Fern Foster Inquest – Kieran Foster

The final witness that the court heard from on Day One of Fern’s inquest was her father, Kieran.

The coroner thanked him for his detailed report with annexes, as part of his investigation. He said he believed the intention was that Kieran would read his statement, that we would hear that in its entirety and then “see where we get to” in terms of questions.

Kieran started by telling the court he was Fern’s father, and he had compiled his statement from his own recollections, his emails, discussions he had with Dominique [whose evidence you can read here] and from records disclosed as part of the inquest process.

As he continued Kieran’s voice broke, he paused, composed himself and continued:

I am devastated by the death of my beautiful daughter and there is no doubt in my mind that Fern took the act to end her life on 8 July 2020 as a direct result of the communication of the decision by Buckinghamshire Council to seek to place her baby for adoption.

I stress it was a decision to seek to place the baby for adoption, it wasn’t a final decision, we would have continued fighting it.

Kieran told the court that he missed his daughter constantly, that he bursts into tears unpredictably at the slightest memory of the good times he had with Fern. He said he has lost his grandchild as a result of this, having never had the opportunity to meet them.

He said his hope was that the inquest would consider how Fern came by her death, and examine how she was treated during child protection processes. He said that he hoped it would “confirm that she never rejected her baby, but rather was in desperate need of help and support that people simply failed to give her”.

Kieran told the court Fern was born by emergency c-section on 14 August 1997 and that himself and Fern’s mother, Dominique, had separated when Fern was a young child. Fern lived with her mother, but he told the court that they had extensive contact including regular weekends and over half of the holidays.

He said that Fern was diagnosed autistic around the age of 15. She did well at school getting A and A* grades in her GCSEs. Kieran told the court Fern “really struggled with social interactions, absorbing and processing information” and she became overwhelmed and anxious. He also added that Fern had insight into changes she needed to make in order to cope.

He told the court about the first time Fern was sectioned under the Mental Health Act, after a relationship broke down with a fellow student at a residential college she was attending for young autistic adults. He said that in her late teen years Fern regularly took overdoses, when emotionally overwhelmed.

I do not believe these were attempts to end her life, but more a way of communicating her distress.

He said a cycle developed where police would intervene under S135 of the Mental Health Act resulting in Fern being taken to a place of safety, usually A&E, occasionally with short stays in hospital, followed by a discharge home, usually without any immediate or long term support provided. Kieran told the court predictably this meant Fern would be overwhelmed again, harm herself, and end up back in A&E.

Kieran said when Fern’s symptoms were short lived and reactive, she would be discharged from A&E within 24 hours.

These multiple incidents were Fern having an autistic meltdown, rather than a mental health crisis, where she would not know how to react or cope in a particular situation, but frequently would be out of that short lived state of distress within a couple of hours. Sometimes the self-harm or other act would almost act like a pressure relief valve and she would be out of crisis within minutes.

Kieran told the court that by the time Fern was seen by mental health teams in A&E she would often have calmed down and no longer be a risk to herself, which meant she was sent home without whatever the anxiety inducing stimulus was in the first place being addressed.

So the cycle rapidly repeated.

Kieran said Fern felt that she needed, and repeatedly asked for, specialist help. He said she would sometimes be told she was being referred, but to his knowledge she was never offered any care or treatment from specialist autism services. She was offered group therapy, which Kieran said Fern would be unlikely be able to benefit from.

There appeared to be a complete lack of understanding of Fern’s wishes, and little or no understanding of the role autism played in her behaviour, or the need to accommodate her autism in any care plans or treatment.

Kieran told the court about Fern meeting Max and described their relationship as “thoroughly positive for Fern” adding that they saw significant improvements in Fern’s self worth and motivation. He said that Fern and Max had periods of homelessness and life was tough.

He acknowledged to the court the support that Dominique had provided to Fern and Max, often having them staying with her, but understandably she could not provide them with permanent housing or the full support that Fern needed.

Kieran told the court about hearing the news about Fern’s pregnancy on a message Dominique posted in the family group chat to share the news. He said the news had a hugely positive impact on Fern, breaking the cycle so Fern completely stopped self-harming behaviours, instead focusing on learning how to parent.

She viewed the future with a renewed positivity, making plans to best care for her baby accepting she would need help and support.

She planned to stay with her mum in the immediate period after the birth and hoped housing would be arranged close by so she had easy access to support in an area she knew.

It was not long after Fern discovered she was pregnant that Buckinghamshire Council Social Services became involved.

I’ve said social services there, I suppose it should say Children’s Social Services more accurately. We thought they were going to offer Fern and Max support, and we expected an assessment of Fern’s needs to take place.

Kieran told the court that Fern’s housing situation began to worry her. He said that he thought it was from Dominique that he learned Buckinghamshire Council were starting child protection processes.

He said this caused Fern worry, as it would any loving parent. He said it was obvious Fern would need, and she asked for, reasonable adjustments to be made to allow her to properly participate in the processes. 

Kieran quoted from a letter Dr Grant, a Consultant Psychiatrist dated 3 September 2019, that he said to his knowledge was never acted on. It said:

“Of course, we understand that a degree of interaction and engagement from your team is necessary, but we ask that you take this information into consideration and afford Fern any appropriate adjustments that is within your power to provide during her recovery. We would particularly request any amendments that might be made to limit the number and frequencies of Fern’s visits from yourselves or contractors. Given the degree of support that Fern requires; we would also ask that you make any allowances that are possible in facilitating accommodation close to Fern’s mother’s address”.

Kieran told the court of concerns raised about professionals needing training in autism and a request for a single point of contact in order for Fern not to have multiple visitors. He said “again, these requests, were rebuffed”.

He mentions several times that Fern was willing, and keen, to accept help and support, but none was offered to her. He also details changes in personnel involved in Fern’s life through different processes.

Fern was very anxious about being under the spotlight as a new parent and rather than being supported by professionals who understood her disability, she felt she was already being labelled as someone who would not be able to care for her child.

Kieran told the court that it all became too much for Fern in mid December, she became overloaded and had an autistic meltdown.

This was in my view quite predictable given the pressure she was under and as seemingly no adjustments had been made to help her cope with the pre-birth assessment processes.

He said Fern did not harm herself, and as people took holidays over the Christmas period, meetings and contacts with her reduced and she seemed much calmer. Kieran told the court since Fern’s death he had learnt that Fern was refused the support from the perinatal service, because she was stable and well when pregnant, then after the baby was born she was later refused support as her baby was not in her care.

I find this very confusing and contradictory. One agency appears to be saying Fern was fine, while another agency was saying that Fern’s issues were such a matter of concern that they needed to invoke statutory child protection procedures.

Kieran described the period immediately after Fern gave birth, telling the court the sudden change in plans, together with no advocate being provided to Fern in the discharge meeting, was “hugely traumatic”. He said by preventing Max being with Fern, social services had removed a key part of Fern’s support network.

Fern began to fixate on the idea that social services had already decided to take her baby away from her and Max.

He said that Fern’s support had been removed and her anxiety had increased greatly. He told the court he recalled her saying she felt like she was being set up to fail.

Kieran told the court that when Fern missed the last bus home from a visit to Max and that resulted in social services saying she couldn’t leave the house alone with her daughter, it was clear to him that “events were either being misinterpreted or misrepresented”. He said he had a number of phone calls with Fern’s social worker, Ms Jillani, about the pressure he felt they were putting Fern under.

It was clear Fern was being viewed as having abandoned her baby, which was not at all what had happened.

Kieran said towards the end of January they became aware Buckinghamshire Council intended to send a Public Law Outline (PLO) letter to Fern. They understood this to be the first step in the process for the council to remove Fern’s baby from her care. Kieran emailed Fern’s social worker, Ms Jillani, stating that she had a legal right to independent advocacy. He again expressed their concern that Fern was being “pushed into a corner”.

Kieran told the court that Ms Jillani replied saying she had emailed Fern’s care coordinator about advocacy support, and she had emailed “senior management” to respond to Keiran. He told the court he didn’t hear anything from senior management.

Kieran described a series of email exchanges between himself and Ms Jillani about the PLO letters. All of which are exhibits to his statement. He told the court of a phonecall he then received from Ms Jillani where she told him that she had refused to deliver the PLO letter to Fern “as she agreed in the absence of proper advocacy and support, doing so could push Fern to self-harm or attempt suicide”. He then said that Ms Jillani had gone further than this and she told him she had threatened to resign if she was forced to deliver the letter.

Kieran said that he had seen in the disclosure for the inquest, an email between Ms Jillani and Ms Hopkins that confirms would put on hold the PLO letter and processes “pending an advocate”.

The failure of social services to provide the PLO letter and ensure Fern understood it, such as through the provision of an advocate, meant she was placed at an impossible disadvantage from the outset. In our view this was a contributing factor to the events that followed.

Kieran told the court that all of this was on a backdrop of continuing meetings with multiple professionals, without the requested single point of contact, and that Fern felt she was being put under the spotlight as a mother.

He said that he could not understand why the threshold for statutory intervention with Fern and her baby had been met, so he emailed Ms Jillani asking for confirmation in writing. Kieran told the court he had looked at relevant guidance and could not understand the basis for the actions the council were taking.

I hoped if I could get a clear answer I could at least try and explain what was happening to Fern.

Kieran continued to read his statement to the court, including a number of sections that included quotes from previous case law and guidance he had researched.

Kieran read from a judgement made in the High Court in Northern Ireland In the Matter of G and A (Care Order: Freeing Order: Parents with a Learning Disability that Sir James Munby, President of the Family Division in the case of In the Matter of D referred to as “profoundly important” observations. In fact Munby went further stating:

I respectfully agree with everything said by Gillen J. I commend his powerful words to every family judge, to every local authority and to every family justice professional in this jurisdiction.

Anyhow, this was the profoundly important observation that Kieran quoted to the court:

The court must also take steps to ensure there are no barriers to justice within the process itself. Judges and magistrates must recognise that parents with learning disabilities need extra time with solicitors so that everything can be carefully explained to them. Advocates can play a vital role in supporting parents with learning difficulties particularly when they are involved in child protection or judicial processes. In the current case, the court periodically stopped (approximately after each hour), to allow the Mencap representative to explain to the parents what was happening and to ensure that an appropriate attention span was not being exceeded. The process necessarily has to be slowed down to give such parents a better chance to understand and participate. This approach should be echoed throughout the whole system including LAC reviews. All parts of the Family justice system should take care as to the language and vocabulary that is utilised. In this case I was concerned that some of the letters written by the Trust may not have been understood by these parents although it was clear to me that exhortations had been given to the parents to obtain the assistance of their solicitors (which in fact was done). In terms therefore the courts must be careful to ensure that the supposed inability of parents to change might itself be an artefact of professionals ineffectiveness in engaging with the parents in appropriate terms. Courts must not rush to judge, but must gather all the evidence within a reasonable time before making a determination. Steps must be taken to ensure that parents have a meaningful and informed access to reports, time to discuss the reports and an opportunity to put forward their own views. Not only should the hearing involve special measures, including a break in sessions, but it might also include permission that parents need not enter the court until they are required if they so wish. Moreover the judges should be scrupulous to ensure that an opportunity is given to parents with learning disabilities to indicate to the court that something is occurring which is beyond their comprehension and that measures must be taken to deal with that. Steps should also be taken throughout the process to ensure that parents with learning disabilities are not overwhelmed by unnecessarily large numbers of persons being present at meetings or hearings.

Kieran also quoted from government guidance issued about working with parents with a learning disability. He said that whilst Fern did not have a learning disability in the sense of a lower than average IQ, having autism hugely impacted on her functional ability to absorb and process verbal information.

He told the court it was clear to him that Buckinghamshire Council had legal obligations to Fern, not just to her baby, and she ought to have received an assessment, reasonable adjustments should have been made and services provided to her, to support her parenting her baby.

Kieran went on to describe receiving an extremely distraught phonecall from Fern once her baby was placed in the care of the council under a Section 20 agreement. He was in Wales at the time and said it was clear to him that Fern was under extreme pressure and exhausted, with lots of people telling her what to do.

I do not feel her consent was freely given. Fern set out how she felt about the Section 20 agreement and how she had made the decision, with the benefit finally of an advocate, because of overbearing pressure by the multiple health and social care professionals involved in her and her baby’s life.

He attached Fern’s letter as an exhibit to his statement, and highlighted that Fern described having an advocate in her letter as a revelation. He said she was clear that this was the first time throughout the entire process where she felt someone was listening and explaining things to her.

Had this been in place from the start I would not be in the emotional state of fear and anxiety I am now. I know I need support.

Kieran told the court of references he had found to previous Family Court cases involving parents with a learning disability “where the court has been concerned by Section 20 processes and a failure to provide services”. He quoted from Medway Council v A & Ors (Learning Disability; Foster Placement) [2015]:

I have already dealt with their inappropriate obtaining and reliance on a section 20 agreement, and consider that the case should have been dealt with either by way of intensive Learning Disability support that would then been unlikely to have required section 20 to be employed and/or by the issue of proceedings to ensure that proper legal advice and representation was available to the family.

and continued

The SW acknowledged that a specialist foster placement or a ‘specialist placement setting’ (as in her email of 10.9.14 to her managers) should have been provided. She asked for a specialist foster placement and was offered this placement. I appreciate that Mother and Baby placements are a scarce resource, but if it was not suitable it was not suitable and an alternative resource should have been pressed for. The success of Mother and Baby placements often relies heavily on the direct relationship forged between a mother and the foster carer. This will become all the more crucial and potentially fragile where the mother suffers from a difficulty such as a learning disability. I find that Medway fundamentally let down A, his Mother and indeed Ms McG, by placing them together in what should have been evident at the time was an unsuitable arrangement.

Kieran told the court that he was worried this was happening to Fern and she was not receiving the care and support she was entitled to. He told the court that promises were made that the baby was going into care as a temporary arrangement while additional support was sourced to help Fern cope, but he said immediately once the baby went into care “the goalposts seemed to be moved once again”.

Kieran told the court that there was a “woeful lack of consideration of Fern’s disability and support needs”. He quoted from an email that Fern had sent her social worker, Ms Jillani, in early February having met with her advocate. It contained four requests for support, including a referral to a mother and baby unit at Bethlem Royal Hospital.

Fern forwarded the very short reply from her social worker to her father. It said that “the request would be considered with court proceedings as agreed by senior management”. Kieran told the court it was not clear what the request was, given Fern had made several requests including for reasonable adjustments, adding:

I have never known exactly who senior management refers to and whether they knew anything about Fern.

He told the court he had emailed Ms Jillani for clarification on the 6 February, chased on 10 February and Ms Jillani said she would reply after a meeting with her manager. Kieran told the court having had no reply he made a formal complaint 11 days later.

Kieran told the court that they heard on 17 February that Fern was considered unsuitable for a referral to a specialist mother and baby unit. He told the court she never underwent any assessment, and they understood the decision was made by people who had never met Fern.

He told the court a specialist foster placement for Fern and her baby was mentioned by her care coordinator but there were no meetings to discuss reuniting Fern with her baby, or to explore the support that would need to be in place for such a placement.

This was in my view a crucially missed opportunity to support Fern and to see whether she could, with support, be reunited with her baby. I believe that this failure was part of the circumstances that caused Fern’s death.

Kieran told the court that Fern was served with court proceedings for a hearing 5 days away (including a weekend). Fern had one meeting with a solicitor, no time to understand what was happening or process the paperwork.

This single appointment, without any advocate being provided for Fern and all very rushed, was the only advice Fern received before being in Family Court for the first time. I was livid and very worried about Fern. I remember calling social services and telling them if Fern took her own life, I would seek a prosecution of corporate manslaughter. I said this because I did not, and I still do not, believe the correct procedure was followed, or Fern given the right support, such that it was inevitable Fern would lose her baby and lose all hope for the future. 

Kieran told the court of the email exchanges that follows, how court proceedings developed, the fact some report included inaccurate claims about Fern, and some made no mention of her disabilities. He told the court Ms Jillani said Fern had not been provided an advocate due to cost. He said there was another change of social worker because Fern’s baby moved from the child protection team to the court team. A change for their own administrative ease, not taking into account Fern’s disability or the fact she had built a relationship with her current solicitor, Ms Jillani. Kieran told the court he had made a complaint about this, but the council refused to investigate whilst care proceedings were ongoing.

Kieran told the court this was “torture” for him to watch his daughter go through this, with no one listening or offering help.

Every conversation would end up with people saying that that was not their responsibility or that their service had no control over things.

He told the court Fern took an overdose in March. He said he was distraught by this as it was clear Fern was losing hope completely and her baby had been such a strong protective factor.

I entirely agreed with Fern that with support she could be a good mother. Indeed she had shown that right from the start, but the lack of any support and the endless lack of any adjustments to account for her disability was gruelling, so the risk to her life grew stronger than it had ever been.

Kieran told the court he could not understand why Fern was not being referred to a Mother and Baby Unit. He sent an email quoting guidance from the Royal College of Psychiatrists with eligibility criteria. It included the line:

Who on earth do I have to complain to, to get someone to start giving my daughter the help she deserves?

Kieran said he received a short reply from Ruth House who told him that getting into a Mother and Baby Unit was quite complicated, and provided him with the details for PALS (the Patient Advice and Liaison Service).

Kieran told the court that he was desperate to get help for his daughter and her baby. He read his email setting that out to the court. It included that:

  • so far there had been no meaningful support for Fern
  • there had been no assessment of what Fern’s needs were
  • there had been no sign of anyone seeking advice from clinicians with specialist understanding of autism.

Kieran’s email, he told the court, pointed out that the longer the delays were in arranging contact between Fern and her baby, the harder it was getting for Fern.

How much more can any of us take? Fern is being pushed to the edge because nobody is doing anything … Why isn’t anybody doing anything? How much longer can this go on? What actual practical support has Fern had? How much of a chance to try and be a parent has Fern actually been given? How much of a focus has there actually been on trying to reunite Fern and her baby, offering Fern actual support and therapy in order to work towards reuniting them. Literally nothing … Please can someone start coming up with some solutions, rather than passing the buck and blaming everyone else. Fern and her baby deserve so much more.

He told the court that he could not recall, and could not find, any response to his email.

Kieran recalled that Fern felt very low, and felt that it was inevitable she would not see her baby again. She felt there was no hope of a placement for them both together, and so it would be better for her baby to grow up without her.

