The deaths of three men murdered by a terrorist in a Reading park were avoidable, an inquest has concluded.
Khairi Saadallah killed James Furlong, David Wails, and Joe Ritchie-Bennett, in Forbury Gardens in June 2020.
He was given a whole-life term under anti-terror laws in 2021 after admitting murder and the attempted murder of three other men.
Judge Coroner Sir Adrian Fulford found major problems with intelligence sharing between authorities.
Addressing the court, he described Saadallah’s “volatility” and said he had a “terrorist mindset”.
Saadallah arrived in the UK in 2012 as a teenage refugee, having fought in the Libyan revolution, and suffered from PTSD, among other conditions.
He had extensive contact with mental health services, but Sir Adrian said he was “caught in a catch-22” with no continuity of care.
He concluded that it was “at least possible” that Saadallah would never have attacked the men if his mental health had been correctly managed by authorities.
Sir Adrian also said if intelligence about the high risk he posed had been shared properly he might have been detained by police.
He also found “significantly troubling failings” by counter-terrorist police officers, who lacked understanding and did not share information with other forces and the probation service.
Counter-terror programmes, such as Prevent, did not provide any “effective intervention” to address Saadallah’s threats.
Reports about the risk he posed were “markedly deficient”, the judge coroner said, and one intelligence assessment was “simply inadequate”.
Sir Adrian said Saadallah had “demonstrated capacity for violence” on many occasions, and his behaviour had “markedly deteriorated” in the 18 months before the attack.
He should have been recognised as a high-risk patient, he added.
Saadallah was released from prison on 5 June 2020 and went to live in a flat in Basingstoke Road in Reading before he started preparing the attack.
He visited Forbury Gardens, researched it online and bought a knife in a Morrisons supermarket.
The night before the murders, local officers visited Saadallah after his brother rang police to raise concerns about his mental state.
Body-worn video from the two-minute encounter shows Saadallah reassuring the officers, who asked how he was feeling and if he had enough food.
A carrier bag containing a knife was visible on the floor behind him.
On 20 June, his attack was “ruthless and lethal”, prosecutors at his murder trial said. He attacked his victims so quickly that those who died had no idea what was happening.
He shouted “Allahu Akbar [God is greatest]” as he attacked, and again as he ran away into Reading town centre, where he was chased and arrested by unarmed police.
When he was sentenced in January 2021, Judge Mr Justice Sweeney said Saadallah carried out a “ruthless and brutal” attack.
He said the three men “had no chance to react, let alone defend themselves”.
The judge added he was sure the attack “involved a substantial degree of premeditation or planning” and was carried out “for the purpose of advancing a political, religious, or ideological cause”.
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