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INQUESTS ARISING FROM

THE DEATHS IN THE LONDON BRIDGE TERROR ATTACK ON 3rd JUNE 2017

___________________________________________________________________________ CITY OF LONDON POLICE RESPONSE TO PFD REPORT ___________________________________________________________________________

INTRODUCTION 1 This is the response of City of London Police (CoLP) to the matters of concern (MCs) addressed to CoLP in the Coroner’s Prevention of Future Deaths report dated 1st November
2019. In this response CoLP only addresses those MCs directed at CoLP.

2 MC13 – Addressed to the LAS, MPS and CoLP: The evidence in these Inquests gave rise to concerns that procedures for emergency response to marauding terrorist attacks were inflexible. In particular, the evidence suggested that large areas could be designated hot and warm zones for long periods and formally placed out of bounds to most ambulance and paramedic staff. This feature of the procedures gave rise to a risk of delay in getting medical help to casualties. While this lack of flexibility has apparently been addressed in the revised Joint Operating Principles, I suggest that procedures generally be reviewed to ensure that they accord with the requirements of speed and flexibility of response which appear to be recognised in that

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document. I also suggest that training exercises be devised which address demanding situations with features such as (a) hot and warm zones of uncertain extent; (b) a need for re-assessment of hot and warm zones; and (c) a need to locate and assist casualties in dangerous areas. Response to MC13
2.1 Joint Operating Principles (JOPs) are regularly reviewed and updated. Following the attacks in 2017 and before the hearings commenced in 2019 significant amendments were made to the MTA JOPs to reflect the changing nature in the threats presented. As the Coroner records, the current MTA JOPs recognises the requirements of speed and flexibility of response. The Operation Plato guidance has also been amended to reflect the change in approach. CoLP can confirm that the new JOPs and guidance are adopted and embedded in the CoLP force area.
2.2 The issue is how the JOPs and Plato guidance translate into action on the part of responders. CoLP regards the key to this as being familiarisation with the new principles through comprehensive training and exercising in the form of both table top and live exercises.
2.3 The City of London police participate in a number of test exercises that assess the operational and strategic command and response, including Marauding Terrorist Attack (MTA) specific exercises which include Hot/Warm/Cold zone working. In 2019, CoLP participated in 3 such MTA exercises. In 2020, CoLP officers are currently scheduled to attend 4 such MTA exercises, three of which are live play exercises and one which is a table top exercise, with further exercises likely to be added to the Training and Exercise calendar.
2.4 CoLP can confirm these exercises will include the issues identified by the Coroner at MC13 (a)-(c)

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2.5 Authorised Firearms Officer training In addition to the above MTA exercises there is specific MTA training and exercising for Authorised Firearms Officers. All CoLP AFO’s have received the latest JOPs updates. JOP updates were refreshed on a recent phase of British Transport Police Command refresher training during September and October 2019. Many of CoLP’s Tactical Firearm Commanders (TFC’s) participated in this Command refresher training which included specific actions in relation to the new zonal guidance. For example, TFCs were encouraged to utilise London Ambulance Service (LAS) responders directly behind the lead firearms teams attempting to confront the subjects in order to safely assess, triage and evacuate victims. This was performed with armed protection and jointly involved LAS teams working in warms & hot zones. The emphasis here was on not designating vast areas as hot zones if precise information on the whereabouts of the subjects are known, for instance, subjects are located on a specific level of a building. Additionally, in November and December 2019 CoLP ARV teams participated in the joint MTA phase training run by the MPS.
3. MC15 – Addressed to the MPS and CoLP: I suggest that the emergency services give serious consideration to enhancing first aid capabilities and equipment of either police officers generally or groups of officers (e.g. firearms officers or officers designated for advanced medical aid training). This should include consideration of training some officers in advanced life-saving procedures analogous to battlefield medicine. It should also include considering (a) wider provision of equipment such as tourniquets and “stop the bleed” kits and (b) the inclusion of more spare equipment in officers’ vehicles.

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Response to MC15
3.1 The size and agility of CoLP, as a relatively small force, and its relationship with the local community in the square mile means that it has already taken significant steps to enhance the first aid capability of its officers well beyond the national standards, details of that enhanced training programme are set out below. However, it should be recognised that the ambulance service is the lead agency in casualty management and the overarching aim is to secure their attendance upon casualties as soon as practicable. The first aid capabilities of police officers are intended to be only a temporary measure, although, as stated, First Aid capabilities have been enhanced.
3.2 First Aid Training: All CoLP Officers and front-line Police Staff (PCSO’s, Detention Officers) are first aid trained. CoLP Officers up to the rank of Chief Inspector are trained to the College of Policing standard ‘Emergency First Aider at Work’ (EFAW) module 2 (there are 5 in total – Module 1 Basic Life Support, Module 3 Custody, Module 4 Initial and Requalification, Module 5 – enhanced skills). The Emergency First Aider at Work is defined by the Health and Safety Executive. EFAW module 2 covers the following:
1. Manage a first aid scene
2. Assess a casualty
3. Perform basic life support (including adult, child and infant)
4. Demonstrate safe use of an Automated External Defibrillation (AED)
5. Manage a choking casualty (including child or infant)
6. Place a casualty in the recovery position
7. Report casualty information

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8. Manage a casualty with shock
9. Manage a casualty with chest pain
10. Manage a casualty who has fainted
11. Manage a casualty who is bleeding
12. Manage a casualty with spinal injury
13. Manage a casualty who is convulsing
14. Manage the control of infection With effect from 3rd June 2019 CoLP has changed its First Aid training provider to a company called Lazarus, whose trainers are ex-Military or ex-Emergency Services in order to reflect the most realistic injury scenarios. All officers complete an initial 2 day course, called Initial Operational First Aid and thereafter attend an annual refresher course. All officers with an AFO role in CoLP receive enhanced First Aid training, with emphasis on treatment of ballistic injuries. Following the London Bridge incident, further response officers received the same enhanced First Aid Training, the same as CoLP AFOs. CoLP now plans to train all frontline officers to an enhanced level. This training commenced in Q3 2019 and will continue into 2020. As part of this training, officers receive further training in the use of tourniquets which will be issued to each officer upon completion of training. It is anticipated that the training programme will be complete by Q2 2020. In addition, CoLP is rolling out a four day Pre-Hospital Trauma Care (PHTC) training course to a further 36 front line officers drawn from Uniform Response, Project Servator Teams, Support Group and Roads Policing. Once trained, these officers will be issued an enhanced medical kit that includes tough cut scissors, a tourniquet, compression dressing, chest seals and Celox, a blood clotting agent for all types of bleeding including moderate and severe bleeding.

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3.3 First aid kits: All CoLP response vehicles, including ARVs, contain an emergency first aid kit, along with a defibrillator. (CoLP first aid kits and a defibrillator were used by officers responding to casualties at London Bridge in June 2017). Following the London bombings on 7th July 2005, a number of Emergency Dressing Packs were supplied by the NHS to mainline railway stations for responders to use following a Major Incident. There are 17 Emergency Dressing Packs at 10 stations across the City of London force area. CoLP has initiated the Emergency Trauma Pack (ETP) scheme. ETPs have been reviewed by the London Ambulance Service and contain specialist medical equipment. ETPs are not conventional first aid kits. The aim of this scheme is to work alongside businesses to enhance the accessibility and availability of industry leading lifesaving medical equipment. ETPs are embedded into businesses that sign up to the scheme and their details are centrally stored by CoLP control room staff who would coordinate the response to a mass casualty incident. The location of the nearest specialist first aid kits can be ascertained from the CoLP control room.
3.4 Bleed Control Kits Recognising the increasing prevalence of serious injuries caused by firearms and bladed weapons, in November 2019 CoLP provided life-saving ‘Bleed Control Kits’ to late-night venues in the City of London. A total of 300 Bleed Control Kits are being distributed across the City in partnership with The Daniel Baird Foundation. The Bleed Control Kits may help to save precious time until paramedics arrive at the scene and help prevent catastrophic bleeding. Staff at venues who receive these kits will be given training to ensure they feel confident in using the equipment. There are also plans to increase the distribution of kits in 2020 and beyond with the ultimate aim of providing all licensed premises in the City of London with such a ‘Bleed Control Kit’.

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3.5 The future Notwithstanding the significant strides already made to improve its First Aid response, training and equipment, CoLP is always looking to improve first aid capability and is currently considering the viability of still further enhanced first aid training similar to that of battlefield medicine. The need for this level of first aid training, the identification of the officers to be trained to this level and the consequential funding, equipment and human resources issues are all being considered. However, whilst Police have core operational duties which include protecting life, and acknowledging that it is a primary responsibility under Article 2 ECHR, it should be noted that the first aid offered by police officers is only an interim measure and it is not the primary role of the police service. The LAS are necessarily trained and equipped to a higher level than the police, the provision of medical treatment being their primary function and would retain primacy in responding to casualties requiring medical assistance and treatment. In addition to its first aid provision outlined above, CoLP will be enhancing its front line officers through the recruitment of 61 additional police officers, funded through the City of London (Corporation). 4 MC16 – Addressed to the MPS and CoLP: The evidence in the Inquests raised a concern that there will often be communications difficulties in the early stages of a major incident, including

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difficulties resulting from multiple officers attempting to make urgent radio transmissions at the same time. In the ongoing work of reviewing and improving communications technology to address these difficulties, consideration should be given to whether it may be possible for control room staff to isolate and record messages so that they can be listened to separately. Response to MC16
4.1 This is a national issue which will require consideration at a national not local level. Delivery of a solution does not sit solely with CoLP.
4.2 Notwithstanding the above, the following observations may be relevant. The technology currently allows only one officer/user to broadcast on an Airwave channel or talkgroup at any given moment in time. As only one message at a time on any given channel or talkgroup can be transmitted over the radio network, it follows that only the message currently "live" and audible to the control room and other officers on that channel or talkgroup can be recorded. The ability to record and playback that message already exists. The practical issue in the early stages of a fast moving incident is firstly the fact that technology limits the ability of more than one officer to transmit on one channel and the fact that there is rarely likely to be time for the control room to replay messages when it is still receiving multiple messages in very quick succession in live time. Currently CoLP and the MPS are undertaking a joint piece of work to establish a formal collaboration agreement, whereby the command of all initial firearms incidents occurring in the geographical area of the City of London would fall under the command of the MO19 Tactical Firearms Command, MPS based at Lambeth SOR. Additionally COLP will seek to second a qualified Tactical Firearms Commander of the rank of Inspector to be part of the Pan- London joint command response.

