Angela Best
PFD Report
All Responded
Ref: 2021-0194
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Other related deaths
All 1 response received
· Deadline: 30 Jul 2021
Coroner's Concerns (AI summary)
A high-risk individual's critical discharge condition, requiring disclosure of intimate relationships, relied solely on his self-reporting despite known untruthfulness, with no independent verification mechanism.
View full coroner's concerns
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.
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.
Responses
Action Taken
The MoJ is drafting discharge guidance for the Mental Health Casework Section (MHCS), identifying patients discharged prior to 2003 for MAPPA consideration, and revising court orders for new patients to highlight MAPPA responsibilities. They are also reviewing warrants issued in prison transfers to incorporate similar changes. (AI summary)
The MoJ is drafting discharge guidance for the Mental Health Casework Section (MHCS), identifying patients discharged prior to 2003 for MAPPA consideration, and revising court orders for new patients to highlight MAPPA responsibilities. They are also reviewing warrants issued in prison transfers to incorporate similar changes. (AI summary)
View full response
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 Dartmouth Park Hill, London.
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
2 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.
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 Dartmouth Park Hill, London.
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
2 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.
Sent To
- Ministry of Justice
Response Status
Linked responses
1 of 1
56-Day Deadline
30 Jul 2021
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
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.
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.
He had already been convicted of the manslaughter of his wife in 1981 and then his partner in 1992.
Copies Sent To
Camden & Islington NHS Trust
Barnet, Enfield & Haringey NHS Trust
, general practitioner
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.