Response to Coroner's report following inquest

Our response to the Preventing Future Deaths Report following the inquest into the deaths of Emma, Lettie and George Pattison.

Our response to the PFD report following the inquest into the deaths of Emma, Lettie and George Pattison:

We have reviewed the concerns raised in the Preventing Future Deaths Report by Richard Travers, the Senior Coroner for Surrey, following the inquest into the deaths of 45-year-old Emma Pattison, seven-year-old Lettie Pattison and 39-year-old George Pattison in February 2023.

The inquest, which took place on 30 July at Woking Coroner’s Court, concluded that Emma and Lettie Pattison were unlawfully killed after being shot by George, and that George died by suicide after he shot himself with the same gun. All three were found dead at their home in the grounds of Epsom College on 5 February 2023.

Following the inquest, Mr Travers published a Preventing Future Deaths Report in which he raised a number of concerns, including an applicant for a shotgun certificate being able to obtain medication from an on-line doctor without the knowledge of their GP or the licensing authority. He raised a further concern in relation to an applicant being able to avoid full disclosure of their previous and current medical history by consulting an on-line doctor.

The Coroner also asked for consideration to be given as to how a licensing authority could obtain full and accurate disclosure of an applicant’s history of coercive controlling behaviour towards another/others.

 

Mr Pattison’s shotgun certificate was originally issued by Surrey Police in 2012. In 2016, Mr Pattison alleged that he been assaulted by Emma Pattison.

The shotgun certificate was removed from Mr Pattison temporarily while the matter was being investigated. 

An investigation was carried out, but the matter was not progressed due to a lack of evidence.

There was no reason not to return Mr Pattison’s certificate, and a renewal application in December 2016 was granted. There was a further application for renewal in 2022, which was also granted. 

Chief Superintendent Clive Davies said: “We have reviewed the concerns identified in the Coroner’s Preventing Future Deaths Report.

“If an applicant for a firearms licence consults an on-line doctor, or obtains medication on-line, the onus is on the applicant to disclose this to their GP. Mr Pattison obtained medication to treat anxiety on-line but did not disclose this to his GP. Our firearms licensing department would not have been aware that Mr Pattison obtained medication on-line at the point the renewal was granted.

“The Preventing Future Deaths Report has been shared with National Police Chiefs’ Council lead for Firearms, Chief Constable Debbie Tedds, who will work with partners and other agencies, as outlined below,  to ensure that learning points are addressed as a result of the facts of this case.

“The report has also been sent to the Secretary of State for the Home Department, the Secretary of State for Health and Social Care and the Chair of the Chair of the General Practitioners Committee UK of the British Medical Association for further consideration.”

Ch Supt Davies continued: “The allegation of assault made by Mr Pattison against Mrs Pattison in 2016 was investigated thoroughly at the time and coercive controlling behaviour (CCB) was not identified.

“Although Mrs Pattison never made any allegations of domestic abuse or coercive controlling behaviour against her husband, our understanding and response to CCB is significantly more advanced now, and our officers and staff are trained to recognise the signs of CCB, the homicide timeline and high-risk factors.

“Looked at through the lens of what ultimately happened, the incident in 2016 was clearly part of Mr Pattison’s controlling behaviour.

“The tragic deaths of Emma and Lettie draw attention to the need to dispel and challenge myths and stereotypes around who may or may not be victims of domestic abuse, and who indeed may be capable of causing such harm. Otherwise, we know that many victims will feel unable to reach out, and will continue to suffer in silence, while those causing harm in relationships are able to exist unchecked.

"I would urge anyone who believes they, or a friend or family member, may be experiencing abuse to report it. We know sometimes the signs that someone is suffering from domestic abuse can be subtle and difficult to spot. However, if you have any concerns at all for yourself, or a loved one, please contact the Surrey domestic abuse helpline which can provide access to independent advice and support in confidence, by calling 01483 776822 or visiting https://www.healthysurrey.org.uk/domestic-abuse/help     

“For anyone who feels they may be exhibiting harmful behaviour in their relationships, please contact the Surrey Steps to Change Hub via email: [email protected] or telephone 01483 900 905.”

Ch Supt Davies added: “Domestic abuse in its many forms, whether coercive, controlling, physical, sexual, financial or emotional, must not be tolerated and we will do everything we can to support those who are being abused and ensure that those perpetrating it are brought to justice.”