Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0073, written 28 Feb 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Feb 2023 |
|---|---|
| Reference | 2023-0073 |
| Deceased | Stephen Chapple and Jennifer Chapple |
| Coroner | Samantha Marsh |
| Coroner area | Somerset |
| Category | Other 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used before an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Military of Defence Defence Inquest Unit (DIU) Directorate of Judicial Engagement Policy MOD Main Building London SW1A2HB 2. Secretary of State for Defence (Mr Ben Wallace) House of Commons London SW1A 0AA 1. 1 CORONER I am Mrs Samantha Marsh senior coroner, for the coroner area of Somerset. 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 On 22 nd November 2021 my predecessor, Mr Tony Williams, commenced an investigation into the joint deaths of husband and wife, Stephen Roy Chapple and Jennifer Chapple. Inquests were opened and adjourned on the 9th December 2021. Upon Mr Williams' retirement, I took over conduct of the above cases on 01 April 2022 The investigation was suspended under Schedule 1 of the Coroners and Justice Act 2009 on the basis that an individual was charged with their murder. 4 CIRCUMSTANCES OF THE DEATH Stephen and Jennifer Chapple lived on a residential housing development in Norton Fitzwarren. They became involved in a parking dispute with their neighbour, Jennifer, in particular, parkinQ her vehicle in a particular location and manner It would appear that took umbrage at simply didn't like it and took petty action of moving his within the development. She was perfectly legally entitled to park how and where she did ; bins to block spaces and/or parking his own vehicle in an inconsiderate manner to cause a nuisance. There were some instances of police involvement, but this was largely either deemed to be a civil matter or verbal harassment by who embarked on a course of conduct designed to intimidate or frighten Mr, but more particularly Mrs Chapple. On the 21 st November 2021 at 09:45am Constabulary and informed the call-taker that he had stabbed his neighbours, Mr and Mrs Chapple . They suffered significant wounds and were sadly pronounced deceased at the scene . telephoned Avon and Somerset The IOPC Report concluded that the Police acted appropriately to the incidents reported at the time and there was no indication from the previous conduct that physical violence and/or a double homicide offence was even a remotely foreseeable possibility. was charged with the double murder and after a trial was sentenced at Bristol Crown Court on the 21 st June 2022 to a fixed minimum custodial term of 38 years. 5 CORONER'S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern . In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. - The murder weapon was a ceremonial dagger that had been presented to following his retirement from the British Army. was in the British Army was 2002 - 2017 (Royal Engineers) and, on leaving , he was presented with the ceremonial dagger as a commemorative token of his service. The dagger was not a blunt replica, it was a fully functional weapon capable of causing significant harm, injury and sadly in the Chapple's case, death. Please reconsider the appropriateness of providing anyone leaving the British Army, regardless of rank or status, with what is (to all intents and purposes) a deadly weapon. Such presentation/gifting has essentially put a deadly weapon in the community (where I understand it sadly remains, having never been recovered as it was removed from the scene prior to police attendance) and I am not persuaded that this is appropriate. During the trial, evidence was adduced by the poor mental health of ~ountries. This is not an uncommon feature of those serving in and/or leaving the Army and adds further weight to my concerns around the appropriateness of such items (whether ceremonial or not) being issued in the first place, but secondly being issued to those who may have a propensity for mental health issues. because of combat and tours of war-torn defence team to allude to 6 ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths 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 25th April 2023 , the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, ~etting 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 I have also sent it to the Chief of Avon and Somerset Constabulary 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 28th February 2023
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.
