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Failings by the police, probation service and MI5 contributed to the deaths of two graduates killed by a convicted terrorist, a jury has found.
University of Cambridge alumni Saskia Jones and Jack Merritt were stabbed by Usman Khan at a rehabilitation event at Fishmongers' Hall on 29 November 2019.
Khan, 28, had been released from prison 11 months previously, the inquests at London's Guildhall heard.
The jury concluded that both victims were unlawfully killed.
Khan, who had spent eight years in jail for planning to set up a terrorist training camp in Pakistan, was chased on to London Bridge by people at the event who were armed with a fire extinguisher and a narwhal tusk plucked from a wall.
The terrorist, who wounded three others in the attack, was shot dead on the bridge by police.
Could Fishmongers' Hall attacker have been stopped?
'They clearly touched the lives of so many'
Jurors found there had been unacceptable management and a lack of accountability in the oversight of Khan, who had been allowed to travel on his own to London from his hometown of Stafford.
They concluded there had been failures in the sharing of information between state agencies responsible for monitoring him.
Deficiencies in the organisation of the event at Fishmongers' Hall, including inadequate security measures, were also found to have been a factor in the deaths.
Darryn Frost carrying tusk
IMAGE COPYRIGHTMET POLICE
image captionOne man pursued Khan on to London Bridge armed with a narwhal tusk he had removed from a wall at Fishmongers' Hall
After the conclusions were delivered, the jury forewoman said the jurors wanted to send "heartfelt condolences to the families of Saskia and Jack" who "clearly touched the lives of so many, ours included".
"We are so incredibly sorry. The world lost two bright stars that dreadful day," she said.
The forewoman added the jury wanted to "thank the astonishing individuals who put themselves in real danger to help and our incredible emergency services for their response, both that day and every day".
media captionJack Merritt was killed by Usman Khan, a convicted terrorist still considered dangerous by MI5
At the conclusion of the inquests, Ms Jones's family, from Stratford-upon-Avon, said there were still "unanswered questions relating to failures of a number of organisations and individuals".
"It is beyond understanding and astonishing that not one of the state agencies sufficiently considered the associated risk and therefore questioned the wisdom of sending Usman Khan unaccompanied to London," the family said in a statement.
Fake suicide vest
image captionThe Guildhall heard Khan had been wearing a fake suicide vest
They also criticised Learning Together, which ran the prisoner rehabilitation programme, and the Fishmongers' Company over failures to keep those at the event safe.
Mr Merritt's father David, from Cottenham in Cambridgeshire, said it was "clear... that the arrangements put in place for managing Usman Khan after his release from prison in 2019 were not fit for purpose, despite the authorities having had six years to plan for this".
"We hope that all other agencies and organisations involved with Khan will learn the lessons highlighted by the inquest and will make changes to their systems and working practices," he added.
IMAGE COPYRIGHTGEOGRAPH/N CHADWICK
image captionFishmongers' Hall, beside London Bridge, was the venue for the event where Khan struck
By Dominic Casciani, home and legal correspondent
These verdicts are so clear and damning that they have far wider implications than this terrible tragedy.
They raise questions about the competence and ability of state agencies to properly manage the risk of men as dangerous as Usman Khan. If they wanted to, the families could now try to sue the agencies involved for a finding they breached their duty to take reasonable steps to protect life. The mistakes and omissions were clear to the jury - from the inexperience of the officers managing Khan in the community, through to a dreadful muddle over who should have passed them critical MI5 intelligence.
All of it, in the jury's view, was "unacceptable". There are questions too for Cambridge University, where the chiefs of a rehabilitation scheme believed Khan was such a success he could come to their reunion in London, despite the city being such an obvious target for a convicted, deviant and unrepentant terrorist.
A Court of Appeal ruling meant Khan had to be automatically released on licence from prison, with the Parole Board having no say as to whether he was safe to be freed.
Throughout his time in jail, he was classed among the 70 highest-risk inmates in the country, was frequently involved in violence and radicalisation and spent a significant period under investigation by MI5.
Upon his release, Khan was assessed as being more dangerous than when he went into prison, and there was seen to be an imminent risk of him causing serious harm to the public.
While he was still an inmate, the security services launched a new covert investigation, which became a priority inquiry after intelligence was received that Khan would carry out an attack once he was freed.
But the intelligence was never shared with Khan's probation officer nor the Multi Agency Public Protection Arrangements (MAPPA) panel that managed him in the community. MAPPA did not even know that Khan was being investigated by MI5 - one of whose officers often secretly attended the panel's meetings.
media captionSaskia Jones' uncle says the conclusion of the inquest "does not in any way ease the pain"
While in HMP Whitemoor, Khan was allowed to attend a prisoner education project run by Cambridge University called Learning Together.
After his release, he remained in touch with Learning Together staff, even appearing as a case study of successful change in a project video and publication. He was consequently invited to the anniversary celebration at Fishmongers' Hall.
Police, MI5 and probation services all knew that Khan was going to attend the event, which was his first unescorted trip out of Staffordshire after leaving prison.
But the inquests heard none of them considered the potential risks nor took any steps to guard against them.
In the days before the event, Khan bought knives and items for a fake suicide vest. He made his way to London having had his licence conditions relaxed to allow unaccompanied travel by train.
Still from a video clip showing Usman Khan praising Learning Together
IMAGE COPYRIGHTMET POLICE
image captionUsman Khan, seen here in a video recorded for Learning Together, took his first post-release unescorted trip out of Staffordshire on the day of the killings
Assistant Commissioner Neil Basu, the national lead for Counter Terrorism Policing, said the way offenders were managed in the community had been improved but he was "so deeply sorry we weren't better than this in November 2019".
He added: "The jury has today concluded that Jack and Saskia were unlawfully killed.
"This reflects the fact that whilst we, along with our partners, will constantly strive to improve, the ultimate responsibility for this barbaric act lies with the attacker."
Home Secretary Priti Patel said it was "important that the government and operational partners learn lessons to prevent further incidents like this" and she would "consider the inquest findings".
In a statement, the co-founders of Learning Together - a University of Cambridge programme - said they were "determined to reflect on the lessons of these inquests as we move forwards".
The university also said it would consider the "lessons to be learned".