Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0509, written 15 Jul 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Jul 2019 |
|---|---|
| Reference | 2019-0509 |
| Deceased | Christine Lee |
| Coroner | Richard Travers |
| Coroner area | Surrey |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Re : Christine Ann LEE and Lucy Daisy LEE Deceased
Regulation 28 Report to Prevent Future Deaths
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. The Chief Constable of Surrey Police (in relation to the concerns
in paragraphs 5 A and 6 B below)
2. Assistant Chief Constable David Orford as the National Police
Chiefs’ Council’s Lead on Firearms Licensing (in relation to the
concerns in paragraphs 5 A and 6 B below)
3. The Home Secretary (in relation to the concern in paragraph 5 B
below)
4. The Secretary of State for Health (in relation to the concern in
paragraph 5 B below)
5. Dr Richard Vautrey as Chair of the General Practitioners
Committee UK of the British Medical Association (in relation to
the concern in paragraph 5 B below)
1 CORONER
I am Richard Travers, HM Senior Coroner for the coroner area of Surrey.
2 CORONER’S LEGAL POWERS
1
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
I commenced investigations into the deaths of Christine Ann Lee and
Lucy Daisy Lee, both of whom died on 23rd February 2014.
The investigations concluded on 21st June 2019 after I had conducted
inquests into the deaths, held with a jury, which began on 23rd May 2019.
4 CIRCUMSTANCES OF THE DEATH
Christine Lee and Lucy Lee died on the 23rd February 2014 at Keepers
Cottage Stud, Tilford, Surrey after being shot with a shotgun.
The perpetrator, who was later convicted of the murder of both women,
was in lawful possession of the shotgun at the time under a shotgun
certificate issued to him by Surrey Police.
Christine Lee and Lucy Lee were mother and daughter who had lived
and worked at Keepers Cottage Stud, intermittently, for many years.
There was a complex history of personal relationships between the
perpetrator and the two women and their families.
In March 2013 the daughter and sister of Christine and Lucy Lee
contacted the police and alleged that the perpetrator, who was then in his
80s, had threatened her in person with a shotgun at Keepers Cottage Stud
and had threatened to kill her. She also raised concerns regarding his
health, in particular that he may have Alzheimer’s Disease.
Surrey Police attended Keepers Cottage Stud and removed the
perpetrator’s shotguns and shotgun certificate later that day. They
subsequently conducted a criminal investigation in to the threat to kill
allegation, in the course of which the complainant (whilst maintaining
the truth of the allegation) withdrew her support for prosecution of the
2
perpetrator. As a result, Surrey Police decided that there was no realistic
likelihood of a successful prosecution and the investigation was marked
as ‘No Further Action’ and closed.
The Firearms Licensing Department of Surrey Police (the FLD) then
commenced a review of whether or not to return the perpetrator’s
shotguns and shotgun certificate to him. They had available to them,
from a number of sources, relevant information and evidence relating to :
the recent allegation of the threat to kill,
earlier allegations against the perpetrator of threats to kill and
domestic violence (which had previously resulted in consideration
of his shotgun certificate being withdrawn on the basis that he
posed a risk of extreme violence),
an ongoing criminal investigation of the perpetrator for fraud,
the perpetrator’s convictions for failing to comply with conditions
on his licence to run a dog breeding establishment and for running
an establishment when disqualified from doing so,
the perpetrator having some criminal associates,
the perpetrator’s health, and
the perpetrator’s failure to make full and accurate disclosure of his
previous convictions, and of his medical conditions, when last
applying for a renewal of his shotgun certificate in 2010.
On 8th July 2013 staff from the FLD visited the perpetrator at home to
assess his health and whether it was safe for him to have his shotguns
and shotgun certificate returned to him. On 9th July 2013 a staff member
from the FLD made the decision to return to the perpetrator his shotguns
and shotgun certificate. The jury found that the decision was made by a
person with lawful authority, under written delegation from the then
Chief Constable, but that the decision maker had not taken account of all
relevant information which could have been obtained and considered,
had not applied the correct standard of proof, and had not postponed the
decision pending the outcome of the ongoing fraud investigation. As a
result of the decision, the perpetrator’s shotgun certificate and shotguns
were returned to him on 11th July 2013.
