Date of report: 08/02/2023
Deceased name: Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington and Kate Shepherd
Coroner name: Ian Arrow
Coroner Area: Plymouth, Torbay and South Devon
Category: Other related deaths
This report is being sent to: The Home Secretary, Minister of State for Crime, Policing and Fire, NPCC, Chief Constables and The College of Policing
|REGULATION 28 REPORT TO PREVENT FUTURE DEATHS|
|THIS REPORT IS BEING SENT TO:
Rt Hon. Suella Braverman MP, The Home Secretary
Rt Hon Chris Philp MP, Minister of State for Crime, Policing and Fire
NPCC lead for policing, CC Tedds
All Chief Constables in England and Wales
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.
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
Lee Raymond John Martyn
Sophie Iris Martyn
|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.
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 –
‘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.’
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.
‘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.’
The Home Secretary (The Rt Hon Theresa May MP) responded on 17 June 2013 stating that:
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.
That 2015 HMIC report also stated that
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.
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.
‘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.’
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:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
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)
The Home Secretary and The Minister of State for Crime, Policing and Fire
|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.
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|
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