Sean Duignan

Deputy Chief Constable of Bedfordshire Police 

By Email only 

Dr Sean Cummings 

Assistant Coroner for Bedfordshire & Luton 

Dear Dr Cummings, 

9 March 2023 

RE:  Regulation 29 response to Coroners’ regulation 28 report to prevent future 

deaths in relation to the inquest into the death of Sergeant Sean Duignan 

I write in my capacity as the Deputy Chief Constable of Bedfordshire Police and in response 

to the regulation 28 notice issued to the force. I provide details of the action taken in 

response to the concerns you have identified; 

1.  Single access to the armoury and incorrect access levels 

2.  Awareness of who should not have access to the armoury 

3.  Failures by senior management to effectively and safely manage the south base 

armoury 

4.  ICT failures resulting in armoury access challenges 

5.  Safety and security at the south base armoury 

1. 

Single access to the armoury and incorrect access levels 

This  area  was  highlighted  as  the  officer  who  admitted  Sergeant  Sean  Duignan  had  single 

access to the armoury, when standard practice is that all officers should be seconded into the 

armoury. 

A review of armoury access was commissioned by the Operations Superintendent on 3 June 

2021 which found that two officers within the unit had incorrect access, and this was rectified 

immediately.  The IOPC report of 28 June 2021 also highlighted this (see appendix 1). 

Single  access  was  therefore  confirmed  as  restricted  to  National  Firearms  Instructors, 

Armourers and Operational Firearms Commanders  and this  was communicated  across the 

unit. This is common practice nationally and in line with operational requirements. 

 
 
  
 
 
 
      
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 On  28  June  2021,  the  Eastern  Region  Armed  Policing  Coordinator  also  shared  these 

recommendations with regional colleagues. 

These restrictions were specified in the amended Standard Operating Procedures, as detailed 

in the initial College of Policing report (see appendix 2). 

These restrictions are reviewed monthly under a standing agenda item at the armed policing 

managers  meeting  to  confirm  access  is  still  afforded  at  the  correct  levels.  The  Chronicle 

system holds the single access user list which is checked line by line within the meeting. There 

have  been  no 

further 

incidents  of 

incorrect  single  access 

records 

to  date. 

2. 

Awareness of who should not have access to the armoury 

The regulation 28 report highlighted that the officers who were present on that day were not 

aware of the restriction from accessing the armoury already placed on Sgt Duignan, following 

his arrest on 29 May 2021. 

This was rectified following Sgt Duignan’s death. On 28 June 2021 we introduced a standard 

email which is sent to all officers with armoury access, advising of individuals who have had 

their armoury access removed. The most recent example of a teamwide authority email was 

sent by the base inspector on 9 January 2023 (see Appendix 3). Since the introduction of this 

process  the  armed  policing  management  team  have  sent  15  such  emails.  Whilst  this  is  a 

balance  of  privacy  against  safety,  safety  must  be  the  overriding  factor.  This  was  a 

recommendation of the original College of Policing report (see Appendix 2). 

The  decision  was  briefed  to  all  officers  and  commanders  and  included  in  the  Standard 

Operating Procedures. 

3. 

Failures by senior management to effectively and safely manage the south 
base armoury 

Following  the  death  of  Sgt  Duignan  and  the  subsequent  coronial  process,  communication 

between managers and armed officers has been brought into sharp focus. Significant steps 

have  been  taken  to  enhance  the  security  provision  regarding  armoury  access,  the 

communication to officers and the governance that supports this updated operating model. 

Structured  meetings  are  routinely  scheduled,  both  daily  and  monthly.  A  daily  meeting  is 

chaired by a duty manager often independent from armed policing; also in attendance is the 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 Operations  Superintendent.  The  purpose  of  this  meeting  is  to  discuss  any  staffing 

abstractions,  sickness,  health  and  safety  issues  and  any  current  operational  challenges 

including a review of the armoury access status. The daily meeting provides greater situational 

awareness for senior officers with a focus on issues faced by staff on the ground. 

A monthly meeting, chaired by the Operations Chief Superintendent is held to cumulatively 

review operational and tactical issues through the strategic lens. This will include items bought 

to the daily meeting which have not been successfully actioned the same day. The strategic 

overview of outstanding matters ensures there is a method for escalation to resolve problems 

both in a timely manner and within the best possible terms. This meeting is attended by all 

members  of  the  Joint  Protective  Services  (JPS)  Operational  Senior  Management  Team. 

Further oversight is maintained through the Bedfordshire, Cambridgeshire and Hertfordshire 

(BCH) Firearms Strategic Board chaired by the JPS Assistant Chief Constable. 

4. 

ICT failures resulting in armoury access challenges 

The areas covered in the Prevention of Future Death notice relate to access to the armoury. 

The clarification between the areas that are covered by the phrase ‘Chronicle’ are detailed in 

the report submitted to yourself from the owners JML, dated 16 February 2023. 

The access issue as detailed focused on single access as addressed in point 1 above. Access 

can also be granted via the emergency access function should either the door access fail or 

due to an overall power failure. 

Following the death of Sgt Duignan, the access code for the emergency access at the southern 

base  was  reviewed  and  amended  so  that  only  the  Force  Incident  Manager,  stationed  at 

Bedfordshire  Police  Headquarters,  and  the  Superintendent  of  Specialist  Operations  were 

aware of the code. Any requirement for use would necessitate a request directly to the Force 

Incident Manager and confirmation of the presence of a second officer. Following use of the 

code, it would be changed immediately by the Superintendent or the Chief Superintendent in 

their absence. Since the introduction of the armoury access outage recording process on 11 

November 2022 there have been 15 access issues identified. The majority have been resolved 

without  any  requirement  for  support  from  ICT  or  JML  by  ‘rebooting’  the  computer,  the 

remainder have resulted in the utilisation of the backup system where a pin code change was 

required. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 We have also introduced a specific escalation process should any difficulties be found in our 

use of Chronicle. This increases our ability to monitor the effective functioning of the systems 

and  processes,  including  the  escalation  to  ICT  and  JML.  These  have  been  reviewed, 

introduced and are now well-embedded across the unit to ensure that any impasses are easily 

identified and strictly monitored. As the access failures referred to above identify, there are 

still problems with the computer hardware, specifically in relation to USB ports, these are being 

addressed by ICT and JML. A USB fix was implemented on the 24 February 2023, since that 

date there has been no related outages. Access failures do not result in any risk to the public 

or officers. Access to the armoury can be carried out via keys through the secure and managed 

process outlined above. 

This escalation process was part of the work completed in conjunction with JML and BCH 

ICT following the inquest. This included: 

• 

• 

• 

• 

identifying previously unknown USB settings which hampered the system, 

increasing cameras across BCH armouries, 

connection and broadband monitoring at relevant sites, 

and increasing knowledge of both officers, supervisors and ICT around the 

capabilities and functions of the Chronicle system. 

5. 

Safety and security at the south base armoury 

The safety of the public and our people is paramount which is why the security surrounding 

armoury  access  at  the  base  is  of  a  high  standard.  All  our  security  enhancement  actions 

following  the  death  of  Sgt  Duignan  are  captured  within  the  Armed  Policing  Unit  Standard 

Operating Procedures (SOPs) and have been communicated to all officers in the unit. 

SOPs are supported by relevant risk assessments, there are currently 34 relating to the Armed 

Policing Unit  including a specific  assessment pertaining to armoury access  at the southern 

base. These assessments are further supported by site inspections by both the armed policing 

health and safety single point of contact and the armed policing senior responsible person, 

these inspections being quarterly and every six months respectively. 

