Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0534, written 12 Dec 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Dec 2014 |
|---|---|
| Reference | 2014-0534 |
| Deceased | Jason Palmer |
| Coroner | John Tomlin |
| Coroner area | Exeter and Greater Devon |
| Category | Police related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Devon and Cornwall Constabulary 1 | CORONER | am John Geoffrey Tomalin, Deputy Coroner for the coroner area of Exeter and Greater Devon. 2 | 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. 3 | INVESTIGATION and INQUEST On 18 July 2013 | commenced an investigation into the death of Jason Geoffrey PALMER. The investigation concluded at the end of the inquest on 6" November 2014. The conclusion of the inquest was that Mr Palmer had taken his own life. 7 | 4 | CIRCUMSTANCES OF THE DEATH Mr Palmer died from a shotgun injury to the head. The shotgun used was his own shotgun. At the time, Mr Palmer had consumed a large quantity of alcohol. He and his wife had also separated. 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) Mr Palmer applied for a shotgun certificate in December 2004. His licence was granted in January 2005. The licence was for renewal in 2009 and the Firearms Officers were aware there had been certain domestic incidents involving Mr Palmer and his wife but were assured by Mr Palmer these were no longer of significance. Mr Palmer's licence was renewed on 19 January 2010. The Firearms Licencing Operations cfficer TE commented in a Statement at the Inquest that if he and his colleagues has been aware the number of police incidents relating to Mr Palmer's domestic situation, then they would have made more robust enquiries into the suitability of Mr Palmer to possess shotguns at the time of his renewal. That information was contained within secure Police Logs for the protection of Officers. Whilst it is understandable for confidentiality reasons and the protection of Officers in circumstances where personal incidents had occurred, if Mr Palmer had been a member of the public, as opposed to a serving Police Officer, then the Firearms Unit would have been aware of these incidents from the Police logs. It may be prudent for such information to be made available to the Firearms Unit and the restricted logs reviewed perhaps at Senior Officer level and if appropriate that information passed to the Firearms Unit for assessment. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Friday 6" February 2015. 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and _to the following Interested Persons, EEE (\Vife of Deceased) and | (Father of Deceased). | 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. Signed: wed John G. Tomalin H. M. Deputy Coroner Dated: 12 December 2014
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.
Devon & Cornwall Police Building safer communities together Your ref. i’ Mr John G. Tomalin H.M Deputy Coroner Assistant Chief Constable Exeter and Greater Devon Coroner's Office ; Force Headquarters Room 226, Devon County Hall Devon & Cornwall Police Topsham Road Middlemoor, Exeter Exeter Devon | EX2 7HQ EX2 4QD . RECEIVED - 5 FEB 205 Tel. 101 4 February 2015 Dear Mr Tomalin RE: JASON GEOFFREY PALMER (DECEASED 13 JULY 2013) | write further to your letter of 12 December 2014 and the attached Regulation 28 report addressed to the Chief Constable, in respect of which | hereby provide a substantive response on behalf of the organisation. | understand the Regulation 28 report to have been prepared arising from the Inquest into the death of Mr Jason Palmer, which concluded on 6 November 2014. As | understand it, the issue which has caused you concern in relation to Mr Palmer’s death is that you had before you evidence or TT siting that when he had been considering Mr Palmer’s application for the renewal of his shotgun certificate, he had not been aware of a number of police incident logs relating to Mr Palmer’s domestic situation as they were restricted, and that had he been aware of their content, further - enquiries would have been undertaken as to his suitability to possess shotguns at the time of the renewal in 2009. A thorough review has been undertaken of the procedures and policies in place to ensure that this concern is addressed. The process which is followed upon receipt of an application for the granting or renewal of . a certificate is that a Firearms Enquiry Officer (FEO) will interrogate the relevant police systems for any incidents of concern,-as a part of their investigation into the applicant’s suitability to possess firearms. As part of this process, all logs relating to the applicant will be seen by the FEO. This includes the presence of any restricted logs, albeit that the content can only be viewed by an officer of the rank of Inspector or above. The FEO is required to make contact the Control Room in order that the content of any restricted log is viewed, and any relevant information contained therein is communicated to the area the purposes of any decision regarding the application. NOTE: We are not prepared to accept service of documents by electronic mail OJ / 0043847 354788 Goverment tantars # CUSTOMER SERVICE EXCELLENCE f 101 &) www.devon-cormwall.police.uk SF61S Whilst this process is already followed within the Firearms Licensing Unit, a written working practice is currently being developed which formally captures this detail. In addition, a significant change has been made to the method by which the Firearms Licensing Unit are alerted to any incident log which relate to an existing certificate holder. An electronic system has now been introduced which “sweeps” all police incident logs every ten minutes. In the event that any log relates to an existing certificate holder, an immediate alert is sent to the Firearms Licensing Unit, where the log content will be checked to identify whether any concern arises as a result as to that individual's suitability to possess a firearm. In the event that the log is restricted, a request can be made to the control room for the log to be reviewed and any relevant information provided. 1 trust that this adequately deals with the concern raised within your Regulation 28 report, however in the event that you have any questions or require any further information, please do not hesitate to contact me. Yours sincerely Assistant Chief Constable OJ / 004384 / 354788 Page 2
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