Action to prevent future deaths is being sought after the inquest of a young teacher murdered on a first date revealed significant failings by Herts police and other public bodies.
Among the failings was that a judge was without all the facts when, three weeks before the killing, he handed the murderer a suspended sentence for threatening to kill two women.
Katie Locke, 23, was murdered on Christmas Eve in 2015 by Carl Langdell - a man she had met through an internet dating site about two weeks earlier.
After a date in a London bar, they returned to Hertfordshire and booked into a hotel, arriving in the early hours of December 24.
At some point that morning, Langdell strangled Katie to death and inflicted serious sexual violence. He wrapped her body in bedclothes and left it in the hotel grounds.
In 2016, Langdell pleaded guilty to her murder and was jailed. This February, Langdell, 30, died in prison after slashing his throat.
Evidence heard during Katie's inquest, which concluded last month, has compelled assistant Herts coroner Alison McCormick to now write to Herts police and Herts Partnership NHS Foundation Trust to call for action to prevent future deaths.
Langdell, who had been diagnosed with emotionally unstable personality disorder with narcissistic and antisocial traits, was known to several public bodies - including Herts police and Herts Partnership NHS Foundation Trust - each of whom had information relevant to his risks to women.
Ms McCormick said: "There were, however, significant gaps in the information available to each public body, and insufficient sharing of the available information between agencies to enable a fully informed assessment of his risks.
"Three weeks before the killing, the murderer had been given a suspended sentence, having been convicted of making threats to kill two other women.
"Whilst it is not possible to say what sentence the judge would otherwise have given, a fully informed picture had not been placed before the crown court.
"There were a number of lost opportunities for sharing information between the public bodies regarding the murderer.
"Action should be taken to prevent future deaths."
Herts police's Chief Constable, Charlie Hall, said: “We owe it to Katie and her family to do everything we can to learn from her tragic death and work to prevent anything of this nature from ever happening again.
"Since her death we have worked with a large number of partners to identify the gaps in service delivery that fell short in this case.
"Public safety is at the heart of our response. We have examined our processes and procedures around the management of potential dangerous people, and adopted a more robust information sharing approach, and will continue to work with relevant partners to ensure standards are maintained.
"Any further learning recommended after Katie’s inquest will be taken forward as a matter of priority.”
Professor Asif Zia, executive director of quality and medical leadership at Herts Partnership University NHS Foundation Trust, said: “I would like to offer our sincere condolences to Katie’s family, her friends and everyone affected by this tragedy.
“We fully accept the coroner’s conclusion and recommendations for further learning between organisations, and will ensure these are acted upon rapidly to build on learning already in place and to make changes to further improve our processes.”
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