Preventing Future Deaths: inquests into the mass shootings in Keyham, Plymouth
On 12 August 2021, Jake Davison killed his mother Maxine Davison at their home. He then shot six members of the public, killing four including a three-year-old child. His shotgun had been licensed to him by Devon & Cornwall Police in 2017 and handed back to him one month before the shootings.
Article 2 inquests into the deaths were held over five weeks in Exeter before HM Senior Coroner for Plymouth, Torbay and South Devon Mr Ian Arrow.
Questioning elicited admissions that the firearms licensing system operated by Devon and Cornwall Police was a ‘dangerous shambles’ which was systematic only in its failure properly to assess risk.
The jury found that each victim had been unlawfully killed and that:
“The death was caused by the fact that the perpetrator had a lawfully held shotgun; the following contributed to this position.
There were serious failures by Devon & Cornwall Police [Firearms and Explosives Licensing Unit (FELU)] in granting and, later, failing to revoke the perpetrator’s shotgun certificate.
In licencing the perpetrator to have a shotgun there was a serious failure by Devon & Cornwall Police to protect the deceased.
There was a failure of Devon & Cornwall Police to have in place safe and robust systems. Foremost, the training of FELU staff, governance of the FELU, quality assurance of FELU staff’s decision-making and ensuring decisions were made at the correct level.
There was a failure by Devon & Cornwall Police FELU staff to obtain sufficient medical information in respect of the perpetrator’s application for a shotgun certificate and also on review.
There was a failure by Devon & Cornwall Police FELU staff to properly seek out and consider all the relevant evidence and information available before deciding whether to grant the perpetrator a shotgun certificate.
Following the perpetrator having assaulted two children in 2020, there was a failure by Devon & Cornwall Police to protect the public and the peace. Firstly, within the Local Investigation Team regarding the [unreasonable decision to charge the assault as battery] and secondly, within the FELU to sufficiently investigate whether it was safe to return to the perpetrator his shotgun and certificate after initially seizing them.
Incorrect application of the [force’s] risk matrix meant there was a serious failure by Devon & Cornwall Police to implement an adequate system to ensure that the decision whether or not to (i) grant or (ii) return a shotgun certificate following review, was made or approved by a manager of sufficient seniority.
A lack of national accredited firearms licensing training has and continues to fail to equip police staff to protect the public safety.
There was a catastrophic failure in the management of the FELU, with a lack of managerial supervision, inadequate and ineffective leadership. This was compounded by a lack of senior management and executive leadership who failed to notice or address the issues.”
On Friday 10 March 2023 HM Coroner sent Preventing Future Death reports to the Home Secretary, all Chief Constables in England and Wales, the College of Policing and the Lord Chief Justice.
HM Coroner identified serious failures by successive governments, the Home Office and College of Policing. He is concerned inter alia that the Firearms Act 1968 is ‘at odds with public safety’, that the 2023 Home Office Statutory Guidance may not reflect risk and that Crown Court judges in firearms licensing appeals may require training (for the first time) on suitability and risk.
Nick Stanage represented the brother and sister of Jake Davison, instructed by Graeme Rothwell of Duncan Lewis solicitors.
Press coverage: BBC, Devon Live, Plymouth Herald, The Guardian, ITV, The Times, The Guardian, BBC
