Dear Mr Arrow

Response to Regulation 28 Report

I write to provide a response on behalf of Dorset Police to the Regulation 28 Report, received on the 8 March 2023, following the conclusion of the inquest touching the deaths in Keyham on 12 August 2021 of Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington and Kate Shepherd.

This response is provided in relation to:

a. Concerns raised of the Chief Constable of Dorset Police as a properly interested party in the Keyham Inquests. (Firearms Licensing currently operates as an Alliance function as part of the Devon and Cornwall and Dorset Police Alliance arrangements.)
b. Any concerns raised of all Chief Constables in England and Wales.

I set out below the specific paragraphs subject of this response under Regulation 29 for ease of reference.

Report to: All Chief Constables in England and Wales

Further Review of all certificates seized/refused/revoked or surrendered and then approved over the past 5 years

I am concerned that the figures provided to the Home Secretary in 2021 may not reflect the accurate position, and that if sufficiently stringent checks are performed these may reveal other cases where a firearm or shotgun certificate had been seized, refused, revoked or surrendered but was subsequently issued/returned in circumstances when the certificate should not have been approved. I am concerned that if there are other cases that were not subject to a proper or thorough review of the risk of returning the weapons then the person may continue to have a Chief Constable MSt (Cantab) Dorset Police Force Headquarters Winfrith DORCHESTER DT2 8DZ

3 May 2023 Mr Ian Arrow HM Senior Coroner for Plymouth, Torbay, and South Devon 1 Derriford Park Derriford Business Park Plymouth PL6 5QZ

firearms/shotgun certificate and hold weapons in circumstances that place the public and certificate holder themselves at risk.

I am concerned that in light of the lessons learned in the Keyham inquests of the attitude towards risk, a further review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the past five years may be required to be assured of public safety.

Response

We agree with the submissions made by the families during the inquest, and we do so for the reasons set out below.

In August 2021 the Home Secretary wrote to all Chief Constables asking for an urgent review of cases where guns had been seized, surrendered, refused or revoked over the previous 12 months. As a result, research was conducted, and a response provided. An independent peer review, completed by Durham Police in September 2021 reviewed some of these cases in more detail, and these cases were reviewed again by Devon and Cornwall Chief Superintendent , the senior officer appointed to manage the response to the Keyham tragedy. It is also noteworthy that throughout this process, the department has regularly engaged with the NPCC lead force (Warwickshire).

In all cases where certificates/gun(s) were returned following an issue affecting a holder’s suitability, these were independently reviewed by someone not involved in the original decision making process. 8 cases were identified to have issues and as a result remedial action taken or learning identified.

With over circa 12,000 firearm and shotgun certificate holders in Dorset, the vast majority of certificate holders have no issues affecting suitability, and the decision making, within the parameters of the law, APP and statutory guidance, is straightforward.

Dorset Police has held all certificate holders on our record management system, Niche, since 2018 which enables the unit to be notified automatically of any adverse incident affecting the Dorset certificate holder or their address allowing early intervention and investigation.

In addition to the scrutiny applied through the review for the Home Secretary and the Durham Peer Review (September 2021), the Police Gold Commander commissioned the Performance and Analysis Department to conduct further research into certificate holders in order to identify issues regarding their ongoing suitability.

Taking the result of this research into consideration, the additional supervisors recruited into unit were tasked to complete, in priority order:
• A detailed review of the initial cases included in the response to the Home Secretary’s letter and the Durham Peer Review to ensure each case was dealt with appropriately against APP and statutory guidance.
• A dip sample of the cases involving the decision makers in the case of Jake Davison.
• A review of the cases identified by the research conducted by the Performance and Analysis Department.

In addition to managing the core demand of the unit such as grant and renewal applications, the prioritisation of this work sought to address the known risk first (i.e. that identified through the Durham Peer Review), before reviewing the potential risk such as that contained in cases involving the decision makers who had been involved in the Davison case, and then finally the further potential risks identified through the targeted research conducted by our analysts.

Our position is that with the number of certificate holders within our force area, it is not proportionate to review all the certificates over a five year period. Since 2018, Niche has provided flagging for all certificate holders and their addresses giving continual monitoring for any adverse incidents. The majority contain no issues regarding suitability, and many of these cases will now have been through a renewal process. An additional full review of all certificate holders would be likely to transfer risk elsewhere within the unit by moving staff away from the focussed activity associated with the normal operation of the unit. This is particularly relevant when considering the need to ensure that the staff involved are adequately trained and experienced in making licensing decisions. Consequently, the approach undertaken was evidence-led using criteria informed through the various inspections undertaken following the incident.

In writing this response, our position is that the date from which the five-year period is considered should be the date of submission of this response. Considering this, it must be noted that the substantial changes implemented in Dorset Police Firearms and Explosives Licensing Unit cover a significant part of this period. As presented at the inquest, following the incident, all decisions were paused until a new leadership structure was created and embedded. This was augmented by a comprehensive training and CPD programme for all staff, a portfolio assessment for FEOs and a robust dip sampling framework (see below). Consequently, all decisions regarding grants, renewals and case reviews since August 2021 have been subject to the new robust process which includes all of the lessons identified through the inquest, and applies a rigour beyond that set within the statutory guidance and APP. The evidence for this conclusion is found through the internal peer review conducted since the inquest, the preparatory work conducted before it, and the sustained rate of refusals and revocations.

In addition to this, the period 1st August 2020 to 18th August 2021 is covered by the response to the Home Secretary in September 2021, and the additional (independent) review of cases by Durham Police and the remedial work completed as a result by Devon and Cornwall Chief Superintendent . Consequently, we suggest that the requirements of the PFD report are met for the period 1st August 2020 to the date of submission of this document.

Considering the above, our response for this report relates to this remaining period. It has been decided that a further review of cases over this period will be carried out to identify any remaining risk to the public that requires remedial action. Our position, based on the experience of reviewing the decision making in cases prior to August 2021 (completed for the inquest), is that further work is required notwithstanding that the passage of time will diminish any risk in the vast majority of cases.

In addition, and in parallel to this, we will review the analytical product and use this to complete further targeted reviews of certificate holders who may have had an involvement with the police that is capable of affecting their suitability to hold a certificate. However, experience has shown that this research frequently identifies matters that are either irrelevant to the certificate holder (e.g. a road traffic collision that is recorded in the same street as the holder), or that have already been reviewed as part of a renewal or case review. This review process should take a matter of months to complete.

The NPCC lead for firearms licencing and all other Chief Constables in England and Wales

Training of Police Officers and Police Staff involved in firearms licencing decisions

So that each Chief Constable is made are of my concern that, despite the many recommendations made of 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 relevant Guidance.

I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licencing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.

Response

Dorset Police fully support the National Police Chiefs’ Council (NPCC) and the College of Policing (CoP) in developing a national accredited training program for staff involved in making licensing decisions. We agree with the PFD submissions made on behalf of the families during the inquest and will continue to support the national training program as it develops; advocating for sufficient funding to enable this to deliver at pace. We will also support its delivery where requested, ensuring that lessons from Keyham are integrated into the fabric of the course.

As expressed in evidence during inquest, the training provision for the Firearms and Explosives Licensing Unit within Dorset Police has been completely revised since the incident, creating clear expectations of staff and auditable records of training delivered. There is a clear focus on decision making, risk identification and the implementation of statutory guidance. This has included training to all staff within the unit and key operational managers who are responsible for making dynamic decisions to revoke certificates.

Immediately following the tragic incident in Keyham, a manager was appointed to create a training and continual professional development plan, and to deliver this to all staff within the unit. In the absence of a national accredited training package, we have created and delivered a bespoke training program to all staff working within the Firearms Licensing and Explosives Unit including those responsible for making high risk decisions.

At the time of writing, all staff working within the unit have undertaken a Firearms Enquiry Officer (FEO) course provided by a Firearms Licensing Manager from South Yorkshire Police. This course has a positive reputation across UK policing and is one of only a handful of options available. The content covers the use of the National Decision Model (NDM) in addition to a vulnerability assessment framework, core investigative principles, the grant and renewal application process, suitability criteria, powers and appeals, the National Intelligence Model, domestic abuse, security arrangements, mental health, and the statutory guidance. Importantly the course integrates these issues with the revised processes created within Dorset Police since the incident; for example, the completion of enquiry forms by FEOs.

By mandating attendance for all staff within the unit, this provides a consistent approach for both existing staff and new members, providing a baseline from which individuals can perform their role to a high standard. A handbook for staff is also shared following the course, and all staff have been provided with a copy of the most

recent statutory guidance with clear instructions for its use, linking this with a risk identification tool which was referred to in the inquest as the Risk Matrix. It is noted that the unit is in the process of reviewing the use of this risk identification tool alongside the NPCC in light of both the statutory guidance released in February 2023 and the issues raised during the inquest.

As a result of the work conducted after the incident, we have also received additional training in risk assessments and decision making. This training has been delivered by a barrister who specialises in firearms licensing and focuses on the practical identification of risk through the THRIVE (Threat, Harm, Risk, Investigation, Vulnerability & Engagement) assessment process, as well as the application of the national police risk principles and the use of the NDM in case and appeal management. This training, initiated soon after the incident, is clearly relevant to the matters subjected to appropriate examination at the inquest. Suitability decisions are now recorded on separate documents, including all relevant detail that could affect the suitability of an applicant to hold a certificate. The records are comprehensive and apply the statutory guidance through the use of the NDM.

In terms of managing the various IT systems used in making and recording licensing decisions, all staff within the unit have completed awareness or training courses in the following computer systems:
• Police National Computer – PNC
• Niche – the new records management system
• Police National Database – PND – a national intelligence database
• National Firearms Licensing Management System - NFLMS

To assist FEOs in the conduct of their public facing role, all undertake training in first aid and personal safety which are based on the (NPCC) Personal Safety Manual and covers a vast range of subjects. Until a national qualification is made available through the College of Policing, FEO’s are accredited ‘in force’ with a qualification from the course provided by the Licensing Manager from South Yorkshire Police. This process is coordinated internally with individual records maintained, enabling automatic reminders to be sent to staff and their line manager to alert them when this skill is due to expire. At this time there is no formal requirement across England and Wales in relation to either accreditation or refreshing existing skills and learning. We will continue to engage and work closely with the NPCC and College of Policing during 2023 to assist in delivering the national course and in defining a period for reaccreditation which is robust and pragmatic. Following the inquest, a comprehensive response to the College of Policing was submitted to assist this process, and Dorset’s future policy will reflect the national position and any requirements set by the NPCC and the College of Policing.

Following the completion of the mandatory training requirements listed above, we have also started to receive a three-year continual professional development

programme comprising training to staff online and from experts in mental health and domestic abuse. This training reflects the core issues examined during the inquest. In addition, we continue to work with the NPCC lead to ensure that these issues are reflected within the national planning for accredited training and annual CPD requirements which are further set out within the NPCC portfolio.

The decision to temporarily remove the decision-making capability of FEOs and FEO supervisors articulated during the inquest by Devon and Cornwall Chief Superintendent provided an immediate response to the issues identified. Following the delivery of the training described above, two additional training related actions have been pursued to augment the decision-making process: the creation of a portfolio for assessing and performance monitoring FEOs, and a comprehensive dip sampling regime involving both the Assistant Chief Constable (Operations) and the Senior Management Team (SMT) within the unit. This involves new and experienced police supervisors within the unit reviewing FEO decisions via an enquiry form, assessing their rationale, and providing feedback to them directly. Significant issues or more systemic ones are regularly discussed within the risk management meetings led by the ACC (Operations) as described during the inquest. This system provides a clear and robust process for assessing the quality of the investigations conducted by FEOs following their training.

During the next 18 months we intend to provide additional training to further enhance the quality of FEO investigations. This will be delivered through the national Professionalising Investigations Programme at level 1, which is the nationally recognised standard and includes an investigative accreditation that applies to investigators at all levels within policing. It is a structured framework running through every aspect of investigation and will improve the professional competence of all officers and staff. It also enables supervisors to manage performance of their staff and to identify areas for development.

Noting that the Authorised Professional Practise (APP) for firearms licensing is under consultation and is due for imminent renewal in 2023, the current training providing within Dorset exceeds the current requirements in APP.

In addition to the CPD for our staff, a presentation of the key learning from the incident to a CPD event for all Firearms Licensing Managers will be delivered in May
2023.

Following this incident, Dorset Police in alliance with Devon and Cornwall Police have invested in the Firearms and Explosives Licensing Unit and continue to be involved in sharing advice and learning concerning policies and procedures with other police forces and the NPCC.

Finally, although this represents a significant amount of activity since August 2021, I hope that it demonstrates that Dorset Police are committed to learning from this

PREVENTION OF FUTURE DEATHS REPORT RESPONSE

APRIL 2023 Prevention of Future Deaths Report Response

This document forms the official response from Avon and Somerset Police to the Prevention of Future Deaths report, published by Mr Ian M Arrow, Senior Coroner for Plymouth, Torbay, and South Devon on 8th March 2023.

Overview

On 12th August 2021, Jake Davison fatally shot Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington, and Kate Shepherd in Keyham, Plymouth.

The Senior Coroner for Plymouth, Torbay, and South Devon, Mr Ian Arrow, led the inquest into their deaths and, following its conclusion in March 2023, he produced a number of Prevention of Future Deaths reports documenting key findings and learning to be considered by relevant agencies. A request was made for all subsequent responses to be completed within 56 days; by 3rd May 2023.

The report below documents the response of Avon and Somerset Police to the ‘Matters of Concern’ raised by the Senior Coroner for consideration by Chief Constables in England & Wales and those relating to ‘Training.’

‘Matters of Concern’ – All Chief Constables

‘I am concerned that in the light of the lessons learned in the Keyham inquests of the attitude towards risk, a further review of all certificates seized, refused, revoked, or surrendered and then subsequently approved over the past five years may be required to be assured of public safety.’

Response from Avon & Somerset Police:

Following the fatal shootings in Plymouth in 2021, the Home Office requested a review of the last five years of cases where licenses had been seized, revoked, or refused and then subsequently approved again. Avon and Somerset Police completed a thorough and comprehensive review and found no cases where the approval should not have been granted.

We are satisfied that our decision-making in each of these reviews was appropriate, and that our ongoing review processes are necessarily stringent. Our rationale for this is as follows:

Prior to the Home Office request in 2021, Avon and Somerset Police appointed a new Firearms Licensing Manager (FLM) in 2020, who sought to undertake assurance surrounding all risks within the department as a priority. This was particularly relevant given the context of the COVID-19 pandemic and the reduction of face-to-face contact with applicants, in addition to the number of licensing appeals that were going to the Crown Court.

Court files and revocations were reviewed, and learning was identified surrounding the quality and detail of rationales for revocations and subsequent approvals. The FLM also identified a culture which didn’t support staff to effectively challenge decisions. Standards and

PREVENTION OF FUTURE DEATHS REPORT RESPONSE

APRIL 2023 expectations were quickly articulated, and processes were tightened within the department to ensure transparency and robust decision making.

Following the Plymouth shootings in 2021, the process in Avon and Somerset Police was amended to add a further layer of scrutiny and oversight. This new approach required that all decisions to grant a certificate, where the certificate had previously been revoked / refused, must be authorised by an Assistant Chief Constable. This chief officer is provided with the relevant threat, harm and risk assessment, intelligence, case law, and relevant options and recommendations from the FLM. The process is in place for all applicants, irrespective of how much time has elapsed between the original revocation and the renewal.

Furthermore, Avon and Somerset Police have a number of established practices and processes which already mitigate against a number of the risks identified in the learning from Plymouth. Indeed, in October 2020, the following measures and processes were adopted:

• Avon and Somerset Police Firearms Licensing Team have implemented and maintained a position that any caution or restorative justice disposal should be considered as a conviction when assessing suitability.
• The responsibility for authorising the return of firearms was removed from investigating officers and sits solely with the Firearms Licensing Team - specifically Firearms Licensing Officers and the Firearms Licensing Manager.
• Any incident which requires the seizure or voluntary surrender of guns and certificates is subject to a suitability review.
• To ensure managerial supervision, completed reviews are signed off by the Firearms Licensing Officer and Firearms Licensing Manager, with additional oversight where necessary being provided by the Criminal Justice Chief Inspector and Assistant Chief Constable.
• Avon and Somerset have adopted the NDM RISK MATRIX (see Appendix A), which is supported by the Firearms and Explosive Licensing Risk Management Procedure consultation document and the College of Policing Risk Principles.

The Avon and Somerset Firearms Licensing Team have also reviewed the effectiveness with which overall risk is managed, and certificates and weapons are returned to those persons where they have been:

• Revoked,
• Seized during or following contact with the Police,
• Surrendered on advice from Police / Firearms Licensing / Third Parties.

Procedures have been amended to ensure that every incident, although considered on its individual merits, is scrutinised with the same objective curiosity and that all decisions are properly recorded and reviewed.

Avon and Somerset Police have been instrumental in shaping best practice nationally and have supported peer reviews across the South-west region. We have confidence in the robustness of our decision making and are assured that our processes enable high levels of public safety.

PREVENTION OF FUTURE DEATHS REPORT RESPONSE

APRIL 2023 ‘Matters of Concern’ - Training

‘Despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for Firearms and Explosives Licensing Unit (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 the 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 Licensing 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.’

Response from Avon & Somerset Police:

All Firearms Enquiry Officers in Avon and Somerset complete the South Yorkshire Police three-day Firearms Enquiry Officer course (see Appendix B).

Our Firearms Licensing Team have a dedicated senior Firearms Enquiry Officer who trains, coaches, and mentors all new Firearms Enquiry Officers in line with the College of Policing Assessment Guidance for Firearms Licensing (See Appendix B), ensuring consistency in the operational approaches that staff take.

