Transcript of Day 16 – Thursday, 27th March 2025

Thursday, 27 March 2025 (9.59 am)

SIR ROSS CRANSTON: Yes. Well, good morning, everyone.

We are going to continue today with the evidence from those loved ones of the people who died in the tragedy.

Mr Phillips.

MR PHILLIPS: Yes, sir. We will continue to hear statements, eight further statements today in respect of three Ethiopian victims. The original language in all cases is Amharic.

But before the first recording is played I should give a warning: what we are about to hear during the morning may be distressing to those in the room or those following on the livestream and if so, they should leave the room or look away as the case may be.

The first two recordings and statements you will hear are made by the brother and wife of Fikiru Shiferaw who was born in 1975.

Statement of MR ANDARGACHEW SHIFERAW read (in Amharic) (Audio played to the Inquiry)

MS LE FEVRE: I am Andargachew Shiferaw, the brother of Fikiru Shiferaw.

Fikiru and I had a particularly close relationship within the family. We confided in each other and I was one of the few people who knew that Fikiru was struggling before he left Addis Ababa. My brother was the strongest member of our family so he could not show weakness.

He carried everyone and he did not want to disappoint them.

When Fikiru was still alive, he was the rock of our family. He was an incredibly supportive man, who would care for anyone that needed his help. He was living a very good life with his wife and children Addis Ababa. He was doing very well financially and was able to share this with his family.

He was supporting our younger brother by paying for his medical treatment and helping my parents with their rent, their medical bills and their daily costs such as groceries.

He was like a pillar of strength to everyone that knew him and when he died, this came crashing down and changed the lives of everyone who knew him.

After Fikiru left Ethiopia, I had very little contact with him because I rarely had phone signal or internet when I was working outside the city. Our conversation in Addis Ababa had not been very specific. He simply told me he was going to find somewhere safe.

I first found out about the accident more than a week after it happened. At that time, no one had heard from Fikiru for 11 days. Since Fikiru has died, our entire family have suffered a terrible emotional loss and on top of that, we have lost the key financial provider.

Losing the breadwinner in the family has had a huge impact on us. My parents had to move out of their home, my father cannot pay for his medical bills anymore and Emebet and the children are relying on her great uncle to look after them.

The consequences have been catastrophic.

I want my parents to be able to lead a decent life, but we are struggling to support them through this.

My parents have explained that everything in their lives fell apart after Fikiru died. My mother used to run a small kiosk which brought in some money. However, my father had a stroke when he heard the news of Fikiru’s death and has, since then, needed constant care. He can no longer move around independently.

My mother stopped working and now acts as his full time carer. They are now entirely dependent on my other siblings to support them.

They have moved to an area on the edge of Addis Ababa, where they do not know their neighbours and they feel very lonely, but they could not afford to stay in their old neighbourhood.

My mother continues to suffer a lot from the loss of her son. She cannot speak about him without feeling this pain. She was in a state of complete disbelief when she heard that he had died in the Channel. When she heard the news that many people on the boat were calling for help, but no one came to them, she was distraught.

We do not understand how the coastguard could ignore the plight of these people. Fikiru died so far away from home in a place where we do not speak the language or understand the customs. This is very painful for us. We hope that this Inquiry will help us to understand what happened to Fikiru and will result in holding those responsibility for his death accountable. We pray every day for his wife and children.

We pray that they will find the strength that they need to carry on with their lives. We pray that we will be able to survive without Fikiru.

MS LE FEVRE: And we will next hear the recording and statement of Emebet, Fikiru’s wife.

Statement of MRS EMEBET KEFYALEW read (in Amharic) (Audio played to the Inquiry)

MS LE FEVRE: I am Emebet Kefyalew, the wife of Fikiru Shiferaw. I met Fikiru in Addis Ababa in 2012. We met through a mutual friend. We became best friends very quickly. We later fell in love and decided to be in a relationship. We got married in Addis Ababa on 10 November 2015.

Fikiru and I were living together in our own rented home in Addis with our two children before he left. Our son was born around a month before Fikiru left Addis Ababa.

In October 2021, around the time of our son’s birth, Fikiru told me that he was very afraid and that he felt he had to leave Ethiopia or his life would be at risk. He left about a month later and he did not tell me specifically where he was going. He just said that he was going to look for somewhere safe.

I was in frequent contact with him after he left Ethiopia. We were speaking on the phone and on WhatsApp. I find it very hard to remember the details from this time. I think it is because my memory has been damaged by the grief and suffering that I went through directly after this time, after the incident on 23 November 2021.

I spoke to him on the phone in the afternoon on 23 November 2021. I cannot recall the exact time. We had a video call so that our daughter could see him because she was missing him a lot. I missed a call from him later that night and then received a voice note at 12.12 am Ethiopian time, saying, “We have already boarded the boat. We are on the way. I will turn off my phone now. Goodnight, I will call you tomorrow morning.”

I did not have any contact with Fikiru since our WhatsApp messages on 23 November 2021. I had no information about what had happened to him for almost two weeks. I did not know where he was and I had no news of him. Waiting in the face of the unknown was traumatic.

On Sunday, 5 December 2021, I found out that Fikiru had drowned in the Channel. At around 4 am GMT some of my family members including Andargachew, Fikiru’s uncles and my cousins came to my home to tell me the news.

After they told me, I think I lost consciousness or maybe the grief has made me forget exactly what happened.

When I went home with my children after the funeral, I realised we were facing serious financial problems without Fikiru to support us. We had to leave our home because it was too expensive and I had to take my daughter out of her school. We now live with my great uncle and he supports us.

We are making things work, but it has been difficult for all of us since Fikiru passed away because he was the one who was supporting all of us and looking after us.

I am struggling to go back to work after what happened. I do not feel strong enough. I try to work part-time, but this is not enough. I am also trying to complete my Master’s degree, which I had to stop for a while after Fikiru’s death. I am currently completely dependent on my great uncle and other family members.

My daughter and Fikiru were best friends. She was a real daddy’s girl. They would go everywhere together. She still remembers so much about him and is always telling stories about the things that they used to do together. I found this very hard at first because I was missing him so much and I was coping with his loss very differently.

But as time moves on, I try my best to talk about him with her and keep the memory of him alive. She does not know how her father died, but she understands that he is no longer with us and that he is with God and at peace. My son was only a month old when Fikiru left and he is still too young to really understand that he does not have a father anymore.

Fikiru’s older brother, Andargachew, comes to visit my children every Sunday and the whole family come together to visit Fikiru’s parents as much as possible. Fikiru’s father became very ill after Fikiru died and he is not able to move around easily.

Fikiru’s mother has had to stop working so that she can be his full-time carer. Following Fikiru’s death they could not afford it stay in their home anymore because Fikiru financially supported them and so they now live much further away on the outskirts of Addis Ababa.

Fikiru’s death changed all of our lives forever. We have all had to adapt to living life without him and finding ways to support ourselves, given that so many of us in the family were dependent on him. It is so hard to accept that this is how Fikiru lost his life. He was a man that was loved by all and he was a lifesaver for all. He would do everything he could to make life easier for other people.

Fikiru was such a humble and kind person. He was a people pleaser and he had a kind heart. He loved his family so much and he would never have left us if he had not felt threatened in Ethiopia. Fikiru was a committed family man who felt very strongly about his country.

He always tried to help others, especially those who were struggling and who had less. He always told me to help others and he never failed to do that himself. Seeing others smile warmed his soul and heart. His beliefs were based on God’s word and sharing. He was a family man and he spent time on work, doing charity works and with his family.

His daughter was his favourite companion. He enjoyed taking care of her and playing with her. They always went to church together on Sundays. She has been asking for her dad and her best friend every day since he left home and she still does not understand why her dad is not here, and why he is not playing with her, even if just through a phone call.

His hobbies were cooking and reading books. He was the best cook I know. He was loved by his family, friends and colleagues. His mother was his best friend and adviser; his voice always changed when he called her name and talked about her. He adored her so much and she has been broken after losing her beloved son and friend.

He was such a great husband and friend, too. He never failed to love and care for me until death stopped him. We had such a beautiful bond and totally loved each other. He knew how to take care of me and be my best friend, husband and life partner. He deserves every admiration in the world since he was the perfect man and partner and I thank him for that, for the love and respect he gave me until death took him away from me and our beautiful kids.

I know that nothing can bring him back and nothing can take away my pain or save me from my sleepless nights. Nothing can bring back the loving father and son. No one will bring my best friend back. But I do hope that this does not happen to anyone else because no one deserves to endure this pain, no daughter, no son, no mother, no father, no wife, no sibling.

I hope that people will get more protection in the future. I hope those who are responsible will understand how serious this is and understand that the people on that boat were humans as much as anyone else.

MR PHILLIPS: The next recordings and statements you will hear are made by the mother, father, and brother of Niyat Ferede Yeshiwendi, who was born in 1999.

Statement of MR FEREDE YESHIWENDIM NADEW read (in Amharic) (Audio played to the Inquiry)

MS ONABANJO: I am Ferede Yeshiwendim Nadew, the father of Niyat Ferede. I miss my daughter and although I have tried to recall every detail of what she told me, I cannot remember everything. We have been in mourning for a long time and everyone is still devastated. We have lived through a war and my family and I have been through difficult times.

Niyat had a happy childhood. She was an extraordinary girl. She was so thoughtful and loving towards her family. She grew up with her brothers in our home and went to school and then later to university in Mekelle. She was determined to become a pharmacist in Mekelle and to devote her life to helping people.

Before the Tigray war, my family and I had a good and comfortable life in Mekelle. The fighting started in the outskirts of Mekelle and in the west of Tigray before the conflict reached the city.

We left Mekelle around 23 or 24 November 2020. This was the last time I saw my daughter. I was able to speak to Niyat regularly on the phone after she left Addis Ababa. I was in Sudan, where there was no active conflict at the time, so I had signal and was able to communicate with her.

The whole of Tigray was in danger at the time and the rest of my family were trapped there.

I could not communicate with them to get confirmation that they were safe. It was so important to be able to speak with Niyat during this time. We spoke so often because we needed each other. Then suddenly, in mid-November 2021, I did not hear from her.

I found out about the incident and Niyat’s death when Morris called me approximately 10 or 15 days after the incident. He told me that she had drowned in the Channel. He said that the boat had not been rescued and that Niyat had died. I flew to France from Sudan. In France, I met Morris, who had travelled from Dubai.

Before her burial, we were allowed to see her body. Morris and I identified Niyat. This was an extremely emotional experience for me and I broke down in tears. I was devastated. We attended Niyat’s burial together on 29 December 2021.

Niyat was buried in Lille.

We were not able to repatriate her body at the time because of the war in Tigray, and we decided to have her laid to rest in France. The war in Tigray meant that I was barely able to make contact with my wife or my other children for around two years after I left Ethiopia because all communications in Tigray were cut off for the majority of that period.

I could not tell them anything that I knew about Niyat or that I had gone to her burial. We lost our daughter in a place that we do not know or understand. When she told me that she was in Europe, I really hoped that she would be safe. We are a very close family who have suffered a lot in different ways.

My wife has shared in her statement how special Niyat was and how much we all loved her. It is too much to bear that we lost our daughter because she was trying to find somewhere safe.

MS ONABANJO: We will next hear the recording and statement of Freweyni, Niyat’s mother.

Statement of MRS FREWEYNI HAYIEMARIAM GITET read (in Amharic) (Audio played to the Inquiry)

MS ONABANJO: I am Freweyni Hayiemariam Gitet, the mother of Niyat Ferede. My husband and I married in April 1997. Niyat was born in Mekelle, Ethiopia, on 14 June 1999.

She was the third of my four children and the only girl.

After Niyat finished high school in around 2018, she started studying at Sheba University College in Mekelle to become a pharmacist.

Around two years into her studies, in November 2020, the war between the Ethiopian Federal Government and Tigray People’s Liberation Front started in Tigray. Niyat would never have left Mekelle if the war had not started. She was excited about her studies and about becoming a pharmacist. She wanted to set up her own pharmacy in Mekelle. She did not show any interest in going to Addis Ababa before the war started.

We lost her because of this war. She tried to escape so she could survive. My daughter was a truly exceptional person. From an early age, she was known for her kindness and generosity. She often helped our neighbours, especially the elderly and her greatest dream was to, one day, build a shelter where they could be cared for and feel safe.

Niyat was deeply spiritual, spending much time in prayer at churches and monasteries. Her connection with elderly monks may have driven her attachment to the elders around her. Her connection to her faith was evident in everything she did and she constantly sought ways to uplift others.

In our home, she took on significant responsibilities even though she was still a teenager.

Her maturity and sense of duty were beyond her years. Her school friends described her as someone who would put other own needs aside just to help others.

