Fern was a quiet, thoughtful, introverted and unassuming individual who was never happier than when she was curled up with a book. Fern loved reading. She found peace and comfort in character’s lives, walking in their shoes, living in other fantasy universes. Fern was an excellent student and loved literature so much her dream was to become an English teacher. Fern also loved drama and acting in school plays.

Fern had patience, dedication and attention to detail too. This was evidenced in her teaching her younger sister Rowan to read, in her bead crafting and pottery, and in her work as a volunteer archaeologist with the Risborough Countryside Group Archaeology Team. Her friend and team leader, Paul remembered Fern not just for her skill and ‘meticulous and careful work’, but also for her homemade cakes, her stories of her pets and wildlife, her love of crafting and her friendship.

Fern had a strong sense of right and wrong, of injustice and unfairness. She supported her mother to fight to ensure her younger brother’s autism and need for 1-1 support was recognised, and to secure him the specialist education he required. He was offered the new school place she so hoped for, ten days after her death in July 2020.

Fern’s younger sister Rowan, who is older now at 23 than Fern was when she died, last saw her sister a month or so before her death. They attended a Black Lives Matter protest together. Rowan remembers it was challenging for Fern as it was loud, busy and unfamiliar, but that she was determined to attend as it important to her, a cause they both believed in.

Fern was autistic, although like so many other females with autism, it was not identified in early childhood. Fern’s mental health deteriorated when she hit puberty, and she would often feel overwhelmed. At 13 she was diagnosed with obsessive compulsive disorder, and two years later with autism.

Fern’s autism diagnosis marked the start of a journey of self-understanding and the creation of an identity and relationship with a community that supported her. Her diagnosis helped explain why she had always felt different to others, and to a degree helped her to understand better how to navigate the world. Fern was proudly autistic.

It was not all positives though. Her mum remembered Fern referring to herself as a ‘canary in a coalmine’, who ‘if you plugged her into any system would highlight its faults’. Fern took to Twitter, to find a community, and her activism included highlighting the difficulties she was having accessing autism-informed support for her mental health. She tweeted as @ElyssaLeopard.

When overloaded Fern’s response would be fairly typical, she would respond by fight or flight. This took the form of meltdowns or shutdowns for Fern, where she would often lose her ability to process information or communicate through words. Fern would sometimes self-harm if she were unable to communicate her distress in other ways.

Fern was analytical and reflective. When well supported she could describe her overwhelm, knew what she was capable of, and perhaps most importantly she had insight into the help she required to stay safe and achieve her goals.

Fern was aware that she benefited from support with emotional regulation, communication, and independence skills, on a day to day basis and especially when her mental health was deteriorating, or life was stressful.

Along the way, like so many other young autistic women, she was mis-diagnosed with Emotionally Unstable Personality Disorder. A diagnosis linked to her self-harming behaviour and coping strategies. Fern’s mother considers that Fern had learnt the only way she would actually get any help was by harming herself.

A couple years later a Consultant Psychiatrist removed this diagnosis, but the damage was already done. It had been entered onto Fern’s records and would reappear throughout the rest of her life. Her father recalls if Fern disputed having EUPD, health and social care professionals would accuse her of lacking insight, unsurprisingly causing Fern great distress and leading to her feeling completely misjudged.

In her late teens and early twenties Fern became what her mum describes as a ‘revolving door patient’. She would be admitted to hospital for short periods when her mental health was poor, she would then be discharged with an insufficient level of support, inevitably Fern would become overwhelmed again, she would self-harm, and the cycle would repeat, again and again.

Fern asked for specialist help, from people who understood autism, but never received any. Her father considers throughout Fern’s life the people and services who were meant to support her didn’t understand Fern, or her wishes. He says they had “little or no understanding of the role autism played in her behaviour” and consequently failed to consider or accommodate her autism in any care or treatment provided to or considered for her.

Two years before her death Fern met her partner, Max. Her family describe this relationship as being a real positive for Fern, improving her self-worth and her motivation. They felt the couple complimented each other, Fern was more cerebral and Max was good at some of the more practical day to day tasks that Fern struggled with. They made a good team.

Fern became homeless after the Supported Living placement she was in ended, in part because they wouldn’t let Max stay over with her and in part because Fern’s self-harming had escalated. During a hospital admission in July 2019, Fern discovered she was pregnant with their child. This was a complete surprise to the couple, but a very welcome one.

Fern’s family remember her as ‘delighted’ and ‘full of hope’ at the news, with a renewed positivity about the future. Her father described the pregnancy as ‘breaking the cycle’ and that from the moment Fern found out she was pregnant, until her baby was removed from her care, she did not once self-harm or put herself at risk. Fern turned all her attention to learning how to parent, and to keeping herself safe.

Fern understood she would need help and support to be a parent, and so when Buckinghamshire Council social services became involved, shortly after she discovered she was pregnant, her family remember that she did all she could to engage with them, and do as they asked. Throughout her pregnancy Fern regularly engaged with her psychiatrist, her GP, a midwife and her care coordinator and she repeatedly requested support and reasonable adjustments to enable her to engage with the requirements asked of her. When social services began child protection processes, Fern’s psychiatrist wrote to the team asking them to make reasonable adjustments to support her to engage with them.

