Emma Ellette and George Pattison: Prevention of Future Deaths Report
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Date of report: 8/8/2024
Ref: 2024-0438
Deceased name: Emma, Ellette and George Pattison
Coroner name: Richard Travers
Coroner Area: Surrey
Category: Suicide (from 2015) | Other related deaths
This report is being sent to: Surrey Police | National Police Chiefs’ Council | The Home Office | Department of Health and Social Care | The General Practitioners Committee
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: The Chief Constable of Surrey Police, [REDACTED] (in respect of paragraphs 5.1,2 & 3) [REDACTED} as the National Police Chiefs’ Council’s Lead on Firearms Licensing (in respect of paragraphs 5.1,2 & 3) [REDACTED], The Secretary of State for the Home Department (in respect of paragraphs 5.1,2 & 3) [REDACTED], The Secretary of State for Health and Social Care (in respect of paragraphs 5.1 & 2) [REDACTED] as Chair of the General Practitioners Committee UK of the British Medical Association (in respect of paragraphs 5.1 & 2) | |
| 1 | CORONER Richard Travers HM Coroner for Surrey |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. |
| 3 | INVESTIGATION and INQUEST The inquests into the deaths of Emma and Ellette Pattison were opened on the 2nd March 2023 and the inquest into the death of George Pattison was opened on the 28th February 2023. All three inquests were resumed and concluded on 30th July 2024. The causes of death were: Emma Pattison: 1.a: Shock and Haemorrhage 1.b: Shotgun wounds to chest and abdomen Ellette Pattison: 1.a: Shotgun Wound to the Head George Pattison: 1.a: Shotgun Wound to the Head The conclusions were: Emma Pattison: Unlawfully killed Ellette Pattison: Unlawfully killed George Pattison: Suicide |
| 4 | CIRCUMSTANCES OF THE DEATH At a time, unknown between 22:49 hours on the 4th February 2023 and 00:40 hours on 5th February 2023 George Pattison shot and killed his wife Emma Pattison aged 45 years and his daughter Ellette Pattison aged 7 years. Thereafter he shot himself intra-orally. At the time of her death, Emma Pattison was the headteacher at Epsom College, Epsom, Surrey and she lived with her family at the head teacher’s house which was situated within the College park. The firearm which George Pattison used was a shotgun lawfully held by him under Shotgun Certificate Number [REDACTED]. That certificate was originally issued by Surrey Police in 2012. In 2016, the police were notified of a domestic violence incident, whereby it was alleged that Emma Pattison had assaulted George Pattison. The matter was investigated and, although the certificate was removed temporarily, it was later returned. There was a renewal application in December 2016 which was granted and a further application for renewal in 2022, which was also granted. The last renewal application required completion of a new form by the applicant, providing details of the applicant’s GP and answers by him to medical questions, which included, have you ever been diagnosed or treated for any of a number of medical conditions, which included ‘Depression or anxiety’, to which the applicant responded ‘No’. The inclusion of the GP’s details and medical questions is a safeguard to ensure that the Licensing Officer is aware of an applicant’s medical history. (Please see my earlier PFD Report dated 15th July 2019 relating to the inquests touching the deaths of Christine and Lucy Lee.) However, George Pattison had consulted an on-line GP and, over the course of 2019 to 2021, had been prescribed a significant amount of Propanolol, the purpose of which was to assist with the symptoms of anxiety. It is unknown whether knowledge of that medical history on the part of the Licensing Officer would have affected the renewal of the shotgun certificate to Mr Pattison. Further, as set out above, in 2016 there was an allegation of assault made by Mr Pattison against Mrs Pattison. It would appear that, at the time, no consideration was given as to whether this might have been an example of coercive controlling behaviour on the part of Mr Pattison. However, there was evidence within the papers of subsequent domestic abuse / coercive controlling behaviour on the part of Mr Pattison towards Mrs Pattison. That evidence does not appear to have come to attention of the Licensing Officer at the time of Mr Pattison’s most recent application for renewal of the licence. |
| 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters that gave rise to concerns that circumstances creating a risk of other deaths will continue to exist in the future unless action is taken. The MATTERS OF CONCERN are as follows. – 1. An applicant for a shotgun certificate is able to obtain medication from an on-line doctor without the knowledge of their GP, giving rise to a risk that a licensing authority might grant a shotgun certificate to an applicant who has a relevant previous medical history about which the authority is not aware. 2. In consulting an on-line doctor, it is possible for an applicant for a shotgun certificate to avoid the current safeguards relating to full disclosure of their previous and current medical history. 3. Consideration should be given as to how a licensing authority can obtain full and accurate disclosure of an applicant’s history of coercive controlling behaviour towards another / others. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that those people identified in the first section of this report have power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise, you must explain why no action is proposed. |
| 8 | COPIES I have sent a copy of this report to the following Interested Persons in the Inquest and to the Chief Coroner. 1. [REDACTED] 2. [REDACTED] 3. [REDACTED] – DWF on behalf of Epsom College |
| 9 | Signed: Richard Travers DATED this 8th day of August 2024 |