The morning of Day 10 of Fern Foster’s inquest was mostly given over to hearing the evidence of Richard Nash, the Service Director for Children’s Social Care at Buckinghamshire Council.

The coroner asked him to move to the witness table and after he took an oath set the scene for those in court.

“IPs will appreciate and understand … I reiterate no individual or organisation is on trial at this inquest, every witness giving evidence is trying to assist me factually in terms of what happened to Fern and in some cases what’s been learnt from what happened to Fern. That’s the context in which we hear from you today”.

The coroner said that he had two statements from Mr Nash, the first detailing who he is and what his role was in relation to Fern’s care. The coroner thought it would help the court to hear that statement. He invited Richard Nash to read his statement to the court and “where things had moved forward” or he had come to a different view as a result of the coronial investigation, to comment on that.

Richard Nash told the court that he was the Service Director for Children’s Social Care for Buckinghamshire Council. He qualified as a Social Worker at Buckinghamshire College of Higher Education in 1992 and he is a registered member of Social Work England. He told the court he’d practiced as a social worker since 1992 with a number of different employers including three London boroughs and latterly he was an inspector with Ofsted.

In his role as Service Director for Children’s Social Care, which he took up in April 2018, he reports to the Corporate Director of Children’s Services. He told the court that he is responsible for all children’s social work teams in Buckinghamshire.

“Our job ensures services to vulnerable children who meet thresholds in the Children’s Act are robust and effective”.

He said that his statement was prepared from his knowledge and a review of the case files. Richard Nash told the court that he was not directly involved in the case work regarding Fern and her baby, but he was involved in approving the care plan for the baby. He said that he was involved in making best interests decision for the baby, based on the evidence in the child protection proceedings.

He told the court he had conducted a “detailed review of Children’s Services records” and that he had seen Susan Jillani [the baby’s first social worker] and Stacey McKenzie [whose maiden name is Connors, I’m telling you that because it was used interchangeably throughout his evidence. She was the baby’s social worker in the court team] give their evidence to the court, and he confirmed that was a “true reflection of the work undertaken by Buckinghamshire Children’s Services”.

Richard told the court that Children’s Services received a referral on 25 July 2019. The referral had been made by the hospital, as they were concerned that Fern had taken an overdose. He told the court at that stage the unborn child was 18 weeks old. [I believe this was the hospital admission where Fern found out that she was pregnant, she was not aware before taking the overdose]. He said that Fern had been known to the department herself as a child, due to her mental ill-health.

He said in light of the “identified concerns” safeguarding processes were started for the unborn child, who was placed on a Child Protection Plan. He told the court as part of Section 47 enquiries, the social worker Jane Murdoch from the High Wycombe Team, contacted all relevant individuals “with knowledge of the child and family”. [The child is Fern’s unborn baby].

He said that the ICPC [the Initial Child Protection Conference] was rescheduled to allow for reasonable adjustments to be made, on the basis of a recommendation from Fern’s mental health and autism advocate.

“As part of the preparation for the Child Protection Conference, an assessment completed by Ms Murdoch identified some positives but ultimately recommended due to the risk… the unborn child should be placed on a child protection plan”.

He said that the conference was explained to Fern before it took place by the social worker, and the conference chair, however she felt unable to attend but made input by way of written submissions. He also told the court that Fern’s mother, Dominique Jowett, and an advocate from the National Autistic Society, Ian King, were also in attendance.

He told the court that the outcome of that meeting was that “all professionals except Ms Shah, the adult mental health care co-ordinator, felt that a Child Protection Plan was required to protect the unborn child”.

Consequently Fern and her unborn baby were transferred to a new social worker, Ms Jillani, on 4 November 2019. He said that unfortunately due to a communication breakdown Ms Jillani had not been aware of a core group meeting taking place on 7 (?) November 2019, but, he said she went to meet the family the same day. He told the court that there were core group meetings, held at Dominique’s home, on 7 November 2019, 4 December, 8 January 2020 and 11 February. He also told the court about further meetings, a pre-birth discharge meeting on 28 November 2019, a family group conference, a discharge planning meeting on 6 January following the baby’s birth. He said that a planned review just before the baby was born was cancelled, but there was a review conference in January and a review in February.

He said that review did not take place in Fern’s preferred venue because it was “only flagged 10 days before and the venue was not available”. He said due to the nature of the timescales being statutory set by law, they could not be rescheduled.

He then told the court that there were concerns in relation to the baby and that Fern appeared to “struggle with her mental health”.

“Unfortunately Ms Foster felt unable to cope and left the baby in her mother’s care”

Richard Nash, reading his statement, then went on to tell the court about the PLO [Public Law Outline] process. He said this was a “pre proceedings process where the local authority were sufficiently concerned about the need for care proceedings”. He said Fern’s family objected as she had not had access to independent advocacy, a meeting was scheduled for 4 February 2020 and “arrangements began to ensure an advocate would be in place for this meeting”.

“Baby X became looked after by Buckinghamshire Council on 28 January 2020, as Ms Foster said she was struggling with her mental health and was not coping”.

He said that at that stage they had to issue care proceedings straight away and an application was made, an interim care order was granted.

He outlined the processes and said proceedings took place at Milton Keynes, that the local authority had requested a non-urgent listing to ensure papers could be served properly on Ms Foster and Mr Newman.

He told the coroner that the court directed Buckinghamshire Council to serve both parties by the end of the day, 13 February and the court hearing was set for Monday 17 February at 10am. He said that they were unable to source advocacy as there was none available and they were unable to delay serving the papers.

Mr Nash said that they were under the direction of the judge and therefore the local authority’s final evidence was filed and served, as directed on 7 July 2020. He said that they were also directed to issue a new placement application by 8 July 2020.

He said that he was aware, “given the parent’s vulnerabilities” that arrangements were made to send these papers to their legal representatives.

“Sir, I’ve heard evidence on that matter and understand where this court has got to in relation to that”.

[This comment relates to evidence heard while I’ve been away from court. From what I’ve pieced together, one of the social workers told the court that there was a safety plan in place to ensure such decisions were not relayed by post to Fern and Max, and that the plan was that decisions would be communicated to them via their legal representatives. Max’s solicitor, Mr Smith, was called to give evidence and he told the court he had no memory of any such plan being put in place. This comes up again later, but that is roughly what that refers to].

Richard Nash then told the court about the changes in social workers allocated to Fern and her baby.

“Three social workers, from three different teams, in a relatively short period of involvement”.

He said that changes occur as the child moves through the processes in the local authority. His statement said that Buckinghamshire were about to embark on a service change to reduce the number of changes, but he told the coroner that took place on the 2 April, so is past tense now.

“It won’t eradicate this problem completely but has been undertaken to reduce the social worker changes for children … I recognise our processes at the time meant the family experienced changes … I would like to sincerely apologise for any additional stress this put on Ms Foster, and the family under”.

He told the court that now more complex cases such as these would be identified at an earlier stage. He said he was also aware that concerns were raised around the frequency of social worker visits and the impact that had on Fern.