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. MC17 – Addressed to the LAS, MPS and CoLP: I suggest that consideration be given to introducing / improving technical measures to assist in identifying the exact locations of emergency services personnel so that they can be communicated reliably to other first responders. Response to MC17
5.1 A CoLP Airwave Refresh Project was initiated in summer 2019 to refresh all the Airwave devices within CoLP, including radio handsets, desktops and in-vehicle devices. GPS location of officers through the Airwave network was explored within the scope of this project. The new radios that are available have GPS capability. In order to enable this functionality within CoLP, a further uplift in the control room IT is required to introduce an interface that will extract the location data from the Officers radio onto a map within in the control room. This is a capital project which has been approved and the award of contract has now been made by the Metropolitan Police Service, with a very tight delivery timescale of 8 months. CoLP have allocated a control room manager (Police Staff) full time to the MPS project team to ensure the interests of CoLP are maintained along with the joint working capability. This will include the connectivity between the CAD2 system and the CoLP Record Management System (RMS) Niche which holds Intelligence, Crime, Case and Custody data. CoLP has a seat at the executive Board. Through the allocated full time member of staff the interests of Business As Usual (BAU) and Secure City Programme (future operating of the City of London) are addressed and maintained. This will provide an interim solution until the ICCS and CAD upgrades referred to below are completed and prior to the ESN launch. Completion of the ESN project, which is owned by the Home Office, is not expected until
2023. As part of the process of development CoLP and other forces have requested that geolocation be included. It is currently anticipated that ESN will use data rather than voice

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information. It is therefore considered likely to provide quicker and more reliable information as to the location of the assets of the emergency services. The National programme is still ongoing with no firm dates set for data or voice. CoLP is part of the Pan London group working collectively with monthly Pan London ESMCP Group (PLEG) meetings attended by a CoLP representative. This group consists of Met and British Transport Police as well as London Ambulance and Fire Service representatives. ESMCP remains a project with resources allocated to it by CoLP.
5.2 The CoLP Control room uses the MPS Integrated Command and Control System (ICCS) and Computer Aided Dispatch Systems (CAD). CoLP is aware that the MPS, as owner of these systems, is carrying out system upgrades and CoLP is engaging with the MPS in the ICCS and CAD upgrade projects in relation to CoLP requirements. The interim solution in CoLP, pending completion of the upgrade, is set out at 5.1 above.

Dear Sir Re: Inquests arising from the deaths in the London Bridge and Borough Market terror attack The BVRLA recognises it has an important role to play in ensuring its members take all necessary steps to prevent future deaths occurring from terrorism where rental vehicles are used as a weapon. We are saddened by the events that took place at London Bridge and Borough Market in 2017 and offer our condolences to the families who lost loved ones. The BVRLA and its members have been working with the Department for Transport (DfT) and the law enforcement counter terrorism community to review what processes are in place to prevent vehicles being used as weapons in terrorist attacks and ensure the industry does all it can to protect itself and the wider community. Significant steps have been taken by the BVRLA to ensure its members adopt a robust security culture across their business that will protect the general public as well as their employees, premises and their assets. We have done this through training, guidance and engagement opportunities. These initiatives have been made available free of charge to anyone involved within our industry. We welcome the suggestion in the Prevention of Future Deaths report that consideration is given to taking further measures to reduce the risk of rental vehicles being used in terrorist attacks. The report notes that measures to be considered should include (a) introducing a scheme for real-time reporting of rentals and automated checking of the results against lists of SOIs and (b) making the current RVSS scheme mandatory. Real-time reporting of rentals BVRLA members already carry out robust checks to safeguard their businesses using RISC, the BVRLA’s digital risk management tool for rental and leasing companies, and other proprietary systems. The vehicle rental industry is prepared to share data and information that can be utilised by the authorities to prevent crime. Careful consideration needs to be given to the type of system which can communicate with the security services in ‘real time’ and what information could be usefully shared. The scaling and costing of such a system needs to be considered and it should not place a disproportionate burden on the rental sector. We will continue to work closely with counter terrorism police, the Home Office and the DfT to look at ways in which information can be shared which will not overwhelm the security services. With around 16.2 million car and van UK rental transactions per annum the security services would need to set out how any information should best

BVRLA Ltd River Lodge, Badminton Court, Amersham, Bucks HP7 0DD tel: 01494 434747 fax: 01494 434499 e-mail: info@bvrla.co.uk web: www.bvrla.co.uk Chairman: Nina Bell Chief Executive: Gerry Keaney A company limited by guarantee Registered Office as above Registered in England No. 924401 be received and agree on how this could be processed in a timely manner to reduce the risk of a future attack. A mandatory RVSS The BVRLA is delighted to report that we have recently been recognised as an approved authorised partner by the Department for Transport. This means that the BVRLA can now effectively make this a mandatory requirement for our members through the BVRLA’s Code of Conduct, which is a condition of membership. Principle 9 requests that members ensure that staff are trained to recognise and report suspicious behaviour, support counter terrorist campaigns and to adhere to the Department for Transport’s Rental Vehicle Security Scheme. The BVRLA monitors adherence with our Code of Conduct via our compliance programme. From 1st January 2020 we have included additional criteria within our member audits which specifically monitor awareness, training and compliance against the key principles set out in the scheme. We are delighted to have been recognised as a trusted partner and will be working hard with members to ensure they have all the training and support necessary to comply with the RVSS and to ensure the benefits of the scheme are fully recognised.

Dear Sir Regulation 28; Prevention of Future Deaths Report arising from the inquests into the deaths of Xavier Thomas; Christine Archibald; James McMullan; Alexandre Pigeard; Kirsty Boden; Sébastien Bélanger; Sara Zelenak; and Ignacio Echeverria Miralles de Imperial. Thank you for your Regulation 28 Report dated 1st November 2019 setting out matters of concern regarding the circumstances creating a risk of future deaths. I would like to begin by again expressing sincere condolences on my own behalf and on behalf of the LAS Board to the families of the eight deceased victims, Xavier Thomas; Christine Archibald; James McMullan; Alexandre Pigeard; Kirsty Boden; Sébastien Bélanger; Sara Zelenak; and Ignacio Echeverria Miralles de Imperial. I would like to also express my thanks for the rigorous investigation into the facts and evidence that was presented at the inquests. I hope that this reply will be helpful in detailing the consideration given and actions taken to demonstrate how the matters of concern have been addressed and the ongoing work to make improvements within the London Ambulance Service NHS Trust (LAS). It remains our intention to continue working with our fellow emergency service partners both locally and on a national level on the issues raised. I will address your concerns, as directed to the LAS as follows: MC13 – “Procedures generally be reviewed to ensure that they accord with the requirements of speed and flexibility of response.…. I also suggest that training exercises be devised which address demanding situations which features such as (a) hot and warm zones of uncertain extent (b) a need for re-assessment of hot and warm zones and (c) a need to locate and assist casualties in dangerous areas.” Joint Operating Principles of the Emergency Services (JOPs) As previously reported to you, the Joint Operating Principles of the Emergency Services (JOPs) were completely reviewed and updated in February 2019 and have now been implemented as a new first edition. This new edition JOPs is titled “Responding to a Marauding Terrorist Attack (MTA)”, rather than “Marauding Terrorist Firearm Attack (MTFA)” as was the case in the 2017 edition. The new edition covers various types of attack methodology,

rather than only firearms attacks. These new JOPs also incorporate wider learning from the incidents of 2017, in that the principles are now designed to be more adaptable and flexible to allow a scalable response for varied methods of terrorist attack and include the deployment of both specialist and non-specialist responders. With regard to the issues of the identification and flexibility of zoning, the new JOPs now include additional clarifications on each of the following specific definitions: The Hot Zone; an area assessed to contain a credible and continuing threat to life, including the presence of attackers with weapons. Therefore, the hot zone will initially include both specialist and non-specialist police responders, dependent upon the nature of the threat(s) present and attack methodology. LAS resources will not proactively be deployed into this zone, unless the situation warrants an exceptional deviation from guidance. The Warm Zone; an area where the attackers are not believed to be present at this time, but an identified threat remains. In the light of learning from the incidents in 2017, the response in the warm zone will now vary depending on the attack methodology, the threat, and measures in place to mitigate that threat. Therefore, multi-agency responders in the warm zone can now include a combination of both specialist and non-specialist responders. Such changes in the JOPs enable the LAS to initiate a more flexible and dynamic approach at an incident, thus achieving a greater speed of deployment and increasing the availability of clinicians to treat patients. In addition to this, the principles further state that the availability of armed police officers to escort responders is not guaranteed and should not delay responder deployment, again allowing the LAS greater flexibility of response as required and as indicated by dynamic risk assessments on scene. The Cold Zone; an area where no known threat exists or where appropriate control measures have been implemented. Potential control measures and their necessity will be determined by attack methodology and proximity to the hot and warm zones. Some cold zones will not require any control measures. It is expected that Forward Command Points will be established on the edge of cold and warm zones. The updated JOPs sets out that the size, location and necessity for zones should be continuously reviewed and every effort should be made to reclassify zones to accurately reflect constantly evolving threat and risk. It specifies that zones should be no larger than absolutely necessary and their size should relate directly to the attack methodology. It provides an example where there is a firearms threat, the hot and warm zones may be considerably larger than those for an incident involving bladed weapons or a hostile vehicle attack. The aim is to move the hot zone to warm as soon as practicable to enable the rapid deployment of responders to deliver clinical care to save life. As soon as it is confirmed that any threat has been mitigated, this information should be shared immediately with responding organisations. National Ambulance Resilience Unit (NARU) The National Ambulance Resilience Unit (NARU) acts as a central support unit for all UK ambulance services, to ensure that they as a whole can respond to a variety of hazardous and challenging incidents in the safest and most effective way possible. NARU’s key role is to maintain and develop the high standards expected of all the NHS ambulance service’s specialist interoperable capabilities so they are always high quality and always fit for purpose.

Maintaining contract standards, ensuring safe systems of work, training and equipping specialist operational staff from each service so that they have the right tools, knowledge and attitude to be able to enter challenging and hazardous situations with the confidence and ability to save lives (while mitigating the risks to their own safety) is key to NARU’s work. Accordingly, NARU works closely with a range of stakeholders to support the national development of Emergency Preparedness, Resilience and Response (EPRR) related policy. Given NARU’s role the LAS continues to work closely with it to develop guidance and standard operating procedures to support the deployment of staff into appropriate zones at future incidents. This will ensure the broadest experience and input is secured for this work. NARU will be providing greater clarity on the expectations of how and when Ambulance responders should deploy into the warm zone of incidents. This will be in the next edition of the JOPs, subject to the agreement of all relevant agencies. It remains the LAS’ expectation that its staff will receive support from Police and Fire Service responders under the Joint Emergency Services Interoperability Principles (JESIP) when operating in a warm zone. NARU has representation on the JESIP MTA JOPs working group who will ensure these issues on behalf of ambulance services continue to be represented and reviewed. In line with NARU responsibility for maintaining contractual standards it has agreed to undertake a formal review of the national contract standards for ambulance services’ MTA interoperable capability. An audit of the current national MTA capability has been completed, which included a compliance assessment for every Ambulance Trust in England, including the LAS. Both the findings of this audit and the recommendations in the Regulation 28 Report will inform NARU’s review of the MTA capability contract standards. The updated MTA contract standards will be in place for the new commissioning period (start of the new financial year 2020). Furthermore, NARU is also undertaking a formal review of the national MTA Standard Operating Procedures (and corresponding generic rescue plan, generic operational risk assessment, equipment data sheets and training information sheets including core competencies) which enable the local implementation of the JOPs, with the intention to include further clarification of warm zone responders and deployments. The formal process for making changes to national provisions is clearly defined within the NARU ‘National Provisions for Interoperable Capabilities’ and will be followed. NARU has confirmed that, once updated, these provisions will become mandatory for all NHS Ambulance commanders, HART and MTA responders. They will be required to be included on all subsequent MTA training courses (national and local) and they will be communicated to all relevant responders via the existing Proclus Standard Operating Procedures platform. The updated MTA standard operating procedures and safe system of work provisions will be in place by July 2020, subject to NARU’s workplan being agreed by NHS England. LAS policies and procedures In order to embed the changes in the February 2019 JOPs, the LAS training and exercise packages, action cards and procedures were reviewed. March 2019. These will be undergoing a further review following the detail of your Regulation 28 Report and following the formal review by NARU. This further review will be complete by September 2020. Training of LAS staff Upon implementation of the updated JOPs in February 2019, the LAS commenced a 10 week specialist training programme for specialist responders and commanders (Hazardous Area Response Team (HART), Tactical Response Unit (TRU) and commanders) to ensure they are all fully up to date with the changes and new

