A coroner has concluded that the death of an autistic mother who took her own life almost four years ago was due to two contributing factors.  

Fern Elisabeth Foster from Monks Risborough, died on July 8, 2020, just six months after she gave birth to her daughter.

The three-week hearing, which took place at Beaconsfield Coroner’s Court, heard how Fern passed away after discovering that her baby, who was put in foster care a month after being born, would be placed under adoption.

She took her own life just hours after receiving the news from Buckinghamshire Council.

On the final day of the inquest on Thursday, April 18, Senior Coroner Crispin Butler concluded there was a 'lack of independent advocacy to help Fern'. 

He said: "We have heard about evidence of recent physical and mental health diagnosis, evidence of state of mind, points of crisis and potential triggers.

"But in the latter parts of 2019 when she discovered her pregnancy, she had a new purpose to her life.

"There were opportunities in 2019 to put in place a structure to focus on her, along with the future of her child as paramount, but these were missed.

"The issues arose when Fern’s needs needed to be adjusted without impacting the child’s needs.

"Formal meetings, meetings face-to-face, scheduling, regular changes, timings...these elements compromised Fern’s engagement due to her autism. 

"Fern said herself that 'she was set up to fail' but it’s more complex than that.

"There should have been a clear communication plan for Fern - better and earlier decision-making to accommodate her needs was needed.

"This [news of the adoption] shouldn't have been in writing - the absence of planning from the local authority meant the opposite regarding safeguarding.

"The lack of an independent advocacy on a regular, consistent and constant basis, not just for meetings, but for communication with the Child Protection Services, was needed.

"This is the single largest adjustment for Fern's needs which was not met.

"Secondly, how Fern found out about the news was a key trigger for her to act as she did."

Before her death, the young mother had been in and out of temporary accommodation and had a history of self-harming, which she used as a coping mechanism when feeling overwhelmed due to her autism.

Throughout the time she was pregnant and in the final months of her life, Ms Foster was supported by her mother, Dominique, and the father of her child, Max Newman.

Family and friends of Fern heard from two delegates at Oxford Health NHS Trust who explained how they help people with autism.

Consultant Psychiatrist and Clinical Director, Tina Malhotra, told the court: “The Trust has revamped its autism strategy.

“This idea is to help oversee the care for those who have autism as some of the needs weren’t met.

“Autism is everyone’s business and everyone needs to be informed.

“All our staff members are being trained nationally to help those with autism. 

"Instead of putting blame, this is a learning culture for us.”

Members of Fern’s family, along with many of her friends, were seen wearing pink clothing during the inquest’s final day on April 18, whilst donning a badge reading ‘Go Pink for Fern’.

Fern’s sister, Rowan, who was wearing a pink dress in court, told the Free Press that whilst the campaign is very much in its early stages, those close to Fern aim to launch a website to ‘help women and girls with autism.’

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