Specific training courses for Firearms Licensing Administrators are delivered through Mowbray Partners. Staff from the department also maintain their own continuous professional development by participating in regional events which involve inputs from national shooting bodies, the British Association for Shooting and Conservation (BASC), and the National Gamekeepers Organisation.

Avon and Somerset Police comply with the Authorised Professional Practice (APP) and the Firearms Licensing: Statutory Guidance for Chief Officers of Police, February 2023. The Firearms Licensing Team are presently using the latest publication to establish further areas for additional improvement.

In response to the publication of the aforementioned guidance, and in recognition of the learning from the deaths in Keyham, the Firearms Licensing Team are reviewing their training requirements and will be implementing additional mandatory training for all staff working in the team.

These training inputs will include:

• Completion, by the Firearms Licensing Manager and Firearms Licensing Officers, of the Professionalising Investigations Programme (PiP) Level 1 training, focussing on decision making, managing risk, and supervising investigations. This course will mirror the input that is given to all police supervisors of investigations.

Dear Mr Arrow,

I write in relation to your correspondence dated 8th March 2023 pertaining to the inquests you heard surrounding deaths in Keyham in August 2021.

In respect of your observations, I report the following:

In terms of training and continuous professional development, all Merseyside Police Firearms Enquiry Officers have completed the nationally recognised training package delivered by South Yorkshire Police. Furthermore, all staff are enrolled on the online training offered by Mowbray Partners. I welcome the recommendation that all Firearms Licensing staff are appropriately accredited.

Within force, we have a robust governance structure in place which includes the provision of a risk matrix. In terms of the delegated authority, all revocations and refusals are signed off at Assistant Chief Constable level. The presence of regular dip-sampling in relation to all work, including files within the department ensures compliance. I have also asked our independent audit team to examine the processes and procedures that we have put in place to ensure that we have a critical eye to objectively assess our action plan and response to your recommendations. Whilst I understand that a national form detailing Mr Ian M Arrow HM Senior Coroner 1 Derriford Park Derriford Business Park Plymouth PL6 5QZ

28th April 2023

Chief Constable Rose Hill, 15 Cazneau St, Liverpool L3 3AN Tel 0151 777

referee support of an application is still under consultation, we have devised our own document to implement this process in the meantime.

Moving forward our processes will include reviewing within one month all cases where firearms have been seized or surrendered to the police pending a review of suitability to have a licence, but subsequently returned. We will also review applications that have been refused or licences have been revoked, but where subsequent applications or appeals by the same licence holder have resulted in the granting of a licence. We will endeavour to ensure that this is completed by 2nd October 2023. All cases will be reviewed by the Firearms Licensing Manager and escalated to the Chief Superintendent and/or Assistant Chief Constable where appropriate.

In response to the request by the Home Secretary, my Firearms Licensing Manager in conjunction with the relevant Chief Superintendent reviewed 8 cases from 2021. During this period:

• 2 licenses were revoked and have not been subsequently reissued.
• 2 applications were refused, and the applicants have not reapplied.
• 4 cases - licence holders voluntarily surrendered their licence and weaponry. Of these:  1 has had their licence cancelled.  1 risk involved a family member who has since moved on negating that danger.  2 have appropriate control measures which include regular monitoring and unannounced visits.

It would be remiss of me not to highlight the work undertaken by Merseyside Police Head of Crime . commissioned a report entitled ‘The Threat, Harm and Risk

Dear Mr M Arrow,

With regards to the Report to Prevent Future Deaths dated 8th March 2023.

The following concern were raised:

“I am concerned that the figures provided to the Home Secretary in 2021 may not reflect the accurate position, and that if sufficiently stringent checks are performed these may reveal other cases where a firearm or shotgun certificate had been seized, refused, revoked or surrendered but was subsequently issued/returned in circumstances when the certificate should not have been approved. I am concerned that if there are other cases that were not subject to a proper or thorough review of the risk of returning the weapon then the person may continue to have a firearms/shotgun certificate and hold weapons in circumstances that place the public and the licence holder themselves at risk.”

To address the concerns raised regarding the accuracy of the 2021 review, it is relevant to detail the steps that we took as a Force to assure ourselves and the Home Secretary. At the time, North Wales Police identified 34 cases where firearms and shotgun certificates had been seized,

SWYDDFA’R PRIF GWNSTABL Pencadlys yr Heddlu, Glan-y-Don, Bae Colwyn LL29 8AW Ffôn (Cymraeg): 0300 330 0101 CHIEF CONSTABLE'S OFFICE Police Headquarters, Glan-y-Don, Colwyn Bay LL29 8AW Tel (English): 0300 330 0101

refused, revoked, or surrendered and subsequently returned to the certificate holder over the specified time period.

A full review was conducted by a Chief Superintendent with a panel including an operational Superintendent, a Solicitor from the Force Legal Service Team and members of the Firearms Licencing Team operating as subject matter experts. All 34 cases were reviewed, and the decisions made in returning the weapons were found to be correct. I am confident, based on the 2021 review and reinforced with the subsequent implementation of the Home Office Statutory Guidance, that an accurate set of figures were submitted to the Home Secretary.

The current practice is as follows for context:

• All high-risk decisions as defined in the relevant guidance are made by the Head of Firearms Licensing. These decisions which involve refusal, grant, revocation and return of seized firearms are subject to dip sample review on a bimonthly basis by the Force Solicitor and a Superintendent. In addition, the Head of Firearms dip samples the decisions made by the other two members of the team monthly. These reviews are recorded and archived for audit purposes and the overall process was recently identified as best practice in the recent external audit (March 2023).

Furthermore, in May 2022 the North West Regional Organised Crime Unit identified that for the period 2020/21, the Force refused the most firearms related certificates in England and Wales. In addition, we revoked more certificates than any other Force in the North West region and were amongst the top 5 Forces nationally for the same period.

SWYDDFA’R PRIF GWNSTABL Pencadlys yr Heddlu, Glan-y-Don, Bae Colwyn LL29 8AW Ffôn (Cymraeg): 0300 330 0101 CHIEF CONSTABLE'S OFFICE Police Headquarters, Glan-y-Don, Colwyn Bay LL29 8AW Tel (English): 0300 330 0101

I am fully cognisant of the risks and public expectations for the issuing of firearms licenses. My risk tolerance in this area is extremely low however I acknowledge that providing additional assurance in the context of national events has significant merit. I am also fully aware that there is no room for complacency, and I will always be seeking to make improvements in our working practises.

Therefore, in response to the concerns raised I propose to review all cases over the last 5 years where applications have been refused or licences revoked, but where subsequent applications or appeals by the same licence holder resulted in a grant. If the Crown Court ordered the return or grant, we will note this and review with our Force legal team.

I will aim to complete this review by 2nd October 2023 and hope that this step and the demonstrable rigour applied to the 2021 process provide the required assurance.

Your Sincerely

Prif Gwnstabl / Chief Constable

Dear Mr. Arrow Pencadlys Heddlu Police Headquarters Heel y Bont-faen Cowbridge Road Penybortt Bridgend CF31 3SU CF31 3SU Mewn argyfwng ffoniwch 999 In an emergency dial 999 fel arall, ffoniwch 101 Non-emergencies dial 101

REPORT TO PREVENT FUTURE DEATHS I write with reference to your report to all Chief Constables in England and Wales following the tragic deaths in Keyham on the 12 August 2021 . Following the incident, the Home Office requested that all Chief Constables carry out a full review of all certificates that had been seized, surrendered, revoked or refused in the previous 12 months and subsequently approved. To provide reassurance, the review conducted in South Wales Police in October 2021 was peer reviewed by the firearms licensing managers in Avon & Somerset and Gwent Police with a positive outcome. Your request to conduct a further review over a 5-year period is underway and has identified approximately 1300 records where certificate holders were subject of a suitability review. Each record is being checked to establish if certificates were seized, surrendered, revoked or refused and subsequently approved. Once this preliminary work has been completed, we will then be in a position to provide a timescale for completion of the review. Additionally, since 2021 , South Wales Police and Gwent Police have been working together to establish best practice and align processes across both forces. Monthly continuous improvement meetings take place and regular peer reviews are conducted. Where matters of concern are identified, a case will be referred to a different force for external scrutiny. We are in the process of arranging an annual peer assessment for a set number of cases to test and evaluate our approval to firearms licensing.

Dear Mr Arrow

Re: Prevention of Future Death Report (PFD) under Regulation 28 Coroners (investigation) Regulations 2013

Thank you for your letter dated 8th March and the accompanying notices.

We have noted the details of the Regulation 28 Notice, sent to ‘All Chief Constables in England and Wales’. We note your concerns detailed in section 5 and we are committed to ensuring that we address these concerns and are undertaking the following.

We have established a Gold group, chaired by myself to oversee our response and any required actions to the PFD reports distributed to us.

We have commenced a review of all our records, aiming to identify which records meet the criteria set out in your notice, ‘a further review of all certificates seized, refused, revoked, or surrendered and then subsequently approved over the last 5 years’. Early indications suggest that this would involve a review of approximately 2000 records, however we are still working through our records and do not have a final figure. We aim to have this completed in late April 2023.

We will review all records that we identify and consider the most recent decision first. We will ensure that where our decisions have been subject to an appeal and a return ordered by the Crown Court, we will appropriately flag to our Force Legal Services Department for any action.

We will aim to complete the full review of all records by 2nd October, however, until we have understood the number of records that we need to review, we are unable to confirm this to date. We will create an assessment framework to test our decisions and record any actions that we take. This will of course be made available on request to evidence our activities.

| Head of Custody & Firearms Licensing Crime & Justice Operations | Athena House | Kettlestring Lane | York | YO10 4XF DX No: 729961 YORK 29 Non – emergency Number We are in the process of developing an Action Plan to manage our response to the reports and we also have in place an Action Plan to manage our Gold group and record any decisions that we take.

I trust that you will find our actions agreeable, please do not hesitate to contact me if you require any further clarity.

Dear Mr Arrow, Regulation 28 Prevention of Future Deaths following the tragic shootings in Keyham on 12th August 2021 On behalf of Lancashire Constabulary, I send our sincere condolences to the families of Maxine Betty Davison, Lee Raymond John Martyn, Sophie Iris Martyn, Stephen John Godfrey Washington and Kate Jane Shepherd. Lancashire Constabulary supports the recommendations you have made, and updates as follows: Report to all Chief Constables in England and Wales regarding the return of weapons after review of suitability. A programme to review all certificates refused, revoked, seized or surrendered and then subsequently approved over the past 5 years has commenced. This is being undertaken against the March 2023 Home Office Statutory Guidance. We expected to complete this work by the end of October 2023. Several process and scrutiny changes have been introduced in relation to refused, revoked, seized and surrendered licenses as well and initial and renewal applications. The reviews will be carried out with in line with these processes and additional scrutiny. The following changes have been introduced: Governance:
• A dedicated Chief Inspector responsible for Firearms Licensing who reviews all decisions at a senior level in line with 3.50 Home Office Statutory Guidance. o During the 12-month period April 22 - March 23, a total of 313 decisions were reviewed, each having a documented assessment of all the evidence available and reasons for the decision. These included cases where a relevant medical condition had been identified. 10% of these reviews resulted in refusal or revocation of a certificate.

• A dedicated Superintendent who reviews any decision to return a certificate following a voluntary surrender, or request/review to allow storage of weapons back to the certificate holders home address.
• An Assistant Chief Constable with responsibility for Firearms Licensing meets with the Chief Inspector every 6 months to scrutinise a random selection of high-risk decisions to ensure consistency and effective decision making.
• Governance is recorded through quarterly Firearms Policy Management Group meetings. Process:
• No application or renewal is processed without receiving a GP report. In some cases, we seek further specialist advice if there are specific ongoing conditions that could impact on a person's suitability e.g., Liver Function tests or Carbohydrate-deficient transferrin.
• An automated system alerts the Licensing team when an incident is reported at a certificate holders address. This instigates a review of the license. This reduces the risk of relevant information being missed and not acted on.
• PNC Markers on licensed certificate holders creates an automated alert to the department and Force Incident Commander if any holder is arrested.
• In collaboration with the Force Intelligence Bureau, a process is being introduced identifying any new intelligence submitted by officers and staff that is connected to a licensed certificate holder and/or their address to be automatically highlighted to the team for a review.
• Colleagues from Counter Terrorism policing review any new piece of intelligence quickly if it relates to either a certificate holder, their address or a telephone number associated with them and inform the licensing team, resulting in a joint review.
• The number of PND checks undertaken have increased and checks are now carried out on initial application, first renewal and at any reviews following an adverse incident. PND checks will be carried out on all renewals prior to the end of 2023.
• Nationally we are monitoring two pilots: o PND being used to automatically update NFLMS. o Automated social media checks.
• A process where Body Worn Video is now viewed when available as part of reviews where certificate holders have interacted with police but resulted in no formal action being taken. This has led to further revocations. Lancashire Constabulary fully accepts the recommendation to review the previous 5 years cases, and the identified a risk-based approach to prioritise the review. The above processes that have been implemented ensure increased scrutiny, consistency of decision making and a risk-based approach to all decisions for return, initial application, and renewal. Report on training of Firearms Licensing Decision makers. In the absence of any current formal training from the College of Policing, Lancashire has introduced the following:
• In November 2021 staff from the Firearms Licensing Department received a 3-day training package, referred to in your report as the South Yorkshire Training Package, this included the Chief Inspector.
• A programme of CPD which has included topics such as Domestic Violence awareness and Intelligence grading. Further training for this year includes, Neurodiversity, National Decision Model and Statement writing.
• Our scheme of delegation allows for a Force Incident Commander (a Chief Inspector role) to revoke either a Firearm or Shotgun Certificate. They have received inhouse training into this procedure.
• This year further training delivered through Mowbray Partners has been agreed. This online package is updated to reflect changes in the Statutory Guidance.

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Lancashire Constabulary fully support the recommendation for additional training and CPD for firearms licensing decision makers. We welcome the nationally accredited training being developed by the College of Policing which we will prioritise for all our staff. Our internal processes ensure staff with delegated authority will only make decisions consistent with their level of training. We are not complacent and recognise the need for all staff within the Firearms Licensing Department to have adequate training of a satisfactory standard in applying both the Home Office Guidance on Firearms Licensing Law (November 2022) and the Statutory Guidance for Chief Officer of Police (February 2023). We will continue to embed training, CPD and ensure training records are updated to ensure we keep our staff up to date with any legislative changes and do all we can to keep the public safe.

Dear Mr Arrow 26th April 2023 Re Regulation 28 reports following the inquest into the deaths of Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington and Kathryn Shepherd. Thank you for your report dated 8 March 2023 in the respect of the tragic deaths of Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington and Kathryn Shepherd and pursuant to Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 and Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009. Having carefully considered your reports I make the following observations to hopefully address your matters of concern;
1. Further review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the past five years may be required to be assured of public safety. Greater Manchester Police have an established Senior Officer Panel. This panel guides decision making at a level senior to that of the Firearms and Explosives Licensing Manager. This mechanism has assessed all cases where guns have been returned to certificate holders. This also includes the renewal or granting of certificates where guns had previously been removed or surrendered. We are currently examining all available information to identify those cases where certificates have been seized, refused, revoked or surrendered and then subsequently approved and guns returned. Based on the volume identified to date it is forecasted that GMP will review in total, for the five-year period, between 70-80 cases at Senior Officer Panel. All reviews will be against the updated Statutory Guidance and we believe it to be practicable to review these cases over the course of the next 3 months.
2. (Forces to ensure) 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 Licensing Law (Nov 2022) and the revised Statutory Guidance for Chief Officers of Police (Feb 2023) All Firearms Enquiry Officers (FEO) have completed training with an external partner, Mowbray Partners titled "Firearms Licensing ". FEO's are the frontline of the Firearms Licensing Unit and make all initial decisions based on the current legislation, statutory and non-statutory guidance and Approved Professional Practice. The training by Mowbray addresses these fundamental issues. Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS

Cont.d pg 2 .....
3. Only delegated decision making to persons who have undergone adequate training in firearms licensing and in applying that recent guidance The current Firearms Licensing Manager has completed training, procured through an external partner Mowbray Partners, this training is titled "Firearms Licensing - Decision Makers". The Firearms Licensing Manager and Detective Sergeant will additionally be attending a two-day continuous professional development (CPD) event delivered by Chief Constable Tedds at the College of Policing on the 18th and 19th May 2023. Furthermore, the Firearms and Explosives Licensing Unit (FELU) have all reviewed the new 2023 Home Office Statutory Guidance and 2023 College of Policing Approved Professional Practice. The Detective Sergeant will complete the training "Firearms Licensing" with external training partner Mowbray Partners. They will additionally complete the training "Firearms Licensing - Decision Makers" by the end of April 2023. To reassure you further, only those trained personnel above are permitted to make decisions in line with the updated statutory guidance.

