Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0341, written 8 Jul 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Jul 2025 |
|---|---|
| Reference | 2025-0341 |
| Deceased | Sean Fitzgerald |
| Coroner | Sir John Saunders |
| Coroner area | Coventry and Warwickshire |
| Category | Police related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
The Hon. Sir John Saunders Sitting as Coroner in the Coroner Area of Coventry and Warwickshire INQUEST INTO THE DEATH OF SEAN FITZGERALD REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Chief Executive Officer of the College of Policing, Rugby Building Leamington Road Ryton-On-Dunsmore Coventry CV8 3EN 2. The Chief Constable of West Midlands Police, Police Headquarters, Lloyd House Colmore Circus Queensway Birmingham B4 6NQ 1 CORONER I am Sir John Saunders, a former judge of the High Court. Under paragraph 3 of Schedule 10 to the Coroners and Justice Act 2009, I was nominated by the Lady Chief Justice to conduct an investigation and inquest into the death of Sean Patrick Fitzgerald (“Mr Fitzgerald”). Following that nomination, I have exercised the functions of senior coroner in the coroner area of Coventry and Warwickshire in relation to the investigation and inquest. 2 CORONER’S LEGAL POWERS I make this report under: 1 (a) Paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 (https://www.legislation.gov.uk/ukpga/2009/25/schedule/5); and (b) Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 (https://www.legislation.gov.uk/uksi/2013/1629/part/7/made). 3 INVESTIGATION AND INQUEST This investigation concerns the death of Mr Fitzgerald, who was fatally shot by a West Midlands Police (“WMP”) officer (known as Officer K) on 4 January 2019 during an armed operation at a residential address in Coventry. The investigation commenced on 10 January 2019 and concluded at the end of an inquest hearing on 21 May 2025. In summary, the conclusions at the end of the hearing were as follows: (a) The medical cause of death was: 1a. Gunshot Wound of the Chest. (b) The jury returned a short-form conclusion of death by lawful killing, supplemented with (i) a narrative setting out the circumstances of death and (ii) answers to two supplementary questions which concerned the planning and preparation, and the implementation, of the police firearms operation. The jury’s narrative and answers to the two questions are set out in the next section of this report. 4 CIRCUMSTANCES OF THE DEATHS The jury returned a supplementary narrative as to the circumstances of Mr Fitzgerald’s death, as follows: “On 4 January 2019, Sean Fitzgerald was at a house at in Coventry. A team of police firearms officers from West Midlands Police arrived at the house to perform a search warrant. At shortly after 6.20pm, officers at the front of the house began using a chainsaw to break down the front door. At this point, Sean Fitzgerald went to the back door, opened it and emerged. A police firearms officer in position about 7.5 feet from the back door discharged his firearm towards Sean Fitzgerald. The shot struck him in the chest and caused serious internal injuries. Despite prompt first aid from police officers and from paramedics and a doctor, it was not possible to resuscitate him, and he died of the gunshot wound. He was declared dead at 6.55pm.” The first supplementary question asked: “Do you consider that there was any failure in the planning and preparation for the police firearms operation on 4 January 2019 which may have or did materially contribute to Sean Fitzgerald’s death?” The jury answered “Yes” to the first question, providing the following explanation: “1. We are unanimously agreed on the following failures in planning and preparation. It was important that the planning should have stated that MOE [method of entry] would not commence until [Officers] K & F had verbally confirmed they were in place on rear containment. This was a missed opportunity 2 2. Due to the lack of intelligence on the rear of the property and the surrounding alleyway, it is a serious omission in standard procedure to not consider and assign secondary roles to a certain number of AFO’s [authorised firearms officers] should officers F & K request assistance at the rear. 3. Due to the nature of the MOE used, it was seriously inadequate that the Armed Police challenge is not announced before the commencement of MOE.” The second supplementary question asked: “Do you consider that there was any failure in the implementation of the police firearms operation on 4 January 2019 which may have or did materially contribute to Sean Fitzgerald’s death?” The jury answered “Yes” to the second question, providing the following explanation: “- We agree with a majority of 10-1 that [Officers] K & F acted reasonably in choosing the positions they took up based on the briefing and the intelligence about the property. - We agree with a majority of 10-1 that [Officers] K & F acted reasonably in not requesting the deployment of further officers to the rear based on the briefing. - We unanimously agree that the officers should have announced ‘Armed Police’ on the front of the premises, earlier than they did, at a point before MOE [method of entry] commenced. - We agree with a majority of 10-1 that officers K + F should have announced Armed Police on the rear of the premises at the point the curtain moved behind the rear door. - We agree on a majority of 10-1 that officers K & F should have turned on their torches at the rear of the property at the point MOE [method of entry] commenced on the front door.” 5 CORONER’S CONCERNS During the course of the inquest, the evidence revealed matters giving rise to concerns. In my opinion there is a risk that future deaths could occur unless action is taken. In these circumstances it is my statutory duty to report to you. The matters of concern set out below relate to the training and guidance provided to firearms officers performing tactical options in the context of armed operations. Although firearms operations by their nature vary, my concerns have broad application because they relate