Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0349, written 10 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 | 10 Jul 2025 |
|---|---|
| Reference | 2025-0349 |
| Deceased | Jairus Earl |
| Coroner | Rachael Griffin |
| Coroner area | Dorset |
| Category | Child Death (from 2015) · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Secretary of State for the Home Department 2. Secretary of State for Health 1 CORONER I am Rachael Clare Griffin, Senior Coroner, for the Coroner Area of Dorset. 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 16th April 2024, I commenced an investigation into the death of Jairus Joshua Timothy Earl, born on the 8th June 2008, who was aged 15 years at the time of his death. The investigation concluded at the end of the Inquest on the 1st July 2025. The medical cause of death was: Ia Fatal shotgun injury to the head The conclusion of the Inquest was suicide. 4 CIRCUMSTANCES OF THE DEATH Jairus was 15 years old when he died on the 14th April 2024. He had a history of mental ill health and had been under the care of his General Practitioner, a Chartered Psychologist and a Consultant in Child and Adolescent Psychiatry. He had disclosed to them thoughts of ending his life and although he had no plans to do so, he had talked about methods of doing this which included shooting. His father, who Jairus resided with, was a shotgun licence holder. Jairus enjoyed outdoor life and would go out with his father and other family members shooting. The family resided in London, which is where the shotgun licence was held, however they had another home in Dorset. At the end of March 2024, the family travelled to Dorset to spend some time together at their home in Dorset. They took with them a number of shotguns which were then placed in a secure cabinet at the home address in Dorset. Dorset Police were not advised of the location of these guns in the Dorset area as there is no current legal requirement to notify the force where additional places of residence may be. On the 14th April 2024 Jairus and his father were due to return to their home in London and were closing down the property. Jairius’ father was in the process of packing the guns into his car to transport them to London when Jairus went into the office at the property where he used one of the shotguns to end his life. 5 CORONER’S CONCERNS During the course of the investigation the evidence provided 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. – (1) I have concerns in relation to gaps in the regulation of shotgun licences especially when a licence holder has more than one property where the guns may be used or stored. The Firearms Act 1968 (The Act) is the primary legislation that governs the possession and handing of firearms. This is supported by statutory guidance, Firearms Licensing: Statutory Guidance for Chief Officers of Police and non statutory Home Office guidance, Guide on firearms Licensing Law. Section 2 of the Act deals with the requirement of certificate for possession of shotguns. Evidence was given at the Inquest by Acting Chief Inspector of Dorset Police who works within the Dorset Firearms and Explosive Licensing Unit and also works with the College of Policing and the national Firearms & Explosive Licencing Working Group to review and update the Home Office statutory guidance and support the national training effort in response to the Prevention of Future Deaths report from the Inquest touching upon the deaths in Keyham on 12th August 2021. He gave evidence that the regulation for shotguns is different to the regulations for firearms which is governed by Section 1 of The Act. There seems to be a great deal of difference in the regulation of firearms and the regulation of shotguns, however both can equally cause death. I am concerned that the lack of regulation around shotguns could lead to future deaths. For example, he explained that there is no obligation on a licence holder of a shotgun licence to notify the approving force they are moving to or visiting another property In his written evidence to the Court, which was further expanded on orally at the Inquest, he explained: “Under section 26B(1) of the 1968 Act, an application for the grant of a shotgun shall be made to the chief officer of police where the applicant resides, there is nothing within the firearms act to define a residence or when applicants have properties in different force areas, the non-statutory guide tells me that where an applicant has a residences in different force areas, it is for the individual to decide which force issues their certificate. Shotgun certificates are issued by individual forces’ and will display the force crest and signature of the chief officer of the issuing force, however they are valid throughout England and Wales, and allows the holder to travel with their shotguns anywhere in the United Kingdom. … Shotgun certificates differ from firearm certificates in a number of ways, for firearms, possession of each and every gun must satisfy individual good reason, whereas a good reason for a shotgun is a collective term, and more relaxed, for example a request for a firearms certificate for target shooting will require that the applicant is a member of a Home Office approved club and shoots regularly, whereas a mere intention to undertake clay pigeon shooting would satisfy good reason for a shotgun