Shortcomings in Durham Police’s Firearms Licensing Unit, including a focus on administration rather than investigating applicants, have been highlighted during an inquest into the deaths of Michael Atherton, 42, his partner Susan McGoldrick, 47, her sister Alison Turnbull, 44, and Alison’s daughter Tanya, 24. Atherton blasted the women in the back following a row at his home in Horden, near Peterlee, on New Year’s Day 2012, then shot himself in the head. The weapon, a Hatson Escort Magnum semi-automatic shotgun, was one of six he was entitled to own despite a history of drunken domestic violence, and threatening to “blow his head off” in 2008. On that occasion police removed his weapons but returned them a few weeks later with a warning to behave responsibly in future. Speaking to bereaved relatives at the inquest in Crook, Chief Constable Michael Barton said: “I apologise on behalf of the organisation that your family and friends have been put through what nobody would want to go through.” Coroner Andrew Tweddle reached verdicts that the women were unlawfully killed and that Atherton, a keen shooter, took his own life. The four-day hearing has concentrated on failings within the licensing unit which have left Mr Tweddle concerned they may exist in other forces. Poor record-keeping, a lack of training, a reluctance to seek legal advice or inquire deeper into applicants are issues that have been raised. An internal review since the tragedy found many licences had been granted to improper people, the coroner said, so it was “fortuitous that, significant as this incident has been, there has not been more”. Mr Tweddle will write to the Home Office calling for “root and branch” changes and possibly legislation surrounding how police license shotguns. Durham’s licensing 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 revealed the lack of organisational control in the way licences were granted by the unit. Mr Barton agreed it was an opportunity lost. The unit has since been overhauled, the hearing was told. The coroner 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 acted 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. Peter Atherton, the taxi driver’s father, said the inquest had not provided an explanation for what “pushed Michael over the edge”. After sending “sincerest regret” to the family of his son’s victims, Mr Atherton said: “We never tried to justify or condone Michael’s actions that night or take away from the devastation that he has caused.” The UK’s largest shooting organisation, the British Association for Shooting and Conservation, said “several clear opportunities” to prevent the massacre were missed. “After this tragedy we have to ask ourselves if 43 different police forces operating different systems with no common training or standards and varying interpretations of government guidance is the right way to protect public safety and ensure efficient licensing,” a spokesman said. A Home Office spokesman pointed out that the UK had some of the toughest gun laws in the world but added: “We are working with Acpo to strengthen the guidance on firearms licensing so intelligence about domestic violence is properly taken into account when police consider applications.”