Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0194, written 4 Jun 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Jun 2021 |
|---|---|
| Reference | 2021-0194 |
| Deceased | Angela Best |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Community health care · Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Angela Rosemary BEST (died 15.12.16)
THIS REPORT IS BEING SENT TO:
1. The Rt Hon Robert Buckland QC MP
Lord Chancellor and Secretary of State for Justice
c/o
Ministry of Justice
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
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.
4
CIRCUMSTANCES OF THE DEATH
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.
5
CORONER’S CONCERNS
1
During the course of the inquest, the evidence revealed matters giving
rise to concern. In my opinion, there is a risk that future deaths will occur
unless action is taken. In the circumstances, it is my statutory duty to
report to you.
The MATTERS OF CONCERN are as follows.
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.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
2
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 2 August 2021. 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 following.
• The family of Angela Best
c/o
, Deighton Pierce Glynn
• Camden & Islington NHS Trust
• Barnet, Enfield & Haringey NHS Trust
•
, general practitioner
• HHJ Thomas Teague QC, the Chief Coroner of England & Wales
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 other 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.
9
DATE SIGNED BY SENIOR CORONER
04.06.21 ME Hassell
3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Ms M Hassell, Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP The Right Honourable Robert Buckland QC MP Lord Chancellor & Secretary of State for Justice 27 July 2021 Dear Ms Hassell, RESPONSE TO REGULATION 28: PREVENTION OF FUTURE DEATHS REPORT Thank you for your Regulation 28: Prevention of Future Deaths report dated 4 June 2021 following the inquest into the death of Angela Rosemary Best who died on 15 December 2016 at Hill, London. Dartmouth Park I met members of Ms Best’s family in my role as Solicitor General when I referred the case to the Court of Appeal under the Unduly Lenient Sentence Scheme and personally appeared to present the case there. At that time they were going through excruciating pain and were desperate for justice to be done. I can understand why they may still have many questions about how it was able to happen, especially given previous homicide convictions. The pain and heartache of losing Angela will never leave them and I understand why they may be interested in what the authorities will do to try to prevent any similar tragedies happening. I wish all her family the very best and I hope they are able to find some peace. Following evidence heard at the inquest you have raised concerns, namely the unreliability built into the system that relied upon self-reporting from a known killer who had a vested interest in withholding relevant information. The Mental Health Casework Section (MHCS) in HMPPS exercises the Secretary of State’s statutory powers under the Mental Health Act 1983, and whilst the day to day supervision of conditionally discharged patients is the responsibility of the care team in the community, I recognise that there are improvements we can make to the way MHCS and care teams work together. In response to the concerns you have raised, MHCS have identified a number of actions they propose to take forward: Review of Conditions of Discharge and Associated MHCS Guidance: Mr Johnson had a condition ‘to notify his/her supervising team (his Responsible Clinician and Social Supervisor) of any close relationship he/she was having or was developing’. Conditional discharge reports routinely provided updates on Mr Johnson’s relationship status, based on his own self reporting. Officials will review the MHCS condition applied to relationships, to explore whether additional or amended conditions may assist. This will be subject to informal consultation with stakeholders (such as the Forensic Faculty of the Royal College of Psychiatrists). MHCS guidance on managing discharged patients will be revised to promote and support the sort of professional curiosity and challenge that is acknowledged practice in fields of probation supervision, social work, domestic violence, safeguarding and adult social care. We will encourage a F 0870 761 7753 E https://contact-moj.dsd.io/ www.gov.uk/moj 102 Petty France London SW1H 9AJ more investigative approach, being vigilant and inquisitive in seeking out information from a wide range of sources to inform ongoing assessment. MHCS receives regular reports on conditionally discharged patients, this is a statutory requirement. MHCS will revise the template for conditional discharge reports alongside the guidance thereby facilitating the sharing of information between supervision care teams and MHCS, setting the expectation that reliance on self-reporting is not sufficient. MHCS will also work with partner agencies in support of delivering this different approach to supervision of discharged patients. The Government’s White Paper Reforming the Mental Health Act (January 2021) set out aspirations to strengthen and further develop the role of the social supervisor; including a consultation question asking stakeholders how best to achieve this. The consultation has now closed and responses are being considered. MHCS will continue to work with DHSC to deliver on this ambition and the proposals on qualifications and training requirements. Discharge applications and associated guidance: MHCS has not formally published discharge guidance before now; officials are in the process of drafting it and it will, in due course, be published on gov.uk. I can confirm the current drafting contains information on MAPPA and the responsibilities of responsible clinicians in this regard. Communications to care teams of discharged patients in the community: in response to the recommendations of the Domestic Homicide Review into the death of Angela Best, MoJ took a number of follow up actions. These included identifying patients that met criteria similar to that of the case of , namely they were discharged prior to 2003 (so may not have been automatically MAPPA- eligible), and had the same condition (to notify their care team of any developing relationship). At that time a small number cases were identified and MHCS wrote to the clinicians responsible for their care seeking reassurance that MAPPA management had been considered. Officials have subsequently identified a further 250 cases, without the specific condition, but whom were also discharged prior to 2003, and are in the process of writing to those supervising teams to ensure they are aware of their own responsibilities in respect of MAPPA. Hospital Orders and MHCS Issued Warrants: For new patients in receipt of hospital orders from the Crown Court, there is now clear wording on the Court Order aimed at responsible clinicians, highlighting their statutory responsibility to identify and refer patients for MAPPA management. We are working to see similar changes implemented for orders issued via the Magistrates court. MHCS will also review the warrants they issue in prison transfers to incorporate similar changes. Thank you for bringing these concerns to my attention. I trust that this response provide assurance that action is being taken to address the matters you have raised. Yours sincerely RT HON ROBERT BUCKLAND QC MP 2
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