The man who killed Conservative MP Sir David Amess was released from the Prevent anti-terror programme “too quickly”, a review has found.

Sir David was stabbed to death by Islamic State (ISIS) supporter Ali Harbi Ali during a constituency surgery at a church hall in Leigh-on-Sea in October 2021.

The killer, who was given a whole-life sentence, had become radicalised by ISIS propaganda and had been referred to the anti-terror programme Prevent before the attack.

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His case had been closed five years before, after just one meeting for coffee at a McDonald’s to deal with his interpretation of “haram” (forbidden under Islamic law), as well as texts and calls with an “intervention provider”.

Despite Prevent policy and guidance at the time being “mostly followed”, his case was “exited too quickly”, security minister Dan Jarvis told the House of Commons on Wednesday.

Following the publication of a review into Prevent’s handling of Southport child killer Axel Rudakubana earlier this month, Mr Jarvis said a Prevent learning review into Sir David’s killing would be released this week in a commitment to transparency over the anti-terror programme.

Matt Juke, head of counter-terrorism policing, said it is clear the management and handling of Ali’s case by Prevent “should have been better” and it is “critical” the review is acted on “so that other families are spared the pain felt by the loved ones of Sir David”.

The review found:

• Ali was referred to Prevent in 2014 by his school after teachers said his demeanour, appearance and behaviour changed from a previously “engaging student with a bright future” with aspirations to be a doctor to failing his A-levels and wanting to move to a “more Islamic state because he could no longer live among unbelievers”

• Prevent quickly took his case on and he was referred to Channel, part of the programme that aims to prevent involvement in extremism

• He was “exited from Prevent too quickly”, Mr Jarvis said, just five months later “after his terrorism risk was assessed as low”

• A review by police 12 months after he was released from Prevent “also found no terrorism concerns” and the case was closed. This was not uploaded for eight more months due to an “IT issue”

• People released from Prevent are meant to have a review at six and 12 months

• The assessment of Ali’s vulnerabilities “was problematic and outdated” as it did not follow the proper procedure, which led to “questionable decision-making and sub-optimal handling of the case”

• Ali’s symptoms were prioritised over addressing the underlying causes of his vulnerabilities – and support provided did not tackle those issues

• Record keeping of decisions, actions and rationale was “problematic, disjointed and lacked clarity”

• The rationale for certain decisions was “not explicit”

• Ali’s school was not involved in discussions to help determine risk and provide appropriate support – they were only called once to be told the “matter was being dealt with”

• A miscommunication led to only one intervention session being provided, instead of two.

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The review found most of the failures in Ali’s case would not be repeated today as the guidance and requirements are much clearer.

It said referrers, in Ali’s case his school, are kept informed and engaged, and different departments and agencies – not just police – have clear roles.

Which records need to be kept is now clear and guidance for detecting underlying vulnerabilities has changed and would have made a difference, the review added.

It said a Prevent “intervention provider” met Ali at a McDonald’s to deal with his understanding of “haram” (forbidden under Islamic law).

No risk assessment was made but they suggested one more meeting, however a breakdown in communication between the police and the provider meant there were no more meetings.

Training for providers is “substantially different” now and the review says this would not be repeated today, with the provider in question saying the process is “a completely different one today”.

However, the review said there are still problems – not just in Ali’s case – with the Vulnerability Assessment Form, an “incredibly complex document that is vital to Channel” and the progression of a case.

It also found a more recent decision by the College of Police to only hold Prevent case data for five years “may prove to be problematic” and if Ali’s case material had been deleted under that ruling “it would have been nigh on impossible to conduct this review”.

Sir David’s daughter, Katie Amess, 39, last week welcomed the announcement to publish a review into Ali’s case but said every victim failed by Prevent deserves an inquiry, not just the Southport victims.

“We potentially wouldn’t be in the same situation today with repeat failings of Prevent had somebody had just listened to me back when it [her father’s killing] happened and launched a full public inquiry,” she told LBC.

Ms Amess said she believes if the Southport attack had not happened, the review into Prevent’s handling of her father’s killer would never have been released into the public domain.

An NHS trust has been fined £1.6m after admitting it failed to provide safe care and treatment to three babies who died within days of their births.