Kieran told the court Dominique had emailed the local mental health team warning them of Fern’s continuing, and rising, suicide risk. She did not receive any reply. He told the court she included the information that Fern had written farewell letters. Finally it was agreed that Fern would be admitted to a psychiatric hospital, he said.

He outlined further emails sent by Dominique, copied to him, outlining their concerns for the lack of support being provided to Fern.

During May 2020 Fern underwent various assessments but as far as we recall she was never provided with an advocate, nor did she have her own social worker to support her. Dominique supported Fern as best she could, and we would discuss things together, but it was very distressing for Fern and without an advocate the process was confusing and very overwhelming.

Kieran told the court repeated requests were made for advocacy support for Fern for meetings with her solicitor, and to support her with the child protection processes. On the 8 June 2020 advocacy was granted, with the sum of £400 authorised for Fern to have an advocate with her when she accessed legal advice.

Frankly, this was far too little, far too late. It was clear to me that Fern simply didn’t understand what was happening or what was likely to happen next.

Kieran told the court of Fern’s wrongful EUPD (Emotionally Unstable Personality Disorder) diagnosis. He said although it had been corrected it was “continually repeated by health and social care professionals” during the processes. When Fern disputed the diagnosis she was considered to lack insight, and he said she was completely misjudged.

Despite all the repeated calls for reasonable adjustments, from Fern, from Dominique, from Kieran, he told the court they continued to be routinely ignored.

The situation was dire.

He told the court that the studio flat Fern was allocated in late June was “a complete disaster” and in a state of disrepair. It had:

  • no gas
  • an electricity meter Fern had did not know how to use
  • no furniture
  • no carpets
  • no curtains and
  • no white goods.

It was also relatively far from her mother’s house, a journey requiring two fairly long bus journeys.

There was no support provided to help Fern move in, no visit in advance for Fern to know where she was moving to, and she spent the first night without any proper bed, with no electricity or heating, before we realised what was going on and helped her. Completely foreseeably Fern was unable to cope and this caused her further significant stress. I was very upset that there had been no support with transition to this flat, or even to signpost her to charities that could help with furniture.

Kieran told the court of tweets that Fern sent in early July that clearly showed that Fern considered her mental health problems were a direct result of having unmet disability support needs.

On the 8 July 2020 he sent a further email to Fern’s social worker, saying she wanted contact with her baby and did not clearly understand the process. He said that Fern required counselling and support through the process. Kieran said Fern’s advocate responded to his email saying:

I agree entirely. I think Fern has been abandoned in the cruellest possible manner. The case has dragged on far too long and this in itself has been an additional stress and will undoubtedly impact in some way in the long term.

Kieran told the court later that morning he received an extremely distraught phonecall from Fern telling him Buckinghamshire Council were putting her baby up for adoption. He said he tried his best to calm her down and made calls to her social worker to find out what was happening.

He told the court about the letter Max had received from his solicitor that morning stating Buckinghamshire Council had decided to seek adoption for their baby. He recalled what happened next and told the court that Fern did later that day.

Kieran composed himself again, before continuing to finish reading his statement.

At the time of Fern’s death, the State had taken her child away. Not as a result of any harm that had been caused to her baby, but because of professional anxiety over her ability to cope as a parent, without ever having given her a chance to prove herself or any attempt to support that mother and baby relationship as a family unit … at no point did professionals properly assess Fern’s care and support requirements … no single person, or seemingly anyone with seniority took the lead or coordinated care and support for Fern. Instead she had multiple different care coordinators, social workers and others involved. Professionals had repeatedly refused requests for reasonable adjustments and advocacy, both of which were clearly established legal duties, and which would have allowed Fern to understand and engage properly in both her own care planning and the family court process.

Kieran told the court that Fern was “tarnished with an inaccurate EUPD diagnosis” and that the Root Cause Analysis found none of the staff supporting Fern had any training in autism.

Fern then discovered that the council were looking to have her baby adopted, no reliable plan having been put in place to support Fern on the delivery of this crushing news, and Fern predictably lost all hope.

He told the court that he believed Fern [withheld] with the intention of ending her life. Kieran then outlined the steps he had taken after Fern’s death to ensure there was some scrutiny into what had happened.

I only learnt after Fern’s death, when we received the Root Cause Analysis report from Oxford Health, that two adult safeguarding alerts were raised regarding Fern in March and April. I had not known about these at the time.

Kieran pointed out that these were clearly opportunities for a full and proper assessment of Fern’s situation, of her care plans and support needs but nothing happened as a result of these alerts.

Again Fern was left to be pushed further into a dark place by those responsible to care for and support her.

