In the wake of the Keyham Shootings inquest, can we now feel safe from those in lawful possession of shotguns?

The Keyham Shootings inquest recently concluded with damning findings levelled at Devon and Cornwall Police (‘DCP’), and the Home Office. Indicative of the serious ongoing risks to life posed by the current system of gun licensing, the Senior Coroner has now issued no less than 5 Reports to Prevent Future Deaths.

Clare Evans who represented one of the family members at the inquest, considers whether the current system of gun licensing is fit for purpose.


On 12th August 2021, Jake Davison was the perpetrator of a mass shooting in Keyham, Plymouth. First he shot and killed his mother. He then proceeded to shoot 6 people unrelated to him, killing 4 of them, including a young child. Jake then proceeded to shoot and kill himself.

Jake was lawfully in possession of the pump-action shotgun used in the killings. DCP had first considered his application and granted his shotgun licence, in 2018. This was in the knowledge of his self-declared conditions of Asperger’s Syndrome and Autism, of his past history of escalating violence, and of his attendance as a child at a school for children with special educational needs.

In September 2020, Jake violently assaulted 2 children in an unprovoked attack in a park. He admitted his guilt. However, despite having a firearms ‘marker’ on his police records, the police dealing with the criminal investigation failed to notice this. It was a different team who later came to deal with Jake, that noticed the marker in late November 2020. It was only in early December that the police seized Jake’s shotgun and licence.

From there, Jake’s suitability to continue as a licence-holder was reviewed by DCP. In July 2021, one month before the tragedy which ensued, DCP returned Jake’s shotgun and licence to him.

Public Safety is paramount

At the heart of any police gun licensing decision, is the need to protect public safety. For this reason, the Home Office Guidance on Firearms Licensing Law states:

GB firearms policy is based on the fact that firearms are dangerous weapons and the State has a duty to protect the public from their misuse. Gun ownership is a privilege, not a right”.

For this reason, the police are expected to apply an enquiring mind to the assessment of an applicant’s suitability. They should not make assumptions or take all information received at face value. Throughout their investigation, they should remain ‘professionally curious’.

Unfortunately, the reality revealed in this inquest, is that gun ownership was treated as more of a right than a privilege in Devon and Cornwall. What’s more, some of the failures highlighted are seemingly not unique to DCP.

Keyham Shootings Inquest findings

Some of the key conclusions of the jury at the Keyham Shooting inquest, are illustrative, and include that:

  • There was a ‘catastrophic failure’ in the management of the DCP Firearms and Explosives Licensing Unit (‘FELU’) at DCP, with a:
  • lack of managerial supervision; and
  • inadequate and ineffective leadership
  • DCP failed to have in place safe and robust systems. Foremost, in respect of training, governance, quality assurance of decision-making, and ensuring decisions were made at the correct level within DCP FELU.
  • There was a failure of DCP FELU staff to obtain sufficient medical information in respect of Jake’s application for a shotgun licence, and in respect of the later review of his suitability to possess a shotgun licence.
  • DCP FELU staff failed to properly seek out and consider all relevant evidence and information available as to Jake’s suitability to possess a shotgun licence, before deciding whether to grant the licence.
  • The DCP FELU’s own ‘risk matrix’ was incorrectly applied by both junior and senior staff. This represented a serious failure to implement an adequate system to ensure that decision-making was made or approved by a manager of sufficient seniority
  • A lack of nationally accredited firearms licensing training has and continues to fail to equip police staff to protect public safety.

The jury also noted the following relevant circumstances in the lead up to the tragedy:

  • There was a lack of scrutiny and ‘professional curiosity’ at all levels when it came to firearms licensing decision-making.
  • There was a seriously unsafe culture within the DCP FELU. The default position appears to have been to grant the licence, or return it after a review.
  • Accordingly, particularly following the serious assault in 2020, DCP failed to protect the public by allowing him to have a shotgun. They had not sufficiently investigated whether it was safe to do so.

The police decision-making in the context of Jake’s background, was shocking on any view. But it is suspected that there are many more cases where thoroughly unsuitable individuals have been entrusted with a gun. The potential to slip through the net is too high. That will likely remain the case unless and until wide-ranging changes are made at both a local and national level.

History of concerns (before the Keyham Shootings inquest)

The following history is also relevant:

  • In 1996, after the Dunblane tragedy, Lord Cullen’s report made the following recommendation:
    • Enquiry officers should be given as much training and guidance for their work as is practicable’.
  • Since then, despite multiple other similar recommendations, lessons still have not been learnt. In 2015, for example, the HMIC ‘Targeting the Risk’ inspection report again raised concerns over lack of training nationally. It stated:
    • ‘On too many occasions, the police are not following the Home Office guidance or the Authorised Professional Practice. And, the guidance and practice in many respects are inadequate, allowing room for interpretation and the creation of inconsistency in the way firearms licensing is undertaken within and between police forces… Often, forces are working outside the Home Office guidance and the Authorised Professional Practice and they are sometimes inexcusably compromising public safety... We cannot make our position any clearer: it is now for others to accept the need for change. If they do, perhaps the life of the next victim of firearms misuse might be saved. What is highly likely is that, if change is not effected, there will be another tragedy”.
  • Yet in spite of this chillingly-accurate prediction, the Home Office Guidance amended in 2016 (no longer current) still made no mention of the need for accredited or even non-accredited training.
  • Even today, some 8 years later, accredited training for those charged with making firearms licensing decisions does not exist.
  • Accordingly, the Senior Coroner takes the view that the risk to life will continue until action is taken.

