Plymouth shooting: 'Catastrophic' failings at Devon and Cornwall Police before deadly attack - what the inquest jury said
There was a "catastrophic failure" in the management of a policing firearms unit that led to the Plymouth gunman's weapon being returned just weeks before his attack which left five people dead.
Jake Davison, 22, shot his mother Maxine, 51, before killing three-year-old Sophie Martyn, her father, Lee, 43, Stephen Washington, 59, and Kate Shepherd, 66, in August 2021 in the Keyham area of Plymouth. It was one of the worst mass shootings in UK history.
After being confronted by an unarmed officer, he then turned the gun on himself.
A coroner ruled Davison's five victims were all unlawfully killed, with the inquest jury critical of the failings within Devon and Cornwall Police's licensing unit, which handed Davison back his shotgun five weeks before the killings.
The jury said: "There was a catastrophic failure in the management of the firearms and explosives licensing unit, 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.
"There was a lack of scrutiny and professional curiosity at all levels.
"There was a seriously unsafe culture within the firearms and explosives licensing unit of defaulting to granting licences and to returning licences after review."
Questions over the return of his gun
In 2020, Davison was arrested for an assault of two teenagers after they called him "fat". But the incident was not taken to court and he was instead referred to Pathfinder, a restorative justice programme.
His gun, initially taken from him, was then returned in July 2021.
The jury said: "The decision to return the shotgun and licence to the perpetrator in July 2021 was fundamentally flawed and as a result failed to protect the public and the peace."
The jury also found: "The use of the Pathfinder scheme in this instance was wholly inadequate in reducing the perpetrator's future offending."
The jury also found a "serious failure" at a national level by the government, Home Office, and National College of Policing to implement recommendations made in the wake of the Dunblane massacre in 1996.
This included a failure "to provide training for firearms inquiry officers and the subsequent recommendation in Her Majesty's Inspectorate of the Constabulary's Targeting the Risk Report in 2015 for an accredited training regime for firearms enquiry officers".
The Independent Office for Police Conduct (IOPC) watchdog found two employees of Devon and Cornwall Police had a case to answer for misconduct over the way they dealt with Davison's gun licence.
But no officers or staff will lose their jobs.
One firearms licensing supervisor failed to ensure Davison's shotgun certificate application was correctly risk assessed and failed to ensure that he could be permitted to possess a shotgun without danger to public safety. They received a written warning.
A firearms inquiry officer (FEO), who has since retired, would have had a case to answer for misconduct had they still been serving, for failing to make adequate inquiries as part of a case review following the September 2020 park assaults, and failing to correctly risk assess Davison.
The force said failings by individual staff were substantially mitigated by weaknesses in the force overall.
An act of 'pure evil'
In a statement, the families of Davison's victims said his actions that day were "an act of pure evil", which were "facilitated and enabled by a series of failings and incompetence from the people and organisations that are supposed to keep us safe".
They said: "It is beyond us how Davison, a man with a known history of violence, mental health issues, and with no real need to own a firearm, was granted a licence to possess a gun in the first place.
"Warning signs were ignored and a licence to kill was granted."
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How Devon and Cornwall Police responded
Will Kerr, chief constable of Devon and Cornwall Police, said since the shootings, the force had invested £4m into the firearms and explosives licensing unit and has nearly doubled the staff working there.
Refusal rates for applications for both firearms and shotguns are also now the highest in the country.
"Investment into the firearms and explosives licensing unit in terms of staffing and resourcing has and will continue to be significant," Mr Kerr said.
"Indeed there are now almost 100 police officers and staff in our licensing team.
"The communities of Devon and Cornwall should be reassured that there is a vastly increased grip and scrutiny around applications to ensure my force is doing everything possible to make possession of weapons as safe and regulated as possible."
A Home Office spokesman said: "Our thoughts are with the loved ones of Maxine Davison, Lee and Sophie Martyn, Kate Shepherd and Stephen Washington.
"This was a devastating tragedy and we thank the coroner for their investigation.
"Once received we will reflect on the coroner's report, including any recommendations, and respond in due course."