Chief Constable Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M 11 2NS

Dear Mr Arrow, This response is submitted on behalf of the College of Policing ('the College') in reply to your reports on Preventing Future Deaths (PFD) following the Keyham inquests. Firstly, I wish to extend my deepest condolences to the families and friends of those murdered and injured as a result of the shootings. We also wish to state our appreciation of all of those who contributed to the proceedings. It is incumbent on the College and others in policing to ensure lessons are learned. College Response to Matters of Concern The College is named as a joint addressee for the PFD report that focuses on the training of firearms licensing decision makers, and you have made us aware that:
• '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'
• 'neither the current CoP APP guidance on firearms nor the proposed update includes any requirement that FELU staff are trained in firearms licensing generally or trained in conducting suitability assessments in particular' The College is currently developing significantly revised and updated Authorised Professional Practice (APP) on firearms licensing. The APP - and other national products such as the Home Office's Statutory Guidance - will underpin the development of a national training course for staff involved in firearms licensing. This will include Firearms Enquiry Officers (FEOs) and others who may have delegated authority to make decisions. We will adapt national approaches to training used in other high-risk areas of policing, for example, armed policing. As part of this approach, national materials and accompanying quality assurance (QA) processes will be developed to ensure a consistent approach to training across forces in England and College of Policing Limited is a company registered in England and Wales, with registered number 8235199 and VAT registered number 152023949. Our registered office is at College of Policing Limited, Leamington Road, Ryton-on-Dunsmore, Coventry CVS 3EN

Wales. The material and QA will be based on national learning outcomes which are also currently being reviewed and updated. It is our intention to incorporate an assessment component to the training, to help ensure and reinforce occupational competence. We also intend to develop a framework that can help ensure operational competence (for example, ongoing assessment against learning outcomes evidenced through mechanisms such as portfolios; performance and development reviews; and Continual Professional Development). Once the training course has been designed, we will state in the APP that chief officers should only delegate their firearms licensing decisions to people who have been trained to take those decisions. It is also noted that the PFDs could lead to other significant developments for firearms licensing. We will continue to monitor developments in firearms licensing to ensure our training and guidance reflect the highest standards. This is so that only those who should have access to firearms do so and that the licensing system contributes to the safety of the public to the extent that it can.

Dear Sir, Re: Report regarding training of firearms licencing decision makers ......

Chief Constable 28th April 2023 I write in response to your report, and subsequent requirement placed upon Surrey Police following the inquest into the deaths of five people shot in Keyham on 12th August 2021. In the absence of any national training product accredited by the College of Policing, all Surrey Police Firearms Enquiry Officers {FEOs) and supervisors have attended a firearms licensing course that is designed and delivered in Yorkshire. This has only resumed this year due to the impact of Covid and as such some recent joiners into the department have not yet attended. However, we have commissioned a bespoke course with the same provider exclusively for Surrey Police which is scheduled for May 2023. There is currently no nationally available course for office based Firearms Registration Officers (FRO) however this training is internally delivered and managed by the office supervisor. A schedule of additional training is also being delivered this year to supplement the external training. This will cover issues relating to safeguarding, intelligence gathering, application of the National Decision Making Model and the safe handling of firearms. The work that has been developed has been recognised by an external audit carried out by the Southern Internal Audit Partnership (SIAP) with its final report due to be released imminently. All staff received training on the Statutory Guidance in 2022 by the previous Chief Inspector in charge of the Firearms and Explosives Licensing Unit (FELU). Following the publication of the revised guidance February 2023, this has been updated and refreshed for all FELU staff as part of their continuous professional development. There is a force policy in place (seizure of legally held firearms and certificates) and a standard operating procedure is being developed to ensure clear processes and procedures are applied consistently. There are seven staff trained across different senior ranks and roles who are authorised to carry out delegated authorities - the review function within the FELU. All have received training and have relevant experience to perform this role within the department. All have delegated authority for the force and complete regular professional development. The Tel 101 Email Website www.surrey.police.uk

Superintendent has delegated authority to enable effective oversight of the Detective Chief Inspector and to provide additional capacity to allow for the return of certificates and weapons following revocation decisions. Quality assurance is carried out for all roles and responsibilities in the department to ensure Statutory Guidance is followed. Surrey Police have been supporting the national NPCC lead and the College of Policing over the past 12 months in developing a national curriculum and learning outcomes for Firearms Enquiry Officers. The intention is. that the training will be delivered this year, which will be aligned with quality assurance and mandatory professional development. Surrey Police FELU will be active participants at the two day CPD event hosted by the College of Policing in May
2023. This will enable critical learning from the detailed de-brief of the lessons from the Keyham Shootings Inquests and the new Home Office Statutory Guidance. I am satisfied that based on the information available to me, that all staff have received and will be continuing to receive appropriate training, proportionate to their respective roles within the Surrey Police FELU. Yours sincerely,

Chief Constable

Ian Arrow

Dear Sir, Re: The return of weapons after review of suitability

Chief Constable 28th April 2023 I write in response to your report, and subsequent requirement placed upon Surrey Police following the inquest into the deaths of five people shot in Keyham on 12th August 2021. I specifically respond in relation to the fact that we are one of 41 forces who responded with a view that they had no concerns regarding decision making in those cases that were requested to be reviewed following intervention from The Home Secretary in 2021. Surrey Police currently have a joint team working with Sussex Police in the arena of Firearms and Explosives Licensing who I have asked to carefully reviewed the findings of the inquest leading to the above, and other PFD reports shared with Chief Constables. It is the belief of the Firearms and Explosives Licencing Unit (FELU) that the process followed prior to return of a certificate is suitably stringent in providing effective scrutiny and oversight in cases where Firearms and/or Shotguns have been seized within our policing area, carrying out appropriate due diligence prior to their return, or formally revoking as appropriate. This is catered for within a force policy specifically dealing with the seizure of legally held firearms and certificates. This includes a full review overseen by a manager within the department and the Chief Inspector head of FELU. Both serve with delegated authority from the Chief Constable to perform this function alongside the wider experience within Firearms Licensing, prior to return of any certificates. This process is further supported through dip checking by a Superintendent responsible for Firearms Licensing within the force. Surrey Police follow the national Home Office guidance and legislation in respect of Firearms and Shotgun licencing and work within the regional group of forces around our processes to ensure consistency. Furthermore the Force also plays an active part in the national Firearms and Explosives Licencing working group (FELWG). Tel 101

Surrey Police FELU have been externally reviewed by the Southern Internal Audit Partnership {SIAP) for the last two years and no recommendations have been raised in response to our processes for suitability reviews or delegated authorities. In 2021 the review of all certificates that had been seized, refused, revoked or surrendered in the previous twelve months, and subsequently approved by the police, were carried out following concerns raised by the Home Secretary. This review consisted of 95 Certificates and was carried out by managers within the team. At the time no concerns were raised. However, in light of the Coroner's report, we have decided that we will adopt the national guidance from FELWG National lead CC Tedds to provide further reassurance. Therefore, I can confirm that Surrey Police will undertake the following approach for a review of firearms and shotgun licensing and prioritise this review as follows in line with the national proposal and this review will cover the last 5 years:
• We will prioritise for review cases where firearms have been seized or surrendered to police pending a review of suitability to have a licence, but then subsequently returned.
• We will review the most recent decisions first, as the most recently returned licences arguably pose the biggest risk. They will be closest to the events which justified . seizure or surrender in the first place, and there will have been less reassurance in the passing of time without new incidents.
• We will review in slower time cases where applications have been refused or licences revoked, but where subsequent applications or appeals by the same licence holder resulted in a grant, however these will be completed.
• We will review previous decision-making against the current (February 2023) Home Office Statutory Guidance, in order to promote public safety by today's standards. Additional resource of a sufficient rank and experience has been allocated to perform this review and has been seconded into the department from 17th April 2023 to expedite this review and provide me with a full report, which will be available by 2nd October 2023. I am satisfied that based on the information available to me that whilst our processes are sufficient currently, this will provide an additional scrutiny to provide additional reassurance of this.

Dear Sir,

I am responding on behalf of Gloucestershire Constabulary in respect of the ‘Report to Prevention of Future Deaths’ under paragraph 7, Schedule 5 Coroners and Justice Act 2009 and Regulations 28 and 29 Coroners (Investigations) Regulations 2013, issued by you on 8 March 2023.

The matters of concern are outlined in the report:-

Following evidence from Devon and Cornwall Police at the Inquests, the Coroner’s recent PFD reports state:

“I am concerned that the information from those 41 police forces who indicated that they had made no incorrect decisions to return a weapon/certificate may need to be further tested and explored.

I am concerned that the figures provided to the Home Secretary in 2021 may not reflect the accurate position, and that if sufficiently stringent checks are performed these may reveal other cases where a firearm or shotgun certificate had been seized, refused, revoked or surrendered but was subsequently issued/returned in circumstances when the certificate should not have been approved. I am concerned that if there are other cases that were not subject to a proper or thorough review of the risk of returning the weapon then the person may continue to have a firearms/shotgun certificate and hold weapons in circumstances that place the public and the licence holder themselves at risk.

I am concerned that in the light of the lessons learned in the Keyham inquests of the attitude towards risk, a further review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the past five years may be required to be assured of public safety.”

Specifically in respect of the ‘Actions Should be Taken’, I can confirm:- A review will take place as per the letter dated 24 March 2023 from Chief Constable Debbie Tedds, Warwickshire Police NPCC lead for National Police Firearms Licensing and we will endeavour to achieve such reviews over the next six months by 2 October 2023.

Dear Sir,

I write to you in order to provide a response, on behalf of Norfolk Constabulary, to the Preventing Future Deaths report issued under Regulation 28 of the Coroner (Investigations) Regulations 2013.

The Firearms Licensing Unit (FLU) for Norfolk Constabulary is part of the Joint Protective Services Command; a collaborated command between Norfolk and Suffolk Constabularies under Section 22 of the Police Act 1996.

The Preventing Further Deaths (FPD) report contained two issues for police forces to consider. The first being the training of firearms licensing decision makers and the second, the review of the return of weapons after a review of suitability. I will address both of these issues.

Training

The two forces recognise the need to ensure that those with delegated responsibility from the Chief Constables should be appropriately trained in the application of the Home Office Guidance on Firearms Licensing Law (Nov 22) and the Revised Statutory Guidance for Chief officers of Police (Feb
23).

The FLU has commissioned an external provider, Mowbray partners, through Durham Constabulary to provide training to all FLU Enquiry officers and Licensing officers over the next 12 months, with training commencing in May 23. In addition, we are currently exploring training for those staff who undertake administrative role within the FLU.

Senior Coroner Plymouth, Torbay and South Devon

28th April 2023

Review

I have carefully considered the requirement to carry out a full review of all certificates that have been seized, refused, revoked or surrendered and then subsequently approved over the last five years. I know that my Head of Protective Services Command has engaged with the office of the National Police Chiefs Council lead for Firearms Licensing in respect of the PFD.

Norfolk Constabulary absolutely acknowledge the seriousness of the issues raised.

A review of all cases, under the criteria within the PFD, for the five-year period, indicates just short of eight hundred that would be considered for review. All of these cases have been reviewed by those with designated decision-making responsibility in line with the guidance and regulations that would have been in place at the time. There is a significant resource commitment that would be required to review all eight hundred cases and I am conscious this may require resources being diverted away from the current FLU business demand.

In order to ensure that our focus is on the areas that may present the greatest risk Norfolk and Suffolk Constabularies will carry out a review in line with the strategy articulated below. This approach would see a significant and meaningful sample of cases being reviewed. If issues of concern are identified, then this will trigger a wider review of cases.

Where certificates are either refused or revoked then access to a firearm can only be achieved through the submission of a further application. This would then require consideration of the application in full as with any other first-time application.

Where firearms are seized as a result of an incident, event or due to information received by police then decisions are taken by those with delegated responsibility as to whether to return the firearm to the certificate holder of to revoke the certificate.

In Autumn 2021 a review of cases between the date parameters of August 2020 and August 2021 was undertaken at the request of the then Home Secretary. The cases reviewed were those in which firearms were seized and returned, but where the certificate was not revoked, and all refused, revoked, and surrendered certificates.

295 cases were identified of which eighty-five were found to be relevant for the purposes of the review. Of these four cases were referred to Superintendent rank with responsibility for Firearms licensing. One certificate was revoked.

Under this review:

1. Those cases that relate to a certificate issued before April 19 will be subject to a full renewal review against the current guidance and regulations within the next 12 months as part of the 5-year renewal cycle. As this will allow a timely approach to review, we do not propose to review these ahead of that process, this will allow us to focus on those cases that are not due a renewal review.

2. Those case between April 2019 and August 2020 will be reviewed.

3. Those case between August 2020 and August 2021 are those already reviewed as articulated above. We will review 30% of these again to understand whether application of the current regulations and guidance would result in different decision making. If this review highlights any concerns, we will conduct a wider review of cases.

4. For those case between August 2021 to Feb 2022, these would have been reviewed having benefited from the learning and approach of the Home Office requested review and therefore benefit from this learning and so we would expect robust decision making has taken place. We will again dip-sample 30% of cases. If this review highlights any concerns, we will conduct a wider review of cases.

5. For cases dating between February 2022 and April 2023, these have been reviewed against the relevant guidance in place at the time. An escalated decision-making process has been in place for tis period and all cases where a n incident or intelligence has led to the removal of firearms has been considered by the Superintendent with responsibility for Firearms licensing. Whilst we remain confident in this approach and the high standard of decision making our intention is to review 30% of all these cases. If this review highlights any concerns, we will conduct a wider review of cases.

I have also considered those cases where certificates have been revoked leading to the removal of firearms but where the certificate holder makes a subsequent application within 12 months. This review will look to ensure that the decision making was based on the current circumstances and not on the basis that the holder was previously granted a certificate.

I trust that the following approach provides you the reassurance that Norfolk Constabulary take full cognisance of the importance of the PFD and that we are committed to undertake a review and identify and address any issues.

Dear Mr Arrow, gJ.:] ~rt ESSEX ~ij~ POLICE Protecting and serving Essex Essex Police Headquarters, PO BOX 2, Springfield, Chelmsford, Essex

1nd May 2023 I write in response to your prevention of future deaths report, made under Regulation 28 of the Coroners (Investigation) Regulations 2013, relating to the tragic deaths in Keyham on 12th August
2021. I set out below the action Essex Police has taken in relation to the two matters you have required all Chief Constables to respond to, and our progress tow ards completion. Review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the past five years I have directed that Essex Police will review all decisions to return firearms over a five year period. The prioritisation is in line with that outlined by the National Police Chiefs' Council (NPCC) lead for National Police Firearms licensing: We are prioritising review cases w here firearms have been seized or surrendered to police pending a review of suitability to have a certificate, but then subsequently returned. There are circa 900 incidents in Essex w here certificate holders have come to the adverse attention of police. A detailed screening of these incidents is underway to identify how many involved a return of certificate and guns decision.
• We will review the most recent decisions first, as the most recently returned licences potentially pose the greatest risk.
• We will review all cases w here applications have been refused or licences revoked, but where an application or appeal by the licence holder resulted in the grant of a certificate.
• All these cases w hereby a certificate was granted following appeal or further application (circa 200) will have previous decision making reviewed utilising the current Home Office Statutory Guidance (February 2023)
• The review will be completed by October 2023 Essex Police, PO Box 2, Headquarters, Springfield Road, Chelmsford, Essex CM2 6DA Report non-emergency crime and anti-social behaviour online at www.essex.police.uk or ring 101 If a crime is in progress or someone is in immediate danger, always ring 999 If you have a hearing or speech impairment, use our textphone service 18000 or the 999 BSL app

In the absence of nationally accredited training, the steps being taken to ensure local training is of a satisfactory standard for all staff and supervisors involved in firearms licensing, and that decision making authority is delegated only to persons who have undergone adequate training in firearms licencing and in applying that guidance. Essex Police are engaged w ith the NPCC Lead, Chief Constable and College of Policing in the development of the national training package. We have delivered local training to ensure continuous professional development, including an input on the Home Office Guide on Firearms Licensing Law in November 2022 and the updated Statutory Guidance for Chief Officers of Police on Firearms Law in February 2023, as well as risk matrix development, National Decision Making model, Keyham Inquiry recommendations and impact, 'Managing Risk and Firearms Licensing', Domestic Abuse and Stalking inputs and Welfare and Counselling Support guidance. Local development events in the form of classroom days are regular, varied, and relevant to the role. All new team members are given bespoke inhouse training delivered and monitored by their supervisor and w ith the exception of two new members of staff my team have all attended the training course in West Yorkshire. Essex and Kent Police have a collaborated Learning and Development Command, who are developing a lesson plan to further enhance professional development and ensure currency of knowledge. I anticipate this will be in place by the end of August 2023. I am satisfied that, in the absence of a national accredited training product that a local training programme is in place to ensure all member of staff and supervisors to whom decision making authority is delegated have received, and w ill continue to receive, adequate local training. Since September 2021, all decisions to return certificates following a suitability review are made by the Superintendent for Armed Policing. As part of our joint force audit process, external auditors will be commencing a review of our Firearms Shotgun and Explosive Licencing team commissioned by me and the Essex Police Fire and Crime Commissioner to provide independent reassurance regarding our compliance w ith national and local policy and ability to respond to changes in legislation and other recommendations. We will also continue to work with the NPCC lead to ensure our processes in Essex are focused on keeping people safe and working in accordance with statutory guidance and recommendations. If I can be of any further assistance, please do not hesitate to contact me.

Dear Mr Bolter I write to you following the release of the Preventing Future Deaths (PFD) Reports by your predecessor HM Coroner Ian Arrow, following the tragic events in Plymouth, in August 2021, and the subsequent Keyham Shooting Inquests. The Plymouth, Torbay and South Devon area HM Coroner overseeing the inquest into the shootings in Plymouth (2021) has issued a Regulation 28 notice (paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulation 28 and 29 of the Coroners Investigations Regulations 2013) to the police service in relation to the events leading to the Plymouth shooting. Specifically:
• In the absence of [such] 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 l) Adequate local training of a satisfactory standard has been universally delivered to all [their] FELU staff in applying the HO guidance on Firearms Licensing Law (Published November 2022) and the revised statutory guidance for Chief Officers of Police (Published February 2023) and ii) they have
• only delegated decision making to persons who have undergone adequate training in firearms licensing and in applying that recent guidance.
• The decision to return the shotgun and licence to the perpetrator [In July 2027) was fundamentally flawed and as a result failed to protect the public and the peace.

