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8 March 2013, 13:25 | Updated: 30 March 2016, 13:50
A coroner's called for "root and branch'' changes to gun licensing at the conclusion of an inquest into a taxi driver who shot dead three members of his family before killing himself in Peterlee.
Andrew Tweddle said that with the current "flawed'' system it was "fortuitous'' there had not been more incidents like the one in Horden, near Peterlee, County Durham, on New Year's Day 2012.
42 year old Michael Atherton, killed his partner, 47 year old Susan McGoldrick, her sister, 44 year old Alison Turnbull, and Ms Turnbull's 24 year old daughter, Tanya, before turning the gun on himself.
Mr Tweddle, sitting in Crook, reached a verdict that the women were unlawfully killed and that Atherton killed himself.
The inquest heard that Atherton, despite a history of domestic abuse and threats to self-harm, legally owned six weapons, including three shotguns. The inquest also heard that there was no formal training for police officers involved in granting firearms licences.
A note attached to Atherton's first application for a firearms licence in 2006 said:
"Four domestics, last one 24/4/04, was cautioned for assault. Still resides with partner and son and daughter.
Would like to refuse, have we sufficient to refuse re public safety?''
Atherton was nevertheless granted a shotgun licence and then a firearms licence two years later. His weapons were confiscated after he threatened to "blow his head off'' in September 2008.
But weeks later the guns were returned to him, with a final written warning telling him to behave responsibly.
Mr Tweddle said Durham Police had conducted a thorough review of its firearms licensing practices since the tragedy.
He said it highlighted that many other licences had been issued to "improper'' people.
He will write to the Home Office calling for "root and branch'' changes and possibly legislation to how police license shotguns.
Police Issue Apology
Durham Police chief constable Michael Barton offered an apology to the bereaved families.
Giving evidence at the hearing, he said prior to the shootings the Firearms Licensing Unit was too focused on administration and not enough on investigating whether applicants should be granted licences.
The unit had come under investigation in 2008 and 2009 when Pc Damien Cobain and a colleague were found to be selling on shotguns that had been handed in by the public.
Mr Barton said he was "appalled'' by the officers' conduct - they have now left the force having been convicted - but said that was not linked to issues surrounding Atherton's licences.
But Mr Tweddle said an investigation of their crimes could have also revealed the lack of organisational control in the way licences were granted by the unit. "Was it an opportunity lost,'' Mr Tweddle asked. "Yes, sir,'' the chief constable replied.
Victim's Family Speak Out
Outside the hearing, Bobby Turnbull, Alison's son and Tanya's brother, said:
"We consider the inquest has exposed some serious flaws in the way applications for shotguns and firearms were managed by Durham Constabulary Firearms Licensing Unit.
This includes lack of training if any at all, lack of process, lack of accountability, poor leadership and poor communication structure.
The family have had a very emotional and upsetting week but we will continue with our commitment to improvements to public safety, to ensure no other family have to endure what we have gone through and will go through for the rest of our lives.''
Mr Turnbull, who works at Hartlepool Golf Course, is urging people to sign his e-petition on tightening gun licensing laws.
In his judgment, Mr Tweddle said:
"In my opinion, these deaths were avoidable.
The systemic shortcomings highlighted by me today lead me to conclude that, on a balance of probabilities, the four deceased would not have died when they did in the manner in which they did had there been robust, clear and accountable procedures in place.''
The coroner accepted that no-one in the Firearms Licensing Unit was guilty of acting in bad faith, but said "the system in place at that time was not fit for purpose so that the decision-making process was flawed''.
He said staff gave "undue significance'' to the possibility of losing an appeal if they revoked or refused a licence.
Mr Tweddle said shotgun and firearms licensing was being considered by the Government.
"In my opinion, the issues revealed by my inquiries into these deaths have made it absolutely clear and beyond doubt that a root and branch review of policy, guidance and procedures and indeed possibly legislation too, to ensure... that the protection of the public is paramount.''