10 Feb 2026 Samuel John DICKINSON · Prevention of Future Deaths report Manchester West
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Concerns raised 2
Failure to require General Practitioner practices to report relevant health issues to firearms licence units View source Lack of a self-reporting requirement for firearms certificate holders to report relevant illness or mental health conditions View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Samuel John DICKINSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Samuel John DICKINSON, a 39-year-old farmer who held firearms and shotgun licences, was found on 15 September 2025 with a shotgun wound to the head in an outbuilding at the farm where he lived. The inquest concluded that his death was suicide, with the medical cause recorded as severe head injury. Concerns were raised about gaps in firearms legislation and General Practitioner recording and reporting obligations relating to licence holders’ illnesses or mental health conditions.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to require General Practitioner practices to report relevant health issues to firearms licence units
Wider context from the report “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 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.
” Source location Samuel John DICKINSON · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a self-reporting requirement for firearms certificate holders to report relevant illness or mental health conditions
Wider context from the report “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 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.
” Source location Samuel John DICKINSON · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out digital markers for firearms certificate holders across all GP IT systems in England.
Verbatim wording from the response “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.” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a digital firearms marker across GP surgeries to alert doctors about relevant conditions and prompt police notifications.
Verbatim wording from the response “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.” Source location Response from Home Office
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review whether and how to mandate the digital firearms marker in future.
Verbatim wording from the response “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.” Source location Response from Home Office
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a licensing condition requiring holders to report new relevant medical conditions or significant worsening of existing conditions to police.
Verbatim wording from the response “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.” Source location Response from Home Office
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing medical suitability controls, GP markers, and police-reporting arrangements are considered sufficient to address relevant-condition recording and reporting concerns.
Verbatim wording from the response “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.” Source location Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Firearms legislation and certificate-holder self-reporting concerns will be led by the Home Office ministerial colleague.
Verbatim wording from the response “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.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 1
Failure of the police process to notify the Firearms Licensing Department of the Environment Agency’s prosecution View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Richard Haddock · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Richard Haddock died on 25 June 2023 after using his shotgun. The report identified concerns that the police process failed to notify the Firearms Licensing Department of an Environment Agency prosecution, and that the Department had not checked his PNC record before returning his firearms. The inquest conclusion was suicide.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the police process to notify the Firearms Licensing Department of the Environment Agency’s prosecution
Wider context from the report “(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.
” Source location Richard Haddock · Prevention of Future Deaths report
Open source report
10 Jul 2025 Jairus Joshua Timothy Earl · Prevention of Future Deaths report Dorset
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Concerns raised 3
Lack of inter-force sharing and flagging of information about shotgun licence holders and shotgun locations View source Lack of requirements for shotgun licence holders to notify police forces of additional properties and visits to other force areas View source Lack of police access to medical information about other residents during firearm and shotgun licence applications View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jairus Joshua Timothy Earl · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jairus Joshua Timothy Earl, aged 15, died by suicide on 14 April 2024 after using one of his father’s shotguns at the family’s Dorset property. The concerns relate to gaps in the regulation of shotgun licences, including the lack of requirements to notify police about additional properties, inadequate information-sharing and address flagging between police forces, and limited access to medical information about other people living at a licence holder’s property.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of inter-force sharing and flagging of information about shotgun licence holders and shotgun locations
Wider context from the report “(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 handling 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 licences , 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.
” Source location Jairus Joshua Timothy Earl · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of requirements for shotgun licence holders to notify police forces of additional properties and visits to other force areas
Wider context from the report “(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 handling 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 licences, 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.
” Source location Jairus Joshua Timothy Earl · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of police access to medical information about other residents during firearm and shotgun licence applications
Wider context from the report “(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 shotgun licence applications. Acting Chief Inspector ████████ advised the 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.
” Source location Jairus Joshua Timothy Earl · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop proposed changes with the Home Office to require declaration of second-home firearm storage in statutory guidance and application forms.
Verbatim wording from the response “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.” Source location Response from National Police Chief's Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop the National Firearms Licensing Management System to provide consistent national licensing processes and enable second-home firearm notifications to local force systems.
Verbatim wording from the response “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.” Source location Response from National Police Chief's Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend firearm and shotgun applications to capture additional residences and update NFLMS to record those locations.
Verbatim wording from the response “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.” Source location Response from Home Office
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore options and implications for broadening police access to relevant medical information about others living at firearms licence holders’ addresses.
Verbatim wording from the response “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.” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen statutory guidance by requiring separate home-visit interviews with applicants’ partners and household members, unless an agreed and recorded reason prevents this.
Verbatim wording from the response “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.” Source location Response from National Police Chief's Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Firearms Licensing Authorised Professional Practice to promote communication, curiosity and clues when assessing risk and suitability.
Verbatim wording from the response “In addition to the Home Office 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 officers and staff in delivering effective, 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 official 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:” Source location Response from National Police Chief's Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver an additional two-day firearms licensing course covering domestic abuse, family turmoil, mental health and wellbeing for Firearms Licensing Enquiry Officers.
