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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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 North Yorkshire Police; 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 North Yorkshire Police; 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 North Yorkshire Police; 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
27 Oct 2016 Samuel Thomas Lindor Carroll · Prevention of Future Deaths report North Yorkshire (West)
View report summary
Concerns raised 2 Failure of ambulance services to ask for consent before sharing information about suicidal feelings or hospital attendance View source Failure of police officers to ask for consent before sharing information about suicidal feelings or hospital attendance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Samuel Thomas Lindor Carroll · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Samuel Thomas Lindor Carroll contacted emergency services stating that he felt suicidal and wanted to jump off a bridge, and was taken to hospital for a mental health assessment before being discharged. He was later found hanging from a tree and died from asphyxia due to hanging by ligature. The report raised concerns that police and ambulance staff did not ask whether he consented to family or friends being informed, meaning no family or friends were alerted to his hospital attendance or discharge.
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 North Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance services to ask for consent before sharing information about suicidal feelings or hospital attendance
Wider context from the report “1. The Police Officers did not ask Mr Carroll whether he wished, or consented to, anyone being told of the fact he was feeling suicidal or that he was being taken to the Hospital.
2. The Ambulance service did not ask Mr Carroll if he wished, or consented to, anyone being told of the fact he was feeling suicidal and being taken to Hospital.
3. As a consequence no family or friends were alerted to Mr Carroll being taken to or discharged from Hospital following an earlier expression of suicidal ideation.
” 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 North Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure of police officers to ask for consent before sharing information about suicidal feelings or hospital attendance
Wider context from the report “1. The Police Officers did not ask Mr Carroll whether he wished, or consented to, anyone being told of the fact he was feeling suicidal or that he was being taken to the Hospital.
2. The Ambulance service did not ask Mr Carroll if he wished, or consented to, anyone being told of the fact he was feeling suicidal and being taken to Hospital.
3. As a consequence no family or friends were alerted to Mr Carroll being taken to or discharged from Hospital following an earlier expression of suicidal ideation.
” 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 Add instruction to training on eliciting consent to inform a nominated person about a suicidal individual's location and mental wellbeing concerns.
Verbatim wording from the response “In light of your report, I will make sure that this training includes instruction to staff to make sure that steps are taken to elicit consent to inform a nominated person of their location and the concerns for their mental wellbeing. This must be balanced against considerations of whether that nominated person may potentially exacerbate the situation, given that feelings of suicidality often emanate from relationship / familial difficulties.” Source location 2016-0384-Response-by-North-Yorkshire-Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Because Mr Carroll appeared capacitated, was an adult, and had been handed over to professionals, officers had no expectation to notify friends or relatives.
Verbatim wording from the response “As you have noted, officers did not make contact with friends or relatives before Mr Carroll was taken by ambulance to hospital. Given his apparent possession of mental capacity, his adulthood and the handover to other professionals for his onward care, there has previously been no expectation that officers would make such intimations.” Source location 2016-0384-Response-by-North-Yorkshire-Police
Open published response
22 Jan 2014 Paul Alan Rogerson · Prevention of Future Deaths report York City
View report summary
Concerns raised 11 Lack of a protocol for dealing with untidy or disordered rescue equipment View source Lack of hypothermia coverage in police first aid training View source Insufficient police familiarity with current Fire and Rescue water rescue methods View source Insufficient procedures for robust action against deliberate damage or theft of life buoys View source Insufficient police training in current river rescue and water safety protocols View source Failure to maintain securely positioned, intact and sufficiently long river rescue equipment View source Insufficient police communication of detailed information during river rescues View source Lack of a system for reporting missing life buoys View source Lack of prominent warning signs along the river bank and in accessible public house areas View source Insufficient checks on the condition of life buoys View source Failure to protect river rescue equipment from vandalism and weather View source See 8 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 Alan Rogerson · 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 Alan Rogerson, aged 26, fell into the River Ouse in York on 26 March 2011 after consuming several pints of beer and drowned. The report raised concerns about inadequate life-buoy and throwing-line provision and maintenance, a lack of warning signs, and shortcomings in river-rescue training, communication and procedures.
