Recipient

British Medical Association

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First report 21 Jan 2014•Latest report 28 Apr 2022

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Trade union and professional body. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
9

Naming this recipient

Published responses
11%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
1

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

11%published responses found
1stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from British Medical Association linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Avon

    AI-generated summary

    Susan Elizabeth Carling · 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

    Susan Elizabeth Carling, a General Practitioner, died by suicide at her home address on 2 January 2022. The report raises concern about suicide among health-service professionals and the need to highlight available support for GPs and this vulnerable professional group.

    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. The report was sent to British Medical Association; that does not assign responsibility.

    PFD Monitor interpretation

    Suicides among health service professionals

    Wider context from the report

    “Her family brought to my attention that there are approximately 100 people in the health service who commit suicide each year. They requested that in my role to prevent future deaths that this is considered by someone who could potentially take action to prevent future deaths in this profession going forward. I am aware and made it clear to the family that there are organisations that GP’s can access for support however they like I agree that this needs to be highlighted if suicides are to be prevented in this vulnerable professional group. ”
    Open source report

  2. West Sussex

    AI-generated summary

    Pauline McInroy ALLISON · 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

    Pauline McInroy Allison died at hospital on 26 March 2021 from significant burns sustained in a house fire after smoking materials came into contact with flammable materials on her bed. She was largely bedbound and unable to escape. The principal concerns were the fire risks associated with emollient creams, smoking in bed, and air mattresses, and whether patients, families and carers were sufficiently aware of these risks and referred for fire safety advice.

    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. The report was sent to British Medical Association; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to refer patients using emollient creams to their local Fire & Rescue Service for advice and assistance

    Wider context from the report

    “(1) Mrs Allison used emollient creams containing flammable ingredients. I heard evidence that these ingredients can build up on clothing and bedding. The effect of this build up is to make material ignite more easily and burn more quickly. In addition to this the presence of an air mattress (often used by those with limited mobility) can further facilitate the ignition and spread of a fire by introducing additional air to the fire if it melts or punctures. The West Sussex Fire & Rescue Service informed me that they are trying to improve awareness amongst families, care providers and GPs of the increased risk of fire posed by the use of these types of emollient creams especially by immobile persons who smoke. I am concerned that not enough is being done to ensure that these patients, their families, and carers are aware of the risks and to ensure that they are referred to their local Fire & Rescue Service for advice and assistance. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Medical Association; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient provision of fire-risk information to patients, families and carers using emollient creams

    Wider context from the report

    “(1) Mrs Allison used emollient creams containing flammable ingredients. I heard evidence that these ingredients can build up on clothing and bedding. The effect of this build up is to make material ignite more easily and burn more quickly. In addition to this the presence of an air mattress (often used by those with limited mobility) can further facilitate the ignition and spread of a fire by introducing additional air to the fire if it melts or punctures. The West Sussex Fire & Rescue Service informed me that they are trying to improve awareness amongst families, care providers and GPs of the increased risk of fire posed by the use of these types of emollient creams especially by immobile persons who smoke. I am concerned that not enough is being done to ensure that these patients, their families, and carers are aware of the risks and to ensure that they are referred to their local Fire & Rescue Service for advice and assistance. ”
    Open source report

  3. Staffordshire South

    AI-generated summary

    MAUREEN MILTON · 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

    Maureen Milton, aged 74, died after her clothing caught fire while she was attempting to light a cigarette with a long match; petrol-based emollient cream on her clothing likely accelerated the fire, and she was pronounced dead at the scene. The principal concern was a lack of awareness among medical professionals, carers, victims and families about the fire risks associated with petrol-based emollients.

    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. The report was sent to British Medical Association; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of awareness of petrol-based emollient fire risks

    Wider context from the report

    “Evidence given by fire investigators was that they are increasingly attending fires involving (mostly) the elderly where there is evidence of petrol based emollient cream in use. The petrol base is found in a significant number of prescribed creams and creams (such as moisturisers) which are readily available over the counter. This cream impregnates clothing and is not washed away during a normal washing programme. In the event of a fire the victim is rapidly engulfed by flames with little chance of survival. The cause of death is generally burns, not inhalation of smoke. The concern is the lack of awareness of this problem by medical professionals, carers, victims and their families. It is felt appropriate heighten awareness of this growing problem amongst health professionals and others who work in the field of prescribing such creams and those caring for patients using petrol based emollients. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Medical Association; that does not assign responsibility.