provisions within the JOPs. This training, which is the consolidation of the theoretical learning form the JOPs and its practical application in a multi-agency scenario setting includes classroom based learning, table top exercises and physical MTA live exercises conducted on a multi-agency basis (alongside the Metropolitan Police Service (MPS) and London Fire Brigade (LFB)). Currently, 100% of TRU staff, 94% of HART staff and 100% of commanders have completed the training. In addition to specialist teams and commanders, the LAS is also training front line (non-specialist) staff through its annual Core Skills Refresher (CSR) training programme, identified as CSR 2019.3. This particular module started on 1st December 2019 and will run through to 31st March
2020. Alongside classroom based learning, the LAS also continues to instigate and engage in multi-agency MTA training exercises with both specialist and non-specialist responders, including the ‘Yellow Penguin’ Exercise which took place at Chessington on 6th March 2019, Exercise ‘Red Botham’ at Lords cricket ground on 30th March 2019 and Exercise ‘Eleanor’ on 28th October 2019. In addition, the LAS has undertaken further live exercises to test particular elements of the JOPs. An example of this is the ‘Autumn Falls’ Exercise which specifically included the identification and response to hidden casualties. This took place on 29th September 2019 and was a large scale Chemical Biological Radioactive and Nuclear (CBRN) training exercise. Exercise ‘Autumn Falls’ was located at a sporting stadium; information relating casualty locations within the stadium was fed into the LAS Specialist Operations Centre (SOC) and venue control room to test the information flow between these areas and the exercise commanders and responders on the ground, to ensure that information was received and acted on, finding the exercise casualties hidden within the stadium. The exercise debrief is currently being finalised, and by the end of January 2020 the relevant SOC action cards will be updated to ensure that learning is incorporated in LAS response to incidents. Further information can be found below regarding the location and assistance of casualties. In addition to multi-agency training exercises, the LAS is providing a teaching session to MPS staff on their tactical firearms commander course, which explains the LAS response to MTA incidents and the principles of casualty management from an LAS perspective. The session covers the LAS duty of care to patients, the incident response structure and the LAS’ pre-determined response to a MTA or major incident. It also includes information relating to casualty collection points, the purpose and benefit of these and how the MPS and LAS work jointly during a major incident. It stresses the importance of recognising and understanding the use and process of casualty collection points and how patients can be brought directly to them for medical treatment. Effective joint decision making is crucial for multi-agency working during an MTA or major incident and the session also covers best practice in this respect and sets out examples of how working well together will increase the speed of deployment of ambulance resources to provide life-saving intervention. The LAS commends the actions of police officers who worked bravely and tirelessly on scene to treat the many injured patients and the LAS fully supports the work being undertaken to expand the police first aid training and provision of equipment, recognising the benefit this will bring to those officers who may arrive first on scene. MC14 – “the LAS review its guidance documents and training exercises to ensure that they stress this point and indicate practical means of locating casualties (e.g. from information in emergency call records)” Locating and assisting casualties – changes to LAS guidance and procedures as a result of training exercises The location and assistance of casualties in dangerous areas has been a clear area of focus for all agencies responding to an MTA, as evidenced by the “Autumn Falls” Exercise and training programmes referenced above.

In response to the issues raised by the 2017 incidents and the learning from the ‘Autumn Falls’ Exercise, when faced with a MTA or major incident, the LAS has decided to designate specific roles SOC Manager (to ensure the information is considered and actioned), a Critical Loggist and a SOC Allocator) within its control room to undertake the task of identification and recording of casualty locations to prevent any oversight. Those within these roles are tasked with ensuring that identification of casualty locations is prioritised, with a designated person responsible for constantly monitoring, reviewing and linking up information coming from members of the public via 999 calls, the MPS CAD link, ES5 (emergency services radio communication channel) and the call log so that it can be actioned. By operating in this manner the LAS can mitigate against a single point of failure and in smaller incidents where not all roles are filled, at least one of these roles will be present. All patient information received will be cross referenced to ensure that a full picture of patients’ injuries and locations is captured. Action Cards will also detail the process of passing the information to the Ambulance Commander at the Forward Command Point. Once in receipt of patient location information, the commander at the Forward Command Point will coordinate extraction of the patient. It is detailed in the JOPs that this type of information will form part of the commander’s casualty management plan. Control room staff will be updated in the use of this process so that, by March 2020, there will always be a staff member on shift on a 24/7 basis with the capability of undertaking these roles. Training for control room staff will be provided via a bulletin for Emergency Operations Centre (EOC) staff with the updated Action Cards. It is also currently being explored whether a session can be incorporated into the EOC Core Skills Refresher training for the coming year. MC17 – “consideration be given to introducing/ improving technical measures to assist in identifying the exact locations of emergency services personnel so that they can be communicated reliably to other first responders” NARU is nationally responsible for the development and introduction/improvement of technical measures to assist in the identification of casualties and emergency service responders during an MTA. Its aim is to ensure that a nationally-appropriate solution is adopted, which can be accessible by all emergency services (fire, police and ambulance). In light of its experience in responding to these and other major incidents, the LAS has been asked by NARU to take the lead in the practical assessment of these technical measures. Over the course of 2020, the LAS will therefore be working to review the technical solutions currently available, including those which are already in use by different emergency services. As the successful roll out of these technical solutions will be dependent on their interoperability with current or any new Computer Aided Dispatch (CAD) systems, it is not anticipated that a solution will be implemented before 2023. MC18 – “consideration be given (including through the Blue Light Collaboration Programme) to the possibility of having a small number of LAS and London Fire Brigade staff stationed in the MPS control room at all times” The LAS continues to work together with the MPS and the LFB through the Blue Collaboration Programme to explore all possibilities for improved joint-working and communication, including the implications of co-locating a small number of LAS and LFB staff in the MPS control room on a permanent basis. A table top exercise to explore co-location of some staff in the MPS control room has already been completed in November 2019. The involved operational staff from LFB, LAS and MPS. The team examined calls during a six- hour late duty in October, to see what effect the immediate triaging of calls may have had on deployments for each of the services during this period.

A further live trial is planned for seven days in February 2020. This will see a member of LAS staff based in the MPS control room with a member of the LFB, 24 hours a day. The focus on this test of concept is on timely and accurate situational information sharing. The outcome of this trial will be analysed and a recommendation based upon the results will be considered for approval by the Autumn of 2020. Finally, I very much hope this response helps in setting out the ongoing work that the LAS is engaged with to ensure front line and command personnel are fully up date and trained in the latest JOPs, when faced with a major incident or MTA in the future. Learning and development from Serious Incidents are never a finished task and the LAS will continue to work with its emergency service partners to promote best practice in sharing information and collaborating as part of a multi-agency approach. The LAS is committed to continuing its local and national work in its ongoing effort to perform at its best for all patients, whenever they need it. The LAS Board takes its responsibilities very seriously and has emphasised the importance of ensuring that the organisation’s ongoing capability to respond to MTA and other major incidents remains a matter of focus. To this end it has increased its visibility of the HART and TRU teams through visits to these teams and enhanced reporting on their readiness and performance. A lead Non-Executive Director for EPRR issues has been identified and the Board will be receiving regular updates on the progress of the actions set out in this response. My thoughts and those of my colleagues at LAS remain with the families of the victims.

Dear They -

Rt Hon Priti Patel MP

Response_to MCLand MC2 (addressed together_as they both concern sites and criteria for bespoke engagement) MC1 Addressed to the Secretary of State for the Home Department and NaCTSO: | suggest that there be a review of the sensitive national criteria and tests for identifying sites as priority Crowded Places (or for otherwise designating sites at national level as justifying proactive advice on protective security): In that review, one aim should be to ensure that the criteria are not excessively rigid so as to exclude sites which may be particularly attractive and vulnerable to terrorists. If and to the extent that the Secretary of State considers that any other Government agencies should play a part in addressing this concern, their assistance should be enlisted; MC2 Addressed to the Secretary of State for the Home Department and NaCTSO: suggest that consideration be given to putting in place systems of periodic review assurance to ensure that the criteria for identifying priority sites for protective security advice remain fit for purpose and that the list of such sites remains appropriate. The Government accepts these recommendations Co-ordination of work on crowded places The Government's approach to crowded places (which includes crowded spaces) , is overseen and co-ordinated by the Office for Security and Counter Terrorism (OSCT') in the Home Office_ Through this approach advice and guidance is provided to all parties responsible for crowded places to: Raise awareness of the terrorist threat and attack methodologies; Provide advice as to appropriate and proportionate protective security measures; Provide advice on public vigilance , the reporting of suspicious behaviour or activity and appropriate action to be taken following a terrorist attack; and Inform planning and preparation for possible terrorist attacks can take place, for example through staff training and awareness raising and the testing and exercising of emergency procedures. Crowded places encompass a number of different crowded public locations: Permanent buildings which are open to the public; Temporary events (such as festivals or sporting events). Crowded spaces encompass locations such as city centre squares, the public realm, bridges or busy streets where there is mixed and diverse ownership. In these locations, it can be difficult to control and co-ordinate security efforts_ how

There are variety of mechanisms to provide this advice and guidance. These include; Engagement with stakeholders for crowded places by Counter Terrorism Security Advisers ('CTSAs') who provide advice to site owners and operators, local authorities and others; Targeted awareness-raising sessions and training courses delivered by CTSAs and Counter Terrorism Awareness Advisers ('CTAAs') with crowded places managers, front of house and other staff; Engagement with representatives of leading crowded places sectors (e.g. sports grounds, shopping centres, entertainment centres) , member associations and organisations who own or are responsible for crowded places; Advice provided to local authorities, planners, developers and architects by CTSAs, the Centre for the Protection of National Infrastructure (CPNI), and by the Ministry of Housing, Communities and Local Government through the National Planning Policy Framework and associated Guidance,2 designed to ensure that proportionate security measures are considered for appropriate new builds and refurbishments; Online advice and guidance, regularly reviewed and updated, for responsible parties from Counter Terrorism Policing and CPNI; and Targeted communications to crowded places stakeholders from Counter Terrorism Policing: Review of_crowded places As the Government witness for the SSHD at the Inquests acknowledged, the process for prioritising CTSA engagement at sites at the time of the London Bridge and Borough Market Attacks was based on the terrorist threat picture at the time, and its criteria had the potential to exclude a number of locations from being considered for engagement It is estimated that there are over 625,000 organisations which operate at least one crowded place in the UK. All of these are potentially vulnerable and to attack by terrorists It would not be appropriate or proportionate to visit each of these organisations individually to provide advice and guidance. Advice is available for all stakeholders through the above highlighted mechanisms. https Ilgov uklgovernmentlpublicationsInational-planning-policy-framework-2

