PFD report

Emma Pattison and 2 others · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 8 Aug 2024•Surrey

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.

View original report
Concerns
2

Raised in this report

Recipients
5

Named on the report

Responses found
5

Of 5 recipients

Stated actions
16

Described in responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Report evidence summary

Concerns raised2

  1. Failure to ensure full and accurate disclosure of shotgun certificate applicants’ history of coercive controlling behaviour
    Part of recurring concern: Unreliable firearms licensing risk assessment and information sharing
  2. Failure to ensure full disclosure of shotgun certificate applicants’ medical history
    Part of recurring concern: Unreliable firearms licensing risk assessment and information sharing
Responses linked to these concerns

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

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.14

  1. Action

    Require a medical declaration and specific GP or third-party medical report before considering a firearms licence application.

    Stated by National Police Chiefs’ CouncilStated completedThe respondent said that this action was complete when they made their response on 12 August 2024.
  2. Action

    Develop a right to draw adverse inferences when firearms licence applicants are evasive about family members or previous partners.

    Stated by National Police Chiefs’ CouncilStated in progressThe respondent said that this action was in progress when they made their response on 12 August 2024.
  3. Action

    Roll out the nationally designed Firearms Enquiry Officer course, including testing, mandatory specialist training, portfolio assessment and external moderation.

    Stated by National Police Chiefs’ CouncilStated in progressThe respondent said that this action was in progress when they made their response on 12 August 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.10

  1. Position

    The Home Office is responsible for implementing proposed firearms licensing reforms, including GP requirements, seizure powers and application restrictions.

    Stated by National Police Chiefs’ CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 ensure full and accurate disclosure of shotgun certificate applicants’ history of coercive controlling behaviour

Wider context from the report

“3. Consideration should be given as to how a licensing authority can obtain full and accurate disclosure of an applicant’s history of coercive controlling behaviour towards another / others. ”

Is this part of a recurring concern?

Yes — 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 ensure full disclosure of shotgun certificate applicants’ medical history

Wider context from the report

“1. An applicant for a shotgun certificate is able to obtain medication from an on-line doctor without the knowledge of their GP, giving rise to a risk that a licensing authority might grant a shotgun certificate to an applicant who has a relevant previous medical history about which the authority is not aware. 2. In consulting an on-line doctor, it is possible for an applicant for a shotgun certificate to avoid the current safeguards relating to full disclosure of their previous and current medical history. ”

Is this part of a recurring concern?

Yes — Unreliable firearms licensing risk assessment and information sharing.

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

Require a medical declaration and specific GP or third-party medical report before considering a firearms licence application.

Verbatim wording from the response

“Changes have been made to the medical declaration required from an applicant and the requirement for a specific GP report has been introduced – no licence is now considered without the opinion of the applicant’s GP as to any relevant medical concerns or other medical issues which could affect an applicant’s suitability to possess a licence.”

Source location

Response from NPCC
Page 2 · response
Published 12 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop a right to draw adverse inferences when firearms licence applicants are evasive about family members or previous partners.

Verbatim wording from the response

“Moving forward, national FEO training will further encourage positive engagement with the applicant and their family/others in their household. FEOs will be expected to ascertain the “domestic health and wellbeing” of the applicant on both initial grant and any renewal. We are hopeful that revised statutory guidance will require interviews and wider engagement with families and FEOs will be required to cover these matters on the new FEO report on suitability. We are also looking to introduce the right to draw adverse inference if an applicant is evasive about family/previous partners and so on.”

Source location

Response from NPCC
Page 5 · response
Published 12 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Roll out the nationally designed Firearms Enquiry Officer course, including testing, mandatory specialist training, portfolio assessment and external moderation.

Verbatim wording from the response

“Substantial changes are being introduced around training and accreditation of Firearms Enquiry Officers (FEOs) (who, in most cases provide the report to decision makers assessing the applicant’s circumstances and comment on suitability following appropriate conversations and visits).”

Source location

Response from NPCC
Page 1 · response
Published 12 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Introduce a nationally standardised Firearms Enquiry Officer report form requiring comprehensive enquiries, information received and suitability reasoning.

Verbatim wording from the response

“We are also introducing a new FEO Report Form for national use which will require more comprehensive detailing of enquiries undertaken, information received (from in person interviews, police systems and wider investigations deemed appropriate on each individual application) and the rationale for their view on suitability. It is intended that this will act both as a prompt to FEOs to ensure all aspects of suitability are properly considered and also build on the increasing focus in more recent versions of the HO guidance around the importance of exercising professional curiosity in all cases.”