She considered that we had a privileged life because we had a house to sleep in and food to eat. She often compared her life to those who did not have basic housing or enough food.

Niyat was loved by her friends and the entire community. She was the most kind-hearted, humble and intelligent person we have known. Her memory forever live on in the lives she touched.

When the war in Tigray broke out in 2020, Niyat showed remarkable strength. Despite the dangers and challenges we faced as a family, she continued to help, not only us, but also the elderly in our neighbourhood, putting their needs above her own. Eventually, she fled the war hoping to survive and one day achieve her dreams one.

We were not able to speak with Niyat through normal means of communication because the federal government shut down all telecommunication and internet services in Tigray. I did not have any direct contact with Niyat after she left.

In or around December 2021, we had a phone call with my son Morris, who told us that Niyat had died. This came completely out of the blue. I had no idea she had gone to France. All communication was still cut off in Tigray, but we had managed to get access to the satellite phone through an NGO to speak to Morris.

My immediate grief as a mother was indescribable. My husband was away in Sudan, I had lost my daughter, and we, in Tigray, had suffered more than I can describe.

The war was still going on and we could not speak to anyone to find out more information about what had happened to Niyat.

The Pretoria Agreement was signed on 2 November 2022 and we slowly started to get communication services back in Tigray. At first, it was only local phone calls, so we still did not know much about what had happened to Niyat. In around January 2023, we were able to start making international calls again. It was only then, over a year after the incident, that we were able to communicate regularly with Morris and speak with him properly about what had happened.

In March 2023, I was able to travel to France to visit Niyat’s grave near Lille. The pain that I feel when I think about this is overwhelming. I want her body brought to Ethiopia, so that at least we can have her here with us and we can visit her.

There was no way her body could be brought back at the time when she died because of the war. But I wish that somehow we could arrange this, now that the tensions have settled in Mekelle and we are able to have international communication again.

MS ONABANJO: We will next hear the recording and statement of Morris, Niyat’s brother.

Statement of MR MORRIS SLESHI TEWELDE read (in Amharic) (Audio played to the Inquiry)

MS ONABANJO: I am Morris Sleshi Tewelde, the brother of Niyat Ferede Yeshiwendim. Before the war broke out in Tigray in November 2020, I was based in Mekelle.

Both my mother and father have described what the situation was like in Tigray after the war started in November 2020. Niyat left by bus to Addis as soon as the roads re-opened. Addis Ababa was not safe for Tigrayans either. After the Tigrayan Forces retook Mekelle in June 2021, Tigrayans were hunted down everywhere in the country. People were being arrested and detained simply for being from Tigray or having Tigrayan connections.

My sister experienced this. She was arrested when she arrived in Addis Ababa and detained for one week in Katalit Prison. This is why me and her decided that she should leave Ethiopia. Niyat would never have left Ethiopia if war had not broken out. None of us would. We had good lives in Mekelle before the war.

I helped Niyat in every possible way I could before she left Ethiopia. We spoke almost every day — every other day after she left. We kept contact until five or six days before she died. I first heard a boat had sunk in the Channel two or three days after it happened. I was very worried because I had not heard from Niyat for several days and she was not answering my calls.

I found a number for someone from Care4Calais through a social media post and I called her.

After a few days, I was put in touch with the French investigation team. Niyat was buried with Meron in Lille on 29 December 2021. Because of the war, she could not be repatriated to Mekelle where our family was.

Niyat was so loved and was an incredibly special person. Losing my little sister has been devastating for me and for the rest of my family. Our family has been through so much and all we wanted was for Niyat to be safe. I am older than Niyat and I felt it was my responsibility to keep her safe. I did everything I could, but it was not enough. I feel an overwhelming sense of guilt for not being able to protect her. I just wished I had been a bit faster at finding a solution before she decided to take this route.

Niyat had never even seen the sea before she came to Europe. It must have been so terrifying for her. As a family, we need to understand what happened and why Niyat was not rescued. I carry so much guilt for not being able to protect my little sister.

We need to grieve as a family and find some sort of closure, which we cannot do until we know the truth.

We hope that the Inquiry will be able to establish the truth and help to ensure that no other family will have to go through what we have gone through.

MR PHILLIPS: Sir, would that be a convenient moment for a break?

SIR ROSS CRANSTON: Yes, I think so. So, 15 minutes. Thank you. (10.55 am) (A short break) (11.10 am)

SIR ROSS CRANSTON: Mr Phillips.

MR PHILLIPS: Sir, the final three recordings and statements you will hear are made by the father and two brothers of Meron Hailu Gebrehiwot, who was born in 1996.

Statement of MR HENOK HAILU GEBREHIWOT read (in Amharic) (Audio played to the Inquiry)

MS WOODS: I am Henok Hailu Gebrehiwot, the brother of Meron Hailu Gebrehiwot.

I grew up in Adigrat, Tigray with my parents and siblings. I was the second youngest sibling and Meron was the youngest, so we were very close. I know Meron was under a lot of stress before she left Ethiopia. She felt a lot of fear being in Tigray and was very worried about our family.

I know the war was a frightening and difficult time for my family who remained in Tigray. Although Meron did not share anything with me about her mental health generally, she had suffered a lot of trauma as a result of having to flee our home in Adigrat and move around to find refuge from the Tigray war. Meron moved from Tigray to Addis Ababa in mid-February 2021.

She felt very unsafe and scared. She often talked about how this was no life and she needed to leave Ethiopia and go somewhere safe. Psychologically, she was impacted very badly by this. I could see the effect it was having on her. She was scared because of her Tigrayan identity.

We also had no contact with our family in Adigrat because during the war, there was a communication black out. This meant phone lines and internet services were down and it was nearly impossible to speak with anyone in Tigray.

We had no idea if they were alive or how they were. She decided she needed to flee. I spoke to my sister almost every day after she left Ethiopia. I last spoke to my sister on around 22 or 23 November 2021, in the afternoon. She told me to take care of myself and asked if I had any news about the family.

She mentioned she was worried about our father who had not been in the best health when she left Tigray. On 24 November 2021, I saw on BBC news that a small boat carrying migrants had sunk and that some people had died.

I had not heard from Meron since we spoke on the afternoon of 22 November 2021 and I was worried, as we usually spoke almost every day.

We have a cousin from my mother’s side who lives in the United States. I think she saw that a boat had sunk, and that Meron was one of the victims, on social media. My cousin travelled to France from the United States to identify Meron’s body. She then called my uncle who lives Addis Ababa and told him.

One of my other cousins who lives in Addis then called me and said my uncle was sick and I had to go see him. This was not true, but they wanted me to go to his house so he could tell me that Meron was dead. My family wanted to make sure I was told in person, surrounded by family.

This was approximately two weeks after I saw the BBC news report. During that time, I had been worried, but I believed she was alive. Due to the conflict in Tigray, we were unable to safely repatriate Meron’s body to Tigray as there were limited flights and the region was unsafe.

To this day, our cousin who identified the body is the only member of our family to have seen the grave. We have only seen photos. My family and I are desperately trying to get her back to Ethiopia. It is our wish that Meron’s body can come home so that she can be with her family and we can visit her grave.

Meron was the youngest, but she was the rock of our family. She was the one who kept us all close. The family bond was really based on our love for Meron. We miss her and feel the loss of her every day. It is a great sorrow.

We are all so sad and we will never be back to normal following this loss. The mourning period is over, but it continues for my family. My parents cry a lot about this. Meron was the youngest child and so they have lost their baby and I do not believe they will ever recover.

MS WOODS: The next statement and recording is from Tesfahun, the brother of Meron Hailu Gebrehiwot.

Statement of MR TESFAHUN HAILU GEBREHIWOT read (in Amharic) (Audio played to the Inquiry)

MS WOODS: I am Tesfahun Hailu Gebrehiwot, the brother of Meron Hailu Gebrehiwot.

Meron was born in Adigrat, Tigray. My father and mother had seven children. We all lived in Adigrat as a family when we were growing up.

Meron was the youngest and was the centre of our family bond. She was the one who always brought us all together. Before the conflict, she was living a happy life. She was a beautiful woman.

Meron came to Addis Ababa for the first time in 2014. She studied computer science at Addis Ababa University, but she left university in her third year without graduating because she was more interested in being a business owner than studying. When she left university, she opened a take away food business.

After her business closed in 2019, Meron moved back to Adigrat to be with our parents.

Meron and my other sister decided to go into business together. They opened a juice bar, serving fresh fruit juice and milk shakes. They were quite successful and were making a good profit. Meron and our other sister continued to run their juice business until the war broke out in November 2020.

At the time that the war broke out, all of my family, except my brother Henok, was still in Tigray. As a family, we felt that we needed to flee Adigrat as it was not safe. In mid-November 2020, I left Adigrat with my wife and son, my mother, Meron, my other sister, and her eight-year-old and four-year-old sons.

We travelled around to lots of different towns and villages in Tigray, sometimes returning to places we had been. We could not stay anywhere too long.

It was a horrific life. It was a war zone. I felt a lot of responsibility, as the man, to care for my family. I think that Meron was deeply affected and traumatised by this period of our lives. The war and the displacement were extremely difficult for her. Meron was having nightmares about what she was seeing when awake.

We saw total destruction of buildings, homes and lives completely destroyed. The whole region was a battlefield with constant gunfire, overturned cars, crying and bullets.

I could not soothe her. Meron tried to be strong and although she never explicitly said to me that her mental well-being was suffering, I could see that the situation had taken a huge toll on her. Meron left Ethiopia in October 2021.

Our family, who were still in Tigray at this point, did not know that Meron had left Ethiopia. I spoke to Meron about twice a week on the phone after she left Tigray, until around a week before she passed away. I was in South Sudan when I learnt that Meron had passed away, a few weeks after the incident. My friends in Juba became aware of the tragedy and took my phone away from me so I did not read it online.

They were trying to protect me.

My friends sat me down and told me. I could not believe it. I cannot put the grief into words. I could not control my grief and avoided speaking to my family from a few weeks after that.

Due to the conflict in Tigray, Meron had to be buried in Lille in France. This is a great source of pain for our family, especially my mother. It is our wish that her body is returned to Ethiopia.

Everyone is feeling grief and sadness and the family cannot cope with the loss. We cannot bear to spend time together as a family anymore because we feel Meron’s absence. We cannot be together without thinking of her and what we lost. It is a misery every day. Our mother cries every day thinking of Meron.

Recently, we went to our family home and removed some pictures of Meron, because our mother cannot cope with seeing them every day. Even though it has been nearly three years, it still feels like a fresh wound for our family. This has been a heartbreaking experience and we hope to find closure once and for all.

That is our ultimate desire, but every time we have to think about what happened to her, it rips the pain open again. We want her to be remembered and respected. We need to be able to process the pain we are feeling so we can continue living our lives.

We hope that the Inquiry can give us the answers and closure we need to be able to continue our lives without her.

MS WOODS: The final statement and recording is from Hailu Gebrehiwot, the father of Meron Hailu Gebrehiwot.

Statement of MR HAILU GEBREHIWOT read (in Amharic) (Audio played to the Inquiry)

MS WOODS: I am Hailu Gebrehiwot, the father of Meron Hailu Gebrehiwot. My wife and I raised our seven children in Adigrat, Tigray. Meron was my youngest child. I am struggling with immense grief.

I lost my youngest daughter and I find it extremely hard to talk, or even think, about her. Meron was an extraordinary woman; she was kind, devoted and an amazing daughter.

Meron grew up in Adigrat in the family home and lived with us her whole life, except when she lived Addis Ababa. She was a happy child and we had a good life when she was young.

Meron had left Tigray to attend university in Addis Ababa in 2014 and started a business there. But she returned to Tigray in 2019.

Before the war, she had been setting up a business with her sister, and was trying to build a life for herself in Tigray.

She had no desire to leave Ethiopia and our home in Tigray before the war started. She had a good life and she was happy there. She had big ambitions. She was committed to helping her parents and siblings before settling down to get married.

She would care for me and her mother and her siblings, even though she was the youngest, both emotionally and financially, including by helping to support the family with the money she earnt from the juice bar.

She was very kind and humble.

War broke out in Ethiopia in November 2020. My wife, Meron, and my other children, were together as a family during the bombing of Adigrat on 13 November 2020. Everyone in Adigrat was terrified and we did not feel that any Tigrayan was safe.

We were afraid that there would be more mass killings. Meron left Tigray in early 2021. We cried a lot when we had to say goodbye to Meron and we knew we would miss her. But we had no idea that would be the last time we saw her.

During the war, communication was cut off in Tigray. This meant that there was no internet service, no telephone line and no ability to communicate, either within Tigray or with loved ones outside of Tigray. We did not hear from Meron again after she fled Tigray.

