Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0118, written 25 Mar 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Mar 2015 |
|---|---|
| Reference | 2015-0118 |
| Deceased | Harold Ambrose |
| Coroner | Eleanor McGann |
| Coroner area | Essex |
| Category | Other related deaths |
| Organisation named | North Essex Partnership University NHS Foundation Trust |
| 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.
ANNEX A 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: Theresa May MP, Home Office CORONER | am Mrs Eleanor McGann, HM AREA Coroner, for the coroner area of Essex 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 28" May 2014 ! commenced an investigation into the death of Mr Harold Ambrose, 82 years of age and Mrs Wendy Ambrose, 77 years of age. The investigation concluded at the end of the inquest on 17" March 2015. The conclusion of the inquest was — Mr Harold Ambrose took his own life Mrs Wendy Ambrose was unlawfully killed. CIRCUMSTANCES OF THE DEATH .On Saturday 24" May Mr Ambrose telephoned Essex Police and told the operator that he had just shot his wife and was going to shoot himself in the very near future. Police attended and found the bodies of Mr and Mrs Ambrose. The subsequent investigation established beyond reasonable doubt that Mr Ambrose had indeed shot his wife and then himself. That is the conclusion that | returned. 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. — Mr Ambrose had held a shotgun licence since November 1987. This was renewed every 5 years at which time there was a full review. The last review was in 2011. On 18" November 2011 a letter from Essex Police Firearms Department was sent to his GPs surgery notifying them that he was a shotgun holder. No further details from this letter were entered onto his medical record and the fact that he was a firearms holder was not flagged on their system. In 2011 Mr Ambrose did not have any mental health problems. In September 2012 he was diagnosed with mixed dementia and this gradually worsened. He was receiving some input from the North Essex Partnership University NHS Foundation Trust (NEPT) following a referral from the GP in October 2012. Mr Ambrose made NEPT aware that he had a shotgun license in his initial assessment in November 2012. | In May 2013 he was prescribed Alzheimer's medication and was advised not to drive by his GP due to his cognitive impairment. In January 2014 it was clear that there had been | a decline in his mental abilities and this decline continued. Although his mental health was clearly deteriorating neither the GP or NEPT referred this case to Essex Police Firearms Department. In evidence a representative of Essex Police said had they been made aware of his Mental Health problems they would have initiated a review of Mr Ambrose’s fitness to hold a shotgun licence. There is no requirement that GPs or Mental Health Trusts notify the police of concerns about a patients mental health when they are aware that they have a firearms licence. be RR ee 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action. —— SS SO 7 | YOUR RESPONSE You are under ; a duty to respond to this report within 56 days of the date of this report, | namely by 22" May 2015. |, 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. OO 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons Niece of Mrs Ambrose. HM Inspectorate of Constabulary DC! SE Firearms Licencing, Essex Police | 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 | [DATE] [SIGNED BY CORONER] 25 March 2015
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