Skip to content
recurance

Katie Madden

30 May 2024 · Coroner Nigel Parsley · Suffolk

A similar concern from this report was raised again 1 time later. See the linked reports.

The coroner's concerns

  1. 1. lack of vulnerability assessment for domestic violence recipients

    “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 [name redacted]'s children. There was however no formal system in place”
  2. 2. risk assessment omission for mental health impact

    “It was identified that when [name redacted] 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 Pub”
  3. 3. isolated safeguarding referrals

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

    “In 2022 it was recognised by a Clinical Psychologist that [name redacted] could benefit from Schema-based Cognitive Behavioural Therapy, which is not routinely available on the NHS”

Linked reports

Raised again laterSuseel Rana4 May 2026 · 1 year 11 months later
Closely relatedConfidence 0.80 · moderate

This report

“No evidence was seen that recipients of a 'Claires Law' Domestic Violence Disclosure are treated as being of greater vulnerability”

Later report

“In seeking some reassurance as to her safety, the Deceased had made a Clare's Law application under the Domestic Violence Disclosure Scheme (DVDS) prior to her death; however, this was had not been progressed by Police.”
Original on judiciary.uk ↗
Full chain: Lack of vulnerability assessment for domestic violence recipients

Responses

2024-0295-Response-from-DHSC.pdf ↗· Department of Health and Social Care

Stated action

“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”

2024-0295-Response-from-Norfolk-Waveney-ICB.pdf ↗· The Norfolk and Waveney Integrated Care Board

2024-0295-Response-from-NSFT.pdf ↗· Suffolk Constabulary Police Headquarters

Stated action

“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”

2024-0295-Response-from-SCC.pdf ↗· Home Office

Stated action · September

“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.”

2024-0295-Response-from-Suffolk-Constabulary.pdf ↗· Suffolk Constabulary Police Headquarters

  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error