Serious failings found by coroner
A vulnerable woman died in a hotel room on the same day she was released from prison, an inquest has found, after agencies responsible for her care failed her repeatedly.
Colleen Madden, 31, was placed in temporary accommodation in Kings Cross without support on 13 January 2025, the day she left prison. She died there that same day.
The inquest, held at Bow Coroner’s Court last month, found “serious failings” by the agencies responsible for her care contributed to a chain of missed opportunities before her death.
The coroner concluded that “without a doubt”, Ms Madden had been placed in “unsuitable accommodation in an unsuitable location” and that she “deserved and should have been given something better”.
A woman with complex needs
Ms Madden, described by her family as “much loved”, had a brain injury, learning disabilities, attention deficit hyperactivity disorder (ADHD), mental health challenges and substance dependency.
She had been released from prison four times between September 2024 and January 2025. On the first three of those occasions she was recalled to prison after the accommodation arrangements made for her broke down.
A recall means a person released on licence is returned to prison, usually because the conditions of their release — very often including where they will live — have not held. For Ms Madden, the cycle repeated three times in four months before her final release in January 2025, when she was again placed in temporary accommodation without the support she needed.
Family: “she deserved compassion, dignity, and proper care”
In a statement, her family said: “We miss our sister beyond words. She was our everything, and she deserved compassion, dignity, and proper care.”
“Instead, we feel she became little more than an administrative task, with no one taking responsibility for her needs.”
The inquest identified multiple failures, including poor planning, unclear responsibility between agencies, the lack of a mental capacity assessment, weak sharing of information, and a failure to consult her family.
“Shameful” failures, charity says
Catriona McGregor, of Bhatt Murphy Solicitors, who represented the family, said: “This inquest exposed repeated failures to assess, coordinate and plan for the safe release from prison of an exceptionally vulnerable woman whose risks and support needs were well known.”
Selen Cavcav, co-lead of casework at the charity INQUEST, which supports bereaved families through inquests, called the failures “shameful”.
Ms Cavcav said: “Colleen needed care, housing and support, not repeated recalls to prison and release into homelessness.”
“Her death is a stark reminder that prison is not the answer to poverty, homelessness, poor mental health and substance use.”
What happens now
An inquest establishes who died, and when, where and how. Where a coroner finds that failings contributed to a death, the findings are placed on the public record, and the agencies involved are expected to answer for them.
An inquest does not decide criminal or civil liability. Its purpose is to establish the facts of a death on the public record, and where the evidence shows failings, the coroner can raise them with the organisations involved so that lessons are learned.
The case is the latest inquest conclusion in London to highlight how vulnerable people are supported — or not — after leaving custody. An inquest opened at East London Coroner’s Court this week named a man who died after a fall in Stratford, while Greenwich has drawn up a plan to end rough sleeping in the borough by 2030, part of a wider effort across London to make sure people leaving institutions and care do not end up without a home.
Ms Madden’s family said she was “our everything”. No cause of death has been published in the inquest reporting.
