Samuel Dickinson: Prevention of future deaths report
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Date of report: 10/02/2026
Ref: 2026-0082
Deceased name: Samuel Dickinson
Coroner name: Michael Pemberton
Coroner Area: Manchester West
Category: Other related deaths
This report is being sent to: Department for Health and Social Care | Home Office
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1 THE SECRETARY OF STATE FOR THE HOME DEPARTMENT 2 THE SECRETARY OF STATE FOR HEALTH | |
| 1 | CORONER I am Michael James Pemberton, HM Area Coroner for the coroner area of Manchester (West). |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 3 | INVESTIGATION and INQUEST On 16 September 2025 I commenced an investigation into the death of Samuel John DICKINSON aged 39. The investigation concluded at the end of the inquest on 10 February 2026. The conclusion of the inquest was Suicide, and the medical cause of death was 1a Severe head injury |
| 4 | CIRCUMSTANCES OF THE DEATH On 15 September 2025 the deceased who was a farmer and held both a firearms and shotgun licence, was found with a shotgun wound to the head in a shed at the farm where he resided with his family. He had left the house earlier that morning and his family called police concerned, when they found that a shotgun was missing from the gun cabinet where it was stored. A member of the family discovered the deceased in an outbuilding on the farm after a brief search. |
| 5 | CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) 1. During the course of evidence it was reflected that Firearms Legislation relating to the holding of a shotgun or firearms licence (or both) contains no provision that a person holding a certificate must self report any illness or mental health condition which may give rise to a change in circumstances from the time when a grant of licence has been made, differing from obligations for example on a person holding a driving licence to do so. 2. Further it was stated that there is no obligation or provision requiring a General Practitioner practice to: a. Clearly record the holding of a licence on medical records when advised of the grant, in order to assist with flagging any relevant issues that may need reporting (such as conditions listed on an initial firearms/shotgun application form or renewal) b. Requiring the reporting of such issues on a reasonable basis to a firearms licence unit of a local police force 3. The above were described as ‘gaps’ in the legislation which may give rise to the risk of future death. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 7 April 2026. I, 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. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] Greater Manchester Police Lancashire & Cumbria NHS Trust I have also sent it to Royal College of General Practitioners National Police Chiefs Council British Association for Shooting and Conservation who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. |
| 9 | 10 February 2026 Michael J. Pemberton HM Area Coroner Manchester West |