'Prevention of Future Deaths’ report released following the inquest into deaths during terror attacks at the Fishmongers’ Hall in 2019

Tue, 16 Nov 2021

The former Chief Coroner, and Recorder of London, HHJ Lucraft QC has released a ‘Prevention of Future Deaths’ report following the inquest into deaths during terror attacks at the Fishmongers’ Hall in 2019.

A ‘Prevention of Future Deaths’ report (a ‘Regulation 28’ report) is not created in every inquest. It is only created following an inquest where the Coroner considers that there is a risk of future deaths occurring in circumstances revealed by the investigation.

The inquests into the deaths of Saskia Jones and Jack Merritt have revealed a catalogue of failings throughout the prison and Multi-Agency Public Protection Arrangement supervision system which ultimately allowed Usman Khan to commit his terrible attack. Following the jury’s damning conclusions, HHJ Lucraft QC received submissions from all those representing interested parties as to the changes they would wish to see implemented. That included submissions from Henry Pitchers QC, Philip Rule and Ramya Nagesh, instructed by Hodge Jones & Allen solicitors, who represented the family of Saskia Jones at the inquest.

A summary of the submissions made by Henry Pitchers QC, Philip Rule and Ramya Nagesh can be found here. These have been very largely upheld by the Coroner.

The state authority’s failings are numerous but not exclusive. Within his report, the Coroner encouraged those with relevant responsibilities within the University of Cambridge and the Learning Together programme to reflect on this tragic case. He observed that 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.

The Coroner’s very detailed report identifies a total of 22 areas for concern for response and appropriate action to be taken:

Rehabilitation and Education of Offenders and Ex-Offenders

  • Significant events and courses held outside of university premises should be subject to a formal risk assessment. The Coroner considered it a matter of concern that there was no such risk assessment for the Learning Together events (one of which was the event at the Fishmongers’ Hall) [MC1];
  • 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 the attendance of the same [MC2];
  • Consideration should be given to the risks involved in placing serious offenders in close and continuing contact with young people;and to targeted means of mitigating them [MC3];
  • 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 as to procedures put in place to ensure or at least encourage information as to the risk profiles of offenders in prisons to be shared with education providers who are working in prisons [MC4];
  • Consideration should be given as 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 [MC5];

National Probation Service (NPS) and MAPPA risk assessment and management

  • Thought should be given to requiring Extremism Risk Guidance assessment reports to be completed or reviewed by a forensic psychologist [MC6];
  • Consideration should be given to enabling the attendance of a forensic psychologist who prepared an ERG assessment prior to the prisoner’s release at appropriate MAPPA panel meetings [MC7];
  • This case gives rise to a concern that an OASys risk rating for an offender may be changed without the offender manager completing the full assessment exercise, and that the change may be recorded without proper rationale [MC8];
  • 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. This was a significant step. The jury found “serious deficiencies in the management of Khan by MAPPA” and a “blind spot to Khan’s unique risks”. Consideration should be given to ensuring, by means of National Probation Service guidance, that offender managers should (a) always record a rationale for giving any permission for variation or relaxation of licence conditions; and (b) in the case of offenders subject to Level 2 or 3 MAPPA management, record whether that decision has been taken with express approval from the MAPPA panel [MC9];
  • The facts of this case gave the Coroner concern that important decisions in relation to relaxing licence prohibitions may be taken without clearly reasoned discussion and decision-making in MAPPA panels [MC10];
  • Consideration should be given as to whether there can be further guidance to ensure that the risks and potential benefits of decisions to vary licence conditions are carefully examined [MC11];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 ought to be given in training of probation officers to emphasising the importance of paying regard to potential dishonesty in self-presentation by extremist offenders [MC12];
  • Though is required to be given to training and guidance that warns offender managers about placing too much reliance on the apparent compliance of extremist offenders with their licence conditions and exhibition of polite behaviour [MC13];
  • Consideration should be given to encouraging communication between probation and police officers with event organisers and/or venue hosts where an extremist offender is to attend a particular event [MC14];
  • Khan, a terrorist offender on licence, who was subject both to strict licence conditions and to a priority investigation, obtained and used Class A drugs without that being detected. Consideration should be given as to whether further steps can be taken to facilitate random drug testing of offenders on licence (especially those who have committed serious offences), whether living in approved premises or independently [MC15];

Desistance and Disengagement Programme

  • Measures should be taken to prevent recurrence of disruption of mentoring arrangements, social isolation and deprivation of means to find work in cases where a person’s risk is known to be related to social isolation [MC16];

Information Sharing between Agencies

  • Consideration should be given to modifying guidance so as to ensure that all MAPPA meeting attendees receive meeting minutes: in this case not all attendees did. [MC17];
  • The Coroner is concerned 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 better minuting of key up-to-date intelligence; and including a summary of the key conclusions of the most recent Extremism Risk Guidance assessment [MC18];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 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 [MC19];
  • 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 as to how procedures can best be operated to avoid the risk of MAPPA panels not being able to pay sufficient regard to security sensitive information in their decision-making [MC20];

Management and monitoring of terrorist offenders by the Police and the Security Service

  • The concern is raised that MAPPA panels responsible for managing terrorist offenders may be unaware of the regularity and form of contact between the offender and police officers responsible for overt offender management [MC21];
  • To resolve a difference of opinion expressed by some police officers on the ability to have lawfully searched Khan’s bag, consideration should be given to the introduction of a licence condition to 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 [MC22].


The recommendations have been addressed to the following (as variously applicable):

  • 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.

Each body’s response must contain details of action taken or proposed to be taken with a timetable for action (or it must explain why no action is proposed).

Henry Pitchers QC, Philip Rule and Ramya Nagesh welcome the numerous recommendations made in this report. They sincerely hope that these issues will be addressed, and future tragic loss of lives such as Saskia’s might be avoided.

The full copy of the ‘Prevention of Future Deaths’ report can be accessed here:






Related articles

The Administrative Court shall today hear a permission application for a judicial review of the alleged failure of the Secretary of State to discharge his fundamental duty to protect life, public health and safety through the duties...

Date: Tue, 25 Jan 2022
Appeal for 233 houses allowed with a full award of costs for BDW...

Date: Fri, 07 Jan 2022
View our Christmas Opening Hours here...

Date: Mon, 13 Dec 2021