Matilda Rose Davis · Prevention of Future Deaths report

I conducted an inquest into the death of Matilda Rose Southall. The inquest concluded on the 20th March 2026.

Matilda died on the 3rd October 2025 at her home address of ████████
████████ The medical cause of death was confirmed as 1a) Suspension by a ligature around the neck.

I recorded a short-form conclusion of Suicide.

On 3rd October 2025, Matilda was found deceased at her home in Stratford-upon-Avon. Earlier that day, Warwickshire Children’s Social Care had conducted an urgent safeguarding visit following concerns raised by her estranged husband regarding her mental health and the welfare of their two children.

During the visit, Matilda reported experiencing emotional and psychological strain arising from relationship conflict, financial pressures, and the ongoing divorce proceedings. She also described recent episodes of head-banging behaviour and confirmed aspects of her medical history, including discontinued antidepressant medication and a current prescription for diazepam. She stated that she intended to arrange a further GP appointment.

Before concluding the visit, the attending social worker and the support worker noted that Matilda’s demeanour was calm and that she expressed no suicidal ideation.

Shortly after their departure, Matilda was found hanging by a ligature attached to ████████
████████ There was no evidence of forced entry. The emergency services attended, but Matilda was pronounced deceased at 16:26 hours on 3rd October 2025.

Evidence heard during the inquest confirmed that suicide prevention training is not mandatory for frontline practitioners and staff within Warwickshire Children’s Services. The social worker and support worker who visited Matilda had not received suicide prevention training, although such training was available within the organisation.

In the absence of mandatory suicide prevention training, Matilda was not asked directly about suicidal ideation during the visit, where reference was made to suicidal thoughts within the referral context. It was also noted that she was not signposted to crisis support services at that time.

The non-mandatory nature of suicide prevention training may give rise to variability in practice when practitioners are required to explore, record, or respond to indications of possible self harm or suicidal thoughts.