Coroner flags lack of mandatory suicide training

A coroner has highlighted a lack of mandatory suicide prevention training for frontline practitioners and staff working within a council's children's services department.

An inquest into the death of Matilda Davis heard the mother-of-two took her own life at her home in Stratford-upon-Avon on 3 October 2025.

Earlier that day a social worker and support worker had conducted an urgent safeguarding visit following concerns raised by her estranged husband regarding her mental health and the welfare of their two children.

Assistant coroner Deborah Sewell said the training was available to the Warwickshire Council workers, but they had not taken part in it.

In a prevention of future deaths report, the coroner said the mother had not been "asked directly about suicidal ideation" during the visit, although reference was made to suicidal thoughts.

She was also not signposted to crisis support services at the time, the report states.

During the visit, the mother had reported experiencing "emotional and psychological strain arising from relationship conflict, financial pressures, and the ongoing divorce proceedings," the report said.

She also described recent episodes of head-banging behaviour and confirmed aspects of her medical history, including discontinued antidepressant medication and a current prescription for diazepam.

"The non-mandatory nature of suicide prevention training may give rise to variability in practice when practitioners are required to explore, record, or respond to indications of possible self harm or suicidal thoughts," the report continues.

Warwickshire County Council has until 2 June to respond.

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