Matilda Davis
7 Apr 2026 · Coroner Deborah Sewell · Warwickshire
The coroner's concerns
1. lack of mandatory suicide prevention training for frontline practitioners
“Evidence heard during the inquest confirmed that suicide prevention training is not mandatory for frontline practitioners and staff within Warwickshire Children's Services”
2. absence of suicide prevention training for social worker and support worker
“The social worker and support worker who visited [the deceased] had not received suicide prevention training, although such training was available within the organisation”
3. lack of signposting to crisis support services
“It was also noted that she was not signposted to crisis support services at that time”