He said that they had awareness “from the start of their involvement that this was an issue”. He said it was recorded that the social worker liaised with mental health around visits, “so as not to distress the mother”. He said visits were arranged in advance, at approximately two weekly intervals.

He told the court that the expectation was that a child in care was visited every 10 working days, and that was subject to review by Ofsted, their regulators. He said the paramount principle of the Children’s Act “has to be reflected in the work of child services”.

He said he had “carefully reviewed” the concerns of the family that escalation into care proceedings weren’t warranted at the time. He told the court “delay was not appropriate” and that the PLO process introduced additional safeguards such as free legal advice from a lawyer.

“The decision to issue care proceedings was made following Ms Foster leaving her child in her mother’s care. Again, I do consider this was the correct and proportionate response given the deterioration in Ms Foster’s mental health … and she was no longer able to care for her child … The Family Court agreed that was necessary and proportionate.

I do accept the whole process was very difficult for Ms Foster to manage and additional time would have been advantageous for her… but our priority was the child”.

He said that it was key that adults were supported withint the child centred process, but he said there was not provision under Section 47 of care proceedings for any different order.

He told the court that “attempts were made” to provide “proper and sufficient support” in light of Fern’s identified needs. He said the Social Work Team asked Fern what support she wanted and sought support from her family. He listed adjustments that he said had been made to their usual practice, including Fern being allowed to submit written comments, email being used “as per her request” and the attendance of an advocate.

He said that it was not in Fern’s baby’s best interests to have the PLO proceedings delayed “in this particular case”.

“Sir I would add to that I fully acknowledge more could have been done in line with the conversations that have taken place arounds an independent advocate”

He told the court that he was aware that the family felt a Mother and Baby Unit should have been found for Fern. He said “enquiries were made” and the “adult mental health team did not consider this suitable for Ms Foster’s needs”.

“I’m aware further enquiries were made with that hospital [Bethlem Royal] about the availability or not of local authorities paying for a bed. A local authority, I believe that to be Oxfordshire, have paid for a bed at that resource, that was not a resource open to ourselves… does not change my comment on that option”.

He said that the option was ruled out by the adult mental health team on the basis that Fern was unable to have contact with her baby.

He then moved on to tell the court about partnership working, saying “some working in partnership is more effective than others”, adding that “unfortunately, it was less effective with mental health services and housing”

He talked through changes since Buckinghamshire County Council ceased to exist, being replaced by Buckinghamshire Council, a new unitary authority. [I missed a chunk of this].

“This is without doubt a very sad and tragic case… child protection proceedings are always difficult and challenging for adults and parents involved in them…. Expectations, framework and actions of the local authority, child protection and care proceedings are heavily regulated… which is necessary as intervention of the State into family life is a matter of upmost importance and seriousness.

Actions for the local authority children’s services must be child focused and focus on the best interest of the child, not the best interest of the parents…. Timescales are largely non-negotiable”.

Richard Nash then told the court that they do also have a duty of care to parents. He said in this matter, particularly in the lead up to care proceedings “I do consider we met this duty of care”.

He said that throughout their work their duty of care was to Fern’s baby, who was their “client and primary responsibility” and that they discharge their responsibilities to the baby “as the law requires us to do”.

He said there are “always things that could have been better” and that “learning from this is always important” and his job was to ensure that they tracked those lessons.

He told the court that there was evidence of service improvement through visits by Ofsted. He said that the Ofsted website has a chronological list of inspection activity [you can find that here]. He said the last full inspection was in December 2021.

“Which was significant as the service was no longer judged inadequate for the first time since 2014”.

He said it was clear improvement had been made, and what was still to do. He said it takes time to make changes to a Children’s Services department after several years of poor practice.

He finished his statement by expressing that it was incredibly sad that Ms Foster ended her life, and by taking the opportunity on behalf of Buckinghamshire Children’s Services to express his condolences to Ms Foster’s family and friends.

He then read his second supplemental report to the court. The first matter addressed was an entry in the case notes on 25 February 2020 which he said sets out “based on the support implemented… it was agreed by senior managers an advocate was not required for Ms Foster at this time, this would be kept under review”.

He said the local authority decision making was that care proceedings on 13 February 2020 were due to “escalating concerns regarding both parents, and due to the fact the child is now Section 20 accommodated”.

Good practice, he said, was that it should now be overseen by the Family Court. He talked about the Children’s Act and the policy frameworks, stressing that the “welfare of the child is paramount” and delays were likely to prejudice matters.

“In practice the principle of putting the welfare of the child first means no other issues have equal status”

He said the local authority would “of course always wish to work in partnership with individuals, especially parents” but that this could not happen at the expense of the child. He told the court that the local authority has to find the best way “of supporting competing needs”.

“The Family Court agreed the actions of the local authority and issued care proceedings, and made subsequent decisions in line with the evidence presented to it”.

He told the court that a directions was made at a court hearing on 17 February that there needed to be a cognitive assessment of Fern, with regard to future use of a court intermediary.

He said consideration was given by the PLO Tracking Manager at the time about whether it was necessary, or proportionate, for the local authority to utilise an advocate.

He said they took into account Fern’s circumstances, how supported or isolated she was. He told the court that Fern had the benefit of her solicitor when proceedings commenced, which was provided free of charge.

With regards an intermediary he said Fern had the support offered by her family and by her legal representative and “an additional person was unlikely to help” and he said they would be likely to overwhelm Fern who said that she struggled with additional and new faces.

He told the court that having “carefully reviewed the decision” with the benefit of hindsight “it remains a rational and understandable decision made at the time”.

The coroner said that a number of additional documents had been provided as well and asked Mr Nash if there was anything that he wanted to comment on in terms of the documents.

He said that he would say a little about what they were to assist the court.

4.9.1.1 Child Protection Conference Information for Parents and Famliies

“It is what it says on the tin, information for parents at case conferences”

“4.9.1.6 is a very important document, pre-birth proceedings. This is a Buckinghamshire Safeguarding Children’s Board document, not a Children’s Services one … it is something that is in place, something Ofsted commented on its application, very positively in its [Joint Area Child Protection] inspection I’ve already referred to.

Appendices to that. High Risk Pre-Birth Flowchart is I think significant in this matter sir, and I think it demonstrates where we recognise the need to have the right social worker at the right point in time, which is the earliest point in time possible, so that there is consistency and so we can manage this very significant issue around advocacy and support for parents.

4.9.1.3 All Age Autism Strategy produced by my colleagues in Adult Services but as it says on the tin, all age autism strategy.

It’s a very important document allows the whole of council services to be as one for … autistic people and people we work with who are neurodiverse… reference to extensive training now have for all staff including induction when staff join Children’s Services.

Also a briefing on that strategy.

We have also provided at 4.9.1.7 a very important strategy guidance July 2018, Working together to safeguard children”

The coroner then had questions for Richard Nash.

C: Before I move on to some slightly broader questions … was it possible to identify the date of the decision for the Care Act Assessment we discussed yesterday, and how that was communicated to Oxford Health?

RN: I can’t find any evidence how it was communicated to Oxford Health.

My understanding is that was independent social worker assessment requested by the court, my understanding filed at court for the hearing in June we’ve referred to in these proceedings

C: The evidence we heard was it was something needed to be commissioned, Oxford Health to do that, you couldn’t identify when that assessment was required?