In  conjunction  with  the tri  force  Health  and  Safety  department,  we  have also  carried  out  a 

comprehensive and in-depth review of all those armed policing-related risk assessments. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Whilst we do continue to have ICT challenges where officers are on occasion refused access 

to  the  armoury,  we  now  have  robust  measures  in  place  that  ensure  these  are  recorded, 

effectively  managed,  and  follow  an  escalation  process  through  to  resolution.  The  backup 

armoury  key  safe  code  is  only  known  to  the  Bedfordshire  control  room  inspector  and  the 

Operations Superintendent, so whilst failures are frustrating for officers there is no risk to the 

public or workforce. 

We are, of course, working with both ICT and JML to ensure the armoury access hardware at 

the southern base is as reliable as the other two armouries within our organisation. This work 

is  captured  within  an  action  tracker  that  I  attach  for  reference.  (see  appendix  4). 

Conclusion 

In  conclusion,  I  sincerely  hope that  the above actions  along with  our  engagement  with the 

College of Policing (CoP) in terms of armoury reviews provides you reassurance that we have 

taken all possible measures to prevent future deaths. 

In relation to future auditing and monitoring, on 10 January 2023, there was a follow-up review 

of  the  armouries  within  BCH  by  the  College  of  Policing  (see  Appendix  5),  confirming  the 

completion of the amendments already made from the initial inspection, carried out on 16 July 

2022. 

As detailed in the letter from HMICFRS dated 31 January 2023, armouries within Bedfordshire, 

Cambridgeshire  and  Hertfordshire  will  be  specifically  included  within  their  next  set  of 

inspections over the next two years. 

With  regard  to  the  attached  action  tracker  (see  Appendix  4),  we  have  made  significant 

progress but still have four actions being progressed; the first is in relation to some residual 

issues  pertaining  to  ICT  armoury  hardware  improvements  and  monitoring  at  the  southern 

base. I am assured these will be addressed in the coming weeks, however the installation of 

CCTV  is  an  action that  is  currently  pending  due to the  base  being  within a  building  that  is 

shared with users outside of policing. We are currently at the final stages of agreeing a contract 

for a new south base premises, which will see CCTV installed at point of build. The remaining 

three actions relate to feedback from the CoP following their visit to our northern base armoury 

in January 2023. Work is in progress to make all the required changes and should be in place 

by 30 April 2023. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We  have  continued  to  work  on  any  issues  identified  or  raised  following  the  death  of  Sgt 

Duignan to negate the possibility of future deaths in this area. I extend an open invite to you, 

and your office, to attend armed policing bases within BCH to see for yourself the measures 

and  governance  that  are  in  place  to  ensure  the  department  can  operate  efficiently  and 

effectively at keeping the public safe, whilst also ensuring the safety of our officers and staff. 

Yours sincerely 

Deputy Chief Constable

23 Stephenson Street 
Birmingham B2 4BH 

His Majesty’s Inspector of Constabulary 
His Majesty’s Inspector of Fire and Rescue Services 

16 August 2024 

Sent by email: 

Dr Sean Cummings 
Assistant Coroner 
Bedfordshire & Luton Coroner Service 
The Court House 
Woburn Street 
Ampthill 
MK45 2HX 

Dear Dr Cummings, 

Re: Regulation 28: Report to prevent future deaths 

I am writing to provide you with an update on my letter dated 31 January 2023. In this 
letter to you, I said I would instruct my team to monitor Bedfordshire Police’s 

armoury processes. This was as part of the HMICFRS police efficiency, effectiveness 
and legitimacy (PEEL) inspection programme 2023–25. 

Since my last correspondence, my team has been reviewing Bedfordshire Police’s 
armoury processes. It has focused on the Regulation 28 ‘Prevention of future deaths 
report’ published on 16 January 2023. The report detailed five concerns: 

1.  Single access to the armoury and incorrect access levels. 
2.  Lack of awareness of who shouldn’t have access to the armoury. 

3.  Failures by senior management to effectively and safely manage the South 

Base armoury. 

