Tears in court as inquests call for changes after Plymouth shootings
An inquest has found all five victims of a mass shooting in Plymouth were unlawfully killed - and called for changes
Last updated 20th Feb 2023
'Serious failings' by police which 'failed to protect the deceased' were today outlined at the inquest into the five people killed in Plymouth by gunman Jake Davison.
Families of the victims have sat through all of the five weeks of evidence, and tears could be heard today as the names of the deceased were read out - particularly when three year old Sophie Martyn's details were recorded.
Senior coroner Ian Arrow recorded the exact details of each 'unlawfully killed' victim of Davison, following his 12-minute shooting spree on August 12, 2021.
In their narrative, the jury recorded a 'serious failure' by the police 'to protect the public and the peace' when they granted a shotgun licence to Jake Davison
They noted an 'insufficient degree of professional curiosity' by the police firearms licensing when they assessed his suitability for a gun and a 'flawed' and 'inadequate' police investigation into an assault in a Plymouth Park in Autumn 2020 - where the officer failed to notice Davison was a shotgun licence holder,
The jury heard the police and Home Office made a 'serious failure' when they failed to act on recommendations made in 1998 after the Dunblane school shootings in 1996.
The process of granting shotguns to people was described as a 'seriously unsafe culture' and the jury found the licensing department at the time operated with a 'dangerous lack of understanding' of the force risk matrix - and was more likely to award a gun licence then remove it.
The jury outlined 'serious failures' by the police both in the training and operation of their licensing department at the time - which led to a "serious failure to protect the deceased."#
The coroner says he will now spend time preparing a 'preventing future deaths' report to ensure lessons are learnt - and told the families 'how very sorry I am' and praised them for the way they have sat thorough the inquests in a 'very dignified way'.
What have the families said?
In a statement released after an inquest jury concluded the five people gunned down during the Keyham shooting were unlawfully killed, 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.”
What happened during the inquest?
During the past five weeks of evidence, the jury heard from police, a GP, a former teacher, the Home Office, his employer and from people who knew or came into contact with Davison.
They've also looked in detail at incidents of violence and heard about his online usage, including a digital montage detailing a timeline of events during the 12-minute shootings on August 12, 2021.
The jury were set a number of questions to answer- which relate to whether there were failings by Devon and Cornwall Police when they allowed Jake Davison to have a shotgun and also return it to him weeks before he killed five people
During the inquest a coroner's commendation was awarded |newtab) after a police officer spoke about the moment he confronted gunman Davison minutes after he'd shot five people dead.
Pc Zach Printer sprinted towards the 22-year-old while unarmed, telling him to "stand still", hoping that he could talk him down. But seconds later Davison - who had his pump-action shotgun positioned under his chin - pulled the trigger and slumped to the ground.
The inquest heard it was the culmination of a 12-minute long attack on August 12 2021 that began with Davison killing his mother.
Maxine Davison, 51, was killed in her home in Biddick Drive, while three-year-old Sophie Martyn, and her father, Lee, 43, were killed as they walked home. Stephen Washington, 59, was shot while walking his dogs and Kate Shepherd, 66, was fatally wounded returning from the supermarket.
Do we know what the motive was?
Investigators found in the hour before the killings Davison was almost constantly online. His search history showed a 'deeply disturbing' pattern and a hostile relationship with his mother, was misogynistic and showed he viewed women with contempt and had 'great sympathy with incel culture' and 'had explored - on numerous occasions - mass killings and referred to people idolised within incel community for perpetrating mass killings'.
The inquest also heard that Mr Davison's Reddit account was deleted the day before the attacks - but the US-based firm has declined to say why the decision was made - and give British police detailed access to the account.
In the hours before the killings he'd searched for porn and 'gay transition' and had previously been on a Reddit forum regarding incel culture - looking at advice for how to potentially get a girlfriend and reading threads of people asking 'if I’m ugly'.
