that in his or her opinion, action should be

taken to prevent the occurrence or continuation of such circumstances, or to

eliminate or reduce the risk of death created by such circumstances. Each of these

issues, especially the second, is a matter of judgment.

The coroner must form this judgment based on information revealed by the

particular coronial investigation.

It is not necessary for the coroner to conclude that the particular death under

investigation was caused by the circumstances or risks which may be the subject

of the report. However, it is usually necessary for the coroner to find that general

or systemic risks or failures have been highlighted by the material in the particular

investigation.

It is perfectly proper for a coroner to say that a risk or issue has apparently been

addressed, or that on the available material he/she cannot be satisfied that

preventive action need be taken. In making a decision, the coroner is entitled to

take account of the passage of time and changes of circumstances since the deaths.

Before deciding whether to make a report, the coroner should consider whether it

would be directed to improving public health, welfare or safety and whether it

would be focussed, practical and within the statutory remit.

41. Finally, it is important to note that PFD reports will often draw attention to matters of

concern or to risks, rather than prescribing particular solutions. A coroner is often not

qualified to propose specific action and may not be aware of all the consequences of

taking such action. A coroner may be unaware of exactly what remedial action is

practicable, or unaware of competing demands for resources. These considerations

should not, of course, lead to paralysis in the preparation of PFD reports. A coroner may

raise a concern and later be properly told that there is no perfect or practicable solution.

Topic 1: Rehabilitation and Education of Offenders and Ex-Offenders

42.

It is appropriate to begin with this topic, since it was plainly a matter of interest and

concern to Saskia Jones and Jack Merritt. They were two young people with strong

values who were both committed to making a positive impact on their society and

improving the lives of others. They both played a part in Learning Together, although it

is fair to say that Jack was more deeply involved with that programme, while Saskia

pursued other areas of concern to her (including in relation to victims of serious crime,

in particular sexual violence).

Risk assessments and mitigating risk at events

43. An issue explored extensively in evidence was whether risk assessments should have

been prepared for the Learning Together event at Fishmongers’ Hall. The University of

Cambridge had internal guidance (at university level) on risk assessments and risk

management for travel, fieldwork and work away from Cambridge. As I understand it,

that guidance would have extended to an event such as that on 29 November 2019 and

would have required a formal risk assessment to be produced. However, it appeared from

the evidence of the founding directors of Learning Together (Dr

and Dr

) that this guidance had not been implemented at departmental level, such

that it was not expected that risk assessments would be produced for such an event, or

indeed for any of the prison-based courses or community events run by Learning

Together.

44. The preparation of a risk assessment for a major event such as this, or indeed for courses

run in environments such as prisons, is an inherently valuable exercise. It requires the

organisers to apply a structured approach to considering risk and it may highlight risks

which would otherwise be missed even by diligent and intelligent people.

45.

It is evident that the University of Cambridge had and has a well-developed set of risk

management procedures at university level, as one would expect of a university with the

prestige and resources of Cambridge. However, it is a matter of significant concern that

risk assessment procedures appear not to have been implemented at departmental level

(the Institute of Criminology), especially in relation to courses in prisons and major set-

piece events attended both by ex-offenders and by senior figures from the field of

criminal justice. Furthermore, the academics who appeared at the Inquests gave credible

evidence that it is commonplace not to have structured risk assessments for academic

events generally. I have no reason to believe that this was a problem limited to the

University of Cambridge.

46. The witnesses from Learning Together expressed the view that, if a formal risk

assessment had been undertaken for the event at Fishmongers’ Hall, it would not have

resulted in any different measures being taken. However, that evidence was necessarily

speculative and may have been coloured by the events which followed. In my view, a

proper risk assessment may well have caused some consideration to be given to

discussing security measures with the Fishmongers’ Company and specifically informing

it of the background of some of those who would be attending (i.e. some current prisoners

and former inmates convicted of very serious offences).

MC1 – Addressed to the University of Cambridge, Learning Together, the

Secretary of State for Education and the Office for Students: Significant academic

events and courses held outside of university premises should be subject to proper

formal risk assessment, especially if they take place in environments with particular

risk (such as prisons) and if they are attended by individuals who pose particular

risks. It is a matter of concern that there was no such risk assessment for Learning

Together events as set out above. The University of Cambridge and those

responsible for guidance to UK higher education institutions should consider

whether further steps can be taken to encourage the making of such risk

assessments.

47. Another issue raised by the evidence in the Inquests concerned whether and how clearly

the Fishmongers’ Company was informed that current and recently released prisoners

would be attending the event. There was evidence that representatives of the

Fishmongers’ Company had attended Learning Together events and had a good idea of

what the initiative involved. It appears that the directors of Learning Together took the

view that the Fishmongers’ Company must have been aware that ex-offenders would or

might be attending the event, and were not told of any concern. However, the Clerk of

the Fishmongers’ Company gave evidence that he would have been surprised to be told

that some attending had been in prison for serious offences. All this evidence suggests

to me that there were failures of communications between Learning Together and the

Fishmongers’ Company. It is important that comparable failures of communication do

not take place in future. Without knowing that current inmates and recently released

serious offenders are to attend an event, those responsible for a venue cannot conduct

their own risk assessment and, if appropriate, put risk mitigation measures in place.

48.

It should be noted that, following an internal security review after the attack, a new

procedure for categorisation of events was implemented by the Fishmongers’ Company.

Any event attended by high-risk individuals or convicted offenders would now be a

category D event, for which there would be a rebuttable presumption that the event would

not be permitted to take place at Fishmongers’ Hall. It is of course a matter for any host

organisation to adopt its own procedures, and I would not want to discourage the holding

of events to which ex-offenders can be invited. However, this does show that safe

procedures depend upon good communications about the nature of an event and the

profile of attendees.

MC2 – Addressed to the University of Cambridge, Learning Together, the

Secretary of State for Education and the Office for Students: It is a matter of

concern that a major event could be held by a University at a livery company hall

in London without clear communication of the fact that it would be attended by

serving and recently released serious offenders. Consideration should be given to

guidance requiring higher education institutions to inform host venues of high-risk

features of events, including for instance the attendance of such persons.

Risk assessments and mitigating risk in relation to offenders

49. The concern expressed above relates to the risk of a violent or other criminal act occurring

at an event. However, the evidence also indicated a more subtle and long-term type of

risk which can arise when young undergraduate students are involved in a programme

alongside those convicted of serious offences. As the head of counter-terrorism at HMP

Whitemoor acknowledged, some such people can be manipulative and predatory.

50. The Learning Together programme started at HMP Grendon in 2015 and was soon

afterwards rolled out to HMP Warren Hill. HMP Grendon is a category D prison with a

therapeutic community and some democratic involvement by which the prisoners

contribute to the running of the prison to an extent. HMP Warren Hill is a category C

prison. In late 2016 and early 2017, Learning Together began its work at HMP

Whitemoor, a Category A high security prison in Cambridgeshire. The directors of

Learning Together were aware that HMP Whitemoor housed many terrorism offenders

and others serving long sentences for other very serious and violent crimes.

51.

It was clear from the evidence that proper measures were put in place by HM Prison and

Probation Service (“HMPPS”) to keep the visiting students physically safe while they

were inside HMP Whitemoor. However, there were other risks of having young people

associating closely with these offenders, and it does not appear that those involved in

Learning Together gave focussed consideration to those risks. Such risks became more

acute in the context of the substantial alumni and community element of the Learning

Together programme.

52. A potential measure which many witnesses were invited by counsel to consider during

the Inquests would be a regime whereby offenders who have committed certain

categories of offence (such as terrorism offences and/or certain other serious offences)

might not be permitted to take part in Learning Together courses. However, I appreciate

that there may be real value in keeping such courses open to a wide range of offenders.

One possible approach suggested during the hearing was for such a regime of “category

exclusions” to be put in place temporarily, pending further research or safeguarding

measures being pursued.

MC3 – Addressed to Learning Together and the University of Cambridge: It is a

matter of concern that focussed consideration was not given to the risks of serious

offenders being placed in close and continuing contact with young students.

Consideration should now be given to such risks and targeted means of mitigating

them.

53.

In order for Learning Together to operate safely in future and to make proper assessments

of the risks posed by offenders, it is important that its staff should be able to access

information about the risk profiles of offenders joining courses. The same point would

apply to other comparable higher education providers working in prisons. This may be

a difficult issue, as there are likely to be limits to the information which HMPPS could

provide to an organisation such as Learning Together. However, it should be possible to

supply some information about offending history and a basic risk profile. In this case, it

is troubling that those responsible for Learning Together had no knowledge that Usman

Khan was regarded by the prison authorities as a dangerous, radicalising figure in the

prison community.

MC4 – Addressed to the Secretary of State for Justice: It is a matter of concern that

Learning Together could operate courses in prisons in the way it did without being

given

information about the risk profiles of offenders joining courses.

Consideration should be given to whether further procedures can be put in place to

ensure or at least encourage some such information to be shared with higher

education providers working in prisons.

54. The concerns expressed above relate specifically to the process by which a prisoner might

be accepted onto a programme run in a prison by a higher education provider such as

Learning Together. However, the facts of this case gave rise to a distinct concern as to

whether such programmes ought to maintain contact with serious offenders after their

release into the community and, if so, subject to what safeguards. The prison authorities

cannot, of course, manage the risks involved in these alumni or community programmes.

55. Such programmes should not be ruled out entirely, since re-integrating ex-offenders into

the community is a laudable aim. However, it is important to recognise that not all ex-

offenders are alike. Many prisoners on their release will be well rehabilitated and ready

to contribute as productive members of society, whereas others will re-offend and may

pose a serious threat to those placed in contact with them.

56.

If providers of higher education are to have alumni or community programmes which

maintain contact with offenders after their release from prison, such programmes should

be the subject of careful risk management. This might in practice involve the

organisation having procedures governing what types of offenders might be involved in

such a programme; how contact might be maintained and supervised; and what types of

events might be arranged. Learning Together did not have such procedures governing

its alumni programme.

MC5 – Addressed to the Secretary of State for Justice, the Secretary of State for

Education, the Office for Students, the University of Cambridge and Learning

Together: Consideration should be given to whether further measures of risk

assessment and management can be introduced for any higher education

programmes running in prisons which involve continued contact with offenders

after their release into the community.

57. Some of the submissions made on behalf of the bereaved families have addressed the

future of Learning Together itself as an educational initiative. It would not be appropriate

in a report such as this to advocate the winding-up of an initiative for the education of

offenders, especially one such as Learning Together which has evidently done a great

deal of good.

58. The representatives of the families have submitted that the directors of Learning Together

did not, in their evidence to the Inquests, show sufficient concern to learn from this

experience and specifically to reconsider possible weaknesses in their procedures for

assessing and managing risk. It is not the function of this report to comment on particular

individuals, either by criticising or defending them. Nevertheless, I would encourage

those with relevant responsibilities within the University of Cambridge and the Learning

Together programme to reflect on the contents of this Report and more generally on the

lessons they may be able to learn from this tragic case. Usman Khan was a very

dangerous man, who was recognised as such by the prison and probation authorities and

by the police. However, as the jury found, many of those who dealt with him were

unaware of the risk he posed or even chose not to consider it, preferring to accept his

self-presentation as a reformed individual.

Topic 2: National Probation Service (NPS) and MAPPA risk assessment and management

59. The matters of concern set out above, insofar as they are addressed to the Secretary of

State for Justice, concern the management of risk by the prison service in the context of

higher education programmes. This next section of this Report addresses matters which

concern the work of the NPS.

Extremism Risk Guidelines

60. As already observed, Usman Khan was the subject of an ERG 22+ assessment while in

prison in early 2018. That assessment was carried out by a forensic psychologist, as was

the norm for such assessments in the prison environment, and it clearly demonstrated

Usman Khan as presenting a very serious threat of extremist offending. The report from

that assessment illustrates that the ERG 22+ tool can be a useful one in assessing the risk

posed by extremist offenders. I am aware that ERG reports prepared in relation to Sudesh

Amman, who committed the terror attack on Streatham Hill in February 2020, were

similarly thorough and prescient.

61. After Usman Khan’s release, his NPS offender manager was tasked with the preparation

of a revised ERG assessment, with assistance from a specialist counter-terrorism

probation officer (“CTPO”). At the time, it was standard practice for any such

assessment of an offender in the community to be carried out by a probation officer with

relevant training in the assessment tool. In this case, the assessment was carried out in

mid- to late 2019 and a draft report, which was almost in final form, had been prepared

just before the attack. It is striking that this assessment was much less detailed and

analytical than that prepared by the forensic psychologist in early 2018 and that it

presented a very optimistic picture of Usman Khan, suggesting that his risk be markedly

down-graded.

62.

It would be unfair to criticise the offender manager for the weaknesses apparent from

that draft report. He was a conscientious probation officer, but had very little experience

of dealing with terrorist offenders and did not have the professional background in

psychological assessment which aspects of the assessment tool appear to require. The

CTPO was similarly lacking in practical experience.

63. Some important observations were made by two of the witnesses:

First,

, the Chief Probation Officer, accepted that it is beneficial for an

ERG 22+ assessment to be prepared by a forensic psychologist, as opposed to a

probation officer. Since the attack at Fishmongers’ Hall, the NPS has introduced

the support of psychologists in the community to assist in the preparation of such

assessments, with the reports themselves being written by CTPOs. Furthermore, a

rule has since been introduced that it should not be the probation officer who acts

as a person’s offender manager who completes the assessment.

Secondly,

, the forensic psychologist who conducted the

assessment of Usman Khan in 2018, gave evidence that in principle it would be

helpful for a MAPPA panel to hear from a person in her position summarising

findings from the assessment. Although professional guidelines for the completion

of an ERG assessment specified that such an assessment could be completed by “a

fully qualified professional who has experience of working in forensic settings for

example, a registered forensic psychologist/clinical psychologist or an experienced

probation officer”, the evidence of

was that in completing her

assessment she relied upon training which probation officers do not receive.

MC6 – Addressed to the Secretary of State for Justice: Notwithstanding the

measures which the NPS has put in place since the attack, there remains cause for

concern that ERG 22+ assessment reports may be prepared by a CTPO without the

direct involvement of a forensic psychologist. Consideration might usefully be given

to (a) requiring that every such report be completed by a forensic psychologist or

(b) requiring that every such report on an offender in the community is either

prepared by, or subject to detailed critical review by, a forensic psychologist.

MC7 – Addressed to the Secretary of State for Justice: It is a matter for concern

that MAPPA panels managing even the most serious offenders may not have the

benefit of hearing directly from a forensic psychologist who has prepared an ERG

report shortly prior to the offender’s release. Consideration should be given to

introducing procedures or guidance to require or encourage the attendance of such

a psychologist at appropriate MAPPA panel meetings.

OASys assessments

64. OASys is a tool for structured risk assessment of offenders both in prison and in the

community. It involves the completion of a lengthy report form by a probation officer

based on evidence from a range of sources. The risk of serious harm posed by the

offender to various categories of person (including the general public) is expressed in a

series of risk gradings.

65. As noted above, before Usman Khan’s release from prison, an OASys assessment was

carried out in August 2018. The conclusion of this assessment was that Usman Khan

posed a “very high” risk of serious harm to the general public. No updated OASys

assessment was prepared in the year following his release. The evidence was that the

responsible probation officers decided to have an ERG assessment performed first in

order to inform the updated OASys assessment, and that (as noted above) the ERG

assessment report was just being completed at the time of the attack.

66. On 15 May 2019, Usman Khan’s offender manager, in discussions with his line manager,

determined that the risk of serious harm rating for Usman Khan should be reduced to

“high”. This was recorded in very brief terms on the NPS Delius Notes system. The

decision appears to have been reached in quite an informal manner and no detailed

rationale was recorded anywhere.

67. An OASys assessment is a designed to allow the assessor to reach conclusions as to an

individual’s likelihood of re-offending, using a structured risk assessment tool. The risk

rating arrived at by this assessment tool is used by the MAPPA agencies in formulating

their risk management plan. The OASys risk rating for an offender should not be changed

without an offender manager conducting a full re-assessment, using the structured form,

so that any change is made in a careful and informed manner. Otherwise, there is a real

chance that changes will take place without proper critical thinking. Although it appears

that the MAPPA agencies in this case continued to proceed on the basis that Usman

Khan’s risk rating was “very high”, the facts give rise to a concern that an OASys risk

rating may be changed without proper use of the assessment tool.

68. The Secretary of State for Justice has stated in submissions that there is new Risk of

Serious Harm Assessment Guidance (published in July 2020) which stresses the need for

clear and recorded decision-making. However, it is not clear to me that it would be

impossible in future for an offender’s risk rating to be changed in an informal manner as

happened in this case.

MC8 – Addressed to the Secretary of State for Justice: The facts of this case give

rise to concern that an OASys risk rating for an offender may be changed without

the offender manager completing the full assessment exercise (using the structured

form) and that the change may be recorded without proper rationale. Given the

importance placed on the risk ratings in management of dangerous offenders, this

requires specific consideration.

Management of offenders’ licence conditions

69. Offenders such as Usman Khan are often subject to licence conditions which preclude

them from doing certain things or going to certain places without approval of their NPS

offender managers. The evidence in this case gave rise to concern that such approvals

may be given without clearly reasoned decision-making and clear lines of accountability.

70. The most significant example in these Inquests concerned the approval of Usman Khan’s

attendance at the Learning Together event at Fishmongers’ Hall on 29 November 2019.

He was subject to licence conditions which precluded him from (a) attending a railway

station or (b) attending a gathering without the prior approval of his offender manager.

While the offender manager was responsible for granting such approvals, the evidence

was that he would follow any instructions or guidance given by the MAPPA panel.

71.

In this instance, the probation officer granted permission for Usman Khan to attend the

event. However, there was no formal record of his decision or the reasoning behind it.

While there were records of the event having been brought to the attention of the MAPPA

panel in August 2019 and again in November 2019, there is no record of it having been

the subject of detailed discussion and certainly no record of the attendees having

considered the risks or benefits of him attending the event. By contrast, there are

substantial records of their having considered the risks and benefits of other potential

activities, such as Usman Khan participating in the dumper truck course. More worrying

still, there were conflicts in the evidence as to whether or not the MAPPA panel had

endorsed the decision by the probation officer to grant permission for Usman Khan’s

attendance at the event.

72. This was a decision to permit a terrorist offender, who was still regarded as posing a high

or very high risk of serious harm to the general public, to use the rail network

unaccompanied and to attend a major event at an iconic location in central London. It

was an important decision which should have been the subject of specific discussion at

the MAPPA meetings, with proper consideration of the risks and potential benefits. The

decision to grant permission should have been recorded with a full rationale (on the

Delius system, in the MAPPA minutes or in both those records). It should have been

clear from the records whether the decision had been taken by the probation officer alone

or with express consideration and approval by the MAPPA panel.

73. The Chief Probation Officer said that she would have expected to see the licence

condition permissions, including permission to attend the event, recorded on Delius or

elsewhere. It was a significant step, and she expected probation officers to record their

rationale in such cases. However, it would not be fair to lay the blame on the offender

manager, when in fact there appears to have been a collective failure by the MAPPA

participants to give any thought to the risks arising from the prospective visit to London.

In this regard, it should be noted that the jury found “serious deficiencies in the

management of Khan by MAPPA” and a “blind spot to Khan’s unique risks”.

74.

If there had been a requirement for the decision permitting Usman Khan to attend the

event in London to be properly recorded, then it would have been possible for the jury

and me to see and consider a contemporaneous account of the reasoning behind that

decision. More importantly, such a requirement would assist in ensuring that those

responsible for such decisions apply their minds to the competing risks and advantages

of granting approvals under licence conditions.

75. According to submissions made in advance of this Report being produced, the new Risk

of Serious Harm Assessment Guidance encourages probation officers to record the

rationale for key decisions, without making it mandatory. The submissions of the

Secretaries of State also indicated that further guidance which was to be produced by the

end of August 2021 would make recording of such key decisions mandatory.

76. NPS offender managers should not be subject to such onerous obligations of record-

keeping that they are unable to perform their primary role of supervising offenders and

helping to equip them for life in the community. However, where a decision is taken to

grant an approval under a licence condition, the decision and the underlying reasoning

should be recorded in the Delius system or an equivalent system, even if only briefly. If

an offender is subject to MAPPA management, it should be clear from the record of the

decision whether the offender manager has taken the decision with or without express

approval from the MAPPA panel.

MC9 – Addressed to the Secretary of State for Justice: This case gives rise to

concern that offender managers may take significant decisions to give approvals

under licence conditions without those decisions being properly reasoned and

recorded. Consideration should be given to ensuring, by means of NPS guidance,

that offender managers always (a) record a rationale for giving any permission for

approval, variation or relaxation in relation to licence conditions and (b) in the case

of offenders subject to Level 2 or 3 MAPPA management, record whether or not

the decision has been taken with express approval from the MAPPA panel.

77. As indicated above, there was conflicting evidence as to whether or not the key decision

to permit Usman Khan to attend the event at Fishmongers’ Hall was actually considered

or approved by the MAPPA panel. Some participants in the meetings said that it had

been specifically discussed, whereas others had no recollection of such specific

discussion. The Chair of the MAPPA panel believed that there had been some discussion

but could not recall the detail. He said that he would have expected any lengthy

discussion to be minuted and he acknowledged that the minutes did not reflect detailed

consideration of the decision.

78.

It will not always be possible for an offender manager’s decision to grant an approval in

relation to a licence condition to be endorsed by the MAPPA panel. Sometimes,

decisions will have to be taken without waiting for the next MAPPA panel meeting.

However, there was no dispute that important decisions of this character should be placed

before the MAPPA panel where that is possible. At minimum, there should be a

requirement for MAPPA minutes to record any approval of a decision to grant an

approval, variation or relaxation in relation to a licence condition (with brief reasons).

79. Such a requirement would also assist in achieving accountability for decisions. Either

the offender manager would take a decision without reference to the MAPPA panel, in

which case his or her decision and its reasons would appear in the Delius notes and he or

she would bear sole responsibility for it; or the decision would be approved by the

MAPPA panel, in which case the approval and its rationale would appear in the MAPPA

minutes and all the MAPPA participants would bear responsibility.

MC10 – Addressed to the Secretary of State for Justice, the College of Policing, the

Chief Constable of West Midlands Police and the Chief Constable of Staffordshire

Police: The facts of this case give rise to concern that important decisions on

approvals, variations and relaxations in relation to licence conditions may be taken

without clearly reasoned discussion and decision-making in MAPPA panels. This

issue could be addressed by requiring MAPPA minutes to record any discussion or

decision on such a matter. In addition, for the benefit of future inquiries and

reviews, consideration should be given to having digital audio recordings made of

all MAPPA meetings.

80. This case also raised a more general issue concerning the approach of probation officers

to granting permissions, variations and relaxations in relation to licence conditions.

Usman Khan’s probation officer saw Learning Together as having a very positive

influence on him. He thought that it was an important aspect of rehabilitation and

personal development, although he was unaware that Usman Khan was not doing any

actual work with Learning Together and had only sporadic contact with the organisation.

81. Meanwhile, the probation officer and the MAPPA panel appear not to have considered

the attendance at the London event from a risk perspective. Some participants sought to

justify this approach by saying that Usman Khan could have travelled around the country

without special permission and that it was impossible to risk-assess his every move.

However, there is a reason why terrorist offenders are often subject to licence conditions

requiring approval for them to use major public transport networks and/or to attend major

events. These conditions exist to allow for proper risk management, and it is important

that decisions in relation to them should be taken with some specific consideration of the

risks entailed.

MC11 – Addressed to the Secretary of State for Justice: This case gives cause for

concern that an offender manager and/or MAPPA panel participants could approve

a permission, variation or relaxation in relation to a licence condition without

directly addressing the potential risks involved. Consideration should be given to

whether there can be further guidance to ensure that the risks as well as the

potential benefits of such decisions are carefully examined.

Specific matters relating to the management of terrorist offenders in the community

82.

In addition to the concerns raised above about the procedures followed by probation

officers and in MAPPA meetings, it is appropriate to raise a specific issue about

substantive decision-making.

gave evidence that, when assessing the

risk of an individual engaging in extremist activity, it is important to consider whether

the person’s self-presentation is deceptive. It is apparent from her own assessment report

that rigorous assessment often involves considering the offender’s accounts on subjects

such as the conduct and events which led to arrest and his/her behaviour in prison, and

comparing those accounts to objective evidence.

83.

In the case of Usman Khan, there are numerous examples of him being dishonest to his

probation officers, especially when speaking about his offending behaviour and his time

in prison. For instance, when speaking about his offending, he claimed on many

occasions to have been intending to set up a mosque or a genuine religious school, and

on another occasion that he had only intended to have weapons there for self-defence.

These statements were squarely at odds with the express basis of his guilty pleas. When

speaking about his time in prison, he claimed to have stood up to and challenged

extremists, when in fact he had remained a leading radicalising influence in the various

prisons. The offender manager attached very little weight to these apparent instances of

dishonesty, while the CTPO involved in the case suggested in his evidence that they were

unimportant.

84. The facts of this case show the value of being alert to instances of significant dishonesty

in self-presentation by terrorist offenders. I am aware that similar instances of dishonesty

were seen in the case of the Streatham Hill attacker, Sudesh Amman.

MC12 – Addressed to the Secretary of State for Justice: The facts of this case give

rise to concern that probation officers may give insufficient regard to instances of

dishonesty in self-presentation by extremist offenders. Consideration should be

given to having this aspect of assessment emphasised in training of offender

managers.

85. A related concern is that too much weight may be placed by those managing an extremist

offender on purely passive “compliance” (i.e. the person not actually breaching licence

conditions or committing criminal offences). The risk posed by such offenders, as

recognised explicitly by the prison authorities is that of “deceptive compliance”.

86. The forensic psychologist who assessed Usman Khan differentiated between an absence

of poor behaviour and evidence of positive behaviour. By contrast, those in the NPS

responsible for managing Usman Khan and those in the PREVENT team placed much

reliance on Usman Khan’s self-presentation and his “compliance”. This case provides a

powerful example of an extremist offender remaining apparently compliant with licence

conditions for a year before staging a murderous attack.

MC13 - Addressed to the Secretary of State for Justice: Based on the facts of this

case, there is cause for concern that probation officers may attach excessive weight

in their management of extremist offenders to “compliance” (i.e. absence of

evidence of breach of licence conditions and polite behaviour). Consideration

should be given to training and guidance warning offender managers about placing

too much reliance on this feature.

87. As explained above, the particular decision under the spotlight in this case was that

Usman Khan should be permitted to attend the event at Fishmongers’ Hall alone and

without any measures being taken to mitigate risk. The determinations made by the jury

were critical of the procedures followed in making that decision.

88. When such a decision is to be taken whether or not to permit an extremist offender to

attend an event or venue (whether for work, education or social purposes), full

consideration should be given to the risks which might arise. In order to address those

risks properly, probation officers and police officers involved should ordinarily obtain

details of security measures in place at the venue.

89.

It was submitted on behalf of the family of Saskia Jones that, when an extremist offender

is permitted to attend a venue or event, those managing the offender ought to contact the

hosts or organisers, so as to obtain information on security measures and, where

appropriate, offer appropriate advice and guidance to strengthen those measures. The

concern behind this submission is entirely reasonable, but it may be too prescriptive to

require this to happen in all cases, given the wide range of situations which may arise in

future. For instance, there may be cases where it would be detrimental to a covert

investigation to require such communication to take place. However, it would be

beneficial for the authorities to consider including in future training and guidance the

point that communication about security measures with event organisers and venue hosts

will often be advisable.

MC14 – Addressed to the Secretary of State for Justice, the College of Policing, the

Chief Constable of West Midlands Police and the Chief Constable of Staffordshire

Police: This case gives rise to concern that an extremist offender may be permitted

to attend an event or venue without there having been proper communication

between the probation and police officers responsible for managing the offender

and the event organisers and/or venue hosts. Consideration should be given to

encouraging such communications within the training and guidance given to

probation officers and police responsible for managing extremist offenders.

Drug testing of offenders on licence

90. Toxicology analysis carried out on samples from the body of Usman Khan after his death

demonstrated that he had used cocaine in the period relatively shortly before his death.

Despite the strict licence conditions controlling him and despite the various means by

which he could be monitored (including the GPS tag), he was able to obtain and use

cocaine while living in Stafford without that being discovered. I am well aware how easy

it can be to buy Class A drugs in many town and city centres. Nevertheless, it is a matter

of concern that his use of Class A drugs could not be detected, since detection would

have revealed that Usman Khan was not in fact compliant with his licence conditions and

it would have provided a basis for recalling him to prison. The submissions of the

Secretaries of State helpfully explain that work is being done to extend the use of random

drug testing of offenders on licence while they are living in approved premises, and that

steps are being taken to ensure that necessary statutory powers are available.

Consideration should also be given to whether anything can be done to facilitate such

testing continuing for serious offenders after they have left approved premises (e.g. by

developing licence conditions for the purpose).

MC15 – Addressed to the Secretary of State for Justice: The facts of this case give

cause for concern that a terrorist offender on licence, who was subject both to strict

licence conditions and to a priority investigation, could obtain and use Class A drugs

without that being detected. Consideration should be given to whether further steps

can be taken to facilitate random drug testing of offenders on licence (especially

those who have committed serious offences), including both those living in approved

premises and those living independently.

Topic 3: Desistance and Disengagement Programme

91. The DDP is a Home Office programme for the rehabilitation of individuals who have

been involved in terrorism or terrorism-related activity. It also aims to reduce the risk

they pose to national security. One aspect of this programme is the appointment of

mentors for offenders on licence.

92. Usman Khan had a theological mentor and a practical mentor. With his practical mentor

he was able to have supervised access to the internet, so that he could seek employment

and rebuild his life in other ways. His allocation of a practical mentor ended abruptly, as

the Secretaries of State acknowledge in their written submissions. The Secretaries of

State also accept that such sudden ceasing of mentoring should be avoided if possible.

93. The sudden end to the mentoring arrangement had the effect that one of the few social

connections Usman Khan had in late 2019 was broken and that it became much more

difficult for him to search for work. Isolation and a failure to integrate in the community

had previously been identified as particular risk factors which might lead him to re-

engage in extremism. Although it is unclear whether the ending of the mentoring

arrangement actually contributed to Usman Khan conceiving a desire to carry out an

attack, it is obviously undesirable that such mentoring arrangements should be disrupted

in this way.

94. Following the end of the mentor arrangement, there was confusion between the various

state agencies over whether it was a priority for Khan to be allocated a new mentor. He

was not allocated a new practical mentor before his death. The Secretaries of State

acknowledge in their submissions that there was some miscommunication on this subject.

MC16 – Addressed to the Secretary of State for the Home Department: This case

gives rise to concern that mentoring arrangements under the DDP could be

disrupted suddenly in the case of a person whose risk of re-engaging in extremism

was known to be related to social isolation. It also gives rise to concern that an

offender could be suddenly deprived of the means to use the internet under

supervision to search for work. Measures should be taken to prevent a recurrence

of these circumstances.

Topic 4: Information Sharing between Agencies

95. A recurring theme in evidence in the Inquests, and a criticism identified by the jury

determinations, concerned

limitations

information-sharing between agencies

responsible for managing and investigating Usman Khan. The concern arose in various

contexts, including the sharing of information between overt and covert police teams; the

sharing of information between the Security Service and the police; and the sharing of

information between the police and NPS (in both directions). Relatedly, the evidence

gave cause for concern regarding procedures for communicating and recording

information and intelligence for MAPPA panel participants. This included issues about

the content and dissemination of MAPPA meeting minutes.

Minutes of MAPPA meetings

96.

In order that MAPPA panel meetings can be effective in managing the risks posed by

offenders, it is important that all participants are appraised of relevant information and

intelligence about the offender, subject to the point that some security intelligence

information may not be capable of being shared with all those who may usefully

participate in MAPPA meetings.

97. Although there was always detailed guidance requiring that all MAPPA panel

participants should receive minutes of meetings and approve them at subsequent

meetings, some participants did not in fact receive and read the minutes. It appears that

some participants received minutes by secure emails and that others were expected to

review minutes on the ViSOR system, but that some of the latter did not actually have

access to that system.

98. A related problem was that the membership of the panel varied from meeting to meeting

and some participants were not aware of the prison security intelligence information

which featured in MAPPA F forms and/or minutes of earlier meetings. If Usman Khan

had not committed the attack and been killed, he would have been under MAPPA

supervision for a considerably longer time. There would have been further changes to

the membership of the panel and further risks of loss of institutional memory.

99. The Secretaries of State point out in their submissions that current statutory MAPPA

guidance provides that meeting minutes will normally be sent via secure email to those

who attended a meeting and to those who were invited but did not attend. In this respect,

the current guidance seems to be very similar to that in place during 2019. Furthermore,

the submissions do not make clear whether there is any means for ensuring that

individuals joining an existing MAPPA panel should read in and bring themselves up to

date on previous intelligence and the content of previous meetings.

100. Against that background, there remains cause for concern that the statutory guidance does

not in practice ensure (a) that MAPPA meeting minutes are received and reviewed by all

attendees and (b) that new members of MAPPA panels appraise themselves of the

contents of previous minutes.

MC17 – Addressed to the Secretary of State for Justice, the College of Policing, the

Chief Constable of West Midlands Police and the Chief Constable of Staffordshire

Police: Based on the evidence in this case, there is cause for concern that effective

procedures are not in place to ensure that all MAPPA meeting attendees receive

meeting minutes. Consideration should be given to modifying guidance to ensure

that this happens, for example by (a) providing for all MAPPA panel participants

to receive minutes by secure email (rather than by having to access an online

system); (b) requiring that all acknowledge safe receipt and indicate whether or not

they wish to make amendments (to include provision of “nil returns”); and/or (c)

requiring attendees at the start of each MAPPA meeting formally to confirm that

they have read the minutes of the previous meeting or meetings as appropriate.

Information available to the MAPPA panel

101. So far as possible, those attending a MAPPA meeting should have updated information

relevant to assessing the risks posed by the offender and taking decisions on managing

that risk. In these Inquests, there were three particular sources of information which were

not available to all MAPPA participants. First, the MAPPA F form from the prison

authorities was a valuable source of information for early MAPPA meetings, but was not

always available to or considered by those participating in later meetings. Secondly, not

all participants were aware of the helpful conclusions of the ERG 22+ assessment report,

including the list of risk factors with which it concluded. Thirdly, there was intelligence

held by the Security Service and counter-terrorism police of which most participants were

ignorant (including intelligence which it seems could properly have been shared with

them).

102. Ensuring that the contents of MAPPA F forms and the key conclusions of ERG

assessment reports are known to all MAPPA participants should not present too great a

challenge. It should be possible to circulate the most recent MAPPA F form with every

subsequent set of MAPPA minutes, so that those managing an offender in the community

always have access to the most recent intelligence provided by the prison authorities prior

to the offender’s release. As for ERG assessment reports, it would for instance be

possible to add a short section to MAPPA minutes for a summary of relevant conclusions

and risk factors from such reports to be set out.

103. The sharing of security intelligence information with MAPPA panels presents a greater

challenge. There is a positive value in MAPPA panels being attended by some people

who cannot be realistically expected to receive details of secret intelligence from a covert

investigation. This includes not only the offender manager and police officers

responsible for overt supervision of terrorism notification requirements but also

authorities such as housing and education. Procedures therefore have to be devised for

MAPPA panels, or at least some participants of such panels, to receive the information

they need in a way which respects the integrity of covert investigations.

104. The approach currently taken is for counter-terrorism police to attend MAPPA meetings

and to act as the conduit or “bridge” for provision of security intelligence, including from

any covert investigation. A significant problem which arose in the present case was that

the Senior Investigating Officer (“SIO”) and Deputy SIO for the covert investigation into

Usman Khan did not generally attend MAPPA meetings and were not aware what

information was and was not being communicated to MAPPA participants. A senior

counter-terrorist police officer from West Midlands Police did attend the MAPPA

meetings and contributed to discussions, but she was not directly involved in the covert

investigation into Usman Khan and so could not be expected to ensure that all relevant

information was being taken into account.

105. A very unsatisfactory situation arose whereby there was a strand of intelligence received

shortly prior to Usman Khan’s release from prison that he intended to carry out an attack,

but the MAPPA panel participants were in the main entirely ignorant of that intelligence.

A number of the witnesses acknowledged that this would have been valuable to the

decision-making of the panel. The officer who was SIO of the covert investigation was

under the impression that this intelligence had been communicated to the MAPPA panel,

and it appears that the intelligence could have been communicated to them without

compromising security interests. Every effort should be made to ensure that a situation

of this kind does not occur again.

106. In my view, the best means of addressing this problem would be to require that, where

an extremist offender under MAPPA management is the subject of a counter-terrorist

policing investigation (with or without the involvement of the Security Service), either

the SIO or the Deputy SIO should be nominated as the person responsible for ensuring

that relevant information from the investigation is taken into account by the MAPPA

panel. If the SIO or Deputy SIO does not actually attend MAPPA meetings, he or she

should at least be provided with all minutes of MAPPA meetings, should be expected to

read them and should be under an obligation to ensure that information and intelligence

relevant to the management of the offender is taken into account by the MAPPA panel.

Where the information or intelligence is secret, this may require the SIO or Deputy SIO

to speak to a person attending the next MAPPA meeting who has the appropriate security

Text truncated at 80,000 characters — see the source PDF for the remainder.

Responses

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

Response from College of Policing (PDF)

(Partner) 

BDB Pitmans LLP 
One Bartholomew Close 
London 
EC1A 7BL 
22 December 2021 

Dear 

, 

This response is submitted on behalf of the College of Policing (‘the College’) in reply to the 
Coroner’s Report to Prevent Future Deaths (RPFD) following the Fishmongers’ Hall terror attack 
inquests. 

Firstly, I wish to extend my deepest condolences to the families and friends of those murdered 
and injured as a result of the terror attack. We also wish to state our appreciation of all of those 
who contributed to the proceedings. It is incumbent on the College and others in policing to 
ensure lessons are learned. 

Before providing a response to the specific matters of concern (MCs) that include the College, I 
would like to explain our role and remit in the policing landscape. 

Formed on the 1st December 2012, the College is a company limited by guarantee, owned by 
the Secretary of State for the Home Department, but operating at arm’s length from the Home 
Office.  

Our purpose is to connect everyone in policing to reduce crime and keep people safe by 
setting standards, providing training and sharing good practice. We have five key areas of 
responsibility, which were set out in the Explanatory Notes to the Anti-Social Behaviour, Crime 
and Policing Act 2014. These are also included in the Terms of Reference of the Company’s 
Board:  

a.

b.

setting standards and developing guidance and policy for policing,

building and developing the research evidence base for policing,

 
 c. 

d. 

supporting the professional development of police officers and staff, 

supporting the police, other law enforcement agencies and those involved in crime 
reduction to work together, and 

e. 

identifying and developing the ethics and values of the police. 

The College’s remit is limited to police officers and staff, other police force employees, and 
volunteers, such as Special Constables in England and Wales. We work alongside experts from 
other law enforcement and non-law enforcement agencies to develop expert knowledge that 
ensures College standards and products, such as Authorised Professional Practice (APP) and 
training, are well informed, relevant and based on the best available evidence. 

Staff also represent the College at various meetings established by the National Police Chiefs’ 
Council, National Crime Agency, Home Office and other bodies. Our role here is to support 
discussions and identify any work required.   

The College does not have an operational policing role. 

College Response to the Matters of Concern  

The College is named as a joint addressee for the following MCs: 

MC10 – Addressed to the Secretary of State for Justice, the College of Policing, the 
Chief Constable of West Midlands Police and the Chief Constable of Staffordshire Police: 
The facts of this case give rise to concern that important decisions on approvals, 
variations and relaxations in relation to licence conditions may be taken without clearly 
reasoned discussion and decision-making in MAPPA panels. This issue could be 
addressed by requiring MAPPA minutes to record any discussion or decision on such a 
matter. In addition, for the benefit of future inquiries and reviews, consideration should be 
given to having digital audio recordings made of all MAPPA meetings. 