certificate. A shotgun certificate also will also authorise a person to have in their possession, purchase or acquire and unlimited number of shotguns without the need for approval in respect of individual guns, that is to say that so long as the shotguns are stored securely a person may have as many as they want. Another nuance of the shotgun certificate is the ’72-hour rule’ that it will allow a certificate holder to borrow a shotgun for up to 72 hours without the need to have to record the shotgun on the certificate or notify the police of the transfer. … Section 28(2)(a) of the 1968 Act provides that a shotgun certificate is granted subject to any prescribed conditions, and no others, that is that these conditions must be applied to the certificate, but the chief officer cannot add additional conditions. …. There is no onus on an applicant to notify another force area where they hold a certificate and have another address in that force area, this is only the case if the certificate holder changes their permanent address that this would be captured by the third condition. There is also no obligation on a certificate holder to notify a chief officer of police when they intent to visit another force area in possession of their shotguns. Acting Chief Inspector explained that on the Tuesday following Jairus’ death he briefed the national coordinator from the Firearms & Explosive Licencing Working Group to raise matters arising from the circumstances of Jairus’ death so there is awareness of the issues relating to second homes, however, there is no legal requirement for second homes to be declared by licence holders. He further told the Court that in 2015, HM Inspection of Firearms Licencing recommended that forces must have a notification system on their local records to identify addresses and people where firearms are held. He explained that these systems are local rather than national and his recommendation to the Firearms & Explosive Licencing Working Group following Jairus’s death was that where an applicant declares a second home, the force where that home is located should be notified. Dorset Police have taken action and put a system in place that when they are notified of the above, they will create a record on their system to flag the address as if that were a Dorset certificate holder, however it is not a legal requirement for forces to do this, and it is unknown if other forces nationally are doing this. I therefore have concerns there is a lack of a system of sharing and flagging information between Police forces regarding shotgun licence holders and the location of shotguns, which could lead to future deaths. Accordingly, emergency services may attend an address where shotguns are held without knowledge of that fact due to the lack of a marker being placed on the address. This causes a risk to all those attending unmarked addresses as they would potentially be ill prepared for what they could face which could lead to future deaths. Additionally failing to have such markers on additional homes means that if the police are called to the address for other reasons such as a concern for welfare, they may miss the opportunity to put in place additional security measures ,or even revoke the licence, as required for the safety of the occupants at the address, and others. Evidence was heard that Dorset Police were called to Jairus’s family address in Dorset on the 28th March 2024 following a report that Jairus was missing. It was not apparent from the Police system at the time that there would be shotguns at the address. Jairus’s mental health was discussed during the report of this incident. Had the flag system been in place then, consideration could have been given to the continued possession of the shotgun in a property where Jairus could access them. (2) Further I have a concern around the access that police forces have to medical information about other persons living at the same property as the applicant, or at their second homes, when considering firearm and advised the shotgun licence applications. Acting Chief Inspector Court that whilst Police forces can look at the medical history of the applicant and can speak to others present at the address, they have no legal right to access the medical records of others residing at the property. The medical history of Jairus came as great surprise to the attending Police officers at the Inquest. I am concerned that the lack of access to this medical information of others residing at the address of a licence applicant, especially in relation to mental health, when considering firearms or shotgun licence applications could lead to 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 You are under a duty to respond to this report within 56 days of the date of this report, namely by 4th September 2025. 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 via their legal representatives: (1) Jairus’ family I am also under a duty to send the Chief Coroner a copy of your response. I have also sent this report to the following who may find it of interest: (1) Chief Executive Officer of the College of Policing (2) Chair of the National Police Chiefs’ Council (3) Dorset Child Death Overview panel 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 Signed Rachael C Griffin, HM Senior Coroner for Dorset 10th July 2025
3 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.
