Saskia Jones and 2 others · Prevention of Future Deaths report

4. 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.

6. 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.

7. 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.

8. 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/

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.

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. 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 the 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.

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.

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.

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.

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.

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.

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.

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.

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 conducting 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.

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.

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.

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.

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 police behaviour). Consideration should be given to training and guidance warning offender managers about placing too much reliance on this feature.

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.

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.

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.

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; (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.

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).

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.

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.

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.

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.