MC 14 – Addressed to the Secretary of State for Justice, the College of Policing, the Chief 
Constable of West Midlands Police and the Chief Constable of Staffordshire Police: This 
case gives rise to concern that an extremist offender may be permitted to attend an event 
or  venue  without  there  having  been  proper  communication  between  the  probation  and 
police  officers  responsible  for  managing  the  offender  and  the  event  organisers  and/or 
venue hosts. Consideration should be given to encouraging such communications within 
the training and guidance given to probation officers and police responsible for managing 
extremist offenders. 

MC 17 – Addressed to the Secretary of State for Justice, the College of Policing, the 
Chief Constable of West Midlands Police and the Chief Constable of Staffordshire Police: 
Based on the evidence in this case, there is cause for concern that effective procedures 

 
 
 
 are not in place to ensure that all MAPPA meeting attendees receive meeting minutes. 
Consideration should be given to modifying guidance to ensure that this happens, for 
example by (a) providing for all MAPPA panel participants to receive minutes by secure 
email (rather than by having to access an online system); (b) requiring that all 
acknowledge safe receipt and indicate whether or not they wish to make amendments (to 
include provision of “nil returns”); and/or (c) requiring attendees at the start of each 
MAPPA meeting formally to confirm that they have read the minutes of the previous 
meeting or meetings as appropriate. 

MC 18 – Addressed to the Secretary of State for Justice, the College of Policing, the 
Chief Constable of West Midlands Police and the Chief Constable of Staffordshire Police: 
The facts of this case give cause for concern that some members of MAPPA panels 
responsible for managing extremist offenders may not be aware of important information 
from the offender’s time in prison. Consideration should be given to (a) ensuring that the 
latest MAPPA F form from the prison authorities should be circulated with every 
subsequent set of MAPPA minutes; (b) including a section in MAPPA minutes for key up-
to-date intelligence; and (c) including a further section in MAPPA minutes for a summary 
of the key conclusions of the most recent ERG assessment (including risk factors 
identified). 

MC 19 - Addressed to the Secretary of State for Justice, the Secretary of State for the 
Home Department, the College of Policing, the Chief Constable of West Midlands Police 
and the Chief Constable of Staffordshire Police: This case gives cause for concern that 
counter-terrorism police may be in possession of intelligence or information which may 
be useful to the management of an offender by the MAPPA panel, but that such 
intelligence or information may not be brought to the knowledge of or taken into account 
by MAPPA agencies. This issue should be addressed, preferably by ensuring that a 
single police officer from any covert investigation (such as the SIO or Deputy SIO) is 
responsible and accountable for ensuring that intelligence and information is properly 
shared and taken into account. Consideration should also be given to how intelligence 
known only to the Security Service may be taken into account for the purposes of 
MAPPA management. 

MC 20 – Addressed to the Secretary of State for Justice, the Secretary of State for the 
Home Department, the College of Policing, the Chief Constable of West Midlands Police 
and the Chief Constable of Staffordshire Police and the College of Policing: The facts of 
this case give cause for concern that security sensitive information may not be properly 
taken into account in decision-making by MAPPA panels concerning the management of 
terrorist offenders. Consideration should be given to how the new procedures can best 
be operated to avoid this problem recurring. This might include a requirement that, 
wherever possible, the MAPPA Panel Chair (or one Co-Chair) should be a member of 

 
 
 the Core Group. It might also include a requirement for the Core Group to consider what 
intelligence can be supplied (perhaps in sanitised form) to the broader panel. 

MC 21 – Addressed to the Secretary of State for Justice, the Secretary of State for the 
Home Department, the College of Policing, the Chief Constable of West Midlands Police 
and the Chief Constable of Staffordshire Police: The facts of this case give cause for 
concern that MAPPA panels responsible for managing terrorist offenders may be 
unaware of the regularity and form of contact with police officers responsible for overt 
offender management. Consideration should be given to providing guidance that officers 
with such responsibilities should report to MAPPA panels on the regularity of their 
meetings with offenders and take account of any recommendations by MAPPA panels. 

In developing our response, we are grateful to the other addressees (and national Counter 
Terrorism policing) who have shared their responses with us. We note from their responses that 
these addressees have taken forward, or plan to take forward, substantive work to address the 
seven MCs listed above.   

While we do not currently provide, or have been approached to provide, specific guidance or 
training on terrorist offender management, we are committed to supporting the other bodies 
mentioned in the MCs to achieve improvements. We are also concerned not to replicate work 
that is being done by others in this area. We will continue to work closely, with these bodies to 
make sure that the College contributes to managing the risks posed by terrorist offenders.  

The College also provides broader offender management training products and guidance, for 
example, on the police role in managing sexual offenders, violent offenders, and potentially 
dangerous persons (PDPs) as part of major investigation and public protection APP1. 
Additionally, there are learning products available through the ‘College Learn’ platform that 
cover: 

• 
training and development 
•  management responsibilities 
•  multi agency working (MAPPA) 
•  staff welfare 
•  managing workload 
•  ensuring management of sexual offenders and violent offenders (MOSOVO) units are 

staffed appropriately. 

The ‘offender management’ guidance and products have been developed over a number of 
years and we will continue to work with partners and stakeholders to ensure they are updated to 

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

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

Yours sincerely  

Chief Constable 
Chief Executive Officer 
College of Policing

Response from Department for Education (PDF)

Rt Hon Nadhim Zahawi MP 
Secretary of State 

Sanctuary Buildings   Great Smith Street   Westminster   London   SW1P 3BT 

   www.education.gov.uk/contactus/dfe 

, Partner, BDB Pitmans LLP 

  7th January 2022 

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

Dear 

, 

I am responding to your letter dated 3 November 2021 regarding the inquests 
into the deaths arising from the attack at Fishmongers' Hall on 29 November 
2019.  

Thank you for bringing these findings to my attention. I am committed to 
working with colleagues across Whitehall and the higher education sector to 
ensure these tragic events are not repeated. My sympathies are with the 
families of the victims of the attack, Saskia Jones and Jack Merritt, and all 
those affected.  

I have taken note of the recommendations addressed to me in the Coroner’s 
Prevention of Future Deaths (PFD) report and accept them in full. I have 
responded in detail below.  

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

Yours sincerely, 

Rt Hon Nadhim Zahawi MP 
Secretary of State for Education 

 Annex – Secretary of State for Education response to Prevention of Future Deaths 
(PFD) report recommendations  

MC1 – Addressed to the University of Cambridge, Learning Together, the Secretary of 
State for Education and the Office for Students: Significant academic events and courses 
held outside of university premises should be subject to proper formal risk assessment, 
especially if they take place in environments with particular risk (such as prisons) and if they 
are attended by individuals who pose particular risks. It is a matter of concern that there was 
no such risk assessment for Learning Together events as set out above. The University of 
Cambridge and those responsible for guidance to UK higher education institutions should 
consider whether further steps can be taken to encourage the making of such risk 
assessments. 

Secretary of State for Education response: Accept the recommendation in full  

• 

• 

I accept this recommendation in full.  

I will engage with colleagues in the higher education sector to encourage action be 
taken to implement this recommendation.  

•  Higher education providers are independent autonomous institutions and therefore 

responsible for their own governance and risk management.  

•  My officials have spoken to colleagues at the Office for Students to encourage them 
to take action and I welcome their intention to write to all English higher education 
providers to draw their attention to the report and its recommendations, to encourage 
them to ensure significant academic events and courses held outside of university 
premises should be subject to proper formal risk assessment, especially if they take 
place in environments with particular risk (such as prisons) and if they are attended 
by individuals who pose particular risks. 

•  Furthermore, my department is working closely with colleagues at the Home Office 
on the development of legislation (the Protect Duty) to improve the safety and 
security of public venues. 

MC2 – Addressed to the University of Cambridge, Learning Together, the Secretary of 
State for Education and the Office for Students: It is a matter of concern that a major 
event could be held by a University at a livery company hall in London without clear 
communication of the fact that it would be attended by serving and recently released serious 
offenders. Consideration should be given to guidance requiring higher education institutions 
to inform host venues of high-risk features of events, including for instance the attendance of 
such persons. 

Secretary of State for Education response: Accept the recommendation in full  

• 

I accept this recommendation in full.  

•  Higher education providers are independent autonomous institutions and therefore 

responsible for their own governance and risk management. 

 • 

I will engage with colleagues in the higher education sector to encourage action be 
taken to implement this recommendation.  

•  My officials have spoken to colleagues at the Office for Students to encourage them 
to take action and I welcome their intention to write to all English higher education 
providers to draw attention to this recommendation, with the aim of encouraging them 
to consider effective communications between event organisers and host venues as 
part of their event and risk management procedures.  

MC5 – Addressed to the Secretary of State for Justice, the Secretary of State for 
Education, the Office for Students, the University of Cambridge and Learning 
Together: Consideration should be given to whether further measures of risk assessment 
and management can be introduced for any higher education programmes running in 
prisons which involve continued contact with offenders after their release into the 
community. 

Secretary of State for Education response: Accept the recommendation in full  

• 

I accept this recommendation in full.  

•  My officials have engaged with colleagues in Her Majesty’s Prisons and Probation 
Service (HMPPS) and I welcome the planned work to design a new framework to 
clearly define the roles and responsibilities of prisons and higher education providers 
when they work in partnership to deliver learning where students study alongside 
serving prisoners or those released on licence. This will include reference to risk 
assessment guidance that has been developed for partner organisations who hold 
events where prison leavers may be invited to attend. I have asked my officials to 
continue engaging in this process.  

•  My officials have spoken to the Office for Students and I welcome their intention to 

write to all English higher education providers to draw attention to this 
recommendation.

Response from Home Office (PDF)

Home Secretary 

     2 Marsham Street 

 London SW1P 4DF 

     www.gov.uk/home-office 

7 January 2022 

Partner BDP Pitmans LLP 
One Bartholomew Close 
London 
EC1A 7BL 

Dear Sinead 

Fishmongers’ Hall Inquest: Prevention of Future Deaths (PFD) Report 

Thank you for sending to me His Honour Judge Mark Lucraft QC’s Prevention of 
Future Deaths (PFD) Report, following the inquest into the appalling attack at 
Fishmongers’ Hall on 29th November 2019. I am grateful to HHJ Lucraft for drawing 
his concerns to my attention. As Home Secretary, I am responsible for ensuring that 
matters of concern and recommendations relating to national security are properly 
addressed. Please accept this response on behalf of the Home Office and Security 
Service collectively.  

Comments on each of the specific recommendations addressed to the Secretary of 
State for the Home Department are annexed to this letter. Those matters on which 
you have not felt that a formal recommendation is appropriate are also noted, and 
we will continue to keep the wider issues under review.  

While much of the Report covers issues of policy and practice, the Determination 
Sheets for the two victims underline the sobering circumstances of the inquest. It is 
right to keep in our thoughts Saskia Jones and Jack Merritt: two innocent young 
people who tragically lost their lives in this attack; as well as consider what steps we 
should take in response. 

Yours sincerely 

Rt Hon Priti Patel MP 
Home Secretary 

 
 Thank you for issuing the Prevention of Future Deaths (PFD) Report for the Inquests arising 
from the deaths in the Fishmongers’ Hall Terror Attack. 

Set out below are responses from the Home Office and MI5 to the five recommendations 
relevant to those organisations.  

The Home Office has liaised closely with operational partners and other Government 
Departments regarding the collective Matters of Concern (MCs). Three MCs - 19, 20 and 21 
- will be addressed by the Chief Constables of West Midlands Police and Staffordshire 
Police and the Secretary of State for Justice. The Home Office has reviewed these 
responses and agrees with their content.  

Response to MC16 – Addressed to the Secretary of State for the Home Department: 
This case gives rise to concern that mentoring arrangements under the DDP could be 
disrupted suddenly in the case of a person whose risk of re-engaging in extremism 
was known to be related to social isolation. It also gives rise to concern that an 
offender could be suddenly deprived of the means to use the internet under 
supervision to search for work. Measures should be taken to prevent a recurrence of 
these circumstances. 

The Government accepts these recommendations and can confirm that there have been 
significant changes in the way that Desistance and Disengagement Programme (DDP) 
operates as the programme has matured. These include:  

•  diversification and increase in the number of suppliers;  
•  enhanced performance management of suppliers, including monthly review meetings 
which started in September 2019; and key performance indicators were reviewed 
and strengthened in January 2021;  

•  Home Office training programme with a mandatory professionalisation programme 

for all Intervention Providers;  

•  expansion of DDP to prisoners, to enable more offenders to start DDP engagement 

before leaving prison. 

Introducing these measures has enabled DDP to develop resilience in providing Intervention 
Providers to programme participants and to prevent gaps in service provision.  

Probation staff, through partner agencies, support offenders in seeking employment. 
Processes are in place to avoid service users being left without access to the internet if that 
would impact on their ability to find work. In Usman Khan’s case (which would be true of 
other terrorist offenders), there were numerous avenues for him to seek permission to use 
the internet for legitimate purposes and the mentor was just one of these: he had access to 
Ixion (an employment agency which was authorised to supervise his internet use), and the 
Approved Premises key worker and Offender Manager who could also have accessed the 
internet with him to search for employment. Not having a mentor does not equate to having 
no internet access. Probation are able to facilitate searches for employment in the absence 
of a mentor, as they did in Usman Khan’s case. In general, control measures around internet 
access are considered by Probation whenever an individual exits the DDP process and are 
agreed by MAPPA (Multi Agency Public Protection Arrangements). Any changes are 
recorded by Probation on the OASYs system and in the MAPPA minutes, with DDP 
Intervention Providers kept informed by Probation. 

It is important to note that the relevant licence condition to which Usman Khan was subject 
was not a blanket ban on internet access: it permitted access with prior approval of a 

 
 
 
 
 
 
 
 
 
 
 supervising officer for specific purposes1.   There are alternative options available should a 
mentor be unable to provide supervision for any reason: 

•  Approved individuals may provide supervision to allow service users to access the 

internet – this might include Approved Premises staff, trusted family members, or 
probation officers;  

•  Job Centres provide internet access for job searches, providing a link to employment 

opportunities; 

•  Probation Service regions have arrangements with independent employment training 
and education providers through the Dynamic Framework (which is the arrangement 
by which the Probation Service commissions services from partnership agencies). 
Service users can be referred to these providers, allowing them approved internet 
access; 
Internet monitoring software can be installed on a service user’s computer, allowing 
them supervised internet access. 

• 

Response to MC19 – Addressed to the Secretary of State for Justice, the Secretary of 
State for the Home Department, the College of Policing, the Chief Constable of West 
Midlands Police and the Chief Constable of Staffordshire Police: This case gives 
cause for concern that counter-terrorism police may be in possession of intelligence 
or information which may be useful to the management of an offender by the MAPPA 
panel, but that such intelligence or information may not be brought to the knowledge 
of or taken into account by MAPPA agencies. This issue should be addressed, 
preferably by ensuring that a single police officer from any covert investigation (such 
as the SIO or Deputy SIO) is responsible and accountable for ensuring that 
intelligence and information is properly shared and taken into account. Consideration 
should also be given to how intelligence known only to the Security Service may be 
taken into account for the purposes of MAPPA management. 

We have liaised with West Midlands Police, Staffordshire Police and the Ministry of Justice 
regarding this MC. This recommendation will be addressed by the Chief Constable of West 
Midlands Police, the Chief Constable of Staffordshire Police and the Secretary of State for 
Justice as it is predominantly an operational issue. Since the attack, steps have been taken 
to address the issue of information and intelligence sharing with MAPPA including how 
information is shared by the Security Service. 

The response from the Security Service is set out below:  

Security Service response 

At the time of the attack perpetrated by Usman Khan at Fishmongers’ Hall in 2019, the 
Security Service relied on counter-terrorism police (“CTP”) to pass intelligence to and 
represent the Security Service’s interest in MAPPA.  As indicated to the inquest, CTP were 
the bridge between the Security Service and MAPPA.  This is no longer the case.  In direct 
response to Jonathan Hall QC’s MAPPA review, the Joint Counter Terrorism Prisons and 
Probation Hub (“JCTPPH”) was set up with the aim of ensuring that there is a shared 
understanding of who poses a risk, and why, and to enable management of those individuals 

1  Usman  Khan’s  licence  conditions  around  internet  access:  “Not  to  use  or  access  any  computer  or 
device which is internet enabled without the prior approval of your supervising officer; and only for the 
purpose, and only at a public location, as specified by that office. Not to delete the usage history on 
any internet enabled device or computer used and to allow such items to be inspected as required by 
the  police  or  your  supervising  officer.  Such  inspection  may  include  removal  of  the  device  for 
inspection and the installation of monitoring software.” 

 
 
 
 
 
 
 
 
 
 
 through multi-agency partnerships and engagement with the appropriate statutory bodies.  
The JCTPPH composes staff from the Security Service, CTP and HMPPS.  The key piece of 
work that is being undertaken to achieve this aim is the JCTPPH-owned “Covert / Overt 
Bridge”.  The Bridge will facilitate the sharing of sensitive intelligence into the MAPPA 
process and, importantly, other key forums.  The JCTPPH has created a mechanism for 
directly sharing sensitive intelligence with those within the MAPPA process, most notably the 
MAPPA Chair(s), as well as others who hold appropriate clearances, regarding individuals 
subject to MAPPA.  Use of the Bridge will support MAPPA in making informed decisions but 
will also ensure that the intelligence is shared in a way which ensures that the Security 
Service complies with the requirements as set out in the Security Service Act 1989.  The 
Security Service are now actively using the JCTPPH to share sensitive intelligence into the 
MAPPA process. This closer working will be yet further enhanced by the co-location of the 
JCTPPH in the Counter-Terrorism Operations Centre (CTOC) alongside Security Service, 
CT police and other CT partners, both overt and covert.  We expect this co-location to be 
fully implemented by February 2024. 

The JCTPPH is also working with other forums in the case management of those of counter-
terrorism interest in the Prisons and Probation sector to enable further co-ordination of 
covert and covert risk management, such as Pathfinder, the Parole Board and the Prison 
Separation Centre Management Committee.  This will provide us with the ability to share 
intelligence, where assessed to be necessary and proportionate, with HMPPS from the 
moment an individual enters the Prison estate, meaning that case management decisions 
will be able to take into account the entirety of what is known about the individual rather than 
a part of the picture. Once in place, this means that towards the end of a prisoner’s 
sentence, when the individual is managed by MAPPA, there will be a full and detailed 
narrative that draws on all sources of information and intelligence to inform decision-making. 

Response to MC20 - Addressed to the Secretary of State for Justice, the Secretary of 
State for the Home Department, the College of Policing, the Chief Constable of West 
Midlands Police and the Chief Constable of Staffordshire Police and the College of 
Policing: The facts of this case give cause for concern that security sensitive 
information may not be properly taken into account in decision-making by MAPPA 
panels concerning the management of terrorist offenders. Consideration should be 
given to how the new procedures can best be operated to avoid this problem 
recurring. This might include a requirement that, wherever possible, the MAPPA Panel 
Chair (or one Co-Chair) should be a member of the Core Group. It might also include a 
requirement for the Core Group to consider what intelligence can be supplied 
(perhaps in sanitised form) to the broader panel. 

We have liaised with West Midlands Police, Staffordshire Police and the Ministry of Justice 
regarding this MC. As it is predominantly an operational issue, this matter will be addressed 
by the Chief Constable of West Midlands Police, the Chief Constable of Staffordshire Police 
and the Secretary of State for Justice. The Secretary of State for the Home Department fully 
endorses the significant steps which have been taken by the Ministry of Justice and 
operational colleagues to address the issue that gave rise to this MC.  

Response to MC21 - Addressed to the Secretary of State for Justice, the Secretary of 
State for the Home Department, the College of Policing, the Chief Constable of West 
Midlands Police and the Chief Constable of Staffordshire Police: The facts of this case 
give cause for concern that MAPPA panels responsible for managing terrorist 
offenders may be unaware of the regularity and form of contact with police officers 
responsible for overt offender management. Consideration should be given to 
providing guidance that officers with such responsibilities should report to MAPPA 

 
 
 
 
 
 
 
 
 panels on the regularity of their meetings with offenders and take account of any 
recommendations by MAPPA panels. 

