Concerns raised 3 Failure to condition firearms licensing delegation on adequate training View source Absence of a mandatory requirement for role-specific firearms licensing training View source Lack of nationally accredited training for firearms licensing staff 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
Maxine Betty Davison and 4 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
On 12 August 2021, Jake Davison used a lawfully held shotgun to kill his mother, Maxine Davison, and four other people in Keyham, Plymouth. The inquest identified serious failures in firearms licensing, including inadequate training, governance, supervision, scrutiny, information gathering and decisions to grant and return the shotgun certificate. The report expressed particular concern about the continuing lack of nationally accredited and mandatory training for firearms licensing staff and the risk of incorrect licensing decisions and 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. The report was sent to Norfolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to condition firearms licensing delegation on adequate training
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training .
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff.
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists.
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training .
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of 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 Norfolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Absence of a mandatory requirement for role-specific firearms licensing training
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training . I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff.
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists.
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular .
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff ;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of 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 Norfolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of nationally accredited training for firearms licensing staff
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff .
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists .
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” 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 Deliver externally commissioned firearms licensing training to all Firearms Licensing Unit enquiry and licensing officers.
Verbatim wording from the response “The two forces recognise the need to ensure that those with delegated responsibility from the Chief Constables should be appropriately trained in the application of the Home Office Guidance on Firearms Licensing Law (Nov 22) and the Revised Statutory Guidance for Chief officers of Police (Feb 23).”
Source location Response from Norfolk Constabulary Page 1 · response Published 10 March 2023
Open published response
11 May 2021 Paul Steven Reynolds · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 13 Failure to place a person subjected to prone restraint in the recovery position View source Lack of accurate and clear guidance on information to share with police View source Failure to provide or arrange additional training for security staff View source Failure to control the scene to facilitate assessment of a person’s condition View source Lack of clarity about incident command and staff responsibilities View source Failure to closely and effectively monitor breathing during prone restraint View source Failure to restrict restraint participation to appropriately badged staff View source Physical intervention policy permitting ground restraint methods not taught in accredited courses View source Reduction in time allowed for officer training View source Officers’ misunderstanding of the circumstances in which pain or pressure testing is justifiable View source Insufficient officer skills in non-physical aspects of conflict management View source Lack of consistency in the training curriculum View source Failure to document staff induction and training View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Paul Steven Reynolds · 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
Paul Steven Reynolds died on 16 February 2017 after being restrained by the neck and placed in a prone position at Pontins Pakefield in Lowestoft. The principal concerns included inadequate monitoring of his breathing, failure to place him in the recovery position, insufficient staff training, unclear responsibilities, and poor sharing of information with police.
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 Norfolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to place a person subjected to prone restraint in the recovery position
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for staff.
” 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 Norfolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of accurate and clear guidance on information to share with police
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for staff.
” 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 Norfolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to provide or arrange additional training for security staff
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for staff.
” 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 Norfolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to control the scene to facilitate assessment of a person’s condition
Wider context from the report “(4) Officers did not control the scene by clearing the ballroom and switching off the music which would have improved their ability to assess Mr Reynolds’ condition .
” 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 Norfolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about incident command and staff responsibilities
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for staff.
” 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 Norfolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to closely and effectively monitor breathing during prone restraint
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for staff.
” 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 Norfolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict restraint participation to appropriately badged staff
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for staff.
” 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 Norfolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Physical intervention policy permitting ground restraint methods not taught in accredited courses
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses .
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for staff.
” 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 Norfolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Reduction in time allowed for officer training
Wider context from the report “(2) The time allowed for training had been reduced from 12 to 4.25 hours. Positional asphyxia training had been reinforced, but there were questions about the impact of the reduction upon officers.
” 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 Norfolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Officers’ misunderstanding of the circumstances in which pain or pressure testing is justifiable
Wider context from the report “(1) Officers appeared to be under the impression that pain/pressure testing to determine whether a person was unconscious or simply asleep was an assault rather than being justifiable in certain circumstances.
” 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 Norfolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Insufficient officer skills in non-physical aspects of conflict management
Wider context from the report “(3) The College of Policing and NPCC Officer and Staff safety Review made two recommendations to include revising the curriculum to ensure greater consistency, and to implement guidelines to ensure officers are sufficiently skilled in non-physical aspects of conflict management . The time scales for implementation were not stated.
” 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 Norfolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of consistency in the training curriculum
Wider context from the report “(3) The College of Policing and NPCC Officer and Staff safety Review made two recommendations to include revising the curriculum to ensure greater consistency , and to implement guidelines to ensure officers are sufficiently skilled in non-physical aspects of conflict management. The time scales for implementation were not stated.
” 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 Norfolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to document staff induction and training
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for staff.
” Open source report
4 Mar 2014 RYAN JAMES PETTENGELL · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 3 Failure to maintain existing safety signage View source Lack of signage prohibiting swimming around the lake View source Failure to prevent public access to the officially closed site 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 action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
RYAN JAMES PETTENGELL · 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 16 July 2013, Ryan James Pettengell entered a lake at a disused quarry and drowned while attempting to swim to a nearby island. Concerns included continued public access, absent or damaged swimming-prohibition signage, and no action having been taken six months after safety recommendations.
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 Norfolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain existing safety signage
Wider context from the report “(6) Some of the existing signage is damaged and/or has been removed .
” 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 Norfolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of signage prohibiting swimming around the lake
Wider context from the report “(5)There is no signage around the lake prohibiting swimming in the area where Mr Pettengell entered the water ;
” 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 Norfolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent public access to the officially closed site
Wider context from the report “(1) The site has been officially closed since this incident (and another drowning on the same day) whilst meetings are ongoing with the community as to the best way to provide recreational facilities to the public whilst having regard to the public’s safety;
(2) Recommendations were put forward by the King’s Lynn and West Norfolk Council on 20 August 2013 with regard to increasing safety at the site;
(3) Six months later, no action has been taken with regard to increasing safety at the site;
(4) Evidence was given at the inquest that the public are still gaining access to the site ;
” Open source report