The jury’s conclusion as to the death, in both inquests, was :
3
Unlawful Killing
The death was more than minimally contributed to by:
1
A failure by Surrey Police to have in place a system to ensure
that the decision whether or not to return a shotgun certificate
and shotgun to a certificate holder following removal pending
a criminal investigation was made or approved by a senior
police officer.
2
A failure by the Firearms Licensing Department of Surrey
Police to investigate sufficiently whether it was safe to return to
the perpetrator his shotgun certificate and shotguns following
an allegation made in March 2013 that he had used one of his
shotguns to make a threat to kill.
3
A failure by the Firearms Licensing Department of Surrey
Police to consider all the evidence and information available to
it before deciding whether to revoke the perpetrator’s shotgun
certificate or to return his shotgun certificate and shotguns to
him, following the March 2013 allegation.
4
A failure by the Firearms Licensing Department of Surrey
Police to apply the correct standard of proof when deciding
whether to revoke the perpetrator’s shotgun certificate, or to
return his shotgun certificate and shotguns to him, following
the March 2013 allegation.
5
A failure by the Firearms Licensing Department of Surrey
Police to recommend revocation of the perpetrator’s shotgun
certificate in July 2013 and the consequential failure by Surrey
Police to revoke the certificate.
4
5 CORONER’S CONCERNS
During the course of the inquests the evidence revealed matters giving
rise to a number of concerns, many of which have now been addressed.
However, in my opinion there is a risk that future deaths will occur
unless action is taken in respect of two matters which have not yet been
addressed or sufficiently addressed, as identified below.
In the circumstances it is my statutory duty to report to you.
A. To : (1) The Chief Constable of Surrey Police
(2) Assistant Chief Constable David Orford as the
National Police Chiefs’ Council’s Lead on Firearms
Licensing
The MATTER OF CONCERN is as follows :
It was apparent from the evidence that, at the time of the deaths, there
was no national training course for staff working in police firearms
licensing departments as Firearms Enquiry Officers (“FEOs”). I was told
that work is now being undertaken by the College of Policing to produce
an accreditation process for FEOs, but that this work is not yet complete.
Currently, what is known as “the South Yorkshire Training Course” is
available. This is a five day, residential course which appears to be
comprehensive. I was told that all Surrey Police’s current FEOs have
completed the South Yorkshire Training Course, but that it is not
mandatory for them to do so.
I am concerned that, pending the introduction of a full accreditation
scheme, the absence of a mandatory requirement for all new FEOs
(whether in Surrey or elsewhere) to undertake comprehensive training
for the role, in the form of the South Yorkshire Training Course or
5
equivalent, will result in the risk of insufficient training, incorrect
decision making concerning certification and, consequently, future
deaths.
B. To : (1) The Chief Constable of Surrey Police
(2) Assistant Chief Constable David Orford as the
National Police Chiefs’ Council’s Lead on Firearms
Licensing
(3) The Home Secretary
(4) The Secretary of State for Health
(5) Dr Richard Vautrey as Chair of the General
Practitioners Committee UK of the British Medical
Association
The MATTER OF CONCERN is as follows :
It was apparent from the evidence that, prior to the deaths of Christine
and Lucy Lee, (i) the perpetrator had failed to declare medical conditions
from which he was suffering on his most recent application to renew his
shotgun certificate and (ii) following a concern being raised that he may
be suffering from Alzheimer’s Disease, Surrey FEOs had been required to
visit the perpetrator in order to assess whether he was suffering from that
condition, but that they had not had the skills or training to enable them
to do so reliably.
I also heard further evidence concerning the system currently in place for
assessing the medical fitness of an applicant to hold a shotgun certificate.