    PFD Monitor interpretation

    Fire ignition of clothing impregnated with petrol-based emollient cream

    Wider context from the report

    “Evidence given by fire investigators was that they are increasingly attending fires involving (mostly) the elderly where there is evidence of petrol based emollient cream in use. The petrol base is found in a significant number of prescribed creams and creams (such as moisturisers) which are readily available over the counter. This cream impregnates clothing and is not washed away during a normal washing programme. In the event of a fire the victim is rapidly engulfed by flames with little chance of survival. The cause of death is generally burns, not inhalation of smoke. The concern is the lack of awareness of this problem by medical professionals, carers, victims and their families. It is felt appropriate heighten awareness of this growing problem amongst health professionals and others who work in the field of prescribing such creams and those caring for patients using petrol based emollients. ”
    Open source report

  4. Surrey

    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.

    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. The report was sent to British Medical Association; that does not assign responsibility.

    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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Medical Association; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of skills and training for Firearms Enquiry Officers assessing applicants’ medical fitness

    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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Medical Association; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of mandatory comprehensive training for new Firearms Enquiry Officers

    Wider context from the report

    “It was apparent from the evidence that, at the time of the deaths, there was no national training course for staff working in police firearms licensing departments as Firearms Enquiry Officers (“FEOs”). I was told that work is now being undertaken by the College of Policing to produce an accreditation process for FEOs, but that this work is not yet complete. Currently, what is known as “the South Yorkshire Training Course” is available. This is a five day, residential course which appears to be comprehensive. I was told that all Surrey Police’s current FEOs have completed the South Yorkshire Training Course, but that it is not mandatory for them to do so. I am concerned that, pending the introduction of a full accreditation scheme, the absence of a mandatory requirement for all new FEOs (whether in Surrey or elsewhere) to undertake comprehensive training for the role, in the form of the South Yorkshire Training Course or equivalent, will result in the risk of insufficient training, incorrect decision making concerning certification and, consequently, future deaths. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Medical Association; that does not assign responsibility.

    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. ”
    Open source report

  5. Surrey

    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. The report was sent to British Medical Association; that does not assign responsibility.

    PFD Monitor interpretation

    Absence of mandatory comprehensive training for Firearms Enquiry Officers

    Wider context from the report

    “It was apparent from the evidence that, at the time of the deaths, there was no national training course for staff working in police firearms licensing departments as Firearms Enquiry Officers (“FEOs”). I was told that work is now being undertaken by the College of Policing to produce an accreditation process for FEOs, but that this work is not yet complete. Currently, what is known as “the South Yorkshire Training Course” is available. This is a five day, residential course which appears to be comprehensive. I was told that all Surrey Police’s current FEOs have completed the South Yorkshire Training Course, but that it is not mandatory for them to do so. I am concerned that, pending the introduction of a full accreditation scheme, the absence of a mandatory requirement for all new FEOs (whether in Surrey or elsewhere) to undertake comprehensive training for the role, in the form of the South Yorkshire Training Course or equivalent, will result in the risk of insufficient training, incorrect decision making concerning certification and, consequently, future deaths. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Medical Association; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of relevant training and competence among Firearms Enquiry Officers assessing medical fitness

    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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Medical Association; that does not assign responsibility.

    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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Medical Association; that does not assign responsibility.

    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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Medical Association; that does not assign responsibility.

    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. ”
    Open source report

  6. Brighton and Hove

    AI-generated summary

    Ross REEVES · 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

    Ross REEVES died after taking more than one week’s worth of Gabapentin, Zomorph and Mirtazapine, which caused profound stupor and respiratory depression; he subsequently developed lobar pneumonia. The principal concern was that his transfer to a new GP was likely unsafe and that better handover information might have led to different prescribing arrangements.

