Three months ago the Senior Coroner for Buckinghamshire, Crispin Butler, concluded the inquest into the death of Fern Foster (almost concluded, at that point he was still to make a ruling on Prevention of Future Death matters**).

You can find links to read my introduction to Fern, my coverage of her inquest and the coroner’s summing up and conclusion here.

In this post I’m sharing the thoughts of Dominique Jowett, Fern’s mother, and her sister Rowan who I caught up with to ask their thoughts, a few weeks after the inquest had concluded. We had no agenda as such, I just wanted to know how they were doing, and gather any thoughts they had on the inquest process, or how they’re feeling now.

Dominique started by saying she was “really tired”. Fern’s inquest took place over the course of three weeks, and there was a lot of information introduced, some of which was new to the family. She then went on to explain that she did not feel that the inquest process had necessarily made any progress.

“I feel a little bit that I’m not really any further than I was at the beginning of the inquest, because Oxford Health, like they did from the beginning admitted the mistakes, it was clear it was basically… the resources weren’t there, no one knew where to find them etc etc. They were pretty consistent with everything they said from the beginning… makes sense in a way”.

There were 7 sets of Interested Persons at Fern’s inquest. Her family, her partner, Oxford Health (who were responsible for her mental health care), Buckinghamshire Adult Social Care (who were responsible for social care support for Fern), Buckinghamshire Children’s Social Services (who became involved once Fern was pregnant), and Thames Valley Air Ambulance and South Central Ambulance Service (who were involved on the day Fern died).

Dominique said that she was torn when it came to Buckinghamshire Children’s Services. She said that she was stuck between thinking it was a “massive conspiracy” and thinking that they are “just really incompetent”.

She said she felt guilt for trusting the staff from social services, and working alongside them. She described the conspiracy argument being that social care go after people who are vulnerable, without providing them with any support.

“I went through a period of beating myself up really, thinking how stupid I was to be honest with them, and work with them… I would now slam the door in their faces and tell them they need to get a warrant if they want to come in. I feel a bit stupid for that. Yeh, part of me feels a bit stupid”.

Dominique has clearly been replaying the events of the inquest, and of Fern’s life, in her mind. She says that she is still seeking to understand what happened. The other explanation, or potential scenario Dominique offers for what happened, is incompetence.

“The other angle is whether they’re just really incompetent. That’s quite a hard thing to process in a way. If they’re really incompetent, in a way that’s worse than it being a conspiracy. That means it could have been done differently”.

At this point Rowan chips in to back her mum up, she had been allowing her space to speak first but these are clearly arguments they have discussed before, even if they think differently about certain aspects.

Rowan: At least if it’s a conspiracy they know what they’re doing, if it is incompetence they don’t.

Dominique explains that they have been trying to come to terms with those things and reconcile them.

“The other thing with social services is the inquest didn’t really make any of those things clearer to me”.

She explains that she is not able to put things to rest like she had wanted to. She is still trying to understand what it is that went wrong. She found the Buckinghamshire Council staff defensive, she believes some told lies, and their focus was on “covering up as much as possible”. This combination of events meant that the inquest did not really make anything clearer.

Dominique is clear that the reports produced by council staff were littered with inaccuracies. These were not explored during Fern’s inquest as the coroner was explicit that the decisions of the Family Court fell outside of scope.

“It’s really frustrating. Lots of their actions, or reactions were based on false information. Fern never went off and left her baby with me, she didn’t go AWOL, we agreed, any mother would do that, it’s perfectly normal behaviour to leave a baby with their grandmother”.

At this point Rowan chips in again. She believes this particular event, around which so much appears to have turned, the starting point for the domino effect of actions that followed, only occurred because Social Services had imposed a condition that meant Max (Fern’s partner) could not freely visit Fern and their new baby. Therefore, one evening Fern arranged with Dominique to leave the baby with her, and visit Max.

Dominique said there were quite a few occasions were something like that happened, where Social Services “reasons” for action, were taken or “escalated out of false information”.

“How does that happen? Is it they make a decision very early on and then build their facts around that narrative? Is that because they want to get their way, or is it because of the way if your mind is set on something, your brain is set on something, it only sees it? If you say you have a fixation with yellow cars, you’ll see lots of yellow cars, that kind of thing.