We have liaised with West Midlands Police, Staffordshire Police and the Ministry of Justice 
regarding this MC. As it is predominantly an operational issue, this matter will be addressed 
by the Chief Constable of West Midlands Police, the Chief Constable of Staffordshire Police 
and the Secretary of State for Justice. The Secretary of State for the Home Department fully 
endorses the significant steps which have been taken by the Ministry of Justice and 
operational colleagues to address the issue that gave rise to this MC, including the 
strengthening the existing Ministry of Justice MAPPA guidance.  

Response to MC22 - Addressed to the Secretary of State for Justice and the Secretary 
of State for the Home Department: The facts of this case gave cause for concern that 
those involved in managing terrorist offenders on licence may lack a valuable means 
of addressing risks they pose, namely an ability to carry out a search on a 
precautionary basis. Consideration should be given to the introduction of a licence 
condition which could be imposed on terrorist offenders requiring them to submit to a 
search by a police officer without the officer establishing specific legal grounds for 
the search. 

The Government accepts this recommendation.  

We understand the concern raised with respect to current powers for managing terrorist 
offenders on licence and recognise the proposal to enable personal searches of such 
offenders on a precautionary basis, including without requiring the officer to have reasonable 
suspicion when conducting the search.  

Following the Fishmongers’ Hall terror attack, Jonathan Hall QC, the Independent Reviewer 
of Terrorism Legislation (IRTL), was asked by the Home Secretary and then Lord Chancellor 
to conduct an independent review of MAPPA used to supervise terrorist and terrorism-risk 
offenders. Mr Hall QC’s recommendations included the creation of new police powers, 
including the consideration of whether a new power of personal search is required. 

As set out in the Government’s response to Mr Hall QC’s report, following engagement with 
relevant operational partners we accepted his recommendations in relation to police powers 
and we are currently legislating for these through the Police, Crime, Sentencing and Courts 
(PCSC) Bill. The new power of personal search will be available for use on terrorist 
offenders in the community whose licence conditions require them to submit to such a 
search. In these circumstances, a police officer will be able to stop and search the offender if 
they are satisfied that it is necessary to do so for purposes connected with protecting 
members of the public from a risk of terrorism. 

The PCSC Bill is currently before the Lords and we look forward to it receiving Royal Assent 
early in the new year so that important new powers such as this can come into force and 
support efforts to manage the risk posed by terrorist offenders on licence.

Response from Learning Together Network Cic (PDF)

INQUESTS INTO THE DEATHS ARISING FROM

THE FISHMONGERS’ HALL AND LONDON BRIDGE TERROR ATTACK

RESPONSE OF THE DIRECTORS OF LEARNING TOGETHER NETWORK CIC

TO PREVENTION OF FUTURE DEATHS REPORT

INTRODUCTION

This is the response on behalf of the Directors of the Learning Together Network CIC

(“the CIC”) in relation to the ‘Regulation 28 Report on Action to Prevent Future
Deaths’ (“the PFD Report”)1 made on 3 November 2021 by the coroner in relation to

the deaths arising from the attack at Fishmongers’ Hall on 29 November 2019.

Recommendations MC1, MC2, MC3 and MC5 in the PFD Report are addressed to the

Directors of the CIC.

ROLE OF THE CIC

Learning Together at the University of Cambridge (“the University”) involved

partnership working between the University and three local prisons. It brought

together prison-based students and University-based students to study higher

education courses (“UC Learning Together partnerships”). These UC Learning

Together partnerships were, and always have been, part of an educational initiative

based at the University. The staff working on the UC Learning Together partnerships

have always been employed by the University and based at the Institute of

Criminology (“the Institute”) – a department within the Faculty of Law, which is itself

a component faculty of the School of the Humanities and Social Sciences.

The CIC did not employ any staff and was not involved in the running of any

Learning Together partnerships, at any point, at 29 November 2019 or subsequently. It

played no part in arranging the alumni and anniversary event at Fishmongers’ Hall.

All UC Learning Together partnership activities, including the Fishmongers’ Hall

1 Under paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 and regulations 28 and 29 of the
Coroners (Investigations) Regulations 2013 (here)

event, were University activities. The CIC was established in April 2019 as one of the

deliverables of the HMPPS Innovation Grant brought into the University. In

November 2019, discussions with the University were still ongoing about the

relationship between the work of Learning Together within the University and any

work that might be done by the CIC in the future.

An application to voluntarily strike the CIC off the Companies Register was made on

4 November 2021 and a first notice was published in the Gazette on 16 November

2021. The CIC will be dissolved in January 2022.

RESPONSE ON BEHALF OF THE CIC

In light of the above, the CIC is not able to take steps in relation to any of the

recommendations in the PFD Report. It has no power to act upon them. It is a matter

for the University to respond to these recommendations in so far as they relate to UC

Learning Together partnerships.

The event at Fishmongers Hall on 29 November 2019 was organised in accordance

with and adhered to all of the established risk management, safeguarding and

governance frameworks of the University that were effectively communicated to and

implemented within the Institute. It is regrettable that relevant risk assessment

frameworks were not in place within the Institute at the time of the event at

Fishmonger’s Hall.

take this opportunity to reiterate that

their personal and professional reflection, profound grief, and trauma is deep and
ongoing following the tragedy of 29 November 2019. As employees of the University,

they have taken every possible opportunity to contribute to the University’s process of

reflection, consideration and further action, an update about which was provided in

the ‘Submissions on Behalf of the University of Cambridge on a Prevention of Future

Deaths Report, dated 28 July 2021’ (published on the website for the inquests).

It is hoped the University will further develop its risk management, safeguarding and

governance frameworks, and the systems through which their distribution and

effective implementation are monitored within University departments in light of the

Coroner’s recommendations, so as to provide assurance of appropriate frameworks to

support the safety of all employees, and all others involved in University activities.

PFD Report and give their utmost commitment that these lessons will inform their

take very seriously the lessons from the inquest and the

work moving forwards.

Response from Moj (PDF)

The Right Honourable
Dominic Raab MP
Deputy Prime Minister
Lord Chancellor & Secretary of State
for Justice

7 January 2022

Partner
BDB Pitmans LLP
1 Bartholomew Close
London EC1A 7BL

Dear

FISHMONGERS’ HALL INQUESTS: RESPONSE TO PREVENTION OF FUTURE DEATHS
REPORT ISSUED BY HHJ MARK LUCRAFT QC

Thank you for sending me the Report on Action to Prevent Future Deaths (PFD), issued by His Honour
Judge Mark Lucraft QC, following the completion of the Inquests arising from the deaths into the
Fishmongers’ Hall terror attack.

I am grateful to you for bringing these matters to my attention, and for the work of HHJ Lucraft QC in
thoroughly exploring the tragic events of 29 November 2019. My sympathies are with all the victims of
the attack, including the families of Saskia Jones and Jack Merritt, and with all those affected.

Please accept this response on behalf of the Ministry of Justice. Comments on each of the specific
recommendations are annexed to this letter.

If there are any further matters of concern, then please do not hesitate to raise these.

Yours sincerely

RT HON DOMINIC RAAB MP

Page 1 of 14

Fishmongers’ Hall Prevention of Future Deaths report:
Ministry of Justice response to recommendations

MC4 - Addressed to the Secretary of State for Justice

It is a matter of concern that Learning Together could operate courses in prisons in the way
it did without being given information about the risk profiles of offenders joining courses.
Consideration should be given to whether further procedures can be put in place to ensure
or at least encourage some such information to be shared with higher education providers
working in prisons.

Response to MC4:

• We accept this recommendation.

• Following the events at Fishmongers’ Hall all activity with Learning Together was

paused.

• Ahead of any decision to restart we are designing a new framework to clearly define the
roles and responsibilities of prisons and universities when they work in partnership to
deliver learning where students study alongside serving prisoners or those released on
licence. This will include guidance setting out the responsibility for risk assessment and
the circumstances in which risk information will be shared. We expect to complete initial
work in January 2022 and will then consult with prisons and universities to ensure it
meets requirements with the ambition of having it in place by April 2022.

• We are considering what additional safeguards might be required and the implications
for other civil society and third sector organisations working in partnership with prisons.

MC5 – Addressed to the Secretary of State for Justice, the Secretary of State for
Education, the Office for Students, the University of Cambridge and Learning
Together

Consideration should be given to whether further measures of risk assessment and
management can be introduced for any higher education programmes running in prisons
which involve continued contact with offenders after their release into the community.

Response to MC5:

• We accept this recommendation.

• The framework referred to in MC4 will set clear expectations about roles and
responsibilities of prisons and universities entering into partnerships and clear
expectations around protocols for further engagement with ex-prisoners in the
community. This will include reference to risk assessment guidance that has been
developed for partner organisations who hold events where prison leavers may be
invited to attend.

Page 2 of 14

MC6 – Addressed to the Secretary of State for Justice

Notwithstanding the measures which the NPS has put in place since the attack, there
remains cause for concern that ERG 22+ assessment reports may be prepared by a CTPO
without the direct involvement of a forensic psychologist. Consideration might usefully be
given to (a) requiring that every such report be completed by a forensic psychologist or (b)
requiring that every such report on an offender in the community is either prepared by, or
subject to detailed critical review by, a forensic psychologist.

Response to MC6:

• We accept option (b) of this recommendation.

• We have reviewed best practice relating to the delivery of ERGs in the community.
We agree that forensic psychologists should be directly involved in every ERG
assessment carried out in the community.

• The optimal delivery model is one that makes best use of both forensic psychologists,
who have expertise in structured professional judgement and risk assessment tools,
and CT probation specialists, who have expertise in the management of community-
based risk. Through this blended approach, ERGs in the community will be completed
by CT probation specialists or forensic psychologists depending on the case
characteristics (e.g., forensic psychologists will complete ERGs where there are
significant mental health or other complex needs). Each will provide a formal critical
review of the other’s ERG assessment.

• We believe that this will provide the best ERG delivery model. It maximises the skills
and experience of our specialist staff and means that we will always deliver ERG
assessments to the highest professional standard.

• All psychology and probation staff now go through the same assessed pass/fail

training to complete ERGs, and from the start both sets of staff have been assessed
as having sufficient baseline skills from their professional training to complete these
assessments after the ERG specialist training.

• A Quality Assurance process for ERG assessments will be available from April

2022.

• We have strengthened our current operational processes with the introduction of a
Standard Operating procedure (SOP), drawing upon several guiding principles to
provide all Extremism Risk Guidance trained assessors, supervisors and staff
involved in the management of terrorist cases with guidance regarding the completion
of ERGs in HMPPS.

These principles include:

• The ERG will be completed by trained qualified staff. In custody, the ERG assessment
will usually be completed by a trained psychologist. In the community, the ERG
assessment will usually be completed by trained CTPOs. Forensic psychologists will
complete ERGs in the community where the offender has significant mental health or
complex needs.

• The ERG must be completed by a CTPO or psychologist who has not had a

therapeutic or management relationship with the offender being assessed.

• An ERG assessment will be completed to inform any significant points of progression
for the offender. Significant points of progression are considered to be the points
where progression will result in significantly less supervision or oversight of the
Page 3 of 14

offender. For example, release or move from approved premises to other
accommodation.

• We will monitor how well these processes work to ensure high standards of ERG and

will review the SOP in 18 months.

MC7 – Addressed to the Secretary of State for Justice

It is a matter for concern that MAPPA panels managing even the most serious offenders may
not have the benefit of hearing directly from a forensic psychologist who has prepared an
ERG report shortly prior to the offender’s release. Consideration should be given to
introducing procedures or guidance to require or encourage the attendance of such a
psychologist at appropriate MAPPA panel meetings.

Response to MC7:

• We accept this recommendation.

• Psychologists are routinely attending MAPPA meetings to present their report where

invited.

• We will update the MAPPA statutory guidance by April 2022, to make it a requirement
that psychologists attend MAPPA meetings – and, specifically, to require them to be
invited to present their ERG assessment to the MAPPA meeting. The updates will form
part of a wider revision of the chapter on meetings in the MAPPA Guidance.

• Furthermore, each unit in the Probation Service National Security Division (NSD) has a
dedicated forensic psychologist working alongside a
team of probation
practitioners. The revised statutory MAPPA Guidance will stipulate that psychologists
will provide professional advice and attend all meetings at MAPPA Level 3 (the highest
level) and inform all core group meetings. A core group will bring together a smaller
group of professionals across a range of specialisms to support the effective
management of the offender. This will ensure that the assessment of the offender’s risk
and the plan to manage that risk benefit from their professional advice.

MC8 – Addressed to the Secretary of State for Justice

The facts of this case give rise to concern that an OASys risk rating for an offender may be
changed without the offender manager completing the full assessment exercise (using the
structured form) and that the change may be recorded without proper rationale. Given the
importance placed on the risk ratings in management of dangerous offenders, this requires
specific consideration.

Response to MC8:

• We accept this recommendation.

• We will issue an instruction to staff by January 2022 that sets out the requirement that
changes in recorded risk level must be informed by completing a formal risk assessment
and may never be reduced without such an assessment regardless of wider resource
constraints.

Page 4 of 14

• We recognise there are times when resources must be prioritised on acting in the face
of escalating risk. Therefore, where agreed by a senior manager, a probation practitioner
will be able to indicate they judge that risk has escalated to a new level based on new
information and take necessary action in the face of escalating risk prior to completing
a full structured risk assessment on the approved tool. However, the updated formal risk
assessment should follow as soon as practical, to ensure that the assessment and
associated risk management plan are comprehensive.

• Formal risk levels must not be reduced without the use of the approved risk assessment
tool to ensure any reduction is supported by a structured critical thinking process and
risks to the public are not overlooked.

MC9 – Addressed to the Secretary of State for Justice

This case gives rise to concern that offender managers may take significant decisions to give
approvals under licence conditions without those decisions being properly reasoned and
recorded. Consideration should be given to ensuring, by means of NPS guidance, that
offender managers always (a) record a rationale for giving any permission for approval,
variation or relaxation in relation to licence conditions and (b) in the case of offenders subject
to Level 2 or 3 MAPPA management, record whether or not the decision has been taken with
express approval from the MAPPA panel.

Response to MC9:

• We accept this recommendation.

• We have published guidance on Licence Variation and Authorisation. A draft version of
the Licence Conditions Policy Framework is currently being considered by stakeholders
and will update and consolidate all changes into policy following the Royal Assent for
the Police, Crime, Sentencing and Courts Bill, expected in February 2022. This
Framework will set out expectations of probation and prison staff in relation to both
changes in licence conditions and the specific authorisation which must be obtained
before an offender is permitted to undertake an activity which would otherwise be
prohibited by the licence. One of the key policy changes will be the introduction of a
requirement that practitioners ensure that any discussions and decisions around
whether or not to vary a licence condition or authorise activity outside of a condition are
recorded in case notes on NDelius. The Framework will also cover other mandatory
actions, such as discussing with partner agencies and stakeholders any proposed
changes to licensed supervision.

•

In August 2021, the NSD issued its Delius Gold Standard Guidance which emphasises
the importance of recording any decisions making. The Guidance also sets out the
expectation that summaries of key discussions at MAPPA should be recorded on
NDelius and that senior probation practitioners must be consulted about key case
management decisions.

MC10 – Addressed to the Secretary of State for Justice, the College of Policing, the
Chief Constable of West Midlands Police and the Chief Constable of Staffordshire
Police

Page 5 of 14

The facts of this case give rise to concern that important decisions on approvals, variations
and relaxations in relation to licence conditions may be taken without clearly reasoned
discussion and decision-making in MAPPA panels. This issue could be addressed by
requiring MAPPA minutes to record any discussion or decision on such a matter. In addition,
for the benefit of future inquiries and reviews, consideration should be given to having digital
audio recordings made of all MAPPA meetings.

MC11 – Addressed to the Secretary of State for Justice

This case gives cause for concern that an offender manager and/or MAPPA panel
participants could approve a permission, variation or relaxation in relation to a licence
condition without directly addressing the potential risks involved. Consideration should be
given to whether there can be further guidance to ensure that the risks as well as the potential
benefits of such decisions are carefully examined.

Response to MC10 and MC11:

• We accept these recommendations.

• The guidance referred to in MC9 above sets out clear expectations for probation
practitioners to engage with MAPPA partners when making decisions about licence
conditions.

• We updated the MAPPA statutory guidance chapter on managing terrorists in July 2021
in response to several of the recommendations made by
in his
Independent Review of MAPPA and Terrorist Risk Offenders. The new revised guidance
states explicitly that significant decisions made at MAPPA meetings should be clearly
recorded, along with the rationale underpinning them.

• Relevant parts of the statutory MAPPA Guidance will be amended and re-issued in April
2022, with an updated template for minutes of MAPPA meetings and guidance of the
digital recording of MAPPA meetings.

• The National MAPPA Team is currently reviewing the meeting template and associated
guidance so that it better supports both the process and the recording of decision making
including that related to licence conditions. The documents will be available for formal
consultation this month with publication due by April 2022. We will consider the use of
audio recordings and are already consulting with stakeholders on the audio-recording
meetings. We will formulate guidance, taking into account the legal and logistical
complexities relating to audio recording the sensitive information exchanged in meetings
by April 2022.

• Assessment of risks involved in amendments to licence conditions was included in the
guidance on Licence Variation and Authorisation and was distributed in December 2021.
This will be included as part of the Licence Conditions Policy Framework update due in
February 2022.

• The final decision for applying/removing/authorising a licence condition is not made by
MAPPA: these decisions will be recorded on case management systems, including
where stakeholders have been involved including MAPPA and the Police. The new
model introduced by the NSD will enable greater oversight of cases and decision-making
by Senior Managers. Management oversight will be monitored through performance and
quality assurance measures.

• New guidance was introduced in December 2021 which ensures that decisions to vary
or relax licence conditions must always be subject to an up to date and reviewed

Page 6 of 14

assessment of the risk at the time that the relaxation comes into force. For TACT
offenders, the process for sharing information has been strengthened by the JCTPPH
and a more co-ordinated approach to managing offenders has been implemented as
part of the CT Step Up Programme.

MC12 – Addressed to the Secretary of State for Justice

The facts of this case give rise to concern that probation officers may give insufficient regard
to instances of dishonesty in self-presentation by extremist offenders. Consideration should
be given to having this aspect of assessment emphasised in training of offender managers.

MC13 - Addressed to the Secretary of State for Justice

Based on the facts of this case, there is cause for concern that probation officers may attach
excessive weight in their management of extremist offenders to “compliance” (i.e. absence
of evidence of breach of licence conditions and polite behaviour). Consideration should be
given to training and guidance warning offender managers about placing too much reliance
on this feature.

Page 7 of 14

Response to MC12 and MC13:

• We accept these recommendations.

• The OASys Guidance for TACT and TACT related offenders, dated April 2018 stated:
“Extremist offenders can have a well-rehearsed script in relation to their offending and
may not be open or candid about their thinking, associations and affiliations. They may
also have been advised by extremist associates how to respond to professionals”. We
encourage report authors and case managers to take a triangulation approach whereby
they consider a range of sources including the offender's account to understand the risk.
In addition, the core group approach will guard against conditioning and manipulation as
the group will provide check and balances for all decisions.

• This Guidance has recently been reinforced by specific training and strengthened by
further bespoke guidance. Training in relation to ‘Safeguarding Against Conditioning and
Manipulation’ for probation practitioners took place on 15 and 29 March 2021. NSD
guidance has been provided to staff setting out expectations for supervision, highlighting
the importance of “Professional Curiosity” and the need to explore key risk issues. In
addition, MAPPA meetings will be co-chaired by Counter Terrorism Police (CTP),
bringing a Police perspective to decision making.

• Current Probation Service policy is a blended supervision model which includes both
office visits and home visits. In addition, expectations for ERG delivery have been
clarified such as completion of assessments by those not responsible for case
management in order to provide other perspectives to risk assessment.

• The Counter Terrorism and Sentencing Act 2020 legislation came into effect on 29 June
2021. This gave the power to conduct polygraph examinations on any offender under
statutory supervision convicted of a relevant terrorist offence as defined in section
28(4A) and (4B) of the Act. We are now using polygraph examinations to support the
monitoring of compliance with licence conditions and information obtained during testing
is used by probation practitioners to refine and improve risk management plans.

