Fern Foster Inquest – Coroner’s opening and family’s pen portrait

Day one of Fern’s inquest was opened just after 10am at Beaconsfield Coroners Court by Senior Coroner Crispin Butler.

There are seven interested person’s. Fern’s family are represented by Sam Jacobs, instructed by Merry Varney and Caleb Bawdon of Leigh Day and Fern’s partner Max Newman is represented by Freddy Powell instructed by Charlotte Haworth Hird of Bhatt Murphy. Oxford Health NHS Trust are represented by Amina Graham, Buckinghamshire Council Children’s Services are represented by Angela Hodes and Buckinghamshire Council Adult Services are represented by James Trumble. South Central Ambulance Service are represented by Claire Anderson and Thames Valley Air Ambulance by Gareth Williams.

The coroner addressed the court and said Fern’s inquest would look at the evidence gathered since her tragic death in July 2020. He said that her inquest is directed at addressing who the deceased was, what the medical cause of Fern’s death was, and how, where and when Fern came about her death. He told those assembled in court that an inquest is not concerned with blame or liability and it is the culmination of a fact finding investigation.

The Senior Coroner referenced the Chief Coroner’s report published in January of this year The coroner service 10 years post-reform. He reminded the court that an inquest “is a form of summary justice” and not a forensic examination of Fern’s life or every interaction she had within it. He told the court Fern’s inquest does not address why this sad event happened, beyond having consideration for the context in which circumstances arose that provides assistance with understanding what Fern intended on 8 July 2020.

The coroner told the court that there had been two reviews conducted following Fern’s death, a Root Cause Analysis by Oxford Health NHS Foundation Trust, and a Safeguarding Adults Review conducted by Buckinghamshire Safeguarding Adults Board. He said that they had different purposes and in the limited remit of the inquest would form part of the evidence considered, particularly in the context of learning and the prevention of future deaths.

He then ran through discussions that had been held in pre-inquest review hearings and outlined the evidence that the inquest would consider including the immediate circumstances concerning Fern’s death, including scene and eye witness evidence, verification and medical cause of death, evidence relating to Fern’s recent physical and mental health history, evidence about her state of mind and intentions, and about her engagement with local authority adult and children’s and any other services. The coroner outlined the contents of the bundles and additional evidence that had been added to them.

The coroner said it was his intention on the first day to ensure those close to Fern had an opportunity to assist the inquest with their recollections of, and reflections on, the chronology of events which culminated in Fern’s sad death. He provided an outline of how he expected the day to run, and he reminded the press about the Samaritans Guidance and recommendations around reporting (or really not reporting) detail about how Fern died. He also directed the press not to report the name of Fern and Max’s child if it were used in court, noting that it was not relevant to proceedings in the inquest at all [the child’s name], although the fact of the child was highly relevant to what he would be looking at.

The first person the court then heard from was Fern’s younger sister, Rowan Foster, who read out the family’s pen portrait which she had written with members of her family. Rowan told the court “First and foremost Fern was a human who touched lives”.

She said:

Fern was a daughter, a step daughter, a big sister, a granddaughter, a niece, a cousin, a best friend, a partner and a mother … she was deeply loved by those around her

Rowan described Fern as a “young, bright and brilliant 22 year old” who wanted to travel the world, go to university and have a good life.

She told the court Fern loved to read, that she was happy in her own company and she had a passion for drama, history and english. She said Fern was “thoughtful, intelligent and kind”.

Fern was diagnosed with autism at 15, and Rowan said this helped her to finally understand why she felt different to others. She told the court Fern was “proudly autistic”.

We heard that while at first glance Fern might appear shy or introverted, she possessed a strength and sharp wit and a keen sense of justice. Rowan adding “despite her own battles, she always found a way to lift others up”.

Rowan told the court when she was born it became Fern’s personal mission to teach her to read, something she could do by the time she was two. She said Fern was incredibly patient and this shone through in her passion for gentle and intricate crafts like jewellery making and pottery. She said the family still had her pottery rabbits in their garden today.

The court was told that when Fern laughed, she laughed with her whole body and that it was hard not to laugh when Fern did. Fern’s mum described her as someone who you always wanted to talk to. We heard she would explain complicated things to her much younger brother, who is also autistic, in a way that he could understand.

Fern cared deeply about her loved ones, she was excited to be a mother… excited to have something she felt she could do, it gave her purpose, a reason to live…

The family said while pregnant Fern was the healthiest and most happy they had ever seen her. Rowan told the court “Fern excelled in anything she put her mind to”. She described a community excavation at St Dunstans, very close to their house, that Fern was involved with. She read the court a tribute that had been written about Fern by her friend and archeological dig colleague.

The family’s pen portrait ended by stating how hard it is for Fern’s loved ones to conceptualise the loss of Fern and spoke of their “unsurmountable grief” and the “untimely death of her potential and all she could have been”.

We will love and miss her forever.

Rowan then introduced a video the family had put together and said they hoped it gave those in court an idea of who Fern was. She requested we keep the pictures in mind throughout the inquest.

The video which was a compilation of photos to music was just short of three minutes and included photos from throughout Fern’s life.


The coroner then confirmed the administrative details required to register Fern’s death before taking a break. Fern’s mother, Dominique gave evidence late morning, her sister Rowan before lunch, Fern’s partner Max gave evidence immediately after lunch and her father, Keiran, in the afternoon. I’ll report their evidence tomorrow.

With thanks to my crowdfunders who support my reporting. Thanks also to those reading and commenting. Comments are turned off until the inquest concludes but will be posted then.

4 comments on “Fern Foster Inquest – Coroner’s opening and family’s pen portrait”

Ru Carter says:

I am so thankful that I had the opportunity to meet Fern when she stayed with my family for a short while during the time she had housing issues. Despite these difficulties I remember Ferns smile that lite up the room, her infectious laugh, her iridescent glow that radiated so much hope for the future. I remember Fern for being engaging, warm and gentle, and able to connect with my own daughter Liz who was struggling emotionally when her best friend moved away. I remember Fern showing Liz how to make jewellery and how I got roped in to take them shopping in Aylesbury, for them both to return with beaming smiles having both bought same dress.

I still struggle to understand why someone who had so much hope is no longer here. I know in my heart that Fern had the qualities to be a remarkable mum, it is absolutely heartbreaking that this has happened. The pain her family must be feeling must be so immense. To say that I am so sorry for their loss is an understatement.

Fern was a young woman who has left such an imprint on myself and my family, she will never be forgotten.

Abi says:

I am so sorry you faced such injustice at the hands of social services, mental health services and the courts. I’m an autistic woman myself with ocd and it is a daily battle at times. I hope you get some sort of justice for Fern, she will be her child’s forever guardian angel. My heart goes out too you as a family at this horrific time. Fern sounded like an amazing woman, rest in peace

David Garrick Vincent Protheroe-Beynon says:

I would love to have seen that. I am talking about Fern’s story later and in doing so I want to celebrate her life as much as the circumstances that led to her death.

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