I have already reported the coroner’s conclusion in Fern’s inquest here, but for completeness wanted to also write up his summing up (as far as I am able, it was fast).

Senior Coroner Crispin Butler started by thanking those who have assisted the court. He said that he would present his brief summary, which led to his decision on Article 2 engagement and his conclusion.

He said that evidence had been gathered through the investigation, for and during the inquest and since Fern’s tragic death on 8 July 2020.

The inquest is not concerned with blame, nor liability, nor the underlying motivational justifications for the actions Fern took.

He added that it could not, and should not, be an analysis of the Family Court decisions. However he said understanding the impact of that process, and Fern’s engagement with that process, was key.

This was the “culmination of a non-adversarial fact finding investigation” the coroner said, a form of summary justice. Inquests cannot address broader questions as to why the event happened, he said.

To the extent that particular circumstances had contributed, they should be reflected. The coroner said it was right to spend time to consider “the complexity of context within which Fern’s death arose”, to provide him assistance in determining what Fern probably intended on 8 July 2020.

The coroner told the court that an ancillary function of the inquest was learning, in a number of areas. He said there had been clear areas of learning identified in a number of areas.

The coroner said that Fern’s identity was never in doubt, and had been confirmed by her partner Max Newman, and by Thames Valley Police.

He said the court had heard evidence of Fern’s recent physical and mental health, of her diagnoses, evidence of her state of mind, points of crisis and potential triggers.

He said Fern had experienced difficult times in 2019 and 2020. Fern’s engagement with the local authority, Buckinghamshire’s, Children’s Services was in the context of Child Protection proceedings. The local authority were also involved with Fern in terms of housing, and procurement of independent advocacy.

Underpinning all of this, is an attempt to shine a light on the impact that Fern’s diagnosis of autism spectrum disorder had on her means of processing the complexities of her evolving situation, and the way it appeared to play a part in obstacles to [missed, sorry].

The coroner said that Fern had points of crisis, self-harm and suicidal thoughts. These were features seen for Fern at times of heightened anxiety and associated with her OCD and autism.

Significant positivity and stability was also seen… particularly in the latter part of 2019 when Fern discovered she was pregnant, and discovered a new purpose to her life.

The coroner said there was evidence that Fern had a caring and supportive family. He said they were key to understanding where Fern saw positive and negative in her life. The coroner also acknowledged he had heard Fern’s own words, through her discussions with her family and professionals. He described them as “well-reasoned, detailed and potentially prophetic written communications”.

The coroner said that Article 2 wouldn’t have made any significant difference to the matters considered in the scope of the inquest, nor to the evidence heard in court.

The coroner again wished press warnings and requested sensitivity of reporting facts. He advised that “reporting the fundamental mechanism [by which Fern came by her death] may do more harm than good in this case” [I have intentionally withheld any details about how Fern came by her death and will not report her medical cause of death publicly to preserve that position].

The coroner said that there were elements of the chronology that he’d paid particular attention to in 2019 and 2020, and that some overlap. Despite that he said no one person or agency had oversight of everything that was happening for Fern.

There was significant engagement between Fern, her family, healthcare professionals and different aspects of Local Authority Social Care, it is probably the case that no one individual or agency had a complete understanding of all the issues, emerging trigger events… and acute risks to Fern, particularly in 2020.

The coroner said that “issues did arise in multiagency communication processes”. He said “not withstanding Fern’s undoubted intelligence, her research and her understanding of her own needs” she had struggled to tease out the logic if the child protection processes.

He told the court that “everyone, Fern’s family, Fern herself, mental health professional, local authority professionals and others” knew that Fern had a significant history of mental health concerns.

Fern evolved her own expertise in her conditions and cooping mechanisms and whilst accepting, and looking to understand and work with, her diagnoses of autism and obsessive compulsive disorder. She did not accept a diagnosis of personality disorder.