Verbatim wording from the response “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 Officers where we focus on important subject areas relating to domestic abuse, family turmoil together with mental health and wellbeing.” Source location Response from National Police Chief's Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish statutory guidance requiring police to consider the mental wellbeing of applicants and household members during firearms licensing home visits.
Verbatim wording from the response “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.” Source location Response from Home Office
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage DHSC on access to household members’ health information and ways to mitigate associated firearms licensing risks.
Verbatim wording from the response “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 issues involved.” Source location Response from Home Office
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Policing lacks capacity to check and authorise temporary firearm storage arrangements away from a licence holder’s declared home.
Verbatim wording from the response “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.” Source location Response from National Police Chief's Council
Open published response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police cannot directly access the medical records of people living with or associated with a firearms licence applicant.
Verbatim wording from the response “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 Office to further strengthen the statutory guidance on this specific point, which now reads:” Source location Response from National Police Chief's Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Department of Health and Social Care will address police access to health information about people other than firearm or shotgun licence applicants.
Verbatim wording from the response “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 issues involved.” Source location Response from Home Office
Open published response
8 Aug 2024 Emma Pattison and 2 others · Prevention of Future Deaths report Surrey
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Concerns raised 2
Failure to ensure full and accurate disclosure of shotgun certificate applicants’ history of coercive controlling behaviour View source Failure to ensure full disclosure of shotgun certificate applicants’ medical history View source
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AI-generated summary
Emma Pattison and 2 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Between 22:49 on 4 February 2023 and 00:40 on 5 February 2023, George Pattison shot and killed his wife, Emma Pattison, and daughter, Ellette Pattison, before shooting himself. The report raises concerns about online medical consultations potentially bypassing disclosure safeguards for shotgun licensing and about obtaining full information concerning coercive controlling behaviour.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure full and accurate disclosure of shotgun certificate applicants’ history of coercive controlling behaviour
Wider context from the report “3. Consideration should be given as to how a licensing authority can obtain full and accurate disclosure of an applicant’s history of coercive controlling behaviour towards another / others .
” Source location Emma Pattison and 2 others · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure full disclosure of shotgun certificate applicants’ medical history
Wider context from the report “1. An applicant for a shotgun certificate is able to obtain medication from an on-line doctor without the knowledge of their GP , giving rise to a risk that a licensing authority might grant a shotgun certificate to an applicant who has a relevant previous medical history about which the authority is not aware .
2. In consulting an on-line doctor, it is possible for an applicant for a shotgun certificate to avoid the current safeguards relating to full disclosure of their previous and current medical history .
” Source location Emma Pattison and 2 others · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out the nationally designed Firearms Enquiry Officer course, including testing, mandatory specialist training, portfolio assessment and external moderation.
Verbatim wording from the response “Substantial changes are being introduced around training and accreditation of Firearms Enquiry Officers (FEOs) (who, in most cases provide the report to decision makers assessing the applicant’s circumstances and comment on suitability following appropriate conversations and visits).” Source location Response from NPCC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a nationally standardised Firearms Enquiry Officer report form requiring comprehensive enquiries, information received and suitability reasoning.
Verbatim wording from the response “We are also introducing a new FEO Report Form for national use which will require more comprehensive detailing of enquiries undertaken, information received (from in person interviews, police systems and wider investigations deemed appropriate on each individual application) and the rationale for their view on suitability. It is intended that this will act both as a prompt to FEOs to ensure all aspects of suitability are properly considered and also build on the increasing focus in more recent versions of the HO guidance around the importance of exercising professional curiosity in all cases.” Source location Response from NPCC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage partner organisations to improve inter-agency information-sharing for firearms licensing suitability assessments.
Verbatim wording from the response “As a police service, we will continue to engage with partners to improve upon partnership working and inter-agency information-sharing to ensure that those charged with determining firearms licensing applications have as much relevant information as possible to assess an applicant’s suitability to hold a firearms licence in the context of ensuring public safety.” Source location Response from NPCC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a right to draw adverse inferences when firearms licence applicants are evasive about family members or previous partners.
Verbatim wording from the response “Moving forward, national FEO training will further encourage positive engagement with the applicant and their family/others in their household. FEOs will be expected to ascertain the “domestic health and wellbeing” of the applicant on both initial grant and any renewal. We are hopeful that revised statutory guidance will require interviews and wider engagement with families and FEOs will be required to cover these matters on the new FEO report on suitability. We are also looking to introduce the right to draw adverse inference if an applicant is evasive about family/previous partners and so on.” Source location Response from NPCC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consult the College of Policing and NPCC lead about adding certificate conditions reminding holders to report changes in domestic and health circumstances.
Verbatim wording from the response “Surrey Police licensing officers take a negative view of applicants who fail to disclose relevant information. However, there seems to be little within legislation to require a holder to disclose a change in personal circumstances during each 5-year period. Therefore, I am consulting with the College of Policing and the NPCC lead on the potential to add a condition to holder certificates, reminding them of their obligations to inform the police of any changes in domestic and health situation. I believe this would allow more robust oversight between renewals.” Source location Response from Surrey Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue refreshed firearms guidance strengthening police assessment of domestic abuse, coercive control and other violence allegations, including sensitive confidential interviews.