Minister of State for Health (Secondary Care) 39 Victoria Street London SW1H 0EU HM Senior Coroner Rachael Clare Griffin Coroner’s Office for the County of Dorset, BCP Civic Centre, Bourne Avenue, Bournemouth, BH2 6DY 12th September 2025 Dear Ms Griffin, Thank you for the Regulation 28 report of 10/07/2025 sent to the Department of Health and Social Care about the death of Jairus Joshua Timothy Earl. I am replying as the Minister with responsibility for data and technology. Firstly, I would like to say how saddened I was to read of the circumstances of Jairus’ death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are deeply tragic and I am grateful to you for bringing them to my attention. The report raises concerns over gaps in the regulation of shotgun licenses, especially when a licence holder has more than one property where the guns may be used or stored, and the lack of access police forces have to medical information about persons other than the registered applicant living at the same property, or at their second homes, when considering firearm and shotgun license applications. The Department have worked closely with the Home Office and the British Medical Association to ensure there are strong controls in place in relation to an applicant’s medical suitability which is an important element of the application process that the police consider when deciding if an applicant can hold a firearms or shotgun certificate. An applicant is required to declare all relevant medical conditions upon applying and they must provide details of their GP, giving approval for their GP to share any concerns with the police for the application and throughout the period of firearms or shotgun licence, if granted. The proforma is then completed by their GP or an independent General Medical Council registered doctor. The doctor completing the proforma checks the GP medical record and must provide details of all relevant medical conditions to the police. This process has been further strengthened within GP IT systems, where a GP adds a digital marker to the patient record, to note that the patient has a firearms certificate. This was fully rolled out to all GP IT systems in England by May 2023. If the patient begins to experience a relevant medical condition while the certificate is valid, upon discussion with the GP, the GP will see an alert and can flag this to the police allowing them to review the person’s suitability, and if necessary, revoke the certificate. Ensuring that health and non-health data is linked effectively is vitally important to making the best decisions possible to ensure the safety and security of all. In relation to firearms licences, we must do this in a way that is proportionate and balances individuals’ rights to confidentiality with the safety of those holding firearms licences and others who could potentially access that firearm. Considering the matters you raise in connection to Mr Earl’s death, we will carefully explore the options for and implications of broadening access to relevant medical information of others residing at licence-holders' addresses. Dependent on the outcome of an initial implications appraisal we would look to engage with GP profession representatives and, in the meantime, work with them to ensure that operational guidance relating to the existing Digital Firearms Marker policy remains fit for purpose and considers ongoing learnings. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR HEALTH
Minister of State for Policing, Fire and Crime Prevention 2 Marsham Street London SW1P 4DF 4th September 2025 Mrs Rachael C Griffin HM Senior Coroner for Dorset Civic Centre Bourne Avenue Bournemouth BH2 6DY BY EMAIL ONLY Dear Mrs Griffin, INQUEST FOLLOWING THE DEATH OF JAIRUS JOSHUA TIMOTHY EARL REPORT TO PREVENT FUTURE DEATHS UNDER REGULATIONS 28 AND 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 I am writing to thank you for your Regulation 28 report of 28 July 2025 following the inquest into the death of Jairus Joshua Timothy Earl on 14 April 2024, which involved the use a licensed shotgun. You reference in your report the differences in the controls that apply to the licensing of shotguns and other firearms, and you have highlighted two specific concerns that you consider present a risk of future deaths unless action is taken. We are grateful for your report as we are always looking to ensure we have effective controls to mitigate potential firearms risks. The first of these concerns was about the lack of a system for sharing and flagging information between police forces regarding shotgun licence holders and the location of shotguns. This applies in particular to situations where shotguns are located from time to time in a certificate holder’s second home, which could be without the knowledge of the relevant police force, if that force is different to the force that issued the certificate holder’s firearm at their primary address. All police forces have been alerted to this as an issue. It is possible for the police to check whether an individual is a firearm or shotgun certificate holder, for example, when responding to an incident by checking the firearms licensing data system, known as the National Firearms Licensing Management System (NFLMS). Also it is a requirement that all firearm and shotgun holders must keep their firearms stored and locked securely away at all times when not in use to ensure that no one else can access them. There is, however, presently no requirement on those applying for a firearm or shotgun certificate to provide details of a second home when submitting their application, and the details of the second home will not, therefore, be routinely recorded on the NFLMS. In the light of your Regulation 28 Report, we will be amending the firearm and shotgun application form as soon as is practicable to request details of any second (or additional) residences where guns may be held, so that police are aware of where firearms are being stored, including where guns are being stored in different police force areas. This change to the application form will be implemented via Statutory Instrument and will also require a change to the NFLMS