The psychiatrist’s letter acknowledged that a degree of engagement and interaction was required from the social services team and requested them take into account Fern’s autism and make any reasonable adjustments within their power to support her. He asked that adjustments were made to keep visits and meetings to a minimum, and to provide accommodation close to her mother’s home to enable her to support her. Fern’s family believe this advice went unheeded.

There were numerous meetings, some at short notice. Fern was expected to engage with numerous professionals from social services, who changed frequently, and only one of whom appeared to have any understanding of autism or how to support autistic people. Fern hated that her unborn child was subject to child protection processes.

Her mum remembers Fern researched everything about child protection to try and make sense of the idea her child needed protecting from her. It made Fern feel like a bad person, and she was unable to make sense of it, as someone with strong morals and values. Her family consider that the psychiatrist’s advice was ignored and remember constant visits and meetings with social services were held, further fuelling Fern’s concerns. Fern became more anxious, her OCD and anxiety were triggered, and yet despite the additional pressure she did not engage in self-harming behaviour, and she worked hard to remain positive about her future.

Fern’s much loved baby was born in early 2020. The plan made before birth was that Fern, Max and the baby would return to her mother’s home. However immediately after birth, social services informed them Max was not allowed to stay with them and he would need to have very limited contact with his child.

Fern’s mum remembers they would have agreed to anything social services said, to ensure that Fern could keep her baby. Her father recalls how this sudden change of plan, and the discharge meeting where no advocate was provided for Fern, was deeply traumatic for her and seriously damaged her trust in social services.

A social worker in the discharge meeting said to Fern “we are not taking your baby yet”. Fern took the word yet literally, and this led her anxiety to spike. Her mum says they did not feel like the baby was theirs, they felt they were being tested.

What followed felt almost inevitable to Fern’s family.

Fern and her baby returned to her mum’s house without her partner. Fern told her father she felt she was being set up to fail. Fern’s anxiety was raised, and she was left to cope with a new baby without Max for emotional and practical support. Fern and her mother were not provided with any practical support from social services.

Fern’s family remember her requests for reasonable adjustments to engage with social services processes fell on deaf ears. A child protection conference held a few weeks after her baby was born concluded the baby should remain under a child protection plan, as they were at risk of neglect. Her mum recalls no one explained to Fern what she had, or had not, done. She was caring for her baby, feeding them, cuddling them, they had bonded well and the baby was gaining weight, was happy and healthy.

Social services involvement continued. Fern struggled with this additional pressure, on top of being a new mum and requested that she and the baby go to a mother and baby hospital placement, or a joint foster placement. Fern was becoming consumed with thoughts that she was a bad mother, and she recognised she required help.

Her family recall how it was suggested that she was not unwell enough to require a specialist placement, so Fern felt she were left with no option but to agree to her baby going into foster care without her.

That happened just before the baby was a month old. Fern really struggled to engage with what followed. She had to travel over an hour to a contact centre to spend time with her baby. The journey involved two buses and a long walk, even with her mother supporting her, Fern struggled. Her mum believes if an adjustment had been made, such as a taxi being provided for the journey, or moving contact sessions to a local venue, that Fern would have been able to continue with contact and spend time with her baby.

Instead, without adjustments, Fern was unable to cope with the demands on her and she only managed to attend that first contact session. She told her family that she felt like a criminal attending the secure contact centre. She never saw her baby again.

Two weeks later Fern found out social services had started court proceedings. Fern’s family describe how her mental health sharply deteriorated, and she was now expected to engage in Family Court proceedings, with social services and with mental health services. All at a time when she was even more vulnerable.

Fern was admitted into a psychiatric hospital in March but discharged a few days later. Her father recalls desperately sending emails to various professionals involved in Fern’s case, one acknowledged his “frustration” but told him that finding a mother and baby placement was “quite complicated”.

Her family consider that Fern slowly gave up all hope of being reunited with her child.

She repeatedly self-harmed and was admitted to hospital for days at a time. They believe each time Fern was discharged she was not provided with the support she required. Her family repeatedly asked for her to be referred to a placement where she could be reunited with her baby and be provided support.

In July, Max received an email from his solicitor with a letter attached. He didn’t understand what it meant and asked Fern to read it. This correspondence confirmed Buckinghamshire Council had decided to seek adoption for their baby.

Fern was distraught, calling both her parents, then her health visitor. About an hour later she called her mum again, to tell her that she loved her. Shortly after Fern’s mother received a frantic call from Max saying that Fern had self-harmed.

Fern died later that day.

Her parents believe Fern’s death was predictable and completely avoidable. Her mother recalls how Fern described social services involvement as a ‘runaway train’ which became a self-fulfilling prophecy. She believes with more and more pressure being placed on Fern, without any support being provided, her health deteriorated reducing her ability to cope as a new parent and her ability to engage with their processes.

Fern’s family hope the inquest process will explore how Fern came to die and the involvement of all the professionals involved in Fern’s life and the child protection processes.

Most of all they hope that the inquest will confirm Fern did not reject or neglect her baby, but was in fact desperately seeking support that was never provided.

Fern’s inquest will be heard over the next three weeks at Beaconsfield Coroners Court [3-5, 8-11 and 15-18 April]. I will report from court on Day One and hope to return for the conclusion.