“Systemic failings” were made at an NHS trust caring for a young woman with autism, who later went on to end her own life a coroner has ruled.
Zoe Zaremba was just 25 when she was found dead beneath hedgerow adjacent to the Bedale bypass in North Yorkshire, on June 21, 2020. The young woman’s body had been discovered by a member of the public, a week after Zoe’s mother had reported her missing from her home in Aiskew.
A four-day inquest in Northallerton concluded on Thursday. A coroner saying her death de ella was contributed to by the actions and inactions of the mental health clinicians at Tees Esk and Wear Valleys NHS Foundation Trust entrusted to keep her safe, Yorkshire Live reports.
North Yorkshire assistant coroner John Broadbridge said he would write to ministers and the NHS urging changes in autism care.
Zoe’s passing followed the tragic deaths of Christie Harnett, Nadia Sharif, both 17, Emily Moore, 18 and Jadzia Todd, 19, who were all also under the care of the trust at the time of their death or before.
The inquest heard that concerns had immediately been raised about Zoe’s safety when she went missing, “not least because she’d made previous attempts to end her life or, at least, efforts to endanger her life”, Mr Broadbridge said.
Between 2016 and the time of her death, she had been admitted to A&E 37 times for self-harming behaviour, which often included the ingestion of substances and other efforts to end her life.
She had also spent 17 occasions as an inpatient at a specialist mental health unit. Zoe was pronounced dead at 6.40pm on June 21, 2020, by ambulance crews that she had attended following a call from a member of the public.
An autopsy revealed that she had died as a result of toxicity linked to the consumption of a fluid and Mr Broadbridge said that he was satisfied she would have “understood the effect” of ingesting such a substance.
The inquest heard that no suicide note was found, but “electronic records” – including a series of tweets – indicated “over a long period, her state of mind”.
Mr Broadbridge said that these tweets demonstrated “intense feelings of anxiety and distress” and signified Zoe’s desire to harm herself. The inquest heard that Zoe’s mental ill health had been exacerbated in the final years of her life, by the discovery of a diagnosis for a personality disorder that was on her medical records.
Zoe already had a diagnosis for autism, which was diagnosed when she was 16, and it was also suggested at that time that a diagnosis of Asperger’s Syndrome may be appropriate.
The youngster had “struggled” in secondary school “in particular”, but also in primary school and found social situations difficult. However, Zoe was known to have engaged in a number of activities which she enjoyed, namely gymnastics, cheerleading and horse riding.
The court heard that, during the last two years of her school education, Zoe had a lot of absences due to her mental health, but was still able to achieve success in her GCSE exams and subsequent A-Levels.
Zoe later gained a qualification in accounting and began working in a “professional environment”, but found this environment difficult.
An employment tribunal followed this difficult period and this contributed to a worsening of her mental health issues; Mr Broadbridge said that this period in her life became “one of the so-called traumas that she relived time and time again”.
But the catalyst for Zoe’s death came in October 2018, when she learned that there was a diagnosis of Emotionally Unstable Personality Disorder (EUPD) on her record, a condition that is often known by the term Borderline Personality Disorder.
This diagnosis, which the inquest heard had not been disclosed to Zoe, caused her significant distress and left her feeling as though she had been “turned into someone she was not”.
Mr Broadbridge said: “She challenged the view of the community mental health team repeatedly. Clinicians within the trust were aware of how deeply difficult she found this and Zoe’s sense of injustice and distress was profound.”
He added that, although clinicians were “aware” of Zoe’s concerns, it “did not equate to understanding Zoe’s antipathy.” The inquest also heard that, when it was found that the diagnosis was incorrect, it took far too long for the record to be removed, despite Zoe’s insistence that it be taken off her record from her.
Mr Broadbridge said: “Knowing how she felt and behaved, nothing was done to add to or expunge the record for a long time.”
He added: “It is a matter of record that, during those 18-19 months, from October 2018, when the first movements were made to remove [the diagnosis] from clinical records; to the time of her death de ella or at least to May 2020, she had presented to A&E around 25 times with overdoses, ingestion of toxic fluids, or being brought in by police or ambulances.
The inquest heard that, during those same months, Zoe had spent 12 occasions as an inpatient at a mental health unit with just three of these being “informal” stays, and the remainder being under a section.
Mr Broadbridge said: “Each precipitating event took a mental toll on Zoe who recounted her experience time and time again with distress. These were again part of a trauma pattern of recollection and unpleasantness.” ‘She could not live with an incorrect diagnosis’
When the process was eventually started to remove the incorrect diagnosis of EUPD from Zoe’s record, the inquest heard that it “took just days to remedy”. Mr Broadbridge said that he could see “very little justification” for the delay and, by this point, Zoe’s trust in her in NHS staff had already been shattered.
Referencing a statement made by Zoe’s mum, Jean Zaremba, Mr Broadbridge said that the incorrect diagnosis had been “impossible” for Zoe to come to terms with and she “could not live” with it.
As a consequence of the breakdown of trust, the court heard that no effective care plan or care coordinator had been appointed to Zoe by Tees, Esk and Wear Valleys NHS Trust and, as a result, her final discharge from inpatient treatment in May 2020 had been “improvised”.
Mr Broadbridge said that she had been discharged with “some, but no effective care” and described her subsequent treatment as “reactive not proactive”.
He described Zoe as having “lurched from crisis to crisis” and said that the “care or lack of care that she underwent” posed a “real and immediate risk” to her life, adding that she received “very limited support”.
In concluding Zoe’s inquiry, Mr Broadbridge said: “[Zoe] had a history of repeated self harm and repeated attempts on her own life and should have received mental health care from community mental health service as well as inpatient care.
She withdrew from those services because she did not trust those to keep her safe, in part because of clinicians failure to understand her autistic condition and their reliance on an unsubstantiated, attributed mental disorder instead.”
He added: “I find that Zoe died because of suicide, and to which I’m going to add a brief narrative and that narrative will be that her death was contributed to by the actions and inactions of the mental health clinicians entrusted to keep her safe, within a care system that was underdeveloped to manage an autistic individual with complex needs.”
The inquest heard that, while engaging with adult mental health services, Zoe’s autism was “not understood” by those tasked with caring for her.
Mr Broadbridge said: “Her condition was regarded as for others to address, not for all to do so. There was a want of working in partnership with her.
“Zoe’s distress was overwhelming over a long period, she died because she could no longer cope with that distress caused by the perceived injustice caused by others.”
He recommended that a Section 28 report – that is intended to help prevent future deaths – be sent to the Minister of State for Care and Mental Health, Gillian Keegan.
He said that he also intends to write a letter to the NHS trust, indicating a concern for the way the trust handles patients diagnosed with autism.
Speaking to Zoe’s mum, Mr Broadbridge said: “Mrs Zaremba, I can’t even begin to imagine the distress you’ve gone through but to those of your family who are here, her friends and those involved I offer my deepest condolences for your loss.”