That’s correct sir, sharing with Oxford Health would require the local authority to get permission from the Court to do so… it’s court commissioned… I can’t see evidence of that being requested either

C: Right. Looking at broader sense, as Director of Children’s Social Care… what learnt from Fern’s death? I understand prioritisation of child in your service, but … what service learned around reasonable adjustments and support for a mother with autism, obsessive compulsive disorder and the anxiety that Fern had?

RN: I’ve referred in part to it, my analysis and that of the service, is the learning leads to information, how we go about making sure we assess all parents, but particularly vulnerable parents comprehensively, at the beginning, at the first time of asking.

That means if a similar scenario presented today, the pre-birth processes would mean a member of the Court Team would be the first allocation, so there wouldn’t be those changes of social worker.

The way we work now is informed by clear practice methodology, focused on making sure the individual needs of all relevant people, including parents but first and foremost the child… are exclusively clear in our documents.

In order to make sure that happens, not just words in a training event or communication I have with my staff, is incumbent on supervisors of social workers that that happens… audit… case reviews… that is happening in the right way.

The second part of the learning for me is not just about having assessment leading to a plan for the child, but when necessary a very clear and upfront plan for the adult or adults involved.

What would have greatly assisted in my view is a plan that set out what, how advocacy and independent advocacy would be approached. Is clear understanding across my service to think about advocacy, take into account and apply it. Some issues of consistency, we need a plan to apply it upfront.

Some complications come out in evidence, in circumstance where parent says very clearly they want family member act in that place… it’s difficult to impose an independent advocate on somebody who may not want it… key they know from that point opportunity exists and here it is in a written plan they could have.

Matters change around advocacy to an extent in terms of the legal arena and once someone is legally represented. It is important learning we proactively talk to parents legal representatives, and talk about advocacy in a proactive way and talk about their views.

Wouldn’t want to get into situation where advocate is then disputed by legal presentative… wouldn’t be helpful at all… key learning point around that indication at that point in time.

I think its also really important that we continue to the work already done in terms of the multi-agency work of Children’s Services… look at Safeguarding Partnership Board, effectiveness of the arrangements, particularly with adult mental health colleagues and children’s staff about joint understanding, or basic principles that cannot be changed. That notion of leaving a child with a parent because it’s helpful for the parent’s mental health irrespective of the risk of child, is not a legitimate position for any of our colleagues to take, contrary to Working Together, outside our statutory obligations.

Adults and children need be 100% confident won’t be repeated … Something for me about a proactive approach about what could be reasonably predicted in Fern’s case…. Her presentation in June 2019, when she discovered she was pregnant, and that overdose [withheld]

Her history was known to mental health colleagues would be its entirely predictable, given she’s pregnant, what that would that mean in terms of Child Protection processes, there would be much more pressure for her.

Its unfortunate we didn’t keep our adult mental health colleagues very closely involved in the process, and they didn’t keep us involved in their processes.

The coroner then asked Mr Nash if he had identified any further professional learning as a result of the area of evidence considered during this inquest.

C: Have your thought processes evolved as a result of what we’ve heard in this inquest?

RN: Yes sir I’ve already referred to one of them. The concept of that plan for that vulnerable adult that would describe what the offer is around independent advocacy and removing the mystery of it, seems to me having listened to the evidence, a further step we need to take in those circumstances.

Whilst its my job to make sure the services I’m responsible for are the best they can possibly be, and learning has to be continual, we have to be not shy of reflection and considering what could be better, would argue is essential … there has to be continual focus on that, I also have to be minded not to make big changes to a whole service on the dynamics of one, very important and significant case … balance to be struck there.

It was then over to Sam Jacobs, for questions on behalf of Fern’s family.

SJ: Could I begin perhaps just by a moment of clarity in case it is needed, you refer to the notion of leaving a child with a parent because it’s better for a parent’s mental health. That’s not something we’ve put to any witness, is that understood? It’s certainly not a notion advocated by my clients.

RN: I’m fairly confident I didn’t hear that from you

SJ: In relation to your witness evidence, do I understand correctly that your direct involvement with events at the time was as Agency Decision Maker and the decision around the plan for adoption?

RN: Correct

SJ: Did you have any direct involvement prior to that?

RN: No

SJ: So do I understand correctly that the witness statements you drafted, designed to assist the court, were drafted from having reviewed the records after the event?

RN: Yes

SJ: Would you acknowledge some of the evidence heard by this court puts a different complexion on certain matters that appear in the records?

RN: Yes

SJ: Do I also understand from your evidence that in fact … your own reflections as Director of Service have changed on hearing some of the evidence?

RN: They’ve developed further

SJ: One matter you indicate in your statement, is at the time of interactions with Fern and her baby, the service was rated inadequate by Ofsted. You make the observation several years of poor practice, as you put it, requires change that’s achieved gradually. I don’t need chapter and verse on what poor practices were, but can you give us a general sense of what led to that inadequate rating? … especially relavant to proceedings for Fern?

RN: Yes those Ofsted reports are published and are in the public domain, one can read them for oneselves. From memory, it’s not difficult to recall, they were very poor, wordy assessment evident in lots of places. Plans for children weren’t focused enough. The effectiveness of management oversight was weak. In some cases risk wasn’t recognised. That’s not comprehensive.

SJ: Of course. When you say risk wasn’t recognised, are you talking generally or risk to children, the main client as you put it, or also risk to parents?

RN: Risk to children

SJ: Um, in relation to advocacy. I just want to, you obviously already said very fairly been some acknowledgment things could be done differently around independent advocacy. I Just want to understand that in more detail.

We heard from Ms Patkar, Team Manager on Fern’s first interaction, and the Public Law Tracking Manager, that there ought to have been independent advocacy from the start of the process. Is that a reflection you agree with?

RN: Yes

SJ: We’ve also heard certainly from Ms Munt, more could have been done to support advocacy around the first court hearing, is that something you agree with?

RN: Yes the point I’m trying to make is the opportunity to get things right  is right at the beginning… there are a number of variables, never going to be case an independent advocate would be found and they’d act for that adult in every single interaction… why needs be in writing… what we’re looking for. Is of course the whole issue SAR referred to around commissioning of advocates, don’t have line of people employed by Buckinghamshire Council, have to go to number of organisations routinely go to… there’s more to do to satisfy ourselves around availability of advocates are there.

Possible could implement actions we take for improvements and have another case because there is not an advocate to be found… dramatic example, am sure reality might be delay in getting someone. More work to do around that commissioning, yes.

SJ: Will come back to commissioning in a moment if I may. In relation to support around the first hearing, I think you made the observation Ms Munt was making, actually needs to be earlier in the process. The good practice guidance we looked at on day one is crystal clear on that point. Advocacy, independent advocacy should be in place from the start of child protection processes if needed.

RN: [missed start] That guidance does primarily refer to adults with learning disabilities… a grey area to an extent… usually working with adults with learning disability who become parents, usually they’ll already have an advocate… that makes that whole piece around whose the advocate we need to commission, there’s usually one there and they’re appropriate to continue, and helpful because they continue afterwards… the needs of that adult will still be there. There’s something very critical about us as a service identifying those occasions, relatively uncommon, where situation such as Fern’s and not an advocate already working with that person.