Throughout 2021, I was having a lot of nightmares about what was happening to my children who were no longer in Adigrat. I could not speak with or see Meron and my sons, Henok or Tesfahun, and my mind would often start to think the worst. I needed to know how my children were doing and my health was suffering as a result of the stress I was under.

I felt constantly unwell and struggled with deep feelings of worry and fear. I was very depressed and am still struggling today. I am often extremely tired and too sad to speak to anyone and I continue to have very disrupted sleep.

The war traumatised me, as it did my whole family.

Towards the end of 2021, my oldest son went to the border between the Tigray and Amhara regions, to try to find information to give me and my wife some peace. There was some communication there, as people were able to pass on messages on behalf of others by word of mouth. This was the only way to get information in and out of Tigray.

He was hoping that someone might have news of Meron, Henok and Tesfahun. He heard from someone at the border that Meron had died.

Shortly after, he came home and told us that Meron was dead. This was around the 10 December 2021. It is hard to remember the exact date as that time is such a horrible memory. We could not believe the news. We did not even know she had left the country.

A terrible grief came over our family, the feeling was indescribable. Meron was an extraordinary daughter. Meron was the youngest and yet, she was always taking care of us. I was very close with her and feel her loss deeply. Meron was extremely generous. She used to give her clothes away to the needy. It was in her nature to always think of others before herself. She was very responsible. We miss her kind spirit and generosity.

She was our youngest child and such a sweet girl.

Meron’s mother has suffered so much after Meron’s death. She is devastated by what has happened and has many health problems. We both have problems with our eyes and struggle with our sight, alongside various other health issues. We are also both older now and have suffered a lot in our lives. To lose a child who was still so young has been extremely hard for us and especially a child as kind and beautiful as Meron.

We are struggling a lot with our grief. It is a great source of pain for us that Meron is not buried at home. Her body could not be repatriated. The Tigray region was in the middle of an armed conflict and it was too dangerous and expensive to fly her body home. This meant she had to be buried in France. For that reason, we have not been able to visit and had not even seen a photo of her grave until this year, 2024, when our solicitor went to visit the grave and sent us pictures.

We desperately want her buried close to our home, but bringing her body home would be very expensive and we cannot afford it. Because of the war, we were also unable to hold a proper wake and could not be visited by the community or relatives, as the region was too dangerous.

I find it very difficult to talk about this. No parent should ever have to endure the loss of their child. My daughter deserves better. She deserves to be buried at home with her family and given a proper send off. We have been deeply affected by this situation. We believe that every human being should be treated with dignity and kindness. We would like to thank the Inquiry for investigating the death of Meron and we hope that she is treated with respect and mourned throughout the investigation.

The loss of Meron will stay with me and my family forever and she will never be forgotten and we hope that this tragedy will not be forgotten by the UK.

MR PHILLIPS: Sir, that concludes the evidence you will receive in the course of the hearings as to the impact of this tragedy from the loved ones of those who died. Sir, that also concludes the evidence at these full hearings.

SIR ROSS CRANSTON: Well, what we have heard over the last day and a half, has been very upsetting and deeply moving. As I said yesterday, and as I have said on previous occasions, it was important that we gave voice to those who are so deeply affected by the tragedy. It has been — their evidence has been central to our work. So I understand we are coming back at 1 o’clock for closing hearings. So, thank you very much. (11.49 am) (The Lunch Break) (1.00 pm)

SIR ROSS CRANSTON: Well, we now come to the closing statements and I am going to call upon Sonali Naik, King’s Counsel, representing the survivor and the families, to begin.

Closing submissions by MS NAIK

MS NAIK: Thank you very much, sir. As you know, we represent many of the bereaved families and Issa Mohamed, one of two survivors of the tragedy on 24 November 2021.

The survivor and the bereaved families are deeply grateful to you and your team for the humanity, dedication and rigour with which you have conducted the Inquiry hearings. This oral closing statement is made after the closure of four weeks of evidence and after the Inquiry has just heard the powerful family impact evidence yesterday and this morning.

This Inquiry is presented with a historic opportunity to examine the adequacy of the UK search and rescue response on 23 and 24 November 2021 and to expose the dysfunction in the system then tasked with protecting life at sea. That task matters. It matters because of the memories of those lost by our clients that deserve to be vindicated. It matters because you have heard people continue to be at risk and to lose their lives making small boat crossings across the English Channel and your Inquiry matters because it provides a crucial and unique opportunity to prevent the further loss of life at sea.

In this oral statement, we focus on four key submissions; first, we focus on our clients’ loved ones, we emphasise the centrality to the Inquiry of our clients’ voices being heard, we emphasise the preventability of their loved one’s deaths. Second, we submit that this disaster was predictable.

Third, we focus on the discriminatory stereotypes and attitudes towards migrants on small boats, which fatally affected the SAR response. Fourth, we summarise briefly the state failings, both individually and institutionally, which led to the disaster. And fifth, we emphasise that in order for any recommendations you make to protect lives and futures, that the state authorities have to be willing to reflect on and learn from their failings.

So, first, at its most fundamental, this Inquiry is about giving the deceased and our clients a voice, and over the past few days, our clients’ voices have been heard in this room. But what’s vital is that they are listened to and that includes first, their unfathomable grief and trauma of losing loved ones in such uncertain circumstances at sea. And in Issa Mohamed’s case, of surviving such a horrific ordeal.

The victims of this tragedy need to be recognised, not as a homogeneous group of nameless migrants or numbers in Home Office statistics, but they were a collection of individual human beings, each with their own reason for finding themselves on board the boat that night. Some had fled their homes to escape the bullets of a brutal civil war. Others left behind a life without hope for the future, but they were so much more than people on the move and one thing they all had in common, as you have heard so clearly, is that each and every one of them leave behind family and friends who loved them dearly and miss them desperately.

Three of our clients’ loved ones were never found. The failure to find their bodies is a further aspect of this tragedy. Without that certainty, there can be no real closure for the mothers and fathers who may never be able to let go of the hope that one day their sons will be found alive. But second, it also includes listening to their anger, their justified visceral anger at the catalogue of state failures and the discriminatory attitudes that led to the disaster. Their anger at the smugglers who ruthlessly exploited their loved ones. And finally, it means listening to their resolve, their resolve that further tragedies can be prevented so that no family should have to relive their suffering and trauma in the future.

It should be remembered that this Inquiry was only established as a result of our clients’ determination and perseverance in uncovering truth of what happened on the night. They sought the initial confirmation that the disaster engaged the UK’s authorities’ responsibility. They threatened legal proceedings, and they sought disclosure of the documents that would uncover the truth.

Our clients’ grief and anger are magnified by the uncontested evidence before the Inquiry that had the search for Charlie been continued and not abandoned, we say negligently, their loved ones may well have survived. The most basic facts are stark. The coastguard was first made aware of the small boat Incident Charlie at 01:06 am. The last call from the boat was not until an hour and 24 minutes later, at 03:12 am.

We heard from Simon Ling, that had the RNLI all-weather lifeboat been tasked, it could have made it to the location provided for Charlie in an hour and 13 minutes. So there was time; there was time for the vessel to reach the area.

Professor Tipton’s evidence is that although some would have died upon entering the water, the majority of the occupants of Incident Charlie survived entry into the water and were alive 12 minutes after the last call from the boat, at 03:24 am.

We know that the Border Force boat, the Valiant, reached the original co-ordinates to which it had been directed just three minutes after that, at 03:27 am.

Professor Tipton’s evidence is that by 07:03, when the Valiant returning to base and the search for Charlie had been abandoned, some would have died. But the corollary is, of course, that some were alive. That means it may have been possible for more to be rescued alive, right up until just after 1 pm in the afternoon, 12 hours after the first call from the boat. And the evidence from Issa Mohamed certainly suggests that Mohammed Hussein Mohammedie was alive 30 minutes, he thinks, before he, Issa, was finally rescued.

Even on this most stripped back version of the facts of the night, then, we say but for the core SAR failures, some, if not most, of our clients’ loved ones would have survived and could and should have been rescued.

But this stripped down version of events ignores the wider catalogue of operational and systemic failures which contributed to the disaster. It ignores the gross understaffing and under-resourcing, the lack of training and the focus on border securitisation over saving human lives at sea.

The bottom line is this: the tragedy of 24 November was preventable and it should never have happened. But as the numbers of people risking their lives in crossing the Channel rose exponentially from a handful in 2018, the coastguard buried its corporate head in the sand. The Home Office focused on deterrents and security, to the detriment of developing more effective SAR capability. And both failed to meet the most basic and fundamental of their legal obligations; to protect life at sea.

Second, as to predictability, you have heard from the witnesses and will no doubt be told by other full participants’ representatives today, that the increase in small boat crossings in 2021 in November, in the words of the corporate witnesses, wasn’t predictable and was unusual. You will be told, no doubt, to be wary of viewing events in hindsight. But siren calls to resist the use of hindsight should not prohibit proper scrutiny of the steps that should have been known and should have been taken by the state authorities at the time.

As Lord Bingham emphasised, regarding the duty to protect life in the 2009 House of Lords case of Van Colle: stupidity, lack of imagination and inertia do not afford an excuse to national authority which reasonably ought, in light of what it knew, or was told, to make further investigations or enquiries. It is then to be treated as knowing what such further enquiries or investigations would have elicited.

So with that warning in mind, we make eight points on the issue of predictability.

First, at its core, this disaster was caused by the state SAR system being overwhelmed by insufficient staff, inadequate systems for the identification of boats, inadequate communication systems and insufficient surface and aerial assets. Simply put, the system was not fit for purpose.

But, second, whether systems were likely to be overwhelmed depends, in large part, on the numbers of people and boats undertaking the crossing. And the numbers who crossed on 23 and 24 November 2021 was by no means unprecedented. It had been exceeded in both August and September 2021 and it was exceeded five times in the 21 days before the tragedy.

Third, a key aspect of the disaster was lack of aerial surveillance, but Daniel O’Mahoney accepted that it was known to Border Force a year in advance that where aerial surveillance wasn’t able to be put in place, including due to poor weather, that the result would be a detrimental impact on the situational awareness. But there were still no backup systems in place in November 2021.

Fourth, the Home Office’s own Operation Deveran predictions were that risk to life would increase over the winter. The previous year, in December 2020, Daniel O’Mahoney told the then Home Secretary that: we will see an increase of small boat arrivals, likely concentrated on a single day with favourable conditions.

In 2021, Border Force intelligence analysis assessed the risk to life to be high and liable to increase during the winter months. Fifth, the coastguard red migrant days meetings, from September to November 2021, repeatedly raised concerns about the adequacy of staffing levels.

On 22 November 2021, just the day before the incident, the chief coastguard himself commented: the amber days are starting to look more red than amber. But still, resources and assets were not increased.

Sixth, officials at the highest level in the coastguard and Border Force were well aware, months in advance, of the risk of the SAR response being overwhelmed. At a senior meeting in June 2021, attended by the director general of the migration and borders and key corporate reasons witnesses from whom the Inquiry has heard, including Daniel O’Mahoney, Stephen Whitton and James Driver, the situation was described as a humanitarian crisis waiting to happen and it was: amazing that more people haven’t lost their lives already.

As early as 17 August 2021, divisional commander, Mike Bill, wrote a key email to the chief coastguard warning of a risk of overwhelm and stated that: high intensity crossing days meet our definition of a major incident. However, we are not declaring it as such.

Seventh, when those warnings of overwhelm were raised and the response of the senior officials was to be — the response of senior officials was to be concerned at the political impact of initiating a response in an environment of overt hostility and discrimination towards migrants. The reaction at that June 2021 meeting was that ministers viewed the numbers of people crossing as a political problem, which doesn’t fit with the narrative of taking back control of borders.

A decision was then made to proceed with the plan to conduct dangerous pushbacks at sea.

Mike Bill warned, in his August 2021 email, that the reason a major incident was not being declared was political. In his evidence, he said: some of it was possibly political. It was high profile with Government and migrant crossings and they probably didn’t want that in the news. Should we have declared a major incident, it was bound to hit the news, and things like that. So that’s what I mean by “political”.

This was a crucial email that forewarned of subsequent tragedies and provided an opportunity to put systems in place to save lives, but Mike Bill said he didn’t even recall receiving a response.

The 21 August 2021 Migrant Activity Debrief, similarly recorded the declaration of a major or critical incident would be politically sensitive. It also recognised: if we don’t declare, there is a risk that we could be seen not to have acknowledged or realised the significance in any subsequent enquiry.

That statement, of course, proved to be sadly prescient.