• The reduced caseloads in NSD enable Senior Probation Practitioners (SPPs) to provide
greater management oversight of cases. SPPs countersign all OASys assessments and
provide regular supervision for Probation Practitioners (PPs) creating opportunities to
review cases and ensure PPs are taking a balanced view.

MC14 – Addressed to the Secretary of State for Justice, the College of Policing, the
Chief Constable of West Midlands Police and the Chief Constable of Staffordshire
Police

This case gives rise to concern that an extremist offender may be permitted to attend an
event or venue without there having been proper communication between the probation and
police officers responsible for managing the offender and the event organisers and/or venue
hosts. Consideration should be given to encouraging such communications within the
training and guidance given to probation officers and police responsible for managing
extremist offenders.

Page 8 of 14

Response to MC14:

• We accept this recommendation.

• MAPPA guidance requires disclosure to be considered at every discussion, and
disclosure will be made where the MAPPA agencies conclude that the offender’s risk
may be effectively managed only by making disclosure to specified individuals or bodies.
We will revise the guidance, so that it states explicitly that consideration must be given
to disclosure to an event host organiser, where relevant, which would facilitate wider
discussion outside MAPPA around event security. The MAPPA minutes template is
being updated so that decisions on disclosure are more clearly recorded.

• The presence of CT Police in MAPPA will provide an access route to the National CT
Security Office, which is a police-hosted unit that supports the Protect and Prepare
strands of CONTEST.

• Probation practitioners should gather as much information as possible about any event
that an offender requests to attend. This may inform risk assessments and decisions on
offenders taking part in activities and events. This information can be passed to police
colleagues and MAPPA for consideration. Additional learning resources have been
provided to Probation staff about disclosure under MAPPA.

• Specific guidance for probation officers responsible for managing extremist offenders

will be implemented by the NSD.

MC15 – Addressed to the Secretary of State for Justice

The facts of this case give cause for concern that a terrorist offender on licence, who was
subject both to strict licence conditions and to a priority investigation, could obtain and use
Class A drugs without that being detected. Consideration should be given to whether further
steps can be taken to facilitate random drug testing of offenders on licence (especially those
who have committed serious offences), including both those living in approved premises and
those living independently.

Page 9 of 14

Response to MC15:

• We are considering this recommendation to ensure that we are making best use of our

drug testing abilities.

• Currently, a licence condition to comply with drug testing is considered in all cases where
substance abuse is linked to the index offence. All licence conditions must meet the
‘necessary and proportionate’ test and current policy (PI 2014 32) states that to impose
a drug testing condition/requirement:

the misuse by the offender of a specified class A drug or a specified class B drug
caused or contributed to an offence of which the offender has been convicted or is
likely to cause or contribute to the commission of further offences by the offender;
and,

ii.

that the offender is dependent on, or has a propensity to misuse, a specified class
A drug or a specified class B drug.

•

Intelligence-led multi agency case management will assist to identify signs that an
offender may be using illegal substances, which would allow drug testing to become part
of their licence conditions if it was deemed that an offender's risk of reoffending was
increased by drug use.

• Terrorist offenders can be held in enhanced Approved Premises for at least 12 months

post-release, where they are subject to drug testing.

MC17 – Addressed to the Secretary of State for Justice, the College of Policing, the
Chief Constable of West Midlands Police and the Chief Constable of Staffordshire
Police

Based on the evidence in this case, there is cause for concern that effective procedures are
not in place to ensure that all MAPPA meeting attendees receive meeting minutes.
Consideration should be given to modifying guidance to ensure that this happens, for
example by (a) providing for all MAPPA panel participants to receive minutes by secure email
(rather than by having to access an online system); (b) requiring that all acknowledge safe
receipt and indicate whether or not they wish to make amendments (to include provision of
“nil returns”); and/or (c) requiring attendees at the start of each MAPPA meeting formally to
confirm that they have read the minutes of the previous meeting or meetings as appropriate.

Response to MC17:

• We accept this recommendation.

• Current statutory MAPPA Guidance is written with the expectation that MAPPA meeting
minutes be sent via secure email to those who attended the meeting and to those who
were invited but did not attend as well as being stored on ViSOR. It also expects
attendees who wish to ask for amendments and corrections to notify the Chair promptly
and the Chair to confirm that the minutes are correct at the next meeting. It allows for
the MAPPA chair to decide not to send minutes to certain attendees and record their
reasoning - this is to support exceptional attendance of an individual outside of the
Responsible Authority or Duty to Co-operate agencies who can make a contribution to
the meeting, but who does not have facilities for safe storage of MAPPA minutes. We
are strengthening the guidance to set a clear MAPPA standard for the prompt distribution
of MAPPA minutes via secure email and confirmation of accuracy of minutes. Revisions
Page 10 of 14

will also specify that attendees confirm receipt of minutes and confirm at the start of each
meeting that they have received and read the appropriate minutes of previous meetings.
This will be published by April 2022.

MC18 - Addressed to the Secretary of State for Justice, the College of Policing, the
Chief Constable of West Midlands Police and the Chief Constable of Staffordshire
Police

The facts of this case give cause for concern that some members of MAPPA panels
responsible for managing extremist offenders may not be aware of important information
from the offender’s time in prison. Consideration should be given to (a) ensuring that the
latest MAPPA F form from the prison authorities should be circulated with every subsequent
set of MAPPA minutes; (b) including a section in MAPPA minutes for key up-to-date
intelligence; and (c) including a further section in MAPPA minutes for a summary of the key
conclusions of the most recent ERG assessment (including risk factors identified).

Response to MC18:

• We accept this recommendation.

• We will amend the document set to ensure that key information from the MAPPA F is
retained for future meetings post release from custody. The new MAPPA meeting
template will include a section for key up-to-date intelligence, key conclusions of the
most recent ERG assessment and provide for a clear record of risk factors.

• We are also ensuring that there are processes in place to enhance the quality of the

information provided.

MC19 – Addressed to the Secretary of State for Justice, the Secretary of State for the
Home Department, the College of Policing, the Chief Constable of West Midlands
Police and the Chief Constable of Staffordshire Police

This case gives cause for concern that counter-terrorism police may be in possession of
intelligence or information which may be useful to the management of an offender by the
MAPPA panel, but that such intelligence or information may not be brought to the knowledge
of or taken into account by MAPPA agencies. This issue should be addressed, preferably by
ensuring that a single police officer from any covert investigation (such as the SIO or Deputy
SIO) is responsible and accountable for ensuring that intelligence and information is properly
shared and taken into account. Consideration should also be given to how intelligence known
only to the Security Service may be taken into account for the purposes of MAPPA
management.

Page 11 of 14

Response to MC19:

• We accept this recommendation.

• The Joint Counter-Terrorism Prisons and Probation Hub (JCTPPH) is a collaboration
between HMPPS, CTP and the Security Service to ensure the right information gets to
the right place at the right time. Launched in 2021, a major focus has been the
development and operationalisation of a covert-overt bridge framework. This provides
an effective, safe, process through which sensitive intelligence can be revealed and
subsequently, appropriately, disclosed to support defensible decision-making regarding
risk management. Originally focused on supporting better disclosure into the Parole
Board, the framework is now being applied to MAPPA where the bridge has been tested
using information previously only known to the Security Service.

• The covert-overt bridge framework applies a four-stage process: Identify, Review,
Reveal and Disclose (IR2D). The process takes advantage of the JCTPPH’s line of sight
across all the key intelligence systems in the sector. This provides the sector with – for
the first time - a central point where all intelligence can be reviewed by officers from all
agencies to enable decision making about how to manage national security risk.

MC20 - Addressed to the Secretary of State for Justice, the Secretary of State for the
Home Department, the College of Policing, the Chief Constable of West Midlands
Police and the Chief Constable of Staffordshire Police and the College of Policing

The facts of this case give cause for concern that security sensitive information may not be
properly taken into account in decision-making by MAPPA panels concerning the
management of terrorist offenders. Consideration should be given to how the new
procedures can best be operated to avoid this problem recurring. This might include a
requirement that, wherever possible, the MAPPA Panel Chair (or one Co-Chair) should be a
member of the Core Group. It might also include a requirement for the Core Group to
consider what intelligence can be supplied (perhaps in sanitised form) to the broader panel.

Response to MC20:

• We accept this recommendation.

• The July 2021 update to the MAPPA statutory guidance chapter on managing terrorists
states that for this group of offenders, formal Level 3 meetings should be underpinned
by the ongoing active management of the case and by meetings between a concentrated
core group of professionals involved in the management of the case. The core group
may include appropriately security-cleared professionals to allow the effective
management of offenders based on access to the necessary sensitive information in
real time.

•

It will be for the Chair of the Level 3 meeting having liaised with the JCTPPH to identify
a requirement for ensuring that sensitive information is available to the Level 3 panel,
which properly informs decision making and the risk management plan.

• The JCTPPH’s covert-overt bridge framework will ensure the right information gets to

the right place at the right time.

Page 12 of 14

MC21 - Addressed to the Secretary of State for Justice, the Secretary of State for the
Home Department, the College of Policing, the Chief Constable of West Midlands
Police and the Chief Constable of Staffordshire Police

The facts of this case give cause for concern that MAPPA panels responsible for managing
terrorist offenders may be unaware of the regularity and form of contact with police officers
responsible for overt offender management. Consideration should be given to providing
guidance that officers with such responsibilities should report to MAPPA panels on the
regularity of their meetings with offenders and take account of any recommendations by
MAPPA panels.

Response to MC21:

• We accept this recommendation.

• Chapter 12 of the MAPPA Statutory Guidance sets out clear expectations upon MAPPA
agencies in relation to risk management which includes offender management activity. It
states, ‘Every level 2 or 3 MAPPA offender has a RMP (risk management plan) agreed
by the MAPPA Chair’. The lead agency RMP and ViSOR are updated after every
MAPPA meeting’. The guidance breaks the RMP down into four domains, known as the
‘Four Pillars’ of risk management (Supervision, Monitoring and Control, Interventions
and Victim Safety). Supervision is not limited to statutory supervision by the Probation
Service and the guidance is clear that information on police home visits should be
included in the plan.

• We will strengthen the MAPPA meetings chapter of the statutory guidance to put beyond
doubt the expectation that police share full information about regularity and outcomes of
any contact and consider recommendations of the panel.

MC22 - Addressed to the Secretary of State for Justice and the Secretary of State for
the Home Department

The facts of this case gave cause for concern that those involved in managing terrorist
offenders on licence may lack a valuable means of addressing risks they pose, namely an
ability to carry out a search on a precautionary basis. Consideration should be given to the
introduction of a licence condition which could be imposed on terrorist offenders requiring
them to submit to a search by a police officer without the officer establishing specific legal
grounds for the search.

Page 13 of 14

Response to MC22:

• We accept this recommendation.

• The Police, Crime, Sentencing and Courts Bill provides a power enables the Police to
make a personal search of a terrorist offender on licence provided their licence includes
a search condition. It forms one of several measures included in the Bill in response to
independent review of MAPPA and the management of terrorist
offenders. This new power will enable the search to be conducted without reasonable
suspicion and outside exceptional circumstances. For the police to use this power, we
will create a new licence condition that requires offenders to submit to a personal search.

•

If agreed, this will be added into the updated Licence Conditions Policy Framework when
it is published in February 2022, with the Statutory Instrument and policy timed to
coincide with the Royal Assent of the PCSC Bill.

Page 14 of 14

Response from Office for Students (PDF)

Nicholson House 
Lime Kiln Close 
Stoke Gifford 
BRISTOL 
BS34 8SR 

www.officeforstudents.org.uk 

BDB Pitmans LLP 
One Bartholomew Close  
London 
EC1A 7BL 

14 December 2021 

Dear 

Regulation 28 report on action to prevent future deaths  

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

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

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

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

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

Yours sincerely 

Chief Executive 

2

Response from Staffordshire Police (PDF)

Sent by email  

From the Office of the Chief Constable 

BDB Pitmans LLB  
One Bartholemew Close 
London  
EC1A 7BL  

Dear Sir/Madam 

Date: 

6 January 2022 

Chief Constable of Staffordshire Police Response to HH Judge Lucraft QC’s 
Regulation 28 Report on Action to Prevent Future Deaths Following the 
Inquests Arising from the Deaths in the Fishmongers’ Hall Terror Attack  

Further to His Honour Judge Lucraft QC Regulation 28 Report and the letter from the 
Solicitor to the Inquest dated the 3 November 2021 I enclose the attached response 
to the Matters of Concern directed to Staffordshire Police which has been prepared 
on my behalf.  

The Coroner has identified seven Matters of Concern for the Chief Constable of 
Staffordshire Police and others to address.  In order to ensure the response to these 
Matters is as complete as possible Counter Terrorism Policing Headquarters (CTPHQ) 
and West Midlands Counter Terrorism Unit (WMCTU) have been approached and 
have provided responses to the Matters of Concern which are incorporated with the 
Staffordshire response.  

I would like to offer on behalf of myself and all officers and staff of Staffordshire 
Police my sincere and heartfelt condolences to the families of Saskia and Jack and to 
all those affected by the Fishmongers' Hall terror attack.  

Yours faithfully 

Chief Constable 

 
 
 
 
 
 
 Chief Constable of Staffordshire Police  Response to the Regulation 28 Report 
on  Action  to  Prevent  Future  Deaths  Following  the  Inquest  into  the 
Fishmongers Hall  Terror Attack. 

The Coroner HH Judge Lucraft QC has raised, following the inquest, a number of matters 
of concern directed to The Chief Constable of Staffordshire Police. 

In  formulating  the  below  responses  raised  by the  Coroner, Staffordshire  Police  have 
considered the comments of both Counter Terrorism Policing Headquarters (CTPHQ) and 
West Midlands  Counter Terrorism Unit (WMCTU).  

WMCTU are responsible  for coordinating the nationally -set  direction for CT Policing  at a 
Regional  level,  whilst  the  four  respective  Forces  (West  Midlands,  West  Mercia, 
Warwickshire and Staffordshire) retain responsibility for delivering the Policing response. 

The WMCTU have direction and control of CT Policing  within  the West Midlands  Region 
with  these arrangements being reviewed  as part of project AMPLIFY.  This  was  further 
strengthened in  April  2020  when  further  integration  and  collaboration  was  formally  
agreed. As  part of this  agreement the Staffordshire  Police  Special  Branch Department 
was rebranded and is  now officially  known as the WMCTU Northern Hub. 

Part  of  the changes to  this  enhanced Regional  collaboration  saw  Staffordshire  Police 
personnel  cease  to attend CT MAPPA  meetings.  Further, the well-established  working 
practices  (Post  November  2019)  were  maintained  with  the  WMCTU  Northern  Hub 
continuing to provide intelligence  support to CT Policing where nominals with established 
links  to the Staffordshire Force area are subject to MAPPA proceedings. 

These collaborative working arrangements should be borne in mind with regards to the 
matters of concern raised at MC 10, 14, 17, 18, 20 and 21, as they focus heavily on CT 
MAPPA processes and procedures. 

To  detail  the  responses  of  Staffordshire  Police  in  relation  to  the  above  highlighted 
matters of concern would be to duplicate those responses provided by the WMCTU, such 
are  the  collaborative  arrangements  in  place  within  the  Region.  However  where 
appropriate additional  comment has been made.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 It  is  important that the responses of  the CTPHQ, WMCTU and Staffordshire  Police  are 
read  in  conjunction with  each  other to  accurately reflect  the  joined-up nature  of  CT 
Policing  within  the  Region  and  the  Staffordshire  Force  area.  For  this  reason,  the 
responses of all  three organisations are outlined below. 

•  MC10 – Addressed to the Secretary of State for Justice, the College of Policing, 
the Chief Constable of West Midlands  Police and the Chief Constable of 
Staffordshire Police: The facts of this case give rise to concern that important 
decisions on approvals, variations and relaxations in relation to licence conditions 
may be taken without clearly reasoned discussion and decision-making in MAPPA 
panels. This issue could be addressed by requiring MAPPA minutes to record any 
discussion or decision on such a matter. In addition, for the benefit of future 
inquiries and reviews, consideration should be given to having digital audio 
recordings made of all MAPPA meetings. 

Response from CTPHQ 

The Ministry of Justice has revised its approach to the management of terrorist offenders 
following  the  Independent  Reviewer  of  Terrorism  Legislation, 
‘Terrorist  Risk  Offenders:  Independent  Review  of  Statutory  Multi-Agency  Public 
Protection Arrangements’ (‘the Independent Review’). CTPHQ was fully consulted in this 
process as a Responsible  Authority in MAPPA and is fully  committed to support the new 
‘Category  4’  arrangements  following  anticipated  legislative  changes  in  2022.  This 
includes  co-chairing  MAPPA with  the Probation Service at a  senior  level  with  a  clearly  
identified  accountable Local CTP specialist  senior officer. 

Licence conditions are a matter for HMPPS but if it is  determined a discussion at MAPPA 
would be helpful  then Local CT policing will  support this through new specialist  CT MAPPA 
arrangements.  The  Probation  Service  National  Security  Division  have  specialist 
administrators to support the new operating model for specialist  CT MAPPA and to ensure 
effective  minute taking  and sharing  which  are  set out in  more detail  at  paragraph 12 
below.  

Digital  audio recordings of MAPPA meeting present logistical  and operational challen ges 
that policing  will  consider alongside MAPPA partners through MoJ.  

CTPHQ has had the benefit of considering the response on MC10 filed  by the Secretary 
of State for Justice and fully endorses it.  

Response from West Midlands  Police 

As  the  Coroner is  aware,  West Midlands  Police  has  had a  CT MAPPA  arrangement in 
place  for  some  years.  It  has  included  regular  discussions  around  proposed  licence 
conditions and any variations  through the MAPPA  process. Licence conditions are  now 

2 

 
 
 
 
 
 
 
 
 
 
 
 firmly  a  matter  for  HMPPS  but  if  MAPPA’s  input  is  required,  as  CTPHQ  describe  at 
paragraph 7 above, there is  a clear  process for this  to take place  in a  structured way. 
Since the attacks at Fishmongers’ Hall,  developments have also taken place to improve 
the structure and quality of decision-making,  including the introduction of Core Groups 
which consider the operational detail  of a particular case, and enable detailed  discussion 
by key professionals  involved in  that case. These Core Groups make recommendations 
to the MAPPA panel for debate and final  sign off.  

Agencies  work  together  to  consider  other  decisions  such  as  suitability  of  work  and 
training  opportunities, with third party disclosure  decisions taking place  collaboratively. 
WMCTP support HMPPS in this respect.  

A dedicated Minute Taker (Probation Service National Security Division) will  be recruited 
to provide consistency and continuity in note-taking, and final  minutes are reviewed by 
the MAPPA Chair prior to dissemination,  to ensure accuracy. Additionally,  where events 
are  urgent  and  require  a  more  timely  response,  emergency  MAPPA  panels  can  be 
arranged  at  short  notice  with  documented records made  of  decisions  and  rationale. 
These  improvements, fully  supported by a  senior  CTWM Manager,  have enabled  the 
MAPPA panel to operate in a more efficient  and structured way and ensured that notes 
taken can more accurately reflect the more focussed discussion taking place.   

Response from Staffordshire Police 

In  line  with  the  collaborative  arrangements  between  West  Midlands  CTU  and 
Staffordshire  Police,  all  nominals  who are  subject to the  CT MAPPA  process are  now 
owned by the CT Nominal  Management Team from within  WMCTU. They are therefore 
managed in the manner outlined within the West Midlands  Police response above. 

The WMCTU Northern Hub continues to provide the Force link with Intelligence  support 
from a local  prospective via communication channels with senior  CT Managers who are 
personally in attendance at the MAPPA meetings. 

Personnel  from  the  WMCTU  Northern  Hub  no  longer  attend  the  MAPPA  meetings, 
thereby ensuring roles and responsibilities  are clear  to all  MAPPA attendees. 