By definition, any prioritisation system will focus more attention on some locations and organisations than others. It is also important to acknowledge that; as the Government witness highlighted at the Inquests, engagement by a CTSA at a site or with a stakeholder does not necessarily provide any certainty of protection. This is because currently the decision to implement protective security advice lies with the ownerloperator of the site_ Taking all of above into account; the Government is reviewing the basis on which engagement with stakeholders is undertaken in future to report to Ministers in early
2020. The review is complete re-examination of the Crowded Places model including whether it would be appropriate and proportionate for more to be achieved through a legislative approach. Periodic review Counter Terrorism Policing have also committed to institute a periodic review / assurance process to ensure that the locations and stakeholders identified for CTSA engagement will be regularly reviewed. The Government will provide oversight and assurance of this process_ Qther Government action since the 2017 attacks Government's efforts to provide advice to the range of individuals and organisations responsible for crowded places continues to evolve and improve_ Changes since the 2017 attacks have included: programme of sectoral and regional engagement days (branded Action Counters Terrorism: Corporate) initiated by Counter Terrorism Policing to provide advice and guidance to a range of parties responsible for crowded places; An e-learning awareness training programme (covering spotting the signs of suspicious behaviour and what to do if an attack should take place) has been broadened so that it is freely available to all;3 New and revised training and awareness products for managers, front of house and other staff at crowded places, delivered by CTSAs; and https Ilww gov uklgovernmentnewslact-awareness-elearning the

range of new advice and guidance provided by Counter Terrorism Policing and CPNI; including for certain sensitive issues to trusted stakeholders Government will continue to consider how and where our engagement approaches can be improved to ensure we deliver appropriate advice to all stakeholders using cross-Government levers. We are exploring more tailored guidance and communications to different target audiences We are also considering how the crowded places programme can better evaluate the effectiveness of our activity (in particular where and how it leads to meaningful learning or security improvement activity), and based on this, how and where we can most efficiently focus our future efforts_ Response to MC3 and MC4 (addressed together_as_they_both_concern public_authorities; their_roles and responsibilities and how_they are provided with expert advice) MC3 Addressed to the Secretary of State for the Home Department: suggest that consideration be given either (a) to introducing legislation governing the duties of public authorities (including highway authorities) regarding protective security or (b) to producing guidance indicating what existing legal duties require in practice of public authorities regarding assessment of sites for protective security needs and implementing protective security measures MC4 Addressed to the Secretary of State for the Home Department and NaCTSO: I suggest that consideration be given to producing guidance for CTSAs explaining what existing legal duties require in practice of public authorities regarding assessment of sites for protective security needs and implementing protective security measures: The Government accepts recommendation MC3. With respect to recommendation MC4, the Government is considering the scope of existing legislation and whether new legislation is required to improve the safety and security of public venues Existing legislation and current public authority actions Section 17 of the Crime and Disorder Act 1998 (as amended) requires all public authorities to exercise their functions with due regard to their likely effect on

crime and disorder; and to do all reasonably can to prevent crime and disorder_ Crime for these purposes includes terrorism: This requirement was noted by Transport for London in the Inquests as the basis upon which undertake considerations of protective security in all their schemes. The Government is aware of other public authorities which also undertake considerations of terrorism threats and their mitigation with relevant local partners through their Community Safety Partnerships (or County Strategy Partnerships in county councils) or CONTEST Boards: However; it is unlikely that all public authorities have comprehensive systems and processes in place to assess the threat from terrorism as it affects their interests, and to consider reasonable mitigation to these threats through their systems and processes The Governments role in this process is to engage and provide advice to all crowded places" stakeholders to develop an understanding of attack methodologies, threat assessment processes, the range of appropriate and proportionate protective security measures and how to plan and prepare for terrorist attacks. For those stakeholders with an interest in public spaces, such as public authorities, these differ vastly in their nature, and each has different organisational structures, staff skills and capabilities, business processes and plans, and funding cycles: It is for each responsible party to consider specific details regarding the requirements for sites, staff awareness and training, their organisation's security systems and processes, including how assess threats and mitigating measures. The_Government's actions to_improve_ engagement with crowded places stakeholders who OWn_operate or_have an interest in public spaces The Government recognises that more can be done to improve the CO- ordination and consistency of our engagement with stakeholders, including public authorities, who own, operate or have an interest in security at public spaces. With specific regard to public authorities, since the 2017 attacks efforts have been increased to improve this position including: Establishing regular engagement with Local Authority Chief Executives and others in strategic positions, in order to ascertain how considerations of threat can be undertaken and to share best practice; Developing the Security Considerations Assessment4 to provide robust; evidence-based and documented processes relating to the identification and, where applicable, development and ongoing management of security-related vulnerabilities; and https Ilw cpni gQv uklsecurity-considerations-assessment they they they key

Writing to all local planning authoritiess and revised and updated the National Planning Policy Framework and Guidance6 both of which emphasise the role the planning system plays in ensuring that appropriate security measures are in place to help mitigate terrorist threats_ The Government will continue to evaluate how and where our engagement_ advice and communications can be improved, to assist public authorities and other stakeholders to understand threats, and analyse how can better assess and effectively mitigate them through their processes Government is considering the effectiveness of the existing system by which security outcomes are realised through the exercise of their functions, and whether it would be appropriate to revise or develop new legislative requirements. Guidance to highways authorities The Department for Transport (DfT), working with the UK Roads Liaison Group and CPNI; will by the end of 2020 provide additional guidance to all local highways authorities in the United Kingdom. This will build on guidance already available to highway authorities as set out in the Well Managed Highway Infrastructure Code of Practice and other channels: The existing guidance encourages local highways authorities to adopt a security-minded approach to their assets, information and people to ensure appropriate and proportionate security measures are applied to deter andlor disrupt hostile, malicious, fraudulent and criminal behaviours or activities_ Response to MCS MC5 Addressed to the Secretary of State for the Home Department and NaCTSO: suggest that consideration be given to taking measures to make CTSAs, police forces and local authorities aware of protective security equipment infrastructure which can be installed in response to emerging threats (including the criteria and timescales for making particular forms of asset available): also suggest that consideration be given to encouraging highway authorities and other public bodies, especially in metropolitan areas, to adopt security boards similar to the PRSAB adopted in London, with a view to ensuring that there is good understanding of what measures can be taken in the short and longer term to protect sites and areas assessed to be vulnerable Shttps Jlassets publishing service gov uklgovernmentluploadslsvstemluploadslattachment_datallile/627395/Chief_Pla nner etter security_and planning pd https WWWgv Uklquidancelhealth-and-wellbeing they

Awareness of_protective security equipment infrastructure The first part of this recommendation will be addressed by CT Policing, who will give details of the training and continuous professional development provided to CTSAs and briefings provided to Counter Terrorism Security Co-ordinators and other relevant police functions on vehicle threats and the means to mitigate them: The Government's role is one of strategic oversight: This is predominantly an operational issue, and whilst we would not be sighted on the detail of measures which are the responsibility of CT Policing and other partners, we will consider more broadly, through the review of the crowded places model where working with stakeholders across Government can improve engagement and advice to responsible parties, including local authorities_ Consideration of security boards similar to the PRSAB First; it is important to consider the existing legal landscape: Section 17 of the Crime and Disorder Act 1998 (as amended) requires all public authorities in England and Wales to exercise their functions with due regard to their likely effect on crime and disorder, and to do all they reasonably can to prevent crime and disorder. Crime, for these purposes, includes terrorism: This statutealso established the Community Safety Partnerships (CSPs) for local authorities , the police and other partners to work together to tackle identified safety problems. Legislation in Scotland provides for similar local authority led planning, taking into account the resilience and safety of communities. In Northern Ireland, Policing and Community Safety Partnerships were established under the Justice Act (Northern Ireland) 2011,as local independent statutory bodies, which focus on policing and community safety issues_ Second, defining the issues to be addressed is the responsibility of each local authority. The Government is aware of a range of mechanisms through which protective security issues are addressed , including using CSPs, local CONTEST boards, and sometimes Local Resilience Forums. The Government therefore considers that there are number of local mechanisms, including statutory bodies, which are able to deliver local coordination of effort_ That is not to say that if there is a need, particularly in metropolitan authorities for an additional specific group to focus on the consideration of threats in the public realm and their mitigation, that we would not welcome such

developments: The Government considers , however; that the appropriate forum for consideration of protective security issues, ought to be decided by the relevant local authority based upon the specific requirements of its area It is important thatall local protective security forums receive appropriate advice regarding assessment processes which can be undertaken to consider terrorist threats, and what constitutes appropriate and proportionate mitigation. Expert security advice has already been provided to the types of forum mentioned above by CTSAs and CPNI; for example to advise on physical and personnel security measures or products which can be used by local authorities_ This provision of engagement and advice continues at a local level. There is also ongoing engagement by CPNI, for example, with institutions of engineering and other professionals responsible for the creation, maintenance and improvement of the public realm, providing advice through their publications and advice, and speaking at their regional lectures and conferences If groups such as the PRSAB were to become more widely established, Government would consider how it could best continue to provide specialist expert input to them as required. Recommendation MC6 tothe Secretary of State for the Home Department and the Director Genera _ for the Security Service: The Chief Coroner has made recommendation which relates to the suspension of investigations: The MIS investigation into Khuram Butt was suspended twice: from 26 February 2016 to 24 March 2016; and from 21 March 2017 to 5 May 2017. The Chief Coroner concluded in his Article 2 determination that no criticism of the decisions to suspend the investigation on those two occasions is justified. The Chief Coroner notes in his Preventing Future Deaths Report that it is possible however; but for the latter suspension, further useful intelligence about Butt could have been obtained, including more information about his links to the other attackers. The Chief Coroner has recognised that although MIS must be able to prioritise and divert resources at times of greatest demand; the suspension of priority investigations is a matter of iegitimate public concern. Accordingly, the Chief Coroner has recommended that the systems for suspending such investigations (including the criteria for suspension; recording of suspension decisions and systems for re-building intelligence after suspensions) should be specifically considered in the continuing work of review and improvement: That work should also give consideration to the potential value of flexible systems for scaling back, rather than necessarily suspending, investigative work at times of high demand.

