Fern Foster Inquest – Narrative Conclusion

Fern Foster’s death was verified at around 15:20 on 8 July 2020 at her current accommodation. Fern had received news that day concerning the intended adoption of her child, in circumstances where professional support, including independent advocacy was not physically present at the time, to try to assist Fern with processing the information to safeguard her mental wellbeing, and to address her likely increased risk of suicide.

Fern had previously indicated her intention to end her life were her child to be adopted and had also taken two overdoses in March with likely intention of ending her life, although she received treatment and survived on both occasions.

Fern had procured a different substance at the end of March, when on 8 July 2020 she consumed some of the contents from the package in her possession she intended her death to result.


Since I found Fern undertook the act that ended her life, and she intended that outcome, will include short form suicide within my conclusion, technically regarded as narrative as follows:


To which the following contributed more than minimally

  1. Fern Foster did not have access to independent advocacy from an early stage in 2019 and thereafter on a regular, consistent and continuous basis, nor on the 8 July 2020 when she learned of significant news likely to trigger suicidal intention
  2. The manner in which Fern learned of the significant adverse news, in the absence of physical professional support, probably caused Fern to act as she did, at the time she did, with the intention of ending her life.

The coroner said in terms of learning from Fern’s death, there have been a number of areas we’ve been considering. He said he will raise a report to prevent future deaths in context categorisation response time/carrying antidote emergency services, and Interested Persons have a week to make submissions on other matters, which may or may not lead to further Prevention of Future Death Reports.

[I will write up this morning’s evidence on Prevention of Future Deaths from Oxford Health once I get home/tomorrow. Will also share a family statement in due course].

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