PFD report

Maxine Betty Davison and 4 others · Prevention of Future Deaths report

Get email alerts

Request correction

Issued 8 Mar 2023•Plymouth, Torbay and South Devon

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: 3
Recipients: 46
Responses found: 35
Stated actions: 275

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Investigation and inquest

On 19 August 2021 I commenced an investigation into the deaths of Maxine Davison (age 51), Lee Martyn (age 43), Sophie Martyn (age 3), Stephen Washington (age 59) and Kate Shepherd (age 66). The investigation concluded at the end of the inquest held before a jury on 20 February 2023. The conclusion of the jury in respect of these five conjoined inquests was as follows:

Maxine Betty Davison
On the 12ᵗʰ August 2021 between 18:05-18:08, Maxine Betty Davison died as a result of shotgun wounds to the head and torso. This occurred at her address, 17 Biddick Drive following an argument with the perpetrator.

Lee Raymond John Martyn
On the 12ᵗʰ August 2021 between 18:08-18:10, Lee Raymond John Martyn died as a result of shotgun wounds to the head and torso. This occurred whilst walking with his daughter Sophie Iris Martyn in the street, Biddick Drive, Keyham, Plymouth.

Sophie Iris Martyn
On the 12ᵗʰ August 2021 between 18:08-18:10, Sophie Iris Martyn died as a result of a shotgun wound to her head. This occurred whilst walking with her father Lee Raymond John Martyn in the street, Biddick Drive, Keyham, Plymouth.

Stephen John Godfrey Washington
On the 12ᵗʰ August 2021 between 18:10-18:12, Stephen John Godfrey Washington died as a result of a shotgun wound to his chest. This occurred whilst walking on Snakey path (Linear Park), a footpath behind Biddick Drive, Keyham, Plymouth whilst walking with his dogs.

Kathryn Jane Shepherd (known as Kate).
On the 12ᵗʰ August 2021, Kathryn Jane Shepherd received a shotgun wound to her abdomen at 18:13 outside Blush Salon, Henderson Place, Plymouth and subsequently died later that day in Derriford Hospital, Plymouth.

In respect of each deceased the jury also found as follows

Under Section 3 of the Record of Inquest

‘The perpetrator came to be and remain in lawful possession of a shotgun at the material time due to the following circumstances:

The initial shotgun licence application
In 2017, given the absence of medical information, the known history of assaults and the intelligence held by Devon & Cornwall Police suggesting involvement in other violent episodes, it was a serious failure to protect the public and the peace to grant a licence to the perpetrator.

There was a serious failure within the Firearms and Explosives Licensing Unit (FELU) to heed and apply the 2016 Home Office guidance, that high risk decisions on grant of a licence should be made by the Firearms Licensing Manager (FLM).

Despite the 2016 Home Office guidance in force at that time, inadequate steps were taken to obtain specific medical evidence regarding the extent to which the perpetrator’s declared autism and Asperger’s might impact upon his suitability to hold a shotgun licence.

This was further compounded by the confusion caused by the move from the use of a post to pre-grant letter, without the update to the Home Office guidance which previously stated would be provided.

It was not a safe system to assume that in the absence of a substantive response to the standard pre-grant letter from the GP, there were no relevant medical conditions that could affect the perpetrator’s suitability to hold a shotgun licence.

The mechanism agreed by the FLM and Local Medical Committee to obtain specific factual information about a self-declared medical condition was not communicated to or followed by the Firearms Enquiry Officer (FEO) or the Firearms Licensing Supervisor (FLS).

The referee’s tasks and responsibilities were not made clear and insufficient inquiries were made of the referee given the known history of assaults at school.

Reflecting the culture within the FELU at the time, an insufficient degree of professional curiosity was demonstrated by the FEO and FLS.

The review of the licence

The decision to return the shotgun and licence to the perpetrator in July 2021 was fundamentally flawed and as a result failed to protect the public and the peace.

The officer investigating the skate park assaults in September 2020 should have noted that the perpetrator was a firearms certificate holder and taken immediate steps to alert the FELU to the incident.

It was unreasonable to categorise the level of the assault upon the boy in the skate park as battery. There were clear aggravating factors to suggest this should have been charged at a higher level and there was inadequate investigation of whether the assault on the boy in the skate park had led to his unconsciousness.

The use of the Pathfinder scheme in this instance was wholly inadequate in reducing the perpetrator’s future offending.

On reviewing the perpetrator’s suitability to retain the shotgun certificate, the FEO ought to have shown a greater degree of professional curiosity in obtaining and evaluating further information. The case was not passed to the FLM for review which was against Home Office guidance.

General
There was a serious failure at a national level by the government, Home Office and National College of Policing to implement the recommendation from Lord Cullen’s Report in 1996 arising out of the fatal shootings in Dunblane, to provide training for FEOs and the subsequent recommendation in Her Majesty’s Inspectorate of the Constabulary’s Targeting the Risk Report in 2015 for an accredited training regime for FEOs. The most recent statutory guidance from the Home Office (2021) has failed to include any mention of FEO specific training.

The training and informal mentoring was insufficient to enable the FEOs to safely discharge their duties. Informal mentoring had inherent limitations, meaning incorrect processes were perpetuated and not formally recorded as an agreed training method to deliver learning outcomes.

There was a catastrophic failure in the management of the FELU, with a lack of managerial supervision, inadequate and ineffective leadership. This was compounded by a lack of senior management and executive leadership who failed to notice or address the issues.

There was a lack of scrutiny and professional curiosity at all levels. The ineffective auditing and governance of the FELU in place led to an inadequate system of dip sampling, qualitative assessment of staff’s decision-making, and learning from the results of the same.

There was a seriously unsafe culture within the FELU of defaulting to granting licences and to returning licences after review.
There was a dangerous lack of understanding on the part of the Devon and Cornwall Police FELU staff regarding the use and application of the FELU risk matrix.

Incompatible IT systems both within Devon and Cornwall Police and outside agencies contributed to a failure to communicate effectively.

Budgetary limitations and staff shortages within Devon and Cornwall Police increased the probability of risk being incorrectly assessed which led to unsafe licences being issued. These limitations were not confined to Devon and Cornwall Police but also existed at a national level, for example the National College of Policing not assigning resources to run an accredited national FEO training course.’

The jury’s conclusion in respect of each death under Section 4 of the Record of Inquest was as follows:

‘The deceased was unlawfully killed.

The death was caused by the fact that the perpetrator had a lawfully held shotgun. The following contributed to this position.

There were serious failures by Devon and Cornwall Police FELU in granting and, later, failing to revoke the perpetrator’s shotgun certificate.

In licencing the perpetrator to have a shotgun there was a serious failure by Devon and Cornwall Police to protect the deceased.

There was a failure of Devon and Cornwall Police to have in place safe and robust systems. Foremost, the training of FELU staff, governance of the FELU, quality assurance of FELU staff’s decision-making and ensuring decisions were made at the correct level.

There was a failure by Devon and Cornwall Police FELU staff to obtain sufficient medical information in respect of the perpetrator’s application for a shotgun certificate and also on review.

There was a failure by Devon and Cornwall Police FELU staff to properly seek out and consider all the relevant evidence and information available before deciding whether to grant the perpetrator a shotgun certificate.

Following the perpetrator having assaulted two children in 2020, there was a failure by Devon and Cornwall Police to protect the public and the peace. Firstly, within the Local Investigation team regarding the downgraded charge and secondly, within the FELU to sufficiently investigate whether it was safe to return to the perpetrator his shotgun and certificate after initially seizing them.

Incorrect application of the risk matrix meant there was a serious failure by Devon and Cornwall Police to implement an adequate system to ensure that the decision whether or not to (i) grant or (ii) return a shotgun certificate following review, was made or approved by a manager of sufficient seniority.

A lack of national accredited Firearms licensing training has and continues to fail to equip police staff to protect the public safety.

Coroner’s concerns

Evidence I heard at these inquests revealed that numerous recommendations arising from previous inquiries and reviews regarding the training of police officers and police staff involved in firearms licensing decisions had not been put into effect. This is not a new concern but one that has previously been raised by at least two other coroners in earlier ‘Prevention of Future Deaths’ reports in other coronial jurisdictions. If any lessons had been learned in the aftermath of earlier tragedies, they have been forgotten and that learning had been lost.