Source location

Response from NPCC
Page 2 · response
Published 12 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Engage partner organisations to improve inter-agency information-sharing for firearms licensing suitability assessments.

Verbatim wording from the response

“As a police service, we will continue to engage with partners to improve upon partnership working and inter-agency information-sharing to ensure that those charged with determining firearms licensing applications have as much relevant information as possible to assess an applicant’s suitability to hold a firearms licence in the context of ensuring public safety.”

Source location

Response from NPCC
Page 5 · response
Published 12 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Update guidance to reflect the potential information gap when external prescribers do not share relevant information.

Verbatim wording from the response

“This report identifies a possible information gap for NHS General Practitioners when providing factual medical information to the police as part of the firearms licensing process. We will update our own guidance to reflect that this potential gap exists if external prescribers are not sharing information, or have not been supplied by the patient with information that would be relevant.”

Source location

Response from GPC
Page 2 · response
Published 12 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Consider whether private online prescribers should inform patients’ NHS GPs about prescribed medication.

Verbatim wording from the response

“In response to the issue you raise that an applicant for a shotgun certificate is able to obtain medication from an on-line doctor without the knowledge of their GP, there is no legal requirement for a GP to be informed about medication from a private online prescriber. This is an issue which the Government is considering. Third party (non-NHS) doctors or prescribers cannot share confidential patient information with a person’s NHS GP if that person objects unless they believe there is an overriding public interest justifying consent for doing so (e.g. to protect a third party from serious harm). Third party prescribers are also reliant on the patient fully disclosing all medical conditions and existing medication to be able to prescribe safely.”

Source location

Response from DHSC
Page 2 · response
Published 12 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Maintain a firearms-certificate digital marker in GP IT systems so relevant medical conditions can be flagged for police review.

Verbatim wording from the response

“We have worked closely with the Home Office and the British Medical Association to ensure there are strong controls in place in relation to an applicant’s medical suitability which is one”

Source location

Response from DHSC
Page 1 · response
Published 12 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Consult the College of Policing and NPCC lead about adding certificate conditions reminding holders to report changes in domestic and health circumstances.

Verbatim wording from the response

“Surrey Police licensing officers take a negative view of applicants who fail to disclose relevant information. However, there seems to be little within legislation to require a holder to disclose a change in personal circumstances during each 5-year period. Therefore, I am consulting with the College of Policing and the NPCC lead on the potential to add a condition to holder certificates, reminding them of their obligations to inform the police of any changes in domestic and health situation. I believe this would allow more robust oversight between renewals.”

Source location

Response from Surrey Police
Page 2 · response
Published 12 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Require Firearms Enquiry Officers to ask applicants about medical treatment obtained outside their GP practice.

Verbatim wording from the response

“I share your concern that any certificate holder or applicant can, it would appear, hide certain medical treatment by using an online facility. The national application form asks, “Are there any periods in the past 10 years when you have not been registered with a UK GP or have consulted medical practitioners other than at your GP practice?” In this case, Mr Pattison answered “no” in both his 2016 and 2022 renewals. Surrey Police acknowledge that, although the force re-asks all other questions on the medical form during the Firearms Enquiry Officer (FEO) visit, Surrey Police did not ask about the use of other medical services in this visit. Surrey Police has, because of this case, revised our practice, and FEOs now do cover this in their visits to try and elicit the information from an applicant.”

Source location

Response from Surrey Police
Page 1 · response
Published 12 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Issue refreshed firearms guidance strengthening police assessment of domestic abuse, coercive control and other violence allegations, including sensitive confidential interviews.

Verbatim wording from the response

“In your report you have also proposed that consideration is given to how the police can obtain full and accurate disclosure of an applicant’s history of coercive controlling behaviour. The Home Office publishes Statutory Firearms Guidance for Chief Officers of Police which sets out the processes and criteria for assessing an applicant’s suitability to possess firearms. This assists the police in their firearms licensing functions and promotes high standards and consistency between forces. We are intending to issue a refreshed version of the Statutory Guidance early in 2025 which will include additional guidance for the police to help ensure that those who are the perpetrators of domestic abuse, coercive or controlling behaviour, do not have access to firearms.”

Source location

Response from The Home Office
Page 2 · response
Published 12 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Amend firearm and shotgun application forms to require disclosure of consultations with online or third-party prescribers.

Verbatim wording from the response

“I have taken careful note of the issue you raise in relation to the medical checks, that there is no requirement for an online or third-party doctor to inform a patient’s GP about medication they have prescribed for them. This is an issue which the Government is considering. In the meantime, in order to further strengthen the firearms licensing process I intend to make arrangements to amend the firearms and shotgun licence application form so that in future applicants are required to provide details if they have consulted an online or third party prescriber who is not their GP. This will enable further enquiries to be made with the online or third-party prescriber, and the police may require the applicant to provide a completed medical proforma from their prescriber in relation to any relevant medical conditions.”

Source location

Response from The Home Office
Page 1 · response
Published 12 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Amend firearm certificates to require holders to notify police about relevant medical consultations with online or third-party doctors.

Verbatim wording from the response

“I also intend to amend the firearm certificate to include a new condition requiring the holder to inform the police if they consult an online or third-party doctor about a relevant medical condition during the five years the licence is valid. These changes will”

Source location

Response from The Home Office
Page 1 · response
Published 12 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Consider measures to address online or third-party prescribers not informing applicants’ GPs about prescribed medication.

Verbatim wording from the response

“I have taken careful note of the issue you raise in relation to the medical checks, that there is no requirement for an online or third-party doctor to inform a patient’s GP about medication they have prescribed for them. This is an issue which the Government is considering. In the meantime, in order to further strengthen the firearms licensing process I intend to make arrangements to amend the firearms and shotgun licence application form so that in future applicants are required to provide details if they have consulted an online or third party prescriber who is not their GP. This will enable further enquiries to be made with the online or third-party prescriber, and the police may require the applicant to provide a completed medical proforma from their prescriber in relation to any relevant medical conditions.”

Source location

Response from The Home Office
Page 1 · response
Published 12 August 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The Home Office is responsible for implementing proposed firearms licensing reforms, including GP requirements, seizure powers and application restrictions.

Verbatim wording from the response

“• HO to proceed with implementation of the outcomes from their August 23 consultation, in particular we would welcome early implementation of ◦ Mandatory requirements for GPs to support the licensing process and complete the medical proformas on every application, ◦ Police being granted powers to enter properties to seize firearms for the purpose of reassessing suitability of licence holders, ◦ A statutory prohibition on applying for a licence for 5 years for anyone who has been sentenced to serve 0-3 years in prison, including suspended sentences.”

Source location

Response from NPCC
Page 4 · response
Published 12 August 2024

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

Police have little ability to address deliberate concealment of relevant medical information, apart from revoking a licence.

Verbatim wording from the response

“There has already been a significant improvement in the medical information available to Firearms Licensing teams through the introduction of the mandatory GP report or medical report from a third party medical provider on application. However, it remains the case that where an applicant deliberately withholds relevant information – not only from the Firearms Licensing team but from their own GP – there is little that police forces can do in many cases to address deliberate dishonesty, save for revoking a licence (which is made clear on the application form and within the HO guidance).”

Source location

Response from NPCC
Page 2 · response
Published 12 August 2024

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

Regulation of online doctors and information-sharing with registered GPs is a matter for DHSC, with Home Office colleagues progressing it.

Verbatim wording from the response

“It is, of course, outside the role and remit of policing to regulate or manage the health sector; this would be a matter for the Department of Health and Social Care and we understand that our HO colleagues are working with their counterparts in the DHSC to progress this issue. As the NPCC Lead, I would welcome any positive moves that are possible to regulate online GPs/prescriptions and require any relevant information to be passed to the GP with whom the individual is registered, so that it is accessible to Firearms Licensing Units when required, to enable a fuller picture to be available to support risk assessments and suitability assessments on applications for grant or renewal of firearms licensing. Exactly the same concerns arise where applicants use private GPs or consultants (outside of a GP referral) which may also remain unknown to firearms licensing teams.”

Source location

Response from NPCC
Page 3 · response
Published 12 August 2024

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

Policing cannot regulate or manage online healthcare providers because health-sector regulation falls outside its remit.

Verbatim wording from the response

“It is, of course, outside the role and remit of policing to regulate or manage the health sector; this would be a matter for the Department of Health and Social Care and we understand that our HO colleagues are working with their counterparts in the DHSC to progress this issue. As the NPCC Lead, I would welcome any positive moves that are possible to regulate online GPs/prescriptions and require any relevant information to be passed to the GP with whom the individual is registered, so that it is accessible to Firearms Licensing Units when required, to enable a fuller picture to be available to support risk assessments and suitability assessments on applications for grant or renewal of firearms licensing. Exactly the same concerns arise where applicants use private GPs or consultants (outside of a GP referral) which may also remain unknown to firearms licensing teams.”

Source location

Response from NPCC
Page 3 · response
Published 12 August 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The circumstances of deliberate online medical concealment and dishonest declarations appear difficult to address through legislation.

Verbatim wording from the response

“The difficulties posed by this case however appear difficult to legislate against;”

Source location

Response from NPCC
Page 5 · response
Published 12 August 2024

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

Any change to professional guidance on information-sharing between online doctors and GPs is for the GMC to consider.