The coroner said Dr Grant [one of the psychiatrist’s who reviewed Fern] agreed with Fern’s view. The coroner said it was “unfortunate this diagnosis crept back into the mental health records”.

The coroner said there was agreement that OCD and ASD with associated anxiety, were key features of Fern’s presentation.

He said early on the Children’s Social Worker after Fern discovered she was pregnant, Rohini Patkar, had knowledge of her conditions and vulnerability, which he said was clear.

The coroner said there were early opportunities in 2019, before Fern’s child was born, where she was “very stable and looking forward to motherhood”, to put in place “a structure to support Fern”. He said that would of course need to take the needs of the child as paramount.

He said this was acknowledged in the evidence of Rohini Patkar, Alison Munt [Head of Children’s Care Management at Buckinghamshire Children’s Services] and Richard Nash [Director of Children’s Services].

[This structure] could have included earlier consideration of independent advocacy, in my view it should have, and would not have comprised the duty of holding the needs of the child as paramount… possible might have enhanced the duty if Fern was in a better place to be a mother… inquest does not and should not speculate on whether that would have been the case.

With regards to her diagnoses, the coroner said whilst Dr Afghan acknowledged features of personality disorder “he did not himself make that diagnosis”. He said he had only had one, significant, meeting with Fern and whilst she could have been discussed at regular multidisciplinary team meetings and her Care Co-ordinator could have brought issues to Dr Afghan if needed, no-one did and there were very few records evidencing Fern was discussed again.

Ultimately, I do not find there was any issue about lack of knowledge about the appropriate diagnoses amongst professionals … the issues arising relate to individual decisions about how Fern’s needs could be addressed with reasonable adjustments, without compromising the child safeguarding aspects.

The coroner said that reasonable adjustments were required to be made to enable Fern to engage in professional’s processes.

With regards features with Fern’s engagement with services, formal meetings, multiple appointments, face to face engagement, the numbers of meetings, scheduling, timing and location were all real and ongoing issues for Fern… reasonable adjustments to reflect her needs was required, the absence of that or falling short of that, would mean that compromised Fern’s ability to engage… with healthcare or those involved in Child Protection and housing process.

He said the absence of reasonable adjustments would “generate negative obstacles to progress within the process”. He gave the example of how Eve Fletcher’s approach was “well considered and structured” and reflected Fern’s requests [Eve was Fern’s Care Co-ordinator from November 2019 to March 2020], whereas Zoe Wilkinson [Fern’s Care Co-ordinator from March to June 2020] took a different approach, with regular telephone contact.

The coroner said there was some rationale behind both approaches and “it would be too simple to make a direct correlation between those methods alone and the different levels of risk as to how Fern presented”.

The coroner said that “although Fern said herself she was set up to fail, it’s more complex than that”. He said he was not indication that there would have been a different outcome in relation to the child that Fern and Max had, he made no judgement about that.

It is a fact, however, that the Child Protection process had met a critical point by July 2020.

The coroner said that the way Fern found out, and her ability to process that news is “a fundamental aspect of explaining how Fern came by her death”.

That event arose from a single decision in the process which should not have been undertaken in the way it was.

The coroner said there had been clear progress for Fern from 2019 and 2020, and that was significant in all the mental health evidence.

Real positivity, Fern was looking forward to becoming a mother, self-harm and suicidal thoughts stopped … at that time I really do get the sense of positive transformation …. importance of her family, and her relationship with Max … significantly enhanced by Fern’s pregnancy and where Fern saw that leading.

The coroner said that Fern’s pregnancy had become the central stabilising feature of her life in August 2019, and that there was clear potential that protective feature would not last [if her child was removed from her care].

Probably became the central stabilising feature of Fern’s life in August 2019 … when all of this started to become uncertain for Fern, particularly in early 2020, was clear potential for this protective feature to diminish or be extinguished.

The coroner said that Fern was researching child protection processes to try and understand and when she concluded that her child would need to be protected from her, that was a trigger for her.

The Child Protection process was complex. This is why Fern really needed help at a much earlier stage, and on regular and consistent basis from an independent advocate.

This needed to be someone who Fern could place her trust, who could help her process the child protection process and who could assist Fern in articulating her views in a positive way.

Critical to such involvement … assist and support with understanding of, and reaction to, bad news. Always possibility of bad news… Fern’s bewilderment and engagement with the process increased in 2020… planning for that should have been engaged much earlier. Mr Nash acknowledged weeks, if not months, earlier.

As early as 29 January 2020, the day after Fern felt she had to sign the Section 20 agreement for her baby, Fern identified in detail in writing all key issues affecting, and that would continue to affect her engagement with the child protection process… the love Fern felt for her child, outweighed by all the problems with the process.

The coroner said that Fern’s one rare positive engagement with independent advocacy she had described as “a revelation”. The coroner said that Fern had said the “whole thing was becoming a self-fulfilling prophecy”. The coroner said that Fern’s mother, looking after her child in January “heightened their concern” [Children’s Services] and he said that if Fern had had more support with advocacy, post birth, in her mother’s home, in the context of the child protection processes, “she may have been in a better place to understand”.

The coroner also acknowledged the “protective factor of Max”, although he said that was impacted by his living arrangements at the time.

The coroner said he made “no criticism of the fact the child being left in the care of the maternal grandmother had [to be] taken into account”, although he added that it was another example where advocacy for Fern, might have helped her to better understand the context of how her actions would be perceived in the context of Child Protection proceedings.

The coroner then moved on to discuss Fern’s deteriorating mental health. On 8 March 2020 a referral was made about Fern took an overdose. PIRLS [Psychiatric In-reach Liaison Service] identified that Fern had the intention to end her life.

She thought she was not good enough to be a mother.

11 March 2020, Fern “expressed the view it was better for her child to grow up without her”. The coroner added that the Health Visitor was also concerned about Fern’s intent and plans in mid March.

26 March 2020 Fern took another overdose. She said that she regretted receiving treatment the last time.

She felt a failure as a mother and could not remove her autism.

Fern was a voluntary inpatient at Warneford Hospital from 30 March to 7 April. She was immediately, on discharge, looking to see if therapy was available and, the coroner said, she was moving towards giving up on child protection proceedings.

She said amongst other things, that she would kill herself if the adoption proceeded. Seems to me a red flag … in my view, a contingent risk, rather than something immediate … communication of it … needed to be better.

The coroner said whether or not that had been communicated to colleagues by Ms Connors, a plan to give Fern the news that the adoption process was proceeding needed to be in place for 8 July.

That level of communication however, does not negate the requirement for a full and effective plan for the communication on 8 July … irrespective of whether it was flagged by Ms Connors.

The coroner said that Fern’s making the connection between her child being permanently removed and ending her life, should have been regarded as a trigger.

Since I found from evidence that Fern herself made direct connection between her child being removed permanently and her life ending, it must be regarded as a likely trigger moving forward, which would become acute if the point in the process arrived, which it did in July 2020.

He said that this was important when considering the evidence of Fern’s intention. He said neither overdose had been drawn to the attention of Dr Afghan [Fern’s psychiatrist] and that would have been reliant on the assessment of the PIRLS and inpatient teams and their decisions on discharge back to the Community Team.

The coroner said there did appear to be some period of improvement from the end of March into June. He said he did not find Dr Afghan’s limited involvement to be a significant factor. Fern was not an inpatient, she was not being treated for a long term psychotic illness and the State did not assume, and did not need to assume, responsibility for Fern’s care.

[The coroner then said something about the child protection processes and latterly housing, which I missed, apologies].

The coroner said that the stability of March 2020 was followed by the June 2020 “negatives about the court process traumatising her” which Fern described as a “runaway train”. The coroner said that she didn’t understand what had been happening or was expected of her.