0 @westmerciapolice 0 @WMerciaPolice @) @westmerciapolice

West Mercia POLICE HM Coroner further stated: '/ am concerned that in the light of the lessons learned in the Keyham inquests of the attitude towards risk, a further review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the past five years may be required to be assured of public safety.' I would like to detail the internal actions currently being taken, and those proposed within West Mercia Police Firearms Licencing Unit (FLU) to provide you with reassurance that this will ensure full compliance with the recently issued Regulations. Delegated Decision Maker: West Mercia Police have an experienced Inspector overseeing decision making within the Firearms Licensing Unit (FLU). This role is supported by a cadre of Delegated Authorities who also provide scrutiny, advice and decisions on revocations and returns at Chief Superintendent, Superintendent and Senior Police staff member level. Training: West Mercia Police have a robust scrutiny and assessment process and have taken the initiative to develop a training package for the receipt by all staff as part of initial induction and Continuous Professional Development (CPD). This training package has been subject of a local Learning Needs Assessment (LNA) with colleagues in Learning and Development, set against the Statutory Guidance that existed at that time. In absence of a national or College of Policing accredited training package, West Merci a Police are currently working with the Firearms and Explosives Licensing Working Group (FELWG) to present the locally developed material to College of Policing and to the NPCC Lead for Firearms and Explosive Licensing with a view that it is considered for adoption (or further developed by COP) as the national Firearms and Explosive training programme. Administrator Role: Occupational Competence: There is a structured training and guidance manual for all their processes. Operational Competence: is assessed through a development and mentoring process where newly appointed staff are audited and given feedback until competence is assured. Caseworker role: Occupational Competence: There is an initial training input 2 days to understand statutory guidance, NDM, 'good reason' and suitability assessment There is a have a structured training and guidance manual for all their processes. Operational Competence: A mentoring process exists entailing newly appointed staff being audited and given feedback until competence is reached.

0 @westmerciapolice O @WMerciaPolice @ @westmerciapolice

West Mercia POLICE Firearms Enquiry Officer Role: Occupational Competence: Two-week training input (internal) that meets the learning descriptors from College of Policing. Operational Competence: Competency portfolio to be completed, under mentor supervision. Ongoing CPD portfolio overseen by FEO Supervisor HSE approved national qualification as an Explosives Liaison Officer (external) Decision Makers: FLU management team are in the process of composing a structured guidance and workbook for decision makers around COP learning outcomes. Police Staff Investigators: This role receives the same training requirements of any existing Police Staff Investigator. (i.e. PIP) delivered by L&D and nationally accredited. Licence Returns: The removal of a firearms from a registered firearms holder is a significant step and is indicative of there being a breach in licence conditions or a recognisable and potential threat to public safety and peace. The decision to return a firearm or shotgun must therefore be fully assessed against the cause for the initial removal and the threat of misuse or harm arising based on a revisited assessment and all available information. Specific challenge was presented during the inquiry to the assumption that the 'balance of probabilities' is the threshold by which to assess suitability and the relevance of information in decision making. All available information should be used to make an informed decision and not weight it to the 'balance of probabilities' threshold- which may adversely limit the considerations. In 2021 the then Home Secretary requested response to three questions:
7. Provide information on how many firearm and shotgun certificates have been seized, refused, revoked or surrendered in your force, and how many of those were subsequently returned to the certificate holder in the last twelve months;
2. Report on the outcome of your review of all certificates that have been seized, refused, revoked or surrendered in the past twelve months, and subsequently approved by the police; and
3. Confirm that you are satisfied that the processes that you follow in terms of returning a certificate are appropriate when set against the current Home Office guidance and legislation. West Mercia Police have previously provided 1 year's data report to the NPCC which subsequently appeared and was cited within the Inquest. West Mercia police have previously undertaken a review of all firearms and shotguns returns during the 12 months in 2021 with the following methodology:
• No. of $G's or Firearms Seized, Refused, Revoked, Returned
• No. of those removed which went on to be returned
• No. of reviews which led to a change in that decision

0 @westmerciapolice 0 @WMerciaPolice @westmerciapolice

West Mercia POLICE
• Was initial decision of return guidance-compliant?
• Is any change in decision guidance-compliant? Methodology: West Mercia Police hold a file on each person who previously held a firearms and/or shotgun certificate and has been the subject of refusal or revocation of that licence. This is a group of people who have been directly managed by the Firearms Licensing Manager (FLM). This identified one group to review. The Home Office have supplied a search facility on National Firearms Licensing Management System (NFLMS) to identify those firearms and shotgun certificates that have been refused, revoked, surrendered or seized and then returned in the past 12 months. This has understandably identified an overlap with those cases being managed by the FLM (as above) but identified a second group to review. A third group were identified by searching all the West Mercia Police property entries for firearms that had been returned to their owner. This group was targeting those whose firearms and shotguns had been returned without involvement of the Firearms Licensing Unit. During the 12-month review of 2021, these three groups identified 164 cases in total which were thoroughly reviewed by the FLM and then quality assured by their line manager. None identified any danger to public safety. It is my intention to repeat the review using the same methodology, but to cover the period of 8th March 2018 to 31 st March 2023, so that the entire 5 years is covered. This process remains appropriate and will satisfy the following requirements:
1. How many firearm and shotgun certificates have been seized, refused, revoked or surrendered in your force, and how many of those were subsequently returned to the certificate holder between 1st April 2018 and 31 st March 2021?
2. Carry out a review of all certificates that have been seized, refused, revoked or surrendered between 1st April 2018 and 31 st March 2023, and subsequently approved by the police. The inclusion of the data between August 2020 and August 2021 is necessary as there is a possibility that certificates may have been returned to any of the 164 cases reviewed after the original report from August 2021 and to further ensure that the assessment made at that time is compliant with the latest 2023 revision of guidance. To complete the enquiry a recently retired Police Officer has been re-employed as a Police Staff member to complete the enquiry. This employee is ideally suited as they have 23 years' experience as an Authorised Firearms Officer, firearms instructor and tactical advisor. They have a clear understanding of managing threats, assessing performance and are confident in articulating this back to senior members of staff. Throughout the review, any matters requiring remedial action, intervention or senior decision making will be escalated to the Firearms Licensing Manager and Ch. lnsp overseeing FELU. In addition, a regular progress report will be assessed by Head of Public Contact.

0 @westmerciapolice O @WMerciaPolice ® @westmerciapolice

West Mercia POLICE The intention to satisfy the Regulation 28 concerning 'returns· will follow an identical methodology and provide greater assurance beyond binary figures. It is anticipated that the review spanning 5 years data will entail: 10 working days initial data retrieval from Cyclops, NFLMS and PMS 21 working days to review all applicable incidents 5 working days for a senior review /FLM of the findings. The review will be completed by the end of October this year. West Mercia undergo regular Firearms Licensing Independent Audits and have recently undergone an external audit by Warwickshire County Council. I am satisfied that these thorough measures will ensure full compliance with the Regulation 28 requirements and provide you with the necessary reassurances that as Chief Constable of West Mercia Police, I have taken specific steps to satisfy myself that adequate local training of a satisfactory standard will be delivered to all of the West Mercia FELU staff in applying the HO guidance on Firearms Licensing Law (Published November 2022) and the revised statutory guidance for Chief Officers of Police, and, that a detailed review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the past five years is in progress.

Chief Constable West Mercia Police

0 @westmerciapolice 0 @WMerciaPolice @) @westmerciapolice

Dear Mr Arrow,

Re: Preventing Future Deaths Report

I write in relation to your prevention of future deaths report, made under Regulation 28 of the Coroners (Investigation) Regulations 2013, relating to the tragic deaths in Keyham on 12th August
2021. You have required all Chief Constables in England and Wales to respond in relation to two important firearms licensing issues: cases when firearms license certificates have been seized, refused, revoked or surrendered and then subsequently returned; and, in the absence of nationally accredited training, the provision of local training to a satisfactory standard for all staff involved in firearms licensing. This letter sets out the actions Kent Police has taken, or proposes to take, with regards to these two areas and the timetable for such action to be completed.

1. Review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the past five years

In response to your concerns, and following consultation with the National Police Chiefs’ Council (NPCC) lead for National Police Firearms Licensing, I have directed a review of firearms and shotgun licensing within Kent Police focussed on the above area of concern and prioritised in the following manner:

 We are prioritising review cases where firearms have been seized or surrendered to police pending a review of suitability to have a licence, but then subsequently returned. There are 102 license holders in Kent who have their certificates returned following suitability reviews between 2019 and 2023.  These cases will be progressively reviewed, starting with the most recent cases which, arguably, pose the greater risk due to being closest to the events that justified seizure or surrender, and which have not had the benefit of the passage of time without further incident to provide reassurance.  The review will also cover cases where the applications have been refused or licenses revoked but where subsequent applications or appeals by the same licence holder resulted in a grant. There are 32 license holders who have a current certificate having been granted at new application or on appeal at court.  The decision-making in all 134 of these cases will be reviewed and assessed against the current (February 2023) Home Office Statutory Guidance.

Dear Sir,

Chief Constable Re: The return of weapons after review of suitability Tuesday 2nd May 2023 I write in response to your report, and subsequent requirement placed upon Sussex Police following the inquest into the deaths of five people shot in Keyham on 12th August 2021. I specifically respond in relation to the fact that we are one of 41 forces who responded with a view that they had no concerns regarding decision making in those cases that were requested to be reviewed following intervention from The Home Secretary in 2021. Sussex Police currently have a joint team working with Surrey Police in the arena of Firearms and Explosives Licensing w ho I have asked to carefully review ed the findings of the inquest leading to the above, and other PFD reports shared with Chief Constables. It is the belief of the Firearms and Explosives Licencing Unit (FELU) that the process followed prior to return of a certificate is suitably stringent in providing effective scrutiny and oversight in cases w here Firearms and/ or Shotguns have been seized within our policing area, carrying out appropriate due diligence prior to their return, or formally revoking as appropriate. This is catered for within a force policy specifically dealing with the seizure of legally held firearms and certificates. This includes a full review overseen by a manager within the department and the Chief Inspector head of FELU. Both serve with delegated authority from the Chief Constable to perform this function alongside the wider experience within Firearms Licensing, prior to return of any certificates. This process is further supported through dip checking by a Superintendent responsible for Firearms Licensing within the force. Sussex Police follow the national Home Office guidance and legislation in respect of Firearms and Shotgun licencing and work within the regional group of forces around our processes to ensure consistency. Furthermore the Force also plays an active part in the national Firearms and Explosives Licencing working group (FELWG). Sussex Police FELU have been externally reviewed by the Southern Internal Audit Partnership (SIAP) for the last two years and no recommendations have been raised in response to our processes for suitability reviews or delegated authorities. 001273 Y @CCJoShiner Sussex Police, Malling House, Church Lane, Lewes, East Sussex, BN 7 2DZ

In 2021 the review of all certificates that had been seized, refused, revoked or surrendered in the previous twe lve months, and subsequently approved by the police, were carried out following concerns raised by the Home Secretary. This review consisted of 95 Certificates and was carried out by managers within the team. At the time no concerns were raised. However, in light of the Coroner's report, we have decided that we will adopt the national guidance from FELWG National lead CC to provide further reassurance. Therefore, I can confirm that Sussex Police will undertake the following approach for a review of firearms and shotgun licensing and prioritise this review as follows in line with the national proposal and this review will cover the last 5 years:
• We will prioritise for review cases where firearms have been seized or surrendered to police pending a review of suitability to have a licence, but then subsequently returned.
• We will review the most recent decisions first, as the most recently returned licences arguably pose the biggest risk. They will be closest to the events which justified seizure or surrender in the first place, and there will have been less reassurance in the passing of time without new incidents.
• We will review in slower time cases where applications have been refused or licences revoked, but where subsequent applications or appeals by the same licence holder resulted in a grant, however these will be completed.
• We will review previous decision-making against the current (February 2023) Home Office Statutory Guidance, in order to promote public safety by today's standards. Additional resource of a sufficient rank and experience has been allocated to perform this review and has been seconded into the department from 17th April 2023 to expedite this review and provide me with a fu ll report, which will be available by 2nd October 2023. I am satisfied that based on the information available to me that whilst our processes are sufficient currently, this will provide an additional scrutiny to provide additional reassurance of this. Yours sincerely,

Chief Constable

Dear Sir,

Chief Constable Re: Report regarding training of firearms licencing decision makers Tuesday 2nd May 2023 I write in response to your report, and subsequent requirement placed upon Sussex Police following the inquest into the deaths of five people shot in Keyham on 12th August 2021. In the absence of any national training product accredited by the College of Policing, all Sussex Police Firearms Enquiry Officers (FEOs) and supervisors have attended a firearms licensing course that is designed and delivered in Yorkshire. This has only resumed this year due to the impact of Covid and as such some recent joiners into the department have not yet attended. However, we have commissioned a bespoke course with the same provider exclusively for Sussex Police which is scheduled for May 2023. There is currently no nationally available course for office based Firearms Registration Officers (FRO) however this training is internally delivered and managed by the office supervisor. A schedule of additional training is also being delivered this year to supplement the external training. This w ill cover issues relating to safeguarding, intelligence gathering, application of the National Decision Making Model and the safe handling of firearms. The work that has been developed has been recognised by an external audit carried out by the Southern Internal Audit Partnership (SIAP) w ith its final report due to be released imminently. All staff received training on the Statutory Guidance in 2022 by the previous Chief Inspector in charge of the Firearms and Explosives Licensing Unit (FELU). Following the publication of the revised guidance February 2023, this has been updated and refreshed for all FELU staff as part of their continuous professional development. There is a force policy in place (seizure of legally held firearms and certificates) and a standard operating procedure is being developed to ensure clear processes and procedures are applied consistently. There are seven staff trained across different senior ranks and roles who are authorised to carry out delegated authorities - the review function within the FELU. All have received training and have relevant experience to perform this role within the department. All have delegated authority for the force and complete regular professional development. The Superintendent has delegated authority to enable effective oversight of the Detective Chief Inspector and to provide addit ional capacity to allow for the return of certificates and weapons following revocation decisions. Quality assurance is carried out for all roles and responsibilities in the department to ensure Statutory Guidance is followed. 00121s - e Y @CCJoShiner Sussex Police, Malling House, Church Lane, Lewes, East Sussex, BN 7 2DZ

Sussex Police have been supporting the national NPCC lead and the College of Policing over the past 12 months in developing a national curriculum and learning outcomes for Firearms Enquiry Officers. The intention is that the training will be delivered this year, which will be aligned with quality assurance and mandatory professional development. Sussex Police FELU will be active participants at the two day CPD event hosted by the College of Policing in May 2023. This will enable critical learning from the detailed de-brief of the lessons from the Keyham Shootings Inquests and the new Home Office Statutory Guidance. I am satisfied that based on the information available to me, that all staff have received and will be continuing to receive appropriate training, proportionate to their respective roles within the Sussex Police FELU.

Dear Mr Arrow,

Re: Response to all Chief Constables to prevent further deaths

I write in response to your report to all Chief Constables to prevent future deaths; made under Regulation 28 of the Coroners (investigative) Regulations 2013 dated 8th March 2023.

On behalf of Bedfordshire, Cambridgeshire, and Hertfordshire Police I write to confirm that through our collaborated Firearms and Explosive Licencing Unit as Chief Constables we have instructed the following reviews:

• A review of all firearms seized and returned over the last five years, sequenced with those returned soonest reviewed first.
• A review of all certificate holders refused or revoked, but subsequently successful with a new application over the last 5 years.
• A review of all holders subject to a police intelligence report over the last five years, prioritised in order of risk identified through initial triage.

In each case our reviews will ensure that processes and outcomes align to the most recent guidance and standards, and where required we will revoke certificates to be assured of public safety. This work undertaken by us will deliver retrospective application of the standards currently applied to Grants, Renewals, and Revocations to these past cases and incidents. To achieve this work, we are providing additional investigative resource uplift to our Firearms and Explosive Licencing Unit dedicated to these reviews, and it is estimated that the work will take six months to complete in full.

Bedfordshire Police, Woburn Road, Kempston, Beds, MK43 9AX Cambridgeshire Police, Hinchingbrooke Park, Huntingdon, Cambs, PE29 6NP Hertfordshire Police, Stanborough Road, Welwyn Garden City, Herts, AL8 6XF

We have worked hard to deliver improvements to strengthen our processes and decision making within the Firearms and Explosive Licensing Unit, and following the publication of the Statutory Guidance in November 2021 we reviewed our policy and procedures to ensure that they aligned with the new guidance, and recently the revised version. This work included escalating the authority level to Assistant Chief Constable (November 2021) to authorise the return of a firearm or shotgun following seizure, and the alignment of force policy and processes to the Home Office Statutory Guidance. The BCH firearms and Explosive Licensing Unit has been subject to several changes to strengthen processes and outcomes, and we have already seen a step-change in outcomes as a result of this work which has sought to reposition the Unit from an administrative led function to one with an investigative mindset and professional curiosity. Having reviewed the data for the 2022/23 policing year (April – March) 49 Grant applications were refused, 15 Renewals refused, and 58 certificates revoked, and a review of the quality of decision making has provided assurance that our policy and procedures are being complied with by our staff.

The retrospective review work that we are undertaking around past decision making will ensure that we apply these standards and processes to those legacy cases, and where risk or incorrect decision making is identified we will take immediate steps to rectify that. During 2023 to date we have revoked 7 certificate holders who were previously refused/revoked and subsequently successful in an application, and a further 3 certificate holders following a review of their circumstances.

