IN THE WESTMINSTER TERROR ATTACK OF 22 MARCH 2017 REGULATION 28 REPORT ON ACTION TO PREVENT FUTURE DEATHS Addressees This Report is being sent to the following: (a) The Commissioner of Police of the Metropolis; (b) Speaker’s Counsel, for the attention of the Parliamentary Authorities at the Palace of Westminster; (c) The London Ambulance Service; (d) Transport for London; (e) The Secretary of State for the Home Department; (f) The Maritime and Coastguard Agency; (g) The Secretary of State for Transport; (h) The British Vehicle Rental and Leasing Association. Coroner
1. I am the Chief Coroner of England and Wales. I am also a Senior Circuit Judge. 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”).
2. The address of my office is 11th Floor – Thomas More Building, Royal Courts of Justice, London, WC2A 2LL. Coroner’s Legal Powers
3. I make this report under paragraph 7 of Schedule 5 to the CJA and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Investigation and Inquests
4. 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.
5. 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.
6. 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. Circumstances of Deaths
7. 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.
8. 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.
9. 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. Coroner’s Concerns
10. During the course of the Inquests, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths could occur unless action is taken. In the circumstances, it is my statutory duty to report to appropriate persons who may be able to take remedial action. In the following paragraphs, I address various public authorities and I explain what concerns I am reporting to them. Each matter of concern is denoted by an “MC” reference and is highlighted in bold.
11. In preparing this Report, I have taken into account the submissions from the bereaved families of what matters I should consider raising and the responsive submissions from institutional Interested Persons. Metropolitan Police Service Post Instructions and Deployment of Armed Officers at Parliament
12. Post Instructions are the written orders given to police officers as to where and how to conduct their routine patrols. During the Inquests, concerns arose about communication of and compliance with Post Instructions for AFOs of the Parliamentary and Diplomatic Protection (“PaDP”) Command who were posted at the Palace of Westminster. For example, some officers (a) were unaware of their Post Instructions; (b) regarded them as open to interpretation; and/or (c) had not been using the computer system which had been introduced to give access to updated instructions (ADAM). As regards the ADAM system, it was telling that when usage was checked in August 2016, only 13% of officers had logged onto the system in the eight-month period since the previous revision of Post Instructions.
13. With specific reference to New Palace Yard, tactical assessments had determined that AFOs should be close to Carriage Gates at all times when they were open (i.e. throughout working hours). This was because Carriage Gates presented a prominent and vulnerable entrance to the Palace grounds. Nevertheless, there was substantial evidence that many AFOs were not aware of the requirement to remain close to Carriage Gates when on duty in Sector 3 and that supervising officers were not communicating that important instruction. This gave me cause for concern both about the security of New Palace Yard at the time of the attack and about systems and practices for ensuring that Post Instructions were understood and followed.
14. The MPS has provided detailed submissions explaining steps taken to address these problems since the attack and (in some cases) since the Inquests hearing. I have taken those submissions fully into account. I have also taken account of the fact that New Palace Yard is now subject to entirely different and improved security arrangements.
15. 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.
16. 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.
17. 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. Post Instructions are written following a tactical assessment and security review. It was clear in the evidence I heard that significant work goes into the formulation of the policing plan at the Palace of Westminster. All of this work becomes wasted effort if the Post Instructions are not readily accessible by those who are required to follow them. The MPS may wish to consider (a) whether the current computer facilities at the Palace of Westminster are fit for purpose and (b) how time might be specifically set aside in an officer’s routine for maintaining up-to-date knowledge of his/her Post Instructions. I do not know whether officers at the Palace of Westminster have access to smartphones or tablet computers in addition to desktop computer terminals. If such technology has been provided to these officers, the MPS may wish to consider whether updated Post Instructions can be made available on those devices for ease of access and reference.
18. 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.