By mid June 2020 “Fern was indicating the anticipation of the forthcoming court decision about her child may cause her mental state to deteriorate”. The coroner said that the evidence from Pamela Yates [the independent advocate] was “compelling” in terms of her knowledge of Fern.

Her experience with autism was valuable in assisting Fern, she was proactively trying to assist with additional support, enquiring about Bethlem … it is obvious Fern found her advocacy skills beneficial… her involvement was limited.

The coroner said that the use of Pamela Yates was an example of bringing in and funding appropriate advocacy, albeit the family were the ones who made an introduction, given their local knowledge, not the local authority.

The coroner said the involvement of Fern’s mother, whilst a support, would not be the same as independent advocacy.

Reinforced my view better, earlier decision making was required on this aspect.

The coroner said Rohini Patkar acknowledged the need for advocacy “although that did not happen for Fern at that early stage”.

Alison Munt, the coroner said “also acknowledged the benefit advocacy could have brought for Fern, but outlined issues of funding … and the role that Fern’s solicitor should plan”.

Mr Smith [Max’s child protection social worker] had outlined for the court his difficulties in trying to procure Legal Aid funding.

Mr Nash was not “aware in a general sense of any decision for advocacy being refused on the grounds of funding”.

Pamela Yates was only able to be involved when the Section 20 foster arrangement was initiated, the coroner said.

Seems to me that’s probably too little, and too late… Fern could have been in a better place in terms of understanding the process towards that point with advocacy at an earlier stage, and may be in a better place to demonstrate something in the process.

The coroner said it was “very clear” there was “significant positive benefit” for Fern from engaging with Pamela Yates, but Fern could not rely on Ms Yates support [due to the limitations of what she was commissioned to provide].

Could not be said to be a protective feature on which Fern could place any reliance, I make absolutely no criticism here of Ms Yates… Ms Yates services were not provided for the traumatic court hearing on 17 February.

The coroner said that Children’s Social Work handed over from Ms Jillani to Ms Connors. That Fern’s father had concerns about the handover and that it was clear from the evidence that it was difficult for Fern.

Looking back over events, it is no surprise to see Fern withdrawing from contact after the Section 20 arrangements were implemented… no surprise Fern formed the view forming a bond with her child through contact would be more difficult for her if they were not permanently reunited…

The coroner said that the fact Fern was not with her child, and could not engage with contact were “further obstacles for support for her”.

He said Dr Elkin’s evidence was that Fern and her family had researched and requested the consideration of a mother and baby unit. The coroner said Bethlem Hospital at the time had 11 psychiatric beds for mother and baby care “although we don’t have evidence of the day to day availability” and Dr Elkin and Dr Afghan’s evidence was that Fern was not receiving treatment for a long term psychiatric illness.

The coroner said that the other possible option included mother and baby foster placement. He mentioned the way this was recorded as being described to Fern, and Fern felt that she would be “being watched and judged”.

In any event, Fern and her child were not together and contact was not sufficient for this … the longer this went on for, the more this became impossible … so another obstacle in the path to motherhood.

The coroner said that the court had no evidence about the availability of mother and baby foster placements.

No evidence it assists with the logistics, practicalities and suitability to Fern’s needs and those of the child.

The coroner said Mr Nash was of the view that Fern would not have been suitable for various options.

Although there could have been better consideration of these options and better communication with Fern about what was, or was not, possible, I do not feel this ultimately contributed to Fern’s death.

The coroner said that Kieran, Fern’s father, had made the insightful observation to Ruth House [Fern’s health visitor] that Fern’s disability was acting as a barrier to contact.

Fern’s father raised … his insightful observation to Ruth House that Fern’s disability was causing so much anxiety, it was now a barrier to contact with child, is I think, on balance, correct.

The coroner then discussed Fern’s accommodation needs. He said it was clear that the move from the earlier short term accommodation to the intended new accommodation “where Fern sadly also died, was likely to be seriously unhelpful to Fern”.

