Fern Elisabeth Foster · Prevention of Future Deaths report

On 15th July 2020 I commenced an investigation into the death of Fern Elisabeth Foster, aged 22. The investigation concluded at the end of the inquest on 18th April 2024.
The medical cause of Fern’s death was ████████
A narrative conclusion was recorded:
“Suicide to which the following contributed more than minimally: (a) 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 8th July 2020 when she learned of significant news likely to trigger suicidal intention; (b) 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.”

Fern Foster’s death was verified at around 15:20 on 8th 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 the 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 and when, on 8th July 2020, she consumed some of the contents from the package in her possession, she intended her death to result.
Fern had a pre-existing, well-established, accepted, and recognised diagnosis of Autism Spectrum Disorder

(1) The process for triaging and prioritising ambulance attendance to an incident involving the suspected ingestion of ████████ (intentionally or otherwise) does not provide sufficient opportunity for travel, attendance, conveyance to hospital for emergency treatment and/or provision of antidote treatment at scene, which may provide the only likely means of prevention of death where sufficient quantity has been ingested.

(2) The carrying by ambulance services of appropriate antidote medication for on-scene administration (such as Methylene Blue), whilst trialled elsewhere, is not part of regional or national protocol. Swift access to this in circumstances where ████████ is suspected, and timings mitigate against survival by the time of arrival at the nearest Emergency Department, could prevent future deaths in some cases.