Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0195, written 25 Jun 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Jun 2018 |
|---|---|
| Reference | 2018-0195 |
| Deceased | John Hill |
| Coroner | Rachael Griffin |
| Coroner area | Dorset |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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. Rt Hon Sajid Javid MP, Home Secretary, Home Office, 2 Marsham Street, London, SW1iP 4DF 2. Mr James Vaughan, Chief Constable of Dorset Police, Force Headquarters, Winfrith, Dorchester, Dorset, DT2 8DZ 1 | CORONER I am Rachael Clare Griffin, Senior Coroner, for the Coroner Area of Dorset 2 | CORONER’S LEGAL POWERS 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. 3 | INVESTIGATION and INQUEST On the 9" June 2017, an investigation was commenced into the death of John Edward Hill, born on the 22" January 1940. The investigation concluded at the end of the Inquest on the 224 June 2018. The Medical Cause of Death was: 1a Head Injury due to skull penetrated by rifle bullet The conclusion of the Inquest was Suicide. 4 | CIRCUMSTANCES OF THE DEATH On the 26" May 2017, the deceased was found in a collapsed and unresponsive condition in the living room at his home address with a .22 calibre long barrelled rifle in his hands and a bullet wound to his forehead. 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. During the inquest evidence was heard that: vi. Mr Hill was granted a firearms certificate to acquire a firearm on the 13" April 2017 by the Firearms Unit at Dorset Police following an application received from him dated the 4" November 2016. Following receipt of that certificate Mr Hill acquired a .22 calibre long barrelled rifle which he used to end his life 6 weeks later on the 26 May 2017. Mr Hill’s son had no knowledge of the application his father had made until after it was granted. He and his sister had concerns with their father having access to a firearm, as Mr Hill had told them that when the time came he would end his life by shooting himself with a rifle. At the time of Mr Hills application, enquiries were made by Dorset Police which did not include any enquiries with the family of Mr Hill or his wife with whom he was living, although the Firearms Enquiry Officer did see Mrs Hill when she went to interview Mr Hill on the 20" March. There is national guidance from the Home Office called “Guide on Firearms Licensing Law” which was issued in April 2016. Chapter 12 is entitled Assessing Suitability and paragraphs 12.35 to 12.42 deal with applications and background checks to be undertaken. At paragraph 12.35 the Guidance states that "in circumstances where there is information indicating domestic violence or abuse wider interviews or enquiries should be considered with a range of family, friends or associates” prior to the issue of the certificate. There is no further reference to speaking to family members, friends or associates under any other circumstances. Evidence was further given that in the Dorset Police policy entitled ‘Firearms and Explosive Licensing Risk Management Procedure’ dated the 8" May 2015 there is no reference to such contact with family members, friends or associates and that family members or those living at the same address of the applicant, will not be contacted as standard practice. They may, as above, be contacted where there is evidence of domestic abuse. Evidence was given that it would be beneficial for the Firearms Unit at Dorset Police to write to those living with the applicant to invite them to raise any concerns they wish to in relation to the application. Although this may not be responded to, at least it gives those close to the applicant an opportunity to raise their concerns. There may be for example domestic violence ongoing at the address that has not been brought to the Police Force's attention due to lack of reporting. This would be key to the firearm application. 2. Ihave concerns with regard to the following: i. When the Police consider a firearm application, there may be valuable information that those close to the applicant may have, in circumstances where there is no domestic abuse or violence. Those living with the applicant may have vital information, which could impact upon the grant of a firearms certificate. This information may therefore be key to preventing a future death. ii. In view of this I would request that consideration is given to reviewing the national and local guidance in relation to the assessment criteria and enquiries to be considered regarding applications for firearm certificates, and for consideration to be given that those enquiries involve the applicant's family members, or the at the very least those living with the applicant. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I 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, 20" August 2018. 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) BB © Hitrs wire on behalf of the family (2) PY Lead Investigator for the Independent Office for Police Conduct 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. Dated Signed 25" June 2018 Rachael C Griffin Madhu |
3 responses 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.
Mr Christopher Wilkinson Assistant Coroner CFOA Chief Fire Officers Association The professional voice of the UK Fire & Rescue Service Chief Fire Officers Association 9-11 Pebble Close Amington West Sussex Record Office & NA ett! Orchard Street, Chichester 05 NOV 2015 LY) Son West Sussex, PO19 1DD B77 4RD (SR AD_AD TROD GR TDS SD SO. SS TOG SS Sh — Telephone +44 (0)1827 302300 4" November 2015 Fax +44 (0)1827 302399 Dear Mr Wilkinson Re: Inquest into the death of John HILLS — 23 June 2015 Thank you for your letter dated 11"" August 2015 and follow up letter dated 28" October; my apologies for our delayed response. The Chief Fire Officers Association (CFOA) appreciates the opportunity to provide feedback on this important issue. As CFOA’s lead officer for home safety, | have been asked to respond on behalf of CFOA President Peter Dartford. For the sake of clarity, | must point out that CFOA has no regulatory or enforcement powers which require change from fire and rescue service. However, we do provide advice and guidance to fire and rescue services and are keen to ensure we learn lessons at every opportunity and share vital safety messages. The dangers posed by emollient creams has been highlighted before, and a number of fire and rescue services already include warnings about flammable emollient creams as part of their fire safety messages, in particular targeted towards older people. We have taken steps to disseminate the information from this particular case (and the previous information relating to the 2007 case) to all fire and rescue services through our internal communications channels. CFOA also run our own safety campaign weeks and regularly promote safety messages online and via the press. We will use these channels to promote safety warnings relating to these creams. CFOA are currently working closely with NHS colleagues on the development of an expanded version of the usual fire service Home Fire Safety Check, called a “Safe and Well” visit. This will take account of a wider range of health and safety issues, and make use of the 670,000 or so home visits undertaken by services each year to promote undertake health interventions. We will be sure to consider emollient creams as one of the issues to be included as part of these visits. We would also support any move to ensure that these creams are properly labelled by the manufacturer, as well as efforts to ensure doctors and pharmacists are aware of the potential hazards to ensure they can give appropriate advice to patients. Chief Fire Officers Association | 9-11 Pebble Close | A Telephone +44 (0)1827 302300 | Fax +44 (0)1827 30: imited Company: No 03677186 T Reg 302 1954 46 This matter will be considered in greater detail by the CFOA Home Safety Committee with a view to establishing what further ways we can promote safety messages around the use of paraffin based emollient creams. Yours sincerely, CFOA Home Safety Lead
Durham Constabulary David Orford MSc Assistant Chief Constable Chief Constable’s Office s Constabulary Headquarters 4 Aykley Heads a a He Atoogther Better Policing County Durham DH1 5TT Tel. No.: (0191) 375 2207 DX: 68850/Peterlee 8 Web Site: www.durham.police.uk Your Ref: Our Ref: ACC/CG 25 March 2019 Dear Mr Allen, Thank you for the opportunity to discuss, in a little more depth, the possible ways we can leam important lessons from the tragic death of John Hill. | was grateful for your understanding of the complexities surrounding guidance that can be issued to Firearms Enquiry Officers in terms of the steps they might want to undertake in order to make recommendations to a Chief Constable under Section 27 of the Firearms Act 1968. That section has a key paragraph that | feel is very relevant to your section 28 notice. (c) that in all the circumstances the applicant can be permitted to have the firearm or ammunition in his possession without danger to the public safety or to the peace. In determining what might constitute “all circumstances’, | outlined how | expect Firearms Enquiry Officers (FEO) to carry out diligent enquiries with appropriate professional curiosity during their home visits and interactions with applicants for a firearms certificate. Because of the very diverse nature of applicant situations it is very challenging to give a prescribed series of steps that must be carried out in each case, over and above existing intelligence convictions and medical checks. We discussed how there are situations where this could give a false perception that an applicant could be suitable were further investigations not carried out by the FEO. As | outlined, | have been informed that the Home Office are preparing to go to public consultation on their guidance to forces on issuing firearms certificates later this year, and | will endeavour to include the lessons learned from Mr Hill’s death. tn particular, for FEO’s to ensure MOT: sVY5 A = EMERGENCY WE www.durham.police.uk ALWAYS | that they examine the domestic and family circumstances of an applicant should this appear to be relevant under Section 27 of the Firearms Act 1968. Thank you again for taking the time to discuss this in more detail, and if you wish to be involved in the future consultation please let me know. Yours sincerely Assistant Chief Constable Mr Brendan Allen Assistant Coroner Town Hall Avenue Road Bournemouth Dorset BH2 6DY
Rt Hon Nick Hurd MP Minister of State for Policing and the Fire Service 2 Marsham Street London SW1P 4DF Home Office www.gov.uk/home-office Brendan J Allen HM Acting Senior Coroner for Dorset Town Hall Avenue Road Bournemouth BH2 6DY 02 January 2019 Thank you for letter of 26 October about the death of John Hill, who killed himself with a rifle he held lawfully under a firearm certificate. In my letter of 13 August, | undertook to seek police views before responding further to the letter of 25 June from Rachel Griffin, the Senior Coroner for Dorset. In her letter, Rachel Griffin asked that consideration be given to whether national and local guidance on the assessment of applications for firearms certificates should provide for police enquiries to involve the applicant's family members routinely. | have obtained the views of the National Police Chief Council on this issue, which were informed by discussions with members of the Firearms and Explosives Licensing Working