19. 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. It is a defining feature of Parliament that it is open to the public. The Rt Hon Tobias Ellwood MP described a need for “transparency”, consistent with the democratic processes of the United Kingdom. Eric Hepburn, the Director of Security for Parliament spoke about the need to strike a balance between openness and security, respecting the democratic right of the public to be able to come to Parliament and meet their representatives. However, it was a recurring feature of reviews of Parliamentary security that public entrances, including Carriage Gates, presented vulnerabilities. In the case of Sector 3, particular vulnerability was recognised and there was a need for armed police to be near to Carriage Gates. Given the nature of terrorist threats to this country and its Parliament, it is difficult to imagine circumstances in the near future when an open public entry point to the Palace should not be protected by armed guards. I am concerned that, as matters stand, there is no mechanism for preventing inadvertent change to Post Instructions leaving an entrance without armed police. Furthermore, in the event of uncertainty as to the content of the Post Instructions, a standing order of the kind mentioned above would provide clarity and a minimum level of protection. Supervision of Armed Officers at the Palace of Westminster
20. In my determinations in the Inquest of PC Palmer, I concluded that had armed police officers been stationed at Carriage Gates at the time of the attack it is possible that they may have been able to prevent PC Palmer suffering fatal injuries. I identified that there were shortcomings in the supervision of police officers at the Palace of Westminster.
21. I heard some evidence from unarmed officers, armed officers and a supervisor suggesting that at least a proportion of armed officers believed Post Instructions (or some such instructions) to be advisory only. By contrast, I heard unequivocal evidence from senior police officers that Post Instructions were mandatory and must be followed to the letter. Moreover, whatever the reason, at least a proportion of armed police constables were not acting in compliance with the Post Instructions at the time of the attack. This was the underlying cause of the absence of armed officers from Carriage Gates. Chief Superintendent Aldworth gave evidence that, whilst responsible for Parliamentary security, he would have considered it to be a serious problem were armed officers not positioned in close proximity to an exit point such as Carriage Gates. Weak supervision of Post Instructions can impair Parliamentary security and expose those in the Estate to serious danger.
22. 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. As long as the ADAM System remains a principal means for officers to access and review Post Instructions, supervision ought in my view to include some review of officers’ use of the System. It is clear from the written submissions concerning this report on behalf of the MPS that significant remedial steps have been taken across the Command in respect of supervision, but I am concerned that no reference is made to regular audit of usage of the ADAM System.
23. 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. On the evidence, it appeared that many armed officers in an important area of the Palace were regularly patrolling in a way which was not compliant with their instructions, and that this was not being effectively corrected by their supervisors. This problem appeared to have been in existence for some time, but had not been identified. Rather than leaving identification of such practices to irregular major security reviews, it strikes me that there could be real benefit in having a periodic unannounced audit or review by an officer from outside the Command, who could check practical compliance with Post Instructions and other standing orders. As in other fields of life, assurance is often best carried out by somebody outside the body or department under scrutiny. Training
24. Submissions by the sisters and parents of PC Palmer express some concerns in respect of training of police officers at the Palace of Westminster. In response, the MPS makes the point that the detail of MPS training of armed and unarmed officers was not within the scope of the Inquests. However, I did hear evidence referring to the training which officers received and I heard evidence about the practices of those responsible for Parliamentary security (including unarmed officers, AFOs and security officers). In the circumstances, I am in a position to raise some points of concern.
25. 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. Some features of the evidence gave rise to concerns that officers in different groups and areas worked in “silos”. For instance, Mr Hepburn made reference to concerns of this kind in his evidence. I am aware that, following the attack and before the Inquests, steps were taken to improve the situation by introducing joint briefings of police and security officers. In my view, this concern about officers operating in “silos” might also be usefully addressed through joint training exercises. It may of course be that the MPS already is already alive to the need to achieve this objective through joint training.
