Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0269, written 21 Oct 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Oct 2013 |
|---|---|
| Reference | 2013-0269 |
| Deceased | Robert Wilkinson |
| Coroner | Andrew Tweddle |
| Coroner area | County Durham & Darlington |
| Category | Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Constable, Durham Constabulary 1 CORONER I am Andrew Tweddle, Senior Coroner, for the coroner area of County Durham and Darlington CORONER’S LEGAL POWERS 2 I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. (see attached sheet) 3 INVESTIGATION and INQUEST On10th June 2013 I commenced an investigation into the death of Robert Wilkinson aged 65 years. The investigation concluded at the end of the inquest on 18th October 2013. The conclusion of the inquest was that the deceased intentionally took his own life Medical Cause of Death 1a,. Fatal Gunshot Injuries CIRCUMSTANCES OF THE DEATH 4 The deceased had been a firearms and shotgun certificate holder for a number of years. Although there had been some historic incidents with regard to his licence, no issues of concern had been raised with the Constabulary for many years. In late 2012, the Police became aware, through a change in family circumstances, that a question of the deceased’s suitability to continue being a certificate holder was raised and enquiries and reports received led to Deputy Chief Constable signing a Letter of Revocation for the certificates on 3rd May 2013. It was intended that the revocation letter being personally served upon the deceased. It was not so served prior to his death. The deceased was a very keen shooter and was suffering from a terminal illness. The deceased shot himself with one of his firearms the day after being discharged from hospital. It was never thought by the Police that the deceased was a threat to any third party. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) As part of the process leading to the decision to revoke, although there had been contact with the deceased/his family/medical practitioner, there had not been a face to face meeting between a member of the firearms licensing team and the deceased. Such a meeting would have provided better quality of information to enable those considering the issue of revocation to have made the decision on the best possible information (2) The revocation letter was never personally served. The deceased was in hospital for some of the time. Contact had been made with the deceased’s family, in particular his son, and whilst it may not have been said in clear terms, the inference clearly was that the deceased was to have his certificates revoked and it was the deceased's son who communicated this information to his father and not the Police. Further consideration needs to be given as to the most appropriate means by which a decision to revoke should be made known to the certificate holder. It is accepted that this was a difficult case for the Police to manage, but clearly if the deceased had not had access to his guns on the day that he shot himself then he would not have been able to take his own life in the way that he did on the day that he did. Thus, an objective review how this case was managed should be undertaken so that improvements to the system might be identified with the result that similar fatalities in the future might be avoided. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16th December 2013. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Person I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 21st October 2013 Signed…………………………………… HM SENIOR CORONER COUNTY DURHAM AND DARLINGTON
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
16 DEC 2913 DURHAM CONSTABULARY = Mike Barton LL.B. Chief Constable Chief Constable’s Office Constabulary Headquarters. Aykley Heads Aiming for DURHAM EXCELLENCE County Durham DH1 5TT DX: 68850 Web Site: www.durham.police.uk E-mail: Your Ref: Our Ref: CC/CR Date: 10 December, 2013 Re: Inquest into the death of Robert Wilkinson b.20/06/1947 Thank you for your letter of 21st of October 2013 subsequent to the inquest which you held into the death of the above named person and in accordance with regulation 28 & 29 of the Coroner's (Investigations) Regulations 2013. | note your comments in Section 5 of your letter that you accept that this was a difficult case for the police to manage. Having considered your letter | will respond now to the two matters of concern you raise. 1. The benefit of a face to face meeting between a certificate holder and a member of the Firearms Licensing Team. | acknowledge that such a meeting could provide better quality of information to enable more informed decision making. Indeed | am aware that Chief Inspector EI acknowledged this point in his evidence before you, on the 18th October 2013. | would confirm that when such a meeting RESTRICTED Mr Andrew Tweddle H.M Coroner's Office PO Box 282 Bishop Auckland Co Durham DL14 4FY RESTRICTED would add value to any review of a shotgun/firearms certificate holder then this will be undertaken and now forms part of the structured review process. | would add that it is important that such a meeting should have a specific aim in view of the numbers of reviews currently undertaken by Durham Constabulary. | am pleased to report that the Constabulary’s efforts to monitor 8,500 certificates has led to over 100 refusals and revocations so far this year. In many of these cases the behaviour of the certificate holder was sufficiently disturbing that a face to face meeting would not have added value to the refusal/revocation process. 2. You requested an objective review of how the Robert Wilkinson case was managed so that improvements to the system might be identified. After the sudden death of Mr Robert Wilkinson was reported to the police a Gold Group was set up and managed by Deputy Chief Constable and the facts of the case reported to the Independent Police Complaints Commission (IPCC). As a consequence the decision making around this case was scrutinised by the IPCC who forwarded the Constabulary a number of key questions to answer. I MEE also referred the matter to the Professional and Legal Services Department (PS & LS) for investigation with a specific focus on the rationale around the circumstances of Mr Wilkinson retaining his firearms and the related record keeping. | know the IPCC were satisfied once their queries were answered that this case should be investigated locally. The subsequent review by the PS & LS Department was undertaken with specific terms of reference and a particular focus on whether agreed protocols and procedures had been followed (post Atherton). What became apparent from these processes was the amount of information provided to the Licensing Authority by Robert Wilkinson’s immediate family in mitigation of the seriousness of his health issues and his passion for shooting. My staff endeavoured to balance Mr Wilkinson’s wishes to continue with his pastime and have to a great extent relied on his family’s on-going support. On reflection an earlier meeting with Mr Wilkinson once the initial GP report was received and lesser emphasis on the information from his family may have led to a different outcome. My Professional Standards Department reported that procedures were indeed followed. Lessons were also identified and these highlighted the potential weaknesses with the current paper format of Firearms Licensing files; the number of systems used to record actions and decisions and the volume and apparent dis- organised state of the (Robert Wilkinson) Licensing files which made prompt retrieval of information problematic. These matters are currently being addressed with a considerable investment in time by the Firearms Licensing Department in the rationalising and indexing of the 8,500 live certificate files. The aim is to convert all of the certificate files into a more efficient electronic format. RESTRICTED 2 RESTRICTED | hope the evidence presented by Chief Inspector Hi at the inquest and my response here provides you with reassurance that Durham Constabulary continues to invest to ensure the effective and efficient management of Firearms Licensing. We are also working closely with our Local Medical Committee and the Counties ninety GP surgeries in a pilot that seeks to more effectively and proactively identify medical risks relevant to firearms and shotgun certificate holders. This has national implications and our work is being closely followed by ACPO and Home Office. If | can be of any further assistance to you in these issues please do not hesitate to contact me. Yours sincerely fo Michael Barton Chief Constable RESTRICTED 3
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