to the performance of commonly used tactics and to general principles which apply in armed policing. In considering these matters, I have taken account of evidence from (a) the officers involved; (b) witnesses with experience of local and national training, policies and guidance (including senior firearms training officers); and (c) a range of experts who gave evidence on topics including (i) the conduct of police tactics and (ii) the operation of human perception, cognition and visual processing. Given the risks to life inherent in armed policing, both to the officers and to members of the public, it is important that firearms officers are given the best 3 possible training and support to perform their role. I hope that this report will be considered carefully. The MATTERS OF CONCERN are as follows: (1) Training and practice in relation to timing of any announcement of “armed police” in police firearms operations involving containment of properties In the police operation in which Mr Fitzgerald was killed, the officers employed the tactic of “contain and call out with limited entry.” This involves firearms officers “containing” a property by surrounding it and providing firearms cover with their weapons; creating a breach by forcing entry; and “calling out” the subjects inside (directing them to leave through the point of breach), without the officers themselves entering. In evidence, it was explained that this is a very common tactic, which is used in a range of scenarios. , a former senior firearms officer and armed policing lead within the College of Policing, gave evidence in the inquest. He explained that an integral part of the tactic is for officers to announce their presence by loud shouts of “armed police.” This warns those inside the property that it is the police forcing entry and informs them that the officers are armed. It was explained that this warning helps to avoid confusion and encourage compliance, thereby reducing the risk of harm to officers and occupants. The timing of the announcement is plainly important, and any potential for confusion or for making the announcement at the wrong time risks fatal consequences. said that the timing of any such announcement is not prescribed by national training or guidance, and that there is no “template” for when it should be done, although he understood that it would usually be made after achieving a breach (e.g. breaking down a door). The procedural and training documents (both national and from WMP) which were put in evidence in the inquest gave no detailed guidance on the subject. The Chief Firearms Instructor at WMP, , gave evidence that WMP trains its officers to make the announcement after achieving a breach. The evidence of the officers involved in the operation as to the recommended or standard practice was inconsistent. The Strategic Firearms Commander said that he expected officers to announce themselves as armed police as soon as they were in position. The Operational Firearms Commander said that the shout should first be made as soon as the chainsaw was being applied to the door and again as the breach was made. One further member of the team said that he thought best practice was to give the shout as the chainsaw was being applied, but he acknowledged that he had not done so on this occasion. Several other members of the team thought that proper practice was only to make the announcement after the door had been breached. The firearms briefing told the officers that method of entry would be conducted and “[o]nce breached, challenges will be made at the threshold and suspects will be handcuffed”. There was no further discussion or direction about when the officers should first announce their presence. 4 In the event, the officers at the front of the property did not shout “armed police” before breaking down the two doors at the front of the property. Before any announcement was made, Mr Fitzgerald left through the rear door of the premises and was shot by Officer K, who was providing rear containment. In these circumstances, I am concerned that the guidance and training given to firearms officers on tactics of containing and entering properties (and specifically in relation to the containment and call out with limited entry tactic) does not ensure a clear and consistent understanding of when they should announce their presence, or what factors to consider in deciding when to make the announcement. I am also concerned that the topic was not the subject of more specific discussion or direction in the briefing. It is important that officers conducting these kinds of highly challenging firearms operation should have proper guidance on this subject. If the approach of different officers is inconsistent, there is the clear potential for mistakes to be made and for the lives of officers and others to be put at risk. I appreciate that expert firearms training officers are best placed to produce any further guidance, and that it may not be possible to have a hard and fast rule. However, the inconsistent views of highly trained officers which were given in this inquest indicate that the subject ought to be further addressed in training and in formal guidance. (2) Training and practice in relation to positioning of firearms officers in operations against properties (including consideration of the reactionary gap) As set out above, in this case, Officer K was standing between 7 and 8 feet from the rear door of the property as Mr Fitzgerald left. He discharged his firearm within just over half a second of the door beginning to open. The jury found that he had acted lawfully, meaning that he had perceived a threat and had used force commensurate with the threat he perceived. They also found that he had acted reasonably in taking up the position which he took, given the briefing he had received. Nevertheless, the evidence at the inquest gave cause for concern in relation to the training and guidance given to firearms officers on how they should position themselves in operations against properties. In the inquest, two experts in cognition and perception, and , explained that close proximity to a potential source of danger can have a psychological impact, significantly elevating a person’s perception of threat and potentially increasing the likelihood that they will respond with force. The experts considered that, in this case, such proximity was likely to have heightened Officer K’s perception of threat. The inquest heard evidence about the concept of the “reactionary gap”, a distance which officers are often trained to maintain between themselves and a subject who presents a threat. In evidence, discussed this concept, explaining that distance gives officers more time to assimilate information and respond to an approaching threat. explained that maintaining a reactionary gap prevents officers from being “closed down” by subjects. He said that officers are trained on the importance of distance in the context of containment tactics. 