Keyham shootings: recommendations made to Devon and Cornwall Police

Letter information

From
Wendy Williams CBE
His Majesty’s Inspector of Constabulary
His Majesty’s Inspector of Fire & Rescue Services

To
The Rt Hon Suella Braverman KC MP
Home Secretary

Cc
Alison Hernandez
Police and Crime Commissioner

Chief Constable Debra Tedds
National Police Chiefs’ Council Lead for Firearms and Explosive Licensing

Sent on
28 July 2023

Background

I write in response to your letter dated 24 April 2023 concerning the tragic events in Plymouth on 12 August 2021.

As requested, HMICFRS has undertaken an urgent review of the progress Devon and Cornwall Police has made in relation to: the recommendations issued by the Independent Office for Police Conduct (IOPC) in its Operation Begna report; and the comments made by Mr Ian Arrow, Senior Coroner, in section 3 of his Prevention of future deaths report.

The review considered: the leadership and governance of the force’s firearms and explosives licensing unit (FELU); the policies and processes used by the force, and how this affects decision-making; the resourcing of the FELU; and the training provided.

As part of the review, we have:

• conducted national interviews with the National Police Chiefs’ Council (NPCC) lead for firearms licensing, the College of Policing and the Home Office;
• reviewed national data, documents and guidance;
• reviewed 136 documents provided by the force;
• completed 105 firearms licence case file reviews; and
• conducted 20 interviews and focus groups with personnel from Devon and Cornwall Police.

In April 2023, the force conducted its own internal review of firearms licensing matters. Many of our findings reflect the findings in the force’s review.

Summary

The force has implemented four of the five IOPC recommendations. The force doesn’t agree with the wording of recommendation 4, which relates to guidance to evidence review officers (EROs). We are satisfied that the force is entering into constructive dialogue with the IOPC, putting forward a strong case for its disagreement.

We also consider that the force has made substantial progress in relation to almost all of the comments made by the coroner.

While we are generally satisfied that the force has a sufficiently strong focus on public safety in relation to firearms licensing, we do have some concerns. These relate to the backlog of applications for licences and renewals, and the force’s extraordinarily high reliance on the issue of temporary permits.

These permits create inefficiency because they must be renewed frequently. And the level of checks required for the issue of a temporary permit isn’t as extensive as for the issue of a licence or renewal.

Leadership and governance

We found there was a clear governance structure in the FELU. There is active involvement by senior officers and supervisors in the day-to-day management of the unit. The staff we spoke to understood their roles within the unit and who their leaders were.

At the time of the inspection, the force was still in an alliance with Dorset Police for firearms licensing. However, in April 2023 the force took the decision to separate from this alliance. It hasn’t yet implemented this decision. This creates the opportunity to simplify the force’s processes for firearms licensing.

There is a good structure of governance meetings that provides oversight of firearms licensing matters. Despite this, we found limited evidence of performance management arrangements or strategic priorities that the unit was working to.

The force needs to introduce strategic priorities for the FELU and to make sure there is a performance framework to monitor progress against these.

IOPC recommendations and coroner’s comments

Recommendation 5 from the IOPC report states:

“The IOPC recommends that Devon and Cornwall Police ensures that there is a clear and shared understanding of governance, structures and working practices in the Firearms and Explosives Licensing Unit (FELU).”

We consider that recommendation 5 has been implemented.

The coroner, in his report, referred to a “catastrophic failure in the management of the FELU”. The force has made significant progress in this area with new management structures.

However, due to the lack of strategic priorities and the use of temporary permits, the force needs to do more. The introduction of a performance framework would go some way to addressing this.

Policies and processes, and decision-making

The use of temporary permits and licence extensions

As of 19 May 2023, the force had responsibility for the largest number of firearms licences of all forces in England and Wales. This, coupled with the changes it needed to introduce after the tragic events in Plymouth, has placed significant demands on the force.

At the time of our inspection, the force had 3,698 temporary permits out of a combined total of 37,885 licences and permits. During our review, it was apparent that the force was using extensions and temporary permits to manage its demand.

Section 7 and section 28B of the Firearms Act 1968 give chief constables the power to issue temporary permits or extensions to firearms licences. Statutory guidance for chief officers of police on firearms licensing makes it clear that forces should only use these powers in “exceptional” circumstances.

Another firearms licensing unit in a different part of England and Wales, which had responsibility for approximately 35,000 firearms licences, had granted only 10 temporary permits. Most forces have very low numbers of temporary permits.

Statutory guidance is explicit: “Chief officers should also avoid routinely using temporary permits as a means of managing licensing caseloads within their force.”

Devon and Cornwall Police’s use of temporary permits to manage demand goes against statutory guidance and must stop.

Backlogs remain a significant challenge

At the time of our review, the force had a substantial backlog of applications for renewals of firearms licences.

We found the reasons for the backlog included:

• inefficient processes;
• inappropriate issuing of temporary permits, distracting from the effective processing of renewals;
• the force not taking legitimate opportunities to reduce demand; and
• unreliable legacy IT systems.

Inefficient processes

Following the tragic events in Plymouth, the force implemented a policy that prevented firearms enquiry officers (FEOs) from making any decisions relating to the issuing of licences until they had completed relevant training and a ‘competency portfolio’. Meanwhile, supervisors took responsibility for all decisions.

The force recognised that this policy would have an adverse effect on the length of time taken to process applications. However, it demonstrates the force’s clear intention to put public safety first.

The force intended that this would be a temporary measure and that, on completion of the training and portfolio, FEOs would be authorised to make decisions on low-risk applications. But this approach has, in many cases, remained in place.

We found that suitably qualified staff were still having their decisions verified by supervisors, even in straightforward, non-contentious cases. This has created an unnecessary burden for FELU supervisors and has resulted in an inefficient and bureaucratic system for processing applications.

We also found evidence that administration staff and FEOs were working in isolation, resulting in duplication of effort. For example, when the FELU received an application or renewal for a licence, the administration staff conducted initial background checks on the applicant. The application was then allocated to an FEO, but some weren’t progressed for months, which meant that administration staff had to repeat the checks as the results were no longer valid.

Inappropriate issuing of temporary permits

The force’s use of temporary permits is inefficient. Background checks are required each time a licence is issued. Normally the licence would last five years, however temporary permits issued by the force are for a much shorter period. In most cases we reviewed, a temporary permit was valid for only six months, requiring a background check each time.

This is especially problematic where temporary permits are repeatedly issued to the same applicant over lengthy periods.

The tragic events of 12 August 2021 have understandably resulted in the force increasing its scrutiny of decisions when issuing firearms licences. The additional supervision has resulted in lengthy delays. One officer told us, “Clearly the balance has swung too much and requires a reset.” The delay in processing renewals also presents a potential risk to public safety. The force should complete a review for each stage of the firearms licensing application process to identify inefficiencies and help with demand management.

The force isn’t taking legitimate opportunities to reduce demand

The statutory guidance states: “The onus for making a timely application for the renewal of a certificate… rests with the holder.” We saw evidence of licence holders failing to submit their applications within the required timescale and yet the force still issued temporary permits. If the force doesn’t receive applications within the correct timeframe, with all the correct documentation, a temporary permit shouldn’t be issued. Instead, the licence holder should lodge their weapons until the force can process their renewal.

Unreliable legacy IT systems

The force has moved from UNIFI to Niche as its records management system. This helps the force to record both the names and addresses of licence holders on a single force‑wide system. These details are now visible to operational personnel.

As a result of adopting Niche, the FELU now receives an automated email notification whenever a licence holder comes to notice within the force area. We therefore consider the force now has a process for continually assessing a person’s suitability to possess a firearm in line with authorised professional practice on firearms licensing.

The force is in the process of migrating all firearms licensing records on to Niche with a target date of completion by June 2024. Until then, the force remains partly reliant on its legacy IT system to manage licence applications. Many of the personnel we spoke to had concerns about the reliability of this old system. Examples given included duplicate entries, case reviews disappearing and an inability to extract performance data.