I was told that all Chief Officers of police ought to be satisfied that they only delegate their authority to issue and revoke firearms and shotgun licences to appropriately trained and skilled personnel. However, over the past 27 years, there has been an abject failure to ensure that nationally accredited training for firearms licensing staff has been developed and its currency maintained. Specifically –

1. In 1996, following the murders at the primary school in Dunblane Lord Cullen’s report (see here) recommended as follows:

‘Enquiry officers should be given as much training and guidance for their work as is practicable.’

The Government responded (see here) stating that

‘The Government accepts this recommendation. Existing Home Office advice to police forces is that ‘enquiry, administration and decision making processes’ in each police force should all be controlled by a centralised firearms administration and that all inquiries should be made by nominated, trained staff. The Guidance to the Police will be amended to emphasise the point.’

In fact the guidance subsequently issued by the Home Office, in March 2002, entitled ‘Firearms Law, Guidance to the Police’, (here) made no recommendation regarding the training of staff. The 2002 guidance merely stated (at §1.5)

‘Firearms legislation and the subject of firearms generally is complex and highly specialised. It is not practicable to provide comprehensive training for every police officer on the administration of the Firearms Acts. It is therefore essential that this guide is available to all police officers and civilians directly involved in the licensing process. Where difficulties arise, advice may be sought from the firearms department at the appropriate police force.’

Indeed by March 2002 there was no accredited training for the role of firearms enquiry officers (FEOs) or firearms licensing managers (FLMs). The Home Office guidance to police did not contain any proposal or requirement that FEOs or FLMs should undergo training specific to their role. There was no requirement that FEOs or FLMs should undergo any training in assessing the suitability of applicants to be granted a licence.

2. Later in 2002 The Firearms Licensing Thematic Review entitled ‘Safe Hands = Secure Arms’ (here), conducted by Her Majesty’s Inspector of Constabulary (HMIC) recommended as follows:

‘Recommendation 2.
Her Majesty’s Inspector of Constabulary recommends that force policy and procedure in respect of firearms licensing should mirror Lord Cullen’s Recommendations and ACPO Policy, Home Office Guidance and ACPO, ‘Procedural Good Practice Guide’.

Recommendation 3.
Her Majesty’s Inspector of Constabulary recommends that forces ensure that staff conducting firearms enquiries are trained, conversant with current ACPO /Home Office guidance and competent to fulfil their role.’

However, despite those recommendations the absence of formal training courses for FELU staff in firearms licensing remained unaddressed.

3. In March 2013 the Senior Coroner for Durham issued a report under rule 43 Coroners Rules 1984 following the inquests into the deaths of Sam McGoldrick, Alison Turnbull, Tanya Turnbull and Michael Atherton:

The r.43 report, sent to the Chief Constable of Durham Police and the Home Secretary raised the following concern (among others):

‘The inquest has revealed disturbing issues on the question of training. Notwithstanding the significant importance of the shotgun firearms licencing process there was no formal training courses available in 2006/2008 and even limited formal training available now. Training was by virtue of learning on the job and by making enquiries oneself and familiarising oneself with the Home Office and ACPO guidance. Durham Constabulary did not have its own local policy relating to firearms/shotgun licencing. Durham Constabulary was not alone in not having such a policy. Not all individuals involved in the licencing process were aware of the existence of the Home Office and ACPO guidance documents, both published in 2002, let alone the detailed contents thereof…. This case has illustrated that the administration of firearms shotgun licencing system was… unclear on occasion and confusing. And with the absence of training and clear guidance either locally or nationally, it created an environment in which it was easier for less than optimal standards to be achieved.’

The Home Secretary (The Rt Hon Theresa May MP) responded on 17 June 2013 stating that:

‘Nationally a recognised training course is available for firearms enquiry officers and a system of mentoring uses the expertise of more experienced enquiry officers or managers.’

If it was indeed the case that a national training course for course for firearms enquiry officers was available as the Home Secretary suggested in June 2013 this was no longer the case by 2014. I have been informed that in 2014 there was still no nationally accredited training available for the role of FEOs or FLMs. The College of Policing Authorised Professional Practice (APP) in 2014 (see here at section 2.6) merely stated that chief police officers should be ‘seeking to develop appropriate accredited training for firearms licensing staff.’

Furthermore the Home Office guidance published in 2014 still did not contain any proposal or requirement that FEOs or FLMs should undergo any (even non-accredited) training specific to their role. In particular, there was no requirement that FEOs or FLMs should undergo any training in assessing the suitability of applicants to be granted a licence.

4. In September 2015, HMIC conducted another ‘inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales’ entitled ‘Targeting the Risk’ (see here).

This report yet again raised concerns at the continuing absence of nationally accredited training for firearms licensing decision makers. The HMIC report stated that:

‘While some training has been made available, we are concerned at the continuing absence of nationally accredited training. Its absence has meant that some staff involved in the licensing arrangements, in particular those charged with making firearms licensing decisions, have yet to receive sufficient training, commensurate with their role and responsibility.’

HMIC noted in 2015 that proposals for accredited training were ‘under consideration’ by the national policing lead for firearms licensing and the College of Policing. However, the evidence I heard at the inquest was that this ‘consideration’ did not result in any accredited training being developed. Even today, some eight years later, accredited training for those charged with making firearms licensing decisions does not exist.

In 2015 HMIC recommended to the national policing lead for firearms licensing, in conjunction with the College of Policing that:

‘Within 12 months, the national policing lead for firearms licensing, in conjunction with the College of Policing, should identify the skills required by those staff involved in the firearms licensing process. Thereafter they should introduce professional development arrangements to ensure a consistent national approach to firearms licensing. Consideration should also be given to the accreditation of these arrangements.’

That 2015 HMIC report also stated that

‘On too many occasions, the police are not following the Home Office guidance or the Authorised Professional Practice. And, the guidance and practice in many respects are inadequate, allowing room for interpretation and the creation of inconsistency in the way firearms licensing is undertaken within and between police forces….

We cannot make our position any clearer: it is now for others to accept the need for change. If they do, perhaps the life of the next victim of firearms misuse might be saved. What is highly likely is that, if change is not effected, there will be another tragedy.’

The Home Office guidance on firearms licencing was subsequently updated in 2016. However, that guidance made no reference to the need for firearms licensing staff to undergo accredited training. The 2016 Home Office guidance did not contain any proposal or requirement that FEOs or FLMs should undergo any (even non-accredited) training specific to their role. There was no requirement that FEOs or FLMs should undergo any training in assessing the suitability of applicants to be granted a licence.

Evidence presented at the inquests was that the College of Policing’s Coordination and Delivery Group had declined requests made to it to develop a national training package in Feb 2016 and January 2019.

5. In 2019 Mr Richard Travers Senior Coroner for Surrey issued a report to prevent future deaths following the killings of Christine and Lucy Lee (see here).

That report, which was sent to Chief Constable of Surrey Police, the NPCC lead for firearms and the Home Office, raised the following concern:

‘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.’

By 2021, when Jake Davison’s gun was returned to him, there was still no accredited training for the role of FEOs or FLMs, nor was there any mandatory requirement for FEOs or FLMs to undergo even non-accredited training specific to their role. In particular, there was no requirement that FEOs or FLMs to undergo any training in assessing the suitability of applicants to be granted a licence.

It is against this background of 27 years of wholesale failure to devise and maintain adequate training provision for firearms licensing staff nationally that the jury in the Keyham inquests returned their findings above, including that:

‘There was a serious failure at a national level by the government, Home Office and National College of Policing to implement the recommendation from Lord Cullen’s Report in 1996 arising out of the fatal shootings in Dunblane, to provide training for FEOs and the subsequent recommendation in Her Majesty’s Inspectorate of the Constabulary’s Targeting the Risk Report in 2015 for an accredited training regime for FEOs. The most recent statutory guidance from the Home Office (2021) has failed to include any mention of FEO specific training.

The training and informal mentoring available at Devon & Cornwall police was insufficient to enable the FEOs to safely discharge their duties, meaning incorrect processes were perpetuated and not formally recorded as an agreed training method to deliver learning outcomes.’

The evidence I heard suggested the absence of training was not merely a local problem for Devon & Cornwall Police. I have been assured that work towards an accredited training package is now ongoing and I was also informed that that some police forces, do currently have in-house training programmes that firearms licensing staff from other forces may attend. However I have been informed that the availability of such local in-house training remains sporadic.

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.

