Forbury Gardens terror attack victims’ families call for urgent change after Judge Coroner says state agencies could have prevented deaths

James Furlong, Dr David Wails and Joseph Ritchie-Bennett were killed by Khairi Saadallah, who was convicted of their murders and is now serving a whole life sentence in prison.

Before committing the attack, Saadallah was known to multiple state agencies, including counter-terrorism police, Prevent, MI5, prison and probation and mental health services. 

A judge-led inquest was opened into the deaths.  The inquest heard six weeks of evidence in the Old Bailey earlier this year and examined the management of Saadallah by these state agencies.  The Judge Coroner Sir Adrian Fulford gave his conclusion at the Old Bailey on Friday 26 April 2024.

Following his lengthy findings of fact, delivered in a seven-hour hearing, Sir Adrian concluded the following in relation to the mental health services involved with Saadallah:

• Berkshire Healthcare NHS Foundation Trust, (BHFT) who provided community mental health services in Reading, placed Saadallah in a “Catch-22” dilemma because the treatment programmes for the mental health disorders he was thought to suffer with (PTSD and Personality Disorder) required a patient to demonstrate a lengthy period of stability before treatment was commenced, however they simultaneously failed to provide the care coordination role that would help to achieve that stability.  
• BHFT tended to wrongly characterise Saadallah as having multiple social care issues which were the stressors in his life, rather than mental health issues.  
• Midlands Partnership NHS Foundation Trust (MPFT), who provided mental health services in prison, similarly never provided Saadallah with therapy, as he was incorrectly labelled as someone who was uninterested in treatment.  
• There was a failure to provide a joined-up approach between BHFT and MPFT as Saadallah moved between the community and periods of imprisonment. This contributed to Saadallah’s probation officer’s inability to obtain assistance for him upon his release from prison on 5 June 2020, despite his significant psychiatric difficulties and risk of serious violence. 

Sir Adrian concluded that, in his view, “it is at least possible that the failure to provide long-term therapy, at least from 2016, meant that KS failed to achieve the level of stability that would have avoided him “finally (settling) on jihad as the solution to his turmoil”. 

Sir Adrian found that consistent case management and long term therapy “provided a real potential to reduce his aggressivity, impulsivity and substance abuse, along with his offending, between 2015 and 2019”. Sir Adrian relied upon the evidence of an expert forensic psychiatrist, who was of the view that it should have been anticipated that there was a real risk that Saadallah would commit a violent office on his release from prison on 5 June 2020, including the risk that he would kill someone. Sir Adrian considered it at least possible that this risk could have been avoided, had the above failures not occurred. 

In relation to the management of Saadallah’s risk of extremism, Sir Adrian concluded:  

• Saadallah had repeatedly indicated (albeit inconsistently) over a number of years that he had a terrorist “mindset” along with a capacity to kill, and he was rendered additionally dangerous by his serious psychiatric problems. There were a number of significant failings in inter-agency intelligence and information sharing in this respect, stemming back a number of years.  
• Adequate details of this background information, together with informed appraisals of the extent of the very high risk Saadallah posed, should have been shared with probation and the police, in a form that was readily available to the police control room and Saadallah’s probation officer. 
• If that information had been available, Sir Adrian was of “no doubt” that immediate steps would have been taken to recall Saadallah to prison on the 19 June 2020, following receipt of a 999 call that he had threatened to blow himself up and harm others. Sir Adrian found that he would have been returned to custody that night, thus preventing him from carrying out his attack the following day.  
• If the relevant background material relating to KS had been shared appropriately and he had been designated as “very high risk”, as he should have been, Sir Adrian found on the evidence that he would have been accepted into an Approved Premises. Given the structure of the regime and consequent CCTV monitoring, this could have also changed the outcome.  

In summary, Sir Adrian concluded that the deaths of James, Joe and David “would probably have been avoided if, first, the mental health services had given greater priority to stabilising KS and securing access to long term psychological therapy. Had they done so it is at least possible that the attack would have been prevented by the reduction of KS’s aggressivity, impulsivity, substance abuse and extremism, although the effect on extremism is more difficult to determine. Second, if his extremist risk had been better analysed, KS would probably then have been recalled to custody on 19 June 2020 meaning these attacks would never have happened”.  

Sir Adrian indicated within his findings that the evidence heard gave rise to concerns that future deaths could occur if further action is not taken. He therefore intends to issue Prevention of Future Deaths reports setting out these concerns to Berkshire Healthcare NHSFT, Midlands Partnership NHS Foundation Trust, The Chief Constable of Thames Valley Police, The Secretary of State for the Home Department and The Secretary of State for Justice. He hopes to send the reports within the next three weeks.  

The families of James Furlong, Dr David Wails and Joseph Ritchie-Bennett are represented by Leigh Day partner Benjamin Burrows, Leigh Day solicitor Lily Hedgman and Leigh Day partner Fiona Huddleston. 

Following the conclusion, Gary Furlong, father of James Furlong, and Andrew Wails, brother of Dr David Wails, issued statements calling for urgent change. 

Andrew Wails said:  

“We have heard that, despite his background and ongoing behaviour, the State catastrophically failed in its duty to identify the risks Khairi Saadallah posed and protect the public from that risk. These were not just single failings on behalf of one state agency. These were a catalogue of failings on behalf of multiple state agencies, including the police, mental health services, the Home Office, and prison and probation services. 

“These state agencies have let us down. Their failure to prevent this attack has destroyed our lives. I am grateful that they have had to account for their failings through this inquest process, and I am grateful to the Judge Coroner for recognising in his conclusion that the State could have prevented David, James and Joe’s murders. 

“When I told my mother that David was dead, she screamed "not my David".   

“Next time it could be your David, your James or your Joe, if your State does not accept the Judge Coroner’s findings and implement change. If nothing is done, my fear is that there will be other families standing where we are now, raising the same concerns while grieving for the avoidable loss of their loved ones.” 

Gary Furlong said:  

“We have been sat in court demoralised, bewildered and disillusioned by the agencies’ failure to effectively communicate, assess the risk and protect the public. It is clear to us that the boys were failed by the agencies who were entrusted to protect them.  

“Our objective from the beginning of this process has been to do all we can to prevent any further similar tragedies. We cannot carry on listening to agencies saying, ‘lessons will be learnt’. What we now need to hear is ‘what actions will be taken’ by the Government and agencies involved. We cannot change what has happened to the boys, but we wish that the outcome of this Inquest leads to positive reform. 

“We must try and find a way to live our lives without James. The pain of his loss, under such horrific circumstances, is with his family, friends and former colleagues and students, forever.”  

Leigh Day partner Benjamin Burrows said: 

“The families we represent have waited four years, with enormous resolve and patience, to know if and how the murderous attack on their loved ones could have been prevented.

“Despite understandable anger, they have shown strength and dignity as evidence unfolded during the inquest of the extent of failings by multiple state agencies over several years.

“The evidence painted a picture of none of these agencies wanting to take the overall lead in managing the complex individual who killed our clients’ loved ones, instead doing their utmost to shift the responsibility on to others.

“Although the evidence heard was wide-ranging and complex, the Judge Coroner’s findings are clear.  There were key failings by those state agencies entrusted to protect the public and without those failings it is likely that Khairi Saadallah would have been prevented from carrying out his horrific crime and James, Joseph and David would not have died at Forbury Gardens on 20 June 2020.

“They were in essence let down by the very ones responsible for keeping them safe.  It is a day of very mixed emotions for the families we represent as they begin to come to terms with the reality of the Judge Coroner’s clear finding that the loss of their loved ones was preventable.

“This conclusion is important not only in giving answers to the families we represent, but also in making sure that the same failings do not repeat themselves.  It is now up to the relevant state agencies to show that lessons have been learnt from this, and that similar events with such tragic consequences can be prevented from happening in the future.”

LINKS TO FULL STATEMENTS ISSUED BY GARY FURLONG AND ANDREW WAILS

Timeline of Saadallah in the UK leading up to Forbury Gardens attack 

In 2011, Khaira Saadallah, a Libyan national, joined Ansar al-Sharia, a proscribed Islamist terrorist organisation, as a child soldier, during the uprising against Muammar Gaddafi.

In 2012, Saadallah came to the UK. His asylum claim, and subsequent appeals were rejected.

After July 2014, the situation in Libya deteriorated to such an extent that there was no realistic chance of deporting Saadallah. He received leave to remain in 2018.

In September 2013, Saadallah was arrested in possession of a bladed article.

Between 2013 and 2019, Saadallah had nine convictions for 20 offences and accumulated a further 27 charges.

By May 2015, Saadallah was serving his first of five custodial sentences.

In 2016, Saadallah moved to Reading where he regularly came into contact with mental health services but did not receive secondary treatment for his personality disorder throughout his time there.

In November 2016, Saadallah returned to prison for his second custodial sentence.

Between 2016 and 2019, three triage assessments of Saadallah were carried out by MI5 but were not taken any further.

In January 2017, during his second prison sentence, intelligence was submitted that Saadallah was keen to associate with Omar Brooks, an extremist Islamist preacher.

In February 2017, the first Prevent referral was made on the basis of disclosures that Saadallah wished to return go to Libya to avenge his family’s deaths but was closed with the reasoning that he had received a long custodial sentence.

In December 2017, the second Prevent referral was made following Saadallah’s recall to prison and probation’s concern about his vulnerability to extremism. This was closed on the basis that having received leave to remain, this had mitigated his risk.

In November 2018, the third Prevent referral was made after Saadallah was arrested with a large kitchen knife, and in police custody disclosed he hated England and wanted to return to Libya to shoot people. This referral was closed on the basis that his disclosures were made in the context of mental health difficulties, rather than because of an ideological mindset.

In March 2019, Saadallah returned to prison.

In May 2019, a final Prevent referral was made after Saadallah disclosed he wanted to go to Libya and fight for ISIS. This was closed in December 2019 with the assertion that he showed no signs of extremist views and was not a national security threat.

In May 2019, MI5 opened their first lead investigation to determine Saadallah’s desire to travel to Libya for extremist purposes but was closed after an assessment that he did not have a genuine intention to travel to Libya

By August 2019, Saadallah was serving his fifth, and final prison sentence before the attack. 

On 5 June 2020, Saadallah was released on licence and was being managed by the National Probation Service and was assessed as high risk of harm. He was not placed at an approved premises, he was not discussed at a MAPPA meeting after his release, he was not on any mental health caseload and was not subject to any counter terrorism policing oversight.  

On 17 June 2020, Saadallah reconnoitred Forbury Gardens and confirmed it as the venue for his attack.

On 19 June 2020, Saadallah purchased the  kitchen knife used in the attack. The same day, Saadallah’s brother called 999 expressing concern that Saadallah had made threats to blow himself up and indicated he was going to harm himself or others. Counter-terrorism police were contacted who responded that they had no current intelligence of concern. The response to the 999 call was to send police out to a welfare visit to Saadallah. The police did not pass any information about the 999 call to the probation service.

On 20 June 2020, Saadallah carried out his planned attack, killing James Furlong, David Wails and Joseph Ritchie-Bennett as they sat in the park with their friends. 

The findings from the inquest can be accessed here.