Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0376, written 24 Nov 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Nov 2022 |
|---|---|
| Reference | 2022-0376 |
| Deceased | Keith Weston |
| Coroner | Catherine Cundy |
| Coroner area | North Yorkshire and York |
| Category | Suicide (from 2015) |
| 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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 HMRC (PROSECUTIONS) 1 CORONER I am Catherine CUNDY, Area Coroner for the coroner area of North Yorkshire and York 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 14 March 2022 I commenced an investigation into the death of Keith Andrew WESTON aged 68. The investigation concluded at the end of the inquest on 16 November 2022. The conclusion of the inquest was that: On the 9th of March 2022 the deceased shot himself with a licensed firearm in the garden of his home address of , Knaresborough. 4 CIRCUMSTANCES OF THE DEATH On the 9th of March 2022, the deceased was found on the ground in the garden of his home , and severe trauma to his head. He had sent address with a shotgun concerning messages to family and friends and a detailed note of intent was found near to his body. The note attributed his actions to a combination of declining health and the fact that he was due to appear in court that day on charges of tax fraud. The deceased had been licensed to possess firearms for a number of years. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In the In my opinion there is a risk that future deaths could occur unless action is taken. circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) During the course of the inquest, evidence was heard from a Detective Inspector with North Yorkshire Police who is a Firearms Licensing Manager. The evidence was that, unlike standard police prosecutions, prosecutions of individuals by other authorities do not involve automatic checks of the Police National Computer which would flag whether that individual is licensed to possess a firearm. The appearance of such an alert allows the firearms licensing authority to assess the individual’s continuing suitability to possess a firearm in the context of the prosecution and its possible outcomes. In this instance, the deceased was being prosecuted for tax fraud by HMRC and was due to make a court appearance on the day of his death. He left a note of intent, indicating that the prosecution and its likely outcome were central to his decision to end his life. Had it been flagged that the deceased was facing such a prosecution, I was informed that it was OFFICIAL Regulation 28 – After Inquest Document Template Updated 30/07/2021 'highly likely' that his access to licensed firearms would have been restricted and the weapons removed from him in accordance with statutory guidance. While it cannot be said that this would have prevented the deceased's death by his own hand from some other means, it would have prevented the unlawful discharge of the weapon as a means of suicide. I understand that this issue has been escalated to the NPCC Lead for firearms licensing with a view to highlighting the concern with all non-police prosecuting authorities. I also understand that the HMRC investigator did not respond to the officer's contact with the agency to flag this issue. I am writing to HMRC to draw this concern to its attention and to invite it to respond directly, as well as to engage with the NPCC in this regard. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 January 16, 2023. 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 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to , NORTH YORKSHIRE POLICE , WARWICKSHIRE POLICE (NPCC LEAD FOR FIREARMS LICENSING) who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 Dated: 24/11/2022 Catherine CUNDY Area Coroner for North Yorkshire and York OFFICIAL Regulation 28 – After Inquest Document Template Updated 30/07/2021 OFFICIAL Regulation 28 – After Inquest Document Template Updated 30/07/2021
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