The work that we are undertaking has identified areas for improvement beyond our force areas which we have escalated to the NPCC lead and Home Office. These emerging issues includes concerns around the disparity between the shotgun and firearm application process, namely there being no minimum age limit for shotgun applications. We have an appeal currently progressing through Crown Court relating to a child that applied for a shotgun certificate aged 8 years old, and unlike firearms there is nothing definitive in legislation or guidance to prevent young children making such application and appealing police refusal decisions. We have raised further concerns regarding the Crown Court appeal process whereby those appealing decisions based upon domestic abuse factors can cross examine vulnerable DA victims in such hearings which may present significant safeguarding and vulnerability issues for such victims, we have one such case also progressing through Crown Court. Finally, we have identified a potential intelligence gap/risk in relation to cases that are progressing through family court and civil courts which involve persons or members of the family who are licenced firearms holders. At present there is no requirement to disclose the presence of firearms within such cases, and a good preventative step could be a change in the

Bedfordshire Police, Woburn Road, Kempston, Beds, MK43 9AX Cambridgeshire Police, Hinchingbrooke Park, Huntingdon, Cambs, PE29 6NP Hertfordshire Police, Stanborough Road, Welwyn Garden City, Herts, AL8 6XF law or, if a change in law is not deemed proportionate then some other form of positive action such as OP ENCOMPASS which is in place across schools and Police around DA disclosure information sharing, but between courts and Police so that a risk assessment can be undertaken around the presence of such firearms within family settings with high level civil disputes.

Acknowledging a lack of nationally accredited training for Firearms Explosives Licencing Units, a review of our training has been conducted, with new role specific training currently being undertaken by all Firearms Explosives Licencing Unit staff. Continued professional development will be achieved through a planned annual training schedule, and we have purchased an external training package for all FELU staff dedicated to firearms licencing roles whilst a nationally accredited package is developed. Delegated decision maker authority is only given to those who have undertaken adequate training. Finally in January 2023 a full Change Team review of our Firearms and Explosive Licencing Unit commenced and is due to report in May. This review is undertaking a root and branch review of the firearms and explosive licencing reviews, updated guidance, future demand, and requirements, and seeking areas of national best practise in place across other forces. This work will ensure that we are able to deliver a service aligned to requirements, public expectations, and embedded the required staffing levels and skills to deliver this service to meet future demand and standards.

Dear Mr Arrow,

RE: Preventing Future Deaths (PFD) Notice

I write in response to your report, sent to all Chief Constables, dated the 8th of March 2023, following the Inquests into the shootings at Keyham in August 2021.

I would like to detail the plans for review which Nottinghamshire Police have put in place in response to that report.

Our response is based largely on the correspondence you will have received from Chief Constable , which outlines guidance for police forces across the UK to aid their approach and response:

• We have identified a dedicated resource to undertake the review. All reviews will be undertaken through the lens of the current (February 2023) Home Office Statutory Guidance.

• We will prioritise cases where firearms have been seized or surrendered to police pending a review of suitability to have a licence, but then subsequently returned. We will then review those cases that have been refused or revoked and subsequently returned.

• We have already commenced the review and are working backwards from 1st April 2023 for a period of 4 years. We have started by reviewing the most recent decisions first.

• We will not review cases in years 4 to 5, as these are (to differing degrees) moving naturally toward the normal 5-yearly renewal process (which will be undertaken against current standards.) I am content with this approach, because we do not have a significant backlog for renewal applications, nor many temporary licences.

• We will not fully re-review those licences from the 12-month period that were completed as part of the 2021 review. I had oversight of that review and am compelled by its thoroughness at the time. To repeat this work now would impact our capacity (and pace) to undertake the other years that are now in need of review. Instead, and to provide me with additional reassurance, I have commissioned a re – review of a sample of those cases which is to be conducted independently, by a neighbouring police force.

Force Headquarters Sherwood Lodge Arnold Nottingham NG5 8PP

• All the above will be completed over the next six months and by 2 October 2023.

As the portfolio lead for firearms licensing within Nottinghamshire, I will maintain a personal oversight of these reviews and on receipt of the resultant reports, will provide the scrutiny required to identify where improvements can be made.

I trust this approach provides the reassurance you require and demonstrates our commitment and support to fully meet the requirements of your prevention of future death notice.

Dear Mr Arrow

Response to Regulation 28 Report regarding the inquest touching the deaths in Keyham on 12 August 2021 of:

- Maxine Davison
- Lee Martyn
- Sophie Martyn
- Stephen Washington
- Kate Shepherd

I respond to the Reports to prevent future deaths issued by the Senior Coroner under paragraph 7, Schedule 5 Coroners and Justices Act 2009 and Regulation 28 Coroners (Investigations) Regulations 2013, dated 8 March 2023.

This is the formal response in accordance with the requirements under Regulation 29 Coroners (Investigations) Regulations 2013.

This response is provided in relation to:

a. Concerns raised of the Chief Constable of Devon and Cornwall Police as a properly interested party in the Keyham Inquests.

b. Any concerns raised of all Chief Constables in England and Wales.

Before setting out our specific response below, Devon and Cornwall Police shares the concerns raised to you by the families directly affected by the tragic events of 12 August 2021. As we stated at the inquest, we will continue to work with National Police Chiefs’ Council (NPCC) colleagues to support efforts to seek substantial changes to primary legislation and statutory guidance. As we stated at the inquest, this incident and the learning from it represents a unique opportunity for enacting the comprehensive reform that is required.

Chief Constable

Police Headquarters, Middlemoor, Exeter, Devon, EX2 7HQ

Page | 2

Following this incident, Devon and Cornwall Police invested approximately £3 million into the force’s Firearms and Explosives Licensing Unit (FELU), and we continue to be involved in sharing advice and learning concerning policies and procedures with other police forces and the NPCC.

Set out below are the specific paragraphs subject of this response under Regulation 29, for ease of reference.

Report to: All Chief Constables in England and Wales

Re: Further Review of all certificates seized/refused/revoked or surrendered and then approved over the past five years

I am concerned that the figures provided to the Home Secretary in 2021 may not reflect the accurate position, and that if sufficiently stringent checks are performed these may reveal other cases where a firearm or shotgun certificate had been seized, refused, revoked or surrendered but was subsequently issued/returned in circumstances when the certificate should not have been approved. I am concerned that if there are other cases that were not subject to a proper or thorough review of the risk of returning the weapons then the person may continue to have a firearms/shotgun certificate and hold weapons in circumstances that place the public and licence holder themselves at risk.

I am concerned that in light of the lessons learned in the Keyham inquests of the attitude towards risk, a further review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the past five years may be required to be assured of public safety.

Response

I agree with the submissions made by the families during the inquest, and we do so for the reasons set out below.

As described during the evidence of Chief Superintendent during inquest, Devon and Cornwall Police have completed a full evaluation of all ‘case reviews’ from the period January 2020 onwards. This included a review of all certificates seized, refused, revoked or surrendered which were then subsequently approved, as part of these review parameters.

For the period May 2018 to December 2019 (to complete the full five year period referred to by HM Coroner), Devon and Cornwall Police are committed to reviewing the cases during this period which fit the same criteria.

Full details are contained in the paragraphs below.

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In August 2021 the Home Secretary wrote to all Chief Constables asking for an urgent review of specific cases; research was conducted and the number of cases included in the table below were identified (as reported during the inquest).

In the last 12 months (01/01/2020 to 18/08/2021) how many shotgun and firearm certificates were:

How many of those removed were subsequently returned: firearm removed from certificate holder by being seized, surrendered or revoked refused of those with firearms that were seized, refused or surrendered of those revoked 123 27 42 0

In August 2021 all 42 cases where certificates/weapon(s) were returned following an issue affecting a holder’s suitability were reviewed by an experienced Firearms Enquiry Officer who was not involved in the original decision. The result of this review, as reported to the Home Secretary, was that any issues identified were administrative in nature. As expressed by Chief Superintendent during live witness evidence, further scrutiny established that the issues were not purely administrative in nature, and steps were subsequently taken to understand and rectify the position.

The independent peer review completed by Durham Police in September 2021 reviewed these cases in more detail, and these cases were reviewed again by Chief Superintendent , the senior officer appointed to manage the response to the Keyham tragedy. As expressed at inquest, 12 of the 42 cases were identified to have substantive issues affecting the suitability of the licence holder which required further remedial action. As a result, further revocations were instigated where relevant, while others voluntarily surrendered their weapons and certificates.

With over 40,000 firearm and shotgun licences in Devon and Cornwall, the vast majority of licence holders have no issues affecting suitability, and the decision making, within the parameters of the law, Authorised Professional Practice (APP) and statutory guidance, is straightforward.

In addition to the scrutiny applied through the review for the Home Secretary and the Durham Peer Review (September 2021), the Police Gold Commander commissioned our Performance and Analysis Department to conduct further research into licence holders in order to identify issues regarding their ongoing suitability.

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As expressed in the witness evidence of Chief Superintendent , this identified those cases which were likely to present a potential risk using the following criteria:

a. Where a case review has been completed;

b. Where a crime has been recorded against licence holder/address;

c. Where a GP had highlighted a concern (noting that before November 2021, neither APP nor statutory guidance addressed the issue of a failure to respond by a GP);

d. Where intelligence was attached to licence holder and/or their address;

e. Where there was an incident log involving a licence holder and/or their address.

Taking the result of this research into consideration, the additional supervisors recruited into FELU were tasked to complete, in priority order:

• A detailed review of the initial cases included in the response to the Home Secretary’s letter and the Durham Peer Review to ensure each case was dealt with appropriately against APP and statutory guidance;

• A dip sample of the cases involving the decision makers in the case of

• A review of the cases identified by the research conducted by the Performance and Analysis Department articulated above.

In addition to managing the core demand of the FELU such as grant and renewal applications, the prioritisation of this work sought to address the known risk first (ie that identified through the Durham Peer Review), before reviewing the potential risk such as that contained in cases involving the decision makers who had been involved in the Davison case, and then finally the further potential risks identified through the targeted research conducted by our analysts as articulated above.

Our position is that with the large number of certificate holders within our force area, it is not proportionate to review all the certificates over a five year period, or indeed all those made by the staff involved in the Jake Davison case. The vast majority will contain no issues regarding suitability, and many of these cases will now have been through a renewal process. An additional full review of all licence holders would be likely to transfer risk elsewhere within the FELU by moving staff away from the focussed activity associated with the normal operation of the unit. This is particularly relevant when considering the need to ensure that the staff involved are adequately trained and experienced in making licensing decisions. Consequently, the approach followed was evidence-led using criteria informed through the various inspections undertaken following the incident.

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It is relevant to highlight that since the incident we have voluntarily sought a review by an independent police force (Durham), conducted our own peer review post- inquest, and are now supporting the delivery of an independent inspection by HMICFRS (May 2023) following the request of the Police and Crime Commissioner and Policing Minister. It is also noteworthy that throughout this process, we have regularly engaged with the NPCC lead force for firearms licensing (Warwickshire).

In writing this response, our position is that the date from which the five-year period is considered should be the date of submission of this response (3 May 2023). Considering this, it must be noted that the substantial changes implemented in Devon and Cornwall Police cover a significant part of this period. As presented at the inquest, following the incident all decisions were paused until a new leadership structure was created and embedded. This was augmented by a comprehensive training and Continuing Professional Development (CPD) programme for all staff, a portfolio assessment for Firearms Enquiry Officers (FEOs) and a robust dip sampling framework (see below). Consequently, all decisions regarding grants, renewals and case reviews since August 2021 have been subject to the new robust process which includes all of the lessons identified through the inquest, and applies a rigour beyond that set within the statutory guidance and APP. The evidence for this conclusion is found through the internal peer review conducted since the inquest, the preparatory work conducted before it, and the sustained rate of refusals and revocations which is now consistently higher than the national average.

In addition to this, the period 1 January 2020 to 18 August 2021 is covered by the response to the Home Secretary in September 2021, and the additional (independent) review of these cases by Durham Police and the remedial work completed as a result by Chief Superintendent Linden. Consequently, we suggest that the requirements of the PFD report are met for the period 1 January 2020 to 3 May 2023.

Considering the above, our response for this report relates to this remaining period (3 May 2018 to 31 December 2019 inclusive). I have decided that we will conduct a further review of cases over this period in order to identify any remaining risk to the public that requires remedial action. Our position, based on the experience of reviewing the decision making in cases prior to August 2021 (completed for the inquest), is that further work is required notwithstanding that the passage of time will diminish any risk in the vast majority of cases.

By October 2023 Devon and Cornwall Police will have reviewed cases using the same identification criteria used in the submission to the Home Secretary in 2021 and, importantly, reviewed using the standard applied during the remedial work that was completed prior to the inquest. We will prioritise the review of cases using the most recent statutory guidance for this period as follows:

• Cases where firearms have been seized or surrendered to police pending a review of suitability to have a licence, but then subsequently returned. These will be reviewed with the most recent cases first (ie where the risk is closest to the current time).

• Cases where grants or renewals have been refused but where applicants have been successful at appeal.

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In addition and in parallel to this, we will review the analytical product articulated above, and use this to complete further targeted reviews of licence holders who may have had an involvement with the police that is capable of affecting their suitability to hold a licence. However, experience over the last 20 months has shown that this research frequently identifies matters that are either irrelevant to the licence holder (eg a road traffic collision that is recorded in the same street as the holder), or that have already been reviewed as part of a renewal or case review.

Report to: The NPCC lead for firearms licencing and all other Chief Constables in England and Wales

Re: Training of Police Officers and Police Staff involved in firearms licencing decisions

So that each Chief Constable is made aware of my concern that, despite the many recommendations made of 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 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 relevant Guidance.

I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licencing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.

Response

Devon and Cornwall Police fully support the NPCC and the College of Policing (CoP) in developing a national accredited training program for staff involved in making licensing decisions. We agree with the PFD submissions made on behalf of the families during the inquest and will continue to support the national training program as it develops; advocating for sufficient funding to enable this to deliver at pace. We will also support its delivery where requested, ensuring that lessons from Keyham are integrated into the fabric of the course.

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As expressed in evidence during inquest, the training provision for the FELU within Devon and Cornwall Police has been completely revised since the incident, creating clear expectations of staff and auditable records of training delivered. There is a clear focus on decision making, risk identification and the implementation of statutory guidance. This has included training to all staff within the FELU, key operational managers who are responsible for making dynamic decisions to revoke licences, and those responsible for making decisions within criminal investigations, known as Evidence Review Officers (EROs).

Immediately following the tragic incident in Keyham, a senior manager was appointed to create a training and continual professional development plan, and to deliver this to all staff within the unit. In the absence of a national accredited training package, we have created and delivered a bespoke training program to all staff working within the FELU including those responsible for making high risk decisions.

At the time of writing, all staff working within the FELU have undertaken a Firearms Enquiry Officer course provided by a Firearms Licensing Manager from South Yorkshire Police. This course has a positive reputation across UK policing and is one of only a handful of options available. The content covers the use of the National Decision Model (NDM) in addition to a vulnerability assessment framework, core investigative principles, the grant and renewal application process, suitability criteria, powers and appeals, the National Intelligence Model, domestic abuse, security arrangements, mental health, and the statutory guidance. Importantly the course integrates these issues with the revised processes created within Devon and Cornwall Police since the incident; for example, the completion of enquiry forms by FEOs.

By mandating attendance for all staff within the FELU, this provides a consistent approach for both existing staff and new members, providing a baseline from which individuals can perform their role to a high standard. A handbook for staff is also shared following the course, and all staff have been provided with a copy of the most recent statutory guidance with clear instructions for its use, linking this with a risk identification tool which was referred to in the inquest as the FELU Risk Matrix. It is noted that Devon and Cornwall Police are in the process of reviewing the use of this risk identification tool alongside the NPCC in light of both the statutory guidance released in February 2023 and the issues raised during the inquest.

As a result of the work conducted after the incident, we have also delivered additional training in risk assessments and decision making. This training has been delivered by a barrister who specialises in firearms licensing and focuses on the practical identification of risk through the THRIVE (Threat, Harm, Risk, Investigation, Vulnerability) assessment process, as well as the application of the national police risk principles and the use of the NDM in case and appeal management. This training, initiated soon after the incident, is clearly relevant to the matters subjected to appropriate examination at the inquest. Suitability decisions are now recorded on separate documents, including all relevant detail that could affect the suitability of an applicant to hold a licence. The records are comprehensive and apply the statutory guidance through the use of the NDM.

Page | 8

In terms of managing the various IT systems used in making and recording licensing decisions, all staff within the FELU have completed training courses in the following computer systems:

• Police National Computer – PNC;
• UNIFI – our previous records management system;
• Niche – the new records management system;
• Storm – our incident management system;
• Police National Database – PND – a national intelligence database.

To assist FEOs in the conduct of their public facing role, all undertake training in first aid and personal safety which are based on the (NPCC) Personal Safety Manual and covers a vast range of subjects. FEOs also complete Firearms Safety Training which is delivered by our accredited Force Armourers. This covers the safe handling of firearms and shotguns and how to make weapons ‘safe’ during their duties. Prior to the incident this training was taken every five years until 2019; FEOs now have refresher training every three years.

Until a national qualification is made available through the College of Policing, FEOs are accredited ‘in force’ with a qualification from the course provided by the Licensing Manager from South Yorkshire Police. This process is coordinated internally with individual records maintained, enabling automatic reminders to be sent to staff and their line manager to alert them when this skill is due to expire. At this time there is no formal requirement across England and Wales in relation to either accreditation or refreshing existing skills and learning. We will continue to engage and work closely with the NPCC and College of Policing during 2023 to assist in delivering the national course and in defining a period for reaccreditation which is robust and pragmatic. Following the inquest we submitted a comprehensive response to the College of Policing to assist this process, and Devon and Cornwall’s future policy will reflect the national position and any requirements set by the NPCC and the College.