IOPC recommendations and coroner’s comments

Recommendation 1 from the IOPC report states:

“The IOPC recommends that Devon and Cornwall Police amends UNIFI to enable markers for both shotgun and firearms certificates to be added to individual nominals as well as to addresses.”

We consider that recommendation 1 has been implemented.

Recommendation 2 from the IOPC report states:

“The IOPC recommends that Devon and Cornwall Police puts in place measures to ensure it is able to monitor certificate holders to ensure that all relevant incidents, information and intelligence are available for continuous assessment of a person’s suitability to possess firearms, in line with Authorised Professional Practice (APP) on Firearms Licensing.”

We consider recommendation 2 has been implemented.

The coroner, in his report, wrote: “Incompatible IT systems both within Devon and Cornwall Police and outside agencies contributed to a failure to communicate effectively.”

During this inspection we only reviewed IT systems for Devon and Cornwall Police. We didn’t include the compatibility of other agencies’ systems. We are satisfied that Devon and Cornwall Police has made progress in this area by its transition to Niche, a more integrated system. The force plans to have fully implemented this by June 2024.

Use of the risk matrix

In August 2021, the force used a risk matrix to assist in assessing suitability for an individual to hold a firearms licence. The matrix categorises applications into high, medium, and low risk. Not all forces use a risk matrix.

At the time of our inspection, we found that senior officers considered applications that had been identified as high risk. Inspectors consider those deemed to be medium risk. Supervisory oversight of these high-risk or medium-risk cases is carried out to a consistently good standard, with effective decision-making and risks identified and mitigated.

The consistent use of the matrix was scrutinised during the inquest. Although the matrix is still available for FELU staff, the force doesn’t mandate its use. Instead, it is left to the discretion of individuals. We found personnel were aware of how to use the matrix but they were divided about its benefit.

In his report, the coroner referred to “a dangerous lack of understanding on the part of the Devon and Cornwall Police FELU staff regarding the use and application of the FELU risk matrix.”

During our inspection we found personnel understood how to use the risk matrix. If Devon and Cornwall Police is going to continue to use the matrix, it should make sure the matrix is used consistently.

In addition, the coroner also referred to “a serious failure within the Firearms and Explosives Licensing Unit (FELU) to heed and apply the 2016 Home Office guidance, that high risk decisions on grant of a licence should be made by the Firearms Licensing Manager.”

In the cases we reviewed, we found that senior officers and staff now made decisions in high-risk cases, in line with statutory guidance.

Decision-making and dip sampling

We found the force was more robust in its decisions to refuse firearms licences than it had been in the recent past. The coroner, in his report, referred to “a lack of scrutiny and professional curiosity”. From the case files we reviewed, we were pleased to find a culture of curiosity and motivation to thoroughly assess the appropriateness of applications.

In the year ending 31 March 2021, the force refused only 0.8 percent of new firearm licence applications. This was lower than the refusal rate of 2.5 percent across all forces in England and Wales. However, by the year ending 19 May 2023, the force’s refusal rate had risen to 7.0 percent, higher than the rate across all forces of 3.7 percent.

FELU personnel told us that the force dip sampled one in every five cases, but we didn’t find any written evidence of this being force policy. Nor has the force provided any guidance on how personnel should record dip sampling and make improvements.

During our case file review, we found supervisors’ comments in nearly all cases. Arguably, this would make dip sampling unnecessary and time-consuming. The force needs to get the balance right between supervisory oversight, including dip sampling, and having confidence in those staff who are trained and competent. This will make decision-making more efficient and keep the public safe.

We believe the force should clearly document the policy for dip sampling and rely on this as the primary means of assessing the quality of the decision-making of accredited staff.

IOPC recommendations and coroner’s comments

Recommendation 3 from the IOPC report states:

“The IOPC recommends that Devon and Cornwall Police dip samples and reviews a substantial proportion of licensing decisions made by Firearms Enquiry Officers (FEOs) prior to their individual completion of FEO role-specific training.”