Concerns and recipient responses

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

Concerns raised3

Failure to condition firearms licensing delegation on adequate training
Absence of a mandatory requirement for role-specific firearms licensing training
Lack of nationally accredited training for firearms licensing staff

Responses linked to these concerns

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

Actions described in response 71

Action
Support development of the national Firearms Enquiry Officer curriculum and learning outcomes with the NPCC lead and College of Policing.
Stated by Surrey PoliceStated in progress
Action
Maintain trained delegated-authority reviewers across senior ranks and provide additional senior oversight capacity for returning certificates and weapons after revocation decisions.
Stated by Surrey PoliceStated completed
Action
Create FEO portfolios for assessment and performance monitoring.
Stated by Devon & Cornwall PoliceStated completed

Action
Provide replacement training for new FELU starters in cohorts as required until the national qualification is delivered.
Stated by Devon & Cornwall PoliceStated in progress
Action
Continue supporting development and delivery of the national accredited firearms-licensing training programme with the NPCC and College of Policing.
Stated by Devon & Cornwall PoliceStated in progress
Action
Revise FELU training and deliver mandatory firearms-enquiry training to all unit staff and relevant decision-makers.
Stated by Devon & Cornwall PoliceStated completed
Action
Accredit FELU firearms-enquiry officers internally and maintain qualification records with expiry reminders until national accreditation is available.
Stated by Devon & Cornwall PoliceStated completed
Action
Deliver a three-year continuing professional development programme for FELU staff covering mental health, domestic abuse, risk assessment and decision-making.
Stated by Devon & Cornwall PoliceStated in progress
Action
Implement an annual schedule for continuing professional development of Firearms and Explosive Licensing Unit staff.
Stated by Bedfordshire Police and Cambridgeshire Constabulary and Hertfordshire ConstabularyStated planned
Action
Deliver role-specific training to all Firearms and Explosive Licensing Unit staff.
Stated by Bedfordshire Police and Cambridgeshire Constabulary and Hertfordshire ConstabularyStated in progress
Action
Provide an external firearms licensing training package for Firearms and Explosive Licensing Unit staff.
Stated by Bedfordshire Police and Cambridgeshire Constabulary and Hertfordshire ConstabularyStated completed
Action
Deliver a three-day firearms licensing training package to department staff, including the Chief Inspector.
Stated by Lancashire ConstabularyStated completed
Action
Train Force Incident Commanders in the procedure for revoking firearm and shotgun certificates.
Stated by Lancashire ConstabularyStated completed
Action
Deliver the agreed Mowbray Partners online training package, updated for statutory-guidance changes.
Stated by Lancashire ConstabularyStated planned
Action
Continue embedding training and CPD for Firearms Licensing Department staff while updating training records for legislative changes.
Stated by Lancashire ConstabularyStated in progress
Action
Deliver the expanded firearms licensing training package covering triage, safety, decision-making, safeguarding, domestic abuse, neurodiversity, range assessment, social media and administration.
Stated by Staffordshire Police and West Midlands PoliceStated in progress
Action
Provide Police National Decision Model training to all decision makers with delegated authority.
Stated by Staffordshire Police and West Midlands PoliceStated completed
Action
Train and mentor the Deputy Manager holding delegated firearms licensing responsibilities.
Stated by Staffordshire Police and West Midlands PoliceStated in progress
Action
Complete the Mowbray Associates firearms licensing decision-making course for delegated decision makers.
Stated by Staffordshire Police and West Midlands PoliceStated in progress
Action
Develop national firearms licensing training materials and accompanying quality assurance processes.
Stated by College of PolicingStated planned
Action
Adapt national high-risk policing training approaches for firearms licensing.
Stated by College of PolicingStated planned
Action
Develop a national training course for staff involved in firearms licensing, including firearms enquiry officers and delegated decision-makers.
Stated by College of PolicingStated planned
Action
Review and update national learning outcomes for firearms licensing training.
Stated by College of PolicingStated in progress
Action
State in Authorised Professional Practice that chief officers should delegate firearms licensing decisions only to trained decision-makers.
Stated by College of PolicingStated planned
Action
Present the locally developed training material to the College of Policing and NPCC licensing lead for consideration as a national programme.
Stated by West Mercia PoliceStated in progress
Action
Deliver the locally developed firearms licensing training package to all Firearms Licensing Unit staff through induction and continuing professional development.
Stated by West Mercia PoliceStated planned
Action
Review Firearms Licensing Team training requirements against the latest statutory guidance.
Stated by Avon and Somerset ConstabularyStated in progress
Action
Provide dedicated senior Firearms Enquiry Officer training, coaching, and mentoring for new officers.
Stated by Avon and Somerset ConstabularyStated completed
Action
Provide PiP Level 1 training for the Firearms Licensing Manager and Firearms Licensing Officers on decision-making, risk management, and investigation supervision.
Stated by Avon and Somerset ConstabularyStated planned
Action
Deliver the South Yorkshire Police three-day Firearms Enquiry Officer course to all Firearms Enquiry Officers.
Stated by Avon and Somerset ConstabularyStated completed
Action
Train all Firearms Licensing Team staff in the National Decision Model.
Stated by Avon and Somerset ConstabularyStated planned
Action
Deliver specific training for Firearms Licensing Administrators and maintain staff continuing professional development through regional events.
Stated by Avon and Somerset ConstabularyStated completed
Action
Implement additional mandatory training for all Firearms Licensing Team staff.
Stated by Avon and Somerset ConstabularyStated planned
Action
Provide the Firearms Licensing Manager and Detective Sergeant with additional firearms-licensing decision-maker training.
Stated by Greater Manchester PoliceStated planned
Action
Permit only trained personnel to make firearms-licensing decisions under the updated statutory guidance.
Stated by Greater Manchester PoliceStated completed
Action
Attend a two-day continuous professional development event on firearms licensing for the Firearms Licensing Manager and Detective Sergeant.
Stated by Greater Manchester PoliceStated planned
Action
Deliver firearms-licensing training to all Firearms Enquiry Officers through an external training partner.
Stated by Greater Manchester PoliceStated completed
Action
Provide annual risk-assessment, continuing professional development and development training for all firearms licensing team members.
Stated by City of London PoliceStated planned
Action
Require firearms licensing decision-makers to complete current training and accreditation, with supervisory accreditation and governance oversight before independent decision-making.
Stated by Metropolitan Police ServiceStated completed
Action
Deliver and update local firearms licensing training for all officers, supervisors and management in line with current statutory, non-statutory and College of Policing guidance.
Stated by Metropolitan Police ServiceStated completed
Action
Maintain continuous professional development through mentoring, supervised competence assessment, quarterly training and enhanced decision-making and risk-management instruction.
Stated by Metropolitan Police ServiceStated in progress
Action
Train all Firearms Enquiry Officers through external training and local continuous professional development.
Stated by Derbyshire ConstabularyStated completed
Action
Provide bespoke training and competence portfolios for new firearms licensing team members, retaining completion records for staff and supervisors.
Stated by Kent PoliceStated completed
Action
Develop and deliver a modular local training and continuous professional development programme for firearms licensing staff and supervisors.
Stated by Kent PoliceStated in progress
Action
Deliver externally commissioned firearms licensing training to all Firearms Licensing Unit enquiry and licensing officers.
Stated by Norfolk ConstabularyStated planned
Action
Complete nationally recognised training for all firearms enquiry officers.
Stated by Merseyside PoliceStated completed
Action
Enrol all firearms licensing staff in Mowbray Partners’ online training.
Stated by Merseyside PoliceStated completed
Action
Operate FEO portfolios and comprehensive dip sampling, with supervisors reviewing decisions, assessing rationale and providing direct feedback.
Stated by Dorset PoliceStated completed
Action
Engage with the NPCC and College of Policing to assist delivery of national accredited training and define robust, pragmatic reaccreditation arrangements.
Stated by Dorset PoliceStated in progress
Action
Provide specialist training on risk assessment, THRIVE, national risk principles and the National Decision Model, and record suitability decisions comprehensively.
Stated by Dorset PoliceStated completed
Action
Deliver a mandatory, bespoke firearms-licensing training programme covering risk identification, decision making, statutory guidance and relevant operational systems.
Stated by Dorset PoliceStated completed
Action
Support development of a national FEO curriculum and learning outcomes aligned with quality assurance and mandatory professional development.
Stated by Sussex PoliceStated in progress
Action
Refresh all FELU staff training on the revised February 2023 Home Office Statutory Guidance through continuing professional development.
Stated by Sussex PoliceStated completed
Action
Commission a bespoke firearms licensing course for Sussex Police FEOs and supervisors through the existing provider.
Stated by Sussex PoliceStated planned
Action
Deliver additional training on safeguarding, intelligence gathering, the National Decision Making Model and safe firearms handling.
Stated by Sussex PoliceStated in progress
Action
Introduce a Deputy Manager with delegated firearms licensing responsibilities and provide training and mentoring.
Stated by Staffordshire Police and West Midlands PoliceStated in progress
Action
Deliver the extensive firearms licensing training package, including decision-making, safety, safeguarding, domestic abuse, neuro-diversity, range assessment and social-media training.
Stated by Staffordshire Police and West Midlands PoliceStated in progress
Action
Develop a joint Essex and Kent lesson plan to enhance firearms licensing professional development and maintain current knowledge.
Stated by Essex PoliceStated in progress
Action
Participate with national policing and professional bodies in developing a national firearms licensing training package.
Stated by Essex PoliceStated in progress
Action
Restrict decisions to return certificates after suitability reviews to the Superintendent for Armed Policing.
Stated by Essex PoliceStated completed
Action
Maintain and deliver a local firearms licensing training programme for staff and supervisors exercising delegated decision-making authority.
Stated by Essex PoliceStated completed
Action
Provide training for firearms licensing administrators and decision makers, and consider retraining firearms licensing officers.
Stated by Gloucestershire ConstabularyStated planned
Action
Provide annual approved-practice training and continuing professional development, with tutoring and mentoring for new firearms licensing staff.
Stated by Durham ConstabularyStated completed
Action
Deliver externally commissioned firearms licensing training to enquiry and licensing officers over the next 12 months.
Stated by Suffolk ConstabularyStated planned
Action
Provide £500,000 funding to the College of Policing to support development and adoption of firearms licensing training.
Stated by Home OfficeStated completed
Action
Determine with policing bodies how to mandate firearms licensing staff completion of the national accredited training programme once finalised.
Stated by Home OfficeStated planned
Action
Develop national accredited firearms licensing training modules for Firearms Enquiry Officers, caseworkers and decision makers, including risk assessment and the National Decision Model.
Stated by Warwickshire PoliceStated in progress
Action
Work with the College of Policing to determine delivery arrangements for national firearms licensing training and align them with quality assurance and continuing professional development.
Stated by Warwickshire PoliceStated in progress
Action
Secure funding to support implementation of national accredited firearms licensing training.
Stated by Warwickshire PoliceStated completed
Action
Develop a quality assurance framework to assess competency, validate licensing departments and support consistent delivery of national firearms licensing training.
Stated by Warwickshire PoliceStated in progress
Action
Work with the Home Office to progress the firearms licensing fees review and develop sustainable funding for training, quality assurance and national coordination.
Stated by Warwickshire PoliceStated in progress