In order to maintain this standard of training for new starters, Devon and Cornwall Police will re-engage with South Yorkshire Police to provide training to staff in cohorts as and when required. It is envisaged that this process will continue until the new national qualification is delivered through the College of Policing.

Following the completion of the mandatory training requirements listed above, we have also started to deliver a three-year continual professional development programme comprising dedicated training to FELU staff from experts in mental health and domestic abuse. This training reflects the core issues examined during the inquest. In addition, we continue to work with the NPCC lead to ensure that these issues are reflected within the national planning for accredited training and annual CPD requirements which are further set out within the NPCC portfolio.

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The decision to temporarily remove the decision-making capability of FEOs and FEO supervisors articulated during the inquest by Chief Superintendent provided an immediate response to the issues identified. Following the delivery of the training described above, two additional training related actions have been pursued to augment the decision-making process: the creation of a portfolio for assessing and performance monitoring FEOs, and a comprehensive dip sampling regime involving both the Assistant Chief Constable (Operations) and the Senior Management Team (SMT) within the FELU. This involves the new supervisors within the unit reviewing FEO decisions via an enquiry form, assessing their rationale, and providing feedback to them directly. Significant issues or more systemic ones are regularly discussed within the risk management meetings led by the ACC (Operations) as described during the inquest. This system provides a clear and robust process for assessing the quality of the investigations conducted by FEOs following their training, and one which will be part of the forthcoming HMICFRS inspection.

During the next 18 months we intend to provide additional training to further enhance the quality of FEO investigations. This will be delivered through the national Professionalising Investigations Programme at level 1, which is the nationally recognised standard and includes an investigative accreditation that applies to investigators at all levels within policing. It is a structured framework running through every aspect of investigation and will improve the professional competence of all officers and staff. It also enables supervisors to manage performance of their staff and to identify areas for development.

Noting that the APP for firearms licensing is under consultation and is due for imminent renewal in 2023, the current training provided within Devon and Cornwall exceeds the current requirements in APP.

The post incident review following the tragedy clearly identified a need to consider training to roles outside those which deal solely with firearms licensing. With a total workforce of over 5000 staff, this is a challenging issue, particularly when considered alongside other mandatory training requirements such as Personal Safety Training, role specific training, and training to support business change processes (ie the delivery of the new records management system). At this time, Devon and Cornwall Police have adopted a targeted approach to wider organisational training, specifically to EROs and those in investigative roles.

In addition to the CPD for FELU staff, in 2023 the following training is planned:

a. The integration of firearms licensing into the nationally mandated practical scenarios for Personal Safety Training for all sworn (and some unsworn) staff;

b. Presentation of the key learning from the incident to a CPD event for Firearms Licensing Managers in May 2023;

c. Presentation of the key investigative learning to the annual CPD event for Senior Investigating Officers, Silver and Gold Commanders, and the submission of lessons learned to the NPCC via the Homicide Working Group.

Dear Senior Coroner Arrow, Prevention of Future Deaths Report – Judicial Training in Firearms Licensing Thank you for your report of 8 March 2023 following the inquests into the deaths of Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington and Kate Shepherd who were shot by Jake Davison in Keyham in August 2021. I understand that following the inquest you have made a number of reports under regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, identifying a range of matters of concern which you consider may give rise to a risk of future deaths unless action is taken. Your report to me outlines your concerns about judicial training on firearms licensing. In particular, as a result of the evidence you heard during the inquest, you are concerned that judges may be unfamiliar with the nature of the decision they must make in firearms licensing appeals and may be incorrectly applying the relevant statutory guidance. These tragic and appalling killings were not committed by someone whose firearm certificate had been revoked by the Chief Constable and who had subsequently successfully appealed to the Crown Court. The subject matter of your report about judicial training was not investigated at the inquests (because it was not relevant to the function of the inquest to answer the statutory questions) although you appear to have received some anecdotal evidence in passing. I proceed on the basis that your report summarises the totality of the evidence you received on the matter. Responsibility for the training of the judiciary in England and Wales rests with the Lord Chief Justice, as Head of the Judiciary. Under section 7 of the Constitutional Reform Act 2005 I have a duty to maintain appropriate arrangements for judicial training and guidance, which I exercise through, and with the support of, the Judicial College. The statutory duty reflects the fundamental constitutional principle of judicial independence; judges must be independent of government and other public bodies, including in the training they receive to undertake their role. The Judicial College, under my authority, regularly reviews the training it offers, but ultimately the content and focus of judicial

training courses is a matter for me as the independent Head of the Judiciary. All judges are required to complete an induction course before they sit in any jurisdiction and regular annual continuation training thereafter. As you will be aware, there are specialist training courses for those who sit in the Crown Court. The Crown Court exercises a very wide jurisdiction in the criminal sphere and by virtue of statute in discrete areas such as under the Firearms Act 1968. No training course can hope to cover everything a judge might encounter. The judges of the Crown Court are senior members of the judiciary and appeals against the revocation of firearms licences are usually heard by salaried Circuit Judges, rather than fee paid Recorders. They can be expected, with or without the assistance of the lawyers who appear before them, to familiarise themselves with the law and procedure relevant to a case they are hearing. It is against that background that I have considered your report. I have noted that this was not a case involving an appeal to the Crown Court under section 44 of the Firearms Act 1968 because Devon and Cornwall Police had not revoked the shotgun certificate. The circumstances of the granting and retention of the shotgun licence were not therefore considered by a court in an appeal. The concerns outlined in your report appear to have arisen because of evidence given by the Chief Constable that around 50% of appeals against police decisions to revoke shotgun licences are successful. You cite as an example an unidentified case summary in which the Court granted an appeal against a decision of the Chief Constable to revoke a firearms licence. It is said that in that particular case the court ‘appears’ to have taken an approach that allegations were unproven and could not be taken into account and the court’s approach to risk ‘appears’ to have set too high a threshold for revocation when considerations of violence and intemperate habits were in play. You were informed that this case is not untypical and the Chief Constable ‘strongly suspects’ that it is indicative of a national problem. Section 44 of the Firearms Act 1968 provides for appeals against decisions of Chief Constables made under the 1968 Act to be made to the Crown Court. Appeals are determined on the merits and the court may consider any evidence or other matter, including matters which post-date the decision of the Chief Constable. You rightly point out that under section 44(3A) the court is obliged to have regard to the relevant statutory guidance issued by the Secretary of State, which is publicly and easily available. Procedural aspects of such appeals are set out in Schedule 5 to the 1968 Act, which makes it clear that the Chief Constable may appear and be heard at such an appeal. Indeed, it would be very odd were the Chief Constable not to take a full part in the appeal. Further practice guidance was issued by the Divisional Court of the High Court in R (Mason) v Crown Court at Winchester [2018] EWHC 1182 (Admin), which sets out an appropriate approach to the case management of such appeals, in order to ensure a fair hearing. It is clear in this guidance that evidence and submissions are expected from both parties. In Chief Constable of Essex Police v Campbell [2012] EWHC 2331 (Admin) the Divisional Court clearly established that an individual’s overall conduct and the context of the decision to revoke a licence must be taken into account. In Campbell Sir John Thomas, President of the Queen’s Bench Division, stressed the overwhelming public interest in the exercise of strict controls over those who possess firearms, and the consequent need to ensure that appeals under section 44 of the 1968 Act are given the most careful and detailed consideration. The questions to be answered by the court in appeals under section 44 of the 1968 Act, and the procedure for hearing such appeals, are therefore clear and well-established. They are to be found in a small number of readily accessible places. I have considered the concerns you raise but do not think that your report substantiates the suggestion that judges are not giving such appeals the necessary careful and detailed consideration, are applying the incorrect legal test or are failing to have regard to the statutory guidance.

Dear Mr Arrow, His Majesty's Senior Coroner for the area of Plymouth, Torbay and South Devon I write to you in response to the Report to Prevent Future Deaths issued to the Chief Constable of Durham Constabulary under Regulation 28 of the Coroners (Investigations) Regulations 2013. I note that all Chief Constables have received the same Prevention of Future Deaths report and that this is one of a number of reports issued by you following the hearing of the Keyham inquests. I am required to respond to the Regulation.,28 Report by 3rd May 2023. The report raises a number of concerns identified during the Keyham inquests and whilst this report is my formal response to the Regulation 28 report issued by you, I also wanted to take this opportunity to provide further assurance regarding Durham Constabulary's approach to the grant and management of lawfully held firearms. As referenced at point 3 on page 6 of your Regulation 28 report to the Home Secretary: In March 2013, His Majesty's Senior Coroner for Durham issued a report, under rule 43 Coroners Rule 1984, following inquests into the deaths of Sam McGoldrick, Alison Turnbull, Tanya Turnbull and Michael Atherton. This report and its concerns led to wholesale reform within Durham Constabulary and its approach to firearms licensing. It is noteworthy that, whilst NPCC portfolio lead from 2016, Durham Constabulary led the way to formalising the need for medical information to be a mandatory requirement of all renewals and grants; a process that was formally adopted nationally in November 2021. As a Constabulary, the force has sought to ensure that the failings identified in 2013 are never repeated in County Durham and Darlington, and that learning from this has informed national practice. I trust that the following information provides you with the assurance you require with regards to Durham Constabulary's processes surrounding firearms licensing, as well as addressing the concerns you raise within the Regulation 28 report. Scrutiny of initial licence applications: Within Durham, every initial grant and renewal application is subject to enhanced checking DURHAM CONSTABULARY

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against both internal (intelligence/safeguarding) systems and national systems (PNC, PND and Special Branch) as a matter of routine. These enquiries not only focus on the applicant, but also the residence and wider known associates. Additional scrutiny is applied on a case-by-case basis involving enhanced checks on financial anc;l social media platforms (in excess of that currently mandated by extant guidance), scrutiny of body-worn video and evidence linked to incidents involving the applicant or licence holder. Since November 2021, this information is further overlayed with medical proforma information from the applicant's GP, thereby providing a holistic view of an individual's circumstances and suitability. The outcome of these enquiries is then scrutinised by a decision maker and supervisor within the firearms licensing team. Any concerns highlighted or further identified at this stage are subject to further and more detailed or intrusive investigation, for example, where a GP response identifies concerns regarding mental health, the department will explore these further to fully understand the impact of these issues on the applicant's suitability to hold a firearms licence. With regards to the referees nominated by the applicant: Durham's firearms licensing team contact named referees and complete prescribed enquiries which fully explore the relationship with the applicant and the responsibility that comes with the role of referee. Referees may be contacted by telephone, email or home visit depending on the risk assessment. The professional curiosity and proactive approach of the firearms licensing team has led to several broader interventions across the constabulary both in respect of lawfully held firearms and illegal possession of firearms. In the past 12 months the team has initiated the execution of a number of search warrants and subsequently seized over 200 lawfully held firearms, as well as prohibited firearms. This has also led to the revoc~tion of a registered firearms dealer licence. The team's broader appreciation of harm has led to a number of intelligence submissions and has initiated force activity around county lines, domestic abuse, child sexual exploitation, drug cultivation and unlawful firearms manufacture. Ongoing review of licence holder fitness: Durham Constabulary takes a proactive approach to any incident or intelligence relating to its licence holders. All licence holders have a 'live' profile within both force and national systems. As part of embedded risk management practice, the Force Incident Manager reviews all incidents reported to the force that involve a licence holder and will take positive action to seize all weapons and certificates at the time of reporting. This is a daily review of incidents conducted independently of the firearms licensing team, so that immediate action is taken. The firearms licensing team is also notified and will then review the licence holder's circumstances and suitability. The force also operates a 'wash-through' process that affords additional reassurance. This process will highlight any licence holder referenced on either a command-and-control incident log or wider intelligence/information submission (including those from partner agencies) and is scrutinised by the firearms licensing team within 24 hours of the incident. As part of this 'wash- through' process, the firearms licensing team will undertake additional enquiries to confirm or negate any elevated concerns. This review will also trigger action to remove weapons from licence holders where concerns have arisen, to allow a full review of suitability to be undertaken. This holistic approach allows the licensing team to conduct a full review of any licence holder that 2

comes to the attention of the force, without weapons remaining within the public arena. Only after being subject to a full review will consideration be given to the return of any firearms/certificates to a licence holder. This process is overseen by the firearms licensing Inspector and delegated authority (Superintendent) where any concerns are highlighted. In 2022, Durham seized weapons from 116 licence holders using this process. To date, 22 licence holders ( 18%) have subsequently had their firearms/certificates returned following a full review. Durham also operates a live 'Watch List', which monitors licence holders that trigger one of the following criteria: known associations, medical conditions, hold over 12 weapons, or intelligence linked to their nominal record. The firearms licensing team conduct regular and enhanced assessments of these licence holders to review their ongoing suitability. Approximately 10% of all licence holders are on this rolling list at any given time. General: When reviewing any previous intelligence or antecedents that relate to any grants or renewals, Durham's licensing team ensures that the modus operandi, as well as the offence recorded, are scrutinised in full. This is accompanied by a full review of any available digital evidence, such as body worn video or incident recordings of 101/999 calls. In the past 18 months Durham has successfully defended 7 appeals against a refusal/revocation decision at Crown Court; many cases of which explored the entirety of the information available surrounding the Appellant's conduct - the reach of which extended beyond the balance of probabilities and focused upon the foreseeable risk to the public. .. Whilst I welcome the important work being done by Chief Constable that addresses national standardisation, formal accreditation and training for firearms licensing staff, all of Durham Constabulary's Firearms Enquiry Officer's currently receive training/CPD in approved practice on an annual basis. New staff joining the department are further supported throughout this process by a period of tutorship, mentoring and CPD to ensure they are both confident and competent within the role. In January 2021, Durham Constabulary's four FEOs were the first in the country to successfully complete the online Mowbray Partner's training package, aligned to the College of Policing learning outcomes. The use of this online training has evolved, with all members of the firearms licensing team completing a training package for their respective roles, supported by additional in-house CPD. The governance structure of firearms licensing within Durham is robust and can be evidenced from at all stages of decision making, from an operational level on receipt of an application- all the way through to quarterly Chief Officer accountability meetings with by the Deputy Chief Constable. (For your information, my Deputy Chief Constable is a highly experienced firearms commander and has experience operating as a Delegated Authority in his previous forces so is well acquainted with the risks in this area of policing.) These processes include monthly performance meetings, chaired by the Delegated Authority (at Superintendent Rank), to monitor, dip-sample and manage the performance of the unit and escalate firearms licensing related issues. The firearms licensing Inspector also forms part of the core membership of Durham's Firearms Threat Group which meets monthly to discuss all aspects of both lawful and unlawful possession of firearms. Additional scrutiny is further afforded by Durham's Ethics Committee - which meets quarterly and is independently chaired. This committee scrutinises firearms licencing 3

processes and decision making. To mitigate the projected increase in demand on the firearms licensing team in 2019, Durham Constabulary employed 5 additional staff to assist.in managing the cyclical workload of review and renewals. Much of the current workstreams that exist within the department are intrinsically linked to the enhanced governance processes and checks that are in existence, as articulated above. These processes are pivotal in keeping the public safe; focusing on foreseeable and avoidable harm, careful risk assessment based on all available information, not expediency. Matters of concern: In light of the above response to the Regulation 28 notice and further to Chief Constable

letter to all Chief Constables, dated 24th March 2023, I am satisfied that the review of the original request from the Home Secretary in August 2021 remains accurate. The review of all decisions to return firearms to licence holders after seizure or surrender (35 in total) over the previous 12 months, were appropriate and were subjected to the appropriate level of scrutiny and oversight. Durham Constabulary has an embedded cycle review and revocation in respect of risk-based assessments of licence holders, whether as part of a cycle of review of certificates or when a licence holder comes to the force's attention. It is my view that these mechanisms remain more effective than retrospective review of all certificates over the last 5 years. The proactive approach of the force and the triggers in place for managing and reviewing current certificates is effective. Based on the above, I do not propose to commission further review of certificates granted beyond that already undertaken. '

Dear Mr Arrow Force Executive Team West Midlands Police Headquarters Lloyd House PO Box52 Colmore Circus Queensway Birmingham B46NQ

: Date: 3 May 2023 I would firstly wish to offer my deepest condolences to the families of Maxine Davison, Lee Martyn, his daughter Sophie, Stephen Washington and Kathryn Shepherd on behalf of West Midlands Police. I hereby attach the Staffordshire Police and West Midlands Police response to the two Preventing Future Death Reports arising from the inquests that were directed to all Chief Constables. As explained in the attached report, the Firearms and Explosives Licensing Unit provides a collaborated service to both forces. The response relating to the review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the last 5 years provides details of the action taken and proposed to be taken as requested. The second response details the level of training undertaken by staff in the Firearms and Explosives Licensing Unit and the proposed training to be undertaken as other details in response to the matters of concern raised in the report. It is understood that the responses may be published.

Dear Mr Arrow,

Ref: Preventing Future Deaths (PFD)

In response to your report, sent to all Chief Constables dated the 8th of March 2023 in relation to your concerns regarding Firearms Licensing as a result of the Inquests into the shootings at Keyham in August 2021, I would like to detail the plans which Northamptonshire Police have in place.

You will have by now received correspondence from Chief Constable with regard to an agreed national response, which Northamptonshire Police have agreed to, and which includes the following:

• Prioritise review cases where firearms have been seized or surrendered to police pending a review of suitability to have a licence, but then subsequently returned.

• Review cases where applications have been refused or licences revoked, but where subsequent applications or appeals by the same licence holder resulted in a grant.