SJ: Yeh, on the issue of the needing to be a clear plan. I’m going to ask you to look at one record so we can understand that, it’s the Children Services Case Notes. Page 994.

Email from Social Worker Stacey Connors on 4 March 2020, context of course, family generally and Mr Foster been asking for independent advocacy to be in place. Ms Connors writes, Good morning just wanted to send an email to discuss where we are in regards advocacy … hope now assessment completed an intermediary will be implemented… courts not agreed fund advocacy services, therefore any sessions required LA will have to request funding for… I’ve emailed my manager and will let you know when I hear back.  

We can see communication at that stage is perhaps some uncertainty around what happening in court proceedings, request for funding made to the Social Work Manager. Certainly for our reading of records the trail runs cold until the beginning of June where Ms Yates is commissioned for one meeting…. problematic, last correspondence is we’re going to ask for funding and then the trail runs dry. Do you agree with that?

RN: Yes

SJ: … is that where need for plan in place…?

RN: And the purpose, so the request for independent advocacy is the right request. Did you want me to comment on the funding piece as well?

We work in local government, its public money, is bureaucracy. Steps have to go through, not aware of any incident where we’ve said no… but there’s a process to go through and will be today and tomorrow and next week, a local authority process around finance and budget management.

SJ: Email says Ms Connors says I’ll request funding for meeting with guardian, then there wasn’t an advocate for that meeting, so implication seemed to be funding was refused

RN: I cant recall the detail of this… I’m aware of conversation around funding, and I’m being absolutely open that there’s a process we have to go through as a LA to do with financial regulations as much as anything else, who signs off and how’s it done… if I was budget holder would have to ask who, what, where, when and why, and is that a reasonable use of our funds… often will be have we got confirmation Legal Aid won’t pay for that… I would suggest because that’s a problem it isn’t automatic that the LA should pick up the tab for it.

SJ: I agree we’re probably not benefitted by significant debate about Legal Aid but we can see is tension between expectations that the local authority pay for it, local authority wanting Legal Aid to pay for it. Do you agree with the solicitor’s observation, can be a situation where people fall between services?

Richard Nash said he agreed with that, and that he regularly attends a meeting with the judiciary in Milton Keynes and he would take it to that liaison meeting.

RN: It’s not in my gift to nudge the local authority further about financial reach…. It’s less than straight forward

SJ: Yes, but ultimately your evidence, needs to be a clear plan and understanding amongst those involved whose providing it and in what circumstances

RN: If get it right at the beginning, that’s the most effective way of adding value to that whole process.

SJ: Ok, this clear view advocacy needs to be in place from the beginning and that’s the way forward, it’s not something indicated in any of your statements is it.

Not suggesting it’s a criticism, we want public authorities here listening with an open mind, but should we be concerned from the top of Children’s Services, there hasn’t been a clear understanding of the importance of independent advocacy?

RN: Over what period of time?

SJ: At the time of Fern’s interactions with the services through to the time of your statement?

RN: I think, there hasn’t been an absence of thinking around it, there is clearly more to do and the point you’ve just made, I’ve said something in addition, more detail here than in my statements, is really confirming what I said before, learning is continued, got to be open to this and listening to all those opportunities. So then as a service we need to apply it. We weren’t a service unaware of independent advocacy, or a service unaware of making reasonable adjustments. It could have been much better and I agree should have been much better in ways I’ve discussed. Because ones fixing more recently, over last couple of years put a lot of things in place, had they been in place at the end of 2019 would have been impactful, its continual learning.

To extent if I may, coming into Buckinghamshire around 2018 with my eyes open around Ofsted and outcomes, and needing to fix things. Easy thing is to write what needs fixing, skill is in saying doing a b c first… that prioritisation around wellbeing of children and young people, that’s our primary focus.

SJ: Can I go back to your evidence about commissioning … principle is one thing, practicality is another.

We heard evidence in this case Pamela Yates was identified by Fern’s family and their knowledge of services with expertise in autism. Has there been a specific piece of work done around commissioning of advocacy service, extent to which appropriately skilled advocates are available, generally and in respect of autism?

RN: That point talks to the Safeguarding Adults Review, at which I’m at a distance from, I’m not part of the Safeguarding Adults Board. That review not yet published in full, which is problematic in some ways. Buckinghamshire Council have centralised commissioning team, Safeguarding Board where need go back to to ensure… understand over last year some of that work has happened, but don’t have detail of that, or evidence of impact or change.

SJ: Might it be actually it’s a further piece of work required as part of this process of improvement you describe?

RN: Yes

Sam Jacobs then says he’ll move onto the issue of the communication of the local authority final care plan to Max and Fern. He points out that obviously this is where Richard Nash did have some involvement and he suggests that they look at the letter sent to them.

The pro forma letter was sent to Max and Fern, separately but identical dated 7 July. It’s read to the court.

SJ: Would it be fair to say the letter is not written with comfort or reassurance in mind?

RN: Yes

SJ: Is that in your view a problem, or is it simply that that support doesn’t come from this agency decision maker or needs to come from elsewhere?

RN: Yes, and it would already be in place

SJ: Ok, when you signed this letter you would have by that stage read all the reports from the care proceedings is that right?

RN: Yes

SJ: Were there discussions between you and Ms Connors, the Social Worker, as to the support that might be required to safeguard Max and Fern?

RN: I had a discussion with Mr Albert, who had a managerial position, I don’t think he was Stacey’s direct line manager, think may be one removed. Wasn’t in the case notes, from my memory. I remember distinctly, I initiated that conversation and I asked how this information was going to be communicated effectively to both parents, given what I had read about their background.

Again I recall, was Mr Albert assured me there was a plan, and he spoke about the legal representatives of both parents sharing information simultaneously and doing it in a way that support would be provided.

My recall is fairly close to what I head Ms McKenzie and Ms Connors say in evidence in this hearing

SJ: Um, had you and others within Buckinghamshire Council understood that this letter is dated 7 July 2020. Fern took her own life on 8 July 2020. That presumably had, the potential link had been drawn, had it?

RN: At the time of this letter?

SJ: Subsequent to Fern’s death and before this inquest?

RN: Yes

SJ: Was it appreciated how this communication took place was potentially an important issue in understanding the circumstances of Fern’s death?

RN: My understanding from that situation, and subsequent ones immediately after Fern’s death and in preparation for this hearing, was fairly held view in my service, and with Stacey that we did have a plan, but clearly heard evidence is not a record of that, and I heard Mr Smith’s evidence as well. The learning for me…

SJ: Sorry before we come onto learning. Why is this detailed plan not mentioned in either of your detailed statements, or the detailed statement of Ms McKenzie?

RN: Sorry, why I didn’t put what I just said to you in my statement? Because it’s a conversation that wasn’t on the case file. I can’t talk to Ms Connors or Ms McKenzie’s statement

SJ: It’s not on the case file, but if it happened it’s still obviously relevant isn’t it?

