Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0085, written 8 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 | 8 Feb 2023 |
|---|---|
| Reference | 2023-0085 |
| Deceased | Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington and Kate Shepherd |
| Coroner | Ian Arrow |
| Coroner area | Plymouth, Torbay and South Devon |
| Category | Other related deaths · Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 34 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
The Public Inquiry into the Shootings at Dunblane Primary School on 13 March 1996 The Hon Lord Cullen The Public Inquiry into the Shootings at Dunblane Primary School on 13 March 1996 ISBN 0 10 133862 7 Cm. 3386 Contents Title Page Foreword List of Victims Chapter 1 Summary of the Report Chapter 2 The scope and conduct of the Inquiry Chapter 3 The events of 13 March 1996 Chapter 4 Events in the life of Thomas Hamilton Chapter 5 The last six months Chapter 6 Thomas Hamilton's possession of firearms and ammunition Chapter 7 The control of firearms and ammunition Chapter 8 The certification system relating to section 1 firearms Chapter 9 The availability of section 1 firearms Chapter 10 School security Chapter 11 The vetting and supervision of adults working with children and young people Chapter 12 Summary of recommendations Appendix 1 List of the parties and their representatives Appendix 2 List of witnesses Appendix 3 Discussion relating to decisions taken by Procurators Fiscal Appendix 4 List of submissions Appendix 5 Publications taken into consideration Appendix 6 Target shooting competitions for handguns Foreword The Rt Hon Michael Forsyth MP Secretary of State for Scotland Dear Secretary of State On 21 March 1996 it was resolved by both Houses of Parliament that it was "expedient that a Tribunal be established for inquiring into a definite matter of urgent public importance, that is to say, the incident at Dunblane Primary School on Wednesday 13 March 1996, which resulted in the deaths of 18 people." In terms of the Warrant of Appointment dated 21 March 1996, you appointed me to be a Tribunal for the purposes of this Inquiry in virtue of Section 1 of the Tribunals of Inquiry (Evidence) Act 1921; and you declared that that Act should apply to the Tribunal and that the Tribunal was constituted as a Tribunal within the meaning of Section 1 of that Act. In a Parliamentary reply to Mr George Robertson MP on 21 March 1996 you set out that the Inquiry's terms of reference should be:- "To inquire into the circumstances leading up to and surrounding the events at Dunblane Primary School on Wednesday 13 March 1996, which resulted in the deaths of 18 people; to consider the issues arising therefrom; to make such interim and final recommendations as may seem appropriate; and to report as soon as practicable." I have carried out the Inquiry and now respectfully submit my Report thereon. A list of the names of the persons who were the victims of the incident, both the dead and the surviving, follows. W Douglas Cullen 30 September 1996 List of Victims Deceased Victims Surviving Victims Victoria Elizabeth Clydesdale Emma Elizabeth Crozier Melissa Helen Currie Charlotte Louise Dunn Kevin Allan Hasell Ross William Irvine David Charles Kerr Mhairi Isabel MacBeath Gwen Hodson or Mayor Brett McKinnon Abigail Joanne McLennan Emily Morton Sophie Jane Lockwood North John Petrie Joanna Caroline Ross Hannah Louise Scott Megan Turner Aimie Lauren Adam Coll Austin Matthew Alexander Birnie Mary Blake Scott Elliot Crichton Eileen Mary Harrild Steven James Hopper Robbie Hurst Amy Louise Hutchison Ryan Thomas Liddell Mark James Mullan Andrew O'Donnell Victoria Elizabeth Porteous Robert Raymond Purves Grace Tweddle Ben Vallance Stewart Campbell Weir Chapter 1 Summary of the Report 1.1 Through the Inquiry I sought the answers to the following questions: o what were the circumstances leading up to and surrounding the shootings at Dunblane Primary School on 13 March 1996? o what should I recommend with a view to safeguarding the public against the misuse of firearms and other dangers which the investigation brought to light? 1.2 In Chapter 2 I give an account of the investigation of the circumstances and the steps which were taken to prepare the way for my consideration of possible recommendations. 1.3 In Chapter 3 I describe how Thomas Hamilton, having entered the school, shot Mrs Gwen Mayor and 16 members of her Primary 1/13 class and inflicted gunshot wounds on 10 other pupils and three other members of the teaching staff. I then describe the response of the teaching staff, emergency services and police to the incident, with an account of various lessons which have been learned from the experience. I narrate that an examination of the scene showed that, having entered the school with 4 handguns and 743 rounds of ammunition, Thomas Hamilton fired 105 rounds with a 9 mm Browning self-loading pistol over a space of about 3-4 minutes before committing suicide with one shot from a .357 Smith & Wesson revolver. 1.4 In order to provide the full background to this outrage the Inquiry had to investigate events in the life of Thomas Hamilton, and in particular over the last 23 years. The results of that investigation are set out in Chapter 4 with the exception of the last 6 months which are covered by Chapter 5. In Chapter 4 I describe how the withdrawal of his warrant as a Scout leader in 1974 led to his undying resentment against the Scouts who, he claimed, undermined his work with various boys clubs which he ran from the 1970s onwards. However, the way in which he ran those clubs, and in particular his insistence that the boys should wear brief swimming trunks which he provided and be photographed in them while performing gymnastic exercises caused complaints from parents and led to his coming into contention with a number of local authorities which owned the school premises where his clubs met. His summer camps in 1988 and 1991 and his residential sports training course in 1992 were investigated by the police, but he was never prosecuted. Thomas Hamilton countered these complaints and investigations with complaints of his own against the police and local authority officials. In 1995 Central Regional Council was still endeavouring to find ways of making it more difficult for him to obtain the let of their premises. The chapter also deals with allegations as to his conduct with firearms, and in particular showing them to others and an occasion on which he is said to have threatened Mrs Doreen Hagger with a gun. I do not find it proved that this incident occurred or was reported to the police. 1.5 In Chapter 5 I deal with a number of possible pointers as to the factors which were at work in the mind of Thomas Hamilton in the period leading up to 13 March 1996. His clubs were then in decline. He was in serious financial difficulties. His mood was low and he was deeply resentful of those who had claimed that he was a pervert and had discouraged boys from attending his clubs. After a gap of about 8 years his interest in firearms was resurgent. There is evidence which points to his making preparations for what he did, including the questions which he put to a boy about the layout and timing of events at the school and his questioning of a retired police officer about the time which the police would take to respond to an incident. In the light of expert evidence from a psychologist and psychiatrist I conclude that Thomas Hamilton was not mentally ill but had a paranoid personality with a desire to control others in which his firearms were the focus of his fantasies. The violence which he used would not have been predictable. His previous conduct showed indications of paedophilia. 1.6 In Chapter 6 I am concerned with the question - How was it that Thomas Hamilton came to hold the firearms and ammunition which he did on 13 March 1996? I set out the history as from February 1977 of the firearms and ammunition which he was authorised to and did acquire. In the light of the legislation and the official Guidance to the Police I examine the operation of the certification system by Central Scotland Police. I find that the reasons which were given and accepted for his being authorised to hold more than one handgun of the same calibre were unsatisfactory. The authority which he had for the possession of firearms and the acquisition of ammunition was renewed without enquiry as to the use which he was making of the firearms. The underlying reason for this was the unsatisfactory way in which the Guidance was expressed. His fitness to be entrusted with a firearm was challenged by Detective Sergeant Hughes in a memorandum of 11 November 1991 after the police investigation of the summer camp of that year. However, it was decided that no action should be taken against Thomas Hamilton. A similar decision had been taken in 1989 after he had behaved inappropriately in showing firearms to a family in Linlithgow. I reach the conclusion that in the response of senior police officers to the memorandum of Detective Sergeant Hughes an unduly narrow view was taken of "unfitness" as a ground for the revocation of a firearm certificate; and that in view of various considerations Deputy Chief Constable McMurdo should have made further enquiries. On balance there was a case for revocation which should have been acted upon. The same considerations should have led in any event to the refusal of Thomas Hamilton's subsequent applications for renewal of his firearm certificate. However, the eventual outcome would have depended on the outcome of the appeal to the sheriff which I have no doubt that Thomas Hamilton would have taken. The chapter concludes with some observations on what I regard as weaknesses in the system used by Central Scotland Police for the carrying out of enquiries and the making of decisions about firearm applications. 1.7 As I explain in Chapter 7, there are essentially two methods of control of firearms and ammunition under the Firearms Acts. The first is the regulation by means of the certification system of the authority to possess, or as the case may be, to purchase or acquire them. The second is the imposition of restrictions on certain categories of firearms and ammunition by reference to their relative dangerousness. At the outset of my discussion of the future of legislative control I consider the submission that all guns should be banned, from which it would follow that there would no longer be a certification system. For the reasons which I give I do not recommend such a wholesale prohibition. 1.8 It is logical that I should next consider what could be achieved by improvements to the certification system. I do this in Chapter 8. As regards the work of the police I do not favour the removal from them of any of their functions but I point out that in a number of respects there is a need to strengthen the support which is given to those who carry out enquiries; and to extend the powers available to police officers and civilian licensing and enquiry officers. I also endorse the steps which are being taken to enable police forces to hold and exchange information on computer as to the individuals who hold firearm certificates and those whose firearm applications have been refused or certificates revoked. 1.9 The history of Thomas Hamilton's possession of firearms and ammunition shows that there is a need to ensure that a person does not retain the authority to possess a firearm or ammunition for it when he no longer can show "good reason" for doing so. There requires to be a power to revoke a firearm certificate on this ground, in whole or in part. However, if the police are to have the opportunity to consider revocation it is essential that there should be a means by which the use of firearms and ammunition can be ascertained; and that the police are made aware of circumstances indicating lack of use. This leads me to discuss the need for each holder of a firearm certificate to be a member of at least one club which is approved for the purposes of section 15 of the Firearms (Amendment) Act 1988; and for approved clubs to keep a record of the activities of their members who are holders of firearm certificates and to inform the police of the termination of membership or non-attendance for a substantial period. 1.10 The suitability of a holder of a firearm certificate is linked even more closely with the safety of the public. The fitness of a person to be entrusted with a firearm should become one of the conditions on which the granting and renewal of a firearm certificate depends. I also consider what additional steps should be taken to guard against "prohibited" persons becoming members of an approved club. I discuss the current requirement for a counter-signatory in support of a firearm application, and recommend that it should be replaced by a system for the provision of two references. I turn then to the provision of medical and psychological information. I do not consider that it would be practicable for general practitioners to be required to provide a medical report on each applicant, or for a psychiatric examination or a psychological test to be carried out. In any event in each case there are grounds for considerable reservations as to the effectiveness of such a measure. However, the proposal that general practitioners should provide information as to applicant's medical history for consideration by a forensic medical examiner should be the subject of consultation with the interested bodies. Lastly, I discuss the present system for appeals against the decisions of the chief officer of police, and express the view that it would be more appropriate that the scope for appeal should be restricted to enumerated grounds which did not trench on the exercise of his discretion; and that this be the subject of further study and consultation. 1.11 Despite the fact that there is room for improvement in the certification system I conclude that there are significant limitations in what can be done to exclude those who are unsuitable to have firearms and ammunition. There is no certain means of ruling out the onset of a mental illness of a type which gives rise to danger; or of identifying those whose personalities harbour dangerous propensities. On this ground alone it is insufficient protection for the public merely to tackle the individual rather than the gun. This brings me to the discussion in Chapter 9 of the availability of section 1 firearms, and in particular handguns held for target shooting, with which the Inquiry was directly concerned. I discuss the uses of such handguns and the dangers which may be posed by their misuse - the part they play in crime and their relative lethality, ease of use and rapidity of fire. I consider the risk which arises from their present legal availability and reach the conclusion that there is a case for restricting the possession by individuals of self-loading pistols and revolvers of whatever calibre which are held for target shooting. 1.12 I then proceed to examine the evidence which was before me as to the practicability and effectiveness of various measures for restricting the availability of handguns in target shooting - (i) limiting the number of handguns or the number of a particular calibre which may be held; (ii) separating the handguns from their ammunition; (iii) restricting the capacity of multi-shot handguns; (iv) temporarily disabling multi-shot handguns; and (v) the banning of the possession by individuals of multi-shot handguns. I then consider the implications of the imposition of a restriction of one kind or another on the availability of handguns. 1.13 In reviewing my conclusions I note that of all the measures which stop short of a ban the one which is open to the least objection on the ground of practicability is the temporary dismantling of self-loading pistols and revolvers by the removal of major components. Any difficulty on this ground could be met by a requirement for the fitting of locked barrel blocks. It does not eliminate all possibility of evasion by a determined would-be killer but such a system would effect a substantial reduction in the opportunity for misuse of lawfully held handguns. I also require to consider what would be proportionate and just, having regard on the one hand to the scale of risk and on the other to the implications of one course of action or another. The banning of multi-shot handguns would have a very damaging effect on the sport of target shooting and would give rise to claims for compensation and adverse effects on the economy. I point out that the ultimate decision raises a number of matters of policy which are peculiarly for the Government and Parliament to decide. For that reason I direct my recommendation to what should be considered. My conclusion is that consideration should be given to restricting the availability of self-loading pistols and revolvers of any calibre which are held for use in target shooting preferably by their disablement, while they are not in use, by either (i) the removal of the slide assembly/cylinder, which is to be kept securely on the premises of an approved club of which the owner is a member or by a club official; or (ii) the fitting of a locked barrel block by a club official. If such a system is not adopted, consideration should be given to the banning of the possession of such handguns by individual owners. 1.14 In Chapter 10 I am concerned with the safety of staff and pupils in schools, and in particular with their protection against violence. Guidance has been published on the subject of violence to staff but little, if any, on tackling the dangers to pupils. However, it is clear that the solution to the problem of protection is to be found through the application of sound principles of safety management. I point out the legal responsibility for safety of employees and pupils which arises from the provisions of the Health and Safety at Work Act 1974. There should be no uncertainty as to the personnel to whom safety roles are allocated. The risks against which staff and pupils at school are to be safeguarded includes the possibility of attack by an intruder, and the existence of that risk calls for the working out of a preventive strategy with an action plan appropriate to the particular features of each school. While the approach to be adopted in such an action plan and the measures which it should include must depend on the particular case I set out an outline of the main points which were put to me in the submissions which I received. 1.15 Chapter 11 is concerned with the means of protecting children and young people who attend clubs or other groups against abuse by leaders or others who have regular contact with them; and in particular with the steps which can and should be taken to vet such persons and supervise their conduct. Having reviewed existing controls and advice I concentrate on situations in which children and young people under 16 years of age voluntarily attend clubs or groups for their recreation, education or development. It is unsatisfactory that it should be left to individual clubs or groups to carry out their own checks and to adopt whatever practice they please. Parents are not always in a position to make adequate enquiry into the way in which clubs or groups are run or their personnel are checked. There may be difficulties facing smaller organisations in carrying out effective checks. As matters stand there is no system for co-ordinating information between different areas of the country as to persons who are regarded as potentially unsuitable to work with children and young people. As I explain, these and other considerations indicate that, in my view, a system should be instituted to ensure that clubs and groups use adequate checks on the suitability of the leaders and workers who have substantial unsupervised access to them. Having reviewed various possible approaches to such a system I reach the conclusion that what is required is one for the voluntary accreditation of clubs and groups, and that such a system should be operated by means of a national body. Such a body would also be responsible for drawing up or selecting guidelines, collecting information in regard to any matter which might reflect on a person's suitability and monitoring the conduct of clubs and groups which are accredited. 1.16 Chapter 12 contains a summary of my recommendations. Chapter 2 The scope and conduct of the Inquiry Preliminary matters 2.1 The preliminary investigation for the Inquiry was carried out under the authority of the Lord Advocate. The bulk of the investigation was carried out by Central Scotland Police under the direction of Mr John Miller, Procurator Fiscal at Stirling. This involved a painstaking and detailed examination of the conduct of Thomas Hamilton over many years; his relationship with a considerable number of bodies and officials; and the actions of the police in investigating his conduct and authorising his holding of firearms and ammunition. I would like to acknowledge the considerable assistance which the Inquiry derived from being able to draw on the results of that investigation which placed great demands on Central Scotland Police. 2.2 In regard to two subjects, namely (i) the adequacy of the procedures and actions taken by Central Scotland police in regard to Thomas Hamilton's firearm certificate; and (ii) the reports concerning Thomas Hamilton which were made by Strathclyde Police and Central Scotland Police to the Procurators Fiscal at Dumbarton and Stirling, the Lord Advocate very properly decided that it was appropriate to obtain independent evidence for the assistance of the Inquiry. This was provided in the form of reports by Mr J Richardson, Deputy Chief Constable, Strathclyde Police and Mr Alfred D Vannet, Regional Procurator Fiscal of Grampian, Highland and Islands, Aberdeen, respectively. 2.3 In addition to the preliminary investigation, the Lord Advocate, along with counsel appointed by him to act on his behalf, Mr Iain Bonomy QC and Mr Jonathan Lake, Advocate, undertook responsibility in the public interest of presenting evidence to the Inquiry. The general lines to which the evidence should be directed were worked out in consultation with myself. To them I would like to express my profound gratitude for their assistance in achieving the objects of the Inquiry. 2.4 Mrs Glynis McKeand was appointed Clerk to the Inquiry. Her unfailing support and dedication have been invaluable. She has done far more than respond to the call of duty. Mrs Christine McGowan-Smyth assisted me by marshalling information contained in certain parts of the factual evidence. Miss Rachel Gwyon analysed the content of the written submissions relating to matters of school security and the vetting and supervision of adults working with children. Mrs Dorothy Gordon has borne the burden of typing the text of this Report and the preliminary drafts and revisals. To all these members of the Inquiry team I am most grateful. 2.5 From the time when my appointment was announced I received over 1600 letters from a wide variety of correspondents, concerned mainly with the control of firearms and ammunition. While these letters were not intended to be, nor were they, treated as evidence I took account of the concerns which were expressed in them in determining what I would examine. In addition I received petitions supported by 33,739 signatures. 2.6 In order to make myself more familiar with what would be discussed at the Inquiry I took a number of steps. I visited the gymnasium at Dunblane Primary School during the week following the shootings. Arrangements were made for me to see a demonstration of the operation of firearms by Mr Alastair Paton, a firearms expert, who in due course gave evidence at the Inquiry. I also requested that arrangements should be made to enable me to visit Bisley during the holding of the competitions known as Pistol '96 in order to see how they were conducted. I would like to record my thanks to the National Rifle Association for their responding to this request. I also attended as an observer at a meeting of a pistol club near Edinburgh. 2.7 A preliminary hearing was held at the Albert Halls, Stirling on 1 May 1996. At this hearing I disposed of applications by persons who wished to be parties to the Inquiry and dealt with various matters of procedure. Under the Tribunals of Inquiry (Evidence) Act 1921 I had the power to authorise the representation of any person who appeared to me to be "interested", that is to say interested in the circumstances leading up to and surrounding the incident. A list of the parties to the Inquiry and their representatives is contained in Appendix 1. One of the rules of the Inquiry was that if any party formed the intention at any stage to criticise another person, whether or not his or her interests were already protected by representation, that party should promptly inform the Inquiry Office so that whatever steps were appropriate might be taken, including, where necessary, giving the opportunity for representation to be obtained. 2.8 At the preliminary hearing I also invited written submissions in regard to three particular topics and any other topic which was relevant. This invitation was repeated in a press notice on 3 May 1996. The three particular topics were: i. ii. iii. control of the possession and use of firearms and ammunition; school security; and vetting and supervision of adults working with children. The Inquiry 2.9 The Inquiry was held at the Albert Halls, Stirling. It sat for 26 days, opening on 29 May and closing on 10 July 1996. The whole proceedings were held in public and recorded by shorthand writers, Wm. Hodge & Pollock Ltd, Glasgow. The arrangements for the accommodation of the participants, the public and the press were made by the Scottish Courts Service. I am most grateful to them for their assistance. 2.10 Shortly before the opening of the Inquiry I and the Lord Advocate had a meeting with the relatives of the victims of the shootings in order to discuss any concern or anxiety which they had in regard to the taking of evidence at the Inquiry. With my approval and in accordance with their wishes, details of the injuries suffered by individual victims were not explored in evidence. However, as was stated at the opening of the Inquiry, I was supplied with a set of files relating to the victims for my personal consideration. 2.11 At the opening of the Inquiry the Lord Advocate made a statement that, while it was extremely unlikely that any witness should have any concern about self-incrimination, he considered that it was appropriate in the public interest to give an undertaking that anything which a witness said in evidence at the Inquiry would not be used in evidence against him or her in any criminal proceedings in Scotland, except in relation to any offence of perjury or against the course of justice. 2.12 The witnesses who gave evidence at the Inquiry did so on oath or affirmation. In a few instances the evidence of a witness was submitted in writing and read to the Inquiry. Copies of the statements which had been taken from witnesses before they gave evidence were issued in advance to the parties. In no case did it prove necessary for me to exercise the power to enforce attendance which is contained in section 1 (1) of the 1921 Act. A list of the witnesses is contained in Appendix 2. In all but one instance the witness was led by the Lord Advocate or counsel acting on his behalf. 2.13 Copies of the documents which had been assembled for the Inquiry were made available in advance to the parties. The statements of witnesses and the documents were made available on the basis that they were solely for the use of parties and their representatives in connection with their preparation. The parties were asked to give, and gave, their undertakings for this purpose in the normal way. In no case was it necessary for me to exercise my power to compel the production of a document under section 1(1) of the 1921 Act. I should add that the documents assembled by Central Scotland Police included a copy of the draft (as at February 1996) of the thematic report of Her Majesty's Inspectorate of Constabulary for Scotland on the subject of the Administration of the Firearms Licensing System in 1995. This was referred to during the course of the evidence; and I was also provided with a copy of a later draft of April 1996. I was informed that the decision on whether or not the report should eventually be published would be taken when I had completed my deliberations. 2.14 With my approval and the agreement of parties evidence was taken at the Inquiry in such a way as to avoid the identification of any persons who had come into contact with Thomas Hamilton during their childhood. 2.15 I endeavoured to ensure that the Inquiry had before it the evidence which would enable me to make the findings which are expected of a fatal accident inquiry in Scotland. 2.16 During the course of the Inquiry evidence was led as to information submitted to the Procurators Fiscal of Dumbarton and Stirling by Strathclyde Police and Central Scotland Police during the years from 1988 to 1993; and the reasons stated by the Procurators Fiscal for their decisions in relation to the matters reported to them. As I have already stated the Inquiry was provided with a review by Mr Vannet of the reports and information which were submitted to the Procurators Fiscal by those police forces. On 24 June 1996 Mr Bonomy on behalf of the Lord Advocate made a statement of the Lord Advocate's position in relation to that evidence and the question of enquiring into the decisions taken by those Procurators Fiscal. On the following day I heard submissions from Mr C M Campbell QC and Mr Bonomy in regard to the proper scope for questioning in regard to these matters, after which I gave my decision. The statement made on behalf of the Lord Advocate, a note of the submissions which were addressed to me and the terms of my decision are set out in Appendix 3. 2.17 In the latter part of July it was drawn to my attention that a telephone conversation between two police officers on the morning of 13 March concerning the situation at the school had been accidentally recorded by a telephone answering machine in Motherwell: and that the cassette on which it had been recorded had come into the hands of Central Scotland Police later that day. I was provided with a transcript of the recorded conversation. I was satisfied that it did not contain anything which was of value to the Inquiry. 2.18 As the Inquiry was held not long after the shootings it is not surprising that someone who did not come forward or could not be traced at an earlier stage should claim later that he was able to contribute information about the behaviour of Thomas Hamilton. I deal with a particular instance of this in para 4.15. Evidence in regard to possible recommendations 2.19 I received a considerable number of contributions in response to the invitation for written submissions which I had issued. In selecting those which were to form part of the written evidence before the Inquiry I had regard to a number of considerations, the most important of which were the qualifications and responsibilities of the contributors and the desirability of obtaining a full range of views. Appendix 4 contains a list of the organisations and persons whose written submissions were selected. Copies were made available for inspection by the press and the public as from 10 June 1996 (Day 10): and thereafter as further written submissions were received and accepted in evidence. I would like to express my appreciation for the high quality of these submissions. They have been of considerable assistance to me in evaluating a wide range of proposals. It is not practicable for me to set out every contention in this Report, let alone all the supporting arguments, but every point has been considered. 2.20 In addition to these written submissions I also had available to me i. evidence submitted on behalf of the Secretary of State for Scotland and the Home Secretary on 30 April 1996, which contained background information about the licensing of firearms and ammunition; together with comments about the advantages and disadvantages of a number of suggestions for changes in the law which had been made since 13 March 1996, which I will refer to in this Report as the "Green Book". the report of the Working Group on School Security for the DfEE, which was published in May 1996, along with a commentary by The Scottish Office Education and Industry Department; and a paper by The Scottish Office on the recruitment and supervision of adults working with children which was published in June 1996. ii. iii. 2.21 Since the written submissions raised a number of points which had practical implications I considered that it would be appropriate to obtain certain additional factual evidence. For this purpose the Inquiry heard evidence in regard to the operation and use of firearms and ammunition; the operation of the certification system; the practice of shooting disciplines and the operation of rifle and pistol clubs; and the extent to which medical practitioners could assist in the assessment of applicants for firearm certificates. 2.22 It was clear to me that it would be of assistance to have a contradictor to oral submissions by the parties which had not been anticipated in the written submissions. I invited legal representatives of the British Shooting Sports Council, the Scottish Target Shooting Federation, the Stirling Rifle and Pistol Club and the Callander Rifle and Pistol Club to address the Inquiry at the stage of closing submissions. I am grateful to them for their assistance in helping me to focus the points at issue. 2.23 In connection with possible recommendations I had available to me by way of background a number of publications, which are listed in Appendix 5. In addition I received a number of papers relating to firearms laws in the Republic of Ireland, Northern Ireland, Australia and Japan. 2.24 At an early stage of the Inquiry it was clear that a number of the written submissions were critical of the research material referred to in Annex G to the Green Book which had been provided by the Research and Statistics Directorate of the Home Office. I decided at that stage that I should seek the Directorate's comments on these submissions. A note of their comments was received by the Inquiry Office on 29 July. As their comments had been requested while the Inquiry was in progress I decided that the appropriate course was to treat the note as part of the evidence before me. Copies of the note were supplied to the critics of the research material and arrangements were made for notification of the press. A similar procedure was followed when the results of studies of statistics relating to certain cases involving firearms in England and Wales in 1992-94 and in Scotland in 1993 were submitted to the Inquiry Office in the latter part of August. The scope of recommendations 2.25 In considering the evidence before me I have endeavoured to identify the lessons of the incident and of the circumstances which led up to it, with a view to avoiding the misuse of firearms and other dangers which the investigation brought to light. Every inquiry of this kind involves an extrapolation from the particular circumstances of the case. However, I have borne in mind, as I said at the Inquiry, that, consistently with my terms of reference, I am concerned with issues which arise from the circumstances leading up to and surrounding the incident. For that reason I have concentrated on matters which have some tenable connection with those circumstances. While this is the approach which I would have adopted in any event it is particularly necessary for me to point this out in view of the range of subjects with which some of the submissions relating to the control of firearms were concerned. How I have followed out that approach will be seen from Chapters 7-11. I did not consider that, in regard to any of the matters with which my recommendations are concerned, it was necessary or appropriate for me to present them as interim recommendations. 2.26 I have worked out my recommendations by reference to the evidence, both oral or written, which was before me. I have applied my own independent judgment to the task. I say that with added emphasis in view of a report in the Sun newspaper on 15 August which stated that, following a remark attributed to the Prime Minister, I would abandon a first draft of my report and rewrite my proposals. I would add that at that time no text of my recommendations, draft or otherwise, was in existence. The shootings also prompted the House of Commons Home Affairs Committee to initiate an inquiry into matters of general public policy relating to the possession of handguns. The Committee received both written evidence and oral evidence at a hearing on 8 May. Their report was published on 13 August. Some of the written evidence which was presented to the Inquiry was also presented to the Committee. I should make it clear that, while there was an overlap with the matters which I considered, I did not feel in any way inhibited in reaching my own conclusions. Chapter 3 The events of 13 March 1996 Introduction 3.1 In this chapter I will describe the circumstances of the shootings, and the response of teaching staff, emergency services and police to the incident. I will also set out a number of findings in regard to the firearms, ammunition and other equipment carried by Thomas Hamilton. The Shootings 3.2 About 8.15 am Thomas Hamilton was seen by a neighbour to be scraping ice off a white van outside his home at 7 Kent Road, Stirling. They had a normal conversation. Some time later he drove off in the van in the direction of Dunblane. At about 9.30 am he parked the van beside a telegraph pole in the lower car park of Dunblane Primary School. (See Photograph). He took out a pair of pliers from a toolwrap and used them to cut the telephone wires at the foot of the telegraph pole. These did not serve the school but a number of adjoining houses. He then crossed the car park, carrying the weapons, ammunition and other equipment which I will describe later, and entered the school by way of a door on its north west side which was next to the toilets beside the gym. Had he used the main entrance to the school it was more likely that he would have been seen as there were many persons in the vicinity of the entrance at that time. The main school building had six entrances and two doors controlled by push bars for emergency exit. In addition to the main school building there were six hutted classrooms in the playground. Most of the huts had two doors, not including fire exits. 3.3 The school day had started at 9 am for all primary classes. Morning assemblies were held in the school's Assembly Hall which was situated between the dining area and the gymnasium. The school had 640 pupils, making it one of the largest primary schools in Scotland. The Assembly Hall was not large enough to accommodate the whole school at one time, with the consequence that assemblies were limited to certain year groups in rotation. On 13 March all primary 1, 2 and 3 classes had attended assembly from 9.10 am to 9.30 am. They consisted of a total of about 250 pupils, together with their teachers and the school chaplain. They included Primary 1/13 which was a class of 28 pupils, along with their teacher Mrs Gwen Mayor. This class had already changed for their gym lesson before attending assembly. 25 members of the class were 5 years of age: and 3 were 6 years of age. Mrs Mayor was 47 years of age. 3.4 At the conclusion of assembly all those present had dispersed to their respective classrooms, with the exception of Primary 1/13 who with Mrs Mayor had made their way to the gymnasium, passing the entrance which Thomas Hamilton used to gain access to the school, and entering the gymnasium by the doorway at its north end. A physical education teacher, Mrs Eileen Harrild, had already arrived there along with Mrs Mary Blake, a supervisory assistant, who was to relieve Mrs Mayor in order to enable her to attend a meeting. The children had been instructed to go to the centre and away from the equipment which was at the south end. Mrs Harrild had been talking to Mrs Mayor for a few minutes. As she was about to attend to the waiting class she heard a noise behind her that caused her to turn round. This was probably the sound of Thomas Hamilton firing two shots into the stage of the Assembly Hall and the girls toilet outside the gym. He then entered the gym. He was wearing a dark jacket, black corduroy trousers and a woolly hat with ear defenders. He had a pistol in his hand. He advanced a couple of steps into the gym and fired indiscriminately and in rapid succession. Mrs Harrild was hit in both forearms, the right hand and left breast. She stumbled into the open-plan store area which adjoined the gym, followed by a number of the children. Mrs Mayor was also shot several times and died instantly. Mrs Blake was then shot but also managed to reach the store, ushering some children in ahead of her. 3.5 From his position near the entrance doorway of the gym Hamilton fired a total of 29 shots in rapid succession. From that position he killed one child and injured others. During this shooting four injured children made their way to the store. In the store Mrs Blake and Mrs Harrild tried to console and calm the terrified children who had taken refuge there. The children cowered on the floor, lying helplessly in pools of blood hearing the screams and moans of their classmates in the gym, and waiting for the end or for help. Thomas Hamilton walked up the east side of the gym firing six shots. At a point midway along it he discharged 8 shots in the direction of the opposite side of the gym. He then advanced to the middle of the gym and walked in a semi-circle systematically firing 16 shots at a group of children who had either been disabled by the firing or who had been thrown to the floor. He stood over them and fired at point-blank range. 