4.  IT failures resulting in armoury access challenges. 

5.  Safety and security at the South Base armoury. 

I am pleased to report that the force has made progress in all five areas listed above to 
make sure access to the armoury is regulated and controlled. The force has introduced 
systems and technology to control access to the armoury. These are working effectively. 
Senior management are now able to effectively manage the armoury to make sure their 
officers are safe. 

As part of our PEEL inspection of Bedfordshire Police’s armoury procedures, we carried 
out interviews and ran focus groups with both senior leaders and practitioners. We also 
inspected the Luton Firearms base. 

1 

 We have reviewed a range of strategic and tactical documents which illustrate policy, 
procedure and audits of key decisions, actions and risks. And we attended key 
governance forums, boards and meetings across the collaborated firearms provision. 
Bedfordshire Police is part of the Joint Protective Services Command (JPS) which is a 
collaborated service with Hertfordshire and Cambridgeshire Constabularies. This provides 
armed policing across the three counties. 

Key progress against the five areas 

Single access to the armoury and incorrect access levels 

The force has reduced single access to the armoury to make sure that only officers who 
need single access can have it. Only five people have single access to the armoury. 
All five are operational firearms commanders and armourers. The force has taken the 
added precaution of removing single access to the armoury from national firearms 
instructors. The force states these restrictions in its standard operating procedures, which 
have been distributed to all officers. Managers review these restrictions at the monthly 
managers’ meeting which is audited and recorded. We found that this process was tightly 

managed and regularly scrutinised. 

Awareness of who shouldn’t have access to the armoury 

Officers can choose not to carry firearms. They can also request that their armoury 
access is revoked for a defined period, should any welfare/well-being or professional 
standards concerns arise. Managers can also restrict armoury access if a person meets 
the same criteria. The firearms command has focused on enhancing its culture around 
‘it’s ok not to be ok’. And we found that the force has made significant progress with its 
well-being/welfare provision. We found evidence of officers feeling supported and cared for 
by their leaders. 

Once access for a person is restricted, the sergeant sends an email to all officers 
informing them of who has had their access revoked. The force duty inspectors are 
also made aware, and a restricted duties note is placed on the individual’s shift 
management system. We found improvements to the culture around carriage of firearms 
and to the way the command communicates with officers. These were effective in keeping 
officers safe. 

Failures by senior management to effectively and safely manage the South 
Base armoury 

The force holds a daily management meeting chaired by the duty manager with the 
operations superintendent in attendance. We found these meetings are effective at 
monitoring the times when officers are diverted from their duties. They are also effective at 
monitoring operational challenges, armoury access status, health and safety and sickness. 
There is good senior officer oversight through the monthly managers’ meetings. At these 
meetings, managers identify themes and trends and monitor armoury access. Key risks 
and issues are used to inform the firearms strategic board. The JPS assistant chief 
constable chairs this board, which provides good senior officer oversight and support. 

2 

 IT failures resulting in armoury access challenges 

The firearms command has invested in new and improved technology to reduce the 
number of Chronicle failures. Chronicle is the system that the force and the firearms 
command use to manage firearms accreditations and armoury access. The firearms 
command has moved to new premises at Luton airport. This means that there are better 
wiring and charging points to service Chronicle. As a result, the number of Chronicle 
system faults has reduced to zero in the last six months. 

JPS tracks and monitors system faults through the monthly managers’ meeting. JPS has 
a manual key process which provides access to the armoury when Chronicle faults occur. 
The force’s daily manager checks the manual key process following a clearly defined 

procedure. This makes sure the workforce is safe and secure. We found the new 
processes were effective in keeping officers safe. 

Safety and security at the South Base armoury 

The new firearms base in Luton is a modern, secure premises. It is fit for purpose, with 
several enhanced security measures. The new site has fencing to restrict access and 
enhanced 360-degree CCTV coverage in the armoury. It also has an enhanced armoury 
design, to control the access and distribution of weapons to officers. We found moving to 
the new site has significantly increased the safety and security of the officers. 