Or is it like Chinese Whispers, one person says something, one person hears it like that, another person reports like that … I’ve experienced [that] not just in Fern’s case, but other parents having that sort of scenario”.

Dominique again wonders aloud whether this is about a deliberate or accidental narrative, and whether there is a problem with the accuracy of record keeping.

Rowan comments that record keeping was touched on a lot during Fern’s inquest. She has reviewed the clinical notes and records relating to Fern. She tells me she’d recently reminded a colleague that clinical notes are “a snapshot of a snapshot. What one person has heard, or seen, at one point in time”. She is clear they lack context, and the mere process of capturing them, and transferring them to notes holds significant power.

Dominique and Rowan both reflect that once something is added into someone’s notes it is treated as fact. They refer to the inaccurate note that Fern was diagnosed with Emotionally Unstable Personality Disorder, added to her record erroneously by a nurse, that Fern repeatedly asked to be removed. A psychiatrist agreed it was an inaccurate diagnosis, but it still reappeared throughout her clinical records.

Rowan referred to it as “like banging your head against a brick wall”. She said that they could not at any point, say ‘no, that’s not what happened’.

Dominique described an identical situation with Care Proceedings.

“In the very beginning the reports were inaccurate, if they’re not put right it just snowballs. You’re going around on falsities getting bigger, bigger and bigger. To get them changed isn’t easy”.

Rowan says she has been through the records and is unclear where some of the narratives came from. She says some situations she recognises, although her interpretation and memory of what happened is different to what is recorded. Other events in the records she believes are made up, not even misunderstandings.

It is clear that Dominique and Rowan are both left with unanswered questions. Rowan references the Safeguarding Adults Review (still unpublished but submitted in evidence to the inquest) had a list of dates by which actions would have been completed, by July and September 2023 “but no one mentioned if they had been done”.

Fern’s family are left wondering what happens next. They ask the rhetorical question of what is the point of the Root Cause Analysis report, or the Safeguarding Adults Review, if no clear change is identified and made.

Rowan references the evidence given by the Director of Children’s Services, Richard Nash. He had answered a question with the comment that the world is not neurodiverse friendly. Rowan points out that this is a decision that we all make, it is not a fact, but an active choice.

Rowan: They offered to do co-production with us…. to my knowledge it’s still all quiet, even though they said in court they were up for it… a little part of me does wonder if we’ll ever hear from them.

At this stage in time Fern’s family have not heard how many matters the coroner will be raising in the Prevention of Future Deaths report he has said he will be making. Submissions have been made, and they are waiting to hear back**.

Rowan says that she was really struck by the differences between the lawyers, their advocacy style and personal demeanour. Her observations extend to those witnesses that gave evidence in court, those who approached the family afterwards, and those who she feels avoided them.

Dominique references one witness, Alison Munt, who had been involved in the Safeguarding Adults Review as the Children’s Services representative. She says she is still confused as to what her role was, she said she had not met her prior to the inquest. Rowan is annoyed that she was involved with the safeguarding review process, and yet still defended everything that was done when on the witness stand.

Rowan: Still after all of this, I thought it would make more sense, it kind of doesn’t. I thought maybe in the inquest would be someone that said here’s how we screwed up, here is how we went wrong, but they don’t seem to understand how they screwed up… what have you guys been doing over the past four years?

Rowan references a witness who had not checked before taking the stand whether she had written an email that she then would try and rely on in court.

Rowan simmers with frustration. She is eloquent, considered and angry. It makes no sense to her that professionals can appear so ambivalent to wanting to know more and be better.

Rowan: Fern was put under a microscope and treated like this. Everything she did was hyper analysed… Fern was put in a court room over care proceedings, with no support…. We don’t get paid to feel these feelings, to go through this. We don’t make our livings out of it, we have to do that separately.

We have to survive. It makes me angry they can go home and get on with their lives… they don’t have to think about Fern if don’t want to, am sure some wont.

Fern’s case is so complicated, you can’t draw it to one thing. It is a gross failure on so many different levels, in so many different ways, by so many different people, you can’t fire someone and then it be fixed, you can’t put in a nice report and then it be fixed…. I don’t think Children’s Services understand why they were wrong.