Superintendent Rachel Bentley, the senior investigating officer, said there was no evidence of planning - or that they formed the inspiration for the killings that night.
The accounts of neighbours in Biddick Drive were read to the jury |newtab) at the ongoing inquests into the five people shot dead in Plymouth in August 2021.
One neighbour, Sharon Hellier, recounted hearing what she originally thought was fireworks but then saw Jake Davison walking with a shotgun in a 'really calm' way. She described seeing a dad - with a gunshot wound to the head - cradling his three-year-old daughter, who was also dead.
The process of a 'high-risk' decision to award a shotgun |newtab) license to someone where it has previously been removed was outlined at the inquest
The jury were also told about a 2015 report called 'targeting the risk' looking into the way 11 forces operated their firearms licensing department.
The jury heard from Davison's former teacher, GP, employer and those who knew him
The inquest focused on the lack of medical information with Davison's shotgun application when it was approved. The jury were told it was 'not unusual' for police licensing officers not to get everything they wanted from GPs |newtab) when they asked for information after someone had self declared a condition
Doctor Benjamin Dawson, Davison's GP, told the inquest he did not feel able to give a view on whether Jake Davison was fit to hold a shotgun
He also showed advice - being circulated to GPs in Devon at the time - which suggested they only answered if qualified.
Josephine Duffy, from Mount Tamar school for children with special needs, was asked by Davison for help with a passport application. She said when she learnt what happened the next day she was 'devastated'.
Ms Duffy also revealed she was a reference in Davison's 2017 application for a shotgun - which she agreed to after arranging a meeting with Jake and his mum at their house beforehand.
During his time at the school, Ms Duffy said Davison had a 'special interest' in guns, artillery, firearms technology, history and evolution - which would have made him a 'good historian' or 'museum tour guide in another life'.
She believed the special interest - partly due to autism - was a 'healthy focus' for him at the time and he even gave an assembly on the subject to staff and pupils. He was also once given the head teachers' award for his progress, which included improvements to his social skills.
When Davison first emailed Ms Duffy asking for a gun licence reference, she visited his house and said he looked 'well' ánd told her 'life was good' and he was still in touch with school friends. She recalled that mum Maxine looked 'happy and relaxed' and the teacher was told Jake was going to the gym and had an apprenticeship as a scaffolder. Ms Duffy was told the weapon was for clay pigeon shooting and he already went to Cornwall with his uncle to go clay pigeon shooting. Ms Duffy told the inquest Jake's mum thought it would be 'fantastic to get him out the house and have a hobby'.
Another witness claimed Davison's mum 'feared her son' and her sister had urged Jake to stop threatening his mum
Darren Wood who lived with the pair for around four months said Maxine 'was treated like a slave' by her son who would leave rubbish on the floor and was 'dirty'.
He says it was a 'tense atmosphere' and there was always shotgun cartridges lying around - with Jake the main breadwinner who had to pay £400 a month to help them keep their home which was always a point of contention.
The jury heard he worried: "I think she (Maxine) feared Jake for best part of her life."
The jury were told Davison called police, and admitted to a violent offence in a park, after being urged to by his mum - largely because of likely incriminating video evidence which had been released as part of a police appeal for information.
Mr Wood said the day Davison returned home from the park, after the incident, he could 'feel anger coming off him'. Davison took his gun out of the cabinet and said: "I'm going to kill someone."
The dad of the Plymouth gunman told the jury he warned police that Jake was not fit to hold a gun licence - although police were unable to find the call.
Former Brixham fisherman Mark Davison - who did not live in Keyham- said he told officers Jake lived in a 'volatile household, he's autistic and I don't want him having a gun'.
The inquest heard the gunman was due to have a follow-up session with his employer the day after he killed five people. The trainee crane operator had been referred to occupational health at Devonport after being found asleep in a safety training session.