Eighth, the response of the Home Office, in particular, was not to focus on saving lives, but to channel time, money and resources into a dangerous and doomed plan, to conduct forcible pushbacks on migrant boats at sea. Daniel O’Mahoney, the small boats tactical commander in charge of the policy, accepted in his evidence to the Inquiry that a very considerable amount of time and resource was spent on Operation Sommen. He said that it was directed by the Home Secretary and the Prime Minister themselves.

He maintained it didn’t detract from planning for an improved SAR response, but that contention does in the withstand basic scrutiny. Stephen Whitton, the head of Border Force Maritime Command, candidly gave evidence that it did have a detrimental impact on SAR, stating: we had a huge amount of pressure to try and develop tactics and operations to try and prevent small boats crossing. That pressure was right across the command and organisations, including the coastguard, were on our knees in terms of the pressure we were under and it was getting hugely challenging.

Turning to the third issue which we address, which is that of discrimination, both the right to life under the European Convention on Human Rights and duty to ensure assistance under the Search And Rescue Convention must be discharged without discrimination, but we know from the evidence that we have heard, that the victims’s identities as migrants and as foreigners shaped the authorities’ response and the outcomes they faced with tragic consequences.

That emerged from the evidence in at least three ways; first, assumptions and stereotypes about migrants on small boats infected the SAR response. Most obviously, the response to small boats was permeated by an assumption from callers — that callers from small boats tended to exaggerate their level of distress. The pervasive and unchallenged nature of that belief was stark. The Inquiry heard evidence that there was a widely held belief that nine times out of ten, a caller from a small boat would exaggerate. Stuart Downs of the coastguard, operated under the belief that migrants were handed out leaflets, instructing them to exaggerate the levels of distress, but was forced to accept in oral evidence that the facts underpinning his belief were not necessarily accurate.

The dismissive attitude at the core of the belief is evidenced most viscerally by language used by the senior commander Dominic Golden and I quote: now, as usual, the catalogue of phone calls is beginning to trickle in of the, you know, the classic, ‘I am lost, I am sinking, my mother’s wheelchair is falling over the side, etc. Sharks with lasers surrounding boat’ and ‘we are all dying’ type of thing coming in. So legally, we are now dealing with a distress.

Mr Golden described his words as unwise or flippant, but they are more than that. They reveal the perceptions held by those in response — involved in the response to the small boats about the occupants. They are not unwise, they are discriminatory. They are a stereotype and the most obvious risk of this stereotype is that call operators and other frontline professionals engaged in the SAR response are sceptical about the veracity of the distress calls and jump to premature conclusions.

Second, we know that this stereotype, not just infected, but affected, the authority’s SAR responses. We know it had a material effect on the way in which the state authorities fulfilled, or failed to fulfil, their duty to protect life. Witnesses repeatedly bore out that by November 2021, there was, in effect, a two-tier system in place, whereby small boats were subject to lesser SAR standards, which put the lives of migrants at risk.

We know, from the evidence, that small boats were not treated in the same way that other vessels in distress were. George Papadopoulos, Small Boats Tactical Commander, told the Inquiry that if a fishing boat makes a distress call to the coastguard, they will, “throw all available resources at it”. In stark contrast, Mr Gibson, the SAR Mission Co-ordinator on shift on Dover on the night, with over 10 years’ experience in the coastguard, told us that he would seek to corroborate information before making a tasking decision because of the assumptions that those on small boats will exaggerate their situation.

Thomas Willows of Border Force was clear that those responding did not believe or treat small boats as genuinely in distress. And in a candid moment of evidence, Dominic Golden, the Commander responsible for the air response, was unable to maintain the fiction that the belief that migrant calls were exaggerated had no effect on SAR responses.

He accepted: there is at the back of your mind a nervousness about how significant is that incident, in terms of distress? And a specific consideration for him was: if I allocate a resource to a call that has said that they are sinking, that that asset is now tied into something that could be a false alarm, a cry wolf, when I now have a real incident 10 miles along the coast.

Neal Gibson, whose evidence is — and conduct is so central to this Inquiry, said that senior mission commanders and SAR professionals questioned: can we take what we are told at face value? He said this led to the need to verify, assess and analyse the information provided from distress calls. He wanted visual confirmation or ‘eyes on’ to observe the callers were not, in fact, all sat there quite happy.

That wasn’t enough for Mubin Rizghar to say to him repeatedly, and in English, on the first call at 01:48 am: we are finished. Or on a second call, 48 minutes later, at 02:31 am, that there were 40 people: we are dying and two are children.

Neal Gibson said he was left unaware of the nature of the distress of Incident Charlie, that the occupants hadn’t satisfied him of whether the boat was just full of water or whether it was, in fact, sinking.

He even went so far as to ask the Inquiry to accept that: “we are all going to die” unfortunately, is not very specific in what’s actually going on in a situation.

These are marks of a SAR response so heavily infected by prejudicial stereotypical views as to render it ineffectual. Shockingly, Neal Gibson’s evidence was that he used a Mayday Relay, the highest alert available to mariners, which, by law, conveys a grave and imminent danger, requiring immediate assistance, merely to get some sort of visual confirmation of what the level of distress was.

The Mayday was then terminated on no adequate basis before the Valiant had even rescued a single boat. It cannot seriously be maintained that any other craft, other than a migrant small boat, would have been subject to such incredulity, second-guessing and doubt by the coastguard.

The third way in which discrimination emerged in the evidence is the authorities’ failure to take positive steps to address the different challenges that small migrant boats presented, when compared with conventional SAR taskings. That long-term systemic failing allowed the discriminatory attitudes and conduct, just referred to, to fester and endure. November 2021 was three years after Savid Javid, as Home Secretary, had declared a critical incident in Parliament in relation to small boat crossings.

But despite this, the authorities failed, over an extended period, to provide any specific training to those charged with responding to small boat crossings in the Dover Straits. Informal and flawed practices developed without assurance testing, which were not reflected in operational policies. Operators were given no guidance or training on how to assess information from small boat callers. Operators had no specific training on language barriers and call handling. And even where the level of English spoken was understandable and conversable, what was said was not taken at face value.

So the fear, the urgency and the sheer terror conveyed directly to him by Mubin and the occupants of Charlie by telephone should have been enough, on any view, to mandate an urgent, persistent and comprehensive response.

Turning to the State failings, the Inquiry has heard, over four weeks, that bears out a litany of failures on the night from the evidence. The families were particularly shocked to hear on Monday, from Matthew Leat, that several of the failures are not accepted on a corporate level by the coastguard. Mr Leat, however, is not a witness of fact. The facts, sir, are for you — a matter for you alone and the evidence of his employees on the ground who had to work in the system tells a very different story.

And the full extent of those failures will be detailed in our written closing. Some, I have referred to already, but we will just list a few here.

The chronic understaffing at MRCC Dover; the exhausted, fatigued and overwhelmed coastguard and Home Office staff; the failure to ask the French coastguard for their tracker, resulting in hours of lost preparation time; the failure to have contingency plans in place for air cover; failure to gather basic information from distress calls and to use translation services; a Mayday Relay, the gravest of maritime warnings, being cancelled without any justification whatsoever; the failure to task an RNLI specialist SAR boat that could have reached the scene earlier; the use of a single informal mobile phone manned by a trainee, which wasn’t even connected to the ViSION log system and which staff had not been trained to use.

The desperate calls to the mobile phone which were missed; the updated co-ordinates which were never recorded or passed on to the Valiant; the failure to directly request that the French authorities task the Flamant to assist, that Neal Gibson said was due to political sensitivities. An astounding admission, given the situation in the Channel at the time, and the duty on states to co-operate with SAR.

And finally, and most fundamentally, the decision to abandon the search for Charlie at 07:03 am, when none of the boats found by 06:30 am, came anywhere near the levels of distress conveyed on the calls to the coastguard and the French authorities.

As to the recommendations and lessons learnt, the families wish to reflect on the evidence before making detailed submissions to you in writing, sir. But the simple point we make here today is that it’s clear that there are vital lessons to be learnt from this tragedy, but in order to learn the lessons, the relevant State agencies and Government departments must accept that there were failings and why they occurred.

The families and survivor were shocked to hear Matthew Leat’s evidence that the coastguard’s corporate position is that little or nothing would have been done differently today, even with the benefit of hindsight. That’s quite an astonishing conclusion and, we say, a hubristic one for a learning organisation, as Matthew Leat repeatedly referred to. The coastguard, as an organisation, does not appear to have been willing to learn or reflect at all.

The families and survivor were equally shocked to hear that the Home Office has never even undertaken an internal review of its actions and systems, some three and a half years after the disaster.

We submit that those are, frankly, arrogant responses to the clear failings that occurred in the run-up to the 24 November 2021. And the families and survivor trust that any recommendations you make will be fully implemented and that the State authorities will demonstrate a willingness to learn lessons for the future.

In conclusion, sir, we wish to emphasise again to you that this Inquiry — your Inquiry matters and why it matters. First, it matters to our clients and earlier this week, several of the bereaved families boarded a boat across the Dover Straits and visited the area around the Sandettie Lightvessel. They gave the captain Charlie’s last known co-ordinates and, in silence, paid their respects at the location where their loved ones lost their lives. Some of our clients’ loved ones’ bodies, as you know, have never been found and their suffering is unimaginable.

Others have been unable to bring their loved ones’ bodies home. And Issa Mohamed, he will be forever scarred by the trauma of what happened to him that night.

Everyone in this room has seen the photos of the missing and the dead on the screens over the past four weeks. Over the past two days, everyone in this room has been moved by the words of the families, including in their own languages. And the families and survivors will always be grateful to you and your team for the way in which you have conveyed their voices, their grief, their anger and their dignity.

But second, your Inquiry matters because it presents an opportunity to emphasise the vital importance of placing equal value on the lives and safety of those who cross the Channel in small boats. One cannot escape the political context in which this tragedy occurred. The fixation on stopping the small boats at all costs and extension of the hostile environment on land, created by the Home Office over the last decade, to the sea, contributed to an environment which permits and sanctions discriminatory treatment.

The daily diet of negative stereotypes in the media of migrants in this country breeds a pervasive and dehumanising culture. Against that background, we heard Mr O’Mahoney tell the Inquiry that the decision not to deploy an emergency rescue vehicle in the Channel, which would have freed up other assets to rescue more people, was abandoned because ministers felt it would effectively act as a magnet for migrants. That it might, in fact, encourage migrants to cross the Channel rather than deter them.

For the reasons given here, we ask you to consider whether our clients were treated by the State authorities as deserving of equal respect and dignity by those responsible, both institutionally and individually.

And third, sir, your Inquiry matters because we know that small boat crossings do and will continue and that since these hearings began on 3 March alone, at least four more lives have been lost.

So, increased securitisation and enforcement measures in the absence of other adequate, safe and viable routes, have failed to stop the crossings. We know that smuggling gangs adapt their tactics in response and ultimately, place people at increased risk. Your Inquiry matters because it provides an opportunity to learn lessons and protect lives in the future from risks that remain acute today.

And this is all in keeping with the purpose of an inquisitorial process, whose purpose is the protection of life, as you know, sir. And again, in the resonant words of Lord Bingham in Ameen that includes: ensuring, so far as possible, that the full facts are brought to light; that culpable and discreditable conduct is exposed and brought to public notice; that dangerous practices and procedures are rectified; and that those who have lost their relatives, may at least have the satisfaction of knowing that lessons learned from his death may save the lives of others.

The bereaved families and the survivor have every faith that you will hold fast to that purpose.

Thank you very much.

SIR ROSS CRANSTON: Yes. Well, thank you very much. I am now going to call on Mr Maxwell-Scott King’s Counsel, who represents the Maritime Coastguard Agency.

Closing submissions by MR MAXWELL-SCOTT

MR MAXWELL-SCOTT: Thank you. Sir, the evidence that you have heard over the last four weeks and in particular the last one and a half days has been a powerful reminder that this Inquiry is, above all, about people.

It is an Inquiry into a human tragedy, in which at least 27 people lost their lives. On behalf of the MCA, I offer our sympathies to everyone affected and our thanks to you and your team for the thorough, focused and efficient way in which the hearings have been conducted.

During the hearings, you have heard from the commander of the Valiant, the captain of R163, and the RNLI’s head of lifeboats. Their crews are on the frontline, rescuing people from the wholly unsuitable and unsafe small boats provided by the criminal gangs. Carrying out those rescues is challenging, and sometimes dangerous.

A clear theme running through the evidence of those three witnesses was their abiding respect for the principle of saving lives at sea.

You also heard from 10 current and former officers of His Majesty’s Coastguard. Their work did not put them in physical danger, but the actions of the criminal gangs also took its toll on them. Christopher Barnett’s evidence was that driving to work on a sunny evening, he would be filled with dread, knowing that there were desperate people putting themselves in a small boat in one of the busiest waterways in the world. He said: the calls are extremely distressing for those of us that take them and repeated night after night, this takes its toll on you. I feel it will have an impact on me for the rest of my life. We do the best we can to get those on small boats to a place of safety. We are coastguards because we care and want to help anyone that finds themselves in difficulty at sea.

Sir, I invite you to agree with me that the witnesses from HM Coastguard who gave evidence were professional and helpful. They were committed to the principle that all passengers on migrant small boats in the UK search and rescue region need to be rescued, whatever their race or nationality. All are classed as in distress.

I have divided my statement today into the following seven points: 1) the real causes of this incident were a number of factors which were outside the control of HM Coastguard. 2) the challenges faced by HM Coastguard in November 2021 and which affected the search for small boat Charlie did not have quick and easy solutions. 3) the best evidence available to the Inquiry about how to co-ordinate search and rescue comes from HM Coastguard and the US coastguard.

4) with migrant small boats, the distinction between what is reported and what can be verified is important. 5) co-ordinating the search and rescue of migrant small boats inevitably requires difficult judgment calls. 6) the need to guard against hindsight. 7) the importance of adopting a realistic approach, rather than an excessively forensic approach when making your judgments about the judgments made by coastguard officers.

Before I turn to my first point, I should say that I have reviewed the contents of the MCA’s written and oral opening statements. I stand by them and they should be regarded as forming part of the MCA’s closing submissions.

My first point is that the real causes of this incident were a number of factors which were outside the control of HM Coastguard. Let me explain why. November 2021 was statistically an outlier. There was no precedent for the number of crossings that took place that month and it still holds the record for the most small boat crossings in a single month.

Dan O’Mahoney told you it was a complete anomaly which, in his professional opinion, was not predictable.

Simon Ling of the RNLI noted that November 2021 formed part of a period, from September to November 2021, in which the spike in rescue demand was simply unprecedented. He said that it was a very difficult period. However, HM Coastguard and all of its search and rescue partners, were under immense strain and pressure, with unprecedented increases in rescue demand. All of this was outside the control of HM Coastguard.

The 23 and 24 November came towards the end of that period of immense pressure. Criminal gangs launched many boats that night, not just the one which is the focus of this Inquiry. HM Coastguard needed to co-ordinate the rescue of each of those boats that entered the UK search and rescue region. Importantly, each of those boats would, on average, generate several new incidents and each new incident would need to be opened, managed, evaluated and closed.

Disaster struck at the worst possible stage of the crossing, when the small boat was essentially in the middle of the English Channel, furthest from land, furthest from help and in the area where mobile phone signal was likely to be at its weakest and least reliable. A further factor, obviously the control of HM Coastguard, was the weather. The night of 23 and 24 November was a rare night on which the planes contracted to provide the overall maritime picture were unable to fly.

The news that they would not be able to fly came very late. It was unexpected. 2Excel had not predicted any problems at the red day meeting at 4 pm on 22 November. It was not until just after 2 am on 24 November that 2Excel definitively stated that all of its planned overnight flights would be cancelled.

The captain of an aircraft has the final say in whether it can fly, and rightly so. Witnesses from HM Coastguard and its search and rescue partners explained the central importance of aerial surveillance in providing a maritime picture. HM Coastguard was deprived of that picture when it needed it.

A further point about the weather is that one cannot view the night of 23 and 24 November in isolation. The Operation Deveran forecast predicted that crossing attempts were likely that night, but that crossings would be highly likely from 6 pm on 24 November.

As I will explain later, this had implications for resource planning.

Other factors outside HM Coastguard’s control were the fact that none of the calls linked to Incident Charlie yielded any ISEK information; the length of time it took Valiant to clear the port of Dover and cross the traffic separation scheme; the technical problem which delayed the takeoff of R163; the response to the Mayday Relay broadcast. Finally, HM Coastguard had no control over three crucial decisions made by the French coastguard: not tasking the Flamant to Charlie; not relaying the report it received from the Concerto; not passing on what those on board Charlie said to the French coastguard in a 17-minute long call which ended at 03:33 am.

Sir, my second point is that the challenges faced by HM Coastguard in November 2021 did not have quick and easy solutions. If the planes could not fly, there was no like-for-like replacement. Helicopters have different capabilities. Given the technology available to 2Excel and the cloud cover present on 24 November, it is unlikely that 2Excel would have been able to provide a maritime picture, even if their planes had been able to fly.

Technology is not available until it becomes available. As Dan O’Mahoney told you, current equipment uses technological enhancements, not available at the time.

Putting in place more assets and more staff takes time. Even if HM Coastguard had been warned at the start of November 2021 that it would be the busiest month ever, there are limits to what it could have done. HM Coastguard had taken steps, before this incident, to increase the headcount at Dover, but it takes months to become a fully trained maritime operations officer. And it takes several more years to become a qualified SMC.

Turning to aerial assets. The MCA had, before this incident, set out a detailed case for Operation CAESAR, which would lead to a significant increase in aerial assets in 2022. Such a project inevitably takes time.

The fact that it led to concrete change as early as March 2022 should be regarded as an achievement.

Finally, surface vessels. The first crew transfer vessel had been deployed in July 2021. This was part of a process of Border Force enhancing its fleet, a process that, inevitably, took time.

In November 2021, HM Coastguard had to work with the staff and assets available to it and to manage them judiciously.

Crew safety is a vital consideration. Captain Trubshaw gave a compelling explanation of the nature of fatigue and its dangers. There is a reason why working hours in the air and at sea are tightly regulated.

Simon Ling told you that by late November 2021, lifeboat crews were under immense pressure. He pointed out that you can’t mandate volunteers and said that crews were experiencing what he called “red day stress”. At the red day meeting on 19 November, the chief coastguard said: if we burn all our assets on Saturday, we won’t be able to respond on the Sunday.

This comment captures the need to manage resources judiciously. It is a point that came up many times in the evidence. Dominic Golden told you that the search and rescue helicopter was the Crown Jewel, but because it could only fly for a short period of time, he had to think very carefully about when best to task it. It would have been irresponsible for HM Coastguard to have deployed all its assets on an amber night, knowing that it would be followed by a busy day and then a red night. If doing so had left it unable to respond to a disaster at sea on the red night, it would be criticised and rightly so.

Point 3. The best evidence available to the Inquiry about how to co-ordinate search and rescue comes from HM Coastguard and the US Coastguard. Who has the Inquiry heard from who has expertise in co-ordinating search and rescue? The answer is the eight coastguard officers who had gained a qualification in search mission co-ordination.

The Inquiry did not hear from any other witnesses with qualifications or experience in the co-ordination of search and rescue. The Inquiry also has the benefit of the report by the US Coastguard. There is a reason why it was necessary for HM Coastguard to reach out to the US Coastguard when it wanted someone to carry out an independent case study. It could not have approached a peer organisation in the UK because there isn’t one. HM Coastguard is the national emergency service for rescue at sea. No other organisation in the UK has the necessary expertise.

My fourth point is that with migrant small boats, the distinction between what is reported and what can be verified is important. There were occasions during the questioning when it was put to witnesses that they knew something. Great care needs to be taken with this concept. It is reasonable to describe any telephone numbers provided by the ISEK system as “known”. It is reasonable to describe sightings by search and rescue assets as “known”, but that’s it. When you are dealing with migrant small boats, every other item of so-called knowledge is, in fact, an unverified report which needs to be evaluated and ideally, to be verified.

A telephone number provided verbally during a call can be misheard or misstated. It’s not known until it is verified. A WhatsApp position can be inaccurate. The actual position of the boat is not known until it is verified.

The reported condition of a boat underway, taken on water, sinking, can be inaccurate or out of date; it’s not known until it is verified. The reported number of men, women and children on board can be inaccurate. It’s not known until it is verified.

Coastguard officers emphasised the importance of verification in their oral evidence. George Papadopoulos spoke of a need for reliable, credible evidence. Neal Gibson talked about the desirability of corroborating, verifying or confirming information. The problem of exaggeration makes reliable information particularly important. The evidence suggests that exaggeration is an umbrella term for two related problems; 1) innocent overstatement, and 2) deliberate exaggeration.

Overstatement and exaggeration cause problems for HM Coastguard. Not so much at the initial response stage, because HM Coastguard took, at face value, that the callers were in distress and HM Coastguard’s policy was to respond to every small boat in order to rescue those on board.

Where the tendency of migrants to overstate and exaggerate caused significant problems was at the stage of attempting to reconcile and close incidents. This brings me to my fifth point.

Co-ordinating the search and rescue of migrant small boats inevitably requires coastguards to make difficult judgment calls. If a fishing vessel broadcasts a Mayday and GPS position in the middle of the Atlantic Ocean, the SMC will have regard to what the IAMSAR manual says about potential survivability when considering for how long to continue active searching.

That model could not be directly applied to shifts involving migrant small boat activity. Consider a call from a boat saying it had 40 people on board and was sinking. An element of judgment had to be used when determining whether such a call was a repeat incident of a previous call referring to 35 people. If a boat was then found which had taken on water and had 33 people on board, an element of judgment had to be used when determining whether it was a new incident or a repeat.

In November 2021, if active searching had continued for every incident opened until there was definitive evidence that it was a repeat, all available assets would have been exhausted very quickly. SMCs had to use their had experience and judgment to reconcile incidents and determine that everyone involved had been rescued, to close incidents as repeats, whilst being willing to re-open them if new information came to light. And when reconciling incidents, they had to bear in mind their awareness, based on personal and institutional experience, that persons on board a single small boat would make multiple calls and would often overstate or exaggerate their predicament.

Point 6, the need to guard against hindsight. 6,971 migrants would cross to the UK in November 2021. But HM Coastguard was not to know that earlier that year or even earlier that month. As it happened, more small boats were launched on the night of the 23rd than on the night of the 24th November, but HM Coastguard was not to know that either. The most recent occasion when there had been an amber day followed by a red day was 10 and 11 November, when 22 boats had crossed on the first night, followed by a record 36 boats the following night.

HM Coastguard was not involved in the creation of the Operation Deveran forecasts. Its role was to make its plans in the light of them, not to attempt to second-guess them. At no point did Mr Gibson know how many small boats were on their way from France. At no point did he know how many small boats were in the vicinity of the Sandettie Lightvessel. At no point did he know that any boat had capsized, or that there were people in the water.

The fact that HM Coastguard had successfully rescued over 35,000 migrants by 23 November 2021 does not mean that rescue was guaranteed or that any fatality was preventable.

To reach that conclusion would be to ignore all of the evidence about the dangerous nature of small boat crossings and the problems that they posed for search and rescue services. To ignore the view of the Court of Appeal, that migrant small boats pose a serious and obvious risk of death, to ignore the very reason why they are rightly categorised as in distress, you must guard against thinking that someone in addition to the smugglers must be responsible for this tragedy.

His Majesty’s Coastguard should not be regarded as the guarantor the smugglers’ dangerous, flawed and criminal business model.

I turn to my final point, the importance of adopting a realistic approach, rather than an excessively forensic approach when making your judgments about the judgments made by coastguard officers. You should recognise and respect their expertise, you should also recognise and respect the expertise and opinions of the US Coastguard.

Coastguard officers are trained to make contemporaneous entries in logs. Such entries give an indication of their thinking at the time. Coastguard officers are also trained to re-evaluate. The fact that Mr Gibson had certain thoughts at 2 am, does not mean that he held the same thoughts five hours later, nor should it do. He was concerned by his call with Moomin, which started at 01:48 am and he took appropriate action.

A Mayday Relay was broadcast, Valiant and R163 were tasked. Valiant was tasked to the Mayday Relay co-ordinates. Once there, Commander Toy decided to head towards the Sandettie Lightvessel. That was a sensible decision, based on his maritime experience and the direction of the tide. Turning to the search carried out by R163, it illustrates an essential point: rescue is not guaranteed.

The section in the MAIB report on effectiveness of search, pattern and detection probabilities has been misunderstood, or the MAIB has, itself, misunderstood the IAMSAR manual.

Flying a search pattern with a track spacing of 0.0 nautical miles means maintaining a permanent hover over a single point. But one would only do that if one could be absolutely confident in one’s choice of point over which to hover.

Nobody with any expertise in search and rescue would recommend that R163 should have flown to a set of co-ordinates, hovered over them for the duration of its mission and then returned to base. Judgment has to be exercised. A balance has to be struck between the size of the search area and the nature of the search within it.

Using track spacing of 0.2 nautical miles, will result in a much smaller search area than using track spacing of 0.7 nautical miles. An expanding square search with track spacing of 0.7 nautical miles was entirely sensible, given that the search was for an inflatable boat and approximately 40 persons, irrespective of whether any or all of them were in the water.

