Angela Rosemary BEST · Prevention of Future Deaths report

On 19 January 2017, I commenced an investigation into the death of Angela Best, aged 51 years. The investigation concluded at the end of the inquest yesterday. I made a narrative determination at inquest, a copy of which I attach.

Angela Best’s former partner was convicted of her murder.

He had already been convicted of the manslaughter of his wife in 1981 and then his partner in 1992.

The man who killed Angela Best was made the subject of a hospital order in 1993. He was discharged from hospital in 1997. One of the conditions of his discharge was that he had to disclose to his clinical and social supervisors if and when he entered into an intimate relationship with a woman.

His risk to others was, over the years, consistently judged to be low if he was not in a relationship, but high if he was in a relationship. Knowing about a new relationship would allow the man’s behaviour to be explored in a meaningful way by those treating him. It would allow the Ministry of Justice to be informed of the increase in risk. It would allow the woman to be informed of his history and to be offered specialist support, both during the relationship and if she chose to end it. It would allow more effective risk assessment and safety planning to try to protect her.

In fact, he was in a relationship with Ms Best for approximately 20 years without detection. He killed her when she ended the relationship.

The successive mental health trusts who acted as lead agency had the responsibility for monitoring the man’s relationship status and his mental health (which never deteriorated). However, no person or organisation had the role, responsibility or power to investigate his relationship status. The monitoring of whether he was in a relationship was almost entirely based upon his self reporting.

In fact, when this condition of discharge was imposed in 1997, the man was already known to have been untruthful about his relationship status. He continued to be untruthful about it.

In such a situation, evidence may come to light via other agencies, for example if complaints of domestic violence are made to the police, but it did not in this instance. Thus, a matter important enough to be made a condition of discharge, depended upon the truthfulness and openness of an untruthful, two time killer who had a vested interest in withholding the relevant information. Unreliability was built in to the system.