Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0627, written 16 Dec 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Dec 2025 |
|---|---|
| Reference | 2025-0627 |
| Deceased | Richard Haddock |
| Coroner | Alison Longhorn |
| Coroner area | County of Devon, Plymouth and Torbay |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Devon & Cornwall Constabulary
1 CORONER
I am Alison Longhorn, Area Coroner for the coroner area of the County of
Devon, Plymouth & Torbay.
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 31st May 2023 I commenced an investigation into the death of Richard
Haddock, 66 years of age. The investigation concluded at the end of the inquest
on 24th November 2025. The conclusion of the inquest was suicide.
4 CIRCUMSTANCES OF THE DEATH
Richard Haddock was a shotgun certificate holder. In February 2020, a member
of the public contacted the police as Mr. Haddock’s wife was requesting that
they seized his guns for safekeeping; Mr. Haddock was suffering from stress
due to a civil legal dispute, and his wife was concerned that he would use the
guns to ‘hurt himself or her’.
The police duly seized the guns, and a suitability review took place. In the
intervening period Mr. Haddock’s certificate was also due for renewal and he
submitted his renewal application.
The shotgun certificate remained under review for some time; information was
sought from his GP which did not note any concerns, but the police were aware
that Mr. Haddock had a significant civil court judgment made against him which
resulted in the family farm being sold. On 7th November 2022, the police
returned Mr. Haddock’s firearms to him.
On 25th June 2023, Mr. Haddock used his shotgun
. During the hearing, evidence was heard that Mr. Haddock had
been charged with several criminal offences by the Environment Agency and
had entered guilty pleas at Crown Court just days before his death. His wife
explained that he was very concerned about receiving a sentence of
imprisonment. Despite the fact that the Environment Agency had followed the
correct procedure to notify the police of their prosecution, and it was showing on
Mr. Haddock’s PNC record on 11th October 2021 (before the firearms were
returned to him), the inquest was told that the Firearms Licensing Department
were completely unaware of the prosecution.
giving evidence, told
the court that had the Department been aware of the prosecution, it is likely that
the guns would not have been returned to him at that time.
5 CORONER’S CONCERNS
During the course of the inquest 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. –
(1) The police process which should have ensured that the Firearms Licensing
Department was notified of the Environment Agency’s prosecution of Mr.
Haddock failed to be effective
(2) The offences with which Mr. Haddock had been charged by the Environment
Agency were correctly placed onto Mr. Haddock’s PNC record on 11th October
2021 – a year before the final decision was made to return his shotgun to him in
November 2022. The Firearms Licensing Department had not checked his PNC
record since 4th August 2021 (more than a year before the final decision to
return his guns was made) and were therefore unaware of the prosecution.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
and your organization 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 March 2026. 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 (
, the Environment Agency)
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 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.
9 DATE: SIGNED BY CORONER
16/12/2025
Area Coroner
County of Devon, Plymouth and Torbay
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.
• 101 Non Emergency 12igra.Lj Non Emergency (BSL video relay) (I) 999 Emergency (i) Non Emergency Text 67101 (Deaf only) • dc.police.uk 999 co, 999 BSL Emergency (BSL video relay) e dc.police.uk/webchat Text 999 (Deaf only - must pre-register at www.emergencysms.org.uk ) Alison Longhorn Area Coroner for The County of Devon, Plymouth and Torbay County Hall Topsham Road Exeter EX2 4QD 2 March 2026 Dear Ms Longhorn Assistant Chief Constable Devon and Cornwall Police Headquarters Middlemoor Exeter EX2 7HQ INQUEST INTO THE DEATH OF RICHARD ANTHONY HADDOCK PREVENTION OF FUTURE DEATHS REPORT Introduction I am writing in response to the Prevention of Future Deaths report (the "PFD Report") sent to the Chief Constable of Devon & Cornwall Police, . The Chief Constable has asked me to respond to the PFD Report as the matters of concern raised therein fall within my area of policing responsibility. Please therefore treat this correspondence as the Chief Constable's formal response to the PFD Report. In the first instance, both the Chief Constable and myself want to take this opportunity to express our condolences to Mr Haddock's family and friends. Secondly, the Chief Constable and I also want to thank you for bringing the matters of concern that you have set out in the PFD Report to our attention. We welcome opportunities to give serious consideration to any matters of concern such as this with a view to improving the service that we provide the public, and to assist you and your coronial colleagues in your investigations. NOTE: With effect from 1 January 2019, fax communication will not be possible. Documents can either be sent via hard copy post or via email to legalservices@devonandcornwall.pnn.potice.uk Joint Legal Services for Devon & Cornwall Police and Dorset Police gather and hold personal data. This may be shared where necessary with third parties acting for and on behalf of the Chief Constable. Personal data is processed securely at all times and is held no longer than is necessary. The retention period is six years in accordance with the Limitation Act 1980. Retention can be longer on a case by case basis where this is necessary and in accordance with the Management of Police Information (MoPI). If you wish to know more about how we process personal data please do visit our respective websites at: https://www.devon-cornwall.police.uk/your-right-to-information/data-protection-requests/privacy-noticefalr-processing/ http://www.dorset.police.uk/default.aspx?page=3882 www.devon-cornwall.police.uk www.dorset.police.uk For what I hope will be your ease of reference, and for the ease of anyone reading this response once it is made public, I will respond to each of the two concerns that you have expressed in box 5 of the PFD Report using the same wording that you have used therein. Concern 1 "The police process which should have ensured that the Firearms Licensing Department was notified of the Environment Agency's prosecution of Mr. Haddock failed to be effective." As you are aware, the Police National Computer (PNC) is a centralised database that can be accessed and edited by all police forces in the country. The PNC contains real- time information in relation to matters of policing interest, including criminals, missing and wanted people, and vehicle records. Whenever a PNC record is updated, a so-called Daily Activity File (DAF) report is generated and provided to the relevant police force via an automatic file transfer from PNC Hendon. Any DAF reports that are specific to firearm and shotgun certificate holders in the Devon & Cornwall Police area are assigned a code of '50H L' and forwarded to our Firearms Licensing and Explosives Unit (FELU) via email. Insofar as the receipt and review of DAF reports by Devon & Cornwall Police is concerned, there are now the following processes in place: • The FELU have implemented a process whereby any such DAF reports are automatically re-directed to the inbox for a new Continuous Assessment Team (CAT), who are responsible for the ongoing review of the suitability of firearms and shotgun licence holders. • Any DAF reports which reflect a prosecution of the type that Mr Haddock was subject to are subject to a suitability review by the CAT. The National Firearms Licensing Management System (NFLMS) is updated to reflect that this review is underway. The NFLMS is viewable by all police forces and other law enforcement agencies. • Measures have been implemented by the FELU to ensure that the member of police personnel conducting the review, and the review itself being completed, can be clearly identified. • The CAT supervisor is required to `dip sample' this work to ensure that any such reviews have been actioned and recorded appropriately. • When a suitability review is finalised and a decision is made to return a certificate / licence and firearms to the certificate / licence holder, the CAT are also now required to review the PNC to ensure that it contains no new updates of relevance. If any such updates are identified, a further suitability review takes place. I am confident that these measures represent a significant improvement in our working processes in this regard and will significantly mitigate against any such DAF reports being overlooked or misplaced by Devon & Cornwall Police. Concern 2 "The offences with which Mr. Haddock had been charged by the Environment Agency were correctly placed onto Mr. Haddock's PNC record on 11th October 2021 — a year before the final decision was made to return his shotgun to him in November 2022. The Firearms Licensing Department had not checked his PNC record since 4th August 2021 (more than a year before the final decision to return his guns was made) and were therefore unaware of the prosecution." While I appreciate that this detail is beyond the scope of the PFD Report and this response, I believe that you may find some brief context useful before I reply to this specific concern. In 2021 there was a significant backlog of outstanding reviews in the FELU as a result of both the Covid-19 pandemic adversely impacting on the FELU's ability to undertake related enquiries, and the Devon & Cornwall Police response to the tragic events of August 2021 in Keyham in Plymouth, which you will be aware of. A significant additional number of police personnel have since been allocated to the FELU, and there is significant additional senior oversight of the FELU within Devon & Cornwall Police. In general terms, there has been a significant improvement in the FELU's ability to undertake reviews of the type that we are concerned with presently. More specifically in relation to the concern that you raise, the following processes are now in place: 1. The FELU undertake a check on the PNC as a part of their initial enquiries in the aforementioned suitability reviews. More generally, suitability reviews encompass research of other databases. 2. Where a PNC check highlights a prosecution such as that undertaken by the Environment Agency in the present case (or any other matter of concern), additional checks are undertaken with other agencies, licensing or regulatory bodies or government enforcement agencies, to ensure all information is reviewed and considered as part of the suitability review. 3. Crucially, and as set out above, when a suitability review is finalised and a decision is made to return a certificate / licence and firearms to the certificate / licence holder, the CAT are also now required to review the PNC immediately prior to the return of any firearms to ensure that it contains no new updates of relevance. If any such updates are identified, a further suitability review takes place. Again, I am confident that these measures represent a significant improvement on our working processes in this regard and will maximise our potential to ensure that appropriate PNC checks are undertaken by the FELU team, including prior to any decision to return firearms to a relevant member of the public. Conclusion I hope that this response provides you with sufficient reassurances that the concerns that you have raised have been taken seriously by Devon & Cornwall Police, and that a repeat of the concerns that you have highlighted is unlikely. If you have any residual concerns then I would be happy to discuss them with you further. Thank you again for bringing these matters to our attention. Yours sincerely Assistant Chief Constable
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