•  MC14 – Addressed to the Secretary of State for Justice, the College of Policing, 
the Chief Constable of West Midlands  Police and the Chief Constable of 
Staffordshire Police: This case gives rise to concern that an extremist offender 
may be permitted to attend an event or venue without there having been proper 
communication between the probation and police officers responsible for 
managing  the  offender  and  the  event  organisers  and/or  venue hosts. 
Consideration should be given to encouraging such communications within the 
training and guidance given to probation officers and police responsible for 
managing extremist offenders. 

3 

 
 
 
 
 
 
 
 
 Response from CTPHQ 

CTPHQ has had the benefit of considering the response on MC14 filed  by the Secretary 
of State for Justice and fully endorses it.  

CTPHQ recognises the  value  of information  sharing  with  partners  and does so  where 
there is a need and a legal  basis for doing so. Additionally,  where offenders are managed 
under MAPPA, the MAPPA guidance provides guidance on third party disclosures. 

CTPHQ  is  working  with  MoJ  to  develop  MAPPA  practice  in  line  with  accep ted 
recommendations  from  the  Independent  Review.  CTP  will  include  in  its  Manual  of 
Guidance  to specially  trained CT Nominal  Management  officer’s  advice to ensure  they 
fully  consider disclosures  to third parties, record rationales  for making such disclosures  
or not doing  so.  This  will  cover and  ensure  the use  of  risk  assessments  to influence 
protective measures.  This  is  covered on  the  new  CTP Nominal  Managers  foundation 
course  and  will  be  further  supplemented  with  ongoing  continuous  professional 
development in MAPPA.  

Furthermore, CTPHQ has since invested c.£12million  per year in dedicated and specially  
trained  CT  Nominal  Management  officers  who  will  attend  all  CT  specialist  MAPPA 
(Category 4)  meetings.  Their  training  includes  proper communication between  those 
managing the offender and event organisers  and/or venue hosts. Additionally,  CTPHQ 
are  committed to ensuring  terrorist  offenders  are  managed  by trained  officers,  with 
appropriate guidance, and senior  roles  have been assigned  in  each region  of the CTP 
network  to provide  accountability  for  the  management  of  all  terrorist  risk  nominals, 
including  specialist  CT MAPPA  arrangements in  line  with  the Independent Review  and 
recommendations on ‘core group’ joint case work.  

Response from West Midlands  Police 

These  changes have been put into  practice locally.  MAPPA  and CTPWM have already 
drawn  on the experience  and learning  from these  inquests  and,  applying the  MAPPA 
guidance  they have  recently considered  a  wide  range  of  disclosures  including  those 
relating  to work, training,  education, gym membership, religious  practices, and parents 
of  offenders,  amongst  others.  Any  further  new  training  and/or  guidance  can  only 
strengthen confidence in  those processes. All  decisions on disclosures are signed off by 
the joint MAPPA Chairs. 

Staffordshire Police  Response 

Given the changes in structure such that CT nominal management sits with the WMCTU, 
Staffordshire Police adopt and rely upon the response provided above.  

4 

 
 
 
 
 
 
 
 
 
 
 
 •  MC17 – Addressed to the Secretary of State for Justice, the College of Policing, 
the Chief Constable of West Midlands  Police and the Chief Constable of 
Staffordshire Police: Based on the evidence in this case, there is cause for 
concern that effective procedures are not in place to ensure that all MAPPA 
meeting attendees receive meeting minutes. Consideration should be given to 
modifying guidance to ensure that this happens, for example by (a) providing for 
all MAPPA panel participants to receive minutes by secure email (rather than by 
having to access an online system); (b) requiring that all acknowledge safe 
receipt and indicate whether or not they wish to make amendments (to include 
provision of “nil returns”); and/or (c) requiring attendees at the start of each 
MAPPA meeting formally to confirm that they have read the minutes of the 
previous meeting or meetings as appropriate. 

Response from CTPHQ 

CTPHQ has  had the benefit  of  considering the response by the Secretary of State for 
Justice on MC17 and fully endorses it.  

The introduction of CT Nominal Management officers and the assignment of senior roles 
as outlined above will  reduce and focus the number of attendees at MAPPA meetings to 
specialist  staff.  CTP have governance now in  place  through the Nominal  Management 
Capability Board to oversee continuous improvement.  

The Probation Service National  Security Division  are recruiting specialist  admin istrators 
to support the new  operating model and receive appropriate training  in  minute-taking 
as well  as induction to the particular  requirements of taking minutes for formal  MAPPA 
meetings. Recommendations on chairing responsibilities  will  be built into CT MAPPA Chair 
training due to be rolled out ahead of Category 4 changes.  

Response from West Midlands  Police 

Following  the Independent Review conducted by
 in 2020 WMP have 
been  responding  to the  recommendations  and  are  working  with  HMPPS  and  CTPHQ 
regarding the changes they are making or intend to make and will  support accordingly 
in the light of the MAPPA review.  

Staffordshire Police  Response 

Staffordshire Police personnel from the WMCTU Northern Hub do not attend CT MAPPA 
meetings as a matter course. The ownership and decisions on attendance rests with the 
WMCTU Nominal  Management  Team  and  Senior  CT  Managers.  As  a  result  of  these 
arrangements Staffordshire  Police  personnel  from the Northern Hub no longer receive 
the  minutes  from  MAPPA  meetings,  however  there  are  clear  information  sharing 
processes in place between the Northern Hub and W MCTU attendees of CT MAPPA.  

5 

 
 
 
 
 
 
 
 
 
 The West Midlands  CT Offender Management Team are the CT Policing representatives 
present at CT MAPPA  meetings  within  the West Midlands  (including  Staffordshire  and 
Stoke on Trent) Region. Fixed Intelligence  Management Units (FIMU)  within  the region, 
namely  of the  WMCTU, Northern Hub (Staffordshire  Police)  and Southern Hub (West 
Mercia  Police)  no  longer  receive  material  relating  to  the  Offender  Management  of 
nominals  who are subject to Part 4 TACT conditions from partner agencies i.e.  MAPPA, 
Probation or  Mentoring  schemes.  Any relevant  intelligence  is  submitted by the  West 
Midlands  CT  Offender  Management  Team  to  the  appropriate  FIMU  in  line  with  the 
National  Standards of Intelligence  Management (NSIM). 

•  MC18 - Addressed to the Secretary of State for Justice, the College of Policing, 
the Chief Constable of West Midlands  Police and the Chief Constable of 
Staffordshire Police: The facts of this case give cause for concern that some 
members of MAPPA panels responsible for managing extremist offenders may 
not be aware of important information from the offender’s time in prison. 
Consideration should be given to (a) ensuring that the latest MAPPA F form from 
the prison authorities should be circulated with every subsequent set of MAPPA 
minutes; (b) including a section in MAPPA minutes for key up-to-date intelligence; 
and (c) including a further section in MAPPA minutes for a summary of the key 
conclusions of the most recent ERG assessment (including risk factors identified).  

Response from CTPHQ 

A Joint Counter Terrorism Prison and Probation Hub (‘JCTPPH’) has been formed. This is 
a  collaboration  between  HMPPS,  CTPHQ  and  the  Security  Service.  One  of  its  core 
functions is to enhance the flow of intelligence  and information between covert and overt 
functions,  noting that  there  is  an  obvious and  necessary  ‘firewall’  between  the  two. 
MAPPA chairs will  consider how core groups will  contribute in each case. The creation of 
core  groups  will  ensure  a  secure  and  clear  pathway  for  the  sharing  of  sensitive 
intelligence/information  into  MAPPA.  CTPHQ  have  provided  guidance  through  their 
Manual  of  Guidance  to require  CTP Nominal  Management specialist  officers  and Lead 
Responsible Officers to ensure that all relevant information is at hand to develop effective 
risk  management  plans  for  their  allocated  nominal,  including  those  managed  under 
MAPPA. This  will  include ensuring relevant assessments are shared and included in risk 
management planning.  

CTPHQ has had the benefit of considering the response on MC18 filed  by the Secretary 
of State for Justice and fully endorses it.  

Response from West Midlands  Police 

MAPPA F forms are shared alongside  MAPPA Minutes  for some attendees to consider at 
the panel meeting as detailed  in paragraph 22 above.  

6 

 
 
 
 
 
 
 
 
 The MAPPA F forms and minutes are sent to the Standard Panel members prior to the 
MAPPA meetings. The current 2021 MAPPA guidance states at para 13 b (4):  

“Given the highly confidential nature of the minutes, all agencies should ask themselves 
whether they actually need to keep a copy of the minutes in their files, or whether a 
record of the actions for their agency and a reference to the fact that the minutes are 
held on ViSOR would be sufficient.”  

Where there  are  delays  in  receipt  of  the  Form F,  these  are  escalated  as  a  matter of 
urgency to the prison concerned. The quality of the Form F can be variable,  and locally  
the West Midlands  MAPPA chair is  challenging  this position, and seeking a greater level 
of  analytical  support from the  JCTPPH around security information,  to better support 
MAPPA decisions. 

The MAPPA agenda is  structured to ensure each relevant agency has the opportunity to 
provide full  and detailed  updates in relation  to their  work with a nominal.  This includes 
intelligence  updates, where  appropriate, including  clear  handovers from an offender’s 
time  in  prison  Where  sensitive  or  secret  intelligence  is  concerned,  CTP  WM  are 
supporting the development of the Covert-Overt bridge process, involving CT Police SIOs 
directly, and providing a suitable  ‘bridge’ to the MAPPA chair to allow  the information to 
be ‘known’ and considered appropriately within  the MAPPA  meeting.  Already we  have 
operationalised  this approach in a small  number of cases, both for MAPPA Panel and for 
Parole Boards.  

There are now co-chair arrangements in place. The CTPWM LRO will  co-chair MAPPA CT 
cases  with  the  NSD Senior  Regional  Lead  for  Probation. It  is  understood that all  CT 
MAPPA cases will  be managed in this format and will  ensure consistent representation.  

The prisons representatives conduct handovers with the probation service outside of the 
MAPPA meetings through their OMIC  process however there will  be clear updates from 
the prison’s reps during the MAPPA meetings and discussions are held during the MAPPA 
meetings to ensure this handover has taken place and held accountable by the chair.   

ERG assessments are  shared with  CT Police  NMs,  and the ERG is  discussed at MAPPA 
Panel  to  allow  a  full  understanding  of  a  nominal  risk  and  to  ensure  CT  Police  risk 
management plans  reflect  this information.  There is  no specific  section in  the minutes 
for the ERG summaries however the Counter Terrorism Probation Officer (CTPO) would 
talk  the  panel  through the  findings  once  the  ERG  had  completed  within  prison  and 
therefore documented in their section.  

Staffordshire Police  Response 

Given the changes in structure such that CT nominal management sits with the WMCTU 
the above response is  adopted and relied  upon.  

7 

 
 
 
 
 
 
 
 
 
 •  MC19 – Addressed to the Secretary of State for Justice, the Secretary of State 
for the Home Department, the College of Policing, the Chief Constable of West 
Midlands Police and the Chief Constable of Staffordshire Police: This case gives 
cause for concern that counter-terrorism police may be in possession of 
intelligence  or information which may be useful to the management of an 
offender by the MAPPA panel, but that such intelligence or information may not 
be brought to the knowledge of or taken into account by MAPPA agencies. This 
issue should be addressed, preferably by ensuring that a single police officer from 
any covert investigation (such as the SIO or Deputy SIO) is responsible and 
accountable for ensuring that intelligence and information is properly shared and 
taken into account. Consideration should also be given to how intelligence known 
only to the Security Service may be taken into account for the purposes of MAPPA 
management. 

Response from CTPHQ 

The JCTPPH will  ensure the right information gets to the right place at the right time. A 
major  focus, in  its  first  year,  has  been  the  development and  operationalisation  of  a 
covert-overt bridge framework. This provides an effective,  safe, process through which 
sensitive  intelligence  can  be  revealed  and  subsequently,  appropriately,  disclosed  to 
support defensible  decision-making  regarding risk  management. Originally  focused on 
supporting better disclosure into the Parole Board process learning  has been taken and 
applied  to MAPPA  where the bridge  has already  been tested on five  cases bringing  to 
the attention of MAPPA information previously only known to the security service.  
CTPHQ has had the benefit of considering the response on MC19 filed  by the Secretary 
of State for Justice and fully endorses it. 

Response from West Midlands  Police 

West Midlands  Police would simply repeat the CTPHQ’s response above but add that we 
have been at the forefront in  exploring this  approach, and have been directly involved 
in  developing  the  process,  as  well  as  supporting the  JCTPPH in  managing  sensitive 
information through to parole boards and the MAPPA chair in a small  number of cases.   

Staffordshire Police  Response 

Given the changes in structure such that CT nominal management sits with the WMCTU, 
Staffordshire Police adopt and rely upon the response provided above.  

•  MC20 - Addressed to the Secretary of State for Justice, the Secretary of State 
for the Home Department, the College of Policing, the Chief Constable of West 
Midlands Police and the Chief Constable of Staffordshire Police and the College 
of Policing: The facts of this case give cause for concern that security sensitive 
information may not be properly taken into account in decision-making by MAPPA 

8 

 
 
 
 
 
 
 
 
 panels concerning the management of terrorist offenders. Consideration should 
be given to how the new procedures can best be operated to avoid this problem 
recurring. This might include a requirement that, wherever possible, the MAPPA 
Panel Chair (or one Co-Chair) should be a member of the Core Group. It might 
also include a requirement for the Core Group to consider what intelligence can 
be supplied (perhaps in sanitised form) to the broader panel. 

Response from CTPHQ 

Guidance for specialist  CT MAPPA is  currently being finalised  and it  is  anticipated it will 
be implemented  once the Police, Crime, Sentencing and Courts Bill  has passed through 
Parliament  (its  third reading took place on 5 July 2021). The terms of reference for CT 
MAPPA are likely  to be those individuals  subject of Category 4 (as defined under the new 
Act) both terrorist offenders and those identified  as ‘relevant terrorist offenders.’ These 
arrangements include MAPPA panels being jointly chaired by Local CTP officers (leading 
regional  CT  Nominal  Management  teams)  and  National  Security  division  (Probation) 
senior leads.  Both Chairs  will  be vetted and able  to receive sensitive  information if  it  is 
appropriate for  them to do so, using  the JCTPPH covert-overt bridge processes. Core 
Groups will  be embedded in to CT MAPPA, details  of which are currently going through 
a consultation stage.  

CT MAPPA  chairs  are  now Develop Vetted,  and  that the  key staff  (CTNM  &  National 
Security Division)  who  actively  manage  the  offenders,  have  specialist  roles,  are  also 
vetted  to  a  level  suitable  for  CT  and  work  together  outside  of  the  formal  MAPPA 
meetings. The Chairs now work with the Joint Extremist Unit to facilitate  intelligence  into 
MAPPA meeting to ensure risk management plans reflect the full  context of any concern.  

As described above, the JCTPPH leads  on a covert/overt bridge which enables  sensitive 
information to be identified,  reviewed, revealed and disclosed to MAPPA Chairs or other 
relevant individuals  linked  with the MAPPA process. It is  expected that an outcome from 
the covert/overt bridge process will  be an agreement on what information can be shared 
from the MAPPA Chairs to others involved in the MAPPA process.  

CTPHQ has had the benefit of considering the response on MC20 filed  by the Secretary 
of State for Justice and fully endorses it.  

Response from West Midlands  Police 

West Midlands  Police repeat the CTPHQ’s response above. 

Staffordshire Police  Response 

Given the changes in structure such that CT nominal management sits with the WMCTU, 
Staffordshire Police adopt and rely upon the response provided above.  

9 

 
 
 
 
 
 
 
 
 
 
 •  MC21 - Addressed to the Secretary of State for Justice, the Secretary of State 
for the Home Department, the College of Policing, the Chief Constable of West 
Midlands Police and the Chief Constable of Staffordshire Police: The facts of this 
case give cause for concern that MAPPA panels responsible for managing terrorist 
offenders may be unaware of the regularity and form of contact with police 
officers responsible for overt offender management. Consideration should be 
given to providing guidance that officers with such responsibilities should report 
to MAPPA panels on the regularity of their meetings with offenders and take 
account of any recommendations by MAPPA panels. 

Response from CTPHQ 

Following  investment of c.£12million  as described at paragraph 16 above, CTPHQ now 
has  CT  Nominal  Management  specialist  trained  officers,  operating  to  a  standardised 
Manual  of Guidance who will  attend all  future CT MAPPA (Category 4) cases. They are 
responsible for designing and delivering a risk management plan (RMP) with the National 
Security Division  and other MAPPA  partners. This  will  include  an  approach to a  home 
visit  regimes  based on the assessment  of risk  and need which will  be formally  agreed 
through the MAPPA co-chairs. Full  visibility  of police activities in supporting this RMP will 
be made available  to MAPPA panels.  

CTPHQ has had the benefit of considering the response on MC21 filed  by the Secretary 
of State for Justice and fully endorses it.  

Response from West Midlands  Police 

Locally  CTP  West  Midlands  Nominal  Managers  exceed  the  national  guidance  for 
Registered  Terrorist  Offenders/Pathfinder  visits.  National  guidance  on  visits  set  a 
minimum  standard of  one  visit  per  month for  those considered  to  be  ‘intensive  risk’, 
three  visits  per  year  for  those  considered  ‘enhanced risk’  and  one  visit  per  year for 
‘standard risk’ nominals. West Midlands Police’s regime involves two visits per month for 
‘intensive risk’,  one per month for ‘enhanced risk’ and quarterly visits for those who are 
standard risk. Additional visits can be added if required. Performance on this is monitored 
at Force level.   

CTP West Midlands  now feed this  into  the MAPPA  panel  to ensure  synchrony of visits 
across agencies, and to take account of any MAPPA requirements.  

Staffordshire Police  Response 

The Staffordshire  response to MC21 is  as outlined  by the West Midlands  Police  above, 
such are the collaborative CT MAPPA working arrangements within  the WMCTU Region. 

10 

 
 
 
 
 
 
 
 
 
 
 
 The regularity and form of overt contact by the Police with Terrorist Offenders released 
into the communities of Staffordshire  and Stoke on Trent is  managed by the Nominal 
Management Team within  the WMCTU.  

11

Response from University of Cambridge (PDF)

The Vice-Chancellor  

7 January 2022 

BDB Pitmans 
One Bartholomew Close  
London  
EC1A 7BL 

Dear Ms Lester 

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

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

•  The  University’s  new  ‘Policy  and  Guidance  for  staff  and  students  working,  managing  or 

engaging with activities involving people who have offended’; and 

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

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

Yours sincerely, 

The Vice-Chancellor 

Enclosures 

Vice-Chancellor’s Office 
The Old Schools 
Trinity Lane 
Cambridge CB2 1TN  

www.cam.ac.uk 

 
 
 
 
 
 
 
 
 
 
  
  
 
 
 
 
 
 
 
 
 INQUESTS INTO THE DEATHS ARISING FROM  

THE FISHMONGERS’ HALL AND LONDON BRIDGE TERROR ATTACK  

RESPONSE OF THE UNIVERSITY OF CAMBRIDGE  

TO PREVENTION OF FUTURE DEATHS REPORT 

INTRODUCTION 

1. 

This  is  the  response  on  behalf  of  the University  of  Cambridge  (“the  University”)  in 

relation to the ‘Regulation 28 Report on Action to Prevent Future Deaths’ (“the PFD 
Report”)1 made on 3 November 2021 by the coroner in relation to the deaths arising 

from the attack at Fishmongers’ Hall on 29 November 2019. Recommendations MC1, 

MC2,  MC3  and  MC5  in  the  PFD  Report  are  addressed  to  the  University.  This 

response is structured in five main parts, as follows: 

(a) 

(b) 

(c) 

Part One: Response to MC1 (formal risk assessments) 

Part Two: Response to MC2 (informing host venues) 

Part Three: Response to MC3 (young students and those convicted of serious 

offences) 

(d) 

Part Four: Response to MC5 (engagement with those convicted of offences in 

the community) 

(e) 

Factual Matters 

2. 

