Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0015, written 18 Jan 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Jan 2021 |
|---|---|
| Reference | 2021-0015 |
| Deceased | Michael Woods |
| Coroner | Brendan Allen |
| Coroner area | County of Dorset |
| Category | Suicide (from 2015) · Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
18 January 2021
Our ref:
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: National Rifle Association, National Small Bore
Rifle Association
1 CORONER
I am Brendan J Allen, Acting Area Coroner for The County 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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3 INVESTIGATION and INQUEST
The Coroner's Office for the County of Dorset, Bournemouth Town Hall, Bournemouth, BH2 6DY
T. 01202 454910 F. 01202 454977 E. coroner.service@bcpcouncil.gov.uk DX 156942 Bournemouth 3
On 17 October 2019 I commenced an investigation into the death of Michael Jonathan Woods.
The investigation concluded at the end of the inquest on 11 January 2021.
The conclusion of the inquest was that Mr Woods died by Suicide.
The medical cause of death was:
1a Traumatic Brain Injury
1b Gun Shot Wound to Head
1c
II
4 CIRCUMSTANCES OF THE DEATH
Michael Jonathan Woods died at Southampton Hospital on 9th October 2019. Mr Woods had
been admitted to Southampton Hospital on 8th October 2019 after using a rifle to shoot himself
while on a rifle range in Charmouth, where he was taking part in a shooting experience.
Mr Woods had contacted the Target Sports Centre ("the shooting range") on 8th October 2019,
asking to arrange a tour of the site with a view to arranging a day out for his work colleagues.
When he attended that afternoon, he requested availability of a "shooting experience" and was
told there was availability on the 25 metre range for one hour of shooting, supervised by a
qualified range officer. Mr Woods agreed, underwent a safety briefing and then proceeded to the
25 metre range together with one other participant and the range officer. It was towards the
end of the hour of shooting, when, without warning, Mr Woods turned the rifle on himself.
Mr Woods' death was investigated by the police and the Dorset Council Environmental Health
Department. Four recommendations were made to the shooting range by
, the
Environmental Health Officer investigating the death. All recommendations have been adopted
by the shooting range. In addition, of their own volition, the shooting range will no longer take
bookings from non-club members to shoot on the day they make the inquiry: bookings can only
be for the following or subsequent days to allow a "cooling off" period.
5 CORONER’S CONCERNS
The Coroner's Office for the County of Dorset, Bournemouth Town Hall, Bournemouth, BH2 6DY
T. 01202 454910 F. 01202 454977 E. coroner.service@bcpcouncil.gov.uk DX 156942 Bournemouth 3
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. –
, who gave evidence at the Inquest, recommended that staff at the range undergo
(1)
training in identifying signs of abnormal behaviour on the part of anyone wishing to take part in
a shooting experience, to ensure that person is in the appropriate frame of mind to shoot. The
shooting range have adopted the recommendation and identified a training provider, though the
training itself has yet to be delivered due to covid restrictions. I heard evidence from
, owner of the shooting range, that he is not aware of similar training being made available
to staff at other shooting ranges.
would be of value nationally, and could form part of a range officer's training.
went on to give evidence that he believes such training
also recommended that staff periodically carry out "emergency response" exercises
(2)
to improve the staff response for this type of serious incident. Again,
recommendation has been adopted and training identified, but not yet delivered due to covid
restrictions.
gave evidence that such training would be of value nationally.
confirmed the
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisations 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 16th February 2021. 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:
1.
2.
3.
4.
, wife of Mr Woods;
, mother of Mr Woods;
, brother of Mr Woods;
, sister of Mr Woods;
I have also sent it to
and
who may find it useful or of interest.
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
The Coroner's Office for the County of Dorset, Bournemouth Town Hall, Bournemouth, BH2 6DY
T. 01202 454910 F. 01202 454977 E. coroner.service@bcpcouncil.gov.uk DX 156942 Bournemouth 3
18 January 2021
Signature
Brendan J Allen HM Acting Area Coroner
for The County of Dorset
The Coroner's Office for the County of Dorset, Bournemouth Town Hall, Bournemouth, BH2 6DY
T. 01202 454910 F. 01202 454977 E. coroner.service@bcpcouncil.gov.uk DX 156942 Bournemouth 3
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.