Respondent positions 10

Position
Existing training arrangements are considered appropriate and proportionate to staff roles.
Stated by Surrey PoliceExisting arrangements considered sufficient

Position
Operational demands and resources prevent immediate full implementation of the Coroner’s recommendations, requiring staged completion.
Stated by Thames Valley PoliceUnable to act
Position
Only personnel who have completed relevant firearms licensing training are permitted to make decisions under the updated statutory guidance.
Stated by Greater Manchester PoliceExisting arrangements considered sufficient
Position
Existing local training, accreditation, oversight and continuous development are considered adequate despite no nationally accredited training package.
Stated by Metropolitan Police ServiceExisting arrangements considered sufficient
Position
Adequate local firearms licensing training is considered sufficient while nationally accredited training is unavailable.
Stated by Kent PoliceExisting arrangements considered sufficient
Position
Existing reviews and the post-incident robust decision-making process are considered sufficient to meet the report's requirements for the covered period.
Stated by Dorset PoliceExisting arrangements considered sufficient
Position
Existing and continuing training is considered appropriate and proportionate to staff roles within the firearms licensing unit.
Stated by Sussex PoliceExisting arrangements considered sufficient
Position
Existing local training is considered adequate for firearms licensing staff and supervisors despite the absence of nationally accredited training.
Stated by Essex PoliceExisting arrangements considered sufficient
Position
Police training provision is primarily the responsibility of the College of Policing and police forces, rather than central government.
Stated by Home OfficeRedirects responsibility
Position
Existing local training and supervision are considered adequate for licensing staff and delegated decision-makers to meet legislative and guidance requirements.
Stated by Warwickshire PoliceExisting arrangements considered sufficient

