Over the course of the inquest the jury heard details of mistakes made by Devon and Cornwall Police in the granting of Jake Davison’s shotgun certificate  and the later seizing and returning of his weapon and certificate.

Here is a list of them:

– Failures in the firearms licensing unit

There were multiple failures within Devon and Cornwall Police’s firearms licensing unit.

High risk decisions were downgraded, those decisions were not passed to senior managers for reviewing, and dip sampling did not take place.

Staff were also failing to follow statutory Home Office guidance for assessing applications and were not using the force’s own risk assessment matrix to assess suitability.

They had also not received nationally recognised training, which had been recommended in the aftermath of the Dunblane tragedy.

Superintendent Brent Davison, who became head of unit after the incident, said the decision-making system was “fundamentally flawed” and was in place for at least five years.

– Granting the application

Superintendent Adrian Davis, the firearms licensing co-ordinator for the National Police Chiefs Council, said Davison should never have been granted a shotgun certificate because of a flawed assessment of his application.

He said there were far too many gaps in the then 18-year-old’s original application that, had he been reviewing it, he would have wanted further information.

With a full picture of Davison’s violent history, including the incidents at school and a domestic argument with his father, he would have refused the application.

David Rees, a firearms enquiry officer, assessed Davison’s risk as “very low” even though it should have been high risk and recommended granting.

Supervisor Steve Carder, who signed off the recommendation, accepted his role had become a “box ticking exercise”.

Chief Superintendent Roy Linden, of Devon and Cornwall Police, said Davison should never have been granted the certificate.

“Jake Davison should not have had a licence. Jake Davison should not have had a licence again in 2020. For that, we very much apologise. It should not have happened,” he said.

– Lack of medical information

Davison’s GP followed BMA advice not to supply information to the police because he was not qualified to comment on the “assessment of behavioural and personality disorders”.

Police never sought any further information and did not inform Davison’s doctor he had been granted a shotgun certificate.

– Should Davison have been charged with assault after attacking two teenagers?

Detective Inspector Debbie Wyatt, who decided to refer Davison to the deferred prosecution Pathfinder scheme, maintained she had made the right decision.

A lawyer representing Davison’s victims suggested Det Insp Wyatt’s decision to treat the incident as battery rather than the more serious assault occasioning actual bodily harm was “plainly wrong”, which she rejected.

Her colleague, Detective Sergeant Edward Bagshaw, said the case should have been sent to prosecutors to consider charges but officers were under “pressure” to use out-of-court disposals due to an increased backlog in the courts caused by the pandemic.

– The delay in informing the firearms licensing unit

The detective constable who investigated the assaults had seen an “FC” marker about Davison on the police national database but did not know it meant he held a firearms certificate.

It led to a two-month delay in the firearms licensing unit learning of the incident when they were told by a Pathfinder scheme worker.

– Seizing Davison’s certificate and shotgun

Mr Rees assessed Davison risk to the public as medium, which he had downgraded from high risk because of the passage of time.

He seized the shotgun and certificate pending the outcome of the Pathfinder scheme.

Experts agreed it was the correct decision to seize them, but Mr Davis said they should not have been returned because of the history of violence.