In 2021, following the outcomes of reports by other University-commissioned bodies, 

the  University  established  a Transition  Board  to  consider  the  future  of  the  Learning 

Together  (“LT”)  programme  (i.e.  the  educational  initiative  based  at  the  University’s 

Institute of  Criminology  (“the  Institute”)  and  comprising  LT  partnerships  associated 
with  the  University).2  In  December  2021,  the  recommendations  of  the  Transition 

Board went to the General Board (which is the body responsible for the academic and 

educational  policy  of  the  University)  and  the  Council  (which  is  the  executive  and 

1  Under  paragraph  7  of  Schedule  5  to  the  Coroners  and  Justice  Act  2009  and  regulations  28  and  29  of  the 
Coroners (Investigations) Regulations 2013 

1 

 
 
 
 
 
 
 
 
 
 
 
                                                
 
 policy-making  body  of  the  University  and  whose  members  constitute  the  charity 

trustees  of  the  University).  The  recommendations  were  approved  by  the  General 

Board and by the Council, including that there now needs to be a “clear stop” to the 

delivery of the LT programme in the University, both within and beyond prisons. The 

LT programme in the University is therefore at an end. 

PART ONE: RESPONSE TO MC1 (FORMAL RISK ASSESSMENTS) 

MC1 – Addressed to the University of Cambridge, Learning Together, the Secretary of State 
for  Education  and  the  Office  for  Students:  Significant  academic  events  and  courses  held 
outside of university premises should be subject to proper formal risk assessment, especially 
if  they  take  place  in  environments  with  particular  risk  (such  as  prisons)  and  if  they  are 
attended by individuals who pose particular risks. It is a matter of concern that there was no 
such  risk  assessment  for  Learning  Together  events  as  set  out  above.  The  University  of 
Cambridge  and  those  responsible  for  guidance  to  UK  higher  education  institutions  should 
consider  whether  further  steps  can  be  taken  to  encourage  the  making  of  such  risk 
assessments. 

The University and the issue of risk assessments 

3. 

Prior to 29 November 2019, the  University did  have in  place a  requirement  for risk 

assessments  to  be  conducted  in  relation  to  events.  This  was  contained  within  the 

University  Health  and  Safety  Policy;  its  Guidance  on  Managing  Risks  from  Travel, 

Fieldwork  and  Work  Away  (“the  Work  Away  Guidance”),  which  has  been  in  place 

since  January  2019;  and  its  Guidance  for  the  organisers  of  activities:  Events, 

Festivals, Outreach Programmes, School Visits, Public Engagements etc (“the Events 

Guidance”), which has been in place since 2017. 

4. 

The  University’s  aim  is  to  ensure  that  a  formal  written  risk  assessment  is  always  in 

place for similar activities in the future. Work has been ongoing to advance that aim, 

notably:  

(a) 

In  mid-2021,  the  Health  &  Safety  Executive  Committee  and  the  Registrary 

(the Head of the University’s Unified Administrative Service) commissioned a 

review of the University Health and Safety Policy and the underlying relevant 

procedures  and  guidance,  focussing  particularly  on  event-specific  risk 

assessment and on work with offenders and ex-offenders, whether taking place 

as  part  of  the  LT  programme  or  not.  Although  taking  the  view  that  the 

University’s overarching health and safety policies and  guidance were fit  for 

2 

 
 
 
 
 
 
 
 
 purpose,  the  University  took  the  opportunity  to  refine  and  enhance  them 

further to ensure they remain so.  

(b) 

To  that  end,  and  with  an  abundance  of  caution,  the University  has  sought  to 

enhance  its  procedures  and  documents  by  establishing  dedicated  new  health 

and safety documentation in the form of a University of Cambridge Policy and 

Guidance for staff and students working, managing or engaging with activities 

involving  people  who  have offended  (“the Working With  Offenders  Policy”), 

to address working with ‘People Who Have Offended’. A copy is enclosed and 

key  terms  and  roles  capitalised  and  in  single  quotation  marks  in  this  sub-

paragraph,  sub-paragraphs  4(c)  and  4(d),  and  paragraphs  6,  7,  11,  14  and  17 

below  are  defined  there.  This  new  documentation  specifically  addresses  the 

safety risks which may arise in such circumstances and has been created with 

specialised  input  from  an  external  expert  organisation,  NACRO.  The 

University’s Health & Safety Executive Committee approved the final version 

of the above documentation on 5 January 2022, and this will be considered by 

the Council on 24 January 2022 and, once approved, will be implemented as 

soon  as  possible.  The  new  documentation  will  be  disseminated  by  the 

University’s  Safety  Office  to  all  ‘Heads  of  Department’,  Departmental 

Administrators and Departmental Safety Officers, as well  as being placed on 

the University website. The new Working With Offenders Policy applies to all 

employees, students and anyone else engaged by the University as part of its 

undertaking  to  organise,  deliver  or  participate  in  a  ‘Relevant  Activity’  that 

involves  ‘People  Who  Have  Offended’.  It  applies  to  a  diverse  range  of 

‘Relevant  Activities’  (e.g.  prison  visits,  conferences  and  seminars,  teaching 

and rehabilitation workshops or social events). In relation to risk assessment, it 

makes clear the division of responsibilities between the University, ‘Heads of 

Department’,  ‘Activity  Organisers’  and  others.  It  also  mandates 

the 

preparation  of  a  risk  assessment  by  the  ‘Activity  Organiser’,  which  must  be 

submitted to the appropriate ‘Head of Department’. The ‘Head of Department’ 

must  then  share  the  risk  assessment  with  the  new  ‘Advisory  Committee  on 

Working with People who have Offended’ (“ACWPO”) as soon as reasonably 

practicable  and  preferably  at  least  2  to  3  months  before  the  intended  date of 

the ‘Relevant Activity’, bearing in mind that major events or activities where 

3 

 
 
 
 the risks are  high  will  require more time for  consideration  than  some others. 

ACWPO advises the ‘Head of Department’, who makes the ultimate decision 

whether  to  approve  or  decline  the  proposed  activity  (or  approve  it  with 

appropriate  control  measures).  Guidance  on  possible  risks  and  control 

measures is included in the Working With Offenders Policy. 

(c) 

The  University  will  reinforce  the  new  Working  With  Offenders  Policy 

documentation  by  providing  specific  training  where  appropriate,  developed 

with  support  from  the  external  expert  organisation  NACRO.  For  example, 

bespoke training  will  be  offered  to  cover  certain  identified  areas  such  as  the 

role  of  ACWPO  and  the  responsibilities  of  the  ‘Activity  Organiser’.  The 

training will have a particular focus on how to carry out risk assessments both 

prior to and during a ‘Relevant Activity’. 

(d) 

The  University  will  shortly  be  revising  its Work Away  Guidance and  Events 

Guidance  to  clarify  where  additional  procedures  must  be  followed  when 

working with ‘People Who Have Offended’. 

5. 

The  University  monitors  general  compliance  with  its  health  and  safety  policies 

through  a  programme  of  regular  audits  of  departments  conducted  by  the  Safety 

Office. The  Safety Office  audits specifically  consider the systems and procedures in 

place and whether relevant policies are followed. The Safety Office is also responsible 

for reviewing and updating health and safety policy documents as and when necessary 

and disseminating the revised versions throughout the University.  

6. 

In relation to the monitoring of the new Working With Offenders Policy specifically, 

the  policy  expressly  provides  for  each  ‘Relevant  Activity’  to  be  reviewed  by  the 

‘Activity  Organiser’  and  the  Departmental  Safety  Officer  immediately  after  it  has 

ended, as well as reported to and discussed by the department’s safety committee. Any 

findings that may be of use to the wider University should be communicated by the 

Departmental Safety Officer to the Safety Office, so that Safety Office staff can take 

them  into  account  in  its  reviews  and  disseminate  them  where  appropriate.  The 

Working  With  Offenders  Policy  also  contains  specific  monitoring  and  review 

provisions  stipulating  that  the  Safety  Office  will  conduct  a  review  of  the  Working 

4 

 
 
 
 
 
 
 With  Offenders  Policy  and  associated  documents  one  year  after  implementation  (or 

sooner if necessary); and thereafter every three years (or sooner if necessary). 

The Institute and the issue of risk assessments 

7. 

‘Heads of Department’ are responsible within their own domain for ensuring that their 

department  complies  with  the  University’s  health  and  safety  requirements  and  has 

effective  systems  in  place  for  the  management  of  health  and  safety.  Under  the 

University  Health  and  Safety  Policy  they  must  set  out  their  own  organisational 

arrangements for safety. The Institute draws on the University’s policies and guidance 

and  applies  them  to  the  specific  circumstances  of  its  own  work  to  prepare  its  own 

health and safety policies. 

8. 

The Institute has taken further steps to contribute to the aim of ensuring that a formal 

written risk assessment is always in place for similar activities in the future, notably:  

(a) 

The Institute has reviewed, and introduced refinements to, its own policies and 

procedures  to  maximise  compliance  by  staff  and  students.  The  Institute’s 

review  has  included  further  development  of  its  ‘Risk  Assessment  Form  for 

Fieldwork’,  which  has  now  been  renamed  ‘Risk  Assessment  Form  for  All 

Activities (including Fieldwork)’ and now expressly applies to external events 

of the type held at Fishmongers’ Hall. A copy is enclosed. 

(b) 

The  Institute’s  Departmental  Administrator  is  currently  working  on  a  flow 

chart to make everything easy to understand in terms of who needs to do risk 

assessments, for what  and when. There is also reference to  health  and safety 

and  risk  assessment  requirements  on  the  Institute’s  ‘Desk  Card’  (which 

contains key contacts and sources of information together with guidance that: 

‘when in doubt, ask’). 

(c) 

The  Institute  now  forwards  a  list  of  current  officers  in  the  Institute  to  key 

offices within the University, including the Safety Office, at the start of every 

academic  year  (1  October)  to  avoid  any  risk  of  important  health  and  safety 

related information failing to be communicated effectively to, and within, the 

Institute.  The  Safety  Office  is  introducing  an  electronic  checklist  so  that 

5 

 
 
 
 
 
 
 
 
  report  on  policy  and  practice  developments  regarding  risk  assessment  to  its 

Committee of Management. This committee is chaired by the Chair of the Faculty of 

Law  and  includes  academics  from  within  the  Institute,  academic  colleagues  from 

across  the  University,  the  current  Head  of  Research  for  the  HM  Inspectorate  of 

Probation,  a  former  Director-General  of  the  Prison  Service/Head  of  the  National 

Offender Management Service and a former Chief Inspector of Constabulary. 

10.

Since the tragic events of 29 November 2019 all courses, events and other meetings

organised  by  the  LT  programme  in  the  University  which  bring  together  University

staff,  students,  former  students  and  visitors  with  those  in  prison  or  under  criminal

justice supervision in the community were paused. This means that, since the tragedy,

the  LT  programme  in  the  University  has  not  given  rise  to  any  of  the  potential  risks

referred  to  in  MC1  (formal  risk  assessments),  MC2  (informing  host  venues),  MC3

(young students and those convicted of serious offences) and MC5 (engagement with

those  convicted  of  offences  in  the  community).  As  paragraph  2  above  explains,  in

December 2021 the University’s General Board and Council approved a clear stop to

the delivery of the LT programme in the University, both within and beyond prisons.

The LT programme will not, therefore, continue in the University.

PART TWO: RESPONSE TO MC2 (INFORMING HOST VENUES) 

MC2 – Addressed to the University of Cambridge, Learning Together, the Secretary of State 
for Education and the Office for Students: It is a matter of concern that a major event could 
be held by a University at a livery company hall in London without clear communication of 
the  fact  that  it  would  be  attended  by  serving  and  recently  released  serious  offenders. 
Consideration should be given to guidance requiring higher education institutions to inform 
host  venues  of  high-risk  features  of  events,  including  for  instance  the  attendance  of  such 
persons. 

The University and the issue of informing host venues 

11.

The question of information sharing with host venues has been specifically included

in the University and department level reviews of policies and procedures described in

Part One above (and will be covered in the forthcoming revisions to the Work Away

Guidance and Events Guidance referred to in sub-paragraph 4(d)). The new Working

With  Offenders  Policy  referred  to  in  sub-paragraph  4(b)  specifically  provides  that

when  a  ‘Relevant  Activity’  (e.g.  an  organised  event)  is  taking  place  away  from

University  premises,  information  about  the  attendance  of  ‘People  Who  Have

7 

 Offended’ (as defined in the Working With Offenders Policy) must be communicated 

to  the  host  venue,  even  where  their  presence  will  be  known  to  the  venue  as  a 

consequence of other communication.  

The Institute and the issue of informing host venues 

12. 

The  University-wide  position  is  being  taken  into  account  by  the  Institute  and  other 

departments across the University as part of their ongoing further reviews.  

13. 

The  LT  programme  in  the  University  was  based  at  the  Institute.  The  University’s 

review  of  the  future  of  the  LT  programme  in  the  University  expressly  included 

consideration  of  how,  if  it  continued  to  be  active  in  the  community  in  some  form, 

information about attendees at LT events should be shared with the venue proprietors. 

As paragraph 2 above explains, however, the University’s General Board and Council 

have  now  confirmed  that  there  will  be  a  clear  stop  to  the  delivery  of  the  LT 

programme in the University, both within and beyond prisons. 

PART  THREE:  RESPONSE  TO  MC3  (YOUNG  STUDENTS  AND  THOSE 
CONVICTED OF SERIOUS OFFENCES) 

MC3  – Addressed  to  Learning  Together  and  the  University  of  Cambridge:  It  is  a  matter  of 
concern  that  focussed  consideration  was  not  given  to  the  risks  of  serious  offenders  being 
placed  in  close  and  continuing  contact  with  young  students.  Consideration  should  now  be 
given to such risks and targeted means of mitigating them. 

The University and the issue of young people and those convicted of serious offences 

14. 

The approach to risk assessing situations where young people may associate closely 

with  those  convicted  of  serious  offences  has  been  specifically  included  in  the 

University and department level reviews of policies and procedures described in Part 

One  above  (and  will  be  covered  in  the  forthcoming  revisions  to  the  Work  Away 

Guidance and Events Guidance referred to in sub-paragraph 4(d)). The new Working 

With  Offenders  Policy  referred  to  in  sub-paragraph  4(b)  above  highlights  the 

particular  risks  around  coercive  or  abusive  behaviour  that  may  arise  when  ‘People 

Who Have Offended’ (as defined in the Working With Offenders Policy) are placed in 

close/continuing  contact  with  young  students  and  emphasises  the  need  for  close 

supervision,  mentoring  and  appropriate  support  to  be  provided  by  experienced  staff 

who are capable of detecting potentially subtle behavioural changes. 

8 

 
 
 
 
 
 
 
 
 
 
 The Institute and the issue of young people and those convicted of serious offences  

15. 

The  University-wide  position  is  being  taken  into  account  by  the  Institute  and  other 

departments  across  the  University  as  part  of  their  ongoing  further  reviews.  All 

University students and personnel going into prisons for activities are subject to safety 

protocols  and  instruction  from  the  prison.  Students  at  the  Institute  are  told,  among 

other  things,  that  while  they  are  inside  they  must  comply  with  each  and  every 

instruction given to them by prison officers or other prison staff; they must not give 

out  any  personal  information;  and  they  should  not  enter  a  prisoner’s  cell  but  must 

remain within sight of  prison officers or other prison staff  at all  times. The  Institute 

also attends to the emotional needs of students by discussing with them the ‘emotional 

labour’ of doing research in prisons or in engaging in other such activities in prisons 

or  with  people  who  remain  under  formal  community  supervision.  To  supplement 

support  for  students  from  the  University  Counselling  Service  and  from  College-

Counsellors, the Institute pays for specialist counselling to support the wellbeing and 

progress of those researching particularly emotionally demanding topics such as child 

sexual abuse, domestic abuse or drug-related research.  

16. 

The  University’s  review  of  the  future  of  the  LT  programme  in  the  University 

expressly  included  consideration  of  whether,  if  it  continued,  there  should  be  any 

exclusion  from  LT  activities  of  individuals  who  have  been  convicted  under  the 

Terrorism  Act  2000  (TACT  offenders)  or  any  other  exclusions  (e.g.  by  conviction 

type,  security  category  etc.).  As  paragraph  2  above  explains,  however,  the 

University’s General Board and Council have now confirmed that there will be a clear 

stop to the delivery of the LT programme in the University, both within and beyond 

prisons.  

PART FOUR:  RESPONSE  TO  MC5 (ENGAGEMENT WITH  THOSE  CONVICTED 
OF OFFENCES IN THE COMMUNITY) 

MC5 – Addressed to the Secretary of State for Justice, the Secretary of State for Education, 
the Office for Students, the University of  Cambridge and Learning Together: Consideration 
should  be  given  to  whether  further  measures  of  risk  assessment  and  management  can  be 
introduced for any higher education programmes running in prisons which involve continued 
contact with offenders after their release into the community. 

9 

 
 
 
 
 
 
 
 
 
 
 The University and the issue of community interactions with those convicted of offences  

17. 

The  approach  to  risk  assessing  situations  where  those  convicted  of  offences  may 

participate  in  activities  in  the  community  has  been  specifically  included  in  the 

University and department level reviews of policies and procedures described in Part 

One  above  (and  will  be  covered  in  the  forthcoming  revisions  to  the  Work  Away 

Guidance and Events Guidance referred to in sub-paragraph 4(d)). The new Working 

With  Offenders  Policy  referred  to  in  sub-paragraph  4(b)  above  highlights  the 

particular risks that may arise when engaging with ‘People Who Have Offended’ (as 

defined in the Working With Offenders Policy) in the community and emphasises the 

special  importance  of  close  supervision,  mentoring  and  appropriate  support  from 

experienced staff in that context.  

The Institute and the issue of community interactions with those convicted of offences 

18. 

The  University-wide  position  is  being  taken  into  account  by  the  Institute  and  other 

departments  across  the  University  as  part  of  their  ongoing  further  reviews.  The 

Institute  continues  to  review  all  policies  and  practices  in  the  light  of  changes  in 

University policies and guidance. The Institute will not permit its staff and students to 

organise  community  engagement  activities  through  the  Institute  that  involve  those 

who have committed serious offences, beyond research initiatives which may involve 

follow-up  research  interviews.  Such  interviews  will  generally  require  the  express 

permission  of  HM  Probation  Service  and  any  other  relevant  authorities;  will  be 

subject to risk assessment; and will often take place in criminal justice system venues. 

19. 

The  University’s  review  of  the  future  of  the  LT  programme  expressly  included 

consideration of whether, if it continued,  LT’s activities should be restricted to taking 

place only in prisons, or whether (and, if so, in what form) LT should also continue in 

the  community.  As  paragraph  2  above  explains,  however,  the  University’s  General 

Board and Council have now confirmed that there will be a clear stop to the delivery 

of the LT programme in the University, both within and beyond prisons. 

10 

 
 
 
 
 
 
 FACTUAL MATTERS 

20. 

Paragraph  50  of  the  PFD  Report  suggests  that  the  LT  programme  started  at  HMP 

Grendon in 2015 and that it  was “soon afterwards rolled out to HMP Warren Hill”. 

The  first  course  at  HMP  Grendon  started  in  January  2015. The  first  course  at  HMP 

Whitemoor started in January 2017 and the first course at HMP Warren Hill started in 

November 2018.  

CONCLUSION 

21. 

The  University  is  committed  to  learning  from  the  events  of  29  November  2019  in 

everything  it  does  moving  forwards.  The  work  described  above  demonstrates  the 

University’s  commitment  to  addressing  in  full  the  concerns  arising  from  the  tragic 

events at Fishmongers’ Hall. 

22. 

It is  clear that projects  and programmes that involve students and prisoners learning 

alongside each other, in a controlled environment, can deliver positive benefits to all 

involved. A commitment to offenders and former offenders having access to education 

fits  with  the  University’s  mission  to  contribute  to  society  through  the  pursuit  of 

education, learning and research at the highest international levels of excellence. The 

University  will  reconsider  student-prisoner  education  within  prisons  if,  and  when,  a 

suitable  new  framework  for  such  work  is  developed  by  HM  Prison  Service  and/or 

other relevant authorities.  