We consider recommendation 3 has been implemented.

The coroner wrote: “There was a lack of scrutiny and professional curiosity at all levels. The ineffective auditing and governance of the FELU in place led to an inadequate system of dip sampling, qualitative assessment of staff’s decision-making, and learning from the results of the same.”

The force has made substantial progress in this area, with high levels of supervision. But it could do more with a clear policy on dip sampling that identifies learning and promotes improvements in decision-making.

In addition, the coroner wrote: “There was a seriously unsafe culture within the FELU of defaulting to granting licences and to returning licences after review.”

We are satisfied that the force now makes more robust decisions on firearms licensing, refusing more applications.

The force’s strategic plan

Prior to our review, the force didn’t have a clear plan for how it intended to reduce the significant backlog.

On 22 May 2023, the force provided us with an outline plan that the chief officer team had agreed. The force told us it was still developing the detail of the plan, which would be implemented by the middle of June 2023, and that the backlog would be cleared by December 2024.

As the plan was still in development at the time of our review, we can’t provide any assurance that the force will meet this objective by December 2024.

Resourcing

Investment in the FELU

The force has increased the number of posts in the FELU from 45 to 99. It has significantly invested in supervisory roles. Some of the additional staff have come from an investigative background, which has helped promote a change in culture to one of professional curiosity.

Although this is positive, at the time of our review the FELU still had a high number of vacancies in administrative roles. Staff told us this was due to the low pay grade compared to the level of responsibility.

The coroner, in his report, stated: “Budgetary limitations and staff shortages within Devon and Cornwall Police increased the probability of risk being incorrectly assessed which led to unsafe licences being issued.”

The force has addressed this comment in relation to staffing and budgetary limitations.

Case file review

We reviewed 105 firearms licensing cases. These included cases where firearms had been surrendered, seized, returned and revoked, as well as new and renewal applications, and temporary permits. We also considered the FELU’s communication with referees and use of medical information.

Surrendered, seized, returned and revoked

Of the ten cases in this group, we found in nearly all there had been effective decision‑making by the force, with relevant risks considered and mitigated. The recommendations made by the officer conducting the review, and the decisions of senior officers for the return of the firearms, were clearly recorded with supporting rationale. We found one case where we disagreed with the decision. We also felt that in this case there was too much oversight and additional work required, creating an unnecessary burden on the system. We referred this case to a senior officer for review.

We reviewed five cases where the force had taken the decision to revoke licences in response to trigger events. In all cases, there had been prompt action taken by the FELU to correctly revoke certificates, with professional curiosity evident.

Grants and renewals

We reviewed 15 grant applications and 15 renewal applications. We found relevant enquiries were completed, and any issues identified were subject to further scrutiny.

Temporary permits

We reviewed 60 cases where temporary permits had been issued. We found the force routinely used temporary permits to manage demand, contrary to statutory guidance.

In our review, we found that 53 temporary permits had been issued to 43 individuals after their certificates or previous temporary permits had expired. This means these individuals may have been in possession of firearms without a valid certificate, which makes possession unlawful.

We found seven cases where the force had received renewal applications less than eight weeks before the expiry of the relevant licence. This is outside the timescale permitted by section 28B of the Firearms Act 1968, but the force still issued a temporary permit, in most cases without any recorded justification.

Referees and medical checks

During the review of these files in relation to applications and renewals, we saw cases where FELU staff contacted referees to explain what was expected from them. In addition, medical checks were carried out and formed part of the decision-making in line with guidance.

In his report, the coroner wrote: “The referee’s tasks and responsibilities were not made clear.” He also referred to the force not conducting effective medical enquiries.

From the interviews and case files we reviewed for applications and renewals, we are satisfied that Devon and Cornwall Police is now complying with the current guidance in relation to referees and to obtaining medical information.

