Source · Prevention of Future Deaths
Harold Ambrose
Ref: 2015-0118
Date: 25 Mar 2015
Coroner: Eleanor McGann
Area: Essex
Responses identified: 0 / 1
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There is no requirement for GPs or Mental Health Trusts to notify police about mental health concerns for firearm licence holders, and licence information was not properly flagged in medical records.
Date
25 Mar 2015
56-day deadline
20 May 2015 est.
Responses identified
0 of 1
Coroner's concerns
There is no requirement for GPs or Mental Health Trusts to notify police about mental health concerns for firearm licence holders, and licence information was not properly flagged in medical records.
View full coroner's concerns
Mr Ambrose had held a shotgun licence since November 1987 This was renewed every 5 years at which time there was a full review. The last review was in 2011. On 18"h November 2011 a letter from Essex Police Firearms Department was sent to his GPs surgery notifying them that he was a shotgun holder: No further details from this letter were entered onto his medical record and the fact that he was a firearms holder was not flagged on their system: In 2011 Mr Ambrose did not have any mental health problems. In September 2012 he was diagnosed with mixed dementia and this gradually worsened: He was receiving some input from the North Essex Partnership University NHS Foundation Trust (NEPT) following a referral the GP in October 2012. Mr Ambrose made NEPT aware that he had a shotgun license in his initial assessment in November 2012. May from
In 2013 he was prescribed Alzheimers medication and was advised not to drive by his GP due to his cognitive impairment: In January 2014 it was clear that there had been decline in his mental abilities and this decline continued: Although his mental health was clearly deteriorating neither the GP or NEPT referred this case to Essex Police Firearms Department: In evidence a representative of Essex Police had they been made aware of his Mental Health problems would have initiated a review of Mr Ambrose's fitness to hold a shotgun licence: There is no requirement that GPs or Mental Health Trusts notify the police of concerns about a patients mental health when they are aware that have a firearms licence.
In 2013 he was prescribed Alzheimers medication and was advised not to drive by his GP due to his cognitive impairment: In January 2014 it was clear that there had been decline in his mental abilities and this decline continued: Although his mental health was clearly deteriorating neither the GP or NEPT referred this case to Essex Police Firearms Department: In evidence a representative of Essex Police had they been made aware of his Mental Health problems would have initiated a review of Mr Ambrose's fitness to hold a shotgun licence: There is no requirement that GPs or Mental Health Trusts notify the police of concerns about a patients mental health when they are aware that have a firearms licence.
Report sections
Investigation and inquest
On 28'h May 2014 commenced an investigation into the death of Mr Harold Ambrose, 82 years of age and Mrs Wendr Ambrose 77 years of ageThe investigation concluded at the end of the inquest on 17 March 2015. The conclusion of the inquest was Mr Harold Ambrose took his own life Mrs Wendy Ambrose was unlawfully killed:
Circumstances of the death
On Saturday 24h May Mr Ambrose telephoned Essex Police and told the operator that he had just shot his wife and was going t0 shoot himself in the very near future. Police attended and found the bodies of Mr and Mrs Ambrose: The subsequent investigation established beyond reasonable doubt that Mr Ambrose had indeed shot his wife and then himself. That is the conclusion that returned:
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action: Your RESPONSE You are under a to respond to this report within 56 of date of this report; namely by 22n 2015. |, 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:
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Report details
- Reference
- 2015-0118
- Date of report
- 25 March 2015
- Coroner
- Eleanor McGann
- Coroner area
- Essex
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 20 May 2015 (estimated).
Sent to
- Home Office