Inquest Finds Gaps in Suicide Prevention Training Before Matilda Davis's Death

Death and Inquest Findings Matilda Davis took her own life at her home in Stratford-upon-Avon on 3 October 2025.

She was a mother of two children. An inquest into her death was held, during which Assistant coroner Deborah Sewell noted that Warwickshire County Council workers had not taken part in available suicide prevention training. A coroner highlighted a lack of mandatory suicide prevention training for frontline practitioners and staff working within Warwickshire County Council's children's services department.

The inquest followed concerns raised by Matilda Davis's estranged husband regarding her mental health and the welfare of their two children. uk reported on the inquest details, including the safeguarding visit conducted on the same day as her death.

Safeguarding Visit Details A social worker and support worker conducted an urgent safeguarding visit to Matilda Davis on 3 October 2025.

During the visit, Matilda Davis reported experiencing emotional and psychological strain arising from relationship conflict, financial pressures, and ongoing divorce proceedings. Matilda Davis described recent episodes of head-banging behaviour during the safeguarding visit.

She confirmed aspects of her medical history, including discontinued antidepressant medication and a current prescription for diazepam.

Matilda Davis was not asked directly about suicidal ideation during the safeguarding visit, although reference was made to suicidal thoughts. She was not signposted to crisis support services during the visit.

Prevention of Future Deaths Report The prevention of future deaths report outlined the gaps in the safeguarding process.

It detailed Matilda Davis's statements on her strain, head-banging behaviour, and medical history. The report also noted the absence of direct questions on suicidal ideation and lack of referral to crisis services. Warwickshire County Council has until 2 June to respond to the prevention of future deaths report.

The report stems from the inquest findings on training deficiencies and procedural oversights. uk reported the report's requirements and the council's response deadline.