Kurt Cochran and 5 others · Prevention of Future Deaths report

These Inquests included those of the five victims of the attack: Kurt Cochran; Leslie Rhodes; Aysha Frade; Andreea Cristea; and PC Keith Palmer. They also included an inquest of the attacker, Khalid Masood. Dr Fiona Wilcox, Senior Coroner for Inner West London, opened inquests into all six deaths and held a Pre-Inquest Review (“PIR”) hearing on 19 May 2017. I took conduct of the Inquests and held PIR hearings on 15 January and 2 July 2018. I held a hearing of the Inquests of the victims of the attack (without a jury) from 10 September 2018, which ended on 3 October 2018. Immediately afterwards, I held a hearing of the Inquest of the attacker (with a jury), which ended on 12 October 2018.

In the Inquests of the victims of the attack, I determined that each had been unlawfully killed and gave further narrative conclusions for each. Attached to this Report are copies of the Determinations sheets for the five victims.

In the Inquest of the attacker, the jury returned a conclusion of lawful killing and added further narrative conclusions. Attached to this Report is a copy of the Determinations sheet for the attacker.

On 22 March 2017, Khalid Masood drove a Hyundai Tucson vehicle across Westminster Bridge from the South Bank side towards the North Bank side. At 14:40:08, his vehicle mounted the pavement several times and struck a number of pedestrians. Four people sustained fatal injuries as a result: Kurt Cochran; Leslie Rhodes; Aysha Frade; and Andreea Cristea. A number of others were also struck by the vehicle as it was driven across the bridge, with 29 further people suffering serious injury. The vehicle went on to crash into the railings at the perimeter of the Palace of Westminster, at 14:40:38.

After the vehicle had crashed into the railings, Masood got out and continued on foot. He ran through the Carriage Gates vehicle entrance to the Palace of Westminster. He was holding two knives. He attacked PC Keith Palmer, a Metropolitan Police Service (“MPS”) police officer stationed at the Gates. In the course of a short and brutal attack, he inflicted stab wounds on PC Palmer, one of which proved fatal. As he went after PC Palmer, further into the grounds of the Palace, Masood was confronted by plain-clothed armed police officers. He was shot and killed. The shots were fired at 14:41:30, which was 82 seconds after the attack had begun.

At the time of Masood’s attack, there were two uniformed Authorised Firearms Officers (“AFOs”) of the MPS stationed in New Palace Yard. AFOs were routinely deployed in various locations around the Palace of Westminster, with the area divided into a number of sectors. Carriage Gates and New Palace Yard fell within Sector 3. The two AFOs were conducting a patrol around the whole of the sector prior to and at the time of the attack and were not in close proximity to Carriage Gates.

MC1: I suggest that the MPS gives consideration to providing revised Post Instructions to relevant groups by direct emails, in hard copy and/or via electronic devices (as well as their being accessible through ADAM) and to providing them in a way that requires the recipient to respond indicating safe receipt. I was concerned that, when Post Instructions were updated, they were apparently not emailed or provided in hard copy to relevant officers directly. The system relied upon officers’ use of the ADAM System, which was sporadic. I am aware from the submissions of the MPS that, since the attack, an update is sent to all relevant officers advising them of a revision of Post Instructions and telling them to view the new version on ADAM. The MPS has provided a copy of an example email, which was sent on 11 October 2018. However, it may be valuable for the MPS to go further than this by supplying revised instructions directly to the officers and in requiring an acknowledgement of safe receipt is sent back by the officers.

MC2: I suggest that the MPS considers making it mandatory for officers on the Command to register for ADAM and to access it at specified intervals (perhaps supplemented by an instruction to confirm review of material on the system). I was concerned that a proportion of officers on the Command had not registered for the ADAM System despite it having been in use for six years. Furthermore, I heard evidence that officers were under instructions to access the system “regularly” but no definition of that term could be given. Given that the ADAM System is the repository for the authorised versions of Post Instructions, these were troubling features of the evidence. In short, a proportion of the officers had no means of accessing their instructions and officers generally had no clear guidance on how regularly they should be checking the system. Although the MPS has provided submissions referring to improvements in the ADAM System and improved systems of supervision, these would be relatively simple rules which would be readily enforceable through the disciplinary process.

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

MC4: I suggest that the MPS considers a periodic audit of all extant Post Instructions for the Parliamentary Estate to ensure their consistency and fitness for purpose. This might be part of the supervisory audit discussed at MC7 below, or separate from it. On the evidence I heard, Post Instructions are prepared after careful work by relevant experts within the MPS (firearms tactical assessors, in the case of AFO Post Instructions). Nevertheless, there were deficiencies in the expression of some Post Instructions, and some officers when presented with them found it difficult to interpret parts. It is important that each Post Instruction should be clear and internally consistent, and should be consistent with the broader tactical plan for the Estate. It was clear from the evidence of Commander Usher that Post Instructions should be followed precisely. They should not be subject to personal interpretation, since that would introduce inconsistent practice and would undermine the tactical rationale behind the instructions. Where the content of Post Instructions is ambiguous or not consistent with other orders or practices, security can be undermined.

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

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

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

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

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

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

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

MC12: I suggest that the automation of Carriage Gates and their general ease of use be specifically and expressly considered as part of the ongoing renewal project.

MC13: I suggest that consideration be given to an external security reviewer being involved in approval of project plans from a security perspective, before any irreversible steps are taken.

MC14: I suggest that the Secretary of State for the Home Department asks the authorities responsible for preparing and delivering advice on protective security to consider whether any further work can usefully be done on this subject, particularly in preparing and delivering consistent and up-to-date national advice. I also suggest that TfL considers whether there is any further work it can do to improve protective security on major roadways and bridges in the capital, in response to national advice and known threats.

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

MC16: I suggest that the Security Service considers whether it would be practicable and beneficial to introduce a procedure whereby any decision to close a person as a Subject of Interest is recorded with brief reasons.

MC17: I suggest that the Maritime and Coastguard Agency considers whether it or some other body could provide guidance on the removal of unconscious persons or bodies from the water close to those operating on navigable rivers and canals.

MC18: I recommend that the Department for Transport and the British Vehicle Rental & Leasing Association consider introducing a Code of Practice (or at least guidance) on checks to be carried out and/or enquiries made before vehicles are rented.