• Review all previous decision-making against the current (February 2023) Home Office Statutory Guidance, in light of the concerns you have referred to.

• All the above will be completed over the next six months and by 2 October 2023.

In preparation for the reviews, we have already secured temporary additional resources into our Firearms Licensing Unit, including at senior management level.

We have also recently engaged with two separate external companies to carry out audits of the unit, as well as a peer review conducted by a neighbouring Force, and we await their respective reports. These will provide the scrutiny required to identify where improvements can be made, and to provide reassurance to us and the public that our processes support your aspiration in preventing future deaths.

Deputy Chief Constable Wootton Hall Wootton Hall Park Northampton Northamptonshire NN4 0JQ

3rd May 2023

Marking Restricted Date 02/05/23 Title & Version Prevention of Future Deaths Report – Keyham Inquest

Reference

The Report to Prevent Future Deaths: Made Under Regulation 28 Of the Coroners (Investigations) Regulations 2013.

Duty to respond to report within 56 days (namely by 3rd May 2023).

HANDLING INSTRUCTIONS: This document must be handled in accordance with the protective security marking shown at the top of the document and should not be disseminated to outside agencies/partners without the consent of the authorising officer.

Background

The case relates to the Plymouth shooting where the Jake Davision had his shot gun returned via the Force Firearms Licensing unit and subsequently shot and caused the death of five people in Keyham on 12th August 2021. The Coroner recommends all Forces review all their decisions to return firearms to a license holder.

Coroner Report Key Learning

• The death was caused by the fact the perpetrator has a lawfully held shotgun.
• Serious failures in FELU in granting and later failing to revolve the perpetrators shotgun certificate.
• Failure of Police to have in place safe and robust systems, foremost the training of FELU staff, governance of the FELU, quality assurance of FELU staffs decisions making and ensuring they were made at the correct level.
• There was failure of Police FELU staff to obtain sufficient medical information in respect of the perpetrator’s application for a shotgun certificate and on review.
• Failure of Police FELU staff to properly seek out and consider all the relevant evidence an information availability before decision whether to grant the shotgun certificate.
• Following the perpetrator having assaulted two children in 2020, there was a failure by Police to protect the public and the peace. Firstly, with downgraded charge and secondly with in the FELU to sufficiently investigate whether it was safe to return after initially seizing them.
• Incorrect application of the risk matrix meant decision were not approved by a manager of sufficient seniority.
• Catastrophic failure in the management of the FELU, with a lack of managerial supervision, inadequate and ineffective leadership which was compounded by a lack of senior management addressing the issues.
• Evidence 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 licencing decision has not been put into effect. Chief Officers ought to be satisfied that they only delegate their authority to issue and

revoke firearms licenses to appropriately trained and skilled personnel. There continues to be a lack of nationally accredited training for FELU staff.

COLP Specific Data / Procedures in relations to Firearms Licensing

COLP currently have the following 36 live certificates COLP have not returned any certificates having confiscated them in recent years.

Current CoLP procedure

The decision to return a firearm is made by Licensing Team members, quality assured by Inspector with final authority to return being made by Firearms Portfolio holder Commander Ops & Security.

CoLP Actions

Learning from this case should also be applied to the initial application and annual re- licensing processes.

• What are the Common National Standards for Firearms License Applications / Renewals / Return of firearm following suspension? –
• Match CoLP SOP to ensure standards are met or exceeded.
• Review SOP to ensure procedures for - Application / Annual Renewal / Return – Ensuring robust checks across medical, crime recording and Risk Assessment.
• Risk assessment training and CPD training for all licensing team - Annual cycle of training and development.

Recommendation /Response

• City of London Police acknowledge the findings and learnings from the Keyham Inquest.

• These findings have been brought to the attention of the respective operational leads and further governance will be provided through the the Operational Learning Forum for actions to be set and tracked across CoLP. The next OLF is scheduled to for 23rd May at 1330-1500hrs, papers to be submitted by 16th May.

Commander City of London Police. Lead for Ops and Security Chair Org Learning Board.

Dear Coroner, Please find below the response from Leicestershire Police in respect of your report to prevent future deaths made under Regulations 28 and 29 of the Coroners (Investigation) Regulations 2013. Please accept my apologies for our slightly delayed response as a result of a prolonged local protest which has resulted in the abstraction of a number of my senior colleagues over the last 7 days. I would like to reassure you that we have taken your concerns seriously and have put in place immediate steps to address these. By way of context our force currently interacts with:
• 10,819 Shotgun certificate holders
• 2,407 Firearm Certificate holders
• 492 Coterminous certificate holders
• 40 Firearms dealers
• 15 Rifle and Pistol Clubs
• 164 Acquire and Keep Explosive Certificates
• 32 Acquire only explosive certificates
• 15 Explosive Store Licences You will be only too aware that this is a significant administrative and risk management undertaking. All these certificate holders must be reviewed on renewal and suitability questioned on their mental health, criminal convictions and suspected behaviour based on police intelligence. These processes are well defined within the Statutory Guidance for Chief Officers of Police and Guide on Firearms Licensing law (November 2022) and Force Procedure.

Leicestershire Police provide this service through a centralised department which receive and process the applications, make enquiries, compile reports to the Firearms manager and in a majority of cases subsequently issue the appropriate licence(s). Current processes involve the completion of nationally approved forms which are submitted to the department with the appropriate fee and medical report. These are checked in all cases against various national and local intelligence data bases. An entry is made against the National Firearms Licensing Management System (NFLMS), and, in in most cases, a visit to the applicant to confirm various details, discuss medical history, and check the security arrangements for the weapons. Subsequently, subject to the various checks, enquiries, contact with a minimum of one reference of good character and other information reaching an acceptable threshold; a certificate is granted. This certificate in all cases is signed by the Firearms manager or the Firearms Supervisor both of whom have delegated authority of myself as the Chief Constable. I can confirm that in response to the concerns you have raised, namely that I should consider reviewing all certificates seized, refused, revoked or surrendered and then subsequently approved over the past five years we have put in place the following action:
• We will be reviewing all such cases from pt April 2023 for the past 5 years (1st April
2018) commencing with the most recent decisions first.
• The individual/s used to conduct this review will be independent from the original decision makers with experience in criminal investigations and suitably qualified to PIP2.
• Findings will be reported to the strategic lead for Firearms Licensing who is an Assistant Chief Constable.
• Priority will be given to those cases where firearms have been seized, surrendered to police pending a review of their suitability to possess a firearm or certificate and subsequently approved.
• We will aim to complete the review by 2nd October 2023.
• We will then review those cases where applications have been refused or licences revoked, but where subsequent applications or appeals by the same licence holder resulted in a grant. (If the return or grant has been ordered by the Crown Court the strategic lead will give direction which maybe consultation with the force solicitor. There are two such cases)
• Review all previous decision-making against the Home Office Statutory Guidance (Feb
23) from 1st April 2018 to provide a consistent approach across decision making
• To continue monthly governance meetings on future decisions with Chief Inspector (Firearms Licensing), the firearms manager and the new reviewing staff member to continue an effective and consistent approach moving forwards.

The proactive steps Leicestershire have taken indicate our support to manage risk as highlighted in the report. We are keen to ensure that we continually improve the management of the process and support lessons learnt for such tragic circumstances

Dear Mr Arrow

I am the Deputy Assistant Commissioner for the Directorate of Professional Standards in the Metropolitan Police Service (“MPS”). On behalf of the Commissioner of Police of the Metropolis, I write to provide the response to the matters of concern addressed to the MPS in your Report to Prevent Future Deaths dated the 8th March 2023.

On behalf of the MPS may I first of all express my sincere condolences to the family and friends of Maxine Betty Davison, Lee Raymond John Martyn, Sophie Iris Martyn, Stephen John Godfrey Washington and Kate Jane Shepherd, our thoughts and sympathies are very much with them.

The Coroner’s “Matters of Concern” (Training)

The Prevention of Future Deaths report dated 8th March 2023 records:-

“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 of firearms licensing staff has been developed and its currency maintained.

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”.

MPS Response

MPS arrangements for “Delegated Authority” under the Firearms Act 1968 state that all members of the Firearms Enquiry Team (FET – MPS Designation for FELU) of Sergeant rank or above possess full decision making powers. This is then supplemented by a separate Decision Making Governance, which ensures that appropriate oversight is given. All decision makers have received the current agreed training package and undertaken accreditation which is overseen by the FET Inspector. Each new Supervisory officer joining the team receives an accreditation meeting with the FET Inspector and the MO19 senior leader responsible for FET, before being authorised to undertake independent decision making.

There is currently no nationally accredited training package, which the MPS has sought to resolve by MPS FET development of their own training. The content of this training has always sought to take account of nationally identified risks arising from cases across the country where learning or best practice has been identified. The content of the training is reviewed each time a case is identified or when legislation and national guidance has been issued. The MPS notes the commitment from the NPCC lead for Firearms Licensing and the College of Policing to re-invigorate work in this area. The FET Manager and relevant member of the senior leadership team will be attending a national conference at the College of Policing later in 2023.

The Directorate of Audit, Risk and Assurance (DARA) are a part of the Mayor’s Office for Policing and Crime (MOPAC) and provide an internal audit function for the MPS. DARA commenced a review of FET operations in September 2022, which concluded the MPS had “Adequate Assurance”. The DARA audit finding is that “the control framework over the administration of Firearms Licensing is adequately designed and the majority of controls are operating effectively. Risks are generally managed effectively and some minor improvement in the design and application of controls is required to strengthen the overall control framework.” The MPS is already addressing the points raised through the audit and DARA have been requested to undertake a future audit to review progress against findings and recommendations.

In February 2023, an internal review was conducted by the MPS Specialist Firearms Command’s senior leadership team. This specifically considered current MPS arrangements and anticipated learning to come from the inquests and response to the shootings in Keyham. An outcome of this is an MPS review

of the existing FET training, to ensure it remains up to date with developments in national firearms licensing.

The MPS assessment is that adequate local training has been implemented to all staff operating within their Firearms FET. This includes both the original statutory and non-statutory guidance to police and subsequent iterations of these. This training has been delivered to all Firearms Enquiry Officers (FEO), supervisors and the MPS FET management team has an ongoing continuous development programme, overseen by a newly implemented monthly board.

In 2018 the College of Policing published FEO Learning Standards. Following this in 2019 the issue of training was carefully considered against those learning standards, in light of the absence of an accredited product and arguably inconsistent local practices. As a result of this work, a three day FEO course was created focusing on critical risk assessment and decision making. The content of this course also incorporated reference to the relevant Home Office (non-Statutory) guidance of that time.

Statutory guidance followed in November 2021 and a stand-alone training package was devised and delivered to all staff. This was a substantial change to law and process in Firearms Licensing and the training investment reflected this. The MPS joined a working group of other Firearms Licensing Managers from across the UK and a detailed analysis of the requirements to ensure our compliance with these substantial changes was undertaken.

In February 2023 this Statutory Guidance was updated. The amendments to the guidance did not necessitate fundamental changes to existing working practices and therefore the changes were briefed to officers in writing. The existing FEO course was also updated to reflect this change in legislation. The College of Policing FEO learning standards remain the latest guidance and the MPS is fully compliant.

FEOs are mentored by an experienced member of staff and their practical application of knowledge is assessed by supervisors against 23 key areas of competence, which reflect the FEO Learning Standards and most recent statutory and non-statutory guidance. Ongoing training to all FET staff and new joiners is a key performance indicator. Continuous professional development is embedded within the FET with staff trained quarterly. Training content follows trends identified in the national Firearms and Explosives Licensing Working Group (FELWG) as well as any local or national learning opportunities identified by the FET management team. Supervisors and decision makers have been provided with an enhanced level of training in relation to decision making, risk management and professional curiosity. This is delivered in partnership with colleagues from the MPS Directorate of Legal Services. The MPS is also working with police force across the south east region, to share information and embed peer reviews and quality assurance.

The MPS has exercised significant effort to assure itself that the FET is compliant with all available College of Policing, Statutory and Non-Statutory guidance. Furthermore, the FET has taken a proactive position in keeping pace with any learning resulting from occurrences related to firearms licensing.

The Coroner’s “Matters of Concern” (Review of the return of guns)

The Prevention of Future Deaths report dated 8th March 2023 records:- “I was informed that all police forces then reviewed their decisions to return a weapon in the previous year and only one police force (not Devon and Cornwall Police) identified any case where firearms had wrongly been returned to ce1tificate holders in the previous year. I was told there were 9 cases identified in that one force. Whereas the remaining 42 forces (including Devon and Cornwall Police) found no incorrect decisions to return a certificate had been made.

In the light of this information I am concerned that the information from those 41 police forces who indicated that they had made no incorrect decisions to return a weapon/ certificate may need to be further tested and explored.

I am concerned the figures provided to the Home Secretary in 2021 may not reflect the accurate position, and that if sufficiently stringent checks are performed these may reveal other cases where a firearm or shotgun certificate had been seized, refused, revoked or surrendered but was subsequently issued/returned in circumstances when the certificate should not have been approved. I am concerned that if there are other cases that were not subject to a proper or thorough review of the risk of returning the weapon when the person may continue to have a firearms/shotgun certificate and hold weapons in circumstances that place the public and the licence holder themselves at risk.

I am concerned that in the light of the lessons learned in the Keyham inquests of the attitude towards risk, a further review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the past five years may be required to be assured of public safety”.

MPS Response

In August 2021, the MPS responded to a request from the Home Secretary for a review of all firearms returned to members of the public in the preceding 12 months. These cases were identified utilising a “search string” provided by Home Office colleagues for use with the National Firearms Licensing Management System (NFLMS). This process highlighted 33 such cases, which were reviewed by the FET Manager and a nominated Sergeant, then subsequently signed off by the Firearms Commander.

Dear Sir, I would firstly wish to offer my deepest condolences to the families of Maxine Davison, Lee Martyn his daughter Sophie, Stephen Washington and Kathryn Shepherd on behalf of Staffordshire Police.

I hereby attach the Staffordshire Police and West Midlands Police response to the two Preventing Future Death Reports arising from the inquests that were directed to all Chief Constables.

As explained in the attached report the Firearms and Explosives Licensing Unit provides a collaborated service to both forces.

The response relating to the review of all certificates seized, refused, revoked or surrendered and then subsequently approved over the last 5 years provides details of the action taken and proposed to be taken as requested. The second response details the level of training undertaken by staff in the Firearms and Explosives Licensing Unit and the proposed training to be undertaken as other details in response to the matters of concern raised in the report. It is understood that the responses may be published.

Dear Mr Arrow,

INQUEST FOLLOWING THE DEATHS OF MAXINE DAVISON, LEE MARTYN, SOPHIE MARTYN, STEPHEN WASHINGTON AND KATE SHEPHERD IN KEYHAM ON 12 AUGUST 2021: REPORT TO PREVENT FUTURE DEATHS UNDER REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013

I am writing to thank you for your Regulation 28 Reports which we received on 8 March and which followed the inquest into the deaths of those who were fatally shot by Jake Davison in Keyham, Plymouth, on 12 August 2021. I am very grateful to you for granting extensions to the deadline for the Government’s formal response.

The Home Secretary and I are very grateful for your very detailed consideration of the controls relating to firearms licensing and for highlighting areas where changes may help to improve public safety. The impact of fatal shootings on the victims’ families and friends, as well as the wider community, is devastating. It is right that we learn carefully from any such shooting incidents which occur to see whether and how we can strengthen the controls on access to firearms to try to prevent similar shootings happening in the future.

We have carefully considered your Regulation 28 Reports alongside the summary report published by the Independent Office for Police Conduct (IOPC), on 21 February, following its investigation into Devon and Cornwall Police’s decision- making in relation to Jake Davison’s possession of a shotgun and shotgun certificate. We have also been considering the report published by the Scottish Affairs Select Committee on 22 December 2022 following its review of firearms licensing regulation in Scotland. The Scottish Affairs Committee’s inquiry was established following the fatal shooting of John MacKinnon on the Isle of Skye on 10 August 2022. Both of these reports cover similar ground to that addressed in your Regulation 28 Reports.

Rt Hon Chris Philp MP Minister of State for Crime, Policing and Fire 2 Marsham Street London SW1P 4DF

I provide an overview below of the Government’s position in respect of the issues that you covered in your Regulation 28 Report for the Government. You will have seen today that we started a consultation for eight weeks on the recommendations made to the Government in your reports and those by the IOPC and Scottish Affairs Committee. I enclose a copy of the Government’s consultation paper which was published today.

The consultation is to invite responses to the recommendations that have been made and on which we are consulting. However, if we decide that new legislation is necessary in response to any of the recommendations, we will bring forward a further consultation on the specific Government proposals on legislation, accompanied by assessments of the impact of those changes on all those potentially affected.

I now turn to the specific issues you raised.

Legislative presumption in favour of grant

We have noted your concern that the words ‘shall be granted’ in sections 27 and 28 of the Firearms Act 1968 may create a presumption in favour of grant, and that this should be reversed in future legislation. We have carefully considered the point you raised, but we have decided not to progress this particular recommendation as we do not agree with your interpretation of these specific provisions. Sections 27 and 28 are drafted to support consistency in police decision-making and give certainty to the applicant. Specific criteria must be met in order for a shotgun or firearm certificate to be granted, including the applicant meeting the required suitability checks to the satisfaction of the police. This supports public safety and the need for the applicant to only be granted a firearms or shotgun certificate if the police judge that person as fit to have a firearm.

