“Root and branch reform” of firearms legislation and training required

The Senior Coroner for Plymouth, Torbay and South Devon has issued five ‘Prevention of Future Deaths’ (‘PFD’) reports (see here) calling for “root and branch reform of firearms legislation and training following the shooting of seven innocent people by Jake Davison with a legally-held shotgun in Plymouth in 2021.

The Senior Coroner, Mr Ian Arrow, concluded the five-week inquests into five victims’ deaths in February 2023 at which the jury not only found “catastrophic failures” by Devon and Cornwall Police but also noted confusing Home Office Guidance. The jury recorded a “serious failure at a national level” by the government, Home Office and National College of Policing to implement the recommendation from Lord Cullen’s Report in 1996 arising out of the fatal shootings in Dunblane. The jury considered that “a lack of national accredited firearms licensing training has, and continues, to fail to equip police staff to protect the public safety.”

‘Abject failures’ have persisted for 27 years

The Five PFD reports are variously directed at the Home Secretary, Suella Braverman MP, Chris Philp MP, the Minister of State for Crime, Policing and Fire, as well as all Chief Constables in England and Wales and, unusually, the Lord Chief Justice in respect of judicial training regarding firearms appeals.

In his report directed at the dearth of adequate training Mr Arrow notes that, since Lord Cullen’s 1996 recommendation regarding the need for training after Dunblane, there have been two coronial PFD reports issued following shotgun killings (by the  Senior Coroner for Durham in 2013 and Senior Coroner for Surrey in 2019) both of which highlighted the absence of training. This still has not led to adequate training being available to firearms licensing staff.

“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…..If any lessons had been learned in the aftermath of earlier tragedies, they have been forgotten and that learning had been lost.”

The Senior Coroner’s concerns are now raised with:

The Home Secretary regarding the adequacy of the current firearms legislation, Home Office Guidance and the requirements for police staff training;

Chief Constables in England and Wales are informed of the Senior Coroner’s concern about the lack of accredited training for their staff and invited to consider a further review of gun licences approved over the past five years;

The College of Policing is told of the Senior Coroner’s concern that, despite the repeated recommendations being made over the past 27 years, there remains an urgent need to develop a national accredited training for Firearms and Explosives Licencing Unit staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence;

The Lord Chief Justice is informed of the Senior Coroner’s concern that there may be a need for specific training of those judges who hear firearms appeals in how to apply the recently re-issued statutory guidance for firearms licensing and in the conduct of suitability assessments.


The purpose of a PFD Report

PFDs are vitally important if society is to learn from deaths. They are made for the benefit of the public and should be intended to improve public health, welfare and safety.

The coroner’s power to issue a PFD report arises under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009, and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, where an investigation gives rise to concern that future deaths will occur, and the investigating coroner is of the opinion that action should be taken to reduce the risk of death, the coroner must make a report to the person they believe may have the power to take such action. The PFD report need not be restricted to matters causative (or potentially causative) of the death in question, but may shed light on a system failure that has regional or even national implications.

A prevention of future deaths report raises issues and is a recommendation that action should be taken, but it may not dictate what that action should be. The latter is a matter for the person or organisation to whom the PFD report is directed.  The coroner can not require any particular step to be taken.

The recipient of the report must respond within 56 days. In the present cases, that will be by 3 May 2023, unless the coroner extends the period for response.



Bridget Dolan KC was instructed as Counsel to the Coroner at the five-week hearing.

Dijen Basu KC and Aaron Rathmell represented a current lead officer of the National Police Chiefs’ Council.

Edward Pleeth represented the Independent Office for Police Conduct.


“Bridget Dolan KC, the diligent and highly-skilled counsel to the inquest, left no stone unturned in her efforts to help the jury understand not just the incident in Keyham, not just the failings which led up to it, but the wider context of firearms licensing; policing in the time of Covid; mental health services; domestic violence; government legislation; primary care; special educational needs; and much more besides.”   ITV News (here)