The decision to give gunman Jake Davison his shotgun and certificate back after he assaulted two teenagers was not reviewed by a senior manager, an inquest heard.
The pump-action shotgun was confiscated by Devon and Cornwall Police weeks after Davison was arrested following an altercation in a park in September 2020.
Davison’s case would have been automatically classed as “high risk” because he had been accused of assault and any decision to return his weapon and certificate should have been reviewed by the firearm licensing unit’s head of department.
Michelle Moore, who became head of the department in 2017, told the inquest that the decision was made by a firearms inquiry officer and not reviewed by her – even though it should have been.
On July 9 2021 shotgun and certificate were returned and on August 12 the trainee crane operator killed five people, including his mother, in the Keyham area of Plymouth.
Maxine Davison, 51, was shot dead following a row at their home in Biddick Drive.
Davison then shot dead Sophie Martyn, three, her father Lee Martyn, 43, Stephen Washington, 59, and Kate Shepherd, 66.
He then turned the black Weatherby pump-action shotgun on himself before armed police officers reached him.
Giving evidence at the inquest in Exeter, Mrs Moore said she learned during 2018/19 that high risk decisions were not being passed to her and she confirmed she did not issue any instructions to rectify this.
Bridget Dolan KC, counsel to the inquest, asked: “That’s an unsafe way to work?”
Mrs Moore replied: “Yes.”
Davison applied for a shotgun certificate in July 2017 and declared his autism and Asperger’s on his application form and gave consent for his GP to share information with police about his medical history.
The letter, which was based on a standard template from the National Police Chiefs’ Council, gave the GP 21 days to reply if they had concerns.
It also asks them to add a firearm code to the patient’s record and if the patient begins to suffer from a “relevant medical condition” to contact police.
Ms Dolan asked whether this could be regarded as a safe way to operate, which Mrs Moore described as “not ideal”.
Dr Ben Dawson wrote back to police, declining to assist, saying: “Thank you for your request for medical information relating to the above-named individual for the purposes of assessing them for suitability in issuing them with a firearms certificate.
“I decline to provide the requested report because it seeks an opinion on matters falling outside my medical expertise namely assessment of behavioural and personality disorders.”
Devon and Cornwall Police later issued a firearms certificate in January 2018 which was valid for five years.
In September 2020 Davison assaulted a boy and girl in a park after another child had called him “fat”.
The child who made the comment ran off and Davison hit two others present – drawing blood from the boy and slapping the girl.
Davison was arrested, and this incident was brought to the attention of the firearms licensing unit who seized his shotgun and licence.
The inquest also heard police knew of two incidents of violence when Davison was aged 12 and 13.
The unit manager should review all “high risk” decisions, which would have included Davison’s, the jury was told.
Following the incident, a superintendent was brought in as the acting head of department, and Mrs Moore still works there reviewing high risk cases.
Between January 2020 and the killings, 123 cases were reviewed, and a shotgun seized and licence revoked, the court heard. Of those cases, 42 shotguns were returned to the owner.
In a letter to the Home Office in the days following the tragedy, the then Chief Constable, Shaun Sawyer, said that in 20 of those 42 cases the procedures had not been followed properly.
Referring to that letter, Chief Superintendent Roy Linden said: “The qualitative decision-making was below the standard to be expected too frequently.”
The inquest was adjourned until Wednesday.