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 North Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol for dealing with untidy or disordered rescue equipment
Wider context from the report “(6) There are insufficient checks upon the condition of life buoys. It is understood that City of York Council have officers who conduct periodic checks; North Yorkshire Police Officers and Community Support Officers conduct foot patrols. There appears to be no protocol for routine dealing with a buoy and line which are untidy or in disarray . There is no system of reporting a missing buoy. North Yorkshire Police may need to revisit procedures to take robust action in the event of deliberate damage or theft.
” 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 North Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of hypothermia coverage in police first aid training
Wider context from the report “(5) North Yorkshire Police officers receive first aid training in CPR and wounds but Hypothermia is currently not covered .
” 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 North Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient police familiarity with current Fire and Rescue water rescue methods
Wider context from the report “(4) North Yorkshire Police work with the Fire and Rescue Service in river rescues. The Fire and Rescue Service need to receive detailed information from Police Control; mutual assistance can be given during rescues; there may be a lack of sufficient communication from the Police on these occasions and a need for the Police to familiarise themselves with current Fire and Rescue methods of water rescue .
” 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 North Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient procedures for robust action against deliberate damage or theft of life buoys
Wider context from the report “(6) There are insufficient checks upon the condition of life buoys. It is understood that City of York Council have officers who conduct periodic checks; North Yorkshire Police Officers and Community Support Officers conduct foot patrols. There appears to be no protocol for routine dealing with a buoy and line which are untidy or in disarray. There is no system of reporting a missing buoy. North Yorkshire Police may need to revisit procedures to take robust action in the event of deliberate damage or theft .
” 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 North Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient police training in current river rescue and water safety protocols
Wider context from the report “(3) North Yorkshire Police Officers may require further training in current protocols for River Rescue and Water 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 North Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain securely positioned, intact and sufficiently long river rescue equipment
Wider context from the report “(1) The position and protection of life buoys and throwing lines is inadequate . Buoys are not securely placed on the river bank and at least one was found discarded some 20 metres from the river bank. Some throwing lines are frayed, discarded and of insufficient length to reach far across the river . The integrity of this equipment is insufficiently protected from vandalism and the weather.
” 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 North Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient police communication of detailed information during river rescues
Wider context from the report “(4) North Yorkshire Police work with the Fire and Rescue Service in river rescues. The Fire and Rescue Service need to receive detailed information from Police Control ; mutual assistance can be given during rescues; there may be a lack of sufficient communication from the Police on these occasions and a need for the Police to familiarise themselves with current Fire and Rescue methods of water rescue.
” 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 North Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for reporting missing life buoys
Wider context from the report “(6) There are insufficient checks upon the condition of life buoys. It is understood that City of York Council have officers who conduct periodic checks; North Yorkshire Police Officers and Community Support Officers conduct foot patrols. There appears to be no protocol for routine dealing with a buoy and line which are untidy or in disarray. There is no system of reporting a missing buoy . North Yorkshire Police may need to revisit procedures to take robust action in the event of deliberate damage or theft.
” 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 North Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of prominent warning signs along the river bank and in accessible public house areas
Wider context from the report “(2) There are no warning signs in place along the river bank within the city walls in York . Only one was found in the course of my enquiry, this being attached to a life buoy harness and being smaller than an A4 piece of paper . Public Houses near the river are not encouraged to display prominent warning signs in areas that their customers have access to 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 North Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient checks on the condition of life buoys
Wider context from the report “(6) There are insufficient checks upon the condition of life buoys . It is understood that City of York Council have officers who conduct periodic checks; North Yorkshire Police Officers and Community Support Officers conduct foot patrols. There appears to be no protocol for routine dealing with a buoy and line which are untidy or in disarray. There is no system of reporting a missing buoy. North Yorkshire Police may need to revisit procedures to take robust action in the event of deliberate damage or theft.
” 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 North Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to protect river rescue equipment from vandalism and weather
Wider context from the report “(1) The position and protection of life buoys and throwing lines is inadequate. Buoys are not securely placed on the river bank and at least one was found discarded some 20 metres from the river bank. Some throwing lines are frayed, discarded and of insufficient length to reach far across the river. The integrity of this equipment is insufficiently protected from vandalism and the weather .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations