After a short morning break on Day One of Fern’s inquest her mother, Dominique Jowett, gave her evidence to the court. The Senior Coroner Crispin Butler read Dominique’s statement to the court and onto the record, before then calling her to the witness box (which is actually a witness table in this court).

In her statement Dominique told the court that she is Fern’s mother and the former partner of Keiran Foster. She said that Fern was her eldest child, she also has a younger sister who is now an adult (Rowan who addressed the court with Fern’s pen portrait yesterday) and a half brother. Dominique told the court that all her children have ASD, Autistic Spectrum Disorder and Fern had been diagnosed aged 15, two years after being diagnosed at 13 with OCD, Obsessive Compulsive Disorder.

Dominique described Fern as an “intelligent and caring person” whose mental health deteriorated at puberty, when she would struggle with being overwhelmed at times. She told the court that Fern enjoyed school and did well in her GCSEs, although post GCSEs were difficult because Fern was articulate and people would not realise, or recognise, that she had autism.

Fern struggled to get the support she needed.

The result of this was that the lack of support prevented Fern from doing her A Levels, or keeping up with her peers, which had a negative effect on Fern.

Dominique described to the court how Fern articulated feeling overwhelmed as like a traffic jam of cars backed up in a tunnel. She would say that the cars, which represented all of the sensory, emotional and social pressures that Fern experienced, could not move. The tunnel represented the “limit of her brain to deal with too many at once”.

She explained to the court that when she was overwhelmed it would cause a fight/meltdown, or flight/shutdown response, which would often result in Fern temporarily losing control of her behaviour, which in turn would odten result in Fern harming herself as she was unable to express her distress in other ways.

Dominique told the court that Fern wanted to be an English teacher, but without her A Levels that was “never going to happen”, and as Fern struggled to get help, she became more overwhelmed, and harmed herself more regularly.

This then became seen as part of who Fern was.

Dominique told the court that the reality was it was the only way of Fern communicating her level of distress, and she felt the only way to get help was to hurt herself, although as a consequence later Fern was wrongly diagnosed with a personality disorder. Dominique told the court how she had spent Fern’s teenage years trying to get appropriate support for Fern, including sending photographs of Fern about to harm herself to Fern’s GP, to CAMHS (Child and Adult Mental Health Services) and to the local authority. Dominique described this as “a desperate attempt to get help”, for Fern and her other children, but she does not remember ever receiving a reply to that.

Dominique said that Fern seemed to become a “revolving door patient”. Fern would be hospitalised for short periods, discharged without sufficient support, become overwhelmed, hurt herself and the cycle would repeat. Dominique told the court that Fern variously lived with her, with other family members, in supported living placements and at times she was homeless.

Dominique said that in 2016/17 Fern was wrongly diagnosed with a personality disorder. In 2018 she met Max. She told the court that Fern and Max’s relationship was “mutually beneficial, Fern was intellectually smarter, but Max was better at every day practical skills … together they could make a good team”.

At that time Fern was living in Moat House. Dominique recalled that was not going well and Fern’s self-harming was increasing. Fern was the only female resident and considerably younger than the other living there. It also had shared facilities “which with her needs she really struggled with”. Dominique said that Fern moved a couple times after Moat House, sometimes staying with Max, and sometimes Max and Fern would stay with Dominique. Dominique said in early 2019 Fern moved to The Orchards, but found it difficult to settle there, and she was regularly staying with her or with Max. Fern was homeless from February or March 2019 and after that she regularly stayed with her mother, Max or her father. Dominique told the court that at that time Fern had a “good care coordinator”, Malvi Shah [sp?] who was providing support to Fern and trying to secure her suitable housing.

Dominique then went on to tell the court about the time in July 2019 when Fern discovered that she was pregnant during a routine test having taken an overdose, during a particularly difficult time.

Fern was delighted when she found out she was pregnant. It completely changed her outlook.

Dominique told the court that Fern was so happy and “full of hope” as being a mother, and loving her baby, was something that she could do, even if she needed support to do so. She told the court that from the moment Fern found out she was pregnant, until her baby was removed from her care, Fern did not hurt herself or self-harm again.

Dominique described the strain of social services involvement on her family life and how her younger, disabled child was still waiting for a specialist school placement at the time. She told the court that her husband had to step in which caused a strain on her marriage and family life. She told the court that Fern and Max often stayed at her house, and “sometimes it did become too much”.

Dominique told the court Fern accepted she would need support as a mother.

As an autistic person, Fern lacked certain practical skills which Max was better at … [Fern] could be taught skills effectively through scaffolding.

Dominique told the court that if all the people involved in supporting Fern had had training in autism she believed “the outcome would have been very different”. She told the court about Dr Grant, a Consultant Psychiatrist who reviewed Fern in September 2019, with her care coordinator present.

Dr Grant confirmed Fern did not have a personality disorder, but had OCD and ASD.

Dominique said that Dr Grant was clearly impressed with Fern’s “stability and use of safe coping mechanisms” since she found out she was pregnant. She said that he recommended discharging Fern back to her GP, and recognising the difficulties there would be from “intensive and uninformed involvement by social services” he recommended reasonable adjustments were made, the frequency of professional’s visits was limited and accommodation was provided for Fern close to Dominique.

