Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0295, written 30 May 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 May 2024 |
|---|---|
| Reference | 2024-0295 |
| Deceased | Katie Madden |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 6 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Rt Hon Victoria Atkins MP Secretary of State Department of Health and Social Care 39 Victoria Street London SW1H 0EU Right Hon Laura Farris MP Under-Secretary of State Victims and Safeguarding House of Commons London SW1A 0AA The Chief Executive Norfolk and Suffolk NHS Foundation Trust, Trust Headquarters Hellesdon Hospital Drayton High Road Norwich NR6 5BE. Suffolk County Council Head of Adult and Child Services Endeavour House 8 Russel Road Ipswich Suffolk CEO of the NHS Norfolk and Waveney Integrated Care Board County Hall Martineau Lane Norwich NR1 2DH The Chief Constable Suffolk Constabulary Police Headquarters Portal Ave Martlesham Heath Ipswich IP5 QS 1 CORONER I am Nigel Parsley, Senior Coroner, for the coroner area of Suffolk. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST 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 4 CIRCUMSTANCES OF THE DEATH 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. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters given rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you; the MATTERS OF CONCERN as follows. – 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 focussed 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 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 Kate 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 the 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. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken in order to prevent future deaths, and I believe you or your organisation have the power to take any such action you identify. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 25th July 2024 I, the Senior Coroner, may extend the period if I consider it reasonable to do so. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons;- 1. Kate’s next of kin. 2. Suffolk Safeguarding Partnership I am under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 30th May 2024 Nigel Parsley
6 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Parliamentary Under Secretary of State For Patient Safety, Women’s Health and Mental Health. 39 Victoria Street London SW1H 0EU 6 September 2024 Our Ref: Nigel Parsley Senior Coroner Beacon House Whitehouse Road Ipswich, Suffolk IP1 5PB By Email: Dear Mr Parsley, Thank you for your Regulation 28 report to prevent future deaths dated 30 May 2024 about the death of Katie Madden. I am replying as the Minister with responsibility for mental health and patient safety. Firstly, I would like to say how saddened I was to read of the circumstances of Katie’s death and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are deeply concerning and I am grateful to you for bringing these matters to my attention. I understand the concerns raised in your report about ‘Claires Law’, Domestic Violence Disclosures, the Public Law Outline process, the support Katie received from Social Services and the safeguarding referrals made to the Multi-Agency Safeguarding Hub. I see that Suffolk County Council and the Suffolk Constabulary have addressed these in their responses to you. Regarding your concern that, following a psychological review ordered by the Family Court, the Schema-based Cognitive Behavioural Therapy treatment recommended for Katie was not made available. I regret that Katie did not get this therapy as it is not routinely available on the NHS. In such instances, the normal process would be for an individual funding request application to be made by the appropriate clinician to the relevant integrated care board (in this instance, Norfolk and Waveney ICB). This would then be considered by an independent panel made up of doctors, nurses, public health experts, pharmacists, NHS England representatives and lay members. 1 Whilst it is not clear from your report how the recommendation from the psychological review was communicated to the NHS, Norfolk and Suffolk NHS Foundation Trust has said in its response to you that it has asked all its clinicians that receive referrals into mental health services to identify those where treatments have been recommended by clinicians from outside the Trust in order to offer an assessment prior to any decision being made on the most appropriate way forward. If you are able to share any further information on this aspect of Katie’s care, I would be happy to look into this further. In addition, I understand that the Norfolk & Waveney ICB will be working with partners to ensure that learning and action is taken forward from this case. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely,
Minister for Safeguarding and
Violence Against Women and Girls
2 Marsham Street
London SW1P 4DF
www.gov.uk/home-office
19 September 2024
Mr Nigel Parsley LLM, DipFHID
HM Senior Coroner for Suffolk
Beacon House
White House Road
Ipswich
IP1 5PB
By email:
DECS Reference:
Dear Mr Parsley,
Thank you for your letter of 18 August about the Prevention of Future Deaths Report for
Ms Katie Madden.
I would like to thank you for sharing a copy of this report with me, into what was clearly a
tragic case. In my role as the Minister for Safeguarding and Violence Against Women and
Girls, I am absolutely committed to improving the Government’s response to these horrific
crimes and ensuring that victims of domestic abuse receive the support they need.
Reports like this one help me to know what we must focus on, and I am encouraged that
you sent it to me. I would encourage others to do the same regardless of if there is a
statutory requirement to do so. It is so important that I keep across that is happening on
the ground.
I would be grateful if you could confirm whether the local social services involved in this
case have advised whether they will be acting upon the recommendations made to ensure
that in future cases, support is given directly to victims of domestic abuse as well as their
children.