    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. The report was sent to British Medical Association; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide adequate information during transfer of patients between GP practices

    Wider context from the report

    “(1) The transfer of this patient to his new GP was likely ‘unsafe’. I am particularly concerned because in Brighton and Hove we have an extremely high rate of drug related deaths. It seems to me that there were clues to this man’s death and if there had been more information available to the new GP it is highly likely that they would have taken different action with regard to him. In particular, they may well have prescribed his medications weekly rather than monthly. At the Inquest it was clear that only he had access to the medications that he collected on the 3rd October, 2017 and that with regard to Gabapentin, Zomorph and Mirtazapine he took over one week’s worth of each. This caused his sudden collapse, his state of profound stupor and his ultimate death due to a lobar pneumonia which developed during the time he was in such a state of profound respiratory depression due to the drugs that he had been able to take. I would like it made clear that the Inquest is not a vehicle for apportioning blame however lessons must be learned and it was clear that better hand over of patients from one practice to another would provide a better chance for the manipulative patient who lies to his new GP to be picked up and dealt with adequately, hopefully preventing his death. ”
    Open source report

  7. Surrey

    AI-generated summary

    Ernest Higgs · 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

    Ernest Higgs, a resident of a nursing home, was admitted to hospital after his health deteriorated and died there on 20 January 2015 from aspiration pneumonia. Concerns included unclear and poorly recorded telephone advice from a GP, uncertainty over responsibility for recording clinical advice, and conflicting information about out-of-hours pathology services that contributed to a delay in blood testing.

    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. The report was sent to British Medical Association; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure telephone clinical advice is accurately recorded and communicated in writing

    Wider context from the report

    “(2) Advice given by the GP over the telephone to make Mr Higgs “nil by mouth” was not recorded and no confirmation of that advice in writing was sent by email. There did not appear to be a safe system in place to ensure telephone advice was accurately sent and received. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Medical Association; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clarity about responsibility for recording visiting GPs' advice in multidisciplinary notes

    Wider context from the report

    “(1) It was clear from the evidence that confusion arose over what advice had been given by the GP on the 15th January 2015. No record was made in the multi-disciplinary notes by the GP of her attendance at Milner House. Care UK the parent company of Milner House offered to liaise with their local surgeries to ensure the records were made by visiting GPs. However it appears that the BMA advice to GPs “Quality First Managing Workload To Deliver Safer Patient Care” advises against GPs filling in multi-disciplinary notes. There was no clarity about whose responsibility it was to fill in the notes. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Medical Association; that does not assign responsibility.

    PFD Monitor interpretation

    Unclear out-of-hours pathology laboratory provision for community care providers

    Wider context from the report

    “(3) There was conflicting evidence from Care UK and Epsom hospital about OOH provision at the hospital pathology laboratory for community care providers resulting in a significant delay to a diagnostic blood test being undertaken. ”
    Open source report

  8. Swansea and Neath Port Talbot

    AI-generated summary

    Patricia Margaret Thomas · 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

    Patricia Margaret Thomas died at Morriston Hospital on 30 October 2013 after suffering an intracerebral haemorrhage, following an episode of unresponsiveness and left-sided weakness. The report identified a potential interaction between Miconazole Gel and Warfarin, a lack of awareness of this interaction among health professionals, and possible difficulties locating clear interaction-checking resources.

    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. The report was sent to British Medical Association; that does not assign responsibility.

    PFD Monitor interpretation

    Potential for Miconazole Gel and Warfarin interaction causing increased blood clotting time and INR

    Wider context from the report

    “It became apparent in the course of the evidence that (1) There is a potential for Miconazole Gel to have an interaction with Warfarin such as to increase the blood clotting time and hence a higher INR reading than should be expected. This could lead to significant uncontrolled bleeding. (2) There is a significant lack of knowledge of the interaction among health professionals and/or (3) The resources available to check the interaction may not be entirely clear on this issue or readily straight forward to locate. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Medical Association; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of knowledge of the Miconazole Gel and Warfarin interaction among health professionals

    Wider context from the report

    “It became apparent in the course of the evidence that (1) There is a potential for Miconazole Gel to have an interaction with Warfarin such as to increase the blood clotting time and hence a higher INR reading than should be expected. This could lead to significant uncontrolled bleeding. (2) There is a significant lack of knowledge of the interaction among health professionals and/or (3) The resources available to check the interaction may not be entirely clear on this issue or readily straight forward to locate. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Medical Association; that does not assign responsibility.

    PFD Monitor interpretation

    Unclear or difficult-to-locate resources for checking the Miconazole Gel and Warfarin interaction

    Wider context from the report

    “It became apparent in the course of the evidence that (1) There is a potential for Miconazole Gel to have an interaction with Warfarin such as to increase the blood clotting time and hence a higher INR reading than should be expected. This could lead to significant uncontrolled bleeding. (2) There is a significant lack of knowledge of the interaction among health professionals and/or (3) The resources available to check the interaction may not be entirely clear on this issue or readily straight forward to locate. ”
    Open source report

  9. Wiltshire and Swindon

    AI-generated summary

    William Howard DOWLING and Victoria Elaine ROSE · 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

    On 2 March 2013, William Howard Dowling shot Victoria Elaine Rose twice in the head before shooting himself in the head. The report raised concerns about information sharing between general practitioners and firearms licensing authorities, the wider public-safety implications of confidentiality, and the independence and transparency of firearms licensing decisions involving current or former police employees.

    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. The report was sent to British Medical Association; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of arrangements enabling doctors to report relevant information during firearms licence terms

    Wider context from the report

    “(1) During the course of the hearing I heard evidence from ███████ Wiltshire Police Firearms Licensing Manager, who indicated to me that at the present moment in time aside from a letter (copy attached marked A – since July 2011) which is sent to General Practitioners when firearms licence applications are successful or where they are renewed, giving a doctor the opportunity to relay relevant information in relation to their patient within 14 days, there is currently no memorandum of understanding or legislation that allows doctors the ability during the duration of the term of a firearms license, which stands at 5 years, to report matters which may have a bearing on that patient’s suitability to hold a firearms license and possess firearms. Doctors of course are bound at the present moment in time by patient confidentiality. I am concerned that this restriction may impede the firearms authority from making crucial decisions as regards individuals possessing firearms and continuing to hold a firearms licence in circumstances which, at present, may not come before the attention of the Firearms Authority unless the matter has ordinarily come before the police’s attention as a consequence of other aspects of their duties. In evidence from ███████ she made me aware that Wiltshire Police through the cooperation of NHS Wiltshire Clinical Commissioning Group and two Doctor’s Surgeries were piloting a scheme (directly prompted Victoria’s two sons as a result of his tragedy) effective from September 2013, to allow an increase in the sharing of information in particular having a bearing on the suitability of an individual to hold a firearms licence. She indicated that as a result of this pilot scheme an individual’s firearms were taken away at short notice as a result of the information received from the General Practitioner. This pilot scheme seems to me to be an utterly sensible idea although at present it is a pilot scheme and is not a national concept. This ought to be urgently reviewed. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Medical Association; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to enable General Practitioners to share public-safety information with relevant authorities

    Wider context from the report

    “(2) I am also concerned that any review arising out of this letter should not be singularly restricted as regards sharing information solely related to the suitability of somebody to hold a firearms licence. Information sharing with a view to public safety should be a reason for General Practitioners to make relevant authority(s) aware and I have in mind here the example of a driver whose eyesight is failing and where advice given from a GP to inform the DVLA, however that driver chooses not to do so as it will mean their licence may be revoked. If it is a matter of public safety then I am concerned at present moment in time that confidentiality appears to outweigh the concept of public safety. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Medical Association; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of independent and transparent firearms licensing decisions for current or former police employees

    Wider context from the report

    “(3) I am also concerned as regards decisions being made relating to firearms licensing in respect of current employees within that licensing organisation’s (ie the Police) employment or even former employees. Licensing and the determination of such matters should be seen to be transparent and independent. In evidence although relating to matters some 16 years previously there were issues raised by family concerning complaints by Mr Dowling’s ex wife at the time they were getting divorced that appeared to have been “brushed under the carpet” by the police in respect of which Bill was a serving officer. In any event those concerns were not dealt with satisfactorily from the complainant’s perspective. I am concerned that to have a firearms licensing authority dealing with applications from existing police employees or even former employees of that police force is open to possible abuse. Bill Dowling was an exceptionally well known and respected former police employee and my concern is that such matters relative to firearms are so serious that consideration ought to be given to introducing an independent layer so as to ensure independence and transparency. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

11%
11%All other recipients 58%
0%100%

How actions were described at the time

This respondent
100%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026