Christine Ann Lee and Lucy Daisy Lee · Prevention of Future Deaths report

I commenced investigations into the deaths of Christine Ann Lee and Lucy Daisy Lee, both of whom died on 23rd February 2014.

The investigations concluded on 21st June 2019 after I had conducted inquests into the deaths, held with a jury, which began on 23rd May 2019.

Christine Lee and Lucy Lee died on the 23rd February 2014 at Keepers Cottage Stud, Tilford, Surrey after being shot with a shotgun. The perpetrator, who was later convicted of the murder of both women, was in lawful possession of the shotgun at the time under a shotgun certificate issued to him by Surrey Police.

Christine Lee and Lucy Lee were mother and daughter who had lived and worked at Keepers Cottage Stud, intermittently, for many years. There was a complex history of personal relationships between the perpetrator and the two women and their families.

In March 2013 the daughter and sister of Christine and Lucy Lee contacted the police and alleged that the perpetrator, who was then in his 80s, had threatened her in person with a shotgun at Keepers Cottage Stud and had threatened to kill her. She also raised concerns regarding his health, in particular that he may have Alzheimer’s Disease.

Surrey Police attended Keepers Cottage Stud and removed the perpetrator’s shotguns and shotgun certificate later that day. They subsequently conducted a criminal investigation into the threat to kill allegation, in the course of which the complainant (whilst maintaining the truth of the allegation) withdrew her support for prosecution of the perpetrator. As a result, Surrey Police decided that there was no realistic likelihood of a successful prosecution and the investigation was marked as ‘No Further Action’ and closed.

The Firearms Licensing Department of Surrey Police (the FLD) then commenced a review of whether or not to return the perpetrator’s shotguns and shotgun certificate to him. They had available to them, from a number of sources, relevant information and evidence relating to :
• the recent allegation of the threat to kill,
• earlier allegations against the perpetrator of threats to kill and domestic violence (which had previously resulted in consideration of his shotgun certificate being withdrawn on the basis that he posed a risk of extreme violence),
• an ongoing criminal investigation of the perpetrator for fraud,
• the perpetrator’s convictions for failing to comply with conditions on his licence to run a dog breeding establishment and for running an establishment when disqualified from doing so,
• the perpetrator having some criminal associates,
• the perpetrator’s health, and
• the perpetrator’s failure to make full and accurate disclosure of his previous convictions, and of his medical conditions, when last applying for a renewal of his shotgun certificate in 2010.

On 8th July 2013 staff from the FLD visited the perpetrator at home to assess his health and whether it was safe for him to have his shotguns and shotgun certificate returned to him. On 9th July 2013 a staff member from the FLD made the decision to return to the perpetrator his shotguns and shotgun certificate. The jury found that the decision was made by a person with lawful authority, under written delegation from the then Chief Constable, but that the decision maker had not taken account of all relevant information which could have been obtained and considered, had not applied the correct standard of proof, and had not postponed the decision pending the outcome of the ongoing fraud investigation. As a result of the decision, the perpetrator’s shotgun certificate and shotguns were returned to him on 11th July 2013.

The jury’s conclusion as to the death, in both inquests, was :

Unlawful Killing

The death was more than minimally contributed to by:

1 A failure by Surrey Police to have in place a system to ensure that the decision whether or not to return a shotgun certificate and shotgun to a certificate holder following removal pending a criminal investigation was made or approved by a senior police officer.

2 A failure by the Firearms Licensing Department of Surrey Police to investigate sufficiently whether it was safe to return to the perpetrator his shotgun certificate and shotguns following an allegation made in March 2013 that he had used one of his shotguns to make a threat to kill.

3 A failure by the Firearms Licensing Department of Surrey Police to consider all the evidence and information available to it before deciding whether to revoke the perpetrator’s shotgun certificate or to return his shotgun certificate and shotguns to him, following the March 2013 allegation.

4 A failure by the Firearms Licensing Department of Surrey Police to apply the correct standard of proof when deciding whether to revoke the perpetrator’s shotgun certificate, or to return his shotgun certificate and shotguns to him, following the March 2013 allegation.

5 A failure by the Firearms Licensing Department of Surrey Police to recommend revocation of the perpetrator’s shotgun certificate in July 2013 and the consequential failure by Surrey Police to revoke the certificate.

A. To : (1) The Chief Constable of Surrey Police

(2) Assistant Chief Constable David Orford as the National Police Chiefs’ Council’s Lead on Firearms Licensing

It was apparent from the evidence that, at the time of the deaths, there was no national training course for staff working in police firearms licensing departments as Firearms Enquiry Officers (“FEOs”). I was told that work is now being undertaken by the College of Policing to produce an accreditation process for FEOs, but that this work is not yet complete.

Currently, what is known as “the South Yorkshire Training Course” is available. This is a five day, residential course which appears to be comprehensive. I was told that all Surrey Police’s current FEOs have completed the South Yorkshire Training Course, but that it is not mandatory for them to do so.

I am concerned that, pending the introduction of a full accreditation scheme, the absence of a mandatory requirement for all new FEOs (whether in Surrey or elsewhere) to undertake comprehensive training for the role, in the form of the South Yorkshire Training Course or equivalent, will result in the risk of insufficient training, incorrect decision making concerning certification and, consequently, future deaths.

B. To : (1) The Chief Constable of Surrey Police

(2) Assistant Chief Constable David Orford as the National Police Chiefs’ Council’s Lead on Firearms Licensing

(3) The Home Secretary

(4) The Secretary of State for Health

(5) Dr Richard Vautrey as Chair of the General Practitioners Committee UK of the British Medical Association

It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.

I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.

First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.

Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.

Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.

In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”

In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system: 1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”

I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.