Other statements in published responses

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

Recipient-stated actions 204

1
Review all cases from the previous five years where applications were refused or licences revoked but a subsequent application or appeal resulted in a grant.
Stated by North Wales PoliceStated planned
2
Complete a full panel review of all 34 cases involving seized, refused, revoked or surrendered firearm and shotgun certificates that were subsequently returned.
Stated by North Wales PoliceStated completed
3
Ensure firearms enquiry officers and supervisors attend the externally delivered firearms licensing course, including the bespoke Surrey Police course.
Stated by Surrey PoliceStated in progress
4
Develop a standard operating procedure to ensure consistent processes for seizing legally held firearms and certificates.
Stated by Surrey PoliceStated in progress
5
Participate in the College of Policing continuing professional development event on Keyham inquests and revised statutory guidance.
Stated by Surrey PoliceStated planned
6
Review five years of licensing decisions, prioritising returned seized or surrendered firearms, then recent decisions, and reassessing decisions against February 2023 statutory guidance.
Stated by Surrey PoliceStated in progress
7
Carry out quality assurance across firearms licensing roles and responsibilities to ensure compliance with statutory guidance.
Stated by Surrey PoliceStated completed
8
Second sufficiently senior and experienced staff into the department to expedite the licensing review and produce a report.
Stated by Surrey PoliceStated completed
9
Refresh statutory guidance training for all Firearms and Explosives Licensing Unit staff through continuing professional development.
Stated by Surrey PoliceStated completed
10
Adopt the national Firearms and Explosives Licensing Working Group guidance for reviewing firearms and shotgun licensing decisions from the previous five years.
Stated by Surrey PoliceStated planned
11
Deliver supplementary training on safeguarding, intelligence gathering, the National Decision Model and safe firearms handling.
Stated by Surrey PoliceStated in progress
12
Present Keyham learning at firearms licensing managers’ continuing professional development and senior-investigator training events, and submit investigative lessons to the NPCC.
Stated by Devon & Cornwall PoliceStated planned
13
Amend mandatory Police National Computer training plans and learning outcomes to reflect firearms force policy.
Stated by Devon & Cornwall PoliceStated completed
14
Operate comprehensive dip sampling of FEO decisions, with supervisory review, rationale assessment and feedback.
Stated by Devon & Cornwall PoliceStated completed
15
Review firearms policy and licensing procedures and circulate mandatory notification requirements through ERO training and continuing professional development.
Stated by Devon & Cornwall PoliceStated completed
16
Introduce additional FELU supervisors to complete prioritised case reviews and support risk-focused licensing work.
Stated by Devon & Cornwall PoliceStated completed
17
Integrate firearms licensing into nationally mandated personal-safety scenarios for relevant staff.
Stated by Devon & Cornwall PoliceStated planned
18
Conduct further targeted reviews of licence holders identified through analytical research for potential suitability risks.
Stated by Devon & Cornwall PoliceStated planned
19
Review qualifying cases from May 2018 to December 2019 using the established identification criteria and remedial-review standard.
Stated by Devon & Cornwall PoliceStated planned
20
Complete a full evaluation of case reviews from January 2020, including certificates later approved after seizure, refusal, revocation or surrender.
Stated by Devon & Cornwall PoliceStated completed
21
Deliver monthly investigator drop-in sessions on firearms licensing, safeguarding risks, risk mitigation and escalation contacts.
Stated by Devon & Cornwall PoliceStated completed
22
Provide additional FEO investigation training through the nationally recognised Professionalising Investigations Programme level 1.
Stated by Devon & Cornwall PoliceStated planned
23
Invest approximately £3 million in the Firearms and Explosives Licensing Unit.
Stated by Devon & Cornwall PoliceStated completed
24
Review all seized and returned firearms from the previous five years.
Stated by Thames Valley PoliceStated planned
25
Review applications refused or revoked but subsequently granted by the Crown Court on appeal.
Stated by Thames Valley PoliceStated planned
26
Review grants previously revoked, refused or surrendered, prioritising 2022 files before earlier years.
Stated by Thames Valley PoliceStated planned
27
Review certificate holders refused or revoked but subsequently successful with a new application during the previous five years.
Stated by Bedfordshire Police and Cambridgeshire Constabulary and Hertfordshire ConstabularyStated in progress
28
Review firearms seized and returned over the previous five years, prioritising those returned soonest and applying current standards retrospectively.
Stated by Bedfordshire Police and Cambridgeshire Constabulary and Hertfordshire ConstabularyStated in progress
29
Review holders subject to police intelligence reports during the previous five years, prioritised according to risk identified through initial triage.
Stated by Bedfordshire Police and Cambridgeshire Constabulary and Hertfordshire ConstabularyStated in progress
30
Escalate authority for authorising firearm or shotgun returns after seizure to Assistant Chief Constable level.
Stated by Bedfordshire Police and Cambridgeshire Constabulary and Hertfordshire ConstabularyStated completed
31
Provide additional investigative staff capacity dedicated to completing the retrospective firearms licensing reviews.
Stated by Bedfordshire Police and Cambridgeshire Constabulary and Hertfordshire ConstabularyStated in progress
32
Review firearms licensing policy and procedures to align them with updated statutory guidance.
Stated by Bedfordshire Police and Cambridgeshire Constabulary and Hertfordshire ConstabularyStated completed
33
Conduct a root-and-branch review of the Firearms and Explosive Licensing Unit’s processes, guidance, demand, staffing, skills and future requirements.
Stated by Bedfordshire Police and Cambridgeshire Constabulary and Hertfordshire ConstabularyStated in progress
34
Review certificates refused, revoked, seized or surrendered and later approved during the previous five years against statutory guidance.
Stated by Lancashire ConstabularyStated in progress
35
Provide continuing professional development covering domestic violence awareness, intelligence grading and further specified decision-making topics.
Stated by Lancashire ConstabularyStated in progress
36
Automatically alert the Licensing team to incidents reported at certificate holders’ addresses to trigger licence review.
Stated by Lancashire ConstabularyStated completed
37
Require a GP report for every initial application and renewal, seeking specialist advice where specific ongoing conditions may affect suitability.
Stated by Lancashire ConstabularyStated completed
38
View available Body Worn Video during reviews involving police interactions without formal action.
Stated by Lancashire ConstabularyStated completed
39
Use PNC markers to automatically alert the licensing department and Force Incident Commander when a certificate holder is arrested.
Stated by Lancashire ConstabularyStated completed
40
Increase PND checks and extend them to all renewals before the end of 2023, as well as initial applications and adverse-incident reviews.
Stated by Lancashire ConstabularyStated in progress
41
Require dedicated Superintendent review before returning certificates after voluntary surrender or restoring weapons storage at the certificate holder’s home.
Stated by Lancashire ConstabularyStated completed
42
Introduce automated highlighting of new intelligence linked to licensed certificate holders or their addresses for licensing-team review.
Stated by Lancashire ConstabularyStated in progress
43
Conduct prompt Counter Terrorism intelligence reviews and joint reviews with the licensing team when intelligence relates to certificate holders, addresses or associated telephone numbers.
Stated by Lancashire ConstabularyStated completed
44
Record firearms licensing governance through quarterly Firearms Policy Management Group meetings.
Stated by Lancashire ConstabularyStated completed
45
Have the Assistant Chief Constable scrutinise random high-risk decisions with the Chief Inspector every six months.
Stated by Lancashire ConstabularyStated completed
46
Provide senior Chief Inspector review of all firearms licensing decisions with documented evidence assessments and reasons.
Stated by Lancashire ConstabularyStated completed
47
Publish and implement a firearms licensing policy aligned with the 2023 Home Office statutory guidance.
Stated by Staffordshire Police and West Midlands PoliceStated completed
48
Maintain quarterly strategic partnership oversight of operational performance, training, change and external pressures.
Stated by Staffordshire Police and West Midlands PoliceStated completed
49
Maintain biannual collaboration governance oversight of strategic risks, national matters and reputational issues.
Stated by Staffordshire Police and West Midlands PoliceStated completed
50
Review certificates granted before August 2020 that were previously seized and returned.
Stated by Staffordshire Police and West Midlands PoliceStated planned
51
Complete the five-year review of certificates revoked or refused and subsequently re-granted.
Stated by Staffordshire Police and West Midlands PoliceStated completed
52
Reconfirm internally that officers should consider seizing certificates and firearms when attending incidents involving certificate holders.
Stated by Staffordshire Police and West Midlands PoliceStated completed
53
Implement the approved staffing structure, increasing Firearms Licensing Unit police staff from 17 to 27.
Stated by Staffordshire Police and West Midlands PoliceStated completed
54
Introduce Intelligence Officers to conduct enhanced checks, monitor certificate holders, collate suitability information and support related licensing enquiries.
Stated by Staffordshire Police and West Midlands PoliceStated completed
55
Use audit findings to develop decision makers and improve firearms licensing service delivery.
Stated by Staffordshire Police and West Midlands PoliceStated planned
56
Introduce a Deputy Manager role with delegated firearms licensing decision-making responsibilities.
Stated by Staffordshire Police and West Midlands PoliceStated completed
57
Review certificates seized and returned between August 2020 and March 2023, including scheduled revisits.
Stated by Staffordshire Police and West Midlands PoliceStated in progress
58
Continue monitoring firearms licensing developments so training and guidance reflect the highest standards.
Stated by College of PolicingStated in progress
59
Incorporate an assessment component into the firearms licensing training.
Stated by College of PolicingStated planned
60
Develop an operational competence framework using ongoing assessment and professional development evidence.
Stated by College of PolicingStated planned
61
Develop significantly revised and updated Authorised Professional Practice on firearms licensing.
Stated by College of PolicingStated in progress
62
Compose structured guidance and a workbook for firearms licensing decision makers based on College of Policing learning outcomes.
Stated by West Mercia PoliceStated in progress
63
Re-employ a recently retired authorised firearms officer as a Police Staff member to complete the five-year certificate-return review.
Stated by West Mercia PoliceStated completed
64
Repeat the review of certificates seized, refused, revoked or surrendered and subsequently approved, covering the specified five-year period and escalating remedial issues.
Stated by West Mercia PoliceStated in progress
65
Undertake a further review of decision files for seized firearms subsequently returned to holders, using the specified parameters.