3.6 Meanwhile a child from Primary 7 class who had been sent on an errand by his teacher, and was walking along the west side of the gym heard loud banging and screaming. He looked in and saw Thomas Hamilton shooting. Thomas Hamilton shot at him. The child was struck by flying glass and ran off. It appears that Thomas Hamilton then advanced to the south end of the gym. From that position he fired 24 rounds in various directions. He shot through the window adjacent to the fire escape door at the south-east end of the gym. This may have been at an adult who was walking across the playground. Thomas Hamilton then opened the fire escape door and discharged a further 4 shots in the same direction from within the gym. 3.7 He then went outside the doorway and fired 4 more shots towards the library cloakroom, striking Mrs Grace Tweddle, a member of the staff, a glancing blow on the head. A teacher, Mrs Catherine Gordon, and her Primary 7 class who were using hut number 7 which was the classroom closest to the fire escape door saw and heard Thomas Hamilton firing from that direction. She immediately instructed her class to get down on the floor, just in time before he discharged 9 shots into her classroom. Most became embedded in books and equipment. One passed through a chair which seconds before had been used by a child. 3.8 Thomas Hamilton then re-entered the gym where he shot again. He then released the pistol and drew a revolver. He placed the muzzle of the revolver in his mouth, pointing upwards and pulled the trigger. His death followed quickly. 3.9 Mrs Mayor and 15 children lay dead in the gym and one further child was close to death. They had sustained a total of 58 gun shot wounds. 26 of these wounds were of such a nature that individually they would have proved fatal. 3.10 In the result the deaths of the victims listed in the left hand column of the Annex to the Foreword to this Report were caused by gunshot wounds caused by Thomas Hamilton's unlawful actions in shooting them. All of these victims died within the gym, with the exception of the sixteenth child, Mhairi Isabel MacBeath, who was found to be dead on arrival at Stirling Royal Infirmary at 10.30 am. While it is not possible to be precise as to the times at which the shootings took place, it is likely that they occurred within a period of 3-4 minutes, starting between 9.35 am and 9.40 am. 3.11 The survivors of the incident were taken to Stirling Royal Infirmary. They are listed in the right hand column of the Annex. They consisted of the remaining 12 members of the class; two pupils aged 11 who were elsewhere than in the gym when they were injured; and Mrs Harrild, Mrs Blake and Mrs Tweddle. 13 of them had sustained gunshot wounds, 4 being serious, 6 very serious and 3 minor. Of the remaining 4, 2 had sustained minor injuries and 2 were uninjured. The response to the incident The school staff 3.12 Mrs Agnes Awlson, the Assistant Headmistress, was making her way across the playground from her classroom when she heard several sharp metallic noises and screaming coming from the gym. She ran along a corridor and saw what she thought were cartridges lying outside its doorway. Realising that something dreadful was happening she ran back to the office of the Headmaster, Mr Ronald Taylor, who was making a telephone call. The call began at 9.38 am. He was conscious of hearing noises like indistinct bangs. This puzzled him and his reaction was to think that there were builders on the premises about whom he had not been informed. Mrs Awlson entered his office in a crouched position saying that there was a man in the school with a gun. Mr Taylor cut short his call and made an emergency call to the police, which was received at 9.41 am. He then ran along the corridor to the gym. On the way he heard no further noises. A student teacher told him that he had seen the gunman shooting himself. Mr Taylor's estimate was that some 3 minutes had lapsed between his first hearing the noises and being told this by the student teacher. 3.13 Mr Taylor burst into the gym. He was met by what he described in evidence as "a scene of unimaginable carnage, one's worst nightmare". He saw a group of children on the right hand side of the gym who were crying and obviously less injured than the others. He asked the student teacher to take them out of the gym and give them comfort. He then ran back to his office and instructed the Deputy Headmistress, Mrs Fiona Eadington, to telephone for ambulances. That call was made at 9.43 am. He then ran back to the gym calling for adults, and in particular the kitchen staff, to come and help. He moved through the gym along with the janitor Mr John Currie. He noticed Thomas Hamilton lying at the south end of the gym. He seemed to be moving. He noticed a gun on the floor beside him and told Mr Currie to kick it away, which he did. He also removed the revolver from Thomas Hamilton's hand and threw that aside. By this time the Assistant Headmaster, Mr Stuart McCombie, and members of the kitchen staff were in the gym endeavouring to help the injured children until the arrival of the police. When Mr Taylor went to the store area he discovered the injured who were there. Other members of staff arrived and endeavoured to attend to the injured, who were taken to the Assembly Hall. 3.14 By this time the police and medical teams had arrived. Attention was turned to the difficult problem of identifying the children. Since Mrs Mayor was dead, help was sought from members of staff, including nursery staff, who had looked after the children during the previous year. However, not all of the children had been through the nursery. This was an extremely harrowing experience for all the members of staff who were involved. They had to be taken into and out of the gym on several occasions. The record cards were consulted in order to aid identification. Unfortunately the class register had not been marked for Mrs Mayor's class as the class had proceeded directly to the gym after assembly. A further difficulty was encountered when it was discovered that one child was wearing clothing with the name tag of another child. The record card for another child was not in its expected place but this did not delay identification. Mr Taylor and his staff did everything that they possibly could to assist, far beyond what might reasonably have been expected of them. Emergency Services 3.15 The first ambulance arrived at the school at 9.57 am in response to the call at 9.43 am. It left at 10.15 am with the first patient for Stirling Royal Infirmary, and returned later for more patient transfers. 3.16 A team of doctors and a nurse from the Health Centre at Dunblane arrived on the scene at about 10.04 am, followed shortly thereafter by a community nursing sister from the Health Centre. They were involved in immediate resuscitation of injured teachers and children. They were joined by doctors from the Doune Health Centre and from Callander. 3.17 At 9.48 am the accident and emergency department at Stirling Royal Infirmary was notified of the incident and within a few minutes it was known that multiple casualties or fatalities were possible. A major incident was declared and the planned response to such an event was put into operation. At 10.15 am the first of a number of teams from Stirling Royal Infirmary arrived at the school and took up the process of triage which had been initiated by the doctors from Dunblane. This involved working out the priorities according to an assessment of each victim's needs. A decision was then taken as to fitness for evacuation and the order in which evacuation should take place. At the Infirmary operating theatres had been cleared of planned surgical cases. On their arrival at hospital the victims were handed over to the care of teams of surgeons and anaesthetists. Four of the children had sustained potentially fatal wounds. A team from Falkirk and District Royal Infirmary also arrived about 10.35 am. All of the injured victims had arrived at Stirling Royal Infirmary by about 11.10 am. After initial examination some were sent to the Falkirk and District Royal Infirmary and others required to be transferred to the Royal Hospital for Sick Children, Yorkhill, Glasgow, for specialist treatment. The Police 3.18 The first police officers arrived from Dunblane Police Office at about 9.50 am in response to the telephone call from Mr Taylor. They immediately summoned further police assistance and these officers assisted in the gym and took steps to clear the way for the arrival of ambulances. By about 10.10 am senior police officers were on the scene, including the Chief Constable who had put into force the strategy for major incidents. In accordance with this a casualty bureau was set up at police headquarters in Stirling. The Chief Constable also delegated various tasks to his commanders. DCI John Ogg was appointed to be senior investigating officer. The police were faced with a very considerable task in dealing with the incident and its consequences. On 13 March over 100 police officers out of a total force of 658 were involved. 3.19 The first action of the police was to put a cordon around the school buildings with an outer cordon around the road access to the school, in order to restrict admittance to those who could be of assistance. By 10.30 am a considerable number of people had approached the school, not merely anxious relatives of school children but also representatives of the media. The emergency services had to make their way through some 200-300 people in proceeding to and from the school. 3.20 The police then gave priority to ensuring that the injured were taken to hospital. A deliberate decision was taken to refrain from noting their names before they left in order to ensure that they were given medical attention as soon as possible and in order to avoid insensitive intrusion. The next objective of the police was to endeavour to identify the deceased, then institute enquiries, followed by the appointment of production officers and the setting up of an administrative system. 3.21 As I have already indicated the task of identifying the victims was complicated by a number of factors. In addition it was found that two members of Mrs Mayor's class were absent that day. At one point it appeared that a particular child had been apparently identified as being at Stirling Royal Infirmary as well as lying dead in the gym. 3.22 In order to determine the identity of the dead it was necessary for the police to obtain identification of the survivors who had been removed to hospital. However, they had extreme difficulty in communicating with the hospital or the casualty bureau in the manner intended. Apart from a line in the library which was used for the internet facility there was only one telephone line into the school. This was engaged for virtually the whole time by calls from anxious parents or from the media. When the police used mobile telephones they soon found that they also became completely blocked. They decided not to resort to their radio system as the information in which they were interested was extremely sensitive and could have been picked up by scanners. The police did not receive information from the hospital until after mid-day when they obtained two or three names at a time with the use of mobile telephones. They requested British Telecom for additional telephone lines into the school but it was not until 3 pm that the first of these was installed. 3.23 In the meantime arrangements had to be made by the police for the relatives of children who attended the school. They were taken to a private house. From there the parents of children in Primary 1/13 were escorted to a second house before being transferred to a staff room at the school. The process of reuniting parents with children in other classes took up some 2-3 hours. As regards the parents of children in Primary 1/13, the police began to inform the parents of children who were injured and arranged for them to be driven to hospital. By about 1.15-1.30 pm all the injured children had been identified and the necessary information conveyed to their parents. 3.24 In order to communicate information to the parents of children who had died a family liaison team consisting of two police officers and a social worker was organised for each family. These teams required to be assembled and briefed before they spoke to the families and they were also instructed to provide them with continuing counsel and support. The police decided that they should be entirely certain as to the identity of the deceased children before informing their families lest any parents be misinformed. Their concern in this respect was increased by the fact that, as I have already narrated a child had been apparently identified as being both in the gym and at hospital. This necessitated a second round of physical identification of the children in the gym by members of staff. This served only to make their task the more harrowing. As this doubt had arisen the police took the deliberate decision to withhold information about any of the deceased until all of them had been identified. 3.25 Although these procedures were protracted for the reasons that I have explained the parents were not told of the problem and were given no explanation of the reason for the delay. The process of breaking the news to the parents of deceased children did not begin until 1.45 pm. It was not completed until about 3.30 pm. In the meantime doctors from the Health Centre at Dunblane had remained with the families in order to give them whatever comfort they could. The families of each child were called out of the staff room and then escorted by members of their liaison team to one of seventeen rooms which had been made available for the purpose of enabling news to be broken in privacy. The last family remained in the staff room with the members of their team. After the families had received the news they were escorted home by the members of their team who stayed with them as long as was required. It may be noted that at one stage before individual families had been informed there were broadcasts by the media as to the number of children who were thought to have been killed. This had a serious effect on the credibility of the work of the police. 3.26 Mrs Mayor's daughter, Esther, went to Stirling Royal Infirmary where she heard people enquiring about her mother's class at around 12.30 pm. She then left immediately for the school where she was put into the staff room with the parents. Mrs Mayor's husband arrived at the school about 1 pm and was taken to the school library. He was extremely upset and suspected from various media reports that his wife was among the dead. The police officer who escorted him knew that one teacher had been killed but did not know that teacher's identity. Mr Mayor threatened to obtain information from the media if the police would not provide him with it. The officer then left him alone in the library while he sought confirmation of the teacher's identity. After receiving confirmation of Mrs Mayor's death he returned to the library and broke the news to Mr Mayor. This was at least half an hour after he had arrived at the school. The officer then left Mr Mayor in the library in order to go to the briefing room where he was allocated as a member of one of the liaison teams. It appears that neither Mr Mayor nor his daughter was informed of the other's presence in the same building and that it was not until 2.45 pm that they were brought together and informed of what had happened. 3.27 A delay occurred later at Stirling Royal Infirmary where families and their supporters had to wait for some time before they were able to see their child in the mortuary. Lessons from the Incident 3.28 Although the police had received training for emergencies and had participated in disaster planning they could never have envisaged an incident of such magnitude and involving such distressing circumstances as the massacre which Thomas Hamilton perpetrated. During the course of their evidence police officers who were concerned with the maintenance of access and communication to the school and with the provision of information to the parents of victims accepted that there were a number of lessons to be learned from what happened. In addition, during closing submissions, Mr James Taylor for Central Scotland Police presented me with a written submission by the Chief Constable dated 26 June. I have not thought it necessary to make any recommendations of my own in this respect but it may be of assistance if I draw attention to a number of matters which are to receive attention. 3.29 As regards the use of a cordon it appears to have been accepted that it would have been possible to move it further back from the school so as to enable police officers to speak to the families without their being under the gaze of the press and other members of the media. That was clearly desirable. 3.30 It is clearly better that the names of injured should be noted before they leave the scene of an incident involving multiple victims unless this creates a clear risk of prejudice to their treatment. This point has been noted in the Chief Constable's submission at 4.5. 3.31 A number of important points in regard to communications require future attention. In part 5 of his submission the Chief Constable refers to the importance of emergency services having the ability to limit the number of incoming calls in order that operators can continue to make outgoing calls; the use of a facility for re- configuring domestic telephones in order to give priority to outgoing callers; the dedication of several lines for use by emergency services at localised junction boxes; the value to emergency services of message pagers; the use by the police of encrypted radios; the use by family liaison teams of mobile telephones; the need for a communications vehicle for command purposes; and the need for a statement of best practice for adoption by the Association of Chief Police Officers of Scotland. 3.32 As regards the operation of the casualty bureau the Chief Constable has noted (at 9.3 and 9.4) that it is important for the future to ensure the recording of the times when casualties are positively identified and the times when relatives are notified; and that it would be of greater value to the police service if the processes of the casualty bureau were computerised. 3.33 A major incident puts a heavy premium on close co-ordination between the police and emergency services. I note from his submission at 4.8 that the Chief Constable considers that a closer liaison between his own press team and that of other emergency services would be beneficial. 3.34 However, the point which was of most concern to the families in the present case was the delay in their being informed of the fate of their children, and in particular the time which it took before the families of those who had been killed were informed of that fact. These delays were entirely unacceptable, especially when they were combined with the distressing effect of lack of any information, even an explanation that there was a problem and something was being done about it. It should be accepted that the provision of information even of a limited nature should be one of the aims in setting up adequate systems in the immediate aftermath of a major incident. I can appreciate that in the present case the police wanted to ensure that they were in a position to provide accurate information to the parents but the need, as they saw it, to wait until their information was considered accurate in every case, along with the time taken up by the formation of the liaison teams meant that a considerable time elapsed while the parents were left in what was described as a cramped and overcrowded room, experiencing intense frustration, concern and even anger. It is important not merely that as much information should be provided to relatives but also that the means by which that information is provided should be as sensitive and reassuring as possible. I note with approval that the Chief Constable intends (11.7 and 11.8) to consider allocation of officers with particular expertise for this purpose. 3.35 At the same time it is important to keep in view the general quality of the work which was done by Central Scotland Police. At the end of the Inquiry my attention was drawn to the letters in which the school board and Mr Taylor, the Head Teacher, had expressed their gratitude for the help, support and professionalism of the force. Further, as was made plain at the Inquiry the sensitivity and support which were provided to relatives by members of the liaison teams were warmly appreciated. The firearms, ammunition and other equipment carried by Thomas Hamilton 3.36 It is now necessary for me to return to the scene of the shootings. Some time after 11.30 am Mr Malcolm Chisholm, scenes of crime officer and firearms examiner with the Tayside Police Force began a detailed examination of the area in conjunction with DC Donald Scobie, another member of the identification branch of that police force. The examination of the scene was interrupted for some time while the gym was checked for booby traps. The examination of the scene provided the Inquiry with a very detailed account of what was found. For the purposes of this report it is not necessary for me to go into every detail but to mention a number of findings which are of importance. 3.37 It was clear that Thomas Hamilton had with him two 9 mm Browning self- loading (or semi-automatic) pistols and two .357 Smith & Wesson revolvers. These firearms were found beside his body. They were in good condition and full working order. Thomas Hamilton was wearing four holsters of the right-hand draw variety strapped to his waist and a pouch over each of his shoulders. He had also brought with him a large camera bag. 3.38 As regards the pistols, Thomas Hamilton had used one of them in order to fire all of his shots at his victims. This pistol (pistol A) was a competition model with an extended barrel and barrel weight, and an adjustable rear sight. The spur of the hammer had been removed. The reason for its removal is not clear. It could have been done as a consequence of the pistol being damaged or to reduce the time for which the pistol had to be held on aim. In any event the absence of a spur did not impair its use in target shooting to any significant extent. Pistol A had a light trigger pull but not unusually so for a well-tuned competition model. The other pistol (pistol B) was a standard model which was fitted with a device which prevented it from being fired when the magazine was not fitted. As between the two revolvers there were only minor differences, including the fact that in one of them the standard wooden handgrips had been replaced with rubber handgrips. 3.39 The examination of the scene showed that Thomas Hamilton had fired 105 rounds of 9 mm ammunition by means of pistol A. He had with him 25 extended box- type magazines, each of which was capable of holding 20 rounds of 9 mm ammunition and suitable for use with either pistol. (The standard magazine for such pistols was capable of holding 13 cartridges.) Stickers had been attached to each magazine, a yellow sticker to the front and an orange to the back, presumably in order to ensure that it was inserted into the butt of the pistol the correct way round. The magazines were found to contain a total of 393 cartridges, 18 of the magazines being fully loaded with cartridges and 3 being partially loaded. The remaining 4 were empty. Mr Chisholm and DC Scobie reached the conclusion that Thomas Hamilton had arrived at the school with a total of 501 rounds of 9 mm ammunition which, with the exception of one round in the chamber of pistol B, were contained in the 25 magazines. They noted that in the majority of the magazines which still contained ammunition the cartridges had been loaded in uniform sequence - with metal jacket soft-nosed hollow point type at the bottom of the magazine; full metal jacket semi- wadcutter types in the middle; and full metal jacket round-nosed types at the top. In evidence Mr Chisholm and Mr Alastair Paton, another firearms expert, stated that they had never come across such an arrangement in the course of their experience. However Mr Paton accepted that putting round-nosed types at the top of the magazine could have been done with a view to avoiding the risk of a cartridge sticking between the magazine and the chamber. 3.40 Mr Chisholm and DC Scobie later carried out tests on the pistols at the firing range at the headquarters of Tayside Police. These included an exercise in which pistol A, in the cocked and ready to fire position, was used to fire off a full magazine of 20 shots as quickly as possible. The time taken to accomplish this was 5.46 seconds. Also, using pistol A and the 7 magazines which had been used by Thomas Hamilton and the appropriate number of cartridges, they carried out an exercise of firing off 105 rounds and ejecting 6 magazines in the course of doing so, all as quickly as possible. The time taken to accomplish this was 50.4 seconds. Too much should not be read into the evidence about 5.46 seconds. While he had not carried out a similar exercise Mr Paton gave evidence that in general terms it was consistent with his experience for a magazine of 20 rounds to be fired off in 5 or 6 seconds with some degree of accuracy. However, this depended on the expertise and physical make-up of the person firing. It would be unusual for 20 shots to be fired off at any one time. I accept Mr Paton's evidence as a broad indication. However, I note that Mr D J Penn, who is a highly experienced shooter, expressed the opinion that an averagely competent shot could not achieve 20 rounds of aimed fire in 5.46 seconds with an unmodified 9 mm Browning pistol: and that 10 to 12 shots in that time would be a more realistic figure. (This was expressed in a list of points submitted to the Inquiry after he gave his evidence.) 3.41 As regards the revolvers, an examination of the scene showed the presence of 230 live rounds of .357 magnum cartridges suitable for use in either of them. In addition each of the revolvers was fully loaded with six of such cartridges, apart from the single round which Thomas Hamilton had fired in order to kill himself. 3.42 It follows from the above that when Thomas Hamilton arrived at the school he had with him a total of 743 rounds of ammunition, consisting of 501 rounds of 9 mm and 242 rounds of .357 ammunition. He fired 105 rounds of the former and 1 round of the latter. At para 5.38 I will refer to evidence which was given in an interpretation of his intentions. Chapter 4 Events in the life of Thomas Hamilton Introduction 4.1 The events of 13 March 1996 should be seen against the background of certain events in Thomas Hamilton's life and in particular the last 23 years. In this chapter, which of necessity is somewhat protracted, I will endeavour to set out the main events which appear to have a bearing on the outcome, leaving the events of the last 6 months of his life to Chapter 5. After dealing with his family, education and livelihood I will go on to his relationship with the Scouts, his long-standing operation of boys clubs and the circumstances in which he came into contention with local authorities and the police. Finally I will examine his alleged conduct in regard to firearms. Family, education and livelihood 4.2 Thomas Hamilton was born in Glasgow on 10 May 1952. He was the son of Thomas Watt and Agnes Graham Hamilton or Watt. He was named Thomas Watt. Shortly after his birth his parents separated and in 1955 they were divorced. He and his mother moved to the home of his maternal grandparents in Cranhill, Glasgow. On 26 March 1956 he was adopted by them and his name was changed to Thomas Watt Hamilton. In 1963 he accompanied his adoptive parents when they moved to 11 Upper Bridge Street, Stirling. He grew up in the belief that his natural mother was his sister. In 1985 she moved to live in a house of her own. In 1987 Thomas Hamilton and his adoptive parents moved to 7 Kent Road, where he continued to live until 13 March 1996. In August 1987 his adoptive mother died; and 5 years later his adoptive father moved into sheltered housing, so leaving Thomas Hamilton in sole occupation. He remained in contact with his natural mother, visiting her about twice a week. 4.3 After a primary education in Cranhill and Stirling Thomas Hamilton attended Riverside Secondary School, Stirling and Falkirk Technical College, obtaining a number of O Grades in 1968. In that year he became an apprentice draughtsman in the County Architect's Office in Stirling. In 1972 he opened a shop at 49 Cowane Street, Stirling known as "Woodcraft", which specialised in the sale of DIY goods and supplies, ironmongery, and latterly the sale of fitted kitchens. After about 13 years he gave up the shop and registered as unemployed. He received state benefits until November 1993. However, at the same time he carried on the activity of buying and selling cameras and camera equipment and carrying out some free-lance photography. Thomas Hamilton's involvement with the Scouts 4.4 In July 1973 Thomas Hamilton, who was then a Venture Scout, was appointed as Assistant Scout Leader of the 4th/6th Stirling Troop. This followed the normal checks into an appointee's suitability. He seemed very keen and willing and did not present any problems. On one occasion he volunteered to take some boys on his boat on Loch Lomond for their proficiency badge work but this was not permitted as the boat had insufficient lifejackets and no distress flares or oars, and he had inadequate knowledge of the waters. In the autumn of 1973 he was seconded to be leader of the 24th Stirlingshire troop which was to be revived at Bannockburn. 4.5 A number of complaints were made about his leadership, the most serious of which were concerned with two occasions when the boys who were in his charge were forced to sleep overnight in his company in a van during very cold weather at Aviemore. His excuse on the first occasion was that the intended accommodation had been double-booked and he was warned of the need to double-check such arrangements. On the latter occasion it was found that no booking had been made by him on either of these occasions. The County Commissioner, Mr Brian D Fairgrieve had a discussion with the District Commissioner, Mr R C H Deuchars, in which they agreed that Thomas Hamilton should be asked to resign. Thereafter Mr Fairgrieve had a meeting with him. He did not think that Thomas Hamilton was a particularly stable person. He said in evidence "I formed the impression that he had a persecution complex, that he had delusions of grandeur and I felt his actions were almost paranoia". He was doubtful about his moral intention towards boys. Thomas Hamilton was informed that in view of his lack of qualities in leadership his warrant was being withdrawn. On 13 May 1974 Mr Deuchars wrote to him requiring that he return his warrant book. Despite repeated requests he did not do so for some months. 4.6 Mr Fairgrieve wrote to the Scottish Scout Headquarters in order to give them his views about Thomas Hamilton as he considered that he should not be a member of the Scout movement. In this letter dated 29 June 1974 he wrote: "While unable to give concrete evidence against this man I feel that too many 'incidents' relate to him such that I am far from happy about his having any association with Scouts. He has displayed irresponsible acts on outdoor activities by taking young 'favourite' Scouts for weekends during the winter and sleeping in his van, the excuse for these outings being hill- walking expeditions. The lack of precautions for such outdoor activities displays either irresponsibility or an ulterior motive for sleeping with the boys...... His personality displays evidence of a persecution complex coupled with rather grandiose delusions of his own abilities. As a doctor, and with my clinical acumen only, I am suspicious of his moral intentions towards boys". Mr Deuchars also submitted a form to Scout Headquarters to the effect that Thomas Hamilton was not considered to be a suitable applicant due to his immaturity and irresponsibility. This resulted in his name being entered on the "blacklist" which is intended to ensure that unsuitable applicants are denied an appointment in the Scout Association. Such a record is also consulted on occasions when an outside enquiry is made as to whether a former Scout leader has provided satisfactory service. In the case of Thomas Hamilton it was effective in preventing him in his attempt to become a Scout leader in Clackmannanshire. 4.7 During the Inquiry reference was made to a copy of what purported to be a letter written by Thomas Hamilton, dated 28 April 1974 and addressed to Mr Deuchars. In that letter he tendered his resignation as Scout leader of the 24th Stirlingshire troop, criticised the conduct of Mr Deuchars and stated his intention to transfer to another district. Mr Deuchars had no recollection of receiving the letter and there is no record of it on the Scout files. The copy was retrieved from the records of Central Regional Council. I am satisfied that Thomas Hamilton did not write or send the letter on the date which it bears and that it was written by him in order to create a false impression that through his own resignation he had anticipated the withdrawal of his warrant. 4.8 In February 1977 after making a number of attempts to return to Scouting Thomas Hamilton requested the Scout Association to hold a Committee of Inquiry into his complaint that he had been victimised. This request was denied. After some correspondence he stated in April 1977 that he was discontinuing the thought of holding a warrant "as I do not want my good name to be part of this so-called organisation in this district". However, his letters of complaint continued. The response of the Scout Association was that the warrant had been withdrawn on the basis of lack of preparation and planning for his adventure activities at Aviemore. In 1978 he approached Mr David Vass, the District Commissioner for the Trossachs, offering his services as a Scout Leader. After consulting with Mr Fairgrieve Mr Vass responded that they were unable to make use of his services. Thomas Hamilton persistently maintained that the Scouts had not only ruined his reputation by terminating his appointment but that they were linked with the actions taken by other organisations, and in particular the police. In para 4.23 I narrate his later approaches to Scout officials. Thomas Hamilton's boys clubs 4.9 After the withdrawal of his warrant Thomas Hamilton became increasingly involved in the setting up and running of boys clubs. It is not clear when he began this activity but it appears that in the late 1970s he was running the "Dunblane Rovers" in the Duckburn Centre in Dunblane. He also ran a Rovers Group in Bannockburn. There was some evidence that at this time he was permitted to use school premises. In any event it is clear that during the period from November 1981 until his death he organised and operated 15 boys clubs for various periods and that these clubs used school premises in Central, Lothian, Fife and Strathclyde Regions. The clubs, the periods within which they were active and their locations are set out in the accompanying table. CLUBS OPERATED BY THOMAS HAMILTON BETWEEN NOVEMBER 1981 AND MARCH 1996 Club Period Active Location Dunblane Rovers Group* Nov.1981-Oct 1983 Dunblane H.S. Dunblane Boys Club* Oct 1985-March Dunblane H.S. 1996 Bannockburn Boys Club* Lynburn Gymnastics Club/Lynburn Boys Club* Feb.1985- Feb.1986 Dunfermline Boys Sports Club* May 1
Text truncated at 80,000 characters — see the source PDF for the remainder.
The Public Inquiry into the Shootings
at Dunblane Primary School
on 13 March 1996
The Government Response
ISBN 0 10 133922 4
Cm. 3392
The Government Response
Introduction
On 21 March 1996 it was resolved by both Houses of Parliament that it was
"expedient that a Tribunal be established for inquiring into a definite matter of urgent
public importance, that is to say, the incident at Dunblane Primary School on
Wednesday 13 March 1996, which resulted in the deaths of 18 people". The Hon Lord
Cullen was appointed as a Tribunal:-
"To inquire into the circumstances leading up to and surrounding the events at
Dunblane Primary School on Wednesday 13 March 1996, which resulted in
the deaths of 18 people; to consider the issues arising therefrom; to make such
interim and final recommendations as may seem appropriate; and to report as
soon as practicable."
The Report of Lord Cullen's Inquiry ("The Public Inquiry into the Shooting at
Dunblane Primary School on 13 March 1996" Cm 3386) has been published. This
White Paper sets out the Government's response.
The Government is grateful to Lord Cullen for his full and clear report into the
circumstances of the shootings and the lessons which should be learned from them.
Lord Cullen has benefited from a large number of written submissions and 26 days of
oral evidence. He has completed his Report with commendable speed - for which the
Government is grateful, because of its determination to act quickly and decisively on
his recommendations.
Recommendations on the certification system relating to Section 1 firearms
Officers carrying out enquiries should be supplied in advance with full
information about any known change of circumstances and any reason for
exercising particular caution.
The Government accepts this recommendation. The Home Office Guidance to the
Police stresses that the police's decision about whether to issue a firearm certificate is
their most important firearms licensing task. The main consideration is a person's
character - and police forces are expected to provide their officers with all the
necessary information. The Guidance to the Police will be amended to emphasise the
point.
The use of checklists by enquiry officers is endorsed, subject to the need for them
to be alert to and report anything which could be relevant to the suitability of the
applicant or certificate holder.
The Government accepts this recommendation and the Guidance to the Police will be
amended to emphasise the point.
Enquiry officers should be given as much training and guidance for their work
as is practicable.
The Government accepts this recommendation. Existing Home Office advice to police
forces is that 'enquiry, administration and decision making processes' in each police
force should all be controlled by a centralised firearms administration and that all
inquiries should be made by nominated, trained staff. The Guidance to the Police will
be amended to emphasise the point.
The power of search with warrant under section 46 of the Firearms Act 1968
should be extended to cases in which there is reasonable ground for suspecting
that there is a substantial risk to the safety of the public; and to include in such
cases the power to seize and detain any firearm certificate which may be found.
The Government accepts this recommendation and will seek to amend section 46 of
the Act accordingly.
The power of search with warrant under section 46 of the Firearms Act 1968
should be extended to any civilian licensing and enquiry officer who is
authorised in writing for that purpose by the Chief Constable.
The powers enjoyed by police officers to inspect dealers' registers and premises
and approved clubs should be extended to civilian licensing and enquiry officers
who are authorised in writing for that purpose by the Chief Constable.
The Government accepts these two recommendations and will bring forward the
necessary legislation.
The steps being taken to enable police forces to hold and exchange information
on computer as to the individuals who hold firearm certificates, and those whose
firearm applications have been refused or certificates revoked are endorsed.
The Government supports this recommendation and will discuss its implementation
with the police service.
The Guidance to the Police should advise that good reason implies intention; and
that lack of past use prima facie indicates the lack of it.
The Government accepts this recommendation. Lord Cullen criticises the Home
Office Guidance to the Police, which says (6.8e) that a certificate for a handgun
'should not be granted unless the person has regular and legitimate opportunity of
using the weapon e.g. for target shooting as a member of a pistol club'. The Guidance
will be amended to say also that the police should not generally renew a certificate
unless it is clear that the person has actually been making use of his or her gun.
Section 30(1) of the Firearms Act 1968 should be amended so as to provide for -
the revocation of a firearm certificate on the ground that the chief officer of
police is satisfied that the holder does not have a good reason for having in his
possession, or for purchasing or acquiring, the firearm or ammunition in
respect of which the certificate is held; and for partial revocation; and
in the case of the revocation of a firearm certificate in respect of the
ammunition to which it relates, the power to substitute different quantities.
The Government accepts this recommendation and will bring forward the necessary
legislation.
Each club which is approved for the purposes of section 15 of the Firearms
(Amendment) Act 1988 should be required to maintain a register of the
attendance of its members who are holders of firearm certificates, together with
details as to the firearms which they used and the competitions in which they
participated when they attended.
The Government accepts this recommendation. The approval criteria for clubs will be
amended (see recommendation 15).
Every holder of a firearm certificate should be required to be a member of at
least one approved club; and the firearm certificate should specify the approved
club or clubs of which he or she is a member and the firearms which he or she
intends to use in each of them.
The Government accepts this recommendation, for holders of firearm certificates for
target shooting. The Government will bring forward the necessary changes in primary
legislation.
Each approved club should be required to inform the police when a holder of a
firearm certificate has ceased to be a member of the club for whatever reason.
Each approved club should be required to inform the police when a member who
is the holder of a firearm certificate has not attended a meeting of the club for a
period of a year.
The proposal that each club should appoint a person to act as a liaison officer
with the police is endorsed.
