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A lack of independent advocacy contributed to a 22-year-old mother taking her own life after her baby was taken into care, an inquest has found

The lack of an independent advocate on a regular, consistent and continuous basis for a 22-year-old mother whose baby was taken into care contributed to her decision to take her own life, an inquest has found.

Posted on 18 April 2024

Fern Foster, aged 22, of Buckinghamshire, died on 8 July 2020 after being informed that her six-month-old baby might be placed for adoption by Buckinghamshire County Council. Fern’s child had gone into foster care almost a month after she was born, in January 2020, after the support her family believe she was entitled to was not put into place. 

Fern Foster
Image of Fern Foster


The coroner also found that a lack of professional support available to Fern when she was informed of the local authority plan to recommend her baby should be adopted contributed to her death.

During the three-week inquest the court heard that Fern was diagnosed with autism at age 15 and struggled to get the support she needed and would often use self-harm as a way of communicating her distress.

Fern found out she was pregnant on 25 July 2019. Shortly after, Buckinghamshire Children’s Services became involved. 

The court was told that Fern, who aspired to become an English teacher, was delighted when she found out she was pregnant, and the news changed her outlook on life. While she was pregnant, and up to the point of her child being taken from her, she did not engage in any self-harming or other behaviour that would put her or her baby at risk.

It heard how Fern had described the process that ultimately led to her child being taken out of her care as a “runaway train”.

Senior Coroner for Buckinghamshire Crispin Butler said that several healthcare and local government agencies, including Oxford Health NHS Foundation Trust (OHNFT) and Buckinghamshire County Council social services department, had contact with Fern in the months before her death, adding that it was probably the case that no one agency had a complete understanding of Fern’s needs.

The coroner gave a narrative conclusion, recording the cause of death as suicide. He added that the lack of an independent advocate on a regular, consistent and continuous basis, and the way in which news indicating the adoption of Fern’s child was communicated to her, as contributing more than minimally to her decision to end her own life.

The court heard how Fern needed help at a much earlier stage from an independent advocate who could help her understand and engage with professionals and the processes she was going through, and that this was the single largest reasonable adjustment that could have been made to support Fern’s needs. The coroner said this was more important than the sum total of other adjustments made.

Fern had previously indicated intentions of taking her own life were her child adopted, and the court heard that the manner in which plans indicating adoption were communicated to her was a key trigger for Fern’s actions.

No communication plan had been put in place and Fern became aware of the news via an email sent to her partner by his solicitor and was not in the presence of professional support which could have helped her understand the information, and cope with the inevitable distress caused by this communication.

Fern’s family describe her as bright, kind, caring and conscientious and someone who left a lasting impression with everyone she met.

Speaking on behalf of the family, Fern’s sister Rowan said:

“We are pleased that the lack of advocacy provided in Fern’s care, and the inappropriate delivery of the proposed care plan for adoption that the local authority had submitted, have been recognised as the causes of Fern’s death. Mothers who face their children being removed should be supported, especially autistic mothers, as autistic women have a 13 times higher risk of death by suicide. It is tragic that there was never a clear plan to support Fern to be a mother, nor to protect her safety when she was told that would not be possible.

“Fern herself, and we as a family, stressed the importance of proper advocacy and the need for all staff involved to have training in autism and make reasonable adjustments to the way they engaged with her to account for her disability. These essential requirements were repeatedly ignored, inevitably pushing Fern to breaking point. This was no way to treat a vulnerable, disabled, first time mum. 

“We continue to believe that, in refusing to provide the advocacy, support and the reasonable adjustments Fern was entitled to, Buckinghamshire Council cost Fern her life and a baby her mother. With the right support, Fern would have become a wonderful mother. Instead, they made her feel like a bad mother, without telling her why or giving her a chance to try.

“Fern felt she was continuously set up to fail due to lack of reasonable adjustments. She could not process the decisions that were being made that were often based on inaccurate information, and we couldn’t explain those decisions to her, because they didn’t make sense to us either.

“We believe that the lack of understanding and acceptance of autism in women and girls significantly contributed to the poor care that Fern received. She was diagnosed late, repeatedly labelled with a personality disorder that she did not have, and the stigma around this led to her being harmed. Fern was open about her suicidality, yet she was not taken seriously. The misdiagnosis of personality disorders must end, as must the punitive and dangerous culture of care which comes alongside them. Fern felt very strongly about this.

“Finally, we feel that the right of autistic parents to access the support they deserve is not adequately protected in policy or law. It is imperative that this changes and that autistic parents are protected in future.”

Merry Varney and Caleb Bawdon, solicitors at law firm Leigh Day, and Sam Jacobs from Doughty Street Chambers represent Fern’s father, Kieran Foster, her mother, Dominique Jowett and Fern’s sister, Rowan Foster. 

Caleb Bawdon, a solicitor in Leigh Day’s Human Rights team, said:

“Fern’s family welcome the coroner’s conclusion which acknowledges that she was badly let down before her death. It is approaching four years since Fern’s death but her family have been clear from the very start about the difference that access to independent advocacy would have made to the outcome. It is a testament to the strength and courage of her family during this time that the coroner has now agreed with them, and they are grateful for the care and consideration he took in conducting his investigation.” 

Merry Varney
Court of Protection Human rights Inquests Judicial review

Merry Varney

Merry is a partner in the human rights department and head of the Leigh Day inquest group

Caleb Bawdon (1)
Human rights Inquests Judicial review

Caleb Bawdon

Caleb is an associate solicitor in the human rights department

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