5 The firearms training and guidance materials considered in evidence made limited reference to positioning and the reactionary gap. The WMP training materials required students to demonstrate an appropriate reactionary gap in one training exercise and to explain its importance in another. The College of Policing’s Authorised Professional Practice on Armed Containment described the benefit of distance, but in terms of reducing stress, tension and the likelihood of a close quarter confrontation. None of the materials gave any detailed consideration to the risks presented by close proximity (including close proximity to entrances rather than subjects) in the context of armed containment of properties. None explained the potential impact of proximity on threat perception and the likelihood that an officer will respond with potentially lethal force. I am concerned that the training and guidance given to firearms officers on how to position themselves, especially in operations against properties, does not include detailed consideration of the risks of taking up position in close proximity to entrances. It does not appear to address the effects of proximity on threat perception and the use of force. As with the first matter of concern, I recognise that it should be for expert firearms training officers to decide how to deal with this subject in training and guidance, and that there will inevitably be situations where a firearms officer has to take up position very close to a doorway or other entrance when containing a property. However, there appears to be a need for further consideration of this issue in the interest of minimising the risks of mistake of fact shootings in the future. Finally, I should stress that in raising this matter of concern, I am not detracting from the jury’s conclusions that Officer K’s use of force was lawful and that his decision on where to position himself was reasonable in light of the briefing and intelligence. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths, and I believe that the College of Policing and West Midlands Police are bodies which have the power to take such action. The College of Policing has responsibility for overseeing training and guidance to firearms officers at the national level and has the power to make changes to address the matters of concern identified above. West Midlands Police is responsible for conducting local training (including refresher training) for its firearms officers and for issuing local guidance. The force thus has the power to make changes to local practices and guidance to address the matters of concern identified above. 7 YOUR RESPONSE A response to this report should be provided within 56 days of the date of this report, namely by 2 September 2025. As coroner, I am able to extend the period if appropriate. 6 Your response should contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you should explain why no action is proposed. 8 COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and to those other than WMP who are Interested Persons in the inquest, namely: (i) the family of Mr Fitzgerald; (ii) Officer K; (iii) West Mercia Police; (iv) Warwickshire Police; and (v) the Independent Office for Police Conduct. I am also under a duty to send a copy of your response to the Chief Coroner and all Interested Persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish this report and/or any response to it in complete, redacted or summary forms. She may send a copy of this report and/or any response 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. 9 Dated 8 July 2025 Sir John Saunders 7
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Coroner’s Office
Coventry Register Office
Manor House Drive
Coventry CV1 2ND
Tel: 02476 975509
19 February 2026
Dear Sir John Saunders (Acting Coroner),
Inquest into the death of Sean Fitzgerald. Letter of concern
I am writing in response to your letter dated 8th July 2025, and as a follow up to my letter to you
dated 26th August 2025. This letter relates to the coronial inquest into the death of Mr Sean
Fitzgerald and a matter of concern arising from that inquest. I acknowledge your concern in
respect of the provision of key police witness accounts in the post incident context and I would
like to take the opportunity to update you on the work undertaken to address your concern.
Following consultation with stakeholders, most notably the Independent Office of Police
Conduct (IOPC), who were also in receipt of a letter of concern regarding the same matter,
additional guidance has been drafted for inclusion within The College authorised professional
practice on armed policing (APP-AP) and the authorised professional practice on post-incident
procedures following death or serious injury. The amended APP will be published within the
next 2-3 weeks and in the interim the guidance has been published in a National Police Chiefs’
Council (NPCC) national circular and circulated to all police forces in the UK for immediate
implementation. The amended guidance has been included in a practical scenario that formed
the basis of this year’s annual College national Post Incident Manager (PIM) training which all
PIMs must receive.