NATIONAL RIFLE ASSOCIATION Her Majesty’s Coroner for the County of Dorset Regulation 28 Report to Prevent Future Deaths (Ref IED Investigation into the death of Michael Jonathan Woods Response on behalf of the National Rifle Association (NRA) and National Smallbore Rifle Association (NSRA) We extend our sincere condolences to the family and friends of Mr Woods. The circumstances described in the Coroner’s report will clearly have caused pain and distress to the family and friends of Mr Woods. We also offer our heartfelt sympathies to the staff at the Target Sports Centre. Dealing with the events on 8" October 2019 must have been deeply upsetting for all concerned. 1. Matters of Concern We have been asked to respond to two Matters of Concern raised by the Coroner: (a) the recommendation of a of the Dorset Council Environmental Health Department that staff at shooting ranges offering shooting experiences should undergo training to ensure customers are in the appropriate frame of mind to shoot; and (b) the recommendation of ; that staff at shooting ranges should periodically carry out “Emergency Response” exercises in response to serious incidents of the type that occurred in this case. 2. Preamble 2.1 The NRA is the national governing body for full-bore target shooting in the United Kingdom. The NSRA is the national governing body for small-bore rifle and pistol target shooting in the United Kingdom. Both organisations are registered charities. The NRA and NSRA operate rifle ranges at Bisley Camp through their respective wholly owned trading subsidiaries. 2.2 The NRA and NSRA publish guidance to assist affiliated rifle range operators across the United Kingdom. 2.3 Safety is an essential element of all shooting activities. It should be embedded into the culture and operation of target shooting ranges, and is built upon the four pillars of “safe place, safe practice, safe equipment and safe person”. 2.4 Suicide on shooting ranges in the United Kingdom is very rare, but the impact on families and friends can be catastrophic regardless of the rarity of the event. 2.5 All operators of shooting ranges are expected to ensure the safety of their staff, customers and visitors. The NRA and NSRA take very seriously their role in contributing to a safe shooting environment, both directly at ranges operated by their subsidiaries and through issuing practical guidance to the wider sector. Both organisations recognise the harm that is caused by such tragic events. 3. Response 3.1 The NRA and NSRA have carefully considered the facts of this particular case and the findings of the Coroner. We have also carefully considered the action that each organisation is able to take to reduce the risk of future deaths and set out below details of that action. We have also set out timetables for implementing these actions. These timetables may vary subject to the easing of current COVID restrictions. 3.2 We have decided to direct our respective commercial subsidiaries that Operate ranges to arrange training of staff employed in the delivery of shooting experiences. The training objective will be to assist staff to identify signs of abnormal behaviour in people who wish to take part in shooting experiences. The intended operational outcomes are to raise awareness of the indications of abnormal behaviour that may suggest that a person is not in an appropriate frame of mind to engage in shooting activities and to provide guidance to staff as to how to respond in that situation. We expect this training to be delivered by 30" September 2021. 3.3 We recognise that people intent on self-harm may show no indication of this intention. However, the training will raise awareness of the risk of self-harm and provide guidance for range staff as to the action they should take if they identify signs of abnormal behaviour. 3.4 The NRA and NSRA will publish specific guidance recommending appropriate training and procedures for staff at other rifle ranges operating in the wider sector offering shooting experiences to the public. We intend to publish this guidance by 30" October 2021 to allow time for the review of the initial training and incorporation of feedback. 3.5 The commercial subsidiaries of the NRA and NSRA already have emergency response procedures in place for the shooting ranges they operate. We will now review our emergency response procedures specifically in relation to documenting the appropriate response to an act of self-harm or a threat of self-harm. We will ensure, commencing April 2021, that these procedures are tested twice yearly. 3.6 We will publish specific guidance to encourage operators of other rifle ranges operating in the wider sector offering shooting experiences to the public to review their own procedures in this area. We intend to publish this guidance, highlighting key points, by 30" October 2021 to allow for review and incorporation of feedback. 4. Publication 4.1 The NRA and the NSRA have no objection to the Chief Coroner publishing this response to any person the Chief Coroner believes may find it useful or of interest. 4.2 We will each publish this response on our respective websites for the benefit of the range operators and the public. National Rifle Association National Smallbore Rifle Association Position: Secretary General Position: Acting Chief Executive Officer Date: 12 March 2021 Date: 12 March 2021
See every Prevention of Future Deaths report matching Suicide (from 2015), 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.