Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0076, written 25 Feb 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Feb 2016 |
|---|---|
| Reference | 2016-0076 |
| Deceased | David Palmer |
| Coroner | Murray Spittal |
| Coroner area | South Lincolnshire |
| 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.
AR W Forrest i, rrcp, FrcPath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire 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: As fF | Assistant Chief Constable, Lincolnshire Police 1 | CORONER lam M J Spittal, Assistant Coroner for the Coroner's area of South Lincolnshire. 2 | CORONER’S LEGAL POWERS and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 3 | INVESTIGATION and INQUEST On 3% November 2015 | commenced an investigation into the death of David Palmer, age 59. The investigation concluded at the end of the inquest on 10" February 2016. The conclusion of the inquest was Narrative Verdict. CIRCUMSTANCES OF THE DEATH Mr Palmer had a licence for 3 firearms which were kept in a locked cabinet. He he did not keep in his gun cabinet in against the possibility of a spot check by Police Officers. He suffered from Lung Cancer and died as a result of a massive head in jury from his unlicensed shot gun. also had a shot gun with a 5 cartridge magazine which was unlicensed and which Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk AR W Forrest ium, rrcr, FRcPath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire 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. In the three and a half years | have investigated 4 deaths resulting from self-inflicted firearm wounds. Three of those involved unlicensed weapons. These weapons are generally not stored securely and are thus available for impulsive use. The MATTERS OF CONCERN are as follows. — 1 Making public the practice | understand to be in place to the effect that the surrender of an unlicensed firearm does not usually result in prosecution might usefully be considered. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 11" April 2016. |, 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 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. 25" February 2016 MJ Spittal sisserssnes istant Coroner for South Lincolnshire Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk
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