Verbatim wording from the response “In your report you have also proposed that consideration is given to how the police can obtain full and accurate disclosure of an applicant’s history of coercive controlling behaviour. The Home Office publishes Statutory Firearms Guidance for Chief Officers of Police which sets out the processes and criteria for assessing an applicant’s suitability to possess firearms. This assists the police in their firearms licensing functions and promotes high standards and consistency between forces. We are intending to issue a refreshed version of the Statutory Guidance early in 2025 which will include additional guidance for the police to help ensure that those who are the perpetrators of domestic abuse, coercive or controlling behaviour, do not have access to firearms.” Source location Response from The Home Office
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require a medical declaration and specific GP or third-party medical report before considering a firearms licence application.
Verbatim wording from the response “Changes have been made to the medical declaration required from an applicant and the requirement for a specific GP report has been introduced – no licence is now considered without the opinion of the applicant’s GP as to any relevant medical concerns or other medical issues which could affect an applicant’s suitability to possess a licence.” Source location Response from NPCC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update guidance to reflect the potential information gap when external prescribers do not share relevant information.
Verbatim wording from the response “This report identifies a possible information gap for NHS General Practitioners when providing factual medical information to the police as part of the firearms licensing process. We will update our own guidance to reflect that this potential gap exists if external prescribers are not sharing information, or have not been supplied by the patient with information that would be relevant.” Source location Response from GPC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain a firearms-certificate digital marker in GP IT systems so relevant medical conditions can be flagged for police review.
Verbatim wording from the response “We 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 one” Source location Response from DHSC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider whether private online prescribers should inform patients’ NHS GPs about prescribed medication.
Verbatim wording from the response “In response to the issue you raise that an applicant for a shotgun certificate is able to obtain medication from an on-line doctor without the knowledge of their GP, there is no legal requirement for a GP to be informed about medication from a private online prescriber. This is an issue which the Government is considering. Third party (non-NHS) doctors or prescribers cannot share confidential patient information with a person’s NHS GP if that person objects unless they believe there is an overriding public interest justifying consent for doing so (e.g. to protect a third party from serious harm). Third party prescribers are also reliant on the patient fully disclosing all medical conditions and existing medication to be able to prescribe safely.” Source location Response from DHSC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require Firearms Enquiry Officers to ask applicants about medical treatment obtained outside their GP practice.
Verbatim wording from the response “I share your concern that any certificate holder or applicant can, it would appear, hide certain medical treatment by using an online facility. The national application form asks, “Are there any periods in the past 10 years when you have not been registered with a UK GP or have consulted medical practitioners other than at your GP practice?” In this case, Mr Pattison answered “no” in both his 2016 and 2022 renewals. Surrey Police acknowledge that, although the force re-asks all other questions on the medical form during the Firearms Enquiry Officer (FEO) visit, Surrey Police did not ask about the use of other medical services in this visit. Surrey Police has, because of this case, revised our practice, and FEOs now do cover this in their visits to try and elicit the information from an applicant.” Source location Response from Surrey Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider measures to address online or third-party prescribers not informing applicants’ GPs about prescribed medication.
Verbatim wording from the response “I have taken careful note of the issue you raise in relation to the medical checks, that there is no requirement for an online or third-party doctor to inform a patient’s GP about medication they have prescribed for them. This is an issue which the Government is considering. In the meantime, in order to further strengthen the firearms licensing process I intend to make arrangements to amend the firearms and shotgun licence application form so that in future applicants are required to provide details if they have consulted an online or third party prescriber who is not their GP. This will enable further enquiries to be made with the online or third-party prescriber, and the police may require the applicant to provide a completed medical proforma from their prescriber in relation to any relevant medical conditions.” Source location Response from The Home Office
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend firearm and shotgun application forms to require disclosure of consultations with online or third-party prescribers.
Verbatim wording from the response “I have taken careful note of the issue you raise in relation to the medical checks, that there is no requirement for an online or third-party doctor to inform a patient’s GP about medication they have prescribed for them. This is an issue which the Government is considering. In the meantime, in order to further strengthen the firearms licensing process I intend to make arrangements to amend the firearms and shotgun licence application form so that in future applicants are required to provide details if they have consulted an online or third party prescriber who is not their GP. This will enable further enquiries to be made with the online or third-party prescriber, and the police may require the applicant to provide a completed medical proforma from their prescriber in relation to any relevant medical conditions.” Source location Response from The Home Office
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend firearm certificates to require holders to notify police about relevant medical consultations with online or third-party doctors.
Verbatim wording from the response “I also intend to amend the firearm certificate to include a new condition requiring the holder to inform the police if they consult an online or third-party doctor about a relevant medical condition during the five years the licence is valid. These changes will” Source location Response from The Home Office
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Policing cannot regulate or manage online healthcare providers because health-sector regulation falls outside its remit.