He was described as a quiet at work, with 'some concerns and frustrations' about not having a driving licence and passport but no mental health conditions were disclosed by him to his employer.
Police failings
'A dangerous shambles which failed to protect the public'
That was how the officer who assessed Jake Davison's shotgun licence described Devon and Cornwall Police – as he admitted the decision to ‘place a weapon in the hands of that man’ was ‘indefensible’.
The jury heard Davison was not expected to have a shotgun at his home. Police expected the shotgun to be kept at Davison's uncle's - who he went clay pigeon shooting with in Cornwall.
The inquest was told the officer felt he had no power to set a licence 'condition' as part of the application |newtab)
The jury were told 'three red flags' were not referred up about Jake Davison's gun application https://planetradio.co.uk/greatest-hits/plymouth/news/three-red-flags-were-not-referred-up-about-jake-davison-gun-application/
The inquest heard potentially similar 'high-risk' decisions were also not routinely referred up between 2018 and the 2021 Plymouth shootings - with a suggestion, during the inquest, the department was operating in an 'unsafe' manner.
When asked, if in his 2021 review, he was 'satisfied' recommendations from the 2015 report were being followed |newtab), Chief Superintendent Roy Linden said he was not.
This week the inquest heard Devon & Cornwall Police has the highest number of shotgun and firearms certificates in the UK. 'Shotgun' and 'firearms' are recorded separately, with a shotgun currently only requiring one reference and a firearm (such as a handgun) needing two.
The inquest heard the police's 'risk matrix' was not being followed- and [a supervisor was even not aware the requirement to check it was part of the form to grant a shotgun license.
Stephen Carder, a firearms licensing supervisor, and longest-serving staff member in the department gave evidence. The jury were told the process followed at the time was one 'we always followed' and he was regularly 'relying on my judgement", which he later accepted was unsafe.
The inquest hard there was a 'default' position within the firearms licensing department at the time that revoking a weapons license was a 'big thing to do'.
Mr Carder was asked if a better ethos would have been to remove a weapon and then focus on whether it should be returned - which he now accepts.
The jury were told, because of Covid restrictions, police were under "pressure" not to send more cases to the courts
A detective admitted the decision not to refer Jake Davison's assault of two teenagers to the Crown Prosecution Service was the wrong one and posed a danger to the public.
Detective Sergeant Edward Bagshaw said attacks by Davison on a 16-year-old boy and a 15-year-old girl in a Plymouth Park should have been sent to prosecutors to consider charging him with assault occasioning actual bodily harm and battery.
What else did the jury hear?
"That doesn't sound right to me. Do they know this? They should know this'."
A police staff member told the jury about the moment he realised Jake Davison had a shotgun licence - following the incident in the Plymouth Park.
David Huggett - who worked for the Pathfinder scheme - was asked to work with Davison after a violent assault in a park. On reading his file, Mr Huggett immediately wrote to the force licensing department asking why Davison was allowed a shotgun - something the force had missed.
The inquest heard police should have known Jake Davison had a shotgun when they investigated him for violence.
While the incident did not involve the gun, the jury were told the force licensing department would have been told about the violence - so they could decide if he was still fit to have a shotgun.
The jury were told a basic search of the police computer would have shown Davison had a shotgun, but the information was missed.
In 2017, the year Jake Davison applied for a shotgun licence, the county had roughly 40,000 gun licences issued and would process or renew 3,000 a year.
The inquest heard that senior police officers were "distracted completely" by the G7 summit in Cornwall. A Devon and Cornwall Police Superintendent has said firearms operations were understaffed in the weeks before the shootings
The jury were told a review of the police processes in place at the time of the shootings had 'only shared recommendations with staff, not specific details of problems
The jury were told the department had a 'flawed system' at the time, due to a lack of resources, which had persisted for at least five years.
The jury were told an independent peer review of the joint Devon & Cornwall and Dorset police firearms' licensing unit - after the Keyham shootings - had raised concerns about a case from February 2021 in which the licensing manager overruled a more junior staff member.