26. 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. The evidence in the Inquests suggested that attacks by lone actors and marauding attacks by multiple attackers are a persistent threat to high-profile sites such as the Palace of Westminster. This feature suggests that further training is needed to deal with a relatively novel danger. I have been informed in submissions by the MPS of improvements which have been made to the training programme since the attacks. However, it is not clear from the summary whether there has been any specific consideration of training exercises in respect of lone-actor and marauding terrorist attacks, each of which is clearly a recurring problem. It is important that those responsible for training consider what exercises can most usefully be provided to officers working at the Parliamentary Estate in order to deal with this threat. Tactical Firearms Reviews
27. Operational decisions and instructions at the Palace of Westminster are informed by tactical assessments carried out by a Security Coordinator from the MPS. At appropriate stages, this work is informed by advisory reports by tactical firearms advisers. For example, in the aftermath of the attack, the assessment recommended an increase in the number of firearms posts in New Palace Yard and more widely across the Parliamentary estate. These assessments are essential to the creation and revision of post instructions. The MPS has explained in submissions that it has introduced bi-annual “Challenge Panels” at which officers of any rank, both armed and unarmed, can constructively challenge the details of an individual post note or the wider security model. As I have already said, the security arrangements at the Palace at the time of the attack were found wanting. I have some suggestions to make in respect of tactical firearms advisers’ work which might improve the situation.
28. 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. In my view, the introduction of “Challenge Panels” is a valuable means both to keep officers informed of amendments and to give front-line officers some influence over security plans; after all, it is those officers who have first-hand experience of putting the instructions into practice. As matters stand, however, it appears that after the assessor has looked in detail at firearms posts and officers’ responsibilities and has given advice on the subject, that assessor has no contact with the officers carrying out the instructions. The MPS could usefully consider taking the principle of Challenge Panels a step further, by providing a forum for a firearms assessor to explain his/her advice and any changes in instructions to the front-line firearms officers. This may help officers to understand the rationale for changes and may enable them to point out any respects in which advice or changes may need to be reconsidered.
29. MC11: I suggest that the MPS considers a periodic audit of Tactical Firearms Reviews. The Inquests heard evidence that the national threat level was raised to Severe in January 2015, but that no tactical review was carried out between November 2014 and June 2015. I have suggested above that the MPS considers instituting audits of Post Instructions and/or of supervision at the Palace. It would also be sensible to consider whether any periodic audits can address relevant tactical advice which underpins instructions, to help ensure that it remains up-to-date and fit for purpose (taking account of any changes in threats and risks). Other matters
30. In their submissions, the sisters and parents of PC Palmer suggest that I should include in this Report a concern about whistleblowing procedures within the MPS. In response to that argument, the MPS has explained in submissions that there is a well-developed whistleblowing policy within the organisation. In my view, it is not appropriate for me to raise any issue of whistleblowing procedures in this Report. First, the evidence at the Inquests did not identify particular flaws in the existing procedures. Secondly, I cannot see that the evidence at the Inquests shows that there is a risk of future deaths by virtue of alleged deficiencies in MPS whistleblowing procedures. I should stress that I am not making any comment as to whether or not the MPS’s procedures are satisfactory. The Parliamentary Authorities Automation of Carriage Gates
31. At the time of the attack, Carriage Gates at the main entrance from Parliament Square into New Palace Yard were manually operated and old-fashioned metal gates. Police officers who were familiar with the gates generally described them as cumbersome to open and close. During the attack, the gates were open throughout the events. It was, at the time, the practice that the gates would remain open throughout Parliamentary sitting hours, with small external crowd control barriers being opened and closed to allow vehicles to enter and exit. During divisions, those barriers too would be left open.
32. The Carriage Gates were open until after the time that Masood had been shot. It was clear in video footage of the events in New Palace Yard that, during the police activity around Masood, a person on a motorcycle entered through the gates unchallenged, before the rider saw the scene and immediately left.
33. The old gates have since been replaced with a modernised set which are easier to open and close, but which are not motorised or automatic. I am aware that there is an on-going project which will involve extensive structural change in the New Palace Yard area, including at its main public entrance. It is also apparent to me that those responsible for the project will have to take account of a range of considerations in the design and construction of the entrance(s). However, the evidence in the Inquests showed that this is an important entrance to the Palace and that its security should be a priority for those responsible for the project. I am concerned that this consideration should not be forgotten in the extensive work being done.
34. 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. During the attack, the physical features of the gates made it harder for police officers to keep New Palace Yard and the Palace secure. While I appreciate that it may ultimately be impossible or inappropriate to have automated gates at this entrance, and that the design of the entrance will have to take account of many considerations, I am concerned that those responsible for the project should have this particular point at the forefront of their minds.