The Government accepts these 3 recommendations and will amend the approval
criteria for clubs (see recommendation 15).
Explicit statutory provision should be made for the laying down of criteria for
the approval of clubs for the purpose of section 15 of the Firearms (Amendment)
Act 1988.
The Government accepts this recommendation. The Government intends to give
statutory force to the approval criteria for clubs (amended in line with
recommendations 10, 12 to 14, 19 and 20).
The language of section 30(1) of the Firearms Act 1968 should be brought into
full correspondence with that of section 27(1); and each revised in order to
achieve a logical and consistent arrangement.
The Government accepts this recommendation and will seek to amend the Act
accordingly.
Section 27(1) of the Firearms Act 1968 should include (as one of the conditions
on which the granting or renewal of a firearm certificate is dependent) that the
chief officer of police is satisfied that the applicant is fit to be entrusted with the
firearm and ammunition to which the application relates.
The Government accepts this recommendation which would replace the present test in
Section 27, that the applicant can be entrusted to have the firearm and ammunition
'without danger to the public safety or to the peace'. The Government will bring
forward the necessary primary legislation.
It is desirable that the (Home Office) Guidance to the Police should contain
advice as to the scope of 'fitness' to be entrusted with a firearm and ammunition.
The Government accepts this recommendation and will amend the Guidance.
Each approved club should be required to inform the police of the receipt of an
application for membership; and the outcome of the application.
Each applicant for membership of an approved club should be required to state
whether or not he or she has submitted any prior application for a firearm
certificate or a shot gun certificate which has been refused; and whether he or
she has previously held such a certificate which has been revoked.
The Government accepts these 2 recommendations, which will be implemented by a
change to the approval criteria for clubs (see recommendation 15).
The current requirement for a counter-signatory of a firearm application should
be abolished; and replaced by a system for the provision of two references.
The Government accepts this recommendation and will bring forward the necessary
primary legislation.
The proposal by the Association of Police Surgeons for the provision by the
applicant's medical practitioner of information as to the applicant's medical
history and its consideration by a forensic medical examiner should be the
subject of consultation with the interested bodies.
The Government accepts this recommendation and will consult as suggested.
Consideration should be given to the reform of the scope for appeal against
decisions of the chief officer of police by restricting it to enumerated grounds
which do not trench on the exercise of his discretion.
The Government accepts this recommendation and, subject as Lord Cullen suggests to
further study and consultation with interested bodies on the exact terms of the change,
will bring forward the necessary legislation.
Recommendations relating to the availability of section 1 firearms
Consideration should be given to restricting the availability of self-loading pistols
and revolvers of any calibre which are held by individuals for target shooting
preferably, by their disablement, while they are not in use, by either (i) the
removal of the slide assembly/cylinder, which is to be kept securely on the
premises of an approved club of which the owner is a member or by a club
official; or (ii) the fitting of a locked barrel block by a club official;
or, if such a system is not adopted, by the banning of the possession of
such handguns by individual owners.
As recommended by Lord Cullen the Government has considered restricting the
availability of self-loading hand guns. It has given careful consideration to Lord
Cullen's suggestions, which fall into two parts. It has concluded that neither would
provide an acceptable level of public safety.
First of all he has suggested two methods by which hand guns might be disabled. The
first involves the removal of key components from the gun. While removal of key
components is feasible for certain types of guns, it is not a practical proposition for
others. Alternatively, Lord Cullen has indicated that weapons might be disabled by
fitting a locked "barrel block" to the gun. He recognised however that such devices
are currently manufactured only for shot guns. Even if they were available, the
Forensic Science Service - which advises the Government on the technical aspects of
firearms including their deactivation - is not convinced that a barrel block or similar
device could not be removed by a determined individual and the Government does
not, therefore, believe that it could rely on such a measure.
Lord Cullen's second suggestion is that if guns cannot be disabled, consideration
should be given to banning the possession of self-loading pistols and revolvers by
individuals. In the light of this the Government has decided to legislate early in the
next session of Parliament to ban all hand guns of more than .22 calibre - including
those used by Thomas Hamilton. This will mean that at least 160,000 guns - 80% of
those legally held at present - will be destroyed. All hand guns chambered for .22
rimfire ammunition, including single shot guns, will also be banned unless they are
kept in licensed gun clubs under conditions of the most stringent security.
This means that, in two important respects, the Government intends to go further than
Lord Cullen's proposals: by banning all higher calibre handguns; and by prohibiting
people from keeping even single shot handguns at home.
Clubs will need a licence from the Home Secretary in England and Wales and the
Secretary of State in Scotland. The Government intends to consult the police and
other interested bodies on the stringent security standards which will be necessary to
protect the public. These will be contained in guidance which the Government will
issue and which will be enforced by the police. The standards will cover matters such
as:
reinforced walls to ensure that thieves could not break into a club building;
the safes in which guns and ammunition would have to be stored;
strong perimeter fences;
burglar alarms linked directly to the police;
access control, including metal detectors, to prevent guns being illicitly
removed;
regular and stringent inspection arrangements to ensure that club security was
of an adequate standard.
Very few, if any, existing gun clubs will meet these security requirements.
Guns will be permitted to be removed only for very limited purposes which will be
specified in law. Each time a gun is removed from a club a police permit will be
required. Owners of .22 hand guns will have to hand in their guns to the police until
they can find a licensed gun club. If, after a specified period, they cannot find a
licensed club, their guns will be destroyed.
The Government considers that these requirements are necessary in order to protect
the public. The responsibility for meeting them will rest with those who wish to
pursue the limited sporting opportunity which will continue to be permitted under
these proposals.
The Government recognises that it may take some considerable time to meet these
standards. If an owner of a .22 calibre handgun is unable to keep his gun at a licensed
club when the legislation comes into force, he will be required to lodge it with the
police. If, after a specified period, he has not placed his gun in a licensed club, it will
be forfeited.
Recommendations relating to school security
Those who have the legal responsibility for the health and safety of the teaching
staff and pupils at school should prepare a safety strategy for the protection of
the school population against violence, together with an action plan for
implementing and monitoring the effectiveness of safety measures appropriate to
the particular school.
The Government supports this recommendation, and agrees that the safety strategy
and action plan should take account of the situation at each individual school. This is
consistent with the recommendations of the Working Group on School Security which
the Government fully accepted in May this year. The booklet "Improving Security in
Schools", published in September 1996 by the Department for Education and
Employment and issued to interested parties in Scotland by The Scottish Office
Education and Industry Department, contains detailed advice to education authorities,
boards of management of self-governing schools and proprietors of independent
schools on managing risks and on possible security measures. In particular, it gives
advice on carrying out the type of security survey and risk assessment which the
Report recommends. School employers are familiar with these approaches through
their management of occupational health and safety. In its discussion with those
responsible for school management, the Government will continue to take every
opportunity to reinforce the importance of reviewing security and safety in this
manner.
It is desirable that the guidance provided by the Education Service Advisory
Committee in regard to violence to staff in the education sector should be
extended to encompass the safety and protection of the school population as a
whole.
The Government supports this recommendation. The report prepared by the Education
Service Advisory Committee (ESAC) "Violence to Staff in the Education Sector",
published in 1990, gave general advice to employers in all sectors of education and
included a list of main factors which might be addressed in a plan of action (see
recommendation 25). ESAC's remit relates to hazards arising from education work;
within this remit its guidance on violence could usefully be updated to complement
the guidance "Improving Security in Schools" issued by DfEE in September 1996.
Recommendations relating to the vetting and supervision of adults working with
children and young people
There should be a system for the accreditation to a national body of clubs and
groups voluntarily attended by children and young persons under 16 years of
age for their recreation, education or development, the main purpose of which
would be to ensure that there are adequate checks on the suitability of the
leaders and workers who have substantial unsupervised access to them.
The Government accepts the need for co-ordination of information at national level
about persons regarded as potentially unsuitable for work with children and young
people. It also accepts the need to ensure that all voluntary youth organisations should
have arrangements to check on the suitability of leaders and workers. The
Government has decided that, following the proposals in the consultation document
"On the Record in Scotland" published in June, access to criminal record checks
should be extended to all voluntary youth organisations. It will also consult
immediately with all interested parties in Scotland on the proposals for the
establishment of arrangements for a national information and accreditation system.
There will be parallel consultations in England and Wales.
Consideration should be given to the development of a Scottish Vocational
Qualification in respect of work with children, including the organisation of
clubs and child development and protection.
The Government accepts this recommendation. It is inviting the Scottish Vocational
Education Council urgently to bring forward proposals for a qualification as
recommended.
Other matters
Lord Cullen's Report notes the concern of the casualties' families at the delay in being
informed of the fate of their children. He concludes that these delays were entirely
unacceptable. The Chief Constable of Central Scotland Police made a written
submission to Lord Cullen drawing attention to a number of procedural improvements
designed to avoid the recurrence of these serious problems. The Government will
ensure that these lessons, which were endorsed by Lord Cullen, are disseminated to
other police forces.
The Government also proposes to take action on four additional matters. They are
a ban on expanding ammunition, except for the purposes of shooting deer;
a requirement that firearms purchased by mail order will require to be
delivered to a gun dealer and given to the certificate holder in person only;
a requirement that, in all circumstances, the disposal of a weapon (including
its destruction) is reported to the police;
a requirement for all handgun shooters to obtain a firearms certificate from the
police, ending the present system where a person without a certificate can
shoot a handgun at an approved club. Special provisional arrangements would
be made for new members.
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
REPORT TO PREVENT FUTURE DEATHS: MADE UNDER
REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013
REPORT REGARDING TRAINING OF FIREARMS LICENCING DECISION MAKERS
THIS REPORT IS BEING SENT TO:
1. Rt Hon. Suella Braverman MP, The Home Secretary
2. Rt Hon Chris Philp MP, Minister of State for Crime, Policing and Fire
3. NPCC lead for policing, CC Tedds
4. All Chief Constables in England and Wales
5. The College of Policing
This document is but one of a number of prevention of future deaths reports that I am
issuing following the inquests into the five deaths of those shot by Jake Davison in
Keyham on 12 August 2021. I shall copy every addressee all other prevention of future
death reports arising from these inquests for their information.
1 CORONER
I am Ian Arrow, Senior Coroner for the coroner area of Plymouth, Torbay and South
Devon.
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 19 August 2021 I commenced an investigation into the deaths of Maxine Davison (age
51), Lee Martyn (age 43), Sophie Martyn (age 3), Stephen Washington (age 59) and Kate
Shepherd (age 66). The investigation concluded at the end of the inquest held before a
jury on 20 February 2023. The conclusion of the jury in respect of these five conjoined
inquests was as follows:
Maxine Betty Davison
On the 12th August 2021 between 18:05-18:08, Maxine Betty Davison died as a result of
shotgun wounds to the head and torso. This occurred at her address, 17 Biddick Drive
following an argument with the perpetrator.
Lee Raymond John Martyn
On the 12th August 2021 between 18:08-18:10, Lee Raymond John Martyn died as a result
of shotgun wounds to the head and torso. This occurred whilst walking with his daughter
Sophie Iris Martyn in the street, Biddick Drive, Keyham, Plymouth.
Sophie Iris Martyn
1
On the 12th August 2021 between 18:08-18:10, Sophie Iris Martyn died as a result of a
shotgun wound to her head. This occurred whilst walking with her father Lee Raymond
John Martyn in the street, Biddick Drive, Keyham, Plymouth.
Stephen John Godfrey Washington
On the 12th August 2021 between 18:10-18:12, Stephen John Godfrey Washington died as
a result of a shotgun wound to his chest. This occurred whilst walking on Snakey path
(Linear Park), a footpath behind Biddick Drive, Keyham, Plymouth whilst walking his
dogs.
Kathryn Jane Shepherd (known as Kate).
On the 12th August 2021, Kathryn Jane Shepherd received a shotgun wound to her
abdomen at 18:13 outside Blush Salon, Henderson Place, Plymouth and subsequently died
later that day in Derriford Hospital, Plymouth.
In respect of each deceased the jury also found as follows
Under Section 3 of the Record of Inquest
‘The perpetrator came to be and remain in lawful possession of a shotgun at the material
time due to the following circumstances:
The initial shotgun licence application
In 2017, given the absence of medical information, the known history of assaults and the
intelligence held by Devon & Cornwall Police suggesting involvement in other violent
episodes, it was a serious failure to protect the public and the peace to grant a licence to
the perpetrator.
There was a serious failure within the Firearms and Explosives Licensing Unit (FELU) to
heed and apply the 2016 Home Office guidance, that high risk decisions on grant of a
licence should be made by the Firearms Licensing Manager (FLM).
Despite the 2016 Home Office guidance in force at that time, inadequate steps were taken
to obtain specific medical evidence regarding the extent to which the perpetrator’s
declared autism and Asperger’s might impact upon his suitability to hold a shotgun
licence.
This was further compounded by the confusion caused by the move from the use of a post
to pre-grant letter, without the update to the Home Office guidance which previously
stated would be provided.
It was not a safe system to assume that in the absence of a substantive response to the
standard pre-grant letter from the GP, there were no relevant medical conditions that could
affect the perpetrator’s suitability to hold a shotgun licence.
The mechanism agreed by the FLM and Local Medical Committee to obtain specific
factual information about a self-declared medical condition was not communicated to or
followed by the Firearms Enquiry Officer (FEO) or the Firearms Licencing Supervisor
(FLS).
The referee’s tasks and responsibilities were not made clear and insufficient inquiries
were made of the referee given the known history of assaults at school.
Reflecting the culture within the FELU at the time, an insufficient degree of professional
curiosity was demonstrated by the FEO and FLS.
The review of the licence
2
The decision to return the shotgun and licence to the perpetrator in July 2021 was
fundamentally flawed and as a result failed to protect the public and the peace.
The officer investigating the skate park assaults in September 2020 should have noted that
the perpetrator was a firearms certificate holder and taken immediate steps to alert the
FELU to the incident.
It was unreasonable to categorise the level of the assault upon the boy in the skate park as
battery. There were clear aggravating factors to suggest this should have been charged at
a higher level and there was inadequate investigation of whether the assault on the boy in
the skate park had led to his unconsciousness.
The use of the Pathfinder scheme in this instance was wholly inadequate in reducing the
perpetrator’s future offending.
On reviewing the perpetrator’s suitability to retain the shotgun certificate, the FEO ought
to have shown a greater degree of professional curiosity in obtaining and evaluating
further information. The case was not passed to the FLM for review which was against
Home Office guidance.
General
There was a serious failure at a national level by the government, Home Office and
National College of Policing to implement the recommendation from Lord Cullen’s
Report in 1996 arising out of the fatal shootings in Dunblane, to provide training for FEOs
and the subsequent recommendation in Her Majesty’s Inspectorate of the Constabulary’s
Targeting the Risk Report in 2015 for an accredited training regime for FEOs. The most
recent statutory guidance from the Home Office (2021) has failed to include any mention
of FEO specific training.
The training and informal mentoring was insufficient to enable the FEOs to safely
discharge their duties. Informal mentoring had inherent limitations, meaning incorrect
processes were perpetuated and not formally recorded as an agreed training method to
deliver learning outcomes.
There was a catastrophic failure in the management of the FELU, with a lack of
managerial supervision, inadequate and ineffective leadership. This was compounded by
a lack of senior management and executive leadership who failed to notice or address the
issues.
There was a lack of scrutiny and professional curiosity at all levels. The ineffective
auditing and governance of the FELU in place led to an inadequate system of dip
sampling, qualitative assessment of staff’s decision-making, and learning from the results
of the same.
There was a seriously unsafe culture within the FELU of defaulting to granting licences
and to returning licences after review.
There was a dangerous lack of understanding on the part of the Devon and Cornwall
Police FELU staff regarding the use and application of the FELU risk matrix.
Incompatible IT systems both within Devon and Cornwall Police and outside agencies
contributed to a failure to communicate effectively.
Budgetary limitations and staff shortages within Devon and Cornwall Police increased the
probability of risk being incorrectly assessed which led to unsafe licences being issued.
These limitations were not confined to Devon and Cornwall Police but also existed at a
national level, for example the National College of Policing not assigning resources to run
an accredited national FEO training course.’
3
The jury’s conclusion in respect of each death under Section 4 of the Record of
Inquest was as follows:
‘The deceased was unlawfully killed.
The death was caused by the fact that the perpetrator had a lawfully held shotgun. The
following contributed to this position.
There were serious failures by Devon and Cornwall Police FELU in granting and, later,
failing to revoke the perpetrator’s shotgun certificate.
In licencing the perpetrator to have a shotgun there was a serious failure by Devon and
Cornwall Police to protect the deceased.
There was a failure of Devon and Cornwall Police to have in place safe and robust
systems. Foremost, the training of FELU staff, governance of the FELU, quality
assurance of FELU staff’s decision-making and ensuring decisions were made at the
correct level.
There was a failure by Devon and Cornwall Police FELU staff to obtain sufficient medical
information in respect of the perpetrator’s application for a shotgun certificate and also on
review.
There was a failure by Devon and Cornwall Police FELU staff to properly seek out and
consider all the relevant evidence and information available before deciding whether to
grant the perpetrator a shotgun certificate.
Following the perpetrator having assaulted two children in 2020, there was a failure by
Devon and Cornwall Police to protect the public and the peace. Firstly, within the Local
Investigation team regarding the downgraded charge and secondly, within the FELU to
sufficiently investigate whether it was safe to return to the perpetrator his shotgun and
certificate after initially seizing them.
Incorrect application of the risk matrix meant there was a serious failure by Devon and
Cornwall Police to implement an adequate system to ensure that the decision whether or
not to (i) grant or (ii) return a shotgun certificate following review, was made or approved
by a manager of sufficient seniority.
A lack of national accredited Firearms licensing training has and continues to fail to equip
police staff to protect the public safety.
There was a catastrophic failure in the management of the FELU, with a lack of
managerial supervision, inadequate and ineffective leadership. This was compounded by
a lack of senior management and executive leadership who failed to notice or address the
issues.
4 CIRCUMSTANCES OF THE DEATH
On 12 August 2021 Jake Davison, who was a licenced shotgun holder, took up his
lawfully held pump action shotgun and loaded it with 12-gauge OOB ‘buckshot’
cartridge. He shot and killed his mother Maxine Davison at their home, and then entered
the street where he shot six people who were strangers to him, four of whom suffered fatal
injuries.
5
4
CORONER’S CONCERNS
During the course of these inquests the evidence 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.
Evidence I heard at these inquests revealed that numerous recommendations arising from
previous inquiries and reviews regarding the training of police officers and police staff
involved in firearms licensing decisions had not been put into effect. This is not a new
concern but one that has previously been raised by at least two other coroners in earlier
‘Prevention of Future Deaths’ reports in other coronial jurisdictions. If any lessons had
been learned in the aftermath of earlier tragedies, they have been forgotten and that learning
had been lost.
I was told that all Chief Officers of police ought to be satisfied that they only delegate their
authority to issue and revoke firearms and shotgun licences to appropriately trained and
skilled personnel. However, over the past 27 years, there has been an abject failure to ensure
that nationally accredited training of firearms licensing staff has been developed and its
currency maintained. Specifically –
1. In 1996, following the murders at the primary school in Dunblane Lord Cullen’s
report (see here) recommended as follows:
‘Enquiry officers should be given as much training and guidance for their work
as is practicable.’
The Government responded (see here) stating that
“The Government accepts this recommendation. Existing Home Office advice to
police forces is that 'enquiry, administration and decision making processes' in
each police force should all be controlled by a centralised firearms
administration and that all inquiries should be made by nominated, trained staff.
The Guidance to the Police will be amended to emphasise the point.”
In fact the guidance subsequently issued by the Home Office, in March 2002, entitled
‘Firearms Law, Guidance to the Police’, (here) made no recommendation regarding the
training of staff. The 2002 guidance merely stated (at §1.5)
‘Firearms legislation and the subject of firearms generally is complex and highly
specialised. It is not practicable to provide comprehensive training for every
police officer on the administration of the Firearms Acts. It is therefore essential
that this guide is available to all police officers and civilians directly involved in
the licensing process. Where difficulties arise, advice may be sought from the
firearms department at the appropriate police force.’
5
Indeed by March 2002 there was no accredited training for the role of firearms enquiry
officers (FEOs) or firearms licensing managers (FLMs). The Home Office guidance to
police did not contain any proposal or requirement that FEOs or FLMs should undergo
training specific to their role. There was no requirement that FEOs or FLMs should undergo
any training in assessing the suitability of applicants to be granted a licence.
2. Later in 2002 The Firearms Licensing Thematic Review entitled ‘Safe Hands =
Secure Arms’ (here), conducted by Her Majesty’s Inspector of Constabulary (HMIC)
recommended as follows:
‘Recommendation 2.
Her Majesty’s Inspector of Constabulary recommends that force policy and
procedure in respect of firearms licensing should mirror Lord Cullen’s
Recommendations and ACPO Policy, Home Office Guidance and ACPO,
‘Procedural Good Practice Guide’.
Recommendation 3.
Her Majesty’s Inspector of Constabulary recommends that forces ensure that
staff conducting firearms enquiries are trained, conversant with current ACPO
/Home Office guidance and competent to fulfil their role.’
However, despite those recommendations the absence of formal training courses for FELU
staff in firearms licensing remained unaddressed.
3. In March 2013 the Senior Coroner for Durham issued a report under rule 43
Coroners Rules 1984 following the inquests into the deaths of Sam McGoldrick,
Alison Turnbull, Tanya Turnbull and Michael Atherton:
The r.43 report, sent to the Chief Constable of Durham Police and the Home Secretary
raised the following concern (among others):
‘The inquest has revealed disturbing issues on the question of training.
Notwithstanding the significant importance of the shotgun firearms licencing
process there was no formal training courses available in 2006/2008 and even
limited formal training available now. Training was by virtue of learning on the
job and by making enquiries oneself and familiarising oneself with the Home
Office and ACPO guidance. Durham Constabulary did not have its own local
policy relating to firearms/shotgun licencing. Durham Constabulary was not
alone in not having such a policy. Not all individuals involved in the licencing
process were aware of the existence of the Home Office and ACPO guidance
documents, both published in 2002, let alone the detailed contents thereof…. This
case has illustrated that the administration of firearms shotgun licencing system
was… unclear on occasion and confusing. And with the absence of training and
clear guidance either locally or nationally, it created an environment in which
it was easier for less than optimal standards to be achieved.’
6
The Home Secretary (The Rt Hon Theresa May MP) responded on 17 June 2013 stating
that:
‘Nationally a recognised training course is available for firearms enquiry officers
and a system of mentoring uses the expertise of more experienced enquiry officers
or managers.’
If it was indeed the case that a national training course for course for firearms enquiry
officers was available as the Home Secretary suggested in June 2013 this was no longer
the case by 2014. I have been informed that in 2014 there was still no nationally
accredited training available for the role of FEOs or FLMs. The College of Policing
Authorised Professional Practice (APP) in 2014 (see here at section 2.6) merely stated that
chief police officers should be ‘seeking to develop appropriate accredited training for
firearms licensing staff.’
Furthermore the Home Office guidance published in 2014 still did not contain any proposal
or requirement that FEOs or FLMs should undergo any (even non-accredited) training
specific to their role. In particular, there was no requirement that FEOs or FLMs should
undergo any training in assessing the suitability of applicants to be granted a licence.
4. In September 2015, HMIC conducted another ‘inspection of the efficiency and
effectiveness of firearms licensing in police forces in England and Wales’ entitled
‘Targeting the Risk’ (see here).
This report yet again raised concerns at the continuing absence of nationally accredited
training for firearms licensing decision makers. The HMIC report stated that:
‘While some training has been made available, we are concerned at the
continuing absence of nationally accredited training. Its absence has meant that
some staff involved in the licensing arrangements, in particular those charged
with making firearms licensing decisions, have yet to receive sufficient training,
commensurate with their role and responsibility.’
HMIC noted in 2015 that proposals for accredited training were ‘under consideration’ by
the national policing lead for firearms licensing and the College of Policing. However,
the evidence I heard at the inquest was that this ‘consideration’ did not result in any
accredited training being developed. Even today, some eight years later, accredited
training for those charged with making firearms licensing decisions does not exist.
In 2015 HMIC recommended to the national policing lead for firearms licensing, in
conjunction with the College of Policing that:
‘Within 12 months, the national policing lead for firearms licensing, in
conjunction with the College of Policing, should identify the skills required by
those staff involved in the firearms licensing process. Thereafter they should
introduce professional development arrangements to ensure a consistent national
approach to firearms licensing. Consideration should also be given to the
accreditation of these arrangements.’
7
That 2015 HMIC report also stated that
‘On too many occasions, the police are not following the Home Office guidance
or the Authorised Professional Practice. And, the guidance and practice in many
respects are inadequate, allowing room for interpretation and the creation of
inconsistency in the way firearms licensing is undertaken within and between
police forces….
We cannot make our position any clearer: it is now for others to accept the
need for change. If they do, perhaps the life of the next victim of firearms
misuse might be saved. What is highly likely is that, if change is not effected,
there will be another tragedy.’
The Home Office guidance on firearms licencing was subsequently updated in 2016.
However, that guidance made no reference to the need for firearms licencing staff to
undergo accredited training. The 2016 Home Office guidance did not contain any proposal
or requirement that FEOs or FLMs should undergo any (even non-accredited) training
specific to their role. There was no requirement that FEOs or FLMs should undergo any
training in assessing the suitability of applicants to be granted a licence.
Evidence presented at the inquests was that the College of Policing’s Coordination and
Delivery Group had declined requests made to it to develop a national training package in
Feb 2016 and January 2019.
5. In 2019 Mr Richard Travers Senior Coroner for Surrey issued a report to prevent
future deaths following the killings of Christine and Lucy Lee (see here).
That report, which was sent to Chief Constable of Surrey Police, the NPCC lead for firearms
and the Home Office, raised the following concern:
‘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 equivalent, will result in the risk of
insufficient training, incorrect decision making concerning certification and,
consequently, future deaths.’
8
By 2021, when Jake Davison’s gun was returned to him, there was still no accredited
training for the role of FEOs or FLMs, nor was there any mandatory requirement for FEOs
or FLMs to undergo even non-accredited training specific to their role. In particular, there
was no requirement that FEOs or FLMs to undergo any training in assessing the suitability
of applicants to be granted a licence.
It is against this background of 27 years of wholesale failure to devise and maintain
adequate training provision for firearms licensing staff nationally that the jury in the
Keyham inquests returned their findings above, including that:
‘There was a serious failure at a national level by the government, Home Office
and National College of Policing to implement the recommendation from Lord
Cullen’s Report in 1996 arising out of the fatal shootings in Dunblane, to provide
training for FEOs and the subsequent recommendation in Her Majesty’s
Inspectorate of the Constabulary’s Targeting the Risk Report in 2015 for an
accredited training regime for FEOs. The most recent statutory guidance from the
Home Office (2021) has failed to include any mention of FEO specific training.
The training and informal mentoring available at Devon & Cornwall police was
insufficient to enable the FEOs to safely discharge their duties, meaning incorrect
processes were perpetuated and not formally recorded as an agreed training method
to deliver learning outcomes.’
The evidence I heard suggested the absence of training was not merely a local problem for
Devon & Cornwall Police. I have been assured that work towards an accredited training
package is now ongoing and I was also informed that that some police forces, do currently
have in-house training programmes that firearms licensing staff from other forces may
attend. However I have been informed that the availability of such local in-house training
remains sporadic.
I am concerned that there is an urgent need to develop a national accredited training for
FELU staff that covers how to apply the relevant Home Office Guidance on firearms
licencing including, in particular, training in assessing the suitability of applicants to be
granted a licence. The development of such accredited training is vitally important to
achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should
undergo mandatory training. I am also concerned that there is currently no requirement
that Chief Officers of Police may only delegate decision making authority regarding issuing
firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working
with the College of Policing and others to develop the required training, I am concerned to
ensure that the momentum to effect change after the horrific tragedy in Keyham should not
be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
9
The NPCC lead for firearms licencing and all other Chief Constables in England and
Wales
So that each Chief Constable is made aware of my concern that, that despite the many
recommendations made over the past 27 years, there continues to be a lack of
nationally accredited training for their FELU staff.
I also report my concern that in the absence of such the training there is a risk that
the Statutory Guidance is not being appropriately applied by FELU staff today, and
so each Chief Constable may need to take steps to satisfy themselves that (i) adequate
local training, of a satisfactory standard has been universally delivered to all their
FELU staff and supervisors in applying the Home Office Guidance on Firearms
Licencing Law (published in November 2022) and the revised Statutory Guidance
for Chief officers of Police (published in February 2023) and (ii) they have only
delegated decision making to persons who have undergone adequate training in
firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the
earlier requests made specifically to the College of Policing asking for such training
to be developed, no accredited training as yet exists.
(2) neither the current CoP APP guidance on firearms nor the proposed update
(which I am aware is still under consultation) includes any requirement that FELU
staff are trained in firearms licencing generally or trained in conducting suitability
assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated
recommendations being made over the past 27 years, beginning with the Cullen
report in 1996:
(i)
successive governments appear to have failed to ensure that any guidance is
produced that makes having training in firearms licencing generally (and in
conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only
delegate authority to issue and revoke licences to officers and staff who have
completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a
mandatory requirement for all those making firearms licensing decisions to undertake
adequate training for their role increases the risk of incorrect decision making and,
consequently, increases the risk of future deaths.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you have the
power to take such action.
7 YOUR RESPONSE
10
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 3 May 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.
8 COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the Interested Persons listed
on the appended document, and to the Local Safeguarding Board/Domestic Homicide
Review authors. I have also sent it to those also named on the appended document 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
8 March 2023
Signed by Senior Coroner Ian Arrow
11
34 responses 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.
