PFD report

Mr Harold Ambrose and Mrs Wendy Ambrose · Prevention of Future Deaths report

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Issued 25 Mar 2015•Essex

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised3

  1. Lack of a requirement for GPs and Mental Health Trusts to notify police of mental health concerns about firearms licence holders
    Part of recurring concern: Unreliable firearms licensing risk assessment and information sharing
  2. Failure to refer firearms licence holders with deteriorating mental health to the police
    Part of recurring concern: Failure to recognise and respond to deteriorating mental health in service usersPart of recurring concern: Unreliable firearms licensing risk assessment and information sharing
  3. Failure to record and flag firearms licence information in medical records and systems
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of a requirement for GPs and Mental Health Trusts to notify police of mental health concerns about firearms licence holders

Wider context from the report

“Mr Ambrose had held a shotgun licence since November 1987. This was renewed every 5 years at which time there was a full review. The last review was in 2011. On 18th November 2011 a letter from Essex Police Firearms Department was sent to his GPs surgery notifying them that he was a shotgun holder. No further details from this letter were entered onto his medical record and the fact that he was a firearms holder was not flagged on their system. In 2011 Mr Ambrose did not have any mental health problems. In September 2012 he was diagnosed with mixed dementia and this gradually worsened. He was receiving some input from the North Essex Partnership University NHS Foundation Trust (NEPT) following a referral from the GP in October 2012. Mr Ambrose made NEPT aware that he had a shotgun license in his initial assessment in November 2012. In May 2013 he was prescribed Alzheimer’s medication and was advised not to drive due to his cognitive impairment. In January 2014 it was clear that there had been a decline in his mental abilities and this decline continued. Although his mental health was clearly deteriorating neither the GP or NEPT referred this case to Essex Police Firearms Department. In evidence a representative of Essex Police said had they been made aware of his Mental Health problems they would have initiated a review of Mr Ambrose’s fitness to hold a shotgun licence. There is no requirement that GPs or Mental Health Trusts notify the police of concerns about patients mental health when they are aware that they have a firearms licence. ”

Is this part of a recurring concern?

Yes — Unreliable firearms licensing risk assessment and information sharing.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to refer firearms licence holders with deteriorating mental health to the police

Wider context from the report

“Mr Ambrose had held a shotgun licence since November 1987. This was renewed every 5 years at which time there was a full review. The last review was in 2011. On 18th November 2011 a letter from Essex Police Firearms Department was sent to his GPs surgery notifying them that he was a shotgun holder. No further details from this letter were entered onto his medical record and the fact that he was a firearms holder was not flagged on their system. In 2011 Mr Ambrose did not have any mental health problems. In September 2012 he was diagnosed with mixed dementia and this gradually worsened. He was receiving some input from the North Essex Partnership University NHS Foundation Trust (NEPT) following a referral from the GP in October 2012. Mr Ambrose made NEPT aware that he had a shotgun license in his initial assessment in November 2012. In May 2013 he was prescribed Alzheimer’s medication and was advised not to drive due to his cognitive impairment. In January 2014 it was clear that there had been a decline in his mental abilities and this decline continued. Although his mental health was clearly deteriorating neither the GP or NEPT referred this case to Essex Police Firearms Department. In evidence a representative of Essex Police said had they been made aware of his Mental Health problems they would have initiated a review of Mr Ambrose’s fitness to hold a shotgun licence. There is no requirement that GPs or Mental Health Trusts notify the police of concerns about patients mental health when they are aware that they have a firearms licence. ”

Is this part of a recurring concern?

Yes — Failure to recognise and respond to deteriorating mental health in service users; Unreliable firearms licensing risk assessment and information sharing.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to record and flag firearms licence information in medical records and systems

Wider context from the report

“Mr Ambrose had held a shotgun licence since November 1987. This was renewed every 5 years at which time there was a full review. The last review was in 2011. On 18th November 2011 a letter from Essex Police Firearms Department was sent to his GPs surgery notifying them that he was a shotgun holder. No further details from this letter were entered onto his medical record and the fact that he was a firearms holder was not flagged on their system. In 2011 Mr Ambrose did not have any mental health problems. In September 2012 he was diagnosed with mixed dementia and this gradually worsened. He was receiving some input from the North Essex Partnership University NHS Foundation Trust (NEPT) following a referral from the GP in October 2012. Mr Ambrose made NEPT aware that he had a shotgun license in his initial assessment in November 2012. In May 2013 he was prescribed Alzheimer’s medication and was advised not to drive due to his cognitive impairment. In January 2014 it was clear that there had been a decline in his mental abilities and this decline continued. Although his mental health was clearly deteriorating neither the GP or NEPT referred this case to Essex Police Firearms Department. In evidence a representative of Essex Police said had they been made aware of his Mental Health problems they would have initiated a review of Mr Ambrose’s fitness to hold a shotgun licence. There is no requirement that GPs or Mental Health Trusts notify the police of concerns about patients mental health when they are aware that they have a firearms licence. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

Open source report
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026