Whilst this recommendation and MC7 , 9 and 10 are addressed to both the SSHD and the Security Service, it is the Security Service which leads on these matters and hence the responses to these recommendations reflect this. However, and for the avoidance of doubt; the SSHD agrees with and adopts the response of the Security Service to recommendations 6,7, 9 and 10 Security Service Response Although the suspension decisions in this particular case were sound, as the Chief Coroner found, the Security Service acknowledges that the suspension of priority investigations is matter of legitimate public concern. MIS has reviewed and refined its processes and the assessment of risk relating to suspension to encourage further good practice_ The Security Service has, since 2017, reviewed and revised the guidance relating to the process of suspension that is provided to its investigators and to management. That suspension process expressly includes, amongst a number of other steps, consulting with management; informing CT Police of the suspension decision, and recording the reason for suspension. Since 2017, the Security Service has also reviewed and refined the process for the assessment of the suspension risk posed by an investigation which feeds into the consideration of its suitability, or otherwise, for suspension. As Witness L explained in evidence the suspension of an investigation does not necessarily mean that intelligence gathering will cease_ Whilst typically during suspension monitoring, investigative and analytical activities will be substantially scaled back, flexibility is buiit into the suspension process to allow the investigator the choice to suspend the collection of certain types of coverage and to keep other intelligence streams active, depending on what is possible and appropriate on the facts of that particular investigation. Under the existing model, all counter-terrorism investigations are reviewed quarterly, including those which are suspended at the end of the quarter: In addition there are measures in place during a suspension to capture particular types of intelligence of a high level of concern: An investigation can then be unsuspended quickly if reported intelligence reveals a particular threat or other point of concern The Security Service has also, since 2017, revised the way in which the team with an internal overview of all suspensions tracks the overall suspension 24 page 24-35 and witness statement paragraph 124. very Day

picture to effectively manage resource. This allows that team, and senior management; a view of the spread of suspended investigations including why have been suspended, how long for; by which investigative teams and team capacity, and recognises trends or insights. It has been considered whether a system of partial suspension, or a scaled back form of investigation, should be developed as an intermediate option between suspended and open investigations. In light of the flexibility within the suspension process and open investigations, the Security Service concludes thata new category of scaled back investigation is not required at this point and would not achieve the important aim of properly diverting specialist resource to those investigations deemed to be of the highest priority at the time in order to minimise the risk from attack plans judged to be imminent or which are deemed on the information available to pose the greatest threat to the public Suspension has been an effective tool in the Security Service's investigative risk management process for many years, and is likely to remain a necessary part of maintaining an agile Counter Terrorism response to a high volume and dynamic threat environment for the foreseeable future. Recommendation MCZ to_the Secretary of State for the Home Department and the Director General for the Security Service: Khuram Butt was the subject ofa Potential Lone Actor assessment twice during the investigation into his activities. In September 2015 he was assessed to have strong intent but weak capability, and was assessed to be of medium risk In May 2017 he was tentatively assessed to have moderate capability and moderate intent and had an overall assessment of unresolved risk. The PLA assessments did not result in any downgrading of investigative work. Witness acknowledged however that PLA assessments can be imprecise and have inherent limitations_ The Chief Coroner's view is that investigators must be able to have confidence in the tool if it is to be used effectively. Accordingly, the Chief Coroner has suggested that Ml5, in its continuing work of review and improvement give consideration to some form of assurance to test the reliability of the Potential Lone Actor process: Security Service Response The Security Service accepts the Chief Coroner's recommendation that the Potential Lone Actor process should be subject to an assurance exercise to test its effectiveness and reliability, as Witness acknowledged in his evidence8 25 page 16_ 10 they Day

The Potential Lone Actor process is part of MIS's wider risk assessment framework which includes risk assessment methodologies, processes and capabilities. A review of this wider framework, which includes the Potential Lone Actor process, is currently underway within MIS. The review is supported by MIS's Behavioural Science Unit; which is a team of behavioural scientists and risk management specialists with close links with external academics, the latest academic research and international partners_ MC8 Addressed to the Secretary of State for the Home Department: suggest that consideration should be given to legislating for further offences of possessing the most serious material which glorifies or encourages terrorism_ The Government accepts this recommendation and is currently considering the necessity for a further offence of possessing the most serious extremist material which glorifies or encourages terrorism. The UK has a robust legislative framework on terrorism The Government is committed to ensuring that this keeps pace with the threat. The current legislative framework includes an ideology-neutral definition of terrorism in addition to a broad range of terrorism-specific powers and offences, including the offence of collecting information of a kind likely to be useful to a person committing or preparing an act of terrorism (s.58 Terrorism Act 2000). The Government and its law enforcement partners recently strengthened the legislation through the Counter-Terrorism and Border Security Act 2019 (CTBSA), which (i) updated offences for the digital age and modern patterns of radicalisation, (i) extended extra-territorial jurisdiction, and (ii) strengthened sentencing and offender management powers As to the S.= 58 offence , the CTBSA: amended s.58 so that it is clear that it is an offence to view or otherwise access information of a kind likely to be useful to a person committing or preparing an act of terrorism online without a reasonable excuse; and increased the maximum sentence available for those convicted under S = 58 (an increase from 10 to 15 years)_ Our operational partners must have the tools and powers require to tackle terrorism. The Government notes the Chief Coroner's comments regarding the evidence at the Inquests, the existence of the offence for person in possession of a prohibited image of a child, and the perception that the lack of 11 they

comparative counter-terrorism offence may sometimes prevent Counter Terrorism Policing from taking disruptive action_ Consideration is ongoing between the Home Office and representatives from Counter Terrorism Policing HQ as to whether there is gap in the current legislation from an operational perspective. Government is currently considering their views and deciding next steps, including further stakeholder engagement in relation to this complex issue_ The Government will continue to work closely with the police, the Security Services and other partners to ensure that the tools needed to counter the evolving terrorist threat are kept under review and up to date, whilst also ensuring that proper balance is struck between robust powers and civil liberties_ Recommendation MC9 to the Secretary of State for the Home Department and the Director General for the Security Service: The Chief Coroner acknowledged the effective cooperation between MIS and CTP . He noted, however; that on a number of occasions during his evidence Witness M accepted that he had been unaware of information in the hands of MIS, and that the Post Attack Review and ISC recognised that more can be done in promoting communication and coordination between MI5 and CTP teams on an investigation_ The Chief Coroner notes that further work is being carried out in this area; including a project leading to co-location of elements of CTP and MIS, and encourages efforts to develop and improve co-working arrangements, including sharing as much information as possible which is relevant to post-attack investigations. As such, the Chief Coroner has identified a need to improve communications and co-working between MI5 and CTP officers working on the same investigation: The ongoing work to improve joint working is to be welcomed. There is in particular a need for the police senior investigating officer in an intelligence-led investigation to be briefed regularly and thoroughly by MlS, especially if JOT meetings are not being held regularly. For the sake of completeness; efforts to improve communications between MI5 and CTP should extend to communications between MIS and post-attack investigation teams: Security Service Response The Security Service recognises that continuing to develop joint working is an important priority and that there is scope for further improvement to the excellent working relationship between MI5 and CT Policing: 12

The Security Service and CT Policing have a strong track record of working and communicating together to counter the threat from terrorism in the UK, allowing them to disrupt together 25 terrorist attacks since March 2017. This is thanks in part to the considerable progress made over the past ten years with, in particular; the introduction and refinement of the Intelligence Handling Model, and further developments in how operate together and how review themselves jointly. Since 2017 detailed consideration has been given during the course of the Operational Improvement Review (OIR) to the nature and extent of joint working arrangements between the Security Service and CT Policing focusing as Lord Anderson recognised, on operational issues. That review highlighted the strength of the relationship, and made a number of specific and technical recommendations for its improvement; By way of example, the Security Service (alongside SIS and GCHQ) and CT Policing are committed, through the "CT Up" programme to sharing their knowledge to enable single , common understanding of SOls, and of capabilities and objectives. Further; the OIR also prompted a review of information sharing arrangements, with particular regard to sharing information relating to SOls. world-leading and unprecedented project is underway to significantly increase the colocation of CTP and Security Service teams. This major multi- year project seeks to strengthen the working relationship between CTP and the Security Service and facilitate further collaboration. CT Policing and the Security Service also continue to work together to build IT structures that facilitate more collaborative ways of working: When considering information sharing between them, it must be appreciated that CT Policing and the Security Service each have distinct roles, expertise and strengths within Counter Terrorism investigations As Witness L explained in his evidence, there must always be as much sharing as possible of information between MIS and CTP (which applies equally to post-attack investigation teams) 9 There must; however; always be threshold applied by an investigator andlor management as to what is deemed to be of significance to the investigation such that it needs to be shared with the Senior Investigating Officer (SIO): That threshold will be dependent on the particular facts and context of the investigation. Because of the amount of information at the hands of the investigator it will often not be a practical or proper use of the SIOs time for MI5 to share every piece of information with that officer: To do so would risk significant duplication in the role of the investigator and the SIO, creating Day 25 page 84. 13 they they the Step

substantial inefficiencies in a system where the appropriate use of finite expert resource is essential. Recommendation MC1O to the Secretary of State _ for the Home Department and the Director General for_the Security Service: Two communications were made by members of the public to report concerns about Khuram Butt to the authorities. One was made anonymously to MIS before Butt became an SOl, and the other by a call from Usman Darr to CT Policing's Anti-Terror Hotline in September 2015. Neither made their way to the MI5 or CTP investigative teams (when formed) looking into Butt's activities. The Chief Coroner recognised that there was no opportunity for MIS to follow up the communication made to them, since the report was made anonymously and included an express desire not to be contacted in future: Further; the Chief Coroner acknowledged that it is debatable how much more intelligence could have been obtained from Usman even if he had been willing to co-operate at a later stage. Nevertheless, the Chief Coroner has recommended, because of the concern that public reporting was not directed to the relevant CT Policing and MI5 investigative teams, that in the continuing work to improve information management; efforts should be made to avoid recurrence of this problem. Security Service Response As Witness L explained in evidence10 , the report relating to Khuram Butt from an anonymous member of the public was received before mid-2015, before the investigation into Butt's activities was opened, and before he was a Subject of Interest The report was to the effect that Butt was an extremist; and was made by an individual who was clear that they did not wish to be contacted further: The content of the report did not reach the threshold requiring it to be made Lead, and thus requiring investigation by Ml5 and CTP.11 Further; there was no MI5 or CTP investigation into Butt's activities in existence at the time to which the report should or could have been directed, nor would it have added new information to what was known of Butt when the investigation was opened. MIS defers to CT Policing in relation to reporting received by the police run Anti- Terror Hotline, but notes as the Chief Coroner recognises, that it is debatable 24, pp.86-87 See Witness L witness statement paragraph 27 and footnote. 14 Darr Day