35. 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. A review was undertaken by Sir John Murphy into perimeter security in the wake of the attack, prudently commissioned by the Parliamentary Authorities. The advantages of an external reviewer conducting such an assessment are clear to the Authorities and to me. I consider that a person of similar experience and independence should be involved in reviewing and commenting on any plans for the re-design of New Palace Yard and its entrance(s) before irreversible design and construction decisions are taken. The London Ambulance Service
36. In my view, it is not appropriate to record any matter of concern in respect of the London Ambulance Service.
37. The representatives of some of the bereaved families suggest that it is a matter of concern that any first responder has the power to make a Major Incident declaration. I am not persuaded that this should be treated as a matter of concern. As the Service has explained in its written submissions, the policy is a prudent one which has important advantages. In particular, the first person on scene will often be an ordinary ambulance officer or paramedic and it may take some time for more senior officers to arrive. There is a clear benefit in having a policy which enables Major Incident procedures to be triggered quickly and without waiting for ranking officers to be on scene. I am aware that this is a matter considered in detail at the recent Hillsborough Disaster Inquests.
38. The same representatives of some families have raised a concern about practices of covering bodies of those who have died in a public place. However, I am satisfied from the submissions of the Service that they are conscious of the proper considerations of dignity, preservation of the scene and prioritisation of paramedic attention. I do not see any need to identify any concern in this respect. However, I should stress that I well understand the distress which families suffer when photographs of their injured or deceased loved ones are taken and later posted on the internet. I deplore this practice in the strongest terms. Transport for London (“TfL”) and the Secretary of State for the Home Department
39. The Inquests heard substantial evidence about the procedures by which protective security in public places is reviewed, advice is given and improvements are made. Protective security measures for buildings are generally the responsibility of the owners. As regards highways, security measures are generally the responsibility of the relevant highway authority. TfL is responsible for many major roads and bridges in Central London. There is a national network of police advisers who identify threats and provide advice to local authorities. Specific security measures apply to areas designated as crowded places and crowded spaces under criteria which are themselves sensitive.
40. There was evidence at the Inquests of a number of pieces of advice given by the police nationally following terrorist atrocities in the years before the attack. However, this advice was largely reactive to the specifics of the attacks elsewhere (e.g. dangers posed to festive markets). It was not clear from the evidence what work is being done at the national level to deliver wide-ranging advice on protective security measures, especially for roadways and public areas in urban areas which may be particularly at risk of terrorist attack. It would obviously be unsatisfactory if such work is limited to a limited group of areas designated as crowded places and crowded spaces.
41. 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.
42. The evidence at the Inquests also revealed that there are substantial differences in the heights of parapets on major bridges in central London. Quite apart from the fact that Kurt Cochran may have been saved by a materially higher wall or railing at the side of Westminster Bridge, it is important from a general viewpoint of safety that bridge parapets or railings be of sufficient height.
43. 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). The Security Service (Secretary of State for the Home Department)
44. The bereaved families represented by Hogan Lovells have submitted that I should make a number of recommendations in respect of operational practices of the Security Service. These include points in respect of record keeping; procedures for reviewing the management of closed subjects of interest (“SOIs”); and processes for obtaining of evidence from the police and other agencies.
45. The Security Service has provided a very significant volume of material to the Inquests Team. It gave access to many highly sensitive documents, including those which underlie the open report written by David (now Lord) Anderson QC. The review carried out by counsel and solicitors to the Inquests for the purposes of disclosure was comprehensive. The Security Service also fielded a senior officer (Witness L) who made a statement and gave evidence for a full day during the Inquests.
46. As part of their work, the Inquests Team considered the Security Service’s Operational Improvement Review which was conducted in the wake of the 2017 attacks across the country. Witness L gave evidence about that review. A particular focus of the Operational Improvement Review was the assessment of SOIs. Based on public information, MI5 had around 3,000 SOIs in March 2017, with around 500 investigations being pursued into individuals and groups linked to Islamist terrorism. There were approximately 20,000 closed SOIs. The scale of work was unprecedented. The Anderson report endorsed as appropriate the processes followed by the review teams. He praised MI5 staff as frank and open to criticism in meetings.
