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Coroner’s reportPrevention of future deaths · 2021-0362

“raised below”

Dated 3 Nov 2021, from the coroner for City of London. Sent to 10 organisations or people.

A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.

Read the full report on judiciary.uk

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The 56-day response deadline

Deadline passed

Replies were due by 29 Dec 2021. A reply may have been sent and not yet published.

Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.

  1. Report dated3 Nov 2021
  2. Deadline29 Dec 2021
  3. Published on judiciary.uk3 Nov 2021
  4. Today23 Oct 2026

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Responses from each recipient

Responses from each recipient
Sent toResponse
Home OfficeResponse publishedPublished on judiciary.uk in November 2021.
Ministry of JusticeResponse published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s.
Department for EducationResponse publishedPublished on judiciary.uk in November 2021.
The Security ServiceResponse published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s.
Office for StudentsResponse publishedPublished on judiciary.uk in November 2021.
College of PolicingResponse publishedPublished on judiciary.uk in November 2021.
West Midlands PoliceResponse publishedPublished on judiciary.uk in November 2021.
Staffordshire PoliceResponse publishedPublished on judiciary.uk in November 2021.
Cambridge University Hospitals NHS Foundation TrustNamed in the report as “University of Cambridge”Response publishedPublished on judiciary.uk in November 2021.
Learning Together Network CICResponse publishedPublished on judiciary.uk in November 2021.

The coroner’s concerns

raised below. Usman Khan: Background 10. Usman Khan was 28 years old at the time of the attack. He had had a history of involvement in events of violence as a teenager. In 2010 (when he was aged 19), he was arrested for offences of acts preparatory to terrorism and was remanded in custody. He pleaded guilty to a number of charges and was sentenced in early 2012, the basis of his plea being that he had sought to set up a militant training camp in Kashmir from which in future attacks might be launched on the UK. He was imprisoned and served his sentence in a number of prisons between mid-2010 and December 2018. 11. While Usman Khan was in prison, intelligence reports consistently showed him to be a leading extremist figure, involved in bullying, violence, radicalising others and serious disruption. An Extremism Risk Guidelines (ERG 22+) assessment report prepared on him in April 2018 by a prison psychologist, , concluded that his intent for and engagement with extremism remained strong and that there was a high risk that he would become involved in extremist activity upon release. 12. At the time of his release, Usman Khan remained a Category A (High Risk) prisoner, one of very few to be released into the community with that status. An OASys assessment by his probation officer shortly before his release concluded that he posed a “very high risk” of serious harm to the public in the community, indicating that a seriously harmful event was imminent and more likely than not to happen. Shortly before his release from prison, there were two strands of intelligence indicating that (a) he intended to return to his old ways upon release (which was interpreted as a reference to some form of terrorist offending) and (b) he intended to carry out an attack after release. 13. While he was in HMP Whitemoor, from November 2017, Usman Khan began to take courses provided by Learning Together, a prisoner educational initiative supported by 3 academics from the Institute of Criminology within the University of Cambridge. The initiative involved undergraduate students studying alongside prisoners within prisons. It had an alumni network which allowed former prisoners to remain involved in its activities after their release. Usman Khan proceeded to take a series of Learning Together courses over his final year in prison, and he remained in contact with Learning Together staff after his release. 14. From June 2018, Usman Khan was subject to management under statutory Multi-Agency Public Protection Arrangements (“MAPPA”). These involved meetings being held at regular intervals involving representatives of police forces, the National Probation Service (“NPS”) and others with relevant responsibilities for him. Reports were made to the meetings and decisions were made with a view to mitigating the risks he posed. 15. On his release into the community, Usman Khan was subject to strict licence conditions which were overseen by an offender manager from the NPS. He was initially required to live in approved premises in Stafford (a probation hostel) and he had to wear a GPS tag. In addition, he was subject to statutory notification requirements under terrorism legislation (Part 4 of the Counter-Terrorism Act 2008), which were managed by Staffordshire PREVENT team officers. Those officers visited him at intervals and prepared general reports about him. Usman Khan also had mentors provided for him under the Home Office Desistance and Disengagement Programme (“DDP”). 16. In preparation for Usman Khan’s release into the community, the Security Service (MI5) and West Midlands Police opened a priority investigation into him. Staffordshire Police Special Branch provided intelligence support to this operation. The investigation carried out a range of monitoring on Usman Khan over the months that he was living in the community, but did not detect any significant suspicious activity. 17. In the months following his release into the community (early 2019), Usman Khan was apparently compliant with his licence conditions and he did not engage with old associates. He was seen regularly by his offender manager and by mentors, and he visited his family in Stoke-on-Trent. His curfew conditions were relaxed progressively. He applied for a number of jobs, but all without success. 4 18. Usman Khan remained in contact with the Learning Together initiative. In June 2019, he attended a Learning Together event at HMP Whitemoor, being taken there by PREVENT officers. He received a non-networked Chromebook computer for creative writing, but there was no evidence that he did any actual project work. His search for employment continued and consideration was given to him applying for a job as a dumper truck driver, but the MAPPA agencies decided that that should not be permitted because of the risk he might pose if given access to heavy vehicles. 19. In August 2019, staff from Learning Together invited Usman Khan to attend an anniversary and alumni event which was due to take place in London in November 2019. The event was arranged to take place on 29 November 2019 at Fishmongers’ Hall, a livery company hall in the City of London adjacent to London Bridge. Prominent figures from the field of criminal justice were invited to attend, and a number did attend. Usman Khan was permitted to go to the event by his offender manager. The prospective event was discussed in either two or three of the MAPPA panel meetings held between August and November 2019, but it does not appear that the MAPPA agencies gave express consideration to the risks of Usman Khan attending such an event or expressly approved his attendance. It is however right to say that none objected. 20. In September 2019, Usman Khan moved from the probation hostel into a one-bedroom private flat. He continued to search for work without success, and this became more difficult when his mentoring arrangements were abruptly ceased and he no longer had the benefit of superv

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source
judiciary.uk, Prevention of Future Deaths reports, 2021-0362
Added to Minute Book
8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0

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