RN: Yeh, I guess that’s for others to decide, but I understand the point you’re making.

SJ: We’ve seen the email from Ms Connors to the legal department, it refers to Ms Connors wondering if the plan can be sent to the parent’s solicitors so they can be shared. That correspondence obviously didn’t convey any plan at all did it?

RN: Is it possible to go to that email I’d like to read for myself

SJ: Yes… I may have misplaced it

There was then some searching for the email in the bundles. Two emails are then read to the court [I didn’t catch them, sorry].

SJ: Firstly, that clearly doesn’t state any plan does it, other than needs to be shared with parents. Perhaps obvious, but do you see that as a problem?

RN: Yes, it talks about vulnerabilities but doesn’t go further

SJ: For completeness, we can see over the page, you see the email from xxx of 5:55 same day 7 July to the solicitors [reads]

RN: Yes

SJ: ‘I also attach the administrator’s decision letters and would be grateful if you could provide them to your clients also’. And again, there’s clearly no plan.

What’s the learning out of these events, apparently being a detailed plan, which hasn’t been written down anywhere, hasn’t been communicated in writing?

RN: Two things I’d like to say, first being I made reference earlier to the quality of and effectiveness of multiagency work … effectiveness of adult mental health colleagues and children’s services to work together, the point of time we’re talking of now, it was completely predictable from potentially before the child was born we’d be into these sorts of difficulties if matters progressed in the way they might given the risks. That wasn’t a mystery in my view, for all agencies, there’s something about proactive and effective joint working rather than passive involvement of my colleagues in adult mental health.

The support for Fern on receipt of that information, she had to receive that information some way or another, had to be immediate after she got that her wellbeing was assessed… wouldn’t be anyone in my service being directly involved with Fern or her partner, right agency is clearly those with expertise and knowledge around that.

Missed opportunity to get that teed up, lined up months before this potentially, certainly weeks.

I think as I understand it Ms Connors attempts to engage with adult mental health services were not successful, and I also am of the view that her recording of this wasn’t of the required standard given the importance, that is quite clear, but the problems were already in existence before this point of time.

Where was the care coordinator and what discussion was had with them about being potentially present in the solicitors office or immediately afterwards, so she could comfort her or her return to the community could be safe?

It is twofold, Ms Munt and I have had conversations about the recording issue, immediately before this hearing and as a result of this hearing.

SJ: Who, um, clearly there’s a communication breakdown, you’ve described this is one incident of broader need to have better coordination between children’s services and adult mental health services. Who drives that forward? In particular have in mind some questions we had in court yesterday about how care coordinators obviously have burden of responsibility to coordinate, but children’s services in practical terms were the ones driving the process in relation to care proceedings side of things. How practically is a better system created and implemented?

RN: I’ll try get my response in order. The Safeguarding Partnership Board, of which is an Independent Chair, same person for adults and children, has executive that meets. The agreed, on a national basis, 2004 Children’s Act, puts that duty on there being a Safeguarding Partnership, or equivalent in every local authority area, their primary reason for existing is effectiveness of multiagency working and holding partners to account… they are a force for good in terms of improvement and working forward.

Have been a number of steps forward in terms of how Children’s Services work with our colleagues in Oxford Health over past couple years, primarily around service Oxford Health provides for CAMHS… well documented increase in number of children and young people who present with description/diagnosis of being neurodiverse, having additional needs and harming themselves.

That has required us to work together effectively and have those difficult conversations … I’m aware there have been similar learning conversations with Adult Social Care and part of Oxford Health that does adult mental health … more to do … still think there is more to do and this inquest has reinforced that notion.

SJ: On that working together between Children’s Services and adult mental health… Dr Elkin, Perinatal Psychiatrist… seemed to express frustration with her service inviting social services to meetings, so there’s shared knowledge and understanding, but social service not attending, so there’s a difficulty there. Is that something you’re familiar with?

RN: No its not, and not sure I agree with that assertion around this particular matter. I don’t want to go back over it. That’s not my sense and not what I see when I do case audit reports and look at pieces of work myself. Is more sophisticated than that about having right level of understanding around what Working Together means… any joint working has to be understood and built upon what are shared things, what have in common and shared goals… in any case where significant risk to life, and self harm, in adult who has child taken by Children’s Services, the relationship has to be equal, not led by one or the other… needs to come from the top, needs to come from the Safeguarding Partnership Board, but doesn’t exclude people like myself from those conversations

SJ: OK. On the issue of recording, you described concern with recording, that the plan wasn’t recorded. A great many of Stacey Connors notes were entered on the 9 July, she described the process of having her own note system and after Fern’s death she realised those notes should be on the system. Even entries of discussion February 2020 were entered on the 9 July 2020. Is that concerning practice from your perspective?

RN: Not necessarily, the devil is in the detail… she’d have known as a result of what happened the file would be electronically closed shortly afterwards, I saw what she did as her being helpful to get on the file. … It is primarily the child’s file and the style of recording we often, frequently, as standard adopt now, we write our case notes to the child, as though we were talking to them directly. Also has to have business of legal matters that aren’t strictly for that child, important part of the record, it isn’t a case every word in every conversation is recorded in case file, has to be judgement made by the social worker as to what is appropriate.

I don’t think is case that case file had huge gaps in it, I understand what Ms Connors did was put more in, people will need to know about X or Y. If I stop clock on any open case in my service, if I asked is anything else to put in, will always be extra.

Sam said that it was unlikely to be causative so he wouldn’t pursue it but he invited Richard Nash to review the records again and reflect on the sheer number that related to 9 July.

The coroner agreed with that suggestion, raising this potential vulnerability that had occurred to him if something were to happen to the person who doesn’t routinely update. He, the Coroner, then discussed the issue of the evidence he’d heard about whether a plan existed.

C: Second stage, where if there had been a written plan but was included on her notes and wasn’t on there, there was a second chance to appear in records, and it never did. In my mind that reconfirmed the position was never any written record of a plan. As I sit here today… did find Mr Smith’s [Max’s child protection solicitor] evidence quite compelling, his experience in this area, the fact he could not recall any single point of what would have been a complex plan. I do find that troubling, and it does need revisited, I’m very likely to find I favour his evidence over Ms McKenzie’s in regard to the plan.

RN: Can I respond to that, is that appropriate?

C: Yes

RN: Two things, point you make about Ms McKenzie’s recording is already part of what we’ll talk to her about when we’re able to. Second point about that plan is it would have been obvious to anyone involved in that case about the risk, and how hearing that news was going to be difficult, whilst we have to take responsibility for our part in that, my thoughts when I heard that evidence, and now, is a number of people could have stepped forward and say what are we going to do.

C: Yes. And I have an account of evidence Mr Smith gave of how he would communicate with his client in a simple and clear matter, he understood the vulnerabilities of Max and the issues Fern had had. And Fern had acted as advocate, small a, in the process in support of Max. He wasn’t someone acting in a knowledge vacuum at all. I found his evidence very, very helpful, he was able to say more than I thought he might … he explained why he did what he did with Max, and I take that into account.

SJ: On others stepping forward, we had evidence from Ruth House if she’d known an adoption plan had been communicated she’d have gone to Fern’s property. Ms McKenzie described she intentionally hadn’t told the professional network because she was so worried about the consequences and she didn’t want Fern or Max to be told inadvertently.

Do you recognise its very difficult for others in the network to step forward, if they’re intentionally not being told what’s happening by Children’s Services?

RN: If they had no knowledge of any of it… Ms McKenzie had rationale, she said why, I go back to the point everyone involved in this matter had enough information to know.

Sam then went on to ask Richard Nash about coproduction of changes to the service in Buckinghamshire. He gave examples of how they had “utilised the experience and expertise of people with lived experience”. He also went on to say “We have members of staff who describe themselves as neurodiverse” and that people had kindly and helpfully contributed to “all sorts of activities, whether coproduction of a process or a training session”.

Sam asked a follow up question and Richard Nash talked about his approach to training and contributions from people with lived experience.

SJ: Sticking with some of the changes implemented, we heard certain cases now go directly to the Court Team, to enable continuity of social worker and professionals involved. We’ve also heard how Fern as an autistic person could become very focused and fixed on terms like child protection. We can see how if her first interaction was ‘hello, I’m with the Court Team’, that could be problematic.

RN: Yes its part of the training everyone has to do … how someone who describes themselves as neurodiverse is likely to interpret information… that training also makes it very clear that the term neurodiverse or ASD is a hugely broad term and within that there’s a whole range of individual positions if you like. Anyone who presents to our service is going to talk about that label, or that label comes with them, whether or not they’ve experienced trauma in their life is all very relevant. Is understanding one has to apply the core principles of any training but still have to take responsibility for assessment to understand where that person sits…

SJ: Just on a basic level, what is the Court Team called?

RN: It is called the Court Team. There’s all sorts of acronyms.

SJ: Is that the external name of the team?

RN: Yes

SJ: That concerns the family, so an email contacting the next Fern is likely to be signed off by the Court Team

RN: Yes … raises an important point, the word is not neurodiverse friendly, as court team is one small cog in the whole wheel… Children and Families Court will still have that name, if we make that change I think that’s fine, I think the impact will be very small because the rest of the world won’t do it

SJ: Do you think it’s possible you’re underplaying the importance of it?

RN: Possibly. I’m happy to seek advice from those we coproduce with.

C: Have to say on this point, when I heard this, Ms Munt referred to streamline process, your precise question occurred to me as well. One interpretation is we’re going straight to that process, and it says court all over it, concern if someone sees in black and white terms, might escalate crisis rather than what seeking… labelled as the outcome already predetermined because it’s got the word court in it, obviously is what prompted your question, so if we both thought that, and the family thought that, something needs addressed. Principle is very sound but the label might be a misdirection for someone with neurodiverse issues in interpreting them, point very well made, occurred to a number of us in here.

SJ: Those are my questions, thank you sir.

Court was then adjourned for a 10 minute break, on return Sam had two additional points, one was about autism expertise in supporting parents, with support. Richard Nash talked about the all age autism strategy and training. Sam’s final point was to ask whether Buckinghamshire Children’s Services would be open to working with Fern’s family as three family members with lived experience. Mr Nash’s response was “yes absolutely”. The coroner added his encouragement to that, and also encouraged Mr Nash to engage with Pamela Yates [Fern’s advocate] who he said had clear expertise and willingness.

Questions then moved to Freddy Powell, who asks questions on behalf of Max Newman, Fern’s partner.

FP: I’d like to ask initially about this plan you’ve referred to about how to communicate information to the parents, Fern and Mr Newman, am going to ask you about that, significant point in terms of record keeping and communication moving forward. My note is you spoke, reviewed documents, spoke to Mr Albert who you say is line manager of Ms McKenzie’s line manager, you asked him how information was going to be communicated to both parents given what you’d read and your clear recall is Mr Albert assured you there was a plan. Is that correct?

RN: Yes

FP: Firstly, why were you asking Mr Albert if there was a plan in place?

RN: The information I was required to look at, read and consider as agency decision maker made it really clear was likely to be vulnerabilities, and impact of sharing that information.

FP: When did that conversation take place?

RN: I can’t recall specifically, as I said I hadn’t written that conversation down, just wanted to check. My best guess would be 4 weeks of date of the letter, possibly few weeks before that

FP: Couple weeks before that would be before the Ground Rules Hearing of 8 June when that plan was supposedly being communicated. Do you mean it took place before the Ground Rules Hearing or after?

RN: I can’t be clear, would have been prompted by information I had to read as agency decision maker. That gives a loose timescale, whether that then

GP: On 8 June, the evidence from Ms McKenzie, if this is correct, was agency decision maker at that point hadn’t made their decision. Does that mean you hadn’t had any involvement at that point, or you’d reviewed the file but hadn’t signed off with your final decision?

RN: Difficult for me to answer, there’s probably not a record of when I made that decision, we could potentially narrow it down but here and now would be guess and speculation on my part.

FP: Is the way it works you review documents, provide informal indication to Ms McKenzie, subsequent firm that up? Or is it situation you look at documents and make a decision, there and then?

RN: It’s the second one primarily, more often than not

FP: So what exactly were you told by Mr Albert, your colleague, about the details of this plan?

RN: I think I’ve already said, to repeat, I asked him how are we going to manage this, I was thinking about the safety of Fern, not necessarily your client Mr Newman, my recall is he told me we’ve talked about it, we’ve got a plan with the solicitors, words to that effect

FP: If you, did you understand for example this was a multi stage plan, whereby would be simultaneous meetings between both Fern and Mr Newman’s solicitors, then plan put in place wraparound support? Did you understand the plan to that extent?

RN: No

FP: Am I right you didn’t ask to see the plan, or any record of it?

RN: No

FP: Did you think on reflection you should have asked to see that plan?

RN: I’ve thought about that a lot, in terms of my job role and need to trust people to do their jobs at various stages, probably not, but I wish I had on this occasion

FP: When did you realise this plan, you say you were told about was not in fact recorded on the case file? Is that something you realised before Fern’s death?

RN: I think the full realisation of it was in these proceedings

FP: You were asked about the plan, told yes there’s a plan in place. You didn’t ask any follow up questions?

RN: I wanted to know that it had been thought about and it had been considered, and the team were ‘on it’ in inverted commas, and I received at that time, in my judgement, sufficient confirmation they were. I didn’t need to know the detail, it’s not my job to do that, in context of 3.5 to 4 thousand children and young people open to the service at any time … if was requirement for me to sign off on those plans I’d see them all, but there wasn’t and there isn’t, I wouldn’t see them now.

FP: You were agency decision maker, had oversight of process, knew the risks and vulnerabilities, knew needed to be plan, you signed off on what you realised was a very significant decision. Do you think its sufficient to be told is a plan and not ask any questions, given the level of risk and inevitable complexity in any …

RN: I saw information, a number of other professional people from a variety of other agencies, that was my reaction to it, I needed to check, that checking could have been done by a variety of people. I’ve given my evidence on oath which is important to me, that’s what I recall doing and that’s what I did.