Conclusion 

In conclusion, I am satisfied that the firearms base at Luton airport is managed correctly. 
It has the correct procedures, policies and processes in place to keep officers safe while 
on the site. I am pleased to report positively on the force’s efforts to improve. They take all 

reasonable steps to continually improve the safety and well-being of their officers. 

Yours sincerely, 

His Majesty’s Inspector of Constabulary 
His Majesty’s Inspector of Fire and Rescue Services 

3

23 Stephenson Street 
Birmingham B2 4BH 
Direct line: 07741 930716 

His Majesty’s Inspector of Constabulary 
His Majesty’s Inspector of Fire & Rescue Services 

31 January 2023 

Dr Sean Cummings 
Assistant Coroner 
Bedfordshire & Luton Coroner Service 
The Court House 
Woburn Street 
Ampthill 
MK45 2HX 

Sent via email 

Dear Dr Cummings, 

Re: Regulation 28: Report to prevent future deaths 

I was saddened to read of the death of Police Sergeant Sean Duignan in such regrettable 
circumstances. Mr Duignan’s untimely death will undoubtedly have had a dreadful impact 
on his family, friends and colleagues. HMICFRS’s purpose is to promote improvements in 
policing and fire and rescue services to make everyone safer. I am grateful for the 
opportunity to comment and contribute to efforts that seek to prevent future such tragedy. 

In preparing my response I made a number of enquiries. I was encouraged to learn from 
others that the following action has already been taken following Mr Duignan’s death: 

In July 2021, the College of Policing armed policing lead and deputy conducted a 
review of the armoury procedures at Bedfordshire Police, focusing on Luton Airport. 
Observations were made to the Chief Constable of Bedfordshire Police. 

The Independent Office for Police Conduct has carried out an investigation. 

In October 2022, armed policing chief firearms instructors were presented with the 
lessons learned at the national chief firearms instructor seminar, which was overseen 
by the College of Policing. 

In November 2022, temporary Deputy Chief Constable 
Constable 
to advise him of the inquest finding and the work undertaken by Bedfordshire to 
address Independent Office for Police Conduct recommendations and College of 
Policing observations. 

 (National Police Chiefs’ Council armed policing lead) 

wrote to Chief 

• 

• 

• 

• 

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 Coincidently, under the leadership of my colleague, His Majesty’s Inspector 
HMICFRS has very recently completed the fieldwork phase of a national thematic 
inspection of armed policing. The terms of reference for that inspection include elements of 
munitions and weapons storage and issue. We did not specifically test armoury access. 
The inspection visited nine forces; Bedfordshire wasn’t one of these. 

, 

The inspection methodology included a review of those nine forces’ armoury standard 
operating procedures. All use the system known as ‘Chronicle’ to manage access. While 
single access is possible, dual access is the norm. Only a small number of documented 
and authorised individuals (for example, armourer, chief firearms instructor) have single 
access. Manual override processes involve the force incident manager. 

The Armed Policing inspection report is due to be published in summer 2023 and will refer 
to our findings and recommendations, including in respect of force armouries. 

Further to the inspection work, I intend to take the following action: 

•  Make sure the College of Policing and the National Police Chiefs’ Council armed 

policing lead issue a relevant national circular to all forces by 31 March 2023. That 
circular should include the lessons learned and ask for a suitable auditable review of 
all force armoury access procedures. I understand both organisations intend to take 
such action following the inquest conclusion. 

• 

Instruct my team to monitor Bedfordshire Police’s armoury processes as part of the 
HMICFRS police efficiency, effectiveness and legitimacy inspection programme  
2023–25. 

Yours sincerely, 

His Majesty’s Inspector of Constabulary 
His Majesty’s Inspector of Fire & Rescue Services 

Cc:  His Majesty’s Inspector 
Chief Constable 
Chief Constable 

 HMICFRS 

, NPCC Armed Policing Lead 

, Bedfordshire Police 

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