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.”
R.(Police Officer B50) v HM Coroner for East Yorkshire and Kingston Upon Hull  EWHC 81 (Admin) (judgment here)
This case raised two very different questions of ‘safety’.
The first, to be decided by police firearms officers:
A man was in the street carrying an axe and walking with purpose. Police were aware the man had at least some mental health illness. He had not injured anyone, or directly threatened anyone. But he did not stop when police asked him to, or indeed after they Tasered him.
How close should police let a mentally ill, unpredictable man with an axe get to other persons on the street? To what extent should police risk their own safety, getting close enough to disarm him? For how long was it safe to permit this scenario to run?
Officer B50 ultimately discharged his firearm into the man’s back. The bullet hit him, but he did not stop. B50 shot a second time, again in the man’s back, and then wrestled him to the ground. Sadly the man died.
The second question of ‘safety’ was for the coroner, and ultimately the Divisional Court:
Was it safe to leave to an inquest jury the option of a conclusion of unlawful killing?
R (Makki) v South Manchester Senior Coroner and Molnar  EWHC 80 (Admin) 20 Jan 2023 (judgment here)
Yousef Makki was only 17 when he died as a result of a single stab wound to the chest from a flick-knife which had been wielded by another 17-year-old, Joshua Molnar during a confrontation.
When Molnar was acquitted of homicide by a criminal jury the Senior Coroner decided to hold an inquest examining the circumstances of the death. After hearing five days of evidence the coroner concluded that there was insufficient evidence to determine whether the killing had been lawful or unlawful, and so returned a narrative conclusion indicating that Yousef had died from “complications of a stab wound to the chest. The precise circumstances in which he was wounded cannot, on the balance of probabilities, be ascertained.” This narrative finding was, to all intents and purposes, an open conclusion.
There is nothing wrong with a coroner being left profoundly unsure at the end of an inquest. A coroner who has ‘striven hard’ to make a finding about the key issues and who explains the basis for arriving at the conclusion that it is not possible to make findings one way or another, will not be criticised for returning an open finding as a result. But the coroner must at very least explain properly why they have come to that position. In this case, however, the difficulty the Administrative Court identified was that the Coroner’s reasoning for her determination was not at all clear. As a consequence the inquest was quashed and is now to be heard again.
Leeson v HM Area Coroner for Manchester South (Donald McPherson & nine other interested parties)  EWHC 62 (Admin). 18 January 2023 (judgment here)
It is a very unusual coronial judicial review that has ten interested parties. Here nine of the ten were insurance companies with whom the bereaved widower, Mr McPherson, had taken out ‘excessive’ insurance on his wife’s life before she was found drowned in an indoor swimming pool in their remote holiday accommodation.
Mr McPherson was charged with the murder of his wife. Clearly relevant evidence at the criminal trial, when deciding between innocent and sinister explanations for his wife’s drowning, included: the £3.5 million he was set to claim in life insurance, alongside his multiple lies about his background; his substantial debt; his deletion from his dead wife’s iPhone of some call, SMS, chat and image records; his wife’s ignorance of the existence of some of the insurance policies; the false witness signatures on some policies; and his lies to subsequent insurers about having pre-existing life insurance.
The criminal trial judge (Goose J) concluded in a formal ruling that the most ‘likely’ explanation for the death, when taking account of all this circumstantial evidence, was that McPherson had caused his wife to drown. However, the same judge also found that the criminal jury could not be sure of this when the medical evidence was that the blunt force injuries to her body could equally have been caused by unlawful force or her husband’s rescue and resuscitation attempts. A half-time submission made twelve days into the criminal trial, therefore succeeded.
In the face of a criminal acquittal Ms Leeson’s father’s only remaining hope was that an inquest might fully explore and determine how his daughter came to be in the swimming pool that evening and whether her injuries arose from rescue attempts or from actions far more malign.
That hope was thwarted, however, when the Area Coroner determined that the scope of the inquest would only cover events between the couple’s arrival on holiday and the day of the death, thereby ruling out any evidence about multiple life insurance policies and much of the other circumstantial evidence pre-and post-dating the holiday that had been explored in the criminal trial.
It is perhaps no surprise that a judicial review claim followed that decision.
Dillon v Assistant Coroner For Rutland & N Leicestershire  EWHC 3186 KB (Admin) 14 Dec 2022, judgment here
Challenging a Coroner’s refusal to issue a report to prevent future deaths (‘a PFD report’) is always going to be an uphill struggle. Whilst there is no coronial discretion, and a report is mandatory, if a coroner determines action should be taken to prevent a risk of future deaths continuing, the Divisional Court has now made clear that before coming to that position there is a significant subjective element.
Before the duty to issue a PFD report arises, first, there must be a concern (arising from the investigation) that circumstances creating a risk of other deaths will occur or continue in the future. Secondly, and significantly, the Coroner must have formed the opinion that ‘action should be taken’ to prevent that risk of death.
The Coroner must act rationally in coming to the opinion held, but different coroners could reasonably come to opposite opinions on the same facts without either being wrong to do so. In other words, there is no single, objectively correct answer to the question raised by the second criterion in any particular case. It is, therefore, no surprise that the Claimant’s challenge failed in this case.