11

Response from West Midlands Police (PDF)

POLICE HEADQUARTERS
PO Box 52
Colmore Circus Queensway
BIRMINGHAM
B4 6NQ

Switchboard : 101

Email:

31st December 2021

CHIEF CONSTABLE

CReerhi

Sent by email

6 Rue de Guerledan
BDB Pitmans LLB
One Bartholemew Close
London
EC1A 7BL

Saint Aignan,

Dear Sirs/Madam,

56480

Morbihan

Chief Constable of West Midlands Police Response to HH Judge Lucraft QC’s
Regulation 28 Report on Action to Prevent Future Deaths Following the Inquests
Arising from the Deaths in the Fishmongers’ Hall Terror Attack

Bretagne

Further to His Honour Judge Lucraft QC Regulation 28 Report and the letter from the
Solicitor to the Inquest dated the 3 November 2021 I enclose the attached response to the
Matters of Concern directed to West Midlands Police which has been prepared on my
behalf.

France

The Coroner has identified seven Matters of Concern for the Chief Constable of West
Midlands Police and others to address. In order to ensure the response to these Matters is
as complete as possible Counter Terrorism Policing Headquarters (‘CTPHQ’) have been
approached and have provided responses to the Matters of Concern which are
incorporated with the West Midlands response.

I would like to offer on behalf of myself and all officers and staff of West Midlands Police my
sincere and heartfelt condolences to the families of Saskia and Jack and to all those affected
by the Fishmongers' Hall terror attack.

Yours faithfully,

Chief Constable

Chief Constable of West Midlands Police Response to HH Judge Lucraft QC’s Regulation 28

Report on Action to Prevent Future Deaths Following the Inquests Arising from the Deaths in

the Fishmongers’ Hall Terror Attack

1. The Coroner HH Judge Lucraft QC has raised a number of Matters of Concern directed

at the Chief Constable of West Midlands Police arising from the terrorist attack at

Fishmongers’ Hall which caused the deaths of Saskia Jones and Jack Merritt.

2. In order to provide a full response to the issues raised by the Coroner, the response

on behalf of the Chief Constable incorporates responses from Counter Terrorism

Policing Headquarters (‘CTPHQ’) as well as providing those on behalf of West

Midlands Police.

3. The Chief Constable of West Midlands Police is accountable for the operational

delivery of policing services and the effective command and leadership of the policing

response to crime and major incidents, including terrorism, within the West Midlands

Police force area. Along with all other Chief Constables, the Chief Constable of West

Midlands Police has agreed to a formal collaboration with all other police forces to

provide a more effective, efficient and consistent approach to tackling terrorism via a

national Counter Terrorism Policing network.

4. Counter Terrorism Policing Headquarters (‘CTPHQ’) oversees this national Counter

Terrorism Policing network. CTPHQ is hosted by the Metropolitan Police Service but

acts on behalf of all Chief Constables to ensure the Counter Terrorism Policing network

has the necessary resources, capabilities and policies to deliver the national Counter

Terrorism (CONTEST) strategy in order to keep the UK safe from terrorism. CTPHQ

is responsible for working with HM Government to set national policing requirements,

agree national funding, develop national policy and co-ordinate the national and

regional delivery of Counter Terrorism Policing network resources.

5. All West Midlands Police officers and staff allocated to the Counter Terrorism Policing

network are referred to as CTP West Midlands officers and staff. The national

standards and policy are set by CTPHQ but the Chief Constable of West Midlands

Police retains overall responsibility for the effectiveness and efficiency for the WMCTP

officers and staff under his direction and control.

- 1 -

Matter of Concern 10

MC10 – Addressed to the Secretary of State for Justice, the College of Policing, the
Chief Constable of West Midlands Police and the Chief Constable of Staffordshire
Police: The facts of this case give rise to concern that important decisions on
approvals, variations and relaxations in relation to licence conditions may be taken
without clearly reasoned discussion and decision-making in MAPPA panels. This issue
could be addressed by requiring MAPPA minutes to record any discussion or decision
on such a matter. In addition, for the benefit of future inquiries and reviews,
consideration should be given to having digital audio recordings made of all MAPPA
meetings.

Response from CTPHQ

6. The Ministry of Justice has revised its approach to the management of terrorist

offenders following the Independent Reviewer of Terrorism Legislation, Jonathan Hall

QC’s ‘Terrorist Risk Offenders: Independent Review of Statutory Multi-Agency Public

Protection Arrangements’ (‘the Independent Review’). CTPHQ was fully consulted in

this process as a Responsible Authority in MAPPA and is fully committed to support

the new ‘Category 4’ arrangements following anticipated legislative changes in 2022.

This includes co-chairing MAPPA with the Probation Service at a senior level with a

clearly identified accountable Local CTP specialist senior officer.

7. Licence conditions are a matter for HMPPS but if it is determined a discussion at

MAPPA would be helpful then Local CT policing will support this through new specialist

CT MAPPA arrangements. The Probation Service National Security Division have

specialist administrators to support the new operating model for specialist CT MAPPA

and to ensure effective minute taking and sharing which are set out in more detail at

paragraph 12 below.

8. Digital audio recordings of MAPPA meeting present logistical and operational

challenges that policing will consider alongside MAPPA partners through MoJ.

9. CTPHQ has had the benefit of considering the response on MC10 filed by the

Secretary of State for Justice and fully endorses it.

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Response from West Midlands Police

10. As the Coroner is aware, West Midlands Police has had a CT MAPPA arrangement in

place for some years. It has included regular discussions around proposed licence

conditions and any variations through the MAPPA process. Licence conditions are now

firmly a matter for HMPPS but if MAPPA’s input is required, as CTPHQ describe at

paragraph 7 above, there is a clear process for this to take place in a structured way.

Since the attacks at Fishmongers’ Hall, developments have also taken place to

improve the structure and quality of decision-making, including the introduction of Core

Groups which consider the operational detail of a particular case, and enable detailed

discussion by key professionals involved in that case. These Core Groups make

recommendations to the MAPPA panel for debate and final sign off.

11. Agencies work together to consider other decisions such as suitability of work and

training opportunities, with third party disclosure decisions taking place collaboratively.

WMCTP support HMPPS in this respect.

12. A dedicated Minute Taker (Probation Service National Security Division) will be

recruited to provide consistency and continuity in note-taking, and final minutes are

reviewed by the MAPPA Chair prior to dissemination, to ensure accuracy. Additionally,

where events are urgent and require a more timely response, emergency MAPPA

panels can be arranged at short notice with documented records made of decisions

and rationale. These improvements, fully supported by a senior CTWM Manager, have

enabled the MAPPA panel to operate in a more efficient and structured way and

ensured that notes taken can more accurately reflect the more focussed discussion

taking place.

Matter of Concern 14

Addressed to the Secretary of State for Justice, the College of Policing, the Chief
Constable of West Midlands Police and the Chief Constable of Staffordshire Police:
This case gives rise to concern that an extremist offender may be permitted to attend
an event or venue without there having been proper communication between the
probation and police officers responsible for managing the offender and the event
organisers and/or venue hosts. Consideration should be given to encouraging such
communications within the training and guidance given to probation officers and police
responsible for managing extremist offenders.

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Response from CTPHQ

13. CTPHQ has had the benefit of considering the response on MC14 filed by the

Secretary of State for Justice and fully endorses it.

14. CTPHQ recognises the value of information sharing with partners and does so where

there is a need and a legal basis for doing so. Additionally, where offenders are

managed under MAPPA, the MAPPA guidance provides guidance on third party

disclosures.

15. CTPHQ is working with MoJ to develop MAPPA practice in line with accepted

recommendations from the Independent Review. CTP will include in its Manual of

Guidance to specially trained CT Nominal Management officers advice to ensure they

fully consider disclosures to third parties, record rationales for making such disclosures

or not doing so. This will cover and ensure the use of risk assessments to influence

protective measures. This is covered on the new CTP Nominal Managers foundation

course and will be further supplemented with ongoing continuous professional

development in MAPPA.

16. Furthermore, CTPHQ has since invested c.£12million per year in dedicated and

specially trained CT Nominal Management officers who will attend all CT specialist

MAPPA (Category 4) meetings. Their training includes proper communication between

those managing the offender and event organisers and/or venue hosts. Additionally,

CTPHQ are committed to ensuring terrorist offenders are managed by trained officers,

with appropriate guidance, and senior roles have been assigned in each region of the

CTP network to provide accountability for the management of all terrorist risk nominals,

including specialist CT MAPPA arrangements in line with the Independent Review and

recommendations on ‘core group’ joint case work.

Response from West Midlands Police

17. These changes have been put into practice locally. MAPPA and CTPWM have already

drawn on the experience and learning from these inquests and, applying the MAPPA

guidance, they have recently considered a wide range of disclosures including those

relating to work, training, education, gym membership, religious practices, and parents

- 4 -

of offenders, amongst others. Any further new training and/or guidance can only

strengthen confidence in those processes. All decisions on disclosures are signed off

by the joint MAPPA Chairs.

Matter of Concern 17

Addressed to the Secretary of State for Justice, the College of Policing, the Chief
Constable of West Midlands Police and the Chief Constable of Staffordshire Police:
Based on the evidence in this case, there is cause for concern that effective
procedures are not in place to ensure that all MAPPA meeting attendees receive
meeting minutes. Consideration should be given to modifying guidance to ensure that
this happens, for example by (a) providing for all MAPPA panel participants to receive
minutes by secure email (rather than by having to access an online system); (b)
requiring that all acknowledge safe receipt and indicate whether or not they wish to
make amendments (to include provision of “nil returns”); and/or (c) requiring attendees
at the start of each MAPPA meeting formally to confirm that they have read the minutes
of the previous meeting or meetings as appropriate.

Response from CTPHQ

18. CTPHQ has had the benefit of considering the response by the Secretary of State for

Justice on MC17 and fully endorses it.

19. The introduction of CT Nominal Management officers and the assignment of senior

roles as outlined at paragraph 16 above will reduce and focus the number of attendees

at MAPPA meetings to specialist staff. CTP have governance now in place through the

Nominal Management Capability Board to oversee continuous improvement.

20. The Probation Service National Security Division are

recruiting specialist

administrators to support the new operating model and receive appropriate training in

minute-taking as well as induction to the particular requirements of taking minutes for

formal MAPPA meetings. Recommendations on chairing responsibilities will be built

into CT MAPPA Chair training due to be rolled out ahead of Category 4 changes.

- 5 -

Response from West Midlands Police

21. Following the Independent Review conducted by

in 2020 WMP have

been responding to the recommendations and are working with HMPPS and CTPHQ

regarding the changes they are making or intend to make and will support accordingly

in the light of the MAPPA review.

Matter of Concern 18

Addressed to the Secretary of State for Justice, the College of Policing, the Chief
Constable of West Midlands Police and the Chief Constable of Staffordshire Police:
The facts of this case give cause for concern that some members of MAPPA panels
responsible for managing extremist offenders may not be aware of important
information from the offender’s time in prison. Consideration should be given to (a)
ensuring that the latest MAPPA F form from the prison authorities should be circulated
with every subsequent set of MAPPA minutes; (b) including a section in MAPPA
minutes for key up-to-date intelligence; and (c) including a further section in MAPPA
minutes for a summary of the key conclusions of the most recent ERG assessment
(including risk factors identified).

Response from CTPHQ

22. A Joint Counter Terrorism Prison and Probation Hub (‘JCTPPH’) has been formed.

This is a collaboration between HMPPS, CTPHQ and the Security Service. One of its

core functions is to enhance the flow of intelligence and information between covert

and overt functions, noting that there is an obvious and necessary ‘firewall’ between

the two. MAPPA chairs will consider how core groups will contribute in each case. The

creation of core groups will ensure a secure and clear pathway for the sharing of

sensitive intelligence/information into MAPPA. CTPHQ have provided guidance

through their Manual of Guidance to require CTP Nominal Management specialist

officers and Lead Responsible Officers to ensure that all relevant information is at hand

to develop effective risk management plans for their allocated nominal, including those

managed under MAPPA. This will include ensuring relevant assessments are shared

and included in risk management planning.

23. CTPHQ has had the benefit of considering the response on MC18 filed by the

Secretary of State for Justice and fully endorses it.

- 6 -

Response from West Midlands Police

24. MAPPA F forms are shared alongside MAPPA Minutes for some attendees to consider

at the panel meeting as detailed in paragraph 22 above.

25. The MAPPA F forms and minutes are sent to the Standard Panel members prior to

the MAPPA meetings. The current 2021 MAPPA guidance states at para 13 b (4):

“Given the highly confidential nature of the minutes, all agencies should ask
themselves whether they actually need to keep a copy of the minutes in their
files, or whether a record of the actions for their agency and a reference to the
fact that the minutes are held on ViSOR would be sufficient.”

26. Where there are delays in receipt of the Form F, these are escalated as a matter of

urgency to the prison concerned. The quality of the Form F can be variable, and locally

the West Midlands MAPPA chair is challenging this position, and seeking a greater

level of analytical support from the JCTPPH around security information, to better

support MAPPA decisions

27. The MAPPA agenda is structured to ensure each relevant agency has the opportunity

to provide full and detailed updates in relation to their work with a nominal. This

includes intelligence updates, where appropriate, including clear handovers from an

offender’s time in prison Where sensitive or secret intelligence is concerned, CTP WM

are supporting the development of the Covert-Overt bridge process, involving CT

Police SIOs directly, and providing a suitable ‘bridge’ to the MAPPA chair to allow the

information to be ‘known’ and considered appropriately within the MAPPA meeting.

Already we have operationalised this approach in a small number of cases, both for

MAPPA Panel and for Parole Boards.

28. There are now co-chair arrangements in place. The CTPWM LRO will co-chair MAPPA

CT cases with the NSD Senior Regional Lead for Probation. It is understood that all

CT MAPPA cases will be managed in this format and will ensure consistent

representation.

29. The prisons representatives conduct handovers with the probation service outside of

the MAPPA meetings through their OMIC process however there will be clear updates

from the prisons reps during the MAPPA meetings and discussions are held during the

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MAPPA meetings to ensure this handover has taken place and held accountable by

the chair.

30. ERG assessments are shared with CT Police NMs, and the ERG is discussed at

MAPPA Panel to allow a full understanding of a nominal risk and to ensure CT Police

risk management plans reflect this information. There is no specific section in the

minutes for the ERG summaries however the Counter Terrorism Probation Officer

(CTPO) would talk the panel through the findings once the ERG had completed within

prison and therefore documented in their section.

Matter of Concern 19

Addressed to the Secretary of State for Justice, the Secretary of State for the Home
Department, the College of Policing, the Chief Constable of West Midlands Police and
the Chief Constable of Staffordshire Police: This case gives cause for concern that
counter-terrorism police may be in possession of intelligence or information which may
be useful to the management of an offender by the MAPPA panel, but that such
intelligence or information may not be brought to the knowledge of or taken into
account by MAPPA agencies. This issue should be addressed, preferably by ensuring
that a single police officer from any covert investigation (such as the SIO or Deputy
SIO) is responsible and accountable for ensuring that intelligence and information is
properly shared and taken into account. Consideration should also be given to how
intelligence known only to the Security Service may be taken into account for the
purposes of MAPPA management.

Response from CTPHQ

31. The JCTPPH will ensure the right information gets to the right place at the right time.

A major focus, in its first year, has been the development and operationalisation of a

covert-overt bridge framework. This provides an effective, safe, process through which

sensitive intelligence can be revealed and subsequently, appropriately, disclosed to

support defensible decision making regarding risk management. Originally focused on

supporting better disclosure into the Parole Board process learning has been taken

and applied to MAPPA where the bridge has already been tested on five cases bringing

to the attention of MAPPA information previously only known to the security service.

32. CTPHQ has had the benefit of considering the response on MC19 filed by the

Secretary of State for Justice and fully endorses it.

- 8 -

Response from West Midlands Police

32. West Midlands Police would simply repeat the CTPHQ’s response above but add that

we have been at the forefront in exploring this approach, and have been directly

involved in developing the process, as well as supporting the JCTPPH in managing

sensitive information through to parole boards and the MAPPA chair in a small number

of cases.

Matter of Concern 20

Addressed to the Secretary of State for Justice, the Secretary of State for the Home
Department, the College of Policing, the Chief Constable of West Midlands Police and
the Chief Constable of Staffordshire Police and the College of Policing: The facts of
this case give cause for concern that security sensitive information may not be properly
taken into account in decision-making by MAPPA panels concerning the management
of terrorist offenders. Consideration should be given to how the new procedures can
best be operated to avoid this problem recurring. This might include a requirement that,
wherever possible, the MAPPA Panel Chair (or one Co-Chair) should be a member of
the Core Group. It might also include a requirement for the Core Group to consider
what intelligence can be supplied (perhaps in sanitised form) to the broader panel.

Response from CTPHQ

33. Guidance for specialist CT MAPPA is currently being finalised and it is anticipated it

will be implemented once the Police, Crime, Sentencing and Courts Bill has passed

through Parliament (its third reading took place on 5 July 2021). The terms of

reference for CT MAPPA are likely to be those individuals subject of Category 4 (as

defined under the new Act) both terrorist offenders and those identified as ‘relevant

terrorist offenders’. These arrangements include MAPPA panels being jointly chaired

by Local CTP officers (leading regional CT Nominal Management teams) and National

Security division (Probation) senior leads. Both Chairs will be vetted and able to

receive sensitive information if it is appropriate for them to do so, using the JCTPPH

covert-overt bridge processes. Core Groups will be embedded in to CT MAPPA, details

of which are currently going through a consultation stage.

34. CT MAPPA chairs are now Develop Vetted, and that the key staff (CTNM & National

Security Division) who actively manage the offenders, have specialist roles, are also

vetted to a level suitable for CT and work together outside of the formal MAPPA

meetings. The Chairs now work with the Joint Extremist Unit to facilitate intelligence

- 9 -

into MAPPA meeting to ensure risk management plans reflect the full context of any

concern.

35. As described above, the JCTPPH leads on a covert/overt bridge which enables

sensitive information to be identified, reviewed, revealed and disclosed to MAPPA

Chairs or other relevant individuals linked with the MAPPA process. It is expected that

an outcome from the covert/overt bridge process will be an agreement on what

information can be shared from the MAPPA Chairs to others involved in the MAPPA

process.

36. CTPHQ has had the benefit of considering the response on MC20 filed by the

Secretary of State for Justice and fully endorses it.

Response from West Midlands Police

37. West Midlands Police repeat the CTPHQ’s response above.

Matter of Concern 21

Addressed to the Secretary of State for Justice, the Secretary of State for the Home
Department, the College of Policing, the Chief Constable of West Midlands Police and
the Chief Constable of Staffordshire Police: The facts of this case give cause for
concern that MAPPA panels responsible for managing terrorist offenders may be
unaware of the regularity and form of contact with police officers responsible for overt
offender management. Consideration should be given to providing guidance that
officers with such responsibilities should report to MAPPA panels on the regularity of
their meetings with offenders and take account of any recommendations by MAPPA
panels.

Response from NCTPHQ

38. Following investment of c.£12million as described at paragraph 16 above, CTPHQ now

has CT Nominal Management specialist trained officers, operating to a standardised

Manual of Guidance who will attend all future CT MAPPA (Category 4) cases. They

are responsible for designing and delivering a risk management plan (RMP) with the

National Security Division and other MAPPA partners. This will include an approach to

a home visit regimes based on the assessment of risk and need which will be formally

agreed through the MAPPA co-chairs. Full visibility of police activities in supporting

this RMP will be made available to MAPPA panels.

- 10 -

39. CTPHQ has had the benefit of considering the response on MC21 filed by the

Secretary of State for Justice and fully endorses it.

Response from West Midlands Police

40. Locally CTP West Midlands Nominal Managers exceed the national guidance for

Registered Terrorist Offenders/Pathfinder visits. National guidance on visits set a

minimum standard of one visit per month for those considered to be ‘intensive risk’,

three visits per year for those considered ‘enhanced risk’ and one visit per year for

‘standard risk’ nominals. West Midlands Police’s regime involves two visits per month

for ‘intensive risk’, one per month for ‘enhanced risk’ and quarterly visits for those who

are standard risk. Additional visits can be added if required. Performance on this is

monitored at Force level.

41. CTP West Midlands now feed this into the MAPPA panel to ensure synchrony of visits

across agencies, and to take account of any MAPPA requirements.

31.12.21

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The report

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