Aligning shotguns and firearms controls

You were concerned that the criteria for issuing shotgun certificates are less stringent than those for ‘section 1’ firearm certificates and that they should be brought into alignment so that shotguns are subject to the same controls as firearms. Public safety is our priority, but the measures to manage the risk to public safety must be proportionate and balanced with the fact that the vast majority of licensed firearms holders are law abiding and cause no concern. It is for this reason that the Government has decided not to proceed with the recommendations made to align shotgun and firearms legislation. Shotguns are already subject to significant controls on their use and they are important in helping farmers control vermin on their land and in rural pursuits. We will keep this under review, but we are concerned that additional controls on shotguns are unnecessary and would have a negative impact on their legitimate use.

Power of entry to seize firearms

You were concerned that the police require a magistrate or sheriff’s warrant prior to entering premises to seize licensed firearms which creates a potential public safety risk. We are therefore consulting on whether the police should be granted a specific power of entry, without a warrant issued by a magistrate or sheriff, to be able to seize shotguns, firearms and ammunition where there is a risk to public

safety or the peace and the certificate holder does not cooperate with the police and agree to voluntary surrender.

Mandatory prohibition

You said the thresholds for prohibition of possession of firearms, provided by section 21 of the Firearms Act 1968, are outdated and should now relate to risk rather than length of custodial sentence on conviction. We are therefore consulting on whether the law should be amended accordingly.

Statutory Guidance to the police – balance of probabilities

The Statutory Guidance for Chief Officers of Police came into effect on 1 November 2021 and was updated and re-issued on 14 February 2023. You questioned whether its requirement that the police use a balance of probabilities test when assessing applications was the right approach. You considered that the Statutory Guidance does not clearly reflect that the issue of risk and suitability to hold a certificate should be based on the totality of the risk information available to the Chief Constable or Court, applying appropriate weight to that information on a case-by-case basis, and without a requirement that the facts need to be proven on the balance of probabilities. We are considering this matter carefully and this includes consulting on this issue. Following this, if we conclude that the Statutory Guidance needs to be changed on this issue, we will move to give effect to such a change. Referees

We have noted the concerns you raised about the system of referees in support of shotgun and firearms applications. We are therefore consulting on the changes that have been recommended to us in respect of the current arrangements on referees. This includes seeking views on whether two, rather than one, referees should be required as part of the shotgun certificate application process, whether the application form should include a checklist for referees on the information that they should provide to the police, and whether referees should be required to provide a written declaration that they have disclosed all relevant facts to the police. The consultation will also seek views on whether there should be more detailed guidance for the police in the Statutory Guidance about the information they should be looking to elicit from referees. Following this consultation, and in light of the responses received, we will give further consideration to making changes to the Firearms Rules 1998 and to the Statutory Guidance in line with the recommendations made.

Firearms Licensing fees

We have noted your view that the firearms licensing process should be self-funding to ensure that police force firearms licensing units are properly resourced. The level of fees charged by police forces for firearms licensing is currently being reviewed. Work on this started in April 2022, and this has included an extensive data collection exercise held in 31 police forces across England, Wales and Scotland, in January this year, in order to collect data on costs and the time spent on licensing related activities by police forces. This work will inform proposals for new fees

which, in line with HM Treasury guidance, should enable full-cost recovery for the police. The intention is to consult on proposed new fees this Summer and to introduce a new set of fees by Statutory Instrument later in 2023.

Medical checks

You looked at the system for medical checks for firearms applicants and the use of the firearms reminder code. There has been significant strengthening of the medical checks for firearms licensing in the past couple of years, including making it a requirement for all applicants to provide relevant medical information to the police, and the development and introduction of a new digital firearms marker to ensure that the police are notified by the GP if there is a concerning deterioration in the certificate holder’s physical or mental health at any point after the grant of the certificate. We understand the point you made about the value of placing a firearms marker on all medical records within a unified records system, to ensure that the police are notified if a certificate holder begins to suffer from a relevant medical condition or a relevant medical condition worsens significantly and the individual is in contact with health professionals other than his or her GP. The Home Office is working with the Department of Health and Social Care, NHS England and medical representative bodies to ensure that the medical checks system operates as effectively as possible and can continue to be improved when necessary. We will therefore consider with the Department of Health and Social Care and NHS England how your concern about the visibility of the digital marker across all health service providers might be addressed. We will seek to develop any new solutions that may be required as quickly as is practicable in consultation, as necessary, with relevant medical representative bodies. Training for firearms licensing staff

We have noted your concerns about the lack of accredited training for firearms licensing staff and a mandatory requirement to undertake necessary training. The provision of police training is primarily a matter for the College of Policing and police forces, and a programme of work is already being taken forward since 2022 by the College and the National Police Chiefs Council to develop the required training package. The Government accepts the need for such a training package, and today I was pleased to announce that funding of £500,000 to the College of Policing has been made by the Home Office specifically to ensure this training is taken forward and adopted by police forces. The training will be reinforced and supported by the refresh of the relevant Authorised Professional Practice by the College of Policing, which was the subject of a consultation from January to March
2023. The finalised Authorised Professional Practice will in due course sit alongside the Statutory Guidance to provide support and guidance. In consultation with the College and the National Police Chief Council, we will determine how best to mandate and require firearms licensing staff to undertake the new national accredited training programme when it is finalised. Once again, I would like to thank you for your reports, and I hope that this letter, and the accompanying consultation paper provides assurance that the Government is taking the action necessary to strengthen firearms licensing arrangements.

I will write to you again later this year to update you on the work that is being done.

Thames Valley Police - response to Coroners report

Thames Valley Police will comply with the Coroners recommendations in the following stages due to operational demands and resources:

1. First stage - review all seized and returned guns over a 5 year period.
2. Second stage - review all grants that have previously been revoked, refused or surrendered. 2018 files are coming up for renewal so we are focusing on 2022, 2021, 2020 and 2019. We are starting with 2022 as the most recently issued licences arguably pose the biggest risk.

3. Third stage - review applications that have been refused/revoked but subsequently granted by the Crown Court via the appeal process.

We aim to complete the above stages by 2 October 2023.

If you would like to discuss this matter with me further please do not hesitate to contact me.

Kind regards

Central Intelligence Manager Force Intelligence and Specialist Operations I Thames Valley Police

Acting Chief Constable MBA CMgr MCMI a Police Headquarters, Middlemoor, Exeter, Devon, EX2 ?HQ Devon & Cornwall 101 Non Emergency Ll;,,u,!J Non Emergency (BSL video relay) 999 Emergency Non Emergency Text 67101 (Deaf only) tJ POLICE 6 de.police.Uk 999 BSL Emergency (BSL video relay) @) dc.police.uk/webchat @ Text 999 (Deaf only - m ust pre-register at

HM Senior Coroner Mr Philip Spinney 1 Derriford Park Derriford Business Park Plymouth Devon PL6 5QZ 22 January 2024 I write further to Chief Constable letter to you of 3 May 2023, which provided a response to your Regulation 28 Report issued following the Inquest touching the deaths of the five victims of the Keyham shooting on 12 August 2021. That letter represented a formal response to the Prevent Future Deaths (PFD) report issued by HM Senior Coroner on 8 March 2023, in accordance with the requirements under Regulation 29 Coroners (Investigations) Regulations 2013. Since the date of that response, further review work has been undertaken within our Firearms and Explosives Licencing Unit (FELU) and, as such, it is appropriate for me to provide you with this updated information, for completeness and transparency. Within your Regulation 28 Report, you sought the following: " ... a further review ofall certificates seized, refused, revoked or surrendered and then subsequently approved over the past five years may be required to be assured ofpublic safety." The response of 3 May 2023 confirmed that much of this review work had already been completed and provided the outcome of that work. However, one period remained outstanding, and this was the period 3 May 2018 - 31 December 2019 inclusive. It was confirmed within the previous response that: By October 2023 Devon and Cornwall Police will have reviewed cases using the same identification criteria used in the submission to the Home Secretary in 2021 and, importantly, reviewed using the standard applied during the remedial work that was completed prior to the inquest. We will prioritise the review of cases using the most recent statutory guidance for this period as follows: @DCPolice 0 DevonAndCornwallPolice 0 @DC_Police ® dc_police

Cases where firearms have been seized or surrendered to police pending a review of suitability to have a licence, but then subsequently returned. These will be reviewed with the most recent cases first (i.e., where the risk is closest to the current time). Cases where grants or renewals have been refused but where applicants have been successful at appeal. This work has now been completed using SharePoint Case Management System and data held on the National Firearms Licencing System (NFLMS). A total of 611 licence holders were identified meeting the criteria above and have been subject to review. Of the 611 cases, 11 of these cases identified internal processes which did not meet the expected standards and have been subject to further review. No ongoing risks were identified. As described during the Inquest, the processes surrounding such reviews within our FELU have improved significantly and I am confident that such examples would not occur again under the current regime. There are no current risks requiring any remedial action and Devon and Cornwall Police FELU are confident we can identify any contemporary risk, with the new automated systems in place, and ongoing scrutiny in processes specific to grants, renewals and suitability assessments. The following table contains the relevant data for ease of reference: In the 20 months 03/05/2018 to 31/12/2019) how many shotgun and firearm certificates were: How many of those removed were subsequently returned: Firearm removed from certificate holder by being seized, surrendered or revoked (by no. of certificate holders) refused of those with firearms that were seized or surrendered of those revoked 411 73 42 04

I trust the above additional information assists. If you require any further information, please do not hesitate to contact me.

Force provided to the Home Office in response to the then Home Secretary’s request in August 2021 for forces to report on licence applications which had been refused or revoked but subsequently granted, then I have suggested that they respond to you in those terms, advising them:

You are not being asked to duplicate past reviews or audits for the sake of it. If you have already conducted such a review, or you are clear that your force’s response to the Home Secretary in 2021 was accurate and that your current procedures are sound, then you could respond to the Coroner to that effect, ideally with evidence so as to reassure him and the public.

To date, the feedback we have received indicates that most forces will either undertake a full 5 year review as you have suggested or will adopt the very slightly adapted process which I have ordered within my own force (and which I have shared with all Chief Constable colleagues) which is:

To direct a review of firearms and shotgun licensing and prioritise the review in the following way which is intended to be practical and effective.
• Prioritise for review cases where firearms have been seized or surrendered to police pending a review of suitability to have a licence, but then subsequently returned. This was one of the major concerns in the Keyham Shootings Inquests.

• Start by reviewing the most recent decisions first, as the most recently returned licences arguably pose the biggest risk. They will be closest to the events which justified seizure or surrender in the first place, and there will have been less reassurance in the passing of time without new incidents.

• Review in slower time cases where applications have been refused or licences revoked, but where subsequent applications or appeals by the same licence holder resulted in a grant.

• If the return or grant has been ordered by the Crown Court, consider with the Force Legal Services department what, if anything, can be done, recognising your PFD Report in respect of training for Crown Court Judges who hear and consider appeals against police refusals to grant licences.

• If it is not practical to review the last 5 years of decisions, then consider progressively reviewing the last 4 years. Licence holders in their 4th to 5th year can be managed through the normal 5-yearly renewal process against current standards. (I have advised colleagues whose forces may have significant backlogs for renewal applications, or many temporary licences, then a review of the last 4 years alone may not be sufficiently reassuring).

• Review all previous decision-making against the current (February 2023) Home Office Statutory Guidance, in light of the concerns referred to in your PFD Report, in order to promote public safety by today’s standards.

I have suggested to colleagues that adopting this unified approach to the reviews may also have the added benefit of consistency of response.

I have further proposed that we try to achieve such reviews in each force over the next six months (from the date of your report) so by 2 October 2023. It is my intention that national progress in undertaking this review is monitored and tracked through the national Firearms and Explosives Licensing Working Group, which is led by Temporary Superintendent , from whom you heard evidence during the recent Inquests.

I hope that this response offers some reassurance of the national approach which I have endorsed, which will be adopted within Warwickshire Police, to undertaking a timely and proactive review of decisions where following initial concerns about suitability, an applicant has eventually secured lawful possession of a firearm or shotgun. Such reviews will be assessed against the most recent Home Office guidance and, within Warwickshire Police, with your further recommendations around other areas of concern (the need to address legislative shortcomings and revision to guidance, training recommendations and so on) very much in mind.

Mr Arrow,

Heddlu Police DYFED POWYS Prif ct.Ynltlbl ~Aallflrlt~CcNratlle Pencadlya Heddlu Dyfed-?owya, Blwch Polit 09, LJangynnwr, Ceerfylodln, SA31 2PF. Dyfad-~ Palloe Heaclqwirtars, PO Box 99, Uangumor, ~. SA31 2PF. 2nd of May 2023. I write to you in response to your letter, dated the 8"' of March 2023 pertaining to the Keyham Inquest where several recommendations were made. Further to your recommendation, whilst Dyfed Powys Police are assured that our processes are sufflclently robust to ensure public safety, In the interests of transparency and public safety, we will undertake a further review of decision files where firearms have been seized following any Incident and subsequently returned to the holder, in accordance with the parameters as set out In the letter circulated by Chief Constable Debbie Tedda on the 24111 March 2023. In March 2022, a comprehensive review relating to decision making within the Firearms Licensing arena for Dyfed Powys Police was completed. This review was approved by Chief Officers. The review fucused upon on decision making set against the APP and statutory guidance. There has been no requirement identified to make changes since this paper was approved. In respect of matters surrounding training, Dyfed Powys Police engage In available training for Firearms Licensing Staff, however we welcome and support the recommendation of the Coroner to fom,allse a training programme to encompass all Firearms roles and responsibilities. We currently utilise the Firearm Enqurry Officer Course which la offered In West Yorkshire, and Devon and Cornwall. Our supervisors attend Firearms Conferences and CPD events and significant efforts are made to engage on a national basis. Furthermore, staff keep abreast of all national updates, legislation changes and national reports to ensure continuous professional development. I sincerely hope that the Information contained within this letter sufficiently explalns the current position within force, In direct response to your recommendations. Assistant Chief Constable Dyfed Powys Police. @}101)1) 1

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Over the past three years, work has been underway to improve the recording and sharing of IT systems. All firearms licence holders and their addresses have a marker on the Police National Computer, together with the local crime and intelligence system. When any incident, crime report, or intelligence is received involving a firearms licence holder, firearms licence address or any persons linked to that address is recorded within the East Midlands region on our crime and intelligence system, an automatic notification is sent to our firearms licencing team.

All Firearms Enquiry Officers have attended the training course provided by South Yorkshire Police, enhanced further by local internal continuous professional development sessions. The force is also in the process of developing a digital learning package to raise awareness of firearms licensing amongst frontline officers. Members of the Firearms Licensing management team will shortly be attending a two-day event at the College of Policing to debrief the findings of the inquest and identify any learning for inclusion in our local delivery plan.

Derbyshire Constabulary is committed to improving the quality of firearms licensing decision making. One area currently being explored is the possibility of introducing an independent scrutiny panel to further strengthen quality assurance activity.

Finally, in accordance with guidance from the National Police Chiefs’ Council, Derbyshire Constabulary will shortly commence a review of all cases in the last five years where firearms have been seized or surrendered to police pending a review of suitability to have a licence, but then subsequently returned. There will be a staged approach to completion of this task with the most recent decisions being initially prioritised for review. This is a significant undertaking, and our ambition is to complete this work by the end of October 2023.

I hope this provides the necessary reassurance of the commitment of Derbyshire Constabulary to learning the lessons from this tragedy.

A review of all cases, under the criteria within the PFD, for the five-year period, indicates just short of eight hundred that would be considered for review. All of these cases have been reviewed by those with designated decision-making responsibility in line with the guidance and regulations that would have been in place at the time. There is a significant resource commitment that would be required to review all eight hundred cases and I am conscious this may require resources being diverted away from the current FLU business demand.

In order to ensure that our focus is on the areas that may present the greatest risk Norfolk and Suffolk Constabularies will carry out a review in line with the strategy articulated below. This approach would see a significant and meaningful sample of cases being reviewed. If issues of concern are identified, then this will trigger a wider review of cases.

Where certificates are either refused or revoked then access to a firearm can only be achieved through the submission of a further application. This would then require consideration of the application in full as with any other first-time application.

Where firearms are seized as a result of an incident, event or due to information received by police then decisions are taken by those with delegated responsibility as to whether to return the firearm to the certificate holder of to revoke the certificate.

In Autumn 2021 a review of cases between the date parameters of August 2020 and August 2021 was undertaken at the request of the then Home Secretary. The cases reviewed were those in which firearms were seized and returned, but where the certificate was not revoked, and all refused, revoked, and surrendered certificates.

295 cases were identified of which eighty-five were found to be relevant for the purposes of the review. Of these four cases were referred to Superintendent rank with responsibility for Firearms licensing. One certificate was revoked.

Under this review:

1. Those cases that relate to a certificate issued before April 19 will be subject to a full renewal review against the current guidance and regulations within the next 12 months as part of the 5-year renewal cycle. As this will allow a timely approach to review, we do not propose to review these ahead of that process, this will allow us to focus on those cases that are not due a renewal review.

2. Those case between April 2019 and August 2020 will be reviewed.

3. Those case between August 2020 and August 2021 are those already reviewed as articulated above. We will review 30% of these again to understand whether application of the current regulations and guidance would result in different decision making. If this review highlights any concerns, we will conduct a wider review of cases.

4. For those case between August 2021 to Feb 2022, these would have been reviewed having benefited from the learning and approach of the Home Office requested review and therefore benefit from this learning and so we would expect robust decision making has taken place. We will again dip-sample 30% of cases. If this review highlights any concerns, we will conduct a wider review of cases.

5. For cases dating between February 2022 and April 2023, these have been reviewed against the relevant guidance in place at the time. An escalated decision-making process has been in place for tis period and all cases where a n incident or intelligence has led to the removal of firearms has been considered by the Superintendent with responsibility for Firearms licensing. Whilst we remain confident in this approach and the high standard of