Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0082, written 10 Feb 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Feb 2026 |
|---|---|
| Reference | 2026-0082 |
| Deceased | Samuel Dickinson |
| Coroner | Michael Pemberton |
| Coroner area | Manchester (West) |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 THE SECRETARY OF STATE FOR THE HOME DEPARTMENT 2 THE SECRETARY OF STATE FOR HEALTH 1 CORONER I am Michael James Pemberton, HM Area Coroner for the coroner area of Manchester (West). 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 16 September 2025 I commenced an investigation into the death of Samuel John DICKINSON aged 39. The investigation concluded at the end of the inquest on 10 February 2026. The conclusion of the inquest was Suicide, and the medical cause of death was 1a Severe head injury 4 CIRCUMSTANCES OF THE DEATH On 15 September 2025 the deceased who was a farmer and held both a firearms and shotgun licence, was found with a shotgun wound to the head in a shed at the farm where he resided with his family. He had left the house earlier that morning and his family called police concerned, when they found that a shotgun was missing from the gun cabinet where it was stored. A member of the family discovered the deceased in an outbuilding on the farm after a brief search. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) 1. During the course of evidence it was reflected that Firearms Legislation relating to the holding of a shotgun or firearms licence (or both) contains no provision that a person holding a certificate must self report any illness or mental health condition which may give rise to a change in circumstances from the time when a grant of licence has been made, differing from obligations for example on a person holding a driving licence to do so. 2. Further it was stated that there is no obligation or provision requiring a General Practitioner practice to: a. Clearly record the holding of a licence on medical records when advised of the grant, in order to assist with flagging any relevant issues that may need Regulation 28 – After Inquest Document Template Updated 30/07/2021 reporting (such as conditions listed on an initial firearms/shotgun application form or renewal) b. Requiring the reporting of such issues on a reasonable basis to a firearms licence unit of a local police force 3. The above were described as ‘gaps’ in the legislation which may give rise to the risk of future death. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 7 April 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 Greater Manchester Police Lancashire & Cumbria NHS Trust I have also sent it to Royal College of General Practitioners National Police Chiefs Council British Association for Shooting and Conservation who may find it useful or of interest. 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 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 by the Chief Coroner. 9 Dated: 10 February 2026 Michael J. Pemberton HM Area Coroner Manchester West Regulation 28 – After Inquest Document Template Updated 30/07/2021
2 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.
HM Coroner Michael J. Pemberton The Manchester West Coroner’s Office First Floor, Paderborn House Howell Croft North Bolton, BL1 1QY Parliamentary Under-Secretary of State 39 Victoria Street London SW1H 0EU 7 April 2026 Dear Mr Pemberton, Thank you for the Regulation 28 report of 10 February 2026 sent to the Department of Health and Social Care about the death of Samuel John Dickinson. 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 Samuel’s 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 these matters to my attention. The report raises concerns over firearms legislation relating to shotgun or firearms licensing (or both) and provisions on certificate holders to self-report any illness or mental health condition that may change the circumstances from the time at which the license was granted. My ministerial colleague in the Home Office will lead the response to this concern. The report also raised concerns around the obligation and provision for a General Practitioner to record the holding of a license within medical records to ensure any relevant issues are flagged, and provision for reporting of these issues, by GPs, to the local police force. 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 can add 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 upon assessment, can ask the patient to contact the police or the GP can flag this to the police directly, with consent for this provided in the initial application. This allows the police to review the person’s continued suitability, and if necessary, revoke the certificate. Within the existing system there is also provision to record when contact has been made with the police as a result of a digital marker flag. A Memorandum of Understanding between the National Police Chiefs Council, the Home Office and the British Medical Association has been in place since 2019. In addition to Home Office 2021 Statutory Guidance for Chief Officers of Police which includes the role of GPs, the British Medical Association issues its own guidance to GPs. We can see from NHS England’s annual national data counts of clinical (SNOMED) coding that GPs are placing the markers and police contact is being made as a result. We understand the Home Office will continue to monitor usage as part of continuing to make the firearms licensing system as robust as it can be. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, Parliamentary Under-Secretary of State for Health Innovation and Safety
Minister of State for Policing and Crime 2 Marsham Street London SW1P 4DF www.gov.uk/home-office Michael Pemberton HM Area Coroner HM Coroner’s Court and Office for Manchester (West) Paderborn House Howell Croft North North Bolton BL1 1QY March 2026 INQUEST FOLLOWING THE DEATH OF SAMUEL JOHN DICKINSON 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 10 February following the inquest into the death of Samuel John Dickinson. I would like to pass on my condolences to Samuel’s family and friends about this tragic loss of life. In your report you highlighted two specific concerns relating to perceived gaps in firearms legislation and controls. The first relates to the absence of a specific requirement for a firearms or shotgun licence holder to report the onset of any illness or mental health condition which amounts to a change in circumstances from when the licence was issued. We recognise this as a potential area for strengthening. We are therefore shortly bringing forward a new Statutory Instrument to add a new condition to firearms and shotgun licences to require the holder to inform the police if they begin to suffer from a new relevant medical condition, or if an existing condition significantly worsens, during the lifetime of the licence. This will enable the police to assess whether the change affects the person’s suitability to continue to possess the firearm or shotgun. At the same time, we will also be introducing a new licensing condition to require the licence holder to inform the police if they consult a third-party medical practitioner who is not their GP, to ensure that the police have a full picture of the licence holder’s health. Your second concern is that there is no obligation on GPs to record the holding of a firearms or shotgun licence on the holder’s medical records when advised that such a licence has been granted, or on them to report any relevant medical issues to the police. It is, mandatory for all firearm and shotgun licence applicants to provide information from their doctor about whether they have experienced any relevant medical conditions, including mental health conditions and drug and alcohol abuse, at the time of application. This requirement was introduced in the Statutory Guidance to Chief Officers of Police on firearms licensing, which was first issued by the Home Office in November 2021. GPs are also asked to put a firearms marker on the GP patient record when the person is granted a firearm or shotgun certificate, and this remains on the system for the five years’ duration of the licence. If a certificate holder sees their GP regarding a relevant medical condition during this period, the doctor can advise the police of this, enabling the police to carry out a review as to whether the person remains suitable to have a licence. A new digital version of the firearms marker was introduced to all GP surgeries in England in May 2023. The digital firearms marker automatically alerts the doctor if a patient is seen regarding a relevant medical condition and reminds the GP to advise the police. This improves the safety of the system and helps to ensure that the firearms marker is not missed by GPs. The data we have on the use of the digital marker shows that it is now being applied by GPs. In 2024-25, over 98,000 digital markers were applied by GPs to the medical record of those granted or renewed a firearm or shotgun certificate and there were over 1,100 cases in which the GP notified the police of a medical concern about a licence holder, following a review prompted by the digital firearms marker. We are however actively reviewing whether and how the digital firearms marker should be mandated in the future so that we can ensure that we build on the very encouraging use of the digital marker so far by GPs. We are also intending to consult on strengthening shotgun controls in due course. The Government response to the 2023 consultation on firearms licensing, published in February 2025, included a commitment to consult on improving and aligning the controls on shotguns with other firearms. Thank you again for your report. Very best wishes, Minister of State for Policing and Crime
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