Dominique told the court that Fern wrote a diary about various meetings that were held when she was pregnant. She said Fern’s entries match her recollection of events. We were told she had attached these as exhibits to her statement.

Dominique said that they were told, and they believed, that a ‘child in need’ approach would be taken to supporting Fern and Max and their child, rather than any child protection action. She said that this mattered hugely and that Fern was “reassured from the outset there was no intention to take her baby from her”.

Dominique told the court that she agreed with this approach, but instead it turned out, as Fern recorded in her diary, that a different approach was taken. She told the court that child protection processes were started “almost immediately” and that Fern did not have an advocate at this time. She described Fern being overwhelmed by the speed of the process and the lack of adjustments to accommodate her disability.

Neither of us understood why this change in approach was taken.

Dominique said that despite all of this, Fern’s mental health stayed relatively stable. She did not engage in any self-harm or behaviours that would put herself or her unborn baby at risk.

Dominique said that at this time she was trying to support Fern and Max to get suitable housing, near her. She told the court that when they were eventually offered accommodation, they had been told the scrutiny from children’s services would be lesser if they were living with Dominique, so they turned it down.

We had been told if they lived with me there would only be a child in need plan, rather than child protection, so we agreed with that.

Dominique then outlined the processes and meetings that continued throughout Fern’s pregnancy. She outlined requests made for reasonable adjustments, for meeting chairs to be trained in autism, for Fern to have an advocate, for there to be a single point of contact for Fern who understood autism. She told the court that many of Fern’s difficulties were very common traits in people with autism (e.g. finding new people and places overwhelming) but these were “never build into planning for Fern”.

Dominique told the court that Fern was very upset that Children’s Services were taking a child protection rather than a child in need approach. She said that reports stated Fern had a personality disorder, which she did not.

Dominique detailed many of the meetings held between Fern and representatives from Children’s Services. She told the court that Fern had needed to leave a meeting with the Chair of the Child Protection Conference as she was unable to participate. Dominique told the court that they had anticipated the purpose of the meeting was for the Chair to understand Fern and hear her views, but “instead it felt like an interrogation”.

Dominique said that a social worker, Jane Murdoch, who had authored a report appeared to show no understanding of Fern’s disability. Dominique requested reports were shared in advance of meetings to give Fern time to process them and prepare, Jane refused the request but “did say management could authorise sharing the report by email”. Dominique said that she requested Jane seek that authorisation.

It was exhausting, and frustrating, constantly having to remind professionals of Fern’s disability and push to have adjustments made. 

Dominique’s statement outlined a Child Protection Conference that took place on 25 October, which she described as “really difficult and one of the most intimidating events I have ever experienced”. She told the court Fern had not been able to attend, instead staying home to care for her brother, who was still waiting for a school placement. Dominique attended with Max and a representative and friend from the local National Autistic Society.

The day before Fern was called to ask if a student health visitor could attend the meeting. Fern noted in her diary this showed no understanding of her autism or the impact this would have.

Only one of the professionals at the Child Protection Conference knew Fern, her care coordinator Malvi Shah. Dominique described how it opened with a police representative reading out all the times Fern and Max had involvement with the police. She said there was no context given, it was not made clear Fern had often had interactions with the police due to her unmet needs and because they could be really helpful when she was in autistic meltdown.

It just gave a really bad, and uninformed impression, of Fern and Max

Dominique’s statement details the numerous engagements Fern had with services whilst pregnant. It referenced Fern’s accounts of these in her diary, those that were positive and those that were not.

Dominique recalled a November meeting held at her house as “a shambles”, with the promised new allocated social worker changing, the new social worker not attending and the midwife also unable to attend. Fern and Dominique had understood the meeting to be to discuss plans for after the baby’s birth. They found out that Fern was also being allocated a new care coordinator as a new area were now responsible for her care. Later that day Fern’s new social worker, Susan Jillani [sp?], visited to meet with her. Dominique told the court that she, Ms Jillani, agreed with her concerns that “things had not been handled well so far”.

Dominique said multiple meetings, with different people, at short notice were difficult for Fern due to her disability. She said that Fern repeatedly asked to be contacted by email, not phone, and these requests were increasingly ignored. She told the court that professionals would also contact Fern by calling her, Dominique’s, phone.

Dominique said that the meetings continued, and save for one meltdown in mid December, “Fern did really well coping with the numerous interventions and the scrutiny of her”. Dominique told the court about further interactions between Fern and services, and that Ms Jillani seemed understanding of their concerns and agreed that a child protection plan was too severe, and not needed.

She said there were multiple meetings including a final pre-birth meeting. Dominique recalled that there were less meetings over the Christmas period as people were off work, and that Fern was doing really well. Dominique described the new social worker, Ms Jillani, as seeming “sympathetic and understanding” and that she had agreed “implementing child protection processes had been completely rushed”. This reassured Fern.

Fern was reassured there was no intention to take her baby from her.

Dominique referenced Fern’s diary entries at this time, saying that they accorded with her memory of things. She told the court that the plan was that Fern would come back to her home with the baby after birth, that Max would be there, and that a visiting schedule for professionals to visit would be agreed.

Fern, she said, was being supported by Ms Jillani to make complaints about how she had been treated. Dominique told the court that they all felt positive about what was to come, albeit the weight of child protection processes remained.

Dominique told the court that Fern had very high moral standards and values, and felt anyone harming another person, never mind a child, was wrong.

The idea of her baby needing protection from her made her feel like a bad person. In trying to make sense of it she researched everything about child protection. Not being able to work out why she came within this category, this became an obsession. 

Dominique told the court despite the constant visits and meetings from social services, Fern did not return to self-harming. She said that she had clearly bonded with her unborn baby, smiling when talking about them. She described a positive Family Group Conference that family and friends had attended. On this occasion adjustments had been made to help Fern, such as changing the venue and photos of the venue being provided in advance. Dominique told the court that this greatly helped Fern.

Fern had also been discharged from the perinatal mental health team as there were no concerns about her mental health. 

Dominique said that she was with Fern and Max throughout Fern’s long labour, and the baby was born healthy in early January 2020. Dominique said that Fern fell in love with her baby as soon as they were born. She told the court it was emotional for her to see them together.

[I’m deliberately not reporting some details, such as the date of birth, to prevent jigsaw identification of the baby, which is also why I am not mentioning their gender. We have been directed not to disclose their name].

Dominique stayed with Fern throughout her time in hospital. She told the court that Fern felt like everything she said and did was being judged. She felt constantly watched.

As a mother of three this made me feel inadequate and I felt awful about the impact on Fern as a first time mother. The joy of having a new baby, my first grandchild, was totally drowned out. Instead it was frightening. 

Dominique explained to the court that sudden change is well known to be difficult for autistic people, despite this, there was a change of plan and Dominique was told Fern and the baby could only go to her house if Max was not there. Dominique said that it was not accurate that Fern and her had wanted Max to leave her home “but we would have agreed with what social services wanted as we did not want them to take away the baby”. She said Fern and herself understood Fern and the baby would not be discharged, if they did not agree to this.

Dominique told the court that the removal of Max’s support for Fern and their new baby was “very unhelpful and unnecessary”. Dominique remembers that her and Keiran told Max to goto the council offices and refuse to leave until they gave him housing. Dominique told the court that on her way home from the hospital she received a phonecall from someone at the council telling her evicting Max “was not legal”, she said she told them that she had no choice and she felt like she had a knife to her throat.

Dominique said Fern had no advocate at the discharge meeting at the hospital, but she had needed one and she didn’t believe that Fern understood what was happening. She said Fern did not want to do anything wrong, so agreed with what was suggested. She said a social worker at that meeting said that they were not taking her baby yet, and Fern took the word yet literally. Dominique told the court that they did not feel like the baby was theirs, they felt they were being tested.

She remembered that Fern was exhausted “as many new mothers are”, and the baby did not sleep well at night. She told the court of multiple visits from healthcare professionals, and that Fern’s OCD had worsened, but this did not stop her caring for her daughter.

Dominique said Fern did not understand the restrictions on Max visiting. She told the court that Fern had gone to visit Max on 13 January, and had left the baby with her, all of which had been agreed in advance. She said that she wanted to give Fern some time out “which all new mums need”. Dominique told the court that Fern had missed the last bus home, so she went to the police station for help. They advised her to stay in a hotel for the night, which she did, and Dominique said that this was “wrongly seen as her abandoning her baby”.

Dominique told the court that it was overcrowded at her home and there were multiple visits. She said that Fern said she was a failure and did not understand what would happen to her baby. She said she thinks she was told not to let Fern out with her baby on her own, but it was not explained why. She said Fern felt trapped at home.

Dominique told the court that Ruth House, a specialist midwife, wrote Fern a note to reassure her that she was a good mother. She said this was exhibited to her statement.

Dominique outlined the meetings that followed and that Fern was struggling with her OCD. On one occasion Fern missed an appointment with a midwife, having fallen asleep and not heard the door. She told the court that this missed appointment was used against Fern.

Dr Afghan, a Consultant Psychiatrist attended a meeting at Dominique’s home in late January, with Eva, Fern’s latest care coordinator. She told the court they discussed treatment for Fern’s OCD and her difficulties engaging with the child protection processes. She recalls Dr Afghan seemed pleased with Fern, given the stress she was under. Dr Afghan recommended reasonable adjustments needed to be made, and that Fern required an advocate.

Dominique told the court that there were also meetings with Ms Jillani, with Fern’s GP and with a midwife. She explained to the court that Fern struggled with so many meetings, that they left her exhausted from the processing required to understand what was happening. She said that Fern was required to make additional effort to be able to participate in meetings, particularly with those professionals untrained in autism.

Dominique told the court that she emailed Ms Jillani and explained how difficult this was for Fern and said that an advocate could have greatly assisted.

I think had Fern had an advocate for these meetings, the outcome would have been different. Instead I had to do my best as an advocate for Fern, but the problem was I did not really understand what was happening either.

She said Fern described things as a runaway train. She told the court Keiran repeatedly raised concerns by email.

It felt Fern was being punished for being autistic … Fern felt everything focused on what she couldn’t do, not what she could. She called it the un-CV.

Dominique described a number of conversations and meetings with Ms Jillani, who she said finally agreed to secure advocacy for Fern.

Fern continued to have what seemed like endless meetings with different people, and it was very overwhelming.

She told the court about a midwife who came to their home, and put multiple questions to Fern. When Fern struggled to answer she rudely commented asking how Fern would cope when her child was at school if the teacher was asking her questions. Dominique told the court she recommended Fern take a short break from the meeting, and when she returned she was able to answer all the questions that had been put to her, as she had had time to process them. They made a complaint about this midwife, which was upheld, and she had to go on training to learn how to communicate with disabled people with communication difficulties.

Dominique told the court that her mother had come to visit to help out. Dominique had work commitments, Fern and the new baby staying with them, and her autistic son was still out of school as the local authority had not provided him with education.

My mum wrongly thought that if she told social services we were not coping we would get help.

She said that her mum had not anticipated that would lead to Fern’s baby being removed permanently. Dominique told the court that Fern wanted a specialist placement, it did not matter whether it was a mother and baby unit or a foster placement, as long as the placement would support Fern’s needs. She told the court that Fern was becoming consumed with the idea that she was a bad mother, as it was all social services were focused on.

Dominique said without any placement being made available for Fern and her baby, Fern had felt like she had no option but to agree to her baby going into foster care.

Fern’s baby was taken on 28 January 2020. Ms Jillani said to us that night, that management were “shitting themselves” because they knew the situation had been badly handled. 

Dominique told the court that they felt cheated as they were told the baby had not settled that first night and so they were given a dummy, something that they had resisted up until that point. She said that Fern had an advocate for the first time at the meeting on 28 January when she signed the Section 20 agreement.

Dominique said Fern’s advocate, Pamela Yates, had experience and could communicate well with Fern. She said she left them to meet alone and Pamela appeared to quickly understand the situation. Fern described having a professional advocate as “a revelation” in a letter she sent social services the following day.

That same evening Fern was visited by some mental health nurses, who said that they had been told Fern “was not coping”. Dominique told the court this was not the case, and that Fern was doing ok and had not self-harmed since finding out she was pregnant.

The issue for Fern was getting the support she needed to be able to be with her baby.

Dominique told the court about Fern’s first contact visit with her baby, recalling that they had to get two buses to the centre and that it had felt stigmatising. The centre had locked doors and Fern told her mum she felt like a criminal, Dominique said she could understand why and she had emailed Ms Jillani about that.

Dominique told the court that Fern could not cope with the contact arrangements. She said she felt if adjustments had been made, a taxi had been provided, or a change to a more local venue, Fern would have been able to attend. Dominique told the court that instead Fern became more unwell as she missed out on contact with her child.

Dominique outlined emails that Fern’s advocate had sent to various professionals at this time, requesting adjustments be made to enable her to engage with the child protection processes.

I was really worried for Fern, the lack of contact with her baby and the continued lack of adjustments and support was taking its toll. 

In mid February Dominique told the court that Fern and the family found out that social services had issued court proceedings relating to Fern’s baby. She said Keiran requested Fern have professional advocacy but it did not happen. Dominique told the court that the hearing did not go well and the barrister said Fern had agreed to an interim court order. She told the court that after the hearing a new social worker was appointed, and that this was really difficult for Fern.

Dominque described how that evening Ms Jillani had forwarded an email from Eva, saying that Fern could not be admitted to a mother and baby unit.

It was confusing, Fern was not unwell enough for a mother and baby unit, but she was considered too unwell to look after her baby.

Dominique told the court that Fern was really worried about having her baby taken from her, and she did not feel that she had had a chance to be a good mother. She said Fern knew if she did bond with her baby, and they were taken from her, it would destroy her.

Dominique told the court, that predictably, Fern’s mental health deteriorated. She said in March 2020 Fern started harming herself for the first time since she had found out she was pregnant. She told the court that Fern had been aware of other inquests into deaths of young girls like her, and was aware of the methods that they used to end their lives. Dominique said she was not aware of a forum supporting people to end their lives, or readily available information, so she was not particularly worried.

Dominique told the court Fern was seen by the mental health liaison team at the hospital, following an overdose, and Dominique was present when Fern had spoken to a consultant at that time.

I remember that he mentioned there had been a lot of internal communications between the mental health team and social services. He rolled his eyes, insinuating social services were being very difficult. 

Dominique said that Fern was discharged back to her home. She describes Fern being “still really fragile” but being contacted about Family Court proceedings by her solicitor and social services. Dominique wrote to Fern’s solicitor saying how unwell Fern was, and reiterating Fern’s need for an advocate.

Dominique told the court Eva, Fern’s care coordinator, visited the following day after she’d emailed her with her concerns about how Fern was being treated by social services. Fern had been “told off” by social services for copying her mother, father and advocate into an email, which Dominique said was “ridiculous” and “again showed no understanding of Fern’s disability and the need for adjustments”. 

Dominique said Fern was crying all the time and saying she wished that she had not accepted treatment for the overdose. She felt by this time no one was going to support her to be reunited with her baby. Dominique recalled that on top of this, Eva, Fern’s care coordinator told her that she was being allocated a new care co-ordinator. Dominique told the court that Eva had some understanding towards Fern and a bit of experience of autism. She advised them to make a complaint about how Fern was treated, which she said they later did.

Dominique continues, stating “entirely predictably” on the 26 March 2020, Fern took another overdose. She was taken to hospital by ambulance and seen by someone from the psychiatric liaison team. She was given a “glimmer of hope of receiving support” when she was told there was a Learning Disability Team she could be referred to, Dominique said this was sufficient for her to accept treatment.

Once she was medically fit, Fern was discharged back to her mum’s house. She told the court that Fern continued to talk about suicidal ideation. Dominique tells the court that she was desperate, so her and Fern prepared a document setting out Fern’s support needs, which they emailed to Ruth House (the specialist midwife), social services and the mental health team on 27 March 2020. It was also shared with Fern’s solicitor.

Dominique said that she had persuaded the mental health team to admit Fern into a psychiatric hospital which Fern agreed was necessary. By this time Fern had a third care coordinator, Zoe Wilkinson, who had not yet met her. Dominique emailed her on 3 April 2020 stating that Fern needed support, and needed reuniting with her baby. She said that without support Fern was likely to try and end her life again.

With Fern’s agreement Dominique emailed the professionals involved, social services, mental health services, Fern’s solicitor and health visitor, with suggestions to try and help Fern to be reunited with her baby. Dominique told the court that Fern was doing well in hospital, but in her view was discharged too soon.

At a ward round on 6 April, Zoe told Fern that she could not go into a mother and baby unit as Fern did not have her baby in her care. Dominique and Fern both understood this to be a positive, as they thought it was a way that Fern and her baby could be reunited, as a possibility. She told the court she emailed to check their understanding.

Dominique told the court that Fern never in fact met Zoe in person. She said that Zoe would call Fern by telephone, not Fern’s preferred method of contact, and that she wouldn’t give her prior notice of when she would call. She contacted Fern through the general switchboard, which meant it was harder for Fern to contact her as she had no direct dial number, which made it seem less personal. Dominique said that Fern found this difficult and it became clear that Zoe had little experience of working with people with autism. Dominique emailed the mental health team saying Fern needed a new care coordinator, as Zoe wasn’t a good fit for Fern.

Fern was discharged back to her mum’s house, for an agreed one week stay. Fern was struggling to cope with the noise of Dominique’s home and her lack of space. Dominique said that she told authorities that she could not cope with having Fern at her home, as her and Fern thought that this would be the only way that Fern would be provided with her own accommodation.

Dominique said around about this time her husband made the decision to give up work to help the family. With the possibility of the support of Learning Disability Services, she said she thought things may get better.

She said that one day before the week agreed was up and Fern had to move out, they still had no idea what would happen, so she emailed the housing officer and Fern’s care coordinator, asking for help and an urgent review. She told the court Fern also wrote to those involved in her care (health visitor, solicitor, social services and the mental health team) clearly expressing how she felt and the support she needed.

Fern was offered temporary accommodation in a hotel, which Dominique recalled was calm, self contained and quiet. A small step forward and Fern seemed to immediately improve. It wasn’t a long term solution though.

As life resumed after the initial shock of lockdown restrictions, Fern was on the receiving end of a flurry of phonecalls requesting appointments 

Dominique told the court that this was overwhelming for Fern and she had to again email professionals involved asking them to use email, or contact her (Dominique). Family Court proceedings continued, and Fern still had no advocate, which Dominique told the court “seriously disadvantaged her”.

Around about this time Fern was told that her IQ was too high to receive support from the Learning Disability Team.

I was shocked no additional support was put in place for Fern given what had happened over previous months and it being clear Fern was at high risk of harming herself. 

Dominique told the court Fern was only given an advocate for one meeting, in June, by which time all the child protection reports were completed. Fern had refused contact with her baby due to the lack of reasonable adjustments, and without a plan for them she felt being reunited seemed like punishment for her and her baby, allowing them to bond and then pulling them apart.

Around that time Dominique recalls Fern’s care coordinator changing again. Towards the end of the month Fern was told she had been allocated new accommodation, which was much further away from Dominique’s home, and from Max. Dominique described how it was in a busy area and could in no way support Fern being reunited with her baby. When Fern visited she called Dominique very distressed as she had found her new accommodation was uninhabitable. It had no gas or electricity, no carpets, furniture or white goods and needed decorating. Dominique told the court she had asked if Fern could return to her previous accommodation whilst they prepared the new place for her but was told if she did that she would lose the accommodation. Fern went to stay with her father, whilst Dominique, her husband and Max decorated and tried to get it to a habitable state. Dominique told the court that the gas was not turned on before Fern died.

Dominique said with the exception of Fern’s advocate, no one seemed to understand her autism. Fern expressed how she felt about this in tweets, which are included within the Root Cause Analysis report. Fern’s new care coordinator visited Fern a couple of days later and agreed the accommodation was not suitable and said she would request an urgent meeting about it.

Dominique told the court that on the day before her death, 7 July 2020, Fern had a phone assessment with Respond, to try and access therapy. Dominique thought Fern was pleased about the prospect of this, and was in “fairly good spirits that day”.

Dominique said the next day Max received an email from his solicitor which he asked Fern to explain to him. She told the court it said social services had a strong case to keep their baby, and they may as well agree to it. Dominique said Fern called her, distraught. She asked if Max was with Fern and she said he was, but he was sleeping, which was a common side effect of his medication. Dominique suggested Fern contact Ruth House, the specialist mental health midwife who had understood Fern well. Dominique told the court when she tried to call Fern back she got her voicemail so she assumed that she was talking to Ruth. She said Fern called her at about 12:15 and they talked for about twenty minutes. Ruth had told Fern that she would still be able to write to her baby, but Dominique told the court that Fern was focused on the fact that she wouldn’t be able to sign the letters from mum, or say that she loved her. Dominique said she tried to tell Fern that they would fight it together.

Dominique said that Fern ended the call, but she was still upset and Dominique was worried about her. She called her back and encouraged her to do something with her day. She told the court it was a short call.

Fern then called her back for about ten minutes and she kept telling her mum that she loved her.

This was the last time I spoke to her and I think she had decided by then what she was going to do. 

Dominique told the court what happened next, that about an hour later she received texts and calls from a distraught Max who was waiting for an ambulance for Fern. She told the court that the police arrived soon after at her house and told her that Fern had died.

Dominique concluded her statement to the court by saying when Fern discovered she was pregnant it brought a complete end to a cycle of self-harm and hospital admissions. She told the court that Fern was focused on being a good mother, that she asked for and was willing to accept support. She said Fern found herself in a whirlwind process, a runaway train as she described it, but no-one had any understanding of neurodivergent needs. She told the court it became a self fulfilling prophecy.

Autistic people can, and do, make very successful parents, but I feel neither Max or Fern were given the chance to even try.

Dominique described her and Keiran being in regular contact throughout Fern’s pregnancy, how he had made formal complaints after Fern’s death and that they had continued to work together to understand, and ensure changes are made so other families do not lose people in similar circumstances.

Dominique told the court that she agreed with the RCA conclusion and that if Fern had been supported in a mother and baby unit the outcome would have been different. She listed the reasonable adjustments that were not made for Fern.

Fern never struggled to love or care for her baby… Fern’s mental health deteriorated because of overwhelming and uninformed interventions by social services, which she was left to cope with without the support of an advocate … no-one took any responsibility.

Dominique told the court that she didn’t recall ever seeing any support plan for Fern and her baby. She said it was devastating to read that the mental health team had identified 11 opportunities when Fern should have been referred to specialist help, from professionals trained in autism.

This, just like the psychological input she asked for, was never provided.

Dominique told the court that Fern understood she had a disability and needed support, but that support was not provided. She said that Fern ended up feeling that was because she was a bad person and not good enough to be a mother.

I knew, Keiran knew, multiple professionals knew that Fern would end her life if she lost all hope of being reunited with her baby.

Dominique said that the acts and omissions of Buckinghamshire Council made the outcome “inevitable” and their failings, together with those of mental health services, caused the death of her daughter and the loss of her grandchild for her family.

The circumstances of Fern’s death have had a huge impact on me.

I have been in therapy with a charity since Fern died, diagnosed with ComplexPTSD (Post Traumatic Stress Disorder) and it’s affected my relationships and my ability to work.

Dominique told the court that she now works part time as a cleaner, because she can not manage stress, problem solve or use her brain because she is so mentally tired.

I am scared of people in general. I feel very isolated from society and still stigmatised from my story. I have periods of shutting everybody out. I live in constant fear of not being good enough and making any mistakes in case social services come after me … I have lost the joy of being a parent or a grandparent because it is tarnished in fear and stigma now. I wish for my son to reach 18 so I don’t have to live with this fear. I live in a state of hopelessness that if I tell anyone I am struggling it will be used against me. I have no faith that there is any help out there anyway because of what I saw with Fern. 

That concludes Dominique’s statement which the coroner read onto the record. He then paused for a short break before returning to court where Dominique gave an affirmation and it was over to her legal representative, Sam Jacobs, to ask her clarifying questions.

Sam started by asking Dominique about Fern’s strengths and challenges in communication.

SJ: I ask questions on your behalf, there’s a lot of detail in your statement, small number of topics to ask you about, ok. First, Fern’s strengths and challenges in her communication, like I ask with reference to Fern’s own words, she had quite a good insight into her own strengths and difficulties, is that right?

DJ: Yes

SJ asks for the Oxford Health Records bundle, page 1529, a few pages from the end

C: In the Root Cause Analysis?

SJ: it is, for purposes of Root Cause Analysis report, you provided some tweets from Fern didn’t you?

DJ: Yes

SJ: Just going to ask you about one of those tweets. Towards the bottom of the page, do you see a heading, says tweet from Fern June 2018?

DJ: Yes

SJ: I’ll read for the court ok, a tweet Fern sent, Fern’s words?

DJ: Yes

SJ: She said: One issue I frequently experience being #actuallyautistic is when people assume that being articulate and a good speaker means I can’t have any serious issues with social communication. This is false as talking and communicating are not the same thing at all. I am very good at making speeches and monologuing about my ideas. I have a good vocabulary. I can speak for hours about my special interests, in fact I usually won’t stop talking as I don’t know when people are getting bored. I am good at explaining things.

However in a conversation I struggle to know when it’s my turn to speak. I’ll often interrupt people by accident, and I cant process the other person’s words quickly enough to work out how to respond properly, so I  just agree with anything you say.

I also can’t remember, if you tell me afterwards, I have little ability to absorb verbal or spoken information. Being able to speak does not mean I have no issues with social communication, it just means you can’t see these as easily.

SJ: You knew Fern incredibly well obviously, do you think that accurately describes some of the abilities and difficulties Fern had with communication?

DJ: Yes, absolutely, describes it very, very well

SJ: Some of the challenges, not knowing when her turn to speak, not being able to process quickly enough so agreed with what say and not remembering what told… [missed] how did those matters impact on Fern’s ability to engage with meetings like the child protection conference?

DJ: For example, if she was asked a question, she would answer yes. Sometimes if I was in a meeting and I was able to speak to her I’d ask Fern do you know what you just said then? And sometimes she did, sometimes she didn’t. If I wasn’t able to support her she’d say yes, then a few days later she’d say what was that, what were we talking about, what did I agree to?

SJ: When you went home from the Child Protection meeting, would she have an understanding of what was spoken about?

DJ: No. She’d remember certain words, often words she’d taken literally, meetings would make her anxious, she wouldn’t interpret broader context of what was said, just literal words… would take several days before she were able to process whole thing.

SJ: You give examples in your statement, such as child protection.

DJ: Yes child protection, protecting my child from me.

SJ: And neglect?

DJ: Yes [missed]

SJ: And the social worker saying we’re not taking your baby yet and Fern taking that literally?

DJ: Yes, it had a huge impact.

SJ: Was there to your knowledge or understanding, ever any proper assessment that considered Fern’s needs, her difficulties with communication and how she could be supported through the child protection process?

DJ: Not at all [missed fuller answer]

SJ: In fact, it got to the point didn’t it where you in March 2020, did a sort of assessment of your own?

DJ: Yeh I did, I thought nothing is happening, no one is looking at what’s happening, I’d write something to give a guide of where could start from.

SJ takes to bundle… p258

SJ: At the bottom of that page, is an email from you on 31 March 2020, to House, is that Ruth House, the health visitor?

DJ: Yes

SJ: And Stacey Connors, the social worker?

DJ: Yes

SJ: You say, Dear Ruth, Stacey and Zoe. Is Zoe the care coordinator?

DJ: Yes

SJ: [missed start] Is this something that had been suggested by Ruth House?

DJ: Not really, we’d had a conversation and just the lack of understanding, I was at my wits end and thought I’d write an email to see if that made it any clearer

SJ takes to document in bundle

SJ: We see the attachment to the email you wrote. It starts Fern’s Support Needs, as a care and support plan might. What you write is this is by no means a comprehensive document, is based on my knowledge, experience and support I’ve given Fern, I do not have professional knowledge… would be extremely advisable to get advice from someone like Pamela Yates with specialist qualifications …. [missed]

SJ: This reads as 9 months or so into the process of child in need, child protection and care proceedings?

DJ: Yes

SJ: And it’s come to you as Fern’s mother to attempt an assessment and suggest a specialist assessment is needed?

DJ: Yes

SJ: Describe your level of concern and frustration at that.

DJ sighs and then answers: Nothing was happening, nothing was moving forward, Fern was not getting any help or treatment. No one really seemed to know what they were doing, or understand anything about her. So this was like a last ditch attempt to try and get somebody to listen.

Sam checked that Dominique felt an understanding of Fern should have been the first step in any process, she confirms she does. Sam says that she has spoken in her answers, and in her statement, about some of Fern’s difficulties with communication, that she also outlines in this document of March 2020. He says that he will ask a bit more about that.

SJ: Fern found it important to have information provided to her in writing didn’t she?

DJ: Yes

SJ: Why was that?

DJ: It meant she had the information beforehand, so she could take that information on and remember it. She had a very good memory, which meant when she went into the meeting, all the visual parts of social communication and things she struggled with, it meant some of it was already there, so you were just giving her one step up to cope with something like that.

SJ asked if Fern was able to process information in writing different to in conversation

DJ: Yes, very different

SJ: Was there ever any clear plan by professionals involved about how written communication should be used?

DJ: Pamela Yates wrote… explained to professionals all about that, and she suggested it a few times.

SJ: Was written communication in fact used consistently?

DJ: No

SJ: Give us a sense of the difficulties that would create for Fern?

DJ: She’d go into a meeting, and just the anxiety it caused her, she couldn’t really grasp what was going on, and she got very little out of meetings, very little.

SJ: Did you feel and did Fern feel she was provided with clear written explanations of what the expectations of her were, so for example how she might satisfy Children’s Services concerns?

DJ: No. Fern felt they wanted her to not be autistic anymore. Basically, not to have the disability that she did.

SJ: Did she have an understanding, to your mind, as to why social services were concerned and what social services wanted her to do?

DJ: I think she understood her history was a worry, but she knew that. When she got pregnant she knew she had to be ok and not harm herself… she felt if she could prove that, which she did, she felt that was all that was needed. That was what she thought, that was fine, she stopped doing that, but obviously her autism wasn’t catered for so she’d trip up because of that, she felt that was used against her and she couldn’t stop being autistic.

SJ: On this issue of communications and whether adjustments were made for that, perhaps we could turn again to Fern’s own words… another exhibit to your statement. Right near the beginning of the process, Fern wrote some thoughts down for the purposes of the initial child protection conference didn’t she?

