Recommendations to strengthen firearms licensing controls made following IOPC investigation into Keyham shootings

The Independent Office for Police Conduct (IOPC) has issued a series of recommendations both to Devon and Cornwall Police, and nationally, to strengthen firearms licensing controls following our investigation into the Plymouth mass shooting.

Now the five-week inquests for the victims of Jake Davison have concluded (Monday) with outcomes of unlawful killing, we are able to issue our findings publicly.

At the end of our investigation in March 2022, we submitted our substantial investigation report to the Coroner to help inform the inquest proceedings held in Exeter. We also determined misconduct outcomes for three Devon and Cornwall Police employees we had served disciplinary notices on.

We will now be considering any new evidence that has come to light during the inquest to decide whether any further actions need to be taken by the IOPC.

Our independent investigation began the day after the tragic events unfolded in Keyham, following a referral from Devon and Cornwall Police. We examined the force’s interaction with Jake Davison and others, and the decisions to grant him a shotgun certificate in January 2018 and to return his shotgun to him in July 2021 after it had been confiscated because he was identified as a suspect for assaults on two young people in a park in Plymouth. We examined firearms licensing law and guidance, Jake Davison’s engagement in the Pathfinder scheme, his medical records, education, employment and firearms licensing history, as well as the weapon and ammunition he possessed.

Our recommendations to the force last year included that Devon and Cornwall Police:

• puts in place measures to ensure it is able to monitor certificate holders so that all relevant incidents, information and intelligence are available for continuous assessment of a person’s suitability to possess firearms, in line with policy
• dip samples and reviews a substantial proportion of licensing decisions made by Firearms Enquiry Officers (FEOs) prior to their individual completion of new FEO role-specific training
• issues a further communication to all force Evidence Review Officers (EROs), to the effect that decisions must be made on a case-by-case basis, giving full and appropriate consideration to all aggravating and mitigating factors
• ensures that there is a clear and shared understanding of governance, structures and working practices in the Firearms and Explosives Licensing Unit (FELU).

We have been assured by Devon and Cornwall Police that our learning has been acted on, which we will monitor through our joint meetings. In respect of our force recommendations, we were mindful not to duplicate learning from the Durham Constabulary peer review of the operation of the FELU.

Our recommendations nationally, issued to the Home Office, included the need for clear guidance on checks that should be conducted when assessing applications, removing any distinction between requirements for firearms and shotgun certificates, that referees must have recent knowledge of an applicant, and that interviews with family members or cohabitees should be carried out where a certificate holder is involved in a violent offence. We are continuing to consult the Home Office over implementation of the measures for the police service in England and Wales.

In respect of outcomes for individuals, we found that a firearms licensing supervisor (FLS) had a case to answer for misconduct for failing to ensure Jake Davison’s shotgun certificate application was correctly risk assessed, and for failing to ensure that Jake Davison could be permitted to possess a shotgun without danger to public safety. The individual received a written warning at a misconduct meeting held by the force.

We found that a firearms enquiry officer (FEO) would have had a case to answer for misconduct, had they still been serving, for failing to make adequate enquiries as part of a case review following the September 2020 park assaults, and failing to correctly risk assess Jake Davison. The FEO retired from the force in 2021 so no disciplinary proceedings could be brought. We found no case to answer for the same FEO in respect of their handling of the application for a shotgun certificate in 2017, as evidence indicated that shortcomings were largely attributable to a lack of training, supervision, and inadequate force processes.

We found that the officer in charge (OIC) of investigating the park assaults had no case to answer for misconduct in respect of the allegation that they failed to notify the FELU of Jake Davison's involvement in a violent offence, and/or failed to take any steps to seize his shotgun, certificate or ammunition. The evidence here pointed to systemic issues around guidance and training, rather than an individual failing.

In September 2022, the IOPC began an investigation into Devon and Cornwall Police for potential breaches of health and safety legislation in the running of its Firearms and Explosives Licensing Unit prior to the mass shooting. This further, separate investigation follows consideration of the evidence gathered in our first investigation and specialist legal advice. Our criminal investigation is examining whether the Office of the Chief Constable of Devon and Cornwall Police, as corporation sole, may have committed any offences contrary to the Health and Safety at Work etc. Act 1974. The police force, the Police and Crime Commissioner, the Coroner and families were advised of our decision. Our investigation remains ongoing.

IOPC Regional Director David Ford said: “I again send my heartfelt sympathies to the families of those who died, to those injured, and everyone so deeply affected by the horrific tragedy in Keyham on 12 August 2021. Our role has been to independently and thoroughly examine the police decisions taken to originally grant Jake Davison a shotgun certificate and then to return his certificate and weapon shortly before he killed his mother Maxine and went on indiscriminately to take the lives of Stephen Washington, Kate Shepherd, Lee Martyn and his daughter Sophie, and injure mother and son, Michelle Parker and Ben Parsonage.

“It has become obvious to all in light of the atrocity that Jake Davison should never had been allowed to possess a shotgun. Evidence given at the inquests has clearly demonstrated the impact this incident has had, and continues to have, for the families, friends, and the community as a whole. Our task has been to consider the actions and decision making of police personnel based on what they knew or should have known, given the information available at the time.

“While we found cases to answer for misconduct for two Devon and Cornwall Police employees, we determined that failings by individuals were substantially mitigated by weaknesses in force systems, processes, training, and the departmental resources and culture then in place. The potential corporate failing of Devon and Cornwall Police as an organisation is subject to our separate criminal enquiry into possible health and safety breaches.

“Devon and Cornwall Police accepted our recommendations last year and fully co-operated with our investigation. We have also been in liaison with the Home Office over our recommendations at a national level to help inform improved firearms licensing arrangements and guidance for the police service as a whole.

“The terrible events in Plymouth that day remain understandably raw in many people’s minds. It is vital that meaningful change is implemented to help police personnel responsible for firearms licensing make safe and sound decisions. Those changes are aimed at reducing the risks of a tragedy like this happening again.”

The IOPC is today publishing a summary and learning report from our independent investigation available here. The report reflects the evidence that we obtained during our investigation.