He said Ms Traynor [the Housing Officer] acknowledged that, and said that the property was not acceptable on day one. The coroner said that the property was “also unlikely to address her needs for proximity to her mother and Max… important aspects of her support network”.

The coroner said it did not seem to him that the property would have suited in the medium term. He said discussion of that occupied a “good proportion of the professional meeting on 8 July”.

It is unclear whether this was the main reason it was called … at least three of the participants laid claim to having called it. In any event, it came too late.

The coroner said he did not find that the difficulties and lack of suitability of Fern’s last accommodation met the threshold to be considered as causative to her death.

I do think the most significant feature supportive of Fern’s intentions must be how Fern found out what she would have perceived to be bad news.

The coroner said key individuals “did not appear aware of the previous specific indication of suicidal intentions connected with the loss of her child”. He said Max’s solicitor struggled to remember if he was aware of the specific suicidal risk expressed by Fern.

The coroner said there had been “no immediate advance warning to mental health professionals this communication was happening”. He said that the focus of the interagency contact at that time, if anything, was the inappropriate accommodation Fern had been placed in. He said there was mention that the Care Act Assessment still had not taken place in July 2020, although he could make no finding on whether an assessment would have made any difference.

The plan was either imprecise, or misunderstood, certainly not confirmed in writing following the meeting of 8 June 2020.

Adam Smith did not recall any discussion about this case meeting, had not recorded it in his notes … he said if plan had existed he would have likely have remembered it, and followed it.

I favour the recollection of Mr Smith.

Also accept although he was aware of Fern’s vulnerabilities and issues at previous points in the court process, he had no way of knowing in informing Mr Newman … would lead to the short chain of events which tragically unfolded on 8 July 2020.

At times of this disclosure Fern’s solicitor was not going to be acting for her going forward so had not taken steps to inform Fern of the news.

If there had been a clear communication plan for Fern it would have identified this issue before any action was taken.

Ms Connors recollection of the plan, I do not find compelling evidence being understood in any way by Mr Smith, was to ensure bad news was shared simultaneously to Max and Fern, in circumstances where it could be understood and processed.

The coroner said that Mr Nash did not know the detail of the plan, but trusted one was put in place. Mr Nash and Ms Connors both agreed that it should have been in writing.

In the absence of any plan … the local authority email of 7 July makes no reference to the plan, or any plan, meant entirely the opposite in terms of safeguarding was achieved … significant example of a decision that should not have been implemented in this way.

The coroner said when Max found out, he “entirely understandably” discussed it with Fern. Fern spoke to Ruth House on the phone.

Ruth House struggled to understand what communication to Max and was not aware this was about to happen. In my view there was nothing Ms House was able to do.

At the time Fern found out, she was in new unfamiliar surroundings, and was not proximate to family.

The coroner then quoted Fern’s words, from a tweet she had sent on 5 July 2020, at which time, he said, she did not know about the correspondence Max was to receive three days later.

The one thing I dislike more than the lack of autism trained staff in my area is the unwillingness of services to be honest about this. Rather than accepting their lack of knowledge and asking for help, they blunder in like a bull in a China Shop and cause so much harm.

@ElyssaLeopard 5 July 2020

The coroner went on to discuss the events of 8 July 2020. [I’m not going to report this bit].

I do regard the events of 7/8 July to be representative of the overall mechanism of Fern’s death, intrinsically linked with explaining how Fern came by her death. We know sadly Fern did not survive … her death was verified at 15:20 on 8 July 2020, at her then accommodation.

The coroner said that the greatest period of stability and positivity for Fern and her future was during 2019, after she discovered she was pregnant “and before the child protection process took hold in 2020”.

The coroner said that Fern was a “thoughtful, intelligent and articulate person”. He said that she communicated in a well-reasoned way.

He said the manner in which she learnt about the next stage in the child protection process, without her support network present, “left Fern to rationalise the impact herself”.

She did speak to Ruth House, who was in an impossible position to try and work out what had happened.