Dominique adds that Fern told her that she was fine as a person, until you plugged her into a system, and then she would highlight all the faults.

Our conversation moves onto the Child Protection Proceedings, which were a key yet peripheral part of the inquest. The decisions made were not explored. Rowan is back to questioning whether the way Fern was treated was a conspiracy or negligence. She wonders whether Social Services were rushing things through, because younger babies are more adoptable.

Dominique is reflective. She explains a balance is at play, and it is important for a child’s welfare that they are not involved in a court case for years on end. She understands the desire to create stability for a child as soon as possible, although she does highlight that guidelines suggest that there should be some flexibility for that when working with disabled parents.

Fern’s father’s evidence at her inquest was that they were aware of this guidance, and brought it to the attention of Children’s Services staff, in a desperate attempt to ensure some meaningful support was provided to Fern.

Rowan has many unanswered questions about Social Services involvement before her sister’s death. She does not understand why there was such a rush in proceedings. She believes that decisions were made based on Fern being autistic, not based on things she had or had not done.

Rowan: I still cannot wrap my head around it. Why they did what they did. If they don’t realise what they did was wrong, how can we expect them to change it? Here’s more stress, we’ll watch you under a microscope, see what happens. We’ll say that’s supporting you. Do they tell themselves now they did their best?

Rowan says Children’s Services could not provide any clear examples of any risks Fern posed, or of any support that they offered her. She is left asking the question, ‘what were they doing?’

Dominique says she comes at things with a different view to Rowan. She has been a parent to three children with autism and she considers that Fern was very much one of the first girls to be diagnosed as autistic. She refers to her being at “the crest of the wave of girls being identified”.

“Really I guess, Fern was a spear header, she spear headed the way through with loads now following behind, but I know people don’t just don’t understand autism, generally really”.

Dominique gives an example relating to Fern’s younger brother and his school.

The conversation returning to Fern, they comment that only one person involved in the Child Protection decision making process had ever met Fern. They consider that there was no clear information available for her, and no support put in place for Fern.

Wrapping up our conversation I ask Dominique and Rowan if there is anything they wish they had known in advance of Fern’s inquest, or if they have any advice for any family approaching an inquest.

Dominique was shocked that things would change during the inquest. She had not anticipated that new statements would be given while the inquest proceedings were happening.

Rowan reflected that the inquest was a lot harder than she thought it would be, adding that it was simultaneously quite boring and fascinating. She said that there was a lot of information and she got to a point where it was just another day, you get used to it, and then it ends and you’re left wondering what now to do with your life.

Rowan: Everyone says don’t get your hopes up and I think that’s true… I wish I’d known the inquest wasn’t about Fern, it’s about them.

When I ask who she means by them, she responds the State, authorities and interested persons, but not about Fern.

Rowan: It’s not about Fern, it’s not about the family. It’s about figuring out factually what happens, then that’s about it. There’s no help you get from it … It also doesn’t feel better when they tell you they did it wrong. When they say they screwed up … in some ways that’s really painful, when they admit it, it hurts too … doesn’t bring them back or make you feel much better.

Dominique: You’re not going to win either way, there is no winning in an inquest.

** Our conversation took place in May. It has been confirmed since then that the Coroner will only be issuing one Prevention of Future Death report which was published last month. The coroner also wrote to Buckinghamshire Council and Oxford Health confirming that his duty was not triggered due to the changes they had made since Fern’s death, however he also stated that he would have concerns if learning and improvements were not carried forward, or if things reverted to the situation in which Fern found herself.

Last month Voicing Loss: A research and policy project on the role of bereaved people in coroners’ investigations and inquests was published. This research saw researchers from Birkbeck University’s Institute for Crime & Justice Policy Research and the University of Bath’s Centre for Death and Society interview 89 bereaved people, 82 coronial professionals and 19 witnesses about the inquest process.

Their headline message was that while some people found the inquest process cathartic, more spoke of being negatively impacted by the process. They reported anxiety, uncertainty and severe distress during inquest hearings, and that inquests had a subsequent long-lasting emotional and psychological toll.

It seems that Dominique and Rowan’s experience is far from unique. The Voicing Loss website contains lots of resources and papers about family’s experiences.