Ministry of Defence SECRETARY OF STATE MINISTRY OF DEFENCE FLOOR 5, ZONED, MAIN BUILDING WHITEHALL LONDON SW1 A 2HB 21 April 2023 Dear Senior Coroner, I am writing in response to your Prevention of Future Deaths report delivered under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners' (Investigations) Regulations 2013, in respect of the Inquest held following the double murder trial of Engineer. In your report you set out the circumstances giving rise to your concern. , a former Commando trained Royal The murder weapon in this case was never recovered but the police informed you that, to the best of their knowledge, the dagger was a " These are commonly referred to as a Commando Dagger although are officially termed as Combat Fighting Knife. presented to the perpetrator on his termination of service from the British Army, his final employment being at 24 Commando Engineer Regiment. It is worth noting that, even if the weapon was recovered, it is not possible to determine if it had been supplied through the MOD or legally purchased from a commercial UK source. It has been suggested that a Combat Fighting Knife was ". Where the Regulation 28 Report refers to a "ceremonial dagger'', my response refers to the MOD issued Combat Fighting Knife, although implications will be considered for all combat related knives. Additionally, this response is not restricted to the British Army but has considered Defence as a whole, given that the Combat Fighting Knife is a capability 'owned' by the Royal Navy but is available to specific establishments and personnel from all three Services. However, I hope that this response confirms that the Ministry of Defence has learned lessons from the tragic deaths of Mr and Mrs Chapple and that the necessary corrective action is being taken in response to your report, and that the families draw some comfort from this. As ever, my thoughts remain with them. Samantha Marsh HM Senior Coroner Municipal Buildings Old Corporation Street Taunton TA14AQ Matter of Concern 1 - "Please reconsider the appropriateness of providing anyone leaving the British Army, regardless of rank or status, with what is (to all intents and purposes) a deadly weapon." The MOD does not consider it appropriate to provide Combat Fighting Knives to anyone other than those who require such an item for a specific combat role. The Combat Fighting Knife is available to only 21 accounts within Defence all of which are connected to 3 Commando Brigade Royal Marines or Specialist Military Units. MOD policy is very clear: No-one is permitted to make a gift of MOD property without specific approval from the correct authority. Each MOD business unit has a focal point who provide advice on gifting policy, assess individual gifting proposals and where appropriate give guidance on the approval requirements. Service personnel would not ordinarily be viewed as permitted recipients of gifts although some discretion is allowed which is outlined in Defence policy. The relevant Top Level Budget authorities confirmed that there are no records of Combat Fighting Knives having been gifted. Existing MOD policy clearly states that failure to comply can and does lead to investigation with a range of disciplinary sanctions available. Policy clearly states that any suspicions of fraud, theft, bribery and corruption as well as unethical behaviour, value for money concerns and related irregularity should be reported to the Chain of Command or to an existing confidential hotline/email; furthermore, it outlines Defence's intentions concerning prevention and detection, and sanctions that may be applied to culprits. In this regard, Defence works to the expectation that all staff guilty of committing fraud (including theft) will be dismissed from the Service, be placed on the Government Internal Fraud Database and may be prosecuted. Since 28 Feb 2019 MOD supplied 2031 Combat Fighting Knifes to entitled units. In comparison, over the same period Amazon-UK's 4th best-selling Chef's knife, which has comparable lethality to the Combat Fighting Knife, has been reviewed over 3,300 times, and undoubtedly sold far in excess of this figure: these are sold to the public online and delivered subject to an age check. This is but one of many potentially lethal knives and tools sold legally in the UK. I consider that MOD's existing measures are appropriate, however, I have written to the General Officers Commanding the Units entitled to demand/issue Combat Fighting Knifes, in order to remind them: To ensure there is genuine requirement to issue such items to a. personnel. To ensure misappropriation of such items are thoroughly investigated b. and grounds for prosecution or disciplinary proceedings, applied in the strictest sense. Matter of Concern 2 - "Such presentation/gifting has essentially put a deadly weapon in the community and I am not persuaded that this is appropriate." There is a tradition within the MOD of presenting leaving gifts to individuals when they exit the Armed Forces. A Combat Fighting Knife as part of a presentational display is one of many gifts that may be presented to a Service person departing military units associated with the Commando role , especially with 3 Commando Brigade. Such items are provided using non-public funds such as a collection from colleagues. Combat Fighting Knifes and associated display materials are widely available from a range of suppliers commercially within the UK subject to an age check. Whilst the military chain of command could issue a Standing Order prohibiting Service personnel gifting specific items such as Combat Fighting Knives to Service leavers, such an Order would be of limited utility. It is worth noting that on google.co.uk there are in excess of 160,000 hits on " commercial (and perfectly legal) availability is the primary source of proliferation in the community. knives for sale", thus suggesting that It is worth noting that personnel employed at units entitled to issue the Combat Fighting Knife are trained to a high standard. They are required to conduct annual rules of armed conflict training including rules of engagement and proportionate application of force. This is a population that have a heightened understanding of the Combat Fighting Knife's potential lethality, and to only utilise violence when absolutely necessary. I consider existing restrictions upon gifting of MOD property to be sufficient, however, I have written to the Service Chiefs in order to inform them of this horrific murder and remind them of their duty to ensure that misappropriation of MOD items is identified and investigated. Moreover, that the issue of potentially lethal items should be scrutinised to ensure genuine requirement, and that misappropriation of such items, including combat knives of any type, should be thoroughly investigated and the strictest sanctions applied as a future deterrent. Yours sincerely, THE RT HON BEN WALLACE MP
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