A coroner has concluded that Camden Council and other agencies let down a 31-year-old woman who died on the day she was released from prison, in what has been described as a “chain of missed opportunities”.
Colleen Madden left HMP Bronzefield on January 13, 2025, for the fourth time in five months. That evening, Camden’s adult social care placed her alone in an interim hotel in King’s Cross with no support arrangements in place. She was found dead on January 16.
At an inquest in October 2026, Assistant Coroner Melanie Lee said Colleen was “let down” by agencies and concluded: “Without a doubt, Colleen deserved and should have been given something better”. The coroner found that had Camden Council fulfilled its statutory duties, she may not have died in the place and manner she did.
Inadequate assessment and unsuitable placement
Colleen, who was born and raised in Camden, had lived with ADHD, trauma and learning disabilities. She was a mother of two who had experienced repeated homelessness, physical and sexual harm, and substance dependency. She also sustained a brain injury following a road traffic accident in 2018.
When she presented to Camden’s adult social care on the day of her release, she underwent what the coroner described as an “inadequate and confused assessment”. The council then placed her in what Ms Lee said was “unsuitable accommodation in an unsuitable location” – a temporary hotel in King’s Cross with no support in place.
Social workers attempted to visit on January 15, but Colleen’s body was not discovered until police gained entry to the room the following day. Medical evidence indicated she had died shortly after arriving at the hotel.
Failures in communication and planning
A safeguarding inquiry commissioned after her death found multiple breakdowns in the system. In September 2024, Camden’s housing department decided Colleen lacked capacity to make a homelessness application. This meant responsibility shifted to adult social care, but the council did not communicate this clearly in writing – leaving other agencies uncertain about who was responsible for her support.
The Probation Service requested a Care Act assessment in mid-to-late December 2024, but the prison failed to act on this before her release. The Prison and Probation Ombudsman (PPO) said it referred Colleen’s case to the council that same month, but Camden had no record of the referral on its systems.
Social workers had conducted a single brief assessment on December 31, 2024, at council offices, where they judged Colleen had mental capacity. However, this assessment failed to check whether her capacity was changing, or whether her brain injury and substance dependency caused any cognitive impairment.
Late notice, no social care attendance
The prison called an urgent pre-release meeting on January 10, just three days before Colleen’s release. Camden did not send a representative from adult social care because of the short notice, the council said, adding the prison had only revealed “very late” she was due for release after 12 days’ recall. Because of the late notification, social care services booked her into a temporary hotel for one week.
The safeguarding review noted that Colleen had been recalled to prison repeatedly in her final months, with the “emotional toll” this took on her not properly considered. Although her behaviour could be aggressive and unpredictable, the review found little evidence that this was understood in the context of her trauma, mistrust and fear of being recalled again.
Family’s response and council action
Colleen’s 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.”
They added: “The inquest has highlighted the importance of proper training for those working with vulnerable adults, so that no other woman has to endure what Colleen did.”
Bhatt Murphy Solicitors, representing the family, said the 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”.
Camden Council said it has since improved support for prison leavers and information sharing between the council, probation services and partner agencies. A spokesperson told the Local Democracy Reporting Service: “Our deepest sympathies remain with Colleen’s family and friends following her tragic death. Ensuring vulnerable residents are supported and safeguarded is a responsibility that we take extremely seriously.”
The council said it will “carefully consider” the coroner’s findings to identify further gaps in support for prison leavers and vulnerable residents, and improve staff training.