It was not a search for one person in the water.

Captain Trubshaw chose what he considered to be the most suitable search pattern, based on his experience and the conditions at the time. You should not second-guess the correctness of his decision.

The Inquiry has the benefit of the drift calculations and a report of the US coastguard. In the light of them, you should find that Valiant and R163 searched in the right area. You should also find that they were able to carry out effective searches. Valiant spotted two small boats in the right area, without assistance from R163, and R163 spotted several boats including one outside the perimeter of its expanding square search.

We will never know why it did not spot Charlie.

I would encourage you not to engage in an excessively forensic analysis of which boat Mr Gibson thought was Charlie. By the end of his shift, the position was not the same as it had been several hours earlier. Both Valiant and R163 had proved capable of finding small boats. Several small boats had been found and rescued. There had been no further calls link to Charlie, and no relevant sightings.

Mr Gibson re-evaluated the position and formed the view that Charlie had been found. He was right to re-evaluate and it was reasonable for him, when doing so, to conclude that Charlie had been found.

This is not a case of a search being suspended in the belief people were still missing. Mr Gibson finished his night shift believing that those on board Charlie had been rescued. Neither he nor any of his colleagues had any real doubt about that. Nor did anyone who worked the day shift on 24 November.

The fact that that was not the case is a matter of profound sadness for His Majesty’s Coastguard. On behalf of it and the Maritime and Coastguard Agency, I offer our sympathies to all of those bereaved or affected as a result of this tragic incident.

SIR ROSS CRANSTON: Well, thank you very much. I will now call on Mr Prashant Popat, King’s Counsel, representing the Home Office.

MR POPAT: Sir.

Closing submissions by MR POPAT

MR POPAT: Sir, I begin by repeating the heartfelt condolences of the Home Office and the Minister for Border Security and Asylum, for each loss of life in this terrible tragedy, and to the families of the deceased. And for the traumatic impact of the incident on the two survivors, Issa Mohamed Omar and Mohammed Shekar Ahmed.

Sir, every one of us in this room and everyone following the proceedings at this Inquiry will, undoubtedly, have felt a profound sense of distress and sorrow reading the incredibly upsetting transcripts of calls from the migrant boat, as the tragic events of that night unfolded, the deeply moving oral testimony of Mr Omar and now, the heart wrenching and impactful personal statements from the families of those affected by this horrific incident.

Nothing that I say in the next 30 minutes or so is intended in any way to minimise the tragic events that occurred on 23 and 24 November 2021. Or to detract from those personal accounts and statements.

Imagining the perilous journey that each of these men, women and children took on that freezing November night, boarding a criminally unsafe dinghy, with only the most rudimentary and entirely insufficient seafaring equipment provided to them, to cross a treacherous and, indeed, one of the busiest expanses of water in the world, naturally fills us all with dread and terror.

Sir, whilst this Inquiry has rightly focused on the actions of the UK authorities in conducting the search and rescue for those people, it must, we suggest, not be forgotten that these vulnerable individuals were in that boat on that night as victims of ruthless, criminal people-smuggling gangs, who did not have any regard or concern for the safety of the people they were sending into perilous, dangerous conditions, with the odds of survival stacked against them.

Insofar as those gangs had any belief that these victims, and thousands more like them, would survive this crossing, they were relying on the incredible achievements of the UK authorities and agencies who had searched for, successfully rescued, and saved the lives of almost all of the thousands of people put in a similar position before and after this tragic incident.

Many of those people from the UK agencies, whether Border Force Maritime crew, aircraft crew or volunteers within the RNLI, were, and are frequently, called upon to brave treacherous conditions in effecting rescues, putting their own lives at risk to try and save vulnerable people exploited by criminal gangs, who do not care if people live or die, but who are motivated solely by monetary greed.

We know that the responsibility these gangs have for causing or contributing to the deaths of possibly 31 people that night in November 2021 has not been, and cannot be, within the remit of this Inquiry. But nonetheless, we observe that notwithstanding the admirable and important work of the Inquiry in the collection and consideration of extensive evidence, the attendance of 22 witnesses at these public hearings, and the substantial tasking writing a report, the Inquiry has not covered the gross and appalling behaviour of the criminal perpetrators principally responsible for these deaths.

In making that observation, I wish to be clear that we are not, in any sense, suggesting that the Inquiry has not fulfilled its task or that the Inquiry’s work is not of substantial value. It has, and it is. This is an important exercise and those unfortunate individuals who lost their lives or loved ones on that night deserve it and need it. And the Home Office fully agrees that scrutiny must be applied to the actions of all relevant UK agencies, particularly to see if lessons need to be learnt or changes required to be implemented.

Holding an Inquiry such as this is an appropriate course for any responsible civilised state to take. And we, no doubt like everyone else in this room, are grateful that you have taken on this substantial task.

Sir, we are permitted to provide a fairly detailed written closing in the coming weeks and so this oral statement will seek to do no more than highlight the points that we expect to address in the written document. I will begin with two matters of context, which we contend are important for the Inquiry to have in mind in reaching conclusions about the events leading up to and causing this loss of life. And I will move on, then, to consider what I hope is a fair overview of the conduct of the Home Office and its employees in connection with this particular incident.

That will be the substantial part of what I have to say today.

I will conclude by addressing you briefly on actions taken and the need for recommendations. Again, only from a Home Office perspective.

So let me start with the two important points of context that we invite the Inquiry to bear in mind. The first point is the operational context. This is dangerous work, in response to dangerous crossings. His Majesty’s Coastguard started by reminding this Inquiry in its opening statement that the sea is dangerous. As we sit here today, far removed in time and place from the events in the Channel on 23 and 24 November 2021, it is a point worth repeating for two reasons: first, so that all those here can remind themselves, as I have already mentioned, that individuals who are tasked by HM Coastguard to go to the assistance of those attempting to cross the Channel in small boats, do so at considerable risk to their own personal safety.

It takes a great deal of courage to go into the world’s busiest shipping lane, often at night, sometimes in extremely poor conditions, to rescue people who have undertaken this perilous journey.

You heard from Commander Toy, who described in his witness statement the mental and physical toll of this work. As he explained, he and his team were, I quote: working through the night, rescuing people, physically pulling them out of the migrant boat, on some occasions, the water, and in many cases, literally carrying them on board the Valiant.

That description, no doubt, applies to the many other Border Force crews who conducted the vast majority of small boat rescues in the Channel in ’21, and to the RNLI volunteers who also delivered similar assistance. It also applies to the aircrews.

Dominic Golden has explained how, on the night in question, he was trying to convince Captain Trubshaw, the pilot of Rescue 163, to, in his words, “Put his life and his crew on the line to go and fly in what I would consider extremely marginal conditions.”

Mr Trubshaw and his crew did so and they, and the crew of the Valiant, saved 98 people that night alone.

Second, in relation to the operational context point, I refer to a passage in the opening statement of Mr Phillips King’s Counsel, when he referred to the small boat in question as one that had, and I quote, “A safe capacity of far fewer than the, at least 30 people who boarded it that fateful night.”

To be clear, there is no safe capacity for a vessel of the kind supplied by these organised criminal gangs. Termed “a small boat” only for the sake of consistency, they are fundamentally inadequate as seagoing vessels and wholly unsafe for any journey, let alone crossing the Channel. That applies regardless of the number of people on board. All small boats are categorised by HM Coastguard as being in distress, in part because of this.

Using a small boat to attempt to cross the Channel represents an inherent risk to the lives of all those on board. And as we have heard, these boats are difficult to locate and particularly in the dark, whether by naked eye or with technology. In inclement weather conditions, those challenges are made more difficult still. These are not registered boats, they have no manifest, they are trying to cross a maritime motorway while largely invisible to the often extremely large ships using it.

And that is why it is important to remember the sea is very dangerous. Those who navigate it are always taking a serious risk. Without experience or knowledge of the rules of maritime navigation in an inherently unsafe vessel without proper equipment and in the dark and in poor weather, a risky journey becomes one fraught with peril.

At the second important overarching point, for context, is one which the Inquiry is, of course, aware of. The Inquiry has not had access to material generated by, or for the purposes of, the French criminal investigation, into the actions of the French coastguard and the French patrol vessel, the Flamant, on the night in question.

Flamant did not respond to the Mayday issued by HM Coastguard. The reasons for that decision remain unknown. But as Mr Phillips said in his opening statement: on the face of it, it appears that by failing to respond, the Flamant would have breached its obligation to render assistance to persons in distress at sea under the international convention.

French coastguard was also aware that migrant vessels had left France late on 23 November 2021. Mr Omar’s testimony was that a French coastguard vessel, presumably not the Flamant, trailed his boat for between one and one and a half hours from about 11 pm French time.

However, as noted in the Inquiry’s opening, just before 1 o’clock, presumably UK time, in the morning, Dover coastguard received the French tracker for the first time that night received.

It was only on the basis of that information, that coastguard tasked the Valiant to set sail. It’s unclear why it took so long for this information to be relayed to the UK authorities.

So with those context-setting points in mind, let me turn, please, to the role of the Home Office and what it and its employees in Border Force Maritime did and did not do on that particular night.

You have heard from five witnesses who are employed by the Home Office. They have produced substantial witness statements, have attended this Inquiry voluntarily to try and assist it in discharging its terms of reference, in relation to events that took place several years ago. I have eight subheadings for the points I am going to make in relation to this topic and the Home Office’s role and performance.

Some of these points will address some of the points made by Ms Naik in closing, but not all. Those observations deserve proper consideration and respect and we will seek to address them, insofar as possible, fully in the written closing.

Let me turn to the first sub heading and that is the role of Home Office and Border Force Maritime. We suggest that in considering the evidence you have heard, it is important to bear in mind the roles of the Home Office and Border Force Maritime. It is, as you have heard, the Department of Transport and the Maritime and Coastguard Agency who are responsible for civil maritime search and rescue. It is HM Coastguard’s responsibility to co-ordinate those activities and to task adequate resources for them.

The Home Office’s role in November 2021 was to make its assets available to the coastguard for tasking as additional facilities. At the time of the incident, you have heard that Border Force’s involvement in search and rescue was undertaken under the auspices of Operation Deveran and crucially, the actions taken that night were part of Operation Deveran. You have repeatedly heard that the overarching aim of that operation was to save lives.

That was the stated aim of Operation Deveran.

And that was the objective of the crew of the Valiant and of all Border Force personnel working on Operation Deveran on the night in question.

That aim was realised in respect of some 363 people who were recorded by Border Force as crossing the Channel by 11 pm on 24 November 2021. The Inquiry has briefly heard about other operations, procedures and strategies that were deployed before, after and during the period of the incident. But it is very important to be clear that all the work done by Home Office employees that night, to search for and rescue these migrants, was done pursuant to Operation Deveran.

It follows, and it bears repeating, that the primary aim at all times was to save lives.

The next sub heading is Border Force law enforcement function. It is right, of course, that Border Force had another important function, that of law enforcement. However, there has not been any evidence that the discharge of that law enforcement function in any way compromised or impeded the search and rescue mission on the night. In opening, Mr Phillips King’s Counsel raised the legitimate question of whether the launch of the Valiant was delayed while they waited for the embedded law enforcement officer to embark the vessel.

If that had happened, it could, I suppose, have possibly been a way in which the law enforcement function adversely impacted the search and rescue function that night. However, the clear evidence of Commander Toy was that there was no delay to the departure of the Valiant by reason of the enforcement officer embarking. He was on the cutter within the 30 minutes it took to get the Valiant ready to set off.

The next sub heading is available assets. Also in opening, Mr Phillips raised the question of whether a sufficient number of surface assets were available to be deployed on the night of 23 November, considering the substantial number of migrants expected to be crossing that night. I hope it is now clear that there certainly were a sufficient number of assets available to be deployed, if requested. You have seen that the plan for that night had the Valiant as the primary responder and CPV Hunter on standby and able to be deployed in addition to the Valiant if requested.

The CTV Hurricane was also ready to be deployed from the morning of 24 November, during the expected period of operation. Other surface and drone assets were also identified in the plan as available to be deployed throughout 24 November. In short, this tragedy did not arise because there were insufficient surface assets available, or because the assets that were available were unable to effect the necessary rescues. There is no suggestion that had Valiant or another vessel encountered the small boat in question, that it would have been unable to rescue them.

The next sub heading is causation. And before proceeding to the remaining points in this section of my closing, I hope it is helpful to make clear the Home Office’s position on causation. Sir, the people on that small boat tragically died because the boat that the criminals sent them out in failed. That was the primary cause of the incident itself. The search and rescue mission did not succeed because of multiple contributing factors, including bad weather grounding aircraft, delayed communication from France, failure of nearby French vessels to respond to the Mayday Relay, and HM Coastguard’s understandable, but mistaken, belief that the migrant boat had it had classified as Charlie had been rescued. Had these, and no doubt many other, events not happened, the prospects of success of the search and rescue mission may have been improved.