The Care Quality Commission (CQC) had charged Nottingham University Hospitals (NUH) NHS Trust over the deaths, which all occurred in 2021.

The trust pleaded guilty to six charges of failing to provide safe care and treatment to the three children and their mothers at Nottingham Magistrates’ Court on Monday.

The charges were in connection to the deaths of Adele O’Sullivan, who was 26 minutes old when she died on 7 April 2021, four-day-old Kahlani Rawson, who died on 15 June 2021, and Quinn Parker, who was one day old when he died on 16 July 2021.

District Judge Grace Leong told the hearing, which was attended by the trust’s chief executive since September 2022 Anthony May, that the “catalogue of failures” in the trust’s maternity unit were “avoidable and should never have happened”.

Family members cried in the courtroom as the judge expressed her “deepest sympathy” to each of them and said the trust they put in NUH to deliver their babies safely had been broken.

“The death of a child is a tragedy beyond words, and where that loss is avoidable the pain is even more profound,” she said.

“Three-and-a-half years have gone by, yet for the families no doubt their grief remains as raw as ever and a constant presence in their lives that is woven into every moment.

“The grief of a baby is not just about the past, it is about the future that is stolen. It is a lifetime of missing first words, first steps, first days of school, missing memories that should have been made.

“It is very difficult, if not impossible, to move on from the failures of the trust and its maternity unit.

“The weight of what should have been done differently will linger indefinitely.”

‘Systematic failures’

District Judge Leong highlighted concerns over a lack of escalation of care, an inadequate communications system and a failure to provide “clear and complete” information sharing.

She said: “I accept there were systems in place but there were so many procedures where guidance was not followed or adhered to.

“The failures in combination amounted to systematic failures in the provision of care and treatment.”

The trust has an average turnover of £612m, but District Judge Leong said she was “acutely aware” that all its funds as a publicly funded body were accounted for and that the trust is currently operating at a deficit of around £100m.

“I can’t ignore the negative impact this will have… but the significant financial penalty has to be fixed to mark the gravity of these offences and hold the trust to account for their failings,” the judge said.

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The £1.6m fine was broken down into £700,000 related to the death of Quinn Parker, £300,000 each for the deaths of Adele O’Sullivan and Kahlani Rawson, and three amounts of £100,000 related to the care provided to each of the mothers.

Lawyers acting on behalf of the trust told the families in court they offered their “profound apologies and regrets” and that improvements have been made, including hiring more midwives and providing further training to staff.

‘Contemptuous and inhumane’

The court was told that one of the pregnant women, Emmie Studencki, went to the hospital four times suffering bleeding before her son Quinn was born.

On the final occasion before Quinn was born, Ms Studencki called an ambulance at around 6.15am on 14 July 2021 with paramedics estimating she had lost around 1.2 litres of blood both at home and in the ambulance on the way to City Hospital.

Despite this, the paramedics’ observations did not “find its way into the hospital’s notes”, with staff only recording a 200ml blood loss.

Quinn was “pale and floppy” when he was born via emergency Caesarean section that evening, and despite several blood transfusions, he was pronounced dead after suffering multiple organ failure and lack of oxygen to the brain.

An inquest concluded it was a “possibility” he would have survived had a Caesarean section been carried out earlier.

In a statement, Ms Studencki said the trust’s treatment of her, her son, and her partner Ryan Parker had been “contemptuous and inhumane”.

‘We lost our beautiful daughter’

Adele O’Sullivan died 26 minutes after being born following an emergency Caesarean at 29 weeks in April 2021, the court also heard.

Her mother Daniela had noticed bleeding and suffered abdominal pain but in a victim impact statement said she was left “screaming in pain” with no painkillers. Despite having a high-risk pregnancy, she was not examined for eight hours before Adele was born.

Adele was born in “poor condition” and a decision was made to withdraw care, with a post-mortem examination finding she died as a result of severe intrapartum hypoxia.

Daniela said: “People who were supposed to help me did not help but harmed me mentally and physically forever.

“We lost our beautiful daughter. Instead of bringing her home I had to leave the labour suite empty-handed in a lot of physical and mental pain.”