Yours sincerely,
Minister for Safeguarding and Violence Against Women and Girls
Senior Coroner Nigel Parsley Suffolk Coroner’s Court Beacon House Whitehouse Road Ipswich IP1 5PB E mail: By email only NSFT Trust Management Norfolk & Suffolk Foundation Trust County Hall Martineau Lane Norwich NR1 2DBH Tel: Date: 25 July 2024 Dear Coroner Parsley Regulations 28 and 29 (coroners investigations regulations 2013) notification made in response to the death of Katie Madden I write in response to the Regulation 28 report made on 30th May 2024 in respect of concerns raised at the inquest touch the sad death of Kate Madden which concluded on 21st May 2024. It appears from the report that paragraph 5 of the concerns raised relate to NSFT, namely: 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. NSFT is commissioned to provide mental health services within Norfolk and Suffolk. For service users under the care of NSFT, where a need for treatment that cannot be provided by NSFT is clinically indicated by NSFT clinicians, a process for requesting individual funding is available by way of request to Norfolk & Waveney Integrated Care Board. Where an individual is not under the care of NSFT and a need for treatment is recommended by clinicians instructed privately, independently, and/or for purposes other than mental health provision to recover activities of daily living, as was the case for Ms Madden, two issues arise: Chair: Trust HQ: County Hall, Martineau Lane, Norwich, NR1 2DH Tel: Web: Chief Executive Officer: Caroline Donovan - 2 - 1. If assessed by NSFT clinicians, would the same recommendations for treatment result; and 2. If not, how to manage a service user’s expectations when they have been advised by non-NSFT clinicians of their recommendations. In this matter, Ms Madden was informed by the non-NSFT clinician that the recommended treatment may be available on the NHS and if not, could be sought out privately (with information on where to find details). In view of the above, NSFT has asked all clinicians that receive referrals into services to identify those where treatments have been recommended by non-NSFT clinicians in order to offer an assessment prior to signposting elsewhere on the basis that: • • • there may be an alternative treatment available within NSFT services that is appropriate and could be offered, based on NSFT clinical assessment; and/or if NSFT clinicians agree that a treatment not available within standard services is required and individual funding should be sought, they can submit this application in collaboration with the service user; or if NSFT clinicians do not deem the recommended treatment to be necessary/appropriate, they can provide the service user with a clinical rationale for this and signpost them to other agencies such as charities/private providers who may be able to assist. I am aware that our Clinical Director attended the inquest to give evidence and I wish to reiterate the sincere condolences offered by him at inquest to Miss Madden’s loved ones in such tragic circumstances. Yours sincerely, Chief Executive Officer
Our Ref: Madden PFD 25 July 2024 PRIVATE & CONFIDENTIAL Sent by email Chief Executive of NHS Norfolk and Waveney ICB Floor 8 County Hall Martineau Lane Norwich NR1 2DH Direct Tel: Web: Email: To Nigel Parsley, Senior Coroner for the Suffolk Area Re: Prevention of Future Deaths Report for Ms Katie Madden We are writing in response to the publication of a Prevention of Future Deaths Report (ref. 2024- 0295) dated 30/05/2024 in relation to the death of Ms Katie Madden on 4th June 2023. As the NHS Integrated Care Board for Norfolk and Waveney, we commission mental health care from Norfolk and Suffolk Foundation Trust and coordinate the Mental Health Individual Funding Request process for Norfolk and Waveney patients. We are responding to the last concern raised within your report, as follows: 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 (ICB) Individual Funding Request Panel, Wellbeing Service and Social Services, none of whom provided the funding. We can confirm that we have reviewed our Mental Health Individual Funding Request records and that we have not been able to identify any Individual Funding Request being made to us on behalf of Ms Madden, for Schema-based Cognitive Behavioural Therapy. In providing this response we would wish to reassure you that we have not lost sight of the suffering that has resulted from Ms Madden’s death. As an ICB we will be an active partner in the further review and response to her case, as statutory safeguarding partners work together to ensure that learning and action is taken forward. We hope that the above is helpful. Our thoughts are with the family as they come to terms with their loss. If you require any further information relating to this response, please contact: , Director of Nursing and Quality, NHS Norfolk and Waveney ICB Email: Yours sincerely Page 1 of 2 Chief Executive, NHS Norfolk & Waveney ICB Page 2 of 2
Regulation 28 Response of Suffolk County Council In respect of Ms. Katie Madden We write in response to the Coroner’s Regulation 28 report, dated 30th May 2024 concerning the death of Ms. Katie Madden on 4th June 2023. First of all, Suffolk County Council (“SCC”) would like to express our sincere condolences to Katie’s family and loved ones. SCC are keen to ensure that the family and the Coroner’s concerns are listened to and reflected upon. As the Coroner has already identified, the Children and Young People’s team (“CYP”) have a statutory duty to safeguard the wellbeing of persons below the age of 18. We concur with the Coroner’s observation that there exists no statutory or other national system in place to represent the needs of vulnerable parents facing the prospect of their child/ren being taken into care. SCC welcome any interventions that the appropriate Secretaries of State can offer in this regard, which would assist partnership working, moving forward. Having viewed the Coroner’s Regulation 28 report, the first three points relate to the process of information sharing between the Multi-Agency Safeguarding Hub (MASH), Adult Social Care (“ASC”) and CYP, and the system of risk assessments in place for managing vulnerable parents when they are facing the prospect of their children being taken into care. The “Claire’s Law” disclosure scheme is managed and led by the Constabulary. SCC social care staff, working within the MASH, reviewed the manner in which Katie received that disclosure and were content that all procedures had been complied with, in accordance with established practice. CYP