Prevention of Future Deaths Report Response This document forms the official response from Avon and Somerset Police to the Prevention of Future Deaths report, published by Mr Ian M Arrow, Senior Coroner for Plymouth, Torbay, and South Devon on 8th March 2023. Overview On 12th August 2021, Jake Davison fatally shot Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington, and Kate Shepherd in Keyham, Plymouth. The Senior Coroner for Plymouth, Torbay, and South Devon, Mr Ian Arrow, led the inquest into their deaths and, following its conclusion in March 2023, he produced a number of Prevention of Future Deaths reports documenting key findings and learning to be considered by relevant agencies. A request was made for all subsequent responses to be completed within 56 days; by 3rd May 2023. The report below documents the response of Avon and Somerset Police to the ‘Matters of Concern’ raised by the Senior Coroner for consideration by Chief Constables in England & Wales and those relating to ‘Training.’ ‘Matters of Concern’ – All Chief Constables ‘I am concerned that in the light of the lessons learned in the Keyham inquests of the attitude towards risk, a further review of all certificates seized, refused, revoked, or surrendered and then subsequently approved over the past five years may be required to be assured of public safety.’ Response from Avon & Somerset Police: Following the fatal shootings in Plymouth in 2021, the Home Office requested a review of the last five years of cases where licenses had been seized, revoked, or refused and then subsequently approved again. Avon and Somerset Police completed a thorough and comprehensive review and found no cases where the approval should not have been granted. We are satisfied that our decision-making in each of these reviews was appropriate, and that our ongoing review processes are necessarily stringent. Our rationale for this is as follows: Prior to the Home Office request in 2021, Avon and Somerset Police appointed a new Firearms Licensing Manager (FLM) in 2020, who sought to undertake assurance surrounding all risks within the department as a priority. This was particularly relevant given the context of the COVID-19 pandemic and the reduction of face-to-face contact with applicants, in addition to the number of licensing appeals that were going to the Crown Court. Court files and revocations were reviewed, and learning was identified surrounding the quality and detail of rationales for revocations and subsequent approvals. The FLM also identified a culture which didn’t support staff to effectively challenge decisions. Standards and PREVENTION OF FUTURE DEATHS REPORT RESPONSE APRIL 2023 expectations were quickly articulated, and processes were tightened within the department to ensure transparency and robust decision making. Following the Plymouth shootings in 2021, the process in Avon and Somerset Police was amended to add a further layer of scrutiny and oversight. This new approach required that all decisions to grant a certificate, where the certificate had previously been revoked / refused, must be authorised by an Assistant Chief Constable. This chief officer is provided with the relevant threat, harm and risk assessment, intelligence, case law, and relevant options and recommendations from the FLM. The process is in place for all applicants, irrespective of how much time has elapsed between the original revocation and the renewal. Furthermore, Avon and Somerset Police have a number of established practices and processes which already mitigate against a number of the risks identified in the learning from Plymouth. Indeed, in October 2020, the following measures and processes were adopted: • Avon and Somerset Police Firearms Licensing Team have implemented and maintained a position that any caution or restorative justice disposal should be considered as a conviction when assessing suitability. • The responsibility for authorising the return of firearms was removed from investigating officers and sits solely with the Firearms Licensing Team - specifically Firearms Licensing Officers and the Firearms Licensing Manager. • Any incident which requires the seizure or voluntary surrender of guns and certificates is subject to a suitability review. • To ensure managerial supervision, completed reviews are signed off by the Firearms Licensing Officer and Firearms Licensing Manager, with additional oversight where necessary being provided by the Criminal Justice Chief Inspector and Assistant Chief Constable. • Avon and Somerset have adopted the NDM RISK MATRIX (see Appendix A), which is supported by the Firearms and Explosive Licensing Risk Management Procedure consultation document and the College of Policing Risk Principles. The Avon and Somerset Firearms Licensing Team have also reviewed the effectiveness with which overall risk is managed, and certificates and weapons are returned to those persons where they have been: • Revoked, • Seized during or following contact with the Police, • Surrendered on advice from Police / Firearms Licensing / Third Parties. Procedures have been amended to ensure that every incident, although considered on its individual merits, is scrutinised with the same objective curiosity and that all decisions are properly recorded and reviewed. Avon and Somerset Police have been instrumental in shaping best practice nationally and have supported peer reviews across the South-west region. We have confidence in the robustness of our decision making and are assured that our processes enable high levels of public safety. PREVENTION OF FUTURE DEATHS REPORT RESPONSE APRIL 2023 ‘Matters of Concern’ - Training ‘Despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for Firearms and Explosives Licensing Unit (FELU) staff. I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by the FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that: i. Adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licensing Law (published in November 2022) and the revised Statutory Guidance for Chief Officers of Police (published in February 2023) and, They have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent guidance.’ ii. Response from Avon & Somerset Police: All Firearms Enquiry Officers in Avon and Somerset complete the South Yorkshire Police three-day Firearms Enquiry Officer course (see Appendix B). Our Firearms Licensing Team have a dedicated senior Firearms Enquiry Officer who trains, coaches, and mentors all new Firearms Enquiry Officers in line with the College of Policing Assessment Guidance for Firearms Licensing (See Appendix B), ensuring consistency in the operational approaches that staff take. Specific training courses for Firearms Licensing Administrators are delivered through Mowbray Partners. Staff from the department also maintain their own continuous professional development by participating in regional events which involve inputs from national shooting bodies, the British Association for Shooting and Conservation (BASC), and the National Gamekeepers Organisation. Avon and Somerset Police comply with the Authorised Professional Practice (APP) and the Firearms Licensing: Statutory Guidance for Chief Officers of Police, February 2023. The Firearms Licensing Team are presently using the latest publication to establish further areas for additional improvement. In response to the publication of the aforementioned guidance, and in recognition of the learning from the deaths in Keyham, the Firearms Licensing Team are reviewing their training requirements and will be implementing additional mandatory training for all staff working in the team. These training inputs will include: • Completion, by the Firearms Licensing Manager and Firearms Licensing Officers, of the Professionalising Investigations Programme (PiP) Level 1 training, focussing on decision making, managing risk, and supervising investigations. This course will mirror the input that is given to all police supervisors of investigations. PREVENTION OF FUTURE DEATHS REPORT RESPONSE APRIL 2023
Hertfordshire Constabulary Stanborough Road Welwyn Garden City Herts AL8 6XF olice.uk 02nd May 2023 To: Mr I M Arrow, Senior Coroner, Plymouth, Torbay, and South Devon Via e-mail - Private and Confidential Dear Mr Arrow, Re: Response to all Chief Constables to prevent further deaths I write in response to your report to all Chief Constables to prevent future deaths; made under Regulation 28 of the Coroners (investigative) Regulations 2013 dated 8th March 2023. On behalf of Bedfordshire, Cambridgeshire, and Hertfordshire Police I write to confirm that through our collaborated Firearms and Explosive Licencing Unit as Chief Constables we have instructed the following reviews: • A review of all firearms seized and returned over the last five years, sequenced with those returned soonest reviewed first. • A review of all certificate holders refused or revoked, but subsequently successful with a new application over the last 5 years. • A review of all holders subject to a police intelligence report over the last five years, prioritised in order of risk identified through initial triage. In each case our reviews will ensure that processes and outcomes align to the most recent guidance and standards, and where required we will revoke certificates to be assured of public safety. This work undertaken by us will deliver retrospective application of the standards currently applied to Grants, Renewals, and Revocations to these past cases and incidents. To achieve this work, we are providing additional investigative resource uplift to our Firearms and Explosive Licencing Unit dedicated to these reviews, and it is estimated that the work will take six months to complete in full. Bedfordshire Police, Woburn Road, Kempston, Beds, MK43 9AX Cambridgeshire Police, Hinchingbrooke Park, Huntingdon, Cambs, PE29 6NP Hertfordshire Police, Stanborough Road, Welwyn Garden City, Herts, AL8 6XF We have worked hard to deliver improvements to strengthen our processes and decision making within the Firearms and Explosive Licensing Unit, and following the publication of the Statutory Guidance in November 2021 we reviewed our policy and procedures to ensure that they aligned with the new guidance, and recently the revised version. This work included escalating the authority level to Assistant Chief Constable (November 2021) to authorise the return of a firearm or shotgun following seizure, and the alignment of force policy and processes to the Home Office Statutory Guidance. The BCH firearms and Explosive Licensing Unit has been subject to several changes to strengthen processes and outcomes, and we have already seen a step-change in outcomes as a result of this work which has sought to reposition the Unit from an administrative led function to one with an investigative mindset and professional curiosity. Having reviewed the data for the 2022/23 policing year (April – March) 49 Grant applications were refused, 15 Renewals refused, and 58 certificates revoked, and a review of the quality of decision making has provided assurance that our policy and procedures are being complied with by our staff. The retrospective review work that we are undertaking around past decision making will ensure that we apply these standards and processes to those legacy cases, and where risk or incorrect decision making is identified we will take immediate steps to rectify that. During 2023 to date we have revoked 7 certificate holders who were previously refused/revoked and subsequently successful in an application, and a further 3 certificate holders following a review of their circumstances. The work that we are undertaking has identified areas for improvement beyond our force areas which we have escalated to the NPCC lead and Home Office. These emerging issues includes concerns around the disparity between the shotgun and firearm application process, namely there being no minimum age limit for shotgun applications. We have an appeal currently progressing through Crown Court relating to a child that applied for a shotgun certificate aged 8 years old, and unlike firearms there is nothing definitive in legislation or guidance to prevent young children making such application and appealing police refusal decisions. We have raised further concerns regarding the Crown Court appeal process whereby those appealing decisions based upon domestic abuse factors can cross examine vulnerable DA victims in such hearings which may present significant safeguarding and vulnerability issues for such victims, we have one such case also progressing through Crown Court. Finally, we have identified a potential intelligence gap/risk in relation to cases that are progressing through family court and civil courts which involve persons or members of the family who are licenced firearms holders. At present there is no requirement to disclose the presence of firearms within such cases, and a good preventative step could be a change in the Bedfordshire Police, Woburn Road, Kempston, Beds, MK43 9AX Cambridgeshire Police, Hinchingbrooke Park, Huntingdon, Cambs, PE29 6NP Hertfordshire Police, Stanborough Road, Welwyn Garden City, Herts, AL8 6XF law or, if a change in law is not deemed proportionate then some other form of positive action such as OP ENCOMPASS which is in place across schools and Police around DA disclosure information sharing, but between courts and Police so that a risk assessment can be undertaken around the presence of such firearms within family settings with high level civil disputes. Acknowledging a lack of nationally accredited training for Firearms Explosives Licencing Units, a review of our training has been conducted, with new role specific training currently being undertaken by all Firearms Explosives Licencing Unit staff. Continued professional development will be achieved through a planned annual training schedule, and we have purchased an external training package for all FELU staff dedicated to firearms licencing roles whilst a nationally accredited package is developed. Delegated decision maker authority is only given to those who have undertaken adequate training. Finally in January 2023 a full Change Team review of our Firearms and Explosive Licencing Unit commenced and is due to report in May. This review is undertaking a root and branch review of the firearms and explosive licencing reviews, updated guidance, future demand, and requirements, and seeking areas of national best practise in place across other forces. This work will ensure that we are able to deliver a service aligned to requirements, public expectations, and embedded the required staffing levels and skills to deliver this service to meet future demand and standards. Yours sincerely Bedfordshire Police Cambridgeshire Police Hertfordshire Police Bedfordshire Police, Woburn Road, Kempston, Beds, MK43 9AX Cambridgeshire Police, Hinchingbrooke Park, Huntingdon, Cambs, PE29 6NP Hertfordshire Police, Stanborough Road, Welwyn Garden City, Herts, AL8 6XF
Protected Marking Restricted Date 02/05/23 Title & Version Prevention of Future Deaths Report – Keyham Inquest Reference The Report to Prevent Future Deaths: Made Under Regulation 28 Of the Coroners (Investigations) Regulations 2013. Duty to respond to report within 56 days (namely by 3rd May 2023). HANDLING INSTRUCTIONS: This document must be handled in accordance with the protective security marking shown at the top of the document and should not be disseminated to outside agencies/partners without the consent of the authorising officer. Background The case relates to the Plymouth shooting where the Jake Davision had his shot gun returned via the Force Firearms Licensing unit and subsequently shot and caused the death of five people in Keyham on 12th August 2021. The Coroner recommends all Forces review all their decisions to return firearms to a license holder. Coroner Report Key Learning • The death was caused by the fact the perpetrator has a lawfully held shotgun. • Serious failures in FELU in granting and later failing to revolve the perpetrators shotgun certificate. • Failure of Police to have in place safe and robust systems, foremost the training of FELU staff, governance of the FELU, quality assurance of FELU staffs decisions making and ensuring they were made at the correct level. • There was failure of Police FELU staff to obtain sufficient medical information in respect of the perpetrator’s application for a shotgun certificate and on review. • Failure of Police FELU staff to properly seek out and consider all the relevant evidence an information availability before decision whether to grant the shotgun certificate. • Following the perpetrator having assaulted two children in 2020, there was a failure by Police to protect the public and the peace. Firstly, with downgraded charge and secondly with in the FELU to sufficiently investigate whether it was safe to return after initially seizing them. Incorrect application of the risk matrix meant decision were not approved by a manager of sufficient seniority. • • Catastrophic failure in the management of the FELU, with a lack of managerial supervision, inadequate and ineffective leadership which was compounded by a lack of senior management addressing the issues. • Evidence heard at these inquests revealed that numerous recommendations arising from previous inquiries and reviews regarding the training of police officers and police staff involved in firearms licencing decision has not been put into effect. Chief Officers ought to be satisfied that they only delegate their authority to issue and revoke firearms licenses to appropriately trained and skilled personnel. There continues to be a lack of nationally accredited training for FELU staff. COLP Specific Data / Procedures in relations to Firearms Licensing COLP currently have the following 36 live certificates COLP have not returned any certificates having confiscated them in recent years. Current CoLP procedure The decision to return a firearm is made by Licensing Team members, quality assured by Inspector with final authority to return being made by Firearms Portfolio holder Commander Ops & Security. CoLP Actions Learning from this case should also be applied to the initial application and annual re- licensing processes. • What are the Common National Standards for Firearms License Applications / Renewals / Return of firearm following suspension? – • Match CoLP SOP to ensure standards are met or exceeded. • Review SOP to ensure procedures for - Application / Annual Renewal / Return – Ensuring robust checks across medical, crime recording and Risk Assessment. • Risk assessment training and CPD training for all licensing team - Annual cycle of training and development. Recommendation /Response • City of London Police acknowledge the findings and learnings from the Keyham Inquest. • These findings have been brought to the attention of the respective operational leads and further governance will be provided through the the Operational Learning Forum for actions to be set and tracked across CoLP. The next OLF is scheduled to for 23rd May at 1330-1500hrs, papers to be submitted by 16th May. Commander City of London Police. Lead for Ops and Security Chair Org Learning Board.
Working together
to keep people safe
College of Policing
Leamington Road
Ryton-on-Dunsmore
Coventry, CV8 3EN
contactus@college.pnn.police.uk
college.police.uk
HM Senior Coroner- Mr Ian Arrow
1 Derriford Park
Derriford Business Park
Plymouth
PL6 5QZ
27th April 2023
Ref: Prevention of Future Deaths Reports - Keyham Inquests
Dear Mr Arrow,
This response is submitted on behalf of the College of Policing ('the College') in reply to your
reports on Preventing Future Deaths (PFD) following the Keyham inquests.
Firstly, I wish to extend my deepest condolences to the families and friends of those murdered and
injured as a result of the shootings. We also wish to state our appreciation of all of those who contributed
to the proceed ings. It is incumbent on the College and others in policing to ensure lessons are learned.
College Response to Matters of Concern
The College is named as a joint addressee for the PFD report that focuses on the training of firearms
licensing decision makers, and you have made us aware that:
•
•
'despite the repeated recommendations being made over the past 27 years, and the earlier
requests made specifically to the College of Policing asking for such training to be developed, no
accredited training as yet exists'
'neither the current CoP APP guidance on firearms nor the proposed update includes any
requirement that FELU staff are trained in firearms licensing generally or trained in conducting
suitability assessments in particular'
The College is currently developing significantly revised and updated Authorised Professional Practice
(APP) on firearms licensing. The APP - and other national products such as the Home Office's Statutory
Guidance - w ill underpin the development of a national training course for staff involved in firearms
licensing. This will include Firearms Enquiry Officers (FEOs) and others who may have delegated
authority to make decisions.
We will adapt national approaches to train ing used in other high-risk areas of policing, for example,
armed policing . As part of this approach, national materials and accompanying quality assurance (QA)
processes will be developed to ensure a consistent approach to training across forces in England and
College of Policing Limited is a company registered in England and Wales,
with registered number 8235199 and VAT registered number 152023949.
Our registered office is at College of Policing Limited, Leamington Road,
Ryton-on-Dunsmore, Coventry CVS 3EN
Wales. The material and QA will be based on national learning outcomes which are also currently being
reviewed and updated.
It is our intention to incorporate an assessment component to the training, to help ensure and reinforce
occupational competence. We also intend to develop a framework that can help ensure operational
competence (for example, ongoing assessment against learning outcomes evidenced through
mechanisms such as portfolios; performance and development reviews; and Continual Professional
Development).
Once the training course has been designed, we will state in the APP that chief officers should only
delegate their firearms licensing decisions to people who have been trained to take those decisions.
It is also noted that the PFDs could lead to other significant developments for firearms licensing. We will
continue to mon itor developments in firearms licensing to ensure our training and guidance reflect the
highest standards. This is so that only those who should have access to firearms do so and that the
licensing system contributes to the safety of the public to the extent that it can .
Yours sincerely,
Chief Executive Officer
College of Policing
E:
2 Over the past three years, work has been underway to improve the recording and sharing of IT systems. All firearms licence holders and their addresses have a marker on the Police National Computer, together with the local crime and intelligence system. When any incident, crime report, or intelligence is received involving a firearms licence holder, firearms licence address or any persons linked to that address is recorded within the East Midlands region on our crime and intelligence system, an automatic notification is sent to our firearms licencing team. All Firearms Enquiry Officers have attended the training course provided by South Yorkshire Police, enhanced further by local internal continuous professional development sessions. The force is also in the process of developing a digital learning package to raise awareness of firearms licensing amongst frontline officers. Members of the Firearms Licensing management team will shortly be attending a two-day event at the College of Policing to debrief the findings of the inquest and identify any learning for inclusion in our local delivery plan. Derbyshire Constabulary is committed to improving the quality of firearms licensing decision making. One area currently being explored is the possibility of introducing an independent scrutiny panel to further strengthen quality assurance activity. Finally, in accordance with guidance from the National Police Chiefs’ Council, Derbyshire Constabulary will shortly commence a review of all cases in the last five years where firearms have been seized or surrendered to police pending a review of suitability to have a licence, but then subsequently returned. There will be a staged approach to completion of this task with the most recent decisions being initially prioritised for review. This is a significant undertaking, and our ambition is to complete this work by the end of October 2023. I hope this provides the necessary reassurance of the commitment of Derbyshire Constabulary to learning the lessons from this tragedy. Yours sincerely Chief Constable
a tJ POLICE Devon & Cornwall Acting Chief Constable Police Headquarters, Middlemoor, Exeter, Devon, EX2 ?HQ MBA CMgr MCMI 101 Non Emergency Ll;,,u,!J Non Emergency (BSL video relay) 999 Emergency Non Emergency Text 67101 (Deaf only) 6 de.police.Uk @) dc.police.uk/webchat @ Text 999 (Deaf o nly - m ust pre-register at 999 BSL Emergency (BSL video relay) www.emergencysms.org.uk) HM Senior Coroner Mr Philip Spinney 1 Derriford Park Derriford Business Park Plymouth Devon PL6 5QZ 22 January 2024 I write further to Chief Constable response to your Regulation 28 Report issued following the Inquest touching the deaths of the five victims of the Keyham shooting on 12 August 2021. letter to you of 3 May 2023, which provided a That letter represented a formal response to the Prevent Future Deaths (PFD) report issued by HM Senior Coroner on 8 March 2023, in accordance with the requirements under Regulation 29 Coroners (Investigations) Regulations 2013. Since the date of that response, further review work has been undertaken within our Firearms and Explosives Licencing Unit (FELU) and, as such, it is appropriate for me to provide you with this updated information, for completeness and transparency. Within your Regulation 28 Report, you sought the following : " ... a further review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the past five years may be required to be assured of public safety." The response of 3 May 2023 confirmed that much of this review work had already been completed and provided the outcome of that work. However, one period remained outstanding, and this was the period 3 May 2018 - 31 December 2019 inclusive. It was confirmed within the previous response that: By October 2023 Devon and Cornwall Police will have reviewed cases using the same identification criteria used in the submission to the Home Secretary in 2021 and, importantly, reviewed using the standard applied during the remedial work that was completed prior to the inquest. We will prioritise the review of cases using the most recent statutory guidance for this period as follows: 0 DevonAndCornwa llPolice 0 @DC_Police ® dc_police @DCPolice Cases where firearms have been seized or surrendered to police pending a review of suitability to have a licence, but then subsequently returned. These will be reviewed with the most recent cases first (i.e., where the risk is closest to the current time). Cases where grants or renewals have been refused but where applicants have been successful at appeal. This work has now been completed using SharePoint Case Management System and data held on the National Firearms Licencing System (NFLMS). A total of 611 licence holders were identified meeting the criteria above and have been subject to review. Of the 611 cases, 11 of these cases identified internal processes which did not meet the expected standards and have been subject to further review. No ongoing risks were identified. As described during the Inquest, the processes surrounding such reviews within our FELU have improved significantly and I am confident that such examples would not occur again under the current regime. There are no current risks requiring any remedial action and Devon and Cornwall Police FELU are confident we can identify any contemporary risk, with the new automated systems in place, and ongoing scrutiny in processes specific to grants, renewals and suitability assessments. The following table contains the relevant data for ease of reference: In the 20 months 03/05/2018 to 31/12/2019) how many shotgun and firearm certificates were: How many of those removed were subsequently returned: Firearm removed from certificate holder by being seized, surrendered or revoked (by no. of certificate holders) refused of those with firearms that were seized or surrendered of those revoked 411 73 42 04 I trust the above additional information assists. If you require any further information, please do not hesitate to contact me. Yours sincerely MBA CMgr MCMI Acting Chief Constable
Chief Constable Police Headquarters, Middlemoor, Exeter, Devon, EX2 7HQ 3 May 2023 Mr Ian Arrow HM Senior Coroner for Plymouth, Torbay and South Devon 1 Derriford Park Derriford Business Park Plymouth, PL6 5QZ Dear Mr Arrow Response to Regulation 28 Report regarding the inquest touching the deaths in Keyham on 12 August 2021 of: - Maxine Davison - Lee Martyn - Sophie Martyn - Stephen Washington - Kate Shepherd I respond to the Reports to prevent future deaths issued by the Senior Coroner under paragraph 7, Schedule 5 Coroners and Justices Act 2009 and Regulation 28 Coroners (Investigations) Regulations 2013, dated 8 March 2023. This is the formal response in accordance with the requirements under Regulation 29 Coroners (Investigations) Regulations 2013. This response is provided in relation to: a. Concerns raised of the Chief Constable of Devon and Cornwall Police as a properly interested party in the Keyham Inquests. b. Any concerns raised of all Chief Constables in England and Wales. Before setting out our specific response below, Devon and Cornwall Police shares the concerns raised to you by the families directly affected by the tragic events of 12 August 2021. As we stated at the inquest, we will continue to work with National Police Chiefs’ Council (NPCC) colleagues to support efforts to seek substantial changes to primary legislation and statutory guidance. As we stated at the inquest, this incident and the learning from it represents a unique opportunity for enacting the comprehensive reform that is required. Following this incident, Devon and Cornwall Police invested approximately £3 million into the force’s Firearms and Explosives Licensing Unit (FELU), and we continue to be involved in sharing advice and learning concerning policies and procedures with other police forces and the NPCC. Set out below are the specific paragraphs subject of this response under Regulation 29, for ease of reference. Report to: All Chief Constables in England and Wales Re: Further Review of all certificates seized/refused/revoked or surrendered and then approved over the past five years I am concerned that the figures provided to the Home Secretary in 2021 may not reflect the accurate position, and that if sufficiently stringent checks are performed these may reveal other cases where a firearm or shotgun certificate had been seized, refused, revoked or surrendered but was subsequently issued/returned in circumstances when the certificate should not have been approved. I am concerned that if there are other cases that were not subject to a proper or thorough review of the risk of returning the weapons then the person may continue to have a firearms/shotgun certificate and hold weapons in circumstances that place the public and licence holder themselves at risk. I am concerned that in light of the lessons learned in the Keyham inquests of the attitude towards risk, a further review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the past five years may be required to be assured of public safety. Response I agree with the submissions made by the families during the inquest, and we do so for the reasons set out below. As described during the evidence of Chief Superintendent during inquest, Devon and Cornwall Police have completed a full evaluation of all ‘case reviews’ from the period January 2020 onwards. This included a review of all certificates seized, refused, revoked or surrendered which were then subsequently approved, as part of these review parameters. For the period May 2018 to December 2019 (to complete the full five year period referred to by HM Coroner), Devon and Cornwall Police are committed to reviewing the cases during this period which fit the same criteria. Full details are contained in the paragraphs below. Page | 2 In August 2021 the Home Secretary wrote to all Chief Constables asking for an urgent review of specific cases; research was conducted and the number of cases included in the table below were identified (as reported during the inquest). In the last 12 months (01/01/2020 to 18/08/2021) how many shotgun and firearm certificates were: How many of those removed were subsequently returned: firearm removed from certificate holder by being seized, surrendered or revoked refused of those with firearms that were seized, refused or surrendered of those revoked 123 27 42 0 In August 2021 all 42 cases where certificates/weapon(s) were returned following an issue affecting a holder’s suitability were reviewed by an experienced Firearms Enquiry Officer who was not involved in the original decision. The result of this review, as reported to the Home Secretary, was that any issues identified were administrative in nature. As expressed by Chief Superintendent witness evidence, further scrutiny established that the issues were not purely administrative in nature, and steps were subsequently taken to understand and rectify the position. during live The independent peer review completed by Durham Police in September 2021 reviewed these cases in more detail, and these cases were reviewed again by Chief Superintendent Keyham tragedy. As expressed at inquest, 12 of the 42 cases were identified to have substantive issues affecting the suitability of the licence holder which required further remedial action. As a result, further revocations were instigated where relevant, while others voluntarily surrendered their weapons and certificates. , the senior officer appointed to manage the response to the With over 40,000 firearm and shotgun licences in Devon and Cornwall, the vast majority of licence holders have no issues affecting suitability, and the decision making, within the parameters of the law, Authorised Professional Practice (APP) and statutory guidance, is straightforward. In addition to the scrutiny applied through the review for the Home Secretary and the Durham Peer Review (September 2021), the Police Gold Commander commissioned our Performance and Analysis Department to conduct further research into licence holders in order to identify issues regarding their ongoing suitability. Page | 3 , this identified As expressed in the witness evidence of Chief Superintendent those cases which were likely to present a potential risk using the following criteria: a. Where a case review has been completed; b. Where a crime has been recorded against licence holder/address; c. Where a GP had highlighted a concern (noting that before November 2021, neither APP nor statutory guidance addressed the issue of a failure to respond by a GP); d. Where intelligence was attached to licence holder and/or their address; e. Where there was an incident log involving a licence holder and/or their address. Taking the result of this research into consideration, the additional supervisors recruited into FELU were tasked to complete, in priority order: • A detailed review of the initial cases included in the response to the Home Secretary’s letter and the Durham Peer Review to ensure each case was dealt with appropriately against APP and statutory guidance; • A dip sample of the cases involving the decision makers in the case of • A review of the cases identified by the research conducted by the Performance and Analysis Department articulated above. In addition to managing the core demand of the FELU such as grant and renewal applications, the prioritisation of this work sought to address the known risk first (ie that identified through the Durham Peer Review), before reviewing the potential risk such as that contained in cases involving the decision makers who had been involved in the Davison case, and then finally the further potential risks identified through the targeted research conducted by our analysts as articulated above. Our position is that with the large number of certificate holders within our force area, it is not proportionate to review all the certificates over a five year period, or indeed all those made by the staff involved in the Jake Davison case. The vast majority will contain no issues regarding suitability, and many of these cases will now have been through a renewal process. An additional full review of all licence holders would be likely to transfer risk elsewhere within the FELU by moving staff away from the focussed activity associated with the normal operation of the unit. This is particularly relevant when considering the need to ensure that the staff involved are adequately trained and experienced in making licensing decisions. Consequently, the approach followed was evidence-led using criteria informed through the various inspections undertaken following the incident. Page | 4 It is relevant to highlight that since the incident we have voluntarily sought a review by an independent police force (Durham), conducted our own peer review post- inquest, and are now supporting the delivery of an independent inspection by HMICFRS (May 2023) following the request of the Police and Crime Commissioner and Policing Minister. It is also noteworthy that throughout this process, we have regularly engaged with the NPCC lead force for firearms licensing (Warwickshire). In writing this response, our position is that the date from which the five-year period is considered should be the date of submission of this response (3 May 2023). Considering this, it must be noted that the substantial changes implemented in Devon and Cornwall Police cover a significant part of this period. As presented at the inquest, following the incident all decisions were paused until a new leadership structure was created and embedded. This was augmented by a comprehensive training and Continuing Professional Development (CPD) programme for all staff, a portfolio assessment for Firearms Enquiry Officers (FEOs) and a robust dip sampling framework (see below). Consequently, all decisions regarding grants, renewals and case reviews since August 2021 have been subject to the new robust process which includes all of the lessons identified through the inquest, and applies a rigour beyond that set within the statutory guidance and APP. The evidence for this conclusion is found through the internal peer review conducted since the inquest, the preparatory work conducted before it, and the sustained rate of refusals and revocations which is now consistently higher than the national average. In addition to this, the period 1 January 2020 to 18 August 2021 is covered by the response to the Home Secretary in September 2021, and the additional (independent) review of these cases by Durham Police and the remedial work completed as a result by Chief Superintendent Linden. Consequently, we suggest that the requirements of the PFD report are met for the period 1 January 2020 to 3 May 2023. Considering the above, our response for this report relates to this remaining period (3 May 2018 to 31 December 2019 inclusive). I have decided that we will conduct a further review of cases over this period in order to identify any remaining risk to the public that requires remedial action. Our position, based on the experience of reviewing the decision making in cases prior to August 2021 (completed for the inquest), is that further work is required notwithstanding that the passage of time will diminish any risk in the vast majority of cases. By October 2023 Devon and Cornwall Police will have reviewed cases using the same identification criteria used in the submission to the Home Secretary in 2021 and, importantly, reviewed using the standard applied during the remedial work that was completed prior to the inquest. We will prioritise the review of cases using the most recent statutory guidance for this period as follows: • Cases where firearms have been seized or surrendered to police pending a review of suitability to have a licence, but then subsequently returned. These will be reviewed with the most recent cases first (ie where the risk is closest to the current time). • Cases where grants or renewals have been refused but where applicants have been successful at appeal. Page | 5 In addition and in parallel to this, we will review the analytical product articulated above, and use this to complete further targeted reviews of licence holders who may have had an involvement with the police that is capable of affecting their suitability to hold a licence. However, experience over the last 20 months has shown that this research frequently identifies matters that are either irrelevant to the licence holder (eg a road traffic collision that is recorded in the same street as the holder), or that have already been reviewed as part of a renewal or case review. Report to: The NPCC lead for firearms licencing and all other Chief Constables in England and Wales Re: Training of Police Officers and Police Staff involved in firearms licencing decisions So that each Chief Constable is made aware of my concern that, despite the many recommendations made of the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff. I also report my concern that in the absence of such training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief Officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that relevant Guidance. I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licencing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths. Response Devon and Cornwall Police fully support the NPCC and the College of Policing (CoP) in developing a national accredited training program for staff involved in making licensing decisions. We agree with the PFD submissions made on behalf of the families during the inquest and will continue to support the national training program as it develops; advocating for sufficient funding to enable this to deliver at pace. We will also support its delivery where requested, ensuring that lessons from Keyham are integrated into the fabric of the course. Page | 6 As expressed in evidence during inquest, the training provision for the FELU within Devon and Cornwall Police has been completely revised since the incident, creating clear expectations of staff and auditable records of training delivered. There is a clear focus on decision making, risk identification and the implementation of statutory guidance. This has included training to all staff within the FELU, key operational managers who are responsible for making dynamic decisions to revoke licences, and those responsible for making decisions within criminal investigations, known as Evidence Review Officers (EROs). Immediately following the tragic incident in Keyham, a senior manager was appointed to create a training and continual professional development plan, and to deliver this to all staff within the unit. In the absence of a national accredited training package, we have created and delivered a bespoke training program to all staff working within the FELU including those responsible for making high risk decisions. At the time of writing, all staff working within the FELU have undertaken a Firearms Enquiry Officer course provided by a Firearms Licensing Manager from South Yorkshire Police. This course has a positive reputation across UK policing and is one of only a handful of options available. The content covers the use of the National Decision Model (NDM) in addition to a vulnerability assessment framework, core investigative principles, the grant and renewal application process, suitability criteria, powers and appeals, the National Intelligence Model, domestic abuse, security arrangements, mental health, and the statutory guidance. Importantly the course integrates these issues with the revised processes created within Devon and Cornwall Police since the incident; for example, the completion of enquiry forms by FEOs. By mandating attendance for all staff within the FELU, this provides a consistent approach for both existing staff and new members, providing a baseline from which individuals can perform their role to a high standard. A handbook for staff is also shared following the course, and all staff have been provided with a copy of the most recent statutory guidance with clear instructions for its use, linking this with a risk identification tool which was referred to in the inquest as the FELU Risk Matrix. It is noted that Devon and Cornwall Police are in the process of reviewing the use of this risk identification tool alongside the NPCC in light of both the statutory guidance released in February 2023 and the issues raised during the inquest. As a result of the work conducted after the incident, we have also delivered additional training in risk assessments and decision making. This training has been delivered by a barrister who specialises in firearms licensing and focuses on the practical identification of risk through the THRIVE (Threat, Harm, Risk, Investigation, Vulnerability) assessment process, as well as the application of the national police risk principles and the use of the NDM in case and appeal management. This training, initiated soon after the incident, is clearly relevant to the matters subjected to appropriate examination at the inquest. Suitability decisions are now recorded on separate documents, including all relevant detail that could affect the suitability of an applicant to hold a licence. The records are comprehensive and apply the statutory guidance through the use of the NDM. Page | 7 In terms of managing the various IT systems used in making and recording licensing decisions, all staff within the FELU have completed training courses in the following computer systems: • Police National Computer – PNC; • UNIFI – our previous records management system; • Niche – the new records management system; • Storm – our incident management system; • Police National Database – PND – a national intelligence database. To assist FEOs in the conduct of their public facing role, all undertake training in first aid and personal safety which are based on the (NPCC) Personal Safety Manual and covers a vast range of subjects. FEOs also complete Firearms Safety Training which is delivered by our accredited Force Armourers. This covers the safe handling of firearms and shotguns and how to make weapons ‘safe’ during their duties. Prior to the incident this training was taken every five years until 2019; FEOs now have refresher training every three years. Until a national qualification is made available through the College of Policing, FEOs are accredited ‘in force’ with a qualification from the course provided by the Licensing Manager from South Yorkshire Police. This process is coordinated internally with individual records maintained, enabling automatic reminders to be sent to staff and their line manager to alert them when this skill is due to expire. At this time there is no formal requirement across England and Wales in relation to either accreditation or refreshing existing skills and learning. We will continue to engage and work closely with the NPCC and College of Policing during 2023 to assist in delivering the national course and in defining a period for reaccreditation which is robust and pragmatic. Following the inquest we submitted a comprehensive response to the College of Policing to assist this process, and Devon and Cornwall’s future policy will reflect the national position and any requirements set by the NPCC and the College. In order to maintain this standard of training for new starters, Devon and Cornwall Police will re-engage with South Yorkshire Police to provide training to staff in cohorts as and when required. It is envisaged that this process will continue until the new national qualification is delivered through the College of Policing. Following the completion of the mandatory training requirements listed above, we have also started to deliver a three-year continual professional development programme comprising dedicated training to FELU staff from experts in mental health and domestic abuse. This training reflects the core issues examined during the inquest. In addition, we continue to work with the NPCC lead to ensure that these issues are reflected within the national planning for accredited training and annual CPD requirements which are further set out within the NPCC portfolio. Page | 8 provided The decision to temporarily remove the decision-making capability of FEOs and FEO supervisors articulated during the inquest by Chief Superintendent an immediate response to the issues identified. Following the delivery of the training described above, two additional training related actions have been pursued to augment the decision-making process: the creation of a portfolio for assessing and performance monitoring FEOs, and a comprehensive dip sampling regime involving both the Assistant Chief Constable (Operations) and the Senior Management Team (SMT) within the FELU. This involves the new supervisors within the unit reviewing FEO decisions via an enquiry form, assessing their rationale, and providing feedback to them directly. Significant issues or more systemic ones are regularly discussed within the risk management meetings led by the ACC (Operations) as described during the inquest. This system provides a clear and robust process for assessing the quality of the investigations conducted by FEOs following their training, and one which will be part of the forthcoming HMICFRS inspection. During the next 18 months we intend to provide additional training to further enhance the quality of FEO investigations. This will be delivered through the national Professionalising Investigations Programme at level 1, which is the nationally recognised standard and includes an investigative accreditation that applies to investigators at all levels within policing. It is a structured framework running through every aspect of investigation and will improve the professional competence of all officers and staff. It also enables supervisors to manage performance of their staff and to identify areas for development. Noting that the APP for firearms licensing is under consultation and is due for imminent renewal in 2023, the current training provided within Devon and Cornwall exceeds the current requirements in APP. The post incident review following the tragedy clearly identified a need to consider training to roles outside those which deal solely with firearms licensing. With a total workforce of over 5000 staff, this is a challenging issue, particularly when considered alongside other mandatory training requirements such as Personal Safety Training, role specific training, and training to support business change processes (ie the delivery of the new records management system). At this time, Devon and Cornwall Police have adopted a targeted approach to wider organisational training, specifically to EROs and those in investigative roles. In addition to the CPD for FELU staff, in 2023 the following training is planned: a. The integration of firearms licensing into the nationally mandated practical scenarios for Personal Safety Training for all sworn (and some unsworn) staff; b. Presentation of the key learning from the incident to a CPD event for Firearms Licensing Managers in May 2023; c. Presentation of the key investigative learning to the annual CPD event for Senior Investigating Officers, Silver and Gold Commanders, and the submission of lessons learned to the NPCC via the Homicide Working Group. Page | 9