None, on their own, however, could have guaranteed success. However, Home Office staff did not do, or not do, anything that they were responsible for which could fairly be said to have contributed to the search and rescue mission not succeeding.

Let me expand on that a little by reference to some of the events that occurred that night, starting with the decisions to task the Valiant and the determination that Charlie had been apprehended. And that is the next subheading.

We have heard, from witness after witness, that the decision to request surface assets, from Border Force or RNLI, to search for small boats is HM Coastguard’s decision. On that night, as with previous nights, coastguard knew which vessels Border Force had available and they knew that the Valiant was the primary responder. The Border Force staff based at the Maritime Command Centre could not unilaterally task assets for this purpose. Not only do they not have the statutory responsibility or authority to do so, on a practical level, they did not have the necessary information to do so. Information, such as oversight of non-Border Force assets, eg RNLI lifeboats, the coastguard’s ViSION system. They did not hear the very high frequency radio Mayday or distress calls, nor the calls passed via emergency services. And they had not received the training that maritime operations officers or search and rescue mission co-ordinators receive to enable them to prosus and analyse the information.

The role of the Border Force MCC staff in relation to small boat search and rescue was limited to ensuring that once the assistance of a Border Force asset was requested by coastguard, that vessel was tasked as soon as it was reasonable to do so. And that they did. As you know, sir, the call from coastguard effectively asking for Valiant to be tasked was received at 01:24 and within approximately five minutes of that call, Valiant had been tasked.

As for the responsibility for reconciling small boats encountered with the coastguard’s incident names, again, we have heard from both Border Force and the coastguard that responsibility for that task also rested, at all times, with coastguard. Border Force did not have the information to make that judgment. Again, it had not received or managed the information regarding each incident, the communications with the French authorities, or the calls from the boats themselves. Nor did they have the responsibility or authority to reach any such conclusion.

Giving or even sharing responsibility for that decision would be unsafe and wholly wrong. It would have risked misidentification. It is simply not for the Border Force officers, either at sea or in the MCC, to make the determination to link Incident Charlie with the boats embarked by Valiant or to determine to conclude the search and rescue response.

And for the avoidance of doubt, although it was never suggested, as such, to Ms Whitehouse or Mr Willows, that they did do so, we make it very clear that they did not mark coastguard’s tracker entry for migrant boat Charlie as “closed” and they did not instruct the Valiant on what to do next. Nor did they, in any way, make the decision to stop the search and rescue missions on the 24th.

Let me turn, next, to the Valiant’s work and performance that night. She was expected to be ready to depart within 30 minutes of the tasking and she was.

In his opening, Mr Phillips mentioned that she took over 20 minutes to exit Dover. That is correct. As Commander Toy explained, that is also perfectly reasonable and to be expected. That was a very busy harbour, one of the busiest ports in the world and the space within that harbour was controlled, with considerable restrictions on the movement of traffic.

Once a Border Force vessel, in this case Valiant, was tasked and on its way, it was, again, as you have heard, under the direction of the coastguard. Insofar as Valiant’s speed and course to reach the co-ordinates first given is concerned, there was no challenge to Commander Toy’s explanation that he proceeded at safe speed. That speed was necessarily slowed by the need to avoid numerous other vessels in its path and the need to approach the intended location sufficiently slowly to enable migrant boats to be identified and to avoid a collision with them.

Overall, therefore, Valiant was tasked as soon as required, she was ready to depart as soon as was practicable and under the expert direction of Commander Toy, she proceeded as instructed. And that night, like many others, the crew of that cutter successfully rescued nearly 100 people.

So, the next sub heading under this general topic of Border Force actions is the call at 03:11. That relates to the call between Mr Willows and coastguard. Mr Willows, on that call, was told that the Mayday Relay was issued because the migrant boat was full of water and in an attempt to get the nearby French vessel to attend to it. There was also discussion of the possibility of two or three craft near the Sandettie, and an estimate of a nearby French vessel that there could potential be 110 people in small boats in that location.

In questioning, it appeared to be suggested to Mr Willows and, indeed to Ms Whitehouse, in relation to the same call, that receiving that information could have prompted Border Force MCC to task or suggest tasking another Border Force vessel. If that was the suggestion, with respect, it was plainly wrong.

As I have already said, it was not for Border Force MCC to make any such decision. That was the decision entirely for the coastguard. And the information that was received on that call all came from the coastguard, but the coastguard was not requesting Border Force to task another vessel. And whilst that was entirely a decision for Her Majesty’s Coastguard, it may, sir, seem to you like an understandable decision, in relation at least, to Home Office surface assets.

Coastguard had no certainty as to numbers. They knew that even if there were 110 people in distress, that number could be embarked on to the Valiant if absolutely necessary and crucially, tasking another Border Force vessel to leave Dover at 03:11 am would not have led to that vessel getting to the Mayday location any more quickly than the Valiant.

So the final sub heading in this section relates to trackers and record keeping. I have not taken up my limited time for this closing to address the questioning of Border Force employees about recording matters in trackers or in their daybooks. We will do so in the written submissions.

But for now, I just note that it’s clear that any criticisms that might be levelled against any Home Office employee about record keeping — and we will have something to say about that in the written submissions — do not identify any matter which could properly be said to have caused or contributed to deaths.

So, sir, the overall position, we submit, is that it is clear on the evidence that nothing that the Home Office or its employees did, or did not do, caused or contributed to this tragedy. The Home Office is rightly proud of the heroic work of all of its Border Force Maritime staff on that night and more generally, in the search and rescue of small boats in this position.

They have worked tirelessly in this endeavour and through their efforts with other agencies involved, as Mr Whitton explained, they have saved in the region of 130,000 lives.

And in the month of November 2021, let me be clear, they faced an unprecedented and unforeseeable challenge but they rose to it. As Mr O’Mahoney explained, never been or since have 209 small boats attempted to cross the Channel during a single month. Still, and even with the Covid pandemic raging, crew after crew, staff after staff, turned up to do all that they could to save the lives of these exploited and vulnerable people.

So let me turn briefly, and finally, to the issue of recommendations. The Home Office did not take any new steps as a direct result of this tragic incident that the Inquiry is investigating because, for example, in November 2021, considerable work was already underway to improve, most importantly, the intelligence, surveillance and reconnaissance capabilities available to detect small boat activity in the Channel. Those steps were being taken as quickly as reasonably possibly in challenging circumstances.

I will set out now just a very few of the measures that have been undertaken since the incident, noting though, that the position continues to evolve. In terms of co-operation amongst stakeholders, co-location of relevant search and rescue entities in the joint control room was in place in November ’21. That co-operation has advanced further, such that Border Force Maritime directorate effectively now has a 24/7 presence in the JCR.

Perhaps most importantly, intelligence surveillance and reconnaissance capabilities have evolved significantly since November ’21. This means the Home Office are able to locate the vast majority of small boats in the UK search and rescue region in the Dover Straits and that has enabled the elimination of uncontrolled beach landings. No small boat has landed in the UK undetected since December 2022 and that has considerably helped to ensure safety of those in these boats.

Aerial assets are now deployed for our SAR purposes, which are significantly more resilient than those available in November ’21. And landside facilities for the reception of migrants rescued from small boats have also been improved, with a permanent purpose-built facility constructed at the Western Jetfoil. And finally, sir, in this regard, you have heard that by the time of the department the Home Office was already looking to expand its fleet of surface assets, with a crew transfer vessel in use by November ’21 and the Home Office has now procured five CTVs, three RHIBs and other assets for use in the search and rescue operations.

The Home Office was invited by you, sir, to identify any further changes or improvements to feed into recommendations the Inquiry might make. However, the Home Office is aware that it is in position to make further changes, it has made further changes in this context, and therefore, it does not and cannot, identify any particular recommendations for its own activities.

I make it very clear that that is not an arrogant position, as suggested earlier today. It is the best assessment of those involved in this process. The Home Office is confident that in light of the work that commenced before the 23 November, which has continued subsequently, the chances of a similar incident reoccurring are now as low as they reasonably could be. But of course, sir, if you conclude otherwise, the Home Office will carefully consider any recommendations proposed.

Sir, that concludes all I have to say today. I thank you for the opportunity to deliver this closing. And please allow me to say again that the Home Office expresses its gratitude to you and the whole Inquiry team for taking on this task and performing it so diligently and conscientiously. We also say thank you to all the witnesses who have attended to give evidence and to all the legal representatives of the full participants who have worked so hard and co-operatively to provide information and materials to this Inquiry.

And finally, sir, I remember again the lost souls who must be at the heart of this process, and again, convey to their loved ones our sincere condolences and the hope that this Inquiry will have provided them with some answers to help ease their grief.

Thank you, sir.

SIR ROSS CRANSTON: Well, thank you. David Blundell, King’s Counsel, appears for Department for Transport.

Closing submissions by MR BLUNDELL

MR BLUNDELL: Sir, thank you. As you know, I represent Department for Transport, with Myles Grandison, Harriet Wakeman and Claudia Hyde. Over the past four weeks, the Inquiry has heard and received detailed oral and written evidence from a large number of witnesses which the department has also carefully listened to and read. The department wishes, in particular, to recognise publicly the courage of Mr Issa Mohamed Omar and all of the bereaved families for their participation in the Inquiry. Their evidence was powerful and harrowing.

They have spoken and their voices have been heard. Their experiences have, quite rightly, been at the heart of the Inquiry’s work and it is their evidence which has set the context for everything the Inquiry has done.

At the conclusion of these public hearings, the department wishes to repeat its deepest sympathy to the bereaved, to the survivors, and to all others who have been affected by the events that took place on 24 November 2021.

The department also wishes to thank the Inquiry for its extensive work over the past year and to recognise the very real importance of the Inquiry and the public interest in seeking to understand both what happened on 24 November 2021 and what can be learned from it.

The department has sought to co-operate fully with all requests by the Inquiry and will continue to do so as the Inquiry prepares to conclude its investigation.

The department is grateful to the Inquiry for providing it with the opportunity to give this oral closing statement and, in addition, to submit a written closing statement in due course. In the course of this statement, I will provide what we hope and intend to be a helpful overview of a number of topics which have emerged from the evidence and which we consider to be relevant to the department’s role. We will provide a more detailed analysis of the evidence later in the department’s written closing statement.

So with that introduction, the areas I intend to cover in this closing statement by way of summary, are as follows, and there are four of them: first of all, the department’s role and responsibilities in relation to small boats; secondly, the department’s awareness of and response to the increase in small boat crossings; thirdly, the department’s relationship with and oversight of the Maritime Coastguard Agency, MCA; and fourthly, changes to small boat arrangements since November 2021.

Sir, can I begin with the first of those topics, the department’s role and responsibilities in relation to small boats. Now, as outlined in Mr Driver’s evidence, the department’s core role in response to small boat crossings was in its capacity as the parent department to the MCA. This primarily manifested itself in two ways; first, and most importantly, it oversaw the delivery and maintenance of an adequate and effective civil maritime and aeronautical search and rescue, SAR, service through the MCA, which is, of course, an executive agency of the department and by extension, His Majesty’s Coastguard.

It is through HM Coastguard that the Secretary of State discharges her statutory responsibility to initiate and co-ordinate the operational SAR response within the UK search and rescue region. As the Inquiry has seen, while the department does not, and did not, exercise any operational role in relation to small boats itself, it retains responsibility for the framework within which the MCA operates. And oversees and assures its performance, through a variety of formal and informal mechanisms.

As such, throughout the time period of interest to the Inquiry, the department undertook departmental sponsorship and governance of the MCA, working closely and continuously with the MCA to assure itself that an adequate and effective SAR service was in place.

The steps that the department took in this regard will be considered in more detail in turn.

Secondly, and as an extension of its MCA sponsorship duties, the department worked hard to represent HM Coastguard’s equities and interests in cross-Governmental discussions and above all, the paramount importance of SOLAS and SAR operations. The Inquiry has seen that, following the rapid rise in small boat crossings in 2018, work was preceding at pace across His Majesty’s Government to understand the complex causes of, and develop a response to, small boat crossings in the Dover Strait.

Much of this work was done under the auspices of the Clandestine Channel Threat Command, as outlined in the evidence of Mr O’Mahoney.

As outlined by Mr Driver, in all cross-Government decision-making and policy forums, the department was concerned to support the work being led by Home Office colleagues on border security and illegal migration, while ensuring that the response to small boats did not in any way impinge upon the overriding objective of saving lives at sea.

