Zoe failed by NHS trust before she took own life at just 25

“Systemic failures” were committed at an NHS trust caring for a young woman with autism, who later ended her own life, a coroner has ruled.

Zoe Zaremba was just 25 years old when she was found dead under a hedge adjacent to the Bedale turnoff in North Yorkshire, on June 21, 2020. The young woman’s body had been discovered by a member of the public, a week after the Zoe’s mother reports her disappearance. from her house in Aiskew.

AN four-day investigation in Northallerton concluded on Thursday. A coroner said her death was due to the actions and omissions of mental health doctors at Tees Esk and Wear Valleys NHS Foundation Trust who were tasked with keeping her safe. Yorkshire Live Reports.

Read more: Deaths, inspections and public inquiry calls: Concerns over crisis-hit health trust in Teesside

North Yorkshire Assistant Coroner John Broadbridge said he would write to ministers and the NHS to urge changes to 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 also in the care of the trust at or before the time of your death.

The inquest heard that concerns about Zoe’s safety were immediately raised when she disappeared, “not least because she had made previous attempts to end her life or, at least, efforts to endanger her life,” Broadbridge said.

Between 2016 and the time of his death, he had been admitted to the ER 37 times for self-injurious behavior, which often included substance ingestion and other attempts to end his life.

She had also spent 17 times hospitalized in a specialized mental health unit. Zoe was pronounced dead at 6:40pm on June 21, 2020 by the attending ambulance crews following a call from a member of the public.

An autopsy revealed that she had died as a result of toxicity related to the consumption of a liquid and Mr Broadbridge said he was satisfied that she had “understood the effect” of ingesting that substance.

The inquest heard that no suicide note was found, but “electronic records”, including a series of tweets, indicated “over a long period, his state of mind”.

Broadbridge said these tweets demonstrated “intense feelings of anxiety and anguish” and indicated Zoe’s desire to harm herself. The inquest heard that Zoe’s poor mental health had been exacerbated in the last years of her life by the discovery of a personality disorder diagnosis in her medical records.

Zoe already had a diagnosis of autism, which was diagnosed when she was 16, and it was also suggested at the time that a diagnosis of Asperger’s syndrome might be appropriate.

The young man had “struggled” in high school “in particular”, but also in elementary school and found social situations difficult. However, Zoe was known to participate in a number of activities that she enjoyed, namely gymnastics, cheerleading, and horseback riding.

The court heard that, during the last two years of her school education, Zoe had many absences due to her mental health, but was still able to achieve success in her GCSEs and subsequent A-Levels.

Zoe later got a qualification in accounting and started working in a “professional environment” but found this environment difficult.

An employment tribunal followed this difficult period and this contributed to a worsening of his mental health problems; Broadbridge said that this period of her life became “one of the so-called traumas that she relived over and over again.”

But the catalyst for Zoe’s death came in October 2018, when she learned there was a diagnosis of Emotionally Unstable Personality Disorder (EUPD) on her record, a condition often referred to by the term Borderline Personality Disorder. personality.

This diagnosis, which the inquest heard had not been disclosed to Zoe, caused her great distress and left her feeling that she had been “made into someone she was not”.

Broadbridge said: “She questioned the opinion of the community mental health team repeatedly. Doctors within the trust were aware of how profoundly difficult she found this and Zoe’s sense of injustice and distress ran deep.”

He added that while the doctors were “aware” of Zoe’s concerns, “it was not the same as understanding Zoe’s antipathy.” The inquest also heard that when the diagnosis was found to be incorrect, it took too long to remove her record, despite Zoe’s insistence that she be removed from her record.

Broadbridge said: “Knowing how he felt and behaved, nothing was done to add or remove from the record for a long time.”

And he added: “It is a record that in those 18-19 months, starting in October 2018, when the first movements were made to remove [the diagnosis] clinical records; Until the time of his death or at least until May 2020, he had presented to the ER about 25 times with an overdose, ingestion of toxic liquids or taken by police or ambulances “.

The inquest heard that, during those same months, Zoe had spent 12 occasions as an inpatient in a mental health unit with only three of these “informal” stays and the rest in a ward.

Broadbridge said: “Each precipitating event took a mental toll on Zoe, who recounted her experience over and over again with anguish. These were again part of a traumatic pattern of recollection and disgust.” ‘She couldn’t live with an incorrect diagnosis’

When the process was finally started to remove the incorrect EUPD diagnosis from Zoe’s record, the investigation heard that it “took only a few days to remedy”. Broadbridge said she could see “very little justification” for the delay and, at this point, Zoe’s trust in NHS staff had already been shattered.

Referring to a statement made by Zoe’s mother, Jean Zaremba, Broadbridge said the misdiagnosis had been “impossible” for Zoe to accept and that she “couldn’t live” with it.

As a consequence of the breach of trust, the court heard that Tees, Esk and Wear Valleys NHS Trust had failed to appoint Zoe with any effective care plan or care coordinator and as a result her final discharge from hospital treatment in May 2020. had been “improvised”.

Broadbridge said she had been discharged with “some but not effective care” and described her subsequent treatment as “reactive, not proactive”.

He described Zoe as “flipping from one crisis to another” and said “the care or lack of care she was subjected to” posed a “real and immediate risk” to her life, adding that she received “very limited support”. “.

Concluding Zoe’s investigation, Mr. Broadbridge said: “[Zoe] he had a history of repeated self-harm and attempts on his own life and should have received mental health care from the community mental health service as well as hospital care.

She withdrew from those services because she did not trust them to keep her safe, in part because doctors did not understand her autistic condition and relied on an unsubstantiated attributed mental disorder.”

He added: “I find that Zoe died by suicide, and to which I’m going to add a short narrative and that narrative will be that the actions and inactions of the mental health doctors charged with maintaining her contributed to her death.” sure, within a system of care that was underdeveloped to handle an autistic individual with complex needs.

The inquest heard that while she was engaged in adult mental health services, Zoe’s autism was “not understood” by those tasked with caring for her.

Broadbridge said, “Her condition was seen as one for others to address, not for everyone to address. There was a need to work in partnership with her.”

“Zoe’s anguish was overwhelming for a long period, she died because she could no longer cope with that anguish caused by perceived injustice by others.”

It recommended that a Section 28 report, which is intended to help prevent future deaths, be sent to the Minister of State for Mental Health and Care, Gillian Keegan.

He said he also intends to write a letter to the NHS trust, stating his concern about the way the trust handles patients diagnosed with autism.

Speaking to Zoe’s mother, Mr Broadbridge said: “Mrs Zaremba, I can’t even begin to imagine the heartbreak you’ve been through, but to your family members who are here, your friends and those involved, I I offer my deepest condolences for your loss.”