Kieran’s statement closed with him telling the court that he misses Fern terribly and that he hoped the inquest into her death “fully and fearlessly investigates our belief that those responsible for supporting Fern in fact, through acts and omissions during Fern’s pregnancy and after the birth of her baby, caused Fern to end her life”.

Court then adjourned for a short break, before we returned to questions for Kieran from Sam Jacobs, his legal representative.

SJ: I’ve just a few topics. As we see in your statement and emails, one of the calls at the time you made, numerously, was for the provision of advocacy support?

KF: Yes

SJ: Is it right that came from your understanding of Fern and the need for advocacy, but also from reading case law, guidance and the like?

KF: Yes, absolutely

SJ: I’d like to take you to the guidance document you refer to in your statement, witness bundle p42 [it’s here if you’re interested]

SJ: So we can see this is a document titled Good practice guidance on working with parents with a learning disability 2007. It’s the September 2016 update, date is on the bottom. Update of the Department of Health and Department of Education and Skills guidance.

As you described in your statement, Fern didn’t have a learning disability in the sense of a low IQ, but she did have impaired functional ability to absorb and process verbal information… all associated with her autism, is that right?

KF: Yes

SJ: So did you consider at the very least the principles of this guidance ought to apply?

KF: I’d been led to the guidance from other case law, quoted in major pieces of Family Court case law, talking about parents with disabilities. Broad gist of the judgements, and some extent guidance, was don’t get hung up on the diagnosis, but look at the function of disability. The way I viewed it Fern very clearly did have functional disabilities in way she could cope with parenting… I had written in my statement to the Family Court, of course we can’t go into it, I recognise that, mentioned in there my believe was focus was functional disability not the diagnosis.

SJ [missed]

SJ: Let’s look if we may, at a couple passages from the guidance. Page 43 in the bundle, bottom of the page of 2007 Good Practice Guidance sets out how child and adult services can, and should, work together to improve support for parents with a learning disability.

So just over the page it starts with 5 key features of good practice:

1) accessible information and communication, discussed that with Dominique this morning

2) coordinated referral, assessment processes and eligibility criteria

3) support designed to meet the needs of parents and children based on an assessment of their needs and strengths, again discussed assessment with Dominique this morning

4) long term support if necessary

5) access to independent advocacy

So we can see that access to independent advocacy is put at the outset as one of the factors of good practice?

KF: Yes, case law talked about it, it’s a golden thread throughout case law, being parenting with support and the provision of these 5 key things

SJ: If we turn onto page 69 middle of the page, Access to independent advocacy and to support for self-advocacy, paragraph 1.5.2 Advocacy and self-advocacy should be made available to help parents access and engage with services. There’s a reference to the Care Act imposing a duty on local authorities to provide an independent advocate … the Equality Act 2010 imposes a duty on local authorities to make reasonable adjustments … the Human Rights Act 1998 entitles a parent to participate fully in the process, this includes the stages prior to any formal legal proceedings being initiated.

Just pausing there, the touchstone seems to be what is important is that the parent is able to participate fully in the process?

KF: Yes

SJ: That’s the touchstone and we can see also prior to care proceedings being initiated.

KF: Yes I think the point I started stamping my feet about advocacy was when we got to the point of Section 20. It should have been provided already, but before Section 20 was the PLO process, understood importance of that being the kicking in of legal processes, that’s when I started stamping my feet saying she needs advocacy.

SJ: Yes if we look over the page, paragraph 1.5.3 Independent advocacy should always be provided where children are the subject of a child protection plan and/or care proceedings are instituted so that the parents can participate fully and effectively in the proceedings, as is their legal right. Any parent involved in a child protection conference and/or care proceedings should be informed about local and national sources of independent advocacy. It is particularly important that parents with learning disabilities have access to independent advocacy in these situation … It is very important that parents have access to independent advocacy at an early stage and also that advocates have appropriate skills and knowledge of both learning disability and child protection issues.

We see, don’t we, the reference to advocacy at an early stage

KF: Yes

SJ: If we turn onto page 73, Ensuring equitable treatment for parents with learning disabilities. Similar point is made, parent whose children subject to Section 47 enquiries should always be given information about independent sources of advice and advocacy, both locally and nationally. It will be important that every effort is made to ensure that independent advocates are those who have the necessary skills and expertise concerning both learning disability and child protection.

So, would it be fair to say when you were frequently asking for advocacy, it was both that you felt as a matter of practice Fern needed it, but also seems to be required as clear as day by the relevant guidance?

KF: Yes, both the guidance and case law, which for myself was hugely frustrating, at one point was the comment I was challenging, or people found it difficult to converse with me, I was only asking you to do what the case law or guidance says you are supposed to be doing.