Chief Constable Mr Ian Arrow HM Senior Coroner for Plymouth, Torbay, and South Devon 1 Derriford Park Derriford Business Park Plymouth PL6 5QZ MSt (Cantab) Dorset Police Force Headquarters Winfrith DORCHESTER DT2 8DZ 3 May 2023 Dear Mr Arrow Response to Regulation 28 Report I write to provide a response on behalf of Dorset Police to the Regulation 28 Report, received on the 8 March 2023, following the conclusion of the inquest touching the deaths in Keyham on 12 August 2021 of Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington and Kate Shepherd. This response is provided in relation to: a. Concerns raised of the Chief Constable of Dorset Police as a properly interested party in the Keyham Inquests. (Firearms Licensing currently operates as an Alliance function as part of the Devon and Cornwall and Dorset Police Alliance arrangements.) b. Any concerns raised of all Chief Constables in England and Wales. I set out below the specific paragraphs subject of this response under Regulation 29 for ease of reference. Report to: All Chief Constables in England and Wales Further Review of all certificates seized/refused/revoked or surrendered and then approved over the past 5 years I am concerned that the figures provided to the Home Secretary in 2021 may not reflect the accurate position, and that if sufficiently stringent checks are performed these may reveal other cases where a firearm or shotgun certificate had been seized, refused, revoked or surrendered but was subsequently issued/returned in circumstances when the certificate should not have been approved. I am concerned that if there are other cases that were not subject to a proper or thorough review of the risk of returning the weapons then the person may continue to have a firearms/shotgun certificate and hold weapons in circumstances that place the public and certificate holder themselves at risk. I am concerned that in light of the lessons learned in the Keyham inquests of the attitude towards risk, a further review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the past five years may be required to be assured of public safety. Response We agree with the submissions made by the families during the inquest, and we do so for the reasons set out below. In August 2021 the Home Secretary wrote to all Chief Constables asking for an urgent review of cases where guns had been seized, surrendered, refused or revoked over the previous 12 months. As a result, research was conducted, and a response provided. An independent peer review, completed by Durham Police in September 2021 reviewed some of these cases in more detail, and these cases were reviewed again by Devon and Cornwall Chief Superintendent senior officer appointed to manage the response to the Keyham tragedy. It is also noteworthy that throughout this process, the department has regularly engaged with the NPCC lead force (Warwickshire). , the In all cases where certificates/gun(s) were returned following an issue affecting a holder’s suitability, these were independently reviewed by someone not involved in the original decision making process. 8 cases were identified to have issues and as a result remedial action taken or learning identified. With over circa 12,000 firearm and shotgun certificate holders in Dorset, the vast majority of certificate holders have no issues affecting suitability, and the decision making, within the parameters of the law, APP and statutory guidance, is straightforward. Dorset Police has held all certificate holders on our record management system, Niche, since 2018 which enables the unit to be notified automatically of any adverse incident affecting the Dorset certificate holder or their address allowing early intervention and investigation. In addition to the scrutiny applied through the review for the Home Secretary and the Durham Peer Review (September 2021), the Police Gold Commander commissioned the Performance and Analysis Department to conduct further research into certificate holders in order to identify issues regarding their ongoing suitability. Taking the result of this research into consideration, the additional supervisors recruited into unit were tasked to complete, in priority order: • A detailed review of the initial cases included in the response to the Home Secretary’s letter and the Durham Peer Review to ensure each case was dealt with appropriately against APP and statutory guidance. • A dip sample of the cases involving the decision makers in the case of Jake Davison. • A review of the cases identified by the research conducted by the Performance and Analysis Department. In addition to managing the core demand of the unit such as grant and renewal applications, the prioritisation of this work sought to address the known risk first (i.e. that identified through the Durham Peer Review), before reviewing the potential risk such as that contained in cases involving the decision makers who had been involved in the Davison case, and then finally the further potential risks identified through the targeted research conducted by our analysts. Our position is that with the number of certificate holders within our force area, it is not proportionate to review all the certificates over a five year period. Since 2018, Niche has provided flagging for all certificate holders and their addresses giving continual monitoring for any adverse incidents. The majority contain no issues regarding suitability, and many of these cases will now have been through a renewal process. An additional full review of all certificate holders would be likely to transfer risk elsewhere within the unit by moving staff away from the focussed activity associated with the normal operation of the unit. This is particularly relevant when considering the need to ensure that the staff involved are adequately trained and experienced in making licensing decisions. Consequently, the approach undertaken was evidence-led using criteria informed through the various inspections undertaken following the incident. In writing this response, our position is that the date from which the five-year period is considered should be the date of submission of this response. Considering this, it must be noted that the substantial changes implemented in Dorset Police Firearms and Explosives Licensing Unit cover a significant part of this period. As presented at the inquest, following the incident, all decisions were paused until a new leadership structure was created and embedded. This was augmented by a comprehensive training and CPD programme for all staff, a portfolio assessment for FEOs and a robust dip sampling framework (see below). Consequently, all decisions regarding grants, renewals and case reviews since August 2021 have been subject to the new robust process which includes all of the lessons identified through the inquest, and applies a rigour beyond that set within the statutory guidance and APP. The evidence for this conclusion is found through the internal peer review conducted since the inquest, the preparatory work conducted before it, and the sustained rate of refusals and revocations. In addition to this, the period 1st August 2020 to 18th August 2021 is covered by the response to the Home Secretary in September 2021, and the additional (independent) review of cases by Durham Police and the remedial work completed as a result by Devon and Cornwall Chief Superintendent . Consequently, we suggest that the requirements of the PFD report are met for the period 1st August 2020 to the date of submission of this document. Considering the above, our response for this report relates to this remaining period. It has been decided that a further review of cases over this period will be carried out to identify any remaining risk to the public that requires remedial action. Our position, based on the experience of reviewing the decision making in cases prior to August 2021 (completed for the inquest), is that further work is required notwithstanding that the passage of time will diminish any risk in the vast majority of cases. In addition, and in parallel to this, we will review the analytical product and use this to complete further targeted reviews of certificate holders who may have had an involvement with the police that is capable of affecting their suitability to hold a certificate. However, experience has shown that this research frequently identifies matters that are either irrelevant to the certificate holder (e.g. a road traffic collision that is recorded in the same street as the holder), or that have already been reviewed as part of a renewal or case review. This review process should take a matter of months to complete. The NPCC lead for firearms licencing and all other Chief Constables in England and Wales Training of Police Officers and Police Staff involved in firearms licencing decisions So that each Chief Constable is made are of my concern that, despite the many recommendations made of the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff. I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief Officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that relevant Guidance. I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licencing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths. Response Dorset Police fully support the National Police Chiefs’ Council (NPCC) and the College of Policing (CoP) in developing a national accredited training program for staff involved in making licensing decisions. We agree with the PFD submissions made on behalf of the families during the inquest and will continue to support the national training program as it develops; advocating for sufficient funding to enable this to deliver at pace. We will also support its delivery where requested, ensuring that lessons from Keyham are integrated into the fabric of the course. As expressed in evidence during inquest, the training provision for the Firearms and Explosives Licensing Unit within Dorset Police has been completely revised since the incident, creating clear expectations of staff and auditable records of training delivered. There is a clear focus on decision making, risk identification and the implementation of statutory guidance. This has included training to all staff within the unit and key operational managers who are responsible for making dynamic decisions to revoke certificates. Immediately following the tragic incident in Keyham, a manager was appointed to create a training and continual professional development plan, and to deliver this to all staff within the unit. In the absence of a national accredited training package, we have created and delivered a bespoke training program to all staff working within the Firearms Licensing and Explosives Unit including those responsible for making high risk decisions. At the time of writing, all staff working within the unit have undertaken a Firearms Enquiry Officer (FEO) course provided by a Firearms Licensing Manager from South Yorkshire Police. This course has a positive reputation across UK policing and is one of only a handful of options available. The content covers the use of the National Decision Model (NDM) in addition to a vulnerability assessment framework, core investigative principles, the grant and renewal application process, suitability criteria, powers and appeals, the National Intelligence Model, domestic abuse, security arrangements, mental health, and the statutory guidance. Importantly the course integrates these issues with the revised processes created within Dorset Police since the incident; for example, the completion of enquiry forms by FEOs. By mandating attendance for all staff within the unit, this provides a consistent approach for both existing staff and new members, providing a baseline from which individuals can perform their role to a high standard. A handbook for staff is also shared following the course, and all staff have been provided with a copy of the most recent statutory guidance with clear instructions for its use, linking this with a risk identification tool which was referred to in the inquest as the Risk Matrix. It is noted that the unit is in the process of reviewing the use of this risk identification tool alongside the NPCC in light of both the statutory guidance released in February 2023 and the issues raised during the inquest. As a result of the work conducted after the incident, we have also received additional training in risk assessments and decision making. This training has been delivered by a barrister who specialises in firearms licensing and focuses on the practical identification of risk through the THRIVE (Threat, Harm, Risk, Investigation, Vulnerability & Engagement) assessment process, as well as the application of the national police risk principles and the use of the NDM in case and appeal management. This training, initiated soon after the incident, is clearly relevant to the matters subjected to appropriate examination at the inquest. Suitability decisions are now recorded on separate documents, including all relevant detail that could affect the suitability of an applicant to hold a certificate. The records are comprehensive and apply the statutory guidance through the use of the NDM. In terms of managing the various IT systems used in making and recording licensing decisions, all staff within the unit have completed awareness or training courses in the following computer systems: • Police National Computer – PNC • Niche – the new records management system • Police National Database – PND – a national intelligence database • National Firearms Licensing Management System - NFLMS To assist FEOs in the conduct of their public facing role, all undertake training in first aid and personal safety which are based on the (NPCC) Personal Safety Manual and covers a vast range of subjects. Until a national qualification is made available through the College of Policing, FEO’s are accredited ‘in force’ with a qualification from the course provided by the Licensing Manager from South Yorkshire Police. This process is coordinated internally with individual records maintained, enabling automatic reminders to be sent to staff and their line manager to alert them when this skill is due to expire. At this time there is no formal requirement across England and Wales in relation to either accreditation or refreshing existing skills and learning. We will continue to engage and work closely with the NPCC and College of Policing during 2023 to assist in delivering the national course and in defining a period for reaccreditation which is robust and pragmatic. Following the inquest, a comprehensive response to the College of Policing was submitted to assist this process, and Dorset’s future policy will reflect the national position and any requirements set by the NPCC and the College of Policing. Following the completion of the mandatory training requirements listed above, we have also started to receive a three-year continual professional development programme comprising training to staff online and from experts in mental health and domestic abuse. This training reflects the core issues examined during the inquest. In addition, we continue to work with the NPCC lead to ensure that these issues are reflected within the national planning for accredited training and annual CPD requirements which are further set out within the NPCC portfolio. provided an immediate response to the issues identified. The decision to temporarily remove the decision-making capability of FEOs and FEO supervisors articulated during the inquest by Devon and Cornwall Chief Superintendent Following the delivery of the training described above, two additional training related actions have been pursued to augment the decision-making process: the creation of a portfolio for assessing and performance monitoring FEOs, and a comprehensive dip sampling regime involving both the Assistant Chief Constable (Operations) and the Senior Management Team (SMT) within the unit. This involves new and experienced police supervisors within the unit reviewing FEO decisions via an enquiry form, assessing their rationale, and providing feedback to them directly. Significant issues or more systemic ones are regularly discussed within the risk management meetings led by the ACC (Operations) as described during the inquest. This system provides a clear and robust process for assessing the quality of the investigations conducted by FEOs following their training. During the next 18 months we intend to provide additional training to further enhance the quality of FEO investigations. This will be delivered through the national Professionalising Investigations Programme at level 1, which is the nationally recognised standard and includes an investigative accreditation that applies to investigators at all levels within policing. It is a structured framework running through every aspect of investigation and will improve the professional competence of all officers and staff. It also enables supervisors to manage performance of their staff and to identify areas for development. Noting that the Authorised Professional Practise (APP) for firearms licensing is under consultation and is due for imminent renewal in 2023, the current training providing within Dorset exceeds the current requirements in APP. In addition to the CPD for our staff, a presentation of the key learning from the incident to a CPD event for all Firearms Licensing Managers will be delivered in May 2023. Following this incident, Dorset Police in alliance with Devon and Cornwall Police have invested in the Firearms and Explosives Licensing Unit and continue to be involved in sharing advice and learning concerning policies and procedures with other police forces and the NPCC. Finally, although this represents a significant amount of activity since August 2021, I hope that it demonstrates that Dorset Police are committed to learning from this
Durham Constabulary Chief Constable Chief Constable's Office Constabulary Headquarters Aykley Heads DURHAM County Durham DH1 5TT Dear Mr Arrow, His Majesty's Senior Coroner for the area of Plymouth, Torbay and South Devon I write to you in response to the Report to Prevent Future Deaths issued to the Chief Constable of Durham Constabulary under Regulation 28 of the Coroners (Investigations) Regulations 2013. I note that all Chief Constables have received the same Prevention of Future Deaths report and that this is one of a number of reports issued by you following the hearing of the Keyham inquests. I am required to respond to the Regulation.,28 Report by 3rd May 2023. The report raises a number of concerns identified during the Keyham inquests and whilst this report is my formal response to the Regulation 28 report issued by you, I also wanted to take this opportunity to provide further assurance regard ing Durham Constabulary's approach to the grant and management of lawfully held firearms. As referenced at point 3 on page 6 of your Regulation 28 report to the Home Secretary: In March 2013, His Majesty's Senior Coroner for Durham issued a report, under rule 43 Coroners Rule 1984, following inquests into the deaths of Sam McGoldrick, Alison Turnbull, Tanya Turnbull and Michael Atherton. This report and its concerns led to wholesale reform within Durham Constabulary and its approach to firearms licensing. It is noteworthy that, whilst NPCC portfolio lead from 2016, Durham Constabulary led the way to formalising the need for medical information to be a mandatory requirement of all renewals and grants; a process that was formal ly adopted nationally in November 2021. As a Constabulary, the force has sought to ensure that the failings identified in 2013 are never repeated in County Durham and Darlington, and that learning from this has informed national practice. I trust that the following information provides you with the assurance you require with regards to Durham Constabulary's processes surrounding firearms licensing, as well as addressing the concerns you raise within the Regulation 28 report. Scrutiny of initial licence applications: Within Durham, every initial grant and renewal application is subject to enhanced checking www.durham.police.uk tmll DURHAM CONSTABULARY 101 INAN EMERGENCY ALWAYS CALL 999 against both internal (intelligence/safeguarding) systems and national systems (PNC, PND and Special Branch) as a matter of routine. These enquiries not only focus on the applicant, but also the residence and wider known associates. Additional scrutiny is applied on a case-by-case basis involving enhanced checks on financial anc;l social media platforms (in excess of that currently mandated by extant guidance), scrutiny of body-worn video and evidence linked to incidents involving the applicant or licence holder. Since November 2021, this information is further overlayed with medical proforma information from the applicant's GP, thereby providing a holistic view of an individual's circumstances and suitability. The outcome of these enquiries is then scrutinised by a decision maker and supervisor within the firearms licensing team. Any concerns highlighted or further identified at this stage are subject to further and more detailed or intrusive investigation, for example, where a GP response identifies concerns regarding mental health, the department will explore these further to fully understand the impact of these issues on the applicant's suitability to hold a firearms licence. With regards to the referees nominated by the applicant: Durham's firearms licensing team contact named referees and complete prescribed enquiries which fully explore the relationship with the applicant and the responsibility that comes with the role of referee. Referees may be contacted by telephone, email or home visit depending on the risk assessment. The professional curiosity and proactive approach of the firearms licensing team has led to several broader interventions across the constabulary both in respect of lawfully held firearms and illegal possession of firearms. In the past 12 months the team has initiated the execution of a number of search warrants and subsequently seized over 200 lawfully held firearms, as well as prohibited firearms. This has also led to the revoc~tion of a registered firearms dealer licence. The team's broader appreciation of harm has led to a number of intelligence submissions and has initiated force activity around county lines, domestic abuse, child sexual exploitation, drug cultivation and unlawful firearms manufacture. Ongoing review of licence holder fitness: Durham Constabulary takes a proactive approach to any incident or intelligence relating to its licence holders. All licence holders have a 'live' profile within both force and national systems. As part of embedded risk management practice, the Force Incident Manager reviews all incidents reported to the force that involve a licence holder and will take positive action to seize all weapons and certificates at the time of reporting . This is a daily review of incidents conducted independently of the firearms licensing team, so that immediate action is taken. The firearms licensing team is also notified and will then review the licence holder's circumstances and suitability. The force also operates a 'wash-through' process that affords additional reassurance. This process will highlight any licence holder referenced on either a command-and-control incident log or wider intelligence/information submission (including those from partner agencies) and is scrutinised by the firearms licensing team within 24 hours of the incident. As part of this 'wash- through' process, the firearms licensing team will undertake additional enquiries to confirm or negate any elevated concerns. This review will also trigger action to remove weapons from licence holders where concerns have arisen, to allow a full review of suitability to be undertaken. This holistic approach allows the licensing team to conduct a full review of any licence holder that 2 comes to the attention of the force, without weapons remaining within the public arena. Only after being subject to a full review will consideration be given to the return of any firearms/certificates to a licence holder. This process is overseen by the firearms licensing Inspector and delegated authority (Superintendent) where any concerns are highlighted. In 2022, Durham seized weapons from 116 licence holders using this process. To date, 22 licence holders ( 18%) have subsequently had their firearms/certificates returned following a full review. Durham also operates a live 'Watch List', which monitors licence holders that trigger one of the following criteria: known associations, medical conditions, hold over 12 weapons, or intelligence linked to their nominal record. The firearms licensing team conduct regular and enhanced assessments of these licence holders to review their ongoing suitability. Approximately 10% of all licence holders are on this rolling list at any given time. General: When reviewing any previous intelligence or antecedents that relate to any grants or renewals, Durham's licensing team ensures that the modus operandi, as well as the offence recorded, are scrutinised in full. This is accompanied by a full review of any available digital evidence, such as body worn video or incident recordings of 101/999 calls. In the past 18 months Durham has successfully defended 7 appeals against a refusal/revocation decision at Crown Court; many cases of which explored the entirety of the information available surrounding the Appellant's conduct - the reach of which extended beyond the balance of probabilities and focused upon the foreseeable risk to the public. .. Whilst I welcome the important work being done by Chief Constable that addresses national standardisation, formal accreditation and training for firearms licensing staff, all of Durham Constabulary's Firearms Enquiry Officer's currently receive training/CPD in approved practice on an annual basis. New staff joining the department are further supported throughout this process by a period of tutorship, mentoring and CPD to ensure they are both confident and In January 2021, Durham Constabulary's four FEOs were the first in competent within the role. the country to successfully complete the online Mowbray Partner's training package, aligned to the College of Policing learning outcomes. The use of this online training has evolved, with all members of the firearms licensing team completing a training package for their respective roles, supported by additional in-house CPD. The governance structure of firearms licensing within Durham is robust and can be evidenced from at all stages of decision making, from an operational level on receipt of an application- all the way through to quarterly Chief Officer accountability meetings with by the Deputy Chief Constable. (For your information, my Deputy Chief Constable is a highly experienced firearms commander and has experience operating as a Delegated Authority in his previous forces so is well acquainted with the risks in this area of policing.) These processes include monthly performance meetings, chaired by the Delegated Authority (at Superintendent Rank), to monitor, dip-sample and manage the performance of the unit and escalate firearms licensing related issues. The firearms licensing Inspector also forms part of the core membership of Durham's Firearms Threat Group which meets monthly to discuss all aspects of both lawful and unlawful possession of firearms. Additional scrutiny is further afforded by Durham's Ethics Committee - which meets quarterly and is independently chaired. This committee scrutinises firearms licencing 3 processes and decision making. To mitigate the projected increase in demand on the firearms licensing team in 2019, Durham Constabulary employed 5 additional staff to assist.in managing the cyclical workload of review and renewals . Much of the current workstreams that exist within the department are intrinsically linked to the enhanced governance processes and checks that are in existence, as articulated above. These processes are pivotal in keeping the public safe; focusing on foreseeable and avoidable harm, careful risk assessment based on all available information, not expediency. Matters of concern: In light of the above response to the Regulation 28 notice and further to Chief Constable letter to all Chief Constables, dated 24th March 2023, I am satisfied that the review of the original request from the Home Secretary in August 2021 remains accurate. The review of all decisions to return firearms to licence holders after seizure or surrender (35 in tota l) over the previous 12 months, were appropriate and were subjected to the appropriate level of scrutiny and oversight. Durham Constabulary has an embedded cycle review and revocation in respect of risk-based assessments of licence holders, whether as part of a cycle of review of certificates or when a licence holder comes to the force's attention. It is my view that these mechanisms remain more effective than retrospective review of all certificates over the last 5 years. The proactive approach of the force and the triggers in place for managing and reviewing current certificates is effective. Based on the above, I do not propose to commission further review of certificates granted beyond that already undertaken. ' Yours sincerely Chief Constable 4
Heddlu Police DYFED POWYS Prif ct.Ynltlbl ~Aallflrlt~CcNratlle Pencadlya Heddlu Dyfed-?owya, Blwch Polit 09, LJangynnwr, Ceerfylodln, SA31 2PF. Dyfad-~ Palloe Heaclqwirtars, PO Box 99, Uangumor, ~ . SA31 2PF. Mr Arrow, 2nd of May 2023. I write to you in response to your letter, dated the 8"' of March 2023 pertaining to the Keyham Inquest where several recommendations were made. Further to your recommendation, whilst Dyfed Powys Police are assured that our processes are sufflclently robust to ensure public safety, In the interests of transparency and public safety, we will undertake a further review of decision files where firearms have been seized following any Incident and subsequently returned to the holder, in accordance with the parameters as set out In the letter circulated by Chief Constable Debbie Tedda on the 24111 March 2023. In March 2022, a comprehensive review relating to decision making within the Firearms Licensing arena for Dyfed Powys Police was completed. This review was approved by Chief Officers. The review fucused upon on decision making set against the APP and statutory guidance. There has been no requirement identified to make changes since this paper was approved. In respect of matters surrounding training, Dyfed Powys Police engage In available training for Firearms Licensing Staff, however we welcome and support the recommendation of the Coroner to fom,allse a training programme to encompass all Firearms roles and responsibilities. We currently utilise the Firearm Enqurry Officer Course which la offered In West Yorkshire, and Devon and Cornwall. Our supervisors attend Firearms Conferences and CPD events and significant efforts are made to engage on a national basis. Furthermore, staff keep abreast of all national updates, legislation changes and national reports to ensure continuous professional development. I sincerely hope that the Information contained within this letter sufficiently explalns the current position within force, In direct response to your recommendations. Assistant Chief Constable Dyfed Powys Police. @}101)1) 1 www.clyted-powya.police.uk Pencadlys Heddlu, Blwch SB 99, Uangynnwr, Caerfyrddfn. SA31 2PF Police Headquarters, PO BOX 99, Uangunnor. Carmarthen. SA31 2PF Ma H~ ~Powys ynamuwu~yn 0)flnaa • 8-'lllg. dawta lallh IC nl tydd oedl rnawn partt,,,,,u 1111 urthyw cneblaeltl d,wy'r~rug. Dyfed-Powys Polee welcomM C011111SJOl'IIWIC8 I., 'ltW!lh ll'1d i1 >1"1, IW1d,.. will . -ltllll we IMJ!Ofld to My 00l"ffpOndence tl'lf'm911ht la..,guege of~ thaic:a. Conellp(Mding Ilia the madlum a! W&Jsh W\• r,at endl.le ;my de~. nl'nlllc"1au eln bod nrn elctl
Mr Ian Arrow HM Senior Coroner 1 Derriford Park Derriford Business Park Plymouth PL6 5QZ gJ.:] ~rt ESSEX ~ij~ POLICE Protecting and serving Essex Essex Police Headquarters, PO BOX 2, Springfield, Chelmsford, Essex 1nd May 2023 Dear Mr Arrow, I w rite in response to your prevention of future deaths report, made under Regulation 28 of the Coroners (Investigation) Regulations 2013, relating to the tragic deaths in Keyham on 12th August 2021. I set out below the action Essex Police has taken in re lation to the t w o matters you have required all Chief Constables to respond to, and our progress tow ards completion. Review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the past five years I have directed that Essex Police will review all decisions to return firearms over a five year period. The priorit isation is in line with that outl ined by the National Police Chiefs' Council (NPCC) lead for National Police Firearms licensing: We are priorit ising review cases w here firearms have been seized or surrendered to police pending a review of suitabilit y to have a certificate, but then subsequently returned. There are circa 900 incidents in Essex w here certificate holders have come to the adverse attention of police. A detailed screening of these incidents is underw ay to identify how many invo lved a return of certificate and guns decision. • We will review the most recent decisions first, as the most recently returned licences potentially pose the greatest risk. • We will review all cases w here applications have been refused or licences revoked, but w here an application or appeal by the licence holder resulted in the grant of a certificate. • All these cases w hereby a certificate w as granted following appeal or further application (circa 200) wi ll have previous decision making review ed utilising the current Home Office Statutory Guidance (February 2023) • The review wi ll be completed by October 2023 Essex Police, PO Box 2, Headquarters, Springfield Roa d, Chelmsford, Essex CM2 6DA Report non-emergency crime and anti-social behaviour online at www.essex.police.uk or ring 101 If a crime is in p rogress or someone is in im mediate danger, always ring 999 If you have a hearing or speech impairment, use our textphone service 18000 or the 999 BSL app In the absence of nationally accredited training, the steps being taken to ensure local training is of a satisfactory standard for all staff and supervisors involved in firearms licensing, and that decision making authority is delegated only to persons who have undergone adequate training in firearms licencing and in applying that guidance. Essex Police are engaged w ith the NPCC Lead, Chief Constable development of the national training package. We have delivered local training to ensure continuous professiona l development, including an input on the Home Office Guide on Firearms Licensing Law in November 2022 and the updated Statutory Guidance for Chief Officers of Police on Firearms Law in February 2023, as well as risk matrix development, Nationa l Decision Making model, Keyham Inquiry recommendations and impact, 'Managing Risk and Firearms Licensing', Domestic Abuse and Stalking inputs and Welfare and Counselling Support guidance. and College of Policing in the Local development events in the form of classroom days are regular, varied, and relevant to the role. All new team members are given bespoke inhouse training delivered and monitored by their supervisor and w ith the exception of two new members of staff my team have all attended the training course in West Yorkshire. Essex and Kent Police have a collaborated Learning and Development Command, who are developing a lesson plan to further enhance professional development and ensure currency of knowledge. I anticipate this w ill be in place by the end of August 2023. I am satisfied that, in the absence of a nationa l accredited training product that a local training programme is in place to ensure all member of staff and supervisors to whom decision making authority is delegated have received, and w ill continue to receive, adequate loca l training. Since September 2021, all decisions to return certificates following a suitability review are made by the Superintendent for Armed Policing. As part of our joint force audit process, external auditors w ill be commencing a review of our Firearms Shotgun and Explosive Licencing team commissioned by me and the Essex Police Fire and Crime Commissioner to provide independent reassurance regarding our compliance w ith national and local policy and ability to respond to changes in legislation and other recommendations. We wi ll also continue to work w ith the NPCC lead to ensure our processes in Essex are focused on keeping people safe and working in accordance w ith statutory guidance and recommendations. If I can be of any further assistance, please do not hesitate to contact me. Yours sincerely, Chief Constable
Gloucestershire Constabulary Police Headquarters No.1 Waterwells, Waterwells Drive Quedgeley, Gloucester. GL2 2AN www.gloucestershire.police.uk Ian Arrow Senior Coroner for Plymouth, Torbay and South Devon 1 Derriford Park Derriford Business Park Plymouth, PL6 5QZ Dear Sir, Date: 28 April 2023 I am responding on behalf of Gloucestershire Constabulary in respect of the ‘Report to Prevention of Future Deaths’ under paragraph 7, Schedule 5 Coroners and Justice Act 2009 and Regulations 28 and 29 Coroners (Investigations) Regulations 2013, issued by you on 8 March 2023. The matters of concern are outlined in the report:- Following evidence from Devon and Cornwall Police at the Inquests, the Coroner’s recent PFD reports state: “I am concerned that the information from those 41 police forces who indicated that they had made no incorrect decisions to return a weapon/certificate may need to be further tested and explored. I am concerned that the figures provided to the Home Secretary in 2021 may not reflect the accurate position, and that if sufficiently stringent checks are performed these may reveal other cases where a firearm or shotgun certificate had been seized, refused, revoked or surrendered but was subsequently issued/returned in circumstances when the certificate should not have been approved. I am concerned that if there are other cases that were not subject to a proper or thorough review of the risk of returning the weapon then the person may continue to have a firearms/shotgun certificate and hold weapons in circumstances that place the public and the licence holder themselves at risk. I am concerned that in the light of the lessons learned in the Keyham inquests of the attitude towards risk, a further review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the past five years may be required to be assured of public safety.” Specifically in respect of the ‘Actions Should be Taken’, I can confirm:- A review will take place as per the letter dated 24 March 2023 from Chief Constable Debbie Tedds, Warwickshire Police NPCC lead for National Police Firearms Licensing and we will endeavour to achieve such reviews over the next six months by 2 October 2023. We are committed to being an anti-discriminatory organisation. This means not only acting in a non-discriminatory way, but addressing systemic inequalities, disadvantage and discrimination. Page 1 of 2