It was clear that there are two areas of concern arising in relation to the
current system.
First, whereas an applicant for a shotgun certificate was previously
required to declare any medical condition, the most recent Home Office
6
Guide on Firearms Licensing Law, being that of 2016, suggests that an
applicant should be asked to declare only certain identified conditions, as
well as “any other relevant condition”. No guidance is given to
applicants as to what medical conditions may or may not be relevant to
the safe holding of a certificate. Currently, Surrey Police (and, no doubt,
other Forces) use an application form which reflects this guidance. In my
view, the fact that the responsibility for disclosure is placed entirely on
the applicant, and the lack of clarity as to what medical conditions may
be relevant and must be disclosed, together raise a very real risk of
insufficient evidence gathering prior to a decision being made as to the
applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions
which, I was told, is currently provided to Surrey FEOs as they may be
expected to assess whether an applicant is suffering from a condition on
the list and, if so, its severity. I was told that the FEOs may then be
expected to judge whether a certificate may be granted without more, or
whether a referral to a General Practitioner (or other clinician) should be
made for further assessment. The list of medical conditions is substantial
and wide-ranging, and included not only physical conditions but also
mental health and other complex matters such as (to give two examples
only) autism and post-natal depression. It seems that this approach is
actively encouraged by the 2016 Home Office Guide (at paragraph 10.25)
which indicates that FEOs may make judgements on medical matters
“based on their own knowledge and experience”. However, Surrey FEOs
are provided with no relevant training and, in my view, are almost
certainly without the necessary skills, knowledge or experience to
perform such assessments safely, effectively and reliably. I was told that
the document containing the list of medical conditions, and the system
for assessing applicants, is in use in other police forces also. In the
circumstances, I am concerned that in Surrey, and elsewhere, a
fundamentally unreliable system for assessing medical fitness to hold a
shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk
of future deaths in Surrey and elsewhere resulting from the absence of a
system to ensure that, before a decision is made on the application, the
7
FLD is fully aware of (i) all medical conditions from which an applicant is
suffering and (ii) the relevance of each medical condition to the
application.
In this regard, my attention was drawn to the fact that in September 2015
Her Majesty’s Inspectorate of Constabulary published a report entitled
“Targeting the risk : An inspection of the efficiency and effectiveness of
firearms licensing in police forces in England and Wales”. In that report
HMIC highlighted the same concern, namely that “police forces are
expected to make licensing decisions without confirmation that the
applicant is medically fit to possess a firearm. These unsatisfactory
arrangements leave fundamental gaps in the establishment of a safe and
effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that,
“Immediately, and with a view to implementation within 18 months, the
Home Office should ensure that the current proposals for the sharing of
medical information between medical professionals and the police for the
purpose of firearms licensing, allow the police effectively to discharge their
duty to assess the medical suitability of an applicant for a section 1 firearms
or shotgun certificate. This should have due regard to ensuring the system:
1. Does not allow licensing to take place without a current medical report
from the applicant’s GP, obtained and paid for by the applicant in advance
of an application for the granting or renewal of a certificate, and which
meets requirements prescribed by law; and 2. Is supported by a process
whereby GPs are required, during the currency of a certificate, to notify
the police of any changes to the medical circumstances (including mental
health) of the certificate holder which are relevant to the police assessment
of suitability for such a certificate, and within which the certificate holder
is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is
of concern because, in my view, the ongoing absence of a system such as
that recommended by HMIC does create a risk of future deaths for the
reasons given above.
8
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths by
addressing the concerns set out above and I believe you have the power
to take such action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 9th September 2019. 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.
8 COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following
Interested Persons :
a.
b.
c.
d.
e.
f.
g.
h.
i. The Independent Office for Police Conduct
j. The Safer Waverley Partnership
k. Waverley Borough Council
9
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.
9
15th July 2019 Richard Travers
10
See every Prevention of Future Deaths report matching Richard Travers, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.