Dear Mr Travers,

Thank you for the Regulation 28 report of 8th August 2024 sent to the Secretary of State / the Department of Health and Social Care about the death of Emma Pattison, Ellette Pattison, and George Pattison. I am replying as the Minister with responsibility for NHS Primary Care.

Firstly, I would like to say how saddened I was to read of the circumstances of Emma Pattison, Ellette Pattison, and George Pattison’s deaths and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.

The report raises concerns over:
1. An applicant for a shotgun certificate is able to obtain medication from an on-line doctor without the knowledge of their GP, giving rise to a risk that a licensing authority might grant a shotgun certificate to an applicant who has a relevant previous medical history about which the authority is not aware.
2. In consulting an on-line doctor, it is possible for an applicant for a shotgun certificate to avoid the current safeguards relating to full disclosure of their previous and current medical history.
3. Consideration should be given as to how a licensing authority can obtain full and accurate disclosure of an applicant’s history of coercive controlling behaviour towards another / others.

In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns.

I am responding to your first two concerns regarding medical checks as part of the firearms application process as requested of my Department in your report.

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

element of the application process that the police consider when deciding if an applicant can hold a firearms or shotgun certificate. An applicant is required to declare all relevant medical conditions upon applying and they must provide details of their GP. A proforma is then completed by their GP or an independent General Medical Council registered doctor. The doctor completing the proforma checks the GP medical record and must provide details of all relevant medical conditions to the police. This process has been further strengthened within GP IT systems, where a GP adds a digital marker to the patient record, to note that the patient has a firearms certificate. This was fully rolled out to all GP IT systems in England by May 2023. If the patient begins to experience a relevant medical condition while the certificate is valid, upon discussion with the GP, the GP will see an alert and can flag this to the police allowing them to review the person’s suitability, and if necessary, revoke the certificate.

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

In order to practice medicine in the UK, all doctors must meet the expected standards set out in the GMC’s Good medical practice and for prescribing, the GMC’s Good practice in prescribing and managing medicines and devices.

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

Thank you for bringing these concerns to my attention.

Dear Mr Travers

The Inquests Touching the Deaths of Emma, Ellette and George Pattison NPCC National Lead on Firearms Licensing – Response to the Coroner’s Regulation 28 Report – Action to Prevent Future Deaths.

I have very recently taken over as NPCC Lead for Firearms Licensing upon the retirement of former Chief Constable last week. I have carefully considered the content of the Regulation 28 Report from the Coroner in the above Inquest and have liaised with colleagues in both the College of Policing (CoP) and the Home Office (HO) who are responsible for legislation and guidance in this critically important area of policing.

I note that, as NPCC Lead, I am asked to consider the following specific matters of concern:

1. An applicant for a shotgun certificate is able to obtain medication from an on-line doctor without the knowledge of their GP, giving rise to a risk that a licensing authority might grant a shotgun certificate to an applicant who has a relevant previous medical history about which the authority is not aware.

2. In consulting an on-line doctor, it is possible for an applicant for a shotgun certificate to avoid the current safeguards relating to full disclosure of their previous and current medical history.

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

Following the shootings in Keyham, Plymouth in 2021, the NPCC, CoP and HO have worked to significantly revise and reform the statutory guidance around firearms licensing and the nature and extent of checks which are made on both applications for a grant or renewal of a firearms licence. In particular;

 Firearms Enquiry Officers

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

A new National Firearms Enquiry Officer’s Course has now been designed and developed and will commence its first delivery in November 2024 to forces in Northeast England. This is an intensive programme consisting of pre-learn reading package, and which includes a variety of new training videos. FEOs will then attend a five day ‘in person’ course, which has formal testing scenarios to cross check knowledge and understanding. Following this the FEOs will attend mandatory online training sessions where certain subjects will be discussed in more detail especially around domestic abuse and family turmoil together with mental health and wellbeing. FEOs will then be required to complete a portfolio involving internal assessments, CoP and external moderation to ensure that learning and best practice are embedded in their day-to-day activities and enquiries.

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

 Medical Declaration and GP Report

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

Where an application or their GP disclose any instances of anxiety or depression (or similar) we would expect Firearms Licensing teams to exercise professional curiosity and interview applicants, family and friends and to follow up with the GP or other medical professional/specialist to enable any risks to their suitability to hold a licence to be properly assessed. It is also possible within the licensing framework to accommodate bespoke conditions to address an applicant’s medical pathway if required.

