The gruesome death of a businesswoman who was set alight by her ex-partner could have been avoided if police had warned her of the danger he posed, a sheriff has ruled.
Kevin Marks stood over Ann Drummond, 47, and laughed as she rolled around the ground in a bid to extinguish the flames engulfing her body.
He started the blaze in her car at a road near Bathgate, West Lothian, in June 2019. Medics found more than 80 per cent of Ms Drummond's body was injured by burns. She died at Glasgow Royal Infirmary.
Ms Drummond had picked up Marks from court after he was released on bail for other offences when he committed the lethal attack.
Marks, 52, was charged with murder but prosecutors accepted a not guilty plea on the basis his mental health was so poor he was not responsible for his actions.
Kevin Marks stood over Ann Drummond (pictured), 47, and laughed as she rolled around the ground in agony
Miss Drummond's son Jake Smart (both pictured), who works for a roofing company, took to social media to pay tribute to his mother as she lay dying in hospital. He posted this picture of her with the caption 'my beautiful mum'
In October 2020 Marks was ordered to be held at the State Hospital in Carstairs, Lanarkshire, without limit of time.
A fatal accident inquiry at Livingston Sheriff Court has now found her death could have been avoided if police had shared information on Marks with the NHS, amid concerns for his mental health.
The court heard Marks, who was diagnosed with paranoid schizophrenia after the attack, had previously threatened Ms Drummond and had a history of domestic offending.
Sheriff Peter Hammond said there should have been a 'thorough and effective' risk assessment carried out on Marks and Ms Drummond warned of the potential danger he posed.
The sheriff added the 'inadequate' sharing of information by police and the failure to carry out the risk assessment were defects in the system of working. But Sheriff Hammond made no recommendations after hearing changes to working practices had been made by Police Scotland.
Police told the inquiry it was 'unreasonable and unrealistic' for officers to have articulated concerns for his physical and mental health.
Marks started the blaze in her car at a road near Bathgate, West Lothian pictured), in June 2019
But in a written judgment, Sheriff Hammond said: 'The effective sharing of potentially relevant information held by the police, within the police service and with NHS staff, about the mental health of Mr Marks might have led to the detection of his psychosis and the taking of protective steps.
'As such, that was a precaution which could reasonably have been taken, which might realistically have resulted in the death being avoided.'
Deputy Chief Constable Jane Connors said: 'We will carefully review the determination as we work to improve our response to our communities and vulnerability.'
NHS Lothian was approached for comment.