The coroner requested all forces review all certificates seized, refused, revoked or surrendered and then approved over the past five years. The force responded to the coroner on 3 May 2023 (PDF document), stating that it had reviewed all cases since January 2020. Taking the five years from the date of its response, the force said it would now review all such cases from May 2018 to 31 December 2019, inclusive. The force said this would be completed by October 2023.

Training

The force has made good progress in developing training for FELU personnel. The unit has a dedicated training lead who has developed a training plan.

There is no national firearms licensing course at present. The Home Office has agreed funding for the College of Policing to introduce such a course, but there is no start date yet.

South Yorkshire Police has its own firearms licensing training capability and Devon and Cornwall Police has used this to train its FELU personnel. Over the past 18 months, 92 people have received a 3-day training course. Supervisors and administrative staff have been given additional online training, and the force has introduced a competency portfolio for all FEOs. Staff have also received continuing professional development, such as training from a barrister in court presentation skills and training on neurodiversity.

We consider this to be a positive development. But we would encourage the force to centralise the training records and improve the signing-off process for FEO portfolios. This would enhance the system it has introduced. When the national training for FEOs is agreed, the force should make sure that the training given to its FEOs is consistent with all aspects of the CoP training.

The training and guidance provided to personnel outside the FELU could be improved

FELU senior management and the training lead have made considerable efforts to provide training to operational personnel outside the FELU, including force incident managers, supervisors and new recruits. But the force learning and development department doesn’t provide any co-ordination of this training. As a result, it takes place only when the opportunity arises in otherwise busy training timetables.

This training would benefit from more formal monitoring. For example, the force told us that new EROs had been given training on firearms licensing, but we found there were EROs who had yet to be trained. Given the prominence of EROs in the IOPC report and the inquest, we would encourage the force to make sure all EROs have received training on firearms licensing.

IOPC recommendations and coroner’s comments

Recommendation 4 from the IOPC report states:

“The IOPC recommends that Devon and Cornwall Police 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. EROs should be reminded that a case involving a shotgun or firearm certificate holder may not be suitable for Pathfinder, even if the eligibility criteria are met.”

This recommendation hasn’t been implemented, because the force doesn’t agree with it as it is currently worded. The force wrote to the IOPC on 3 May 2023 explaining the reasons for this. The force has put forward a strong case disagreeing to the wording of the recommendation.

Nevertheless, the force has provided training to EROs and those involved in the Pathfinder scheme. We have said the force would benefit from revisiting the training to EROs.

The coroner, in his report, was critical of the police nationally, as well as the force, for a lack of training in firearms licensing.

We recognise the significant efforts the force has now made to train its staff despite the lack of a national course.

Conclusion

Devon and Cornwall Police has implemented four of the five IOPC recommendations and made significant progress in relation to almost all of the comments made by the coroner.

The force has implemented a clear governance structure, invested heavily in its firearms licensing department and provided training for staff. This, alongside the new IT system, should assist in the continuous assessment of a person’s suitability to possess firearms.

There are inefficiencies in the force’s processes, and its use of temporary permits outside national guidance is compounding this problem. During our case file review, we found numerous examples of temporary permits being issued inappropriately. The force must make sure this stops.

We found that staff were committed and displayed levels of professional curiosity, with a focus on public safety.

We are pleased that the force is in the process of developing a plan to address its backlog and use of temporary permits. As this was being developed during our review, we are unable to provide any assurance as to the effectiveness of the plan at this stage.

Many of the recommendations from the IOPC and comments from the coroner’s report relate to national issues. These are beyond the remit of the force and the scope of this review.

We will be conducting a national thematic inspection of firearms licensing in 2024. Devon and Cornwall Police will form part of this inspection, and we look forward to seeing any further progress it has made.

If you or your officials would like a more detailed briefing, I would be happy to provide it. A copy of this letter has been sent to Ms Alison Hernandez, police and crime commissioner for Devon, Cornwall and the Isles of Scilly. I have also copied this letter to the NPCC lead.

Back to publication

Keyham shootings: recommendations made to Devon and Cornwall Police