So, I go next to the second point I wanted to cover, the department’s awareness of, and response to, the increase in small boat crossings. Again, as the Inquiry has heard, from autumn 2018 onwards, the number of people arriving by small boats across the English Channel started to rise very substantially and the rising numbers accelerated significantly in 2021, in particular. From 2020, to 2021, the number of people crossing the Channel in small boats increased by more than 230%.

However, as was recognised by many of the witnesses the Inquiry has heard from, even against that backdrop of rapidly rising numbers, November 2021 was entirely unprecedented for the season with a record number of 6,971 people crossing.

As counsel to the Inquiry recognised, in his questioning of Mr Leat, November 2021 was a very, very heavy month indeed. As Mr Leat explained, although the Home Office had been able to predict crossing numbers with very good accuracy within a few percent, November very much bucked that trend and the increase was huge.

Mr O’Mahoney who, in his role as Clandestine Channel Threat Commander, led on modelling projections of small boat crossings for the Government, explained that the increase was neither foreseen nor foreseeable.

In his statement, he makes clear that it is now believed that a new batch of boats and engines entered the supply chain at that time, causing a step change in the logistical ability of the facilitators, which allowed a much greater number of crossings to be mounted in a short period of time. This rapid and significant increase presented a unique challenge for Government. The department and the MCA regularly discussed the adequacy of HM Coastguard’s response capability, in light of the increasing numbers, particularly from summer 2021 onwards, when the projections predicted a steep increase in 2022.

The risk of HM Coastguard becoming overwhelmed due to the levels of crossings was then formally added to the MCA’s corporate risk register in November 2021. In the same month, and prior to the incident, the department’s understanding based on the frequent communication it had at all levels with the MCA and the assurances it had received was that although the high numbers of crossings were placing a considerable strain on the response capability and difficulties might arise if the high levels of crossings were to continue in the longer term, HM Coastguard was at that time able to meet its SAR responsibilities.

In light of the recognition that maritime assets were under pressure, and the fact that those pressures were expected to increase with the high numbers of crossings forecast for 2022, in October 2021, work on Project CAESAR commenced.

Project CAESAR involved a 35 million-pound investment over a three-year period, to enable the procurement of unmanned aerial vehicles, to increase aerial surveillance and situational awareness over the Channel.

It was formally endorsed by the department and HM Treasury in February 2022 and mobilised in March 2022. As Mr O’Mahoney explained, the game-changer is surveillance. In a submission dated 26 November 2021, ministers were informed that the high numbers of small boats crossing the Channel was expected to continue and that if they did, that would place pressure on HM Coastguard operational staff, Border Force, and RNLI maritime surface assets.

It also noted that work was underway to address this challenge. Shortly thereafter, a further ministerial submission, dated 14 December 2021, was jointly prepared by the department and HM Coastguard. This asked ministers to agree to a number of proposals, including that HM Coastguard should explore increasing maritime surface SAR assets and developing enhanced situational capabilities.

This was a reference, of course, to the ongoing work of Project CAESAR and other potential technological developments, to enhance surveillance and the SAR response.

That brings me, sir, to the third of my four topics, that is the department’s relationship with, and oversight of, the MCA. As I have explained, the department’s role in relation to the issue of small boats is defined through its work with the MCA and by extension, HM Coastguard. It is important to stress that the MCA is an operationally independent executive agency, led by senior civil servants and entrusted by the Secretary of State to ensure that the United Kingdom’s international maritime SAR obligations are fulfilled.

Although the department provides appropriate support to, and oversight of, the MCA, it is mindful of the MCA’s unrivalled operational experience and expertise. The Inquiry has heard evidence regarding the suite of formal and informal mechanisms that have been implemented to provide oversight and assurance of the MCA and its response to small boats.

This includes, firstly, the MCA sponsorship board, chaired by the agency owner, which ensures sufficient oversight of the MCA strategic direction, as well as the risks it is managing, whilst also providing a senior forum in which the MCA can raise its concerns.

Secondly, since July 2021, the weekly small boats huddles, attended by members of the department, colleagues at HM Coastguard and DfT legal advisers, have provided a focused and regular informal oversight mechanism. Although the original purpose of these meetings was to provide additional support to HM Coastguard, as well as co-ordinating responses to policies introduced by other Government departments, the meetings had the added advantage of providing the department with greater visibility of HMCG small boat operations, thereby ensuring that the department was aware of emerging issues.

Thirdly, the department retains responsibility for the framework within which the MCA operates and of which Her Majesty’s Coastguard — His Majesty’s Coastguard forms part. The framework confirms that key performance indicators will be used and agreed with the department’s ministers. As Mr Driver explained in his evidence, KPIs are a system used across Government. There are three KPIs specifically relating to SAR, but these KPIs are just one tool that the department uses to judge the adequacy of the SAR provision of HM Coastguard.

Fourthly, tailored reviews of the MCA are also used by the department to oversee the MCA. Whilst the most recent review did not provide a full assessment of the effectiveness and efficiency of the MCA, it was still able to provide valuable recommendations, some of which, despite the disclaimer, clearly illustrate the MCA’s effectiveness.

Fifthly, a further level of oversight is provided by the IMO member state audit scheme. Such audits became mandatory in January 2016. Its most recent review, conducted over eight days in October 2021, was undertaken by a four-person team drawn from the United States of America, Thailand and the IMO secretariate. Although the audit was conducted remotely, it was undertaken using, fully, the principles established under the framework and procedures for the IMO member state audit scheme and the III code.

Sixthly, oversight is also provided by the Marine Accident Investigation Branch, MAIB, which has a statutory responsibility for undertaking investigations to determine the causes of accidents at sea.

Seventhly, the department takes additional assurance from the MCA’s commitment to continuous improvement of its SAR provision, illustrated by its thorough internal reviews in conjunction with its willingness to commission peer reviews conducted by other subject matter experts, such as the US Coastguard.

In terms of support provided to the MCA by the department, this includes: first of all, ensuring that the MCA’s role and obligations are fully understood by other Government departments; secondly, supporting the escalation of concerns to ministers; and thirdly, supporting the procurement of additional SAR assets.

In relation to the first of those matters, the department ensured that policies that had been proposed by other Government departments did not impact on the UK’s obligations to safeguard lives at sea. Following the announcement of both Operation Sommen and Operation Isotrope, the department ensured that HM Coastguard’s responsibilities for SAR were both understood by the Ministry of Defence and reflected in the terms of the operations.

Secondly, following the record number of crossings on 11 November 2021, and the projections for numbers in 2022, the department co-authored the submission to DfT ministers, submissions dated 26 November and 14 December, to which I have already referred.

And, thirdly, and allied to this last point, the department supported the MCA in its procurement of various SAR assets. Most notably, of course, Project CAESAR, to which, again, I have already referred. The department supported the funding, by the MCA, of a modification to the contract with Bristow Helicopters, thereby increasing their coverage to meet the rise in demand.

Furthermore, where concerns were raised but did not materialise, as to the possibility of Border Force withdrawing its assets from SAR operations, the department assisted with the strategic outline business case for the purpose of seeking approval in principle, to develop a requirement and commercial framework to procure surface rescue assets in the English Channel.

Sir, I will turn finally, if I may, to my fourth topic, which is changes to sub arrangements since November 2021. Now in addition to the developments I have already outlined, there have been further significant changes and improvements in Channel operations since November 2021.

For instance, through Operation Isotrope, the department worked with the MCA, the MoD, and Home Office colleagues to deliver improvements in assets and capabilities to support SAR operations. As the Inquiry has heard, Operation Isotrope, which entered into effect in April 2022, was a directive from the Prime Minister to the MoD to assume primacy over all aspects of the Government’s operational response to illegal migration by small boats.

The Inquiry has heard evidence that prior to the Prime Minister’s directive, work was proceeding at pace to respond to Home Office predictions that small boat crossing numbers would rise further in 2022.

As I mentioned earlier, ministers were asked in a submission on 14 December 2021, to agree that HM Coastguard should explore increasing additional maritime surface SAR assets. It was under the auspices of Operation Isotrope that this increase was delivered.

The Inquiry has seen that Operation Isotrope provided a significant uplift in infrastructure and capabilities available to respond to small boat crossings. This included the provision of five crew transfer vessels, and a further three fast reconnaissance vessels. It also further strengthened the inter-agency co-operation arrangements in the Channel, such as the joint control room, arrangements which are still in place today.

As outlined in the witness statement of Jennifer Armstrong, the result was tangible improvements that took place against a particularly challenging backdrop. Thus, as a result of the uplifts delivered during Operation Isotrope, Project CAESAR and the modification to HM Coastguard’s contract with Bristow Helicopters, the SAR asset ecosystem in the Channel today is very different from that in place in November 2021.

One of the issues that the Inquiry has explored during the hearings is whether, following the changes that took place during Operation Isotrope, there would be any benefit to HM Coastguard procuring its own surface assets for search and rescue taskings. Although a draft outline business case was prepared to this effect after Operation Isotrope came to an end, as Mr Driver explained, that proposal was not ultimately taken forward following Border Force’s commitment to continue the contract.

As Mr Driver told the Inquiry, there would be some benefits to HM Coastguard procuring its own surface assets because it would be an opportunity to reposition and refine the search and rescue provision. However, it would also potentially lead to inefficient duplication in the number of vessels used, given that Border Force would still need its own vessels in the Channel given ongoing border security concerns, even if it were not carrying out SAR taskings. Whether assets are procured by HM Coastguard or Border Force, the most important consideration is that the current level of SAR assets in the Channel is maintained. As Mr Driver explained in his evidence, the most important thing being there is no interruption of that contract.

HM Coastguard has continued to learn lessons and drive improvements in its Channel operations since the incident, which the department has, in its role as parent department of the MCA, overseen.

Since the period of time of interest to the Inquiry, the department is aware that HM Coastguard has continued to develop its capability, through including increases to staffing numbers, first of all; secondly, the development of further training, standard operating procedures and specialist technology; thirdly, the improvement of its working relationship and liaison systems with the French authorities; fourthly, the implementation of the recommendations of the Marine Accident Investigation Branch’s report into the incident; and fifthly, the implementation of many of the recommendations of the US Coastguard following its peer review of HM Coastguard’s response to the incident.

As an organisation, the department continuously seeks to identify areas of improvement and looks forward to considering this Inquiry’s recommendations with interest in due course.

Sir, in conclusion, the events of 24 November 2021 were acutely significant and tragic. The evidence given by Mr Mohamed Omar about what happened that night in the Channel was harrowing. And the testimony of all those whose loved ones died in this incident, and which the Inquiry has heard this week, was powerful and uniquely poignant.

No one who has heard it will ever forget it. At the close of these hearings, the department wishes to offer its deepest and sincere condolences to the bereaved, to the survivors, and to all others who have been affected by what happened.

It is of the utmost importance that any lessons that can be learned are now identified, to ensure that history does not repeat itself. The department continues to stand ready to provide the Inquiry with all and any assistance it may require as it prepares to conclude its investigation.

Sir, thank you.

SIR ROSS CRANSTON: Well, thank you. That brings us to the end of these full hearings. I want to thank everyone who has taken part in them. I want to thank those who have given evidence, in particular, as Mr Blundell has mentioned, Omar Issa, and of course, also the family members who have given evidence over the last day and a half.

I should also thank the counsellors who have been in attendance, the translators and interpreters, the Opus team, who have been responsible for the cameras and the streaming, as well the ushers and, of course, the staff at the International Dispute Resolution Centre.

My team and I now have to review all the evidence that we have received, together with the other material. We, of course, have already started to analyse that, but I need to produce a report. I can’t give an estimate today as to when it will be produced. However, over the last 15 months, my team and I have worked at pace and with commitment, and we will continue to do so.

So, thank you very much. (2.57 pm) (The Inquiry concluded)

I N D E X

Statement of MR ANDARGACHEW SHIFERAW ……………..1 read (in Amharic)

Statement of MRS EMEBET KEFYALEW read …………….4 (in Amharic)

Statement of MR FEREDE YESHIWENDIM NADEW …………10 read (in Amharic)

Statement of ………………………………….13 MRS FREWEYNI HAYIEMARIAM GITET read (in Amharic)

Statement of MR MORRIS SLESHI TEWELDE ……………16 read (in Amharic)

Statement of MR HENOK HAILU GEBREHIWOT …………..19 read (in Amharic)

Statement of ………………………………….22 MR TESFAHUN HAILU GEBREHIWOT read (in Amharic)

Statement of MR HAILU GEBREHIWOT read ……………26 (in Amharic)

Closing submissions by MS NAIK ………………….31

Closing submissions by MR MAXWELL-SCOTT ………….53

Closing submissions by MR POPAT …………………69

Closing submissions by MR BLUNDELL ………………91