On August 12, 2021 five people died in Keyham, a district of Plymouth in Devon. Jake Davison, aged 22, is the person to whom the deaths are attributed, and he died by suicide the same day. He was never arrested, charged or tried, so no court has convicted him of anything. The only legal findings on the events are those of an inquest jury, which in February 2023 concluded that each of the five victims was "unlawfully killed" and found that serious failings by Devon and Cornwall Police had contributed to the deaths.
The five who died were his mother, Maxine Davison, and four other residents of the district: Lee Martyn, Sophie Martyn, Stephen Washington and Kate Shepherd. Sophie Martyn was a child. Two other people were injured and survived. Everything the courts and public bodies later examined concerned the decisions taken by the police before that day, and the national system those decisions sat within.
All five deaths took place on August 12, 2021 within the Keyham district. The inquest was told the sequence lasted about eight minutes. Davison died by suicide on the same day. No arrest was made and no charge could be brought.
Police cordoned a large area of Keyham in the following days. Officers from Wiltshire Police, West Mercia Police and Avon and Somerset Police assisted Devon and Cornwall Police under mutual aid. The Home Secretary of the day described the events as "tragic beyond words".
The Independent Office for Police Conduct (IOPC) began an independent investigation on August 13, 2021, the day after the deaths, following a mandatory referral from Devon and Cornwall Police. Its subject was not the events of August 12 but the force's dealings with Davison in the years before them. The terms of reference ran to eleven questions, lettered (a) to (k). They asked what steps were taken to check Davison's suitability when he first applied to the force's unit in 2017, whether the decision taken then was reasonable and lawful, why the unit was not told promptly about an incident in September 2020, whether the action taken in December 2020 was timely, why Davison was judged eligible for the Pathfinder scheme and how robust that scheme was, what was done before a decision was taken in July 2021, and whether the unit's processes complied with the law and national guidance.
On December 9, 2021, the day of a pre-inquest review in Plymouth, the IOPC filed a preliminary report and evidence with the coroner and issued an update. Several lines of enquiry were complete. Two force employees had been served with misconduct notices, one of whom had been interviewed and the other of whom had given a written response, and a third employee in the unit, who had been involved in the 2017 decision, had been served with a gross misconduct notice. The IOPC said the notice did not mean that disciplinary proceedings would necessarily follow. Its regional director said the team was working to finalize a substantial report with its conclusions early in 2022.
On March 15, 2022 the IOPC announced that the investigation was complete. A substantial report went to the force and to the coroner, containing its views on whether any individual had a disciplinary case to answer, together with recommendations at force and national level. The regional director said: "we are unable to publish our investigation findings at this time". Publication was held back to avoid prejudicing the inquest, and the IOPC was in contact with the coroner to protect a full inquest.
The findings were published on February 20, 2023, the day the jury returned its conclusions, with a summary and learning report. That report found that the minimum checks had been made when Davison applied in 2017, but that the risk had been rated low when it should have been rated high, and that the police had lacked information from several sources. The officer who handled the application had received no formal training and was in practice without a first-line supervisor. The IOPC traced those shortcomings to inadequate training, supervision and quality assurance. In September 2020 the case of the earlier incident should have been treated as high risk, and the decision to deal with it through an out-of-court scheme misapplied the Crown Prosecution Service charging standard. When the unit reviewed the position in 2021, the review was not rigorous enough, and no formal decision was made by a suitably senior person as force policy required. Across the unit, the flagging system and quality assurance were weak, and the unit lacked strategic leadership.
The IOPC's conclusions on individuals were set out in exact terms. The officer who handled the 2017 application had "no case to answer for misconduct or gross misconduct". The supervisor who approved it had "a case to answer for misconduct (but not gross misconduct)", and received a written warning at a misconduct meeting held by the force. The officer who conducted the 2021 review would have had a case to answer for misconduct, but not gross misconduct, had that officer not left the force, and so no disciplinary proceedings could follow. The officer in charge of the investigation into the September 2020 incident had no case to answer for misconduct or gross misconduct, and the IOPC attributed the shortcomings in that part of the case to systemic issues around guidance and training. The Pathfinder key worker gave rise to no concerns. The IOPC's regional director said individual failings were substantially mitigated by weaknesses in the force's systems, processes, training, resources and culture.
The IOPC made five recommendations to the force in 2022. They were to change the force's records system so that markers could be attached to individuals as well as to addresses; to monitor those under the scheme so that relevant information was available for continuous assessment; to sample a substantial proportion of the decisions of its enquiry officers until they completed role-specific training; to remind its evidence review officers that decisions must be taken case by case; and to secure a clear, shared understanding of governance and working practices in the unit. The force said all five had been implemented or were being implemented. Provisional recommendations to the Home Office asked it to clarify when checks beyond the minimum are expected, to remove a distinction between two sets of national requirements, to require referees to have recent and in-depth knowledge of the applicant, to require private questioning of other adults living with a person who has committed a violent offense, and to require wider checks on all applications.