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

Dealing specifically with the Matters of Concern raised in the PFD Report: 1 & 2 – Online GPs It is, of course, outside the role and remit of policing to regulate or manage the health sector; this would be a matter for the Department of Health and Social Care and we understand that our HO colleagues are working with their counterparts in the DHSC to progress this issue. As the NPCC Lead, I would welcome any positive moves that are possible to regulate online GPs/prescriptions and require any relevant information to be passed to the GP with whom the individual is registered, so that it is accessible to Firearms Licensing Units when required, to enable a fuller picture to be available to support risk assessments and suitability assessments on applications for grant or renewal of firearms licensing. Exactly the same concerns arise where applicants use private GPs or consultants (outside of a GP referral) which may also remain unknown to firearms licensing teams. I understand that the HO is intending to amend the firearms application form so that the applicant must provide details if they have consulted an online or third party/private doctor, enabling further enquiries to be made. It is hoped that there will be provisions for the police to require the applicant to provide a completed medical proforma from this doctor regarding any relevant conditions. Again, this is a step which the NPCC would support. 3 – Applicant’s history of coercive controlling behaviour On both initial grant applications and on renewal, checks are already required to be made on Police National Computer (PNC), the Police National Database (PND) and local policing records. This would disclose to Firearms Licensing teams any convictions, cautions, intelligence or pending matters/investigations. The Statutory Guidance for Chief Officers of Police on Firearms Licensing (2023) at paragraph 2.4 states (our emphasis added) – “All applicants should be checked against the widest relevant databases to gather conviction, intelligence and counter terrorism data.” Guidance sets out detailed considerations for suitability assessments including, at paragraph 2.52 and onwards: Additional checks
2.52 Chief officers should carry out additional, non-routine, checks if, following the initial enquiries above, they believe them to be necessary to assess suitability fully.
2.53 These checks may include, but are not limited to: (i) checks with other agencies, such as health professionals other than the GP, social services, probation services or multi-agency groups; (ii) checks with other licensing or regulatory bodies or Government enforcement agencies; (iii) a drug or alcohol test; (iv) credit or other financial checks; (v) information obtained from open source social media;

(v) interviews with individuals other than the applicant or their referees, for example, partners or representatives of shooting clubs attended by the applicant; (vi) background checks on partners or other individuals living at, or with unsupervised access to, the applicant’s address; and (vii) checks where there is an indication of domestic abuse, as set out in paragraphs 2.54 – 2.59. It is expected that FEOs speak with the applicant and, where relevant, family members and friends and others. In cases of suspected controlling and coercive behaviour, additional safeguards are found in the Controlling or coercive behaviour Statutory Guidance Framework at paragraph 51: “In all domestic abuse cases, if firearms are held by the perpetrator or are in the home, the local police Firearms Licensing Team should be notified so that they can consider seizing the firearms or revoking any licence that the perpetrator holds. It is also important in terms of risk mitigation and intelligence to ensure officers attending future calls have this information. The Firearms Licensing Statutory Guidance for police was published in February 2023 and contains further information about firearms licensing in respect of cases involving domestic abuse”.

Conclusion It is my view that improvements have definitely been made over the past couple of years in respect of the extent of enquiries and evidence gathering to fully inform suitability assessments in applications for firearms licensing. There is, in my opinion, much better joint working between NPCC, CoP and HO to expand the requirements around suitability assessments, medical disclosures, the expectation for professional curiosity to be displayed by all those involved in the licensing process and the introduction of a thorough and accredited national training programme for FEOs. However, as the NPCC (working with the College of Policing) we remain of the view that there is more to do and that changes are still necessary to further improve the ability of the police to properly risk assess an applicant’s suitability to hold a firearms licence:  Mandatory mental health markers on GP files to prompt pro-active disclosures by GPs for licence holders where matters of potential concerns to public safety/suitability are raised.  Neurodiversity must be added to the medical declaration on application for a firearms licence, to enable the police to seek specific medical opinion of the impact of that upon the particular applicant.  Regulation of Online GP services and the introduction of a requirement upon those GPs working online to report to the registered GP any relevant information/disclosures/medications prescribed for inclusion on medical records.  HO to proceed with implementation of the outcomes from their August 23 consultation, in particular we would welcome early implementation of o Mandatory requirements for GPs to support the licensing process and complete the medical proformas on every application, o Police being granted powers to enter properties to seize firearms for the purpose of reassessing suitability of licence holders, o A statutory prohibition on applying for a licence for 5 years for anyone who has been sentenced to serve 0-3 years in prison, including suspended sentences.  More serious potential sanctions upon applicants who deliberately withhold relevant information or are deliberately dishonest on application