Verbatim wording from the response “It is, of course, outside the role and remit of policing to regulate or manage the health sector; this would be a matter for the Department of Health and Social Care and we understand that our HO colleagues are working with their counterparts in the DHSC to progress this issue. As the NPCC Lead, I would welcome any positive moves that are possible to regulate online GPs/prescriptions and require any relevant information to be passed to the GP with whom the individual is registered, so that it is accessible to Firearms Licensing Units when required, to enable a fuller picture to be available to support risk assessments and suitability assessments on applications for grant or renewal of firearms licensing. Exactly the same concerns arise where applicants use private GPs or consultants (outside of a GP referral) which may also remain unknown to firearms licensing teams.” Source location Response from NPCC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Regulation of online doctors and information-sharing with registered GPs is a matter for DHSC, with Home Office colleagues progressing it.
Verbatim wording from the response “It is, of course, outside the role and remit of policing to regulate or manage the health sector; this would be a matter for the Department of Health and Social Care and we understand that our HO colleagues are working with their counterparts in the DHSC to progress this issue. As the NPCC Lead, I would welcome any positive moves that are possible to regulate online GPs/prescriptions and require any relevant information to be passed to the GP with whom the individual is registered, so that it is accessible to Firearms Licensing Units when required, to enable a fuller picture to be available to support risk assessments and suitability assessments on applications for grant or renewal of firearms licensing. Exactly the same concerns arise where applicants use private GPs or consultants (outside of a GP referral) which may also remain unknown to firearms licensing teams.” Source location Response from NPCC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Home Office is responsible for implementing proposed firearms licensing reforms, including GP requirements, seizure powers and application restrictions.
Verbatim wording from the response “• HO to proceed with implementation of the outcomes from their August 23 consultation, in particular we would welcome early implementation of
◦ Mandatory requirements for GPs to support the licensing process and complete the medical proformas on every application,
◦ Police being granted powers to enter properties to seize firearms for the purpose of reassessing suitability of licence holders,
◦ A statutory prohibition on applying for a licence for 5 years for anyone who has been sentenced to serve 0-3 years in prison, including suspended sentences.” Source location Response from NPCC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police have little ability to address deliberate concealment of relevant medical information, apart from revoking a licence.
Verbatim wording from the response “There has already been a significant improvement in the medical information available to Firearms Licensing teams through the introduction of the mandatory GP report or medical report from a third party medical provider on application. However, it remains the case that where an applicant deliberately withholds relevant information – not only from the Firearms Licensing team but from their own GP – there is little that police forces can do in many cases to address deliberate dishonesty, save for revoking a licence (which is made clear on the application form and within the HO guidance).” Source location Response from NPCC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The circumstances of deliberate online medical concealment and dishonest declarations appear difficult to address through legislation.
Verbatim wording from the response “The difficulties posed by this case however appear difficult to legislate against;” Source location Response from NPCC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing GMC guidance and expected information-sharing and medical-history practices address risks from online prescribing, subject to patient refusal.
Verbatim wording from the response “We would therefore expect online doctors to be providing information to GPs in line with the professional guidance available from their Regulator. If a patient does not consent to this sharing of information, then the same GMC guidance advises that the online doctor should explain the risks to the patient and to record the refusal in their medical records. (Paragraph 31) However, the risks that might exist in these circumstances are not further defined. A change to the guidance above would be a matter for the GMC to consider. BMA guidance reiterates the above.” Source location Response from GPC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Any change to professional guidance on information-sharing between online doctors and GPs is for the GMC to consider.
Verbatim wording from the response “We would therefore expect online doctors to be providing information to GPs in line with the professional guidance available from their Regulator. If a patient does not consent to this sharing of information, then the same GMC guidance advises that the online doctor should explain the risks to the patient and to record the refusal in their medical records. (Paragraph 31) However, the risks that might exist in these circumstances are not further defined. A change to the guidance above would be a matter for the GMC to consider. BMA guidance reiterates the above.” Source location Response from GPC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Confidentiality and data protection law restrict third-party prescribers from sharing patient information with NHS GPs without consent, absent overriding public interest.
Verbatim wording from the response “In response to the issue you raise that an applicant for a shotgun certificate is able to obtain medication from an on-line doctor without the knowledge of their GP, there is no legal requirement for a GP to be informed about medication from a private online prescriber. This is an issue which the Government is considering. Third party (non-NHS) doctors or prescribers cannot share confidential patient information with a person’s NHS GP if that person objects unless they believe there is an overriding public interest justifying consent for doing so (e.g. to protect a third party from serious harm). Third party prescribers are also reliant on the patient fully disclosing all medical conditions and existing medication to be able to prescribe safely.” Source location Response from DHSC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Home Office is considering concerns about firearms licensing and will respond to the report.