to ensure such details are recorded. We are therefore adding this change to planned adjustments to the system, which we expect to be completed in early 2026. In the meantime, this issue will be addressed by the police when undertaking suitability interviews with applicants or certificate holders. Your second concern was about police access to medical information about other persons living at the same property as the applicant, or at their second homes, when considering firearm and shotgun licence applications. You will therefore wish to note that the most recent revision of the Statutory Guidance for Chief Officers of Police on firearms licensing, which was published on 5 August, now includes a specific requirement that the police should consider the mental wellbeing of both the applicant and other household members during home visits associated with an application for a firearm or shotgun licence. The Statutory Guidance says that such interviews are crucial in providing the police with a more comprehensive picture of both the applicant and other household members’ circumstances, including in relation to domestic circumstances or possible mental wellbeing issues, in order to assist in undertaking a comprehensive assessment of the safety of the applicant and others, as well as the suitability of the applicant. I am aware that you have also sent your Regulation 28 Report to the Secretary of State for Health and Social Care. That Department will be able to address and respond to the issue of the police having access to information about the health of persons other than those who are seeking to obtain a firearm or shotgun certificate. However, as this is a clear risk which has been identified, we will be engaging with the DHSC directly on this point and how to mitigate that risk despite the data protection and consent issue concerns involved. Public safety, including the safety of shotgun and firearms certificate holders, their families and the wider community, is at the heart of firearms licensing controls. It is right that we learn from the circumstances of all shooting incidents to see whether there are changes that should be made to the controls on firearms to help to prevent future incidents and tragedies. In relation to the differences in the controls on shotguns and other firearms which you referenced in your Regulation 28 Report, you will be aware that this was raised by the Senior Coroner for Plymouth, Torbay and South Devon in his Prevention of Future Deaths Report following the Inquests into the deaths of those who were shot and killed in Plymouth, on 12 August 2021. The previous Government held a public consultation in 2023 on recommendations that had been made by the Coroner, although not those recommendations concerning shotguns, and a formal response to that consultation was published on 13 February this year, in which we therefore committed to having a consultation later this year on the controls on shotguns. This will be consulting on greater alignment between these controls and the controls on other firearms. Thank you again for your report. We continue to keep the controls on firearms under close review to ensure that the strongest possible safeguards are in place. Yours sincerely, Rt Hon Dame Diana Johnson DBE MP
College of Policing Po Box 58323 London NW1W 9HG NPCC Chiefs Council 50 Broadway London SW1H 0BL To Senior Coroner, Mrs Rachael Clare Gri(cid:431)in Coroner Area of Dorset By email 2nd September 2025 Dear Mrs Gri(cid:431)in Thank you for your Regulation 28 Report to Prevent Future Deaths (PFD) dated 10th July 2025, and which was sent to the Secretary of State for the Home Department and Secretary of State for Health. You also sent this to the Chief Executive of the College of Policing and Chair of the National Police Chiefs Council (NPCC) as persons who may find it of interest. I write today on their behalf and that of Deputy Chief Constable Warwickshire Police who leads the NPCC Firearms Licensing Portfolio. I am the NPCC Strategic Coordinator for Firearms Licensing and currently seconded into the College of Policing to deliver the new National Firearms Licensing Training Programme. from This relates to the tragic death of Jairus Joshua Timothy Earl aged 15 years on 15th April 2024. I would like to begin by expressing my sincere condolences to Jarius’s family and friends. I am deeply sorry to learn of the circumstances you described, and I appreciate you taking the time to raise these important concerns to us. I have also engaged with both Dorset Police and the Metropolitan Police Service to learn more about this incident. Whilst my response will confirm our current position and proposals around the issues that you have raised, I must equally highlight the absolute importance and personal responsibility on licence holders for the security of their firearms especially when there are significant known concerns regarding the mental health and vulnerability of those close to them. There is a specific condition on the licence to ensure that shot guns, must at all times be stored securely so as to prevent, as far as is reasonably practicable, access to the guns by an unauthorised person. You have correctly highlighted that there is currently no statutory responsibility on licence holders to inform policing if they store firearms temporarily at second homes. I believe it. Page | 1 would become too complicated for example if new rules were created for licence holders without second homes to inform policing every time their firearms are temporarily away from home when attending shooting locations. We would not have the capacity to check and authorise such short-term arrangements. Some forces have sought to implement local measures to deal with secondary storage locations. For this to be consistently applied nationally, there must be clear guidance in place and onus on licence holders to declare their second homes if they propose on storing firearms there. My intentions therefore are to develop this issue with the Home O(cid:431)ice Firearms and Weapons Policy Unit to establish if the Firearms Licensing Statutory Guidance for Chief O(cid:431)icers and application forms can be