There is already expectation that deliberate failure to disclose criminal history or relevant medical evidence should lead to a refusal. The Statutory Guidance sets out that in the case of deliberately withholding relevant information, applicants should expect to be refused a licence:
3.30 In addition to the most serious factors above, evidence, on the balance of probabilities, of any of the following, although not exhaustive, will tend to demonstrate a potential danger to public safety or to the peace: ……. (iii) deliberate failure to declare relevant convictions or medical conditions, regardless of whether the certificate would have been refused if the appropriate declaration had been made; However, given the potential consequences of dishonesty leading to firearms being held (lawfully) by those who are not safe to do so without causing a potential danger to public safety – as in this case – it must be arguable that stronger sanctions should be available for those who act in this manner and seek to obtain a licence when they are fully aware that, due to current health conditions, they should not be permitted to do so. The difficulties posed by this case however appear difficult to legislate against;  There were no records held of the licence holder’s more recent mental health difficulties as he appears to have taken steps to deliberately by-pass his own GP, presumably recognising that obtaining medication via an online doctor would result in there be no traceable record of his illness.  He has then lied on his application and medical declaration and failed to disclose relevant medical information.  There do not appear to be any record of previous complaints or concerns being raised with police in respect of controlling or coercive behaviour. The licence holder’s wife was apparently interviewed in respect of the licence application and raised no concerns. Systems checks did not disclose any prior reporting – save for a single incident prior to the previous renewal process, where the licence holder was the complainant. Moving forward, national FEO training will further encourage positive engagement with the applicant and their family/others in their household. FEOs will be expected to ascertain the “domestic health and wellbeing” of the applicant on both initial grant and any renewal. We are hopeful that revised statutory guidance will require interviews and wider engagement with families and FEOs will be required to cover these matters on the new FEO report on suitability. We are also looking to introduce the right to draw adverse inference if an applicant is evasive about family/previous partners and so on. As a police service, we will continue to engage with partners to improve upon partnership working and inter-agency information-sharing to ensure that those charged with determining firearms licensing applications have as much relevant information as possible to assess an applicant’s suitability to hold a firearms licence in the context of ensuring public safety.

Dear Mr Travers, write in response to your Regulation 28 report dated 8th August 2024,relating to the inquests touching the deaths of Emma, Ellette and George Pattison: share your concern that any certificate holder or applicant can,it would appear, hide certain medical treatment by an online facility: The national application form asks, there any periods in the past 10 years when you have not been registered with a UK GP or have consulted medical practitioners other than at your GP practice?" In this case, Mr Pattison answered "no" in both his 2016 and 2022 renewals. Surrey Police acknowledge that, although the force re-asks all other questions on the medical form during the Firearms Enquiry Officer (FEO) visit, Surrey Police did not ask about the use of other medical services in this visit: Surrey Police has, because ofthis case, revised our practice, and FEOs now do cover this in their visits to try and elicit the information from an applicant: Surrey Police acknowledges that a applicant could still withhold this information, and there is currently no method for the police to find out if it is being so witheld_ The College of Policing and the NPCC have made recommendations that this national set of questions is re-written to be more explicit: Whilst most applicants understand what is being asked, there is still room for non-disclosure or deception. Additionally, the request for disclosure is limited to information from the previous 10 years only: Surrey Police would also like to relocate the question to a more prominent position within the medical section to ensure its importance and relevance is clear and noted: recognise that the wider regulation of online GPs is being explored as part of your recommendations and would welcome change to make this a more robust process. Police, PO Box 101, Guildford, Surrey, GU1 9PE surrey police.uk surr "Are using Surrey

Surrey Police licensing officers take a negative view of applicants who fail to disclose relevant information. However, there seems to be little within legislation to require a holder to disclose change in personal circumstances during each 5-year period. Therefore, am consulting with the College of Policing and the NPCC lead on the potential to add a condition to holder certificates, reminding them oftheir obligations to inform the police of any changes in domestic and health situation; believe this would allow more robust oversight between renewals_ Controlling and coercive behaviour became an offence in 2016. Since then, there has been a continued learning programme deigned to equip responders to recognise this behaviour: Surrey Police has a dedicated Domestic Abuse Team and continue to work with our partners in the identification and support of victims of domestic abuse: Officers asked Mrs Pattison about her relationship. However, she did not make any disclosures of abuse: Mrs Pattison was also spoken with independently the FEO when conducting the suitability review: No risk factors were identified at that stage and Mrs Pattison stated that she had no concerns regarding the firearms possession. Surrey Police is aware of the Project Titanium trial being conducted by Gwent Police to explore domestic abuse concerns further and are supportive of the aim and objective of this project. We look forward to understanding the finding of this project post review. In the meantime, Surrey Police processes ensure that current partners are independently engaged with and, on a case-by-case basis, previous partners or family members can be spoken to. As licensing authority Surrey Police thoroughly reviews the investigative paperwork completed by police officers. This includes body worn video and Domestic Abuse, Stalking and Harassment & Honour Based Violence risk assessment forms in order to make licensing decisions based on all the information available to us. This work is progressed nationally by Chief Constable Debbie Tedds, the NPCC lead for firearms licensing: She is supported by her officer Chief Superintendent Adrian Davies who is also the College of Policing contact for this area ofwork: Both proposed changes above must be agreed at a national level and there cannot be local differences to the form or process. This work is already underway and the proposed changes will be presented at the National Firearms, Explosive working group by Adrian and, once ratified, will be implemented_ expect this to take 6 12 months_ For assurance, have asked our Assistant Chief Constable with responsibility for Firearms Licensing to report formally to me on progress against your recommendations in 3 months.