Verbatim wording from the response “In your report you raise the issue of whether an applicant can avoid full disclosure of their previous and current medical history. If an applicant seeks treatment from a range of healthcare providers, this is possible. The Home Office is considering the concerns you have raised in relation to the firearms licensing process and will be responding to your report in due course.” Source location Response from DHSC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police currently have no method to detect whether firearms applicants withhold information about medical treatment.
Verbatim wording from the response “Surrey Police acknowledges that an applicant could still withhold this information, and there is currently no method for the police to find out if it is being so withheld.” Source location Response from Surrey Police
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24 Nov 2022 Keith Andrew WESTON · Prevention of Future Deaths report North Yorkshire and York
View report summary
Concerns raised 2
Failure of the HMRC investigator to respond to firearms licensing contact about the concern View source Lack of automatic Police National Computer checks for non-police prosecutions to identify licensed firearm holders View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Keith Andrew WESTON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Keith Andrew WESTON was found in the garden of his home on 9 March 2022 after shooting himself with a licensed firearm. The principal concern was that prosecutions by non-police authorities did not automatically trigger checks of the Police National Computer, meaning firearms licensing authorities might not be alerted to assess a person's continuing suitability to possess firearms.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the HMRC investigator to respond to firearms licensing contact about the concern
Wider context from the report “During the course of the inquest, evidence was heard from a Detective Inspector with North Yorkshire Police who is a Firearms Licensing Manager. The evidence was that, unlike standard police prosecutions, prosecutions of individuals by other authorities do not involve automatic checks of the Police National Computer which would flag whether that individual is licensed to possess a firearm. The appearance of such an alert allows the firearms licensing authority to assess the individual’s continuing suitability to possess a firearm in the context of the prosecution and its possible outcomes.
In this instance, the deceased was being prosecuted for tax fraud by HMRC and was due to make a court appearance on the day of his death. He left a note of intent, indicating that the prosecution and its likely outcome were central to his decision to end his life. Had it been flagged that the deceased was facing such a prosecution, I was informed that it was 'highly likely' that his access to licensed firearms would have been restricted and the weapons removed from him in accordance with statutory guidance. While it cannot be said that this would have prevented the deceased's death by his own hand from some other means, it would have prevented the unlawful discharge of the weapon as a means of suicide. I understand that this issue has been escalated to the NPCC Lead for firearms licensing with a view to highlighting the concern with all non-police prosecuting authorities. I also understand the HMRC investigator did not respond to the officer's contact with the agency to flag this issue . I am writing to HMRC to draw this concern to its attention and to invite it to respond directly, as well as to engage with the NPCC in this regard.
” Source location Keith Andrew WESTON · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of automatic Police National Computer checks for non-police prosecutions to identify licensed firearm holders
Wider context from the report “During the course of the inquest, evidence was heard from a Detective Inspector with North Yorkshire Police who is a Firearms Licensing Manager. The evidence was that, unlike standard police prosecutions, prosecutions of individuals by other authorities do not involve automatic checks of the Police National Computer which would flag whether that individual is licensed to possess a firearm . The appearance of such an alert allows the firearms licensing authority to assess the individual’s continuing suitability to possess a firearm in the context of the prosecution and its possible outcomes .
In this instance, the deceased was being prosecuted for tax fraud by HMRC and was due to make a court appearance on the day of his death. He left a note of intent, indicating that the prosecution and its likely outcome were central to his decision to end his life. Had it been flagged that the deceased was facing such a prosecution, I was informed that it was 'highly likely' that his access to licensed firearms would have been restricted and the weapons removed from him in accordance with statutory guidance. While it cannot be said that this would have prevented the deceased's death by his own hand from some other means, it would have prevented the unlawful discharge of the weapon as a means of suicide. I understand that this issue has been escalated to the NPCC Lead for firearms licensing with a view to highlighting the concern with all non-police prosecuting authorities. I also understand the HMRC investigator did not respond to the officer's contact with the agency to flag this issue. I am writing to HMRC to draw this concern to its attention and to invite it to respond directly, as well as to engage with the NPCC in this regard.
” Source location Keith Andrew WESTON · Prevention of Future Deaths report
Open source report
15 Jul 2019 Christine Ann Lee and Lucy Daisy Lee · Prevention of Future Deaths report Surrey
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Concerns raised 2
Absence of a system providing firearms licensing departments with current medical fitness information View source Insufficient gathering of applicants’ relevant medical information before firearms certification decisions View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Christine Ann Lee and Lucy Daisy Lee · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christine Ann Lee and Lucy Daisy Lee, mother and daughter, died after being shot with a shotgun at Keepers Cottage Stud on 23 February 2014. The jury found that failures in Surrey Police’s firearms licensing decisions contributed more than minimally to the deaths. The report also raised concerns about insufficient mandatory training for firearms licensing officers and an unreliable system for assessing applicants’ medical fitness to hold shotgun certificates.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Absence of a system providing firearms licensing departments with current medical fitness information
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application .
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm . These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system: 1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Source location Christine Ann Lee and Lucy Daisy Lee · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient gathering of applicants’ relevant medical information before firearms certification decisions
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant , and the lack of clarity as to what medical conditions may be relevant and must be disclosed , together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness .
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system: 1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Source location Christine Ann Lee and Lucy Daisy Lee · Prevention of Future Deaths report
Open source report
15 Jul 2019 Christine Ann Lee and Lucy Daisy Lee · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3
Absence of ongoing notification of relevant medical changes during firearms certificate validity View source Insufficient medical-condition disclosure and evidence gathering before firearms licensing decisions View source Absence of a required current GP medical report before firearms certificate applications View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Christine Ann Lee and Lucy Daisy Lee · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christine Ann Lee and Lucy Daisy Lee, mother and daughter, died after being shot with a shotgun at Keepers Cottage Stud on 23 February 2014. The report identified failures by Surrey Police firearms licensing staff to sufficiently investigate and consider relevant information, apply the correct standard of proof, and ensure appropriate senior oversight before returning the perpetrator’s shotgun certificate and shotguns. It also raised concerns about insufficient mandatory training for firearms enquiry officers and an unreliable system for assessing applicants’ medical fitness to hold shotgun certificates.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Absence of ongoing notification of relevant medical changes during firearms certificate validity
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system:
1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes .”
I understand that this recommendation has not been implemented . This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Source location Christine Ann Lee and Lucy Daisy Lee · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient medical-condition disclosure and evidence gathering before firearms licensing decisions
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant , and the lack of clarity as to what medical conditions may be relevant and must be disclosed , together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness .
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system:
1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Source location Christine Ann Lee and Lucy Daisy Lee · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Absence of a required current GP medical report before firearms certificate applications
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system:
1. Does not allow licensing to take place without a current medical report from the applicant’s GP , obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate , and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented . This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Source location Christine Ann Lee and Lucy Daisy Lee · Prevention of Future Deaths report
Open source report
25 Jun 2018 John Edward Hill · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 1
Failure to routinely seek information from family members or cohabitants when assessing firearm applications View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
John Edward Hill · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Edward Hill was found collapsed and unresponsive at home on 26 May 2017, holding a rifle and with a bullet wound to his forehead. The report raised concerns that firearms licensing enquiries did not routinely include family members or others living with the applicant, who might hold important information relevant to the application and prevention of future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to routinely seek information from family members or cohabitants when assessing firearm applications
Wider context from the report “v. Evidence was further given that in the Dorset Police policy entitled “Firearms and Explosive Licensing Risk Management Procedure’ dated the 8th May 2015 there is no reference to such contact with family members, friends or associates and that family members or those living at the same address of the applicant, will not be contacted as standard practice. They may, as above, be contacted where there is evidence of domestic abuse.
vi. Evidence was given that it would be beneficial for the Firearms Unit at Dorset Police to write to those living with the applicant to invite them to raise any concerns they wish to in relation to the application. Although this may not be responded to, at least it gives those close to the applicant an opportunity to raise their concerns. There may be for example domestic violence ongoing at the address that has not been brought to the Police Force’s attention due to lack of reporting. This would be key to the firearm application.
2. I have concerns with regard to the following:
i. When the Police consider a firearm application, there may be valuable information that those close to the applicant may have, in circumstances where there is no domestic abuse or violence. Those living with the applicant may have vital information, which could impact upon the grant of a firearms certificate. This information may therefore be key to preventing a future death.
ii. In view of this I would request that consideration is given to reviewing the national and local guidance in relation to the assessment criteria and enquiries to be considered regarding applications for firearm certificates, and for consideration to be given that those enquiries involve the applicant’s family members, or at the very least those living with the applicant.
” Source location John Edward Hill · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the statutory power introduced through the Policing and Crime Act 2017 to publish guidance on police firearms licensing functions.
Verbatim wording from the response “The Government introduced a power, through the Policing and Crime Act 2017, for the Home Secretary to publish statutory guidance to the police on their firearms licensing functions. The legislation requires that we consult with the police before publishing the new guidance. We intend to consult on the terms of this shortly. We intend that the draft should go further than the current guidance, in inviting the police to consider whether to conduct interviews with individuals other than the applicant or their referees, including neighbours, partners or representatives of shooting clubs attended by the applicant. We intend that these checks be considered where, following initial enquiries, they believe them to be necessary to assess suitability.” Source location 2018-0195-Responses
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consult police on the terms of new statutory guidance for firearms licensing functions.
Verbatim wording from the response “The Government introduced a power, through the Policing and Crime Act 2017, for the Home Secretary to publish statutory guidance to the police on their firearms licensing functions. The legislation requires that we consult with the police before publishing the new guidance. We intend to consult on the terms of this shortly. We intend that the draft should go further than the current guidance, in inviting the police to consider whether to conduct interviews with individuals other than the applicant or their referees, including neighbours, partners or representatives of shooting clubs attended by the applicant. We intend that these checks be considered where, following initial enquiries, they believe them to be necessary to assess suitability.” Source location 2018-0195-Responses
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Draft statutory guidance inviting police to consider interviewing people beyond applicants and referees where necessary to assess suitability.