The frustration came out of sitting there saying, look it’s in the guidance, it’s in the case law, why isn’t this happening?

SJ: Finally on guidance, with slightly different focus, the guidance describes what an advocate does, if we look at page 98.

Heading, parents with learning disabilities value both advocacy services and those which support self-advocacy. Advocates are particularly valued by parents with learning disabilities in helping them to address the environmental disadvantages they experience, such as inadequate housing; making information and communication accessible; and to develop self-esteem and self-confidence.

In your statement you refer both to successful communication, but also Fern’s self-esteem and self-confidence?

KF: Yes

SJ: Then it says the following roles were provided by advocates, a witness to parents’ dealings with officials and practitioners, a buffer by fielding or deflecting matters that might exacerbate stress, a voice to ensure parents voices were heard… interpreter putting information into language parents would understand, a listener… a scribe… a problem solver helping families think things through, a fixer sorting out problems of service delivery and it carries on.

KF: Yes

SJ: Does that appear to you to be the sport of attributes Fern needed as she went through the Child Protection processes?

KF: It does, borne out by her own comments, the way she described it being a complete revelation when she received independent advocacy

Its someone who is independent, as a father I can’t be truly independent… that’s why is so important the advocacy comes from someone who isn’t one of the parents. I remember one comment came out at some point, in council memo, or somewhere along the lines of well they’ve got legal representation, but given the way I saw Fern engaging with her solicitor, it was that interpretation role, that was so important. Fern wasn’t able to process it and wasn’t able to engage properly with her solicitor or barrister at the first hearing… there wasn’t that go between helping her understand what was going on.

SJ: You refer to Fern herself describing the very short period of advocacy she did have as a revelation. Other expressions Fern made about the absence of advocacy, if we look at page 125, a letter that Fern sent in the wake of her baby going into foster care pursuant to Section 20 initially.

She says reason “I felt I had no option… overwhelming pressure placed on me by [lists] extremely negative impact on my health and ability to cope. She is sharing the impact on her, bottom of the page, again Fern’s words, announcement of pre-proceedings without any support or any advocacy has once again ramped up my anxiety… cant help feeling social services are trying to wind me up until I break under the pressure…. I simply feel unable to keep looking after the baby at this point as so stressed and anxious anything I do can be used against me and there is no plan providing support. It continues”.

Did you feel what Fern was expressing there was yet further evidence that advocacy was desperately needed?

KF: Let me explain that day. The day that baby went into care. I’d been in Wales at an Access Reform Advisory Meeting, with my boss Duncan, who is an ex solicitor…. Fern phoned me in absolutely distraught state saying I’ve got no choice, I remember asking his advice in the car, he’s a very good friend, we talked about what was going on. I said to Fern if you let them in, you’ll never get your baby back, but she was desperate for help, desperate to keep her baby and at that time she saw no way out other than asking for her baby to go into Section 20 care.

Nobody was around her at that time, giving her impartial advice, that’s what she needed. That’s why she needed an advocate, she needed impartial advice and support and to understand what was going on, and the consequences of those decisions, and to understand what people were saying to her. On that phone call with broken communication, driving through from Builth Wells, it was hell, I could tell she was going through hell.

SJ: She’s expressing going through those incredibly difficult experiences of whether she consents to her baby going into foster care, all without advocacy, she felt helpless?

KF: Yes absolutely

SJ: Ok, in your statement you’ve read out you describe various occasions on which you raised concern about a number of matters… I’ll not take you to them… is it fair to say the key concerns which you raised on a number of occasions included failure generally to make reasonable adjustments, whether not being assessment, not focusing the number of professionals involved and so on, lack of advocacy, and lack of exploration of that specialist placement for Fern and her baby?

KF: That, and as I said before, what felt like a complete failure to understand core principle of parenting with support. In case law it says parents with disabilities can be good parents, but they need support, it’s imperative on social services, and society, to give those parents that support. What I was watching happening was they’re not trying to deliver that vision of parenting with support, all those other things flowed out of that. They weren’t looking at how they could support Fern to be a mother. When her baby went into care I feel they completely abandoned any focus on how they could reunite.

Sam asked a question, I missed it.

KF: Yes, and she wasn’t given a chance from day one.

SJ: Did you ever feel was a meaningful attempt by the authority to grapple with the concerns you were raising?

KF: It felt like, either the buck would be passed, that’s not our responsibility, that’s someone else’s responsibility, someone else has to do that assessment. When you had them on a point and said you haven’t done this, they went silent and wouldn’t respond to that point.

When you had them, on the case law or guidance, they went quiet and wouldn’t reply to that.

SJ: Those are the questions I had.

There were no questions for Fern’s father, Kieran, from any other counsel.