47. The Inquests Team, like David Anderson QC, adopted a rigorous and challenging approach to the Security Service and its evidence. As counsel to the Inquests submitted at the end of the hearing, the procedures developed by the Security Service for review and investigation of SOIs were explained with clarity by Witness L. He explained cogently the key decisions made in respect of Masood and why no realistic action by the Service could have prevented this attack in the circumstances.
48. I do not consider that it would be appropriate or helpful for me to make vague suggestions that the Security Service makes every effort to ensure that its procedures for managing investigations and SOIs are as good as they can be. It is evident that such efforts are being made and that a huge amount of detailed work has been done to extract learning from the attacks of 2017. Neither am I prepared to prescribe particular practices which would micro-manage the work of the experts and would risk wasting their precious resources. In the circumstances of this case, I consider that there is just one limited matter to raise with the Security Service.
49. 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. In response to this point being raised by the families, the Security Service pointed out that it is not practicable to record reasons for every decision by its officers not to do something. It was suggested that this would not be a good use of finite resources. While I agree that officers need not record reasons for every decision, it strikes me that closing a person as an SOI is a positive decision that further investigation is not justified or necessary. It is not obvious to me that such decisions are so numerous that recording each one with a short rationale would be impracticable. Furthermore, I can see clear operational benefits to corporate memory in having such reasoning recorded which could assist in the fight against terrorist activity. If consideration is given to re-opening a person as an SOI, it would surely be helpful to see easily why the person was closed previously. In this case, when explaining the reason for Masood being closed, the Service had to reconstruct the rationale since it was not documented.
50. It should be stressed that the Security Service are the experts in their craft, and that their work now involves very complex and sophisticated procedures. They have to marshal their scarce resources and I have no wish to drive them to take decisions which would divert resources from their best use. I am simply inviting the Security Service to explore their options.
51. The families represented by Hogan Lovells have asked me to go further and to recommend the form which records should take. I am not prepared to do that, because means of recording investigations and decisions must be left to officers with experience in the field. Knowing the thoroughness with which the Operational Improvement Review was conducted, I am confident that this Report will be treated with appropriate concern and diligence. The Maritime and Coastguard Agency
52. Andreea Cristea was struck by Masood’s vehicle and thrown into the River Thames. As she was unconscious and being carried by the current, she was seen by the crew of a large leisure vessel. One boatman promptly used a boathook to keep hold of her body, whilst he stood on the deck of the vessel some feet above the water level. He did not attempt to lift her, because he did not consider that he could safely and appropriately recover a body or an unconscious casualty with the equipment he had. Andreea was lifted from the water by a Fire Service vessel minutes later, using specialist equipment.
53. 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 to those operating on navigable rivers and canals. From the evidence in the Inquests, it was not apparent that there was any available guidance on this subject. Even though Andreea was quite quickly recovered from the water, it is easy to envisage a situation where a Fire Service vessel with special equipment is not fortuitously nearby and only the crew of a leisure vessel are at hand to recover an unconscious person. It would be beneficial for such individuals to have guidance on how to deal with the situation. I should stress that, in making this point, I am not criticising the response of the staff of the leisure vessel in this case. The Department for Transport and the British Vehicle Rental & Leasing Association
54. The evidence showed that Khalid Masood had intentionally hired a powerful vehicle which would serve as a lethal weapon in his attack. Other recent attacks, both in London and across Europe, have shown that like-minded terrorists look to hire large vehicles to cause maximum damage. I am not aware of any vehicle hire companies conducting any form of checks with any policing or security agencies before agreeing to the hire of a vehicle.
55. 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. This is a matter of particular concern as regards the hire of large vehicles, including heavy and light goods vehicles. However, the Westminster attack makes clear that other vehicles such as large 4x4 vehicles can also cause many fatalities and serious injuries in a short space of time. Miscellaneous Points
56. Some further points have been made in submissions by Interested Persons which I do not consider should be addressed in this Report.