My analysis now, knowing what I know now, is of course I wish I did something different, but doing something different isn’t commensurate with my role in the service.

FP: Your evidence is knowing what you knew at the time, level of risk, need for plan and complexity of arrangement, you didn’t think it was necessary to ask, is it written down, can I look at it?

RN: Correct

FP: If there was a multi-stage plan, as the evidence of Ms McKenzie, it should have been recorded somewhere shouldn’t it?

RN: Yes

FP: No evidence was plan… strong evidence to the contrary from what Mr Smith has said… no evidence from social services before this inquest…. Suggest wasn’t in fact a plan and unfortunately you were misled.

RN: That’s a conclusion one can draw, it’s not the conclusion I’ve drawn.

FP: What conclusion do you draw?

RN: My conclusion is based on my knowledge of the people involved, both Mr Albert and Ms McKenzie, I’m still of the view that was the intent. I absolutely do not believe the plan was a figment of someone’s imagination. I say that because I have evidence of them working in very competent and trustful ways in numerous cases. Haven’t had that concern ever about Mr Albert, for example.

FP: If there was a plan, in terms of this process, when social services discovered what had happened to Fern, someone would have said hang on, would be some record of reflection of how this plan went so wrong. It just seems that issues really needs to be flagged?

RN: The learning comes well before that, this is how multiagency partners work with something that was so obvious in some sense, and predictable, not predictable in the detail but in the risk. That’s where the learning lies, that’s where would be ownership of this risk. Is still my view that ownership needs to be across the board. If I saw documents I had access to, others have access to, why did I want to know what the plan was but no one else did? I think that’s important.

In the days after Fern’s death the understanding we had as the service was Mr Smith had made an error.

C: Perhaps I can interject here for the benefit of Mr Powell and Mr Nash. There are certain situations in an inquest where I sometimes don’t have to favour evidence over another where there’s conflict, these are one of the situations where I do, is a fundamental part of how Fern came by her death. It seems very clear to me, made in asking Ms McKenzie and others, that Children’s Services had control of the information. Loss of control happens when it’s communicated to someone else, in this case, instruction to legal team and they send out on the 7^th, quite late on the 7^th, to the various solicitors. Loss of control happens at that point. In terms of recollection between Ms McKenzie and Mr Smith, nobody is suggesting to me, and no one suggested in questions, I may have intervened anyway, that either of them was lying. The point is one of them was mistaken. In relation to the evidence I favour what Mr Smith said about the recollection of being no detailed plan discussed, and is no other evidence other than Ms McKenzie saying she did.

Interesting to me you said in response to earlier question that was the intention, yes I do believe that was her intention, but when I weigh up the evidence I can’t ever see Mr Smith saw was intention, so I favour his.

If you’d asked to see a written plan we know you wouldn’t have seen one, because the evidence supports on balance, there wasn’t a written plan, and Ms McKenzie never followed up on that.

Does that help you move on Mr Powell?

FP: It does, just one issues sir in relation to PFD duties. What I’m trying to understand is if as Mr Nash is suggesting, Social Services discovered Mr Smith had made an error, what was done to progress that and it seems that issue was just left until this inquest. That’s a matter for you sir, I’ll not ask any more questions about that.

Freddy then went on to ask questions about Fern’s request for a mother and baby placement.

Richard Nash said he was 100% confident there was an understanding amongst his staff of what the placements were for and how they could benefit people.

“100% absolutely confident there is. In general terms, move away from specific, if as LA we think mother and baby unit is appropriate to risk and way forward, we can make enquiries with mother and baby unit and supply them with information with their permission, and seek to secure one. We may be successful, we may not be. We can also choose not to do that, if we don’t think that’s appropriate care plan at that time, and that will be tested in court. There are circumstances where court will direct us to source… might be we go back in week and say we’ve contact 132 and there are no places… or may be we’ve contacted placement and agreed to take for 18 weeks and starts a week on Tuesday”.

Freddy then asks about the timeliness of making those enquiries.

FP: In terms of my questions about the timeliness in which those enquiries should be made. Do you agree it’s not sensible or appropriate, to wait to make those enquiries until care proceedings have been initiated?

RN: It depends on the circumstances

FP: Of course it depends on the circumstances, but the mere fact, it’s not right is it to suggest the sole responsibility for making those enquiries rests with the care proceedings team. Is that fair

RN: It depends on the circumstances, the devil will be in the detail, with some circumstances it doesn’t fit with others

Freddy probed further and there was more discussion similar to above. He then suggested by the time the discussions were happening in April/May it was already too late for Fern because the suggestion was made that she’d been separated from her baby for too long. Mr Nash said that a mother and baby unit was an intense environment where a baby might be harmed.

RN: I understand what you say, what you’re describing is the social work task of balancing risks to children and rights to parents.

Primary carer, in this case Fern, is described as having autistic meltdowns, and finding it difficult to care for her baby. Mother and baby unit might result in situation where baby is harmed… not saying would have… is appropriate for us to make those decision and judgement, we’re accountable for them… more possible you to ask questions, but if you’re asking my professional opinion on those circumstances, I don’t think its incorrect.

FP: The social worker who made decision not to explore placement, Ms Jillani, didn’t say she didn’t explore due to the risk to the child. She said, her explanation was this wasn’t a matter for my team… person who saw Fern in January, who explored what placement looked like, wasn’t saying Fern couldn’t cope there, the baby wouldn’t be safe. What do you say to that?

RN: I heard Ms Jillani’s evidence, the sequencing isn’t quite right, she couldn’t search for mother and baby unit, her manager would have to sign that off. It doesn’t sit with her alone… I haven’t got detail in front of me as to what her supervision was, I know that’s what she said, I’m just saying how we operate and what that should look like.

Even with that, the mother and baby unit wouldn’t have been something I supported for the reasons I outlined.

FP: Even if Ms Jillani thought it was appropriate, Fern was asking for placement, you’d say it’s not on the table, it’s not even worth exploring, that’s your evidence?

RN: I’m not sure that’s what everyone was saying, but that is my evidence yes

Freddy then took him to a record where there was a report of discussion about options, and what Fern had been told about mother and baby foster placements.

After Freddy, it was over to Amina Graham, who asks questions for Oxford Health.

AG: First one relates to the plan, not going into detail, heard the Coroner’s comments, discreet point, you were here when Ms Connors gave evidence, I asked similar question of her. You heard what learned coroner said, Children’s Services hold information in respect of care proceedings, correct?

RN: Yes

AG: You said a few times, other services had a role to play. Of course other services had a role to play not an issue there, in respect of the plan which doesn’t appear to be in any way formularised, its important isn’t it that other services were aware of that in order to support Fern? Isn’t it?

RN: Yes

AG: Can I ask about the Care Act, you gave evidence at the start of evidence, as we know there was an order by the Family Court for a care assessment to be undertaken, correct?

RN: Yes

AG: You said you couldn’t find any information that it was communicated to Oxford Health. You also said you couldn’t identify the information on the system that would have shown that information was shared, you said in order for information to be shared the local authority would need to set permission?

RN: Yes

AG: So the key point Mr Nash you’d accept there’s absolutely no evidence to show that information was ever communicated to Oxford Health?

