Katie MADDEN · Prevention of Future Deaths report

On 7th June 2023 I commenced an investigation into the death of Katie MADDEN

The investigation concluded at the end of the inquest on 21st May 2024. The conclusion of the inquest was that the death was the result of:-

Suicide, whilst the balance of her mind was disturbed.

The medical cause of death was confirmed as:

1a Hanging

Katie Madden was declared deceased on 4th June 2023 at the ████████ in Suffolk.

Kate had been found by a friend, hanging ██████████████████████████████

Kate’s friend had attended after not being able to contact her for a couple of days.

Kate was diagnosed with anxiety, depression, and emotionally unstable personality disorder which made her act impulsively when faced with emotionally painful situations and stress.

Kate had previously received a Claire’s Law Domestic Violence Disclosure, and was known to be in a toxic relationship. Kate had historically and recently been the victim of domestic violence.

Kate was known to both Mental Health Services, and Social Services, and her children were in care.

Despite restrictions in place, Kate had argued with the subject of the Domestic Violence Disclosure just prior to her death. During the argument Kate was told to go and kill herself.

Kate’s toxic relationship, in conjunction with Kate’s known mental health conditions, affected her state of mind and therefore contributed to her death.

1. No evidence was seen that recipients of a ‘Claires Law’ Domestic Violence Disclosure are treated as being of greater vulnerability, or at a higher risk, when Child Services are undertaking investigations regarding the provision of children’s care, and removal of the children from a parent is being considered. It was heard in evidence that the Social Worker appointed to this case, quite properly focused on what was in the best interest of Kate’s children. There was however no formal system in place to provide additional support for Kate herself, even though she was known to be vulnerable.

2. It was identified that when Kate was informed there may be an application to the Family Court to place her children into care (using the Public Law Outline process), the impact of such a decision on her mental health, or physical wellbeing was not taken into consideration. As a recipient of a ‘Claires Law’ Domestic Violence Disclosure, it was acknowledged that she was of greater vulnerability, but no system is currently in place which allows a risk assessment to be undertaken at the time the Public Law Outline notification is given to a parent. The day after Kate was told of the Public Law Outline notification, she had intentionally crashed her car in an unsuccessful attempt to end her life, requiring 4 weeks in an Intensive Treatment Unit to recover from the serious injuries she received.

3. Once the Public Law Outline process was initiated, independent legal advice was provided, and a voluntary sector advocate supported Kate through the legal process. However, Katie received no independent support from Social Services, and had no independent professional to undertake a holistic review of her case, in light of her known circumstances and vulnerabilities. It was heard that mental health professionals had assumed that she had a Social Worker of her own, and expressed surprise when finding out that she did not.

4. Safeguarding referrals made the Multi-Agency Safeguarding Hub in respect of Kate’s children were viewed in isolation, with no system in place to assess any additional risks posed to Kate herself. There were no additional steps, or risk assessments undertaken in relation to Kate, even though she was a recipient of a ‘Claires Law’ Domestic Violence Disclosure and therefore known to be more vulnerable.

5. In 2022 it was recognised by a Clinical Psychologist that Kate could benefit from Schema-based Cognitive Behavioural Therapy, which is not routinely available on the NHS.

The psychological review had been ordered by the Family Court, and funding for this course needed to be applied for.

Applying for funding involved requests to the Legal Aid Board, Integrated Care Board (Individual Funding Request), Wellbeing Service and Social Services, none of whom provided the funding, with each suggesting contacting one of the other agencies involved.

An experienced mental health clinician with many years’ experience described the ‘whole route as very complicated’ and ‘it was difficult to find a solution for funding’. In addition, funding was very rarely made available, and as a service they were usually unable to meet patient expectations (who believe a treatment might be made available), where in reality it almost certainly would not be available.