On September 13, 2022, the day of a further pre-inquest review in Plymouth, the IOPC announced a separate criminal investigation. After taking specialist legal advice it had decided to examine whether the Office of the Chief Constable, as a corporation sole, might have committed offenses under the Health and Safety at Work etc. Act 1974 in the way the unit was run before the deaths. It told the force, the Police and Crime Commissioner, the coroner and the families. The Chief Constable said the development was at an early stage, that the force had co-operated fully with the IOPC and the coroner, and that "no determination in terms of potential corporate culpability has been decided". The force had meanwhile commissioned an independent review of its procedures by Durham Constabulary. When it published its findings on February 20, 2023 the IOPC stated that its investigation remained ongoing. No charge, decision or outcome from that investigation has been published.
The inquests were heard by the Senior Coroner for Plymouth, Torbay and South Devon, sitting with a jury and assisted by Counsel to the Inquest. They engaged the State's investigative obligation under Article 2 of the European Convention on Human Rights. The arrangements were published on December 20, 2022. The hearings were held in person at Exeter Racecourse, at Kennford, with a viewing annex at the Council House in Plymouth for the bereaved families and others directly affected.
The inquests into the deaths of Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington and Kate Shepherd opened on January 17, 2023, and the inquest into Davison's own death was scheduled to begin on February 20, 2023. The hearing ran for five weeks, and more than 50 witnesses gave evidence. Among the interested persons represented were the IOPC and a lead officer of the National Police Chiefs' Council. A superintendent of the force told the jury that the decision-making system in the unit was "fundamentally flawed" and had been in place for at least five years. On February 15, 2023 a Chief Superintendent of the force made the force's first public apology, eighteen months after the deaths, and on the day the jury's conclusions were returned he said that the events "should not have happened".
The jury completed a Record of Inquest for each of the five victims. In the first part of its narrative findings it dealt with the decisions taken about Davison, the national position and the unit's culture. It found that the decision taken in 2017 was "a serious failure to protect the public and the peace". The unit's staff had not applied the Home Office guidance of 2016, under which a decision assessed as high risk had to be made by the unit's manager. The enquiry officer and the supervisor had shown "an insufficient degree of professional curiosity", which the jury said reflected the culture of the unit. It found that the officer investigating the September 2020 incident should have recorded the position and alerted the unit, that it was unreasonable to treat that incident at the level of the offense charged, and that the Pathfinder scheme was "wholly inadequate in reducing the perpetrator's future offending". It found that "the decision to return" in July 2021 "was fundamentally flawed" and that the case was not passed to the unit's manager for review, contrary to Home Office guidance.
On the wider picture the jury found that the Government, the Home Office and the National College of Policing had seriously failed to implement a recommendation made by Lord Cullen in 1996 on training for enquiry officers and a recommendation of Her Majesty's Inspectorate of Constabulary in 2015 for an accredited regime, and that the Home Office statutory guidance of 2021 made no mention of training specific to those officers. It found that "there was a catastrophic failure in the management" of the unit, with poor supervision and inadequate leadership, and that senior and executive leaders had failed to notice or address it. It found "a lack of scrutiny and professional curiosity at all levels", ineffective audit and governance, and "a seriously unsafe culture within the" unit of defaulting to granting applications and to returning items after review. It found that staff had a "dangerous lack of understanding" of the force's risk matrix, that incompatible IT systems hindered communication, and that budget limits and staff shortages "increased the probability of risk being incorrectly assessed".
In the conclusion as to the death, recorded in each record, the jury answered: "The deceased was unlawfully killed." It then listed the failures that contributed. There were serious failures by the unit in the original decision and in later failing to revoke it; a serious failure by the force to protect the deceased; and "a failure of Devon and Cornwall Police to have in place safe and robust systems", covering the unit's training, governance, quality assurance and the level at which decisions were made. There was a failure to obtain sufficient information on the application and on review, and a failure to seek out and consider all the relevant evidence. After the 2020 incident the police had failed to protect the public and the peace, through the downgraded charge and through an inadequate check before the July 2021 decision. The misapplication of the risk matrix meant that no adequate system ensured that a manager of sufficient seniority made or approved the decisions. A lack of national accredited training had failed, and continued to fail, to equip the unit's staff to protect public safety. The jury repeated its finding of a catastrophic failure in the management of the unit, including inadequate leadership and a lack of senior and executive oversight. For Davison, it returned "a conclusion of suicide in respect of Davison".