The guidance now states.
Reference material
Reference material may include:
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•
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•
body-worn video (BWV) footage
incident logs
notes taken at the scene or during the incident
command logs
recording of communications
Any available reference material, documentation and BWV footage, that may be relevant to a
DSI following police contact, will be essential to the subsequent investigation and should be
secured and managed appropriately.
Viewing BWV and other reference material and the provision of accounts
The PIM has responsibility for determining whether an officer/staff member may refer to an item
of reference material when providing their accounts and should make these decisions in
consultation with the IIA and IIO/PSD.
It is essential that a KPW provides the most complete personal initial account that they are able
while their memory is most intact and unaffected, (see Stage three – personal initial accounts).
A KPW should provide an initial account based solely on their personal recollection of the
incident, to preserve the integrity of their evidence and avoid contamination from post-event
information. This accords with the requirements in the Police Reform Act 2002, the Standards of
Professional Behaviour in The Police (Conduct) Regulations 2020 and the IOPC Statutory
guidance which collectively provide the framework for obtaining and preserving evidence in DSI
matters.
The potential impact on the individual’s perception and recollection of events makes viewing
reference material inadvisable prior to completing the personal initial account. In some
circumstances however it may be appropriate for a KPW to view or listen to reference material
other than BWV, (e.g., log information, contemporaneous audio, written notes), before providing
a personal initial account. Such material may have captured information that helps a KPW
accurately recall relevant and essential elements of an incident.
BWV is a valuable corroborative tool but must not replace a KPW’s account. It offers a relatively
limited perspective and should therefore be used in conjunction with other evidence sources. It
may be appropriate for one KPW to view another person’s BWV footage, for example, where
two officers/members of staff were acting in close proximity and one BWV did not record. Where
2
the BWV has recorded footage which provides a significantly different perspective than a KPWs
personal BWV would have captured it should not be viewed. Only in exceptional circumstances,
and with the agreement of the IIA, should remote footage (e.g., CCTV, drone) be viewed.
The human memory system does not work in the same way as a camera. BWV may therefore
present a different visual perspective from that experienced by the KPW at the time. A camera
does not, for instance, accurately capture peripheral vision or tactile cues. BWV may however
provide visual cues that assist a KPW in describing their experience and perception.
Where incidents or ‘use of force’ interactions are uncomplicated, or occur within a short time
period, it may not be beneficial, and could even be prejudicial, to view BWV prior to providing a
detailed account.
Viewing BWV at an appropriate time may assist the KPW in recalling specific details,
particularly sequencing of events in complex or protracted incidents. It may also help ensure
accuracy in describing the use of force and its justification or assist with recall of critical
evidence such as location of objects, demeanour of individuals, or environmental conditions.
Viewing BWV may however influence an officer’s memory, consciously or unconsciously, and
as a consequence their accounts may unintentionally include details they didn’t perceive during
the incident.
KPWs should not therefore feel obligated to describe everything that the BWV has captured if
they have no personal recollection of it. This could prejudice officer’s accounts and lead to
further scrutiny.
Any decision regarding the point at which a KPW views BWV should be made following careful
consideration of the circumstances and the implications for the KPWs memory and recall. The
decision, and supporting rationale, relating to the point at which a KPW views their BWV must
be recorded by the PIM following consultation with the IIA and IIO/PSD.
There may be circumstances where there is an understandable difference between what has
been captured in reference material and what the KPW has recalled and reported in their
personal initial account or detailed account. The KPW may be able to explain any differences
within their detailed account or in a subsequent account, depending on whether they view the
relevant reference material before or after provision of the detailed account.
If BWV is viewed prior to providing a detailed account.
3
•
•
•
•
•
•
the officer/staff member must document the prior viewing of BWV in their account
a personal initial account that meets the APP criteria should have been previously
completed (see stage 3 - personal initial accounts)
the PIM must record the rationale for this
the account should distinguish between what the officer recalls from their own
memory and what is observed from the footage to the extent possible
the reason and timing of the viewing must be included
the account should clarify, where possible, differences in the personal initial account
I would also like to reassure you that The College works proactively with forces, the NPCC and
other stakeholders to ensure that the training and guidance it provides remains operationally
relevant and that lessons are learnt. I would like to thank you for making me aware of your
concern and I trust the response will satisfactorily address that concern.
Yours sincerely,
Chief Executive Officer
College of Policing
4
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