RN: Oxford Health were aware of the information, for the involvement in Fern’s life

AG: Mr Nash, Oxford Health weren’t party to the Family Court proceedings were they?

RN: No [fuller answer missed]

AG: Oxford Health weren’t a party in care proceedings, an order was made in care proceedings and there is no evidence that that was relayed to Oxford Health?

RN: I agree

There were no questions from counsel for the South Central Ambulance Service, for Thames Valley Air Ambulance, or for Buckinghamshire Adult Social Care. Finally it was over to Ms Hodes, Mr Nash’s legal counsel in these proceedings.

AH: Mr Nash just on that last point about the Care Act assessment, we had evidence of the last care coordinator to give evidence to this court that in that professional’s meeting, albeit very late in the day, in fact too late in the day in the point of the view of July, she did say she was going to do the care act assessment did she not?

RN: Yes

AH: So in terms of your understanding who would do it, that was where that responsibility was, at that time?

RN: Yes

AH: In that professional’s meeting

RN: Yes

AH: In relation to other matters that you’ve given long evidence to the learned coroner, you had I understand had the chance to reflect, both before this inquest and importantly during the inquest. Possibly today, having given evidence, you’ve been asked about various matters that you’ve said you would look at again, that you would revisit, you’d think about. Is there anything particular that has come out this morning, that you feel would be useful for you to take back?

RN: In addition to those I’ve already said, I think the commentary around some of the detail from emails from court team, and certainly the offer from the family in terms of coproduction.

When one has the opportunity to do this level of reflection, learning and analysis, it’s always helpful to think how can we take that forward, how can we do better next time. I think the wider piece for me is around working with the Safeguarding Board, Children and Adults, making sure high level of confidence multiagency work is stronger and dynamic, in way I’ve talked about. More work to be done around the commissioning of independent advocacy, is something that should be part of the routine business of the Safeguarding Partnership Board, will make that suggestion to them, will be up to them whether they agree.

AH: The matters you’ve told the learned coroner about are in some ways new learnings, the children’s transformation strategies. This court is concerned about what happened to Fern, so looking through that prism, are you able to say to this court you would take back any particular matters, not just if you like in the high level of agency work, but in terms of the on the ground sensitivities, you may think this case has realised?

RN: Yeh I think there’s something for me about sharing that detail and making sure that’s reflected in our training programmes we have. There’s an extensive array of those relevant to autism spectrum disorder. They have to be continually reviewed, am keen just because we have training doesn’t guarantee has impact. Something about marrying up… to ensure as many of the things that could have been better are delivered in practice.

Other part is impact of our quality assurance processes in Children’s Services and that the Safeguarding Partnership Boards adopt.

There was a fuller answer, missed, sorry. Although Mr Nash did end with this:

“The service is only as good as its last piece of work, and where there are several thousand pieces of work one has to pay attention to ways I can satisfy myself that that is good enough, and better”.

Then Ms Hodes had further questions.

AH: Is an example, the example given by my learned friend Mr Jacobs, reflects what the learned coroner has said. Something as example as changing the name, or the trajectory, making it more streamlined for someone coming into the service, would indeed have detrimental effect by simply not looking at the naming of parts.

RN: Absolutely, two parts … also about how sensitively we communicate with ASD about the process … there’ll be a solicitor, or a health communication that might have the same impact, key to this is talking that through and understanding what might happen next to this person and being more practice about it.

If one looks at this case, because there were changes of social worker and the service was fragmented at the time, wasn’t long enough view about something that was fairly predictable… doesn’t guarantee engagement but more likely lead to positive outcomes about that.

AH: So communication is key, looking at that and reflecting back of what more could be done, its communication in every respect isn’t it? To the person coming into your service, using the service, prime person would be baby X, but then parents, and communication overall to multi-agencies, to beyond that?

RN: Yes completely, but that communication and the quality of that communication has to be built on sound comprehensive service assessments that have the levels of triangulation and cross checking in them which are sound about individual needs of all the participants … assessments have to lead to plans, plans for children are a part of what we do, there’s a degree of confidence about that. This particular example tells me we also need plans for parents… communication piece we have to get right based on careful thought.

Often its communication… its what’s coming next, if you don’t describe to someone who feels vulnerable and having this significant process imposed on them to protect the child, what happens next is an important part of that.

AH: Finally is there anything else you’ve had time to think through that will assist the coroner?

RN: My fear is I’ll remember something as soon as I leave this building, no thank you

There was then a follow up question from Sam Jacobs. He asked Mr Nash if the lack of a written plan was a matter of professional practice, or should there be a policy clarified, or written about it. Richard Nash said that he couldn’t adapt processes on the back of one case, he would have to be convinced they would reoccur.

RN: My conclusion is it’s about getting it right first time, and in the beginning, so plan and communication about it across partnership is highly likely to be there. That’s the first and more important thing to do.

In all honesty I have an open mind about a policy… if I overload my 360 social workers with policy after policy after policy it becomes meaningless, that’s not to say best way forward … some audit work around prevalence, that will give me an answer around policy or not.

SJ: Clearly communication of bad news in proceedings may be a risk point, would it be the case that not infrequently there will be a need for shared safety plans for some sort with mental health services, with CAMHS or other agencies?

RN: The notion of safety plans is very prominent across my service, for children and adults. Sadly significant increase in self harming and people taking their own life post covid, not a surprise to anyone who reads the news, is a national thing. Practice of having safety plans in place for adult parents and assisting children with knowing their parent made an attempt on their life and what to do next, so safety plans are frequently part of our service, they’re a necessary part.

You’re asking me about safety plans for sharing outcomes of child proceedings I’m aware that has happened, when questions of adults ability to stay safe. Let’s audit what we do and work out again whether there’s something that needs to happen. I’m really clear I’ve got to make my judgements, they’re part of my remit to make.

SJ: Thank you

C: Think that’s a fair observation, we all understand overburden of policy at expense of actual actions, and we all understand situation can arise on only one occasion… that’s what we have here. You have to strike that balance because there probably couldn’t be a more difficult outcome to a plan, from Ms McKenzie’s evidence saying this was not how it was supposed to happen, they’re can’t be a more difficult outcome than what we’ve been considering throughout this inquest. Balance understand that, this is case that demonstrates worse possible outcomes.

I think that probably then is the evidence we need from you. I’m grateful for you coming today, and attending number of days of inquest to assist your view on things… and for the indications you’ve made… particularly engagements with Fern’s own family, and Pamela Yates or someone like her, she probably works in a network.

I’ll give consideration and will give thoughts to the learning, and indications of learning as result of discussions today.

Richard Nash was released. Court was adjourned for lunch. Then we were back at 3pm for legal arguments and submissions. I can’t report them until the case is over (and probably wont choose to anyhow).

We’re back in court tomorrow for more evidence in the morning and the coroner has indicated he intends to conclude tomorrow afternoon. I’ll report as soon as I can, but will also have a 4 hour drive home, so it might not be until Friday.

With thanks to everyone following Fern’s inquest, sharing, discussing, commenting [comments will go live once the inquest has finished], supporting and funding my reporting. Thank you.