Discover and read the best of Twitter Threads about #JusticeForZoe

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CW: Suicide

Zoe's inquest. Day four.

#JusticeForZoe

The coroner begins with a short recap of the inquest, and re introduces all the people present in the court. He provides a description of the day - arguments for whether article 2 is still engaged, submissions from 1/
counsel and arguments for regulation 28 report. Finally, the finding of fact and the inquest conclusion.

Ms Stone, Jean's barrister begins with arguments for article 2. She states that her submission is that this continues to be a case where article 2 is engaged. Her pre 2/
inquest review arguments included a systems duty breach as there was no effective system in place to protect life (in this case specifically autistic people's lives). There was an acceptance by TEWV of findings of the serious incident review (SIR). Nothing in evidence which 3/
Read 88 tweets
CW: Suicide

Zoe's inquest. Day three.

#JusticeForZoe

The day begins with questions posed to Mr Philip Robertson, who conducted the independent review into Zoe's care. The coroner asks Mr Robertson to describe his role and qualifications. Mr Robertson indicates that he has 1/
been a mental health nurse for 42 years - 32 years within the NHS and 10 in independent work. The coroner asks him in what way is the report "independent". Mr Robertson explains that he is not employed by the NHS, has no staff involvement, and has no stake in the outcome of 2/
the report. He explains that the report was commissioned by TEWV, but he is not a TEWV employee. They discuss the duty of candour and the importance of Trusts being open and honest when things go wrong.

Mr Robertson explains that in producing the report he met with Zoe's 3/
Read 167 tweets
🧵 Zoe's Inquest: A collection of threads detailing Zoe's inquest, day by day.

Content warning: While precautions have been taken in terms of not sharing graphic or particularly upsetting details, there is mention of suicide, self-harm, & iatrogenic harm.

#JusticeForZoe
Read 6 tweets
CW: Suicide

Zoe's inquest. Day Two.

#JusticeForZoe

Dr Kuster (Zoe's inpatient psychiatrist) returns to give evidence. First questioned by Jean's solicitor. She asks Dr Kuster about a phone call which had come to her attention, the call was not documented in Zoe's notes. 1/
On May 5th 2020 an MDT took place regarding Zoe's care, and this was attended by Dr Kuster. The meeting included discussion of an advanced directive. The solicitor informs Dr Kuster that Zoe had an appointment with her GP on the 4th but had not ever mentioned an advanced 2/
directive (the advanced directive didn't arrive with the GP until May 12th). She did however tell the GP she would be having a call with Dr Kuster the next day, following the meeting. The solicitor suggests that before the professionals meeting (of which Zoe was not in 3/
Read 122 tweets
CW: Suicide

Zoe's inquest. Day one.

We're at the Northallerton coroner's court. Assistant coroner John Broadbridge (JB) is leading the inquest.

Proceedings began at 10am. Discussed pre inquest review hearings and the evidence submitted to the court.

#JusticeForZoe

1/
Inquests are a fact finding forum. No blame, no determination of criminal responsibility. A discussion of who, how, when, and where, and the important facts surrounding those.

The inquest is for Zoe Emma Zaremba, born 7/1/95 in Northallerton to Jean and John Zaremba.

2/
Zoe died 21st June in Bedale, North Yorkshire.

Coroner (JB) states that this case is broader than a statement of means, as Article 2 is engaged, there will be a more in-depth investigation. JB states that there were breaches of the state to provide a proper framework to

3/
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