Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0027, written 21 Jan 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Jan 2014 |
|---|---|
| Reference | 2014-0027 |
| Deceased | William Dowling & Victoria Rose |
| Coroner | David Ridley |
| Coroner area | Wiltshire & Swindon |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Rt Hon Damien Green MP Minister of State for Policing, Criminal Justices and Victims, House of Commons, London SW1A 0AA 2. Chief Constable Andrew Marsh (Hampshire),ACPO Chair, Firearms and Explosive Licensing Working Group, Hampshire Constabulary, Police Headquarters, West Hill, Romsey Road, Winchester, Hampshire S022 5DB 3. PY Chair British Medical Association, BMA House, Tavistock Square, London WC1H 9JP 4. Chief Constable Patrick Geenty, Wiltshire Constabulary, Wiltshire Police Headquarters, London Road, Devizes, Wiltshire SN10 2DN 5. HR ittshire Clinical Commissioning Group, Southgate House, Pans Lane, Devizes SN10 5EQ CORONER | am David Ridley, Senior Coroner for the Coroner area of Wiltshire and Swindon CORONER’S LEGAL POWERS | 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. INVESTIGATION and INQUEST On 07 March 2013 | opened the Inquests into the deaths of William Howard DOWLING and Victoria Elaine ROSE aged 59 and 58 respectively at the time of their deaths. On 14 January 2014 | concluded their Inquest. The conclusion reached at the end of the inquest were that Victoria was unlawfully killed and William, known as Bill, took his own life although | did add was suffering with depression and general order anxiety. | found that the cause of death of Victoria was 1a) Shotgun wounds to the head and in the respect of Bitl | found that the cause of his death was 1a) Shotgun wound to the head. CIRCUMSTANCES OF THE DEATH Bill had sought professional medical help on 12 February 2013. He was having difficulties at work and the evidence also pointed to him never really coming to terms with the death of his mother in 2011. He saw his General Practitioner a total of 7 times between then and his death on 02 March 2013. Bill was experiencing insomnia and the medication focussed on addressing that together with depression and anxiety. As a result of feedback from Bill to his General Practitioner the medication was modified but the post mortem report following Bill's death found that he had not been taking his medication as prescribed by his GP. The last contact with his GP was on the day before his death and in evidence (MJ indicated that there had been a degree of improvement as regards the anxiety and that they were then going to be focussing on medication for depression as it appeared that Bill had voluntarily ceased taking the anti- depressive medication. On the morning of Saturday 02 March 2013, Bill just after 8 o'clock telephoned his ex- girlfriend Victoria Rose who had been supporting Bill through his illness, complaining of bleeding from various parts of his body and coughing up blood. None of these symptoms were proven at post mortem. Victoria arrived at Bill's home at 4 Moonrakers Estate, London Road, Devizes, Wiltshire shortly before 8.40. She entered the property and the evidence pointed her confronting Bill armed with a shotgun. He then proceeded to take aim and as Victoria attempted to leave the property she was shot twice in the back of the head in the porch area of the front of the property. Bill then reloaded the shotgun and shot himself in the head. At the time of his death Bill had retired from Wiltshire Police where he served as an Inspector at the end of 2007 before becoming an MOD employee in January 2008. 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 those concerns to you. The MATTERS OF CONCERN are as follows. — (1) During the course of the hearing | heard evidence from Wiltshire Police Firearms Licensing Manager, who indicated to me that at the present moment in time aside from a letter (copy attached marked A — since July 2011) which is sent to General Practitioners when firearms license applications are successful or where they are renewed, giving a doctor the opportunity to relay relevant information in relation to their patient within 14 days, there is currently no memorandum of understanding or legislation that allows doctors the ability during the duration of the term of a firearms license, which stands at 5 years, to report matters which may have a bearing on that patient's suitability to hold a firearms license and possess firearms. Doctors of course are bound at the present moment in time by patient confidentiality. | am concerned that this restriction may impede the firearms authority from making crucial decisions as regards individuals possessing firearms and continuing to hold a firearms licence in circumstances which, at present, may not come before the attention of the Firearms Authority unless the matter has ordinarily come before the police’s attention as a consequence of other aspects of their duties. In evidence from i she made me aware that Wiltshire Police through the cooperation of NHS Wiltshire Clinical Commissioning Group and two Doctor’s Surgeries were piloting a scheme (directly prompted by Victoria's two sons as a result of this tragedy) effective from September 2013, to allow an increase in the sharing of information in particular having a bearing on the suitability of an individual to hold a firearms licence. She indicated that as a result of this pilot scheme an individual's firearms were taken away at short notice as a result of the information received from the General Practitioner. This pilot scheme seems to me to be an utterly sensible idea although at present it is a pilot scheme and is not a national concept. This ought to be urgently reviewed. (2) | am also concerned that any review arising out of this letter should not be singularly restricted as regards sharing information solely related to the suitability of somebody to hold a firearms licence. Information sharing with a view to public safety should be a reason for General Practitioners to make relevant authority(s) aware and | have in mind here the example of a driver whose eyesight is failing and where advice given from a GP to inform the DVLA, however that driver chooses not to do so as it will mean their licence may be revoked. If it is a matter of public safety then | am concerned at present moment in time that confidentiality appears to outweigh the concept of public safety. (3) | am also concerned as regards decisions being made relating to firearms licensing in respect of current employees within that licensing organisation’s (ie the Police) employment or even former employees. Licensing and the determination of such matters should be seen to be transparent and independent. In evidence although relating to matters some 16 years previously there were issues raised by family concerning complaints by Mr Dowling’s ex wife at the time they were getting divorced that appeared to have been “brushed under the carpet” by the police in respect of which Bill was a serving officer. In any event those concerns were not dealt with satisfactorily from the complainant's perspective. | am concerned that to have a firearms licensing authority dealing with applications from existing police employees or even former employees of that police force is open to possible abuse. Bill Dowling was an exceptionally well known and respected former police employee and my concern is that such matters relative to firearms are so serious that consideration ought to be given to introducing an independent layer so as to ensure independence and transparency. ACTION SHOULD BE TAKEN In my opinion action should be taken with a view to reviewing the position as regards an introduction of a memorandum of understanding, guidance or even the introduction of legislation so as to ensure that there is sharing of information, the purpose of which is to ensure public safety and to minimise risks, so that those that have the power to take action can make an informed decision based on as much information as is reasonably available. |! would also like the review to consider other areas not just firearms for the reason indicated in Item 2 above and finally insofar as ACPO and Wiltshire Police are concerned to review matters having regard to my concern itemised at 5(3) above. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 18 March 2014. |, 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. COPIES and PUBLICATION | have sent_a copy of my report to the Chief Coroner and to the f i Person (son of Bill) for the Dowling Family and (son of Victoria) for the Rose Family. lam 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. S22 21 January 2014 HM Senior Coroner
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