On March 8, 2023 the Senior Coroner issued a prevention of future deaths report. It was sent to the Home Secretary, the Minister for Crime, Policing and Fire, the national police lead, all Chief Constables in England and Wales and the College of Policing, and it was published on the coroner's judiciary page on March 10, 2023. A further report on the concern about judicial training went to the Lord Chief Justice. The report was made under paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, and was categorized as "other related deaths" and "child death". Responses were due by May 3, 2023, 56 days after the date of signature, though the coroner could extend the period.
The matters of concern traced a long failure to provide nationally accredited training for the unit's staff. The coroner listed a report by Lord Cullen in 1996, a review by Her Majesty's Inspectorate of Constabulary in 2002, a report by a Senior Coroner for Durham in 2013, a further inspectorate report in 2015 and a report by a Senior Coroner for Surrey in 2019. He wrote: "If any lessons had been learned in the aftermath of earlier tragedies, they have been forgotten." He recorded "an abject failure" over a period of about 27 years to ensure that nationally accredited training was developed and maintained, and his concern that there was no requirement or guidance that the unit's staff should undergo mandatory training, and no requirement that Chief Officers delegate decisions only to adequately trained staff. The lack of accredited training, combined with the absence of a mandatory requirement, increased the risk of wrong decisions and of future deaths.
The action requested was specific. Chief Constables were asked to confirm that adequate local training had been delivered to all staff and supervisors in their units, under the Home Office guidance of November 2022 and the statutory guidance of February 2023, and that decisions were delegated only to adequately trained people. The College of Policing was asked to develop nationally accredited training and to update its guidance so that training was required. The Home Secretary and the Minister were asked to ensure that mandatory training was required for all decision-makers and that Chief Officers could delegate only to trained staff. The coroner also recorded concerns about the 1968 statute, which he described as "at odds with public safety", about Home Office guidance, and about whether judges hearing appeals against revocation might need training on suitability and risk, and he called for fundamental reform of the law. The Home Office later declined to proceed with part of this.
About thirty responses were published on the coroner's page, from police forces including the Metropolitan Police, Devon and Cornwall Police, Dorset Police, Avon and Somerset Police and West Midlands Police, from the College of Policing, the Home Office and the Lord Chief Justice.
Devon and Cornwall Police replied on May 3, 2023. Its review of earlier cases had covered January 1, 2020 to August 18, 2021. In August 2021, at the request of the Home Secretary, an experienced officer who had taken no part in the original decisions reviewed 42 cases in which the force had reversed an earlier decision, and found only administrative issues at first. In September 2021 a peer review by Durham Constabulary examined the same 42 cases in more detail and identified 12 with substantive suitability issues, which led to further revocations and to some voluntary surrenders. The force decided that a review of every case over five years would be disproportionate, given the 40,000 or so cases in Devon and Cornwall, and arranged to review the remaining period from May 3, 2018 to December 31, 2019 by October 2023. It said all decisions in the unit had been paused until a new leadership structure was in place, that the force had invested about 3 million pounds in the unit, and that its refusal and revocation rates were now consistently above the national average. All of the unit's staff had completed an enquiry officers' course delivered by a manager from South Yorkshire Police, a barrister had trained staff and key managers on risk assessment and the National Decision Model, and a three-year program of professional development had begun with domestic abuse experts. Decisions were being sampled by supervisors, the Assistant Chief Constable and the senior management team, and staff were to take a Professionalising Investigations Programme course within 18 months. The force noted that no national accreditation yet existed and said it would align its policy with the national position. An inspection requested by the Police and Crime Commissioner and the Policing Minister was scheduled for May 2023.
The Lord Chief Justice replied the same day. He pointed out that the content of judicial training is for him as head of the judiciary, that all judges complete an induction course and annual training, and that appeals of this kind are usually heard by salaried Circuit Judges. He observed that the Davison case had never involved a Crown Court appeal, because the unit had not revoked anything, so its decisions were never reviewed by a court, and that the coroner's own wording on the point was tentative. He concluded that the report did not establish that judges failed to give such appeals careful consideration or applied the wrong legal test, and no change to judicial training was made.
The Home Office did not meet the original deadline, and the coroner agreed an extension at its request. A Home Office minister wrote to the coroner on June 29, 2023, and made a written ministerial statement the same day. The Government did not agree with the coroner's reading of two sections of the 1968 statute, which he had said created a presumption in favor of grant, and it said that applicants must satisfy the suitability conditions first. It decided not to align two sets of national controls, while keeping the matter under review. It opened an eight-week public consultation on a power of entry without a warrant, on mandatory prohibition thresholds, on the balance-of-probabilities test in statutory guidance, and on referees, and it announced funding of 500,000 pounds for the College of Policing and the National Police Chiefs' Council to develop a national training package that would become mandatory. It said a review of fees, to reach full cost recovery for the police, was under way. The minister undertook to write again later in the year.