Stated by Dyfed-Powys PoliceStated planned
66
Complete and obtain Chief Officer approval for a comprehensive review of firearms licensing decision-making against APP and statutory guidance.
Stated by Dyfed-Powys PoliceStated completed
67
Support peer reviews across the South-west region and contribute to national firearms licensing best practice.
Stated by Avon and Somerset ConstabularyStated completed
68
Subject incidents involving seized or voluntarily surrendered guns and certificates to a suitability review.
Stated by Avon and Somerset ConstabularyStated completed
69
Require managerial sign-off and additional oversight for completed firearms suitability reviews.
Stated by Avon and Somerset ConstabularyStated completed
70
Amend procedures to apply consistent scrutiny and record and review every firearms licensing decision.
Stated by Avon and Somerset ConstabularyStated completed
71
Require Assistant Chief Constable authorisation for certificates previously revoked or refused before granting.
Stated by Avon and Somerset ConstabularyStated completed
72
Appoint a Firearms Licensing Manager to provide departmental risk assurance.
Stated by Avon and Somerset ConstabularyStated completed
73
Complete a five-year review of firearms licensing cases involving previously seized, revoked, refused, or surrendered certificates later approved.
Stated by Avon and Somerset ConstabularyStated completed
74
Assign firearm-return authorisation exclusively to Firearms Licensing Officers and the Firearms Licensing Manager.
Stated by Avon and Somerset ConstabularyStated completed
75
Review risk management for returning certificates and weapons following revocation, seizure, or surrender.
Stated by Avon and Somerset ConstabularyStated completed
76
Assess cautions and restorative justice disposals as convictions when determining firearms suitability.
Stated by Avon and Somerset ConstabularyStated completed
77
Tighten firearms licensing processes and articulate standards for transparent, robust decision-making.
Stated by Avon and Somerset ConstabularyStated completed
78
Adopt the National Decision Model risk matrix for firearms and explosives licensing decisions.
Stated by Avon and Somerset ConstabularyStated completed
79
Review the updated Home Office statutory guidance and College of Policing approved professional practice across the Firearms and Explosives Licensing Unit.
Stated by Greater Manchester PoliceStated completed
80
Review five years of cases involving certificates later approved and guns returned against updated statutory guidance.
Stated by Greater Manchester PoliceStated in progress
81
Continue monthly governance meetings involving firearms licensing leadership, the firearms manager and the reviewing staff member to support consistent future decisions.
Stated by Leicestershire PoliceStated in progress
82
Review previous firearms licensing decisions from 1 April 2018 against the Home Office Statutory Guidance to promote consistency.
Stated by Leicestershire PoliceStatus unclear
83
Review certificates and licences seized, surrendered, refused or revoked and later approved, using independent qualified reviewers, prioritising higher-risk cases and reporting findings to the strategic lead.
Stated by Leicestershire PoliceStated planned
84
Align the CoLP firearms licensing standard operating procedure with applicable common national standards.
Stated by City of London PoliceStated planned
85
Bring the inquest findings and learning to operational leads.
Stated by City of London PoliceStated completed
86
Provide further governance through the Operational Learning Forum, setting and tracking resulting actions across CoLP.
Stated by City of London PoliceStated planned
87
Review the firearms licensing procedure to strengthen medical, crime-recording and risk-assessment checks for applications, renewals and firearm returns.
Stated by City of London PoliceStated planned
88
Review firearms returned to members of the public during the preceding twelve months using National Firearms Licensing Management System searches and senior sign-off.
Stated by Metropolitan Police ServiceStated completed
89
Address findings and recommendations from the firearms licensing audit to strengthen the control framework.
Stated by Metropolitan Police ServiceStated in progress
90
Work with south-east police forces to share firearms licensing information and embed peer reviews and quality assurance.
Stated by Metropolitan Police ServiceStated in progress
91
Review firearms licensing processes, working practices and twelve months of data to assess compliance.
Stated by Metropolitan Police ServiceStated completed
92
Arrange a future audit to assess progress against firearms licensing audit findings and recommendations.
Stated by Metropolitan Police ServiceStated planned
93
Develop a digital learning package to raise frontline officers’ awareness of firearms licensing.
Stated by Derbyshire ConstabularyStated in progress
94
Request medical evidence for all firearms licence applications and renewals before progressing applications.
Stated by Derbyshire ConstabularyStated completed
95
Review the Keyham Shooting Inquest findings to identify lessons for firearms licensing.
Stated by Derbyshire ConstabularyStated completed
96
Explore introducing an independent scrutiny panel to strengthen firearms licensing quality assurance.
Stated by Derbyshire ConstabularyStated in progress
97
Provide referees with their obligations and duties alongside the firearms licensing reference proforma.
Stated by Derbyshire ConstabularyStated completed
98
Commission and complete an independent audit of firearms licensing controls and processes.
Stated by Derbyshire ConstabularyStated completed
99
Improve recording and sharing of firearms licensing information through linked markers and automatic notifications to the licensing team.
Stated by Derbyshire ConstabularyStated in progress
100
Review preceding-year firearms certificates that were seized, refused, revoked or surrendered and later approved.
Stated by Derbyshire ConstabularyStated completed
101
Attend a College of Policing event to debrief the inquest findings and identify learning for the local delivery plan.
Stated by Derbyshire ConstabularyStated planned
102
Review five years of cases where seized or surrendered firearms were later returned pending suitability decisions.
Stated by Derbyshire ConstabularyStated planned
103
Ask the Senior Presiding Judge to raise the concerns with Crown Court Resident Judges and provide them with a copy of the letter.
Stated by LORD CHIEF JUSTICE OF ENGLAND AND WALESStated completed
104
Commission the Force Inspectorate to review systems for managing public-safety risks associated with firearms licensing.
Stated by Kent PoliceStated planned
105
Explore wider peer-review opportunities for firearms licensing work.
Stated by Kent PoliceStated in progress
106
Review 134 firearms and shotgun licensing decisions against current Home Office Statutory Guidance, prioritising certificates previously seized or surrendered and later returned.
Stated by Kent PoliceStated in progress
107
Develop lesson plans for joint firearms licensing training with Essex Police.
Stated by Kent PoliceStated in progress
108
Review targeted firearms licensing cases from April 2019 to April 2023, including the specified 30% samples, against current guidance and regulations.
Stated by Norfolk ConstabularyStated planned
109
Complete a review of seized-and-returned, refused, revoked and surrendered certificate cases requested by the then Home Secretary.
Stated by Norfolk ConstabularyStated completed
110
Review decisions on subsequent applications made within 12 months after certificate revocation and firearm removal, using the applicant’s current circumstances.
Stated by Norfolk ConstabularyStated planned
111
Apply an escalated firearms licensing decision-making process under which cases involving firearm removal are considered by the responsible Superintendent.
Stated by Norfolk ConstabularyStated completed
112
Share the regional lawful-firearms study with national law-enforcement and partner organisations.
Stated by Merseyside PoliceStated completed
113
Commission a regional report on threats, harms and risks from lawful firearm and shotgun ownership and unlawful displacement.
Stated by Merseyside PoliceStated completed
114
Require Assistant Chief Constable sign-off for all firearms licence revocations and refusals.
Stated by Merseyside PoliceStated completed
115
Conduct regular dip-sampling of firearms licensing work to ensure compliance.
Stated by Merseyside PoliceStated completed
116
Implement an interim document supporting referee applications while the national form remains under consultation.
Stated by Merseyside PoliceStated completed
117
Adopt preventative recommendations from the regional lawful-firearms report.
Stated by Merseyside PoliceStated completed
118
Have the independent audit team examine firearms licensing processes and procedures against the action plan and response.
Stated by Merseyside PoliceStated planned
119
Maintain a firearms licensing governance structure with a risk matrix.
Stated by Merseyside PoliceStated completed
120
Review, within one month, cases involving returned seized or surrendered firearms and later-granted applications or appeals, escalating cases where appropriate.
Stated by Merseyside PoliceStated planned
121
Review analytical intelligence and conduct targeted reviews of certificate holders whose police involvement may affect suitability.
Stated by Dorset PoliceStated planned
122
Deliver key incident learning through a continuing professional development presentation for Firearms Licensing Managers.
Stated by Dorset PoliceStated planned
123
Review the firearms-licensing risk identification tool with the NPCC against revised statutory guidance and inquest findings.
Stated by Dorset PoliceStated in progress
124
Complete a further review of cases from the remaining five-year period to identify residual public-safety risks requiring remedial action.
Stated by Dorset PoliceStated planned
125
Provide firearms-enquiry officers with first-aid and personal-safety training and maintain internal accreditation records with expiry reminders.
Stated by Dorset PoliceStated completed
126
Complete detailed and sampled reviews of priority firearms-licensing cases, including cases involving the Davison decision makers and cases identified through targeted research.
Stated by Dorset PoliceStated planned
127
Share firearms-licensing policy and procedural advice and learning with other police forces and the NPCC.
Stated by Dorset PoliceStated in progress
128
Deliver a three-year continuing professional development programme covering mental health, domestic abuse and related firearms-licensing risks.
Stated by Dorset PoliceStated in progress
129
Maintain additional supervisory capacity in the firearms licensing unit to undertake prioritized case reviews alongside core licensing demand.
Stated by Dorset PoliceStated completed
130
Provide additional FEO investigation training through the nationally recognised Professionalising Investigations Programme level 1.
Stated by Dorset PoliceStated planned
131
Allocate additional suitably experienced and senior resource to expedite the licensing review and provide a full report by 2 October 2023.
Stated by Sussex PoliceStated completed
132
Review five years of firearms and shotgun licensing decisions against current Home Office guidance, prioritising recently returned seized or surrendered firearms and subsequently granted applications after refusal or revocation.
Stated by Sussex PoliceStated planned
133
Develop a standard operating procedure to ensure consistent processes for seizing legally held firearms and certificates.
Stated by Sussex PoliceStated in progress
134
Participate in the College of Policing’s two-day firearms licensing CPD event in May 2023 to learn from the Keyham inquest lessons and revised statutory guidance.
Stated by Sussex PoliceStated planned
135
Introduce Intelligence Officers to conduct enhanced checks, monitor certificate holders, collate suitability information and support licensing-related enquiries.