Verbatim wording from the response “The Government introduced a power, through the Policing and Crime Act 2017, for the Home Secretary to publish statutory guidance to the police on their firearms licensing functions. The legislation requires that we consult with the police before publishing the new guidance. We intend to consult on the terms of this shortly. We intend that the draft should go further than the current guidance, in inviting the police to consider whether to conduct interviews with individuals other than the applicant or their referees, including neighbours, partners or representatives of shooting clubs attended by the applicant. We intend that these checks be considered where, following initial enquiries, they believe them to be necessary to assess suitability.” Source location 2018-0195-Responses
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The diverse circumstances of firearms applicants make it impractical to prescribe mandatory enquiry steps beyond existing intelligence, conviction and medical checks.
Verbatim wording from the response “Because of the very diverse nature of applicant situations it is very challenging to give a prescribed series of steps that must be carried out in each case, over and above existing intelligence convictions and medical checks. We discussed how there are situations where this could give a false perception that an applicant could be suitable were further investigations not carried out by the FEO.” Source location 2018-0195-Response-by-Durham-Constabulary
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A blanket requirement for routine family interviews is unnecessary because intelligence-based and targeted checks are considered sufficient.
Verbatim wording from the response “I have obtained the views of the National Police Chiefs' Council on this issue, which were informed by discussions with members of the Firearms and Explosives Licensing Working Group. The advice that I have received is that there is no need to introduce a new blanket policy of interviewing members of an applicant's family in the case of all applications for firearms certificates, in order to establish whether they have any concerns. The alternative is an intelligence-based approach, which will now be delivered through new accreditation standards for Firearms Enquiry Officers in police forces, which is being developed by the College of Policing. This will encourage “professional curiosity” to ensure that such avenues are pursued whenever they are likely to be relevant.” Source location 2018-0195-Responses
Open published response
25 Mar 2015 Mr Harold Ambrose and Mrs Wendy Ambrose · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2
Lack of a requirement for GPs and Mental Health Trusts to notify police of mental health concerns about firearms licence holders View source Failure to refer firearms licence holders with deteriorating mental health to the police View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Mr Harold Ambrose and Mrs Wendy Ambrose · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Harold Ambrose shot his wife, Mrs Wendy Ambrose, and then himself; police found both bodies. Mr Ambrose had a shotgun licence and developed worsening mixed dementia, but neither his GP nor the mental health trust referred the matter to the police firearms department. The report identified that there was no requirement for them to notify police about mental health concerns when aware that a patient held a firearms licence.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a requirement for GPs and Mental Health Trusts to notify police of mental health concerns about firearms licence holders
Wider context from the report “Mr Ambrose had held a shotgun licence since November 1987. This was renewed every 5 years at which time there was a full review. The last review was in 2011. On 18th November 2011 a letter from Essex Police Firearms Department was sent to his GPs surgery notifying them that he was a shotgun holder. No further details from this letter were entered onto his medical record and the fact that he was a firearms holder was not flagged on their system.
In 2011 Mr Ambrose did not have any mental health problems. In September 2012 he was diagnosed with mixed dementia and this gradually worsened. He was receiving some input from the North Essex Partnership University NHS Foundation Trust (NEPT) following a referral from the GP in October 2012. Mr Ambrose made NEPT aware that he had a shotgun license in his initial assessment in November 2012.
In May 2013 he was prescribed Alzheimer’s medication and was advised not to drive due to his cognitive impairment. In January 2014 it was clear that there had been a decline in his mental abilities and this decline continued.
Although his mental health was clearly deteriorating neither the GP or NEPT referred this case to Essex Police Firearms Department. In evidence a representative of Essex Police said had they been made aware of his Mental Health problems they would have initiated a review of Mr Ambrose’s fitness to hold a shotgun licence. There is no requirement that GPs or Mental Health Trusts notify the police of concerns about patients mental health when they are aware that they have a firearms licence.
” Source location Mr Harold Ambrose and Mrs Wendy Ambrose · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to refer firearms licence holders with deteriorating mental health to the police
Wider context from the report “Mr Ambrose had held a shotgun licence since November 1987. This was renewed every 5 years at which time there was a full review. The last review was in 2011. On 18th November 2011 a letter from Essex Police Firearms Department was sent to his GPs surgery notifying them that he was a shotgun holder. No further details from this letter were entered onto his medical record and the fact that he was a firearms holder was not flagged on their system.
In 2011 Mr Ambrose did not have any mental health problems. In September 2012 he was diagnosed with mixed dementia and this gradually worsened. He was receiving some input from the North Essex Partnership University NHS Foundation Trust (NEPT) following a referral from the GP in October 2012. Mr Ambrose made NEPT aware that he had a shotgun license in his initial assessment in November 2012.
In May 2013 he was prescribed Alzheimer’s medication and was advised not to drive due to his cognitive impairment. In January 2014 it was clear that there had been a decline in his mental abilities and this decline continued.