the extent to which more intelligence would have been obtained from Mr Darr had his reporting been passed on to the relevant CTP and MIS teams_ Notwithstanding the above, the Security Service would wish to assure the Chief Coroner that the issue of information management is recognised as being of the utmost importance to its work and has been extensively and robustly addressed by MI5 in the form of the Operational Improvement Review (as to which Lord Anderson noted that there had been detailed recommendations made relating to improvement of systems, guidance and practices). Many of those recommendations have been implemented, constituting significant development in MIS's information management capability, and work is ongoing to further continuous improvement in this area_ Recommendation MC1Ltothe Chiefofthe Secret Intelligence Serviceand the Director-Generalof the Security Service Recommendation MC11 - Addressed to the Chief of the Secret Intelligence Service and the Director- General of the Security Service: suggest that consideration be given to improving facilities for translating communications received from foreign security and intelligence services, since the evidence in this case reveals a troubling delay in the translation of such a communication: SlSISecurity Service Response SIS and the Security Service accept that there is a need for improvement in this area. A number of improvements have made in this respect since June 2017 . Since the London Bridge attack, the UK Intelligence Community (UKIC) has enhanced its secure messaging capability with Counter Terrorist Group partners in relation to counter-terrorism investigations. There is also stronger cooperation on language capability across UKIC. In addition, SIS has formed team of linguists dedicated to supporting counter-terrorism work working alongside operational officers and simplified processes for tasking them. SIS has updated its guidance, in consultation with MIS , relating to the appropriate and timely dissemination of information or requests from foreign liaisons, providing a clear set of handling guidelines concerning responsibilities towards data and issuing tactical reporting SIS also continues to upskill overseas officers with language capability: MC12 Addressed to the Secretary of State for the Home Department; the Secretary of State for Transport and the BVRLA: suggest that 15 been

consideration is given to taking further measures to reduce the risk of rental vehicles being used in terrorist attacks. The measures should include (a) introducing a scheme for real-time reporting of rentals and automated checking of the results against lists of SOls and (b) making the current RVSS scheme mandatory: Measures being taken to_reduce the risk of rentalvehicles being used in terrorist attacks The RVSS Scheme: Working with BVRLA to increase RVSS membership The Government agrees consideration should be given to what further measures could be in place to reduce the risk of rental vehicles being used in terrorist attacks_ To this end, the Department for Transport (DfT) continues to work with industry to increase the take up and impact of the Rental Vehicle Security Scheme (RVSS): From 1 January the British Rental Vehicle and Leasing Association (BVRLA) has introduced the RVSS criteria as requirement within its own conditions of membership12. BVRLA will also include compliance with the terms of RVSS within its audit regime_ In addition, DfT has been working with the United Rental Scheme (a vehicle rental network that reaches some of the companies that are not BVRLA members) to promote RVSS with its members at roadshows and through newsletters and on-line communications. This has led to new members joining the scheme. DfT will continue to use this approach to increase RVSS membership_ DfT has also set up an industry-led Advisory Panel, bringing together industry leaders and cross-government and law enforcement representatives to develop the requirements in the RVSS code and explore how the code could be adapted to make it relevant for other parts of the vehicle rental sector such as peer-to- peer rental and car clubs. This work is achieving positive results without regulation and we will continue to push these approaches. We will keep the coverage and impact of RVSS under review and if steps with industry bodies do not result in the vast majority of UK based rental companies joining RVSS, we will consider legislating to The DfT entered into an agreement to this effect with the BVRLA on 5 November 2019 16 put

make mandatory some or all of the elements ofthe Scheme: A progress review is planned for summer 2020. Real time reporting The recommendation on data and real time reporting of rental vehicles is addressed, inter alia, to the Home Office and the DfT . However; the Home Office and DfT work in close collaboration on these issues with the Police and the Security Service. Hence this response is on behalf of the Home Office, DfT , Counter Terrorism Policing and Security Service_ Any scheme for real-time reporting of rentals and checking against SOI databases would need to be driven by a law enforcement requirement and any case for intervention would rest upon this. As the witness for the Home Office noted in evidence during the Inquests 13 there are a myriad of different ways of obtaining vehicle (including stealing, borrowing and purchasing as well as renting). Further; as Witness L explained in evidence at the Inquests14, there are considerable challenges surrounding the introduction of processes of this kind, The Government continues to work with law enforcement agencies and the Security Service to understand how we can support their objectives_ Requirements would first be discussed with the Home Office_ which would coordinate considerations, engaging with other Government Departments as appropriate. Other measures More broadly, DfT is also leading a wider programme of work to develop vehicle focussed initiatives to mitigate the threat from 'vehicle as weapon' attacks. This includes: commissioning research and working with industry partners to identify existing technologies that can provide mitigations in 'vehicle as weapon' attacks. One project is looking into the feasibility of range of vehicle technologies that could be developed to promote earlier crowd dispersal during a vehicle as a weapon attack: These insights be shared with the rental sector in future, to inform their fleet choices. Response to MC13-MC18 Day 31, 21 June 2019, pp217-220 Day 25. 13 June 2019, pp 124-125 17 the will

Recommendations MC13 to MC18 are not specifically directed to Government but are addressed variously to the London Ambulance Service, the City of London Police and the Metropolitan Police Service_ However, these recommendations do relate to the Prepare strand of the CONTEST strategy for which OSCT (within the Home Office) has national responsibility. We provide some comments below from Government regarding these recommendations as appropriate_ The recommendations which are directed at the emergency services are specifically directed to the London emergency services. We address them below on behalf of Government as we consider it important that a national perspective be included in the response from each service as well as, where appropriate, a Government perspective Emergency response to terrorist attacks MC13 Addressed to the LAS, MPS and CoLP: The evidence in these Inquests rise to concerns that procedures for emergency response to marauding terrorist attacks were inflexible. In particular, the evidence suggested that large areas could be designated hot and warm zones for long periods and formally placed out of bounds to most ambulance and paramedic staff: This feature of the procedures gave rise to a risk of delay in getting medical help to casualties. While this lack %f flexibility has apparently been addressed in the revised Joint Operating Principles, suggest that procedures generally be reviewed to ensure that they accord with the requirements of speed and flexibility of response which appear to be recognised in that document also suggest that training exercises be devised which address demanding situations with features such as (a) hot and warm zones of uncertain extent; (b) a need for re-assessment of hot and warm zones; and (c) a need to locate and assist casualties in dangerous areas. As indicated in MC13, changes have been made to the multi-agency Joint Operating Principles (JOPS') since the Manchester attack These changes draw on learning from the 2017 attacks in Manchester and London, as well as wider exercising and learning, and place greater emphasis on the importance of flexibility and on the use of the Joint Emergency Service Interoperability Principles (JESIP'): JOPS is now in its fifth edition, reflecting a continuous process of reviewing procedures and preparedness. There is already considerable training and exercising on the response to range of terrorist attack types across the country within all three emergency services_ The Government agrees that it is important to ensure that the JOPs are being exercised and applied locally: 18 gave

MC14 Addressed to LAS: The evidence in these Inquests highlighted the importance of identifying the location of casualties at an early stage in a marauding terrorist attack: suggest that LAS review its guidance documents and training exercises to ensure that they stress this point and indicate practical means of locating casualties (e.g: from information in emergency call records): The Government considers that this recommendation applies to organisations beyond the ambulance service. While medical responders would normally take the lead on medical aspects of the response, in the early stages of an attack information about the location of casualties is provided and received by number of organisations (e.g: by phone or from responders at the scene). While there may be improvements individual emergency services may wish to make in terms of technical matters, it is the Government's view that this issue should be sufficiently addressed by the emphasis in the JOPs and related doctrine of the importance of effective multi-agency communication. However; as chair of the cross-Government and Emergency Service Joint Operational Working Group, the Government will consider this element as part of its continuous review of doctrine. MC15 Addressed to the MPS and CoLP: suggest that the emergency services give serious consideration to enhancing first aid capabilities and equipment of either police officers generally or groups of officers (e.g: firearms officers or officers designated for advanced medical aid training). This should include consideration of training some officers in advanced life-saving procedures analogous to battlefield medicine. It should also include considering (a) wider provision of equipment such as tourniquets and the bleed" kits and (b) the inclusion of more spare equipment in officers' vehicles. Armed police already have first aid training appropriate to their role, however we refer to the police response for detail on this issue_ MC16 Addressed to the MPS and CoLP: The evidence in the Inquests raised a concern that there will often be communications difficulties in the early stages of a major incident; including difficulties resulting from multiple officers attempting to make urgent radio transmissions at the same time. In the ongoing work of reviewing and improving communications technology to address these difficulties, consideration 19 "stop

should be given to whether it may be possible for control room staff to isolate and record messages so that they can be listened to separately: This is a technical issue for the police and will be considered by them; in collaboration with the Emergency Services Network programme_ MC17 Addressed to the LAS, MPS and CoLP: suggest that consideration be given to introducing improving technical measures to assist in identifying the exact locations of emergency services personnel so that can be communicated reliably to other first responders. The Government understands that considerable work has been undertaken in relation to this issue within the emergency services, and that there is some capability for asset tracking within the emergency services. However; this is largely single service in approach and there is currently no clear technical solution. The National Police Chiefs' Council is leading work in this area on behalf of the police. MC18 Addressed to the MPS and LAS: The evidence at the Inquests indicated that life-saving efforts of the emergency services, especially in major incidents, are improved by better communications between them: Given the challenges of communications in the early stages of incidents _ suggest that consideration be given (including through the Blue Light Collaboration Programme) to the possibility of having a small number of LAS and London Fire Brigade staff stationed in the MPS control room at all times. The JOPs emphasise the importance of an early three-way communication link between the emergency services and sustained effective communications throughout an incident: The JOPs do not prescribe where or_how this should occur_ to preserve the principle of flexibility that is required: The principles of coordination and co-location are also emphasised in the JOPs. The emergency services will respond on the practicality of the specific recommendation. 20 they

IN THE CENTRAL CRIMINAL COURT INQUESTS ARISING FROM THE DEATHS IN THE LONDON BRIDGE AND BOROUGH MARKET ATTACKS OF 3rd JUNE 2017

______________________________________________________ WRITTEN RESPONSE ON BEHALF OF THE METROPOLITAN POLICE SERVICE REGULATION 28 ______________________________________________________

1. This is the response submitted on behalf of the Commissioner of Police for the Metropolis (MPS) to the Chief Coroner’s Report to Prevent Future Deaths (RPFD) following the inquests into the terrorist attacks on London Bridge and at Borough Market.

2. On behalf of the Commissioner may I once again express our deepest sympathies to those who were murdered and injured in these terrible attacks. The police work tirelessly to prevent all terrorist attacks and it is a source of profound regret when we are unable to do so. We are determined to do everything possible to protect the public in future.

3. This document provides the response both on behalf of the MPS and National Counter Terror Policing which includes the National Counter Terrorism Security Office (NaCTSO).

4. NaCTSO is a police unit that sits under the National Counter Terrorism Police Headquarters and reports to the National Coordinator for Protect and Prepare. NaCTSO is responsible for producing guidance and training materials for protective security in crowded places. NaCTSO also trains, licences and coordinates the CTSA network, NaCTSO falls under the Protect and Prepare strands of CONTEST.

MC1 – Addressed to the Secretary of State for the Home Department and NaCTSO: I suggest that there be a review of the sensitive national criteria and tests for identifying sites as priority Crowded Places (or for otherwise designating sites at a national level as justifying proactive advice on protective security). In that review, one aim should be to ensure that the criteria are not excessively rigid so as to exclude sites which may be particularly attractive and vulnerable to terrorists. If and to the extent that the Secretary of State considers that any other Government agencies should play a part in addressing this concern, their assistance should be enlisted.

