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AUTHORITIES could have done more to prevent the killing of pregnant landlady Caroline Evans by a deranged farmer, an inquest decided yesterday.
William Davies is known to have still felt resentment and jealousy against Ms Evans after making initial threats against her in October 2002.
But Pembrokeshire and Derwen NHS Trust did not section him or closely monitor his movements, and just four months later he returned to the Red Lion pub and shot her dead.
Love-obsessed Davies, 59, burst into the kitchen at opening time on February 27 last year and blasted her in the face with a shotgun before turning the weapon on himself.
In Davies’s case the jury of five men and five women took an hour-and-a-half yesterday to return a verdict of suicide. But in Ms Evans’s case the foreman went further and said her death could have been prevented by the authorities.
“Caroline Evans was unlawfully killed in part because the risk of her being so killed was not recognised,” she said.
“And appropriate procedures were not taken to prevent her being so killed.”
An inquest cannot name individuals or bodies who are thought to be to blame when returning a verdict.
But grieving father David Evans has named the local NHS Trust alongside the CPS and magistrates as “three authorities who could have issued more appropriate recommendations” when dealing with Davies.
Coroner John Owen said in his summing up that he could see little causal link between the actions of the CPS and the tragic shootings, and did not ask the jury to consider the magistrates’ role.
But he did focus on the decision making process in terms of the diagnosis by mental health staff from Pembrokeshire and Derwen NHS Trust, who had been caring for Davies.
Davies had been an in-patient at the mental health unit in West Wales General Hospital and also under the care of the local Community Mental Health Team since the incident in October 2002.
John Whitting, on behalf of the NHS Trust, had said that the four months between the two incidents was too long to establish any causal link.
But on Wednesday Dr Peter Wood, an independent forensic psychiatrist who was called in to examine reports made on Davies, said there was a lack of coherent risk assessment during that time which could have seen Davies more closely supervised or sectioned.
He said that mental health staff failed to identify the feature of “morbid jealousy” as contributing to Davies’s depression and alcohol problems that winter.
“Dr Wood said such pathological jealousy occurs mode readily in individuals who are depressed or have problems with alcohol,” said Mr Owen in summing up for the jury.
“As part of the case history he said a few basic questions should have been asked, such as ‘How do you feel about Ms Evans now?’.
“Before making an assessment, Dr Wood said prosecution papers should have been sought and there were ways of going about this.”
But he reminded the jury, “We must all remember that looking back at the eventual outcome is very different from the events earlier on.”
He said that Dr Tracy Maria McGee, the consultant psychiatrist who had been looking after Davies, seemed “caring, and deeply upset at the outcome of this case.”
Mr Evans spoke quietly to a visibly shaken Dr McGee before turning to leave the court yesterday afternoon.
Afterwards he said he still felt most resentment towards the CPS decision to drop charges of threats to kill.
He said he could not say whether he would be taking any further action.
“I still resent the fact that the whole thing would not have happened if the CPS had proceeded as the police wanted them to do,” he said.
After the verdicts a statement made for Pembrokeshire and Derwen NHS Trust said it had learnt lessons from the deaths.
“The Trust would, once again, like to extend its condolences to all involved,” it said.
“Following the deaths in February last year, Pembrokeshire & Derwen NHS Trust immediately established a Serious Incident Review into the care of William Davies by Carmarthenshire Mental Health Services.
“The review reported in August 2003 and made a number of recommendations to improve the integration and co-ordination of services and links with other agencies.
“Action has since been taken on these issues. However, it is important to point out that the review also identified points of good practice.”
It added, “Sadly, despite this high level of input from mental health service professionals, Mr Davies took the action which had such terrible consequences.
“This was a tragic case which obviously had a profound effect on friends and families and, indeed, the whole community of Llangadog.”
A spokesperson for the Trust said it has already apologised to Ms Evans’s and Davies’s families.
A Llangadog resident who knew Ms Evans well said villagers would be glad to get on with life now that the inquest was over.
“That is not to say we will forget Caroline as she was such a big personality and known by everyone in the village,” said the woman, who asked not to be named.
“But here’s hoping we can look to the future now.”
Killer’s farm buildings to be converted into homes
THE REDUNDANT farm buildings of killer William Davies will be converted into plush houses by the county council, it was revealed yesterday.
As the inquest jury reached its verdict in Carmarthen, across town councillors were discussing proposals to transform the rural buildings at Dolau Farm, Llangadog.
They have fallen into the Carmarthenshire County Council’s possession since the double shootings in the Red Lion last year.
William Davies was known locally as “Will Dolau” and had been born and brought up on the farm.
But his depression was precipitated by losing his prized dairy herd, which he called “the best in Carmarthenshire” and had spent a lifetime building up.
Not long after losing this herd and turning to drink he shot Caroline Evans and took his own life.
“As the buildings are no longer required for agriculture they have fallen into the possession of the council,” said a council spokeswoman.
“This is often the case when long-standing farms are left.”
The buildings will be renovated in accordance with guidelines keeping the character of the rural area.
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INDEPENDENT EXTERNAL REVIEW INTO THE HOMICIDE AND SUICIDE IN LLANGADOG ON 27th FEBRUARY 2003
Page 38: 20th November 2002: 13.30 Mr Davies discharged. Care plan reviewed and sent to GP and CPN. Discharge summary prepared for GP Discharge mental state – well-settled, mood euthymic, no ideas of self-harm or suicide, no idea of harming others. Motivated to abstain from alcohol. Well-oriented. Good insight (ICD10 Code F32.1 moderate episode of depression, F10 alcohol abuse). Discharged on anti-depressants.