57. First, I have been asked to consider suggesting measures which might be taken to reduce radicalisation by removing extremist material from the internet. While such material is a proper subject for public concern, I do not consider that I can usefully make a meaningful and practical suggestion for particular action to be taken or considered.
58. Secondly, the problem of radicalisation in prison is brought to my attention. I have been asked to consider measures which might be taken to prevent prisoners being radicalised. I do not consider that the evidence in the Inquests allowed me to explore this subject in such a way as to make properly informed observations. I take the same view in respect of a submission about measures to prevent extremists being involved in the teaching profession. Action Should be Taken
59. In my opinion, action should be taken to prevent future deaths. I believe that the various addressees of this Report have the power to take the action relevant to them (as set out above). Your Response
60. Each addressee is under a duty to respond to this report within 56 days of the date of this report, namely by 12th February 2019. Allowing for the Christmas and New Year break, this date will be extended to 26th February 2019. I, as the coroner responsible for the Inquests, may extend the period upon application.
61. Each response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, it must explain why no action is proposed. Copies and Publication
62. I have sent copies of my report to the following: (a) all Interested Persons in the Inquests (identified in the attached list); (b) the office of the Chief Coroner of England and Wales.
63. This report will also be posted on the Inquests website.
64. I am also under a duty to send a copy of any responses to the office of the Chief Coroner.
65. In my capacity as the Chief Coroner of England and Wales, I may in due course publish this Report and/or any responses in complete or redacted or summary forms. I may send a copy of this Report to any further person who I believe may find it useful or of interest. Addressees and others may make representations to me, in my capacity as the nominated Judge responsible for the Inquests, about the wider release or publication of any responses. HH Judge Mark Lucraft QC Chief Coroner of England and Wales (Sitting as a Nominated Judge) 19th December 2018

Determinations – Kurt William Cochran Kurt Cochran was unlawfully killed. On 22 March 2017 Kurt Cochran was on a visit to London. He had been walking with his wife, Melissa, across Westminster Bridge. They had reached a point near the South Bank side when a Hyundai vehicle was driven deliberately onto the pavement where they stood. This was part of a terrorist attack. Showing no concern for himself, Kurt instinctively and courageously pushed Melissa away from the path of the vehicle and as a result was struck with full force by the vehicle. He was thrown over the parapet of the Bridge to the embankment below, falling from a height of 5.12 metres. In the fall, he suffered a serious head injury which was not survivable. Despite early medical attention from a nurse, an ambulance crew and a hospital doctor, he died at the scene.

Determinations – Leslie Arthur Rhodes Leslie Rhodes was unlawfully killed. On 22 March 2017 Leslie Rhodes was walking from the South Bank side of Westminster Bridge towards the North Bank side. He was struck from behind by a Hyundai vehicle which had been deliberately driven onto the pavement where he was walking. This was part of a terrorist attack. Leslie was carried along into the carriageway a distance of 33 metres. As a result of the impact, he suffered a devastating brain injury, which was not survivable. He was unconscious from the time of the impact until his death. Despite early medical attention from a hospital doctor and paramedics at the scene, and despite proper treatment at King’s College Hospital, Leslie died on 23 March 2017 in hospital.

Determinations – Aysha Frade Aysha Frade was unlawfully killed. On 22 March 2017 Aysha Frade was walking across Westminster Bridge towards Parliament Square on her way home from work. While walking on the pavement, she was struck from behind by a Hyundai vehicle which had been deliberately driven towards her. This was part of a terrorist attack. Aysha was thrown into the air and into the path of the nearside rear wheels of a bus. Those wheels passed over her, inflicting injuries which were immediately fatal. Aysha would not have suffered. She was assessed as dead at the scene by a paramedic and by a doctor.

