Mother-of-four Katie Madden took her own life at the age of 32. In the wake of her death a senior coroner issued a damning report into the services meant to look after her. DONNA-LOUISE BISHOP speaks with Katie's mother to see if lessons have been learned.
It has been more than three months since an inquest into the death of tragic Katie Madden concluded.
The Lowestoft mother, who died by suicide following the revelation of a Clare’s Law disclosure, experienced a series of devastating blows.
But one thing was a constant – the love she had for her children even during her darkest days.
The evidence he heard prompted him to issue a Prevention of Future Deaths (PFD) report after hearing how Katie struggled to get help for her deteriorating mental health.
Speaking after the court proceedings, Katie’s mother, Bernadette Sutton, described how her daughter's life unravelled.
She has now revealed her determination to ensure Katie’s death was not in vain.
WHAT THE CORONER SAID
Mr Parsley condemned the services involved in Katie's case.
He issued the PFD report to the Norfolk and Suffolk NHS Foundation Trust (NSFT), Suffolk County Council and Suffolk Police.
It was also issued to the Department of Health and Social Care, the Secretary of State for Victims and Safeguarding, and Norfolk and Waveney Integrated Care Board (ICB).
The report raised concerns over a lack of support for Katie after she received information under the Domestic Violence Disclosure Scheme, also known as 'Clare's Law'.
This police policy gives people the right to find out if their partner or ex-partner has any history of abuse or violence.
It was introduced 10 years ago after a campaign by the father of Clare Wood, 36, who was strangled and set on fire by an abusive ex-boyfriend in Salford in 2009.
Mr Parsley’s report states: “There was no formal system in place to provide additional support for Kate herself, even though she was known to be vulnerable.”
It goes on to say that any impact on her mental health or physical wellbeing “was not taken into consideration”.
The 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.
THE RESPONSES
The coroner's court has received replies from those the PDF report was issued to.
Suffolk County Council agreed that there is currently no statutory or other national system in place to represent the needs of vulnerable parents facing the prospect of their child or children being taken into care.
It stated it would “welcome any interventions that the appropriate Secretaries of State can offer” in regard to partnership working.
The council said action is already underway to make sure vulnerable parents are referred to Adult Social Care by the Children and Young People’s team.
This is following a Serious Case Review into the death of another Suffolk mother, known as Mandy, who died from an overdose leaving behind six children.
The NSFT went on to say that, following Katie’s death, it would be asking all clinicians to identify where treatments have been recommended by non-NSFT clinicians.
This is to offer a further assessment in case there is an alternative treatment NSFT can provide or further signposting.
The ICB confirmed that it had “not lost sight of the suffering that has resulted from Ms Madden’s death” but confirmed only what was already known, that no funding application was made.
In its response Suffolk Police said it conducts its own risk assessment when delivering Clare’s Law disclosures to include the wellbeing of the recipient.
It added: “We have examined police records and can confirm that at the point of the Clare's Law disclosure (...) this was conducted in accordance with policy and appropriate aftercare.
"Nothing in police records indicates 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.”
Baroness Merron, the parliamentary under-secretary of state for Patient Safety, Women's Health and Mental Health, said the circumstances described in the report were “deeply concerning”.
HAVE LESSONS BEEN LEARNED?
Since her daughter’s passing, Ms Sutton says there isn’t a day that goes by without her thinking about what could have been done differently.
An NHS worker, she says the report has come too late to make a difference and that the responses to the coroner are “inadequate”.
“I keep looking over the report and the replies,” she said. “I make sense of it one minute and I don’t make sense of it the next.
“I beat myself up all the time and it goes around and around in my head.
“There could have been so much more done but it’s not going to bring her back. It’s too late. It’s too late for us now as a family, and for the children.
“I am so angry at times. I just feel I can’t hold anybody accountable for the way they treated her.
“Nobody saw her as an individual, she was nobody in their eyes, but she was screaming out for help.”
“There’s still no joined up collaborative working,” she said.
“All services are struggling, I get that, but mental health has been at the bottom of the pile for many, many years. It’s just a hamster wheel.
"A lot of these laws, like Clare’s Law, they happen and then they get forgotten and buried.
“Katie’s death has been a smack in the face for Clare’s family too.”
Ms Sutton is determined to make sure no parent suffers the way Katie did and has offered to speak to the various organisations and experts involved in Katie’s care to share her story.
“It doesn’t matter if it takes me two years, three years or whatever, I’m not done with this, I’ll never be done with this.
“Something will hopefully be done in Katie’s name. Where would she want me to start? She would probably want me to help others because she was such a kind and caring person.”
- 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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