AN official urgent call for help has been made by a coroner to prevent future deaths and get desperately needed support for autistic people.

John Broadbridge, Assistant Coroner for North Yorkshire was so concerned by the harrowing evidence at the inquest into the death of 25 year-old Zoe Zaremba from Aiskew, Bedale, he has made the special appeal which has gone to the chief coroner, a government minister and health services.

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Zoe killed herself in June 2020, she was found following a six day search by emergency services after taking an overdose.  The coroner heard under the care of Tees, Esk and Wear Valley Foundation although diagnosed as autistic Zoe had also been diagnosed with a personality disorder which she vehemently disagreed with.

In his report Mr Broadbridge said: “ Zoe should have received care from community mental health services as well as inpatient care. She withdrew from engagement with those services because she did not trust those entrusted to keep her safe, in part because of clinicians’ failure to understand her autistic condition and their reliance on an unsubstantiated attribution of a mental disorder instead.

“Zoe was detained 17 times and presented to A and E around 37 times with evident self harm and apparent attempts on her life. She had no Care Co-ordinator nor effective Care Plan, which ought to have been in place, because she had not engaged with TEWV community services. Zoe lurched form crisis to crisis remaining at high risk to her own safety; she died because she could no longer cope with the sense of injustice caused by others that overwhelmed her thinking.

“Both locally,regionally nationally the evidence revealed a number of serious issues that require urgent and immediate action to support autistic people.”

Zoe’s mum Jean said the report recognises the lack of understanding of autism, especially in females. She added: “ I believe concrete changes will happen when action is taken on the Prevention of future deaths. How can it not?

“I find it hard to comprehend that mental health services know so little about autism when psychiatrists and psychologists diagnose it. They were so dismissive and would not listen to Zoe, or myself. They were not open to learning.  I trust no one will ever have to go through 'the hell' that Zoe encountered in asking for help and being driven to her death by the lack of understanding and 'blinkered' thinking of TEWV staff.”

Elizabeth Moody, director of nursing and at Tees, Esk and Wear Valleys NHS Foundation Trust, said: “Our thoughts remain with Zoe’s family and friends during this very difficult time. We are truly sorry for their loss.

“We accept the coroner’s findings and know there is more we must do to better support autistic people, their families and carers.

“We are very grateful to Zoe’s family for working closely with us to better understand autism and improve the support for autistic people who access our services.”


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