Determinations – Andreea Cristea Andreea Cristea was unlawfully killed. On 22 March 2017 Andreea Cristea was walking across Westminster Bridge with her boyfriend, Andrei Burnaz, from the Parliament Square side. She was stopping at times to take photographs with her mobile phone. While on the pavement, she was struck by a Hyundai vehicle which was being deliberately driven towards pedestrians on the pavement. This was part of a terrorist attack. Andreea was thrown into the air and over the parapet of Westminster Bridge, landing in the river Thames below. She was carried by the current a distance of 100 metres and was in the water for around five minutes before she was recovered by a London Fire Brigade boat. She was treated by fire officers and then by an ambulance crew and paramedics, before being taken by ambulance to hospital. While in hospital, she received extensive and complex medical care over the following days. Despite the best efforts of clinicians, she died on 6 April 2017.

Determinations – Keith David Palmer PC Keith Palmer was unlawfully killed. On 22 March 2017 PC Keith Palmer was on duty as an unarmed police officer stationed at the Carriage Gates entrance from Parliament Square into the Palace of Westminster estate. An attacker who had driven his vehicle into multiple pedestrians on Westminster Bridge entered the Gates. PC Palmer stepped forward to challenge him. He immediately began attacking PC Palmer with knives, driving him back into the New Palace Yard area. PC Palmer stumbled against a low wall and the attacker continued his assault. In the attack, PC Palmer suffered a number of injuries, one of which was a serious stab wound to the chest. Although he was able to move away from the attacker, PC Palmer collapsed shortly afterwards. Despite prompt and capable medical attention at the scene, he suffered a cardiac arrest and could not be saved. Before the start of the attack, the armed officers stationed in New Palace Yard had not been in close proximity to the Carriage Gates entrance. They had been some distance away and out of view of the entrance because they had understood their duty to involve a roving patrol around the Yard. In fact, tactical advice and written instructions stated that armed officers should be stationed close to the Carriage Gates entrance so as to protect those in the Estate and their unarmed colleagues. Due to shortcomings in the security system at New Palace Yard, including the supervision of those engaged in such duties, the armed officers were not aware of a requirement to remain in close proximity to the Gates. Had they been stationed there, it is possible that they may have been able to prevent PC Palmer suffering fatal injuries.

17322125.1 DETERMINATION SHEET This is to set out the conclusions of the Jury as to by what means and in what circumstances Khalid Masood came by his death. Short-form Conclusion: Lawful Killing On March 22nd 2017, having driven at speed over Westminster Bridge, killing four people and injuring many others (29 seriously), Khalid Masood crashed into the wall of New Palace Yard. He got out of the car and proceeded to run around the corner to Carriage Gates. Entering New Palace Yard, Khalid Masood attacked PC Keith Palmer, stabbing and fatally wounding him, he pursued unarmed officers through the vehicle exit channel, with knives in his hands. Multiple witnesses noted Khalid Masood’s intention to inflict serious harm and/or take life as he continued his attack. He continued to move towards Westminster Hall without stopping or changing direction. Reacting to the initial crash and commotion, two close protection officers (CPOs) walked towards the vehicle exit channel from the direction of Members’ Entrance. At this point, the unarmed officers ran towards the CPOs, pursued by Khalid Masood. In accordance with their training, the CPOs shouted verbal warnings at Khalid Masood, by which time both CPOs had their pistols drawn and aimed at Khalid Masood-whilst attempting to create distance between themselves and him. The warnings had no effect on Khalid Masood and he continued to move towards the CPOs at speed with knives still in hand. With Khalid Masood approaching striking distance of the CPOs, SA74 shot Khalid Masood three times until he no longer posed a threat. Khalid Masood received immediate first aid and CPR which continued until he was declared dead at St Mary’s Hospital.

17706664.1 INQUESTS ARISING FROM THE DEATHS IN THE WESTMINSTER TERROR ATTACKS OF 22 MARCH 2017 LIST OF INTERESTED PERSONS
- Family of Aysha Frade
- Family of Leslie Rhodes
- Family of Andreea Cristea
- Family of Kurt Cochran
- Family of PC Keith Palmer
- Family of Khalid Masood
- Commissioner of Police of the Metropolis
- London Ambulance Service
- Secretary of State for the Home Department
- Independent Office for Police Conduct
- London Fire Commissioner
- Transport for London
- Barts Health NHS Trust
- Speaker’s Counsel (the Parliamentary Authorities)