A pregnant pub licensee shot by a customer with mental health problems was unlawfully killed, a jury has decided.
The killer, William Davies, shot 27-year-old Caroline Evans in February last year, before killing himself with the same gun. Davies, 59, was a regular at the Red Lion in Llangadog, Wales, where Ms Evans worked.
The inquest in Carmarthen heard that Davies was "obsessed" with his victim, who was six months pregnant at the time of her death, and had made repeated threats to kill her.
The inquest jury ruled that Ms Evans died in part because the risk to her was not recognised and appropriate precautions were not taken to prevent it. They returned a verdict of suicide on Davies.
Davies, a farmer, had been an in-patient at the mental health unit in West Wales General Hospital and was also under the care of the local Community Mental Health Team.
He had been taken to court a few months before the shootings for threatening Miss Evans with a shotgun, but charges of making threats to kill were dropped in favour of lesser charges.
A member of the pub's bar staff, Jane Southard, told the inquest that Davies would harass his victim at the pub. She said: "He was obsessed with her and would often sit at the bar and stare at her."
Another witness, Nigel Bruce, said Davies claimed he was having an affair with Ms Evans and believed the baby was his.
He also said that Davies had stopped taking his psychiatric medication in the days before the shooting. Mr Bruce had advised Davies to go to his doctor, but he refused. In response to the verdicts, a statement from Pembrokeshire and Derwen NHS Trust said: "We have learned lessons from this tragedy and have already taken action to help strengthen services in this area."