Geoff Gray Inquest: PFD report directed at the Chief Coroner

Inquest into the death of Geoff Gray, 20.6.2019 (Findings of fact)

In what must be a coronial first an assistant coroner has issued a ‘PFD report’[1] directed at the Chief Coroner suggesting he may be able to take action himself to prevent future deaths by issuing guidance to coroners regarding post-mortem investigations after shooting cases.

On 20 June 2019 HH Peter Rook QC[2] concluded the second inquest into the death of Geoff Gray. Geoff was 17 years old when he died from two gunshot wounds to the head at Deepcut Barracks in Surrey in 2001. Evidence heard at the fresh inquest revealed that very soon after Geoff’s body being found the assumption had been made by attending civilian and military police and by the coroner’s officer that Geoff’s death was a suicide. Therefore only a ‘routine’ coronial post-mortem was requested which was performed on the day of the death.

Two earlier deaths of young trainees from gunshot wounds[3] at the same barracks in 1995 were also both investigated with ‘routine’ coronial post-mortems. In one case the post-mortem had been carried out by a general histopathologist, who had no experience of performing an autopsy following a death from high velocity gunshot wounds.

But, as the expert forensic pathologist in Geoff Gray’s case stated,

“shooting cases are not routine…if you make assumptions early on in the investigation, then there is the likelihood, and indeed the probability, that vital evidential material is lost”.

Geoff’s post-mortem

The examining pathologist in Geoff’s case was told that his death was not-suspicious – the post-mortem was therefore one of several conducted in that session. In the course of the PM examination: no photographs were taken; there were no x-rays nor other imaging undertaken; a body map was not drawn; there was no attempt to reconstruct the skull or track the bullets; there was no attempt to match entry wounds to the relevant item of clothing and the clothes were sent for destruction the next day rather than retained for chemographic analysis.

Potentially useful evidence had been lost due to the limited nature of the PM investigation.

Absence of guidance

It seems that there is no specific guidance to either pathologists, or coroners, that urges them to consider the nature of the post-mortem examination in cases of death by firearms, even when that death is of a child.

The assistant coroner’s concern was that where assumptions of suicide lead to cursory post-mortem investigations this creates a risk that homicides will go undetected. The higher the possibility that homicides will be distinguished from self-inflicted deaths, the greater the deterrence to those who might have reason to try to make a murder look like a suicide. The use of a forensic post-mortem, or at very least something more than a basic ‘routine’ examination in all cases of sudden death by gunshot may, by enhancing the quality of investigations and ensuring that assumptions of suicide are properly tested, reduce that risk.

The Chief Coroner and the Royal College of Pathologists, have therefore been asked by HH Peter Rook QC to consider whether there is a need for any amendments to their current guidance to suggest that in cases of death from gunshot wounds, even should the initial evidential inquiries point towards self-infliction, fuller consideration should be given to the nature of the post-mortem examination to be carried out and whether if a ‘routine’ coronial autopsy is chosen should nevertheless be enhanced by: (i) photography; (ii) x-ray or CT imaging; (iii) the clear recording of the presence or absence of projectiles; (iv) drawing body maps; (v) the identification of likely wound tracks; (vi) hand swabbing; (vii) recording of any damage to clothing; and (vii) the preservation of clothing for potential chemographic analysis by others.

It seems likely that this is one PFD where the Chief Coroner will feel it appropriate to publish a copy of the recipient’s response[4].

UPDATE: The Chief Coroner and the Royal College of Pathologists have provided their responses to the report. These can be found here and here.



[1] A coroner’s power to make a report to prevent future deaths or a ‘PFD report’ is an important aspect of the Coroner’s public health role that arises under Paragraph 7, Schedule 5 of the 2009 Act, and reg 28 of the Coroners (Investigation) Regulations 2013.

[2] Sitting as an assistant coroner

[3] Private Sean Benton and Ms Cheryl James

[4] as he is empowered to do under reg. 29 Coroners (Investigation) Regulations 2013.


John Beggs QC and Cecily White of Serjeants’ Inn have represented the Surrey Police at each of the three fresh inquests into the deaths at Deepcut Barracks of Ptes Gray (in 2019), Benton (in 2018) and James (in 2016). Bridget Dolan QC and Jamie Mathieson were Counsel to the Inquest.