Landlady's 'terror' before shooting

William Davies, 59, killed pregnant Caroline Evans, 27, before turning the gun on himself.

Mr Davies was said to be "obsessed" and had made repeated threats to kill her and Ms Evans' father said more should have been done to prevent her death.

The jury concluded that Ms Evans died in part because the risk of her being killed was not recognised and appropriate precautions were not taken to prevent it.

A verdict of suicide was returned on Mr Davies.

Coroner Jon Owen had previously told the Carmarthen inquest jury that it was clear that Mr Davies had killed himself at the pub in Llangadog after shooting Ms Evans.

But he asked whether their deaths could have been caused because Mr Davies' behaviour had not been recognised by his doctors.

Ms Evans' father, David, has blamed the police and mental health authorities for failing to prevent his daughter's murder by not taking enough action following Davies' repeated threats.

Mr Davies had been taken to court for threatening Miss Evans

Davies had been taken to court a few months before the fatal shootings for threatening Miss Evans with a shotgun, but charges of making threats to kill were dropped in favour of lesser charges.

"If any of the three (authorities) had issued more appropriate recommendations then the tragic outcome would not have ensued," he told the court.

Responding to the verdict, Carmarthen-based area business manager for Dyfed-Powys CPS Jeff Thomas said the decision to withdraw the threats to kill charge against Davies was made by a senior crown prosecutor.

This, he added, was made in accordance with the code for crown prosecutors, who decided there was no realistic prospect of conviction.

"An internal inquiry by way of review by a chief crown prosecutor from another area upheld his decision.

Mr 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 October 2002.

Shortly after the inquest closed, Pembrokeshire and Derwen NHS Trust issued a statement, the final paragraph of which read: "The trust would like to reiterate the important point that we have learned lessons from this tragedy and have already taken action to help strengthen services in this area."

It was on 27 February 2003 that Davies shot Mr Evans at point blank range as she opened up the pub for business.

He then turned the gun on himself.

The jury was told how Mr Davies was a regular customer at the Red Lion pub and had made repeated threats to kill Ms Evans for no apparent reason.

Barmaid Jane Southard told the hearing how Davies would harass her.

"He was obsessed with her and would often sit at the bar and stare at her," she said.

"He claimed he was in a sexual relationship with her but I'm sure he was not. She and I were very close and she would have told me if she was having an affair with him."

Ms Evans was six months pregnant as a result of a relationship with a pub landlord from another part of Wales whom she met while on a publicans' trip to Paris.

Giving evidence, a friend of Davies', Nigel Bruce, said the farmer claimed he was having an affair with Ms Evans and believed the baby was his.

"But I don't think he had a sexual relationship with her. I think a lot of it was in his mind and a figment of his imagination," Mr Bruce told the court.

He went on to say that Davies had stopped taking his psychiatric medication in the days leading up to the shootings after he complained of headaches.

"He was ranting and raving," he said, "and said 'if you see that bitch Caroline tell her I will slit her throat'. "

Mr Bruce said he advised Davies to go to the doctor, but he refused.