Fern had a plan for this overall eventuality. She implemented that plan. Her plan succeeded.

In relation to Article 2, the coroner said he in no way wanted to stray into areas that might be perceived as a view on liability or blame, “nor in any way diminish the tragedy of the loss of Fern to her family, those close to her or those who knew and worked with her”. He said his decision was also “not intended to reduce the contribution particular decisions had”.

He said he favoured the view of Oxford Health, South Central Ambulance Service and Buckinghamshire Children’s Services.

He said it was very clear to him that there was a “significant multiagency structure in place” including Buckinghamshire NHS Trust and Oxford Health NHS Foundation Trust.

He said there was “clear evidence of many interactions with those services” and “was clear within agencies there was a significant understanding of Fern’s vulnerability, diagnoses and needs”.

He said he made no judgement as to blame or negligence. He said it was clear when any particular events arose as result of an act or an omission of a particular individual, that did not demonstrate to him systemic failure. He also said that even if there were multiple issues, that did not necessarily indicate a failure of the system.

In terms of the operational duty, Fern was not a detained patient and he said he had no compelling evidence that the State should have resumed responsibility for Fern, during the period considered.

I regard Fern as having a chronic, continuing risk of suicide. Crisis points arose, for example in March. Where Fern’s risk could be said to be acute, assessment and treatment was provided.

Presence of a number of crisis points does not represent a real and immediate risk going forward, the situation fluctuates.

The coroner said that he did not think the healthcare professionals could have known, or ought to have known the real and immediate risk to Fern when the bad news was communicated.

He said what could be understood, on Ms Connor’s evidence, was it was understood that a situation like the one they faced, needed an immediate plan in place.

The coroner said there was no plan implemented, but that did not mean that Article 2 was engaged, in line with Maguire.

He said that he gave no indication that the method of communication was, or was not, negligent. He said the other relevant factor, which he regarded in a similar manner, was advocacy.

For these reasons I do not find any arguable case at the end of the evidence process, that Article 2 is engaged on a systemic or operational basis.

The coroner said that he had considered factors that had more than minimally contributed to the circumstances of Fern’s death, and to underpinning of her intentions.

Firstly, the fact Fern did not have access to independent advocacy from a much earlier point back in 2019, and then on a regular, consistent and continuous basis, not just for specific meetings but for challenging aspects of the child protection process … is the single largest reasonable adjustment for Fern’s needs which was not addressed.

There were other adjustments made … but this adjustment was arguably more important than the sum total of the other support.

It set the landscape for how Fern was going to cope. Must be a relevant factor in the events that followed, and in the events of 8 July 2020.

Independent advocacy to assist with the communication of bad news was not there.

The manner in which Fern found out about the news was a key trigger for her to act as she did, it must form part of the mechanics of Fern’s death.

The coroner said that it was incumbent on him to be detailed in Section 3 of the record of inquest. He said the inquest would culminate in a short form conclusion and a brief narrative, consistent with the Chief Coroner’s Guidance 17.

He then read the record of inquest, which I’ve already reported here.

The coroner concluded by expressing his thanks and best wishes to Fern’s family, to Max, and to those who knew and worked with Fern. He asked them to look after themselves as they moved forward.

He thanked counsel and witnesses for assisting the evidence. Mr Jacobs took the opportunity to thank the coroner on behalf of the family, and then Ms Anderson requested permission to address the family, and offered condolences on behalf of all counsel to the family, and commended them for the dignity they had shown in engaging with the inquest.

The coroner again wished everyone well, and asked people to take care.

[That’s all from me on Fern’s inquest, although I’ve offered her family the chance to talk with me and/or write something once they’ve had a chance to decompress and process what has happened over the last three weeks. Thank you to everyone who has been following, sharing, commenting [I’m going to go through comments at the weekend and publish them] and funding my reporting. I would not be able to report without your support, if you wish and can afford to support my reporting financially you can contact me for details of how to support monthly or you can contribute here].