Coroner: Just one question, p2xx Bottom of the 4th paragraph where Fern describes the whole thing as a self-fulfilling prophecy on 29 January, her baby taken and never being returned. Is that what you saw at that stage, far from helping situation to point where she might be with her baby and be with Max it was the opposite?

KF: I absolutely do, and I think it was actively making the situation worse, rather than looking at how we could solve it. There didn’t seem to be any plan. No one had any idea. That’s what it felt like, it didn’t feel like there was any plan, how are we going to bring this back in the right direction. Dominque and Fern both described as a runaway train, every time you asked for guidance or tried to have reasonable conversation…. It just felt like no one was listening, right throughout the whole process, no one was listening to what Fern wanted, or what Fern needed, or had any vision of how to deliver the support Fern needed.

Coroner: We’ve heard from your very candid evidence, and from Dominique’s evidence, about difficulties Fern would have in understanding things verbally. She could process differently things in writing, given time to think, could respond in very intelligent and coherent way. You know her, I don’t, was she someone for whom a plan would help, and for whom a lack of plan was very problematic?

KF: Yes uncertainty, a lack of plan was very problematic. I’ll give you an example, Fern had two phones, her own phone for her family and one she gave to professionals, so she’d know and wouldn’t answer if she wasn’t in a position to process it. They constantly phoned her with things, she couldn’t process that workload through verbal calls. Phonecalls asking questions, all they needed to do was communicate and give her time to respond.

For me as an autistic person, I sit and read cases and judgements and those things, that’s how I went to guidance, that’s my frame of reference. My keystone is going back to a written document that said this is how things should be.

Fern was similar in that way, she processed detailed information very well, but without that certainty she [couldn’t hear].

C: Thank you, that’s very helpful.

The coroner thanked Kieran for coming to court and giving his evidence. He wishes him well, although he says he will also wish him well at the end of the inquest.

There was then a short discussion about timetabling and a reminder not to report the name of Fern and Max’s child, or her method of death.


That will be all my reporting for Fern’s inquest for the next while, I am hoping to return the week after next for the coroner’s summing up and conclusion. With thanks to everyone funding, commenting and sharing my reporting. I couldn’t do it without you.

5 comments on “Fern Foster Inquest – Kieran Foster”

Sarah Spoor says:

Reading this has made me cry as I often do reading George’s reporting.
This time however the story is closer to home.
I’m also extremely extremely angry.
The story has so many overlaps to my own. I have two disabled children , & in 12yrs of interaction with social services (I refuse to call it social care as there is zero care) , I have received no help. The first yr help was requested, none was given despite it being assessed as required. So a yr later I was suicidal because I was so exhausted from caring 24/7 with zero help.
Even when re-referral was done, nothing but utter chaos was rained upon me.
Not only were social workers incompetent at levels that would cause normal companies to dismiss them on the spot, but over the yrs the “senior managers” I’m talking here of directors have steadily become more & more vindictive & blatant in their targeted attacks, & refusal to provide any help or Advocacy.
I even took them to court last year re failure to provide advocacy.
Following entering suicide respite in 2016(which I had to find myself). Not one social worker bothered to check whether my brother who had to fly from Scotland to care for my boys was indeed capable or coping. He had never cared for them before. The didn’t phone or visit during that 5 days.
No support was provided after I returned home. In fact they expected that I attend ELEVEN meetings in 5 days without any advocacy & got all pissy when I said I didn’t think I could cope with that.
NO HELP resulted from those 11 meetings.
This has absolutely nothing to do with lack of social workers or indeed really money ( because they are happy to throw money at appointing barristers against me in small claims court).
They are just poorly educated, incapable of following the law or even bothered to try to.
They are managed by vindictive, quite frankly corrupt directors who need to be sent direct to jail & to not pass go.

David Protheroe Beynon says:

This is a terrible tragedy. Raise the subject of the Suicide Act 1961

Julie Doughty says:

hi George
Having read this, I don’t understand why Fern didn’t have legal advice. The LA should have told her she was eligible for legal aid if they were starting the PLO process. I can’t see any mention of her having a solicitor.

Kieran Foster (Ferns Dad) says:

Julie. This is part of the long story.

The PLO letter was never delivered. Section 20 was undertaken without legal advice (The guardian and ISW both questioned the legality of this, and the issue would have, undoubtedly, come up if it had gone to final hearing…) and in the end, papers were served on Thursday for a court hearing on Monday morning, seeking an interim care order on Monday morning – with no substantive time to instruct solicitors or get proper legal advice (very rushed session on phone with solicitor on Friday and a brief meeting, in a corridor, with barrister outside court, no advocacy in place for either). So, frankly, a travesty of justice (again, all this would have been taken up at final hearing, but Fern died before we got there…)

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