Dear Mr Travers

We write in response to the Regulation 28 report issued by yourself following the inquest into the deaths of Emma, Ellette and George Pattison, and specifically in response to paragraphs 5.1 and 5.2 in that report:

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

In respect of 5.1, we note the concern raised. The GMC has clear guidance that covers the sharing of information between on-line doctors whom the patient may choose to consult, and the patients registered NHS General Practitioner. The guidance: About Good practice in prescribing and managing medicines and devices - GMC (gmc-uk.org) provides at Paragraph [56]:

If you are not the patient’s GP, when an episode of care is completed, you must tell the patient’s GP about:
a. changes to the patient’s medicines along with reasons, including if existing medicines are changed or stopped, and new medicines are started
b. length of intended treatment
c. monitoring requirements, including who will carry this out
d. any new allergies or adverse reactions identified.

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

Paragraph (9) of Good Medical Practice (2024) also creates a responsibility for a doctor to consider whether the mode of consultation is appropriate to providing the safe care the patient needs.

In respect of 5.2, we would expect an online doctor to be prescribing only after having taken an appropriate medical history, which would include, albeit not necessarily exhaustively, their current and past medical history and prescribed medications. This would underpin the clinical basis for deciding whether or not to prescribe. If the medical record is not available, then the only source of information would be from the patient. Communication with the regular GP would mitigate this risk, and as above, that would be the expected practice in this situation, unless the patient refused consent to do so.

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

Dear Mr Travers,

Thank you for your report of 8 August about the deaths of Emma, Ellette and George Pattison, made under paragraph 7(1) of Schedule 5, of the Coroners and Justice Act 2009. I offer my sincere condolences to the family and loved ones of those who have been affected. The safety of the firearms licensing system is paramount and I have carefully considered the matters you raise regarding firearms licensing controls in relation to this most tragic case.

In your report you raise concerns that an applicant for a firearm certificate is able to obtain medication from an online doctor without the knowledge of their GP, giving rise to a risk that a certificate could be granted without the police being aware that the applicant has a relevant medical history, and that this enables an applicant to avoid providing full disclosure of their medical history to the police.

There are already strong controls in place in relation to an applicant’s medical suitability. Every applicant is required to declare all relevant medical conditions when they complete their firearm or shotgun application form and they must also provide details of their GP. A proforma is completed by the applicant’s doctor who checks the GP medical record, and details of all relevant medical conditions must be provided to the police before a firearm certificate can be issued. The GP also places a firearms marker on the patient record so that they can alert the police if the certificate holder begins to experience a relevant medical condition while the certificate is valid, so that the police can review the person’s suitability and, if necessary, revoke the certificate.

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

be implemented by statutory instrument and are planned to take effect in the course of
2025.

In your report you have also proposed that consideration is given to how the police can obtain full and accurate disclosure of an applicant’s history of coercive controlling behaviour. The Home Office publishes Statutory Firearms Guidance for Chief Officers of Police which sets out the processes and criteria for assessing an applicant’s suitability to possess firearms. This assists the police in their firearms licensing functions and promotes high standards and consistency between forces. We are intending to issue a refreshed version of the Statutory Guidance early in 2025 which will include additional guidance for the police to help ensure that those who are the perpetrators of domestic abuse, coercive or controlling behaviour, do not have access to firearms. In particular, we will strengthen the guidance so that it is clear and emphasises the need to interview partners, relatives and possibly former partners if there are allegations or suspicions of domestic abuse, coercive or controlling behaviour in the household. The Statutory Guidance for Firearms will make clear that such interviews need to be conducted with sensitivity, taking into account that a victim of domestic abuse may be unwilling to speak openly with the police for fear of further violence or reprisals, and that information provided during interview must be treated as confidential. We will also ensure that the Statutory Guidance is sufficiently clear in relation to other allegations of violence and the need for the police to investigate such allegations and take this information into account when making their assessment of suitability.

There is a further safeguard contained in the separate Statutory Guidance framework in relation to controlling or coercive behaviour, published by the Department and which was updated in July 2023 and applies to those investigating offences in relation to controlling or coercive behaviour. This states at paragraph 51 that in domestic abuse cases, if firearms are held by the perpetrator or are in the home, the local police firearms licensing team should be notified. The guidance also advises that for intelligence purposes and to mitigate risk officers attending future calls must have this information.

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