staff were aware of the “Claire’s Law” disclosure recorded having had access to all safeguarding referrals relating to the family. However, SCC accept that if a parent demonstrates that they are in need of additional support as a result of the onset of PLO proceedings then CYP staff should make a referral to ASC by way of a referral to its Customer First Team in addition to any support they may already be receiving from other agencies. This is particularly pertinent, in cases such as Katie’s, where a parent has an established history of rumination and behaving unpredictably during stressful life events. The purpose of the referral would be to determine eligibility for assessment and services in accordance with the Care Act 2014. This activity may result in further signposting, including to primary or secondary mental health services. Any referrals related to safeguarding concerns for a parent would be passed to the MASH who will consider any safeguarding actions required in accordance with Section 42 of the Care Act. A practice note and addition to the Standard Operating Procedure for the MASH will be made to remind MASH practitioners of the need to identify the vulnerabilities of any adults involved in safeguarding referrals in respect of children. Action is already underway following a Serious Case Review in respect of MANDY for a process of prompts in both children’s and adult Multi Agency Referral Forms. This is for the practitioner to consider, when putting in a referral related to a child, whether there is an adult involved for whom there are also concerns. The practitioner will be prompted at the end of the referral form to direct the practitioner to submit the additional concerns in relation to the adult to the relevant portal for triaging. This process will also be implemented when referrals are received in respect of adults where the practitioner will be prompted to refer any concerns identified in relation to a child to the relevant portal. Whilst a referral of this type is wholly dependent on the persons consent and may not always result in the aforementioned assessment(s) staff will be reminded that a referral ought to be made, nonetheless. This aspect of identified learning shall become a dedicated focus within our annual PLO training for CYP colleagues working across our operational services to raise awareness of presenting significant MH issues, recognising that SW are not able to undertake specific MH assessments. The voice of parent/carers as “experts by experience” will inform our PLO training programme. We shall work alongside our judiciary partners such as CAFCASS to raise awareness and promote ownership and responsibility across the wider system. We will ensure that advocate support is accessible and appropriate to the needs of parent/carers where risk assessed. CYP staff will also be reminded that the PLO process should be utilised, wherever possible, as a restorative tool which is approached with compassion and from a trauma-informed place. In addition, staff at Legal Services, when accepting a new case from CYP, shall be required to discuss with social workers any relevant vulnerabilities relating to the parent(s) and whether a referral or any further signposting is needed. Finally, a Safeguarding Adults Review Panel (SARP) Meeting took place on 10th July 2024. The SARP is a sub-committee of the Suffolk Safeguarding Partnership, more information in respect of which can be found at https://www.suffolksp.org.uk. As a result of this meeting, a referral has been sent to the Community Safety Partnership for consideration for a domestic homicide review of this case. The SARP would like to explore the opportunities for a joined-up review process as part of this ongoing piece of work. An update regarding the proposal for a domestic homicide review is expected in September. Prepared on behalf of Suffolk County Council Adult and Children Services 25 July 2024
Suffolk Constabulary Police Headquarters Martlesham Heath Ipswich, Suffolk IP5 3QS Senior Coroner Nigel Parsley Coroners Service Beacon House White House Road Ipswich Suffolk IP1 5PB 6 th August 2024 Via email: Cc: Dear Sir Inquest touching on the sad death of Katie Madden Please find this letter as a response to your Regulation 28 Report to Prevent Future Deaths dated 30th May 2024. The inquest concluded on the 21st May 2024 that Katie Madden’s death was as a result of suicide, whilst the balance of her mind was disturbed. In your report you have raised five matters for concern. We note the concerns are general regarding the involvement of social services and what factors are considered when the removal of children is being investigated and whether this includes that a Domestic Violence Disclosure Scheme (Claire’s Law) disclosure may potentially make a person more vulnerable. Further, we note your concerns regarding the limited support that the deceased received from social services during this process and the difficulties in accessing recommended therapy. These are processes that the Constabulary do not have any direct control or involvement in and therefore the Constabulary is very limited in what action it can take in response to those concerns. It is noted by the Constabulary that they conduct their own risk assessments when delivering the Claire’s Law disclosures at the time of the delivery, which would include the wellbeing of the recipient of that disclosure. We have examined police records and can confirm that at the point of the Claires Law disclosure made in 2018 that this was conducted in accordance with policy and appropriate aftercare, with safeguarding advice including information on support services and safety planning was offered by the delivering member of police staff. This was completed as part of a joint visit with a social worker to Katie Madden. Nothing in police records indicate that there was a concern about Katie’s mental health at the time of the disclosure decision or from recorded police incidents prior to this. I can confirm that a domestic homicide review referral was completed on 5th July 2024 by Suffolk Constabulary, and an initial meeting to assess the referral will be held in early August 2024. Suffolk Constabulary will continue to offer appropriate support and co-operation to partner agencies and fully engage with learning reviews. If there are any specific concerns that the Constabulary can address or assist you with, then the Constabulary will of course co-operate with you in that regard. Yours sincerely BSc MPhil FCIPD CF Chief Constable
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