Verbatim wording from the response

“We would therefore expect online doctors to be providing information to GPs in line with the professional guidance available from their Regulator. If a patient does not consent to this sharing of information, then the same GMC guidance advises that the online doctor should explain the risks to the patient and to record the refusal in their medical records. (Paragraph 31) However, the risks that might exist in these circumstances are not further defined. A change to the guidance above would be a matter for the GMC to consider. BMA guidance reiterates the above.”

Source location

Response from GPC
Page 2 · response
Published 12 August 2024

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

Existing GMC guidance and expected information-sharing and medical-history practices address risks from online prescribing, subject to patient refusal.

Verbatim wording from the response

“We would therefore expect online doctors to be providing information to GPs in line with the professional guidance available from their Regulator. If a patient does not consent to this sharing of information, then the same GMC guidance advises that the online doctor should explain the risks to the patient and to record the refusal in their medical records. (Paragraph 31) However, the risks that might exist in these circumstances are not further defined. A change to the guidance above would be a matter for the GMC to consider. BMA guidance reiterates the above.”

Source location

Response from GPC
Page 2 · response
Published 12 August 2024

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

Confidentiality and data protection law restrict third-party prescribers from sharing patient information with NHS GPs without consent, absent overriding public interest.

Verbatim wording from the response

“In response to the issue you raise that an applicant for a shotgun certificate is able to obtain medication from an on-line doctor without the knowledge of their GP, there is no legal requirement for a GP to be informed about medication from a private online prescriber. This is an issue which the Government is considering. Third party (non-NHS) doctors or prescribers cannot share confidential patient information with a person’s NHS GP if that person objects unless they believe there is an overriding public interest justifying consent for doing so (e.g. to protect a third party from serious harm). Third party prescribers are also reliant on the patient fully disclosing all medical conditions and existing medication to be able to prescribe safely.”

Source location

Response from DHSC
Page 2 · response
Published 12 August 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The Home Office is considering concerns about firearms licensing and will respond to the report.

Verbatim wording from the response

“In your report you raise the issue of whether an applicant can avoid full disclosure of their previous and current medical history. If an applicant seeks treatment from a range of healthcare providers, this is possible. The Home Office is considering the concerns you have raised in relation to the firearms licensing process and will be responding to your report in due course.”

Source location

Response from DHSC
Page 2 · response
Published 12 August 2024

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

Police currently have no method to detect whether firearms applicants withhold information about medical treatment.

Verbatim wording from the response

“Surrey Police acknowledges that an applicant could still withhold this information, and there is currently no method for the police to find out if it is being so withheld.”

Source location

Response from Surrey Police
Page 1 · response
Published 12 August 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Request a formal report from the Assistant Chief Constable on progress against the recommendations within three months.

    Stated by Surrey PoliceStated completedThe respondent said that this action was complete when they made their response on 12 August 2024.
  2. 2

    Review firearms licensing to ensure the strongest possible safeguards are in place.

    Stated by Home OfficeStated plannedThe respondent said that this action was planned when they made their response on 12 August 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Changes to the national firearms application form and process must be agreed and delivered nationally, so local differences cannot be made.

    Stated by Surrey PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Request a formal report from the Assistant Chief Constable on progress against the recommendations within three months.

Verbatim wording from the response

“For assurance, I have asked our Assistant Chief Constable with responsibility for Firearms Licensing to report formally to me on progress against your recommendations in 3 months.”

Source location

Response from Surrey Police
Page 2 · response
Published 12 August 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review firearms licensing to ensure the strongest possible safeguards are in place.

Verbatim wording from the response

“Thank you again for your report. We will review firearms licensing to ensure that the strongest possible safeguards are in place.”

Source location

Response from The Home Office
Page 2 · response
Published 12 August 2024

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

Changes to the national firearms application form and process must be agreed and delivered nationally, so local differences cannot be made.

Verbatim wording from the response

“This work is being progressed nationally by Chief Constable Debbie Tedds, the NPCC lead for firearms licensing. She is supported by her staff officer Chief Superintendent Adrian Davies who is also the College of Policing contact for this area of work. Both proposed changes above must be agreed at a national level and there cannot be local differences to the form or process. This work is already underway and the proposed changes will be presented at the National Firearms, Explosive working group by Adrian and, once ratified, will be implemented. I expect this to take 6 – 12 months.”

Source location

Response from Surrey Police
Page 2 · response
Published 12 August 2024

Open published response
Back to top

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

Official responses located
5/5

Data last updated 7 September 2026