Chief Constable Senior Coroner I M Arrow HM Coroners Office 1 Derriford Park Derriford Business Park Plymouth PL6 5QZ Dear Mr Arrow 26th April 2023 Re Regulation 28 reports following the inquest into the deaths of Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington and Kathryn Shepherd. Thank you for your report dated 8 March 2023 in the respect of the tragic deaths of Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington and Kathryn Shepherd and pursuant to Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 and Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009. Having carefully considered your reports I make the following observations to hopefully address your matters of concern; 1. Further review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the past five years may be required to be assured of public safety. Greater Manchester Police have an established Senior Officer Panel. This panel guides decision making at a level senior to that of the Firearms and Explosives Licensing Manager. This mechanism has assessed all cases where guns have been returned to certificate holders. This also includes the renewal or granting of certificates where guns had previously been removed or surrendered. We are currently examining all available information to identify those cases where certificates have been seized, refused , revoked or surrendered and then subsequently approved and guns returned. Based on the volume identified to date it is forecasted that GMP will review in total, for the five-year period, between 70-80 cases at Senior Officer Panel. All reviews will be against the updated Statutory Guidance and we believe it to be practicable to review these cases over the course of the next 3 months. 2. (Forces to ensure) Adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licensing Law (Nov 2022) and the revised Statutory Guidance for Chief Officers of Police (Feb 2023) All Firearms Enquiry Officers (FEO) have completed training with an external partner, Mowbray Partners titled "Firearms Licensing ". FEO's are the frontline of the Firearms Licensing Unit and make all initial decisions based on the current legislation, statutory and non-statutory guidance and Approved Professional Practice. The training by Mowbray addresses these fundamental issues. Postal address: Greater Manchester Police , Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS Cont.d pg 2 ..... 3. Only delegated decision making to persons who have undergone adequate training in firearms licensing and in applying that recent guidance The current Firearms Licensing Manager has completed training, procured through an external partner Mowbray Partners, this training is titled "Firearms Licensing - Decision Makers". The Firearms Licensing Manager and Detective Sergeant will add itionally be attending a two-day continuous professional development (CPD) event delivered by Chief Constable Tedds at the College of Policing on the 18th and 19th May 2023. Furthermore, the Firearms and Explosives Licensing Un it (FELU) have all reviewed the new 2023 Home Office Statutory Guidance and 2023 College of Policing Approved Professional Practice. The Detective Sergeant will complete the training "Firearms Licensing" with external training partner Mowbray Partners. They will additionally complete the training "Firearms Licensing - Decision Makers" by the end of April 2023. T o reassure you further, only those trained personnel above are permitted to make decisions in line with the updated statutory guidance. Chief Constable Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M 11 2NS
Ian Arrow Senior Coroner for Plymouth, Torbay and South Devon HM Coroners Office 1 Derriford Park Plymouth PL6 5QZ Rt Hon Chris Philp MP Minister of State for Crime, Policing and Fire 2 Marsham Street London SW1P 4DF www.gov.uk/home-office 29 June 2023 Dear Mr Arrow, INQUEST FOLLOWING THE DEATHS OF MAXINE DAVISON, LEE MARTYN, SOPHIE MARTYN, STEPHEN WASHINGTON AND KATE SHEPHERD IN KEYHAM ON 12 AUGUST 2021: REPORT TO PREVENT FUTURE DEATHS UNDER REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 I am writing to thank you for your Regulation 28 Reports which we received on 8 March and which followed the inquest into the deaths of those who were fatally shot by Jake Davison in Keyham, Plymouth, on 12 August 2021. I am very grateful to you for granting extensions to the deadline for the Government’s formal response. The Home Secretary and I are very grateful for your very detailed consideration of the controls relating to firearms licensing and for highlighting areas where changes may help to improve public safety. The impact of fatal shootings on the victims’ families and friends, as well as the wider community, is devastating. It is right that we learn carefully from any such shooting incidents which occur to see whether and how we can strengthen the controls on access to firearms to try to prevent similar shootings happening in the future. We have carefully considered your Regulation 28 Reports alongside the summary report published by the Independent Office for Police Conduct (IOPC), on 21 February, following its investigation into Devon and Cornwall Police’s decision- making in relation to Jake Davison’s possession of a shotgun and shotgun certificate. We have also been considering the report published by the Scottish Affairs Select Committee on 22 December 2022 following its review of firearms licensing regulation in Scotland. The Scottish Affairs Committee’s inquiry was established following the fatal shooting of John MacKinnon on the Isle of Skye on 10 August 2022. Both of these reports cover similar ground to that addressed in your Regulation 28 Reports. I provide an overview below of the Government’s position in respect of the issues that you covered in your Regulation 28 Report for the Government. You will have seen today that we started a consultation for eight weeks on the recommendations made to the Government in your reports and those by the IOPC and Scottish Affairs Committee. I enclose a copy of the Government’s consultation paper which was published today. The consultation is to invite responses to the recommendations that have been made and on which we are consulting. However, if we decide that new legislation is necessary in response to any of the recommendations, we will bring forward a further consultation on the specific Government proposals on legislation, accompanied by assessments of the impact of those changes on all those potentially affected. I now turn to the specific issues you raised. Legislative presumption in favour of grant We have noted your concern that the words ‘shall be granted’ in sections 27 and 28 of the Firearms Act 1968 may create a presumption in favour of grant, and that this should be reversed in future legislation. We have carefully considered the point you raised, but we have decided not to progress this particular recommendation as we do not agree with your interpretation of these specific provisions. Sections 27 and 28 are drafted to support consistency in police decision-making and give certainty to the applicant. Specific criteria must be met in order for a shotgun or firearm certificate to be granted, including the applicant meeting the required suitability checks to the satisfaction of the police. This supports public safety and the need for the applicant to only be granted a firearms or shotgun certificate if the police judge that person as fit to have a firearm. Aligning shotguns and firearms controls You were concerned that the criteria for issuing shotgun certificates are less stringent than those for ‘section 1’ firearm certificates and that they should be brought into alignment so that shotguns are subject to the same controls as firearms. Public safety is our priority, but the measures to manage the risk to public safety must be proportionate and balanced with the fact that the vast majority of licensed firearms holders are law abiding and cause no concern. It is for this reason that the Government has decided not to proceed with the recommendations made to align shotgun and firearms legislation. Shotguns are already subject to significant controls on their use and they are important in helping farmers control vermin on their land and in rural pursuits. We will keep this under review, but we are concerned that additional controls on shotguns are unnecessary and would have a negative impact on their legitimate use. Power of entry to seize firearms You were concerned that the police require a magistrate or sheriff’s warrant prior to entering premises to seize licensed firearms which creates a potential public safety risk. We are therefore consulting on whether the police should be granted a specific power of entry, without a warrant issued by a magistrate or sheriff, to be able to seize shotguns, firearms and ammunition where there is a risk to public safety or the peace and the certificate holder does not cooperate with the police and agree to voluntary surrender. Mandatory prohibition You said the thresholds for prohibition of possession of firearms, provided by section 21 of the Firearms Act 1968, are outdated and should now relate to risk rather than length of custodial sentence on conviction. We are therefore consulting on whether the law should be amended accordingly. Statutory Guidance to the police – balance of probabilities The Statutory Guidance for Chief Officers of Police came into effect on 1 November 2021 and was updated and re-issued on 14 February 2023. You questioned whether its requirement that the police use a balance of probabilities test when assessing applications was the right approach. You considered that the Statutory Guidance does not clearly reflect that the issue of risk and suitability to hold a certificate should be based on the totality of the risk information available to the Chief Constable or Court, applying appropriate weight to that information on a case-by-case basis, and without a requirement that the facts need to be proven on the balance of probabilities. We are considering this matter carefully and this includes consulting on this issue. Following this, if we conclude that the Statutory Guidance needs to be changed on this issue, we will move to give effect to such a change. Referees We have noted the concerns you raised about the system of referees in support of shotgun and firearms applications. We are therefore consulting on the changes that have been recommended to us in respect of the current arrangements on referees. This includes seeking views on whether two, rather than one, referees should be required as part of the shotgun certificate application process, whether the application form should include a checklist for referees on the information that they should provide to the police, and whether referees should be required to provide a written declaration that they have disclosed all relevant facts to the police. The consultation will also seek views on whether there should be more detailed guidance for the police in the Statutory Guidance about the information they should be looking to elicit from referees. Following this consultation, and in light of the responses received, we will give further consideration to making changes to the Firearms Rules 1998 and to the Statutory Guidance in line with the recommendations made. Firearms Licensing fees We have noted your view that the firearms licensing process should be self-funding to ensure that police force firearms licensing units are properly resourced. The level of fees charged by police forces for firearms licensing is currently being reviewed. Work on this started in April 2022, and this has included an extensive data collection exercise held in 31 police forces across England, Wales and Scotland, in January this year, in order to collect data on costs and the time spent on licensing related activities by police forces. This work will inform proposals for new fees which, in line with HM Treasury guidance, should enable full-cost recovery for the police. The intention is to consult on proposed new fees this Summer and to introduce a new set of fees by Statutory Instrument later in 2023. Medical checks You looked at the system for medical checks for firearms applicants and the use of the firearms reminder code. There has been significant strengthening of the medical checks for firearms licensing in the past couple of years, including making it a requirement for all applicants to provide relevant medical information to the police, and the development and introduction of a new digital firearms marker to ensure that the police are notified by the GP if there is a concerning deterioration in the certificate holder’s physical or mental health at any point after the grant of the certificate. We understand the point you made about the value of placing a firearms marker on all medical records within a unified records system, to ensure that the police are notified if a certificate holder begins to suffer from a relevant medical condition or a relevant medical condition worsens significantly and the individual is in contact with health professionals other than his or her GP. The Home Office is working with the Department of Health and Social Care, NHS England and medical representative bodies to ensure that the medical checks system operates as effectively as possible and can continue to be improved when necessary. We will therefore consider with the Department of Health and Social Care and NHS England how your concern about the visibility of the digital marker across all health service providers might be addressed. We will seek to develop any new solutions that may be required as quickly as is practicable in consultation, as necessary, with relevant medical representative bodies. Training for firearms licensing staff We have noted your concerns about the lack of accredited training for firearms licensing staff and a mandatory requirement to undertake necessary training. The provision of police training is primarily a matter for the College of Policing and police forces, and a programme of work is already being taken forward since 2022 by the College and the National Police Chiefs Council to develop the required training package. The Government accepts the need for such a training package, and today I was pleased to announce that funding of £500,000 to the College of Policing has been made by the Home Office specifically to ensure this training is taken forward and adopted by police forces. The training will be reinforced and supported by the refresh of the relevant Authorised Professional Practice by the College of Policing, which was the subject of a consultation from January to March 2023. The finalised Authorised Professional Practice will in due course sit alongside the Statutory Guidance to provide support and guidance. In consultation with the College and the National Police Chief Council, we will determine how best to mandate and require firearms licensing staff to undertake the new national accredited training programme when it is finalised. Once again, I would like to thank you for your reports, and I hope that this letter, and the accompanying consultation paper provides assurance that the Government is taking the action necessary to strengthen firearms licensing arrangements. I will write to you again later this year to update you on the work that is being done. Yours sincerely, Rt Hon Chris Philp MP Minister of State for Crime, Policing and Fire
Protecting and serving the people of Kent
Mr Ian M Arrow
His Majesty’s Senior Coroner
Plymouth, Torbay & South Devon
Chief Constable
Date: 2nd May 2023
Dear Mr Arrow,
Re: Preventing Future Deaths Report
I write in relation to your prevention of future deaths report, made under Regulation 28 of the
Coroners (Investigation) Regulations 2013, relating to the tragic deaths in Keyham on 12th August
2021. You have required all Chief Constables in England and Wales to respond in relation to two
important firearms licensing issues: cases when firearms license certificates have been seized,
refused, revoked or surrendered and then subsequently returned; and, in the absence of nationally
accredited training, the provision of local training to a satisfactory standard for all staff involved in
firearms licensing. This letter sets out the actions Kent Police has taken, or proposes to take, with
regards to these two areas and the timetable for such action to be completed.
1. Review of all certificates seized, refused, revoked or surrendered and then
subsequently approved over the past five years
In response to your concerns, and following consultation with the National Police Chiefs’ Council
(NPCC) lead for National Police Firearms Licensing, I have directed a review of firearms and
shotgun licensing within Kent Police focussed on the above area of concern and prioritised in the
following manner:
We are prioritising review cases where firearms have been seized or surrendered to police
pending a review of suitability to have a licence, but then subsequently returned. There are
102 license holders in Kent who have their certificates returned following suitability reviews
between 2019 and 2023.
These cases will be progressively reviewed, starting with the most recent cases which,
arguably, pose the greater risk due to being closest to the events that justified seizure or
surrender, and which have not had the benefit of the passage of time without further incident
to provide reassurance.
The review will also cover cases where the applications have been refused or licenses revoked
but where subsequent applications or appeals by the same licence holder resulted in a grant.
There are 32 license holders who have a current certificate having been granted at new
application or on appeal at court.
The decision-making in all 134 of these cases will be reviewed and assessed against the
current (February 2023) Home Office Statutory Guidance.
OFFICIAL SENSITIVE
Kent Police Headquarters, Thames Way, Northfleet, Gravesend, Kent DA11 8BD
Tel: 01622 690690 www.kent.police.uk
Kent Police : Form No. 3058c rev 5/08 v5.1
. . . . : ·•··· .... .. -.. ·, / -~: . . .· ·• ' Lancashire Constabulary Chief Constable Lancashire Constabulary Headquarters PO Box 77 Hutton Preston Lancashire PR4 5SB Mr Ian M Arrow His Majesty's Senior Coroner for Plymouth, Torbay and South Devon 1 Derriford Business Park Derriford Park Plymouth PL6 5QZ 25th April 2023 Dear Mr Arrow, Regulation 28 Prevention of Future Deaths following the tragic shootings in Keyham on 12th August 2021 On behalf of Lancashire Constabulary, I send our sincere condolences to the families of Maxine Betty Davison, Lee Raymond John Martyn, Sophie Iris Martyn, Stephen John Godfrey Washington and Kate Jane Shepherd. Lancashire Constabulary supports the recommendations you have made, and updates as follows: Report to all Chief Constables in England and Wales regarding the return of weapons after review of suitability. A programme to review all certificates refused, revoked, seized or surrendered and then subsequently approved over the past 5 years has commenced. This is being undertaken against the March 2023 Home Office Statutory Guidance. We expected to complete this work by the end of October 2023. Several process and scrutiny changes have been introduced in relation to refused, revoked, seized and surrendered licenses as well and initial and renewal applications. The reviews will be carried out with in line with these processes and additional scrutiny. The following changes have been introduced: Governance: • A dedicated Chief Inspector responsible for Fi rearms Licensing who reviews all decisions at a senior level in line with 3.50 Home Office Statutory Guidance. o During the 12-month period April 22 - March 23, a total of 313 decisions were reviewed , each having a documented assessment of all the evidence available and reasons for the decision. These included cases where a relevant medical condition had been identified. 10% of these reviews resulted in refusal or revocation of a certificate. • A dedicated Superintendent who reviews any decision to return a certificate following a voluntary surrender, or request/review to allow storage of weapons back to the certificate holders home address. • An Assistant Chief Constable with responsibility for Firearms Licensing meets with the Chief Inspector every 6 months to scrutinise a random selection of high-risk decisions to ensure consistency and effective decision making. • Governance is recorded through quarterly Firearms Policy Management Group meetings. Process: • No application or renewal is processed without receiving a GP report. In some cases, we seek further specialist advice if there are specific ongoing conditions that could impact on a person's suitability e.g., Liver Function tests or Carbohydrate-deficient transferrin. • An automated system alerts the Licensing team when an incident is reported at a certificate holders address. This instigates a review of the license. This reduces the risk of relevant information being missed and not acted on. • PNC Markers on licensed certificate holders creates an automated alert to the department • and Force Incident Commander if any holder is arrested. In collaboration with the Force Intelligence Bureau, a process is being introduced identifying any new intelligence submitted by officers and staff that is connected to a licensed certificate holder and/or their address to be automatically highlighted to the team for a review. • Colleagues from Counter Terrorism policing review any new piece of intelligence quickly if it relates to either a certificate holder, their address or a telephone number associated with them and inform the licensing team, resulting in a joint review. • The number of PND checks undertaken have increased and checks are now carried out on initial application, first renewal and at any reviews following an adverse incident. PND checks will be carried out on all renewals prior to the end of 2023. • Nationally we are monitoring two pilots: o PND being used to automatically update NFLMS. o Automated social media checks. • A process where Body Worn Video is now viewed when available as part of reviews where certificate holders have interacted with police but resulted in no formal action being taken. This has led to further revocations. Lancashire Constabulary fully accepts the recommendation to review the previous 5 years cases, and the identified a risk-based approach to prioritise the review. The above processes that have been implemented ensure increased scrutiny, consistency of decision making and a risk-based approach to all decisions for return, initial application, and renewal. Report on training of Firearms Licensing Decision makers. In the absence of any current formal training from the College of Policing, Lancashire has introduced the following: • In November 2021 staff from the Firearms Licensing Department received a 3-day training package, referred to in your report as the South Yorkshire Training Package, this included the Chief Inspector. • A programme of CPD which has included topics such as Domestic Violence awareness and Intelligence grading. Further training for this year includes, Neurodiversity, National Decision Model and Statement writing. • Our scheme of delegation allows for a Force Incident Commander (a Chief Inspector role) to revoke either a Firearm or Shotgun Certificate. They have received inhouse training into this procedure. • This year further training delivered through Mowbray Partners has been agreed. This online package is updated to reflect changes in the Statutory Guidance. ) Lancashire Constabulary fully support the recommendation for additional training and CPD for firearms licensing decision makers. We welcome the nationally accredited training being developed by the College of Policing which we will prioritise for all our staff. Our internal processes ensure staff with delegated authority will only make decisions consistent with their level of training. We are not complacent and recognise the need for all staff within the Firearms Licensing Department to have adequate training of a satisfactory standard in applying both the Home Office Guidance on Firearms Licensing Law (November 2022) and the Statutory Guidance for Chief Officer of Police (February 2023). We will continue to embed training, CPD and ensure training records are updated to ensure we keep our staff up to date with any legislative changes and do all we can to keep the public safe. Yours sincerely, Chief Constable
Email Mr IM Arrow HM Senior Coroner 1 Derriford Park Derriford Business Park Plymouth PL6 5QZ 5th May 2023 Dear Coroner, Please find below the response from Leicestershire Police in respect of your report to prevent future deaths made under Regulations 28 and 29 of the Coroners (Investigation) Regulations 2013. Please accept my apologies for our slightly delayed response as a result of a prolonged local protest which has resulted in the abstraction of a number of my senior colleagues over the last 7 days. I would like to reassure you that we have taken your concerns seriously and have put in place immediate steps to address these. By way of context our force currently interacts with: • 10,819 Shotgun certificate holders • 2,407 Firearm Certificate holders • 492 Coterminous certificate holders • 40 Firearms dealers • 15 Rifle and Pistol Clubs • 164 Acquire and Keep Explosive Certificates • 32 Acquire only explosive certificates • 15 Explosive Store Licences You will be only too aware that this is a significant administrative and risk management undertaking. All these certificate holders must be reviewed on renewal and suitability questioned on their mental health, criminal convictions and suspected behaviour based on police intelligence. These processes are well defined within the Statutory Guidance for Chief Officers of Police and Guide on Firearms Licensing law (November 2022) and Force Procedure. Leicestershire Police provide this service through a centralised department which receive and process the applications, make enquiries, compile reports to the Firearms manager and in a majority of cases subsequently issue the appropriate licence(s). Current processes involve the completion of nationally approved forms which are submitted to the department with the appropriate fee and medical report. These are checked in all cases against various national and local intelligence data bases. An entry is made against the National Firearms Licensing Management System (NFLMS), and, in in most cases, a visit to the applicant to confirm various details, discuss medical history, and check the security arrangements for the weapons. Subsequently, subject to the various checks, enquiries, contact with a minimum of one reference of good character and other information reaching an acceptable threshold; a certificate is granted. This certificate in all cases is signed by the Firearms manager or the Firearms Supervisor both of whom have delegated authority of myself as the Chief Constable. I can confirm that in response to the concerns you have raised, namely that I should consider reviewing all certificates seized, refused, revoked or surrendered and then subsequently approved over the past five years we have put in place the following action: • We will be reviewing all such cases from pt April 2023 for the past 5 years (1 st April 2018) commencing with the most recent decisions first. • The individual/s used to conduct this review will be independent from the original decision makers with experience in criminal investigations and suitably qualified to PIP2. • Findings will be reported to the strategic lead for Firearms Licensing who is an Assistant Chief Constable. • Priority will be given to those cases where firearms have been seized, surrendered to police pending a review of their suitability to possess a firearm or certificate and subsequently approved. • We will aim to complete the review by 2nd October 2023. • We will then review those cases where applications have been refused or licences revoked, but where subsequent applications or appeals by the same licence holder resulted in a grant. (If the return or grant has been ordered by the Crown Court the strategic lead will give direction which maybe consultation with the force solicitor. There are two such cases) • Review all previous decision-making against the Home Office Statutory Guidance (Feb 23) from 1st April 2018 to provide a consistent approach across decision making • To continue monthly governance meetings on future decisions with Chief Inspector (Firearms Licensing), the firearms manager and the new reviewing staff member to continue an effective and consistent approach moving forwards. The proactive steps Leicestershire have taken indicate our support to manage risk as highlighted in the report. We are keen to ensure that we continually improve the management of the process and support lessons learnt for such tragic circumstances Yours Sincerely Chief Constable
THE RIGHT HONOURABLE THE LORD BURNETT OF MALDON 3 May 2023 Dear Senior Coroner Arrow, Prevention of Future Deaths Report – Judicial Training in Firearms Licensing Thank you for your report of 8 March 2023 following the inquests into the deaths of Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington and Kate Shepherd who were shot by Jake Davison in Keyham in August 2021. I understand that following the inquest you have made a number of reports under regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, identifying a range of matters of concern which you consider may give rise to a risk of future deaths unless action is taken. Your report to me outlines your concerns about judicial training on firearms licensing. In particular, as a result of the evidence you heard during the inquest, you are concerned that judges may be unfamiliar with the nature of the decision they must make in firearms licensing appeals and may be incorrectly applying the relevant statutory guidance. These tragic and appalling killings were not committed by someone whose firearm certificate had been revoked by the Chief Constable and who had subsequently successfully appealed to the Crown Court. The subject matter of your report about judicial training was not investigated at the inquests (because it was not relevant to the function of the inquest to answer the statutory questions) although you appear to have received some anecdotal evidence in passing. I proceed on the basis that your report summarises the totality of the evidence you received on the matter. Responsibility for the training of the judiciary in England and Wales rests with the Lord Chief Justice, as Head of the Judiciary. Under section 7 of the Constitutional Reform Act 2005 I have a duty to maintain appropriate arrangements for judicial training and guidance, which I exercise through, and with the support of, the Judicial College. The statutory duty reflects the fundamental constitutional principle of judicial independence; judges must be independent of government and other public bodies, including in the training they receive to undertake their role. The Judicial College, under my authority, regularly reviews the training it offers, but ultimately the content and focus of judicial The Royal Courts of Justice Strand London WC2A 2LL Telephone 020 7947 6776 Email LCJ.office@judiciary.uk Website www.judiciary.uk training courses is a matter for me as the independent Head of the Judiciary. All judges are required to complete an induction course before they sit in any jurisdiction and regular annual continuation training thereafter. As you will be aware, there are specialist training courses for those who sit in the Crown Court. The Crown Court exercises a very wide jurisdiction in the criminal sphere and by virtue of statute in discrete areas such as under the Firearms Act 1968. No training course can hope to cover everything a judge might encounter. The judges of the Crown Court are senior members of the judiciary and appeals against the revocation of firearms licences are usually heard by salaried Circuit Judges, rather than fee paid Recorders. They can be expected, with or without the assistance of the lawyers who appear before them, to familiarise themselves with the law and procedure relevant to a case they are hearing. It is against that background that I have considered your report. I have noted that this was not a case involving an appeal to the Crown Court under section 44 of the Firearms Act 1968 because Devon and Cornwall Police had not revoked the shotgun certificate. The circumstances of the granting and retention of the shotgun licence were not therefore considered by a court in an appeal. The concerns outlined in your report appear to have arisen because of evidence given by the Chief Constable that around 50% of appeals against police decisions to revoke shotgun licences are successful. You cite as an example an unidentified case summary in which the Court granted an appeal against a decision of the Chief Constable to revoke a firearms licence. It is said that in that particular case the court ‘appears’ to have taken an approach that allegations were unproven and could not be taken into account and the court’s approach to risk ‘appears’ to have set too high a threshold for revocation when considerations of violence and intemperate habits were in play. You were informed that this case is not untypical and the Chief Constable ‘strongly suspects’ that it is indicative of a national problem. Section 44 of the Firearms Act 1968 provides for appeals against decisions of Chief Constables made under the 1968 Act to be made to the Crown Court. Appeals are determined on the merits and the court may consider any evidence or other matter, including matters which post-date the decision of the Chief Constable. You rightly point out that under section 44(3A) the court is obliged to have regard to the relevant statutory guidance issued by the Secretary of State, which is publicly and easily available. Procedural aspects of such appeals are set out in Schedule 5 to the 1968 Act, which makes it clear that the Chief Constable may appear and be heard at such an appeal. Indeed, it would be very odd were the Chief Constable not to take a full part in the appeal. Further practice guidance was issued by the Divisional Court of the High Court in R (Mason) v Crown Court at Winchester [2018] EWHC 1182 (Admin), which sets out an appropriate approach to the case management of such appeals, in order to ensure a fair hearing. It is clear in this guidance that evidence and submissions are expected from both parties. In Chief Constable of Essex Police v Campbell [2012] EWHC 2331 (Admin) the Divisional Court clearly established that an individual’s overall conduct and the context of the decision to revoke a licence must be taken into account. In Campbell Sir John Thomas, President of the Queen’s Bench Division, stressed the overwhelming public interest in the exercise of strict controls over those who possess firearms, and the consequent need to ensure that appeals under section 44 of the 1968 Act are given the most careful and detailed consideration. The questions to be answered by the court in appeals under section 44 of the 1968 Act, and the procedure for hearing such appeals, are therefore clear and well-established. They are to be found in a small number of readily accessible places. I have considered the concerns you raise but do not think that your report substantiates the suggestion that judges are not giving such appeals the necessary careful and detailed consideration, are applying the incorrect legal test or are failing to have regard to the statutory guidance. Page 2 of 3
28th April 2023 Mr Ian M Arrow HM Senior Coroner 1 Derriford Park Derriford Business Park Plymouth PL6 5QZ Dear Mr Arrow, I write in relation to your correspondence dated 8th March 2023 pertaining to the inquests you heard surrounding deaths in Keyham in August 2021. In respect of your observations, I report the following: In terms of training and continuous professional development, all Merseyside Police Firearms Enquiry Officers have completed the nationally recognised training package delivered by South Yorkshire Police. Furthermore, all staff are enrolled on the online training offered by Mowbray Partners. I welcome the recommendation that all Firearms Licensing staff are appropriately accredited. Within force, we have a robust governance structure in place which includes the provision of a risk matrix. In terms of the delegated authority, all revocations and refusals are signed off at Assistant Chief Constable level. The presence of regular dip-sampling in relation to all work, including files within the department ensures compliance. I have also asked our independent audit team to examine the processes and procedures that we have put in place to ensure that we have a critical eye to objectively assess our action plan and response to your recommendations. Whilst I understand that a national form detailing Rose Hill, 15 Cazneau St, Liverpool L3 3AN Tel 0151 777 Chief Constable referee support of an application is still under consultation, we have devised our own document to implement this process in the meantime. Moving forward our processes will include reviewing within one month all cases where firearms have been seized or surrendered to the police pending a review of suitability to have a licence, but subsequently returned. We will also review applications that have been refused or licences have been revoked, but where subsequent applications or appeals by the same licence holder have resulted in the granting of a licence. We will endeavour to ensure that this is completed by 2nd October 2023. All cases will be reviewed by the Firearms Licensing Manager and escalated to the Chief Superintendent and/or Assistant Chief Constable where appropriate. In response to the request by the Home Secretary, my Firearms Licensing Manager in conjunction with the relevant Chief Superintendent reviewed 8 cases from 2021. During this period: • 2 licenses were revoked and have not been subsequently reissued. • 2 applications were refused, and the applicants have not reapplied. • 4 cases - licence holders voluntarily surrendered their licence and weaponry. Of these: 1 has had their licence cancelled. 1 risk involved a family member who has since moved on negating that danger. 2 have appropriate control measures which include regular monitoring and unannounced visits. It would be remiss of me not to highlight the work undertaken by Merseyside Police Head of Crime . commissioned a report entitled ‘The Threat, Harm and Risk Rose Hill, 15 Cazneau St, Liverpool L3 3AN Tel 0151 777 Chief Constable
Mr I M Arrow Senior Coroner Plymouth, Torbay and South Devon Coroner’s Court 1 Derriford Park Derriford Business Park Plymouth PL6 5QZ Deputy Assistant Commissioner Metropolitan Police Service New Scotland Yard Victoria Embankment London SW1A 2JL 5 May 2023 Dear Mr Arrow I am the Deputy Assistant Commissioner for the Directorate of Professional Standards in the Metropolitan Police Service (“MPS”). On behalf of the Commissioner of Police of the Metropolis, I write to provide the response to the matters of concern addressed to the MPS in your Report to Prevent Future Deaths dated the 8th March 2023. On behalf of the MPS may I first of all express my sincere condolences to the family and friends of Maxine Betty Davison, Lee Raymond John Martyn, Sophie Iris Martyn, Stephen John Godfrey Washington and Kate Jane Shepherd, our thoughts and sympathies are very much with them. The Coroner’s “Matters of Concern” (Training) The Prevention of Future Deaths report dated 8th March 2023 records:- “I was told that all Chief Officers of police ought to be satisfied that they only delegate their authority to issue and revoke firearms and shotgun licences to appropriately trained and skilled personnel. However, over the past 27 years, there has been an abject failure to ensure that nationally accredited training of firearms licensing staff has been developed and its currency maintained. I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance”. MPS Response MPS arrangements for “Delegated Authority” under the Firearms Act 1968 state that all members of the Firearms Enquiry Team (FET – MPS Designation for FELU) of Sergeant rank or above possess full decision making powers. This is then supplemented by a separate Decision Making Governance, which ensures that appropriate oversight is given. All decision makers have received the current agreed training package and undertaken accreditation which is overseen by the FET Inspector. Each new Supervisory officer joining the team receives an accreditation meeting with the FET Inspector and the MO19 senior leader responsible for FET, before being authorised to undertake independent decision making. There is currently no nationally accredited training package, which the MPS has sought to resolve by MPS FET development of their own training. The content of this training has always sought to take account of nationally identified risks arising from cases across the country where learning or best practice has been identified. The content of the training is reviewed each time a case is identified or when legislation and national guidance has been issued. The MPS notes the commitment from the NPCC lead for Firearms Licensing and the College of Policing to re-invigorate work in this area. The FET Manager and relevant member of the senior leadership team will be attending a national conference at the College of Policing later in 2023. The Directorate of Audit, Risk and Assurance (DARA) are a part of the Mayor’s Office for Policing and Crime (MOPAC) and provide an internal audit function for the MPS. DARA commenced a review of FET operations in September 2022, which concluded the MPS had “Adequate Assurance”. The DARA audit finding is that “the control framework over the administration of Firearms Licensing is adequately designed and the majority of controls are operating effectively. Risks are generally managed effectively and some minor improvement in the design and application of controls is required to strengthen the overall control framework.” The MPS is already addressing the points raised through the audit and DARA have been requested to undertake a future audit to review progress against findings and recommendations. In February 2023, an internal review was conducted by the MPS Specialist Firearms Command’s senior leadership team. This specifically considered current MPS arrangements and anticipated learning to come from the inquests and response to the shootings in Keyham. An outcome of this is an MPS review of the existing FET training, to ensure it remains up to date with developments in national firearms licensing. The MPS assessment is that adequate local training has been implemented to all staff operating within their Firearms FET. This includes both the original statutory and non-statutory guidance to police and subsequent iterations of these. This training has been delivered to all Firearms Enquiry Officers (FEO), supervisors and the MPS FET management team has an ongoing continuous development programme, overseen by a newly implemented monthly board. In 2018 the College of Policing published FEO Learning Standards. Following this in 2019 the issue of training was carefully considered against those learning standards, in light of the absence of an accredited product and arguably inconsistent local practices. As a result of this work, a three day FEO course was created focusing on critical risk assessment and decision making. The content of this course also incorporated reference to the relevant Home Office (non-Statutory) guidance of that time. Statutory guidance followed in November 2021 and a stand-alone training package was devised and delivered to all staff. This was a substantial change to law and process in Firearms Licensing and the training investment reflected this. The MPS joined a working group of other Firearms Licensing Managers from across the UK and a detailed analysis of the requirements to ensure our compliance with these substantial changes was undertaken. In February 2023 this Statutory Guidance was updated. The amendments to the guidance did not necessitate fundamental changes to existing working practices and therefore the changes were briefed to officers in writing. The existing FEO course was also updated to reflect this change in legislation. The College of Policing FEO learning standards remain the latest guidance and the MPS is fully compliant. FEOs are mentored by an experienced member of staff and their practical application of knowledge is assessed by supervisors against 23 key areas of competence, which reflect the FEO Learning Standards and most recent statutory and non-statutory guidance. Ongoing training to all FET staff and new joiners is a key performance indicator. Continuous professional development is embedded within the FET with staff trained quarterly. Training content follows trends identified in the national Firearms and Explosives Licensing Working Group (FELWG) as well as any local or national learning opportunities identified by the FET management team. Supervisors and decision makers have been provided with an enhanced level of training in relation to decision making, risk management and professional curiosity. This is delivered in partnership with colleagues from the MPS Directorate of Legal Services. The MPS is also working with police force across the south east region, to share information and embed peer reviews and quality assurance. The MPS has exercised significant effort to assure itself that the FET is compliant with all available College of Policing, Statutory and Non-Statutory guidance. Furthermore, the FET has taken a proactive position in keeping pace with any learning resulting from occurrences related to firearms licensing. The Coroner’s “Matters of Concern” (Review of the return of guns) The Prevention of Future Deaths report dated 8th March 2023 records:- “I was informed that all police forces then reviewed their decisions to return a weapon in the previous year and only one police force (not Devon and Cornwall Police) identified any case where firearms had wrongly been returned to ce1tificate holders in the previous year. I was told there were 9 cases identified in that one force. Whereas the remaining 42 forces (including Devon and Cornwall Police) found no incorrect decisions to return a certificate had been made. In the light of this information I am concerned that the information from those 41 police forces who indicated that they had made no incorrect decisions to return a weapon/ certificate may need to be further tested and explored. I am concerned the figures provided to the Home Secretary in 2021 may not reflect the accurate position, and that if sufficiently stringent checks are performed these may reveal other cases where a firearm or shotgun certificate had been seized, refused, revoked or surrendered but was subsequently issued/returned in circumstances when the certificate should not have been approved. I am concerned that if there are other cases that were not subject to a proper or thorough review of the risk of returning the weapon when the person may continue to have a firearms/shotgun certificate and hold weapons in circumstances that place the public and the licence holder themselves at risk. I am concerned that in the light of the lessons learned in the Keyham inquests of the attitude towards risk, a further review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the past five years may be required to be assured of public safety”. MPS Response In August 2021, the MPS responded to a request from the Home Secretary for a review of all firearms returned to members of the public in the preceding 12 months. These cases were identified utilising a “search string” provided by Home Office colleagues for use with the National Firearms Licensing Management System (NFLMS). This process highlighted 33 such cases, which were reviewed by the FET Manager and a nominated Sergeant, then subsequently signed off by the Firearms Commander.
Senior Coroner
Plymouth, Torbay and South Devon
Norfolk Constabulary
Force Executive
Operations & Communications Centre
Falconers Chase
Wymondham
NR18 0WW
28th April 2023
www.norfolk.police.uk
Non-Emergency Tel: 101
Chief Constable
Dear Sir,
I write to you in order to provide a response, on behalf of Norfolk Constabulary, to the Preventing
Future Deaths report issued under Regulation 28 of the Coroner (Investigations) Regulations 2013.
The Firearms Licensing Unit (FLU) for Norfolk Constabulary is part of the Joint Protective Services
Command; a collaborated command between Norfolk and Suffolk Constabularies under Section 22 of
the Police Act 1996.
The Preventing Further Deaths (FPD) report contained two issues for police forces to consider. The
first being the training of firearms licensing decision makers and the second, the review of the return
of weapons after a review of suitability. I will address both of these issues.
Training
The two forces recognise the need to ensure that those with delegated responsibility from the Chief
Constables should be appropriately trained in the application of the Home Office Guidance on
Firearms Licensing Law (Nov 22) and the Revised Statutory Guidance for Chief officers of Police (Feb
23).
The FLU has commissioned an external provider, Mowbray partners, through Durham Constabulary
to provide training to all FLU Enquiry officers and Licensing officers over the next 12 months, with
training commencing in May 23. In addition, we are currently exploring training for those staff who
undertake administrative role within the FLU.
Review
I have carefully considered the requirement to carry out a full review of all certificates that have been
seized, refused, revoked or surrendered and then subsequently approved over the last five years. I
know that my Head of Protective Services Command has engaged with the office of the National
Police Chiefs Council lead for Firearms Licensing in respect of the PFD.
Norfolk Constabulary absolutely acknowledge the seriousness of the issues raised.
A review of all cases, under the criteria within the PFD, for the five-year period, indicates just short of
eight hundred that would be considered for review. All of these cases have been reviewed by those
with designated decision-making responsibility in line with the guidance and regulations that would
have been in place at the time. There is a significant resource commitment that would be required to
review all eight hundred cases and I am conscious this may require resources being diverted away
from the current FLU business demand.
In order to ensure that our focus is on the areas that may present the greatest risk Norfolk and Suffolk
Constabularies will carry out a review in line with the strategy articulated below. This approach would
see a significant and meaningful sample of cases being reviewed. If issues of concern are identified,
then this will trigger a wider review of cases.
Where certificates are either refused or revoked then access to a firearm can only be achieved
through the submission of a further application. This would then require consideration of the
application in full as with any other first-time application.
Where firearms are seized as a result of an incident, event or due to information received by police
then decisions are taken by those with delegated responsibility as to whether to return the firearm
to the certificate holder of to revoke the certificate.
In Autumn 2021 a review of cases between the date parameters of August 2020 and August 2021 was
undertaken at the request of the then Home Secretary. The cases reviewed were those in which
firearms were seized and returned, but where the certificate was not revoked, and all refused,
revoked, and surrendered certificates.
295 cases were identified of which eighty-five were found to be relevant for the purposes of the
review. Of these four cases were referred to Superintendent rank with responsibility for Firearms
licensing. One certificate was revoked.
Under this review:
1. Those cases that relate to a certificate issued before April 19 will be subject to a full renewal
review against the current guidance and regulations within the next 12 months as part of the
5-year renewal cycle. As this will allow a timely approach to review, we do not propose to
review these ahead of that process, this will allow us to focus on those cases that are not due
a renewal review.
2. Those case between April 2019 and August 2020 will be reviewed.
3. Those case between August 2020 and August 2021 are those already reviewed as articulated
above. We will review 30% of these again to understand whether application of the current
regulations and guidance would result in different decision making. If this review highlights
any concerns, we will conduct a wider review of cases.
4. For those case between August 2021 to Feb 2022, these would have been reviewed having
benefited from the learning and approach of the Home Office requested review and therefore
benefit from this learning and so we would expect robust decision making has taken place.
We will again dip-sample 30% of cases. If this review highlights any concerns, we will conduct
a wider review of cases.
5. For cases dating between February 2022 and April 2023, these have been reviewed against
the relevant guidance in place at the time. An escalated decision-making process has been in
place for tis period and all cases where a n incident or intelligence has led to the removal of
firearms has been considered by the Superintendent with responsibility for Firearms licensing.
Whilst we remain confident in this approach and the high standard of decision making our
intention is to review 30% of all these cases. If this review highlights any concerns, we will
conduct a wider review of cases.
I have also considered those cases where certificates have been revoked leading to the removal of
firearms but where the certificate holder makes a subsequent application within 12 months. This
review will look to ensure that the decision making was based on the current circumstances and not
on the basis that the holder was previously granted a certificate.
I trust that the following approach provides you the reassurance that Norfolk Constabulary take full
cognisance of the importance of the PFD and that we are committed to undertake a review and
identify and address any issues.
Yours sincerely
Chief Constable
Date 02/05/2023 Prif Gwnstabl / Chief Constable Dear Mr M Arrow, With regards to the Report to Prevent Future Deaths dated 8th March 2023. The following concern were raised: “I am concerned that the figures provided to the Home Secretary in 2021 may not reflect the accurate position, and that if sufficiently stringent checks are performed these may reveal other cases where a firearm or shotgun certificate had been seized, refused, revoked or surrendered but was subsequently issued/returned in circumstances when the certificate should not have been approved. I am concerned that if there are other cases that were not subject to a proper or thorough review of the risk of returning the weapon then the person may continue to have a firearms/shotgun certificate and hold weapons in circumstances that place the public and the licence holder themselves at risk.” To address the concerns raised regarding the accuracy of the 2021 review, it is relevant to detail the steps that we took as a Force to assure ourselves and the Home Secretary. At the time, North Wales Police identified 34 cases where firearms and shotgun certificates had been seized, www.heddlu-gogledd-cymru.police.uk SWYDDFA’R PRIF GWNSTABL Pencadlys yr Heddlu, Glan-y-Don, Bae Colwyn LL29 8AW Ffôn (Cymraeg): 0300 330 0101 www.north-wales.police.uk CHIEF CONSTABLE'S OFFICE Police Headquarters, Glan-y-Don, Colwyn Bay LL29 8AW Tel (English): 0300 330 0101 refused, revoked, or surrendered and subsequently returned to the certificate holder over the specified time period. A full review was conducted by a Chief Superintendent with a panel including an operational Superintendent, a Solicitor from the Force Legal Service Team and members of the Firearms Licencing Team operating as subject matter experts. All 34 cases were reviewed, and the decisions made in returning the weapons were found to be correct. I am confident, based on the 2021 review and reinforced with the subsequent implementation of the Home Office Statutory Guidance, that an accurate set of figures were submitted to the Home Secretary. The current practice is as follows for context: • All high-risk decisions as defined in the relevant guidance are made by the Head of Firearms Licensing. These decisions which involve refusal, grant, revocation and return of seized firearms are subject to dip sample review on a bimonthly basis by the Force Solicitor and a Superintendent. In addition, the Head of Firearms dip samples the decisions made by the other two members of the team monthly. These reviews are recorded and archived for audit purposes and the overall process was recently identified as best practice in the recent external audit (March 2023). Furthermore, in May 2022 the North West Regional Organised Crime Unit identified that for the period 2020/21, the Force refused the most firearms related certificates in England and Wales. In addition, we revoked more certificates than any other Force in the North West region and were amongst the top 5 Forces nationally for the same period. www.heddlu-gogledd-cymru.police.uk SWYDDFA’R PRIF GWNSTABL Pencadlys yr Heddlu, Glan-y-Don, Bae Colwyn LL29 8AW Ffôn (Cymraeg): 0300 330 0101 www.north-wales.police.uk CHIEF CONSTABLE'S OFFICE Police Headquarters, Glan-y-Don, Colwyn Bay LL29 8AW Tel (English): 0300 330 0101 I am fully cognisant of the risks and public expectations for the issuing of firearms licenses. My risk tolerance in this area is extremely low however I acknowledge that providing additional assurance in the context of national events has significant merit. I am also fully aware that there is no room for complacency, and I will always be seeking to make improvements in our working practises. Therefore, in response to the concerns raised I propose to review all cases over the last 5 years where applications have been refused or licences revoked, but where subsequent applications or appeals by the same licence holder resulted in a grant. If the Crown Court ordered the return or grant, we will note this and review with our Force legal team. I will aim to complete this review by 2nd October 2023 and hope that this step and the demonstrable rigour applied to the 2021 process provide the required assurance. Your Sincerely Prif Gwnstabl / Chief Constable www.heddlu-gogledd-cymru.police.uk SWYDDFA’R PRIF GWNSTABL Pencadlys yr Heddlu, Glan-y-Don, Bae Colwyn LL29 8AW Ffôn (Cymraeg): 0300 330 0101 www.north-wales.police.uk CHIEF CONSTABLE'S OFFICE Police Headquarters, Glan-y-Don, Colwyn Bay LL29 8AW Tel (English): 0300 330 0101
Mr Ian M Arrow
His Majesty’s Senior Coroner
Plymouth, Torbay and South Devon
1 Derriford Business Park
Plymouth
PL6 5QZ
Date: 12th April 2023
Dear Mr Arrow
Re: Prevention of Future Death Report (PFD) under Regulation 28 Coroners (investigation) Regulations 2013
Thank you for your letter dated 8th March and the accompanying notices.
We have noted the details of the Regulation 28 Notice, sent to ‘All Chief Constables in England and Wales’.
We note your concerns detailed in section 5 and we are committed to ensuring that we address these
concerns and are undertaking the following.
We have established a Gold group, chaired by myself to oversee our response and any required actions to
the PFD reports distributed to us.
We have commenced a review of all our records, aiming to identify which records meet the criteria set out in
your notice, ‘a further review of all certificates seized, refused, revoked, or surrendered and then
subsequently approved over the last 5 years’. Early indications suggest that this would involve a review of
approximately 2000 records, however we are still working through our records and do not have a final figure.
We aim to have this completed in late April 2023.
We will review all records that we identify and consider the most recent decision first. We will ensure that
where our decisions have been subject to an appeal and a return ordered by the Crown Court, we will
appropriately flag to our Force Legal Services Department for any action.
We will aim to complete the full review of all records by 2nd October, however, until we have understood the
number of records that we need to review, we are unable to confirm this to date. We will create an
assessment framework to test our decisions and record any actions that we take. This will of course be made
available on request to evidence our activities.
| Head of Custody & Firearms Licensing
Crime & Justice Operations | Athena House | Kettlestring Lane | York | YO10 4XF
DX No: 729961 YORK 29
Non – emergency
Number
We are in the process of developing an Action Plan to manage our response to the reports and we also have
in place an Action Plan to manage our Gold group and record any decisions that we take.
I trust that you will find our actions agreeable, please do not hesitate to contact me if you require any further
clarity.
Yours sincerely
Assistant Chief Constable – Specialist Operations
North Yorkshire Police
| Head of Custody & Firearms Licensing
Crime & Justice Operations | Athena House | Kettlestring Lane | York | YO10 4XF
DX No: 729961 YORK 29
Non – emergency
Number
Deputy Chief Constable
Wootton Hall
Wootton Hall Park
Northampton
Northamptonshire
NN4 0JQ
3rd May 2023
Dear Mr Arrow,
Ref: Preventing Future Deaths (PFD)
In response to your report, sent to all Chief Constables dated the 8th of March 2023 in relation to
your concerns regarding Firearms Licensing as a result of the Inquests into the shootings at Keyham
in August 2021, I would like to detail the plans which Northamptonshire Police have in place.
You will have by now received correspondence from Chief Constable
with regard to an agreed
national response, which Northamptonshire Police have agreed to, and which includes the
following:
Prioritise review cases where firearms have been seized or surrendered to police pending
•
a review of suitability to have a licence, but then subsequently returned.
Review cases where applications have been refused or licences revoked, but where
•
subsequent applications or appeals by the same licence holder resulted in a grant.
Review all previous decision-making against the current (February 2023) Home Office
•
Statutory Guidance, in light of the concerns you have referred to.
•
All the above will be completed over the next six months and by 2 October 2023.
In preparation for the reviews, we have already secured temporary additional resources into our
Firearms Licensing Unit, including at senior management level.
We have also recently engaged with two separate external companies to carry out audits of the unit,
as well as a peer review conducted by a neighbouring Force, and we await their respective reports.
These will provide the scrutiny required to identify where improvements can be made, and to
provide reassurance to us and the public that our processes support your aspiration in preventing
future deaths.
Yours Sincerely,
Deputy Chief Constable
Assistant Chief Constable Robert Griffin command@notts.police.uk 3rd May 2023 Force Headquarters Sherwood Lodge Arnold Nottingham NG5 8PP Dear Mr Arrow, RE: Preventing Future Deaths (PFD) Notice I write in response to your report, sent to all Chief Constables, dated the 8th of March 2023, following the Inquests into the shootings at Keyham in August 2021. I would like to detail the plans for review which Nottinghamshire Police have put in place in response to that report. Our response is based largely on the correspondence you will have received from Chief Constable , which outlines guidance for police forces across the UK to aid their approach and response: • We have identified a dedicated resource to undertake the review. All reviews will be undertaken through the lens of the current (February 2023) Home Office Statutory Guidance. • We will prioritise cases where firearms have been seized or surrendered to police pending a review of suitability to have a licence, but then subsequently returned. We will then review those cases that have been refused or revoked and subsequently returned. • We have already commenced the review and are working backwards from 1st April 2023 for a period of 4 years. We have started by reviewing the most recent decisions first. • We will not review cases in years 4 to 5, as these are (to differing degrees) moving naturally toward the normal 5-yearly renewal process (which will be undertaken against current standards.) I am content with this approach, because we do not have a significant backlog for renewal applications, nor many temporary licences. • We will not fully re-review those licences from the 12-month period that were completed as part of the 2021 review. I had oversight of that review and am compelled by its thoroughness at the time. To repeat this work now would impact our capacity (and pace) to undertake the other years that are now in need of review. Instead, and to provide me with additional reassurance, I have commissioned a re – review of a sample of those cases which is to be conducted independently, by a neighbouring police force. • All the above will be completed over the next six months and by 2 October 2023. As the portfolio lead for firearms licensing within Nottinghamshire, I will maintain a personal oversight of these reviews and on receipt of the resultant reports, will provide the scrutiny required to identify where improvements can be made. I trust this approach provides the reassurance you require and demonstrates our commitment and support to fully meet the requirements of your prevention of future death notice. Yours sincerely ACC Specialist Crime and Operations Nottinghamshire Police
Pencadlys Heddlu Police Headquarters Heel y Bont-faen Cowbridge Road Penybortt Bridgend CF31 3SU CF31 3SU Mewn argyfwng ffoniwch 999 In an emergency dial 999 fel arall, ffoniwch 101 Non-emergencies dial 10 1 www.heddlu-de-cymru.police.uk www.south-wales.police.uk 29 March 2023 Mr. Ian M Arrow Senior Coroner Plymouth, Torbay & South Devon 1 Derriford Business Park Derriford Park Plymouth PL6 5QZ Dear Mr. Arrow REPORT TO PREVENT FUTURE DEATHS I write with reference to your report to all Chief Constables in England and Wales following the tragic deaths in Keyham on the 12 August 2021 . Following the incident, the Home Office requested that all Chief Constables carry out a full review of all certificates that had been seized, surrendered, revoked or refused in the previous 12 months and subsequently approved . To provide reassurance, the review conducted in South Wales Police in October 2021 was peer reviewed by the firearms licensing managers in Avon & Somerset and Gwent Police with a positive outcome. Your request to conduct a further review over a 5-year period is underway and has identified approximately 1300 records where certificate holders were subject of a suitability review. Each record is being checked to establish if certificates were seized, surrendered, revoked or refused and subsequently approved. Once this preliminary work has been completed, we will then be in a position to provide a timescale for completion of the review. Additionally, since 2021 , South Wales Police and Gwent Police have been working together to establish best practice and align processes across both forces. Monthly continuous improvement meetings take place and regular peer reviews are conducted. Where matters of concern are identified, a case will be referred to a different force for external scrutiny. We are in the process of arranging an annual peer assessment for a set number of cases to test and evaluate our approval to firearms licensing . Yours sincerely Chief Constable Copied to: Chief Constable, Gwent Police # CadwDeCymruYnDdiogel # KeepingSouthWalesSafe Mae Heddlu De Cymru yn c,oesawu de,t,yn gohebioelh yn Gymraeg • Saesneg. Bycldwn yn ateb gohebiaeth a dderwn,,iryn (lymraegynGymraegacni f)'dd gohebl yn Cym,aegyn-81oecl. South W.les Poflcewelcomes recelvingco,respondence in Wolsh ond Engtlsl\. My corrMpondenoe received In ln Webhandc:enasp01dn&ln Welsh wtl be ~ Welsh \\ii not lead to a delay In respc,ndlng. south-wales.police.uk O@O swpolice HeddluDeCymru
Mr Ian Arrow 1 Derriford Business Park, Plymouth, PL6 5QZ Dear Sir, From the office of Deputy Chief Constable Staffordshire Police Executive Office, Weston Road, Stafford, ST18 0YY Date: 11 May 2023 I would firstly wish to offer my deepest condolences to the families of Maxine Davison, Lee Martyn his daughter Sophie, Stephen Washington and Kathryn Shepherd on behalf of Staffordshire Police. I hereby attach the Staffordshire Police and West Midlands Police response to the two Preventing Future Death Reports arising from the inquests that were directed to all Chief Constables. As explained in the attached report the Firearms and Explosives Licensing Unit provides a collaborated service to both forces. The response relating to the review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the last 5 years provides details of the action taken and proposed to be taken as requested. The second response details the level of training undertaken by staff in the Firearms and Explosives Licensing Unit and the proposed training to be undertaken as other details in response to the matters of concern raised in the report. It is understood that the responses may be published. Yours sincerely Deputy Chief Constable RESPONSE ON BEHALF OF STAFFORDSHIRE POLICE AND WEST MIDLANDS POLICE-REVIEW OF CERTIFICATES Report to prevent future deaths: made under Regulation 28 of the Coroners (Investigations) Regulation 2013 This is a joint response prepared on behalf of the Chief Constable of Staffordshire and the Chief Constable for West Midlands Police as Staffordshire and West Midlands Police have a collaborated firearms and explosives licensing service. This document is providing in response to the Coroner’s report which raises concern that a further review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the last 5 years should be subject to a further review to provide assurance of public safety. A review of all certificates seized and returned between August 2020 and March 2023 has been commissioned the details are reproduced in Table 1 below. Certificates granted prior to this period will also be subject to review but the outcome will not be available in time to include in this response. The 5-year information relating to revocation and refusal has been completed and is included within this response at Table 2 and Table 3 Table 1: Certificates seized and returned (August 2020 – March 2023): Staffordshire West Midlands *These are scheduled reviews that have been brought forward Seized and Returned 48 16 To be Re-visited following review 2* 0 Table 2 Certificates revoked and then re-issued following application (March 2018 – March 2023): Revoked Re-granted (following re- application) Staffordshire West Midlands 116 102 5 4 Re-granted (following a successful Court Appeal) 1 2 To be Re-visited following review 0 0 Table 3 Certificates refused and then later granted following application (March 2018 – March 2023): Refused Granted (following re-application) Granted (following a successful Court Appeal) To be Re-visited following review Staffordshire West Midlands ** Re-visited to insure satisfactory circumstances (certificate was granted following a Court appeal) ***Re-visited to insure satisfactory circumstances (no concern with the decision-making review) 80 103 1 5 3 5 1** 1*** To provide further assurance as to the quality and consistency of decision-making there has been a series of scheduled quality assurance programmes in relation to internal and external audits over decision making which are listed below: • Plymouth Coroner’s Regulations 28 (PFD) Response – certificates seized, refused, revoked or surrendered and then subsequently approved the outcome of which is included in this report. • External RSM UK – review on certificate applications for initial grant, renewal and suitability reviews (currently ongoing). 1 RESPONSE ON BEHALF OF STAFFORDSHIRE POLICE AND WEST MIDLANDS POLICE-REVIEW OF CERTIFICATES • Home Office review of temporary permits (August 2023). • • ROCU review and scrutiny of prescribed certificate types (May 2023). Information assurance review (currently ongoing). Findings from all the above audits will be used to professionally develop the decision makers and improve the service. 2 RESPONSE ON BEHALF OF STAFFORDSHIRE POLICE AND WEST MIDLANDS POLICE-TRAINING Report to prevent future deaths: made under Regulation 28 of the Coroners (Investigations) Regulations 2013 This response is made on behalf of the Chief Constable of West Midlands Police and the Chief Constable of Staffordshire as the Staffordshire and West Midlands Police have a collaborated firearms and explosives licensing service. After consideration of the Regulation 28 Report which raises matters of concern particularly in relation to training we issue the following response. The Staffordshire and West Midlands Firearms Licensing Unit was restructured following the shootings in Keyham in 2021. The following changes and actions were put in place further to the direction of the Staffordshire and West Midlands Collaboration Governance Board as follows: 1. Resourcing, a new staffing structure was approved in December 2021 with growth from 17 police staff employees to 27 at an additional cost of £220,702. 2. Decision Making, the introduction of a new Deputy Manager to hold delegated responsibilities (under section 55(2) of the Firearms Act 1968). The post holder is currently undertaking training and is being mentored. 3. Policy, a new policy document was published on 16/02/2023 aligning operational delivery to the Home Office Statutory Guidance for Chief Officers of Police (2023). 4. Review of certificate holders coming to police notice, the introduction of Intelligence Officers that have core responsibilities for; completing enhanced police background checks, systems monitoring for certificate holders coming to police notice, collating suitability enquiries, collating information for court appeals, triage of medical certificates (on initial receipt), response to FOI requests and assisting police enquiries in criminal matters that relate to certificate holders and/or firearms licensing matters. In addition, there has been internal communications across Staffordshire and West Midlands re-confirming the need for officers to consider seizing certificates and firearms when they attend incidents involving certificate holders. 5. Historically firearms licensing training has largely been based on local delivery and mentoring. Following the tragic shooting in Keyham significant changes have been made to deliver an extensive training package, which includes: a. National Triage Firearms Classification Course – Durham Police (enquiry officer) b. Firearms Safety handling training – Staffordshire Police (enquiry officer) c. Police National Decision Model training – CoP accredited trainers delivered (all staff) d. Awareness training – Safeguarding and Domestic Abuse (all staff) e. Awareness training – Neuro-Diversion (all staff) f. Range assessment training – Clay Pigeon Shooting Association (CPSA) (enquiry officers) g. Open Source – social media training (Intelligence Officers) h. FEO, Decision Making and Administration Courses – Durham Police/Mowbray Associates (all staff) 1 RESPONSE ON BEHALF OF STAFFORDSHIRE POLICE AND WEST MIDLANDS POLICE-TRAINING In the absence of accredited training, the training has been planned following a benchmarking exercise with police services nationally to explore best practice. All decision makers with delegated authorities have undergone Police National Decision Model training and are undertaking the Mowbray Associates Firearms Licensing Decision Making Course. 6. Governance, there is continued oversight by two separate Executive Officer chaired, governance structures. Firstly, the Staffordshire and West Midlands Strategic Partnership Meeting. This addresses operational matters, including performance, training, change and external pressures. The meeting is quarterly and is chaired by an Assistant Chief Constable. Secondly, there is the Staffordshire and West Midlands Collaboration Governance Board, this Board focuses on strategic governance understanding national matters, addressing reputational risk and creating a consultative forum for the Chief Constables’ and Commissioner’s offices. The meeting is bi-annual and chaired by the Deputy Chief Constable (it is also attended by the Commissioner’s Chief Executive Officers). 2
A review of all cases, under the criteria within the PFD, for the five-year period, indicates just short of eight hundred that would be considered for review. All of these cases have been reviewed by those with designated decision-making responsibility in line with the guidance and regulations that would have been in place at the time. There is a significant resource commitment that would be required to review all eight hundred cases and I am conscious this may require resources being diverted away from the current FLU business demand. In order to ensure that our focus is on the areas that may present the greatest risk Norfolk and Suffolk Constabularies will carry out a review in line with the strategy articulated below. This approach would see a significant and meaningful sample of cases being reviewed. If issues of concern are identified, then this will trigger a wider review of cases. Where certificates are either refused or revoked then access to a firearm can only be achieved through the submission of a further application. This would then require consideration of the application in full as with any other first-time application. Where firearms are seized as a result of an incident, event or due to information received by police then decisions are taken by those with delegated responsibility as to whether to return the firearm to the certificate holder of to revoke the certificate. In Autumn 2021 a review of cases between the date parameters of August 2020 and August 2021 was undertaken at the request of the then Home Secretary. The cases reviewed were those in which firearms were seized and returned, but where the certificate was not revoked, and all refused, revoked, and surrendered certificates. 295 cases were identified of which eighty-five were found to be relevant for the purposes of the review. Of these four cases were referred to Superintendent rank with responsibility for Firearms licensing. One certificate was revoked. Under this review: 1. Those cases that relate to a certificate issued before April 19 will be subject to a full renewal review against the current guidance and regulations within the next 12 months as part of the 5-year renewal cycle. As this will allow a timely approach to review, we do not propose to review these ahead of that process, this will allow us to focus on those cases that are not due a renewal review. 2. Those case between April 2019 and August 2020 will be reviewed. 3. Those case between August 2020 and August 2021 are those already reviewed as articulated above. We will review 30% of these again to understand whether application of the current regulations and guidance would result in different decision making. If this review highlights any concerns, we will conduct a wider review of cases. 4. For those case between August 2021 to Feb 2022, these would have been reviewed having benefited from the learning and approach of the Home Office requested review and therefore benefit from this learning and so we would expect robust decision making has taken place. We will again dip-sample 30% of cases. If this review highlights any concerns, we will conduct a wider review of cases. 5. For cases dating between February 2022 and April 2023, these have been reviewed against the relevant guidance in place at the time. An escalated decision-making process has been in place for tis period and all cases where a n incident or intelligence has led to the removal of firearms has been considered by the Superintendent with responsibility for Firearms licensing. Whilst we remain confident in this approach and the high standard of
Ian Arrow
......
Chief Constable
28th April 2023
Dear Sir,
Re: Report regarding training of firearms licencing decision makers
I write in response to your report, and subsequent requirement placed upon Surrey Police
following the inquest into the deaths of five people shot in Keyham on 12th August 2021.
In th e absence of any national training product accredited by the College of Policing, all
Surrey Police Firearms Enquiry Officers {FEOs) and supervisors have attended a firearms
licensing course that is designed and delivered in Yorkshire. This has only resumed this year
due to the impact of Covid and as such some recent joiners into the department have not
yet attended. However, we have commissioned a bespoke course with the same provider
exclusively for Surrey Police which is schedul ed for May 2023. There is currently no
nationally available course for office based Firearms Registration Officers (FRO) however
this training is internally delivered and managed by the office supervisor.
A schedule of additional training is also being delivered this year to supplement the external
training. This will cover issues relating to safeguarding, intelligence gathering, application of
the National Decision Making Model and the safe handling of firearms. The work that has
been developed has been recognised by an external audit carried out by the Southern
Internal Audit Partnership (SIAP) with its final report due to be released imminently. All
staff received training on the Statutory Guidance in 2022 by the previous Chief Inspector in
charge of the Firearms and Explosives Licensing Unit (FELU). Following the publication of
the revised guidance February 2023, this has been updated and refreshed for all FELU staff
as part of their continuous professional development. There is a force policy in place
(seizure of legally held firearms and certificates) and a standard operating procedure is
being developed to ensu re clear processes and procedures are applied consistently.
There are seven staff trained across different senior ranks and roles who are authorised to
carry out delegated authorities - the review function within the FELU. All have received
training and have relevant experience to perform this role within the department. All have
delegated authority for the force and complete regular professional development. The
Tel 101 Email
Website www.surrey.police.uk
Superintendent has delegated authority to enable effective oversight of the Detective Chief
Inspector and to provide additional capacity to allow for the return of certificates and
weapons following revocation decisions. Quality assurance is carried out for all roles and
responsibilities in the department to ensure Statutory Guidance is followed.
Surrey Police have been supporting the national NPCC lead and the College of Policing over
the past 12 months in developing a national curriculum and learning outcomes for Firearms
Enquiry Officers. The intention is. that the training will be delivered this year, which will be
aligned with quality assurance and mandatory professional development. Surrey Police FELU
will be active participants at the two day CPD event hosted by the College of Policing in May
2023. This will enable critical learning from the detailed de-brief of the lessons from the
Keyham Shootings Inquests and the new Home Office Statutory Guidance.
I am satisfied that based on the information available to me, that all staff have received and
will be continuing to receive appropriate training, proportionate to their respective roles
within the Surrey Police FELU.
Yours sincerely,
Chief Constable
Ian Arrow
Chief Constable
28th April 2023
Dear Sir,
Re: The return of weapons after review of suitability
I write in response to your report, and subsequent requirement placed upon Surrey Police
following the inquest into the deaths of five people shot in Keyham on 12t h August 2021. I
specifically respond in relation to the fact that we are one of 41 forces who responded with
a view that they had no concerns regarding decision making in those cases that were
requested to be reviewed following intervention from The Home Secretary in 2021.
Surrey Police currently have a joint team working with Sussex Police in the arena of Firearms
and Explosives Licensing who I have asked to carefully reviewed the findings of the inquest
leading to the above, and other PFD reports shared with Chief Constables.
It is the belief of the Firearms and Explosives Licencing Unit (FELU) that the process followed
prior to return of a certificate is suitably stringent in providing effective scrutiny and
oversight in cases where Firearms and/or Shotguns have been seized within our policing
area, carrying out appropriate due diligence prior to their return, or formally revoking as
appropriate. This is catered for within a force pol icy specifically dealing with the seizure of
legally held firearms and certificates.
This includes a full review overseen by a manager within the department and the Chief
Inspector head of FELU. Both serve with delegated authority from the Chief Constable to
perform this function alongside the wider experience within Firearms Licensing, prior to
return of any certificates. This process is further supported through dip checking by a
Superintendent responsible for Firearms Licensing within the force.
Surrey Police follow the national Home Office guidance and legislation in respect of Firearms
and Shotgun licencing and work within the regional group of forces around our processes to
ensure consistency. Furthermore the Force also plays an active part in the national Firearms
and Explosives Licencing working group (FELWG).
Tel 101
Surrey Police FELU have been externally reviewed by the Southern
Internal Audit
Partnership {SIAP) for the last two years and no recommendations have been raised in
response to our processes for suitability reviews or delegated authorities.
In 2021 the review of all certificates that had been seized, refused, revoked or surrendered
in the previous twelve months, and subsequently approved by the police, were carried out
following concerns raised by the Home Secretary. This review consisted of 95 Certificates
and was carried out by managers within the team. At the t ime no concerns were raised.
However, in light of the Coroner's report, we have decided that we will adopt the national
guidance from FELWG National lead CC Tedds to provide further reassurance.
Therefore, I can confirm that Surrey Police will undertake the following approach for a
review of firearms and shotgun licensing and prioritise this review as follows in line with the
national proposal and this review will cover the last 5 years:
• We will prioritise for review cases where firearms have been seized or surrendered
to police pending a review of suitability to have a licence, but then subsequently
returned.
• We will review the most recent decisions first, as the most recently returned licences
arguably pose the biggest risk. They will be closest to the events which justified
. seizure or surrender in the first place, and there will have been less reassurance in
the passing of time without new incidents.
• We will review in slower time cases where applications have been refused or
licences revoked, but where subsequent applications or appeals by the same licence
holder resulted in a grant, however these will be completed.
• We will review previous decision-making against the current (February 2023) Home
Office Statutory Guidance, in order to promote public safety by today's standards.
Additional resource of a sufficient rank and experience has been allocated to perform this
review and has been seconded into the department from 17th April 2023 to expedite this
review and provide me with a full report, which will be available by 2nd October 2023.
I am satisfied that based on the information available to me that whilst our processes are
sufficient currently, this will provide an additional scrutiny to provide additional reassurance
of this.
Yours sincerely,
Chief Constable Dear Sir, Tuesday 2nd May 2023 Re: The return of weapons after review of suitability I w rite in response to your report, and subsequent requirement placed upon Sussex Police follow ing the inquest into the deaths of five people shot in Keyham on 12th August 2021. I specifically respond in relation to the fact that w e are one of 41 forces w ho responded w ith a view that they had no concerns regarding decision making in those cases that w ere requested to be review ed follow ing intervention from The Home Secretary in 2021. Sussex Police currently have a joint team w orking with Surrey Police in the arena of Firearms and Explosives Licensing w ho I have asked to carefully review ed the findings of the inquest leading to the above, and other PFD reports shared w ith Chief Constables. It is the belief of the Firearms and Explosives Licencing Unit (FELU) that the process follow ed prior to return of a certificate is suitably stringent in providing effective scrutiny and oversight in cases w here Firearms and/ or Shotguns have been seized w ithin our policing area, carrying out appropriate due diligence prior to their return, or forma lly revoking as appropriate. This is catered for within a force policy specifically dealing w ith the seizure of legally held firearms and certificates. This includes a fu ll review overseen by a manager within the department and the Chief Inspector head of FELU. Both serve w ith delegated authorit y from the Chief Constable to perform this function alongside the wider experience within Firearms Licensing, prior to return of any certificates. This process is further supported through dip checking by a Superintendent responsible for Firearms Licensing w ithin the force. Sussex Police follow the national Home Office guidance and legislation in respect of Firearms and Shotgun licencing and w ork w ithin the regional group of forces around our processes to ensure consistency. Furthermore the Force also plays an active part in the national Firearms and Explosives Licencing w orking group (FELWG). Sussex Police FELU have been externally review ed by the Southern Internal Audit Partnership (SIAP) for the last t w o years and no recommendations have been raised in response to our processes for suitabil ity review s or delegated authorities. 001273 Y @CCJoShiner Sussex Police, Malling House, Church Lane, Lewes, East Sussex, BN 7 2DZ In 2021 the review of a ll certificates that had been seized, refused, revoked or surrendered in the previous twe lve months, and subsequently approved by the police, were carried out fo llowing concerns raised by the Home Secretary. This revie w consisted of 95 Certificates and w as carried out by managers w ithin the team. At the t ime no concerns were raised. Howe ver, in light of the Coroner's report, we have decided that w e w ill adopt the national guidance from FELWG Nationa l lead CC to provide further reassurance. Therefore, I can confirm that Sussex Police w ill undertake the fo llo wing approach for a revie w of firearms and shotgun licensing and prioritise this revie w as follo ws in line w ith the national proposal and this revie w will cover the last 5 years: • We will prioritise for review cases w here firearms have been seized or surrendered to police pending a revie w of suitability to have a licence, but then subsequently returned. • We will revie w the most recent decisions first, as the most recently returned licences arguably pose the biggest risk. They w ill be closest to the events which justified seizure or surrender in the first place, and there w ill have been less reassurance in the passing of time without new incidents. • We will revie w in s lo wer time cases where applications have been refused or licences revoked, but where subsequent applications or appeals by the same licence holder resulted in a grant, howe ver these will be completed. • We will revie w previous decision-making against the current (February 2023) Home Office Statutory Guidance, in order to promote public safety by today's standards. Additional resource of a sufficient rank and experience has been a llocated to perform this review and has been seconded into the department from 17th April 2023 to expedite this review and provide me with a fu ll report, which will be available by 2nd October 2023. I am satisfied that based on the information ava ilable to me that w hi lst our processes are sufficient currently, this w ill provide an addit ional scrutiny to provide additiona l reassurance of this. Yours s incerely, Chief Constable Chief Constable Dear Sir, Tuesday 2nd May 2023 Re: Report regarding training of firearms licencing decision makers I write in response to your report, and subsequent requirement placed upon Sussex Police following the inquest into the deaths of five people shot in Keyham on 12th August 2021. In the absence of any national training product accredited by the College of Policing, all Sussex Police Firearms Enquiry Officers (FEOs) and supervisors have attended a firearms licensing course that is designed and delivered in Yorkshire. This has on ly resumed this year due to the impact of Covid and as such some recent joiners into the department have not yet attended . However, we have commissioned a bespoke course with the same provider exclusively for Sussex Police which is schedu led for May 2023. There is currently no nationally available course for office based Firearms Registration Officers (FRO) however this training is internally delivered and managed by the office supervisor. A schedule of additiona l training is also being delivered this year to supplement the external training. This w ill cover issues relating to safeguarding, intelligence gathering, application of the National Decision Making Model and the safe handling of firearms. The work that has been developed has been recognised by an externa l audit carried out by the Southern Internal Audit Partnership (SIAP) w ith its fina l report due to be released imminently. All staff received training on the Statutory Guidance in 2022 by the previous Chief Inspector in charge of the Firearms and Explosives Licensing Unit (FELU). Following the publication of the revised guidance February 2023, this has been updated and refreshed for all FELU staff as part of their continuous professional development. There is a force policy in place (seizure of legally held firearms and certificates) and a standard operating procedure is being developed to ensure clear processes and procedures are applied consistently. There are seven staff trained across different senior ranks and roles who are authorised to carry out delegated authorities - the review function w ithin the FELU . All have received training and have relevant experience to perform this role w ithin the department. All have delegated authority for the force and complete regular professional development. The Superintendent has delegated authority to enable effective oversight of the Detective Chief Inspector and to provide addit ional capacity to allow for the return of certificates and weapons following revocation decisions. Quality assurance is carried out for all roles and responsibilities in the department to ensure Statutory Guidance is followed. 00121s - e Y @CCJoShiner Sussex Police, Malling House, Church Lane, Lewes, East Sussex, BN 7 2DZ Sussex Police have been supporting the nationa l NPCC lead and the College of Policing over the past 12 months in developing a nationa l curriculum and learning outcomes for Firearms Enquiry Officers. The intention is that the training will be delivered this year, w hich wil l be aligned with qua lit y assurance and mandatory professiona l development. Sussex Police FELU will be active participants at the tw o day CPD event hosted by the College of Policing in May 2023. This will enable crit ica l learning from the detailed de-brief of the lessons from the Keyham Shootings Inquests and the new Home Office Statutory Guidance. I am satisfied that based on the information available to me, that all staff have received and will be continuing to receive appropriate training, proportionate to their respective roles w ithin the Sussex Police FELU . Yours sincerely, Chief Constable
Thames Valley Police - response to Coroners report Thames Valley Police will comply with the Coroners recommendations in the following stages due to operational demands and resources: 1. First stage - review all seized and returned guns over a 5 year period. 2. Second stage - review all grants that have previously been revoked, refused or surrendered. 2018 files are coming up for renewal so we are focusing on 2022, 2021, 2020 and 2019. We are starting with 2022 as the most recently issued licences arguably pose the biggest risk. 3. Third stage - review applications that have been refused/revoked but subsequently granted by the Crown Court via the appeal process. We aim to complete the above stages by 2 October 2023. If you would like to discuss this matter with me further please do not hesitate to contact me. Kind regards Central Intelligence Manager Force Intelligence and Specialist Operations I Thames Valley Police
Force provided to the Home Office in response to the then Home Secretary’s request in August 2021 for forces to report on licence applications which had been refused or revoked but subsequently granted, then I have suggested that they respond to you in those terms, advising them: You are not being asked to duplicate past reviews or audits for the sake of it. If you have already conducted such a review, or you are clear that your force’s response to the Home Secretary in 2021 was accurate and that your current procedures are sound, then you could respond to the Coroner to that effect, ideally with evidence so as to reassure him and the public. To date, the feedback we have received indicates that most forces will either undertake a full 5 year review as you have suggested or will adopt the very slightly adapted process which I have ordered within my own force (and which I have shared with all Chief Constable colleagues) which is: To direct a review of firearms and shotgun licensing and prioritise the review in the following way which is intended to be practical and effective. • Prioritise for review cases where firearms have been seized or surrendered to police pending a review of suitability to have a licence, but then subsequently returned. This was one of the major concerns in the Keyham Shootings Inquests. • Start by reviewing the most recent decisions first, as the most recently returned licences arguably pose the biggest risk. They will be closest to the events which justified seizure or surrender in the first place, and there will have been less reassurance in the passing of time without new incidents. • Review in slower time cases where applications have been refused or licences revoked, but where subsequent applications or appeals by the same licence holder resulted in a grant. • • If the return or grant has been ordered by the Crown Court, consider with the Force Legal Services department what, if anything, can be done, recognising your PFD Report in respect of training for Crown Court Judges who hear and consider appeals against police refusals to grant licences. If it is not practical to review the last 5 years of decisions, then consider progressively reviewing the last 4 years. Licence holders in their 4th to 5th year can be managed through the normal 5-yearly renewal process against current standards. (I have advised colleagues whose forces may have significant backlogs for renewal applications, or many temporary licences, then a review of the last 4 years alone may not be sufficiently reassuring). • Review all previous decision-making against the current (February 2023) Home Office Statutory Guidance, in light of the concerns referred to in your PFD Report, in order to promote public safety by today’s standards. I have suggested to colleagues that adopting this unified approach to the reviews may also have the added benefit of consistency of response. I have further proposed that we try to achieve such reviews in each force over the next six months (from the date of your report) so by 2 October 2023. It is my intention that national progress in undertaking this review is monitored and tracked through the national Firearms and Explosives , from whom Licensing Working Group, which is led by Temporary Superintendent you heard evidence during the recent Inquests. I hope that this response offers some reassurance of the national approach which I have endorsed, which will be adopted within Warwickshire Police, to undertaking a timely and proactive review of decisions where following initial concerns about suitability, an applicant has eventually secured lawful possession of a firearm or shotgun. Such reviews will be assessed against the most recent Home Office guidance and, within Warwickshire Police, with your further recommendations around other areas of concern (the need to address legislative shortcomings and revision to guidance, training recommendations and so on) very much in mind. Yours sincerely Chief Constable It is accepted that the roll out of nationally accredited training for all Firearms and Explosives Licensing staff across all police forces has been the subject of comment and recommendation through a number of reports and previous inquests and, to date, it has not been delivered. Since I took up the role of national lead in this area on behalf of my Chief Constable colleagues nationally, I have worked hard to identify the areas requiring attention and to progress work to achieve improvement, and training has been a priority within that work. We have already scoped out the roles where accredited training should be a requirement (all Firearms Enquiry Officers (FEOs) and all caseworkers and decision makers) and work is now well developed in putting together the modules that will be required for staff to be deemed Competent including by way of example: National Decision Model (NDM), identification of risk and risk assessment. The success of this accredited national training is linked to the current review of firearms licensing fees, which is aimed at increasing the fees paid by applicants to a level where firearms licensing units within police forces are funded by application fees – and not significantly subsidised by general policing budgets which is currently the case - such that it provides the necessary finances to enable the College of Policing to develop and deliver central coordination of a national accredited training programme for firearms licensing teams. Current Firearms Licensing Training The 2015 HMIC Report “Targeting the Risk” identified accredited training as an issue and in 2016, the NPCC Firearms and Explosives Licensing Working Group (FELWG) approached the College of Policing to look at incorporating two “in-house” training courses provided by two forces (South Yorkshire and Dorset) into a national package. This was declined at the time by the College Coordination and Delivery Group due to competing demands. However, further dialogue continued and led to the development of national standards for key roles (FEOs and those with delegated authority for decision making) which were published in August 2018. The College were unable to assist with supporting further work by FELWG to develop a Quality Assurance template and process which would enable them to assess uptake and alignment of forces against the published standards (again due to competing national priorities as explained during my evidence to you at the recent Inquests) however through the FELWG work, an online training package was offered to all Forces from March 2021. This was produced by a company called Mowbray working in partnership with FELWG and assesses individuals against the nationally agreed standards for the key roles. As you heard during the recent inquests, the uptake for this package has not been universal – although it has remained available for forces to adopt and mandate for their teams. New training provision. A draft Learning Curriculum/Outcomes and Standards was developed in December 2022, in line with the new draft Approved Professional Practice for Firearms Licensing which was out for consultation until March 2023 and received in excess of 350 responses, which are currently being worked through. With agreed College of Policing Learning Outcomes now in place for the training, we are also developing an accompanying Quality Assurance framework to assess and ensure operational competency is demonstrated at the conclusion of the training package. The College is committed to implementing this training during the 2023/24 business year, and through recent negotiations, as NPCC lead, I was able to secure £500,000 from the Policing Minister to support with the assisted implementation of National Firearms Licensing Training.
West Mercia ~POLICE 2nd May 2023 Chief Constable West Mercia Police PO Box 55 Hindlip Hall Worcester WR3 8SP Email: HM Coroner Andy Bolter Derriford Business Park Plymouth PL6 SQZ Re: Preventing Future Deaths Reports: Internal firearms licencing review. Dear Mr Bolter I write to you following the release of the Preventing Futu re Deaths (PFD) Reports by your predecessor HM Coroner Ian Arrow, following the tragic events in Plymouth, in August 2021, and the subsequent Keyham Shooting Inquests. The Plymouth, Torbay and South Devon area HM Coroner overseeing the inquest into the shootings in Plymouth (2021) has issued a Regulation 28 notice (parag raph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulation 28 and 29 of the Coroners Investigations Regu lations 2013) to the police service in relation to the events leading to the Plymouth shooting. Specifically: • • • In the absence of [such] training there is a risk that the statutory guidance is not being appropriately applied [by FELU staff today] And so each Chief Constable may need to take steps to satisfy themselves that l) Adequate local training of a satisfactory standard has been universally delivered to all [their] FELU staff in applying the HO guidance on Firearms Licensing Law (Published November 2022) and the revised statutory guidance for Chief Officers of Police (Published February 2023) and ii) they have only delegated decision making to persons who have undergone adequate training in firearms licensing and in applying that recent guidance. The decision to return the shotgun and licence to the perpetrator [In July 2027) was fundamentally flawed and as a result failed to protect the public and the peace. www.westmercia.police.uk 0 @westmerciapol ice 0 @WMerciaPolice @) @westmerciapolice West Mercia POLICE HM Coroner further stated: '/ am concerned that in the light of the lessons learned in the Keyham inquests of the attitude towards risk, a further review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the past five years may be required to be assured of public safety.' I would like to detail the internal actions currently being taken, and those proposed within West Mercia Police Firearms Licencing Unit (FLU) to provide you with reassurance that this will ensure full compliance with the recently issued Regulations. Delegated Decision Maker: West Mercia Police have an experienced Inspector overseeing decision making within the Firearms Licensing Unit (FLU). This role is supported by a cadre of Delegated Authorit ies who also provide scrutiny, advice and decisions on revocations and returns at Chief Superintendent, Superintendent and Senior Police staff member level. Training: West Mercia Police have a robust scrutiny and assessment process and have taken the initiative to develop a t raining package for the receipt by all staff as part of initial induction and Continuous Professional Development (CPD). This training package has been subject of a local Learning Needs Assessment (LNA) with colleagues in Learning and Development, set against the Statutory Guidance that existed at that time. In absence of a national or College of Policing accredited training package, West Merci a Police are currently working with the Firearms and Explosives Licensing Working Group (FELWG) to present the locally developed material to College of Policing and to the NPCC Lead for Firearms and Explosive Licensing with a view that it is considered for adoption (or further developed by COP) as the national Firearms and Explosive train ing programme. Administrator Role: Occupational Competence: There is a structured training and guidance manual for all t heir processes. Operational Competence: is assessed through a development and mentoring process where newly appointed staff are audited and given feedback until competence is assured. Caseworker role: Occupational Competence: There is an initial training input 2 days to understand statut ory guidance, NDM, 'good reason' and su itabi lity assessment There is a have a structured training and guidance manual for all their processes. Operational Competence: A mentoring process exists entailing newly appointed staff being audited and given feedback until competence is reached. www.westmercia.police.uk 0 @westmerciapolice O @WMerciaPolice @ @westmerciapolice West Mercia POLICE Firearms Enquiry Officer Role: Occupational Competence: Two-week training input (internal) that meets the learning descriptors from Col lege of Policing. Operational Competence: Competency portfolio to be completed, under mentor supervision. Ongoing CPD portfolio overseen by FEO Supervisor HSE approved national qualification as an Explosives Liaison Officer (external) Decision Makers: FLU management team are in the process of composing a structured guidance and workbook for decision makers around COP learning outcomes. Police Staff Investigators: This role receives the same training requirements of any existing Police Staff Investigator. (i.e. PIP) delivered by L&D and nationally accredited. Licence Returns: The removal of a firearms from a registered firearms holder is a significant step and is indicative of there being a breach in licence conditions or a recognisable and potential threat to public safety and peace. The decision to return a firearm or shotgun must therefore be fully assessed against the cause for the initial removal and the threat of misuse or harm arising based on a revisited assessment and all avai lable information. Specific challenge was presented during the inquiry to t he assumption that the 'balance of probabilities' is the threshold by which to assess suitability and the relevance of information in decision making. All available information should be used to make an informed decision and not weight it to the 'balance of probabilities' threshold- which may adversely limit the considerations. In 2021 the then Home Secretary requested response to t hree questions: 7. Provide information on how many firearm and shotgun certificates have been seized, refused, revoked or surrendered in your force, and how many of those were subsequently returned to the certificate holder in the last twelve months; 2. Report on the outcome of your review of all certificates that have been seized, refused, revoked or surrendered in the past twelve months, and subsequently approved by the police; and 3. Confirm that you are satisfied that the processes that you follow in terms of returning a certificate are appropriate when set against the current Home Office guidance and legislation. West Mercia Police have previously provided 1 year's data report to the NPCC which subsequently appeared and was cited within the Inquest. West Mercia police have previously undertaken a review of all firearms and shotguns returns during the 12 months in 2021 with the following methodology: • No. of $G's or Firearms Seized, Refused, Revoked, Returned • No. of t hose removed which went on to be returned • No. of reviews which led to a change in that decision www.westmercia.police.uk 0 @westmerciapolice 0 @WMerciaPolice @westmerciapolice West Mercia POLICE • Was initial decision of return guidance-compliant? Is any change in decision guidance-compliant? • Methodology: West Mercia Police hold a file on each person who previously held a firearms and/or shotgun certificate and has been the subject of refusa l or revocation of that licence. This is a group of people who have been directly managed by the Firearms Licensing Manager (FLM). This identified one group to review. The Home Office have supplied a search facility on National Firearms Licensing Management System (NFLMS) to identify those firearms and shotgun certificates that have been refused, revoked, surrendered or seized and then returned in the past 12 months. This has understandably identified an overlap with those cases being managed by the FLM (as above) but identified a second group to review. A third group were identified by searching all the West Mercia Police property entries for firearms that had been returned to their owner. This group was targeting those whose firearms and shotguns had been returned without involvement of the Firearms Licensing Unit. During the 12-month review of 2021, these three groups identified 164 cases in total which were thoroughly reviewed by the FLM and then quality assured by their line manager. None identified any danger to public safety. It is my intention to repeat the review using the same methodology, but to cover the period of 8th March 2018 to 31 st March 2023, so that the entire 5 years is covered. This process remains appropriate and will satisfy the following requirements: 1. How many firearm and shotgun certificates have been seized, refused, revoked or surrendered in your force, and how many of those were subsequently returned to the certificate holder between 1st April 2018 and 31 st March 2021? 2. Carry out a review of all certificates that have been seized, refused, revoked or surrendered between 1st April 2018 and 31 st March 2023, and subsequently approved by the police. The inclusion of the data between August 2020 and August 2021 is necessary as there is a possibi lity that certificates may have been returned to any of the 164 cases reviewed after the original report from August 2021 and to further ensure that the assessment made at that time is compliant with the latest 2023 revision of guidance. To complete the enquiry a recently retired Police Officer has been re-employed as a Police Staff member to complete the enquiry. This employee is ideally suited as they have 23 years' experience as an Authorised Firearms Officer, firearms instructor and tactical advisor. They have a clear understanding of managing threats, assessing performance and are confident in articulating this back to senior members of staff. Throughout the review, any matters requiring remedial action, intervention or senior decision making will be escalated to the Firearms Licensing Manager and Ch. lnsp overseeing FELU. In addition, a regu lar progress report will be assessed by Head of Public Contact. www.westmercia.po lice.uk 0 @westmerciapolice O @WMerciaPolice ® @westmerciapolice West Mercia POLICE The intention to satisfy the Regulation 28 concerning 'returns· will follow an identical methodology and provide greater assurance beyond binary figures. It is anticipated that the review spanning 5 years data will entai l: 10 working days initial data retrieval from Cyclops, NFLMS and PMS 21 working days to review all applicable incidents 5 working days for a senior review /FLM of the findings. The review will be completed by the end of October this year. West Mercia undergo regular Firearms Licensing Independent Aud its and have recently undergone an externa l aud it by Warwickshire County Council. I am satisfied that these thorough measures will ensure fu ll compliance with the Regulation 28 requ irements and provide you with the necessary reassura nces that as Chief Constable of West Mercia Police, I have taken specific steps to satisfy myself that adequate local training of a satisfactory standard will be delivered to all of the West Mercia FELU staff in applying the HO guidance on Firearms Licensing Law (Published November 2022) and the revised statutory guidance for Chief Officers of Police, and, that a detailed review of al l certificates seized, refused, revoked or surrendered and then subsequently approved over the past five years is in progress. Chief Constable West Mercia Police www.westmercia .police.uk 0 @westmerciapolice 0 @WMerciaPolice @) @westmerciapolice
CHIEF CONSTABLE Mr Ian Arrow HM Coroner 1 Derriford Business Park Plymouth PL6 5QZ Force Executive Team West Midlands Police Headquarters Lloyd House PO Box52 Colmore Circus Queensway Birmingham B46NQ : Date: 3 May 2023 Dear Mr Arrow I would firstly wish to offer my deepest condolences to the families of Maxine Davison, Lee Martyn, his daughter Sophie, Stephen Washington and Kathryn Shepherd on behalf of West Midlands Police. I hereby attach the Staffordshire Police and West Midlands Police response to the two Preventing Future Death Reports arising from the inquests that were directed to all Chief Constables. As explained in the attached report, the Firearms and Explosives Licensing Unit provides a collaborated service to both forces. The response relating to the review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the last 5 years provides details of the action taken and proposed to be taken as requested. The second response details the level of training undertaken by staff in the Firearms and Explosives Licensing Unit and the proposed training to be undertaken as other details in response to the matters of concern raised in the report. It is understood that the responses may be published. Yours sincerely Chief Constable Working m partnership, makmg communities safer \' 'est -rn ,<Jland s 1>ul.c e u k RESPONSE ON BEHALF OF STAFFORDSHIRE POLICE AND WEST MIDLANDS POLICE-TRAINING Report to prevent future deaths: made under Regulation 28 of the Coroners (Investigations) Regulations 2013 This response is made on behalf of the Chief Constable of West Midlands Police and the Chief Constable of Staffordshire as the Staffordshire and West Midlands Police have a collaborated firearms and explosives licensing service. After consideration of the Regulation 28 Report which raises matters of concern particularly in relation to training we issue the following response . The Staffordshire and West Midlands Firearms Licensing Unit was restructured following the shootings in Keyham in 2021. The following changes and actions were put in place further to the direction of the Staffordshire and West Midlands Collaboration Governance Board as follows: 1. Resourcing, a new staffing structure was approved in December 2021 with growth from 17 police staff employees to 27 at an additional cost of £220,702. 2. Decision Making, introduction of a new Deputy Manager to hold delegated responsibilities (under section 55(2) of the Firearms Act 1968). The post holder is currently undertaking training and is being mentored. the 3. Policy, a new policy document was published on 16/02/2023 aligning operational delivery to the Home Office Statutory Guidance for Chief Officers of Police (2023). 4. Review of certificate holders coming to police notice, the introduction of Intelligence Officers that have core responsibilities for; completing enhanced police background checks, systems monitoring for certificate holders coming to police notice, collating suitability enquiries, collating information for court appeals, triage of medical certificates (on initial receipt), response to FOi requests and assisting police enquiries in criminal matters that relate to In addition, there has been internal certificate holders and/or firearms licensing matters. communications across Staffordshire and West Midlands re-confirming the need for officers to consider seizing certificates and firearms when they attend incidents involving certificate holders. 5. Historically firearms licensing training has largely been based on local delivery and mentoring. Following the tragic shooting in Keyham significant changes have been made to deliver an extensive training package, which includes: a. National Triage Firearms Classification Course - Durham Police (enquiry officer) b. Firearms Safety handling training - Staffordshire Police (enquiry officer) c. Police National Decision Model training - CoP accredited trainers delivered (all staff) d. Awareness training - Safeguarding and Domestic Abuse (all staff) e. Awareness training - Neuro-Diversion (all staff) f. Range assessment training - Clay Pigeon Shooting Association (CPSA) (enquiry officers) g. Open Source - social media training (Intelligence Officers) h. FEO, Decision Making and Administration Courses - Durham Police/Mowbray Associates (all staff) 1 RESPONSE ON BEHALF OF STAFFORDSHIRE POLICE AND WEST MIDLANDS POLICE-TRAINING In the absence of accredited training, the training has been planned following a benchmarking exercise with police services nationally to explore best practice. All decision makers with delegated authorities have undergone Police National Decision Model training and are undertaking the Mowbray Associates Firearms Licensing Decision Making Course. 6. Governance, there is continued oversight by two separate Executive Officer chaired, governance structures. Firstly, the Staffordshire and West Midlands Strategic Partnership Meeting. This addresses operational matters, including performance, training, change and external pressures. The meeting is quarterly and is chaired by an Assistant Chief Constable. Secondly, there is the Staffordshire and West Midlands Collaboration Governance Board, this focuses on strategic governance understanding national matters, addressing Board reputational risk and creating a consultative forum for the Chief Constables' and Commissioner's offices. The meeting is bi-annual and chaired by the Deputy Chief Constable (it is also attended by the Commissioner's Chief Executive Officers). 2 RESPONSE ON BEHALF OF STAFFORDSHIRE POLICE AND WEST MIDLANDS POLICE-REVIEW OF CERTIFICATES Report to prevent future deaths: made under Regulation 28 of the Coroners (Investigations) Regulation 2013 This is a joint response prepared on behalf of the Chief Constable of Staffordshire and the Chief Constable for West Midlands Police as Staffordshire and West Midlands Police have a collaborated firearms and explosives licensing service. This document is providing in response to the Coroner's report which raises concern that a further review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the last 5 years should be subject to a further review to provide assurance of public safety. A review of all certificates seized and returned between August 2020 and March 2023 has been commissioned the details are reproduced in Table 1 below. Certificates granted prior to this period will also be subject to review but the outcome will not be available in time to include in this response. The 5-year information relating to revocation and refusal has been completed and is included within this response at Table 2 and Table 3 Table 1: Certificates sei zed and returned (August 2020 - March 2023): Staffordshire West Midlands *These are scheduled reviews that have been brought forward Seized and Returned 48 16 To be Re-visited following review 2* 0 Table 2 Certificates revoked and then re-issued following application (March 2018 - March 2023) : Revoked Staffordshire West Midlands 116 102 Re-granted (following re- Re-granted (following a successful Court Appeal) application) 1 2 s 4 To be Re-visited following review 0 0 Table 3 Certificates refused and then later granted following application (March 2018 - March 2023): Refused Granted (following re-application) Granted (following a successful Court Appeal) To be Re-visited following review Staffordshire West Midlands ** Re-visited to insure satisfactory circumstances (certificate was granted following a Court appeal) ***Re-visited to insure satisfactory circumstances (no concern with the decision-making review) 80 103 1 5 3 5 1** 1*** To provide further assurance as to the quality and consistency of decision-making there has been a series of scheduled quality assurance programmes in relation to internal and external audits over decision making which are listed below: • Plymouth Coroner's Regulations 28 (PFD) Response - certificates seized, refused, revoked or surrendered and ther:i subsequently approved the outcome of which is included in this report. • External RSM UK - review on certificate applications for initial grant, renewal and suitability reviews (currently ongoing). 1 RESPONSE ON BEHALF OF STAFFORDSHIRE POLICE AND WEST MIDLANDS POLICE -REVIEW OF CERTIFICATES • Home Office review of temporary permits (August 2023). • Information assurance review (currently ongoing) . • ROCU review and scrutiny of prescribed certificate types (May 2023). Findings from all the above audits will be used to professionally develop the decision makers and improve the service. 2
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