MC2 – Addressed to the Secretary of State for the Home Department and NaCTSO: I suggest that consideration be given to putting in place systems of periodic review /

assurance to ensure that the criteria for identifying priority sites for protective security advice remain fit for purpose and that the list of such sites remains appropriate

5. Due to the close alignment of these recommendations, NaCTSO is responding to both collectively.

6. As it is not possible to deliver bespoke advice to every crowded place, access to guidance works on a process of scaled options and differing delivery mechanisms. It is important to note that CT security measures for crowded places do not only begin when a site is identified as a “priority site”. A huge amount of work has been and is being done across the sector. Free security advice is available to everyone as envisaged by the Lord West report. This is delivered in particular by NACTSO and the Centre for the Protection of National Infrastructure (CPNI).

7. Protective security guidance and training operates on three broad levels; the first two levels provide access to information for sectors and individuals, whilst the third layer comprises bespoke CTSA engagement with specific sites (the priority crowded places identified by the Chief Coroner in MC1). These three levels are each addressed in turn below.

8. In terms of protective security advice available to all, the NaCTSO website provides access to an array of protective security advice, including the Crowded Places Guidance which can be accessed openly and without charge. It also includes a gateway to “ACT (Action Counters Terrorism) e-learning UK” which is specifically designed to provide information to those without direct access to a CTSA. ACT e-learning was initially launched for private sector organisations to use, and was free from the point of registration. From December 2019, the e-learning has been made freely accessible to anyone, removing the registration requirement. Currently nearly 2 million modules have been completed across the UK.

9. NaCTSO also provides communications and briefings for business and others with responsibilities or interest in this area. This includes regular protective security communications delivered under the brand “UK Protect” and disseminated through the Cross Sector Security Communications (CSSC) network to any business who has signed up. It also includes regular updates and specific messages at times of increased risk. Between January 2017 and December 2019, 110 messages were disseminated to the network.

10. Other measures include engagement with representatives of leading crowded places sectors (for example shopping centres, hotels, visitor attractions) through the Crowded Places Information Exchange. This is supported through ACT Corporate events where CT advice and guidance is delivered by experts directly into sector groups on both a national and regional basis.

11. Providing bespoke, site specific CT advice is the primary focus of the national Counter Terrorism Security Advisor (CTSA) network which is overseen by NaCTSO. CTSAs work under a framework to provide advice on protective security measures that could be taken to improve security at a specific site. CTSA delivery is predicated on identifying which sites are considered to be most at risk of attack. In the absence of

specific protective security legislation (covered in more detail in MC3 and MC4), these measures are implemented at the discretion of the owner subject to other non-CT legal obligations as imposed by for example the Crime and Disorder Act 1997 or the Health and Safety at Work etc Act 1974. Sites are selected through a process of prioritisation.

12. The 2017 attacks have brought into focus consideration of which locations receive which level of advice. NaCTSO recognises that this is a complex area and not an exact science. The terrorist threat continues to evolve and is increasingly multi-layered, covering not just the iconic location targeting preferred by Al Qaeda and the IRA but new threats from extreme right wing terrorism and Daesh which promotes the concept that anything is a target and anything a weapon. It is not possible (in terms of CTSA network reach) or desirable (in terms of creating so called “barrier Britain”) to offer every location in the UK the same level of protective security advice or protection and therefore there must be a system of prioritisation and flexibility to ensure the advice provided is appropriate and proportionate to the intelligence and threat assessment.

13. Any system of prioritisation will require an assessment criteria which will result in risk based inclusion and exclusion. NaCTSO accepts that flexibility in this approach is very important and as such has been working closely with the government to review the crowded places policy and delivery model.

14. To address this challenge NaCTSO is seeking to expand both the advice and training we provide and how that advice is delivered. Since 2017 NaCTSO has worked hard to expand the range of products available and sought to adapt these to multiple audiences. The strategic approach is to reach as many people as possible with protective security advice. As outlined above, this ranges from CT awareness suitable for all members of the public, to detailed bespoke security advice appropriate for large corporations with professional security expertise. We will continue to grow and develop the advice and accessibility of these measures.

15. NaCTSO also recognises the need to develop a review process and for greater flexibility within the prioritisation model. The 2014 Crowded Places Model allows a degree of flexibility, such as for example the ability to add additional sites at a local level or to place a location into a maintenance phase once all desirable protective security solutions have been achieved. NaCTSO agrees with the recommendation to review the model to ensure the overall system, and prioritisation process addresses the threat from terrorism. The full details of this process are under consideration with Government and we refer the Chief Coroner to HMG’s response on this point.

16. Finally, it is important to recognise the limits of protective security. Protective security solutions provide the ability to deter, detect or delay a terrorist attack, but they cannot alone prevent every attack. We cannot protect everyone all of the time. Target hardening one area can deflect an attack into another as was seen in Halle, Germany in October 2019, when the attacker was unable to access his initial target, a synagogue, but then proceeded to attack people on the streets nearby. Protective security measures reduce rather than negate impact.

MC3 – Addressed to the Secretary of State for the Home Department: I suggest that consideration be given either (a) to introducing legislation governing the duties of public authorities (including highway authorities) regarding protective

security or (b) to producing guidance indicating what existing legal duties require in practice of public authorities regarding assessment of sites for protective security needs and implementing protective security measures.

MC4 – Addressed to the Secretary of State for the Home Department and NaCTSO: I suggest that consideration be given to producing guidance for CTSAs explaining what existing legal duties require in practice of public authorities regarding assessment of sites for protective security needs and implementing protective security measures.

17. MC3 rests with the Secretary of State for the Home Department, but leads into MC4, so has been included for completeness.

18. The Chief Coroner notes the provisions of the Crime and Disorder Act 1997 which require public authorities to exercise their various functions with due regard to the likely effect of the exercise of those functions on, and the need to do all that it reasonably can to prevent (inter alia) crime and disorder in its area. This has been interpreted by some authorities (including TfL) as including terrorism. The Chief Coroner has noted that there is reason to believe this interpretation is not uniform across the UK.

19. Counter Terrorism Policing has for some time supported the introduction of legislation to govern protective security standards. Moving from the current approach which is predicated upon persuading the owners and operators of crowded places to consider and implement protective security (including public bodies to which MC3 and MC4 are addressed), to one where this is mandatory would be game-changing and we believe is the most effective means to deliver protective security consistently across the country. Any legislation should reflect the key principles of our current approach of appropriateness and proportionality.

20. As outlined in MC3, there is an absence of specific protective security legislation. There is also an absence of case law or guidance in this area. Consequently, provision of clear, definitive guidance for the CTSA network is challenging. Ultimately we can provide as much CT advice as we want but absent a clear legal duty, implementation of that advice is optional. NaCTSO is currently reviewing the various legal provisions which might impose a duty in the public and private sector, but we can only provide (further) advice to the CTSA network internally. Providing legal advice directly to public authorities or others would fall outside the scope of our role. In the event that legal advice received by NaCTSO yields further useful guidance to CTSAs and others then this will be provided as soon as possible and certainly in 2020, however, given the uncertainty as to the nature and extent of such a legal duty there is at present likely to be very limited if any guidance which NaCTSO can usefully provide.

21. As set out above, NaCTSO would welcome the provision of clear guidance from relevant Government departments as to the applicability of existing legalisation.

MC5 – Addressed to the Secretary of State for the Home Department and NaCTSO: I suggest that consideration be given to taking measures to make CTSAs, police forces and local authorities aware of protective security equipment / infrastructure which can be installed in response to emerging threats (including

the criteria and timescales for making particular forms of asset available). I also suggest that consideration be given to encouraging highway authorities and other public bodies, especially in metropolitan areas, to adopt security boards similar to the PRSAB adopted in London, with a view to ensuring that there is good understanding of what measures can be taken in the short and longer term to protect sites and areas assessed to be vulnerable.

22. MC5 poses two recommendations. The majority of the first section sits with NaCTSO. With regards to the second section and the adoption of security boards, NaCTSO is likely to have a role but would not be the lead agency responsible. As such this sits outside the scope of this response and is better addressed by the government.

23. The CTSA network undertakes a comprehensive training programme which takes a minimum of two years to complete. This course is accredited to City and Guilds level and courses are delivered by both NaCTSO and CPNI trainers. All CTSAs must attain this standard and are supported and mentored until this is achieved. Some CTSAs also opt to continue to a further graduate level qualification. Both courses cover the security mitigations that are available in protective security. The course content is regularly updated and those undertaking that task will be fully briefed on all relevant matters including the Chief Coroner’s report.

24. Advances in technology and capabilities present a need to ensure continued professional development of the network. This is achieved through a number of different channels. All CTSAs must attend an annual training event which provides a forum to deliver the latest innovations and share best practice. Additionally, NaCTSO operates a tasking process whereby any changes and developments are sent out to the CT network through the Protect & Prepare leads who also ensure that the network is aware of any relevant new publications by CPNI.

25. Hostile Vehicle Mitigation (HVM) and the National Barrier Asset (NBA) represent an evolving capability that is managed centrally within NaCTSO by the National Vehicle Threat Mitigation Unit (NVTMU). All CTSAs and officers working in CT policing are briefed on HMV and NBA capability. As set out above this is covered by inputs at the CTSA annual training event and as part of the formal CTSA training.

26. Additionally, a brief is distributed to all CTSAs, CT SecCo Leads (who support temporary events), and the Protect and Prepare network covering relevant changes in capability and procedure in relation to HVM.

27. Further, the NVTMU has recently presented directly to Protect and Prepare leads, the National CT SecCo board and nine of the eleven CTSA regions. The remaining two regions will receive presentations in early 2020. The subject matter of these presentations includes the types of asset available, information on the new, modular HVM, VAW attack methodology and VAW tactics. We will deliver updates and advice on other evolving capabilities in a similar manner.

28. We are therefore confident that the matters raised in MC05 are already in hand.

MC10: Addressed to the Secretary of State for the Home Department and the Director-General of the Security Service: The evidence in this case gave cause for concern that calls made by members of the public reporting on a significant SOI were not being communicated to MI5 and CTP officers working on the relevant investigation(s). In the continuing work to improve information management, efforts should be made to avoid recurrence of this problem.

29. Whilst MC10 is not addressed to the MPS, it raises concerns about calls from the public not being passed on to MI5 and CTP officers working on the relevant investigation. At paragraph 45 of the MPS submission dated 06.09.19, the following response was provided:

A learning point in relation to the call handling was identified by Lord Anderson and this has been implemented. Intelligence handling systems have been reviewed, and new processes are in place to ensure intelligence is recorded and disseminated appropriately. ATH technology has been upgraded including an automated answering system and messaging facility. SO15 has placed an extra level of supervision into the process of intelligence handling from the hotline which will ensure that in the event that a human and supervision error occurs again this will be picked up by the extra supervisory check and the intelligence will then be passed on to the appropriate team

30. In addition to the matters set out above, there have been other improvements in intelligence handling which are relevant to the matters the Chief Coroner raises in relation to MC10.

31. Since April 2019, SO15 intelligence has been governed by the National Standards of Intelligence Management (NSIM). Relevant data once received, will now be placed on a National CT database. Where intelligence is matched to the subject of an ongoing CT investigation, it will now be placed directly into that operational intelligence unit and flagged for assessment.

