Fishmongers Hall Inquest: The Jury’s Conclusion

June 1, 2021
Ian Acheson  —  CEP Senior Advisor

This is my final blog on the inquest into the murders of Saskia Jones and Jack Merritt by an Islamist terrorist, Usman Khan, on the 29th of November 2019. Please see the previous blogs here for background information.

The jury delivered its conclusion on the inquest on Friday, 29th May. Up until this point I have been constrained by legal reasons, in providing anything more than a factual account of what has been said and some additional information for international readers on the purpose and operation of the inquest system in England and Wales. The discharge of the inquest jury means that I can now comment freely on matters.

The Coroner asked the jury to consider how Khan’s victims died. This was formality because it has been plainly obvious that Khan unlawfully killed his two young victims by stabbing them to death. However, the Coroner has additional powers to ask the jury to consider the question of how Khan’s victims came to die, and this can include a narrative verdict which looks at causation in more detail—in particular in terms of the responsibility state agencies and others held for the deaths.

The jury’s conclusion was devastating. They said that the deaths were avoidable if key agencies had shared information properly. They pointed to ‘serious deficiencies’ by state agencies at almost every level of Khan’s risk management. The weeks of painstaking examination of witnesses by barristers acting for the families and the Coroner revealed an extraordinary catalogue of naivete, incompetence, and a fair degree of arrogance that let an extremely dangerous terrorist slip through a very big net. The ‘omissions or failures’ that the jury identified include:

  • Khan being permitted to join the Learning Together course in what should be one of Europe’s highest security prisons by managers ‘blinded’ by the cachet of a Cambridge University badged programme that put him in contact with his future victims. This despite huge amounts of intelligence and repeated assessments that confirmed he was a ‘High Risk’ actively subversive terrorist who had not changed his views and was in fact getting worse.
  • The failure of Learning Together managers to take any steps (or believe they had any responsibility) to risk assess the risk Khan and others might pose on a course that was never inspected, never formally evaluated, and had no rehabilitative purpose.  Referring to Learning Together, the family of Saskia Jones commented after the Jury reached their conclusion: “It could be said that their single-minded view of the rehabilitation of offenders — using Usman Khan, in our view, as a poster boy for their programme — significantly clouded their judgment.” This also led to a complete absence of risk planning and management between Learning Together and the authorities at Fishmongers Hall who were given no advance information on security risk and sought none.
  • The failure of the multi-agency risk arrangements (MAPPA) that was supposed to protect the community from Khan to operate competently or effectively. Vital information held by some of these agencies on Khan’s risks and intentions was either withheld from the Probation service who chaired these meetings or lost because of a breakdown in communications. Poorly trained and naïve police officers, overworked and under resourced probation officers, an overly secretive approach by the security service M15, and the overcomplex bureaucracy of regional and national resources were all at fault. These factors  created a perfect storm of information mismanagement that meant Khan was permitted to travel from his home in Staffordshire to London carrying knives and dressed in a fake suicide belt on a mission to murder. 

I have attended several of the inquest hearings and the evidence has been at times harrowing. It also includes individual acts of heroism by the events attendees who, armed only with whatever makeshift weapons they could find in the hall, confronted Khan and incapacitated him until police arrived to neutralise the threat. These included two convicted criminals who saved lives on that day and in my view remain to be properly recognised for their bravery. The inquest also showed the compassion and selflessness of those who battled desperately to save Saskia and Jack despite the lethal threat around them. There can be little solace for their families in this shocking tale of incompetence and missed opportunities but at least they can know that their children did not die alone and at the last they were comforted by the love of strangers.

The Coroner has yet to set out his conclusions to the inquest and these will be extremely important for the families and those agencies that completely failed them. It seems inevitable that he will use his powers to serve notices on agencies to respond to him. These are known as regulation 28 reports which allow him ‘to make reports to a person, organisation, local authority or government department or agency where the coroner believes that action should be taken to prevent future deaths.’ I suspect a significant number of these reports will be generated. The Government must require transparent and meaningful responses. Cambridge University will also likely be required to explain how it met its legal responsibilities under the Health and Safety at Work Act to have suitable and sufficient risk controls in place to protect staff and volunteers at Learning Together from foreseeable harm. There are many, many lessons to learn here for organisations with cultures as well as structures that are insufficient to the task of protecting the public from harm. It simply is not good enough for senior police officers to trot out the line that not all terrorist events can be stopped. That is a statement of the blindingly obvious and a bit of a bureaucratic refuge in my opinion. Khan did not drop out of the sky. He was assessed, surveilled, and supervised for eight years in prison custody. He was subject to elaborate (but ineffectual) supervision on his release. His intent and capability to do murderous harm was hiding in plain sight. This was a catastrophic system failure that exposes just how broken our terrorist risk management processes are. No amount of tinkering can fix the problem. We need a fundamental reset. Things must change. The next Usman Khan is in the pipeline.

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