DJ: Uh hum

SJ: And this is that document?

DJ: Uh hum

SJ: She says I’m writing this down as I have difficulty communicating my feelings in meetings… I feel there is an inadequate understanding of autistic spectrum disorder… as well as institutional unreasonableness [?]…. Seems people are saying the conference has to follow this format, these are rules, you have to do what we say without understanding the real challenges this causes me.

When Fern wrote that, did you understand where she was coming from?

DJ: Yes I did

SJ: Did you feel it was a justified complaint?

DJ: Yes I do

SJ: That feeling Fern describes there, of services not listening to or understanding the real challenges and anxiety she was being caused by how the process was being handled, do you think that changed at any point during the period Children’s Services were involved?

DJ: No I don’t

SJ: If we look over the page to 236, same document, just over half way down, you will see a paragraph written by Fern which begins unfortunately however?

DJ: Yes

SJ: Unfortunately however the focus of discussion appears to be focused on risk avoidance and protection, rather than support…. Whilst acknowledging fully children’s welfare must always be paramount, seems dismissed best way to ensure this is to support me in being a good parent…. current approach social services is to look at me as a threat… rather than look at what forms of support I needed to help me cope.

Similarly did you feel also that concern was a well founded one?

DJ: Yes I do

SJ: Moving to the linked issue of advocacy support, both you and Kieran and Fern asked on a number of occasions for advocacy support didn’t you?

DJ: Yes

SJ: If there was a suggestion that you were able to perform the role of advocate for Fern as someone who knew her well, had insight… what would you say to that?

DJ: I couldn’t be an advocate in this incidence, because I didn’t have any knowledge of the process we were going through… I could offer her no help in that way.

SJ: It sounds like you felt lost, just as Fern did?

DJ: Yes definitely, definitely.

SJ: I’ll ask you to look at the email you wrote during these events which conveys that. These are in the Buckinghamshire Health bundle

Page 17 please

These are records made by Ruth House, the Specialist Health Visitor wasn’t she?

DJ: Yes

SJ: Entry near the top, says date time event recorded 3 April 2020

DJ: Yes

SJ: We can see that Ruth House seems to have copied in an email you have sent, says email received from Dominique?

DJ: Yes

SJ: Your email reads as follows Hi Ruth, promised you an update on Fern at the end of the week… spoken at least once a day, she cannot make sense of what has happened to herself and the baby, I’m not able to understand either… struggles find way forward and feels helpless… told her not to rush out of hospital…. why can’t she go to an MBU, a mother and baby unit, can you remember? Best wishes Dominique.

So we can see you there explaining at the time, you yourself didn’t really understand what was happening?

DJ: Yes

SJ: So, you couldn’t help Fern?

DJ: That’s right

SJ: You didn’t have an understanding, we can see, of why she couldn’t go to a Mother and Baby Unit?

DJ: No, no

SJ: To put this in context there’s been child protection enquiries, interim care order, baby moved into foster care… the understanding you had, let alone Fern, was really quite limited wasn’t it?

DJ: Yes

SJ: Does this give an insight do you think to the runaway train feeling you describe, and Fern described, that’s in your statement?

DJ: Yes it does

Sam Jacobs was at pains to point out that this was in no way a criticism of Ruth House, Fern had a very good relationship with her, but she was not an advocate. He reads Ruth House’s response, that refers to Fern requiring treatment for her anxiety, but not really addressing the questions Dominique had asked about the Mother and Baby Unit.

SJ: It’s no criticism at all, but you’re not getting the clear information you’re clearly struggling for, what is happening and why, the sort of thing an advocate might provide?

DJ: Yes

SJ: There was some brief involvement wasn’t there with Pamela Yates?

DJ: Yes

SJ: With other witnesses we’ll come onto circumstances of why that was so short lived. Give us your impression of the impact having Pamela Yates had, albeit for a short period?

DJ: It was amazing, Fern was able to understand and be understood. It’s a bit like someone who is deaf and needs sign language to hear, that enables you to hear and explain to her in a way she can understand. [Fuller answer – missed]

SJ: Did Pamela Yates appear to have an understanding of Fern and what she needed?

DJ: Yeh she did, she came in straight away and understood what was happening, and why, and what needed to happen.

SJ: If that sort of service had been present throughout, what sort of impact would it have had?

DJ: Fern would have been able to make decisions about what she wanted to do, considering all that was going on, even if that meant giving up her baby voluntarily, I think if it was explained to her that wasn’t possible she’d have coped with that, but needed to be clear. [Fuller answer – missed]

SJ: Might it have avoided the sense she appeared to have of things happening to her, profound things, no longer living with her baby, that she didn’t feel she had any say or agency in?

DJ: Yes

SJ: Those are all my questions. Thank you

There were no questions for Dominique, Fern’s mother, from any other Interested Persons. The Coroner said that he had no further clarifying questions and he thought that had been very helpful. He wished Dominique all the best and releases her from oath.

*****

The court then heard from Rowan Foster before lunch, but I shall write that up later. I am unable to attend Fern’s inquest daily so am taking my time on reporting yesterday’s evidence in detail.

With thanks, as always, to my crowdfunders and those reading and sharing the reports.