further amended to cover these circumstances. In addition to the above there is a significant programme of works underway chaired by the NPCC Firearms Licensing Lead and project managed by Police Digital Services (PDS) to develop a brand-new National Firearms Licensing Management System (NFLMS). Of the various aspirations with this new system, it will deliver the much-needed consistency required as all firearms licensing teams, licence holders and applicants will use it. It will align with many systems already used by policing and in relation to this tragic incident there would be opportunities for second homes to subsequently alert local force systems that firearms may be present on those premises. Finally, on this point our intentions are to review the Firearms Security Handbook (last revised 2020) to ensure that it aligns with the new statutory guidance. We can use this opportunity to further reference second homes within this public document. Your report references the di(cid:431)erence between the Section 1 Firearm and Section 2 Shotgun legislation, highlighting that both are lethal barrelled weapons. The NPCC Firearms Licensing Portfolio acknowledge this and welcome the Government intentions to hold a public consultation later this year to consider the closer alignment of firearm and shotgun legislation. We will respond to this when it occurs and actively engage with all police licensing teams to ensure all opinions are collated and fed back through the Home O(cid:431)ice. The PFD lastly highlights your concerns over the lack of access to medical information of others residing at the address of a licence applicant, especially in relation to mental health. This is a shared concern within police firearms licensing as we should take an active interest in those around the applicant or current licence holder as their behaviour or vulnerability could impact on the statutory test for others to possess firearms i.e not being a danger to public safety or to the peace. Whilst we are unable to directly access the medical records of those around the applicant, because of this case and similar tragedies we have successfully worked with the Home O(cid:431)ice to further strengthen the statutory guidance on this specific point, which now reads: Page | 2 2.16 Home Visits and Inspections The home visit must include an interview to discuss all issues relevant to suitability as set out in this guidance and must include inspection of security arrangements. The police should always interview the applicant’s partner and other members of the household during the home visit unless there is a strong reason for not doing so. Where there are considered to be such strong reasons, the position should be agreed with the relevant manager and properly recorded. Such interviews are crucial in providing the police with a more comprehensive picture of both the applicant & other householder’s domestic and mental wellbeing circumstance, to assist with their suitability assessment. The interview with the applicant’s partner and other members of the household must be undertaken separately from the interview with the applicant, and without the applicant being present, and any disclosure which leads to a decision to refuse (or revoke) a certificate should be carefully communicated so as to minimise to the greatest extent possible the risk to the partner or other household member. If there is the possibility or evidence of domestic abuse (see paragraphs 2.57 to 2.64 below) or other mental wellbeing concerns then wider enquiries and investigations must take place. In addition to the Home O(cid:431)ice Statutory Guidance, as the professional body for policing in England and Wales, the College of Policing is equally committed to setting high standards across the service. The aim is to support o(cid:431)icers and sta(cid:431) in delivering e(cid:431)ective, ethical, and evidence-based policing, which meets both current and future challenges. One of the keyways we do this is through the development of Authorised Professional Practice (APP)—the o(cid:431)icial source of professional guidance for policing in England and Wales. The Firearms Licensing APP was subject of a significant review in 2023 and will encourage to use three overlapping factors that inform professional judgement around risk. These are: communication curiosity clues These three factors are not hierarchical, and they are potentially self-reinforcing. For example, good communication can reveal more clues, which may identify more avenues for investigation (curiosity). This can lead to more focused communication. Good communication allows staff to address and probe sensitive issues that are relevant to the application such as people’s past, health, and vulnerability. Staff should exercise professional curiosity to actively identify and investigate suitability such as asking questions and keeping an open mind. Staff should be alert to and understand the clues that may impact on suitability such as medical conditions or signs of vulnerability Page | 3 The relationship with Police Firearms Licensing Teams and applicants or current licence holders is built on trust. The expectation being that applicants or licence holders declare relevant medical conditions for themselves or in relation to a family member or associate who lives at the address or has unsupervised access to the address. These are just a few of the considerations that we discuss with learners who attend the mandatory firearms licensing training programme. As part of this training, in June 2025 we commenced delivery of an additional two-day course for Firearms Licensing Enquiry O(cid:431)icers where we focus on important subject areas relating to domestic abuse, family turmoil together with mental health and wellbeing. I trust this o(cid:431)ers a helpful response to the concerns that you have raised and would thank you once again for bringing this matter to our attention. I would please ask that you pass on my deepest sympathies to Jairus’s family and loved ones. Yours sincerely, Strategic Coordinator & Policing Standards Manager Firearms Licensing Page | 4
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