The example suggests it took 10 weeks for a person with a 'marker for violence, assaulting police and drugs' to have their shotgun removed - despite information and intelligence to prevent them having a gun in the first place. The inquest was told the detailed findings of the particular case have not been directly shared with the staff members involved, only a summary.
What has changed since the Keyham shootings?
Police have formally apologised and told an inquest they should never have given Jake Davison a shotgun in 2017 - and now refuse more gun applications than the national average.
Chief Supt Linden has told the jury they should also not have returned a pump action shotgun to Davison - just weeks before the killings - because of a violent incident in a park. He accepted the jury could decide the force licensing department at the time was 'dangerously incompetent' but says changes have since been made.
CS Linden said across the 40,000 weapons licences overseen in the year there were cases of guidance 'not being applied', 'ignored' and examples which 'clearly should have been referred to a senior manager'.
He told the inquest - with hindsight - it would have been 'unlikely' a licence would have been given in 2017 had the process at the time been properly followed.
In the weeks after the attack we learnt Devon & Cornwall had looked into 123 cases of weapons being confiscated over the previous year, with 42 cases of weapons being returned and of those 12 were 'wrongly returned'.
At the time Devon & Cornwall police were less likely to refuse a gun request than other forces and the jury were today told that half of current refusals (which is currently higher than the national average) are now being lost at appeal, which means a possible 'high risk' applicant can still get a gun despite the police's initial decision.
Previously police missed the force 'firearms marker' when they initially investigated a violent attack in a Plymouth park by Davison in 2020 – which was later pointed out to them by a worker at the Pathfinder scheme where Davison was referred.
The jury were told automatic updates are now flashed up on a police computer system when anyone is involved in incidents - whether as a witness or suspect.
CS Linden said the force now operates with a 'wholly different culture' and people should 'prove to us why you should' have a gun, rather than a more 'you shall' type approach. He also explained that the joining with Dorset Police and its impact on the licensing department has been looked at.
Earlier this month the Home Office published new guidance, which updates the 2021 rules brought in after the Plymouth shootings.
Police are now required to look at the social media history of those applying for a gun - and can use special powers to help them investigate online history.
Those acting as a reference for a weapons’ licence must know the person for the previous two years - not two years at 'some point' in their lives, which had been the case.
The inquest has previously heard Davison's former head of year acted as the only reference - although expected others to be added – after first going to see Davison and his mum many years after he'd left the school.
From today an automatic marker is now placed on a patients' record when they apply for a gun licence - something that was due to happen when Davison applied for a shotgun in 2017 but wasn't recorded as the GP wanted records at the time to be up-to-date and accurate.
The inquest today heard the British Medical Association - which had previously voiced concerns about the requests for medical information - requested a 'marker' at the application stage and a second updated 'marker' at the weapons-granted stage so any changes are not missed during the application process.
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• Police changes show a 'wholly different culture' to guns, after being 'dangerously incompetent'
• Keyham Inquest - unarmed police officer speaks of confronting gunman
• 'Do they know this? They should know this' -- the moment concerns over Davison's shotgun were raised
• Police 'would have told gun unit about violence' but missed marker
• Police were under "pressure" not to send more cases to the courts
• Police 'relying on judgement' not guidance when giving shotgun licences
• Davison 'was due to review his work situation the day after shootings
• Police made 'indefensible’ decision to award shotgun license
• Davison's shotgun was not kept where police thought it should be
• Mum 'feared her son' and her sister urged Jake to stop threatening her
• Teacher saw 'no indication' when she spoke to gunman night before killings
• GP was 'unable to say if Davison was fit to hold a shotgun licence
• Police 'only shared recommendations with staff, not specific details of problems'
• Plymouth gunman's dad 'warned police not to issue firearms licence'
• 'Three red flags' were not referred up about Jake Davison's gun application
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