32. All staff working in intelligence assessment have completed NSIM assessor training which provides guidance on trace checks and development of intelligence. If for whatever reason (such as a missing “selector”) analysed intelligence is not matched with a subject in a CT investigation then sophisticated systems are in place for the matter to be escalated. Due to sensitivities involved in relation to this form of intelligence handling, it would be inappropriate to include further details within this document.

MC13 – Addressed to the LAS, MPS and CoLP: The evidence in these Inquests gave rise to concerns that procedures for emergency response to marauding terrorist attacks were inflexible. In particular, the evidence suggested that large areas could be designated hot and warm zones for long periods and formally placed out of bounds to most ambulance and paramedic staff. This feature of the procedures gave rise to a risk of delay in getting medical help to casualties. While this lack of flexibility has apparently been addressed in the revised Joint Operating Principles, I suggest that procedures generally be reviewed to ensure that they accord with the requirements of speed and flexibility of response which

appear to be recognised in that document. I also suggest that training exercises be devised which address demanding situations with features such as (a) hot and warm zones of uncertain extent; (b) a need for re-assessment of hot and warm zones; and (c) a need to locate and assist casualties in dangerous areas.

33. As recognised within MC13, changes were made to the MTA Joint Operating Procedures (JOPs) following the 2017 attacks. The changes reflected the broader range of attack methodology experienced and the applicability of the guidance to a wider range of circumstances than the previous Marauding Terrorist Firearms Attack (MTFA) guidance, which it replaced.

34. The revised MTA JOPs place greater emphasis on flexibility in applying the hot, warm and cold zones and in deploying non-specialist responders from all three emergency services within the zones where appropriate.

35. Operational Plato national guidance was also reviewed and is fully reflective of these changes. The new Plato guidance recognises that unarmed responders will play a vital role in the initial stages of the response and that this may include activity within each of the three zones. There is no rigid or inflexible approach taken.

36. CTPHQ staff have undertaken a national programme of assurance visits to all police forces (including the MPS and CoLP) to ensure that the new MTA JOPs and Operation Plato guidance have been fully embedded within local policies, procedures and practices.

37. The MTA JOPs and Operation Plato guidance are regularly reviewed, drawing on learning from major incidents and exercises. This is an ongoing process. The current edition of the MTA JOPs is the fifth edition to be produced, reflecting a continuous process of reviewing procedures and preparedness. We are satisfied that there is no learning from the 2017 attacks which requires further changes to the current edition of the MTA JOPs and Operation Plato guidance.

38. There has been, and continues to be, a significant amount of training and exercising conducted across the country on the response to a MTA. Individual police forces are regularly conducting joint MTA training and exercising with their local emergency service partners. CTPHQ agrees that it is important to ensure that this continues and regularly reminds forces of the importance of this. The matters the Chief Coroner raises at MC13 are reflected in this work.

39. In terms of the MPS; training, testing and exercising is a key focus of the MPS ‘prepare’ strand of CONTEST. The MPS carries out a wide range of CT testing and exercising. As the Chief Coroner would expect these are very significantly above the levels required of policing bodies by CTPHQ and OSCT. These tests and exercises frequently involve multiple agency participation and since 2017, learning from the attacks of that year has been incorporated.

40. Establishing, reviewing and operating within warm and hot zones under the “new” JOPs is a key feature of both the “live play” and “table top” exercises undertaken by both commanders and emergency responders.

41. The emergency services within London have made a significant investment to MTA training and exercising over recent years and are recognised by CTPHQ as being a model of good practice in terms of the quality, complexity and frequency of their MTA exercising programme.

42. We are therefore confident that the important matters raised in MC13 have already been addressed by existing policy and training.

MC15: Addressed to the MPS and CoLP: I suggest that the emergency services give serious consideration to enhancing first aid capabilities and equipment of either police officers generally or groups of officers (e.g. firearms officers or officers designated for advanced medical aid training). This should include consideration of training some officers in advanced life-saving procedures analogous to battlefield medicine. It should also include considering (a) wider provision of equipment such as tourniquets and “stop the bleed” kits and (b) the inclusion of more spare equipment in officers’ vehicles.

43. In the MPS all officers up to the rank of Chief Inspector have to complete standard emergency lifesaving training once a year. The training includes (but is not limited to) inputs on the use of tourniquets, defibrillators, compression bandages, dealing with cuts and lacerations, knife wounds and other penetrating trauma.

44. All armed response vehicle (ARV) officers are mandated to undertake ‘standard’ firearms officer first aid training set to national standards. The National Police Firearms Training Curriculum (NPFTC) provides a list of learning outcomes that must be achieved, and the training must be provided within the context of an armed incident or operation to prepare officers for operational circumstances. Due to the specialist nature of the training the medical content is not detailed within the NPFTC. Each force is required to train officers to meet the identified NPFTC outcomes using material approved by the medical profession and with appropriate clinical governance. This ensures that the training and first aid provision given by armed officers is current and based on medical advice. In addition to a number of general first aid interventions, such as dealing with broken bones, convulsions, spinal injury and choking, officers are also required to ‘Identify ballistic injuries – primary, secondary and tertiary injuries, cavitation, exit and entry wounds and blunt trauma’.

45. In addition to this ‘standard’ level of first aid training provided to all ARV officers, individual forces may choose (based upon a local assessment of strategic threat and risk) to train some (or all) of their ARV officers to an ‘enhanced’ level. In addition to the ‘standard’ training, the ‘enhanced’ level provides the ability to undertake interventions such as; haemostatic dressings, airway management and oxygen therapy, stroke, abdominal wounds and anaphylactic reaction.

46. In the MPS once standard training has been completed, AFOs are required to undergo continuation training every five weeks (ARV officers) or six months (all AFOs). During this training officers will deal with a medical situation using these skills and associated equipment whilst under fire or in a simulated life threatening situation. This is akin to “battlefield medicine”.

47. The MPS also undertakes regular MTA tri-service exercises which includes participation by the London Helicopter Emergency Medical Service (HEMS). AFOs (and others) will in these exercises carry out realistic battlefield triage whilst commanders will receive tactical medical advice to test and improve their response.

48. The most highly trained AFOs are Counter Terrorism Specialist Firearms Officers (CTSFOs). These officers receive an even higher level of medical training which includes the use of oxygen cylinders and casualty extraction. These officers spend a week with HEMS doctors in A&E.

49. Some of the most advanced AFO medics will also attend training events in Hungary every six months for advanced field medicine training where they learn procedures including needle thoracostomy. These officers then use that expertise in exercises and testing and to assist in the development of training in this area.

50. It is a nationally mandated requirement that all ARVs carry a suitably equipped first aid kit commensurate with the level of training of the officers crewing the vehicle. In August 2018 advice was provided to forces that consideration should be given to ensuring that all ARV officers have immediate access to tourniquets and haemostatic wound packing products. The Chief Coroner will recall the evidence from Dr Wrigley that tourniquets are being “rolled out” for use by police officers across London.

51. It should be noted that the primary role of armed police officers during a MTA will be to identify, locate and confront subjects in order to neutralise the threat. The provision of first aid may be a secondary role for armed officers once the threat has been neutralised, or where there is sufficient armed capacity to enable some armed officers to support other lifesaving activity. It is important that this role is not confused with that of the ambulance service.

52. The MTA JOPs make clear that the ambulance service retains the lead responsibility for casualty management. The ambulance on scene commander will direct and coordinate the casualty management process, including joint working with non- ambulance emergency responders to deliver life saving care. It is recognised that responders from the three services have received different levels of first aid training and will be tasked appropriately.

MC16: Addressed to the MPS and CoLP: The evidence in the Inquests raised a concern that there will often be communications difficulties in the early stages of a major incident, including difficulties resulting from multiple officers attempting to make urgent radio transmissions at the same time. In the ongoing work of reviewing and improving communications technology to address these difficulties, consideration should be given to whether it may be possible for control room staff to isolate and record messages so that they can be listened to separately.

53. This is a technical issue and one that should be considered by the NPCC Operational Communications in Policing (OCiP) portfolio as part of the Emergency Services Network Programme (ESNP).

MC17: Addressed to the LAS, MPS and CoLP: I suggest that consideration be given to introducing / improving technical measures to assist in identifying the

exact locations of emergency services personnel so that they can be communicated reliably to other first responders.

54. Police forces currently have the ability, within control rooms, to track the location of their own assets via their Airwave communication and command and control systems.

55. Work is currently underway, led by Chief Constable Simon Chesterman on behalf of NPCC, to enable all police force control rooms to have visibility of armed officers who arrive into their force area to provide operational support. However this is a complex technical area and the identification of a viable and affordable solution is challenging.

56. At this stage, owing to the technical limitations, it is not possible for all three emergency services to have full visibility in their control rooms of other emergency service assets.

MC18: Addressed to the MPS and LAS: The evidence at the Inquests indicated that life-saving efforts of the emergency services, especially in major incidents, are improved by better communications between them. Given the challenges of communications in the early stages of incidents, I suggest that consideration be given (including through the Blue Light Collaboration Programme) to the possibility of having a small number of LAS and London Fire Brigade staff stationed in the MPS control room at all times.

57. The ‘core’ Joint Emergency Services Interoperability Principles (JESIP), the MTA JOPs and the Operation Plato national guidance all stress the importance of effective communication, sharing of information and joint working between the three emergency services. These documents identify the critical importance of establishing an initial ‘tri- service’ communication link between the control rooms, subsequent co-location of on- scene commanders and the establishment of combined tactical and strategic coordinating groups as soon as practicable during a MTA. This was the case during the London Bridge attacks.

58. The permanent embedding of (a small number of) representatives from the fire and ambulance services in police control rooms has been carefully considered but is not currently thought to present sufficient operational benefits. The critical requirement is to effectively link the relevant command points at all levels and during all phases of the response. During the control room based initial coordination of the response, it is critical that the activity being undertaken by the three emergency service control rooms is coordinated and information is shared effectively. This is delivered by the immediate opening of a conference call between the control rooms of the MPS, LFB, LAS, CoLP and BTP to share critical information and the dispatch of LFB and LAS officers to the MPS control room as soon as an Operation Plato declaration is made. However the co- location of appropriately qualified commanders from all three services, under the tactical and strategic coordinating group arrangements should continue to be a priority activity.

59. As the Chief Coroner notes these matters have been discussed between the emergency services under the auspices of the London Resilience structures. This includes a joint control room group which reviews inter-operability performance at major incidents and a “Blue lights Panel” which considers broader joint working arrangements at major incidents and last sat on 10.12.19.

60. Despite the above the MPS continues to seriously consider these matters to see whether there might be opportunity to improve communication between the emergency services. Work is underway to trial a “London Emergency Services Contact Centre”. This will involve representatives from the LFB and LAS being deployed within the Specialist Operations Room. A table top exercise will be conducted with real CADs to finalise working practices followed by a real life 7 day trial early in 2020.

61. The police will learn wherever possible from tragedies such as these evil terror attacks. We will never stop working to protect London and the UK from terrorism.

Assistant Commissioner Neil Basu