David Palmer

Date of report: 25 February 2016 Ref: 2016-0076 Deceased name: David Palmer Coroners name: M Spittal Coroners Area: South Lincolnshire Category: Other related deaths This report is being sent to: Lincolnshire Police

AR W Forrest im, rcp, FrcPath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

As P| Assistant Chief Constable, Lincolnshire Police

1 | CORONER

lam M J Spittal, Assistant Coroner for the Coroner's area of South Lincolnshire.

2 | CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

3 | INVESTIGATION and INQUEST

On 3° November 2015 | commenced an investigation into the death of David Palmer, age 59. The investigation concluded at the end of the inquest on 10” February 2016. The conclusion of the inquest was Narrative Verdict.

CIRCUMSTANCES OF THE DEATH

Mr Palmer had a licence for 3 firearms which were kept in a locked cabinet. He also had a shot gun with a 5 cartridge magazine which was unlicensed and which he did not keep in his gun cabinet in against the possibility of a spot check by Police Officers. He suffered from Lung Cancer and died as a result of a massive head in jury from his unlicensed shot gun.

Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk

AR W Forrest im, ercp, FRcPath GMC Number: 1333523

Her Majesty's Senior Coroner for South Lincolnshire

CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. In the three and a half years | have investigated 4 deaths resulting from self-inflicted firearm wounds. Three of those involved unlicensed weapons. These weapons are generally not stored securely and are thus available for impulsive use. The MATTERS OF CONCERN are as follows. —

1 Making public the practice | understand to be in place to the effect that the

surrender of an unlicensed firearm does not usually result in prosecution might

usefully be considered.

ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and/or

your organisation have the power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 11" April 2016. |, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner 1am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your

response, about the release or the publication of your response by the Chief Coroner.

25" February 2016 M J Spittal...........

stant Coroner for South Lincolnshire

Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk