A senior coroner has issued a damning report in the wake of the death of a young mother-of-four who took her life while struggling to get help for her deteriorating mental health.
Speaking at a recent inquest into the death of Katie Madden, 32, Nigel Parsley condemned the services involved with her care.
Now, following the end of the court proceedings, the coroner has issued a Prevention of Future Deaths report to the Norfolk and Suffolk NHS Foundation Trust, Suffolk County Council, and Suffolk Police.
In it, he says: “In my opinion there is a risk that future deaths could occur unless action is taken."
He raised particular concerns that not enough was done to support Miss Madden after she received a 'Clare's Law' disclosure, whereby people are notified by police about a partner's history of abuse or domestic violence.
The disclosure was made at a time of acute stress for Miss Madden, as the relationship was coming to an end and as she was desperately trying to have her children returned to her care.
The coroner's report states: “No evidence was seen that recipients of a ‘Clare's Law’ Domestic Violence Disclosure are treated as being of greater vulnerability, or at a higher risk, when Child Services are undertaking investigations.
“It was heard in evidence that the social worker 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.”
He went on to say that when Miss Madden was informed there may be an application to the Family Court to place her children into care, the impact on her mental health or physical wellbeing “was not taken into consideration”.
He added: “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 [Family Court application] is given to a parent.”
The day after the application, Miss Madden, from Lowestoft, intentionally crashed her car in an unsuccessful attempt to end her life.
She spent four weeks in an intensive treatment unit as she recovered.
Following this, she was given independent legal advice, and a voluntary sector advocate supported her through the legal process.
But she received no independent support from Social Services, and had no independent professional to undertake a holistic review of her case despite her known circumstances and vulnerabilities.
Her inquest was told that mental health professionals had assumed she had a social worker of her own and expressed surprise when they found out she did not.
Mr Parsley said: “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 ‘Clare's Law’ Domestic Violence Disclosure and therefore known to be more vulnerable.”
The family court requested that Katie undergo a psychological review. A clinical psychologist recommended she would benefit from a course of cognitive behavioural therapy which is not routinely available on the NHS.
Instead, she had to apply for funding. This involved requests to the Legal Aid Board, Integrated Care Board (Individual Funding Request), Wellbeing Service and Social Services.
None provided the funding, with each suggesting contacting one of the other agencies.
Miss Madden’s mother, Bernadette Sutton, said that while nothing would bring her daughter back she hoped the coroner’s report would help "get the message across” to those working in services created to help vulnerable people.
Mr Parsley's report was also issued to MP Victoria Atkins, the health secretary, and Laura Farris, the safeguarding minister.
- To pay tribute to a loved one, email norfolkobituaries@newsquest.co.uk
- To read all obituaries and tributes join the Facebook group Norfolk's Loved & Lost.
- Do you need support? Samaritans can be contacted 24/7 by calling 116 123. Alternatively, the NHS First Response Service can be reached on 111, selecting option 2.
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