Emma Favata represented Robert Chapman, brother of Maxine Davison and uncle of Jake Davison in the inquest, instructed by Clare Evans of Saunders Law.
The final inquest hearing into the tragic deaths of Maxine Betty Davison, Lee Raymond John Martyn, Sophie Iris Martyn, Stephen John Godfrey Washington and Katherine Jane Shepherd, killed by gunman Jake Davison, commenced on 17 January 2023. After a five-week inquest, the jury concluded Jake Davison's five victims were unlawfully killed after a series of police failings.
The Senior Coroner for Plymouth, Torbay and South Devon, Mr Ian Arrow, assisted by Counsel to the Inquest Bridget Dolan KC investigated these deaths in front of a jury.
The jury's conclusion in respect of each death under Section 4 of the Record of Inquest was as follows:
‘The deceased was unlawfully killed.
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 and Cornwall Police 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 and Cornwall Police to protect the deceased.
There was a failure of Devon and 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 and 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 and Cornwall Police to protect the public and the peace. Firstly, within the Local Investigation team regarding the downgraded charge 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 risk matrix meant there was a serious failure by Devon and 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."
The Senior Coroner for Plymouth, Torbay and South Devon, Mr Arrow, released a Prevention of Future Deaths (PFD) report on 8 March 2023 which includes the conclusion of the jury. This was sent to the Home Secretary, all Chief Constables in England and Wales, the College of Policing and the Lord Chief Justice.
In the report, Mr Arrow outlined his concerns:
"Evidence I heard at these inquests revealed that numerous recommendations arising from previous inquiries and reviews regarding the training of police officers and police staff involved in firearms licensing decisions had not been put into effect. This is not a new concern but one that has previously been raised by at least two other coroners in earlier ‘Prevention of Future Deaths’ reports in other coronial jurisdictions. If any lessons had been learned in the aftermath of earlier tragedies, they have been forgotten and that learning had been lost. I was told that all Chief Officers of police ought to be satisfied that they only delegate their authority to issue and revoke firearms and shotgun licences to appropriately trained and skilled personnel. However, 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."