Stated by Staffordshire Police and West Midlands PoliceStated completed
136
Implement the approved staffing increase from 17 to 27 police staff employees in the firearms licensing unit.
Stated by Staffordshire Police and West Midlands PoliceStated completed
137
Review certificates granted before August 2020 and report the outcomes when available.
Stated by Staffordshire Police and West Midlands PoliceStated planned
138
Use audit findings to professionally develop decision makers and improve the firearms licensing service.
Stated by Staffordshire Police and West Midlands PoliceStated planned
139
Complete the five-year review of certificates revoked or refused and subsequently granted.
Stated by Staffordshire Police and West Midlands PoliceStated completed
140
Conduct scheduled internal and external quality-assurance audits of firearms licensing decision-making and certificate applications.
Stated by Staffordshire Police and West Midlands PoliceStated in progress
141
Review certificates seized and returned between August 2020 and March 2023, including certificates scheduled for re-seizure.
Stated by Staffordshire Police and West Midlands PoliceStated in progress
142
Maintain quarterly and biannual executive governance oversight of firearms licensing operations, performance, training, change and strategic risks.
Stated by Staffordshire Police and West Midlands PoliceStated in progress
143
Publish and implement a firearms licensing policy aligned with the 2023 Home Office statutory guidance.
Stated by Staffordshire Police and West Midlands PoliceStated completed
144
Disseminate internal communications reminding officers to consider seizing certificates and firearms when attending incidents involving certificate holders.
Stated by Staffordshire Police and West Midlands PoliceStated completed
145
Review firearm certificate return, refusal, revocation and appeal decisions from the previous five years using current statutory guidance.
Stated by Essex PoliceStated in progress
146
Commission an external audit of the Firearms, Shotgun and Explosive Licensing team’s compliance, processes and ability to respond to legislative and recommendation changes.
Stated by Essex PoliceStated planned
147
Continue working with the NPCC lead to align Essex firearms licensing processes with statutory guidance and safety recommendations.
Stated by Essex PoliceStated in progress
148
Review the Firearms Licensing manager role to assign responsibility for suitability decision making.
Stated by Gloucestershire ConstabularyStated planned
149
Review firearms licensing decisions from the past five years against current Home Office guidance, prioritising recently returned or granted licences and progressively covering four years if necessary.
Stated by Gloucestershire ConstabularyStated planned
150
Introduce two permanent intelligence development police staff posts to research social media intelligence for grants, renewals and suitability cases.
Stated by Gloucestershire ConstabularyStated planned
151
Add a temporary firearms licensing administrator for 18 months to reduce the grant backlog to pre-COVID-19 levels.
Stated by Gloucestershire ConstabularyStated planned
152
Recruit a further permanent Firearms Unit Supervisor accountable to the Unit Manager.
Stated by Gloucestershire ConstabularyStated planned
153
Conduct an independently commissioned neighbouring-force re-review of a sample of cases covered by the 2021 review.
Stated by Nottinghamshire PoliceStated planned
154
Complete a four-year retrospective firearms licensing review, prioritising returned seized, surrendered, refused or revoked firearms cases.
Stated by Nottinghamshire PoliceStated in progress
155
Allocate dedicated resource to undertake firearms licensing reviews under current Home Office statutory guidance.
Stated by Nottinghamshire PoliceStated completed
156
Maintain personal oversight of reviews and scrutinise resulting reports to identify required improvements.
Stated by Nottinghamshire PoliceStated in progress
157
Complete the five-year review of firearms licensing suitability records, checking whether certificates were subsequently approved after seizure, surrender, revocation or refusal.
Stated by South Wales PoliceStated in progress
158
Work with Gwent Police to establish best practice and align firearms licensing processes through continuous improvement meetings and regular peer reviews.
Stated by South Wales PoliceStated in progress
159
Arrange an annual peer assessment of selected firearms licensing approval cases.
Stated by South Wales PoliceStated in progress
160
Provide temporary additional resources, including senior management capacity, to the Firearms Licensing Unit.
Stated by Northamptonshire PoliceStated completed
161
Prioritise reviewing cases involving firearms seized or surrendered, then returned before suitability review.
Stated by Northamptonshire PoliceStated planned
162
Review previous firearms licensing decisions against the February 2023 Home Office Statutory Guidance.
Stated by Northamptonshire PoliceStated planned
163
Obtain scrutiny of the Firearms Licensing Unit through two external audits and a neighbouring-force peer review.
Stated by Northamptonshire PoliceStated in progress
164
Review cases involving refused applications or revoked licences followed by a successful application or appeal.
Stated by Northamptonshire PoliceStated planned
165
Require full review and firearms licensing Inspector or Superintendent oversight before returning seized firearms or certificates to licence holders.
Stated by Durham ConstabularyStated completed
166
Maintain a live watch list and conduct regular enhanced suitability assessments for licence holders meeting specified risk criteria.
Stated by Durham ConstabularyStated completed
167
Maintain live force and national profiles for licence holders and review every reported incident daily, seizing weapons and certificates when necessary.
Stated by Durham ConstabularyStated completed
168
Employ five additional firearms licensing staff to manage cyclical review and renewal workload.
Stated by Durham ConstabularyStated completed
169
Use firearms licensing decision-maker and supervisor scrutiny, with further investigation where application checks identify concerns.
Stated by Durham ConstabularyStated completed
170
Use quarterly independent Ethics Committee scrutiny of firearms licensing processes and decisions.
Stated by Durham ConstabularyStated completed
171
Apply enhanced internal, national, financial, social-media, incident, digital-evidence and medical checks to every firearms grant and renewal application.
Stated by Durham ConstabularyStated completed
172
Contact nominated referees and complete prescribed enquiries, using telephone, email or home visits according to risk.
Stated by Durham ConstabularyStated completed
173
Conduct monthly performance meetings to monitor, dip-sample and manage firearms licensing performance, escalating related issues when necessary.
Stated by Durham ConstabularyStated completed
174
Operate a 24-hour wash-through process to identify licence holders in incident or intelligence records, investigate elevated concerns and remove weapons pending suitability review.
Stated by Durham ConstabularyStated completed
175
Hold quarterly Chief Officer accountability meetings to oversee firearms licensing governance and decision-making.
Stated by Durham ConstabularyStated completed
176
Execute search warrants, seize unlawfully or lawfully held firearms where appropriate, revoke licences and submit intelligence to address wider risks.
Stated by Durham ConstabularyStated completed
177
Include the firearms licensing Inspector in monthly Firearms Threat Group meetings addressing lawful and unlawful firearm possession.
Stated by Durham ConstabularyStated completed
178
Review revoked-certificate cases where the holder reapplied within 12 months, assessing decisions against current circumstances.
Stated by Suffolk ConstabularyStated planned
179
Dip-sample 30% of cases dated August 2021 to February 2022.
Stated by Suffolk ConstabularyStated planned
180
Review firearms seizure-and-certificate cases identified through the Home Secretary’s 2021 review, including referral of four cases and revocation of one certificate.
Stated by Suffolk ConstabularyStated completed
181
Complete a full renewal review against current guidance and regulations for certificates issued before April 2019 within the next 12 months.
Stated by Suffolk ConstabularyStated planned
182
Re-review 30% of cases involving firearms seized and returned between August 2020 and August 2021 against current regulations and guidance.
Stated by Suffolk ConstabularyStated planned
183
Review 30% of cases dated February 2022 to April 2023 against the relevant firearms licensing guidance.
Stated by Suffolk ConstabularyStated planned
184
Review cases dated April 2019 to August 2020 under the firearms licensing review criteria.
Stated by Suffolk ConstabularyStated planned
185
Maintain ongoing scrutiny of firearm-licence grants, renewals and suitability assessments.
Stated by Devon & Cornwall PoliceStated completed
186
Improve FELU processes for reviewing firearm-licence grants, renewals and suitability assessments.
Stated by Devon & Cornwall PoliceStated completed
187
Implement automated systems to identify contemporary risks in firearm-licensing decisions.
Stated by Devon & Cornwall PoliceStated completed
188
Complete the review of 611 firearm-licence cases meeting the specified seizure, surrender, revocation, refusal and appeal criteria.
Stated by Devon & Cornwall PoliceStated completed
189
Maintain an Action Plan governing the Gold group and recording its decisions.
Stated by North Yorkshire PoliceStated completed
190
Develop an Action Plan to manage the response to the Prevention of Future Death reports.
Stated by North Yorkshire PoliceStated in progress
191
Review identified certificates and related records, assess the most recent decisions first, and flag appealed decisions with Crown Court-ordered returns to Legal Services.
Stated by North Yorkshire PoliceStated in progress
192
Create an assessment framework to test certificate decisions, record resulting actions, and provide evidence of the work on request.
Stated by North Yorkshire PoliceStated planned
193
Oversee the response to Prevention of Future Death reports and required actions through an established Gold group.
Stated by North Yorkshire PoliceStated completed
194
Introduce a new set of firearms licensing fees by statutory instrument.
Stated by Home OfficeStated planned
195
Review firearms licensing fees using police-force cost data to develop proposals for full-cost recovery.
Stated by Home OfficeStated in progress
196
Use a digital firearms marker to notify police of concerning deterioration in certificate holders’ physical or mental health.
Stated by Home OfficeStated completed
197
Consult on proposed new firearms licensing fees.
Stated by Home OfficeStated planned
198
Conduct an eight-week consultation on recommendations to strengthen firearms licensing controls, including police entry powers, prohibition thresholds, assessment standards and referees.
Stated by Home OfficeStated in progress
199
Consider with health-sector partners how to improve visibility of the digital firearms marker across health-service providers.
Stated by Home OfficeStated planned
200
Require firearms applicants to provide relevant medical information to police.
Stated by Home OfficeStated completed
201
Direct and undertake a prioritized review of firearms and shotgun licensing decisions against current Home Office guidance within Warwickshire Police.
Stated by Warwickshire PoliceStated planned
202
Monitor and track national progress in completing firearms licensing reviews through the Firearms and Explosives Licensing Working Group.
Stated by Warwickshire PoliceStated planned
203
Hold a two-day continuing professional development event for firearms licensing managers and supervisors on 18 and 19 May 2023.
Stated by Warwickshire PoliceStated planned
204
Share the unified review process and reinforce the need for forces to reassess firearms licensing decisions with Chief Constables nationally.
Stated by Warwickshire PoliceStated completed