Group. The advice that | have received is that there is no need to introduce a new blanket policy of interviewing members of an applicant's family in the case of all applications for firearms certificates, in order to establish whether they have any concems. The alternative is an intelligence-based approach, which will now be delivered through new accreditation standards for Firearms Enquiry Officers in police forces, which is being developed by the College of Policing. This will encourage “professional curiosity” to ensure that such avenues are pursued whenever they are likely to be relevant. The Government introduced a power, through the Policing and Crime Act 2017, for the Home Secretary to publish statutory guidance to the police on their firearms licensing functions. The tegislation requires that we consult with the police before publishing the new guidance. We intend to consult on the terms of this shortly. We intend that the draft should go further than the current guidance, in inviting the police to consider whether to conduct interviews with individuals other than the applicant or their referees, including neighbours, partners or representatives of shooting clubs attended by the applicant. We intend that these checks be considered where, following initial enquiries, they believe them to be necessary to assess suitability. | have seen the letter of 28 September from James Vaughan, the Chief Constable of Dorset, to Rachel Griffin in which he indicates that he wishes to consider this matter further. | will be very happy to consider any recommendations made by Chief Constable Vaughan, and in particular those arising from the sad circumstances of Mr Hill's case, as part of the forthcoming consultation on the statutory guidance which | mention above. | am sending a copy of this letter to Assistant Chief Constable Dave Orford, the National Police Chiefs’ Council lead for firearms, and to Chief Constable James Jade Und RT HON NICK HURD MP Minister of State for Policing and the Fire Service 3 & oserare HM Senior Coroner Rachael Griffin Chief Constable James Vaughan MSi (Cantab) www .dorset.police.uk Dorset Police Force Headquarters Coroner's Office Winfrith Town Hall, DORCHESTER Bournemouth DT2 8DZ BH2 6DY Phone: 101 ext. 3727 ne Date 28 09 2018 Dear Madam Coroner Re: Regulation 28 - Inquest touching the death of John Edward Hill | am now in a position te send you a further response with regards to your regulation 28 recommendations which you raised at the inquest of John Edward Hill: i) When the Police consider a firearm application, there may be valuable information that those close to the applicant may have, in circumstances where there is no domestic abuse or violence. Those living with the applicant may have vital information, which could impact upon the grant of a firearms certificate. This information may therefore be key to preventing a future death. In view of this | would request that consideration is given to reviewing the national and local guidance in relation to the assessment criteria and enquiries to be considered regarding applications for firearms certificates, and for consideration to be given that those enquiries involve the applicant's family members, or at the very least those living with the applicant. | can reassure you that our firearms licensing team in Dorset Police which in fact is.a Strategic Alliance capability across the three counties. of Derset, Protective Marking Status Devon and Cornwall D&C have fully considered your directions and have reviewed local guidance which follows current national guidance. i am now in receipt of a very detailed and comprehensive report which unfortunately | am not yet satisfied meets our obligations to respond appropriately to your directions. This is in no way due to any resistance from my teams or indeed those that govern policy and practice nationally. However, | have called for further work ahead of the submission of a final report. The firearms licensing manager, Po has taken this case study and your recommendations for discussion at national level with the NPCC lead, ACC Orford on Tuesday 11 September, hence our prior need for an extension. The minutes of this meeting are not yet signed off but | have seen the draft minutes and that the specific recommendations were raised at my request. The consensus of the national group was that an arbitrary policy of consultation with wider family members on application and renewal of a firearms license, was not appropriate, given that one could not draw lines of delineation as to how far such enquiries should reach, the depth and nature of the questions and the lack of proportionality involved. The group did consider however that the new Firearms Enquiry Officer accreditation standards focus much more on being professionally curious, and are much more inquisitorial in approach. It was commented on by the group that in some cases, work colleagues would know individuals better than their families might know them - where would one draw the line? The NPCC Lead, ACC Orford is of the view that we cannot have a mandated series of steps but rather address each applicant on its merits and employing the new professional curiosity, in line with the new College of Policing standards. Crime Board chaired b are to go live on the 9" October 2018. These standards will run alongside current authorised professional practice and Home Office Guidance for Firearms Licensing Law 2016. The new standards, e to ratification at the Serious and Organised Therefore, | feel we have only partially fulfilled our obligations under your direction and suspect that you will be unhappy with this outcome. | would ask that you allow my ACC (J who is my Director of Operations DDIMM/IVYY Protective Marking Status Page 2 of 3 tc meet with you and discuss some of the finer detail and challenges posed, so that we are able, to fully deliver the full extent of your directions. | apologise for the length of time this has taken whilst my senior managers have waded through national governance, please be assured that |! fully concur with your directions which are capable of preventing future deaths at scale in England and Wales. Yours faithfully, James Vaughan Chief Constable DD/MM/YY Protective Marking Status Page 3 of 3
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