Although his mental health was clearly deteriorating neither the GP or NEPT referred this case to Essex Police Firearms Department . In evidence a representative of Essex Police said had they been made aware of his Mental Health problems they would have initiated a review of Mr Ambrose’s fitness to hold a shotgun licence. There is no requirement that GPs or Mental Health Trusts notify the police of concerns about patients mental health when they are aware that they have a firearms licence.
” Source location Mr Harold Ambrose and Mrs Wendy Ambrose · Prevention of Future Deaths report
Open source report
12 Dec 2014 Jason Geoffrey PALMER · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 1
Failure to make relevant police incident information available to the Firearms Unit for firearms suitability assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jason Geoffrey PALMER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jason Geoffrey PALMER died from a shotgun injury to the head after consuming a large quantity of alcohol; he and his wife had separated, and the inquest concluded that he had taken his own life. The report raised concerns that information about domestic incidents held in restricted police logs was not available to the Firearms Unit when his shotgun certificate was renewed, limiting the robustness of suitability enquiries.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to make relevant police incident information available to the Firearms Unit for firearms suitability assessment
Wider context from the report “(1) Mr Palmer applied for a shotgun certificate in December 2004. His licence was granted in January 2005. The licence was for renewal in 2009 and the Firearms Officers were aware there had been certain domestic incidents involving Mr Palmer and his wife but were assured by Mr Palmer these were no longer of significance. Mr Palmer's licence was renewed on 19 January 2010.
The Firearms Licensing Operations Officer ████████ commented in a Statement at the Inquest that if he and his colleagues had been aware the number of police incidents relating to Mr Palmer's domestic situation, then they would have made more robust enquiries into the suitability of Mr Palmer to possess shotguns at the time of his renewal . That information was contained within secure Police Logs for the protection of Officers .
Whilst it is understandable for confidentiality reasons and the protection of Officers in circumstances where personal incidents had occurred, if Mr Palmer had been a member of the public, as opposed to a serving Police Officer, then the Firearms Unit would have been aware of these incidents from the Police logs . It may be prudent for such information to be made available to the Firearms Unit and the restricted logs reviewed perhaps at Senior Officer level and if appropriate that information passed to the Firearms Unit for assessment.
” Source location Jason Geoffrey PALMER · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review firearms licensing procedures and policies to address restricted incident-log information concerns.
Verbatim wording from the response “A thorough review has been undertaken of the procedures and policies in place to ensure that this concern is addressed.” Source location 2014-0534-Response-by-Devon-Cornwall-Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a written working practice formally recording how Firearms Enquiry Officers obtain and use information from restricted incident logs.
Verbatim wording from the response “The process which is followed upon receipt of an application for the granting or renewal of a certificate is that a Firearms Enquiry Officer (FEO) will interrogate the relevant police systems for any incidents of concern, as part of their investigation into the applicant’s suitability to possess firearms. As part of this process, all logs relating to the applicant will be seen by the FEO. This includes the presence of any restricted logs, albeit that the content can only be viewed by an officer of the rank of Inspector or above. The FEO is required to make contact with the Control Room in order that the content of any restricted log is viewed, and any relevant information contained therein is communicated to the FEO for the purposes of any decision regarding the application.” Source location 2014-0534-Response-by-Devon-Cornwall-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use an electronic system to scan police incident logs every ten minutes and immediately alert the Firearms Licensing Unit about logs concerning existing certificate holders.
Verbatim wording from the response “In addition, a significant change has been made to the method by which the Firearms Licensing Unit are alerted to any incident log which relate to an existing certificate holder. An electronic system has now been introduced which “sweeps” all police incident logs every ten minutes. In the event that any log relates to an existing certificate holder, an immediate alert is sent to the Firearms Licensing Unit, where the log content will be checked to identify whether any concern arises as a result of that individual’s suitability to possess a firearm. In the event that the log is restricted, a request can be made to the control room for the log to be reviewed and any relevant information provided.” Source location 2014-0534-Response-by-Devon-Cornwall-Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing firearms licensing procedures adequately address restricted incident information when assessing applicants’ suitability to possess firearms.
Verbatim wording from the response “The process which is followed upon receipt of an application for the granting or renewal of a certificate is that a Firearms Enquiry Officer (FEO) will interrogate the relevant police systems for any incidents of concern, as part of their investigation into the applicant’s suitability to possess firearms. As part of this process, all logs relating to the applicant will be seen by the FEO. This includes the presence of any restricted logs, albeit that the content can only be viewed by an officer of the rank of Inspector or above. The FEO is required to make contact with the Control Room in order that the content of any restricted log is viewed, and any relevant information contained therein is communicated to the FEO for the purposes of any decision regarding the application.” Source location 2014-0534-Response-by-Devon-Cornwall-Police
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Includes failures in firearms or shotgun licensing processes to obtain, share, flag, update, verify or act on safety-relevant information needed to assess an applicant's or licence holder's continuing suitability and control firearm access, including cross-authority notifications, relevant medical or household information, cohabitant enquiries, prosecution alerts and information about additional properties or force areas.