The consultation closed on August 23, 2023 and drew 91,385 responses, of which 71,743 were analysed. The Government published its response on February 13, 2025, after the Member of Parliament for Plymouth Sutton and Devonport pressed the Policing Minister in November 2024 and was told that the response would be a priority. The response said the Government would legislate for a new power of entry "when a suitable legislative opportunity arises"; would make no legislative change to the prohibition thresholds but would strengthen the statutory guidance; would require two referees on every application and amend the rules and the application form accordingly; would strengthen the guidance on what police should obtain from referees and on suitability checks, including interviews with partners and relatives where domestic abuse is alleged; would keep the balance-of-probabilities test; and would leave the period of validity unchanged "at this time". It noted that a police and public contact app launched on March 22, 2024 included a reporting option, that a statutory instrument laid on January 15, 2025 introduced full cost recovery from February 5, 2025, and that the College of Policing had begun to roll out mandatory accredited training in November 2024.
In April 2023 the Home Secretary asked His Majesty's Inspectorate of Constabulary and Fire and Rescue Services for an urgent review of the force's progress on the IOPC recommendations and on the coroner's concerns. Devon and Cornwall Police was responsible for more of these cases than any other force in England and Wales. The inspectorate set out its findings in a letter of July 28, 2023. It found that the force had put in place a clear governance structure, had raised the number of posts in the unit from 45 to 99, had moved to a new records system and had run a training program. It found that four of the five IOPC recommendations had been implemented, and the force disagreed with the wording of the fifth, which concerned guidance to evidence review officers, on which the inspectorate was satisfied that discussion with the IOPC was constructive.
The inspectorate also set out concerns. A significant backlog had built up, reliance on temporary measures to manage demand conflicted with the statutory guidance, supervisors were verifying decisions that trained staff could take themselves, the legacy IT was unreliable with migration not due until June 2024, the risk matrix was used inconsistently, there was no written sampling policy, and some evidence review officers had not yet been trained. Its recommendations were to set strategic priorities and a performance framework, to stop the routine use of temporary measures, to review each stage of the process, to streamline supervision, to document a sampling policy that drives learning, to centralize training records and to ensure that all evidence review officers were trained. The force aimed to clear the backlog by December 2024, a target the inspectorate could not yet confirm. It added that several of the issues, including the absence of a national training course, were national matters outside the force's remit, and said it would carry out a national thematic inspection in 2024 that would include Devon and Cornwall Police.
The national inspection followed. On August 28, 2026, five years after the deaths, the inspectorate concluded that the national system was "not fit for purpose". It found inconsistent decisions, unclear guidance and weak oversight, with applicants facing a "postcode lottery" in the scrutiny they received, a legal framework spread across more than thirty pieces of legislation and inconsistent training and suitability checks. It recommended a new national authority to replace the 38 local units in England and Wales, with locally based staff working under a single national structure with central control over decisions, risk management, training and performance, and made 22 further recommendations, among them modernizing the legislation and introducing a standardized competence assessment. The inspector responsible said: "Further tragedies shouldn't be required before action is taken." Devon and Cornwall Police said it had apologized for its failings, that its unit had undergone significant change and investment, and that a single national unit was a matter for the Home Office and national policing bodies.
No court has tried Davison, so the attribution of the five deaths to him rests on the inquest conclusions and not on a conviction. The IOPC's criminal investigation into the force under health and safety law was still open when its findings were published in February 2023, and no charge or decision from it has been published. The Government and the coroner differed on the reading of two sections of the 1968 statute and on aligning two sets of national controls, and the Government declined those recommendations while keeping the second under review.
August 12, 2021: five people die in Keyham, Plymouth; Davison dies by suicide the same day.
August 13, 2021: IOPC investigation begins on referral from Devon and Cornwall Police.
December 9, 2021: preliminary IOPC report filed with the coroner at a pre-inquest review in Plymouth.
March 15, 2022: IOPC investigation completed; findings withheld pending the inquest.
September 13, 2022: IOPC announces a criminal investigation under the Health and Safety at Work etc. Act 1974.
December 20, 2022: arrangements for the inquest published.
January 17, 2023: final inquest hearing opens at Exeter Racecourse.
February 15, 2023: the force makes its first public apology.
February 20, 2023: jury conclusions; IOPC findings published.
March 8, 2023: prevention of future deaths report issued.
May 3, 2023: responses of the force and the Lord Chief Justice.
June 29, 2023: Home Office response and written ministerial statement; consultation opens.
July 28, 2023: inspectorate letter on the force's progress.
August 23, 2023: consultation closes.
February 13, 2025: Government response to the consultation.
August 28, 2026: inspectorate's national report.