The trust also admitted liability in another case involving mother Ellise Rawson, who had reported abdominal pain and reduced foetal movements. She was delayed in receiving an emergency Caesarean section in June 2021. Her son Kahlani suffered a brain injury and died four days later.

Kahlani’s grandmother Amy Rawson told the court that her grandson’s death was a “preventable tragedy” that had left the family “devastated, broken and numb”.

This case is the second time the CQC has prosecuted the trust over failures in maternity care.

It was fined £800,000 for a “catalogue of failings and errors” that led to the death of a baby 23 minutes after she was born at the Queen’s Medical Centre in Nottingham in September 2019.

NUH is also at the centre of the largest maternity inquiry in NHS history, with midwife Donna Ockenden leading the investigation.

In February she confirmed the number of families taking part has increased to 2,032 – forcing a delay to her report’s publication until June 2026.

‘We fully accept the findings’

In a statement released after the hearing, NUH chief executive, Mr May said: “The mothers and families of these babies have had to endure things that no family should after the care provided by our hospitals failed them, and for that I am truly sorry.

“Today’s judgment is against the trust, and I also apologise to staff who we let down when it came to providing the right environment and processes to enable them to do their jobs safely.

“We fully accept the findings in court today and have already implemented changes to help prevent incidences like this from this happening again.”

He added that a CQC report published in September 2023 showed there had been an improvement in the overall rating for the trust’s maternity services.

Helen Rawlings, CQC’s director of operations in the Midlands, said in a statement after the sentencing: “The care that these mothers received, and the death of these three babies is an absolute tragedy and my thoughts are with their families and all those grieving their loss under such sad circumstances.

“All mothers have a right to safe care and treatment when having a baby, so it’s unacceptable that their safety was not well managed by Nottingham University Hospitals NHS Trust.

“The vast majority of people receive good care when they attend hospital, but whenever a registered health care provider puts people in its care at risk of harm, we seek to take action to hold it to account and protect people.

“This is the second time we have prosecuted the trust for not providing safe care and treatment in its maternity services, and we will continue to monitor the trust closely to ensure they are making and embedding improvements so that women and babies receive the safe care they deserve.”

Sir Keir Starmer has told the families of those killed in the Nottingham attacks that a judge-led public inquiry will start in “a matter of weeks”.

The families of Barnaby Webber, Grace O’Malley-Kumar and Ian Coates were told at an emotionally charged meeting at Number 10 that a “number of different agencies” would be scrutinised by the probe.

Students Mr Webber and Ms O’Malley-Kumar, both 19, and 65-year-old caretaker Mr Coates were killed by Valdo Calocane before he attempted to kill three other people in a spate of attacks in the city in June 2023.

Calocane was sentenced to an indefinite hospital order in January last year after admitting manslaughter by diminished responsibility and attempted murder.

Prosecutors accepted a plea of manslaughter after experts agreed his schizophrenia meant he was not fully responsible for his actions. The families said recently that he “got away with murder”.

Speaking outside Downing Street on Wednesday, Emma Webber said: “It’s the first bit of positive news that we’ve been able to have for a very, very long time. We’re still processing it.”

Dr Sanjoy Kumar added: “As we have always said as families, everywhere that Valdo Calocane intersected with the authorities, we were let down.”

He then said the public inquiry “has been fantastic news for all of us, we welcome it, we’ve been working so hard to it”.

“Everyone who has also suffered the way we had, we will make sure that changes come from our inquiry for the betterment of our country that makes… the land safer for all of us.”

Mrs Webber also said the families were told the inquiry would be concluded within two years, and Dr Kumar thanked the prime minister “from a father to a father”.

During the meeting, Sir Keir said focusing on just one aspect of the case would not be right as he did not “think that will do justice,” and said it would be a statutory inquiry.

He added a retired judge is set to be appointed in due course, and said: “As soon as that happens, the process will start.”

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The meeting came after NHS England’s report into Calocane’s mental health care in the lead-up to the attacks, which found treatment available to him “was not always sufficient to meet his needs”.

The report detailed four hospital admissions between 2020 and 2022 and multiple contacts with community teams before he was discharged to his GP because of a lack of interaction with mental health services.

It also found Calocane was allowed to avoid taking long-lasting antipsychotic medication as he did not like needles, and did not consider himself to have a mental health condition.