Recipient positions 35

1
The 2021 review accurately identified the relevant cases and found that decisions to return weapons were correct.
Stated by North Wales PoliceDisputes the concern
2
Existing scrutiny and oversight processes for returning seized firearms and certificates are considered sufficiently stringent.
Stated by Surrey PoliceExisting arrangements considered sufficient
3
A full five-year review is not proportionate because it would divert trained FELU staff from focused work and transfer risk elsewhere.
Stated by Devon & Cornwall PoliceUnable to act
4
Existing reviews, remedial action and strengthened licensing processes are considered sufficient to meet the concern for January 2020 to May 2023.
Stated by Devon & Cornwall PoliceExisting arrangements considered sufficient
5
Issues requiring changes beyond the forces’ areas have been escalated to the NPCC lead and Home Office.
Stated by Bedfordshire Police and Cambridgeshire Constabulary and Hertfordshire ConstabularyRedirects responsibility
6
The existing review methodology is considered appropriate to review certificates returned during the required five-year period.
Stated by West Mercia PoliceExisting arrangements considered sufficient
7
Existing firearms licensing processes and the prior review are considered sufficiently robust, so no changes have been identified as necessary.
Stated by Dyfed-Powys PoliceExisting arrangements considered sufficient
8
Existing stringent review processes are considered sufficient to mitigate identified firearms licensing risks and assure public safety.
Stated by Avon and Somerset ConstabularyExisting arrangements considered sufficient
9
The completed five-year review found no cases in which firearm certificate approvals should not have been granted.
Stated by Avon and Somerset ConstabularyDisputes the concern
10
A further five-year review of returned or reissued firearms certificates is considered disproportionate at this time.
Stated by Metropolitan Police ServiceNo action considered necessary
11
Further consideration of discrete judicial training requires evidence of a training need, which the report does not establish.
Stated by LORD CHIEF JUSTICE OF ENGLAND AND WALESUnable to act
12
Existing statutory guidance and established appeal procedures are clear and accessible, and judges can familiarise themselves with the relevant law and procedure.
Stated by LORD CHIEF JUSTICE OF ENGLAND AND WALESExisting arrangements considered sufficient
13
The evidence does not substantiate that judges are applying the wrong legal test or failing to give firearms licensing appeals careful consideration.
Stated by LORD CHIEF JUSTICE OF ENGLAND AND WALESDisputes the concern
14
Resource demands prevent a full review of all approximately 800 cases, so a risk-based sample review will be undertaken instead.
Stated by Norfolk ConstabularyUnable to act
15
Cases issued before April 2019 will not be reviewed early because the established five-year renewal process will provide a timely full review.
Stated by Norfolk ConstabularyExisting arrangements considered sufficient
16
Previous reviews, current guidance and escalated decision-making are considered sufficient to limit further retrospective review to 30% samples.
Stated by Norfolk ConstabularyExisting arrangements considered sufficient
17
Existing governance, risk assessment, senior sign-off, dip-sampling and audit arrangements are considered sufficient to ensure firearms licensing compliance.
Stated by Merseyside PoliceExisting arrangements considered sufficient
18
A full five-year review is disproportionate and would divert trained staff from focused licensing work, transferring risk elsewhere.
Stated by Dorset PoliceUnable to act
19
Continuous Niche monitoring, renewals and evidence-led reviews make a further full five-year review unnecessary.
Stated by Dorset PoliceExisting arrangements considered sufficient
20
Existing firearms suitability review processes are considered sufficiently stringent, with delegated oversight and policy controls providing effective scrutiny.
Stated by Sussex PoliceExisting arrangements considered sufficient
21
Licence holders in their fourth or fifth year will be managed through the normal five-yearly renewal process against current standards.
Stated by Gloucestershire ConstabularyExisting arrangements considered sufficient
22
If reviewing five years of decisions is impractical, only the previous four years will be progressively reviewed.
Stated by Gloucestershire ConstabularyUnable to act
23
Cases four to five years old will not be reviewed because normal five-year renewal applies under current standards.
Stated by Nottinghamshire PoliceExisting arrangements considered sufficient
24
Licences already reviewed in 2021 will not be fully re-reviewed because repeating the work would reduce capacity for other reviews.
Stated by Nottinghamshire PoliceUnable to act
25
Existing risk-based cycle reviews and revocation mechanisms are considered more effective than retrospectively reviewing all certificates from the previous five years.
Stated by Durham ConstabularyExisting arrangements considered sufficient
26
Cases issued before April 2019 will not be reviewed early because the existing five-year renewal process provides a timely review.
Stated by Suffolk ConstabularyExisting arrangements considered sufficient
27
A full review of approximately 800 cases would require significant resources and divert resources from current firearms licensing demands.
Stated by Suffolk ConstabularyUnable to act
28
Cases from February 2022 to April 2023 were reviewed under applicable guidance and escalated decision-making, requiring only 30% further review.
Stated by Suffolk ConstabularyExisting arrangements considered sufficient
29
Cases from August 2020 to August 2021 were already reviewed, so only 30% will be reviewed again unless concerns emerge.
Stated by Suffolk ConstabularyExisting arrangements considered sufficient
30
Cases from August 2021 to February 2022 benefited from prior review learning and are expected to reflect robust decision-making, requiring only sampling.
Stated by Suffolk ConstabularyExisting arrangements considered sufficient
31
Current automated systems and ongoing scrutiny are sufficient; no current risks require remedial action.
Stated by Devon & Cornwall PoliceExisting arrangements considered sufficient
32
The statutory wording does not create a presumption favouring firearm certificate grants, so reversing it in future legislation will not be pursued.
Stated by Home OfficeDisputes the concern
33
Existing shotgun controls are considered significant and proportionate; aligning shotgun and firearm legislation is therefore not considered necessary.
Stated by Home OfficeExisting arrangements considered sufficient
34
Forces that have already reviewed decisions or have accurate 2021 information and sound current procedures need not duplicate earlier reviews.
Stated by Warwickshire PoliceExisting arrangements considered sufficient
35
The College of Policing could not support development of a firearms licensing quality-assurance process because of competing national priorities.
Stated by Warwickshire PoliceUnable to act

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

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised3

Failure to condition firearms licensing delegation on adequate training

Absence of a mandatory requirement for role-specific firearms licensing training

Lack of nationally accredited training for firearms licensing staff

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.71

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

Actions described in response 71

Respondent positions 10