Preventing Future Deaths Reports

After hearing the jury conclusions, the Senior Coroner confirmed he would be preparing several ‘Reports to Prevent Future Deaths’ (‘PFD reports’). He believes there are continuing risks to life if changes are not made.

Some of the concerns he sets out in his 5 PFD reports include:

  • Training –  the Coroner states:
  • I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licensing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieving consistency and driving up standards.
  • “I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision-making authority regarding issuing firearms licenses to a person who has undergone adequate training.
  • “…I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years”.
  • Need for further review of past licensing decisions (all police forces in England and Wales) –
  • given the dearth of training to FELU staff nationally, the Senior Coroner remains concerned that in all police force areas, weapons may remain in the hands of individuals who pose a danger to the public. This is because 41 out of the 43 police forces in England and Wales have confirmed to the Home Secretary relatively recently, that upon reviewing their firearms licensing decisions over a 12-month period, they found no incorrect decisions were made to return gun licences after a decision had been made to refuse, seize or revoke the person’s licence, or where a person had voluntarily surrendered it. A Chief Superintendent giving evidence at the inquest felt it unlikely that that was the true state of affairs.
  • The Coroner’s view is that a review of such decisions over the past 5 years may be required to be assured of public safety (licences are valid for 5 years at a time).
  • Misunderstanding of the law / guidance on firearms licensing:
  • Some of those making firearms licensing decisions appear to be applying the law incorrectly. They appear only to take a piece of background information into account, if it is more likely than not that the allegation was true. For example, a domestic violence allegation where the applicant was never charged. This is something which a police officer absolutely should consider, along with all of the other information gathered. They cannot form an accurate view as to whether someone is of ‘intemperate habits’, without doing so.
  • Potentially huge amounts of relevant information regarding an applicant’s suitability, may already therefore have been disregarded.
  • The latest version of the Home Office Guidance on firearms licensing (amended in 2023) confuses the position further, providing contradictory guidance on how to treat the information gathered.
  • The Coroner is concerned that the Home Office Guidance is misleading. The correct position is that an assessment of suitability should be based on the totality of risk information available.
  • The Coroner’s concern applies equally to judges hearing appeals of licensing decisions.
  • Referees:
  • each shotgun application requires one referee to be contacted, to provide a reference as to suitability. In this inquest, Jake’s referee had not been asked for and did not volunteer information regarding Jake’s propensity to violence.
  • Concern - the public remain at unnecessary risk whilst there is no national guidance as to the nature and form of referee enquiries.
  • Medical records:
  • Concern - there is no mandatory requirement for medical records to be updated with a ‘firearms reminder’, on a unified system. A reminder would flag up the fact that a patient is a gun licensee, whenever their notes were opened. The should prompt the medic to contact the police if the patient began to suffer from a ‘relevant medical condition’.
  • Without this, the concern is that important information will not come to the attention of the police. For example, if a certificate holder begins to suffer from a mental health condition.
  • The Coroner is concerned that the 1968 Firearms Act is outdated:
  • Firstly, it creates a presumption licences ‘shall be granted’, unless the various requirements are not met. This is at odds with public safety and the fundamental principle that gun ownership is a privilege, not a right.
    • Better protection may come from the wording ‘shall not be granted’.
  • The statutory distinction between ‘firearms’ and ‘shotguns’ contributes to the impression that shotguns are less lethal. Hence the application for a shotgun licence demands less rigour.
    • In the Coroners view, it may be appropriate to harmonise the treatment of shotguns and firearms.
  • There is no power for the police to enter private premises to suspend a firearm or shotgun certificate, pending a review. They are required to obtain a warrant.
  • It is not possible to impose conditions on the grant of a shotgun licence. Contrast this with the position in Northern Ireland. There, conditions can be imposed, for example, on a first-time applicant’s licence, that they only use their weapon under the supervision of an experienced licensee. Had Jake’s gun been stored at someone else’s home, the unlawful killings may have been avoided.


In conclusion, there is much work to be done at both a local and national level, before we can feel truly safe from those lawfully in possession of guns. Until those making firearms licensing decisions are adequately trained, the potential remains for dangerous applicants to slip through the net. Fatal shootings are thankfully rare in this country. However, the potential for harm goes much wider than death. One can easily imagine the fear invoked in victims of domestic violence, where the abuser is a licensed gun owner.


    How can we help?

    Please fill in the form and we’ll get back to you as soon as we can

    We have partnered with Law Share from JMW Solicitors LLP to refer instructions and clients to them, when we are unable to act. By answering yes to this question, you agree that we may pass your details on to Law Share in such circumstances. You are under no obligation to instruct JMW Solicitors LLP after being referred. We may receive a payment from JMW Solicitors LLP further to this referral.